Sepsis, travma ve þok gibi kritik hastalýklarda immünosüpresyon, glutathione (GSH) yetmezliði ile birliktedir. Bu yüzden sepsiste karaciðer hedef organdýr ve sepsiste hepatik GSH düzeyleri düþer. Bu çalýþmada sepsis esnasýnda hepatik GSH düzeylerini Tc 99m GSH sintigrafisi ile inceledik. Sýçanlardaki sepsis, çekal ligasyon ve perforasyon yöntemi ile yapýldý. Sepsisten 24 saat sonra intrakardiak yolla Tc 99m GSH verildi ve hepatik GSH uptake sintigrafisi yapýldý. Sonucunda sepsiste hepatik GSH uptake'inde anlamlý bir deðiþiklik bulunamadý.

Critical illness such as sepsis, trauma and shock is associated with both immunosupression and glutathione (GSH) deficiency. Liver is a target organ during sepsis because of this. Hepatic GSH levels decrease due to sepsis. We have investigated the level of hepatic GSH during sepsis by Tc 99m GSH scanning. Sepsis was induced in rats by cecal ligation and puncture following 24 hours of sepsis, Tc 99m GSH was administered by cardiac puncture and hepatic GSH uptake scanning was performed. As a result no significant changes of hepatic GSH uptakes was determined by Tc 99m GSH in sepsis.

Seftriaksonun toraks cerrahisindeki profilaktik deðerini belirlemek amacý ile yapýlan çalýþmada 19 hasta incelenmiþtir. Hastalarýn 17si akciðer kanseri, 1'i akciðer kist hidatik, 1 'i akciðer karsinoid Tm tanýsý ile ameliyat edilmiþtir. Hastalara ameliyat öncesi intravenöz olarak 1 gram seftriakson uygulanmýþtýr. Hastalardan ameliyat sýrasýnda alýnan kan ve akciðer dokularýndaki antibiyotik düzeyi Bacillus subtilis ATCC 6633 suþu kullanarak agarda kuyu difüzyon yöntemi uyarýnca standart eðriler ile karþýlaþtýrmak suretiyle belirlenmiþtir. Hastalarýn akciðer dokularýnda 12-53.6 µg/g, serumlarýnda 50.1-114.9 µg/ml seftriakson bulunduðu saptanmýþtýr. Elde edilen deðerler birçok bakteriye karþý saptanan seftriakson MÝK'larýdan daha yüksek bulunmuþtur. Ameliyat sonrasý hastalarýn klinik takibi sonucu hiçbirinde yara infeksiyonu ve ampiyem geliþmemiþtir. Bu bulgular toraks cerrahisinde seftriakson proflaksisinin baþarýlý olduðu ve önerebileceði sonucunu vermiþtir.

In this study which was done to determine the value of prophylactic ceftriaxone in thorax surgery, 19 patients have been evaluated. 17 of the patients were operated for lung ca, 1 for cyst hidatic in lung, and 1 was operated for the carsinoid the of lung. Preop I gr IV ceftriaxone was given to the patients. During the operation serum and lung tissue samples were collected from the patients. The antibiotic level in those samples were evaluated by agar well diffusion method using Bacillus subtilis ATCC 6633 as the test organism. The antibiotic level in the tissue was measured as 12-53.6 µg/g and in serum was measured as 50.1-114.9 µg/g. This values were higher than the MIC of ceftriaxone for most of the bacteria. During postop clinical follow-up period none of the patients had wound infection or amphiema. These findings brought the conclusion that prophylactic ceftriaxone is successful and can be suggested in thorax surgery.

Yanýk sonrasýnda glikoneogenez, katabolizma ve bazal enerji harcamasý artar. Çalýþmamýzda; 6 erkek 4 kýz, toplam 10 çocuk yanýk hastasýnda, yanýk sonrasý ilk 24 saat içinde tüp beslenmeye baþlandý. Bu süre içinde ortalama 745 kcal beslenme solusyonu verildi. Ticari olarak hazýrlanmýþ enteral beslenme solusyonlarý kullanýldý. Albumin düzeyi ve kilo takibi yapýldý. Beslenme desteði 20 gün boyunca beslenme pompasý yardýmý ile sürekli infüzyon þeklinde sürdürüldü. Hastalardan birinde albumin düzeyi 2.4 gr/dl seviyesine düþtüðü için albumin replasmaný yapýldý. Diðer hastalarda albumin ihtiyacý olmadý. Hastalarýn %20'sinde 1250 gr kilo kaybý, %80'inde 450 gr aðýrlýk artýþý geliþti. Ciddi komplikasyon görülmedi. Erken yeterli enteral beslenmenin yanýk çocuk hastalarda kalori, protein, vitamin ve diðer besin elemanlarýnýn karþýlanmasýnda etkin, güvenli ve fizyolojik bir yöntem olduðu kanýsýna varýldý.

