BACKGROUND: Achalasia is a rare neurodegenerative disease of the esophagus that causes impaired esophageal peristalsis and the inability of the lower esophageal sphincter (LES) to relax. This results in symptoms such as dysphagia, regurgitation, chest pain, and weight loss. Among the treatment options, Laparoscopic Heller Myotomy (LHM), Endoscopic Balloon Dilation (EBD), and Peroral Endoscopic Myotomy (POEM) are commonly used methods. The aim of this study was to compare the efficacy and clinical long-term results of LHM and EBD in treating achalasia.
METHODS: Patient records from Bezmialem Vakýf University Hospital were reviewed, and 36 patients diagnosed with achalasia who underwent LHM and EBD were included in the study. Patients were evaluated using the Pre-operative Eckardt Score (Pre-ES) for preoperative evaluation, the Post-operative Eckardt Score (Post-ES) for postoperative evaluation, the Achalasia Specific Quality of Life (ASQL) questionnaire, and the Patient Satisfaction Scoring (PSS).
RESULTS: The mean age of the 19 patients who underwent LHM was 49.37±10.48 years. The mean age of the 17 patients who underwent EBD was 59.24±14.39 years. Perioperative complications included esophageal mucosal perforation in one patient in the LHM group, bleeding in three patients (17.64%), and esophageal perforation in one patient (5.88%) in the EBD group. At a mean follow-up of 90 months, gastroesophageal reflux developed in two patients (10.53%) in the LHM group and eight patients (47%) in the EBD group. The Pre-ES was similar in both groups. The Post-ES significantly decreased in the LHM group compared to the EBD group. When ASQL and PSS results were analyzed between the LHM and EBD groups, it was concluded that LHM was more effective than EBD in improving the quality of life and providing patient satisfaction (p-value: 0.001).
CONCLUSION: In light of these findings, it was concluded that LHM is a safer intervention compared to EBD and should be prioritized, considering the low risk of complications, improved quality of life, and high level of satisfaction.

BACKGROUND: Acute appendicitis is one of the most common surgical emergencies. With antibiotic-first treatment strategies gaining importance, the risk of an appendiceal tumor as an incidental finding or as the cause of appendicitis presents an obstacle to a conservative approach. Neuroendocrine tumors, the most frequent type of appendiceal tumors, are difficult to diagnose preopera-tively due to their small size. This study aims to identify predictive factors for neuroendocrine tumors in patients undergoing surgery for acute appendicitis by analyzing imaging and clinical characteristics, thereby enhancing preoperative diagnostic accuracy and guiding surgical interventions.
METHODS: This retrospective observational study included 1,298 patients who underwent appendectomy from January 2014 to May 2024. After excluding 59 patients with normal pathology results, 40 with variable pathologies, and 49 with inaccessible computed tomography (CT) images, 1,150 patients remained (1,135 with acute appendicitis and 15 with neuroendocrine tumors). Abdominal CT scans were evaluated for appendiceal diameter, wall thickness, cecal wall thickness, periappendiceal fat stranding, fluid collection, lymphadenopathy, intraluminal and free periappendiceal air, mucosal hyperenhancement, the presence of appendicolith, mural calcification, and mural nodules.
RESULTS: The presence of a mural nodule protruding into the lumen was significantly higher in neuroendocrine tumor patients compared to those with acute appendicitis, with a sensitivity of 53.3%, specificity of 95.8%, positive predictive value (PPV) of 31.9%, negative predictive value (NPV) of 99.4%, and accuracy of 97.9%. Intraluminal air was also more frequent in neuroendocrine tumor patients, with a sensitivity of 53.3%, specificity of 76.7%, PPV of 2.9%, NPV of 99.2%, and accuracy of 76.4%. Other imaging parameters did not show significant differences between the two groups.
CONCLUSION: This study identifies mural nodules and intraluminal air as significant predictors of neuroendocrine tumors in patients with acute appendicitis, emphasizing the importance of meticulous preoperative imaging evaluations. Incorporating these predictors into diagnostic protocols could improve the preoperative identification of neuroendocrine tumors, enabling more appropriate surgical interventions. Future research should validate these findings through prospective studies and explore advanced imaging techniques to further enhance the detection of appendiceal neoplasms, ultimately improving patient outcomes and reducing overlooked malignancies.

