Albanian Journal of Trauma and Emergency Surgery

361-386

Authors: Kenan Karavdić

Background: An extensive burn is one of the most serious injuries. The conventional methods of local therapy, especially in extensive and deep burns, cannot prevent infection. The fact is that the necrotic burn tissue always gives rise to infection and must therefore be excised. Tangential excision is a diagnostic procedure as well as a surgical preparation of a recipient bed for skin graft. Aim of research: The aim of our research was to demonstrate the efficacy of early tangential necrectomy in the treatment of extensive burns in children as well as in preventing the burn diseases. Material and methods: Clinical parameters of sixty extensively burned children have been evaluated, divided into two groups (surgically and non-surgically treated) and in four subgroups (under and over the 25% TBSA). The following criteria have been used to compare the results: pain, fever, body weight, duration of the hospital stay, wound infection, laboratory values. Results: The boys comprised 58.3% of the respondents and the girls were 41,7% of the respondents. The most common cause was the hot liquid of 73.3%, open flame 23.3% and the contact with hot metal 3.3%. The body temperature was significantly higher in control group compared to the examined group (p <0.001) significantly lower hematocrit values in the control group compared to the examined group (p = 0.002). The results show that hospitalization lasted considerably longer in patients in the control group than in the examined group (p = 0.003). The incidence of bacterial infection of the burns is significantly higher in control compared to the examined group of patients (p = 0.007). The most commonly isolated bacteria in the study group was Staphylococcus aureus (15/30 or 50% of all subjects). Acinetobacter spp. was isolated in 9 patients (30% of respondents). Serratia spp. And Enterococcus Foecalis were isolated in 6 patients (20%). Pseudomonas aeruginosa was isolated in 3 patients (10%). Three patients (10%) did not isolate any bacteria during hospitalization Conclusions: The method of early tangential necrectomy of extensively burned children significantly reduce morbidity and mortality (it improves the general condition of the patient, improves clinical and laboratory parameters, reduces the possibility of infection of the wound, reduces the possibility of sepsis, reduces the length of hospitalization).The most optimal time to perform an early tangential necrectomy is the period between the 4th and the 6th day after the injury. In extensively burned children over 30% of the total body surface, an early tangential necrectomy should be performed on an area of about 20% of the total body surface as a prevention of blood loss due to necrectomy and autotransplantation. With extensively burned children over 40% of the total body surface, taking homotransplants from parents or close relatives reduces morbidity and mortality.

395-402

Authors: Nehat Baftiu, R.Baftiu

Background: Epidural analgesia is a gold standard in post-operative pain control in patients undergoing large abdominal interventions. Different studies report a failure ratio of epidural analgesia of 20-32%. The aim of this study is to analyze the success rate of epidural analgesia and its consequences in patients that have been subject to large abdominal surgeries. Materials and methods: We have prospectively collected the data of 50 patients that were subject to open abdominal surgeries during a 2 year timeframe (September 2015 – September 2017) at University Clinical Center of Kosovo. Experienced anesthesiologists inserted the epidural catheters. A dedicated team used the Verbal Scale to collect the data regarding post-operative pain during coughing or moving. The success rate of eidural catheter was measured in terms of: the scale of pain, pulmonary post-operative infection and length of hospital stay. Results: The study group included 33 males and 17 females, most of whom were subject to liver surgery. The secondary liver formations (70%), primary tumours (20%) as well as beningn liver disorders(10%) were an indication for liver resection. Large resections (≥3 segments) were completed in 44% of patients, small liver resections were (≤2 segments) completed in 48% of patients, while 8% of patients were considered inoperative. Epidural analgesia was successful in 46 patients (92%). Bacterial colonisation of the catheter was observed in only one case. There were no neurological complications. 5 (10%) patients showed radiologicalsigns of a pulmonary infection. Three patients (6%) had surgical wound infection. One patient died of hepatic insufficiency after massive right liver resection and cholecystectomy due to gallbladder carcinoma. The average length of hospital stay was 6 days. Conclusions: Our experience concludes that epidural analgesia is a safe and effective way of pain relief after abdominal surgeries