Gliconeogenesis, catabolism and basal energy expenditure increase after burn injury In this study; ten burned pediatric patients were started early enteral tube feeding within 24 hours after burn injury. Mean value of 745 kcal was administered within 24 hours after burn injury. Commercial feeding solution was used. Serum albumin levels and change in weight were investigated. Nutritional support was administered continuously infusion by using a feeding pomp. Albumin level of one case felt to 2.4gr/dl once. Albumin replacement was made in this patient. Non of the other patients required albumin replacement. Of ten patients, 20% lost weight of 1250gr; 80% gained weight of 450 gr in average. No important complication was observed. In burned pediatric patients, early sufficient enteral feeding is effective, safe and physiologic method to support of calorie protein, vitamin and other nutritional requirements.

Kafa travmasý günümüz nüroþirürji pratiðinin önde gelen morbidite ve mortalite sebeplerindendir. Epidural hematom, subdural hematom, intraserebral hematom ve çökme kýrýklarý kafa travmasýnýn cerrahi ile tedavi edilebilir komplikasyonlarýndandýr. Kafa travmasý komplikasyonlarýnýn erken taný ve tedavisi hayati öneme sahiptir. Son yýllarda bazý yazýlarda cerrahinin endikasyonlarý ve zamanlamasý konusunda tartýþmalar vardýr. Bu çalýþmada kliniðimize kafa travmasý tanýsý ile baþvurup cerrahi tedavi gören 346 hasta retrospektif olarak deðerlendirildi. Hastalar iki ayrý grupda çalýþýldý. Bir grupta ilk müdahale baþka merkezde yapýldýktan sonra kliniðimize refere edilen hastalar diðer grupta ise travmadan sonra direkt kliniðimize baþvuran hastalar deðerlendirildi. Hastalarýn cerrahi tedavi gerektiren patolojilerinde travmadan cerrahiye kadar geçen sürede olan deðiþiklikler çalýþýldý sonuçlar deðerlendirildiðinde, baþka bir merkezden kliniðimize refere edilen hastalarda cerrahiye kadar geçen sürede patolojinin büyüklüðünde deðiþiklik olmasý yada tabloya ek patolojiler eklenmesi ihtimali, direk kliniðimize baþvuranlardan daha yüksek bulundu. Buna göre travmalý bir hastanýn mümkün olan en kýsa sürede gerçek tedavisinin yapýlacaðý bir merkeze ulaþtýrýlmasý ve cerrahinin mümkün olan en kýsa zamanda yapýlmasý gerekmektedir. Yaralýnýn ilk müdahale yapýldýðý yerde gereksiz bir takým tetkik ve tedavilerle oyalanmasý, daha çabuk bir müdahale ile hayat kurtarýcý olabilecek iþlemlerin yapýlmasýna ve bunlarýn yapýlacaðý yere ulaþmasýnýn gecikmesine sebep olacaktýr.

Head trauma is one of the leading causes of morbidity and mortality in neurosergery practice. Epidural hematoma, subdural hematoma, intracerebral hematoma and depression fractures are surgically treatable complications of the head trauma. Early diagnosis and initial management of the head trauma complications, is of vital importance. Recently some reports discuss indications and timing of surgery. We retrospectively evaluated 348 patients admitted to our clinic with the diagnosis of head trauma and operated on. They were studied in the two groups. One is the patients who were referred from another clinic after initial handling posttravmatically, the second group was the ones, directly admitted to our clinic posttravmatically. Change in the surgical pathology during the initial handling and transport period preoperatively was evaluated. Results showed us that in referred patients group, during the time from trauma to surgery surgical pathology either increased in size or an additional pathology was added to the scene. So trauma patients must not be kept waiting in primary handling centers, because pathology may change in size or in nature during the transfer period.

