Karaciðer büyüklüðü nedeni ile künt karýn travmalarýndan sonra en sýk yaralanan intraperitoneal organdýr. Bu yazýda, 182'si trafik kazasý, 96'sý da yüksekten düþmeden oluþan ve 1985-1993 yýllarý arasýndaki 9 yýllýk dönemde acil birimimize getirilip, ameliyat edilen 278 künt karaciðer travmasý olgusu retrospektif olarak incelenmiþtir. Bu olgularýn %64'ü minör, %36'sý majör yaralanma grubundadýr. Minör yaralanma grubundaki olgularýn tümüne basit hepatorafi yapýlmýþtýr. %11 olan mortalitenin nedeni ek intraabdominal ve ekstraabdominal lezyonlardýr. Majör yaralanma grubundaki olgularýn %48'ine hepatorafi, %27'sine rezeksiyon yapýlmýþ ve %25'i de laparotomi sýrasýnda kaybedilmiþtir. %49' olan mortalitenin nedeni daha çok karaciðerdeki kanamaya baðlý olarak geliþen hipovolemik þok tablosudur. Majör yaralanmalarda derin sütürler ile hepatorafi, lober hepatektomi veya hepatik arter ligasyonu gibi agresif cerrahi giriþimler yerine, bir saate kadar uzatýlabilecek olan pringle manevrasý eþliðinde, "finger fracture" yöntemi ile hepatotomi + selektif vasküler ligasyon ve sýnýrlý rezeksiyonel debridman yöntemi tercih edilmelidir, juxtahepatik venöz yaralanmalarda ise total hepatik vasküler izolasyon ile bu damarlarýn tamiri denenmelidir. Genel olarak mortalite oranýmýz %24.8'dir ve %25'lik ortalama deðere yakýn bir deðerdir.

Following blunt abdominal injury, liver is the most injured organ due to its big volume. In this study 278 cases of blunt liver injury were evaluated during a period of 9 years (1985 and 1993). The trauma etiology was traffic accidents in 182 patients and fall from a height in 96 patients. 64% were minor and 36% were defined as major hepatic trauma. Simple hepatoraphy was the precedure for all minor trauma. In this group 11% mortality was attributed to associated intraabdominal and extraabdominal injuries. In the major injury group; 48% had hepatoraphy, 27% partial resection and 25% died peroperatively. 49% mortality of the major trauma group can be explained with hypovolemic shock due to the bleeding of the liver. For major hepatic injuries; by the aid of pringle maneveur hepatotomy with "finger fracture" and selective vascular ligation, and limited resectional debridement is being preferred to aggressive procedues such as hepatoraphy with deep sutures, lobar hepatectomy and hepatic artery ligation. In juxtahepatic venous injuries total hepatic vascular isolation is preffered before vascular repair. The overall mortality rate was 24.8%, which was close to the average 25% literature rate.

Acil Servislere baþvuran multipl travmalý hastalarýn teþhis ve tedavilerinde büyük zorluklar mevcuttur. Ýlk yardýmýn uzman hekimler tarafýndan yapýlamayýþý ve multipl travmalý hastalarýn takipleri hu zorluklarýn baþýnda gelmektedir. Çukurova Üniversitesi Týp Fakültesi Balcalý hastanesi büyük acil polikliniðine Ocak-1992-Ocak 1993 yýllarý arasýnda müracaat eden 17708 olgunun 1742'sini (%9.8 ) travmalý hastalar oluþturuyordu. Travmalý hastalarýn 909'u ( %52.2) büyük travma, 833'ü (%47.8) küçük travma þeklinde idi. Künt travma nedeniyle meydana gelen olgularýn oraný %71, penetran travmalý olgularýn oraný ise %29 idi. Büyük travmalý 312 olgu birkaç servis tarafýndan takip edilmesi gerektiðinden, acil gözlem ünitesine takip için yatýrýldý. Büyük travmalý olgularda en sýk görülen yaralanma bölgesi kafa ve ekstremitenin birlikte yaralandýðý olgular olup 392 (%47 ) hastada mevcut idi.

There are great difficulties in the diagnosis and treatment of polytraumatized patients. The first aid is usually not performed by specialized doctors, and the follow-up of multiple trauma patients is generally a crucial problem. During January 1992 and January 1993 17.708 cases were admitted to the Emergency unit of Çukurova University, Balcalý Hospital. 1742 (9.8%) of these cases were traumatized patients; 909 (52.2%) of whom suffered from major trauma, and 833 patients ( 47.8%) suffered from minor trauma. The trauma mechanism was blunt in 71%, and penetrating in 29%. 312 cases with major trauma were hospitalized at the emergency observation unit, since these had to be followed by several specialties. Upon major trauma cases, the most common was combined head and extremity trauma which was detected in 392 (47%) patients. As a result, wa can state that Balcalý Hospital needs a surgical intensive care unit for the care of polytraumatized patients.

Akut pankreatit (AP) gerek taný gerekse de tedavide güçlükler gösteren bir hastalýktýr. Taný konulduktan sonra tedavi planý için akut ödematöz pankreatit (AÖP) ve akut nekrotizan pankreatit (ANP) ayýrýmý yapýlmalýdýr. 1992-1994 yýllarý arasýnda 3 yýllýk dönemdeki 11 "i ANP (%33), 22 'si AÖP (%67) olan 33 AP vakasý retrospektif olarak incelenmiþtir. Etyolojide %53 biliyer etkenler, %30 idiopatik etkenler, %15 alkol ve %9 oranýnda diabet sorumludur. 9'u AÖP'li 9'u ANP'li 18 vaka (%55) ameliyat edilmiþ, 13'ü AÖP'li 2'si ANP'li 15 vaka (%45) da konservatif olarak tedavi görmüþtür. Ameliyat olarak 9 ANP'li vakanýn 6'sýna debridman + loj drenajý, 2'sine parsiyel pankreatektomi, 1'ine de triostomi uygulanmýþtýr. AÖP'li vakalarýmýzda morbidite %9, mortalite %0; ANP'lilerde morbidite %72, mortalite %64'tür. Bu oranlar AP serimizde sýrasýyla %30 ve %21'dir. AÖP'lerde etken biliyer de olsa erken cerrahi endikasyon yoktur. Definitif biliyer cerrahi giriþim geç dönemde yapýlmalýdýr. ANP'lerde ise operasyon endikasyonu klinik, bakteriyolojik ve morfolojik verilere göre konur. ANP'de savunduðumuz cerrahi yöntem debridman + loj drenajý ve gerekiyor ise relaparotomi ya da relaparotomilerdir.

