Bu çalýþma; son yýllarda yara bakýmýnda yaygýn olarak kullanýlmaya baþlanan enzim preparatlarýndan biri olan kollagenazýn yara iyileþmesi sürecine olan etkisini deðerlendirmek amacý ile, 15'erli iki gruba ayrýlan 30 adet rat kullanýlarak yapýldý. Kollagenazýn çalýþýldýðý grupta clostridium histolyticum kültür filtratýndan elde edilen clostridiopeptidaz-A ve eþlik eden proteazlar içeren pomad (NovuxoV) kullanýldý. Kontrol grubunda ise sadece serum fizyolojik kullanýldý. 48. saatte ve 7. günde yaralardan mikrobiyolojik kültür ve ek olarak yara kenarlarýndan histopatolojik inceleme için kesit alýndý. Histopatolojik kesitlerin deðerlendirilmesi ile elde edilen sonuçlar, yara iyileþmesi açýsýndan kollagenaz grubunun, kontrol grubuna göre belirgin olarak üstün olduðunu göstermektedir (p<0.005). Sadece neovaskülarizasyon ve hücre infiltrasyonu açýsýndan kollagenaz grubu ile kontrol grubu arasýnda istatistiksel olarak anlamlý fark bulunmadý. Ayrýca, enfeksiyonun kontrol grubunda kollagen yoðunluðu ve fibroblast aktivasyonunu anlamlý olarak azalttýðý (p<0.001), kollagenaz grubunda ise kollagen regülasyonunu belirgin olarak bozduðu belirlendi (p<0.001). Sonuç olarak, açýk yara tedavisinde kollagenaz kullanýmýnýn yara iyileþmesini hýzlandýrdýðý, kontrol grubuna göre belirgin olarak daha temiz ve canlý bir granülasyon dokusu saðladýðý, fibroblast ve myo fibroblast aktivasyonunu arttýrdýðý, kollagen liflerinde düzenli ve yoðun bir artýþa neden olduðu görülmektedir.

This study was planned for evaluating the effect of collagenase which is one of the popular enzyme used in wound healing recently. Two groups of rats which consist 15 animals each were used by this aim. On collagenase applied group Novuxol-as ointment- consist of the enzymes as protease and clostrodiopepsidase-A that is obtained from the culture filtrates of clostridium hystoliticum. In the control group serum physiologic was used. At second and seventh days samples were taken from the wound for microbiological and histopathological examinations. Histopathological examinations revealed that wound healing was better in the collagenase group than the control group (p<0.005). There were no significant difference about neovascularisation and cellular infiltration among the groups. It was seen that infection reduced the activation of fibroblasts and density of collagen's in control group (p<0.001) and impaired the regulation of collagen in collagenase treated group (p<0.001). As a result, we saw that treatment with collagenase accelerates healing in open wounds, supports a significantly clean and viable granulation tissue, increases activation of fibroblast and myofibroblast and results in a regular and dens increase in collagen fibrin's.

Ekim 1992 - Eylül 1995 tarihleri arasýnda Kartal Eðitim ve Araþtýrma Hastanesi Genel Cerrahi servislerinde kolon rezeksiyonu sonucu, kolokolik anastomoz uygulanan 20 hastadan bir çalýþma grubu oluþturuldu. Ayný sürede kolon anastomozu yapýlmamýþ, diðer batýn ameliyatlarý geçiren 20 hastadan da bir kontrol grubu meydana getirildi. Her iki gruptaki olgulara, transanal yolla sigmoid kolon tonometri katateri konup, intramural PH'lar postop 1. günden baþlanarak postoperatif beþinci güne kadar takip edildi. Kontrol grubunda PH 5. gün ortalama 7.26 ± 0.022 iken, çalýþma grubunda PH, ortalama 7.06±0.113 idi. Çalýþma grubu içinde yeralan, acil olgularda, çift kat veya stapler ile anastomoz yapýlanlarda, birlikte diðer organ yaralanmalarý olan olgularda, intramural PH ortalamasýnýn diðer olgulara göre daha düþük olduðu gözlendi. PH'nýn 6.9 veya altýna indiði 2 olguda klinik olarak ta anastomoz kaçaðý saptandý ve hastalar relaparotomiye alýndý. Ýstatiksel olarak kontrol ve çalýþma gruplarý arasýnda intramural PH açýsýndan anlamlý fark bulundu (p<0.01). Bu bulgular ýþýðýnda kolokolik anastomozlu hastalarda, sigmoid kolon tonometri katateri ile intramural PH takibinin, anastomoz iyileþmesi hakkýnda bilgi verebilecek bir yardýmcý muayene yöntemi olabileceði ve klinik takip ve diðer laboratuar tetkikleri ile birlikte erken anastomoz kaçaðý açýsýndan klinisyeni uyarýcý olabileceði düþünüldü.