1995 yýlýnda Ege Üniversitesi Týp Fakültesi Hastanesi Acil Servisi'ne kabul edilen hastalar içinde 23 sternum fraktürlü olgu saptandý. Bunlarýn 21'inin trafik kazasý sonucu geliþtiði ve bu 21 hastadan 15'inde (%71) ise emniyet kemeri nedeniyle sternum fraktürü meydana geldiði saptandý. Bu hastalarda hayatý tehdit eden yandaþ yaralanmalarýn olmadýðý, ortalama hastanede kalýþ süresinin iki gün olduðu ve hepsinin komplikasyonsuz olarak taburcu edildikleri belirlendi. Emniyet kemerlerinin hayat kurtarýcý, buna karþýn sternum fraktürü gibi hayatý daha az tehdit edici bazý yaralanmalara neden olduðu gözlendi.

Twenty-three patients with sternum fracture were diagnosed among the trauma patients that were admitted to the Emergency Service of Ege University Medical School Hospital in 1995. In 21 of these, car accident was the main reason and 15 of these patients with sternum fracture were caused by seat belt. There were neither additional life threatened injuries nor related complications and the mean hospital stay was two days. Using seat belt is life saving. Contrary, it was observed that it rarely gives way to life threatening injuries.

Pankreasýn anatomik yeri,eþlik eden diðer organ yaralanmalarý ve klinik görünüme baðlý olarak kolayca gözden kaçabilmesi sebebiyle pankreas yaralanmalarý önemi ölçüsünde dikkati çekmemektedir. Aslýnda künt ve penetran batýn travmalarýnda pankreas yaralanmasý nisbeten daha az olmasýna karþýn nadirde deðildir. Bu yaralanmalarda cerrahi tedavi çok geniþ bir yelpaze oluþturmaktadýr ve % 2-3'ünde travma aðýrlýðý sebebiyle Whipple prosedürü gerekmektedir. Bu yazýmýzda künt ve penetran travma sebebiyle hastanemize baþvuran ve grade 5 pankreas rüptürü nedeniyle Whipple prosedürü uygulanan üç olgu sunumuna yer verilmiþtir. Hastalar yandaþ travmalarý, postoperatif komplikasyonlar, saðkalým açýsýndan incelenmiþtir.

Pancreas injuries cannot be easily noticed because of its anatomic location, clinical presentation and its usually being accompanied with other organ injuries and so attract not enough attention In fact, pancreas injuries in cases of blunt and penetran abdomen traumas are relatively fewer, but not rare. In these injuries, surgery involves a wide spectrum of the treatment and in 2-3% of them Whipple procedure is needed to be done. In this paper, we present 3 cases, treated by Whipple procedure for grade 5 pancreas rupture and examine patients for other injuries, postoperative complications and survival.

Hastanemiz genel cerrahi kliniklerinde 1989-1996 yýllarý arasýnda opere edilen penetre kalp yaralanmalý 34 olgu deðerlendirildi. Yaralanma nedeni 32 olguda kesici-delici alet, 2 olguda ateþli silah yaralanmasý idi. Klinik olarak grup 1 ve II'deki 11 hasta hýzlý resüsitasyonla birlikte hýzlý torakotomi yapýldý. Eks olan 2 olgumuz dýþýndaki tüm olgularýmýzda kalbe penetre tek yaralanma vardý. En çok sað ventrikül yaralanmasý ile karþýlaþýldý. Tüm olgular kardioraphie ile tamir edildi ve perikard açýk býrakýldý. Morbidite oranýmýz %22 mortalite oranýmýz % 6 olarak gerçekleþti. Yaralanmalarýn çoðunun kesici-delici alet ile olmasý, kompleks yaralanma oranýnýn düþük olmasý ve hastalarýn ülkemiz koþullarýna göre kýsa sayýlabilecek sürede acil servise ulaþtýrýlmalarý nedeniyle mortalitemizin düþük gerçekleþtiðine inanýyoruz.

