among all emergency cases the ratio of incarcerated / strangulated hernias differs across the countries .
but it is well known that hernia is the common cause of small bowel obstruction , and mortality and morbidity rates increase in case of strangulation . during acute ischemic conditions , metal binding capacity of albumin
this change is quantifiable and commonly known as ischemia modified albumin ( i m a ) .
recently , i m a measurement has been proposed as a sensitive marker for the diagnosis of myocardial ischemia presenting with typical acute chest pain .
however , i m a levels are also known to increase in other ischemic conditions , as well as to be an indicator of oxidative stress , and may not be specific for cardiac ischemia .
recently , turedi et al .   showed that the level of i m a may be of use in the diagnosis of pulmonary embolism , another ischemic condition .
incarceration is the state of an external hernia which can not be reduced into the abdomen .
roughly 5% of all patients having an operation for external hernia are explored as an emergency . strangulated external hernia is a relatively common and serious surgical emergency and accounts for most of the deaths from this condition .
clinical validation of any test for ischemia is difficult as there is no accepted diagnostic gold standard . and
the preoperative diagnosis or prediction of ischemia is important for surgeons because ischemia changes the operative strategy .
thus we planned this study and aimed to show relation between the intestinal ischemia and i m a .
our study was initiated after anakkale onsekiz mart university ( comu ) animal ethics committee approval ( approval number 2010/11.02 ) and took place in comu laboratories .
twenty wistar albino rats were used weighing 153207  g and were housed in optimum conditions . in this study rats
, they were kept for two weeks in cages with five animals each and 12  :  12-hour artificial light to dark cycles .
we aimed to mimic incarceration by short clamping ( 45 minutes ) and strangulation by 6 hours clamping .
ketamine hcl ( ketalar , pfizer , turkey ) 35  mg / kg and xylazine ( basilazin flacon % 2 , turkey ) 5  mg / kg were administered intraperitoneally as anesthetic agents . 

after midline laparotomy , mesenteric vascular structures of small intestine were clamped by a vascular clamp .
then blood samples were taken [ for i m a ( ima1 ) and lactate dehydrogenase ( ldh ) ] and midline incision was closed separately by polypropylene sutures .
after midline laparotomy , mesenteric vascular structures of small intestine were ligated by 2/0 polypropylene sutures and midline incision was closed separately by polypropylene sutures .
midline laparotomy was done again at 6th hour , intestinal necrosis were seen , and blood samples were taken [ for i m a ( ima2 ) and ldh ] .
after midline laparotomy then blood samples were taken [ for i m a ( ima1 ) and ldh ] and midline incision was closed separately by polypropylene sutures .
but incarceration is a known ischemia reperfusion process and total vascular clamping is a widely used method to investigate ischemia reperfusion in rats .
so we used this method to simulate incarceration in group i. also total occlusion of all vascular support of the small intestine is used in group ii to provide the smaller amounts of ischemic / necrotic tissue in group i and group ii and to prevent the potential effect of ischemic / necrotic tissue amount on i m a levels .
reduced cobalt to albumin binding capacity ( i m a levels ) was analyzed using the rapid and colorimetric method developed by bar et al . .
results higher than 0,4 absu were estimated as ischemia and lower than 0,4 absu were estimated as normal .
kruskal - wallis test was used to compare the groups and probability ( p ) values less than 0.05 were considered significant .
the significance of the parameters in kruskal - wallis test was confirmed by mann - whitney u test and p values less than 0,016 were considered significant .
kruskal - wallis test is the standard variance analysis test to compare the means of 3 or more groups .
kruskal - wallis test gives us the difference between the groups , but it does not give any idea about which group is the cause of this difference .
we used mann - whitney u test with bonferroni correction ( the p value for mann - whitney u test by bonferroni correction is found to be 0,05/number of groups = 0,016 for this study ) .
mean ima1 levels of group i , group ii , and group iii were 0,41  0,01 ( range 0,400,45 ) , 0,46  0,16 ( range 0,440,48 ) , and 0,34  0,03 ( range 0,280,39 ) , respectively
mean ldh levels were 819,71  34,53 ( range 766874 ) , 808,57  24,69 ( range 774841 ) , and 514,14  19,92 ( range 487545 ) for groups i , ii , and iii , respectively .
the difference of i m a levels between group i and group ii was not significant at 6th hour ( ima2 ) ( p : 0,71 )
during acute myocardial ischemia , the ability of binding ions such as copper , zinc , and cobalt is decreased ; therefore a form of albumin is produced , which is described as ischemia modified albumin ( i m a ) .