We created a study group from 20 patients who were performed colocolic anastomosis between October 1992 and September 1995'at Kartal training and research hospital. At the same time, control group was created from 20 patients who underwent abdominal operations without colonic anastomosis. Colonic sigmoid catheter was inserted to all patients transanally and observed their intramural PH posoperatif five days. While in control mean PH was 7.26±0.022 in the fifth day, in study group mean PH was 7.06±0.113. In study group, patients who were performed double row or stapler anastomosis technics or who were urgent cases or multisystem injuries were observed that intramural PH was lower in fifth day than the others. In two patients whose PH were 6.9 or lower, clinical leakage were seen and relaparatomies were performed. Significant differences between control and study groups were seen and relaparatomies were performed. Significant differences between control and study groups were found in statistically (p<0.01). As a result, we consider that intramural PH monitoring by using colonic sigmoid catheter and following clinical and laboratory observation can be useful for clinician in early subclinic anastomotic leakage.

1.4.93-31.3.97 tarihleri arasýnda Kartal Eðitim ve Araþtýrma Hastanesi (KEAH) Acil Cerrahi polikliniðine baþvuran 88.649 hasta birer senelik dört döneme ayrýlarak retrospektif olarak incelendi. Hastalar baþvuru þikayetlerine göre travma (trafik kazasý - delici alet yaralanmasý, ateþli silah yaralanmasý ve düþme-darp) ve travma dýþý olarak sýnýflandýrýldý. Travma hastalarýnda anlamlý bir artýþ vardý ve erkek hakimiyeti gözleniyordu. Kýþ aylarýnda trafik kazasý sebebi ile olan baþvurularda anlamlý bir deðiþiklik gözlenmiyordu. Ancak diðer mevsimlerde travma dýþý sebebi ile olan baþvurular arttýðý için kýþ mevsiminde trafik kazasý sonucu olan baþvurularýn tüm poliklinik hastalarýna oraný göreceli olarak artýyordu.

88649 patients, admitted to Kartal Eðitim ve Araþtýrma Hastanesi (KEAH) Surgical Emergency Policlinics from 1.4.1993 to 31.3.1997 analysed retrospectively by dividing four one-year periods. According to their reasons of apply, patients are classified as traumatic (Traffic accident, penetrating wounds, gunshot wounds and patients have fallen or got thrashings) and non-traumatic. During this period there was a significant increase in trauma patients and a male dominance was visible. In winter season, there was not a significant difference in the number of patients admitted because of traffic accidents. But in other seasons the number of patients without trauma increased so a relative dominance was seen in the number of patients admitted because of traffic accidents when compared with whole policlinic patients.

