September 2010
Do We Know How to Use Oxygen Properly in Emergeny Department?
Orhan Çınar 1, Hülya Türkan 2, Ethem Duzok 3, Serkan Sener 4, Ahmet Uzun 1, Murat Durusu 1, Murat Eroğlu 5
1 Department of Emergency Medicine GATA, 06013, Etlik, Ankara, Turkey, 2 Department of Anesthesiology and Reanimation, Kasımpasa Military Hospital, Kasımpaşa, Istanbul, 3 Department of Emergency Medicine, Etimesgut Military Hospital, Etimesgut/Ankara, 4 Department of Emergency Medicine, Acıbadem Hospital, Bursa, 5 Department of Emergency Medicine, Erzurum Military Hospital, Erzurum Türkiye
DOI: 10.4328/JCAM.261 Received: 21.04.2010 Accepted: 07.05.2010 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):1-3
Corresponding Author: Orhan Cinar, GATA Acil Tıp AD., 06013, Etlik, Ankara, Türkiye. Phone: +903123043031 E-mail: orhancinar@yahoo.com
Aim: The aim of this study was to determine emergency department doctors’ and nurses’ knowledge regarding oxygen therapy.
Material and Methods: A 7-item questionnaire survey was developed and applied to assess knowledge of oxygen therapy. The questionnaire was administered to a total of 100 (20 nurses, 30 resident physicians and 50 intern doctors (last-year medical students) staff from two university teaching hospital in Ankara, Turkey.
Results: A response rate of 100 % was achieved from participants in the study. Only 9 % of the participants answered all the questions correctly on oxygen therapy.
Conclusions: Our study shows that emergency medical staffs have significant gaps in their knowledge on appropriate oxygen therapy. Since deficiencies in emergency medicine staffs knowledge on treatment with oxygen deficits influence patient’s outcome, we recommend that emergency medicine staff should be trained regarding oxygen therapy and medical schools should pay much more attention to this issue in their curricula.
Keywords: Oxygen, Treatment, Emergency, Knowledge, Mask.
Introduction
Oxygen therapy is essential in many clinical situations that cause hypoxemia in emergency department. Therefore it becomes one of the routine interventions which are ordered and applied in everyday practice of emergency department (ED) staff. The idea that oxygen therapy is a simple and routine intervention can cause serious mis- takes. Both insufficient and excessive use of oxygen can be harmful for patient in different clinical situations. Insufficient oxygen can lead tissue damage, on the other hand excessive oxygen therapy can cause respiratory depression and arrest in COPD patient. Be- side this overestimation the risk of respiratory depression can cause insufficient oxygen therapy of COPD patient. There are several ways to administer oxygen such as low flow masks (nasal cannula, simple face masks and face masks with reservoir bag) and high flow masks (sometimes called Venturi masks). It is important to decide mask type and oxygen concentration (FiO2), which should be cho- sen in different clinical situations [1-4]. Because of this emergency staff should know how to provide appropriate oxygen therapy in different clinical situations.
We believed that although oxygen is used routinely in emergency department, ED staff does not know how to use it properly. The aim of this study was to determine emergency department doctors’ and nurses’ knowledge regarding oxygen therapy.
Material and Methods
A 7-item questionnaire survey was developed and applied to assess knowledge of oxygen therapy. The questionnaire was administered to a total of 100 (20 nurses, 30 resident physicians and 50 intern doctors (last-year medical students) staff from two university teach- ing hospital in Ankara, Turkey.
Subjects were questioned to name different oxygen masks, to deter- mine the accurate flow of oxygen delivered in various patients and find out the most appropriate mask for a given clinical situation.
Questions of the survey are shown in Figure1 and the answers of the questions are given in Table-1. After the questionnaires were completed correct answers were given to participants. Statistical analyses were calculated by Statistical Package for Social Sciences (SPSS) for Windows, Version 11.0.
Results
There were 100 participants in the study: 20 nurses, 30 resident physicians and 50 intern doctors. A response rate of 100 % was achieved from participants in the study. Only 9 % of the partici- pants answered all the questions correctly on oxygen therapy. First question was answered correctly by 58 % of participant. The other questions were answered correctly in following order; second ques- tion 27 %, third question 13%, fourth question 13%, fifth question 15%, sixth question 54%, seventh question 96 %. Distribution of accuracy of questions in each group showed in Table-2.
Discussion
Our study showed that there are marked gaps in emergency depart
ment staff’s knowledge about oxygen therapy. Unfortunately only 9% of the participants answered all the questions correctly on oxy- gen therapy. There are a few studies on knowledge of oxygen ther- apy. In one of those studies; Hacıevliyagil and friends showed the educational gaps of resident physicians about oxygen therapy from different clinics [5]. In another study that Ganeshan at al. tested the knowledge of junior doctors and nurses found that their participants do not have sufficient knowledge and understanding of oxygen ther- apy [4]. These study reports are consistent with our results.
On our survey, in the first question that was just asking the rec- ognition of oxygen delivery devices, only %58 of the participants could able to answer it correctly. This unexpected result showed us the uncommon use of some of the oxygen delivery devices such as non-rebreather mask and Venturi mask. But both type of mask have real importance in clinical practice of emergency medicine. Ven- turi masks(high flow mask) fixes oxygen concentration in a desired level (24-60%), so using these masks in patient with COPD and type II respiratory failure reduce the risk of carbon dioxide reten- tion while improving hypoxemia. On the other hand non-rebreather masks give us the opportunity to deliver high oxygen concentration (60-100%) to patients.
Third question gave us the worst news that only 13% of all health professionals (especially nurses which is 0%) working in an acute hospital setting were able to treat the patiens by choosing appropri- ate mask at different clinical situations. We think that the reason of this that they are not aware of the differences of different oxygen delivery apparatus. Whereas all health professionals working in an acute hospital setting should be familiar with all type of oxygen mask and their proper use.
Another worst worrying answer rate was of fifth question regarding
Bag Valve Mask (BVM) oxygen flow rate. Only 15 % of medi- cal staff knew the right answer. Our results showed that BMV was mostly used with low oxygen flow rate like simple face mask. Whereas BVM is mostly used during cardiopulmonary arrest and like each steps of Basic Life Support and Advanced Life Support appropriate application of BMV including right oxygen flow rate affect the successful outcome.
The highest right answer rate 96% of our survey is moisturizing which is another issue regarding oxygen therapy. We have consid- ered that distilled water was well known because of its routine use in daily clinical practice.
As a result of deficient knowledge of oxygen therapy,oxygen ther- apy mistakes showed up at an acute hospital setting. Fitzgerald’s study showed that % 21 of hospitalized patient having insufficient oxygen therapy and %85 of them not properly followed [6]. In an- other study that compared oxygen therapy with antibiotics therapy on internal medicine patient showed that oxygen prescription and delivery is associated with significantly greater error than antibiot- ics [7].
Regarding the educational gap about oxygen therapy , during our study , by giving answers to participants, we aimed to contribute training the emergency medicine staffs at the same time., in order to ensure safe and effective oxygen administration , oxygen orders should cover the flow rate, delivery system, duration, and monitor- ing of treatment according to the guidelines for administration of oxygen [1-3]. Therefore medical schools and residency programs place more emphasis on teaching the principles and applications of oxygen therapy to be able to order and administer the oxygen appropriately and safely.
References
1. Bateman NT, Leach RM. ABC of oxygen: acute oxygen therapy. BMJ.1998;317: 798-801.
2. Thomson A, Webb D, Maxwell SR, Grant I. Oxygen therapy in acute medical care. BMJ.2002;324:1406-1407.
3. Murphy R, Mackway-Jones K, Sammy I, Driscoll P, Gray A, Driscoll R, Reilly J: Emergency oxygen therapy for the breathless patient. Guidelines prepared by North West Oxygen Group. Emerg. Med. J. 2001;18: 421-423.
4. Ganeshan A, Hon LQ, Soonawalla ZF. Oxy- gen: can we prescribe it correctly? European Journal of Internal Medicine. 2006; 17: 355–35.
5. Hacievliyagil SS, Mutlu LC, Günen H, Kizkin O. The evaluation of knowledge about oxygen treatment by doctors taking specialty education. Archieves of Pulmonary.2004; 2: 89-94.
6. Fitzgerald JM, Baynham R, Powles ACP. Use of oxygentherapy for adult patients outside critical careareas of a university hospital. Lancet 1988; 1: 983.
7. Small D, Duha A, Wieskopf B, Dajczman E, Laporta D, Kreisman H, Wolkove N, Frank H. Uses and misuses of oxygen in hospitalized patients. Am.J.Med.1992; 6:591-5.
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Orhan Cinar, Hulya Turkan, Ethem Duzok , Serkan Sener, Ahmet Uzun, Murat Durusu, Murat Eroglu. Do we know how to use oxygen properly in emergeny department?. J Clin Anal Med. 2010;1(3):1-3
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The Effects of Hypericum Perforatum Extract on Topical Burn Injury: A Comparative Study with Iodine
Alper Çelik 1, Ömer Faik Ersoy 1, H. Ayhan Kayaoğlu 1, Namık Özkan 1, Neşe Lortlar 2, Suna Ömeroğlu 2, Ebru Arabacı Çakır 3
1 Department of General Surgery, Gaziosmanpasa University Faculty of Medicine, Tokat, 2 Department of Histology and Embryology, Gazi University Faculty of Medicine, Tokat, 3 Department of Pathology Ankara Ataturk Training and Research Hospital, Ankara, Turkey
DOI: 10.4328/JCAM.249 Received: 10.04.2010 Accepted: 05.05.2010 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):4-7
Corresponding Author: Alper Çelik, Gaziosmanpaşa University Faculty of Medicine Department of General Surgery, 60100 Tokat, Turkey. Phone: +905327059540 Fax: +903562133179 E-mail: doktoralper@hotmail.com
Aim: We aimed to assess the efficacy of topical Hypericum perforatum (HP) extract and compare with topical iodine in a rat model of thermal skin injury.
Material and Methods: Wistar-Albino rats were subjected to two separate heat-induced third degree burn injuries on dorsal skin. Control group was left untreated, and treatment groups received either topical iodine or HP. Seven days later injured areas were macroscopically examined, and ulcerations were calculated. Histological indices of wound healing and expression of Transforming Growth Factor-β (TGF-β) were analyzed in each animal.
Results: Treatment groups had significantly smaller areas of ulceration. We observed 23.94% reduction in iodine (p=0.008) and 42.89% reduction in HP treated rats (p<0.0001). Transforming Growth Factor-β levels were slightly reduced in HP group. Collagenisation and reepithelization were improved in both treatment groups with significant superiority in HP group. Fibroblast proliferation was better in the same group. It was observed that iodine treatment led to higher rates of necrosis.
Conclusions: We state that HP extract might be beneficial for the treatment of topical burn injury.
Keywords: Topical Burn, Iodine, Hypericum Perforatum Extract, Wound Healing, TGF-β.
Introduction
Thermal burns and related injuries are one of the most common causes of disability and death in civil environments and constitute the majority of burns admitted to hospital. Within these admissions pediatric and geriatric subjects are more commonly encountered than others [1]. Thermal burns are usually caused by heat, rarely by cold and chemicals. The severity of injury is highly dependent on temperature, duration, skin thickness, area ex- posed, and presence of clothing [2]. Patients with severe burn injuries may require prolonged reconstructions, rehabilitation, and psychological support [3]. Goal of treatment in burn injury is not only improved survival, but also local wound healing, cosmesis and providence of a well rehabilitated and normally functioning injured area. Civil burns with less than 15% of to- tal body surface area constitute the majority of burn cases and are usually treated by topical wound dressings or ointments [4,5]. Beside cosmesis and wound healing, control of infections is also a major determinant of healing in burn injury. From this aspect, yet there is no single drug that can fulfill the criteria described above. Silver sulphodiasine, iodine and antibiotic con- taining creams are some of the commercially available formulations used in burn patients. Iodine, because of its marked antibacterial properties, is used in the treatment of thermal burns, alkylating agent and mustard-gas induced injuries [6]. In the present study we compared the effects of Hy- pericum perforatum (HP)-a medicinal plant-with iodine. HP contains fla- vonoids, phenolic acids, etheric lipids, carotene and vitamin E. One of its phenolic constituents (Hyperforin) displays antibacterial, anti-oxidative and antiinflammatory effects, and also prevents lipo-oxygenation [7-10]. Recent evidence also suggests analgesic and antidepressive effects of Hypericum derivatives [11,12]. In the present study we evaluated the effects of treat- ment agents by macroscopic ulceration, TGF-β expressions, and histologi- cal indices as indicators of heat-induced skin injury and wound healing. These parameters have been studied extensively in previous reports regard- ing burn injury. To our knowledge our study is the first to demonstrate the effects of HP in burn injury.
Material and Methods
Protocol of this study was approved by the institutional ethical committee. All procedures and follow-up were held according to local animal studies research center regulations. Thirty Wistar-albino rats of both sex weigh- ing 240-360 g were randomly allocated to three groups (n=10 per group). Two to three rats of same sexes were housed in separate wire cages with free access to food and water under standard laboratory conditions (room temperature 23°C, 12 h light-dark cycles). Rats were fasted 12 h before surgery, but had free access to water.
Experimental Procedure and Evaluation
Rats received a third degree scald burn, as previously described [13]. Briefly, rats were anesthetized
by 75 mg/kg ketamin hydro-
chloride and 10 mg/ kg xylazin, and dorsal hair was shaved. Burn injury was performed at two separate sites exposing to heat source (boiling water at 75 oC, for 7 seconds) by the well system. Wells were cy- lindrical plastic tubes with 0.5 cm diameter. One ml of boiling water was introduced into the tubes and kept on the previous- ly marked area for 10 seconds, and aspirated. All animals were resuscitated with Ringer’s lac- tate solution (2 mL / 100 g, IP (Intraperitoneal) and naproxen sodium was used for analgesia. After the heat application both exposed areas were immedi- ately treated with iodine or HP extract. Sham treated rats were
resuscitated with Ringer’s lactate only. All treatment agents were kept in room conditions to minimize the cooling effect. Daily wound examination and treatment was accomplished in treatment arms in an induction chamber under inhalation anesthesia using sevofluorane (3 ml/min) at 9 a.m. every day. Both agents were gently applied using a sterile tongue blade as a trans- parent cover over the heat exposed areas. The amounts of the applicatives were 5 ml for all groups, per animal. Treatment groups were treated with iodine or HP extract. After application the rats were kept in the chamber approximately 10 minutes and observed until their dressings dried. At post- operative 7th day rats were re-anesthetized by ketamin and xylazin, and dermal specimens were resected with wide margins. All specimens were gently manipulated by hand. Ulceration area was drawn on acetate papers and measured as mm2. Thereafter, rats were sacrificed by decapitation. Both areas were kept in formalin. One was sent for histological analysis and the other for evaluation of TGF-β levels.
Medical Agents
Extract of fresh, organically grown Hypericum perforatum tincture (St. John’s Wort) was obtained from Bioforce Ltd. (A. Vogel Comp. Irvine, Scotland). The hypericin content is 4-12 mg per 100g and minimum fla- vonoid content is 200 mg per 100g. Povidone iodine 10% (Isosol, Merkez Lab, Istanbul) was used in iodine group.
Histological Analysis: One skin section from each rat was evaluated ac- cording to a previously modified system [13]. Skin specimens fixed in 10% formaldehyde were embedded in paraffin, sectioned at 5 μm, stained with hematoxylin-eosin and evaluated under light microscope. For each speci- men, epidermal parameters (subepidermal microblister formation, necrosis, crust formation, hyperkeratosis, acanthosis) and dermal parameters (hemor- rhage, inflammation, necrosis, fibrosis) were assessed semi-quantitatively by assigning a score of 0 to 4 representing unremarkable, minimal, mild, moderate and marked changes. In addition, the areas of epidermal acantho- sis were estimated using grades of 0-6 as follows: 0-no acanthosis; 1-less
than 1/3 of the epidermal area acanthotic, the remainder necrotic or ulcerated; 2- approxi- mately 1/3 acanthotic, the remainder necrotic
or ulcerated; 3- approximately 1/2 acan- thotic, the remainder necrotic or ulcerated;
4- more than 1/2 but less than 2/3 acanthotic,
the remainder necrotic or ulcerated; 5- more than 2/3 acanthotic, the remainder necrotic; 6-diffuse acanthosis. Epidermal healing pa- rameters were acanthosis and hyperkeratosis. Parameters indicating epidermal injury were microblister formation, crust, and necrosis. Dermal healing parameter was fibroblastic proliferation. Factors indicating dermal injury were hemorrhage, inflammation and necrosis. These histological parameters and their grad-
ing scales are listed in Table 1. Re-epitheliza-
tion and collagenisation were evaluated using High Score System by two independent his- tologists in double-blind manner. Both indices were scored as 1; none, 2; mild, 3; moderate,
4; severe. Mean score for each specimen was multiplied by five (the number of area inspect-
ed), and final data was used for statistical analysis.
TGF-β Assessment (Immunohistochemistry)
Sections, 5 μ thick were incubated for one night at 37 ̊ C and for 1 h at 60 ̊C. Xylol application (15 min) was performed twice. The slides were then placed in 96% absolute alcohol and 80 % ethanol for 10 min, followed by distilled water, twice for 5 min, and boiled in high temperature microwave oven in 10% citrate buffer. After 20 min at room temperature, tissues were enrolled with a pap-pen (hydrophobic pen), washed with distilled water and phosphate-buffered saline (PBS), and hydrogen peroxide was added drop- wise. This step was followed by ultra V block and application of primary antibody (TGF-β3 /Labvision / NeoMarkers Corporation, Fremont CA, USA) for 1 hour. Samples were washed with PBS, a post-PBS level was applied and specimens were placed in AEC chromogene for 10 minutes. Finally counterstain with Mayer’s haematoxylin was performed for 5 min. All slides were evaluated with Leica DM 400 B light microscope (Wettlar, Germany). For the lymphocyte / inflammatory cell ratio, five microscopic fields were selected randomly in each slide at x400 magnification. Cells were then counted with specialized
microscopy program (Leica Q win analysis program) and used for sta- tistical analysis.
Statistical Analysis
Homogeneity of variances was as- sessed using Levene test. Statistical significance was assessed by one- way ANOVA following Tukey HSD and pathological parameters were assessed by chi-square test (likeli- hood ratio). A difference in p value less than 0.05 was considered sig- nificant.
Results
Macroscopic Evaluation
All rats were sacrificed on postopera- tive seventh day and heat induced ar- eas were macroscopically evaluated for the presence and severity of burn injury and ulceration area. Mean ul- ceration area was 53.05±6.59 mm2 in control, 40.35±7.76 mm2 in io- dine, and 30.3±6.16 mm2 in HP groups (F= 27.535, p < 0.0001). Iodine treatment compared to control (p=0.001), and HP treatment compared to both groups showed better results (p < 0.0001 for control, p=0.008 for iodine).
TGF- β Analysis
Mean TGF-β immunoreactivity was 43.05±17.42 in the control, 44.16±24.96 in iodine, and 40.25 ± 12.4 in HP groups. SJW treated rats expressed lower levels of TGF- β activity. But the difference was not significant (F=0.536, p=0.591).
Histological Evaluation
We analyzed epidermal and dermal indices of injury / healing separately. Among epidermal injury parameters microblister formation was similar in all groups (p=0.505). Epidermal crust formation was markedly higher in untreated rats. Severe (grade 4) crust formation was detected in 50% of control group. Treatment arms were free of severe (grade 4) crust formation. Increased crust formation (grade 3) was similar in both treatment groups (20% vs. 30%) and both treatment options significantly improved rates of crust formation (p=0.004). Epidermal and dermal necroses were the highest in iodine treated group. We observed highest scores of epidermal necrosis (grade 4) in 50%, and dermal necrosis in 70% of iodine arm, with significant difference (p=0.029). HP application improved both epidermal and dermal necrosis compared to other groups (p=0.036), and resulted in 30% epidermal and 40% dermal necrosis-free wound healing (Figure, 1 A-B).
Levels of epidermal healing parameters including hyperkeratosis and acan- thosis were similar between groups (p=0.054, 0.055, respectively). Howev- er, poor acanthosis (grade 1) was more common (40%) in the control group. Dermal injury indices including acanthosis, hemorrhage and inflammation were similar in all rats (p=0.301, 0.22, 0.99, respectively). Fibroblast prolif- eration, the dermal healing index was similar between all groups (p=0.151). But, improved fibroblast proliferation (grade 2) was seen only in HP treated rats. Both collagenisation and re-epithelization scores were significantly bet- ter in HP treated rats (p=0.005 and p=0.007, respectively). Re-epithelization scores were 137±47.85, 156±32.04, 213±58.69; and collagenisation scores were 91±32.12, 113±49.67, 191±60.63 for control, iodine and HP groups, respectively (Figure 2, A-B). Demonstrative sections of inflammation, re- epithelization, collagenisation and TGF- β expressions are shown in Figure 3, A-F.
Discussion
Major thermal injury is associated with significant physiologic stress on the organism, producing a hypermetabolic state leading to alterations in car- bohydrate and nitrogen metabolism [14-16]. This state is further compli- cated by microorganisms in the burned area. In the present study we did not observe any septic condition like purulent discharge. Gross pathological examination showed a significant decrease of ulceration in both treatment groups, and HP application was more potent than iodine.
Wormser, et al investigated the efficacy of iodine formulations on heat in- duced skin injury, and stated that iodine treatment leads to 65-80% reduction in burn injury related skin ulcerations [17]. We also observed a reduction of gross skin ulcers in iodine treated rats, and this improvement was confirmed with better crust formation, epidermal acanthosis, collagenisation, and re- epithelization compared to control animals. But, the percentage of skin sur- vival was much less than that reported by Wormser, et al, and furthermore histological indices of necrosis were markedly worse in the iodine treated group. It is inevitable to accept the beneficial impacts of iodine on wound healing in thermal injury. But, HP application resulted in less ulceration, necrosis, and far most improved collagen formation and re-epithelization compared to iodine.
In addition to macroscopic ulceration we evaluated local TGF-β expression in all rats in order to further evaluate the effects of these on burn injury. This is the first study to assess the effect of HP on TGF-β levels in burn injuries. TGF-β is a cytokine from TGF superfamily that plays important roles in immune function, and wound healing by regulating epithelial cell growth, motility, differentiation, and apoptosis [18,19]. Besides the aforementioned
activities it regulates angiogenesis, haematopoiesis, cell cycle progression and cellular migration [20-22]. For these reasons it has essential functions in regeneration, inflammation and wound healing. The ischemic effects and cell death after thermal injury have been reported to prolong until the end of the first week. The local inflammatory and systemic responses can also be iden- tified during the same period [23]. TGF-β levels increase on day 3 and con- tinues to increase until the end of one week after burn [24,25]. TGF-β levels are related to depth of burn and high levels of TGF-β are indicative of severe burn, prolonged wound healing and hypertrophic scar formation [26,27]. Sakallioglu, et al have shown that full thickness burns express higher levels of TGF- β, indicative of burn induced immunesupression and peak around post-burn day seven [26]. In the current study, although insignificant, HP treatment reduced TGF- β levels compared to iodine treatment. This result suggests a supportive effect of HP in wound healing. Furthermore, improved skin survival in HP- treated rats correlated well with better re-epithelization and collagenisation. In the control group, there were marked dermal edema with disorganized collagen fibers and no epithelization. Marked edema and unimproved epithelization was also constant among iodine treated animals. These rats had mild collagenisation. On the other hand, HP- treated rats showed improved fibrosis, moderate epithelization, and well organized col- lagen fibers. Furthermore, although it is not significant, HP- treated animals demonstrated lower levels of TGF-β, as compared to others. Another pos- sible explanation for the better results seen in HP- treated rats might be its role on wound hydration, which provides a moist environment for the in- jured site. Previous reports have documented the importance of hydration on wound healing [28]. In our experimental protocol we examined all rats for an additional 10 minutes in the induction chamber and observed that the wound site in iodine treated rats was almost entirely dry by the end of this period. Hydration assists in retaining of moisture and thereby, supports re-epithelization, reduces necrosis, and provides a barrier against bacteria [29,30]. Wound healing accelerates in a moist environment [31]. We even- tually observed that HP extract providing a moist, gelatinous environment that well correlated with the healing quality, as confirmed by increased col- lagenisation, epithelization, and decreased ulceration, necrosis, and TGF- β levels.
Our data suggests that, utilization of supportive strategies like HP extract may provide promising outcomes on burn injuries, and modification of topi- cal agents for optimizing wound healing might enhance our approach to this particular field. Possible mechanisms are improved collagenisation, re-epi- thelization, and provision of a moist, well hydrated environment. We believe that our findings can be important for developing new treatment strategies and clinical studies in thermal injuries.
Acknowledgements
The authors would like to thank to Miss Marie Cosgrove from Surugadai University, Japan for English revision of the manuscript.
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Alper Celik, Namik Ozkan, H. Ayhan Kayaoglu, Omer Faik Ersoy, Nese Lortlar, Suna Omeroglu, Ebru Arabaci Cakir. The Effects of Hypericum Perforatum Extract on Topical Burn Injury: A Comparative Study with Iodine. J Clin Anal Med. 2010;1(3):4-7
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Praziquantel-Dymethylsuifoxide Solution: The Side Effect on Hepato-biliary System (An Experimental Study)
İbrahim Yetim 1, Yalçın Büyükkarabacak 2, Kenan Erzurumlu 2, Adem Dervişoğlu 2, Murat Hökelek 3,Sancar Barış 4, Yüksel Bek 5
1 Genel Cerrahi A.B.D., Mustafa Kemal Üniversitesi, Tayfur Atasökme Fakültesi, Hatay, 2 Genel Cerrahi A.B.D. , Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Samsun, 3 Mikrobiyoloji A.B.D. , Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Samsun, 4 Patoloji A.B.D., Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Samsun, 5 Biyoistatistik A.B.D., Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Samsun, Türkiye
DOI: 10.4328/JCAM.10.3.15 Received: 03.02.2010 Accepted: 19.02.2010 Printed: 01.09.2010 J.Clin.Anal.Med. 2010;1(3):39 -43
Corresponding Author: İbrahim Yetim, Mustafa Kemal Üniversitesi Tayfur Ata Sökmen Tıp Fakültesi Genel Cerrahi A.B.D Serinyol, Hatay, Turkey. Phone: +90 326 211 19 00,+90 532 506 00 09 Email: yetim54@gmail.com
Aim: In this experimental study, the side effects of praziquantel and dymethylsulfoxide on the hepatobiliary system has been investigated comparing with alcohol , hypertonic and normal saline.
Material and Methods: This study contains five groups of ten rats each. In all groups, transduodenal choledochal cannulation was done and either dymethylsulfoxide, praziquantel in dymethylsulfoxide solution ,0.9 % NaCI, 20 % NaCI or 98 % alcohol were injected. Before surgery, blood samples were taken for measuring AST, ALT, ALP, GGT levels, and repeated every months for three months period. At the end of study, all rats were sacrificed; hepatobiliary excision was done.