Acute pancreatitis (AP) still remains as a disease with difficulties in diagnosis and treatment. Following diagnosis the distinction between acute edematous pancreatitis (AEP) and acute necrotising pancreatitis should be made. In a 3-year period between the years of 1992 and 1994, 11 cases of ANP and 22 cases of AEP, with a total of 33 cases of AP were evaluated in retrospective manner. The etiological factor was: 53% biliary causes, 30% unknown, 15% alcohol induced, and 9% diabetes mellitus. 9 cases of AEP and 9 cases of ANP (55%) were treated by conservative means. Out of 9 operated cases with ANP; 6 underwent debridement and drainage, 2 partial pancreatic resection and I triostomy. For AEP the morbidity rate was 9%, and the mortality rate was 0%; whereas, in ANP the morbidity was 72% and mortality was 64%. These rates are 30% and 21% consecutively for the AP series. Even the etiological factor is biliary early surgical intervention is not required, and the definitive surgery should be performed in the late phase. The surgical indication in ANP is determined by means of clinical, bacteriological and morphological data. We are in favour of debridement and drainage and if necessary reoperations or relaparotomies for the treatment of ANP.

Künt karýn travmalarý (KBT), ülkemizde trafik kazalarý ile beraber her geçen gün önemli bir artýþ göstermektedir. KBT tanýsýnda son yýllarda deðiþik yöntemler uygulanmaktadýr. Bunlarýn arasýnda sonografinin non-invaziv, ucuz, kolay ve çabuk uygulanabilir olmasý, intraperitoneal sývý miktarýný tespit edebilmesi, solid organ hematomlarýný tespit ve takip edebilmesi, retroperitoneal organlarý görüntüleyebilmesi ve radyasyon içermemesi sebebiyle invaziv bir yöntem olan PL'nin yerine geçebileceði düþünülmektedir. Bizde bu çalýþmamýzda PL ve USG'yi kýyasladýk. KBT'li 72 hastanýn 42'sinde USG normal bulundu. Bu vakalarda klinik takibinin normal seyretmesi üzerine bunlar taburcu edildi. 22 vakada USG'de batýn içinde serbest kan veya solid organ hematomu saptandý. Bu vakalarda PL +,++,+++ sonuç verdi ve tekrarlanan yýkamalarda lavaj sývý rengi açýldý. Hematomlu vakalarýn USG takibinde hematomun büyümediði saptandý ve konservatif kalýndý. 8 vaka ameliyat edildi. Diafragma rüptürü olan vakada USG vePL yanlýþ-sonuç vermiþtir. Böbrek rüptüründe PL yalancý - sonuç vermiþ, USG rüptürü saptamýþtýr. Ameliyat edilen diðer 6 vakada USG batýn içi kanamayý göstermiþ, PL'de bu kanamanýn aktif ve bol olduðunu saptamýþtýr. PL ve USG'nin birbirine rakip olan 2 yöntem deðil, birbirini tamamlayan iki yöntem olduðuna karar verdik. Ayrýca hangi taný yöntemi uygulanýrsa uygulansýn muhakkak dikkatli bir klinik izlemeye göre tedavi seçimine karar vermenin esas olduðunu düþünmekteyiz.

PL is challenged by USG for the premier position in the diagnosis of blunt abdominal trauma, In contrast to PL, USG allows the detection of subcapsuler, intraparenchymal and intramesenterial hematomas. In formation is also obtained about the retroperitoneal surface, bladder and kidneys, and the pleura, pericardium and aorta. In our prospective study, 8 patients of the 72 patients underwent laparatomy. PL and USG could'nt show the rupture of the diafragma. In the kidney rupture, PL was false (-). But USG showed the rupture. In the others 6 cases, both USG and PL showed the intraabdominal blood. The discussion of the advantages and disavantages of both methods shows that USG and PL are not competing but rather are complementery. Ultimately, the most important principle in the management of blunt abdominal trauma is repeat pysical examination by an experienced surgeon.

Toraks travmalarýnýnýn tedavisinde, konservatif tedavinin yaný sýra cerrahi tedavinin de önemli bir yeri vardýr. Bu makalede, 1.1.1991-31.10.1994 tarihleri arasýnda Atatürk Göðüs Hastalýklarý ve Göðüs Cerrahisi Merkezi, Göðüs Cerrahisi Kliniði'ne toraks travmasý tanýsýyla yatýrýlan ve opere edilen 48 vaka ele alýnmýþtýr. Vakalardan 25(%52) 'i künt travma, 17(%35) 'si kesici-delici alet yaralanmasý ve 6(%13) 'sý ateþli silah yaralanmasýdýr. Postoperatif mortalite 4(%8) 'tür. Vakalar çeþitli yönleriyle irdelenmiþ, uygulanan cerrahi yöntemler üzerinde durulmuþ ve literatür bilgileri ýþýðý altýnda deðerlendirilmiþtir.

Conservative and surgical treatment have an important place in the treatment of thoracic trauma. We evaluated 48 patients who had undergone operation due to thoracic trauma at the clinic of Thoracic Surgery, The Atatürk Diseases and the center of Thoracic Surgery between 1.1.1991 and 31.10.1994. The responsible mechanism was blunt trauma in 25 (52%)patients, gunshot wounds in 6 (13%) patients and other penetrating wounds in 17 (%35) patients. Postoperative mortality was 8% (4 patients). Various special features and operative methods applied in these cases were investigated and literature knowledge was evaluated.