Amaç, acil ve elektif koþullarda laparoskopik kolesistektomi yapýlan olgularda postkolesistektomi sendromu oranlarýný ve nedenlerini saptamak, ve sendromun oranlarýný azaltabilecek yaklaþýmlara ýþýk tutmaktýr. Ocak 1995-Mayýs 1996 tarihleri arasýnda laparoskopik kolesistektomi yapýlan (110 elektif-Grup I, 73 acil-Grup II) toplam 183 olgu, prospektif olarak incelenmiþtir. Elektif koþullarda ameliyat edilen hastalarýn ameliyat öncesi þikayetleri bilier kolik, sað üst kadran aðrýsý ve dispepsidir. Asemptomatik hastalarda diabetes mellitus, geçirilmiþ akut pankreatit veya kolesistit ataðý ameliyat endikasyonu olmuþtur. Bir yýllýk takip sonunda Grup I'de 20 olguda (%18.1), Grup II'de 4 olguda (% 5.4) postkolesistektomi sendromu saptanmýþtýr. Sendromun en sýk sebebi her iki grupta da gastroduodenit olarak bulunmuþtur. Diðer nedenler, peptik ülser, koledok taþý, peritonitis karsinomatoza, pankreas kanseri ve trokar yerinde aðrýdýr. Grup I'de postkolesistektomi sendromu anlamlý þekilde yüksektir (p<0.05). Sonuç olarak akut kolesistitte doðru taný için fizik muayene ve ultrasonografi yeterli olabilmekte ve dolayýsýyla hastanýn þikayetlerine yol açan patoloji ortadan kaldýrýldýðýndan postkolesistektomi sendromu oraný düþük olmaktadýr. Elektif olgularda ise sadece ultrasonografi ile yetinilmemeli, özellikle dispeptik þikayetleri olan hastalarda üst gastrointestinal sistem incelenmeli ve hasta ameliyat öncesinde dispeptik þikayetlerinin devam edebileceði konusunda bilgilendirilmelidir.

The aim of this study is to evaluate the causes and rates of postcholecystectomy syndrome after acute and elective laparoscopic cholecystectomy. A prospective analysis was carried out on 110 patients with chronic cholecystitis (Group I) and 73 with acute cholecystitis (Group II) undergoing laparoscopic cholecystectomy at Pamukkale University Hospital between January 1995 and May 1996. The mean follow-up period was 12 months. Postcholecystectomy syndrome rates were 18.1 % in Group I and 5.4 % in Group II. The most common cause in postcholecystectomy syndrome was found to be gastroduodenitis. The other causes were peptic ulcus, peritonitis carcinomatosa, pancreatic carcinoma and choledocholithiasis. In group I, the rate of postcholecystectomy syndrome was significantly higher than in group II (p<0.05). We conclude that, physical examination and ultrasonography is sufficient in diagnosis of acute cholecystitis, and after elimination of the pathology causing the symptoms, rate of postcholecystectomy syndrome will be low. On the other hand, one should not be contented only with ultrasonography for elective cases and further upper gastrointestinal examinations should be carried out, especially for patients with dyspeptic symptoms and the patients must be informed that their symptoms may not subside despite the operation.

Anal kanal - perine yaralanmalarý (AKPY) taný ve tedavi aþamasýnda zorluklara sahiptir. Beraberinde sýklýkla pelvis, rektum ve genito-üriner yaralanmalarýn bulunmasý morbidite ve mortalite oranlarýný artýrmaktadýr. Bu çalýþmada AKPY nedeniyle son 10 yýllýk dönem içinde Çukurova Üniversitesi Týp Fakültesi Genel Cerrahi Anabilim Dalý'nda tedavi edilen 21 olgu yaþ, cinsiyet, yaralanma sekli, yaralanma anýndan tedaviye dek geçen süre, ek organ yaralanmalarý varlýðý ile uygulanan cerrahi prosedürler açýsýndan retrospektif olarak incelendi. Bu parametrelerin morbidite ve mortalite geliþimine etkisi chi-kare ve Fischer kesin olasýlýk testleri ile deðerlendirildi. Yaralanma anýndan 24 saat geçtikten sonra baþvuran olgular ile pelvik fraktürü mevcut olanlarda geliþen morbidite istatistiksel olarak anlamlý bulundu (p<0.05). Postoperatif komplikasyon oraný % 80 olarak saptandý. Sfinkter hasarý 9 olguda gözlendi, 2 olguda primer tamir uygulandý. AKPY nedeni ile baþvuran olgularda kolostomi, nekrotik dokularýn radikal debritmaný, geniþ spektrumlu antibiyotik tedavisi, nutrisyonel destek, uygun olgularda primer sfinkter onarýmý, kemik kýrýklarýnýn uygun ve erken tedavisi ile komplikasyon oranlarýnýn daha azaltýlacaðý inancýndayýz.

