Amaç: Sentetik malzemelerin kontamine alanlarda kullanýmý ile ilgili farklý görüþler mevcuttur. Bu çalýþma, ticari olarak eriþilebilen kompozit yamalardan birinin karýn içi enfeksiyon varlýðýnda kullanýlabilirliðini araþtýrmayý amaçlamaktadýr.
Gereç ve Yöntem: Yirmi adet sýçanda deneysel peritonit oluþturulmasýndan yirmi dört saat sonra, denekler iki adet onarlý gruba randomize edildi. Ýkinci bir laparotomi ile karýn içinin temizlenmesini takiben karýn kontrol grubunda sürekli sütürlerle, deney grubundaysa kompozit yama kullanýlarak kapatýldý. Bundan sonra sýçanlar sepsis bulgularý, ölüm ve yara yeri enfeksiyonu açýsýndan takip edildi. Yirmi sekizinci günde sýçanlar sakrifiye edilerek karýn içi enfeksiyon, karýn içi yapýþýklýklar açýsýndan ve alýnan yama ve doku örnekleri de kültür üremeleri açýsýndan deðerlendirildi.
Bulgular: Mortalite oranlarý kontrol ve yama gruplarýnda sýrasýyla %0 ve %30 (p=0,21) ve yara yeri enfeksiyonu oranlarý ise sýrasýyla %20 ve %57,1’di (p=0,162). Yama grubunda yapýþýklýklar istatistiksel olarak önemli biçimde daha yoðundu(p=0,018) ve doku kültürlerinde önemli ölçüde daha fazla mikroorganizma üremiþti (p=0,003).
Sonuç: Yama grubunda karýn içi yapýþýklýklarýn yoðunluðunun ve bakteri üremesinin önemli ölçüde daha fazla olmasý ve ayný zamanda mortalite ve yara yeri enfeksiyonu oranlarýndaki artýþ eðilimi, bu kompozit yamanýn, karýn içi enfeksiyon varlýðýnda karýn defektlerinin onarýmý için güvenle kullanýlamayacaðýný göstermektedir.

BACKGROUND: There are varying opinions on the feasibility of the placement of synthetic materials in contaminated surgical fields. The aim of this study was to investigate the outcomes of the use of a commercially available composite mesh in the presence of abdominal infection.
METHODS: Twenty-four hours after the induction of experimental peritonitis, 20 rats were randomized into 2 groups of 10 subjects. After abdominal cleansing with a second laparotomy, the abdomen was closed with running sutures in the control group and the composite mesh was applied in the experimental group before closure. The rats were followed up for findings of sepsis, mortality, and wound infection. On the 28th day, the rats were sacrificed and evaluated for abdominal infection, abdominal adhesions, and bacterial growth in the mesh and tissue cultures.
RESULTS: The mortality rate was 0% and 30% in the control and mesh groups, respectively (p=0.21), and the wound infection rate was 20% and 57.1% (p=0.162). In the mesh group, the adhesions were significantly more intense (p=0.018) and significantly more microorganisms proliferated in the tissue cultures (p=0.003).
CONCLUSION: The significant increase in the intensity of adhesions and bacterial proliferation, as well as the higher rate of mortality and wound infection in the mesh group indicated that this composite mesh cannot be used safely in the repair of abdominal defects in the presence of abdominal infection.

AMAÇ: Bu çalýþmada akut mezenterik iskemide yeni iskemik biyobelirteçler olan ENDOCAN ve SCUBE-1'in erken evre hasar, taný ve irreversibýl hasar deðerlerini araþtýrmayý amaçladýk.
GEREÇ VE YÖNTEM: 54 sýçan ile deneysel bir mezenterik iskemi reperfüzyon modeli tasarlandý. Dokuz grup oluþturuldu; Kan ve doku örneklerinin sadece örneklendiði üç sahte grup [Grup I (30.dakika), IV (2. saat) ve VII (6.saat)]; superior mezenterik arter (SMA) baðlandýktan sonra kan ve doku numuneleri örneklenen üç iskemi grubu [Grup II (30. dakika), V (2. saat) ve VIII (6.saat)]; ve SMA dekompresyonundan sonra kan ve doku numuneleri örneklendirilen ve reperfüzyon 1 saat süreyle indüklenen üç reperfüzyon grubu [Grup III (30. dakika), VI (2. saat) ve IX (6. saat)]. SCUBE-1 ve ENDOCAN için kan örnekleri alýndý ve histopatolojik olarak doku örnekleri incelendi.
BULGULAR: SCUBE-1 düzeyleri Ýskemi grubunda sahte gruba göre daha yüksek iken(p <0.05), geç iskemi (6. saat) grubunda ENDOCAN düzeyleri belirgin olarak farklýydý. Bu iki belirteç, histopatolojik incelemeye göre irreversýble mezenterik hasar için birlikte kullanýldýðýnda, reversible-irrreversible hasar ayýrýmýný % 94,1 sensitivite, % 73,7 spesifite ile belirledi.
TARTIÞMA: SCUBE-1'in tek baþýna yükselmesi laboratuvar sýçanlarýnda erken mezenterik iskemiyi öngörmede önemli olarak gözükmektedir. Bununla birlikte, SCUBE-1 ve ENDOCAN eþ zamanlý kullanýmý irreversible baðýrsak hasarýnýn tespitinde daha kullanýlýþlý olabilir.

BACKGROUND: The objective of the current study was to investigate the value of the ischemic biomarkers endothelial cell-specific molecule-1 (endocan) and signal peptide-CUB-EGF domain-containing protein-1 (SCUBE-1) in the diagnosis and assessment of early-stage and irreversible damage in acute mesenteric ischemia.
METHODS: An experimental mesenteric ischemia reperfusion model was designed using 54 rats. Nine groups were created: Three sham groups [Groups I (30th minute), IV (2nd hour), and VII (6th hour)], in which only blood and tissue specimens were sampled; 3 ischemia groups [Groups II (30th minute), V (2nd hour), and VIII (6th hour)], in which blood and tissue specimens were sampled after ligation of the superior mesenteric artery (SMA); and 3 reperfusion groups [Groups III (30th minute), VI (2nd hour), and IX (6th hour)], in which blood and tissue specimens were sampled after declamping the SMA and reperfusion for 1 hour. SCUBE-1 and endocan samples obtained from blood and tissue were examined histopathologically.
RESULTS: The SCUBE-1 level was higher in the ischemia groups when compared with the sham groups (p<0.05), and the endocan level was markedly different in the late ischemia (6th hour) group. When these 2 markers were used together to assess irreversible mesenteric damage in the histopathological examination, the sensitivity in distinguishing between reversible or irreversible damage was 94.1% with a specificity of 73.7%.
CONCLUSION: The elevation of SCUBE-1 alone seems to be significant for predicting early mesenteric ischemia in laboratory rats. The combination of SCUBE-1 and endocan may be useful to detect irreversible intestinal damage.