Results: Biochemical content and blood samples have not statistically significant difference at the beginning of the study. After protoscolocidals injection into common bile duct, ALT, AST and ALP levels were siginificantly found higher at hypertonic saline group than control’s (p<0.05). GGT level in hypertonic saline group was similar to control’s. Also allthe biochemical results were siginificantly higher at dymethylsulfoxide, praziquantel in dymethylsulfoxide solution and alcohol groups than hypertonic saline and control groups (p<0.05). Although ALT, AST and ALP levels were found highest in hypertonic saline group; GGT level were was highest in dymethylsulfoxide group, (p<0.05) (Figure 1, 2, 3, 4). Histopathological research has shown that hepatoceluler changes were siginificantly higher in hypertonic saline group than control group, (p<0.05) Also it was higher in alcohol , dymethylsulfoxide and praziquantel in dymethylsulfoxide solution groups than the others, (p<0.05) Although dymethylsulfoxide and hypertonic saline have similar side effects on biliary tract; praziquantel in dymethylsulfoxide solution solution has stronger side effect then them, (p<0.05) alcohol has strongest side effect on biliary tract, (p<0.05).
Conclusions: As a conclusion, it is thought that praziquantel in dymethylsulfoxide solution solution has similar risk to alcohol and more than hypertonic saline on hepatobiliary tract in intraoperative use for hepatic hydatidosis.
Keywords: Hydatid Cyst, Alcohol, Hypertonic Saline, Praziquantel, Dymethylsulfoxide.
Introduction
Protoscolicidal solutions have great importance in the treatment of hydatid disease. They solutions must be nontoxic and of no side effect. When they pass into the biliary tract, they may cause inflammatory reactions result in caustic sclerosing cholangitis. Praziquantel has been used commonly in hepatic hydatidosis. Because of slightly water-solubility, dymethylsulfoxide is the solvent of choice in parenteral application. In this experimental study, the side effects of Praziquantel and dymethylsulfoxide on the hepatobiliary system has been investigated comparing with alcohol ,hypertonic and normal saline.
Material and Methods
This study contains five groups of ten rats each. In all groups, transduodenal choledochal cannulation was done and either dymethylsulfoxide, praziquantel in dymethylsulfoxide solution, 0.9 % NaCI, 20 % NaCI or 98 % alcohol were injected. Before surgery, blood samples were taken for measuring AST, ALT, ALP, GGT levels, and repeated every months for three months period. At the end of study, all rats were sacrificed; hepatobiliary excision was done After fixation in 10% buffered neutral formaline, sections from the common duct, porta hepatis and liver parenchyma were processed and embedded in paraffin. Tissue sections. 4-6 μm-thick, were stained by hematoxylin and eosin and evaluated under the iight microscope by a pathologist blind to the experimental procedure. Microscopic changes were assessed according to the scoring system presented in table 1 and 2.
The GLM Repeated Measures analysis of variance was performed, because of the same measurement is made several times (on admission, after 1st, 2nd and 3th month) on each subject. The effects of both the between-subjects factors and the within-subjects factors were tested with overall F test. Additionally, after an overall F test, the post hoc tests, the Bonferroni and Tukey’s honestly significant difference tests, were used for multiple comparisons to evaluate differences among specific group means. The profile plots (interaction plots) of the group means and measurement times obtained to visualize some of the relationships easily.
The GLM univariate analyses of variance were also performed for each mesasurement by the groups at each time point, after an overall F test, the post hoc tests (The Bonferroni and Tukey tests) were also performed to evaluate differences among specific group means, the Levene’s test for homogeneity of variance were also done to see if the variances unequal, when the variances were unequal, The Tamhane’s T2 test (conservative pairwise comparisons test) were used. Non-normally distributed measurements were analysed by Kruskal-Wallis one-way analysis of variance and then group comparisons were performed by Mann-Whitney U test. In all evaluations statistical significance were accepted for p<0.05.
Results
Biochemical content and blood samples have not statistically siginificant difference at the beginning of the study. After protoscolocidals’ injection into common bile duct, ALT, AST and ALP levels were found higher at hypertonic saline group than C’s (p<0.05). GGT level in hypertonic saline group was similar to C’s. Also ailthe biochemical results were higher at dymethylsulfoxide, praziquantel in dymethylsulfoxide solution and alcohol groups than hypertonic saline and C groups (p<0.05). Although ALT, AST and ALP levels were found highest in hypertonic saline group; GGT level were was highest in dymethylsulfoxide group (p<0.05) ,(Figure 1, 2, 3, 4).
In histopathological research no abscess formation, heamorrhagea or fibrosis were found in all groups’ hepatic specimens. The other changes, including hydropic and fatty changes, drop out necrosis, portal inflammation were found higher in hypertonic saline group than C group. (p<0.05) The results ofalcoho, dymethylsulfoxide and praziquantel in dymethylsulfoxide groups’ were higher than C and hypertonic saline groups’. It was found highest in praziquantel in dymethylsulfoxide group (p<0.05), (Table 3), (Figure 5).
Histopathological changes in biliary tract were similar in hypertonic saline and dymethylsulfoxide groups, but siginificantly higher than C’s (p<0.05). The results of praziquantel in dymethylsulfoxide group was siginificantly higher than hypertonic saline, dymethylsulfoxide and C groups (p<0.05). Alcohol was found strongest side effect on biliary tree (p<0.05) ,(Table 4),(Figure 6).
Discussion
In the conventional or minimally invasive surgery for hydatid disease, protoscolicidal solutions remain indispensable for the dysinfection of the cyst cavity. This necessity justifies the usage of scolocidal solutions routinely. In the presence of cysto-biliary communications, the passage of these solutions may cause tissue damage and relevant histopatoiogical changes in the hepatic tissue as well as in the biliary tree. So, inflamation of common bile duct wall may result in Caustic sclerosing cholangitis [8-13].
Properties of an ideal protoscolocidal solution would be the absence of local and systemic adverse effects together with a complete and rapid scolex killing. Although the side effects of protoscolicidal solutions such as formalin, ethyl alcohol, hypertonic saline, cetrimide, Ag NO3, polyvinyl pyrolidone iodure, and hydrogene peroxide, have been commonly investigated and shown, there is not a concensus for ideal protoscolicidal solutions [8,11,12,14]. We have shown that albendazole solution is one of the most effective protoscolocidal with no side effect on hepatobiliary system [14,15].
At present the most commonly used protoscolicidal agents are 95-98 % ethyl alcohol and 20 % NaCI. Most of the reports noted that hepatic enzymes have been found high including ALT, AST and ALP by using formaline, alcohol and hypertonic saline [1,8]. In contrast some authors noted no
changes at hepatic enzymes [11].These studies showed that formaline is the most toxic agent used commonly in history. Amongst the agents used today, ethyl alcohol is the most toxic agent; hypertonic saline is the second. All experimental studies about the side effects of protoscolicidal solutions, report severe stasis, widespread hepatocellular necrosis, flattening of the biliary epithelium, ductal proliferation, cholangitis and pericholangitis. These findings, of a milder degree have been reported after alcohol and
hypertonic NaCI solutions. Hydrogen peroxide and cetrimide have similar but lesser side effects [8-10,12,14,16-19]. After alcohol injection, minimal conjestion, mild hydropic degeneration, mild subepithelial biliary fibrosis, proliferation of the bile canaliculi, periductal inflammation and focal necrosis have been reported [11]. After hypertonic NaCI use (10-.20 %) concentric fibrosis around the major bile ducts was additionally reported [1,11]. In this study, enzyme levels showed that direct application of hypertonic NaCI and alcohol not the biliary tract have side effect on hepatobiliary system. But it is stronger for alcohol than hypertonic NaCI. Histopathological findings have supported this decision.
On the other hand, Praziquantel is drug commonly used in the medical treatment of hydatidosis. It is less toxic and better absorbabl than albendazole. After oral administration of praziquantel is rapidly absorbed (80%), subjected to a first pass effect, metabolized and eliminated by the kidneys. It is easily soluble in chloroform and dimethyl sulfoxide, soluble in ethanol and very slightly soluble in water. dymethylsulfoxide is the solvent of choice for parenteral form of praziquantel.
Since 1963, dymethylsulfoxide has been first reported in medical literature by Jacobs, it has been used not only as a solvent but also in the medical treatment of Interstitial Cystitis, Scleroderma , Raynaud’s Phenomenon , Lupus , Arthritis , Ulcerative Colitis, Diabetic Ulcerations [20]. One of our studies has shown that praziquantel in dymethylsulfoxide solution complete protscolocidal effect in concentration of 1mgr %[6]. But the results of topical application of praziquantel in dymethylsulfoxide ,on hepatobiliary systeme is not known. In systemic usage of , praziquantel, minimal increases in liver enzymes have been reported in 3.31 to 27% of patients. So, praziquantel should not be given to patients who previously have shown hypersensitivity to the drug or high hepatic enzymes levels [5,7].
Although praziquantel in dymethylsulfoxide solution has been used for a long time in medical treatment of hydatid cyst, intraoperative use has not been reported. In this study we searched the possibility of intraoperative usage of praziquantel in dymethylsulfoxide solution. In this study, we found statistically significant elevations of hepatic enzymes after choledochal injection of praziquantel in dymethylsulfoxide. They were lesser than alcohol group’s but higher than hypertonic saline group’s. The results showed that it has strong side effect on hepatobiliary system. These results are stronger than hypertonic saline, but comparable with alcohol . Also dymethylsulfoxide alone was found have similar effect.
Histopathological researchs supported the biochemical findings. As a conclusion, it is thought that praziquantel in dymethylsulfoxide solution has similar risk to alcohol and more than hypertonic NaCI on hepatobiliary tract in intraoperative use for hepatic hydatidosis.
References
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2. Dugalic D, Djukic V, Milicevic M, Ste- vovic D, Knezevic J, Pantic J. Opera- tiveprocedures in the management of liver hydatidoses. World J Surg. 1982;6(1): 115-118.
3. Daali M, Fakir Y, Hssaida R, Hajji A, Hda A. Hydatid cysts of the liver opening in the biliary tract. Report of 64 cases. Ann Chir. 2001;126(3):242-245.
4. Ulualp KM, Aydemir I, Senturk H, Ey- uboglu E, Cebeci H, Unal G, Unal H. Management of intrabiliary rupture of hydatid cyst of the liver. World J Surg. 1995;19(5):720-724; discussion 728.
5. Moreno MJ, Urea-Paris MA, Casa- do N, Rodriguez-Caabeiro F. Prazi- quantel and albendazole in the combined treatment of experi- mental hydatid disease. Parasitol Res 2001; 87:235-238.
6 Hokelek M, Erzurumlu K, Uyar Y, Bir- inci A. The effect of praziquantel as a scolocidal agent on the protoscolices of echinococcus granulosus. Turkish Journal of Hygiene and Biology 1999; 56:129-133.
7. Urea-Paris MA, Moreno MJ, Casado N, Rodriguez-Caabeiro F. Echinococ- cusgranulosus: Praziquantel treatment against the metacestode stage. Para- sitol Res 1999;85:999-1006.
8. Erzurumlu K, Tezelman S, Cevikba§ U, Eldegez U. The effects of scolocidal so- lutions on the etiology of to sclerosing cholangitis. Turkish Journal of Surgery. 1990;6:22-26.
9. Houry S, Languille O, Huguier M, Benhamou JP, Belghiti J, Msika S. Sclerosing cholangitis induced by formaldehyde solution inject- ed into the biliary tree of rats. Arch Surg 1990;125:1059-1061.
10. Yilmaz Z, Pekru i, Sozuer E, Kahya AH, Yesilkaya A, Bengisu N: The formation of sclerosing cholangitis by scolocidal agents in rabbits. Turkish Journal of Surgery 1996; 9(3): 172-177.
11. Kozak O, Atak M, Guleg B, Ozcan A, Uzar I.A, Pekcan M. The effects of scolocidal solutions to liver and bilier tract. Gulhane Medical Journal 2000; 42(3):269-275.
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13. Khodadi DJ, Kurgan AA, Schidt B. Scle- rosing cholangitis folllowing the treat- ment of echinococcosis of the liver. Int Surg. 1981;66:361-362.
14. Erzurumlu K, Ozdemir M, Mihmanli M, Cevikbas. U. The effect of intraopera- tive mebendazole-albendazole aplica- tions on hepatobiliary system. Eur Surg Res 1995;27:340-345.
15. Erzurumlu K, Hokelek M, Gbnlusen L, Tas. K, Amanvermez R. The effect of albendazole on the prevention of sec- ondary hydatidosis. Hepato-Gastroen- terology2000; 47:247-250.
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Ibrahim Yetim, Yalcin Buyukkarabacak, Kenan Erzurumlu, Murat Hokelek, Sancar Baris, Yuksel Bek. Praziquantel-Dymethylsuifoxide Solution: The Side Effect on Hepato-biliary System (An Experimental Study). J Clin Anal Med. 2010;1(3):39-43
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Variations in Patterns of Bronchial Tree
Cenk Kılıç, Yalçın Kirici, Hasan Ozan
Department of Anatomy, Gulhane Military Medical Academy, Faculty of Medicine, Ankara, Turkey
DOI: 10.4328/JCAM.10.3.16 Received: 24.01.2010 Accepted: 19.02.2010 Printed: 01.09.2010 J.Clin.Anal.Med. 2010;1(3):34-38
Corresponding Author: Cenk Kılıç, Department of Anatomy, Faculty of Medicine, Gulhane Military Medical Academy, Etlik, Ankara, 06018, Turkey. Phone: +90 312 304 35 09 Fax: +90 312 381 06 02 E-mail: ckilicmd@yahoo.com
Aim: Knowledge of variations in patterns of bronchial tree is useful for diagnosis and surgery of chest diseases. In our study we aimed to expose the variations in patterns of bronchial tree.
Material and Methods: In this study 15 right and 15 left lungs from 15 cadavers were used. All branches of each lobe were dissected from the surrounding parenchyma. Ramification of bronchial tree was displayed. The patterns of segmental and some subsegmental bronchi were determinated and whether accessory bronchus present or not was examined.
Results: We identified that most common variations in the patterns of bronchial tree are B6c, B6a+6b; B7, B8, B9+10 in right side and B1+2, B3; B7+8, B9+10 in left side. The most common accessory bronchi were bronchus subsuperior arising from B10 in right side, and bronchus subsuperior and bronchus subsuperior arising from B10 in left side. Many researchers used different terminologies for identification of branches of bronchial tree. We commonly found patterns of B1+2 (60%) and B7+8 (79,99%) in left lungs.
Conclusion: It is identified that there are 8 segmental bronchi on the left. This study will be helpful for many radiological and anatomical studies.
Keywords: Bronchi, Lung, Thoracic Surgery, Bronchoscopy, Bronchial Diseases, Terminology.
Introduction
Variations of airways may cause unexpected complications during endotracheal intubation and chest surgery. Knowledge of variations in patterns of bronchial tree is necessary for diagnosis and surgery of chest diseases. Thus in our study we aimed to expose the variations in patterns of bronchial tree.
The right superior lobar bronchus arises from the right main bronchus. The right superior lobar bronchus commonly divides into three branches designated apical (B1), posterior (B2) and anterior (B3) [1-4]. Then, the right main bronchus continues as the intermediate bronchus [2-4]. The intermediate bronchus bifurcates to become the bronchi to the middle and lower lobes [2,3]. The middle lobar bronchus bifurcates into lateral (B4) and medial (B5) segmental branches [1-4]. The right inferior lobar bronchus; bifurcates into superior (B6), medial basilar (B7), anterior basilar (B8), lateral basilar (B9) and posterior basilar (B10) segmental branches [1-4].
The left main bronchus divides into the upper and lower lobar bronchi [1-4]. The left superior lobar bronchus commonly bifurcates two divisions. The upper division immediately divides into three segmental branches, B1, B2 and B3. The lower division is the lingular common trunk and divides into superior (B4) and inferior (B5) divisions [2,3]. The left inferior lobar bronchus; bifurcates into B6, B7, B8, B9 and B10 segmental branches [1-3].
Material and Methods
In this study 15 right and 15 left lungs from 15 cadavers fixed with formaldehyde were used. The cases with bronchopulmonary disease were not included in the study. The ages of the subjects were from 37-64 years (8 males and 7 females). Anterior thoracic wall was cut with costotomy and elevated. Then the lung was removed.
All lungs were injected with red ink through the trachea. Then, vessels and lymph nodes in the hilar region was removed. The primary branches of each lobe were dissected from the surrounding parenchyma. Each lobe was also dissected from the anterior surface under the dissecting microscope. Ramification of bronchial tree was displayed and photographied.
The patterns of segmental and some subsegmental bronchi were determinated and whether accessory bronchus present or not was examined.
Results
The patterns of segmental and some subsegmental distribution bronchi and accessory bronchi were displayed in Figure 1-8 and documented in Table 1-3.
Discussion
Many researchers used different terminologies for identification of branches of bronchial tree [1-5]. There are 10 segmental bronchi on each lung as emphasized some authors [1,5]. Others reported that there are 8 or 9 segmental bronchi on each left lung [2-4]. We commonly found patterns of B1+2 (60%) and B7+8 (79,99%) in left lungs. It is identified that there are 8 segmental bronchi on the left.
The results of some researchers [3,6-15] were documented and compared in Table 4-8. It is reported that the most common variation in left upper lobe is three bronchi in the lingular division as our findings [4]. As a result of performing lingulectomy in case of this variation momentous complications may occur. Rate of “B1+2 and B3” in left side in our study is in conformity with results in literature [2,3,16]. Some reports [2,3] comment lingular common trunk is present in left upper lobe of all lungs as our study. Scannell cited that medial-lateral placement instead of superior-inferior is common in B4 and B5 segments of left upper lobe [7]. Ghaye et al [8] found
that rate of this placement is 25%. On the contrary, this placement is absent in our study. In contrast to previous reports [9,10], in this study trifurcate pattern in middle lobe bronchus was not found. Computed Tomography and Magnetic Resonance of the Thorax states that right superior segmental bronchus is usually bifurcate, rarely trifurcate as our study [3]. In present study, B9 and B10 are usually arised from a common root the similarity in previous results [4,16]. General Thoracic Surgery mentions that the most common ramification pattern in left basal root is “B7+8 and B9+10” as our study [4]. We ascertained that rate of “B7+8” is more higher in left side than right side. Also, previous authors [2,4] assumed that “B7+8” is a single bronchus in left side. Variations in the patterns of the bronchial tree, for the most part, due to displacement of segmental and subsegmental bronchi. We thought that knowledge of variations in the patterns of the bronchial tree is necessary for most of the clinical implications. Also, this study will be helpful for many radiological and anatomical studies.
References
1. Bannister LH. Respiratory system. In: Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ, editors. Gray’s anatomy. 38th ed. New York: Churchill Liv- ingstone; 1993. p. 1653-62.
2. Fraser RS, Müller NL, Colman N, Paré PD, edi- tors. Fraser and Paré’s diagnosis of diseases of the chest. 4th ed. Philadelphia: Saunders W.B. Company; 1999. p. 3-629.
3. Naidich DP, Webb WR, Müller NL, Krinsky GA, Zerhovni EA, Siegelma SS, editors. Comput- ed tomography and magnetic resonance of the thorax. 3th ed. Philadelphia: Lippincott Williams & Wilkins; 1999. p. 169-226.
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5. Khurshid I, Anderson L, Downie GH. Tracheal accessory lobe take-off and quadrifurcation of right upper lobe bronchus: A rare tracheo- bronchial anomaly. Journal of Bronchology. 2003;10:58-60.
6. Berg RM, Boyden EA, Smith FR. An analysis of variations of segmental bronchi of the left lower lobe of fifty dissected, and ten injected lungs. J Thorac Surg. 1949;18:216-37.
7. Scannell JG. A study of variations of the bron- chopulmonary segments in the left upper lobe. J Thorac Surg. 1947;31:530-7.
8. Ghaye B, Szapiro D, Fanchams JM, Dondelinger RF. Congenital bronchial abnormalities revisited. Radiographics. 2001;21:105-19.
9. Boyden EA, Hamre CJ. An analysis of variations in the bronchovascular patterns of the mid- dle lobe in fifty dissected and twenty injected lungs. J Thorac Surg. 1951;21:172-88.
10. Gonlugur U, Efeoglu T, Kaptanoglu M, Akkurt I. Major anatomical variations of the tracheo- bronchial tree: Bronchoscopic observation. Anat Sci Int. 2005;80:111-5.
11. Boyden EA, Scannell JG. An analysis of varia- tions in the bronchovascular pattern of the right upper lobe of fifty lungs. Am J Anat. 1948;82:27-72.
12. Ferry RM, Boyden EA. Variations in the bron- chovascular patterns of the right lower lobe of fifty lungs. J Thorac Surg. 1951;22:188- 201.
13. Koshino T, Murakami G, Sato TJ, Tsugane MH, Fujisawa Y, Mawatari T, Abe T. Configura- tions of the segmental and subsegmental bronchi and arteries in the right upper lobe of the human lung with special reference to their concomitant relations and double subsegmental arterial supply. Anat Sci Int. 2002;77:64-73.
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15. Smith FR, Boyden EA. An analysis of varia- tions of the segmental bronchi of the right lower lobe of fifty injected lungs. J Thorac Surg. 1949;18:195-215.
16. Thompson BH, Lee WJ, Galvin JR, Wilson JS. University of Iowa’s virtual hospital: lung anatomy. 1993. Available from: http:// lib.cpums.edu.cn/jiepou/tupu/atlas/www. vh.org/adult/provider/radiology/LungAnato- my/LungAnatomy.html [accessed February, 2008]
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Cenk Kilic, Yalcin Kirici, Hasan Ozan. Variations in Patterns of Bronchial Tree. J Clin Anal Med. 2010;1(3):34-38
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The Quantity and Course Of Paraumbilical Veins in Adults, and Their Topographic Relation with the Umbilical Vein (Ligamentum Teres Hepatis)
Nurcan İmre 1, Cüneyt Bozer 2, Cenk Kılıç 1, Esra Erdoğan 3, Hasan Ozan 1
1 Anatomi AD, Gülhane Askeri Tıp Akademisi, Askeri Tıp Fakültesi, Ankara, 2 Anatomi AD, Trakya Üniversitesi Tıp Fakültesi, Edirne, 3 Tıbbi Histoloji ve Embriyoloji AD, Gülhane Askeri Tıp Akademisi, Askeri Tıp Fakültesi, Ankara, Türkiye
DOI: 10.4328/JCAM.11.1.17 Received: 12.01.2009 Accepted: 09.02.2010 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):31-33
Corresponding Author: Nurcan İmre, GATA Anatomi AD, Keçiören, Ankara, Türkiye. Phone: +903123043503 E-mail: a.circumflexahumeri@hotmail.com
Aim: The paraumbilical veins surrounding umbilical vein and running within falciform ligament is of the following three types: Burows veins, Sappeys superior and inferior group veins. Sappey’s veins are referred to as accessory portal veins. They form the connection between portal vein and systemic veins. Burows veins terminate in the middle third of umbilical veins and do not enter the intrahepatic portal system directly.
Material and Methods: In this study, the falciform ligament specimens from 20 adult cadavers were used to determine the number and course of paraumbilical veins and to expose its topographic relationship with umbilical vein. The falciform ligament separated into four quadrants and examined.
Results: Mean numbers of paraumbilical veins were found 6.65 ± 2.1 in microscopical examination.
Conclusion: In the relevant literature, there is a lack in studies about the quantity of paraumbilical veins and their topographic relation with the umbilical vein. Detailed information on quantitative parameters of paraumbilical veins may prove helpful in determining pathologies of paraumbilical veins and portal- systemic circulation.
Keywords: Paraumbilikal Vein, The Falciform Ligament, The Teres Hepatis Ligament.
Giriş
Ligamentum teres hepatis ve Ligamentum umbilicale medianum boyunca uzanan paraumbilikal venler, karın ön duvarı venleri ile v. portae hepatis arasındaki anastomozu sağlar. Paraumbilikal venler Ligamentum falciforme hepatis içerisinde üç grupta incelenmektedir. Bunlar Burow venleri ile Sappey’in üst ve alt grup venleridir. Sappey venleri aksesuar portal venler olarak kabul edilmekte ve sistemik venlerle portal ven arasında bir köprü vazifesi görmektedir. Burow venleri ise umbilikal venlerin orta 1/3’lük kısmında sonlanmakta ve intrahepatik portal sisteme doğrudan katılmamaktadır. Literatürde paraumbilikal venlerin sayısı ve umbilikal ven ile topografik ilişkisine yönelik bir çalışmaya rastlayamadık. Paraumbilikal venlerin sayısal parametreleri ile ilgili detaylı bilginin portosistemik sirkulasyon ile ilgili patolojilerin tanı ve tedavisinde faydalı olabileceğini düşünerek bu çalışmayı planladık [1-4].
Gereç ve Yöntemler
Çalışmamızda yaşları 45-71 arasında değişen 20 erişkin (12 erkek, 8 kadın), formaldehitle fikse edilmiş insan kadavrası kullanılmıştır. Karın ön duvarında yapısal bir bozukluk ya da patolojik bir durum yoktu. Karın ön duvarı kaldırılarak karaciğer görünür hale getirildi. Ligamentum teres hepatis’ in fissura ligamenti teretis’ te bulunan kranyal ve Ligamentum falciforme hepatis içerisinde bulunan bölümü arasından örnek alındı (Resim 1). Önce Ligamentum teres hepatis’in Ligamentum falciforme hepatis’e göre lokalizasyonu tespit edildi. Sonra paraumbilikal venlerin Ligamentum teres hepatis’le topografik ilişkisine bakıldı. Örnekler parafin bloklara yerleştirildi, 5 μm kesitler alındı, hemotoksilen-eozin ile boyandı ve ligament dört kadrana (sağ-sol,üst-alt) bölünerek ışık mikroskobisiyle (Marka: Nikon , Model:EclipseE600W, Made in Japan) incelendi. Resimleri çekildi (Fotoğraf makinesi Marka: Nikon, Model:UR- E6, Made in Japan).
Bulgular
Işık mikroskopisiyle inceleme sonucunda kesitlerde Li- gamentum falciforme hepatis ters üçgen şeklinde gözü- küyordu ve Ligamentum teres hepatis topografik olarak Ligamentum falciforme hepatis’ in sol-üst köşesine yakındı. Dört kadranın toplamında paraumbilikal
venlerin ortalama sayısı 6,65
± 2.1 idi. Sağ üst kadranda 1.9 ± 1,3, sol üst kadranda 1,9 ± 1,5, sağ alt kadranda 1,6 ± 1,2, sol alt kadranda 1,4 ± 1 bulundu. Paraumbilikal venlerin sağ üst kadranda bulun- ma oranı %28, sol üst kadranda bulunma oranı %28, sağ alt kadranda bulunma oranı %23, sol alt kadranda bulun- ma oranı %21 olarak tespit edildi (Resim 2, Tablo 1).
