Geliþen cerrahi teknikler ve destek tedavilerine raðmen, batýn içi enfeksiyon veya peritonit önemli bir morbidite ve mortalite nedeni olmaya devam etmektedir. Peritonit sebepleri arasýnda, fekal peritonit ayrý bir öneme sahiptir. Çünkü kolon florasý aerob ve anaeroblarý kapsayan geniþ bir spektrumu sahiptir. Sýçanlarda yaptýðýmýz bu deneysel çalýþmada, çekal perforasyon sonucu bir peritonit modeli oluþturulmuþtur, Bu çalýþmada, böyle bir patolojide yer alabilen ajan patojenler ve tedavide batýnýn serum fizyolojik (SF) ile yýkanmasý ve güncel, geniþ spektrumlu antibiyotiklerin etkinlikleri araþtýrýlmýþtýr. Ajan patojen olarak, gram negatif (en sýk E. Coli) ve anaeroblarýn (en sýk B. Fragilis) ön planda yer aldýðý teyid edilmiþ, SF ile yýkamanýn bir faydasý olmadýðý ve uygulanan üç farklý antibiyotik grubunun (Sefriakson-Ornidazol, Seftazidim ve Meropenem) hem anaerob, hem de gram negatif bakterilere etkili olduðu saptanmýþtýr. Monoterapi olarak düþünüldüðünde, penetran batýn yaralanmalarýnda olasý kolon yaralanmasý da düþünülerek, seftazidim ve meropenemin uygun ampirik antibiyotik olarak kullanýlabileceði gösterildi.

Intra-abdominal infection of peritonitis has an important morbidity and mortality rate in spite of developing surgical techniques and supportive treatment. As a cause of peritonitis, fecal peritonitis is a very important type of infection. Antibiotics with a wide spectrum of activity must be chosen, because the colonic flora has a wide range of bacterial pathogens including anaerobesb. In this study, fecal peritonitis was induced by a 5 mm cecal perforation on adult 50 Wistar-Albino rats. The microbiological pathogens in fecal peritonitis and the effect of mechanical lavage of the abdomen with saline, and three different types of antibiotics (Ceftriaxone-Ornidazole, Ceftazidime and Meropenem) were investigated. It was found that gram negative bacteries (especially E. Coli) and anaerobes (especially B. Fragilis) were the dominant pathogens, mechanical lavage with saline wasn't useful and all three type of antibiotic groups were effective in anaerob and in gram negative bacteria. As monotherapy, ceftazidime and meropenem were found to be effective ampiric antibiotics against penetrating abdominal wounds.

Bu çalýþmada pankreas ve safra yolu obstrüksiyonunun pankreatit oluþumuna etkisi araþtýrýldý. Sýçanlar sham grubu (A), ana safra kanalý (AÞK) ligasyonu (B), ASK'nýn pankreatik kýsmýn ortasýndan ligasyonu (C), ASK ve PK'ýn duodenuma açýldýðý noktadan ligasyonu (D) ve duodenumun proksimal ve distalinin ligasyonu (E) þeklinde 5 gruba ayrýldý. Sýçanlardan biliribin, alkalen fosfataz, kalsiyum, amilaz, laktik dehidrogenaz (LDH), C-reaktif protein (CRP) ölçümleri için 6. ve 36. saatlerde kan alýndý. Sýçanlar 36. saatte sakrifiye edilerek pankreaslarý eksize edildi, yaþ aðýrlýklarý tartýldý, histopatolojik olarak incelendi. Pankreatitin þiddeti D grubunda diðer gruplara göre anlamlý olarak yüksek bulundu. Sonuç olarak, pankreatit geliþen sýçanlarda amilazýn yanýnda LDH ve CRP'nin erken dönemde yüksek bulunmasýnýn spesifik olmamakla beraber akut pankreatit tanýsý konulmasýnda yararlý olacaðý düþünüldü. Pankreatik kanal içerisine safra reflüsünün ve kolesistokinin'in obstrüksiyonla meydana gelen akut pankreatitin patogenezinde önemli rol oynadýðý kanýsýna varýldý.

In this study, the effect of common bile and pancreatic duct obstruction were evaluated in the devolepment of acute pancreatitis. Rats were divided into the following groups; group A: Sham ligation, group B: Ligation of common bile duct, group C: Common bile duct ligation in middle portion of pancreas, group D: Ligation of common bile-pancreatic duct (adjacent to the duodenal wall), group E: Duodenum ligation (proximal and distal). Their blood was collected for measurement of amylase, lactic dehydrogenase (LDH), C-reactive protein (CRP), bilirubin, alkaline phosphatase, calcium concentration at 6th and 36th hr after operation. The rats were killed at 36 hr. Each pancreas were excised, weighed and processed for histological examination, the severity of pancreatitis was evaluated. The severity of pancreatitis was significantly increased in group D compared to that in other groups. Amylase, LDH and CRP were found as biochemical markers in early period. We are considered that bile reflux into pancreatic ductal system and cholecystokinin play a role in the pathogenesis of bile and pancreatic duct obstruction-induced acute pancreatitis.