AMAÇ: Eriþim Kýlýflarý (EK) genellikle retrograt intrarenal cerrahide (RÝRC) kullanýlmaktadýr. Avantajlarýna raðmen yerleþtirilmeleri sýrasýnda üreter yaralanmasý ve cerrahi sonrasýnda darlýk riski bulunmaktadýr. Bu çalýþmanýn amacý sarf edilen itme gücünü ve üreter travmasýna etkisini deðerlendirmektir.
GEREÇ VE YÖNTEM: Böbrek taþlarý için RÝRC uygulanmýþ yedi kadýn hasta çalýþmaya dahil edilmiþtir. Bir dijital güç ölçüm cihazý (Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, Florida, ABD) EK’larýn ucuna monte edilmiþ ve EK ile sarf edilen itme gücü, kýlýfýn yerleþtirilmesi sýrasýnda sürekli ölçülmüþtür. Deðiþik boyutlarda EK’lar kullanýlmýþ ve Postüreteroskopik Lezyon Ölçeði (PULS) skoru ile doðrudan görüþ altýnda üreter yaralanmasý deðerlendirilmiþtir.
BULGULAR: Daha önce stent konmuþ beþ ve konmamýþ iki hasta çalýþmaya dahil edilmiþtir. EK’larýn çaplarý daha önce stent konmamýþ hastalarda 9.5/11.5-F ve 10/12-F, daha önce stent konmuþ hastalarýn birinde 11/13-F ve dördünde 12/14-F idi. Daha önce stent konulmuþ hastada 12/14 F EK yerleþtirmek için maksimal 9 Newton’luk (N) itme gücü sarf edildiði gözlenmiþtir. Bu hastada ilk baþarýsýz denemeden sonra ikinci kez deneme yapýlmýþtýr. Bir stent konmamýþ hastada 9.5/11.5-F EK’larý yerleþtirmek için en düþük maksimal EK itme gücü (0.91 N) sarf edilmiþtir. EK’yý yerleþtirmeden önce bu hastaya 7.8-F semirijit üreteroskopi uygulanmýþtý. Ýki stent konmamýþ hastada da PULS skoru 1 ve önceden stent takýlmýþ hastalarýn tümünde 0 idi.
TARTIÞMA: Bu küçük çaplý kohort çalýþmasýnda ameliyat öncesi JJ yerleþtirilmesinin, üreteri 12/14F gibi geniþ çaplý EK’larýn travmasýndan koruduðu görülmüþtür. Önceden stentsiz olan hastalarda RÝRC uygulamasýnda EK yerleþtirilmesi mümkün ise de bu durum düþük dereceli üreter travmasýna neden olabilir.

BACKGROUND: Ureteral access sheaths (UASs) are commonly used in retrograde intra-renal surgery (RIRS). Despite their advantages, there is a risk of ureteral trauma during their placement and subsequent stricture following surgery. The aim of this study was to evaluate the UAS force of insertion (FOI) during placement and its impact on ureteral trauma.
METHODS: Seven female patients who underwent RIRS for kidney stones were included in the study. A digital force gauge (Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, Florida, USA) was connected to the distal end of the UAS and the UAS FOI was continuously measured during insertion. UASs of different sizes were used and ureteral injury was evaluated under direct vision with the Post-Ureteroscopic Lesion Scale (PULS) score.
RESULTS: Five pre-stented patients and 2 non-stented patients were included in the study. The size of the UASs used in non-stented patients was 9.5/11.5-F and 10/12-F, whereas one 11/13-F and four 12/14-F sheaths were used in the pre-stented patients. The highest maximal UAS FOI observed was 5.9 Newton (N) in a pre-stented patient with a 12/14-F UAS, where a second attempt was performed after initial failure. The lowest maximal UAS FOI was 0.91 N in a non-stented patient using a 9.5/11.5-F UAS. A semirigid ureteroscopy with a 7.8-F sheath was performed in this patient prior UAS placement. The PULS score was 1 in the 2 non-stented patients and 0 in all of the pre-stented patients.
CONCLUSION: In this small cohort, a preoperative JJ stent seemed to protect the ureter, even with larger diameter UASs of 12/14- F. Non-stented RIRS with a UAS is possible, but may cause low-grade ureteral trauma.

AMAÇ: Bilateral pnömotoraks (BPTx), özellikle þiddetli multi-travma hastalarýnda tansiyon PTx gibi mortalitenin önemli bir nedeni olabilir. Bu çalýþmada, BPTx tedavisi ve buna baðlý komplikasyon, morbidite ve mortalitenin önemini belirtmek amacýyla multi-travma sonrasý BPTx insidansý, morbidite, mortalite oranlarý ve bunlarla iliþkili faktörlerin analiz edilmesi amaçlanmýþtýr.
GEREÇ ve YÖNTEM: Travma sonrasý baþvuran 3782 hastadan BPTx saptanan 181 hastanýn verileri yaþ, cinsiyet, travma çeþidi, radyolojik bulgular, eþlik eden torasik ve ekstra-torasik yaralanmalar, entübasyon insidansý, mortalite ve travma þiddet skoru (TÞS) açýsýndan retrospektif olarak analiz edildi. Kot fraktürünün tarafý, hemotoraks, ciltaltý amfizemi ve BPTx arasýndaki iliþki ile yaþ ve cinsiyetin bu yaralanma, mortalite ve TÞS’ye etkisi araþtýrýldý.
BULGULAR: Yüzkýrkdördünü erkeklerin oluþturduðu hastalarýn yaþ ortalamasý 36.07 ± 15.77 idi. Travmanýn baþlýca nedeni 67 (%37.0) hastada bildirilen araç-içi trafik kazasýydý. Yetmiþbeþ (%41.4) hastada bilateral kot fraktürü izlendi. Hastalarýn 41’inde (%22.6) BPTx’a bilateral hemotoraks eþlik ettiði belirlendi. Özellikle 60 yaþ üstü hasta grubunda kot fraktürü ve hemotoraksýn tarafý açýsýndan anlamlý fark saptandý (p=0.017, p=0.005). Bu hasta grubunda eþlik eden torasik yaralanmalarýn daha sýk olarak bilateral olduðu belirlendi. Ýzole toraks travmasý olan 12 (%17.6) ve multi-travmasý olan 56 (%82.4) hasta entübe edildi. Ýki grup arasýnda entübasyon açýsýndan anlamlý fark bulunmadý (p=0.532). Toplam mortalite oraný %18.2 idi. Travma þiddet skoru ile mortalite arasýnda anlamlý bir iliþki saptanmadý (p=0.22).
TARTIÞMA: Travma sonrasýnda BPTx insidansý yaklaþýk olarak %5 oranýndadýr; bu nedenle özellikle þiddetli travma sonrasýnda mortalite oranýný azaltmak amacýyla BPTx akýlda bulundurulmasý gereken bir patolojidir. Yaþ ve kot fraktürü sayýsý BPTx saptanan multi-travma hastalarýnda morbidite ve mortalite için risk faktörleridir.

BACKGROUND: Bilateral pneumothorax (BPTx) can become tension PTx and a cause of mortality, especially in severe multi-trauma patients. The purpose of this study was to analyze the incidence, morbidity, mortality, and associated factors of BPTx in multi-trauma patients in order to highlight the importance of the management of these cases, as well as complications, morbidity, and mortality.
METHODS: The data of 181 patients with BPTx, from a total of 3782 trauma patients, were reviewed retrospectively. The details recorded were age, gender, mechanism of trauma, radiological findings, co-existing thoracic and extra-thoracic injuries, incidence of intubation, mortality, and injury severity score (ISS). The association between laterality of rib fracture, hemothorax, subcutaneous emphysema, and BPTx, and the effect of age and gender on these injuries, mortality, and ISS were analyzed.
RESULTS: The patient group included 144 males, and the mean age was 36.07±15.77 years. The primary cause of trauma was a motor vehicle accident, seen in 67 (37.0%) patients. Bilateral rib fractures were detected in 75 (41.4%) patients. Hemothorax accompanied PTx in 41 (22.6%) patients bilaterally. The laterality of the rib fracture and hemothorax demonstrated a significant difference in the patient group over 60 years of age (p=0.017, p=0.005). Co-existing bilateral thoracic injuries were detected more often in this group. Twelve (17.6%) patients with only blunt chest trauma and 56 (82.4%) patients with multi-trauma were intubated. The difference between the 2 groups was not significant (p=0.532). The overall mortality rate was 18.2%. A comparison of ISS and mortality between the groups revealed no significant difference (p=0.22).
CONCLUSION: The incidence of BPTx after multi-trauma is approximately 5%, so it must be taken into consideration, especially in severe multi-trauma patients, to reduce mortality. Older age and the number of rib fractures were determined to be risk factors for morbidity and mortality in trauma with BPTx.