BACKGROUND: This study aimed to elucidate the diagnostic significance of changes in periappendiceal fat density observed on computed tomography (CT) in patients with acute appendicitis (AA).
METHODS: Patients who underwent surgery with a diagnosis of AA based on CT findings from January 1, 2020 to December 31, 2020 were included in the study. Patients were divided into three grades. In Grade 1, the periappendiceal tissue appears hypoechoic, indicative of normal tissue. In Grade 2, the periappendiceal tissue is slightly hyperechoic but confined to the periappendiceal area. In Grade 3, dense hyperechoic areas are present not only in the periappendiceal tissue but also extend into surrounding organs and deeper tissues. The groups were compared in terms of clinical, laboratory, and pathological outcomes.
RESULTS: A total of 195 patients-131 males and 64 females-were included in the study. A correlation was identified between grade and several factors: appendix diameter, appendix wall thickness, incidence of lymphadenopathy, and duration of symptoms onset (p<0.001). Conditions such as appendicolitis, free air, and intra-abdominal abscesses were more frequently observed in Grade 3 patients compared to Grade 1 and Grade 2 patients (p=0.002, p<0.001). Both operative time and length of hospital stay were highest in Grade 3 patients (p<0.001). The rate of patients found to have a normal appendix upon pathological examination was significantly higher in Grade 1 than in Grade 2 (p=0.03).
CONCLUSION: In cases where the diagnosis is uncertain, the hyperechogenicity in periappendiceal tissue observed on CT strengthens the diagnosis of AA. Additionally, cases of AA become increasingly complex as echogenicity in periappendiceal tissue increases.

BACKGROUND: Acute appendicitis is a common surgical emergency that causes acute abdominal pain and affects approximately 7-8% of the population during their lifetime. The closure of the appendix stump during laparoscopic appendectomy is one of the most critical steps of the surgery to prevent life-threatening complications such as postoperative fistula, peritonitis, and sepsis. The mate-rial chosen for appendix stump closure must be effective, safe, and economical. However, there is still no consensus on the optimal method for stump closure. In this study, we aimed to compare the advantages and reliability of three different methods used for appendix stump closure.
METHODS: At Istanbul University-Cerrahpaþa, Cerrahpaþa Medical Faculty, Department of General Surgery, cases that underwent laparoscopic appendectomy for acute appendicitis between January 2022 and April 2024 were retrospectively analyzed using the hospital's data system. The patients' demographic data, laboratory values, pathology reports, surgical notes, duration of hospital stay, duration of surgery, total hospital costs, complications related to the surgery within 30 days postoperatively, and the management of these complications were examined.
RESULTS: The study included a total of 150 individuals, with 83 (55.33%) males and 67 (44.67%) females. The average age of the participants was 38.45±14.48 years. In terms of the materials used for stump closure, endoloop was used in 82 (54.67%) cases, Hem-o-lok clip in 30 (20.00%) cases, and endostapler in 38 (25.33%) cases. In 144 (96%) cases, no Clavien-Dindo (CD) complications were observed, while complications occurred in six (4%) cases. These six complications included two intra-abdominal abscesses (CD Grade 3), two wound infections (CD Grade 1), one case of bleeding (CD Grade 2), and one pulmonary embolism (CD Grade 4).
CONCLUSION: The use of endoloop, polymeric clips, and endostapler in laparoscopic appendectomy is safe and effective for appendectomy. All three methods can be successfully applied without an increase in intraoperative or postoperative complications. However, due to the higher treatment costs associated with endostapler, its use should be reserved for situations where securing the appendix stump cannot be achieved with endoloop or Hem-o-lok clip.