1990 ile 1995 tarihleri arasýnda penetran abdominal travma nedeni ile opere edilen 521 olgudan, mide ve özofagus yaralanmasý saptanan 94(%18) olgu travma etkeni, yandaþ organ yaralanmasý, tedavi yöntemleri, Penetran Abdominal Travma Ýndeksi (PATÝ), morbidite ve mortalite açýsýndan deðerlendirildi. Olgularýmýzýn 74'ü erkek, 20'si kadýn olup, yaþ ortalamasý 33.5 idi. Travma etkeni 26 (%27.7) olguda kesici-delici aletler (KDAY), 68 (%72.3) olguda ateþli silahlardý (ASY). 3 (%3.3) olguda özofagus, 2 (%2.1) olguda özofagus + mide ve 89(%94.7) olguda mide yaralanmasý saptandý. Olgularýn 9 (%9.6)'unda izole mide yaralanmasý görülürken, 85(%90.4) olguda yandaþ intraabdominal organ yaralanmasý okluðu görüldü. Özofagus yaralanmasý olan 5 (%100) ve mide yaralanmasý olan 91 olgudan 88(%96.7)'ine primer sütürle onarým yapýldý. 3 (%3.3) olguda geniþ doku kaybý nedeniyle distal mide rezeksiyonu + gastroenterostomi yapýldý. Olgularýn hiçbirinde özofagus ve mideye yapýlan operasyon ile direkt iliþkili olarak komplikasyon geliþmezken, yandaþ organ yaralanmalarý ile iliþkili olarak 8 (%8.5) olguda majör komplikasyon geliþtiði belirlendi. 8 (%8.5) olgu intraoperatif olmak üzere toplam 15 (%15.9) olgu kaybedildi. Kaybedilen olgularda PATÝ'nin, 6 ile 97 arasýnda olduðu ve ortalama deðerin 46.4 olduðu görüldü. Sonuçlarýmýz, geniþ doku kaybýna neden olmayan mide ve özofagus yaralanmalarýnýn primer sütür yöntemiyle hýzlý ve güvenle onarýlabileceðini, morbidite-mortalitenin daha çok yandaþ organ yaralanmalarýna baðlý olduðunu göstermektedir.

Between the years 1990 and 1995, 521 patients underwent surgery secondary to penetrating abdominal trauma. Of 94 patients (18%) who had sustained injuries to the stomach and esophagus were evaluated according to the etiology of the trauma, associated organ injury, principles of treatment, penetrating abdominal trauma index (PATI), morbidity and mortality rates. Seventy four of patients were male and 20 female with a median age of 33.5. The mechanism of the injuries were stab wounds (in 26 of the patients) and gunshot wound (in 68 of cases) with rates of 27.7% and 72.3% respectively. There were 3 esophageal (3.3%), 89 gastric (94.7%) and 2 combine (2.1%) injuries. Only nine patients (9.6%) had isolated gastric injury while in 85 of them (90.4%) there were associated injured intraabdominal organs. Primary repair was performed in 5 of the esaphageal (100%) and 88 of the gastric (96.7%) injuries. Three patients (3.3%) underwent distal gastric resection and gastroenterostomy because of the extent of the injury. There were no morbidity directly related with the repair of these two organs, but were 8 major (8.5%) complications secondary to the associated injuries. 15(15.9%) cases-eight of them intraoperatively who died-had a mean PATI of 46.4 (ranged 6-97). As a result most of the esophageal and gastric injuries-except the ones with vide loss of tissue - can be repaired quickly by primary repair with safety. Morbidity and mortality cause are belong to the associated organ injuries.