Paraumbilikal venlerin bu klinik önemine rağmen litera- türde sayıları ve topografileri ile ilgili, çalışmamızla karşı- laştırabileceğimiz bir çalışmaya rastlayamadık. Martin ve Tudor çalışmalarında umbilikal ve paraumbilikal venlerle ilgili detaylı araştırma yapmışlar ancak sayısal bir ifade kullanmamışlardır [4]. Ying ve arkadaşları ise lig.teres hepatis flepi ile ilgili çalışmalarında bu ligamente yapışık seyreden 2-4 paraumbilikal ven bildirmişlerdir. Ancak to- pografisiyle ilgili herhangi bir bilgi vermemişlerdir [9]. Paraumbilikal venlerin sayısal parametreleri ile ilgili de- taylı bilginin portosistemik sirkulasyon ile ilgili patoloji- lerin tanı, tedavisi ve kordosentez sırasında bu yerleşimin topografik olarak bilinmesinin faydalı olabileceğini dü- şünmekteyiz.
Kaynaklar
1. Arıncı K, Elhan A. Anatomi ( 2.Cilt). 4. baskı Ankara: Güneş Kitabevi, 2006; 102-104.
2. Ozan H. Ozan Anatomi 2. baskı, Ankara: Klinisyen Tıp Kitabevi, 2005;237.
3. Standring S. Gray’s Anatomy, 39. baskı, Elsevier Churchill Livingstone, 2005.
4. Martin BF, Tudor RG (1980) The umbili- cal and paraumbilical veins of man. J Anat 130 (2):305-322.
5. Widman A, de Oliveira IR, Speranzini MB, Cerri GG, Saad WA, Gama-Rodrigues J. Patent paraumbilical vein: hemodynamic importance in Mansoni’s hepatosplenic portal hypertension (Study with ultrasonography Dop- pler). Arq Gastroenterol. 2001 Oct- Dec;38(4):221-6.
6. Göktay AY, Seçil M, Kovanlikaya A, İğci E, Dicle O. Aneurysmal dilatation of the paraumbilical vein in an infant. Pediatr Radiol. 2000;30(9):604-6.
7. Sacerdoti D, Bolognesi M, Bombonato G, Gatta A. Paraumbilical vein patency in cirrhosis: effects on hepatic hemody- namics evaluated by Doppler sonogra- phy. Hepatology. 1995;22(6):1689-94.
8. Gupta D, Chawla Y, Dhiman RK, Suri S and Dilawari JB, Clinical significance of patent paraumbilical vein in patients with liver cirrhosis. Dig Dis Sci 45, 1861-1864, 2000.
9. Ying DJ, Ho GT, Cai JX. Anatomic bases of the vascularized hepatic teres ligament flap. Surg Radiol Anat 1997;19:293–4.
Ligamentum falciforme hepatis içinde bulunan paraumbi- likal venler portal hipertansiyonda en sık gelişen kollateral yollardır. Portal hipertansiyon tanısı koymada bu venlerin dilatasyonu önemli bir kriterdir.Bundan dolayı bu venle- rin lokalizasyonu ve sayısı portal hipertansiyon ve sirozda önemlidir [5-8]. Vv. paraumbilicales’ler ile karın ön duvarını drene eden v. epigastrica superior ve v. epigastrica inferi- or arasında porto-caval anastomoz bulunur. Portal hiper- tansiyonda, umbilikal bölgede caput medusa denilen venöz genişlemeler olur [2]. Kollateral portosistemik dolaşımın sistemik dolaşım üzerindeki hemodinamik etkisi üzerine çalışmalar sürdürülmektedir. Bu da kollateral portosistemik bir yol olan paraumbilikal venlerin önemini artırmaktadır [5-8]. Ayrıca paraumbilikal venlerin de beslediği Ligamen- tum teres hepatis fleplerinin özellikle ekstrahepatik safra yolları tamirinde kullanılması bu venlerin önemini daha da artırmaktadır. Safra kesesi ve jejunum yamaları ile kıyas- landığında Ligamentum teres hepatis greftlerinin diğer organları kapsamaması ve özel mikrocerrahi donanımı ge- rektirmemesi nedeniyle belirgin bir avantajı vardır [9].
Download attachments: KATD-113.pdf
Nurcan Imre, Cuneyt Bozer, Cenk Kilic, Esra Erdogan, Hasan Ozan. The Quantity and Course Of Paraumbilical Veins in Adults, and Their Topographic Relation with the Umbilical Vein (Ligamentum Teres Hepatis). J Clin Anal Med. 2010;1(3):31-33
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Should Colonoscopy be Administrated to the Patients with Incidental Colorectal FDG PET Absorbtion?
Muammer Kara¹, Aslı Ayan², Murat Kantarcıoğlu¹, Güldem Kilciler¹, Teoman Doğru¹, İlker Turan¹, Özdeş Emer², Melih Akıncı³
¹Gülhane Askeri Tıp Akademisi, Gastroenteroloji BD, ²Gülhane Askeri Tıp Akademisi, Nükleer Tıp AD, ³Sağlık Bakanlığı Dışkapı Hastanesi, Genel Cerrahi Servisi, Ankara, Türkiye
DOI: 10.4328/JCAM.11.1.16 Received: 04.11.2010 Accepted: 19.02.2010 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):28-30
Corresponding Author: Muammer Kara, Gülhane Askeri Tıp Akademisi, Gastroenteroloji BD, 06018, Etlik, Ankara, Türkiye. Phone: +90 312 304 40 52 Fax: +90312 304 40 00 E-mail: drmuammerkara70@hotmail.com
Aim: In this study, we aimed to compare the results colonoscopy and if performed, these of histopathologic examinations in patients which are administered 18- fluoro-2-deoxyglucose positron emission tomography (FDG PET) for different reasons and diagnosed incidental colorectal metastasis.
Material and Methods: 26 cases with established focally increased colorectal activity metastasis and who have been performed FDG PET for various clinical indications are included in the study. Cases are performed colonoscopy for differential diagnosis.
Results: Age average of the 26 cases included in the study (9 females, 17 males) was 61.9 (38-87). Colonoscopic lesion have been established in 10 cases (38.5 %), while there was none in 16 cases (61.5 % false positive). Number of the cases which endoscopic lesions have been indicated at the localization coherent with activity metastasis in FDG PET was 9 ( 34.6 % ). However in one of the cases, colonoscopic lesion was at a different localization from the one defined in FDG PET examination.
Conclusion: We have a high false positive ratio in our study. This can be due to FDG shadowing after a poor bowel lavage. For this reason, an adequate bowel lavage administration to the patients before FDG PET examination can reduce the false positive ratio. Thus we can prevent unnecessary invasive attempts. In medical practice, resection of the colonic adenomas found acceptance in protecting from colon cancer. This study showed us that incidental FDG metastasis can indicate premalign or malign lesions. Therefore, colonoscopoic examination is recommended for the cases who have been performed FDG and found increased radioactive metastasis, whether they have been administered bowel lavage or not.
Keywords: FDG PET, Colorectal Administrated, Colonoscopy.
Giriş
Kolorektal kanserler Batı toplumlarında kansere bağlı ölümlerin ikinci en sık nedenidir. Bununla birlikte bu hastalığa bağlı mortalite 50 yaş üzeri asemptomatik hastaların taranması ile azaltılabilir [1]. 18-fluoro-2- deoxyglucose positron emission tomography (FDG PET) görüntüleme kolorektal kanser saptanmasında ve takibinde yüksek senstivitesi nedeniyle faydalı bir yöntemdir [2-4]. Ancak inflamatuar veya fizyolojik FDG tutulumu nedeniyle özgüllüğü görece düşük bir tekniktir [5-8]. Bu çalışmada farklı nedenlerle FDG PET incelemesi yapılan ve insidental kolorektal tutulum saptanan hastalarda, kolonoskopi ve yapıldıysa histopatolojik inceleme sonuçlarının karşılaştırılması amaçlandı.
Gereç ve Yöntemler
Çalışmaya farklı klinik endikasyonlar nedeni ile GATA Tıp Fakültesi Nükleer Tıp A.D.’ında 2007-2008 tarihleri arasında FDG PET tetkiki yapılan ve fokal olarak artmış kolorektal aktivite tutulumu saptanan olgular dahil edildi. Olgulara ayırıcı tanı amaçlı kolonoskopi yapıldı. Barsakta bilinen kolorektal hastalığı olanlar, kolorektal kanser nüksü düşünülenler veya kirlilik nedeni ile optimum kolonoskopik inceleme yapılamamış olan olgular çalışma dışı bırakıldı. FDG PET tetkiki rutin 6 saat açlık ve yaklaşık 10-15mCi 18-F FDG enjeksiyonunu takiben yapıldı (Siemens ECAT EXACT, full ring, Knoxville, Tenn) ve tüm sonuçlar bir uzman tarafından değerlendirildi. Kolonoskopiler farklı endoskopistlerce, Olympus CLV-180 flexibl video kolonoskop kullanılarak yapıldı. Alınan patoloji materyalleri tecrübeli bir patolog tarafından değerlendirildi.
Hastaların PET görüntüleri, kolonoskopi sonuçları ile patoloji raporları incelendi.
Bulgular
Çalışmaya alınan 26 olgunun 9’u kadın, 17’si erkekti ve ortalama yaş 61,9’du (38- 87). Çalışmaya alınan 26 olgunun 10’unda (%38,5) kolonoskopik inceleme sonucu patolojik lezyon saptanırken, 16 olguda (%61,5 yanlış pozitif) kolonoskopi ile patolojik oluşum tespit edilmedi. Endoskopi ile patolojik lezyon tespit edilen olguların 9’unda (%34,6) lezyon FDG PET’te artmış aktivite tutulumu ile uyumlu lokalizasyonda idi. Bir olguda (%3,8 yanlış negatif) ise kolonoskopik lezyon (polip) FDG PET tetkikinde tanımlanan lokalizasyondan farklı yerleşimdeydi.
Endoskopik olarak patoloji tespit edilen olguların 7’sinde 8 adet polip saptandı. Poliplerin 3’ünün çapı 1 cm’den büyük, diğerleri ise 1 cm’den küçüktü. Poliplerin histopalojik incelemesi sonucu 4 tanesi tubuler, 3 tanesi tubulovillöz adenom olarak rapor edildi. Bu poliplerin 4’ünde hafif displazi, 3’ünde orta derecede displazi mevcuttu. Bir olguda ise rektumda saptanan polip adenokarsinom olarak rapor edildi.
FDG tutulumu olan 2 hastanın endoskopik incelemesinde rektumda 16 mm çapında ve sigmoid kolonda 20 mm çapında ülsere lezyon tespit edildi. Rektumda saptanan ülserin histopatolojik incelemesi malignite bulgusu olmayan rektum ülseri, sigmoid kolondaki ülsere lezyon ise basit inflamasyon olarak rapor edildi. Diğer FDG tutulumu olan hastada ise divertikül tespit edildi. Lezyonların FDG tutulumu SUV Max (lezyon içindeki maksimum aktivite yoğunluğunun kilo başınana enjekte edilen FDG dozuna oranı) değerleri ile ilişkili değildi (Tablo1).
Tartışma
Bu çalışmada yanlış pozitiflik oranı literatüre göre oldukça yüksek olsa da, yanlış negatiflik oranı azdır. Bu bize barsak temizliğinin iyi yapılması halinde FDG PET incelemesinin daha başarılı uygulanabileceğini gösterebilir.
Literatürde kolonda rastlantısal FDG tutulumu saptanması sonucu kolonoskopi yapılan hastalarda, FDG PET bulguları ile kolonoskopik bulguların karşılaştırıldığı çalışmalarda farklı sonuçlar bildirilmiştir.
İnsidental FDG tutulumu saptanan 20 hastanın incelendiği bir çalışmada, hastaların 15’inde endoskopik anormallik saptanmış, 5 (%25 yanlış pozitif) hastada herhangi bir endoskopik anormallik tespit edilmemiştir [2].
Tatlıdil ve arkadaşları kolon kanseri öyküsü olmayan ve farklı nedenlerle yapılan FDG PET incelemesinde insidental kolorektal tutulum saptanan, bu nedenle kolonoskopi ve histopatolojik inceleme yapılan 27 olguyu retrospektif olarak incelemişler. Diffüz FDG tutulumu olan 8 hastada
normal kolonoskopik bulgular; segmental tutulum saptanan 6 hastada inflamatuvar patolojiler; yüksek yoğunlukta nodüler FDG tutulumu olan 13 hastanın ise 10’unda (%79) kolonoskopik olarak polip saptanmış. Bu çalışmada kolonik FDG tutulumları karaciğerin FDG tutulumuna göre karaciğerden düşük, karaciğerle eşit, karaciğer aktivitesinden hafif yüksek ve belirgin yüksek olarak derecelendirilmiş (sırasıyla, Grade1-4). Grade 4 (karaciğerden belirgin yüksek FDG tutulumu) tutulumlarda kolonoskopik patoloji varlığı ispatlanırken (yaklaşık %79) , Grade 1-3 tutulumlarda fokal nodüler FDG tutulumunu açıklayan patoloji izlenmemiştir. Bizim çalışmamızda tanımlanan lezyonlar bu çalışmadaki derecelendirmeye göre fokal nodüler olarak nitelendirilebilir. Kolonik villöz adenomlar üzerinde yapılan bir çalışmada, kolonoskopik olarak saptanan villöz ve/veya tubuluvillöz adenomlu 6 olguda saptanan 16 lezyondan 5’inde değişen yoğunlukta FDG tutulumu izlenmiştir [10].
Kolorektal kanser nedeni ile tedavi görmüş ve takiplerinde FDG PET de yapılan hastaların incelendiği bir başka çalışmada, FDG tutulum yeri ile endoskopik bulguların korele olduğu gözlenmiştir. Bu nedenle kolorektal kanser takibinde FDG PET’in yararlı bir tanı aracı olarak kullanılabileceği belirtilmiştir [8].
Kanser tarama programı çerçevesinde FDG PET ve kolonoskopi yapılan 110 vakalık retrospektif bir çalışmada, kolonoskopi ile 30 vakada değişik çaplarda 59 polip saptanmış; bu adenomların 14’ünde (%24) FDG tutulumu tespit edilmiş ve polip çapı arttıkça PET’de saptanma oranının arttığı belirtilmiş. Örneğin çapı 13 mm.den büyük olan 10 polipten 9’unda (%90) FDG PET tutulumu olduğu bildirilmiştir. Ayrıca aynı çalışmada FDG PET için yanlış
pozitiflik oranı %5,6 (6/110) olarak bulunmuştur [11]. Literatürdeki çalışmalar değerlendirildiğinde yanlış pozitiflik oranı bu çalışmaya göre düşüktür.
Miraldi ve arkadaşlarının yaptığı bir çalışmada, yalancı FDG tutulumları nedeni ile var olan bir lezyonun atlanabileceği gibi, gerçekte olmayan lezyonların da varmış gibi görülebileceği belirtilmiş; bunun önüne geçebilmek içinde iyi bir barsak ve mesane temizliğinin yapılması gerektiği vurgulanmıştır [12]. Çalışmamızda saptanan yüksek yanlış pozitiflik oranı bu çalışmada belirtilen eksik barsak temizliği sonrası oluşan yalancı FDG tutulumuna ve tutulum şeklinin fokal nodüler olmasına bağlı olabilir. Bu nedenle hangi endikasyon ile yapılırsa yapılsın, FDG PET işlemi öncesi olgulara uygun barsak temizliği yapılması yanlış pozitiflik oranını azaltabilir. Böylece gereksiz invaziv işlemlerin önüne geçilmesi sağlanabilir.
Kolonik FDG tutulumu ile ilgili yapılan çalışmalarda, özellikle polip çapı küçüldükçe önemli oranda yanlış negatif sonuç elde edildiği gözlenmektedir [10,11]. Bu çalışmada ise endoskopik olarak saptanan lezyonların yaklaşık %50’si 10 mm’den küçük olmasına rağmen yanlış negatif sonuç sadece 1 olguda gözlenmiştir. Bu olguda ki lezyonun çapı da 10 mm’den küçüktür.
Tıbbi pratikte kolonik adenomların rezeksiyonu, olası kolon kanserinden korunmada genel kabul gören bir yöntemdir [13]. Bu çalışma da bize göstermiştir ki insidental FDG tutulumu premalign veya malign lezyonlara işaret edebilir. Bu nedenle barsak temizliği uygulansın veya uygulanmasın, FDG-PET tetkiki yapılan ve artmış kolonik radyoaktivite tutulumu saptanan olgulara kolonoskopik inceleme yapılması önerilmelidir.
Kaynaklar
1. Engel H, Steinert H, Buck A, Berthold
T, Rahel A, von vSchulthess GK. Whole-
bodyPET: physiological and artifactual fluorodeoxyglucose accumulations. J
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3. Flamen P. Positron emission tomogra- phy in colorectal cancer. Best Pract Res Clin Gastroenterol. 2002;16:237–251.
4. Chen YK, Kao CH, Liao AC, Shen YY, Su CT. Colorectal cancer screening in asymptomatic adults: the role of FDG PET scan. Anticancer Res. 2003; 23:4357–4361
5. Prabhakar HB, Sahani DV, Fischman AJ,,. Mueller PR, Blake MA. Bowel Hot Spots.Radio Graphics. 2007; 27:145– 159.
6. Atkin WS, Morson BC, Cuzick J. Longterm risk of colorectal cancer after excision of rectosigmoid ad- enomas. N Engl J Med. 1992;326:658-662
7. Abouzied MM, Crawford ES, Nabi HA. 18FFDG imaging: pitfalls and artifacts. J Nucl Med Technol. 2005;33:145– 155.13.
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10. Arslan N, Dehdashti F, Siegel BA. FDG uptake in colonic villous adenomas. Annals of Nuclear Medicine. 2005;19:331-334.
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12. Miraldi F, Vesselle H, Faulhaber PF, Adler LP, Leisure GP. Elimination of artifactual accumulation of FDG in PET imaging of colorectal cancer. Clin Nucl Med. 1998;23:3–7.
13. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case control study of screening sigmoidoscopy and mor- tality from colorectal cancer. N Engl J Med. 1992;326:653 -657.
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Muammer Kara, Asli Ayan, Murat Kantarcioglu, Guldem Kilciler, Teoman Dogru, Ilker Turan, Ozdes Emer, Melih Akinci. Should Colonoscopy be Administrated to The Patients With Incidental Colorectal FDG PET Absorbtion?. J Clin Anal Med. 2010;1(3):28-30
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The Effects of Ga-As (904nm) Laser Irradiation on Injured Sciatic Nerves of Rats
Arzu Erbilici 1, Ece Ünlu 1, Yusuf Sinan Şirin 2, Ömer Besalti 3, Aytul Cakci 1
1 Department of Physical Therapy and Rehabilitation, Ministry of Health Ankara Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, 2 Mehmet Akif Ersoy University, Faculty of Veterinary Medicine, Department of Surgery, Burdur, 3 Ankara University, Faculty of Veterinary Medicine, Department of Surgery, Ankara, Turkey
DOI: 10.4328/JCAM.10.3.11 Received: 29.09.2009 Accepted: 02.01.2010 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):23-27
Corresponding Author: Ece Ünlü, Department of Physical Therapy and Rehabilitation, Ministry of Health Ankara Dışkapı Yıldırım Beyazit Education and Research Hospital, 06110, Ankara, Turkey. GSM:+905065595122 E-mail: dreceunlu@yahoo.com
Aim: The purpose of this study was to investigate the effects of Ga-As (904 nm) laser on the crushed nerve region compared with laser of the corresponding spinal cord segments.
Material and Materials and Methods: Thirty Albino Wistar male rats weighing 180-240 g were used in this study. The sciatic nerve was crushed at the middle level with an aneurysm clip (Aesculap FE 751; Tuttingen, Germany) for 4 minutes. The rats were allocated into three groups. In group 1, laser irradiation was applied at the four points along the corresponding spinal cord segments (L3-L6) in contact with the shaved skin. In group 2, the crushed area in contact with the shaved skin was irradiated. In group 3, the same procedure was performed without emission. The first laser treatment was performed on the second day of surgery and was repeated once daily for 21 consecutive days. The measured electrophysiological parameters included compound muscle action potential (CMAP), distal motor latency (DML), and motor nerve conduction velocity (NCV). Measurements were taken just before crushing and were repeated on the 21st day of the treatment and the 42nd day of the follow-up period. Sciatic Functional Index (SFI) and Toe Spread Analysis (TSA) were carried out on postoperative days 2, 7, 14, 21 and 42.
Results: There was no significant difference between groups regarding DML and amplitude of CMAP. The NCV was significantly faster in group 1 on the 21st and 42nd days than in the other groups. The differences between groups regarding SFI and TSA on the 1st, 7th, 14th, 21st, and 42nd days were insignificant (p>0.05).
Conclusion: In conclusion, the use of Ga-As laser did not provide significant benefit on nerve regeneration or functional improvement except for its positive effect on nerve conduction in the crushed area irradiated group.
Keywords: Spread Electrophysiological Parameters, Laser, Nerve Regeneration, Sciatic Functional Index, Toe Analysis.
Introduction
Recovery after injuries to the peripheral nerves remains an important problem, since it is not complete in most cases [1, 2]. The extent of the atrophy of the target muscle following peripheral nerve injury worsens in conjunction with the longevity of the recovery and regeneration period [3, 4]. Other usual results after such an injury are degeneration of the axons and retrograde degeneration of the corresponding neurons of the spinal cord [5, 6]. The enhancement of faster regeneration of the injured axons, preventing anterograde degeneration and preserving the proximal stump from retrograde degeneration and muscle atrophy, are the major goals in peripheral nerve injury recovery [5].
There have been many studies by Rochkind [3-6] related to the use of low–power laser irradiation (LPLI) in the treatment of injured peripheral nerve and spinal cord. The results of his studies have shown an increase in the amplitude of compound muscle action potential (CMAP) in both intact and injured peripheral nerves. Histological studies showed an increase in the blood supply and the number and diameter of the axons in the crushed nerve as well as inhibition of scar tissue [6]. Contrary to these important findings, some researchers have been unable to determine any positive effect of LPLI on the recovery of the injured nerves [7, 8]. On the other hand, LI of the crushed peripheral nerve mitigates the degenerative changes in the corresponding neurons of the spinal cord and induces proliferation of neuroglia both in astrocytes and oligodendrocytes. This change represents the higher metabolism in corresponding neurons of the related spinal cord segment and may facilitate regeneration [3,6].
The aim of this study was to investigate the effects of Ga-As (904 nm) laser on the functional and electrophysiological recovery of crushed rat sciatic nerve comparing two different applications, either on the crushed nerve region or on the corresponding spinal cord segments.
Material and Methods
The present study was carried out on 30 Albino Wistar male rats weighing 180-240 g each. Animals were housed in smooth-bottomed plastic cages at 22oC with a 12:12 h light-dark cycle. Standard laboratory diet and water ad libitum were available. Animals were randomly divided into three groups (n=10 rats each). The rats were anesthetized intraperitoneally with xylazine hydrochloride 10 mg/kg (Rompun, Bayer; Turkey) and ketamine hydrochloride 50 mg/kg (Ketalar, Parke Davis; Turkey) for both surgical and electrophysiological procedures. This study was approved by the local ethics committee.
The left thigh along its lateral side and the thoracolumbar region of the spine were shaved. The left sciatic nerve was exposed and separated from the surrounding muscles from sciatic notch to the furcation area. The sciatic nerve was crushed at the middle level with an aneurysm clip (Aesculap FE 751; Tuttingen, Germany) for 4 minutes. The skin and subcutaneous tissues were sutured with atraumatic 3/0 catgut sutures. After surgery, the rats were assigned an identification number on their ears and the crushed point was indicated with Chinese ink.
Ga-As laser (Petaş; Turkey) was applied with 904 nm wavelength, spot size 0.28 cm2 in diameter, 220 ns pulse duration and 27 W peak powers per pulse. In group 1, the lumbar area was irradiated at the four points along the corresponding spinal cord segments (L3-L6) in contact with the shaved skin. In group 2, the LI was applied to the crushed area in contact with the shaved skin. The incidence angle was 90o to the irradiation surface. The parameters for LI were: pulse repetition rate 1000Hz, average power 0.76 mW, and delivered energy density 19 joul/cm2. In group 3, the same procedure was performed without emission. Each treatment session lasted 10 minutes. The first laser treatment was performed on the second day of surgery and was repeated once daily for 21 consecutive days. The treatment was stopped after 21 sessions and the rats were followed until postoperative day 42 without medication.
The effects of laser were determined by electrophysiological means using an electromyography (EMG) machine (Medelec Synergy 5 Channel; Oxford, UK). A pair of monopolar needle electrodes was used as recording electrode (Medelec, disposable subdermal needle, 18 mm length, 0.30 mm diameter, 017K019), which was placed on the plantar muscles. Another pair of monopolar electrodes was used for stimulation. The sciatic nerve was stimulated supramaximally with a single square pulse (intensity 10V, duration 0.5 ms) from the distal and proximal sites of the injured area. The stimulation sites were 2 cm distal or proximal to the crushed area. The ground electrode was placed subcutaneously between the stimulation and recording electrodes. The measured electrophysiological parameters included CMAP (peak to peak amplitude, mV), distal motor latency (DML) (ms) and motor nerve conduction velocity (NCV) (m/sn, calculated by dividing the distance between the stimulation sites by the difference in latency of the responses).
The electrophysiological investigation was carried out just before crushing, which served as the baseline parameters. Measurements were repeated on the 21st day of the treatment and the 42nd day in the follow-up period. All three recordings were done using the same technique.
Sciatic Functional Index (SFI) was used to quantify the functional recovery in rats after injury to the sciatic nerve. All animals underwent walking track analysis as described originally by de Medinaceli et al. [9] and modified for mice by Inserra et al. [10]. In summary, the rats’ hind paws were dipped into X-ray film developer and they were allowed to walk without assistance along a corridor (8.2 cm [w] x 42 cm [l] x 12 cm [h]). The X-ray film was placed in the path of the rats on the walking track. The formula for SFI, which was standardized by Bain et al. [11], is calculated as follows:
SFI=-38.3(EPL-NPL)/NPL + 109.5(ETS-NTS)/NTS + 13.3 (EIT-NIT)/NIT -8.8
where EPL= Experimental print length, NPL=Normal print length, ETS= Experimental toe spread, NTS=Normal toe spread, EIT=Experimental intermediate toe spread, and NIT=Normal intermediate toe spread.
Toe spread analysis (TSA) was another parameter used to observe the functional improvement after sciatic nerve injury. It is a reflex elicited as the rat was picked up from the body and the legs allowed to hang free and was scored as 0-3 from no spreading of toes to normal full toe spread [12).
SFI and TSA were determined on postoperative days 2, 7, 14, 21 and 42.
Statistical Analysis
Wilcoxon test was used to determine the differences in SFI and TSA from the 1st to 42nd postoperative day. Kruskal Wallis Variance Analysis was used for comparison between the groups. The change in the electrophysiological parameters over time was determined by paired t test, and one way ANOVA was used for investigations between groups. For all data, p< 0.05 was accepted as significant.
Results
Three rats in group 1 and 5 rats in group 2 died after the 21st day. Infection was seen in 1 rat in group 2 (hind foot) on the 21st day and in 1 rat in group 3 (skin over the incision area).