Anal canal - perineal injuries (ACPI) may pose challenging diagnostic and therapeutic dilemmas. These massive soft - tissue injuries overlie fractures of the pelvis and femur, and may involve pelvic floor, rectum and genitourinary tract. Over the last 10 years, 21 patients with complex ACPI managed at Department of General Surgery, University of Çukurova, School of Medicine was reviewed retrospectively. The effects of age, sex, mechanism of the injury, additional injuries, missing time from injury to therapy, the surgical procedures on the development of morbidity were statistically evaluated by using chi-square and Fischer exact tests. Delayed surgical therapy more than 24 hours and the presence of pelvic fractures were the significant factors on morbidity (p<0.05). Total complication rate was 80 %. Sphincter failure was detected in 9 cases, primary repair was performed only in 2. We conclude that total diversion of fecal stream, radical initial debridement of necrotic soft - tissue, exhaustive irrigation of the perineal wounds, parenteral antibiotic therapy, nutritional support, and appropriate management of bone injuries and skin grafts optimize recovery this devastating injury.

Gecikmiþ travmatik intraserebral hematomlar (GTÝSH), nadir rastlanýlan ve etyopatolojisi hala tartýþmalý bir durumdur. Bilgisayarlý tomografi (BT) taný konan olgu sayýsýný arttýrmýþtýr. Kliniðimize, 1 Ocak 1990 ile 31 Aralýk 1996 tarihleri arasýnda 840 kafa travmalý olgu kabul edilmiþtir. Bu gruptan tedavi edilen 10 GTÝSH olgusu bu çalýþmada sunuldu. Olgularýn 9'u (%90) erkek, 1'i (%10) kadýndý. Yaþlarý 6 ile 73 arasýndaydý (ortalama yaþ 43). En sýk rastlanýlan etyolojik faktör, trafik kazasý idi. Olgularýn kabul sýrasýndaki Glasgow Koma Skorlarý (GKS) 10 du. 10 hastanýn 8'i konservatif olarak tedavi edildi. Mortalite oraný % 50 idi (n=5). Bu çalýþma, þiddetli kafa travmasý geçirenlerin (GKS 10), özellikle ileri yaþtaki olgularýn (>50 yaþ), ilk kranial BT'de küçük intraserebral hematomu, kontüzyonu veya ekstraserebral hematomu olanlarýn, kranyal fraktürü olanlarýn, hemostatik parametrelerinde bozukluðu olanlarýn GTÝSH açýsýndan yüksek risk taþýdýðýný göstermiþtir. Bu olgularýn takibinde kýsa aralýklarla BT takibi yapýlmalýdýr.

Delayed traumatic intracerebral hematomas (DTICH) is a rare condition and ethiopatogenesis is still controversial. CT has been helpful to increase the diagnosed patients population. From January 1, 1990 to December 31, 1996, 840 patients, 10 patients developed DTICH were presented. There were 9 males (90%) and 1 females (10%). The ages of the patients ranged from 6 to 73 years (mean 43 years). The most common ethiological factor was traffic accident. Glasgow Coma Scale scores were 10 in all patients on admission. Of 10 patients 8 were treated conservatively. The mortality rate was 50% (n=5). The study indicated that the patients who sustained severe head trauma (GKS 10) the patients with intracerebral hematomas, contusion or extracerebral hematoma on the initial CT, older age (>50 age), one at greatest risk of developing DTICH. Additionally, the presence of a skull fracture and the findings of coagulopathy one the another risk factor. These patients should be followed up by the repetetive CT scans.

Kitle etkisi oluþturmayan ve nörolojik defisite neden olmayan travmatik epidural hematomlar konservatif olarak izlenebilir. Bu çalýþmada, konservatif olarak izlenen 86 olgu ve cerrahi giriþim yapýlan 268 olgu retrospektif olarak analiz edilmiþtir. Sonuçlar, tedavi seçimini belirlemede etkili klinik göstergeler olarak hastanýn yaþý ve nörolojik durumunun, radyolojik bakýmdan da hematomun yeri, kalýnlýðý, hacmi ve kitli etkisinin önemli olduðunu göstermektedir. Konservatif olarak izlenen olgular infant dönemde ve ileri yaþ grubunda daha yüksek oranda görüldü. Temporal ve posterior fossa yerleþimi, çoðunlukla cerrahi tedaviyi zorunlu kýlan bir özellik olarak dikkati çekti; bunun yanýnda, paryetal ve frontal yerleþimde konservatif tedavi oraný yükselmekteydi. Hematomun kalýnlýðý ve hacminin yanýnda kitle etkisi bulgularý tedavi seçiminde önemli bulundu. Genellikle ilk 24 saat tedavi seçimini belirlemek için kritik süre olarak belirlendi. Konservatif kalýnan olgularýn tümü klinik olarak iyileþti, radyolojik olarak da hematomun rezorpsiyonu görüldü. Klinik ve radyolojik belirli koþullarý taþýyan olgularda konservatif tedavi uygulanmasý önerilmekte ve çeþitli yönleri ile tartýþýlmaktadýr.