Þubat-1988 ile Þubat-1996 tarihleri arasýnda torakoabdominal yaralanma nedeni ile laparotomi yapýlan 722 olgu yaþ, cins, travma etkenleri, baþvuru anýnda ölçülen kan basýnçlarý, transfüzyon sayýsý, torakotomi gerekliliði, organ yaralanmalarý ve yaralanma sýklýklarý, morbidite ve mortalite bakýmýndan incelendi. Travma þiddeti, injury severity score (ISS) ve abdominal trauma index (ATI) ile deðerlendirildi. Travma etkeni 387 (%53.6) olguda ateþli silah yaralanmasý (ASY), 157(%21.7) olguda kesici-delici alet yaralanmasý (KDAY), 178(%24.7) olguda ise künt travmalar (KT) idi. Olgularýn 522(%72.3)'sine kapalý toraks drenajý, 96(%13.3)'sýna acil torakotomi, 21 (%3)'ine ise geç torakotomi yapýldý. ISS ve ATI deðerlerinin, travma etkenlerine göre deðiþiklik gösterdiði ve ASY'da sonuçlarýn daha yüksek olduðu saptandý (p<0.001). En sýk yaralanan abdominal organ karaciðer (%37.5) olup, bunu ince barsaklar (%33.1) ve diyafragma (%30) izlemekte idi. Postoperatif geliþen, komplikasyonlar içinde en sýk ampiyem (%5.7) görülürken, bunu ARDS (%2.5) ve intraabdominal abse (%2.1) izliyordu. Çalýþmamýzdaki genel morbidite oraný %19.4'tür. Serimizde en yüksek mortalite %14.2 ile ASY grubunda saptanmýþ olup, bunu %13.5 oraný ile KT ve %4.5 oraný ile KDAY'larý izlemekteydi. Genel mortalite oraný ise %11.9'dur. Sonuç olarak; torakoabdominal yaralanmalarda hemodinamik dengenin ciddi olarak bozulduðunu, bununla iliþkili olarak hýzlý geliþen hipovoleminin mortalite oranýný arttýrdýðýný saptadýk. Ayrýca, yaralanan abdominal organ sayýsý 3'ün ve ATI deðeri 37'in üzerindeki olgularda mortalite oraný belirgin olarak yükselmektedir (p<0.001).

Between February 1988 and February 1996, 722 cases with thoracoabdominal trauma were treated surgically. The cases were examined according to the following criteria: Age, sex, etiology of the trauma, blood pressure at admittance, number of blood transfusions, indications of thoracotomy, involvement of associated organs, morbidity and mortality rates. Severity of trauma was determined by injury severity score (ISS) and abdominal trauma index (ATI). Gunshot wounds were responsible f or 53.6% of injuries (in 387 patient) while stab wounds were responsible for 21.7% (in 157 patients). One hundred seventy eight cases (24.7%) were secondary to blunt trauma. Five hundred twenty two patients (72.9%) underwent tube thoracostomy and in 96 patients (13.3%) urgent thoracotomy was applied. Twenty one patients (3%) underwent delayed thoracotomy. We saw that ISS and ATI depended on the etiology of the injury and were high in gunshot injuries (p<0.001). Empiem (5.7%) was the most common complication seen in thoracoabdominal injuries. While ARDS (2.5%) was the second and intraabdominal abscess (2.1%) was the third. General morbidity rates were 19.4%. The highest mortality rate was 14.2% in gunshot injuries followed by blunt injuries (13.5%) and stab wounds (4.5%). Overall mortality rate was 11.9%. In this study we saw that the hemodynamic instability and rapid development of hypovolemia increased the mortality rates. In addition mortality rates were higher in patients who had 3 or more organs injured and ATI score more than 31 (p<0.001).

Retroperitoneal lokalizasyonu nedeni ile duodenum yaralanmalarý nadir görülür. Yüksek morbidite ve mortaliteye neden olur. Son 10 yýllýk dönemde duodenum yaralanmasý nedeni ile kliniðimizde tedavi edilen 41 olgu, bu çalýþmada retrospektif olarak incelenmiþtir. Olgular Roman Sýnýflamasýna göre grublara ayrýlmýþtýr: Pankreatik yaralanma bulunmayan, komplet veya parsiyel (intramural hematom veya ser-azal yaralanma) yaralanma saptanan 32 (%78) olgu tip I ve II, hafif pankreatik yaralanma bulunan 5 (%12) olgu tip III, aðýr pankreas yaralanmasý, aðýr duktal harabiyetin bulunduðu ve geniþ devitalize duodenal dokunun bulunduðu 4 (%10) olgu ise tip IV olarak belirlendi. Otuz (%73) olguya duodenorafi, 4 (%10) olguya segmental rezeksiyon+anastomoz, 3 (%7.3) olguya divertikülizasyon, 2 (%5) olguya pilorik ekiklüzyon ve 2 (%5) olguya Whipple ameliyatlarý uygulandý. Duodenal fistül 4 (%10) olguda, sepsis 3 (%7.3) olguda geliþti. Peroperatif ve erken postoperatif dönemde 4 (%10) olguda hipovolemik þok; 3 (%7.5) olguda ise geç aperatif dönemde anastomoz kaçaðý, sepsis ve multi-organ yetmezliði nedeni ile mortalite oluþtu. Tip III ve Tip IV olgularýn tümünde mortalite geliþti.