There was no significant difference between groups regarding DML and amplitude of CMAP. However, the differences in CMAP amplitude between baseline and the 21st and 42nd day values were significant. NCV was significantly faster in group 1 on the 21st and 42nd days than in the other groups, and the differences between baseline and the 21st and 42nd days were significant. When the improvement was analyzed within the groups from the beginning till the 42nd day, there were no significant differences in DML and amplitude of CMAP. However, CMAP was significantly lower than the baseline values (Table 1).
The differences between groups with respect to SFI at the 1st, 7th, 14th, 21st, and 42nd days were insignificant (p>0.05). Within groups, significant improvement was determined in groups 1 and 2 between days 1-7, and in each group between days 7-14, and 14-21 (Table 2).
When TSA was compared between groups on days 1, 7, 14, 21, and 42, there was no significant difference. Significant improvement was found between days 1-7 in groups 1 and 2, in each group between days 7-14 , and in groups 1 and 3 between days 14-21 (Table 3).
Discussion
The results of this study showed that low-power Ga-As laser, applied over the skin either at the spinal segment or at the injured sciatic nerve, did not produce significant improvement according to the electrophysiological parameters and the functional scores in comparison with the control group. However, NCV improved more in group 2 after the 21st day.
Many researchers have tried to determine the mechanism by which LPLI affects tissues. Kovacs [13] and Mester [14] suggested that LI increases blood supply and neovascularization of the epithelial tissues. Kiernan [1] emphasized the diffusion of plasma proteins at the site of injury. The newly formed vessels might be more permeable to proteins, which could be an explanation for the effect of LPLI. It has been found that laser induces Schwann cell
proliferation, affects nerve cell proliferation and induces sprouting of cellular processes [15]. In our study, Ga-As LPLI using, significant improvement in nerve regeneration was not observed according to the parameters studied in a model of crush injury of the sciatic nerve of rats.
The biological effects of laser depend on the wavelength and laser dose. Bagıs et al. [8] evaluated the effect of Ga- As laser (904 nm wavelength) on crush-injured sciatic nerve with different repetition rates of 16, 128, 1000 Hz and with energy densities of 0.31, 2.48, 19 J/cm2, respectively, using both electrophysiological parameters and histopathological examination. Their results showed that low energy Ga-As irradiation did not have any effect on nerve regeneration. In our study, we used the same wavelength and energy intensity but we applied irradiation at two different sites, either on the related spinal segment or on the crush injury site, and no positive effect on nerve regeneration was determined at either site with respect to DML and CMAP amplitude. However, in the spinal cord irradiated group, there was a significant improvement in the NCV. This interesting finding might be the positive effect of LI on remyelination of the injured nerve. Because of the short distance, which can confound the results of NCV, the results should be accepted cautiously. Rochkind [3] et al. investigated the effect of He-Ne LI on the corresponding segments of the spinal cord after crush injury of the sciatic nerve. They found that CMAP amplitude increased approximately up to the pre-crush levels and remained so for an extended period. They suggested that applications on the spinal cord induced the regeneration of the injured peripheral nerve. In our comparisons between the groups, we could not find a significant increase in the amplitude of CMAP but we observed improvement in the NCV in the spinal cord irradiated group. Within the groups, the CMAP amplitude increased between days 21-42 but never reached pre-crush levels.
Energies of He-Ne laser below 3.5 J/cm2 or above 7 J/ cm2 were found to be non-effective transcutaneously [4]. Rochkind [5] mentions that there is no effect below a threshold of energy influx, whereas beyond a maximum threshold the effect is reversed. On the other hand,
there are different studies by different authors reporting contradictory data. Khullar [16] used Ga-As laser (830 nm) on an injured sciatic nerve and found no difference in the amplitude of CMAP and the histopathological data. Pogrel et al. [17] found that Ga Al As laser had no stimulatory effect on fibroblast and keratinocyte cultures.
SFI is a well-known index used to quantify functional recovery in rats after sciatic nerve injury. Our results showed that though there was improvement in all data within groups, there was no significant difference between groups indicating that Ga-As laser is effective. In a very recent study, Dos Reis et al. [18] analyzed the influence of AlGaAs laser (660 nm) on the myelin sheath and functional recovery of the sciatic nerve in rats. Although they found significant changes in morphometric investigations in the nerve, they could not find improvement by means of functional recovery using SFI. Mohammed et al. [19] in their study assessed the effect of LPLI on regeneration of the peroneal nerve of rabbits. They found that laser therapy produced a significant amount of structural and cellular changes in the nerves, which they demonstrated in histopathological analyses. Nevertheless, they did not have functional data supporting their findings. Histopathological evaluation is one of the most valuable investigations to support nerve regeneration. One of the limitations of our study is the lack of histopathological data.
There are many studies supporting the effectiveness of LPLI on injured nerve regeneration. Rochkind [20], in their recent pilot study, investigated the effect of LPLI (780 nm) in patients suffering from peripheral nerve and brachial plexus injuries. In this prospective study, they found significant and electrophysiological improvement in these patients. These encouraging results will support the clinical use of this treatment in patients with nerve injury. We believe the contradictory results of the various studies published previously are due to the difference in type, wavelength, intensity and the irradiation site of the LPLI. Further researches should be planned to enlighten the conflicting data of different types of LPLI on nerve regeneration.
References
1. Kiernan JA. An explanation of axonal regeneration in peripheral nerves and its failure in the central nervous system. Med. Hypotheses 1978. 41:15- 26,
2. Lazar D A, Curra F, Mohr B, McNutt LD, et al. Acceleration of recovery after injury to the peripheral nervous system using ultrasound and other therapeutic modalities. Neurosurg Clin N Am 2001. 12(2):353-357,
3. Rochkind S, Nissan M, Alon M, Shamir M, Salame K. Effects of laser irradiation on the spinal cord for the regeneration of crushed peripheral nerve in rats. Lasers Surg Med 2001. 28:216-219,
4. Rochkind S, Barrnea L, Razon N, Bartal A, Schwartz M. Stimulatory effect of He – Ne low dose laser on injured sciatic nerves of rats. Neurosurgery 1987. 20(6):843-847,
5. Rochkind S, Nissan M, Razon N, Schwartz M, Bartal A. Electrophysiological effect of HeNe laser on normal and injured sciatic nerve in the rat. Acra Neurochir (Wien) 1986. 83:125-130,
6. Rochkind S, Vogler I, Barrnea L. Spinal cord response to laser treatment of injured peripheral nerve. Spine 1990. 15(1):6-10,
7. Khullar SM, Brodin P, Messelt EB, Haanes HR. The effects of low level laser treatment on recovery of nerve conduction and motor function after compression injury in the rat sciatic nerve. Eur J Oral Sci 1995. 103:299-305,
8. Bagıs S, Comelekoglu U, Coskun B, Milcan A, et al. No effect of GA-AS (904nm) laser irradiation on the intact skin of the injured rat sciatic nerve. Lasers Med Sci. 2003. 18:83-88,
9. De Medinaceli L, Freed WJ, Wyatt RJ. An index of the functional condition of rat sciatic nerve based on measurements made from walking tracks. Exp Neurol 1982. 77(3):634-643,
10. Inserra MM, Bloch DA, Terris DJ. Functional indices for sciatic, peroneal and posterior tibial nerve lesions in the mouse. Microsurgery 1998. 18(2):119- 124,
11. Bain CR, Mackinnon SE, Hunter DA. Functional evaluation of complete sciatic, peroneal and posterior tibial nerve lesions in the rat. Plast Reconstr Surg 1989. 83(1):129-138,
12. Gale K, Kerasidis H. Spinal cord contusion in the rat: behavioral analysis of functional neurologic impairment. Exp Neurol 1985. 88:123-134,
13. Kovacs L. The stimulatory effect of laser on the physiologic healing process of portio surface. Lasers Surg Med 1981. 1:241-252,
14. Mester E. Clinical results of laser stimulation and experimental studies on the mechanism of action. Minerva Med 1981. 72:2195-2199,
15. Van Bruegel HH, Par PR. He Ne laser irradiation affects proliferation of cultured rat Schwann cells in a dose dependent manner. J Neurocytol 1993. 22;185-190,
16. Khullar SM, Brodin P, Messelt EB, Haanaes HR. The effects of low power laser treatment on recovery of nerve conduction and motor function after compression injury in the rat sciatic nerve. Eur J Oral Sci. 1995. 103:299- 305,
17. Pogrel MA, Chen JW, Zhang K. Effects of low energy gallium-aluminium- arsenide laser irradiation on cultured fibroblasts and keratinocytes. Lasers Surg Med 1997. 20:426-432,
18. Dos Reis FA, Belchior AC, de Carvalho PD, da Silva BA, Pereira DM, Silva IS, Nicolau RA. Effect of laser therapy (660 nm) on recovery of the sciatic nerve in rats after injury through neurotmesis followed by epineural anastomosis. Lasers Med Sci DOİ 2008. 10.1007/ s10103-008-0634-3,
19. Mohammed IF, Al-Mustawfi N, Kaka LN. Promotion of regenerative processes injured peripheral nerve induced by low-level laser therapy. Photomed Laser Surg 2007. 25(2):107-111,
20. Rochkind S, Drory V, Alon M, Nissan M, Ouaknine GE. Laser phototherapy (780nm), a new modality in treatment of long-term incomplete peripheral nerve injury: a randomized double-blind placebo-controlled study. Photomed Laser Surg 2007. 25(5):436-442,
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Arzu Erbilici, Ece Unlu, Yusuf Sinan Sirin, Omer Besalti, Aytul Cakci. The Effect of GA-AS (904nm) Laser Irradiation on Injured Sciatic Nerves of Rats. J Clin Anal Med. 2010;1(3):23-27
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Dermatologic Analysis in Elderly Patients During Balneotherapy
Selçuk Özdogan 1, Erkan Kaya 1, Ali Hikmet Kayar 1, Mehmet Zeki Kiralp 1, Muhammed Erdal 2
1 Cildiye Kliniği, Estetik İnternational Estetik ve Cerrahi merkezi, Bursa Asker Hastanesi, Bursa, 2 Etimesgut Asker Hastanesi, Ankara, Türkiye
DOI: 10.4328/JCAM.10.3.14 Received: 24.12.2009 Accepted: 18.01.2010 Printed: 01.09.2010 J.Clin.Anal.Med. 2010;1(3):18-22
Corresponding Author: Muhammed Erdal, Etimesgut Asker Hastanesi Serpmeevler bulvarı 06790 Etimesgut, Ankara, Türkiye. GSM: 0505 785 58 87 E-mail: muhammederdal@yahoo.com
Aim: The aim of this study was to determine skin changes due to balneotherapy in elderly patients who were treated with termal therapy for rheumatismal pain.
Material and Methods: Older than 50 years old 51 patients with generalize ostoarthritis were treated with balneotherapy enrolled our study in October- November 2009. All patients treated 21 days with balneotherapy. Patient’s skin analyses were done twice, at first day and 19th day of the treatment. Skin analyses were done at face region and fore arm flexor region. Moisturing, elasticity, pigmentation, fat ratio assessed in skin analysis.
Results: 20 male and 31 female, totally 51 patients were enrolled our study. Before balneotherapy, mean moisturing was %67, after balneotherapy mean moisturing decreased %47 at fore arm region. After balneotherapy, mean moisturing at face decreased from %54 to %45. Fat ratio decreased from %28 to %20 Before balneotherapy and after balneotherapy elasticity and pigmentation differences were not significant statistically.
Conclusion: By aging, skin becomes sensitive to environmental factors. Dry skin is a usual problem during balneotherapy. Patients with dry skin have pruritus and discomfort. We suggest patients treated with balneotherapy to use moisturing cream for protecting dry skin problems during balneotherapy.
Keywords: Balneology, Skin Humidification, Geriatrics, Dermatology.
Giriş
Derinin öncelikli görevi vücudu dış çevreden gelebilecek fiziksel veya kimyasal etkilere karşı korumaktır. Koruma görevi özellikle derinin en dışında yer alan, ince ve hete- rojen yapıdaki Stratum Corneum (SC) tabakası tarafından sağlanmaktadır. Enfeksiyonlar, hassasiyet oluşturucu (irri- tan) ve alerjen maddeler, UV, radyasyon, sıcak su gibi çeşitli çevresel faktörler derinin koruma işlevinin bozulmasına ne- den olabilir [1-3]. Bu nedenle de cildin normal kompozisyo- nunun sağlanması hasta sağlığı açısından önemlidir. Balneoterapi (BT), banyo, içme ve inhalasyon yöntemleriyle mineralli ve termal sular gibi doğal faktörlerin kullanılma- sıyla gerçekleşen geleneksel ve eski bir tedavi yöntemidir. İlk çağlarda, koruyucu güçlerin yönetiminde olduğu sanılan termal suların kutsallık taşıdığı düşünülür ve termal sulara özel bir saygı gösterilirdi. Roma lejyonlarının savaş öncesi güçlenmek için kaplıcaya gitmeleri, savaş sonrasında da yaralarını bu kaplıcalarda tedavi etmeleri Eski Yunan ve Roma dönemlerinde de termal suların önemini koruduğu ve gizli güçleri olduğu inancının devam ettiğinin önemli bir kanıtıdır [4]. Günümüzde BT özellikle kas iskelet sistemi rahatsızlıklarında hastaların her hangi bir sağlık çalışanı- na danışmadan da tercih ettikleri bir ağrılardan kurtulma yöntemidir. Herhangi bir amaçla, kaplıca kürüne özgü te- davi yöntemi yaşlılarda gündeme geldiğinde, BT düzenle- mesinde bazı özelliklerin dikkate alınması gerekir. Bunlar arasında, yaşlı kişilerde aynı anda birden fazla patolojinin varlığı ve özellikle pulmoner ve kardiyovasküler işlevler- de sınırlılık ilk akla gelenlerdir [4, 5 ]. BT planlamasında banyo uygulamalarının cilt üzerindeki primer etkilerinin de hesaba katılması gerekir. İlerleyen yaşla birlikte deri du- yarlılığında bozulma (hipertermal banyolarda risk), deri turgorunda azalma (hipertonik tuzlu su banyolarında risk!) ve elastikiyet kaybı ve kılcal damarların zedelenebilirliğinde artış (özellikle su altı tazyikli duş uygulamalarında risk) gibi değişikliklerin göz önünde tutulması gerekir.
Gereç ve Yöntemler
Çalışmamıza hastanemiz yerel etik kurulunun 14 Ekim 2009 tarihli 7 no lu izniyle Ekim-Kasım 2009 tarihlerinde yatarak kaplıca tedavisi görmesi planlanan 50–80 yaş ara- sı 51 hasta dahil edildi. Boyun ve üst ekstremiteye yönelik fizik tedavi ve rehabilitasyon planlanan hastalar çalışmaya dahil edilmedi.
Tüm hastalara 21 seans 20 dakika kaplıca kür tedavisi uygulandı. Hastalara kaplıca tedavisinin nasıl olacağı ko- nusunda grup hemşireleri tarafından eğitimleri verildi ve kaplıca tedavisi sırasından oluşabilecek yan etkiler nede- niyle yakın takipleri yapıldı. Hastanemiz kaplıca suyu 39°C sıcaklığa sahip, 623mg/L konsantrasyona sahip düşük mi- neral yoğunluklu, herhangi bir mineralin kabul edilen eşik değerlerin üstünde bulunmadığı bir sudur [4] Hastaların 20 dakikadan fazla kaplıca tedavisinde kalmasına izin verilme- di. Hastaların özellikle yüz bölgesine herhangi bir kozmetik kullanmasına izin verilmedi.
Tüm hastalara BT’nin 1. günü ve 19. gününde olmak üzere iki kez cilt analizi yapıldı. Cilt analizi Multi Dermascope 800 (MDS800) analizatörü ile alın bölgesinden ve önkoldan yapıldı. Cilt analizinde BT öncesi ve BT sonrası cildin nem, yağ, pigmentasyon ve elastikiyet oranlarına bakıldı.
Elde edilen verilerin değerlendirilmesi SPSS 11.0 progra- mı kullanılarak yapıldı. Ortalamalar ve standart sapmalar tanımlayıcı analizler ile hesaplandı. BT öncesi kadın ve er- kek hastalar arasındaki verilerin ortalaması arasındaki fark Mann Whitney U testi ile değerlendirildi. Verilerin normal dağılıma uyumu One sample Kolmogorov Smirnov testi ile değerlendirildi. BT öncesi ve BT sonrası cildin elastikiyeti, yüz ve ön kol nem oranları, pigmentasyon oranları arasın- daki farklar Paired Sample t-testi ile değerlendirildi. Nor- mal dağılıma uymayan BT öncesi ve BT sonrası cilt yağ oranı arasındaki fark Wilcoxon Signed Rank testi ile değer- lendirildi. Anlamlılık düzeyi p<0,05 olarak kabul edildi.
Sonuç
Kliniğimize Ekim- Kasım 2009 tarihlerinde BT için toplam 114 hastanın yatışı yapıldı. Boyun ve üst ektsremiteden fizik tedavi ve rehabilitasyon uygulanacak 24 hasta, 50- 80 yaş aralığında olmayan 34 hasta çalışmaya dahil edilmedi. 5 hasta da erken taburcu olunması nedeniyle BT sonrası verilerin alınamaması nedeniyle çalışmaya dahil edilmedi. Çalışmaya alınan toplam 51 hastanın 20’si erkek (%39.2), 31’i kadın (%60.8), yaş ortalaması 66,61±7,49 idi.
BT öncesi ve BT sonrasında ön kol cilt nem oranında, yağ oranında istatistiksel olarak anlamlı düzeyde azalma görül- dü (p<0.05). BT öncesi ve BT sonrasında yüz bölgesi nem oranında, elastikiyette ve pigmentasyonda istatistiksel olarak anlamlı bir fark görülmedi (p>0.05), (Tablo 2).
Tartışma
Günümüz dünyasında yaşlı nüfusun yükselen oranı, yaşlılık- taki sağlık sorunları ile daha etkin mücadele etme yanında, yaşlı sağlığını koruma ve sağlıklı bir yaşlanmayı sağlama gerekliliklerini de gündeme getirmiştir. Yaşlılıkla ilgili pre- ventif, küratif ve rehabilitatif süreçlerde de BT etkin bir al- ternatif tedavi şekli olarak değerlendirilebilir. Kaplıca teda- visi yaşlılıkta, günümüzde geçerli olan yaklaşımlar temelin- de birkaç yönden önem kazanabilir ve seçenek oluşturabilir [4]. Birincisi, yaşlılığa bağlı gelişen biyolojik ve fizyolojik değişiklikler üzerine olumlu bir etkisi söz konusu olabilir. Bu değişikliklerin patolojik düzeylere varmasında önleyici ve tedavi edici bir yöntem olarak anlam kazanabilir. Diğer yandan, kaplıcada gerçekleştirilen kompleks bir kür teda- visi geçerli konvansiyonel yöntemlere katkı sağlayabilir ve nihayet, yaşlılıkta sık karşılaşılan durumlar ve hastalıklarda alternatif ve komplementer bir tedavi modalitesi olarak görülebilir.
Doğal olarak sıcaklığı 20o C’nin üzerinde, toplam mineri- lizasyonu 1 gr/l’nin altında olan ve eşik değerin üzerinde mineral içermeyen termal sular, akrototermal sular olarak adlandırılır [4,5]. Merkezimizde ki termal su da akrotermal özelliğindedir.
Çağdaş kaplıca kürü uygulamalarında, endikasyon doktor tarafından belirlenir. Banyo Kürlerinde 20 dakikalık uygula- ma süresi ile günde bir banyo ve toplam 21 günlük kür uy- gulaması yapılır [4,5]. Ancak ülkemizde yapılan uygulamalar çağdaş kaplıca kürü uygulamalarından birçok yönü ile fark- lıdır. Karagülle ve ark. [6] yaptıkları çalışmalarında, hastala- rın %74’ünün herhangi bir doktor kontrolü olmaksızın kap- lıca tedavisi olduğunu, %75’inin kaplıcada 10 gün kaldığını, %66’sının günde iki kez 45-60 dakikalık peloid (çamur te- davisi) banyo uygulamaları yaptıklarını saptamışlardır. Bu bilgiler ışığında hastaların sadece %10’unun çağdaş yön- temlere uygun olarak kaplıca kürü yaptıkları sonucuna var- mışlardır. Merkezimizde ise tamamen çağdaş kaplıca kürü uygulaması yapılmaktadır. Aynı grupta kür tedavisi alacak hastalar için kür aynı gün başlayıp aynı gün bitirilmekte- dir. Hastaların bu şekilde kontrol altında olmaları özellikle kür başlangıçlarında ortaya çıkabilecek kaplıca tedavisine bağlı komplikasyonlar açısından sağlık çalışanlarını uyanık tutmakta ve hasta takiplerini kolaylaştırmaktadır. Bununla birlikte ülkemiz kaplıcalarında kür uygulamalarına yönelik farklılıkların yanında kaplıca merkezlerinde doktor ve eği- timli sağlık personelinin olmamasına rağmen kaplıcaya gi- den hastaların büyük bir kısmı buralardan yarar görmekte ve bu yarar bir yıl süreyle devam etmektedir [5-7].
Sonuçta bir uyan-uyum tedavisi olan kaplıca tedavisinin başarısı, bu uyumun gelişmesinde görev yapan organ ve fonksiyonların yeterli olmasına bağlıdır. BT banyo kürleri şeklinde kaplıca tedavisi planında yer alması, banyo uy-
gulamalarının cilt üzerindeki primer etkilerinin de hesaba katılmasını gerektirir. İlerleyen yaşla birlikte deri duyarlı- lığında bozulma (hipertermal banyolarda risk!), deri tur- gorunda azalma (hipertonik tuzlu su banyolarında risk!) ve elastikiyet kaybı ve kılcal damarların zedelenebilirliğinde artış (özellikle su altı tazyikli duş uygulamalarında risk!) gibi değişikliklerin göz önünde tutulması gerekir [4,5]. Bizim ta- kibimizdeki BT gören hastalarımızda da ciltte kuruma ve kaşınma şikâyetleri oldukça sık görülmektedir.
Kuru deri, pürüzlü veya pullu görünüşle beraber seyredebi- len; deride kırmızılık, çatlama veya kaşınma hissi ile tanım- lanmaktadır [8]. Derinin en üst tabakası olan SC’un içeri- ğini azaltan çevresel faktörlerin rol oynamasının yanı sıra kuru derinin, genetik orijin taşıyabileceği de bilinmektedir. Ayrıca organik çözücüler veya sert etkili deterjanlar, SC tabakasında yer alan lipit tabakaların zarar görmesine ve engel işlevinin azalmasına, dolayısı ile derinin kurumasına neden olmaktadırlar [8-11]. Sabun ve deterjanlar, yün veya sentetik fiberler, bazı parfüm ve kozmetikler, toz, kum ve si- gara dumanı da irritan özellik taşıyan maddeler arasındadır [12.13]. Egzamalı deride, sabun kullanımı deri yüzeyinden daha fazla lipit uzaklaştırmakta ve lezyonlar meydana gel- mesine neden olmaktadır [14].
Bütün bunların yanında deri, yaşlanmadan etkilenen en bü- yük organdır [2]. Korneositler, suyun hücrelerin içinde bağlı kalmasını sağlayan ve doğal nemlendirici faktör ( Natural Moisturising Factor, NMF) olarak adlandırılan maddeleri içermektedir. Kuru deri sendromu ile birlikte seyreden çe- şitli deri hastalıklarında NMF seviyesinde azalma olduğu saptanmıştır [15]. İlerleyen yaş ile birlikte de NMF seviye- sinde gözle görülür düşüş meydana gelmektedir [16, 17]. Östrojen pek çok organ gibi deriyi de etkileyen bir hormon- dur. Bu nedenle eksikliği sonucu menapoz döneminde de- ride pek çok değişiklik oluşmaktadır [1, 18, 19]. Östrojen reseptörlerinin en yoğun olarak bulunduğu genital bölge ve yüz derisinde östrojen düzeyinin değişmesine bağlı olarak önemli değişiklikler gözlenmektedir [18, 19]. Menapozla birlikte, östrojenin deriyi yaşlanmaya karşı koruyucu etkisi çok azaldığı için hormonal yaşlanma belirtileri, kronolojik yaşlanma ve çevresel yaşlanma belirtilerine eklenir. Bu ne- denle menapoz ile birlikte derinin yaşlı görünümü daha da belirgin duruma gelir [1].
Menapoz sonrasında derinin kollajen içeriğinde dolayısıy- la elastikiyetindeki azalmanın doğrudan menapoza bağlı olup olmadığı da araştırılmış ve azalmanın kronolojik yaş- lanmadan çok östrojen düzeyinin azalmasına bağlı olduğu belirtilmiştir [20]. Affinito’nın yaptığı bir çalışmada deri kollajenindeki azalmanın östrojen düzeyine bağlı olduğu, menapoz sonrasındaki azalmanın menopozdan önceki dö- neme göre istatistiksel olarak çok daha hızlı gerçekleştiği saptanmıştır [21].
Yaş ilerledikçe yağ bezi sayısı sabit kalırken bu bezlerin bo- yutları büyür, ancak sebum üretimi azalır [20]. Yapılan çalış- malarda da kadınlarda menapoz sonrası dönemde sebum düzeyinin belirgin olarak azaldığı ve derinin kuruduğu gös- terilmiştir. Bu azalmanın 60’lı yaşlara kadar %40’a ulaştığı
ve yaklaşık 70 yaşından sonra sebum düzeyinde herhangi bir değişimin görülmediği bildirilmektedir [22]. Menapoz sonrası deri kuruluğunun bir sebebi de, sebum düzeyindeki bu azalmaya bağlı olarak derinin su tutma kapasitesinin azalmasıdır [23]. Bizim çalışmamızda da tüm kadın hastalar menapoza girmişti. Ancak çalışmamızdaki hasta grubunun yaş ortalamasının yüksek olması sebebiyle kadın ve erkek hastalar arasında cilt kompozisyonu açısından anlamı bir fark bulunamamıştır.
Çalışmamızda da görüldüğü gibi BT gören yaşlı hastalarda cildin her gün suyla temas edilmesi kuru cilde ve kaşıntıya sebep olmaktadır. Merkezimizdeki kaplıca suyun mineral içeriğinin düşük olması nedeniyle ve BT sırasında sabun kullanılmasına izin verilmemesi sebebiyle ciltteki kuruma- nın kimyasal etkiden daha çok suyun mekanik etkisine bağ- lamaktayız.
Derinin özellikle de SC tabakasının hidratasyon derecesi derinin dış görünüşünü doğrudan etkiler. Dermatolojik açı- dan bakıldığında, yeterli hidratasyon seviyesi sağlıklı deri- nin bir göstergesidir. Kuru deri ise işlevsel bozukluğa işaret etmektedir [23, 24]. Dokunun hidratasyon seviyesinin ko- runması, çeşitli enzimlerin düzenli çalışabilmesi açısından da önem taşır [25]. Sağlıklı bir SC tabakasının su içeriği yüksektir, elastik yapıdadır ve mekanik strese karşı direnç- lidir [26, 27].