Epidural hematomas not causing mass effect and neurological deficit can be managed conservatively. In this retrospective study, 86 patients treated conservatively and 268 patients treated surgically were analyzed. The results demonstrated that age of the patient and the neurological status were important clinically, and location, thickness, volume and mass effect of the hematoma were important radiologically. Conservative treatment is more common in infants and old patients. The temporal and posterior fossa epidural hematomas could be managed conservatively in a higher rate. Not only thickness and volume of the hematoma but also the parameters revealing mass effect were taken into account. Most oftenly a period of the first 24 hours was critical in decision making. All patients treated conservatively did well, and resorption of the hematoma was shown. Conservative management in patients sustaining certain clinical and radiological features is suggested and discussed in detail.

Kafa tabanýnda derin ve ekstansif dura-beyin laserasyonu sonucu geliþen serebrospinal sývý fistülü ve/veya pnömosefali olgularýnda (12 olgu) geniþletilmiþ (bazal) frontal yaklaþým ile ya da geniþletilmiþ (bazal) frontal yaklaþým ve fronto-orbital yaklaþým kombine edilerek intradural yoldan defekt onarýmý yapýlmýþtýr. Optik kanal bölgesinde frontobazal fraktüre baðlý geliþen optik sinir basýsý bulunan altý olguda, sfenoid kanatta parçalý ve yaygýn fraktürün neden olduðu superior orbital fýsür sendromu saptanan beþ olguda ve orbital apeks sendromu bulunan üç olguda ise fronto-orbital yaklaþým uygulanarak travmatize bölge eksplore edilmiþ ve etkilenen II., III.,IV. ve VI. kranyal sinirlerin dekompresyonu gerçekleþtirilmiþtir. Taban durasý defektinin onarýldýðý olgularýn hiçbirinde komplikasyon gözlenmemiþ, fistül ve pnömosefali rekürrensi saptanmamýþtýr. Kranyal sinir dekompresyonu yapýlan olgulardan üçünde vizyonda anlamlý düzelme, birinde vizyonda parsiyel düzelme ve iki superior orbital fisür sendromunda parsiyel iyileþme gözlenmiþtir. Kranyal sinir dekompresyonu olgularýnda sonucu etkileyen en önemli faktörlerin cerrahi giriþim zamaný ve sinirdeki yaralanma tipi olduðu izlenimi edinilmiþtir. Travmatik lezyonlarýnýn cerrahi tedavisi için kafa tabaný yaklaþýmý yapýlan 26 olgunun tümünde de yaklaþýmýn çok geniþ bir ekspojur saðladýðý ve nöral doku retraksiyonunu en aza indirdiði belirlenmiþtir.

Twelve head injured patients with cerebrospinal fistula and/or pneumocephalus due to deep and extensive cranial base dura-brain lacerations were operated upon in order to be repaired of their defects intradurally using extended (basal) frontal approach or combined extended (basal) frontal approach and fronto-orbital approach. Six patients demonstrating frontobasal fracture and presenting with loss of vision, five patients with superior orbital fissure syndrome caused by a comminuted and extensive sphenoid ridge fractures, and three patients with orbital apex syndrome and sphenoid bone fracture were explored using fronto-orbital approach, and the traumatic region was explored and the involved cranial nerves were decompress. All of the patients whose frontobasal dural defects had been repaired did well, and no complications or recurrences the fistula or pneumocephalus occurred. Out of the patients with cranial nerve syndromes, postoperatively, three improved in vision significantly, one had a partial improvement in vision, and two superior orbital fissure patients improved minimally. The other eight cases did not change their neurological findings. The most striking factors in prognosis of the patients with traumatic cranial nerve compression are thought to be time of the surgical intervention and the type of the cranial nerve injury. These cranial base approaches provided a wide exposure and minimised the need of brain retraction.