Duodenal injuries, although relatively infrequent, remain an important cause of morbidity and mortality in the trauma patient. In the last 10 years, 41 cases with duodenal trauma, treated at Department of General Surgery, School of Medicine, University of Çukurova were retrospectively reviewed. The cases were classified according to the system proposed by Roman and colleagues: Complete or partial (intramural hematom or serosal injury) injury in type I and II injuries were seen at 32 (78%); associated minimal pancreatic injury with complet or partial duodenal injury as type III at 5 (12%) and severe pancreatic injury with large duodenal defects or ductal impairment as type IV were obtained at 4 (10%) of the cases. Primary suture was performed to 30 (73%) cases, segmental resection and primary anastomosis to 4 (10%) cases, duodenal diverticulization to 3 (7.3%) cases, pyloric exclusion to 2 (5%) and whipple procedure to 2 (5%) cases. Duodenal fistulae developed at 4 (10%) of the cases and sepsis developed at 3 (7.3%). In the peroperative and the early postoperative period, 4 cases died due to hipovolemic shock and 3 cases died because of anastomotic dehiscence, sepsis and multiple organ failure. In type III and type IV, all of the cases died.

Bu çalýþmada 1996 yýlý içinde acil cerrahi kliniðine baþvurarak kesici delici alet veya ateþli silahlarla yaralanan yada kapalý karýn travmasý nedeniyle kabul edilen olgular ile bunlardan laparotomi yapýlanlar incelendi. Negatif laparotomi olgularý üzerinde dikkatle durularak, sebepleri araþtýrýldý. Görüntüleme yöntemleri ile laboratuvar desteðinin daha çok alýnmasý halinde bu oranýn (%29) düþebileceði belirlendi; ancak gecikmiþ laparotominin morbiditesi ile karþýlaþtýrýldýðýnda anýlan ikinci yolun hasta lehine her zaman tercih edilmesi gerektiði sonucuna varýldý.

The evaluation of patients with localized or general body trauma and laparotomy as the right decision during their therapy is one of the major problems for surgical emergency clinics. The term 'Explorative Laparotomy' is kept out of the explorative procedures within the time. Physical examination, vital findings, peritoneal lavage, the evaluation of the abdomen with the help of different imaging techniques and diagnostic are more guiding, when the surgeon plans to perform a laparotomy, and the number laparotomies is changing parallel to this. It is still not possible to reduce the rate of laparotomies to zero. In this study the cases, who were accepted to the surgical emergency clinic of our hospital because of wounds due to stabbing or gun firing or due to closed abdominal trauma, and the cases among these on whom negative laporotomies were performed, have been evaluated. It as been concluded that this rate (29%) can be reduced by having more laboratory support and with the help of the imaging techniques; but it has also been concluded that the second way should be preferred for the patient when we compare the morbidity of negative laparotomy and of delayed laparotomy.

Patella bipartita radyografik incelemelerde rastlantý olarak görülür. Bu aksesuar kemik çoðunluklu asemptomatik görülmesine raðmen, nadiren aðrýlý olmaktadýr. Patella bipartita'nýn karakteristik aksesuar ossifikasyon merkezi superolateral kadranda bulunur. Aksesuar patella'nýn genellikle klinik öneme sahip olmadýðý düþünülmüþtür. Fakat son zamanlarda, bu kemikçiðin anterior diz aðrýsýna sebep olabileceðine dair artan bir ilgi bulunmaktadýr. Bu çalýþmada Ortopedi ve Travmatoloji polikliniðine müracaat eden hastalardan elde edilen 310 radyografi üzerinde aksesuar patellanýn mevcut olup olmadýðý araþtýrýldý. Olgulardan 3'ünde aksesuar patellaya rastlandý. Üçü de erkek olan olgulardan birisi semptomatik bulundu. Bu kemikçik genellikle anatomik ve radyolojik araþtýrmalarda rastlantý olarak karþýlaþýlan asemptomatik bir varyasyondur. Fakat patella travmatize olduðu zaman aksesuar patella semptomatik hale gelebilir. Aksesuar patella ile patella arasýndaki kýkýrdak dokuda meydana gelen bir fraktür ve kýkýrdak dokunun yeterli iyileþme göstermemesi, semptomlarýn ortaya çýkmasýna neden olmaktadýr.