34 cases, with penetrating wounds to the heart, who were operated in the general surgery clinics of our hospital during 1989 - 1996 were reevaluated. The cause of injury was stab wounds in 32 cases and gunshot wounds in 2 cases, immediate resusitation together with emergency thoracotomy was done to the eleven of the patients in group 1 and 11. In all cases (Except two cases who died) there were only one penetrating wound the heart. Right ventricular injury was the most frequent type. All cases were mended with suturing and pericards were left open. Our morbidity ratio was %22, mortality ratio was %6. We believe that our mortality is low because most of the injuries are caused by stab wounds, complicated injury ratio is low and that patients are taken the emergency services in shorter time in relation with our country's conditions.

Son 5 yýl içerisinde 60 pediatrik olgu künt toraks travmasý (KTT) nedeniyle acil polikliniðimize müracaat ettirilmiþtir. Serimizde karþýlaþýlan yaralanma mekanizmalarýnýn sýklýk sýrasý þöyledir: Araç dýþý trafik kazasý (%55), araç içi trafik kazasý (%30), düþme (% 13) ve ezilmelidir (%2). En sýk karþýlaþýlan intratorasik yaralanmalar; pulmoner kontüzyon (%50), multipl yaralanmalar (%20), pnömotoraks (%7), hemotoraks (%7), ana bronþ rüptürü (%5), diafragma rüptürü (%5) ve izole kot fraktürüdür (%5). Ýlave sistem yaralanmasý olan olgularýn ortalama pediatrik travma skoru (PTS); izole KTT olgularýnýn ortalama PTS deðerinden daha küçüktür. Ayný þekilde hastanede kalýþ süresinde de, ilave sistem yaralanmalarý olan olgularda önemli artýþ görülmektedir. Hastalarýn % 10'u entübe edilerek yoðun bakým ünitesine yatýrýlmýþ ve ortalama 5.8 gün mekanik solunum desteði uygulanmýþtýr. KTT lý olgularýmýzdaki ortalama mortalite oraný %3 olarak saptanmýþtýr.

During last 5 years, 60 children were consecutively admitted to our emergency department with blunt chest trauma. The most common mechanisms of injury were motor vehicle crashes (%30), pedestrian injury (%55) and falling from a high level (% 13). The most common intrathoracic injuries were pulmonary contusion (%50), multiple injuries (%20), pneumothorax (%7) haemothorax (7%), main bronchus rupture (%5), diaphragmatic rupture (%5) and isolated rib fractures (%5). The mean pediatric trauma score (PTS) of the children who had additional system injuries were significantly worse than the children who had isolated blunt chest trauma. Associated system injuries resulted in increase in length of hospital stay, compared to children with isolated chest injuries. Ten percent of the children were entubated and admitted to the intensive care unit, where they stayed an average of 5.8 days. The overall mortality rate for children with thoracic injury is 3%.

Eþ zamanlý trakea ve özefagus yaralanmasý olan olgular trakeoözefageal fistül, özefagus kaçaðý, pnömoni ve mediastinel abse gibi majör komplikasyonlarýn geliþebileceði risk altýnda olan olgulardýr. Ocak 1980 Mayýs 1997 tarihleri arasýnda kliniðimizde 23 trakeobronþial yaralanma olgusu tedavi edilmiþtir. Bu olgularýn 7'sinde (%30.4) eþ zamanlý trakea ve servikal özefagus yaralanmasý vardý. Tüm olgularda etken ateþli silah yaralanmasý idi. Özefagus yaralanmasý tanýsý 5 olguda özefagografi, 2 olguda ise cerrahi eksplorasyon sýrasýnda kondu. Olgularýn yaralanma ile cerrahi tedavileri arasýnda geçen süre ortalama 30 saat (6 saat ile 48 saat arasý) idi. Olgularýn tümüne oblik servikal insizyon (anterior sternokleidomastoid insizyon) ile yaklaþýldý. Özefagus yaralanmasý için 3 olguda sadece drenaj, 3 olguda iki tabaka primer onarým ve drenaj ve 1 olguda ise servikal T-tüp özefagostomi + totale yakýn servikal özefageal eksklüzyon uygulandý. Trakea onarýmý tek tek, tek tabaka olarak polypropylene veya polyglycolic acid sütür kullanýlarak yapýldý. Tüm olgulara geniþ spektrumlu antibiotik verildi. Eþlik eden yaralanmalar pnömotoraks (n=3), hemotoraks (n=2), hemopnömotoraks (n=2), larinks (n=1) ve n.laryngeus inferior (n=1) idi. Larinks yaralanmasý olan olguya yaygýn hasar nedeniyle kalýcý trakeostomi yapýldý. Postoperatif servikal özefageal kaçak (n=1), trakeoözefageal fistül (n=1), özefageal stenoz (n=1) ve pnömoni (n = 1) serimizdeki komplikasyonlarý oluþturdu. Serimizde mortalite oraný %42.8 (3 olgu) dir: Bu üç olguyu sepsis nedeniyle kaybettik. Tüm seri için hastane kalýþ süresi 5 ile 99 gün arasýnda olup ortalama 36.8 gün idi. Komplikasyon sayýsý trakea ve özefagus yaralanmalarýnýn erken taný ve tedavileri ile azaltýlabilir. Özellikle trakeal onarýmýn tehlikeye atýlmamasý ve trakeoözefageal fistül geliþimini önlemek için her iki yaralanmanýn onarýmý bittikten sonra yaralanma zamaný ve cerrahi onarým arasýndaki geçen süreye bakýlmaksýzýn canlý bir doku flebi, sternokleidomastoid adele ilk seçenek olmak üzere konulmalýdýr.