the i m a was registered by the united states food and drug administration as a marker of myocardial ischemia .
the test is based on the decreased ability of albumin to bind cobalt due to the structural change of nh2 which develops in the ischemic environment .
it is important to emphasise that the decreased ability of albumins to bind cobalt occurs in hypoxia , acidosis , sodium and calcium pump malfunctions , and tissue damage caused by free radicals [ 7 , 8 ] .
it has been shown that the concentration of i m a increases within a couple of minutes from the onset of ischemia , remains elevated until 6 to 12 hours , and returns to its normal range after 24 hours .
but recent studies showed that i m a increases in mesenteric ischemia , stroke , and cerebrovascular accidents as well [ 1 , 10 ] .
found significantly higher i m a levels in superior mesenteric artery thromboembolism and they concluded that i m a can be used in the diagnose of mesenteric ischemia .
patients requiring emergency repair tend to be a member of an elderly and unfit population [ 1315 ] .
ge et al . concluded that the main causes of high incarceration rates are economic problems and lack of insurance .
morbidity and mortality risks of incarcerated hernias are increased by longer duration of symptoms [ 1315 , 19 , 20 ] , type of hernia ( femoral rather than inguinal hernia ) , a high american society of anesthesiology ( asa ) score [ 14 , 17 , 19 , 21 ] , the presence of comorbidities [ 14 , 15 ] , and the presence of bowel necrosis [ 14 , 17 , 19 ] .
this study aimed to predict necrosis by i m a levels and explore the impact of ldh .
we can evaluate asa score , duration of symptoms , and the presence of comorbidities preoperatively , but the need for an intestinal resection is unclear until surgery .
this has been reported to be the case even for experienced surgeons where the sensitivity has been reported to be , at best , 48% .
maeda et al . reported that the serum creatine phosphokinase ( cpk ) level was a useful marker for the diagnosis of a strangulated hernia , and ohira et al . found that cpk , lactate dehydrogenase , and metabolic acidosis , in addition to ultrasound and enhanced computed tomography , were of value in diagnosing strangulation of the intestine in some cases .
a definitive diagnosis of strangulation of the intestine , however , can only be made during a surgical exploration [ 5 , 25 ] .
the current series showed a significant increase in the need for a resection of the small intestine when the time from onset of symptoms to surgery was more than 12 hours ; the rate of resection of the small intestine in patients presenting within 12 hours was 14.3% , but it increased to 50% in patients presenting after 12 hours or more ( p = 0.0392 ) .
reported that the resection rate in the bowel operated on within 24 hours was 7% , but when the time increased to 48 hours or more , the resection rate increased up to 27% .
's results.ldh was elevated in both incarceration and strangulation groups but it was failed to predict necrosis . in this study we aimed to predict intestinal necrosis by i
it is important to predict necrosis , because incarcerated hernias are more frequently seen in elderly patients , and their prevalence in the over-60-year - old population ( added comorbidities and anesthetic risks ) has been reported to be 9.8% compared with 1.8% for younger patients . besides it is known that general and spinal anesthesia are both associated with higher rates of serious postoperative complications .
the prediction of necrosis can give both the surgeon and the patient the chance of local anesthesia .
unfortunately the disadvantage of this study is the lack of evaluating other predictive values like cpk levels and since this study is an animal study , pospective human studies must be performed using i m a to be able to suggest that i m a is a gold standard to predict strangulation in the hernia sac .
i m a is a new marker of ischemia and its place in general surgery is not well known yet .
further studies should be done to predict intestinal necrosis in the hernia sac , to be able to protect old and unfit patients from the anesthesia associated mortality and morbidities .
 
 purpose . to evaluate the predictive effect of i 
 m a in incarcerated hernias . methods . 
 three groups ( n = 7 ) of rats were operated . 
 group i aimed to mimic incarceration , group ii aimed the strangulation , and group iii was the sham group . 
 i m a and ldh measurements were made . results . 
 i m a levels were significantly higher in strangulation mimicking group and i m a levels were normal at postoperative 6th hour in incarceration mimicking group . 
 ldh levels were significantly higher in both incarceration and strangulation mimicking groups . conclusion . 
 i m a seems to be an effective marker in incarcerated hernias to predict necrosis . 
 but we need further studies to generalise this hypothesis . 
1. Introduction
2. Results
3. Discussion
4. Conclusion