Bipartite patella is usually an incidental radiographic finding. Though mostly seen as asymptomatic finding, the accessory patella rarely be painful. Its characteristic accessory ossification center is located at the superolateral pole of the patella. Bipartite patella is usually considered to be without clinical importance. Recently, however, there has been an increasing awareness that bipartite patella may be associated with anterior knee pain. In this study, 310 bilateral knee radiographs of patients admitted to Orthopaedics an Traumatology clinic were examined in order to investigate the presence of accessory patella (bipartite patella). The accessory patella was encountered in 3 out of 310 patients (-1%). All cases were male and one was symptomatic. This ossicle is usually an asymptomatic variation encountered during anatomatic and radiographic examination. But when the patella was traumatized, painful bipartite patella was caused by fracture through the interposed cartilage which failed to heal satisfactorily.

1986 ile 1996 yýllarý arasýnda künt abdominal travma sonucu karaciðer yaralanmasý geliþen 129 olguya cerrahi tedavi yapýldý. Olgular travma etkenleri, taný yöntemleri, yandaþ yaralanmalar, morbidite ve mortalite açýsýndan incelendi ve majör yaralanmalarda uygulanan cerrahi tedavi yöntemlerinin etkinliði ve sonuçlarý karþýlaþtýrýldý. Minör yaralanmalarda elektrokoter veya 'U' sütürler kullanýldý. Majör yaralanmalarda Debridman + selektif ligasyon + omental tamponad (DSO), Derin matress sütür (DMS), Rezeksiyonel Debridman (RD) veya Perihepatik Packing (PP) yöntemleri uygulandý. Travma etkeni olgularýn 79'unda trafik kazalarý, 37'sinde yüksekten düþme ve 13 'ünde darp idi. 67 olguda majör, 62 olguda ise minör karaciðer yaralanmasý saptandý. 84 olguda yandaþ abdominal organ yaralanmalarý vardý. Karaciðer yaralanmasýna baðlý komplikasyonlar dikkate alýndýðýnda; DMS uygulanan olgulardaki morbidite oranýnýn, DSO ve RD uygulanan olgulara göre istatiksel olarak anlamlý oranda daha yüksek olduðu belirlendi (p<0.001). Genel mortalite oraný %20.2 olarak bulundu. Kaybedilen 26 olgudan 6 (%23.1)'sý minör yaralanma, 20 (%76.9)'si majör yaralanma grubunda idi. Sonuçlarýmýz, majör yaralanmalarda yaralanma derecesi ile birlikte mortalitenin de arttýðýný, portal triadýn geçici oklüzyonu ile birlikte uygulanan DSO ve RD yöntemlerinin, operasyon süresini uzatmadan, transfüzyon sayýsýnda artýþa neden olmadan, DMS yöntemlerine göre daha az morbidite ve mortalite ile uygulanabileceðini göstermektedir.

Between 1986 an 1996, 129 patients with liver injuries secondary to the blunt abdominal trauma were operated. The cases were evaluated according to those criteria: etiology of the trauma, diagnostic methods, associated organ injury, morbidity and mortality rates, results and effectiveness of the surgical procedures that had been applied for major injuries. In minor injuries electrocoagülation or 'U' sutures were applied. Debridement +selective ligation + omental tamponade (DSO), deep matross sutures (DMS), resectional debridement (RD), perihepatic packing (PP) were the choices of the surgical procedures for major liver injuries. Etiologies of the trauma were traffic accident in 79 patients, falls in 37 and beating in 13 patients. There were 67 major and 62 minor injuries. In 84 cases there were an associated abdominal organ injury. When the morbidity due to liver injury itself was evaluated it was seen that morbidity rate in DMS applied group statistically higher than the group underwent DSO and RD (p<0.001). Overall mortality was 20.2%. Six of the 26 deaths (23.1%) had minor injuries and 20 of them (78.9: ) had major injuries. Conclusion: Mortality rate increases with the gravity of injury. DSO and RD combined with suspending the hepatoduodenal ligament are the procedures that can be applied without lengthening the operative time or increasing the need of transfusions.