409-416

Authors: Salih Tosun, Oktay Yener, Ozgur Ekinci, Aman Gapbarov, Murat Asik, Tunc Eren, Orhan Alimoglu

Background: Cholecystectomy is the standard treatment for patients with acute cholecystitis. On the other hand, percutaneous cholecystostomy (PC) is an alternative for patients at high-risk for surgery. The aim of this study was to evaluate the clinical outcomes of PC. Methods: Surgically high-risk patients with acute cholecystits having undergone PC at our institution between January 2014 – January 2017 were evaluated. Data including the indications for PC, route of insertion, technical success, clinical improvement, length of hospital stay, mortality rates, procedure related complications, subsequent admissions and performance of interval cholecystectomy were recorded and analyzed. Results: The study group consisted of 30 patients with a mean age of 75.3 ( range: 49–99) years. The indications for PC were acute calculous cholecystitis in 28 (93.3%) and acalculous cholecystitis in 2 (6.7%) patients. All procedures were performed via the transhepatic route. Twenty-five PCs (84.4%) resulted in clinical improvement within five days. A repeated PC was performed in two (6.7%) patients. Seven (23.3%) patients underwent a subsequent cholecystectomy after 6 weeks. An emergent cholecystectomy was performed in one (3.3%) patient. Five (16.7%) patients died from underlying comorbid diseases, unrelated to the biliary system, during the follow-up. Conclusions: Patients with acute cholecystitis were promptly relieved from their symptoms following PC. There were only minor complications following the procedure and an interval cholecystectomy was necessary in only 23.3% of the patients. PC is a safe alternative to choecystectomy in high-risk patients with acute cholecystitis with satisfactory results.

424-438

Authors: Agron Dogjani, Kastriot Haxhirexha, Edvin Selmani, Hysni Bendo, Amarildo Blloshmi

Background: Trauma is the leading cause of morbidity and mortality in pediatric age. Abdominal trauma is the third most frequent cause of trauma injuries in children. The purpose of our study is to discuss BATp epidemiology and its relationship with polytrauma, , to recognize and describe the mechanisms of blunt abdominal trauma in pediatric age and to identify the signs and symptoms that associate it. Material and methods: In this retrospective study we reviewed all patients with blunt abdominal trauma in pediatric age who presented in Emergency Department at the University Hospital of Trauma in Tirana, Albania in the period between December 1-st 2017 and June 24-th 2018. The sample in the study was taken randomly. The Injury Severity Score, Revised Trauma Score were used as important points to evaluate gravity of injuries, and method of treatment. The data was introduced in absolute and percentage values and Kendal's tau b correlation coefficient and the regression analysis was used to analyze and to find out any association among the dependent versus independent variable. The type of study is case control with two components; descriptive and analytical. Results: In the time period that we studied, about 25200 patients were presented in Emergency department and 6.68% of these cases were hospitalized. Most frequent causes were motor vehicle accidents (35.4%) and abdominal trauma comprised 25.8% of cases, whereas in children it comprised 13.7% of total pediatric trauma. We have found correlation between the injury severity score and complications rate (r = 0.254, n = 49, p <0.001), and injury severity score with length of hospital stay (r = 0279, n = 49, p <0.001). Conclusions: Blunt Abdominal Trauma in pediatric age is a serious threat to the health of the children. Their treatment should be carried out not only in tertiary trauma centers but in every regional hospital. The trauma score is very valuable to determine the gravity of the injury, method of treatment and is a predictive tool in trauma outcomes.