Aksesuar processus styloideus ulnaris el bileðinde nadir olarak görülen genellikle asemptomatik bir varyasyondur. Fakat travmatize olduðu zaman el bileði ulnar kenarýnda bir aðrýdan sorumlu olabilir. Kronik, tekrarlayan travmalarýn el bileðinde injüri oluþturabilmesi ve tanýda kolayca bir kýrýk ile karýþabilmesi gibi sebeblerle bu varyasyonun iyice tanýnmasýna ihtiyaç vardýr. Bu amaçla, gönüllü ve klinik olgulardan elde edilen grafiler üzerinde aksesuar processus styloideus ulnaris ve varyasyonlarý araþtýrýldý. Bu kemikçiðin insidensi %2.5, erkek/kadýn oraný 7/3 ve bir klinik olgu semptomatik bulundu. Literatür bilgileri ile bu varyasyonun klinik önemi tartýþýldý.

The accessory ulnar styloid process is an uncommon variation in the wrist. This ossicle is generally believed to be asymptomatic but when traumatized, it can be responsible for the pain in the ulnar border of the wrist. Identification of this variation is of importance because the injury may occur as a result of chronic repetitious trauma and the ossicle may easily be mistaken for a fracture. In our study; the incidence, the types and female/male percentages for the accessory ulnar styloid process were investigated by means of radiograps from volunteers and clinic cases. This ossicle was encountered in 10 cases as; incidence 2.5%, male/female persentage 7/3 and one of them is symptomatic. Clinical importance of this variation was discussed by the knowledge of literature.

Bu çalýþmada; 1990 ile 1996 tarihleri arasýnda ateþli silah yaralanmasýna baðlý penetran mesane yaralanmasý nedeni ile ameliyat edilen 28 olgu; taný ve tedavi yöntemleri, yandaþ organ yaralanmasý, morbidite ve mortalite oranlarý açýsýndan deðerlendirildi. Mesane rüptürü tanýsý olgularýn 16'sýnda retrograt sistografi ile, 12'sinde ise laparotomi sýrasýnda konuldu. Yirmialtý hastada intraperitoneal, 2 hastada ekstrapertoneal mesane rüptürü mevcuttu. Tüm hastalarýn mesane rüptürleri primer sütür ile onarýldý. Hiçbir hastada izole mesane yaralanmasý yoktu. Yandaþ organ yaralanmasý olarak 27 hastada intraabdominal organ yaralanmasý, 12 hastada fraktür, 5 hastada diðer organ yaralanmalarý saptandý. Olgularýn hiçbirinde direkt mesane yaralanmasý ile ilgili mortalite görülmedi. Ancak 2 olgu yandaþ organ yaralanmalarý nedeni ile kaybedildi. Sonuç olarak; ateþli silah yaralanmasýna baðlý mesane rüptürleri primer sütürle güvenli olarak onarýlabilir. Ancak yandaþ yaralanmalar ciddi komplikasyonlara neden olabilir.

In this study; 28 patients underwent surgery secondary to penetrating injury of the bladder due to gunshot wounds between 1990 and 1996 were evaluated retrospectively according to the diagnosis and treatment methods, associated organ injury, morbidity and mortality rates. The bladder rupture was diagnosed with retrograde cystography in 16 patients and with laparotomy in 12 patients. Bladder rupture was intraperitoneal in 26 patients and extraperitoneal in 2 patients. Bladder ruptures were repaired with primary suture in all of patients. No patient had isolated bladder injury, while there were intraabdominal injury in 27 patients, fractures in 12 patients and other organ injuries in 5 patients as associated injuries. There were no mortally directly related with the bladder injury, 2 patients died secondary to associated organ injury. As a result; the bladder ruptures due to gunshot wounds can be repaired primarily with safety. But, associated injuries can cause severe complications.