D.Ü. T. F Genel Cerrahi Anabilim Dalýnda Ocak-1990 ile Ocak-1995 tarihleri arasýnda penetran abdominal travma nedeni ile 521 olguya cerrahi tedavi yapýldý. Çalýþma, kaybedilen 61 olguda mortalite nedenleri ve mortalite ile direkt iliþkili f aktörlerin belirlenmesi amacý ile planlandý. Olgular yaþ, cins, travma etkeni, yaralanma-operasyon intervali, þok varlýðý, yandaþ organ ve damar yaralanmalarý, Penetran Abdominal Travma Ýndeksi (PATI), kan transfüzyonu sayýsý açýsýndan deðerlendirildi. Bu faktörler ile mortalite arasýndaki iliþki araþtýrýldý. Olgularýmýzýn 459 (%88.1)'u erkek, 62 (%11.9)'si kadýndý. ASY'na maruz, kalan 352 (%67.6) olguda mortalite oraný %15.6 iken; KDY'na maruz, kalan 169 (%32.4) olguda bu oran %3.6 idi. Yaralanan abdominal organ sayýsý 3'ün üzerinde olan olgularda mortalitenin arttýðý, 5'in üzerinde ise mortalitenin %34.5'e kadar çýktýðý görüldü. PATI ile mortalite arasýndaki iliþki incelendiðinde, 36'nýn üzerinde mortalite oranýnýn arttýðý, 55'in üzerinde ise bu oranýn %35 olduðu belirlendi. Serimizde, penetran abdominal travmalarda ilk 48 saat içindeki ölümlerin temel sebebinin irreverzibl sok ve koagülopati olduðu; bunun yanýnda 4'ten fazla intraabdominal organ yaralanmasý, eþlik eden kranial ve damar yaralanmalarýnýn mortaliteyi arttýran önemli faktörler olduðu saptandý. PATI'nin abdominal travma þiddeti ve morbiditenin belirlenmesinde kullanýþlý bir skorlama sistemi olduðu, ayrýca mortalitenin belirlenmesinde de yardýmcý olabileceði belirlendi.

Between January 1990-January 1995, 521 patients were operated for penetrating abdominal injury in Dicle University Hospital. This study was planned to identify causes of mortality and factors directly related to mortality in 61 patients who died. Patients were evaluated for age, sex, cause of trauma, interval between injury and operation, presence of shock, associated visceral and vascular injuries, Penetrating Abdominal Trauma Index (PATI) and number of transfusions. Relations between these factors and mortality was searched. There were 459 (88.1%) male and 62 (11.9%) female. Mortality in 352(67.6%) gunshot wounds and 169(32.4%) stab wounds were 15,6% and 3.6%, respectively. If the number of injured abdominal organ was more than 3, mortality was increased, especially if it was more than 5, mortality was 34.5%. Mortality was increased if PATI was more than 36, and it was found 35% when PATI was more than 55. In our series, we found the cause of mortality in the first 48 hours as irreversible shock and coagulopathy. The other factors increasing mortality were more than four organ injured, associated cranial and vascular injuries. We found that PATI is a useful scoring system for evaluation of severity of abdominal trauma and estimation of morbidity, and also, it may help in estimating mortality.

1983-1996 yýllarý arasýnda genitoüriner travma nedeniyle kliniðimizde takip edilen 134 hastanýn 102'sinde künt, 23 'ünde penetran travma saptandý. Travma sebebleri arasýnda trafik kazalarý birinci sýrada idi. Genito üriner travmalar içinde birinci sýrayý %29.8 ile üretra rüptürü aldý. Bunu sýrasýyla böbrek, mesane, penis, skrotal ve hem mesane hemde üretra travmalarý takip etti. Üriner sistem travmalarýna %30.5 ile pelvis kýrýklarý ve %9.7 ile gastrointestinal sistem yaralanmalarý eþlik etti. En sýk görülen komplikasyon üretra darlýðý idi. Mortalite oraný %5.2 olarak tespit edildi. Kaybedilen hastalarýn %71 'i 60 yaþýn üzerinde olup hepsinde multipl organ yaralanmasý vardý.

Between 1983 and 1996 years, 102 blunt and 23 penetrating trauma were determined retrospectively in 134 patients with genitourinary trauma follow-up The commonest cause of trauma was traffic accident. Urethra rupture was the first injury in genitourinary trauma (29.8 %), which, in turn, followed by kidney, bladder, penis scrotal, both urethra and bladder. The concurrent injuries were pelvis fracture and gastrointestinal pathology, 30.5% and 9.7 % respectively. The most common complication was urethra rupture in those patients. The mortality rate was 5.2 %in the whole cases. Seventy-one percent of the death people were over the 60 years old and all people have multiply injury.

Acil ve kaza servisleri acil saðlýk zincirinin en önemli birimlerinden birini oluþturur. Bu zincir acil yardým ve kurtarma ile baþlayýp; taþýma, acil ve kaza servisleri ve rehabilitasyon hizmetleri ile devam etmektedir. Bu zincirde yer alan acil ve kaza servislerinin temel ödevi zaman kaybetmeden yaralý hastaya bakým ve tedavi yapmaktýr. Amacýmýz Ýstanbul Ýlinde faaliyet gösteren farklý statüdeki üç eðitim hastanesinin acil ve kaza servislerini genel plan ve fiziksel organizasyon açýsýndan inceleyerek iyileþtirme önerileri getirmektir. Bu amaçla Haseki Devlet Hastanesi, Ýstanbul Týp Fakültesi Hastanesi ve SSK Okmeydaný Eðitim Hastanesi araþtýrýlmýþtýr. Sonuçlar dünya standart ve normlarýyla karþýlaþtýrýlarak iyileþtirme önerileri getirilmiþtir.