Kuru deri tedavisinin asıl amacı, epidermal su bariyerinin yeniden yapılandırılmasıdır. Bu da, deriye haricen uygu- lanan nemlendirici ve yumuşatıcı etkili ürünlerle sağlana- bilmektedir. Ayrıca sert sabun veya deterjanlar yerine etil alkol preparatları gibi sabun türevlerinin kullanılması yerin- de bir yaklaşımdır. Banyo sonrası oklüzif etkili yumuşatıcı ürünlerin uygulanması ve banyo yağlarının kullanılması SC tabakasının hidratasyonunu iyileştirmektedir [8, 10]. Nemlendirici ürünler, derinin hidratasyonunu (nem içeri- ğini) iyileştirir, ayrıca deri yüzeyinde koruyucu, oklüzif bir tabaka oluşturarak nemin derinin üst katmanlarında kal- masına yardımcı olurlar (pasif hidratasyon mekanizması). Bu şekilde derinin esneklik ve yumuşaklığı korunmuş olur [8]. Vazelin çok etkili oklüzif bir nemlendiricidir. Hidrokar- bon yapısındaki diğer oklüzif nemlendiricilere örnek olarak; mineral yağ, parafin, kakao yağı gibi bitkisel yağlar ve la- nolin gibi hayvansal yağlar verilebilir [28].
Humektanlar, derinin dermis tabakasındaki suyu SC taba- kasına çeken ve burada kalmasına yardımcı olan maddeler- dir (aktif hidratasyon mekanizması). Humektan özellikteki maddelere örnek olarak, gliserin, propilen glikol, üre, sod- yum laktat, sorbitol, pantenol, bal ve pirolidon karboksilik asit (PCA) verilebilir [28].
Sadece humektan içeren nemlendirici ürünler, suyu SC ta- bakasına geri döndürür, ancak hidrate olmuş SC tabakasını
artan su içeriğini kaybetmekten koruyamazlar. Dolayısı ile nemlendirici ürünlerin formüllerinde humektan ve oklüzif ajanların birlikte kullanılması yerinde bir yaklaşımdır [28]. Yumuşatma etkisi olan ürünlerin deri üzerinde oluşturduk- ları yağlı tabaka suyun buharlaşmasını engeller. Ayrıca yu- muşatıcılar SC tabakasının derinlerine penetre olarak lipit- lerin bariyer etkilerini taklit ederler. Bu da irritan ve alerjen maddelerin deri üzerinden penetrasyonunu önler. Yumuşa- tıcı ürünlerin dolaylı olarak antienflamatuar etkilerinin de bulunduğu da düşünülmektedir [8, 29]. Deriyi nemlendirme ve yumuşatma etkisi bulunan ürünler arasında krem, mer- hem, losyon, banyo yağları ve sabun yerine geçen ürünler sayılabilmektedir. Ürün yelpazesi çok geniş olmasına rağ- men, her birey için uygun ürünün bulunması kolay değildir, deneme yanılma yöntemi gerektirir.
Yumuşatma ve nemlendirme etkisi bulunan ürünlerin bazı durumlarda etkisiz gibi algılanmalarının nedeni, genellikle yetersiz miktarlarda kullanılmalarından ileri gelmektedir. Yapılan çalışmalarda, günde bir kez nemlendirici uygulan- masının uzun süreli bir fayda sağlamadığı, ama günde iki kez uygulama yapılmasının, en az yedi günlük bir tedavi sü- recinin ardından uzun süreli etki gösterdiğini ortaya çıkar- mıştır. Klinik etkinlik, sadece doğru ürünün seçilmesine de- ğil, aynı zamanda doğru kullanılmasına da bağlıdır [8, 28]. Çağdaş kaplıca küründe, BT yöntemleri yanında, başka te- davi yöntemleri de aynı zamanda uygulanabilir. Tek başı- na monoterapi yeterli olmamaktadır. Bu tedavi yöntemleri arasında ilaç tedavisi, fizik tedavi, egzersiz tedavisi, diyet, psikoterapi, sağlık eğitimi ve sosyal tıp önlemleri yer alır. Ayrıca kaplıca kürü sırasında hastaların günlük yaşantısını düzenleme, doğru ve yeni davranış biçimleri kazanmaları sağlanabilir [4, 5]. Ancak bu şekilde kombine edilmiş kür tedavisi optimal tedavi ve rehabilitasyon başarısı sağlaya- bilir [4]. Bizler de BT sırasında ciltte kaşıntı şikâyeti gelişen hastalara önerilecek uygun bir nemlendirici ve yumuşatıcı ürünün, hastanın kaplıca tedavisinden sağlayacağı faydayı artıracağı kanaatindeyiz.
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Selcuk Ozdogan, Erkan Kaya, Mehmet Zeki Kiralp, Muhammed Erdal. Dermatologic Analysis in Elderly Patients During Balneotherapy. J Clin Anal Med. 2010;1(3):18-22
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Analyses of Preoperative Presumptive Diagnosis in Lung and Mediastinal Lesions
Ekber Şahin 1, Şule Karadayı 2, Aydın Nadir 1, Burçin Çelik 1, Hafize Sezer 3, Melih Kaptanoğlu 1
1 Göğüs Cerrahisi, 2 Acil Tıp, 3 İstatistik, Cumhuriyet Üniversitesi Tıp Fakültesi, Sivas, Türkiye
DOI: 10.4328/JCAM.10.3.13_1 Received: 29.11.2009 Accepted: 06.01.2010 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):13-17
Corresponding Author: Şule Karadayı, Cumhuriyet Üniversitesi Tıp Fakültesi Acil Tıp Anabilim Dalı, 58140, Sivas, Türkiye. Phone : +90346 2580528 Fax: +900346 2581305 E-mail: sulekaradayi73@yahoo.com
Aim: The aim of this study was to investigate the correlation of preoperative presumptive and final histological diagnosis in patients without previous histological evaluation.
Matherial and Methods: We enrolled sixty-five patients who were operated for lung and mediastinal lesions between December 2005 and December 2008. In all patients, three presumptive diagnosises were established and they were compared to final histological diagnosis. ROC curve was used for analysing data.
Results: Postoperative histological diagnosis were as follows: lung cancer 23.1 % (15/65), hydatid cyst 23.1% ( 15/65 ), sarcoidosis 13.8% (9/65), tuberculosis 9.2% ( 6/65) and other disease 30.8 % ( 20/65). Sensitivity of presumption in the diagnosis of lung cancer, hydatid cyst, tuberculosis and sarcoidosis were 80%, 93.3%, 50% , 66.7% respectively.
Conclusion: We think that the exploratory thoracotomy should be performed when the lung cancer and hydatid cyst are suspected for diagnosis. For accurate diagnosis of tuberculosis and sarcoidosis, more detailed and careful preoperative laboratory studies should be done.
Keywords: Computed Tomography, Lung, Lung Cancer, Hydatid disease, Mediastinum
Giriş
Akciğer ve mediastinal lezyonlar, Göğüs Cerrahisi klinikle- rinde en sık karşılaşılan durumlardır. Bu lezyonlarda kesin histopatolojik tanıya ulaşmak ve uygun tedaviyi seçmek algoritmadaki en önemli basamaklardır. Tanıda hastanın hikayesi, özgeçmişi, soygeçmişi ve fizik muayenesine ek olarak yapılan laboratuar, radyolojik ve girişimsel tetkik- ler klinisyenlere yardımcı olmaktadır. Ancak yapılan bütün preoperatif değerlendirmelere karşın kesin tanıya ulaşıla- madığı durumlar hiç de az değildir. Örneğin Sırmalı ve ar- kadaşları [1] ameliyat ettikleri akciğer kanserli hastalarının %21,6’sında preoperatif dönemde yapılan bütün tetkiklere rağmen tanı koyamadıklarını ve tanı olmadan operasyona girmek zorunda kaldıklarını bildirmişlerdir. Nashef ve ar- kadaşları [2] ise kendi hastaları için bu oranı %26 olarak bildirmişlerdir. Bu durumda cerrah bir ön tanıyla (akciğer kanseri, kist hidatik, tüberküloz, lenfoma vb.) ameliyata gir- mekte ve ameliyatı buna göre planlamaktadır. Ancak cerra- hi planlanırken de uygulanan genel anestezi ve operasyon açısından riskler göz önünde bulundurulmalıdır [3]. Çalışmamızın amacı, kliniğimize sevk edilmiş histopatolojik tanısı olmayan, akciğer ve mediastinal lezyonu olan hasta- larda preoperatif dönemde tanı tahminlerinde bulunarak, ameliyat sonrası kesin histopatolojik tanıları ile uyumlulu- ğunu araştırmaktır.
Gereç ve Yöntemler
Bu çalışmada, Aralık 2005-Aralık 2008 tarihleri arasında akciğer veya mediastinal lezyon nedeniyle ameliyat edilen ve preoperatif kesin histopatolojik tanısı olmayan 65 has- ta prospektif olarak incelenmiştir. Çalışmaya preoperatif transtorasik ince iğne aspirasyon biyopsisi (TTİİAB), bron- koskopik biyopsi, balgamda ARB, balgam ya da plevra sıvı sitolojisi incelemeleri gibi tetkiklerle tanı konulan hastalar dahil edilmedi. Hastaların tümüne posteroanterior (PA) ve lateral akciğer grafisi ve toraks bilgisayarlı tomografi (to- raks BT) çekildi. Ön tanı tahmininde bulunurken hastanın yaşı, şikayetleri, özgeçmişi (sigara öyküsü, mesleği vb.), soy geçmişi, fizik muayenesi, görüntüleme yöntemleri (PA ve lateral akciğer grafisi, toraks BT) göz önünde bulunduruldu. Hastaların toraks BT’leri incelenirken lezyonların loka- lizasyonu, büyüklüğü, sınırlarının düzenli olup olmaması ve dansitesine dikkat edildi. Tüm hastalara klinik ve radyolojik özellikleri göz önünde bulundurularak 3 göğüs cerrahisi uzmanı tarafından ortaklaşa karar verilerek üçer adet tanı tahmininde bulunuldu. Tüm hastaların tanı tahminini aynı göğüs cerrahları yaptı. En yüksek olasılık verdiğimiz tanı tahminimiz 1 numaralı tahmin iken, 2. tahminimiz biraz daha az olasılık verdiğimiz tahmindi. Üç numaralı tahmi- nimiz ise en az olasılık verdiğimiz tahminimizdi. Tüm tah- minler preoperatif dönemde kaydedildi ve tanı tahminleri postoperatif kesin histopatolojik sonuçlarla karşılaştırıldı. Preoperatif tahminlerimizde malignite yada hidatik kist şüphesi yüksek olanlara, mediastende 1 cm’in üzerinde lenfadenopatisi olanlara, mediastinal kistik yada kitlesel lezyonu olanlara cerrahi uygulandı. Resim 1 ve 2’de preoperatif tanı tahminlerimiz ile postoperatif sonuçları uyuş- mayan 2 hastanın bilgisayarlı tomografi görüntüleri izlen- mektedir.
İstatistiksel değerlendirmede SPSS 14.0 for Windows ver- siyonu kullanıldı. Hastalara ait parametreler ortalama ± standart sapma olarak verildi. p<0.05 değeri istatistiksel olarak anlamlı kabul edildi. İstatistiksel olarak Alıcı Çalış- ma Karakteristikleri (Receiver Operation Characteristics – ROC) analizi kullanıldı.
Bulgular
Aralık 2005-Aralık 2008 tarihleri arasında kliniğimizce ak- ciğerde, mediastende yada plevrada kitle, kistik lezyon yada LAP nedeniyle opere edilen toplam hasta sayısı 155’dir. Bunlar arasından preoperatif tanısı olmayan ve çalışmaya dahil edilen 65 hastanın 33’ü erkek (%50.8), 32’si (%49.2) kadındı. Hastaların yaş ortalaması 42.2±17.8 (5–76) yıl olarak saptandı. Hastalarda izlenen semptomlar sırasıyla 22 (%33.8) hastada nefes darlığı, 22 (%33.8) hastada gö- ğüs ağrısı, 20 (%30.8) hastada öksürük, 13 (%20) hastada hemoptizi idi. İki hasta ise (%3) asemptomakti. Hastaların %46’sı sigara içicisiydi.
Preoperatif radyolojik değerlendirmeye göre en sık izlenen lezyonlar; 17 (%26.2) hastada parankimal solid lezyon, 16 (%24.6) hastada mediastinal yerleşimli lenfadenopati hastada preoperatif doku tanısı ile ameliyata girmek is- ter [4]. Bu ameliyat öncesi hastanın bilgilendirilmesinde, ameliyat sırasında ortaya çıkabilecek sorunların önceden
(LAP) ve/veya kitle, 14 (%21.5) hasta- da parankimal kistik lezyon şeklindeydi. Preoperatif radyolojik değerlendirmeye göre lezyonların dağılımları Tablo 1’de gösterilmektedir. Hastaların sadece bir tanesinde 2 adet kistik lezyon vardı, bunun dışında çoklu lezyonu olan yoktu. Radyolojik olarak lezyonların çaplarına bakıldığında; solid lezyonların ortalama çapı 4.4±2.31 (2–11) cm iken, kistik lez- yonların ortalama çapı 6.1±2.56 (3–10) cm olarak saptandı.
Preoperatif tanıya yönelik invaziv gi- rişim olarak; 21 hastaya fleksibl bron- koskopi, 5 hastaya rijid bronkoskopi, 2 hastaya TTİİAB uygulandı ancak tanı- ya ulaşılamadı. Preoperatif tahminler arasında 15 (%23.1) hastada akciğer kanseri ve yine 15 (%23.1) hastada kist hidatik en fazla tahmin edilen hasta- lıklardı. Hastaların 48’ine (%74) tora- kotomi, 15’ine (%23) mediastinoskopi, 2’sine (%3) median sternotomi yoluyla girişim uygulandı. Ameliyat sırasında 13 (%20) hastada “frozen” çalışıldı. Postoperatif histopatolojik tanıları ise; 15 (%23.1) hastada akciğer kanseri, 15 (%23.1) hastada hidatik kist, 9 (%13.8) hastada sarkoidoz, 6 (%9.2) hastada tüberküloz ve 20 (%30.8) hastada diğer hastalıklar şeklindeydi (Tablo 2). Akciğer kanserli 15 hastanın 14’ünde (%93.3) (Tablo 3), hidatik kistli hasta- ların ise tümünde (%100) preoperatif üç tahminden en azından biri doğruydu (Tablo 4). Akciğer kanseri, kist hidatik, tüberküloz ve sarkoidoz gibi çalışma- mızda en sık tanı alan hastalıklarda preoperatif tahminlerimizin doğruluk, sensitivite ve spesifite oranları Tablo 5’de gösterilmişlerdir.
Tartışma
Akciğer ve mediastinal lezyonların aydınlatılmasında anamnez ve fizik muayene, labarotuar ve radyolojik in- celemeler (PA akciğer grafi, toraks BT vb.), gerek duyulan hallerde ise bron- koskopi, TTİİAB gibi invaziv girişimler- den yararlanılır. Toraks BT, lezyonların özelliğini belirlemede yüksek spesifite, kabul edilebilir sensitivite ve doğruluk oranları ile iyi bir seçenek olmasına rağmen, cerrah malignite düşündüğü tahmininde ve önlenmesinde, ameliyat sırasında tedavi değişikliği olasılığında, kan ve ürünlerinin kullanımında, nutrisyon ve psikolojik tedavi desteği gibi pek çok konuda
önem taşır. Ancak ameliyat öncesi doku tanısının müm- kün olmadığı durumlarda cerrahın preoperatif ön tanısının ameliyat sonrası tanı ile ne kadar uyumlu olduğu araştır- mamızın konusu olmuştur.
Tanı tahminleri irdelendiğinde yaş, kanser için bağımsız bir faktör olarak dikkatimizi çekti. Otuz yaşın altındaki has- talarda akciğer kanseri, preoperatif tanı tahminlerimizde yoktu. Nitekim Okada ve arkadaşlarının [5] küçük hücre dışı akciğer kanserli (KHDAK) 1465 hastadan oluşan serilerinde erken evre hastalarının yaş ortalaması 63.3 iken geç evre hastalarının yaş ortalaması 65.0’di. Waele ve arkadaşları- nın [6] 104 KHDAK’li hastalarının yaş ortalaması 64.3’dü. Çalışmamızdaki akciğer kanserli hastalarımızın yaş ortala- ması ise 58.1 olarak saptandı. Böylece 30 yaş altı hasta- lardaki preoperatif tahminlerimizde akciğer kanserinin en son düşünülmesi, akciğer kanserinin ileri yaş hastalığı ol- masının doğal bir sonucudur. Tüberküloz, sarkoidoz ve kist hidatik tahmininde bulunurken ise hastaların yaşlarının bir önemi yoktu.
Hastaların sigara içme öyküsü kanser tanı tahmininde göz önünde bulundurduğumuz faktörlerden biriydi. Günde içilen sigara sayısı ve toplam sigara içme süresiyle orantılı olarak akciğer kanseri riski artmaktadır [7]. Shimizu’nun çalışmasın- da [8]; akciğer kanserli 194 hastadan 124’ü (%63.9) sigara içen grupta, 70’i (%36.1) ise sigara içmeyen gruptandı. Ça- lışmamızdaki akciğer kanserli 15 hastamızın 8’i sigara içen grupta (%53.3), 7’si (%46.7) ise sigara içmeyen gruptaydı. Olgularımızdaki sigara içme oranının çok yüksek olmaması hasta sayısının az olmasına bağlanabilir.
Kırsal alanda yaşama, düşük sosyoekonomik durum, hay- vancılıkla uğraşma, evinde hayvan yetiştirme, membran ekspektorasyonu öyküsü, radyolojik olarak kist hidatikten şüphelenilen olgularda tahminimizi etkiledi. Kist hidatik ta- nısında cerrahın yüksek doğruluk oranı ile tahmini ülkemiz- de bu hastalığın endemik görülmesi ve buna ilişkin ameli- yatların sık yapılması ile açıklanabilir.
Ailede ya da yakın çevresinde tüberküloz geçirme öyküsü olması tüberkülozdan şüphelendiğimiz olgularda tanı tah- minlerimizi kuvvetlendirdi. Fizik muayene bulgularından ka- şeksi, solukluk, servikal ve supraklavikular LAP kanser ya da tüberkülozu düşündürdü.
Radyolojik olarak düzensiz konturlu opasite, eşlik eden mediastinal LAP ya da plevral effüzyon maligniteyi düşün- dürürken, bilateral hiler LAP ve/veya eşlik eden pulmoner infiltrasyon sarkoidozu akla getirdi. Soliter pulmoner nodül (SPN) kenar özellikleri, benign-malign ayırımında önem- li ipuçları verebilir. Lezyonun kenarının ışınsal tarzda dü- zensizlik gösterdiği (korona radiata görünümü) olguların %88-94’ünde patolojik tanı malign olarak tanımlamıştır [9,10]. SPN içinde kalsifikasyon varlığı benign lezyon lehi- nedir. Santral yerleşimli bir kalsifikasyon granüloma lehine değerlendirilirken, patlamış mısır tarzında kalsifikasyon
hamartomalar için tipiktir. Diffüz kalsifikasyonlar benign lezyonların karakteristik özelliğidir. Yalnız bütün kalsifikas- yon paternleri benign lezyon olarak değerlendirilmemelidir. Malign SPN’ler % 6–14 oranında kalsifikasyon içerebilir ve bu kalsifikasyonlar genellikle az miktarda ve kenar yerle- şimlidir [10].
Özellikle üst loblarda görülen nodüler lezyonlar, fibrotik artıklar tüberkülozu düşündürürken, düzgün sınırlı homo- jen kistik lezyonlar kist hidatiği düşündürmektedir. Jeong multidedektör dinamik BT ile benign ve malign nodülleri ayırmada %92 doğruluk oranı bildirmektedir [11]. Burns ve arkadaşları [12] akciğerinde nodül ya da kitle olan 107 hastayla yaptıkları bir çalışmada BT raporları ile postope- ratif patoloji raporlarını karşılaştırdılar. Akciğer kanseri için duyarlılık oranları %78 iken diğer tanılar için %65’ti. Bu oran çalışmamızdaki akciğer kanserli hastalardaki tah- minlerimizin duyarlılık oranına (%80) yakındı. İntratorasik yerleşim gösteren lezyonların tanısında noninvaziv ya da daha az invaziv tetkiklerin yeterli olmadığı durumlarda te- davinin yönlendirilmesi açısından tanısal operatif torasik girişimler düşük morbidite ve mortalite ile önemli yer tut- maktadır [3].
Akciğer kanseri olmayan 50 hastamızdan 11’inde preope- ratif tahminlerden biri akciğer kanseri idi. Bu rakam her ne kadar yüksek (%22) gibi görünse de kansermiş gibi hazır- lanarak ameliyata girip kanser çıkmaması, tersi durumdan daha avantajlı gibi görülmelidir. Ayrıca akciğer kanseri olan 15 hastanın 14’ünde tanının preoperatif doğru tahmin edi- lebilmesi de konu kanser olduğunda hassasiyetimizin faz- lalığını gösteriyor olabilir.
Kist hidatikli hastalarımızın %93’ünde ilk tanı tahmini- miz kist hidatikti. Bunun nedeni kist hidatiğin ülkemizde sık görülmesi, cerrahların bu konuda deneyimli olması ve kist hidatiğin görünümünün tipik olması olabilir. Tüber- küloz son yıllarda ülkemizde artmıştır. Resmi rakamlara göre ülkemizde 2004 yılında tüberküloz insidansı 19,799 olgu (27/100,000) olarak bildirilmiştir [13]. Tüberküloz tanı tahminimizdeki düşük duyarlılık (%50) oranı tüberkülozun radyolojik görünümünün tipik olmamasına ve diğer non invaziv tetkiklerin de tanıyı her zaman desteklememesine bağlı olabilir.
Sonuç olarak, çalışmamızdan da çıkarılabileceği gibi ül- kemizde oldukça sık rastlanılan akciğer kist hidatiğinin preoperatif tanısında pek sıkıntı yaşanmamaktadır. Eğer preoperatif tanı akciğer kanseri ile uyumlu ise ve yapılan tüm preoperatif girişimlere rağmen tanıya ulaşılamıyorsa eksploratif torakotomiden kaçınılmamalıdır. Tanı konula- mayan ve cerrahi eksplorasyona gerek duyulan benign has- talıklar arasında tüberküloz ve sarkoidoz ülkemizde ön sı- ralarda gelmektedir. Gerek akciğer gerekse de mediastinal lezyonlarda cerrahi eksplorasyon tanıya ulaşmada önemli bir yer tutmaktadır.
Kaynaklar
1. Sırmalı M, Gürsu S, Demirağ F, Topçu S, Karasu S, Aydın E, et al. Göğüs Cerrahisinde İntraoperatif “Frozen” İncelemesinin Önemi. Solunum Hastalıkları 2002; 13: 292-296.
2. Nashef SAM, Kakadellis JG, Hasleton PS, Whittaker JS, Gregory CM, Jones MT. Histological examination of peroperative frozen sections in suspected lung cancer. Thorax 1993;48:388-389.
3. Gözübüyük A, Yücel O, Çaylak H, Balkan A, Kavaklı K, Gürkök S, et al. Tanısal amaçlı torasik girişimler. Gülhane Tıp Derg 2006; 48:30-33.
4. Choi EJ, Jin GY, Han YM, Lee YS, Kweon KS. Solitary Pulmonary Nodule on Helical Dynamic CT Scans: Analysis of the Enhancement Patterns Using a Computer- Aided Diagnosis (CAD) System. Korean Journal of Radiology; 2008; 9(5):401-408.
5. Okada M, Nishio W, Sakamoto T, Uchino K, Yuki T, Nakagawa A, Tsubota N. Evolution of surgical outcomes for nonsmall cell lung cancer: time trends in 1465 consecutive patients undergoing complete resection. Ann Thorac Surg 2004;77:1926-1930.
6. Waele MD, Mitjans MS, Hendriks J, Lauwers P, Sanchis JB, Schil PV, Porta RR. Accuracy and survival of repeat mediastinoscopy after induction therapy for non-small cell lung cancer in a combined series of 104 patients. Eur J Cardiothorac Surg 2008;33:824-828.
7. Tanoue LT, Matthay RA. Lung Cancer: Epidemiology and Carcinogenesis. General thoracic Surgery.InShields TW, Lo Cicero J, Ponn RB Ed. 5.th Edition, 2000; Philadelphia. Lippincott Williams and Wilkins 1215-1228.
8. Shimizu K, Nakata M, Hirami Y, Maeda A and Tanemoto K. Recent results regarding the clinical impact of smoking history on postoperative complications in lung cancer patients. Interact CardioVasc Thorac Surg 2008;7:1001-1006.
9. Yıldız F, Arslan A. Soliter Pulmoner Nodüle Genel Yaklaşım. Toraks dergisi 2001; 2(3):85-90.
10. Huston J, Muhm JR. Solitary pulmonary opacities: plain tomography. Radiology 1987;481-485.
11. Jeong YJ, Lee KS, Jeong SY, Chung MJ, Shim SS, Kim H, et al. Solitary pulmonary nodule: characterization with combined wash-in and washout features at dynamic multi-detector row CT. Radiology 2005;237:675-683.
12. Burns J, Haramati LB, Whitney K, Zelefsky MN. Consistency of reporting basic characteristics of lung nodules and masses on computed tomography. Acad Radiol 2004;11:233-7.
13. Kılıçaslan Z. Dünyada ve Türkiye’de Tüberküloz. Ankem Derg 2007;21(Ek 2):76- 80.
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Ekber Sahin, Sule Karadayi, Aydin Nadir, Burcin Celik, Hafize Sezer, Melih Kaptanoglu. Analyses of Preoperative Presumptive Diagnosis in Lung And Mediastinal Lesions. J Clin Anal Med. 2010;1(3):13-17
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Value and Implantation Risk of Thin Needle Aspiration Biopsy in The Diagnostic Malign Pulmonary Lesions
Pınar Yaran², Ülkü Yazıcı¹, Erkmen Gülhan¹, Abdullah İrfan Taştepe¹, Funda Demirag¹, Güven Çetin¹, Mehmet Bahadır Berktaş¹
¹Department of Thoracic Surgery, Ataturk Training and Research Hospital for Chest Disease and Chest Surgery, Kecioren, ²Thoracic Surgery Clinic, Akay Hospital, Kavaklidere, Ankara, Turkey
DOI: 10.4328/JCAM.10.3.13 Received: 10.11.2009 Accepted: 22.11.2009 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):8-12
Corresponding Author: Ülkü Yazıcı, Department of Thoracic Surgery, Ataturk Training and Research Hospital for Chest Disease and Chest Surgery, Sanatoryum Caddesi Kecioren, Ankara 06280 Turkey. Fax:+903123552135 Phone : +903123552110 E-mail: ulku_yazici@yahoo.com
Aim: The aim of our study was to investigate the diagnostic value of fine needle aspiration biopsy in malignant lesions, compare the results obtained by a Chiba and an injection needle and determine whether or not malignant cells are implanted on the course of the needle.
Material and Methods: Fine needle aspiration biopsy was done on the resected material from a total of 70 patients (67 male and 3 female) with a mean age of 58.17 years (range: 38-75 years) who underwent surgery for prediagnosed malignancy.For each surgically resected material, the cytological and histopathological findings of the internal aspirates from both the Chiba and injector needles as well as the smears from the external surfaces of these needles were compared.
