Strangulation Group Research Articles

The clinical value of ultrasound in assessing ovarian strangulation in female infants and toddlers with ovarian hernia.

To explore the clinical value of ultrasound examination in evaluating the presence of ovarian torsion in female infants with inguinal ovarian hernia. We conducted a retrospective analysis of 91 cases of ovarian hernia diagnosed by ultrasonography at our institution. Among them, 6 cases were identified as ovarian strangulation, while 85 cases were classified as non-ovarian strangulation. All cases underwent high-frequency ultrasound examination. We analyzed whether there were differences in the associated factors between the two groups and compared the disparities in the urgency of surgery between the two groups. Significant differences were observed between the ovarian strangulation group and the non- strangulation group in terms of ovarian volume, ovarian blood flow, and the presence of incarceration. The need for emergency surgery was significantly associated with the presence of incarceration and ovarian torsion. Ultrasound has good clinical value in diagnosing ovarian hernia and determining the presence of ovarian strangulation. It can assist clinical physicians in determining the timing of surgery for children with ovarian hernia.

Hyoid Bone Fractures in Mechanical Asphyxiation Deaths: A Study at Osmania General Hospital, Hyderabad, India

The fractures of the hyoid bone in the neck are one of the important indicators of any pressure over the neck. Thepresent study includes a huge sample size of mechanical asphyxiation deaths (791 cases) to study the incidence ofhyoid bone fractures in hanging, ligature strangulation, and throttling. Fractures of the hyoid bone were noticed ina total of 12 cases, 9 male and 3 female with 33.33% incidence in the 41-50 years age group. Throttling dominatedthe strangulation group in our study with a share of 42.85%. A total of 6 (5 male, 1 female) cases showed hyoidbone fractures in the strangulation group wherein the predominant incidence is seen in 41-50 years(50%). In ourstudy, right cornu fractures are frequent in hanging and throttling. Except for one outward compression fracturein a hanging instance, all of the fractures identified in our investigation are inward compression fractures. Thepresent study adds to the existing literature that hyoid bone fractures are less common in hanging than throttlingand any fracture of hyoid bone is common after the age of 40 years because of calcification.

Novel and simple method using cable ties to induce intestinal strangulation in a rat model

BACKGROUND The pathogenesis of intestinal fibrosis after strangulation in abdominal surgery is not fully understood. Developing an experimental and reliable method is needed to overcome this problem. This study aimed to develop an effective method for intestinal strangulation leading to fibrosis, which might induce intestinal obstruction.
 METHODS This study was conducted from 2018 to 2019 at the Department of Pharmacology, Faculty of Medicine, Universitas Indonesia. A total of 24 Sprague Dawley rats were used in this study. Artificial intestinal strangulation using cable ties made of durable plastic, which is generally used to ligate objects, was applied, and rats were further classified into control, 6-hour, and 24-hour strangulation groups. At the end of the study, the rats were sacrificed, intestinal tissues were collected, and histomorphological changes were observed using hematoxylin and eosin stain. Moreover, Masson’s trichome staining was used to assess collagen density.
 RESULTS Median collagen density score of the 24-hour strangulation group was higher than the control. A significant difference in collagen density was found between the submucosal layer of the 24-hour strangulation group and the control (45.4 [11.4] versus 32.4 [14.0], p<0.001) and between the mucosa of the 6- and 24-hour strangulation groups and the control (26.9 [17] versus 6.46 [4.3], p = 0.01 and 24.9 [8] versus 6.46 [4.3], p = 0.004, respectively).
 CONCLUSIONS The simple use of cable ties adequately promotes intestinal strangulation.

Manual strangulation of the uterine isthmus after placental removal to reduce blood loss during cesarean section.

IntroductionThis study aimed to evaluate the effect of manual strangulation of the uterine isthmus on the amount of blood loss during cesarean section.Material and methodsThis is a prospective randomized controlled trial. A total of 118 participants were enrolled in the study. Manual strangulation of the uterine isthmus just after placental removal was performed during cesarean section in group I (n = 57; the strangulation group). Strangulation was not performed in group II (n = 61; the control group). Preoperative and postoperative venous blood hemoglobin, capillary hemoglobin, and absorbed blood levels during the operation were compared between the two groups.ResultsThe median age of the patients was 28.5 (19–41). The median body mass index of the patients in the study was 27 (21–42). There were no significant differences in the demographic characteristics of the patients between the groups. The median difference between the preoperative and postoperative 4–6 h capillary hemoglobin values was significantly lower in the strangulation group (2.0 (0–9)) than in the control group (3.0 (0–8)). The amount of absorbed blood during the operation was also significantly lower in the strangulation group (164.5 ml (69–1310)) than in the control group (230 ml (35–3223)).ConclusionsManual uterine strangulation of the uterine isthmus immediately after the removal of the placenta may induce a 30% decrease in blood loss during cesarean section.