Between January 1980 May 1997 23 cases with tracheobronchial injuries were treated in our clinic. In 7 (30.4%) of theses there were combined tracheal and esophageal injuries. The cause was gunshot wound injury in all patients. Diagnosis of esophageal injury has been made by esophagography in 5, and by surgical exploration in two cases. The duration of time between the injury and surgical management was 30 hours frange, 648 hours). Surgical approach was made by anterior sternocleidomastoid incision in all cases. Operative techniques included drainage(3), two-layer dosure(3), and cervical tube esophagostomy + near total esophageal exclusion (1) for esophageal injuries. Tracheal repair was done with a single layer interrupted polypropylene or polyglycolic acid sutures. Associated injuries were pneumothorax (3), hemothorax(2), hemopneumothorax(2), larynx(1), and n.Laryngens inferior(1). Permanent tracheostomy was performed in one patient with severe laryngeal injury. Complications were cervical esophageal leak(1), tracheoesophageal fistula EF(1), esophageal stenosis(1), andpneumonia(1). The morbidity rate in our series was 42.8%. The cause of mortality in these 3 cases was sepsis. The mean length of hospital stay was 36.8 days (frange, 5 99 days). The number of complications can be lowered by prompt recognition of the injuries and repair of the trachea and esophagus. In order to protect the tracheal repair and prevent TEF formation a viable tissue, Sternocleidomastiod muscle being the first choice should be placed between the repairs regardless of the time between the injury and surgery.

Bu çalýþmamýzda Harran Üniversitesi Týp Fakültesi Ortopedi ve Travmatoloji Ana Bilim Dalý'nda 1995 - 1997 tarihleri arasýnda anstabil femur trokanter kýrýklý 22 olguya Dimon - Hýtgston yöntemiyle açýk redüksiyon internal tesbit uygulandý.Olgularýmýzýn yaþ ortalamasý 67.6 yaþ, ortalama takip süresi ise 12.6 ay idi. Hastalarýn deðerlendirilmesi kliniðimizde uygulanan anatomik, radyolojik, ve klinik parametrelere göre yapýldý. Buna göre 18 olgu (% 81.8) iyi, 2 olgu (%9 orta ve 2 olgu (%9) kötü olarak deðerlendirildi. Üç olguda (% 13.6) refraktür ve üç olguda ( % 13.6) varusta kaynama gözlendi. Hiç bir hastamýzda aseptik nekroz ve çivinin baþý delmesi gözlenmedi.

Using the Dimon - Hughston technique, open reduction and internal fixation were applied to 22 patients, Harran University, Faculty of Medicine, Orthopaedic and Traumatology Clinic, between 1995 - 1997, with unstable femur trochanteric fractures. The average age of our cases was 67.6. The mean follow-up period was 12.6 months. The evaluation of the patients was made according to anatomic, radiological and clinical parameters applied in our clinic. To this evaluation, the results were defined as follows, 18 cases (%81.8 ) were good, 2 cases (%9) were modarete, and 2 cases (% 9) were poor. Coxa Vara and refractures were observed in 3 patients (13.6). Aseptic necrosis and the perforated head were observed in no cases.