446-460

Authors: Edvin Selmani, Agron Dogjani

Treatment of chronic ankle instability remains a challenge for orthopedic surgeon. Surgical procedures for this disorder include anatomic direct repair, anatomic reconstruction with an autograft or allograft, and arthroscopic repair. Open direct repair is commonly used for patients with sufficient ligament quality. Reconstruction incorporating either an autograft or an allograft is another promising option in the short term, although the longevity of this procedure remains unclear. Use of an allograft avoids donor site morbidity, but it comes with inherent risks. Arthroscopic repair of chronic lateral ankle instability can provide good to excellent short- and long-term clinical outcomes, but the evidence supporting this technique is limited. Deterioration of the ankle joint after surgery is also a concern. Studies are needed on not only treating ligament insufficiency but also on reducing the risk of ankle joint deterioration.

469-473

Authors: Majlinda Naço, Haxhire Gani, Arvin Dibra, Eden Naço, Suzana Mukaj

Background: Amyotrophic lateral sclerosis (ALS) is a serious disease in which some brain and spinal cells die slowly. These nerve cells are called motor neurons and control the muscles that allow the body parts to move. Initially, the disease causes bodily fatigue and muscular weakness through degeneration of the upper and lower motor neurons, leading to loss of ability to initiate and control the voluntary bodily functions. In late stages this disease causes difficulty in the normal swelling and eating that causes the need for PEG in patients with ALS. This clinical picture increases the difficulty and the anesthetic risk used during the PEG application. Case presentation: We are describing our experience in a 56-year-old male patient, ASA III suffering from ALS and being admitted to our clinic to insert PEG. The patient presented BMI =15.6. After the patient provide informed consent, we were monitoring him for detect changes in pulse oximetry, noninvasive blood pressure, heart rate and visual assessment of ventilator activity, level of consciousness and discomfort. We used balanced propofol for moderate sedation (BPS), loading dose 1mg midazolam, 0.1 mg of fentanyl, and 5-15 mg propofol in smaller bolus dose were applied for more precise dose titration. The operation was performed after the patient lost the consciousness and had no pupil reflex. The EGD entered to the stomach. Fistula was localized after the visualization of light from the tube. Local lidocaine was applied and 1cm incision on the abdominal wall gave the possibility for application of fistula and gastro stoma placement. The patient wakes up 10 minutes after the end of the procedure without using antidotes. The patient after treatment went home in two days using gastro stoma for enteral feeding.

480-483

Authors: Gentian Huti, Asead Abdyli, Rudin Domi, Blerim Arapi, Arben Kojqiqi, Artan Jahollari

Epidural anesthesia has been used widely as a combination to general anesthesia in cardiac surgery since early seventies. The addition of this technique to general anesthesia may have beneficial effects on clinical outcome. Several clinical trials and experiments have shown that there may be significant benefits using epidural anesthesia in cardiac surgery. Somehow neuroaxial blockade manages to attenuate the response to surgical stress and improve perioperative analgesia. Between august 2014 and September 2018, high thoracic epidural anesthesia was applied to 12 patients as a sole anesthetic technique. Epidural anesthesia was chosen because the patients had relative contraindications to general anesthesia and mechanical ventilation. This paper gives an overview of epidural anesthesia usage and our experience.

489-495

Authors: Alfred Ibrahimi, Saimir Kuci, Ervin Bejko, Stavri Llazo, Maksim Llambro

Case report: A 27-year-old previously healthy man was admitted to the ICU complaining nausea, vomiting and disorientation, after he ingested 1500 mg paracetamol, but its relatives explained that they possess in the house only metformin (maybe he ingested metformin instead of paracetamol). First blood gas showed moderate, and hours later severe lactic acidosis Ph 7,01, Lac 25 m mol/L, BE -26,4. Aggressive rehydration and hemofiltration was started, until full recovery after 24 hours of hospital admission. He was discharged after three days in healthy condition. Discussion: Lactic acidosis is a common cause of metabolic acidosis at the ICU. Type A is most common and caused by hypoperfusion or hypoxia, whilst type B has other causes including use of the antidiabetic drug metformin. Metformin associated lactic acidosis (MALA) is an important treatment-associated condition, and although rare, it is very serious. Conclusion: MALA should be strongly suspected in patients presenting with wide anion gap metabolic acidosis and high blood lactate concentration. Bicarbonate hemodialysis or continuous renal replacement therapy should be urgently arranged for patients with MALA.