Results: Of the 70 biopsy materials obtained by the Chiba needle, malignancy was demonstrated in 58, benign lesions in one, while 11 were non-diagnostic. The results obtained with the injector needle revealed 58 malignancies, and 12, without any diagnosis. With both techniques, no false positive results were observed. The diagnostic sensitivity of the techniques was 84% and 82% for the Chiba and injector needles respectively. Examination of the smears obtained from the external surfaces revealed malignant cells in 45 (64.3%) of the 70 smears obtained with a Chiba needle and 42 (60%) of the 70 smears obtained with an injector needle.
Conclusions: Fine needle aspiration is a method with high diagnostic value. It can be easily performed in selected cases with malignant pulmonary lesions. There were no significant differences between the two methods in terms of diagnostic yield. Any intervention targeting the tumor tissue, especially in advanced stage cellular and malignant tumors, carries a significant risk for implantation of malignant tumor cells on the course of the needle.
Keywords: Lung, Needle Biopsy, Malignancy.
Introduction
Transthoracic needle biopsy (TTNB) is an effective diagnostic method with wide range of indications and limited contraindications for thoracic lesions [1, 2]. TTNB was first used in 1883 for isolation of the microorganisms from 3 patients with Leyden pneumonia, and by using this method, Menetrier was the first to diagnose pulmonary cancer [3]. Starting from the second half of the 20th century, the technique has become more popular for the last two or three decades with the introduction of radiological techniques that facilitate imaging in biopsy studies, increased experience of physicians and cytopathologists applying biopsy procedures, improved needle types, and increased ability to control complications [1].
Material and Method
The study involved surgical resection materials of 70 patients (67 male, 3 female; mean age: 58.17 years, age range: 38-75 years) planned for fine needle aspiration biopsy (FNAB). Patients were properly informed about the surgical procedure and a signed approval was received from every patient. The patients were operated in our clinic for prediagnosis of malignancies. For the fine needle aspirations, 20-21 gauge (G) Chiba aspiration needles and 21 gauge injectors were used. Fine needle aspirations were performed on the resected materials in pathology lab without any additional surgical procedure. Immediately after the intraoperative resection procedure was completed, resected materials were evaluated without any formaldehyde fixation. Before the procedure, the materials were palpated with hand and the locations of the lesions were determined. The best point for FNAB was determined for each. The lesion was penetrated with Chiba aspiration needle through the location determined. When the desired depth was reached, introducer was withdrawn, and a 20 ml injector was attached to the outer tip of the needle. The needle was moved back and forth within the lesion for a few times while the piston was being retracted, creating a negative pressure and thus, continuous aspiration was achieved. The same procedure was repeated using another 20 ml injector and its own needle.
After the aspiration procedure was completed, the external surface of each needle was smeared on a separate glass plate for each needle without any contact of the needle to the plate. The aspiration material in the needle and injector was sprayed on separate plates. As soon as the smears were prepared, the slides were sent to the pathology laboratory. The smears prepared using the internal aspirations obtained with Chiba and injector needles were divided into two groups, and depending on the preference of the pathologist, the first half of the preparations were fixed in 70% alcohol and stained with hemotoxylene-eosin. The other half and slides prepared by smearing the external surface of the Chiba and injector needles were air-dried and stained with Giemsa.
The cytological evaluation of the preparations was made by an experienced pathologist, who was blinded to the histopathological diagnosis for resected materials. The histopathological evaluation of surgical resection materials was made by three different pathologists.
The cytological results of the inner aspirate obtained with Chiba and injector needles and the external smear cultures of each resection material were compared with the histopathological results of the same material. In the evaluation of the results, a malign diagnosis that could be established was regarded as ‘true positive’; a diagnosis that was considered malign but turned out to be benign was regarded as ‘false positive’; a benign diagnosis that could be established was regarded as ‘true negative’; the undiagnosed ones were regarded as ‘false negative’.
Results
In 38 (54.28%) patients, right thoracotomy and in 32 (45.72%) cases, left thoracotomy were performed. The distribution of the procedures applied were as follows: pneumonectomy in 27 patients (9 right, 18 left), upper lobectomy in 22 patients (16 right, 6 left), lower lobectomy in 12 patients (4 right, 8 left), bilobectomy superior in 2 patients; bilobectomy inferior in 5 patients, and wedge resection in 2 patients (right).
The distribution of the diagnoses established with FNAB (Chiba needle) for 70 surgically resected materials was as follows: malignant, 58 (82.85%) samples; benign, 2 (2.86%) samples; and no diagnosis, 10 (14.29%) samples. In 52 (89.6%) of 58 malignancies, small-celled lung cancer and lung cancer other than small-celled could be distinguished, while 6 lesions (10.4%) were considered malign only (Table 1).
The distribution of the diagnoses established with FNAB (injector needle) for 70 surgically resected materials was as follows: malignant, 58 (82.85%) samples; no diagnosis, 12 (17.15%) samples. In 49 (84.5%) of 58 malignancies, small-celled lung cancer and lung cancer other than small-celled could be distinguished, while 9 lesions (15.5 %) were considered malign only (Table 2). Histopathological evaluations of the postoperative surgical resection materials obtained from 70 patients revealed that the diagnosis of 69 samples was malign and of 1 sample, benign. Squamous celled carcinoma was
the most common diagnosis (66%) for malign samples. This was followed by adenocarcinoma (23%).
The comparisons of histopathological results and cytological results of Chiba aspiration biopsy showed that the results were compatible for differentiation of small- celled lung cancer and lung cancer other than small-celled, while subgroups of lung cancer other than small-celled were not compatible in 5 lesions. Two squamous-celled carcinomas diagnosed by cytological evaluation were diagnosed as adenocarcinoma in the histopathological evaluation, while 3 adenocarcinomas diagnosed by cytological evaluation were diagnosed as 2 squamous celled carcinomas and 1 pleomorphic carcinoma. The samples that were found to be malign in FNAB cytology were compatible and thus, were considered ‘true positive’. The sample histopathologically diagnosed as organized pneumonia was determined to be benign in cytological evaluations. Thus, it was considered ‘true negative’. The samples that could not be diagnosed by cytological evaluations were considered ‘false negative’. There were no ‘false positive’ results.
The comparisons of histopathological results and cytological results of injector needle aspiration biopsy similarly showed that the results were compatible for differentiation of small-celled lung cancer and lung cancer other than small-celled, while subgroups of lung cancer other than small-celled were not compatible in 2 lesions. Two squamous-celled carcinomas diagnosed by cytological evaluation were diagnosed as adenocarcinoma in the histopathological evaluation. The samples that were found to be malign in FNAB cytology were compatible and were considered ‘true positive’. The samples that could not be diagnosed by cytological evaluations were considered ‘false negative’. There were no ‘false positive’ results (Table 3).
Evaluation of the external smear cultures of both needles on different plates showed malign cells in 45 (64.5%) of 70 smears from China needles and 42 (60%) of 70 smears from injector needles (Table 4).
The histopathological results of the lesions with malign cells according to the cytological evaluation of external smear cultures from both needles were studied. Accordingly, the most common histopathological diagnosis for lesions with malign cells determined in the external smears from Chiba needles was squamous-celled carcinoma (65%), followed by adenocarcinoma (29%). Similarly, the most common histopathological diagnosis for lesions with malign cells determined in the external smears from injector needles was squamous-celled carcinoma (62%), followed by adenocarcinoma (33%).
Discussion
FNAB has high sensitivity and specificity rates. In previous studies, the sensitivity for malign diseases was reported to be 64-97 %. For benign lesions, however, this rate was reported to be 11.7-68% [3]. In the studies by Stanley, Khouri, and Green, the sensitivity rates of FNAB for malignancy were determined as 96.6%, 96%, and 97% [4-6]. On the other hand, for benign lesions, the sensitivity of the method was found to be 68% by Khouri, 44% by Green, and 11.7% by Johnson [5-7]. In our study, the sensitivity rate of FNAB for malign lesions was 84% with Chiba needle and 82.8% with injector needle (p=0.077), which is compatible with the literature. No statistically significant differences were determined between the two needles for diagnostic efficiency.
In primary lung carcinoma, tumor cell type is important for determination of prognosis and proper treatment. Numerous studies have shown compatible diagnoses with cytological and histopathological studies [3, 7, 8 ]. In most of these studies, only some of the cytological diagnoses could be compared with histopathological diagnoses. In our study, however, all the cytological diagnoses were compared with the postoperative histopathological diagnoses, and the results were confirmed. In our study, in the cytological evaluation of 70 surgically resected materials that were performed FNAB with Chiba needles, 58 lesions (82.85%) were diagnosed as malignant. Of these, the types of 38 lesions (65%) were definitely determined, and 52 lesions (89.6%) were differentiated as small-celled lung cancer or lung cancer other than small-celled. Six lesions (10.4%) were considered malign only.
The compatibility rate of cytopathological and histopathological diagnoses was 100% for small-celled lung cancer or lung cancer other than small-
celled, 91% for squamous-celled carcinoma, and 75% for adenocarcinoma. The cytological evaluation of 70 surgically resected materials that were performed FNAB with injector needles revealed that 58 lesions (82.85%) were malignant. Of these, the types of 33 lesions (56%) were definitely determined, and 49 lesions (84.4 %) were differentiated as small-celled lung cancer or lung cancer other than small-celled. Nine lesions (15.6 %) were considered malign only. The compatibility rate of cytopathological and histopathological diagnoses was 100% for small-celled lung cancer or lung cancer other than small-celled, and adenocarcinoma, and 90% for squamous-celled carcinoma.
The location and size of a lesion are believed to affect the diagnostic value of FNAB. Layfield et al have reported that the larger the lesion is, the higher the diagnostic value of FNAB [9]. Westcott, on the other hand, reported false negative results for all the lesions smaller than 2 cm [8]. Severe tumor necrosis and areas with severe inflammation, fibrosis, or pneumonia around the tumor may cause negative results [1, 4].
Radiological tools such as fluoroscopy, US, and CT increases the diagnostic value of the FNAB method. Dash et al have found a sensitivity rate of 97% for FNAB guided by CT and 90% for FNAB that was not radiologically guided [10]. In our study, FNAB was performed directly on palpable, surgically resected material, and thus, factors such as the location and size of the lesion and radiological guidance did not affect the diagnostic value of FNAB. Due to complications of thick and sharp needles such as bleeding, which may rarely be fatal, today fine needles (19 G or thinner) are preferred. On the other hand, it has been reported that with sharp needles of large diameter, it is more likely to obtain sufficient material [1, 3], while with needles of smaller diameter, diagnostic efficiency was not found to be as low as expected [1, 11].
False negative results are an important problem for fine needle aspiration biopsy. Whereas in malign lesions, repetitions of the procedure in the same session increases the diagnostic yield by 35-45%, a negative result does not completely rule out malignancy [1,3]. The primary reasons for false negative results is insufficient sampling, inability to penetrate the lesion, severe necrosis in the lesion, biopsy from areas of inflammation or pneumonia, excessive aspiration of hemorrhage and technical issues. In FNAB with Chiba and injector needles, the rates of false positivity were 15.7% and 17%. Comparisons of the postoperative histopathological results of these lesions showed that 11 lesions (91.6%) were squamous-celled carcinoma and 1 lesion (8.4%) was benign. Almost all of the false negative results were detected for squamous- celled carcinomas. This shows how much the cavity forming characteristic of squamous-celled carcinoma and FNAB performed with the guidance of CT, which is effective in differentiation of the cavity area, affects the diagnostic yield.
The rate of false positive results with FNAB (0.025% – 2.4%) is very low. Various factors that may lead to false positive results are granulomatous reaction, organized pneumonia, pulmonary infarct, radiation and chemotherapy applications. In our study, no false positive results were determined with either of the needles.
The most common complications of FNAB are pneumothorax (5-61%), hemorrhage and hemoptisis (3-10%) [1, 3, 12,13 ]. The implantation and diffusion of the tumor cells on the course of the needle are the rare but serious complications, which are highly debated. Despite difficulty in determining the mechanism of implantation, it has been thought to be associated with such factors as use of needles with large diameters and sharp tips as well as synergic effects of tumors with high degree of malignancy. However, malign diffusion with FNAB has been reported recently [14]. Studies have shown that the number of tumor cells that implant on the course of the needle is relative to tumor redifferentiation. In obtaining diagnostic material from malign tumors with FNAB, tumor cell diffusion is inevitable. Indeed, malign cells were determined in smears of the external surfaces of the needles that were used in biopsy procedure on the resected materials. After fine needle biopsy procedures performed on 70 surgical materials, in 45 (64.3%) of the smears of the external surfaces of the Chiba needles and in 42 (60%) of the smears of the external surfaces of the injector needles, there were malign cell (p=0.6008). Then, do all the malign cells on the external surface of the needle cause implantation on the course of the needle? Earlier studies showed that despite dispersion of millions of cells from a single tumor, very few can lead to metastasis or invasion because in a heterogeneous tumor, subclones with a potential for metastasis must be formed first. The cells in this particular clone gain molecular characteristics that will allow vascular diffusion and implantation of these cells into that medium by extracellular matrix invasion. Even when there are cells with this caharcteristics on the transthoracic biopsy needle, the medium must allow for multiplication of these cells [15]. Thus, despite evidence of more than 90% malign cells on the course of the needle in the experimental studies, the clinical incidence of malignancy is under 1 % [16]. It is known that in transthoracic needle biopsy procedures, particularly for severely cellular and malign tumors, the risk of implantation is increased. The most common view is when possible, the removal of the course of the needle after the biopsy procedure. This has been in general suggested at the time of tumor removal [17].
Conclusion
The diagnostic sensitivity of the technique was 84% and 82% for the Chiba and injector needles respectively and there are no differences between the two needles for diagnostic yield. In fine needle aspiration biopsy procedures applied on peripheral lesions that can be
accessed by a needle, injector needles may be preferred because they are inexpensive and easily accessible. Malign cell implantation on the course of the needle is a rare but serious complication of transthoracic needle biopsy. After FNAB procedures, malign cells were determined in 64.35 of the external surface smears of the Chiba needles and in 60% of the external surface smears of the injector needles. Any FNAB intervention to tumor tissue, particularly to high cellular and malign tumors, poses
a risk of malign cell implantation on the course of the needle. Thus, in operable patients with high potential for malignancy whose lesions can be resected, transthoracic needle biopsy should be avoided. If such patients are performed a needle biopsy and then operated, the course of the needle should also be removed along with the tumor.
References
1. Salazar AM, Westcott JL: The role of transthoracic needle biopsy for the diagnosis and staging of lung cancer. In: Matthay RA (ed): Clinics in Chest Medicine, 1993; 14:99-110.
2. Cham MD, Lane ME, Henschke CI, Yankelevitz DF: Lung biopsy: special techniques. Semin Respir Crit Care Med. 2008; 29:335-349.
3. Weisbrod GL: Transthoracic needle biopsy. World J Surg. 1993; 17:705- 711.
4. Stanley JH, Fish GD, Andriole JG, Gobien RP, Betsill WL, Laden SA, Schabel SI: Lung lesions: Cytologic diagnosis by fine needle biopsy. Radiology 1987; 162:389-391.
5. Khouri NF, Stitik FP, Erozan YS,Gupta PK, Kim WS, Scott WW JR, Hamper UM, Mann RB, Eggleston JC, baker RR: Transthoracic needle aspiration biopsy of benign and malignant lung lesions. AJR 985; 144:281-288.
6. Greene R, Szyfelbein WM, Isler RJ, Stark P, Janstsch H : Supplementary tissue-core histology from fine needle transthoracic aspiration biopsy. AJR 1985; 144:787-792.
7. Johnston WW: Percutaneous fine needle aspiration biopsy of the lung: A study of 1,015 patients. Acta Cytol 1984; 28:218-224.
8. Westcott JL: Direct percutaneous needle aspiration of localized pulmonary lesions: results in 422 patients. Radiology 1980; 137:31-35.
9. Layfield LJ, Coogan A, Johnston WW, Patz EF: Transthoracic fine needle aspiration biopsy: Sensitivity in relation to guidance technique and lesion size and location. . Acta Cytol 1996; 40:687-690.
10. Dash BK, Tripathy SK: Comparison of accuracy and safety of computed tomography guided and unguided transthoracic fine needle aspiration biopsy in diagnosis of lung lesions. JAPI 2001; 49:626-629.
11. Zavala DC, Schoell JE: Ultrathin needle aspiration of the lung in infectious and malignant disease. Am Rev Respir Dis 1981; 123:125-131.
12. Zavala DC, Bedell GN: Percutaneous lung biopsy with a cutting needle. Am Rev Respir Dis 1972; 106:186-193.
13. Khan MF, Straub R, Moghaddam SR, Maataoui A, Gurung J, Wagner TO, Ackermann H, Thalhammer A, Vogl TJ, Jacobi V: Variables affecting the risk of pneumothorax and intrapulmonary hemorrhage in CT-guided transthoracic biopsy. Eur Radiol. 2008;18:1356- 1363.
14. Sacchini V, Galimberti V, Marchini S, Luini A: Percutaneous transthoracic needle aspiration biopsy: a case report of implantation metastasis. Eur J Surg Oncol 1989; 1:179-183.
15. Cotran RS, Kumar V, Collins T: Robbins Pathologic Basis of Disease. Sixth edition, W.B. Saunders Co, Philadelphia 1999; pp260-329.
16. Seyfer AE, Walsh DS, Graeber GM, Nuno IN, Eliasson AH : Chest wall implantation of lung cancer after thin needle aspiration biopsy. Ann Thorac Surg 1989; 48:284-286.
17. Ryd W, Hagmar B, Eriksson O: Local tumour cell seeding by fine-needle aspiration biopsy. A semiquantitative study. Acta Path Microbiol Immunol Scand Sect A 1983; 91:17-21.
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Pinar Yaran, Ulku Yazici, Erkmen Gulhan, Irfan Tastepe, Funda Demirag, Guven Cetin, Bahadir Berktas. Value and Implantation Risk of Thin Needle Aspiration Biopsy in The Diagnostic Malign Pulmonary Lesions. J Clin Anal Med. 2010;1(3):8-12
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Occult Foreign Body; Mimicking Lung Cancer
Koray Aydoğdu 1, Göktürk Fındık 1, Leyla Sağlam 2, Sadi Kaya 1
1 Department of Thoracic Surgery, 2 Department of Chest Disease, Atatürk Chest Disease and Chest Surgery Training and Research Hospital, Ankara, Turkey
DOI: 10.4328/JCAM.10.3.21 Received: 24.09.2010 Accepted: 30.01.2010 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):57-59
Corresponding Author: Koray Aydoğdu, Department of Thoracic Surgery Atatürk Chest Disease and Chest Surgery Training and Research Hospital Ankara, Turkey. Phone : +090 312 355 21 10 Fax : +90 312 355 1 35 E-mail: dr.k.aydogdu@hotmail.com
We describe a case of chronical bronchial foreign body present- ing with cough, dyspnea and recurrent hemoptysis mimicking asthma, chronic bronchitis and lung cancer and undergoing sur- gical resection for diagnosis. Occult tracheobronchial foreign body aspirations are infrequently seen in adults. It may be un- detected for months to years as in our case. Sometimes it can mimic a lung cancer with an endobronchial lesion placed in the bronchus.
Keywords: Foreign Body, Aspiration, Lung Cancer.
Introduction
Tracheobronchial foreign body aspiration is a serious problem among all ages, especially in childhood. If it ca- uses a total airway obstruction, it may lead to asphyxia and it is unfortunately a cause of death in childhood. Ho- wever, it may be asymptomatic for many years or may present with nonspecific respiratory symptoms [1]. Early diagnosis is very important and bronchoscopy is the gold standard for diagnosis. If the diagnosis is in doubt, fle- xible bronchoscopy can be used to examine more distal parts of the bronchial tree because it excludes a foreign body more than rigid bronchoscopy. However, rigid bronc- hoscopy plays more role in extracting foreign bodies [2, 3].
Case
A 35 year old man submitted to our clinic with persistent cough, recurrent fever and intermittent haemoptysis sin- ce 2003. He was diagnosed as asthma and chronic bronc- hitis and treated with bronchodilator and antibiotic drugs for about two years. His symptoms were only slightly re- lieved but they did not subside.
On physical examination, he had ronchi on the right side of the chest and 37.5 centigrade fever. All the laboratory studies resulted normally except for leucocyte rise.
We planned computed tomography [CT] of the thorax and it showed right lower lobe bronchiectasis [Figure 1] and pulmonary artery was wider than normal but there was no thrombus in it. There were precarinal, subcarinal and right hilar calcific lymph nodes and a right sided pleural effusion. [Figure 2]. Fiberoptic bronchoscopy was perfor- med and an endobronchial lesion (EBL) was seen on the entrance of the right lower lobe bronchus and bronchoal- veolar lavage was taken and histopathological examina- tions yielded squamous metaplasia.
So it was doubtful whether the endobronchial lesion was malignant or not. Herein we planned a rigid bronchoscopy to utilize the EBL better. During rigid bronchoscopy we tried to obtain much more biopsy material but we could not manage, because it was as hard as bone. So we suspected whether it might be a foreign body or not.
With a detailed history we learned that, he had aspira- ted a tooth during extraction about 3 years ago which was thought to be swallowed and caused no symptoms of aspiration. His symptoms had begun about two or three months after the extraction of tooth and lasted for three years.
It was obvious that the reason of the symptoms and ra- diological findings was the aspirated tooth. So an opera- tion was planned. Right thoracotomy and right lower lo- bectomy was performed. The necessity of lobectomy was bronchiectasis that caused bronchial obstruction.
Discussion
Tracheobronchial foreign body aspiration is a common problem in childhood especially those below the age of 3 years and it is infrequently seen in adults [4]. In the adult population, such aspiration is most commonly secon- dary to unconscious accidental ingestion during general anesthesia, sedation, intoxication, seizures or neurologic disorders affecting the oropharynx. It was found that the foreign body aspiration resulting from dental surgery ac- cidents is more common in adults, so foreign body aspi- ration can occur in the absence of any predisposing factor.[5]. In fact, the factors predisposing to foreign body aspiration and the type of aspirated object are affected by geographic and cultural differences. Throughout the world, the types and aspiration ratios of aspirated fore- ign bodies change according to nutritional habits, socio- economic status, culture and the traditions and customs of the people [5]. The foreign bodies include stone, tooth fragments, bone fragments, nuts, seeds and needle. A comprehensive study carried out in Turkey showed that the most commonly aspirated foreign body is the turban pin, which is consistent with our experience during the fixation of the turban, the neck is extended and the pins are held between the lips. Meanwhile speech or laughter can cause the deep aspiration of the pin into the trache- obronchial system [2,3,5].
In adults, aspirated foreign bodies generally localize on the right bronchus because of the anatomic angle but it may be localized in both bronchi with the same ratio in child- ren.
Sometimes the parents or patients themselves easily no- tice the symptoms [6]. Clinical manifestations are nons- pesific. Main symptoms are cough, dyspnea and wheezing. Cough changes in character according to the movement of aspirated body, irritation and edema in the bronchus. On physical examination; dyspnea, stridor, wheezing, dec- reased or abnormal breath sounds and fever are the most common signs [1]. It can be misdiagnosed as asthma, chronic bronchitis, pneumonia or croup [1]. Sometimes it can mimic lung cancer [7,8,9]. Our patient had no history of aspiration symptoms after tooth extraction. When his complaints began, he was misdiagnosed as asthma and chronic bronchitis and treated with bronchodilator and antibiotic drugs for years. He underwent bronchoscopy twice and an EBL was seen and biopsy was performed.
With pathological studies it was diagnosed as lung can- cer. We performed rigid bronchoscopy to utilize EBL bet- ter. We recognised that it was a foreign body as hard as bone. So he underwent surgery.
For the diagnosis, radiological techniques such as posterior-anterior chest radiographs and CT can be used. If the diagnosis is in doubt, flexible bronchoscopy can be used to examine more distal parts of the bronchial tree. However, rigid bronchoscopy plays more role in extrac- ting foreign bodies [2,3].
The main complications and necessity of thorocotomy in forein body aspiration are generally pneumothorax, pneu- momediastinum, atelectasia, and lung abscess [10].
In conclusion, tracheobronchial foreign body aspiration may be asymptomatic or misdiagnosed as asthma and chronic bronchitis. Aspirated foreign body can lead to bronchiectasis with a bronchial obstruction. Finally bronc- hiectasis necessitates a thoracotomy and lobectomy.
References
1. T illiard T, Sim R, Saunders M, Hewer SL, Henderson J. Delayed diagnosis of foreign body aspiration in children. Emerg Med J. 2003;20(1):100-1.
2. Kiyan G, Uygun I, Karadag B, Tugtepe H, Iskit SH, Dagli TE. Foreign body aspiration in children,Kulak Burun Bogaz Ihtis Derg. 2004;12(5-6):128- 33.
3. Yilmaz A, Akkaya E, Damadoglu E, Gungor S. Occult bronchial foreign body aspiration in adults: analysis of four cases.Respirology. 2004;9(4):561-3.
4. Lai YF, Wong SL, Chao TY, Lin AS.Bronchial foreign bodies in adults.J Formos Med Assoc.1996;95(3):213-7.
5. Karapolat S, Foreign-body aspiration in an adult.Can J Surg. 2008;51(5):411; author reply 411-2.
6. Dikensoy O, Usalan C, Filiz A. Foreign body aspiration: clinical utility of flexible bronchoscopy.Postgrad Med J. 2002;78(921):399-403.
7. Ochmanski W, Krawczyk K. [Foreign body imitating bronchial neoplasm] Przegl Lek. 1997;54(1):70-2.
8. Nigam BK. Bronchial foreign body masquerading as a lung carcinoma. Indian J Chest Dis Allied Sci. 1990; 32 (1):43-7.
9. Sharma M, Lewis C, Lewis ME, Marzouk JF. Prawns masquerading as endobronchial tumours.Respiration. 2006;73(6):826-9.
10. Grigoriu BD, Leroy S, Marquette ChH. Tracheo-bronchial foreign bodies.Rev Med Chir Soc Med Nat Iasi. 2004; 108(4):747-52
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Koray Aydogdu, Gokturk Findik, Yetkin Agackiran, Leyla Saglam, Sadi Kaya. Occult Foreign Body; Mimicking Lung Cancer. J Clin Anal Med. 2010;1(3):57-59
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Thoracic Wall Necrotizing Fascitis in a Neonate: a Case Report
Serdar Onat, Alper Avcı, Refik Ulku, Menduh Oruç, Cemal Özçelik
Dicle University Faculty Of Medicine, Department of Thoracic Surgery, Diyarbakir, Turkey
DOI: 10.4328/JCAM.10.3.24 Received:27.11.2009Accepted: 07.01.2010 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):54-56
Corresponding Author: Alper Avcı, Dicle University School of Medicine, Department of Thoracic Surgery, 21280 Diyarbakır, Turkey. Phone: +90 412 2488001-16-4993 Fax: +90 412 2488520 E-mail: dralperavci@mynet.com
Necrotizing fasciitis (NF) is a rapidly progressive and potentially life-threatening infection of superficial fascia and subcutaneous tissue. Thoracic wall is one of the rarest locations for NF. Broad-spectrum antibiotics receiving, early surgical debridement, and skin grafting are life saving in NF. We report a 7-day-old female neonate who had left sided thoracic wall NF. She had undergone extensive surgical debridement within 4 hours of hospital ad-mission, and reconstruction of skin defect by split-thickness skin grafting later. Early diagnosis is important, as prompt surgical debridement offers the best chance for survival. Early and exten-sive surgical debridement is a widely accepted clinical approach and the mainstay of effective treatment. The goals of surgi-cal intervention are to remove all necrotic tissues, and to help control the progression of NF. Reconstruction of skin defects should be performed by early split-thickness skin grafting like our patient or primary closure. Because early wound resurfacing prevents fluid, electrolyte, and protein loss from the wound site, and decreases secondary infection. Although chest wall NF is rare in neonates, it is a rapidly spreading, highly lethal infection. A high index of suspicion, early diagnosis, and aggressive ap-proach are essential to its successful treatment.