Amaç: Akut pankreatit gastrointestinal patolojiler arasýnda önemli patolojilerden birisi olup çalýþmadaki amacýmýz eritrosit daðýlým hacmi(RDW) ve CRP/albumin ile prognoz iliþkisini belirleyebilmektir.
Gereç ve Yöntem: Çalýþma retrospektif olup akut pankreatit vakalarý alýnmýþ ve Ranson skoruna göre ýlýmlý ve þiddetli grup olarak iki gruba bölünmüþtür. Bu iki grup arasýnda RDW, CRP/albumin ve hastanede yatýþ ile yoðun bakýmda yatýþ süreleri, komplikasyonlarý karþýlaþtýrýlmýþtýr.
Bulgular: Toplam 264 hasta çalýþmaya dahil edilmiþtir. 204 hastada (%77,2)ýlýmlý pankreatit saptanýrken, 60 hastada (%22,8) þiddetli pankreatit saptandý. (p=0,081) Bu iki grup arasýndaki RDW deðerlerine bakýldýðýnda istatistiksel olarak anlamlý bir farklýlýk olmadýðý gözlendi.(p=0,193) CRP/Albumin deðerlerine bakýldýðýnda þiddetli AP grubunda diðer gruba göre deðerlerin oldukça yüksek olduðu saptandý.( p<0,001) Hastanede toplam yatýþ süreleri ve yoðun bakýmda toplam yatýþ sürelerine bakýldýðýnda ise þiddetli AP grubundaki hastalarýn diðer gruba göre daha fazla hastanede kaldýklarý gözlenmiþtir.(p=0,001,p=0,047)
Tartýþma: Akut pankreatit tablosunda RDW net olarak prognozu ön görmede spesifik bir markýr deðilken, CRP/albumin kolay uygulanabilen, ucuz ve güvenilir bir markýrdýr.

BACKGROUND: Acute pancreatitis (AP) is one of the major pathologies among gastrointestinal system diseases. The aim of this study was to determine the relationship between the red cell distribution width (RDW) value and the C-reactive protein (CRP)/ albumin ratio in patients with AP.
METHODS: In this retrospective study, AP cases were enrolled and divided into 2 groups according to the Ranson criteria as moderate or severe pancreatitis. The RDW and CRP/albumin values, length of hospitalization and stay in the intensive care unit (ICU), and the complications experienced were compared between these 2 groups.
RESULTS: A total of 264 patients were included in the study. Moderate pancreatitis was detected in 204 patients (77.2%) while severe pancreatitis was seen in 60 patients (22.8%) (p=0.081). There was no statistically significant difference in the RDW value between the groups (p=0.193). The CRP/albumin values were significantly higher in the severe pancreatitis group compared with the moderate group (p<0.001). The severe AP group also had a longer period of hospital care, both overall and in the ICU (p=0.001, p=0.047).
CONCLUSION: RDW was not a specific marker for predicting prognosis in AP, but the CRP/albumin ratio is an easy-to-apply, inexpensive, and reliable marker.

BACKGROUND: The aim of this study was to identify factors predicting early mortality in trauma patients.
METHODS: This was a study of 6288 trauma patients admitted to the hospital between July 2011 and June 2016. Among the variables recorded for a prospective trauma registry, the following were selected for analysis: sex; age; a combination of the Glasgow Coma Scale score, age, and systolic blood pressure (SBP) (GAP); a combination of the mechanism of injury, the Glasgow Coma Scale score, age, and SBP (MGAP); SBP; respiratory rate; peripheral oxygen saturation (SpO2 value); the Glasgow Coma Scale score; laboratory variables; and presentation time. Logistic regression analysis was used to explore associations between these variables and early mortality.
RESULTS: In total, 296 (4.6%) patients died within 24 hours. Univariate regression analysis indicated that age, the GAP, the MGAP, SBP, SpO2, the Glasgow Coma Scale score, base excess, hemoglobin level, platelet count, INR, and presentation time predicted early mortality. Multivariate regression showed that the GAP, the MGAP, SpO2, base excess, platelet count, and INR were independently predictive. The areas under the receiver operator curve comparisons for the GAP and MGAP models revealed the superiority of the GAP-based model.
CONCLUSION: The GAP model, SpO2, base excess, platelet count, and INR predicted the early mortality of trauma patients.

AMAÇ: Akut karýn aðrýsý þikayeti ile acil servise müracaat eden hastalarda düz kas proteini Irisin’in serum düzeyini ölçerek tanýsal deðerini araþtýrmak amacýyla bu çalýþma yapýldý.
GEREÇ - YÖNTEM: Bu araþtýrma, tek merkezli, prospektif ve kesitsel bir çalýþma olarak yapýlmýþtýr. Akut karýn aðrýsý þikayeti ile acil servise baþvuran 213 eriþkin hasta ve 140 kiþilik saðlýklý kontrol grubu dahil edildi. Serum irisin düzeyleri, lökosit, CRP, amilaz ve kreatin kinaz deðerleri ile karþýlaþtýrýldý. Serum Ýrisin düzeyleri, yatýþý yapýlan ile taburcu olan ve cerrahi ile týbbi tedavi yapýlan gruplar da karþýlaþtýrýldý.
BULGULAR: Çalýþmaya dahil edilen 213 hasta ve 140 kontrol grubu ortalama Irisin düzeyleri 6,81 ± 3,17 mcg / ml ve 5,69 ± 2,08 mcg/ml idi. Hastaneye yatýrýlan hastalarýn ortalama Irisin deðerleri (7,98 ± 3,11 mcg/ml), taburcu edilen hastalarýn (6,38 ± 3,09 mcg/ml) ve kontrol grubu olgularýn Irisin deðerlerinden (kontrol grubu – taburcu hasta grubu p = 0,202) anlamlý derecede yüksekti (kontrol grubu - hastaneye yatýrýlan grup p <0,001, taburcu edilen grup - hastaneye yatýrýlan grup p = 0,001). Kontrol grubu ile karþýlaþtýrýldýðýnda, safra kesesi hastalýklarý, ürolitiyazis ve akut apandisitte irisin düzeyleri anlamlý olarak daha yüksekti (p = 0.001, p = 0.007, p = 0.007).
SONUÇ: Serum Ýrisin seviyeleri, düz kas yapýsý içeren intraabdominal tübüler organlarýn luminal obstrüksiyonu geliþmiþ akut karýn aðrýlý hastalarda taný ve prognoz belirlemede bir belirteç olarak kullanýlabilir.

BACKGROUND: The aim of this study was to investigate the prognostic value of irisin by examining the serum level of this smooth muscle protein in patients presenting at the emergency department (ED) with acute abdominal pain.
METHODS: This research was performed as a single-center, prospective, cross-sectional study. In all, 213 adult patients presenting at the ED with acute abdominal pain and 140 healthy controls were enrolled. The serum irisin level was correlated with the leukocyte, C-reactive protein, amylase, and creatine kinase values. The irisin level was compared between groups of those who were admitted or discharged, and those who received surgical or medical treatment.
RESULTS: The mean irisin level of the 213 patients and the 140 controls was 6.81±3.17 mcg/mL vs. 5.69±2.08 mcg/mL. The mean irisin value of the hospitalized patients (7.98±3.11 mcg/mL) was significantly higher than that of the discharged patient group (6.38±3.09 mcg/mL) and the controls (control vs. discharged: p=0.202; control vs. hospitalized: p<0.001; discharged vs. hospitalized: p=0.001). When compared with that of the control group, the irisin level was significantly higher in patients with gall bladder diseases, urolithiasis, and acute appendicitis (p=0.001, p=0.007, p=0.007).
CONCLUSION: The serum irisin level in patients with abdominal pain may serve as a guide in diagnostic decision-making and determining the prognosis for cases of acute abdominal pain involving luminal obstruction in tubular intra-abdominal organs

Karaman skoru: Akut apandisit tanýsýnda yeni bir skorlama sistemi
Giriþ: Karaman skorlama sistemi akut apandisit tanýsýnda kullanýlan ve 6 parametreden oluþan yeni bir tanýsal skorlama sistemidir. Bu çalýþmanýn amacý Karaman skorunun akut apandisit taný performansýný Alvarado skoru ile karþýlaþtýrmalý olarak ortaya koymaktýr
Materyal ve Metod: Akut apandisit tanýsý ile apendektomi yapýlan 200 hasta çalýþmaya dahil edilmiþtir.
Bulgular: Karaman skorunun akut apandisiti negatif apandektomiden ayýrmadaki cut off deðeri ≥9 olup, sensitivitesi % 84.3, spesifitesi %64.7, pozitif prediktif deðeri %92.1 ve negatif prediktif deðeri %45.8 olarak saptanmýþtýr. Alvarado skorunun akut apandisiti negatif apandektomiden ayýrmadaki cut off deðeri ise ≥8 olup, sensitivitesi %72.9, spesifitesi %70.6, positif prediktif deðeri %92.4 ve negatif prediktif deðeri %34.8 olarak saptanmýþtýr. Multilojistik regreyon analizinde, yaþ ve cinsiyete göre düzeltme yapýldýðýnda; hem Alvarado ≥8 (OR=6.644, 95% CI: 2.854-15.466, P<0.001) hem de Karaman ≥9 skoru (OR=10.374, 95% CI: 4.383-24.558, P<0.001) akut apandisiti negatif apandektomiden ayýrmada anlamlý olarak etkin saptanmýþtýr. Ancak her iki skor bir arada deðerlendirildiðinde, Alvarado skoru ≥8 etkinliðini yitirirken (OR=1.838, 95% CI: 0.517-6.530 and P=0.347) Karaman skoru ≥9 prediktif etkinliðini göstermeye devam etmektedir (OR=6.586, 95% CI: 1.893-22.917, P=0.003).
Tartýþma: Karaman skoru akut apandisiti negatif apandektomiden ayýrt etmede daha etkin saptanmýþtýr.