197-204

Authors: Ridvan Alimehmeti, Gramoz Brace, Ermira Pajaj, Alda Kika, Jetmira Kerxhalliu, Norik Bardhi, Myfit Saraci, Arsen Seferi

Background: Traumatic injury of the peripheral nerves should be treated in specialized centres. This study presents the epidemiological data of 1368 consecutive patients operated for peripheral nerve injuries beside the Service of neurosurgery, Department of Neurosciences, UHC "Mother Theresa", Tirana. In order to obtain the necessary data for this study we revised the clinical records, surgical registers and pre, intra and postoperative photo/video of the cases operated for peripheral nervous system injuries. A data recording program of the surgery cases was built ad hoc, categorizing the cases according to several variables. The data collected from the operated cases were manually inserted to be processed by the program. Results of informatics elaboration of the data were obtained, reviewed and categorized by: age, gender, type of trauma, localization of injury and type of nerve repair. Future studies to be conducted in this field will focus in determining the level of nerve injury, time from the injury to intervention, distance from the site of trauma to the effector organ. The data will build necessary information for data mining, which based on these important factors that influence the result of nerve repair, will be useful for the prediction of the result in new patients harbouring peripheral nerve injury before undergoing surgery.

214-219

Authors: Basri Lenjani, Premtim Rashiti, Dardan Lenjani, Petrit Borovci, Nuhi Arslani

Background: Traffic accident is when only material damage is caused to the vehicle, track or environment, and there are no casualties. Traffic disaster is such an event in which, besides the material damage, there are human casualties. Traffic disaster is such an event in which, besides the material damage, there are human casualties. Aim: Provision of emergency medical care in all phases of the management of injured persons in traffic accidents with basic and abnormal trauma support in order to reduce: morbidity, validity and mortality and increasing the quality of EMS. Materials and methods: Samples of the survey were only injured in traffic accidents and the main causes were; age, sex, place of residence, seasons, weekdays and months, sleepwalking, drug use, alcohol consumption, and medical assessment, poor quality of roads, speed overtaking, car testing, illness, mobile phone use, eating in the car radio CD player. Result: The research material was obtained from the UCCK - Clinic Clinic in Pristina archive for January - December 2015 and January - October 2016. Research samples were only injured in traffic accidents. In Kosovo, the Emergency Clinic for January- December was 55.294 / 9.32% and 66 injured / 0.11%. Over 3 400 people die in the world's streets every day and tens of millions of people are injured. Conclusions: EMS should be equipped with medical staff, medicines, medical equippment, concrete materials, ambulances with the aim of providing basic and advanced care to the nearest hospital. Educate and train emergency medical professionals with basic and advanced trauma training courses, especially the hospital and prehospital level, and be incorporated as a first class subject at all levels of school.

