Medicine, as a profession, is quite a hard commitment, with the main aim of giving care to patients. Physicians assume professional accountability not only to their patients and relatives but also to legal authorities. In case of insufficiency in exercising this multi-dimensional accountability, they may confront legal and ethical issues. A high index of awareness of responsibility and accountability may help them avoid getting involved in unwilling situations. This article revisits physicians’ and, in particular, surgeons’ legal liability to medical legislation and jurisprudence in Turkey, with emphasis on medico-legal consequences.

BACKGROUND: We compared three repair techniques, namely, simple closure and omentoplasty, simple closure alone, and fibrin tissue adhesive, in the treatment of rat duodenal perforations induced in the postpyloric region. METHODS: Thirty male Sprague-Dawley rats (210-240 g) were included. Under ketamine and ether anesthesia, duodenal perforations of 2 mm were induced in all rats in the postpyloric region. The rats were assigned to three groups equal in number, which underwent repair with the use of simple closure and omentoplasty, simple closure alone, and fibrin glue, respectively. All the animals were sacrificed under deep ether anesthesia on the fourth postoperative day. To assess wound strength, bursting pressure measurements were performed. In addition, hydroxyproline content of the wound site was measured by absorbance spectrophotometry at 560 nm. RESULTS: The mean bursting pressure in the simple closure and omentoplasty group was significantly higher than those of the simple closure (p<0.05) and fibrin glue (p<0.001) groups. No significant difference existed between the simple closure and fibrin glue groups in this respect (p>0.05). Hydroxyproline values of the simple closure and omentoplasty (p<0.05) and simple closure (p<0.001) groups were significantly lower than that of the fibrin glue group. CONCLUSION: Fibrin tissue adhesives may have an application in the treatment of duodenal ulcer perforations, as an adjunct to laparoscopic or open surgical methods.

BACKGROUND: The aim of the study was to evaluate the results of treatment for ano-rectal gunshot injuries in civilian population, caused by low-velocity bullets. METHODS: Nine patients with ano-rectal gunshot injuries were admitted to the emergency department. All the patients were males, with a mean age of 23 years (range 20 to 37 years) and presented within the first two hours following injury. Complete physical and abdominal examinations were performed and injury severity scores (ISS) were calculated. Injuries were evaluated by rectosigmoidoscopy in the operating room. Seven patients had associated tissue or organ injuries including bladder disruption, pelvic bone fractures, and wide muscular defects. Surgical procedures included a diverting ostomy, irrigation of distal rectum, presacral drainage (6 patients), and retrorectal drainage through the abdomen (3 patients). Antibiotic prophylaxis was routinely administered. Control examinations were made at the end of the second month. RESULTS: Seven patients had rectal blood discharge on admission. The mean ISS score was 7.3±3.7, with only one patient having an ISS of 15. Early postoperative complications were urinary infection in three patients, wound dehiscence in five patients, and osteomyelitis in one patient. Anal continence was not adversely influenced after surgery. CONCLUSION: Our results suggest that a diverting ostomy, distal rectal irrigation, and presacral drainage yields favorable outcome in patients with ano-rectal gunshot injuries.

BACKGROUND: A retrospective evaluation was made on iatrogenic cardiac traumas requiring surgical treatment, that were induced by cardiac catheterizations and interventions performed within a 17-year period. METHODS: A total of 64,911 patients underwent cardiac catheterizations and interventions from 1985 to 2002. Complications of iatrogenic cardiac traumas induced by these interventions were examined together with the surgical treatment performed within 24 hours after catheterization. RESULTS: Iatrogenic cardiac trauma requiring prompt surgical intervention was documented in 20 patients (6 females, 14 males; mean age 51 years; range 31 to 69 years). These were due to coronary angiography/balloon angioplasty-stenting in 14 (70%), percutaneous mitral balloon valvuloplasty in four (20%), and to heart catheterization in two patients (10%). Acute cardiac tamponade was detected in 10 patients (50%) resulting from perforations to the cardiac chambers in six, coronary arteries in two, and major vessels in two patients. Surgical interventions included coronary artery by-pass in 14, mitral valve surgery in four, and repair of major vessels in two patients. Perioperative mortality occurred in two patients. Six patients developed complications contributing to morbidity, including perioperative myocardial infarction (3 patients), infection (2 patients), and prolonged intubation (1 patient). CONCLUSION: In case of major cardiac complications induced during cardiac catheterizations, early diagnosis and prompt surgical intervention are of vital importance regardless of considerably high risks.