Analysis of Related Factors in Elderly Patients with Strangulated Small Bowel Obstruction

Objective To investigate the surgery-related factors of strangulated small bowel obstruction in the elderly patients. Methods The clinical data of 261 elderly patients with acute small bowel obstruction treated between July 2010 and September 2016 were analyzed retrospectively. Differences of clinical data,laboratory Results ,and CT findings were compared between the elderly strangulation group(ESt group,n=139)and the elderly simple group (ESi group,n=122). The surgery-related factors of strangulated small bowel obstruction in the elderly were analyzed by univariate and multivariate Logistic regression analysis. Results The ESt group and the ESi group showed significant differences in factors including muscle guarding (χ2=102.331,P=0.000),American Society of Anesthesiologists(ASA) score≥3 (χ2=69.748,P=0.000),leukocyte count (t=7.453,P=0.000),C-reactive protein (t=2.128,P=0.034),segmental mesenteric fluid (χ2=78.655,P=0.000),thick-walled small bowel (χ2=100.806,P=0.000),intestinal wall of hyperattenuation (χ2=69.068,P=0.000),ascites (χ2=89.299,P=0.000),mesenteric fat stranding (χ2=80.255,P=0.000),bird's beak sign (χ2=84.451,P=0.000),and stranding sign (χ2=98.635,P=0.000). Univariate regression analysis indicated the above 11 factors were the surgery-related factors in elderly patients with strangulated small bowel obstruction. Multivariate Logistic regression analysis showed that the surgery-related factors included segmental mesenteric fluid (OR=3.576,95%CI:1.043-12.261,P=0.043),ASA score≥3 (OR=3.463,95%CI:1.149-10.441,P=0.027),muscle guarding (OR=3.288,95%CI:1.010-10.707,P=0.048),thick-walled small bowel (OR=3.046,95%CI:1.074-8.638,P=0.036),and increased leukocyte count (OR=1.307,95%CI:1.170-1.458,P=0.000). Conclusion Muscle guarding,ASA score≥3,segmental mesenteric fluid,thick-walled small bowel,and increased leukocyte count are the surgery-related factors of strangulated small bowel obstruction in the elderly patients.

Penile injuries in children.

Penile injuries are not rare in children. Our aim is to establish their causes and to report our experience in the management of those accidents. A retrospective study of all penile injuries presented from January 2009 to January 2017 was performed. Hemorrhage and excess of mucosa or skin remnants are the most frequent and benign injuries after circumcisions, so they were excluded from the study. Four groups were reported including the circumcision accident group, the traumatic accident group, the strangulation group and the electrocution group. The most frequent cause was circumcision accidents. We performed a penile re-implantation in one, and a glans re-implantation in another patient. Two patients underwent phalloplasty using the stumps of the remaining corpora cavernosa. We performed nine fistulae repair. Follow up showed healing without complication in the majority of the patients but recurrence of fistula was witnessed in four patients. Penile injuries are frequent with a challenging management. Most of the accidents can be prevented by improving conditions of circumcision.

Expression of Glucose-Regulated Protein 78 and miR-199a in Rat Brain After Fatal Ligature Strangulation.

The roles of endoplasmic reticulum (ER) stress and microRNA in the brain tissue after fatal mechanical asphyxia have not been clearly elucidated. We examined the expression of glucose-regulated protein 78 (GRP78), the key regulator of unfolded protein response, and miR-199a in the brain tissues of rats subjected to fatal ligature strangulation to understand the roles of ER stress and microRNA in ligature strangulation. The expressions of GRP78 and miR-199a in rat cortex, hippocampi, and midbrain were measured by immunohistochemistry and Western blot analysis in a rat model of ligature strangulation. Furthermore, the levels of miR-199a-3p and miR-199a-5p were detected by real-time fluorescent quantitative polymerase chain reaction. Glucose-regulated protein 78 was highly expressed in the cortex and midbrain in the ligature strangulation group (P < 0.01) when compared with the control group. The expression of GRP78 in the hippocampi showed no significant difference between the 2 groups. miR-199a-3p in the cortex and midbrain was significantly down-regulated in the ligature strangulation group (P < 0.01). However, miR-199a-5p in each brain region showed no significant difference between the 2 groups. In conclusion, ER stress was involved in the physiological and pathological processes of ligature strangulation. Furthermore, upstream miR-199a may play an important regulatory role in mechanical asphyxia.