Bu çalýþmada 1989-1994 yýllarý arasýnda birimimize baþvurup dalak yaralanmasý saptanarak tedavi edilen 235 hasta deðerlendirildi. 190 olguda künt, 45 olguda penetran yaralanma saptandý. 175 hasta, ameliyat edilirken 60 hasta ise nonoperatif olarak izlendi. Ameliyat edilen hastalarýn 95'inde (%54) izole dalak yaralanmasý tespit edilirken 80 hastada ek organ yaralanmasý mevcuttu. Karaciðer ve böbrek yaralanmalarý en çok izlenen yandaþ yaralanmalar idi. Ameliyat edilen hastalarýn 165'ine splenektomi (%96), 7'sine splenorafi, 3'üne de parsiyel splenektomi uygulandý. Mortalite oraný ameliyat edilen hastalar içinde %11 iken tüm hastalar içinde %9 olarak saptandý.

235patients with splenic injuries were evaluated, between 1989 and 1994. There were 190 blunt, and 45 penetrating injuries. 175 of the patients were operated, and 60 were observed nonoperatively. 95 ( 54%) of the operated patients had isolated splenic injuries and 80 patients ( 46%) had concomitant organ injuries. Liver and kidney were the major concomitantly injured organs. 165 patients (96%) had splenectomy, 7 had splenoraphy, and 3 had partial splenectomy. The mortality rate for operated patients was 11%, and overall mortality rate was 9%.

Sitokin ailesinin üyesi olan interlökinler makrofaj, lenfositlerden salgýlanan, vücudun travma ve infeksiyona immünolojik ve metabolik cevabýnda rol oynayan hormon yapýsýnda elemanlardýr. Bu seriden olan interlökin-6 (ÝL -6) infeksiyöz veya inflamatuar bir uyarana karþý konaðýn verdiði akut yanýtta yer alan bir mediatördür. IL- 6 akut faz proteinleri sekrete edilmesinde de önemlidir. Bu çalýþmada büyük cerrahi giriþim, kontrol grubunu minör cerrahi giriþim geçiren hastalardan randomize olarak seçilen onbeþer kiþi alýnmýþtýr. Hastalardan preoperatif 4., 24., 48., 72. saatlerde serum örneklen alýnarak -20 C'de saklanmýþtýr. IL-6 düzeyleri mikro-ELÝSA yöntemi ile pg/ml, CRP düzeyleri ise nefolometrik yöntemle mg/L olarak ölçülmüþtür. Çalýþma grubunda ortalama IL-6 düzeyleri sýrasýyla 4pg/ml, 500pg/ml, 250pg/ml, 135pg/ml, 75pg/ml; kontrol grubunda ise 0,200pg/ml, 150pg/ml, 88pg/ml, 50pg/ml olarak bulunmuþtur. Komplikasyonlu vakalara ait 24. saatteki ortalama IL-6 düzeyi (355 pl/L) yüksek kalmýþtýr. Bu olgularda 48. saatteki IL-6 düzeyi, komplikasyonsuzlara göre anlamlý olarak yüksek bulunmuþtur ( p<0.005). CRP düzeylerinin çalýþma ve kontrol grubunda 48.saatte en yüksek seviyeye (sýrasýyla 180mg/L, 125mg/L) ulaþtýðý tespit edilmiþtir. Çalýþma grubunda IL-6 düzeyinin 4.saatte kontrol grubuna göre daha yüksek bir pik yaptýðý saptanmýþtýr. IL-6 düzeyinin 24 saatten sonra hala yüksek kalmasýnýn veya artmasýnýn komplikasyon riskinin bir göstergesi olabileceði düþünülmüþtür. IL -6'nýn CRP'ye göre daha erken ve daha anlamlý bir parametre olduðu kanýsýna varýlmýþtýr.

Interleukins which are members of the cytokine family are secreted from cells of the immune system and effect cells from the same system. Interleukin-6 ( IL -6 ) takes place in the acute immune response to an infectious or an inflamatory insult and is an important mediator in the secretion of the acute phase proteins. We investigated the change in IL-6 levels in patients with complications and the correlations between IL-6 and CRP levels. The experimental group consisted of randomly chosen 15 people undergoing minor surgery. Serum samples were taken preoperatively and postoperatively at the 4th, 24th, 48th, 72nd hours and preserved at-20 C. IL-6 levels were 4pg/ml, 500pg/ml, 250pg/ml, 88pg/ml, 50pg/ml in the control group. Median IL-6 levels were the highest at the 24th hour in the complicated cases. IL-6 levels were the highest at the 24th hour in the complicated cases. IL-6 levels were also elevated in complicated groups after 48th hour (p<0.005). CRP' levels were the highest at the 48th hour (180mg/L, 125mg/L respectively ) at both of the groups. IL-6 levels made a higher peak at the 4 th hour in the experimental group than the control group. An exaggerated IL-6 level after the 24 th hour was associated with the subsequent risk of complications. It is thought that IL-6 is an earlier and more sensitive parameter than CRP.

1990-1994 yýllarý arasýnda Kartal Eðitim ve Araþtýrma Hastanesinde tedavi edilen duodenal yaralanmak 7 olgu, künt yaralanmalarda tanýnýn güçlüðü ve gecikmede mortalitenin artacaðý vurgulamak amacýyla retrospektif olarak incelendi. Altýsý erkek (%86), biri kadýn (%14) olan olgularýn yaþ ortalamasý 28'di. Üç olgu ateþli silah, iki olgu kesici-delici alet ve iki olguda trafik kazasý sonucu yaralanmýþtý. Olgularýmýzýn beþinde penetran yaralanma bulunduðundan ve diðer ikisinde de periton irritasyon bulgularý erken ortaya çýktýðýndan taný güçlüðümüz olmadý. Tedavi olarak primer sütür veya primer sütür + dekompresyon ve bir olguda Whipple ameliyatý yapýldý. Hasta kaybýmýz olmadý. Bu hastalarýn mümkün olduðunca erken ameliyat edilmesinin, mortaliteyi düþürdüðü sonucuna varýldý.

Between 1990 and 1994, 7 duodenal injuires were evaluated retrospectively in order to emphasize the difficulty in diagnosis especially in blunt trauma victims and the high mortality rate in delayed cases. Male to female ratio was 6/1 and the mean age was 28. Three of the patients were injured by gun-shoot, two were injuired by penetrating objects and two were injuired by traffic accidents. We did not have any difficulties in diagnosis in our patients at all; five cases were penetrating injuries and fortunately peritoneal tenderness arose early in other two cases. In the majority of cases, primary repair or primary repair with decompression was performed mean while Whipple operation was done in only one case. None of the patients were lost. We claim that, early diagnosis and treatment in these patients is essential for low morbidity and mortality.