Keywords: Chest Wall; Infant, Infection; Surgery, Emergency.
Introduction
Necrotizing fasciitis (NF) is a life-threatening, rapidly progressive and potentially life-threatening infection of the superficial fascia and subcutaneous tissues. It usually occurs in adults and is most often localized to the abdominal wall, the extremities, the perineum, the pelvis, and the thoracic region and it has been reported to be 0.008 per 100000 children per year [1]. Early diagnosis and prompt, aggressive surgical treatment including intravenous, broad-spectrum antibiotic therapy are mandatory to successfully control the disease. We report a case of thoracic NF in a 7-day-old girl who underwent successful immediate surgery and received prolonged intravenous antibiotic therapy.
Case
A 7-day-old female neonate was admitted to the pediatric emergency department with large skin infection. She was full term pregnancy baby, and healthy in the first three days of life. A small red skin swelling had occured in the thoracic wall at the 3rd day of life. Then this lesion grew over all the left hemithoracic wall rapidly, and colour became blue at the 6th day. At the first step examination of the patient; a skin defect of 2×3 cm diameter was seen in paramammarial area of the left side (Figure 1). Duration of illness before admission to hospital was 4 days. She had no history of omphalitis, or skin disease suggestive of obvious trauma to the thoracic wall. NF
developed spontaneously ( primary NF). Body weight was 3450g, arterial blood pressure was 80/40 mm Hg, pulse was 180 ,and the body temperature was 37.8° C. Irritability, rapid spreading inflammation, bluish-red discorolation, edema, and ulceration were the clinical examination findings. Abnormal blood count values were; white blood cell count of 3800 K/UL(4.4- 11.3 K/UL), a platelet count of 97000 K/ uL(142-424 K/uL), and a hemoglobin value of 8 g/dl (12.2-18.1 g/dl). Ceftriaxone and clindamycin were administered intravenous. She had no clinical evidence of any immune system defects.
Patient underwent extensive debridement surgery within 4 hours of hospital admission. During surgery the subcutaneous tissues were grayish and non-bleeding, stripping of necrotic tissues from superficial muscular fascia was easy, superficial fascia and superficial layer of underlying muscles were
edematous. Necrosis of subcutaneous tissue extended beyond the obvious limit of skin necrosis. All the nonviable tissue and skin were debrided until wound edges bleed freely (Figure 2).
Isolated bacteria from the necrotic tissue were Group A Beta-hemolytic streptococcus (S. pyogenes), and Staphylococcus aureus. Antibiotic chemotherapy was continued with ceftriaxone and clindamycin. The dressings were changed and the wound was inspected every days in the operating theatre.
Reconstruction of large skin defect was performed by split-thickness skin grafting at the 4th postoperative day (Figure 3).
The patient was discharged on the 9th postoperative day. At the 3rd month control, the surgical wound was fine. and the chest wall had normal expansion, the patient had no limitation of activity , and she was healthy without any symptoms.
Discussion
NF is a potentially life threatening infection of soft tissues [2]. It is characterized by rapid spread of inflammation and infection of subcutaneous tissues and fascia. NF is usually reported in adults with preexisting medical conditions or compromised immune system. It is rare in neonates, and the reported mortality is almost 50%. Less than 70 cases of neonate NF are reported in the literature [3]. We therefore would like to report this 7-day old female neonate with thoracic wall NF. Primary NF, which implies absence of a known initiating factor is rarely reported in neonates [3]. Presented case did not have any predisposing or initiaiting factor.
Unlike the adults in whom the extremites and perineum
are the most common sites, the disease tends to be located on the trunk in neonates for unknown reasons [4]. Occurence in the thoracic wall in any age is extremely rare, with only 20 published cases, and often fatal ( 60% of reported mortality) [4-6]. Early diagnosis is important, as prompt surgical debridement offers the best chance for survival. Early and extensive surgical debridement is a widely accepted clinical approach and the mainstay of effective treatment. The goals of surgical intervention are to remove all necrotic tissues, and to help control the progression of NF. Freischlag et al [7] reported a doubling of the mortality rate when operation was delayed by more than 24 hours. The survival of our case shows the importance of early surgery in NF. Kologlu et al [8] reported nonoperative treatment is a highly controversial and unsafe approach, when the patients developed NF with extensive involvement and marked skin necrosis. Keratinocyte allografts were found helpful in one case to manage an extensive skin defect[9].
Reconstruction of skin defects should be performed by early split-thickness skin grafting like our patient or primary closure. Because early wound resurfacing prevents fluid, electrolyte, and protein loss from the wound site, and decreases secondary infection. Reconstruction of large skin defect was performed by split-thickness skin grafting at the 4th postoperative day in the present case.
Conclusion
Although chest wall NF is rare in neonates, it is a rapidly spreading, highly lethal infection. A high index of suspicion, early diagnosis, and aggressive approach are essential to its successful treatment.
References
1. Wilson BL. Necrotizing fasciitis. Am Surg 1952; 18: 416-431.
2. Moss RL, Musemeche CA, Kosloske AM: Necrotizing fasciitis in children: prompt recognitionand aggressive therapy improve survival. J Pediatr Surg 1996; 31: 1142–1146.
3. Nazir Z. Necrotizing fesciitis in neonates. Pediatr Surg Int 2005; 21: 641-644.
4. Losanoff JE, Metzler MH, Richman BW, et al. Necrotizing chest wall infection after blunt trauma: case report and review of the litterature. J Trauma 2002; 53: 787-789.
5. Losanoff JE, Richman BW, Jones JW. Necrotizing soft tissue infection of the chest wall. J Cardiovasc Surg (Torino) 2002; 43: 549-552.
6. Frota Filho JD, Drews C, Leales P, et al. Postoperative necrotizing fasciitis of the thorax in cardiac surgery. Arq Bras Cardiol 2001; 76: 250-254.
7. Freischlag JA, Ajalat G, Busuttil RW. Treatment of necrotizing soft tissue infections: the need for a new approach. Am J Surg 1985; 149: 751-755.
8. Kologlu MB, Yıldız RV, Alper B, et al. Necrotizing fasciitis in children: diagnostic and therapeutic aspects. J Pediatr Surg 2007; 42: 1892-1897.
9. Necrotizing Fasciitis in a Neonate – The Role of Keratinocyte Allografts.Lee KH, Hahn WH, Park SS, Cho BS, Kim SD.Neonatology. 2009;7;96(1):19-22.
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Serdar Onat, Alper Avci, Refik Ulku, Menduh Oruc, Cemal Ozcelik. Thoracic Wall Necrotizing Fasccitiss in a Neonate: a Case Report. J Clin Anal Med. 2010;1(3):54-56
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Thyroid Nodule Demonstrating Itself as Calcified Lung Lesion
Ediz Yorgancılar, Müzeyyen Yıldırım, Ramazan Gün, Faruk Meriç, İsmail Topçu
Kulak Burun Boğaz Baş ve Boyun Cerrahisi Anabilim Dalı, Dicle Üniversitesi Tıp Fakültesi, Diyarbakır, Türkiye
DOI: 10.4328/JCAM.10.3.25 Received:13.12.2009 Accepted: 22.12.2009 Printed: 01.09.2010 J.Clin.Anal.Med.2010;1(3):51-53
Corresponding Author: Ediz Yorgancılar, Kayapınar Mah. Altın-1 Sitesi, B-Blok, No:6, 21120, Diclekent, Diyarbakır, Türkiye. Phone: +904122488001/4543 E-mail: edzyrg@hotmail.com
Multinodular goiter (MNG) is the most prevalent thyroid pathol-ogy. Thyroid gland enlarge as a result of MNG, the initial exten-sion is typically outward. After this cervical enlargement, expan-sion may extend in to the mediastinum. As substernal goiters enlarge within the mediastinum, vascular and visceral structures may slowly became compressed. The most common symptoms of substernal goiter result from compression of the trachea and/or esophagus and include dyspnea, choking sensation, cough, and dysphagia. Progressive hoarseness and superior vena cava syndrome are less common symptoms. Substernal goiters can remain asymptomatic for many years and it may be diagnosed incidentally. For example, routine chest radiography may reveal a mediastinal mass or tracheal deviation. Many authors have advocated surgical removal of all substernal goiters, even when these goiters are asymptomatic. In this article, we report a case of substernal MNG which demonstrating itself as a nodular cal-cification on chest X-Ray radiography.
Keywords: Substernal Goiter, Calcific Lung Nodule.
Giriş
Guatr dünya çapında yaklaşık % 5 oranında görülen ol- dukça sık bir tiroid bezi hastalığıdır. Büyük kısmı boyunda yerleşmesine rağmen % 3-%17 arasında değişen oranlar- da toraksa uzanım gösterebilir. Toraksa uzanan guatrlar substernal, intratorasik,retrosternal guatr adını alır [1]. Substernal guatr ilk olarak 1749 yılında Haller tarafından tanımlanmıştır. Primer substernal guatr, vasküler pedikülü intratorasik orijinli olan ektopik intratorasik tiroid doku- sundan kaynaklanır. Sekonder substernal guatr ise vaskü- ler orijini servikal kökenli olan ve daha sık görülen servikal guatrdan kaynaklanan tip substernal guatrdır [2]. Katlic ve ark. [3] substernal guatrı, büyük kısmı torasik girişin in- feriorunda olan guatr olarak tanımlamışlardır. Substernal guatrlar, genelde ön mediastene yerleşirler ama %10-25 oranında arka mediastene de uzanabilirler [4].
Tanıda fizik muayene, ultrasonografi, direk grafi, bilgisa- yarlı tomografi(BT), manyetik rezonans görüntüleme(MRG) ve tiroid sintigrafisi kullanılabilir. Radyolojik görüntüleme hastaların tanısında önemli bir basamaktır. Bu makale- de fizik muayene ile tespit edilemeyen sadece arka-ön akciğer grafisinde (PAAG) kalsifiye lezyon olarak kendini gösteren asemptomatik sekonder substernal guatr olgu- su sunulmuştur.
Olgu
Ellisekiz yaşında bayan hasta, yaklaşık 4 aydır ortaya çı- kan boyunda şişlik şikayetiyle kliniğimize başvurdu. Hasta- nın özgeçmiş ve soygeçmişinde özellik yoktu. Kulak burun boğaz muayenesinde boyunda tiroid bezi lokalizasyonun- da multipl nodüller tespit edildi. Boyun ultrasonografi- sinde multinodüler guatr ile uyumlu bulgular rapor edildi. Tc99m tiroid sintigrafisi, multinodüler guatr ile uyumluydu ve substernal ilerleme olmadığı rapor edilmişti. PAAG’de sol akciğerde aort topuzu üst kısımında yaklaşık 2×2 cm boyutlarında kalsifiye lezyon tespit edildi (Resim 1). Bilgi- sayarlı tomografide lezyonun tiroid bezi ile yakın ilişkili olduğu rapor edildi. Hastanın servikal bölgedeki nodülle- rinden alınan ince iğne aspirasyon biyopsisi benign sitoloji olarak rapor edildi. Hastaya genel anestezi altında total tiroidektomi operasyonu uygulandı (Resim 2). Operasyon sırasında sol tiroid alt lobuna bağlantılı olarak substernal alana uzanan çok sert, tamamıyla kalsifiye olmuş nodül tespit edilerek spesmenle birlikte çıkarıldı (Resim 3). Rekürren laringeal sinir ve paratiroid glandlar her iki tarafta disseke edilerek korundu (Resim 4). Postoperatif dönem- de herhangi bir problem saptanmadı. Hastanın 12 aylık takibinde herhangi bir nükse rastlanmadı.
Tartışma
Substernal guatr insidansı % 3 ile 17 arasında değişmek- tedir. Erbil ve ark. [5] 2650 multinodüler guatr hastasında %6,4 oranında substernal guatr tespit etmişlerdir.
Klinik olarak trakea, özefagus ve mediastinal vasküler yapılara bası yaparak disfaji, dispne, öksürük, ses kısıklığı, süperior vena cava sendromu oluşturabilir. Değişik çalışmalarda % 5 ile %50 arasında değişen oranlarda asemptomatik olabileceği de bildirilmiştir [4, 6]. Sunulan olguda substernal uzanıma bağlı herhangi bir semptom tespit edilememiştir.
Tiroid dokusu progresif olarak büyüdüğü zaman en az di- renç inferiorda olduğundan büyüme aşağıya toraks içine doğru olur. Guatr ağırlığı, yutkunma ve solunum hareket- leriyle olan intratorasik basınç da büyümenin toraks içine olmasında rol oynar [2]. Sunulan olguda toraks içine uzanan nodül ileri derecede kalsifiye olduğundan öncelikle ağırlık sebebiyle toraks içine uzanmış olabilir. İntratorasik uzanımı olan guatrlarda bazen toraks içine uzanan kısım ile servikal guatr arasındaki bağlantı incelir ve fibrotik bant ve vasküleri bir pediküle dönebilir. Bu pedikül bası ile sıkıştığından tiroid sintigtrafisinde nodül radyoaktif madde tutmayarak görünemeyebilir [2]. Bu da yanlış tanıya sebep olabilir. Olgumuzda tiroid sintigrafi- sinde nodül saptanamamıştır. Bunun sebebi nodülün pedikülünün basıya uğraması olabileceği gibi, ileri derecede kalsifiye olması da olabilir.
Substernal guatr tanısında radyolojik incelemeler önemli rol alır. Tanıda ultrason sınırlı yere sahiptir. Ancak PAAG önemli rol oynar [7, 8]. Mediastinal yapıların deplasmanı yanında üst mediastene ve üst akciğer loblarına lokalize her türlü lezyon substernal guatrı düşündürmelidir. Ol- gumuzda substernal nodül akciğer parankiminde kalsifik nodüler lezyon olarak gözlenmiş ve şüphe üzerine tes- pit edilmiştir. Substernal guatr tanısında en değerli tanı aracı bilgisayarlı tomografidir [9]. Ancak her olguda BT veya MRG yapılması gerekli değildir. Sanders ve ark. [10]
preoperatif dönemde sadece % 15 hastaya BT veya MRG yapmışlardır. Erbil ve ark. [5] preoperatif %35 oranında BT ve ya MRG yapmışlar ve sadece solunumsal bulguları olan hastalarda bu tetkiklere gerek duyduklarını bildir- mişlerdir. Bu sebeple şüphe duyulan hastalarda serviko- torasik BT istenmeli ve rapor öncesi radyolog bu konuda bilgilendirilmelidir.
Substernal guatrın tedavisi cerrahidir. Substernal gu- atrların histopatolojik incelemesinde % 7-20 oranları arasında değişen oranlarda malignite riski vardır[5]. Olguların büyük kısmı servikal yolla çıkarılabilir. Servikal in- sizyondan sonra tiroid gland ortaya konmalı, önce orta tiroid ven ve inferior tiroid arter bağlanmalı ve künt di- seksiyonla substernal kısım doğurtulmalıdır. Bu safhada venöz göllenmeden dolayı şiddetli venöz kanama olabilir. Kanama olsada öncelikle substernal kısım doğurtularak venöz göllenme azaltılır ve kanama kontrol altına alınabilir. Kitlenin disseksiyonu sırasında plevra zedelenmesine bağlı pnömotoraks gelişebilir. Substernal uzanan kitle re- kürren laringeal sinirin anatomik seyrini değiştirebilir ve bu değişiklik sebebiyle sinir disseksiyon sırasında zede- lenebilir. İleri derecede inferiora uzanan ve yapışıklıkları olan olgularda sternotomi gerekebileceği akılda tutulmalı ve göğüs cerrahisi görüşü preoperatif dönemde mutlaka alınmalıdır.Ancak sternotomi hastada mortalite ve mor- biditeyi artırmaktadır [11, 12]. Olgumuz servikal yolla ve parmak diseksiyonla çıkarılmış ve herhangi bir komplikasyon oluşmamıştır.
Sonuç olarak guatr cerrahisi yapan kliniklerde her guatr olgusunda substernal uzanımı olan guatr olabileceği akıl- da tutulmalı ve preoperatif dönemde direk grafiler dahil olmak üzere yapılan her tetkik özenle değerlendirilmelidir. Bu şekilde preoperatif dönemde substernal uzanan guatr saptanması cerraha operasyon sırasında hazırlıklı olması- nı sağlayacak ve hastada oluşabilecek morbidite ve mor- taliteyi azaltacaktır.
Kaynaklar
1. Mack E. Management of patients with subster- nal goiters. Surg Clin North Am 1995;75:377- 394.
2. Yılmaz C. Tiroid ve Paratiroid Hastalıkları ve Cerrahisi,2005: Nobel Tıp Kitabevi,3.Baskı; 423- 438.
3. Katlic MR,Wang C,Crillo HC.Substernal Goiter. Ann Thorac Surg. 1985;39:391-9.
4. Madjar S,Weissberg D. Retrosternal Goiter. Chest. 1995;108:78-82.
5. Erbil Y, Bozbora A, Barbaros U, Ozarmağan S, Azezli A, Molvalilar S. Surgical management of substernal goiters: clinical experience of 170 cases.Surg Today. 2004;34(9):732-6.
6. Singh B, Lucente FE, Sahara ATR.Subster- nal goiter: a clinical review.Am J Otolaryngol. 1994;15:409-16.
7. Ben Nun A, Soudack M, Best LA. Retrosternal thyroid goiter: 15 years experience. Isr Med As- soc J. 2006;8(2):106-9.
8. Buckley JA,Stark P.Intrathoracic mediastinal thyroid goiter. AJR. 1999;173:471-5.
9. Ayache S, Mardyla N, Tramier B, Strunski V. Clinical signs and correlation with radiological extent in a series of 117 retrosternal goitre. Laryngol Otol Rhinol. 2006;127(4):229-37.
10. Sanders LE,Rossi RL,Shahian DM. Mediastinal goiters: The need for an aggressive approach. Arch Surg. 1992;127:609-13.
11. Pieracci FM, Fahey TJ 3rd Substernal thyroi- dectomy is associated with increased morbi- dity and mortality as compared with conven- tional cervical thyroidectomy.J Am Coll Surg. 2007;205(1):1-7.
12. Sciumè C, Geraci G, Pisello F, Li Volsi F, Facella T, Modica G. Substernal goitre. Ann Ital Chir. 2 005;76(6):517-21.
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Ediz Yorgancilar, Muzeyyen Yildirim, Ramazan Gun, Faruk Meric, Ismail Topcu . Thyroid Nodule Demonstrating Itself as Calcified Lung Lesion. J Clin Anal Med. 2010;1(3):51-53
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Bilateral Elastofibroma Dorsi: a Case Report
Burçin Çelik 1, Oğuz Aydın 2, Ömer Serdar Bekdemir 1, Cemgil Diren Öztürk 1
1 Göğüs Cerrahisi Anabilim Dalı, 2 Patoloji Anabilim Dalı, 19 Mayıs Üniversitesi Tıp Fakültesi, Samsun, Türkiye
DOI: 10.4328/JCAM.10.3.23 Received: 24.11.2009 Accepted: 23.12.2009 Printed: 01.09.2010 J.Clin.Anal.Med. 2010;1(3):48-50
Corresponding Author: Burçin Çelik, 19 Mayıs Üniversitesi Tıp Fakültesi Göğüs Cerrahisi AD, Kurupelit, 55139, Samsun, Türkiye. Phone: +90 362 312 19 19/2701 Fax: +90 362 457 60 41 E-mail: cburcin@hotmail.com
Elastofibroma dorsi is a rare, slow-growing soſt tissue tumor of the chest wall. The tumor typically located under the lower pole of the scapula. A 57-year-old woman who had retired as a teacher, presented with a 1-year history of pain on the back and with a 3-month history of swelling located under the leſt scapula. Computed tomography and magnetic resonance imaging showed bilateral, solid soſt tissue tumors under the scapula. She underwent total resection of the tumor on the leſt side. Tumor was diagnosed histopathologically as elastofibroma. Elastofibroma dorsi can be undetermined because of its localization. Radiological examination is important especially on diagnosis of bilateral localization.
Keywords: Elastofibroma, Bilateral, Diagnosis, Chest Wall Tumor.
Giriş
Elastofibroma dorsi (EFD), sıklıkla göğüs duvarının sub- skapüler bölgesinde görülen, kapsülsüz, yavaş büyüyen, fibröz dokunun elastin komponentinin proliferasyonu ile karakterize bir yumuşak doku tümörüdür. Etiyolojinin çok faktörlü olduğu belirtilmektedir. Genellikle 4. – 6. dekattaki bayanlardagörülürveolguların%10’undatümörbilateraldir. Hastaların yarısı asemptomatik olup, semptomatik hastalar genellikle hareketle artan omuz ve sırt ağrısından şikayetçidir [1–5]. Burada nadir görülen bir tümör olması, bilateral olması ve kolay gözden kaçabilmesi nedeniyle bir EFD olgusunu sunmayı amaçladık.
Olgu
Elli yedi yaşında, öğretmen emeklisi olan bayan hasta 1 yıldır olan, hareketle artan sol omuz ve sırt ağrısı ve son 3 aydır sol skapula altında şişlik şikayeti ile kliniğimize başvurdu. Hasta daha önce birçok kere doktora başvurduğunu ancak sadece ağrıya yönelik medikal tedavi verildiğini ve bu tedavilerden fayda görmediğini belirtti. Fizik muayenede sol infraskapüler bölgede 7x5cm ebadında, hareketli, yarı sert kıvamda, omuz hareketi ile belirginleşen ve “click” sesi duyulan kitle palpe edildi. Bilgisayarlı tomografide (BT) solda 8×7 cm ebadında, sağda 5×3 cm ebadında skapula ile göğüs duvarı arasında yerleşmiş yumuşak doku dansitesinde iki adet lezyon izlendi. Toraks manyetik rezonans görüntülemede (MRG) aynı boyutlarda, heterojen dansitede, düzgün konturlu, içersinde kas liflerine ait çizgilenmeler bulunan bilateral yumuşak doku lezyonları izlendi (Resim 1). Ameliyat öncesi yapılan laboratuar tahlillerinde herhangi bir patolojiye rastlanmadı. Tanı ve tedavi amacıyla planlanan cerrahi girişimde sol hemitorakstakikitleyeüzerindenyapılaninsizyonilelatissimus dorsi kasları geçilerek ulaşıldı. Kitlenin göğüs duvarına sıkı bir şekilde tutunduğu ve skapula altına doğru uzandığı tespit edildi. Kitleden insizyonel biyopsi alınarak frozen section çalışıldı, patoloji sonucu benign lezyon gelmesi üzerine kitle total olarak eksize edildi (Resim 2). Postoperatif
2. günde taburcu edilen hastanın kesin patolojik tanısı elastofibroma olarak rapor edildi. Histopatolojik tanı için hazırlanan kesitlerde, yer yer hyalinize kollajen ve arada yağ dokusu adalarından oluşan bir zeminde çok sayıda dejenere elastik lifler izlendi ve bu elastik lifler Verhoeff elastica ile boyanarak gösterildi (Resim 3 ve 4). Sağ hemitorakstaki kitlenin de radyolojik olarak EFD ile uyumlu olması, hastanın asemptomatik olması ve kendi isteği ile ileri bir tarihte kitlenin eksize edilmesine karar verildi.
Tartışma
Elastofibroma ilk olarak Järvi ve Saxén [6] tarafından 1961 yılında tanımlanmıştır ve göğüs duvarının diğer yumuşak doku tümörleri ile karışabilen bir tümördür. Yavaş bir büyüme gösterir ve kapsülsüz olduğu için çevre dokularla sınırı net olarak ayırt edilemez. Etiyolojisinin çok faktörlü olduğu belirtilmektedir. İlk dönemlerde skapulanın göğüs duvarına sürtünmesi ile meydana getirdiği travmaya bağlı geliştiği düşünülürken, son yayınlarda genetik dispozisyon, enzim defekti gibi nedenlerden bahsedilmektedir [1, 2, 5]. Asemptomatik yaşlı hastalarda yapılan toraks BT incelemelerinde elastofibroma prevalansı %2 olarak bildirilmiştir [7]. Yine otopsi çalışmalarından birisinde 55 yaş üzeri olgularda prevalans oranı kadınlarda %24, erkeklerde %11 olarak bildirilirken, diğer bir çalışmada ise elastofibroma oranı %13 bildirilmiştir. Kadınlarda erkeklere oranla 13 kat daha sık görülmektedir ancak kadınlardaki bu sıklığın nedeni bilinmemektedir [8, 9]. Vakaların %90’ından fazlasında lokalizasyon subskapüler bölgede, rhomboid ve latissimus dorsi kasları ile göğüs duvarı arasındadır. Bu lokalizasyon dışında; ayak, el, deltoid, aksilla, olekranon, mide, göz, inguinal bölge ve büyük omentumda da tespit edildiği bildirilmiştir. EFD genellikle sağ hemitoraksta izlenmekle birlikte olguların %10’unda bilateraldir [1–5]. Olguların %50’si asemptomatiktir ve bu olgularda kitle rastlantısal olarak tespit edilir. Semptomatik olan olgularda en sık semptom skapula bölgesinde ağrı ve sırtta şişliktir [1,2,10]. Tanıda göğüs grafisi, ultrasonografi, BT ve MRG kullanılmaktadır. Bilgisayarlı tomografide heterojen yumuşak doku kitlesi şeklinde izlenmektedir ve çevre dokulardan sınırının ayırt edilmesi zordur. Manyetik
rezonans görüntülemede, kasa benzer yoğunlukta, yağ dokusuna ait opasiteler içeren yumuşak doku kitlesi şeklindedir ve T1 ve T2 ağırlıklı incelemelerde karakteristik bulgular verir [3,5,11]. Ayırıcı tanıda göğüs duvarı yerleşimli birçok malign ve benign tümör (lipoma, fibroma, schwannoma, desmoid tümör, hemanjiyoma, sarkom) akla gelmelidir ve kesin tanı için histopatolojik inceleme gereklidir [1–5].