Accident and emergency services are one of the most important loops of the emergency health care. This chain starts with the first aid and resusscitation and continues with definitive treatment and finally rehabilitation. The principal task of accident and emergency services is to treat and to care for injured patients as promptly as possible. Our purpose is to offer suggestions for improvement after analyzing accident and emergency services of three teaching hospitals that function in different parts of Istanbul in terms of general planning and physical organization. For this purpose; the Haseki State Hospital, The Hospital of the Medical Faculty of Istanbul and The Okmeydaný Hospital of The State Social Security Department were investigated. By comparing the results with world standards and norms, some suggestions were fraught.

Bu prospektif çalýþma kafa travmalarýnda çeþitli parametrelere göre sonuçlarý tahmin etmek için koagülasyon testlerinden fibrin yýkým ürünleri (FYÜ) ve D-Dimer kullanýlarak yapýlmýþtýr. Çalýþmaya hafif travmalý 31, orta þiddette travmalý 24, þiddetli travmalý 23 hasta alýnmýþtýr. Hafif travma grubunda; FYÜ %32.2, D-Dimer %61.3, orta þiddetli travma grubunda FYÜ %41.7, D-Dimer %75, þiddetli travmalarda FYÜ %86.2, D-Dimer %100 oranýnda yüksek olarak bulunmuþtur. Ýntrakraniyal lezyon tiplerine göre; beyin parenkiminde hasar yapan lezyonlarda (çökme kýrýklarý, intraserebral hematom, ateþli silah yaralanmalarý), FYÜ %75-100, D-Dimer %100, beyinde kompresyon etkisi oluþturan lezyonlarda (epidural hematom, akut subdural hematom, subaraknoid kanama) ise FYÜ %40-63.4, D-Dimer %66-100 arasýnda, bilgisayarlý tomografisi normal olan hastalarda FYÜ %25, D-Dimer %50 oranýnda yüksek olarak bulunmuþtur. Yaþayan hastalarda FYÜ %40, D-Dimer %71.6, ölen hastalarda FYÜ %88.8, D-Dimer %96.4 oranýnda yüksek konsantrasyonda saptanmýþtýr. Bu çalýþmada; FYÜ'leri ve D-Dimer konsantrasyon düzeyleri, travma þiddeti, intrakraniyal lezyon cinsi ve prognozu tahmin etme açýsýndan iliþkili bulunmuþtur.

In this prospective study fibrin degradation product (FDP) and D-Dimer has been used for estimating outcome according to several parameters in head injury. Thirty-one mild head injuries, 24 moderate head injuries and 23 severe head injury cases have been studied. FDP was found 32.2% higher and D-Dimer was found 61.3% higher in mild head injury group. In moderate head injury group FDP showed 41.7% and D-Dimer 75% higher results. These results were 86.2% higher for FDP and 100% for D-Dimer in severe head injury group. According to intracranial lesion types, in the lesions which are with parenchimal injury (depressed fractures, intracerebral hematoma, gun shot wounds) FDP was 75-100% and D-Dimer was 100% higher than normal. In lesions causing parenchimal compression (epidural hematoma, acut subdural hematoma, subarachnoid hemorrhages) FDP was 40-63.4%, D-Dimer was 66-100% higher than normal. In the survived cases FDP was 40% and D-Dimer was 71.6% higher than normal. In mortal cases FDP was 88.8% and D-Dimer was 96.4% higher than normal. This study demonstrated that FDP and D-Dimer concentration levels are correlated with the severity of trauma, the type of intracranial lesion, and estimation of prognosis.

Travma sonrasý þoka eðilimli hastalarýn erken belirlenmesi ve etkili resussitasyon hayat kurtarýcý olmaktadýr. Ýstanbul Týp Fakültesi Travma ve Acil Cerrahi Ünitesine baþvuran ve Travma Þiddet Skoru (ISS) 25'den yüksek olan 25 hastada, spesifik sok parametrelerinin (Laktat Seviyesi, Baz Açýðý, Gastrik Ýntramukozal pH) þok tayini ve mortalite yönünden etkinlikleri araþtýrýldý. Baþvuru anýnda yapýlan ölçümlerde Laktat Düzeyinin þok tayinindeki hassasiyeti %96, Baz Açýðýnýn %64 olarak bulundu. Mortalite yönünden ise son ölçümlere göre Gastrik Ýntramukozal pH'nýn, Baz Açýðýnýn ve Laktat Düzeyinin hassasiyet oranlarý sýrasýyla %100, %66 ve %11 olarak saptandý. Sonuçta þok tayininde Laktat ölçümlerinin, mortalite yönünden de Gastrik Ýntramukozal pH ölçümlerinin daha güvenilir olduðu kanýsýna varýldý.

