Rektus kýlýf hematomlarýnýn tedavisi: Literatür eþliðinde 8 yýllýk tek merkez deneyimi

AMAÇ: Rektus kýlýf hematomu akut karýn aðrýsýnýn nadir görülen ve sýklýkla gözden kaçan nedenlerinden birisidir. Çoðunlukla ileri yaþ ve yandaþ hastalýklarýn eþlik ettiði bu hastalarýn yönetiminde doðru taný ve tedavi yaklaþýmlarýyla, gereksiz cerrahi müdahalelerden kaçýnarak olumlu sonuçlar alýnabilmektedir. Bu çalýþmanýn amacý, rektus kýlýf hematomu tanýlý hastalarýn yönetimindeki algoritma ve optimal tedavi stratejileri eksikliðine olgu yönetim deneyimimizle katkýda bulunmaktýr.
GEREÇ VE YÖNTEM: Çalýþmamýzda Mayýs 2010–Temmuz 2018 tarihleri arasýnda rektus kýlýf hematomu tanýsý ile tedavi uygulanan hastalarýn demografik özellikleri, özgeçmiþleri, tanýya götüren fiziksel incelemeleri, laboratuvar ve görüntüleme yöntemlerindeki bulgularý, tedavi süreç ve yöntemleri, komplikasyonlarý, morbidite ve mortalite oranlarý, yatýþ süresi ve uzun süreli takip sonuçlarý geriye dönük olarak hasta dosyalarý, hastane bilgisayar kayýt sistemi ve görüntüleme arþivleri incelenerek elde edildi. Elde edilen verilerin analizi Microsoft Excel ve IBM SPSS Statistics 24 kullanýlarak deðerlendirildi.
BULGULAR: Çalýþmaya dahil edilen 31 hastanýn yaþ ortalamasý 63.03 yýl (24–85 yýl) olup; kadýn/erkek oraný (21/10) 2.1 idi. En sýk görülen semptom karýn aðrýsý (%100) olmakla beraber; 25 olguda (%80.6) karýn duvarý kitlesi tespit edildi. Antikoagülan ve antiplatelet tedavisi alan 25 olgu (%80.6) vardý. Olgularda taný; 11’inde (%45.4) yalnýzca bilgisayarlý tomografi; beþinde (%16.1) yalnýzca ultrasonografi ve 15’inde (%33.3) ise bilgisayarlý tomografi + ultrasonografi yardýmýyla konuldu. Sekiz olgu (%25.8) Tip 1, 10 olgu (%32.2) Tip 2 ve 13 olgu (%41.9) Tip 3 rektus kýlýf hematomu olarak deðerlendirildi. Ortalama International Normalized Ratio (INR) deðeri 2.59 olarak bulundu. Üç olguda (%9.6) kanama kontrolü cerrahi müdahale ile saðlanýrken; 28 olguda (%90.3) ise konservatif tedavi uygulandý. Olgular ortalama 7.48 gün (4–21) takip edilmiþ olup; 29 olgu (%93.5) taburcu edilirken; cerrahi yapýlan bir olgu ameliyat sonrasý beþinci günde, konservatif takip edilen bir olgu ise yatýþýnýn 14. gününde kaybedildi (%6.45 mortalite). Konservatif ve cerrahi yöntemle takip edilen olgularýn mortalite oranlarý sýrasýyla %3.5 ve %33.3 idi.
TARTIÞMA: Akut karýn aðrýsý, göbek altý palpable veya görüntüsel yöntemlerle desteklenen kitlesi olup; antikoagülan tedavi alan, þiddetli öksürük ataklarý olan ileri yaþlý hastalarda rektus kýlýf hematomundan þüphe edilmelidir. Klinik þüphe halinde ultrasonografi veya bilgisayarlý tomografi yapýlmalýdýr. Erken ve doðru taný konservatif tedavinin baþarýlý olmasýný ve gereksiz cerrahi giriþimleri önler. Klinisyen tecrübesinin ön planda olduðu bu olgularda, olgu çalýþmalarý sunularýnýn artmasýyla birlikte yeni bir etkili algoritma sisteminin ve taný için kýlavuzlarýn tanýmlanacaðýný umuyoruz.

Treatment of rectus sheath hematomas: Eight years of single-center experience with a review of literature

BACKGROUND: Rectus sheath hematoma is a rare and frequently misdiagnosed cause of acute abdominal pain. In the management of the patients with rectus sheath hematoma, which are mostly with advanced age and comorbid diseases, positive results can be obtained by avoiding unnecessary surgical procedures with correct diagnosis and treatment approaches. The presented study aims to contribute to the lack of algorithms and optimal treatment strategies in the management of rectus sheath hematoma patients with the description of our experience in their management.
METHODS: Patients who underwent treatment with the diagnosis of rectus sheath hematoma between May 2010 and July 2018 were retrospectively analyzed. Demographic characteristics, medical histories, physical and laboratory findings and imaging methods, treatment processes, complications, morbidity, mortality, length of hospitalization and long-term follow-up results were searched. Data were analyzed from patient files, hospital computer registry system and radiology archives. Data analysis was performed using Microsoft Excel and IBM-SPSS-Statistics-24.
RESULTS: The mean age of the 31 patients was 63.03 years (24–85 years). The female/male ratio (21/10) was 2.1. The most common presenting sign or symptom was abdominal pain (100%), followed by abdominal wall mass in 25 patients (80.6%). Twenty-five patients (80.6%) were receiving some form of anticoagulation and antiplatelet therapy. Diagnosis was confirmed by Computed Tomography in 11 (45.4%), Ultrasonography in five (16.1%) and Computed Tomography with Ultrasonography in 15 (33.3%). Eight patients (25.8%) were evaluated as Type-1, 10 (32.2%) as Type-2 and 13 (41.9%) as Type-3. Mean International Normalized Ratio (INR) value of patients was 2.59. Bleeding was controlled by surgery in three cases (9.6%). The conservative approach was preferred in 28 cases (90.3%). 29 (93.5%) patients were discharged after an average hospital stay of 7.48 days (4–21). One patient died on the postoperative 5th day and other on the 14th day of conservative treatment (6.45% mortality). The mortality rate of conservatively and surgically treated patients was 3.5% and 33.3%, respectively.
CONCLUSION: Rectus sheath hematoma should be suspected in elderly patients using anticoagulants with acute abdominal pain, severe cough attacks and an umbilical palpable or radiologically supported mass. Computed Tomography and Ultrasonography should be performed in case of clinical suspicion. Early and correct diagnosis ensures successful conservative treatment and prevents unneces-sary surgical procedures. In the management of cases where clinician experience is at the forefront, we are hopeful that a new effective algorithm system and guidelines for the diagnosis will be identified after increasing the presentations of case series and experiences.