BACKGROUND: Pneumomediastinum, defined as mediastinal emphysema, is the term coined for the presence of air in the mediastinum. It is a rare condition that can occur in children due to various etiologies, especially trauma, and may appear without any underlying injury. We investigated the causes of secondary pneumomediastinum and the treatment approaches in children treated at our clinic.
METHODS: We retrospectively assessed 26 patients under the age of 18 diagnosed with pneumomediastinum at our clinic between 2011 and 2023. We reviewed patient files, evaluating clinical data including patient history, physical characteristics, symptoms, examination findings, imaging studies, hospital stay duration, treatment methods, and complications. The necessity for advanced imaging methods, bronchoscopy, and surgical interventions was determined.
RESULTS: Causes of pneumomediastinum included multiple body trauma in three patients, blunt thoracic trauma in four patients, blunt trauma to the cervical region in two, crush syndrome in three, penetrating trauma to the thorax and cervical region in three, hanging from the neck in one, drowning in water in one, birth trauma in one, foreign body aspiration in six, a tracheal polyp in one, and iatrogenic causes in one. Excluding those with foreign body aspiration, computed tomography was performed on all patients. Bronchoscopy was performed in six patients, detecting tracheal lacerations in two. Of these, tracheal lacerations during bronchoscopy were identified in two patients with foreign body aspiration. Twenty-three patients received conservative management, and six patients died. Patients were categorized into two groups: complicated and uncomplicated. It was observed that stays in intensive care and wards were longer in complicated patients (p<0.05). However, no difference was detected in the resolution time of pneumomediastinum between complicated and uncomplicated patients (p>0.05).
CONCLUSION: Although pneumomediastinum is a self-limiting pathology, ventilation difficulties alongside pneumomediastinum should raise suspicion of esophageal and tracheal injuries, necessitating further investigations. Since the etiologies are very different, each patient should be evaluated separately. In most patients, pneumomediastinum regresses on its own. However, patients with complications should be carefully evaluated for accompanying diseases and injuries.

BACKGROUND: Although the ankle clonus test is a pathological finding in neurological examination, it may temporarily occur in neurologically intact individuals during awakening from anesthesia. Some studies suggest it as a marker indicating neural tract integrity in pediatric spinal deformity surgery. This study aims to investigate the consistency of the ankle clonus test under different anesthesia protocols in pediatric patients with spinal deformities.
METHODS: A total of 39 patients diagnosed with Adolescent Idiopathic Scoliosis or Scheuermann Kyphosis were enrolled to this prospective study. Patients were divided into three groups based on the anesthesia protocol used. In Group I and Group II, two different anesthetic agents (pentothal vs. propofol) were administered, while Group III received Total Intravenous Anesthesia. All patients underwent surgery with pedicle screw constructs using a standard posterior approach. The presence of clonus was recorded during awakening.
RESULTS: Bilateral ankle clonus was observed in 10 patients (76.9%) in Group 1, six patients (46.1%) in Group II, and seven patients (53.8%) in Group III. Clonus was absent in 16 patients (41%) across all groups. There was no significant association between the presence of ankle clonus and factors such as group assignment, duration of surgery, level of instrumentation, or blood loss. No neurological deficits were observed in any patient during the postoperative period.
CONCLUSION: The ankle clonus test is not a reliable method for monitoring neurological deficits during spinal surgery. It is not exactly known how such myoclonic contractions occur or how the pathway is inhibited or activated.