Evaluation of sequential organ failure assessment score for patients with strangulation ileus

We examined the effectiveness of sequential organ failure assessment (SOFA) score to describe patients with strangulation ileus. The subjects consisted of 66 patients given a diagnosis of ileus who underwent a surgery during the period from January 2001 to December 2006. On the basis of surgical findings, they were classified into two groups; the strangulation group, consisting of 25 patients, and the control group, consisting of 41 patients with simple ileus. The background factors, SOFA score, blood test findings before treatment, and vital signs were compared between these two groups in a retrospective study. Statistically significant differences between the two groups were observed by univariate analysis in the SOFA score, white blood cell count, CRP, CPK, PaCO2, BE, and pulse rate. The SOFA score, white blood cell count, and pulse rate were significant independent factors in the multivariate analysis. These results showed that it may be helpful to use SOFA score in combination with further diagnostic tools, while the experience of clinicians will be still required for diagnosis of strangulation ileus.

D-Dimer Levels in the Prediction of the Degree of Intestinal Necrosis of Etrangulated Hernias in Rats

The aim of this study was to investigate the time-dependent relation between plasma D-dimer levels and the degree of intestinal necrosis and to compare these parameters with leukocyte counts in an experimental etrangulated hernia model in rats. When the duration of intestinal ischemia was prolonged, serum D-dimer levels increased relative to the control group, with the difference being statistically significant at hour 2 (P = 0.027). In contrast, leukocyte counts in the 2- and 4-h strangulation group were higher that those of the control group, but the difference was not statistically significant (P = 0.625 and P = 0.846, respectively). However, in the 6-h strangulation group the levels of leukocytes were significantly higher that those of the control group (P = 0.015). Serum D-dimer measurements may be used as a more valuable diagnostic parameter than leukocyte count in the early diagnosis of intestinal ischemia, including strangulated hernia.

Predictive Value of Procalcitonin for the Diagnosis of Bowel Strangulation

Intestinal obstruction is responsible for 3% of admissions to hospital emergency surgical departments, but it is difficult to distinguish simple obstruction from strangulation. Simple criteria for this distinction are sought. In this experimental study, procalcitonin, a known marker of bacterial inflammation, was used to detect strangulation. The predictive value of procalcitonin for small bowel strangulation was evaluated. Thirty male New Zealand rabbits (mean weight: 3.0 kg) were divided into three groups. In the first (control) group, only laparatomy was performed. In the second group, simple obstruction was created by ligating a 10-cm distal ileum segment. In the third group, distal strangulation was created by ligating a 10-cm distal ileum segment with the mesentery. Blood (1 cc) was taken from the right auricular vein of each animal for measuring the procalcitonin level. In both the control group and the simple obstruction group the procalcitonin levels were normal. In the strangulation group, elevation of procalcitonin was detected after 30 minutes, and the elevation was statistically significant at 120th minute compared with the control and simple obstruction groups. In patients with small bowel obstruction, measurement of procalcitonin levels is easy to perform and can be used in the follow-up. A more extensive clinical study is needed to evaluate the accuracy of the test as a marker.

Does Serum Hexosaminidase Activity Play a Role in the Diagnosis of Strangulated Bowel Obstruction? An Experimental Study

Strangulation is associated with an increased risk of mortality and morbidity in patients with mechanical bowel obstruction. The accurate and early recognition of the presence of strangulation is important to allow safe nonoperative treatment. A number of studies have shown that there was no single and reliable test to detect or exclude the presence of strangulation. The aim of this study was to evaluate the role of serum hexosaminidase (Hex) levels in recognition of strangulation in an experimental model of closed loop small bowel obstruction. Forty-two Wistar albino rats were divided into four groups: I, control (n = 5); II, sham laparotomy (n = 5); III, simple obstruction (n = 16); and IV, strangulation groups (n = 16). Activity levels of total Hex and its fractions (Hex A and B) were assayed in serum samples obtained from rats after 3 and 8 hr. Samples of small bowel were also evaluated histologically. Histological evaluation of bowel sections obtained from the strangulation group after 8 hr, revealed transmural hemorrhagic infarction in all animals with a mean +/- SD total Hex activity of 978.25 +/- 150 nmol/hr/ml, which was significantly higher than that in the other groups (P < 0.001). Although sections of bowel from the strangulation group after 3 hr showed severe ischemic injury, the activities of total Hex, Hex A, and Hex B were not different from those of the control, sham, and simple obstruction groups. Histological examination of these groups did not show any sign of ischemia. Total Hex, Hex A, and Hex B activities in the strangulation group were all significantly greater than the activities seen in the simple obstruction group (P < 0.001, for all). In conclusion, increased serum hex levels indicate irreversible transmural infarction only in the late period of strangulation in the closed loop small bowel obstruction model. It seems unuseful for detecting reversible and/or irreversible ischemia in the early period of strangulation.