BACKGROUND: The use of an intraaortic balloon pump (IABP) catheter was retrospectively evaluated in terms of risk factors, insertion techniques, and complications in patients with low cardiac output. METHODS: A total of 1036 patients (804 males, 232 females; mean age 53.4 years; range 16 to 75 years) received IABP support from 1985 to March 2002. Of these, 789 patients (76.1%) underwent open heart surgery, 247 patients (23.8%) developed low cardiac output during medical treatment. Insertion of IABP was performed via the femoral artery either percutaneously by the Seldinger technique in 897 patients (86.6%), or by direct surgical exposure in 88 patients (8.5%). Open surgical IABP insertion was performed through an 8 mm Dacron graft placed with an end-to-side anastomosis to the common femoral artery (88 patients) or to the ascending aorta (23 patients). RESULTS: The overall mortality rate was 35.1% (364 patients). Vascular complications were associated with IABP in 104 patients (10%), of which 57 patients (5.5%) required surgical treatment. Major complications were aortic arch dissection in two patients and paraplegia in two patients. Vascular complications tended to increase with female gender, older age, diabetes, and peripheral vascular disease. The mean duration of IABP support in the presence of vascular complications was 7.8 days (range 5 hours to 77 days). CONCLUSION: Application of unsheathed IABP and proper evaluation of peripheral circulation seem to decrease the incidence of vascular complications.

BACKGROUND: We evaluated the results of local tissue plasminogen activator (t-PA) infusion in the treatment of axillary vein thrombosis. METHODS: Fourteen male patients (mean age 23±2 years) who presented with pain and swelling in the arm were diagnosed as having axillary vein thrombosis. Besides physical examination, diagnoses were made with the use of venous Doppler ultrasound, duplex scanning or venography. Complaints were localized in the right upper arm in 10 patients, and in the left upper arm in four patients. Time to presentation from the onset of complaints ranged 1-3 days, 3-7 days, 7-10 days, and 10-14 days in six, three, two, and three patients, respectively. Infusion of t-PA (0.25 mg/kg) was performed for one hour via a venous catheter inserted to the distal part of the brachial vein. Venous patency was evaluated using Doppler ultrasound and venography. RESULTS: Axillary vein was shown to be patent by venous Doppler ultrasound in eleven patients within a mean of 4.2 hours. Three patients who exhibited no improvement received another t-PA (0.05 mg/kg/h) infusion six hours after the initial treatment. Venous Doppler ultrasound showed almost complete patency of the lumen after six, seven, and 11 hours of the subsequent infusion, respectively. Following therapy, all the patients were administered prophylactic anti-aggregating treatment. On control examinations after three months, venous Doppler ultrasound and venography showed that the lumens were almost completely patent in 12 patients and two patients, respectively. No recurrences were detected. CONCLUSION: Fibrinolytic agents yield high efficacy in the treatment of axillary vein thrombosis.

BACKGROUND: Ruptured abdominal aortic aneurysm (RAAA) is a highly mortal entity. In recent years, the role of seasonality has been proposed in the incidence of RAAA. In this study, we sought possible correlations between monthly atmospheric pressures and the number of patients admitted with RAAA. METHODS: Twenty-four patients who were admitted to our Trauma and Emergency Surgery Department with a diagnosis of RAAA from January 1995 to May 2003 were retrospectively evaluated. Data were collected from patient records, admission charts, hospital death certificate registry, and operating-room records. Only patients whose diagnosis of RAAA was confirmed during surgery were included. Atmospheric pressure records of Ýstanbul for individual months covering the study period were obtained from the Meteorology Office. The incidences of RAAA and the mean monthly atmospheric pressures were compared. RESULTS: Most of the patients were admitted in winter months. Admissions culminated in January with six patients, at which time the mean atmospheric pressure was 765.5 mmHg. There were no admissions in May, during which the mean atmospheric pressure was 760.8 mmHg. The distribution of monthly admissions for RAAA was not statistically significant (p>0.05). The mean atmospheric pressures tended to run a higher course before the months in which increased admissions were seen. CONCLUSION: Our findings do not corroborate the presence of a relationship between the incidence of RAAA and the atmospheric pressure.