Künt ya da penetran abdominal yaralanmalarda duodenum nadir olarak etkilenen bir organdýr. Organýn retroperitoneal yerleþim ve pankreasla yakýn anatomik iliþkisi özellikle künt travmalarda birlikte yaralanma potansiyelini arttýrýr. Ocak 1993-Aralýk 1996 arasýnda duodenum yaralanmasý olan 8 olgunun yaralanma tipleri, yaralanma dereceleri, Travma Þiddet Skorlarý, Ortalama Penetran Abdominal Travma indeksleri retrospektif olarak araþtýrýldý. Grade II ve III yaralanmasý olan 4 hastaya primer onarým, Grade IV ve V yaralanmasý olan 3 hastaya Whipple ameliyatý uygulandý. Grade II'deki bir hastaya da primer onarým+tüp duodenostomi uygulandý. Tüm hastalar için yaralanmadan ameliyata kadar geçen süre 8.3 saat, ortalama kan transfüzyonu 6 ünite ve hastanede kalma süresi 27.5 gündü. Hastalarýn 2'sinde intraabdominal abse, birinde pankreatit, birinde duodenum fistülü geliþti. Bir hasta kaybedildi (% 12.5). Çalýþmamýzda duodenum izole basit yaralanmalarýnda primer onarýmýn; pankreasla birlikte olan komplike yaralanmalarda pankreatoduodenektominin güvenilir cerrahi yöntem olduðu sonucuna varýldý.

Duodenum was seldom influenced in blunt or penetrating abdominal injuries. Retroperitoneal localization of duodenum and its anatomical relation with the pancreas are factors that increase potential of injury in blunt abdominal traumas particularly. Between January 1993-December 1996 eight patients with duodenal injury were analysed in terms of tip of injury, grade of injury, Injury Severity Score, The mean Penetrating Abdominal Trauma Index. Four patients with Grade II or III injury underwent primary repair after debridement of the duodenal wound, pancreatoduodenectomy was performed in three patients with Grade IV or V injury and primary repair + tube duodenostomy in one patient with Grade II injury. The mean duration from trauma to surgery was 8.3 hours, mean transfusion requirements were 6 units of blood and mean hospital stay was 27.5 days. The complications developed after surgery were abdominal sepsis in two patients, severe pancreatitis in one patient, duodenal fistula in one patient. The overall mortality rate for the study was 12.5 per cent. We concluded that primary repair is sufficient treatment in simple isolated duodenal injuries. However in cases complicated with excessive peripancreatic homorrhage Whipple procedure should be preferred.

Künt batýn travmalarýnýn sonucu oluþan içi bos organ yaralanmalarý çok sýk rastlanan bir durum deðildir. Ayrýca içi boþ organlara ait yaralanmalarýn saptanmasý için herhangi bir laboratuvar bulgusu ve peritoneal lavaj, ultrasound ve bilgisayarlý tomografi gibi karakteristik taný yöntemi yoktur. Bu çalýþmada bu sýk rastlanmayan yaralanma þeklinin etiyolojisi, taný ve tedavi yaklaþýmlarý ile prognozu belirleyici faktörlerin saptanmasý için deneyimlerimizi gözden geçirmek istedik. Bu çalýþma Cumhuriyet Üniversitesi Týp Fakültesi Uygulama ve Araþtýrma Hastanesi Genel Cerrahi Anabilim dalýnda künt karýn travmasý nedeni ile laparotomi uygulanan ve içi boþ organ yaralanmasý saptanan hastalara ait kayýtlarýn retrospektif ve prospektif incelenmesi sonucu gerçekleþtirilmiþtir. Her hastada yaralanma ciddiyet skoru (ISS), extraabdominal organ yaralanmasý ve hematokrit düzeyi tayin edildi. En fazla yaralanan içi boþ organlar ince barsaklar sonra ise kolon idi. Prognozu belirleyen 5 faktör saptanmýþ olup bunlar hastanýn yaþý, baþvuru anýndaki hematokrit deðeri, þok indeksi, yaralanma ciddiyet skoru ve batýn dýþý organ yaralanmasý idi.