228-234

Authors: Gentian Zikaj, Gjergji Belba, Gezim Xhepa

Background: Even that the entire hand represents 4 percent of the TBSA, The American Burn Association, the Advanced Trauma Life Support, and the Advanced Burn Life Support curricula all recognize the severity of hand burns by classifying these as injuries requiring treatment at a burn qualified centre. Hand burns occur commonly both as part of larger burn injuries as well as isolated injuries. Due to damage to the skin and other parts of the hand, burns can lead to open wounds, disability, severe emotional and psychological complications, and economic burden. Aim: To give an overview of epidemiologic features and outcome of burn hand patients who are admitted in our Service. This current study was performed in University Hospital Centre “Mother Teresa” Tirana which is the only tertiary hospital in Albania. Material and methods: In this retrospective study were included all patients who had combustion of the hands solely or hands accompanied with burns to other areas of the body, treated and followed up during the years 2011-2016. Results: Of the 333 included burn patients, 64% were males.The median age of women is 21.8 years, of men is 27.5 years and the median age total patients’ population is 25.9 years. About half of patients belong to the age group 20-60 years (49.5%) and only 10.2% belong to the age above 60 years. In most of the cases (73.6%), the burn of hands is associated with burn of the other anatomical region, mostly forearm. Conclusion: The goal of wound management is to have the skin healed by post-burn in two weeks’ time. In many cases, this will occur nonoperatively with good wound care. The surgical treatment is used for less 30% than of patients. Surgical excision of the burn with split-thickness skin grafting should be undertaken as soon as it becomes obvious that wound healing will not be complete by post-burn day 14. The undesirable results of the burn of hands are presented in the 33% of the patients. The contractures were the main unfavorable outcome of the burned hand.

245-255

Authors: Orhan Alimoğlu, Nuray Colapkulu, Tunç Eren

Background: Acute biliary pancreatitis (ABP) is one of the most common gastrointestinal events that requires acute admission to the hospital with considerable risks of mortality & morbidity. Laparoscopic cholecystectomy has become the gold standard for the treatment of ABP. Our aim was to determine the safety of cholecystectomy during the first admission by performing a review of the current literature. Waiting for 6 - 8 weeks to perform cholecystectomy may result with an increased incidence of recurrent ABP attacks, which may increase morbidity and the length of the hospital stay. On the contrary, cholecystectomy during the index admission for mild ABP appears to be a preferable and safe approach with better surgical outcomes providing a definitive treatment

262-269

Authors: Nehat Baftiu

Shock represents a condition of inadequate tissue perfusion due to circulatory insufficiency. Hemorrhage is the most common cause of shock in injured patients. Traumatic hemorrhagic shock presents a lifethreatening condition due to the development of multifunctional organ dysfunction syndrome, which can be diagnosed due to symptomatology and changes in vital parameters. This study aims to analyse the epidemiological characteristics of traumatic - hemorrhagic shock and to demonstrate the efficacy of therapy in hemodynamic stabilization in patients with shock during the first 12 hours of intensive treatment at University Clinical Center of Kosovo.

276-282

Authors: Alfred Ibrahimi, Saimir Kuci, Ervin Bejko, Stavri Llazo, Jonela Burimi, Esmerilda Bulku

Aim: Gastrointestinal complications (GIC) following open heart surgery usually are rare but with high morbidity and mortality. The aim of this study was to see the outcome of these patients after complication, compared with a similar study found in literature. Identifying risk factors preoperatively and postoperatively in our patient’s series, for GIC. Materials and methods: Between January 2012 and December 2017 from 1990 operated cardiac patient 34 of them developed GIC, presenting gastro duodenal bleeding due to active ulcer, liver failure, pancreatitis, cholecystitis, or intestinal ischemia. We performed a retrospective analysis. Results: From all consecutive patient only 1.7 % developed GIC. Mortality rate was 55.8%, especially 100 % mortality in intestinal ischemia patient. Regarding risk factors, those were the same found in other similar study (age, atherosclerosis disease, by pass time, postoperative ARF, Low cardiac output syndrome.) Conclusion: GIC after cardiac surgery are rare but when it happens the mortality is very high not even of late diagnosis. In ages patients, diabetes, long by pass time, long hypoperfusion state. It is recommended to be alert for GIC for detection in early phase, and for reducing as much as possible morbidity and mortality.