1988-1995 arasý 7 yýllýk dönemde 57 penetran kalp travmalý hasta Ýstanbul Týp Fakültesi Acil Cerrahi Ünitesinde tedavi edildi. 7(%18.9) hastada kompleks kalp yaralanmasý vardý; 5'inde tru and tru, 2 sinde iki ayrý giriþli. Sað ventrikülde 23, sol ventrikülde 16, atriumlarda ise toplam 11 yaralanma saptandý. 15 hasta kardivak are tablosunda geldikleri için acil torakotomi gerekti. Diðer hastalar ise daha rahat ameliyata alýnmaya müsaade edecek kadar stabil idiler. Toplam 18(%31.5) hastamýzý kaybettik. Kardiyopulmoner bypass hiç bir hastamýzda kullanýlmadý. Penetran kalp travmalý hastalarýn hastane öncesi resüsitasyon ve hýzlý transportlarý mortaliteyi önemli ölçüde etkilemektedir.

During a 7-year period (1988-1995), 57 patients with penetrating wounds to the heart were treated at the Surgical Emergency Unit of Istanbul Medical Faculty. Seven patients (18.9%) had complex cardiac stab wounds, 5 had through and through stab wounds, 2 had two-entrance wounds. Twenty-three wounds were to the right ventricle, 16 wounds were to the left ventricle, and 11 wounds involved the atrial chambers. Fifteen patients required emergency thoracotomy, because of arriving pulseless in the emergency department. The other patients' were stable enough to allow immediate surgery. There were 18 in-hospital deaths (%31.5). Cardiopulmonary bypass was not used during primary surgical repair. The prehospital care and rapid transportation of victims of penetrating heart trauma influence patients survival markedly.

Travma sayýsýnýn artýþý önemli bir toplumsal sorun olarak gözükmektedir. Diðer hastalýklardan daha fazla oranda genç nüfusun kaybýna neden olmaktadýr. Multipl travmalý hastanýn multipl sorunlarý vardýr. Aðýr travmalý olgularda temel amaç ayný anda deðerlendirme, resüsitasyon, tam bir fiziksel muayene, hasta stabilse tanýsal tetkikler ve cerrahi tedavi uygulanmasýdýr. Ýyi donanýmlý acil servis ve kurtarma servisleri, travma resüsitasyonu hakkýnda eðitim ve çalýþma, iyi bir organizasyon, önlenebilir travma ölümlerini azaltacaktýr.

The magnitude of trauma as a major public health problem is well established. It causes death in young adults than any other disease. The multiply injured patient has by definition multiple problems, and adequate treatment necessitates a team approach. The principles of management in all cases of extensive trauma are simultaneous assessment and resuscitation, complete physical examination, diagnostic studies if the patient becomes hemodynamically stable, and life saving surgery. A well equipped emergency department and rescue system, training and education in resuscitation of trauma, excellent trauma organisation will decrease preventable trauma deaths.

Çalýþmamýzda Atatürk Üniversitesi Týp Fakültesi Genel Cerrahi Anabilim Dalý'nda 1.1.1988-31.12.1994 tarihleri arasýnda akut diyafragma yaralanmasý nedeniyle tedavi edilen 35 olgunun analizi yapýldý. Olgularýn 257 (%71.4) penetran 10'u (%28.6) künt yaralanma þeklinde idi. Penetran yaralanmalarýn 11'i (%44) solda, 11'i (%44) saðda 3'ü bilateraldi. Künt yaralanmalarda ise 8'i (%80) solda, 2'si (%20) saðda idi. PA Akciðer grafisinin preoperatif taný deðeri %28.5 olarak bulundu. En sýk yaralanan yandaþ organlar sýrasý ile dalak (%42.8), karaciðer (%40.0) ve mide (%314) idi. En sýk görülen postoperatif komplikasyonlar akciðerlerle ilgili olanlardý (%53.4). Mortalite 8 (%22.8) olguda oluþtu. Bunlarýn tamamý diðer nedenlere baðlý idi. Akut diyafragma yaralanmalarý yandaþ organ yaralanmalarý nedeniyle morbidite ve mortalitesi yüksek olgulardýr. Tanýda en önemli konu bu olguyu hatýra getirmektir. Multisistem yaralanmalarda her iki diyafragma dikkatli bir þekilde gözden geçirilmelidir.

In this study 35 patients who were treated because of acute diaphragmatic rupture at Atatürk University, School of Medicine Department of General Surgery between 1.1.1988-31.12.1994 were analized. Diaphragmatic ruptures were due to penetrating trauma in 25 (71.4%) patients and blunt trauma in 10 (28.6%) patients. There were 11 (44%) left, 11 (44%) right and 3 (12%) bilateral diaphragmatic ruptures in blunt trauma group. Diagnostic value of PA chest x-ray was found to be 28.5. The most frequent concomitant organ traumas were spleen (42.8%), liver (40%) and stomach (31.4%). The most frequent postoperative complications related to lungs (54.3%). There were 8 (22.8%) postoperative mortalities. Diaphragmatic ruptures because of concomitant organ traumas have high morbidity and mortality rates. In diagnosis the most important step is to remember this entity. Diaphragma must be examined carefully in multysystem trauma patient.

1990-1993 yýllarý arasýnda, etyolojik faktörün, hastalýðýn seyrine olan etkilerini araþtýrmak için 126 penetre karýn yaralanmasý olgusunu inceledik. Olgularýn %73.8'i kesici-delici alet yaralanmasý, %26.2'si ateþli silah yaralanmasý idi. Ateþli silah yaralanmalarýnýn %63.7'sinde birden fazla organ yaralanmasý varken, kesici-delici alet yaralanmalarýnda %31.3 idi. %5.6 olguda periton salimdi ve %8.7 olguda organ patolojisi yoktu. En çok yaralanan organlar, karaciðer, kolon, ince barsaklardýr. Genel mortalitemiz %2.4 olup, ateþli silah yaralanmasýnda %9.1, kesici-delici alet yaralanmasýnda %0'dýr. Mortalitenin en büyük nedeni hipovolemidir. Ateþli silah yaralanmalarýnýn komplikasyon ve mortalitesinin daha yüksek olduðu, penetre karýn yaralanmalarýnda erken laparatominin komplikasyon ve mortaliteyi düþürdüðü sonucuna vardýk.