BACKGROUND: The Karaman score is a novel diagnostic scoring system consisting of 6 parameters. The aim of the present study was to assess the diagnostic performance of the Karaman score in comparison with the Alvarado score.
METHODS: A total of 200 patients who underwent an appendectomy were enrolled in the study (research registry number: 2290).
RESULTS: The cutoff threshold of the Karaman score in distinguishing acute appendicitis from negative appendectomy was ≥9 with 84.3% sensitivity, 64.7% specificity, 92.1% positive predictive value (PPV), and 45.8% negative predictive value (NPV). The cutoff threshold of the Alvarado score in distinguishing acute appendicitis from negative appendectomy was ≥8 with 72.9% sensitivity, 70.6% specificity, 92.4% PPV, and 34.8% NPV. In multivariate logistic regression analysis, an Alvarado ≥8 score (Odds ratio [OR]: 6.644, 95% confidence interval [CI]: 2.854–15.466; p<0.001) and a Karaman ≥9 score (OR: 10.374, 95% CI: 4.383–24.558; p<0.001) were each individually predictive in distinguishing acute appendicitis from negative appendectomy when correction was made according to age and gender. However, when both scores were evaluated together, the Alvarado score ≥8 lost its efficacy (OR: 1.838, 95% CI: 0.517–6.530; p=0.347), whereas the Karaman score ≥9 retained its predictive power (OR: 6.586, 95% CI: 1.893–22.917; p=0.003).
CONCLUSION: The Karaman score was more predictive than the Alvarado score in distinguishing acute appendicitis from a negative appendectomy.

Amaç: Bu çalýþmanýn amacý tek bir merkezde apandisit nedeniyle ameliyat edilen gebe kadýnlarda laparoskopik ve açýk apendektominin obstetrik ve cerrahi sonuçlarýný karþýlaþtýrmaktýr. Bu çalýþmadaki ana hipotezimiz bahsedilen sonuçlar açýsýndan açýk ya da laparoskopik apendektomi arasýnda fark olmadýðýdýr.
Yöntemler: Ocak 2009 ile Eylül 2018 arasýnda apendektomi yapýlan 57 ardýþýk gebe kadýnýn týbbi kayýtlarý retrospektif olarak incelendi. Hastalar açýk ve laparoskopik apendektomi olmak üzere iki gruba ayrýldý. Toplanan veriler yaþ, gebelik yaþý, taný yöntemleri, ameliyat süresi, kalýþ süresi, morbidite ve mortaliteyi içermektedir. Veri analizi, Windows için IBM SPSS v. 23 kullanýlarak gerçekleþtirilmiþtir.
Bulgular: On sekiz (% 31) hastaya laparoskopik apendektomi (LA) ve 39 (% 69) hastaya açýk apendektomi (OA) uygulandý. Demografik veriler arasýnda fark yoktu. Laparoskopik grupta cerrahinin süresi anlamlý olarak daha kýsaydý (37 vs 57 dakika, p = 0.005). Derin ve yüzeyel cerrahi alan enfeksiyonlarý, yatýþ süresi, erken doðum ve fetal kayýp gibi sonuçlarda istatistiksel olarak anlamlý bir fark bulunmadý. Her iki grupta da mortalite yoktu.
Sonuç: Genel olarak, bu çalýþma LA'nýn gebe hasta ve fetus için güvenli olduðunu düþündürmektedir. Apandisitli gebe hastalar üzerinde laparoskopinin etkilerini belirlemek için, daha geniþ sayýda olguda prospektif randomize çalýþmalara ihtiyaç vardýr.

BACKGROUND: The aim of this study was to compare the obstetric and surgical outcomes of laparoscopic appendectomy (LA) and open appendectomy (OA) performed for pregnant women at a single center. It was the hypothesis of this study that there would be no significant difference in the results.
METHODS: The medical records of 57 consecutive pregnant women who underwent an appendectomy between January 2009 and September 2018 were reviewed retrospectively. The patients were divided into 2 groups: OA and LA. The collected data included age, gestational age, diagnostic modalities used, duration of surgery, length of hospital stay, morbidity, and mortality.
RESULTS: Eighteen (31%) patients underwent LA and 39 (69%) patients underwent OA. There were no significant differences in the demographic data. The duration of surgery was significantly less in the laparoscopic group (37 vs 57 minutes; p=0.005). There were no statistically significant differences in the outcomes of deep or superficial surgical site infection, length of hospital stay, pre-term delivery, or loss of the fetus. There was no mortality in either group.
CONCLUSION: The results of this study suggest that LA can be a safe option for both the pregnant patient and the child. Further prospective, randomized studies with a larger group of pregnant patients with appendicitis are needed to fully determine the effects of laparoscopy in these circumstances.

Giriþ: Alvarado (AS) and Apandisit Ýnflamatuar Yanýt (AIYS) skorlarý akut apandisit (AA) tanýsý için geliþtirilmiþ skorlardýr. Bu çalýþmanýn amacý AA þiddetinin AS ve AIYS ile deðerlendirmesidir.
Materyal ve Metot: Ocak 2016-Aralýk 2017 tarihleri arasýnda AA nedeni ile opere edilen ve preop AS ve AIYS yapýlan hastalar geriye dönük deðerlendirildi. Yaþ, cinsiyet, patolojik þiddet, lokal peritonit, fekaloid, drenaj, apendix çapý ve operasyon þekli AS ve AIYS göre deðerlendirildi.
Bulgular: 578 hasta çalýþmaya dâhil edildi. Apandisit %44,4 ile en sýk görülen patolojiydi. En sýk ölçülen apandiks çapý ise %59,2 ile 7-10 mm idi. Bütün patolojiler arasýndaki AS ve AIYS istatistiksel olarak anlamlý bulundu (p<0,05). Komplike ve komplike olmayan apandisitler arasýndaki sadece AIYS istatistiksel olarak anlamlý bulundu (p<0,05). Apandiks çaplarý arasýndaki sadece AIYS istatistiksel olarak anlamlý bulundu (p<0,05). Drenaj yapýlan hastalarda AS ve AIYS istatistiksel olarak anlamlý farklýlýk saptandý (p<0,05). AS ile patolojik þiddet, lokal peritonit ve drenajýn korelasyonu, AIYS ile patolojik þiddet, komplike/ komplike olmayan, apandiks çapý ve drenajýn korelasyonu istatistiksel olarak anlamlý bulundu (p<0,05).
Sonuç: AS ve AIYS her ikisi de patolojik þiddeti deðerlendirebilmekte iken sadece AIYS komplike ve komplike olmayan apandisitleri, apandiks çapýnýn daha anlamlý deðerlendirebilmektedir. Bu skorlarý kullanarak gereksiz radyolojik ve cerrahi giriþimlerini azaltabilecektir.