BACKGROUND: We evaluated thoracic trauma cases with regard to etiologic causes, treatment methods, outcome, and factors affecting the results in the light of our experience and relevant literature data. METHODS: A retrospective evaluation was made of 521 patients (399 males, 122 females; mean age 42 years; range 4 to 93 years) who were treated for thoracic trauma from September 1997 to August 2002. RESULTS: Isolated thoracic trauma and multisystem trauma were found in 348 (67%) and 173 (33%) patients, respectively. Blunt injuries accounted for 87%, the most common cause being traffic accidents (62%), and penetrating injuries accounted for 13%. The most frequent thoracic pathologies included multiple (56%) and single (24%) rib fractures, and flail chest (8.4%). Extrathoracic injuries were seen in 33.2%, the extremities (41%) and the skull (40%) being the most commonly involved. Treatment consisted of symptomatic treatment in 159 patients (30.5%), tube thoracostomy in 337 patients (64.6%), and thoracotomy in 15 patients (2.9%). In isolated thoracic trauma and multisystem trauma, morbidity rates were 3.4% and 22%, and mortality rates were 2.5% and 16.2%, respectively. The overall mortality was 7.1% (37 patients). The mean length of hospital stay was 7.1 days (range 1 to 64 days). CONCLUSION: A great majority of thoracic trauma patients can be treated with conservative methods or tube thoracostomy. Accompanying multisystem traumas are associated with dramatic increases in morbidity and mortality rates.

BACKGROUND: We retrospectively reviewed patients who were treated and followed-up for mandibular fractures within a 10-year period. METHODS: A total of 204 patients (158 males, 46 females; mean age 22.4 years; range 5 to 72 years) were retrospectively evaluated with respect to age groups, sex, etiology, associated injuries, localization and type of the fractures, treatment methods, and early and late complications. The follow-up period ranged from four months to 10 years. RESULTS: The most common cause of injury was traffic accidents (44.1%), followed by falling (31.8%), and violence (17.1%). The highest incidence occurred at ages 21 to 30 years. Of 283 fractures detected, the most common fracture sites were the parasymphysis (83 fractures, 29.3%) and the angulus (52 fractures, 18.4%). Forty-eight patients (24%) had associated injuries. The type of the fractures was simple in 80 patients (39.2%), and complex in 62 patients (30.4%). Treatment included open reduction with titanium mini-plates and screws in 130 patients, and intermaxillary fixation in the remaining patients. The fractures recovered without any complications in 167 patients (81.8%). No occlusion-related complications occurred in the late follow-ups. Complications were encountered in 37 patients (18.1%), being in the early (malocclusion in 5.9%, infections in 2.5%, inferior alveolar nerve injuries in 2.5%) or late (plate-screw exposition in 4.4%, ankylosis of the temporomandibular joint in 2%, and orocutaneous fistula in 1%) postoperative periods. CONCLUSION: Rigid fixation should be the first choice of treatment in mandibular fractures.