Between 1990 and 1993, penetrating abdominal wound cases examined for investigating the effect of the etiological factors on progress of the disease. %73.8 of the cases were penetrating stab-wounds and %26.2 of the cases were gun-shot wounds. In % 63.7 of the gun-shot wound cases there was multiple organ injury. In other group this rate was %31.3. There was no peritoneal involvement in %5.6 of cases and in %8.7 of cases there was no organ pathology. Liver, colon and small intestine were the most injured organs. Overall mortality was %2.4. In gun-shot and stab-wounds mortality was %9.1 and %0 respectively. The most important reason of mortality was hypovolemia. Complication and mortality of gun shot wounds are higher and we have come to a conclusion that early laparatomy in penetrating abdominal wounds lead o decreased complications and mortality.

Splenektominin erken postoperatif devrede infeksiyon riskini artýrýp artýrmadýðýný araþtýrmak amacýyla, splenektomi geçiren 39 hasta prospektif olarak incelendi. Yaþlarý 2ay-64 yýl arasýnda deðiþen hastalar, infekte (15 hasta) ve noninfekte (24 hasta) alarak iki gruba ayrýldý. Ýnfekte grupta toplam 21 infeksiyon ataðý gözlendi: 11 solunum yolu infeksiyonu, 3 üriner sistem infeksiyonu, 3 bakteriyemi, 2 intraabdominal abse ve 2 yara yeri infeksiyonu. Alýnan kültürlerden 8'inde (%26.6) Pnömokoklar koagülaz pozitif, 4'ünde (%13.3)beta hemolitik stretokok, 4'ünde (%13.3) E.Koli ve 2'sinde (%6.6) Kandida tek baþlarýna veya kombine halde üredi. Postoperatif devrede 10 gün boyunca beyaz küre sayýmý ve ateþ takibi yapýldý. Ýnfekte grupta ortalama beyaz küre sayýsý 15821.14/mm3 ve ortalama ateþ deðerleri 37.35 idi. Noninfekte grupta ise bu deðerler sýrasýyla 10509.00/mm3 ve 36.75 C idi. 1 hastada postoperatif devrede çok aðýr sepsis geliþti. Yaptýðýmýz çalýþma sonucunda, dalaðýn çýkarýlmasýndan sonra septik komplikasyon riskinin küçümsenemeyecek derecede olduðu ve özellikle beyaz küre (BK) sayýmýnýn postoperatif dönemde fizyolojik olmayýp bir infeksiyon göstergesi olduðu sonucuna vardýk.

39 patients who underwent splenectomy were investigated to determine whether early postoperative injection risk increases after splenectomy. Patients, ranging in age from 2 months to 64 years, were divided into two groups. 1) infected (n=15) and 2) noninfected (n=24). There were 21 episodes of infection: 11 respiratory tract infections, 3 urinary tract infections, 3 bacteremias, 2 intraabdominal abscesses and 2 wound infections. Pneumococcus were cultured from 8 (26.6%) of the septic foci, Enterobacter aerogenes were cultured from (20%), Staphylococcus coagulase positive were cultured from 6 (20%)beta hemolytic streptoccus were cultured from (13.3%), E. Coli were cultured from 4 (13.3%) and Candida were cultured from 2 (6.6%) of the septic foci. Group average alternate daily WBC (white blood cell) counts and daily maximum body temperature of 37.35 C. In the noninfected group, these values were 10509.00/mm3 and 36.75 C, respectively. Only one patient developed overwhelming postspnenectomy sepsis. We concluded that the frequency of septic complications after removal of the spleen is considerable, and WBC count predicts infection in the postoperative period not physiologic.

Eriþkinlerde künt karaciðer ve dalak yaralanmalarýnýn nonoperatif tedavisi bu yaklaþýmýn çocuklarda inkar edilemez yararlarýndan kaynaklanmýþtýr. Olgular hemodinamik yönden stabil olmalý, kan transfüzyon ihtiyacý minimal olmalý ve yaygýn peritoneal hassasiyet olmamalýdýr. Ýleri görüntüleme tekniklerinin (radionüklid sintigrafi, ultrasonografi, kompüterize tomografi) artmasý ve son yýllarda peritoneal lavajýn kullanýlmasý travma niteliðinin belirlenmesine katkýda bulunmuþtur. Gevher Nesibe Hastanesine baþvuran künt karaciðer travmalý 140 ve künt dalak travmalý 144 olgu retrospektif olarak incelendi. 1985 Ocak ve 1994 Aralýk itibariyle ciddi künt karýn ve multisistem travmalý 702 olgu deðerlendirildi. Penetran ve iatrojenik karaciðer ve dalak yaralanmalarý çalýþma dýþý býrakýldý. Hastalar yaþ, cins, travma türü, teþhis yöntemleri ve tercih edilen tedavi yöntemleri açýsýndan sýnýflandýrýldý. 69 olgu nonoperatif olarak tedavi edildi. 42 olguya eksploratris laparatomi, 12 olguya dalak koruyucu cerrahi giriþim, 30 olguya karaciðere basit cerrahi giriþim ve drenaj, 60 olguya karaciðere radikal cerrahi giriþim ve 113 olguya splenektomi uygulandý. Yaygýn periton hassasiyeti olan hiç bir olguya nonoperatif tedavi yapýlmadý. Kan transfüzyon gereksinimi bu grupta ortalama 2.4 Ü idi. Nonoperatif tedavi edilen 69 olgudan 14'ünde (%20.2) komplikasyon geliþti. Yine 69 olgudan 11'i (%15.9) ikincil ciddi komplikasyonlardan kaybedildi. Sonuç olarak karaciðer ve dalak yaralanmalý seçilmiþ eriþkin olgular nonoperatif olarak güvenle tedavi edilebilir.