EFD’nin kesin tanısı ve tedavisi için gereken tümörün komplet eksizyonudur. Tümör fonksiyonel yetersizliğe neden oluyor, bası bulguları var, ağrı ve göğüs duvarında şişliğe neden oluyor ve tümörün çapı 5 cm’i aşıyor ise eksize edilmelidir. 5 cm’den küçük ve asemptomatik olan lezyonlarda cerrahi tedavi uygulanmadan hasta takibe alınabilinir. Cerrahi komplet eksizyon sonrası literatürde bir vaka dışında nüks izlenmemiştir, tümörün malign transformasyon göstermediği belirtilmektedir [1–5]. Literatür ile uyumlu olarak olgumuzda bilateral EFD saptanmıştır. Meslek açısından olgumuzda etiyolojide bahsedilen kronik travmayı düşünebiliriz. Uzun dönem süren ve medikal tedavi ile gerilemeyen ağrı şikayeti olgumuzda radyolojik görüntülemeyi gerektirmiş ve bu sayede tümörün bilateral olduğu tespit edilmiştir. Olgumuzda komplet eksizyon ile hem tanıya ulaşılmış hem de tedavi edilmiştir.
Elastofibroma dorsi nadir bir göğüs duvarı tümörü olması ve fizik muayenede kolaylıkla gözden kaçabilmesi nedeniyle kronik sırt ağrısı bulunan hastalarda ayırıcı tanıda düşünülmeli, radyolojik olarak araştırılmalı ve bilateral olabileceği akılda tutulmalıdır. Tanı ve tedavisinde kitlenin total olarak eksizyonu yeterlidir.
Kaynaklar
1. Kılıç D, Şahin E, Fındıkçıoğlu A, ve ark. Bilateral elastofibroma dorsi. Toraks Derg 2007;8:52–54.
2. Darçın OT, Öztürk A, Özardağ İ, ve ark. Bilateral elastofibroma dorsi: Olgu sunumu. Türk Göğüs Kalp Damar Cer Derg 2004;12:199–201.
3. Köksel O, Özdülger A, Özer C, ve ark. Bilateral elastofibroma dorsi: Olgu sunumu. Türk Göğüs Kalp Damar Cer Derg 2005;13:279– 282.
4. Turna A, Yılmaz MA, Ürer N, et al. Bilateral elastofibroma dorsi. Ann Thorac Surg 2002;73:630–632.
5. Kourda J, Ayadi-Kaddour A, Merai S, et al. Bilateral elastofibroma dorsi. A case report and review of the literature. Orthop Traumatol Surg Res 2009;95:383–387.
6. Järvi OH, Saxén AE. Elastofibroma dorsi. Acta Pathol Microbiol Scand 1961;144:83.
7. Brandser EA, Goree JC, El-Khoury GY. Elastofibroma dorsi: prevalence in an elderly patient population as revealed by CT. Am J Roentgenol 1998;171:977–80.
8. Järvi OH, Lansimies PH. Subclinical elastofibromas in the scapular region in an autopsy series. Acta Pathol Microbiol Scand 1975;83:87–108.
9. Giebel GD, Bierhoff E, Vogel J. Elastofibroma and pre-elastofibroma – a biopsy and autopsy study. Eur J Surg Oncol 1996;22:93–96.
10. Kara M, Dikmen E, Kara SA, et al. Bilateral elastofibroma dorsi: proper positioning for an accurate diagnosis. Eur J Cardiothorac Surg 2002;22:839–841.
11. Malghem J, Baudrez V, Lecouvet F, et al. Imaging study findings in elastofibroma dorsi. Joint Bone Spine 2004;71:536–541.
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Burcin Celik, Oguz Aydin, Omer Serdar, Bekdemir, Cemgil Diren Ozturk. Bilateral Elastofibroma Dorsi: A Case Report. J Clin Anal Med. 2010;1(3):48-50
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Thoracic Esophageal Perforation After Blunt Trauma in a Child: A Delayed Diagnosis and Surgical Management
Alper Avcı, Sevval Eren, Bulent Ozturk
Thoracic Surgery Department, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
DOI: 10.4328/JCAM.10.3.22 Received: 14.11.2009 Accepted: 11.12.2009 Printed: 01.09.2010 J.Clin.Anal.Med. 2010;1(3):44-47
Corresponding Author: Alper Avcı, Dicle University School of Medicine, Department of Thoracic Surgery, 21280, Diyarbakır, Turkey. Phone: +90 412 2488001-16 4993 Fax : +90 412 2488520 E-mail: dralperavci@mynet.com
Esophageal rupture due to external blunt trauma is extremely rare in children. A-13-year old boy was admitted to emergency room with shortness of breath and abdominal pain. His history revealed fall down from 3 metres height, falling of a wooden block over chest, 4 hours before at home. Thoracic esophageal perforation was diagnosed at the 6th day of hospital stay. Surgical management was planned and right-sided thoracotomy was performed at the 7th day after admission. The esophageal layers were closed primarily and separately after muscular and mucosal debridement. Reinforcement of the primary repair was done with pleural and intercostal muscle flaps. The esophagus was tied with absorbable sutures at proximal and distal parts of the perforation to block the esophageal passage. Gastrostomy and jejunostomy were performed for nutrition. We report here a successful management with primary repair of this esophageal perforation of late diagnosis.
Keywords: Esophageal Rupture, Child, Thoracic Injury, Surgery.
Intraduction
The most common causes of esophageal injuries in children are ingestion of caustic liquids and penetrating trauma, which includes iatrogenic instrumentations [1]. External blunt trauma to chest can also cause esophageal injury, though rarely. The incidence of esophageal perforation due to all blunt chest injury in children is <1% [2]. The number of cases of esophageal perforation from blunt trauma reported in the literature is less than 100. Overall mortality of esophageal perforation is about 25% [3]. Traumatic gastro-esophageal perforations are rare, and their mortality is high in children ( up to 60%) [4]. Any delay in diagnosis beyond 24 hours can increase infectious complications. Delayed diagnosis and treatment are most important predictors in mortality of esophageal perforations. Successful management of esophageal perforations requires prompt and accurate diagnosis and treatment. We report a child whose diagnosis was made 6 days after the blunt chest trauma.
Case
A-13-year old boy was admitted to emergency room with shortness of breath and abdominal pain. His history revealed fall down from 3 metres height, falling of a wooden block over chest, 4 hours before at home. On admission, the patient had a pulse of 122/min, was afebrile and the respiratory rate was 32/min. At initial clinical exam, auscultation revealed no audible breath sounds in the lower parts of the right side of the chest, and the abdomen was painful. The rest of the systemic examination was normal. White blood cell count was 21.1 K/UL (4.4-11.3). Plain radiography of neck and chest revealed right-sided hydrothorax ( Figure 1 ). Hemothorax was diagnosed after thoracentesis, and chest tube was inserted into right pleural space. Drainage of the chest was 150 cc initially. There was blood in nasogastric tube. Radiological examination of the abdomen was normal. The patient was hospitalized into thoracic surgery clinic’s intensive care unit. Broad-spectrum antibiotic treatment was started. Abdominal pain disappeared and there was no blood left in the nasogastric drainage at the second day. Nasogastric tube was removed at the third day and oral feeding was started. Chest tube was removed at the 4 th day. Fever of 38.8 centigrade degree was noted at the 5 th day. Despite treatment including broad-spectrum antibiotics, patient’s fever persisted and his white blood cell count continued to rise. Thoracic Magnetic Resonance Imaging was obtained, and it showed right sided pleural effusion, of 8x5x2 cm diametered right paravertebral pus ( Figure 2A and 2B ). Esophagography was obtained with diluted oral contrast, and right-sided thoracic esophageal perforation was diagnosed( Figure 3 ) at the 6th day of hospital stay. Oral feeding was stopped, chest tube and nasogastric tube were reinserted, and total parenteral nutrition was started. Staphylococcus warnei grew in the blood culture, and antibiotherapy was changed. Despite
all efforts, fever, high level of white blood cell count persisted. Surgical management was planned to control septic origin and effective dranaige of pleural space. Right- sided thoracotomy was performed at the 7th day of the hospital stay. Esophageal perforation of 7 cm length was seen between azygous vein and diaphragm There was no emphyema thoracis. Primary closure of the esophageal perforation was planned intraoperatively. The layers were sutured primarily and separately after muscular and mucosal debridement. Reinforcement of the primary repair was done with pleural and intercostal muscle flaps. The esophagus was tied with absorbable catgut sutures at proximal and distal parts of the perforation to block the esophageal passage. Chest tubes were placed for drainage. Gastrostomy and jejunostomy were performed for nutrition. Chest tube drainage yielded Pseudomonas aeroginosa growth during the postoperative course. Vital signs became normal at the 10 th day of postoperative course. Chest tubes were ended at the postoperative 9 th and 18 th days. Oral feeding was started at the postoperative 25 th day after esophagography revealed normal esophageal passage ( Figure 4 ). Patient was discharged home at the 42nd day of the hospital stay ( 35 th day of the postoperative course). He was well at 8 week follow-up postoperatively.
Discussion
Esophageal perforations are the most fatal injuries of the alimentary tract. The majority of blunt esophageal injuries involve the cervical esophagus with intrathoracic esophageal injuries, which are rare. The majority of the intrathoracic esophageal perforation from blunt trauma occurs in adults, as a result of high-speed motor vehicle accidents [2-4]. Thoracic esophageal perforation is a closed space where an infection is more diffucult to treat and can rapidly lead to mediastinitis and sepsis. Some diagnoses are only made at autopsy [5]. The present case had intrathoracic esophageal perforation secondary to blunt trauma. Despite high morbidity and mortality rates, we report a case of successful management.
Diagnosis of an esophageal injury is extremely diffucult following thoraco-abdominal trauma. The perforation is often non-specific and is easily confused with other disorders. The signs and symptoms of the perforation depend on the location, the cause of the trauma. Major symptoms and clinical signs include pain, subcutaneous air, dysphagia, dyspnea, and blood in the nasogastric tube [6]. However, these signs and symptoms have lack specifity in blunt trauma patients. Computed chest tomography helps to diagnose. Diagnosis is confirmed by using contrasted esophagogram or endoscopy or both. Early diagnosis is essential in esophageal perforation. However, in our case, the early diagnosis could not be achieved.
Treatment options include medical or surgical interventions. Various factors have important impacts on the treatment approach. These are as follows: the cause and the location of the perforation, the presence of underlying esophageal disease, the time interval between the perforation and diagnosis, and the age and general status of the patient. Primary closure within 24 hours is the most effective method of treating esophageal perforation. Surgical management must be individulized according to the size of the defect, degree of inflammation, contamination and the overall condition of patient [1-6]. Kiernan reported that early diagnosis (<24 h) combined with aggressive surgical treatment showed a hospital survival of 93% while late diagnosis (>24 h) increased mortality (30%), but even when diagnosis was >24 h the mortality was decreased to 10% when combined with surgery [7]. Surgical interventions may
include an esophageal resection or exclusion, debridement, esophageal repair, reinforcing the repair using adjacent tissues, drainage, diversion and nutrition when possible are key of healing in esophageal injuries.
In our case, despite delayed diagnosis, surgical interventions included debridement, primary repair of the esophageal perforation, blocking esophageal passage with absorbable sutures, reinforcing the repair with pleura and intercostal muscle, drainage and feeding via gastrostomy and jejunostomy were all successful factors in the management.
In conclusion, esophageal rupture due to external blunt trauma is extremely rare in children. Physicans should pay attention to esophageal injury in blunt thoraco-abdominal trauma. Despite delayed diagnosis, primary surgical repair has a significant role in the successful treatment as in our patient.
References
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7. Kiernan PD, Sheridan MJ, Elster E, Rhee J, Collazo R, Byme WD. et al. Thoracic esophageal perforations. Southern Med J 2003; 96: 158-63.
Download attachments: KATD-117.pdf
Alper Avci, Sevval Eren, Bulent Ozturk . Thoracic Esophageal Perforation After Blunt Trauma in a Child: A Delayed Diagnosis and Surgical Management. J Clin Anal Med. 2010;1(3):44-47
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Perfusionist Education in Turkey and in the World
Aydın Bilgili, Türker Şahin, Adem Güler, Harun Tatar
GATA Kalp Damar Cerrahi Kliniği, Etlik, Ankara, Türkiye
DOI: 10.4328/JCAM.10.3.41 Received: 04.03.2010 Accepted: 17.03.2010 Printed: 01.09.2010 J.Clin.Anal.Med. 2010;1(3).60-62
Corresponding Author: Adem Güler, GATA Kalp Damar Cerrahi Kliniği, Etlik, Ankara, Türkiye. Phone: +90 312 304 52 71 GSM: +90 506 531 91 11 E-mail: drademguler@gmail.com
Perfüzyonistler kalp cerrahisi içerisinde aldıkları sorumlulukları nedeniyle önemli bir yere sahiptirler. Açık kalp ameliyatlarında uygulanan kardiyopulmoner baypas desteği ameliyatın başarısını ve hastanın iyileşme sürecine etki eden kriterlerden biridir. Açık kalp ameliyatları günümüzde birçok merkezde uygulanır hale gel-miş ve buna paralel olarak perfüzyonist sayısında önemli derece-de artış olmuştur. Böyle önemli bir görevi üstlenen ve hastanın direkt olarak yaşamsal fonksiyonlarına etki edebilecek perfüz-yonistlerin eğitim düzeyleri çok farklılık göstermektedir. ABD ve Avrupa ülkeleri ile karşılaştırıldığında Türkiye’de perfüzyon eğiti-mi ile ilgili bir standart mesleki bir tanım bulunmamaktadır. Bu ülkelerde perfüzyonistliğin tanımı yapılmış ve belirli standartlar konularak eğitim kalitesinin sürekliliği amaçlanmıştır. Günümüz Türkiye’sinde perfüzyon eğitimi usta çırak ilişkisine dayanmakta-dır. Perfüzyonistler vaka başında bilgi ve becerilerini geliştirmeye çalışmaktadırlar. Kaliteli ve güvenli bir perfüzyon uygulaması için akademik eğitim almış sorumluluklarını bilen perfüzyonistlere ih-tiyaç duyulmaktadır. Anahtar
Keywords: Perfüzyonistlerin Eğitimi; Kardiyopulmoner Bypass; Türkiye.
Giriş
Küreselleşmeyle beraber gelen yenidünya düzeninde perfüzyon uygulaması alanında uluslararası kurallar ve standartlar geliştirilmesi ve bunlara uyulması kaçınılmaz hale gelmiştir. Kalp damar cerrahisi alanındaki hızlı gelişmelerin doğurduğu nitelikli insan kaynağı eksikliği ve eğitim sistemleri arasında işlevsel bir işbirliği olmaması ciddi sorunlar oluşturmaktadır. Bu sorunların aşılabilmesi için uluslararası standartlara göre hazırlanmış bir mesleki sınıflandırma ve seviyelendirme sisteminin hazırlanması gereklidir. Bu sistemin sağlayacağı ilkeler doğrultusunda eğitim programları oluşturulmalıdır. Türkiye’nin Avrupa Birliği uyum çalışmaları sürecinde tamamlaması ger- eken meslek tanımları çalışması işverenlere, çalışanlara ve eğitimcilere çeşitli yararlar sağlayacak ve perfüzyon- istlerin Avrupa Birliği ve diğer ülkelerde, o ülkelerin vatandaşları ile eşit şartlarda çalışabilmelerine olanak sağlayacaktır. Günümüz Türkiye’sinde perfüzyonistin mesleki tanımı yapılmamıştır.
ABD ve Avrupa ülkelerinde yapılan perfüzyonist mesleki tanımı değişkenlik gösterse de genel tanımlama şöyledir; ekstra korporeal sirkülasyon gerektiren kalp ve büyük damarlarda yapılacak müdahalelerde cerrah ve anestezist ile işbirliği yaparak operasyonun yapılabilmesi için kardi- yopulmoner sistemi izole edip ekstra korporeal dolaşım sistemini (Kalp-Akciğer Makinesi ve bileşenleri) kullanarak perfüzyon görevini üstlenen kişi olarak tanımlanmıştır [1]. Profesyonel bir klinik perfüzyonisti, hastaya ekstra kor- poreal dolaşım hizmeti sunmak için klinik ve akademik eğitimi almış nitelikli kişidir [2].
ABD ve Avrupa Ülkelerinde Perfüzyonist Eğitimi
Bu ülkelerde perfüzyonist eğitimi akademik bir düzeyde verilmektedir. Dünya genelinde perfüzyonist eğitimi de- ğişkenlik gösterse de ABD’de oturmuş bir sistem var iken Avrupa ülkelerinde ise ortak bir sertifikasyon programı oluşturmamış her ülke kendi programına göre perfüzyon eğitimini vermektedir [3]. Bu farklılığa rağmen temel ola- rak verilen teorik ve pratik dersler birbirine benzerlik gös- termektedir. Bir öğrencinin perfüzyonist okuluna başvura- bilmesi için belirli standartlara sahip olması gerekir. Ön- celikle lisans mezunu olmalıdır. Biyoloji, kimya, anatomi ve fizyoloji bölümlerinden mezun olmuş veya bu dersleri almış olması gerekir. Eğitim süreleri 8 ay ile 2 yıl arasın- da değişkenlik göstermektedir. Bir perfüzyonistin okuldan mezun olması için teorik sınavda başarılı olması yanında en az 75 vakaya sorumlu olarak girmesi ve başarılı olarak tamamlaması gerekir [1]. Ayrıca ekstra korporeal memb- ran oksijenasyonu (ECMO) ve ventrikül destek sistemleri (ventricular assist device-VAD) konularında hem teorik hemde pratik yönden belirli seviyede olması gerekir.
ABD ve Avrupa ülkelerinde board sınavları mevcuttur. Okuldan mezun olan perfüzyonistler çalışabilmeleri için board sınavına girmeleri gerekir. Girdiği board sınavını kazanan kişi akredite olur. Akredite olan perfüzyonistler Avrupa ve ABD ülkelerinde tam yetkili perfüzyonist olarak
çalışmaya hak kazanırlar. Board sınavını kazanan perfüz- yonist, girdiği board sınavına göre verilen unvanları ismi- nin sonunda kullanır (ABD’de Circulation Technician – CT; Dolaşım teknikeri , Avrupa Ülkelerinde Extra Corporeal Circulation Technician- ECCT; Vücut dışı dolaşım teknike- ri) [1].
Perfüzyonist olarak çalışanlar ise her yıl çalıştıkları kurum tarafından performansları değerlendirilmekte ve 3 yılda bir zorunlu olarak akademik değerlendirilmeye tabii tu- tulmaktadırlar [4]. Akademik değerlendirmeler yine ulusal düzeyde yapılmaktadır.
ABD ve Avrupa ülkelerinde kurumsallaşmış perfüzyon der- nekleri vardır. Bu dernekler perfüzyonist eğitiminde etkin bir role sahiptirler. Bu derneklerin perfüzyonistlere katkı- ları ise: [5]
• Perfüzyonistin hükümet ile ilişkilerinde desteklenmesi
• Profesyonel perfüzyonist yetiştirilmesi için standartların geliştirilmesi
• Perfüzyon uygulama alanlarının kapsamının geliştirilmesi
• Ulusal ve bölgesel düzeyde sürekli eğitim programlarının geliştirilmesi
• Perfüzyonistin almak istediği eğitim programlarına destek verilmesi
• Bilimsel bilginin yayılmasının sağlanması
• Periyodik dergi yayımlanması
• Perfüzyonistlerin sosyo-ekonomik, politik ve yasal etkinliklerini artırmak için desteklenmesi
ABD ve Avrupa ülkelerinde perfüzyon mesleği yasal olarak tanımlanmış ve uygulama alanın kapsamları belirlenmiş- tir. Bu ülkelerde perfüzyon dernekleri etkin bir role sahip- tirler. Belirli kriterlere sahip kişiler perfüzyon okullarına girebilmektedir. Perfüzyon okulundan ise teorik ve pratik olarak belirli bir seviyeye geldikten sonra mezun olabil- mektedirler. Çalışma hayatında ise belirli aralıklarla yapılan yeterlilik sınavları ile perfüzyonist eğitiminin süreklili- ği ve gelişimi amaçlanmaktadır.
Türkiye’de Perfüzyonist Eğitimi
Türkiye’de açık kalp cerrahisi 1960 yılından beri sayılı merkezlerde yapılırken 2000 li yıllardan sonra birçok merkezde yapılır hale gelmiştir. Bu merkezlerde ise görev yapmakta olan birçok perfüzyonist bulunmaktadır. Per- füzyonist olarak çalışanlar sağlık sektöründen veya farklı meslek gruplarından oluşmaktadır. Ülkemizde perfüzyon eğitimi usta çırak ilişkisine dayanmaktadır. Diğer ülkel- ere göre kıyaslandığında Türkiye’de perfüzyonist eğitimi veren bir kurum veya akademik bir okul mevcut değildir. Kurumlar kendi çerisinde düzenledikleri kurslar ile eğitim vermektedir. Bu kurslar birbirinden bağımsız olması nedeniyle belirli bir standardı tutturamamaktadır. Per- füzyonistler çalıştıkları merkezlerin ameliyat çeşitliliğine ve vaka sayılarına göre tecrübe ve bilgi birikimine sahip olmaktadır.
İlk perfüzyon okulu girişimleri 2000 yılında Kadir Has Üni- versitesinde ön lisans düzeyinde Perfüzyon Meslek Yüksek Okulu kurulması ile başlamıştır. Bir dönem öğrenci almış bir kişi mezun olmuş ve sonrasında kapanmıştır. Günü- müzde çeşitli üniversitelerin oluşturdukları perfüzyonist eğitim programları bulunmaktadır. Harran üniversitesi Sağlık Bilimleri Enstitüsü bünyesinde Kalp Damar Cer- rahi Anabilim Dalı Perfüzyonist Yetiştirme Programı adı altında Yüksek Lisans Öğrencisi alarak perfüzyonist yetiştirmektedir.
Ülkemizde perfüzyonistler için Sağlık Bakanlığı tarafından tanımlama ve kadro uygulamasına yer verilmemiştir. Sa- dece GATA bünyesinde Kalp-Akciğer Pompa Teknisyenliği adı altında tanımlanmıştır ve kadrosu bulunmaktadır. 1997 yılında Perfüzyonistler Derneği kurulmuş bakanlık nezdinde perfüzyonistliğin meslek olarak tanımlanması ve kadro açılması konusunda girişimleri olmuş ama net- ice alınamamıştır. Derneğin etkinliği İstanbul bölgesi ile sınırlı kalkmakta Türkiye genelinde aktif bir yapıya sahip olamamaktadır.
Türkiye’de Perfüzyon Eğitiminin Gelişimi için Yapılması Gerekenler
Sağlık bakanlığı tarafından perfüzyonistliğin yasal olarak mesleki tanımının yapılması kadrosunun oluşturulmasını sağlanmalıdır.
Perfüzyon uygulamasının kapsamı ve standartları be- lirlenmelidir.
Perfüzyonistlik eğitimi alacak kişilerin standartları be- lirlenerek belirli bir eğitim seviyesinde ve belirli olan- larda eğitim almış kişilerin başvurması sağlanmalıdır.
Perfüzyon eğitimi için akademik düzeyde perfüzyon
okullarının veya eğitim programlarının açılması
sağlanmalıdır.
• Bu okullardan diğer ülkelerde olduğu gibi teorik sınavın
yanında başarılı olarak belirli vaka sayısına ulaştıktan
sonra mezun olabilmelidirler.
• Sağlık Bakanlığının veya derneğin yapacağı yeter-
lilik sınavında başarılı olanlara sertifika verilmesi
sonrasında perfüzyonist olarak görev yapabilmelidir. • Kalp cerrahisi merkezlerinde sadece sertifikalı per-
füzyonistlerin çalışmasına izin verilmelidir.
• Belirli zamanlarda yeterlilik sınavları yapılmalı per- füzyonistlerin eğitim seviyelerinin sürekli yüksek
tutulması sağlanmalıdır.
• Aktif olarak çalışan perfüzyonistler ise kısa süreli
eğitim programları sonrasında sınav yapılarak
sertifikalandırılmalıdır.
• Perfüzyonist derneği, daha aktif bir yapıya sahip olması
için desteklenmelidir. Dernek ulusal kongre düzenlen- mesinde ve periyodik dergilerin yayımlanmasında öncülük yapmalıdır.
Perfüzyonistlerin yeniliklerden haberdar olması, iş ortamındaki motivasyonun maksimum düzeyde tutulması, değişik bakış açıları ve vizyon kazandırılması, uygulama hatalarının en aza indirgenmesi için yapılması gerek- en etkin ve verimli bir personel eğitimidir. Perfüzyon- ist eğitiminin bilimsel çerçevesi kanıta dayalı tıp ilkeleri doğrultusunda şekillendirilmelidir. Üniversiteler, Sağlık Bakanlığı ve Dernekler eşgüdüm içerisinde çalışarak bu eğitimin içeriğini birlikte belirlemelidirler. Bu amaçla; per- füzyon eğitimi standardizasyonunun sağlandığı, ulusal ve uluslararası kurumların akredite ettiği nitelikli bir per- füzyonist eğitim programı hazırlanmalıdır.
Kaynaklar
1. The Report of the American Cardio- Vascular Perfusion Academy, 2003:1:23- 34
2. American Society of Extracorporeal Technology. Scope of practice for the clinical perfusionist. Retrieved 29 December 2009, from http://www. amsect.org
3. European Board of Cardiovasculer Perfusion. Essentials and Guidelines. Retrieved 29 December 2009, from http://www.ebcp.org/doc/3837
4. Toomasian JM, Searles B, Kurusz M. The Evolution of perfusion education in America. Perfusion 2003;18: 257 -265.
5. American Society of Extracorporeal Technology. Amsect Mission. Retrieved 29 December 2009, from http://www. amsect.org
Download attachments: KATD-221.pdf
Aydın Bilgili, Türker Şahin, Adem Güler, Harun Tatar. The World and in Turkey Perfusionist Education. J Clin Anal Med. 2010;1(3):60-62
Citations in Google Scholar: Google Scholar
Tracheobronchially Placed Nasogastric Tube in an Intubated Patient
Suat Gezer, Bekir Sami Karapolat
Medical Faculty of Düzce University, Clinic of Thoracic Surgery, Düzce, Türkiye
DOI: 10.4328/JCAM.10.3.31 Received: 09.03.2010 Accepted: 17.03.2010 Printed: 01.09.2010
Corresponding author: Suat Gezer, Düzce Üniversitesi Tıp Fakültesi, Göğüs Cerrahisi AD. 81620, Konuralp, Düzce, Türkiye. E-mail : Suatdr@hotmail.com
A 27 years old male patient was referred to our hospital with traumatic asphyxia due to a job accident. He had been intubated before the admission. He was hospitalized in the intensive care unit and a nasogastric tube was inserted. However, radiological investigations showed that the tube was passed just near the endotracheal tube and placed in the tracheobronchial system (Figure 1,2).
A 27 years old male patient was referred to our hospital with traumatic asphyxia due to a job accident. He had been intubated before the admission. He was hospitalized in the intensive care unit and a nasogastric tube was inserted. However, radiological investigations showed that the tube was passed just near the endotracheal tube and placed in the tracheobronchial system (Figure 1,2).
Download attachments: KATD-227.pdf
Suat Gezer, Bekir Sami Karapolat. Tracheobronchially Placed Nasogastric Tube in an Intubated Patient. J Clin Anal Med. 2010;1(3): 10.4328/JCAM.10.3.31
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