BACKGROUND: The Alvarado score (AS) and the Appendicitis Inflammatory Response score (AIRS) were developed to diagnose acute appendicitis (AA). The aim of this study was to evaluate the severity of AA using the AS and the AIRS tools.
METHODS: Patients who presented between January 2016 and December 2017 and underwent surgery for AA and who had a preoperative AS and AIRS value were evaluated retrospectively. The details of age, sex, pathological severity, the presence of local peritonitis or fecaloid, drainage, appendix diameter, and operation type were evaluated according to the AS and the AIRS.
RESULTS: A total of 578 patients were included in the study. Appendicitis was the most common pathological severity classification (44.4%). The most common appendix diameter group was 7–10 mm (59.2%). The difference observed in the AS and AIRS results for all of the pathological severity categories was statistically significant (p<0.05). The AIRS revealed a statistically significant difference (p<0.05) in the detection of uncomplicated and complicated appendicitis. The AIRS difference was statistically significant for appendix diameter (p<0.05). The AS and the AIRS results were both statistically significant for drainage (p<0.05). The AS was correlated with pathological severity, local peritonitis, and drainage, while the AIRS was correlated with pathological severity, uncomplicated/complicated determination, appendix diameter, and drainage (p<0.05).
CONCLUSION: Both the AS and the AIRS can evaluate pathological severity, but only the AIRS can evaluate complicated or uncomplicated appendicitis and the diameter of the appendix. These tools can be used to reduce the number of unnecessary radiological or surgical interventions.

Amaç: Çalýþmamýzda, penetran keratoplasti (PK) sonrasý künt travmaya baðlý yara açýlmasýný etkileyen faktörleri ve klinik sonuçlarý araþtýrmak amaçlanmýþtýr.
Yöntem: 1995-2015 arasýnda PK sonrasý künt travmaya baðlý yara açmasý geliþen olgular retrospektif olarak tarandý. Travma insidansý ve etiyolojisi, keratoplasti ve glob rüptürü arasýndaki zaman, greft durumu, en iyi düzeltilmiþ görme keskinliði (EDGK), komplikasyonlar, ikincil ameliyatlar ve yaralanma boyutunu etkileyebilecek faktörler kaydedildi.
Bulgular: Çalýþmaya yaþ ortalamasý 42.66 ± 16.66 yýl olan, 23'ü erkek, 16'sý kadýn, toplam 39 hasta dahil edildi. Yara yeri açýlma insidansý % 2.3 idi. Penetran keratoplasti ve travmatik yara yeri açýlmasý arasýndaki ortalama süre 25.91 ± 47.24 ay, ortalama takip süresi 34.43 ± 51.02 ay idi. En yaygýn travma mekanizmasýnýn künt bir nesnenin çarpmasý (% 53.8), en sýk yara yeri ayrýlmasýnýn görüldüðü kadranýn temporal (% 30.8) idi ve yara yeri ayrýlma büyüklüðünün 45° ile 270° arasýnda olduðu saptandý.
Hastalar yara yeri ayrýlma büyüklüðüne göre dört gruba ayrýldý; yara yeri ayrýlma büyüklüðü arttýkça, erkek cinsiyete daha sýk rastlandýðý, nazal ve üst kadranlarda yara yeri ayrýlmasýnýn daha sýk görüldüðü, lens hasarýnýn, arka segment komplikasyonlarýnýn daha sýk ve greft þeffaflýðýnýn daha düþük oranda saðlandýðý izlendi.
Sonuç: Penetran keratoplasti sonrasý ortaya çýkan travmatik yara yeri ayrýlmasý nadir görülen ancak ömür boyu karþýlaþýlabilecek bir komplikasyondur. Göz kaybý gibi ciddi sonuçlar doðurduðundan, hastalar yara yeri ayrýlma riskleri ve sekelleri açýsýndan bilgilendirilmelidir.

BACKGROUND: The purpose of this study was to investigate factors affecting wound dehiscence due to blunt trauma following penetrating keratoplasty (PK) and the clinical outcomes.
METHODS: The medical records of patients who experienced blunt traumatic wound dehiscence after PK between 1995 and 2015 were analyzed retrospectively. The incidence and etiology of the trauma, the time interval between PK and globe rupture, final graft clarity, best-corrected visual acuity, complications, secondary surgeries, and factors potentially affecting wound dehiscence size were recorded.
RESULTS: This study included a total of 39 patients with a mean age of 42.66±16.66 years, of whom 23 patients were male and 16 patients were female. The incidence of wound dehiscence was 2.3%. The mean interval between the PK procedure and wound dehiscence was 25.91±47.24 months and the mean follow-up time was 34.43±51.02 months. The most common trauma mechanism was force with a blunt object (53.8%) and the most frequent site of wound dehiscence was the temporal quadrant (30.8%), the wound ranging from 30° to 270° in size. The patients were divided into 4 groups according to wound dehiscence size. As the size of the wound dehiscence size increased, the male ratio increased, wound dehiscence was more commonly located in the nasal and superior quadrants, lens injury and posterior segment complications were more frequent, and graft transparency was achieved at a lower rate.
CONCLUSION: Traumatic wound dehiscence after PK is rare, but may lead to serious, lifelong consequences, including eye loss. Patients should be well informed about the risks and potential sequelae of wound dehiscence.

Amaç: Her ne kadar çocukluk çaðýnda künt karaciðer ve dalak travmasýnda nonoperatif tedavi yaklaþýmý tercih edilir olsa da, klinikler arasýnda kullanýlan algoritmalarda ciddi farklýlýklar bulunmaktadýr. Amerikan Pediatrik Cerrahi Birliði (APSA) rehberinin grade V karaciðer ve dalak hasarýný içermemesi ile birlikte, yüksek dereceli karaciðer ve dalak hasarýna yaklaþým halen tartýþmalýdýr. Bu çalýþmanýn amacý; yüksek dereceli karaciðer ve dalak hasarý olan hastalara nonoperatif tedavi yaklaþýmýyla ilgili tecrübelerimizi sunmaktýr.
Gereç ve Yöntem: Ocak 2012-Ocak 2017 tarihleri arasýnda Marmara Üniversitesi hastanesi acil servisine baþvuran hastalardan künt batýn travmasýna baðlý karaciðer ve dalak hasarý nedeniyle kliniðimizde takip edilen hastalar çalýþmaya dahil edilmiþtir. Hastalarýn yaþ, cinsiyet, travma þekli, organ hasarýnýn derecesi, eþlik eden organ hasarý, yoðun bakýmda ve hastanede kalýþ süresi, transfüzyon ihtiyacý olmasý, tedavi yöntemi (operatif-nonoperatif) þeklinde olan verileri geriye dönük olarak analiz edilmiþtir. Grade I, II, III derece olan organ hasarlarý düþük dereceli olarak; grade IV, V olan organ hasarlarý ise yüksek dereceli olarak sýnýflandýrýmýþtýr.
Bulgular: Acil servisimize baþvuran 2800 çocuk travma olgusundan künt batýn travmasýna baðlý radyolojik görüntülemelerinde karaciðer ve dalak hasarý tesbit edilip kliniðimizde yatýrýlan 88 hasta çalýþmaya dahil edilmiþtir. 41 hastada izole karaciðer hasarý, 39 hastada izole dalak hasarý, 8 hastada ise her iki organda hasar izlenmiþtir. Her iki organda hasar izlenen hastalarda yüksek dereceli hasarý olan organ hangisiyse o gruba dahil edilmiþtir. Yüksek dereceli (29), düþük dereceli (17) karaciðer hasarý izlenmiþtir. Yüksek dereceli (21), düþük dereceli (21) dalak hasarý izlenmiþtir. Hastalarýn 34%’ünde (30 hastada) eþlik eden organ hasarý izlenmiþtir. Nonoperatif tedavi 83 hastaya (94%) uygulanabilmiþtir, 5 hastaya (6%) ise cerrahi uygulanmasý gerekmiþtir. Yüksek dereceli karaciðer hasarý olan hastalarda düþük dereceli karaciðer hasarý olanlara göre, hastanede yatýþ süresi, YBÜ’de yatýþ süresi ve transfüzyon ihtiyacý anlamlý ölçüde yüksek bulunmuþtur (p deðerleri sýrasýyla; 0.001, 0.001, ˂0.001’dir). Yüksek dereceli karaciðer hasarý olan hastalarda düþük dereceli karaciðer hasarý olanlara göre daha fazla cerrahi yaklaþým uygulanmýþtýr (p=0.045). Yüksek ve düþük dereceli dalak yaralanmalarýnda her iki grup arasýnda yaþ, cinsiyet, hastanede yatýþ süresi, YBÜ’de yatýþ süresi, transfüzyon ihtiyacý, eþlik eden organ hasarý açýsýndan fark bulunmamýþtýr (p deðerleri sýrasýyla; 0.254, 0.739, 0.114, 0.135, 0.057, 0.721’dir). Benzer þeklilde yüksek dereceli dalak hasarý olanlarla düþük dereceli dalak hasarý olanlar arasýnda nonoperatif veya operatif tedavi yaklaþýmý açýsýndan da fark izlenmemiþtir (p=0.488).
Sonuç: Yüksek dereceli künt karaciðer ve dalak hasarý olan hastalarda nonoperatif tedavi uygulanabilir bir yöntemdir. Ancak yüksek dereceli karaciðer hasarý olanlarda düþük dereceli karaciðer hasarý olanlara göre cerrahi tedaviye daha fazla baþvurulabileceði dikkate alýnmalýdýr.