Identification of patients having tendency to shock, and adequate resuscitation after major trauma is life saving. In this study 25 patients having Injury Severity Score (ISS) more than 25, admitted to Department of the Trauma and Emergency Surgery of Istanbul Medical Faculty, were evaluated to identify the effectiveness of some spesific shock parameters (Lactate Levels, Base Excess, and Gastric Intramucosal pH) on shock determination and mortality. When the test held during admission, it is found that Lactate Levels has 96%, Base Excess has 64% sensitivity for shock determination. According to final measurements, sensitivity for mortality were 100%, 66%, and 11% for Gastric Intramucosal pH, Base Excess, and Lactate Levels respectively. The result is conduced the Lactate Levels are reliable for determination of shock, whereas Gastric Intramucosal pH measurements are for mortality.

3 yýllýk sürede, künt veya penetran batýn travmasý nedeniyle, acil baþvuran hastalara, prospektif ve randomize olarak açýk ve kapalý tekniklerle lavaj uyguladýk. 134'ü künt, 55'i penetran travmaya karþý kalan 189 hastadan 102'sine açýk, 87'sine kapalý (perkütan) teknikle lavaj yapýldý. Her hastada, uygulanan teknik, lavaj için gereken zaman aktif operasyon süresi, geriye alýnabilen sývý miktarý, mikroskopik sonuçlar, aperatif bulgular ve komplikasyonlar kaydedildi. Sonuçlar Fisher'in exact t testi ile deðerlendirildi. Açýk DPL grubunda belirgin pozitif lavaj süresi ortalama 11±8 dk. (3-24), kapalý grupta ise 3±2 dk.(1-10) oldu (p<0.05). Mikroskopik pozitif lavaj ise açýk grupta 22±16 dk. (8-55), kapalý grupta 24±9 dk. (11-47) bulundu. Bu iþlem esnasýnda harcanan aktif operasyon süresi açýk grupta 12±7 dk. (4-37), kapalý grupta ise 4±2 dk. (1-21) oldu (p<0.05). Geri alýnan sývý miktarý açýsýndan gruplar arasýnda anlamlý bir fark bulunamadý. Çalýþma sonuçlarý göz önüne alýnýnca, kapalý metodun ilk uygulama kolaylýðý ve hastalarýn daha rahat talere etmeleri, gerekse kazandýrdýðý zaman faktörü çerçevesinde ilk tercih edilmesi gereken teknik olduðuna inanýyoruz.

During a three year period patients seen following blunt and penetrating abdominal trauma were managed either with closed or with open lavage technique in a prospective and randomised manner of the 189 patients undergoing DPL 102 of them were accomplished with the open and the remaining 87 with the closed technique. 134 patients had blunt and 55 penetrating abdominal trauma. Applied technique, lavage time, active operation time, volume of aspirated fluid, results of microscopic examination, operative findings and complications were recorded for each patient. Comparisons were made with Fisher's exact t-test. In open DPL group, lavage time for grossly positive and microscopically positive cases were 11±8 mm. (3-24) and 22±16 min (8-55) respectively. The same numbers for the closed group were 3±2 min. (1-10) for the grossly and 24±9 min (11-47) for the microscopically positives. The difference in lavage time of grossly positives between the open and closed technique groups was slightly significant (p<0.05). Active operation time for open and closed groups were 12± 7 min. (4-37) and 4±2 min. (1-21) respectively (p<0.05). There was no significant difference between the volumes of re-aspirated fluid between the two techniques. Considering the results of this study we think the closed technique with its quick and easy application and better patient toleration to be the primary choice in cases of abdominal trauma in whom some form of DPL appears to be necessary.

16 year-old boy was hospitalized for fever, malaise, diarrhea, upper gastrointestinal bleeding and abdominal pain. Despite agressive fluid replacement and blood transfusion, bleeding did not stop. Jaundice developed on the eighth day and endoscopic evaluation revealed hemobilia. Selective arteriel embolisation and bowel resection were performed. Immunosupressive treatment was initiated. The patient recovered and was discharged. In his fourth year follow up, he is well.