The use of selective nonoperative management of blunt splenic and liver trauma in adults is based on the undeniable benefits on this approach in children. Proper patient selection requires hemodynamic stability, lack of generalized peritoneal irritation, and minimal blood transfusion needs. The increased use of sophisticated imaging techniques (radionuclide scintigraphy, ultrasonography, computerized tomography) and peritoneal lavage in the last decade, has contributed to improved characterization of the extent of injury. But the decision for laparotomy is based on clinical grounds. 144 patients with blunt splenic injury and 140 patients with blunt liver injury admitted to Gevher Nesibe Hospital were included in this retrospective study. 702 consecutive adults with serious blunt abdominal or multisystem trauma were evaluated between January 1985 and December 1994. Penetrating and iatrogenic splenic and liver injuries were not included. Patients were seperated into categories based on age, sex, mechanism of injury, diagnostic modality and treatment option employed. Out of the total series, 69 patients were not operated, 42 patients had exploratory laparotomy, and in 12 patients splenic repair, in 30 patients liver repair and drainage, in 60 patients liver resection and 113 patients splenectomy were performed. None of the nonoperatively treated patients had generalized irritation. Blood transfusion requirements were significantly less in the nonoperative groups (average 2.4 U). Fourteen of these 69 patients (20.2%) developed complications. Eleven of these 69 patients (15.9%) died and these were secondary to severe complications. Consequently, liver and splenic injuries in adults can be safely managed nonoperatively in selective patients.

Aðýr akut pankreatitin belirlenmesinin tedavi ve prognoz açýsýndan büyük önemi vardýr. Geçen altý yýl içinde kliniðimizde tedavi edilen 120 hastada 122 akut pankreatit ataðýnda RANSON, IMRIE, BANK, AGARWAL tarafýndan tanýmlanan prognostik sistemlere bakýlarak, bu dört sistemin pakreatit aðýrlýðýný ve prognozunu belirleme kapasiteleri araþtýrýlmýþtýr. 120 hastanýn 79'u kadýn, 43'ü erkektir. 122 ataðýn 21'i (%17.2) aðýr, 101'i (%82.8) hafif þiddette pankreatittir. Bu dört sistemin aðýr akut pankreatiti belirlemedeki sensitivitesi sýrasýyla %85.7, %76.2, %66.7, %71.4'tür. Spesivite ise %86.1, %84.1, %80.2, %82.2 olarak bulunmuþtur. Sonuç olarak, 'pankreatit aðýrlýðýný ve prognozunu belirleme kapasiteleri yönünden bu dört sistem arasýnda büyük bir fark bulunmamakla birlikte; Ranson ve Ýmrie kriterlerinin daha duyarlý olduklarýný söyleyebiliriz.

Early assessment of severe pancreatitis is of major importance in the treatment and prognostic evaluation. The prediction of severity and prognostic capacity of RANSON, IMRIE, BANK and AGARWAL scoring systems were analyzed in a consecutive series of 120 cases presented with 122 acute attacks during the previous 6 years. 79 patients were female and 43 were male. Of the 122 attacks, 21 were severe (17.2%) and 101 were mild pancreatitis (82.8). The sensitivity of these four systems in assessment of severe pancreatitis were 85.7%, 76.2%, 66.7% and 71.4% respectively. The specificity was found to be 96.1%, 94.1%, 80.2% and 82.2% respectively. Although no statistically significant difference in the assesment of disease severity and prognostic capacity was observed between the groups; there existed a statistical trend in sensivity favoring Ranson and Imrie scoring systems.

Bu retrospektif çalýþma 1987-1993 yýllarý arasýnda Çukurova Üniversitesi Týp Fakültesi Genel Cerrahi Anabilim Dalýnda opere edilen 130 künt karýn travmalý olguda mortaliteye etkili faktörleri belirlemek amacýyla yapýldý. Olgularýn yaþ ortalamasý 32 olup, 110'u (%84.6) erkek, 20'si (%13.4) kadýndý. Künt travmanýn oluþunda trafik kazalarý birinci sýrayý almaktaydý. Travma sonucu en sýk yaralanan organ dalaktý. 25 (%19.2) olgu eksitus oldu. Olgularýn 26 (%20) 'sýnda postoperatif majör komplikasyon geliþti. Hipotansiyon (TA 'nýn 90mmHg 'nýn altýnda)'un olmasý, kafa travmasýnýn bulunmasý, iki ve/veya daha fazla karýn içi organ yaralanmasýnýn bulunmasý, 3 ünite veya daha fazla kan transfüzyonu yapýlmasýna gereksinim duyulmasý mortaliteye etkili faktörler olarak bulundu.

In this study; the records of 130 patients whom were treated because of blunt abdominal trauma in Çukurova University Faculty of Medicine General Surgery Department between 1987 to 1993 were reviewed. The aim of study was defined the factors which were affecting postoperative mortality. Of these 130 patients, 110 were male, 20 were female, and mean age was 32 years. Major cause was traffic accidents in 80%. Spleen was the most injured organ in our study group. Mortality rate was 19.2% and major complication was developed in 26 (20%) patients. In conclusion, the presence of head trauma, hypotension (less than 90mmHg), multiple intraabdominal organ injuries, blood tranfusion more than 3 units were considered major factors affecting postoperative mortality.

Son 8 senelik süre içinde kunt ince barsak yaralanmasý nedeniyle tedavi edilen 64 hasta retrospektif olarak incelendi. Künt karýn travmasý nedeni olgularýn 40'ýnda (%62.5) trafik kazasý, 13'ünde (%20.3) yüksekten düþme ve 11'inde (%17.7) darbelerdi. En sýk rastlanan þikayet ve fizik muayene bulgusu abdominal aðrý ve hassasiyetti. Peritoneal lavaj 34 þüpheli hastada yapýldý ve 33'ünde (%97) müsbet olarak bulundu. 31 (%48.4) hastada izole ince barsak yaralanmasý saptandý. 33 hastada ise multipl travma mevcuttu. Tüm tek ince barsak yaralanmalarý iki kat üzerinden tamir edildi. Devaskülarize ince barsak atýþlarý, multipl perforasyonlar ve komplet rüptürlerde rezeksiyon ve primer anastomoz tercih edildi. Künt ÝB yaralanmasýyla ilgili en ciddi komplikasyonlar anastomoz kaçaklarý ve karýn içi abselerdir. Bizim morbidite ve mortalite oranlarýmýz sýrasýyla %17.1 ve %10.9 dur.