BACKGROUND: Degeneration of the spine may affect pelvic parameters and hip mobility. This study aimed to evaluate the effects of degenerative scoliosis and spinopelvic parameters on hip hemiarthroplasty dislocations.
METHODS: A retrospective analysis was conducted on patients who underwent hemiarthroplasty for intracapsular hip fracture over a twenty-year period. Demographic data, dislocation incidence, degenerative scoliosis (DS) status, type of hemiarthroplasty, surgical intervention to the hip, femoral head size, cement use, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and in-hospital mortality were evaluated. The Cobb angle (CA), pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), lumbar lordosis (LL), and thoracic kyphosis (TK) angles were measured and analyzed.
RESULTS: A total of 284 patients were evaluated, with a mean age of 79.07 (±8.21) years. The frequency of hemiarthroplasty dislocation was 13% (n=37). Degenerative scoliosis was detected in 25.4% of the cases and was significantly more common in patients with degenerative scoliosis (p=0.001). Advanced age, higher BMI, higher ASA score, unipolar and cementless hemiarthroplasty, smaller femoral head size, and the posterior approach significantly increased dislocation frequency (p=0.004, p=0.001, p=0.03, p=0.001, p=0.001, and p=0.026, respectively). The mean PI, SS, PT, LL, and TK angles were significantly reduced in patients with dislocation and degenerative scoliosis (dislocation: p=0.001, p=0.001, p=0.001, p=0.003, p=0.048; degenerative scoliosis: p=0.001, p=0.001, p=0.001, p=0.001, p=0.001; respectively).
CONCLUSION: The presence of degenerative scoliosis and low pelvic incidence, sacral slope, pelvic tilt, thoracic kyphosis, and lumbar lordosis angles may increase the frequency of hemiarthroplasty dislocations. The posterior approach and small femoral head size may also elevate the risk of posterior dislocation.

BACKGROUND: Lateral condyle fractures are the second most common peri-elbow fractures in children aged 6-10 years, following supracondylar fractures. In treating these fractures, either open or closed reduction fixation can be performed. However, it is not yet completely clear which type of fracture should be treated and how. The Song classification has been increasingly used by orthopedic surgeons for these fractures in recent years. A review of the literature reveals few studies comparing closed reduction and percutaneous pinning (CRPP) and open reduction and internal fixation (ORIF) in lateral condyle fractures (LCFs) with displacements of 2 mm or more. Based on this, we compared Song stage 4 and 5 fractures operated with open or closed reduction methods in our clinic in terms of radiological and clinical aspects.
METHODS: Patients who underwent surgery in our clinic for Song type 4 and 5 lateral condyle fractures between 2011 and 2016 were included in the study. After obtaining approval from our ethics committee (ID: 00171379117), we retrospectively evaluated the medical records of the patients. Between 2011 and 2016, 213 patients underwent surgery for LCF in our hospital, 24 patients were lost to follow-up, and 78 patients had other types of Song fractures. Our study evaluated 111 patients, who were divided into two groups: the CRPP group and the ORIF group.
RESULTS: A total of 111 patients were included in our study, with 52 undergoing CRPP and 59 undergoing ORIF. There was no difference between the groups in terms of age, gender, side of injury, mechanism of trauma, and follow-up time (p=0.962, p=0.198, p=0.706, p=0.526, p=1.000, p=0.708, respectively). There was also no significant difference in the displacement amounts between the patients (p=0.233). In the postoperative radiological comparison, a lateral spur was observed in 12 patients (23%) in the CRPP group and 28 patients (47.5%) in the ORIF group. Hardacre's criteria were evaluated as excellent in 46 (88.4%) of the patients who underwent CRPP and 50 (84.7%) of the patients who underwent ORIF. No significant result was found between both groups (p=0.769). There was no difference in complications between the groups (p=1.000).
CONCLUSION: This study demonstrates that in pediatric patients with lateral condyle fractures displaced by 2 mm or more, the choice between open or closed reduction has minimal impact on medium and long-term outcomes. Since there are not many studies on this subject in the literature, we believe that our results will provide valuable guidance for treatment decisions.