Travmaya yaklaþýmdaki baþarýnýn deðerlendirilebilmesi için yaralanma þiddetinin objektif ve kantitatif olarak saptanmasý gerekir. Bu çalýþmada Ekim 1995 1996 tarihleri arasýnda Acil Yardým Hastanesi'ne baþvuran 312 travma hastasýnýn yaralanma þiddeti TRISS yöntemine göre ölçüldü ve yaþama olasýlýklarý hesaplandý. Sonuçlar Amerika'da Majör Travma Outcome Study grubunun elde ettiði sonuçlarla Z ve M istatistikleri kullanýlarak karþýlaþtýrýldý. Ayrýca matematiksel olarak beklenmeyen ölümler ve saðkalýmlar ön-kartlarda gösterildi ve nedenleri incelendi. Çalýþmaya dahil edilen 312 hastanýn 31 tanesi kaybedildi ve bunlarýn 7si beklenmeyen (yaþama olasýlýðý % 50'nin üzerinde) ölümlerdi. MTOS grubunun sonuçlarýyla çalýþma grubunun sonuçlarý arasýnda Z ve M istatistikleri ile anlamý bir fark bulunamadý.

Quantitative and objective characterisation of injury was essential for evaluation of accomplishment of management of trauma in this study, injury severity of 312 trauma patients admitted to Emergency Aid and Traumatology Hospital from October 1995 to October 1996 were estimated and probability of survival (Ps) was defined based on TRISS methodology. Conclusions were compared with Major Trauma Outcome Study (MTOS) results by Z and M statistics. Mathematically unexpected deaths and unexpected survivors were denoted on pre - charts. 31 cases of 312 patients died and 7 of them were unexpected (Ps>%50) deaths. There were no differences between study and MTOS results by Z and M statistics.

The patient is male who was 18 years old. Approximately 1 month ago he was taken laparotomy at another hospital because of the penetrating abdominal trauma. It was found a perforation on the surface of the stomach in 1 cm diameter and injury of mesentery of the small intestine. Perforation had repaired primarily and nothing had done anything to the retroperitoneal space and mesentery of the small intestine. He was discharged in the fifteenth day after operation without any problem. He was referred to our center because of an acute abdominal pain, restlessness, and hypotension. We found an aneurysm and hematoma of SMA with doppler ultrasonography and spiral abdominal computerized tomography. We excised pseudoaneurysm of SMA with laparotomy and SMA was repaired primarily. After operation we performed angiography of SMA. We couldn't find any patology on the SMA. After that the patient was discharged in the postoperative thirteenth day without any complication and problem. We concluded that, in the patients which has penetrating abdominal injury, mesenteric pseudoaneurysm must be keep in mind and in such case the surgeon must be explore the abdominal vascular tree.

Akut apendajit nadir görülen bir akut karýn nedenidir. Türkçe literatürde þu ana kadar tek vaka bildirimi tesbit edilebilmiþtir. En sýk akut apandisitle karýþýr. Burada 2 olgu sunulmuþ ve taný-tedavideki özellikler irdelenmiþtir. Ayýrýcý taný çok önemli olmamakla birlikte kesin taný için geniþ eksplorasyon gerekmektedir. Apandisit ön tanýsý ile operasyona alýnýp da apendiksin normal bulunduðu vakalarda meckel divertikülü gibi apendiks epiploikalar da gözden geçirilmelidir.

Acute appendagitis is a rare cause of acute abdomen. There is still only one case report in the Turkish medical literature. We described 2 new cases and examined the properties of diagnosis and treatment. Although the differantial diagnosis is not important from acute appendicitis, good exploration of the abdomen is needed for accurate diagnosis. In the cases of "white appendicitis" acute appendagitis must also be examined like meckel diverticulitis.

Penile tourniquet injury probably is not a rare entity and has been reported following the application of numerous foreign objects, including rings, rubber bands, bottles, pipes and threads. Penile strangulation caused by a coil of hair frequently is an unrecognized clinical entity with severe potential complications, such as urethrocittaneous fistulas, necrosis of the glands and partial or complete amputation of the glands. We report an interesting case of penile strangulation secondary to a strand of human hair and discuss important anatomical considerations, mechanism of injury and methods or treatment.