Sixty-four patients with blunt small bowel injury determined during 8 years were retrospectively reviewed. Causes of trauma were traffic accident in 40 (62.5%), falling down in 13 (20.3%) and blow trauma in 11 (17.7%) cases. The most frequent complaints and physical findings were abdominal pain and tenderness. Peritoneal lavage was positive in 33 (97%) of 34 suspected patients. Isolated blunt small bowel injury was found in 31 (48.4%) patients. The other patients had multiple system injuries. All simple and small perforations and complete rupture were resected with primary anastomosis. The most serious complications related to blunt intestinal injury were anastomotic leakage and intraabdominal abscess. Our morbidity and mortality rates were 17.1%and 10.9% respectively.

Dalak yaralanmalarýnda genellikle künt travmalar neden olurken yüksek mortalite oraný bildirilmiþtir. Bu çalýþmada biz dalak yaralanmasý saptanan 122 hastamýza yaklaþým ve sonuçlarý gözden geçirdik. Yaralanmalarýn nedenleri çoðunlukla trafik kazalarý idi. Yirmi iki hastada yaralanma basit dalak yaralanmasý olarak sýnýflandýrýldý idi. %8.5'lik mortalite oraný ile splenorafi uygulanarak tedavi edildi. Bu grupta mortaliteden özelikle birlikte bulunan diðer yaralanmalar sorumlu idi. Geri kalan hastalar Grade 3,4 ve 5 olarak sýnýflandýrýldý. Toplam 19 hasta eks oldu, mortalite oraný %15.7 idi. Yaralanma ciddiyet skoru splenorafi yapýlan grupta 14 idi. Bu skor yaþayan ve ölen gruplardaki deðerden daha iyi idi. Bu dalak yaralanmalarýnda beþ önemli prognoz belirleyici faktör belirledik. Bu faktörler yaþ, hematokrit, birlikte bulunan ekstraabdominal yaralanmalar, þok indeksi ve yaralanma ciddiyet skoru idi. Bunlar kolayca belirlenebilir ve hastaya saðlýklý yaklaþýma olanak verir.

The splenic injuries are usually caused by blunt trauma, and high mortality rate is generally reported. In this study we reviewed the management and outcome of 122 patients with splenic injury. The reason of splenic injury were traffic accidents at all blunt trauma cases. Twenty-two patients were classified as simple splenic injury and managed by splenoraphy with a mortality rate of 8.5percent. In this group, associated injuries were found to be the most important factor, upon the mortality. The rest of the patients were classified as Grade 3,4 and 5 injuries. Nine-teen of the patients died and the mortality rate was 15.7 percent. Injury severity score was 14 in the group which splenoraphy was performed, but this score was better than that of survivor and non-survivor groups. We determined five important prognostic criteria in these blunt splenic injuries. These factors were age, heamatocrit, associated extraabdominal injuries, shock index and injury severity score. These factors can be easily determined and patient and his/her injury easily and rapidly managed.

Ýstanbul Týp Fakültesi Acil Cerrahi Biriminde son 6 yýl içinde (1989-1995) 101 elektrik yanýðý olgusu tedavi edildi. Bu dönem içinde %10.2'sini elektrik yanýklarýnýn oluþturduðu toplam 985 yanýk hastasý ünitemize kabul edilmiþtir. Düþük voltajlý elektrik yanýklarý 59 (%58.5) vakada görülmüþtür. Bunlarýn çoðu önlenebilir ev kazalarý olup, çocuk ve kadýnlarda görülmüþtür. Bu tip elektrik yanýklarýnda, ayný diðer yanýklardaki cerrahi prensipler geçerlidir. Serimizdeki yüksek voltaj yaralanmalarýnýn insidensi %41.5'dir Bunlar ise genellikle ev dýþý olaylarda ve genç eriþkin erkeklerde görülmüþtür. Amputasyonlar 22 (%52) hasta ile en büyük komplikasyon grubunu uçurmuþlardýr. %76'sý üst, %24'ü ise alt ekstremitelerde uygulanmýþtýr. Mortalite oraný %11.8 (12 vaka ), ortalama hastanede kalýþ süresi ise 25 gündür. 42 vakadan 11'i ünitemize ilk 24 saatten sonra, bunlarýn 7'si de 5.günleri içinde gelmiþlerdir. Biz bu yüksek amputasyon ve mortalite oranýmýzý hastalarýn ünitemize geç geliþlerine baðlýyoruz. Bu gecikme erken-yoðun sývý replasmanýný, sürekli hemodinamik-metabolik destek saðlanmasýný ve erken agresiv cerrahi giriþimde bulunmamýzý engellemektedir.

We have reviewed 101 cases of electrical burns treated at the Emergency Medical School of Istanbul Medical Faculty during the past 6 years (1989-1995). There were 985 acute burns admissions during this period, the incidence of electrical burns being 10.2 percent. Low-voltage electrical burns occured in 59 of the 101 patients (58.5 percent). These were caused mostly by household electricity suplies, occured in children, and were preventable. The surgical management of these burns was similar to other thermal burn injuries. The incidence of high-voltage elected injuries 41.5percent in our series. These tended to occur outside the home in young adult males and were also frequently preventable. Amputations constituted the single largest category of complications. Being neccessary in 22(52 percent). Seventy-six percent of the amputations were in the upper extremity, while twenty-four percent in the lower. The overall mortality rate was 11.8 percent (12 cases) and the mean hospital stay was 25 days. We attribute these high amputation and mortality rates in our series to late transfer of patients to our Burn Unit. 11 of the 42 patients were transferred to our unit after their 1st day and seven of them were in their 5th day. This delay prevented us from providing an aggresive fluid resuscitation, continuous haemodynamic and metabolic support, and early agressive surgical intervention.