BACKGROUND: This study aims to compare the effectiveness of the long-arm cast (LAC) and the single sugar-tong splint (SSTS) in the non-operative treatment of distal radius fractures in the geriatric population.
METHODS: Patients consulted at the Orthopedics and Traumatology Department within the Emergency Department (ED) were reviewed through the electronic archives of a tertiary university hospital over a five-year period. The study included patients aged 65 years and older with a distal radius fracture who required reduction, had successful closed reduction, and had at least six weeks of X-ray follow-up. The patients were divided into two groups based on the immobilization method: the SSTS group (n=88) and the LAC group (n=31). The patients' radiographs taken after reduction in the ED, as well as at the 1st, 2nd, 4th, and 6th weeks, were evaluated. Radial height, radial inclination, volar tilt, and ulnar variance were measured on the radiographs at each visit. The delta value was calculated by subtracting the measurement on the first post-reduction radiograph from the measurement taken at the sixth week. The data obtained were then compared between the two groups.
RESULTS: A total of 119 patients (93 females, 26 males, mean age: 72.9±7.3 years; range, 65 to 90 years) were included. The mean age was 74.6±7.6 in Group 1 and 72.3±7.2 in Group 2 (p=0.135). Group 1 consisted of 26 females and 5 males; Group 2 included 67 females and 21 males (p=0.52). Statistically significant differences were observed in post-reduction volar tilt (p=0.005), first week volar tilt (p=0.020), post-reduction ulnar variance (p=0.044), first week ulnar variance (p=0.037), and second week ulnar variance (p=0.027) between the groups. No statistically significant differences were detected in other radiological parameters, including delta values. Two patients in Group 1 and seven patients in Group 2 required secondary intervention (p=1).
CONCLUSION: In the non-operative management of geriatric distal radius fractures, the SSTS is an immobilization technique that is as effective as the LAC.

In this case report, we presented to a 90-year-old female with multiple comorbidities presented to the emergency department of our hospital three weeks following a fall from standing height. Upon arrival, the patient exhibited a Glasgow Coma Scale (GCS) 12, blood pressure of 100/60 mmHg, heart rate of 117 beats/min, respiratory rate of 24 breaths/min. Examination revealed atrophy, skin color change, sensory disturbance, or motor palsy in the left upper extremity. Chest X-ray showed a fractured left clavicle, with its free fragment dislocated toward the thorax. She was diagnosed with a displaced midshaft clavicle fracture, Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 15.2B2. On doppler ultrasound examination, flow loss secondary to compression was observed in the proximal left subclavian artery (SA). No flow was observed in the axillary, brachial, radial and ulnar arteries. Due to the patient's high number of comorbid diseases and poor general condition, disarticulation was performed from the shoulder joint, which is the proximal region of arterial occlusion. No other symptoms of circulatory dysfunction were observed at the 3 months follow-up. This case report emphasizes that delayed clavicle fracture can lead to catastrophic consequences. Trauma surgeons should also consider surgical treatment of clavicle fractures, depending on the patient's condition.

We present a challenging case at our facility involving a 70-year-old female with a history of hypertension who was diagnosed with malignant ovarian neoplasia. Preoperative imaging revealed a 6 x 6 x 2.5 cm mass in liver segment 6, initially suspected to be metastatic disease. The patient had undergone a laparoscopic cholecystectomy 11 years prior. Despite repeated biopsies and a high fluorodeoxy-glucose (FDG) uptake value of 9.87 on positron emission tomography-computed tomography (PET-CT), the exact nature of the mass remained undetermined. However, during a total abdominal hysterectomy and bilateral salpingo-oophorectomy, an excisional biopsy of the liver lesion identified it as an abscess formed around a gallstone, presumably spilled during the previous cholecystectomy. This case highlights a rare but significant diagnostic challenge, wherein a gallstone shed during gallbladder surgery mimicked a metastatic liver mass. It underscores the importance of considering a patient’s surgical history in differential diagnoses, especially when encountering atypical abdominal masses.

Brachial plexus injuries are the second most common perioperative peripheral nerve injuries. Malposition is a significant predisposing factor to these injuries. Additionally, some drugs, including tacrolimus, are known to predispose individuals to peripheral neuropathy. Herein, we present the electroneuromyography (EMG) findings within the first 48 hours for a patient who has been under tacrolimus treatment for five years due to liver transplantation and developed compression-induced reversible brachial plexopathy. Through this case, we highlighted that brachial plexus injury may not always result in axonal involvement and discussed the findings that may be encountered in early neurophysiological examinations.