Injury to the gastrointestinal tract from blunt trauma which was first reported by Aristotle is a rare event. There are no charecteristic laboratory findings, and diagnostic methods. We there fore reviewed our experience with gastroenteric injuries from blunt trauma to evaluate the etiology, diagnosis, management, and prognostic factors of these unusual injuries. We prospectively and retrospectively reviewed the charts of all patients who sustained gastrointestinal injury from blunt trauma and were treated at the Department of General Surgery in Cumhuriyet University. Injury severity Score (ISS), concomitant extraabdominal organ injury, and shock index were determined for each patient. Small bowell perforations were the most frequent injuries, followed by colorectal injuries. Five prognose predictive factors were determined. These factors were age, initial hematocrit value, shock index, injury severity score and number of concomitant extraabdominal injury.

Hartmann iþlemi, primer anastomozun güvenilir olmadýðý sigmoid ve rektumun üst kesimini içeren, deðiþik patolojiler endikasyonu olan bir giriþimdir. Çalýþmamýzda Dokuz Eylül Üniversitesi Hastanesi'nde 1992-1997 arasýnda Hartmann iþlemi yapýlan 31 hastadaki deneyimimiz incelenmiþtir. Hastalarýn 16'sý erkek, 15'i kadýn olup ortalama yaþ 65 (32-88)'ti. Hastalarýn 27'si (%87,1) acil, 4'ü (%12,9) efektif þartlarda opere edilmiþ olup 19'unda (%61,3) benign, 12'sinde (%38,7) malign patolojiler mevcuttu. Bu hastalarýn 17'sinde (%62,9), ortalama 86 (54-300) gün sonra anastomoz yapýlarak devamlýlýk saðlandý. Primer iþlemde mortalite %12,9; morbidite %29,3'tü. Anastomoz yapýldýktan sonra kaçak ve mortalite izlenmedi. Üç hastada (%17,6) baþka nedenlere baðlý morbidite geliþti. Geçmiþte vurgulanan rekonstrüksiyon güçlüðünün belli oranda aþýlmasý ve yüksek seyreden morbidite ve mortalite oranýnýn giderek azalmasý nedeniyle Hartmann iþlemi, yüksek riskli hastalarda sýrasýnda ilk tercih, sýrasýnda son çare olarak seçilebilen bir yöntemdir.

Hartmann's procedure is suitable operation and its indications are extended for different kinds of pathologies of rectum and sigmoid colon when primary restorative resection cannot be safely performed. During the June 1992 to 1997 time period, we analyze our experience in the 31 patients who underwent Hartmann's procedure at the Department of Surgery, Dokuz Eylül Universty Hospital. There were 16 men and 15 women, with a median age of 65 (range 32-88) years. Twenty seven (87,1%) patients were operated for emergent diseases, four (12,9%) patients for elective conditions. The pathologic process encountered was benign in 19 (61,3%) and malign in 12 (38,7%). The median time interval for Hartmann's procedure to reversal was 86 (range 54-300) days in only 17 (62,99%) of these patients. The mortality rate of primary procedure was 12,9% and important morbidity was 29,3%. No anastomotic leak and mortality was found following ostomy closure. Morbidity due to another reasons occurred in 3 patients (17,6%). There has been a notable but progressive decline in the seemingly high incidence of morbidity and in the technical difficulty frequently associated with Hartmann's procedure and its reversal. So, Hartmann's procedure can be selected as "a first choice" or "a hist resort" operation in high risk patients.

A women who sustained injury to a breast because of falling down is presented. Except isolated seat belt traumas, isolated breast traumas are very rare events. Trauma to the breast can produce lesions which cannot be distinguished from malignant lesions by clinical examination or radiological imaging. If we have any suspicion all such lesions should be biopsied to minimize the risk of missing a carcinoma.

Injuries of iliac veins are uncommon but, frequently fatal. They are usually occurred after penetrating injuries. Two patients who have iliac vein injury were treated by the ligation of veins. Of these two patients, first one had no complication but, severe edema developed in the second one after the operation and adjunctive fasciotomy was used. Both of the patients did not have permanent edema. Although venos repair is often recommended, ligation in extensive injures may be necessary, and is usually well tolerated in young, previously healthy individuals.