Background: Although nonoperative treatment approach is preferred for blunt liver and spleen trauma in childhood, there are significant differences in the algorithms used between clinics. Along with the absence of grade V liver and spleen injury in the American Pediatric Surgical Association (APSA) guideline, approach to high-grade liver and spleen injury is still controversial. The aim of this study is to present our experience in non-operative treatment approach to patients with high-grade liver and spleen injury.
Materials and Methods: Patients who referred to Marmara University Hospital’s emergency department between January 2012 and January 2017 due to liver and spleen injury related to blunt abdominal trauma and followed up in our clinic were included in the study. The data were analyzed retrospectively in terms of age, sex, type of trauma, degree of organ damage, accompanying organ damage, duration of intensive care and hospital stay, need for transfusion, and treatment method (operative-nonoperative). Grade I, II, III organ damage is classified as low grade while grade IV and V organ lesions classified as high grade.
Results: 88 out of 2800 patients who were diagnosed by radiological imaging as liver and spleen injuries due to blunt abdominal trauma and were hospitalized to our clinic were included in the study. 41 of these patients had isolated liver injury while 39 had isolated spleen injury and 8 had injuries in both organs. 30 (34%) of the patients had accompanying organ injury. 83 (94%) patients underwent non-operative treatment and surgical approach was required for 5 patients (6%). Patients with high-grade liver injury had significantly higher duration of hospitalization, duration of ICU stay and transfusion requirement compared to patients with low-grade liver injury (p values are; 0.001, 0.001, and ˂0.001, respectively). Surgical approach was more frequent among patients with high-grade liver injury than patients with low-grade injury (p = 0.045). There was no difference among patients with high and low-grade spleen injury in terms of age, sex, duration of hospitalization, duration of ICU stay, transfusion requirement, and accompanying organ injury (p values were: 0.254, 0.739, 0.114, 0.135, 0.057, 0.721 respectively). Similarly, there was no difference in terms of nonoperative or operative treatment among these two groups (p = 0.488).
Conclusion: Non-operative treatment is feasible treatment method in patients with high grade blunt liver and spleen injury. However pediatric surgeons should consider that patients with high-grade liver damage may require more surgical treatment than those with low-grade liver damage.

Amaç: Tibia diafiz kýrýklarnda intramedüller çivileme yapýlýrken traneksamik asit kullanýmýnýn güvenli olup olmadýðýný, kan kaybýný azaltacaðýný ve maliyet etkinliðini etkilemeyeceðini belirlemek.
Hasta ve Yöntem: tibia diafiz kýrýðý olan 70 hasta randomize olarak iki gruba ayrýldý ve prospektif olarak kan kaybý, tromboz ve kýrýk iyileþmesi açýsýndan izlendi. Birinci gruba preoperatif traneksamik asit intravenöz olarak uygulandý. Ýkinci grup kontrol grubu olarak belirlendi.
Sonuç: Ýki grup arasýnda preoperastif ve postoperatif 1. saat Hb ve Hct deðerleri arasýnda farklýlýk saptanmadý. Ýki grup arasýnda postoperatif 24-48. saat Hb ve Hct deðerleri arasýnda anlamlý farklýlýk saptandý. Traneksamik asit uygulanan grupta (Grup A) postoperatif allojenik kan transfüzyonu gereksinimi olmadý. traneksamik asit kullanýlmayan grupta (Grup B) 2 hastaya Hb ve Hct deðerleri düþük saptanmasý üzerine (Hct<27) 1 ünite eritrosit süspansiyonu uygulandý. Hiçbir hastada DVT ve emboli gözlenmedi.
Sonuç: Ýntramedüller çivileme ile tibia kýrýklarýn tedavisinde preoperatif dönemde intravenöz Traneksamik asit uygulanmasý postoperatif dönemde kanama miktarýný azalttýðý gözlendi. Postoperatif dönemde hastalarda intravasküler tromboza yol açmadýðý gibi kemik iyileþmesini de olumsuz etkilemediði gözlenmiþtir.

BACKGROUND: The aim of this study was to determine if the use of tranexamic acid (TXA) during intramedullary reaming treatment for tibial diaphyseal fractures was safe, reduced blood loss, or affected cost effectiveness.
METHODS: A total of 70 patients with a tibia diaphysis fracture were randomized into 2 groups and prospectively followed for data on blood loss, thrombosis, and fracture healing. Preoperative TXA was administered intravenously to Group A, and Group B served as the control group.
RESULTS: While there was no significant difference between the preoperative and postoperative 1-hour hemoglobin (Hb) and hematocrit (Hct) levels of the patients, there was a statistically significant difference in the comparison of the postoperative 24-hour and 48-hour Hb and Hct levels. There was no need for an allogenic blood transfusion to any patient in Group A; however, 2 patients in Group B each received 1 unit of erythrocyte suspension because their Hct values dropped below 27%. There was no deep vein thrombosis or embolism observed in any of the patients.
CONCLUSION: The application of intravenous TXA during the preoperative period in the treatment of tibial fractures with intramedullary nailing reduced the bleeding seen in the postoperative period. It did not lead to intravascular thrombosis in the postoperative period, and had no adverse effect on bone healing.

Amaç: Bu çalýþmada intertrokanterik femur kýrýklarýnda, oblik pozisyonda uygulanan intramedüller çivileme esnasýnda çift skopi kullanýmýnýn tek skopi kullanýmýna üstün olup olmadýðý araþtýrýlmýþtýr.
Gereç ve Yöntem: Ýntertrokanterik femur kýrýðý sonrasý oblik pozisyon kullanýlarak intramedüller çivileme yapýlan 52 hasta çalýþmaya dahil edildi. Hastalarýn 20’si erkek, 32’si kadýn ve ortalama yaþ: 78,2 (daðýlým: 69-88) idi. Kýrýklar AO/OTA sýnýflamasýna göre tip A1 ve tip A2 kýrýklardan oluþmakta idi. Yirmi beþ hastada çift skopi kullanýlýrken, 27 hastada tek skopi kullanýldý. Anestezi ile cerrahi arasýndaki hazýrlýk süresi, cerrahi süresi, skopi kullaným süresi, kanama miktarý, cerrahi sonrasý kollodiafiziyal açý ve tip-apeks mesafesi iki grup arasýnda karþýlaþtýrýldý.
Bulgular: Cerrahi süresi çift ve tek skopili gruplarda sýrasý ile 34.48±8.92 dakika ve 50.37±16.63 dakika idi (p<0.01). Skopi kullaným süresi çift skopili grupta 42.72±16.00 iken, tek skopili grupta 68.22±21.53 idi (p<0.01). Cerrahi hazýrlýk süreleri, kanama miktarý, kollodiafiziyel açý ve tip-apeks mesafeleri karþýlaþtýrmalarýnda iki grup arasýnda istatistiksel fark saptanmadý (p>0.05).
Sonuç: Ýntertrokanterik femur kýrýklarý cerrahi tedavisinde oblik pozisyonda çift skopi kullanýlarak yapýlan intramedüller çivilemede tek skopi kullanýmýna göre daha az radyasyon maruziyeti ile daha kýsa sürelerde cerrahiyi tamamlamak mümkündür.