Pulmonary and serum surfactant phospholipids and serum catecholamines in strangulation: An experimental study on rats

Elevations of phospholipid and catecholamine concentrations in the blood are regarded as the vital reactions in asphyxial deaths, which leave few or no morphological signs in the body. These vital reactions were tested here, under strict experimental conditions, employing rapid asphyxia. Rats anaesthetized with barbiturate were strangled with a rope 2 mm thick tightened with a force of 29.4 N (3 kp). The main surfactant components, phosphatidyl choline and phosphatidyl ethanol amine, were measured in serum and lung samples, and catecholamines in the serum. The lungs were also investigated histologically. The serum phospholipid concentration in the strangulated rats was 1.36±0.32 g/l, versus 1.04±0.17 g/l in the controls (barbiturate intoxication), P<0.001, but no change in their content was observed in the lungs (26.21±4.04 mg/g vs. 25.15±3.64 mg/g dry weight). Histologically, focal emphysema and tiny haemorrhages were seen in the lungs of both groups with similar frequency. Mean serum noradrenaline (NA) and adrenaline (A) concentrations were significantly higher in the strangulation group (NA=5.4±2.6 ng/ml vs. 2.8±0.1 ng/ml, P<0.001 and A=6.0±3.4 ng/ml vs. 3.8±3.0 ng/ml, P<0.05). The results support the notion that phospholipid and catecholamine concentrations are increased in the blood upon suffocation and could thus be taken as indicators of hypoxia. Further investigations into postmortem phospholipid change or stability are needed. There are reports that phospholipid concentration remain quite stable for two days post mortem, whereas catecholamine concentrations tend to rise quite soon after death.

Conventional radiography and ultrasonography in the diagnosis of small bowel obstruction and strangulation.

Ninety-six patients, 45 men and 51 women (mean age 39 years, range 13- 90 years), with clinically acute abdomen were examined by conventional abdominal radiography and ultrasonography during a period of one year. Ultrasonography was performed with a linear transducer, which permitted study of morphology and motility of small bowel loops: distention, paralysis, intramural thickening, and extraluminal fluid. Nineteen cases of mechanical obstruction (9 simple and 10 of strangulation type) were observed. In the strangulation group ultrasonographic findings were positive in 91% whereas conventional radiography solely was positive in 30%. In the simple obstruction, 89% and 78%, respectively, were correctly diagnosed by the 2 techniques. Ultrasonography is recommended as a routine examination beside conventional abdominal films in acute abdomen.

CT analysis of intestinal obstruction due to adhesions: early detection of strangulation.

We evaluated the CT of intestinal obstruction due to adhesions in 20 postoperative patients, with emphasis on early detection of strangulation. Ten patients with surgically proven strangulated obstruction (strangulation group) were compared with another ten patients (nonstrangulation group) in whom seven improved with conservative management and three had confirmed simple obstruction on surgical exploration. Beak-like luminal narrowing ("beak") was the most common CT finding at the obstructed site in both groups. The CT findings that suggested strangulated obstruction were serrated beaks, mesenteric edema or vascular engorgement, and moderate to severe bowel wall thickening. In contrast, simple obstruction could be assumed when the beak was smooth, there were no mesenteric changes, and the bowel wall was normal or mildly thickened. Computed tomography is a useful tool for detecting strangulation in patients with postoperative adhesive intestinal obstruction.

Catecholamine effects on pulmonary blood vessels in strangulation.

Guinea pigs were killed by strangulation to investigate the vasomotor of pulmonary congestion by asphyxia. The noradrenaline uptake by the endothelial cells of the pulmonary arteries and capillaries was observed by fluorescence histochemistry, peroxidase-anti-peroxidase (PAP) immunocytochemistry, and autoradiography. By radioassay, the volumes of noradrenaline uptake by the pulmonary arteries and capillaries in the strangulation group were at a significantly higher level than in the control groups. Many myoendothelial junctions were observed at the sites of constricted arteries, and the invasive noradrenaline was clearly observed in the myoendothelial junction. The mechanism of the pulmonary vasoconstriction in strangulation is due to the fact that the plasma noradrenaline, increased by asphyxia, invades the endothelial cells of pulmonary arteries and capillaries and causes the vasoconstriction.

EARLY RECOGNITION AND MANAGEMENT OF INTESTINAL STRANGULATION

Although improvements in therapy have resulted in a decided reduction in mortality in simple mechanical obstruction of the small bowel, the mortality in strangulation obstruction is still high. In a recentreport by McKittrick and Sarris,159 per cent of the deaths in their patients with intestinal obstruction occurred in the strangulation group. In the hospitals of the Medical College of Virginia, strangulation of the small bowel has been responsible for more deaths in the years 1941 to 1946 than appendicitis with rupture and peritonitis. Most authors agree that the most important factor influencing a favorable outcome in strangulation of the small bowel is early surgical intervention. A study of the patients seen by us during the past five years has impressed us with the likelihood that if close attention is paid to the clinical history and to the physical observations early and correct diagnosis of intestinal strangulation is usually