291-298

Authors: Vidi Demko, Eni Mehmeti , Besmir Bulku

Background: PTPE is a significant complication and the main cause for 2–10% of victims. MDCT is increasingly used. Our study is an analysis focused on the anatomy of pleura, principles behind fluid formation/reabsorption and an imaging approach to assessing pleural effusion and PTPE under-CT evacuation. Material and methods: The study is conducted on eight (8) patients with PTPE at University Hospital of Trauma, University Hospital Centre “Mother Theresa”, University Hospital “ Shefqet Ndroqi” in Tirana, during the period January 2015 – June 2018, by using a MDCT of 128 slice – 64 detector – dual source, SIEMENS, German machine. Results and conclusions: The frequency of post-traumatic pleural injuries with presence of Hydrothorax is 75.6% in total; second after that of Chest wall injuries (94.2%). Among the variable forms are reported Hemothorax – 17.4 % and Pneumothorax – 7.3 %. Empyema is rare – 2 %. MDCT is the most sensitive, specific and accurate imaging modality in the assessment of PTPE and management of patients: - demonstrates the significant disorder in patients with normal initial radiographs, - indicates changing of management in up to 20% of cases with abnormal initial radiographs, - assists several micro-invasive procedures in order to prevents development of empyema, - enables early prediction of respiratory compromise and limits the severe invasive interventions.

305-314

Authors: Skender Veliu, Jasmina Kröpfl , Dominika Vrbnjak

Chronic wounds represent an enormous health, social and economic burden in modern society. With the increasing incidence of diabetes and obesity as well as the ageing of the population, we correspondingly expect a rise in the incidence of chronic wounds. The latter will reflect in an even heavier burden for individuals , their families and the society. At the General Hospital Dr. Jože Potrč Ptuj we devote a lot of time dealing with this issue, because we are aware of the impact that the chronic wounds have on the quality of life of affected patients. We have been taking care of patients with chronic wounds for several years in the ambulatory and hospital setting. In the article we present our organizational model in the treatment of patients with chronic wounds at General Hospital Dr. Jože Potrč Ptuj. We present the modern approaches in the treatment of chronic wounds at our hospital, our results in the treatment of chronic wounds supported with clinical cases. The key to successful management of patients with chronic wounds are good knowledge, team work and an individual approach to each patient.

319-326

Authors: Judah Morgan, Eva Shagla, Ryan M. Kwok

Cirrhosis describes the end stages of chronic inflammation and progressive scarring of the liver and may lead to hepatocellular dysfunction and portal venous hypertension. Liver cirrhosis in itself is a major cause of mortality worldwide, accounting from more than 1 million deaths in 2010. Esophageal varices are common in cirrhosis such that Christensen et al. documented their occurrence in 90% of patients with cirrhosis within 10 years of follow up, 40% experiencing variceal bleeding. Acute hemorrhage from esophageal varices will classically appear as hematemesis and/or melena in patients with a history of cirrhosis. It is most often diagnosed by performance of an EGD which will reveal actively bleeding varices. Because of the high rate of morbidity and mortality associated with esophageal variceal bleeding, one must have a high index of suspicion in any patient with chronic liver disease or cirrhosis. As such, empiric management for variceal hemorrhage should be initiated any time this diagnosis is considered.

341-348

Authors: Luan Nikollari, Adriana Bejleri, Dorela Vasha, Agron Dogjani

Albania, like all the former communist countries, has inherited in 50 years a large arsenal of weapons and ammunition stockpiles, as shells and projectiles of various calibers, which constituted a negative phenomenon and seriously jeopardized the lives of people and communities throughout the geography of their deployment. After the 1990s, the Albanian Armed Forces embarked on the path of transformation and integration of Albania into NATO. In this framework, the implementation of defense reforms aimed the reduction and modernization of the military. In this context, one of the transformation goals was the getting rid of the remaining excess ammunition that was being destroyed under the programs of the Ministry of Defense and partner countries and the role of the University Hospital of Trauma and the Military Hospital in Tirana, Albania. This paper aims to discuss the security threat that these stockpiles pose to our nation and the wiser region. It also explains how the excess munitions eliminating process was completed in Albania.