BACKGROUND: The purpose of this study was to determine the comparative effectiveness of the use of single fluoroscopy versus double fluoroscopy during intramedullary nailing in the oblique position for intertrochanteric femur fractures in terms of surgery and radiation time.
METHODS: Fifty-two patients (20 men, 32 women; average age: 78.2 years; range: 69-88 years) were included in the study. While double fluoroscopy was used for 25 patients, single fluoroscopy was used for the remaining 27 patients. Data of the preparation time between anesthesia and surgery, surgery time, radiation time, bleeding volume, postoperative collodiaphyseal angle between the fractures and intact parts, and the tip-apex distance (TAD) were compared.
RESULTS: The surgery time in the double and single fluoroscopy groups averaged 34.48±8.92 minutes and 50.37±16.63 minutes, respectively (p<0.01). The radiation time was 42.72±16.00 seconds for the double-fluoroscopy group and 68.22±21.53 seconds for the single-fluoroscopy group (p<0.01). The surgical preparation time, bleeding volume, collodiaphyseal angle and TAD distance did not vary significantly between groups (p>0.05).
CONCLUSION: The use of double fluoroscopy in the oblique position in the surgical treatment of intertrochanteric femur fractures reduced the surgical time and the anesthesia time for patients, as well as the exposure to radiation, thereby also reducing the risk of complications.

AMAÇ: Þarapnele baðlý blastik yaralanmalar çatýþmalar sýrasýnda en sýk görülen yaralanma þeklidir. Bu çalýþmada, þarapnellerin vücuttaki daðýlým karakteristiklerini, bu daðýlýmýn silah tipleri ve çatýþma bölgeleri ile olasý iliþkisini araþtýrmayý amaçladýk.

GEREÇ VE YÖNTEM: Operasyon bölgesinde bulunan hastanemize ateþli silah yaralanmasý nedeniyle getirilen 246 ardýþýk hastanýn medikal kayýtlarý retrospektif olarak deðerlendirildi. Vücuduna radyolojik olarak kanýtlanmýþ en az bir þarapnel isabet etmiþ olan 90 hasta çalýþmaya dahil edildi. Tüm vücut 5 bölgeye (baþ-boyun, göðüs-sýrt, batýn-bel, üst ve alt ekstremite) ayrýlarak þarapnellerin vücuttaki daðýlýmý not edildi. Silah tipi (uzun namlulu silah, roket veya el yapýmý patlayýcý-mayýn), çatýþma bölgesi (þehir içi ve kýrsal alan) ve hastalara ait tüm radyolojik tetkikler (radyografi ve/veya bilgisayarlý tomografi) deðerlendirildi. Þarapnel daðýlýmý ile bu deðiþkenler arasýndaki olasý iliþki araþtýrýldý.

BULGULAR: Roket ve el yapýmý patlayýcý-mayýn yaralanmalarý ile baþ-boyun bölgesi yaralanmalarý arasýnda istatistiksel olarak anlamlý iliþkinin dýþýnda (p= 0.002) silah tipleri ve þarapnel daðýlýmý arasýnda anlamlý fark bulamadýk (p> 0.05). Þarapnel daðýlýmý ile çatýþma bölgesi arasýnda ise anlamlý farklýlýk saptamadýk (p> 0.05).

SONUÇ: Penetran þarapnellere baðlý sekonder blastik yaralanmalar patlayýcý ve çatýþma ile iliþkili yaralanmalarýn en sýk görülen þeklidir. Bu çalýþmada, roket ve el yapýmý patlayýcý-mayýn ile oluþan yaralanmalarda uzun namlulu silah yaralanmalarýna göre baþ-boyun bölgesi þarapnel yaralanmalarýnýn belirgin olarak daha yüksek oranda olduðunu bulduk. Bu tip yaralanmalarýn beklenmedik zamanlarda oluþmasý ve rutin olarak kullanýlmakta olan koruyucu celik yeleðin torakoabdominal þarapnel yaralanmalarýna karþý koruyucu etkisinin bu sonucun ana nedenleri olduðuna inanýyoruz.

BACKGROUND: The aim of this study was to investigate the characteristics of shrapnel distribution in the body and a possible relationship to the type of weapon and type of location of the conflict.
METHODS: The records of 246 patients admitted to a level-III trauma center with any kind of firearm injury were examined retrospectively. Ninety patients who had at least 1 radiologically-proven piece of shrapnel in their body were included in the study. For the purposes of the study, the body was divided into 5 regions (head/neck, thorax/back, abdomen/pelvis/waist, upper extremities, and lower extremities) and shrapnel distribution was noted according to these divisions. Medical data and detailed information regarding the weapon type (long-barreled weapon, rocket-propelled grenade [RPG], or improvised explosive device [IED]), conflict location (residential or rural area), and all radiological examinations (radiography and/or computed tomography) were carefully reviewed. The relationship between these variables and the shrapnel distribution in the body was investigated.
RESULTS: No statistically significant differences were seen between weapon type and shrapnel distribution (p>0.05), except a significantly higher percentage of head/neck region shrapnel injuries as a result of RPG and IED injuries (p=0.002). There was no statistically significant relationship between the shrapnel distribution characteristics and conflict location, classified as either residential or rural (p>0.05).
CONCLUSION: Secondary blast injuries induced by penetrating shrapnel are the most common type of explosion- and combatrelated injuries. In the current study, a significantly higher rate of head/neck region shrapnel injuries was observed in RPG and IED injuries compared with long-barreled weapon-induced injuries. The primary reason is likely the more unexpected nature of those 2 types of attacks, which allow no time to shield that part of the body.

AMAÇ: Kadavradan böbrek nakli yapýldýktan 45 gün sonra acil cerrahi birimine akut mekanik intestinal obstrüksiyon semptomlarý ile baþvuran 48 yaþýnda kadýn hastayý sunmayý amaçladýk.
OLGU SUNUMU: Olgumuz 48 yaþýnda kadýn hasta. Hipertansiyon ve vezikoüretral reflüye baðlý son dönem böbrek yetmezliði nedeni kadavra vericiden böbrek nakli yapýldý. Böbrek nakli sonrasý erken dönemde taþikardi nedeni ile yapýlan tetkiklerinde paroksismal atrial fibrilasyon saptandý ve warfarin tedavisi düzenlendi. INR seviyesi 2,1 olan hasta fonksiyone böbrek ile taburcu edildi. Nakilden yaklaþýk 45 gün sonra bulantý, kusma ve karýn aðrýsý þikayetleri ile acil cerrahi polikliniðine baþvurdu.Batýn muayesinde hafif epigastrik hassasiyet haricinde patoloji saptanmadý. Laboratuar testlerindekaraciðer ve böbrek testleri normal olan hastanýn lökosit (14000 hücre/mm3) deðerleri yüksek saptandý.INR: 6,2 olarak saptanan hastaya eþ zamanlý taze donmuþ plazma ve K vitamini verilerek INR deðeri normal sýnýrlara düþürüldü. Ayakta direk karýn grafisinde intestinal obstrüksiyon bulgularý saptanan hastaya nazogastrik sonda takýldý ve yaklaþýk 1500cc safralý drenajý oldu. Hastaya yapýlan özofgogastroduodenoskopide duodenum 3. kýtada geniþleme ve endoskopun distale geçiþine izin vermeyen tam obstrüksiyon saptandý. Hastaya oral kontrastlý batýn tomografisi çekildi ve duodenum 3. kýtada geniþleme ve duvar kalýnlýk artýþý saptandý. Çekilen baryumlu duodenum pasaj grafisinde verilen kontrast maddenin duodenum 3. kýtada göllendiði görüldü. Mevcut klinik tabloya INR yüksekliðine baðlý geliþmiþ duodenum 4. kýtada intramural hematomun neden olduðu kabul edildi ve nazogastrik dekompresyon ile hasta takibe alýndý. Takiplerinde nazogastrik sonda debisi azalan hastanýn nazogastrik sondasý alýndý. Kademeli olarak oral gýda baþlandý ve hasta tolere etti. Takiplerinde sorun olmayan hasta taburcu edildi. Nakil sonrasý birinci yýlýnda olan hastanýn takiplerinde bir sorun bulunmamaktadýr.
SONUÇ: Warfarin kullanýmý anamnezi olan olgularda akut mekanik intestinal obstrüksiyon ve INR yüksekliði saptanmasý durumunda intramural hematom tanýsýnýn akla gelmesi gereksiz cerrahi giriþimlerin önüne geçebilmektedir.