Genel vücut travmalarý içinde Travmatik Diafragma Rüpterleri'ne (TDR) %4.5-5.8 oranýnda rastlanýr. Taný yöntemlerindeki yetersizlik nedeniyle tanýnýn geç konmasý ve/veya olaya eþlik eden ciddi organ yaralanmalarýnýn varlýðý bu olgularda mortalitenin %2'den %66'lara kadar yükselmesine neden olmaktadýr. Haziran 1990-Ocak 1994 döneminde Þiþli Etfal Hastanesi 3.Genel Cerrahi Kliniðine travma nedeniyle baþvuran olgularýn 20'sinde TDR saptandý. %85'i erkek, %15'i kadýn olan bu olgularýn tümünde taný ilk 6 saat içinde konuldu. Olgularýn %70'inde delici-kesici alet yaralanmasý, %15'inde ateþli silah yaralanmasý, %70'inde künt genel vücut travmasý vardý. Serimizde fizik muayene bulgularý ve toraks grafileri %5 oranýnda diagnostik, %45-50 oranýnda ise patolojik özellikteydi. Erken eksploratris laparotominin %45 oranýnda erken tanýsal deðeri olduðu saptandý. Olgularýn hepsinde diafraðma primer olarak tamir edildi. Mortalite %30 olarak saptanmýþ olup, hepsinde TDR'ye ilaveten ciddi organ yaralanmalarý vardý.

The reported incidence of acute traumatic diaphragmatic ruptures (TDR) varies between 4.5% and 5.8.% Inadequacy of diagnostic procedures along with the associated severe organ injuries are the main reasons of late diagnosis and increasing mortality rates in these patients. TDR was diagnosed during the period of June 1990-January 1994. The diagnosis of TDR was established in these patients within the first 6 hours of their admittance. The diagnostic value of physical examination and chest x-rays were found to be 5% while the incidence of pathologic findings' were evaluated to be 45-50%, Prompt laparatomy was found to have an early diagnostic value in 45% of the cases. Mortality was calculated to be 30% in our cases all of them resulting from the associated severe other organ injuries.

Biz popliteal arter yaralanmalý 22 hastaya cerrahi giriþim yaptýk. Popliteal yaralanmalarýn 12 hastada (%54.54) künt travmaya, 9 hastada (%40.9) saçma ile yaralanmaya, 1 vakada (%4.54) hýzar ile yaralanmaya baðlý idi. 14 vakaya (%63.63) safen ven interpozisyonu, 6 vakaya (%27.27) rezeksiyon ve uç uca anastomoz, 2 vakaya (%9.09) primer tamir yapýldý. Bizim mortalitemiz %0 ve amputasyon oraný %13.63 idi.

We had conducted surgery on 22 patients with popliteal arterial injury. Popliteal injuries were related to blunt trauma in 12 patients (%54.54); in 9 patients (40.90%) the injury were related to the gun shut; in one case (4.54%) the injury was caused by a saw. In 14 cases (63.63%) saphenous vein interposition; in 6 cases (27.27%) resection and to end anastomosis; in two cases (9.09%) primary repair had been done. We had no mortality and the amputation rate was 13.63%.

Þiþli Etfal Hastanesi 3. Genel Cerrahi Kliniðinde 1990-1994 yýllarý arasý akut mekanik intestinal obstrüksiyon tanýsý (AMÝO) ile ameliyat edilen hastalar retrospektif olarak incelendi. Bu 5 yýlda kliniðimizde toplam 2367 ameliyat yapýlmýþ olup, bunun 100 tanesi AMÝO vakasýdýr (%4). AMÝO 'nün sebepleri arasýnda en sýk görülen 45 vaka ile (%45) boðulmuþ fýtýk olup, bunu sýrasýyla 16 vaka ile (%16) adhezyonlar, 15 vaka ile (%15) kolon kanserleri, 5 vaka ile (%5) sigmoid kolon volvulusu, 5 vaka ile (%5) ince barsakta segmenter bir organik lezyon, 4 vaka ile (%4) fitobezoar, 3 vaka ile (%3) ince barsakta invajinasyon ve diðer sebepler izlemektedir.

The patients that have been operated with the diagnosis of acute mechanical intestinal obstruction (AMIO) in the 3rd General Surgery Department of Þiþli Etfal Hospital between 1990-1994 were reviewed retrospectively. In these five years, 2367 operations were performed, and AMIO occured in 10 patients (4%). Among the causes (45%), followed by adhesions (16%), colonic carcinoma (15%), sigmoid volvuli (5%), a segmental organic lesion of the small intestine (5%), bezoar (4%), intussusception (3%) and others.

Kliniðimizde son 4 yýl içinde künt batýn travmasýna baðlý olarak ameliyat edilen 311 vakayý retrospektif olarak inceledik. Bunlar arasýnda 21 izole ince barsak yaralanmasý saptandý. Künt travma genellikle trafik kazalarý sonucu oluþmuþtu. Ýntestinal yaralanmalar primer onarým ya da rezeksiyonla tedavi edildi. Ýnce barsak yaralanmalarý, künt batýn travmalarýnýn %5-10'unu oluþturmasýna raðmen mortalite oraný %25-33 civarýndadýr. Bu yüksek mortalitenin en önemli nedeni tanýdaki güçlüklere baðlý olarak ameliyatýn gecikmesidir. Baþlangýçtaki klinik ve radyolojik bulgular yanýltýcý olabilmektedir. Bundan dolayý klinik muayene sýk aralýklarla tekrar edilmeli ve peritoneal irritasyon bulgularý saptandýðýnda laparotomi yapýlmalýdýr.

Over a 4 year period 311 patients were admitted with blunt injury to the abdomen. Twenty-one of these (%6.7percent) were found to have small bowel rupture. The blunt injuries are mostly result of vehicular trauma. The major of intestinal trauma was repaired by simple closure or resection. The mean time from admission to laparotomy was 17 h. inital clinical and radiological evidence of bowel perforation can be misleading and reliance on such indicators may result in significant diagnostic delay. Frequently repeateted clinical examination is advocated; progression of abdominal sings should alert the clinician to proceed to laparatomy.