BACKGROUND: We evaluated the clinical and functional results of nerve repair in patients with combined tendon-nerve injuries of the forearm. METHODS: The study included 68 patients (58 males, 10 females; mean age 33.5 years; range 5 to 48 years) with combined tendon-nerve injuries of the forearm. A total of 96 nerves were repaired. Patients with nerve defects were excluded. Both median and ulnar nerves were injured in 17 patients; median and ulnar nerve injuries were detected in 17 patients and 34 patients, respectively. The mean time to operation was four hours (range 20 min to 24 h). Primary nerve repair was performed in 60 patients, and secondary repair was performed in eight patients. The interfascicular technique was employed in 18 patients, and epiperineural suture in 50 patients. Rehabilitation included early motion using the Washington regimen. A modified MRC (Medical Research Council) motor and sensory classification system was used for postoperative evaluation. The mean follow-up was at least two years. RESULTS: The modified MRC results were as follows: of 17 patients with median nerve injuries, 10 had excellent, seven had good results. Of 34 patients with ulnar nerve injuries, the results were excellent in nine, very good in 10, good in 10, and fair in five patients. Of those with median and ulnar nerve injuries, four, seven, and six patients had excellent, very good, and good results, respectively. Overall, 61 patients (89.7%) had satisfactory results. A significant correlation was found between age and the MRC results (p=0.016). CONCLUSION: Primary nerve repair followed by early motion results in substantial rates of excellent and satisfactory results in patients with combined nerve-tendon injuries.

Aortic injuries can easily be missed in polytraumatized patients due to either associated injuries or vagueness of physical examination findings. Especially in young adults without associated injuries, relatively low atherosclerotic changes may limit the dissection of traumatic descending aortic injuries. We present a 34-year-old male patient who only had a complaint of back pain following a traffic accident. Upon detection of no abnormalities on plain X-ray films, he was discharged home with analgesics. One week later, he presented with dypsnea and dysphagia. Aortography showed rupture of the aorta and a pseudoaneurysm near the isthmus. Following surgical excision of the pseudoaneurysm and aortic repair with a Dacron graft interposition he was discharged with complete relief of symptoms. This case emphasizes the need for a high index of clinical suspicion in timely diagnosis and prompt treatment of traumatic aortic ruptures.

Acute appendicitis and blunt abdominal trauma are common surgical emergencies. Whether there is a causative relationship between these two entities has long been a subject of debate. A twenty-one-year-old male Japanese tourist presented with vague abdominal pain and dysuria that began after he had been beaten and robbed. No signs of trauma were detected on physical examination; however, there were diffuse abdominal sensitivity with maximal tenderness in the hypogastrium and rebound tenderness in the right lower quadrant. Upon no improvement with medications within 24 hours, laparotomy was performed, which revealed an inflamed appendix, a few enlarged mesenteric lymph nodes, and free peritoneal fluid that was found to be sterile. Following appendectomy, the diagnosis was confirmed by pathologic examination and the enlargement of the lymph node was attributed to non-specific reactive hyperplasia. The patient had an uneventful postoperative course, with relief of pain and fever.

Appendiceal mucocele is a rare clinical condition that causes distension of the appendix lumen with mucus. A seventy-three-year-old female patient presented with complaints of abdominal pain, nausea, and vomiting. Abdominal examination revealed mild tenderness, right lower quadrant pain upon palpation, rebound tenderness and muscular rigidity, and a palpable mass. Abdominal ultrasonography and computed tomography scans demonstrated a cystic lesion in the right iliac fossa, adherent to the cecum, suggesting an abdominal abscess. An emergency operation was performed, during which a diagnosis of a mucocele of the appendix was made. Surgical treatment included appendicectomy, partial resection of the ileum, and resection of the cecum. Histopathologic examination confirmed the operative diagnosis. The role of imaging and clinical approach is emphasized in the treatment of an appendiceal mucocele, especially in emergency settings.

Appendiceal mucoceles are a group of lesions in which the appendiceal lumen becomes distended with mucus. They may be associated with an unusual form of gelatinous ascites termed pseudomyxoma peritonei. We report herein a 77-year-old male patient with appendiceal mucinous cystadenocarcinoma and pseudomyxoma peritonei, whose initial symptoms were abdominal pain and distension and intestinal obstruction. He had a history of explorative laparotomy for an abdominal mass and ascites 14 months ago at another center. He was suffering from abdominal pain and intestinal obstruction on admission to the emergency service. We performed right colectomy and total resection of the mass which originated from the appendix. Pathologic examination of the specimen showed low-grade mucinous cystadenocarcinoma and pseudomyxoma peritonei. The postoperative period was uneventful.