A spontaneous intramural duodenal hematoma is a rare complication in patients receiving anticoagulation therapy. Presently described
is a case of intramural duodenal hematoma in a patient with a cadaveric renal transplant who was under oral anticoagulant treatment
due to paroxysmal atrial fibrillation. The patient was admitted with intense abdominal pain, nausea, vomiting, and a total obstruction of
duodenum. After a diagnosis of intramural hematoma, a good prognosis was achieved with conservative care.

Bireye karþý iþlenen en aðýr eylemlerden olan cinsel suçlar, cinsiyet ve yaþ farký gözetmeksizin giderek tüm toplumlarda artýþ göstermektedir. Çocuklarýn cinsel istismarý; geliþimsel olarak olgunlaþmamýþ çocuklarýn, bilinçli bir þekilde onay vermeye muktedir olmadýklarý ve bütünüyle algýlayamadýklarý cinsel aktivitelerde taraf olmalarýdýr. Cinsel istismarda anorektal bölgenin kullanýlmasý sýklýkla erkek çocuklarýn kurban olduðu olaylarda karþýmýza çýkmaktadýr. Anal yoldan nitelikli cinsel istismara uðrayan çocuklarýn yapýlan muayenesinde; akut bulgu olarak anüs etrafýnda hassasiyet, ekimoz, anal sfinkterde ve rektum mukozasýnda yýrtýlmalar görülebilmekle birlikte; kaza sonucu da anüs veya rektumu ilgilendiren yaralanmalar oluþabilir.

Olgu: Býçaðýn üzerine oturma sonucu yaralandýðý ve hayati tehlikesi olduðu için dýþ merkezden hastanemize yönlendirilen 11 yaþýnda erkek olgunun litotomi pozisyonunda yapýlan muayenesinde; perianal ekimoz, saat 1 ve 6 hizasýnda yüzeyel, saat 7 hizasýnda derin laserasyon hattý görülmüþ, cinsel istismardan þüphelenilmesi üzerine anüs ve rektumdan sürüntü örnekleri alýnmýþ, daha sonra Çocuk Cerrahisi tarafýndan operasyona alýnarak laserasyonlar primer olarak onarýlmýþtýr. Alýnan sürüntülerden hazýrlanan preparatýn mikroskopik incelemesinde sperm morfolojisine sahip hücreler izlenmiþ ve adli bildirim yapýlarak alýnan örnekler genetik çalýþmalar için ilgili yargý makamýna gönderilmiþtir.

Sonuç: Çalýþmamýzda; kaza öyküsü ile baþvuran fakat yapýlan muayenelerinde nitelikli cinsel istismardan þüphelenilenmesi üzerine operasyon öncesi örnekleri alýnan bir olgu sunularak, klinikte cinsel istismardan þüphelenen hekimlerin olguya bakýþ açýsý, delil niteliðinde sayýlabilecek biyolojik materyallerin bozulmadan ve kaybolmadan elde etmenin ve ilgili adli makamlara ulaþtýrmanýn önemi vurgulanmýþtýr.

The reported rate of sex crimes, some of the most severe acts of violence that can be perpetrated against an individual, is increasing across all societies, regardless of gender or age of the victim. Sexual abuse has been defined, in part, as the involvement of a child in sexual activity for which they are incapable of giving consent, that they cannot fully comprehend, or for which they are developmentally immature. Molestation of the anorectal region is frequently encountered when the victim of sexual abuse is a male child. Tenderness around the anus, ecchymosis, and detachment in the anal sphincter and rectum mucosa may be observed in the acute examination of children who have been subjected to aggravated sexual abuse; however, injuries related to the anus or the rectum may also occur as a result of an accident. An 11-year-old male patient was referred from another health center with a report of being at risk of death. The injury that was said to be the result of accidentally sitting on a knife. An examination in the lithotomy position revealed perianal ecchymosis, a superficial laceration at 1 and 6 o’clock, and a deep laceration at 7 o’clock. Based upon a suspicion of sexual abuse, anal and rectal swab specimens were obtained. The pediatric surgery department performed a primary repair of the lacerations. The microscopic examination of the swab specimens revealed cells showing sperm morphology, and therefore the appropriate forensic statements were made and the swab specimens were sent to the judicial authority for genetic analysis. This report emphasizes the importance of the awareness of physicians regarding the prompt collection and submission of potentially evidential biological samples in a case of suspected sexual abuse though it may be presented as an accident.

Radikal total gastrektomi sonrasý postoperatif dokuzuncu günde ozofagojejunostomiden kaçak nedeniyle stent ve vakum yardýmlý kapatma uyguladýðýmýz olguyu sunmayý amaçladýk. Mide corpus küçük kurvatüründe adenokarsinom olan 55 yaþýndaki erkek hastaya radikal total gastrektomi yapýldý. Postoperatif dokuzuncu günde anastomoz kaçaðý saptanmasý nedeniyle, kapsýz stent yerleþtirilmesini de içeren relaparatomi yapýldý. Daha sonra karýn 4 defa yýkandý. Kaçak azalmadýðýndan 22 ve 18 mm çapýnda 80 mm uzunluðundaki 2 kaplý stent içiçe endoskopik olarak yerleþtirildi. Kaçak batýný kirletmeye devam etti. Beþinci defa batýn yýkama esnasýnda vakum yardýmlý kapama (VAC) sistemi ile tedavi yönetimine karar verildi. VAC süngerinin bir ucu anastomozun yanýna yerleþtirildi ve diðer ucu sol üst kadrandan çýkarýldý. Batýn içine baþka bir VAC kapama seti yerleþtirildi. Her iki VAC, 75 mmHg basýnç ile iki ayrý vakum cihazýna baðlandý. VAC deðiþiklikleri her üç günde bir düzenli aralýklarla 21 gün içinde yedi defa tekrarlandý. Kaplý stentler son operasyonda endoskopik olarak çýkarýldý. Postoperatif 36.gündeki fistülografide kaçaðýn tamamen kapandýðýný görüldü ve VAC sistemi çýkarýldý. Cilt, fascia üzerindeki subkütan yað tabakasýný ayýrarak kapatýldý. VAC sistemlerinin uygulanmasý, ciddi batýn içi sepsis tedavisi ve birincil kaynak kontrolü saðlamakla kalmaz ayný zamanda granülasyon geliþimini hýzlandýrýr ve anastomoz kaçaðýný daha kýsa zaman içinde kapatýr.

Presently described is a case treated via stent and vacuum-assisted closure (VAC). The patient developed an oesophagojejunostomy leak (OL) on the ninth postoperative day after a radical total gastrectomy. The patient was a 55-year-old male patient with adenocarcinoma localized to the small curvature on the corpus of the stomach. Relaparatomy was performed for the OL, including placement of an uncovered stent. The abdomen was washed 4 times. As the OL did not decrease, 2 covered stents (22 mm and 18 mm in diameter and 80 mm long) were inserted endoscopically. The OL continued to contaminate the abdomen. One tip of the VAC sponge was placed next to the anastomosis, and the other tip was removed from the left upper quadrant. Another VAC closure set was placed in the abdomen. Both VAC closures were connected to separate vacuum devices with 75 mmHg of pressure. VAC dressings were changed at regular intervals every 3 days, and these steps were repeated 7 times over 21 days. The covered stents were removed endoscopically in the final operation. Fistulography revealed that the OL was completely closed, and the VAC dressings were removed. The skin was closed by separating the subcutaneous oil layer of the fascia. VAC therapy can not only provide serious abdominal sepsis treatment and primary source control, but also accelerate granulation development and, in this case, quickly closed the anastomotic leakage.