Acil saðlýk hizmetleri dünyadaki hýzlý geliþimine paralel olarak son on beþ yýlda ülkemizde de büyük aþama kaydetmiþtir. 1999 Marmara depreminden sonra toplumda önemi daha iyi kavranmýþtýr. Modern týptaki hýzlý geliþim, teknolojik týbbi cihaz olanaklarýndaki artýþ ile birlikte, geliþen ve büyüyen toplumun acil saðlýk ihtiyaçlarýndaki beklentilerinin büyüklüðü, bu hizmetlerde sürekli bir iyileþtirme ve geliþtirme ihtiyacý doðurmaktadýr. Bu yazýda 2005 yýlý Aralýk ayý itibariyle ülkemizde sunulan acil saðlýk hizmetleri ve ihtiyaçlara yönelik çözüm önerileri gözden geçirildi.

In parallel to the rapid progresses throughout the world, emergency medical services (EMC) have recorded a significant development in our country for the last 15 years. Its value has been better understood in the society after the 1999 Marmara earthquake. The expectations of the developing and growing society in terms of emergency medicine needs together with the rapid development in modern medicine and enhancement of medical technology leaded to a continuous requirement for improving and developing these services. In this article, national EMC and recommendations of solutions addressed to the needs have been reviewed as of December 2005.

Bu çalýþmada dalak ototransplantasyonunun immüniteye etkisini göstermek ve ototransplantasyon uygulanan dalak dokusunun canlýlýðýný deneysel olarak araþtýrmak amaçlandý.
GEREÇ-YÖNTEM: Yirmi adet Yeni Zelanda cinsi tavþandan üç grup oluþturuldu. Birinci gruba sham laparotomi, ikinci gruba splenektomi ve üçüncü gruba splenektomi ve dalak ototransplantasyonu yapýldý. Ototransplantasyon uygulanan dalak dokusunun canlýlýðý ve etkinliði, sintigrafi, hematolojik ve immünolojik testler ile histopatolojik inceleme yoluyla deðerlendirildi.
BULGULAR: Histopatolojik olarak ototransplantasyon uygulanan dalak dokusunun sekiz tavþanda geliþip/büyüdüðü, iki tavþanda ise nekroze olduðu saptandý. Ameliyat öncesi ile ameliyat sonrasý altýncý haftadaki hematolojik ve immünolojik bulgular önce gruplarýn kendi içinde karþýlaþtýrýldý. Üçüncü gruptaki ameliyat sonrasý immünglobulin G, immünglobulin M ve interlökin-1 seviyeleri ameliyat öncesi deðerler ile karþýlaþtýrýldýðýnda belirgin olarak artmýþtý. Gruplar arasýndaki deðerlendirmedeyse ikinci grupta ameliyat sonrasý lökosit ve trombosit sayýmý birinci gruba göre belirgin yüksek bulundu. Yine ikinci grubun ameliyat sonrasý trombosit sayýmý, birinci ve üçüncü gruba oranla belirgin olarak yüksekti. Ýmmünglobulin G, immünglobulin M ve interlökin-1 seviyelerinde gruplar arasýnda istatiksel farklýlýk saptanmadý.
SONUÇ: Dalak yaralanmalarýnda konservatif tedavi önemlidir. Bununla birlikte splenektomi endikasyonu olan hastalarda omentum içerisine dalak ototransplantasyonu yapýlmasý dalak fonksiyonlarýnýn yeniden kazanýlmasýnda güvenilir bir yöntemdir. Transplantasyon uygulanan dalak dokusunun iþlevi ve canlýlýðý, sintigrafi ve laboratuvar testleri ile takip edilebilir.

BACKGROUND: The purpose of this study was to establish the effects of spleen autotransplantation on immunity and to examine the viability of autotransplanted spleen tissue.
METHODS: Three groups were assigned and following operations were performed in twenty New Zealand rabbits. 1st group: sham laparotomy, 2nd group: splenectomy and 3rd group: splenectomy and splenic autotransplantation. Scintigraphic methods, hematological-immunological tests and histopathological examination were used to evaluate the effects of splenic autotransplantation.
RESULTS: Histopathological findings showed that eight rabbits had splenic regrowth and two had necrosis of autotransplanted splenic tissue. Preoperative hematological and immunological findings compared with those at sixth week postoperatively. In group 3, postoperative immunoglobulin G, immunoglobulin M and interleukin-1 levels were significantly increased when compared with preoperative levels. Between all groups, postoperative leukocyte counts were found to be significantly higher in group 2 comparing with group 1. In group 2, postoperative platelet counts were significantly higher in comparison to group 1 and 3. No statistically significant difference was detected between the groups for immunoglobulin G, immunoglobulin M and interleukin-1 levels.
CONCLUSION: Conservative treatment is important in patients with splenic injury. However when splenectomy is indicated, splenic autotransplantation into the omentum pouch could be a reliable method for reconstruction of splenic functions and the viability of the implanted spleen tissue can be monitored by scintigraphy and laboratory examination.

Deðiþik tip ve çaptaki silahlarýn etkileri ile etkilerine baðlý tedavi prensipleri farklýlýk gösterir, çalýþma da deðiþik özellikteki silahlarýn vücut dokularý içindeki etkilerini deneysel olarak göstermek amacýyla planlandý.
GEREÇ VE YÖNTEM
Çalýþma için 9x19 mm tabanca ve 7.62 x 51 mm G-3 piyade tüfeði olmak üzere iki tip silah seçildi. Balistik mum eþliðinde oluþturulan izole yumuþak doku, bacak, karaciðer ve baðýrsak modellerine tabanca ve tüfek ile ateþ edilerek yaralanma modelleri oluþturuldu. Saniyede 1000 görüntü alan yüksek hýzlý kameralarla çekimler yapýldý. Görüntüler incelenerek elde edilen yaralanmalar ve oluþum mekanizmalarý deðerlendirildi.
BULGULAR
Kolon yaralanmalarýnda oluþan kavitenin büyük olmasý nedeniyle kolon içeriðinin tabancaya oranda daha fazla çevre dokular arasýna yayýldýðý ve enfeksiyon kaynaðý olabileceði gözlendi. Özellikle kemiðe çarpan mermiler incelendiðinde, mermi deformasyon ve fragmantasyonu nedeniyle yüksek hýzlý mermilerde daha fazla doku hasarý oluþtuðu, kemiðe çarpmadan ekstremitelerden geçen mermilerdeyse tabanca ve tüfek mermisi arasýnda belirgin bir fark oluþmadýðý gözlendi.
SONUÇ
Ateþli silah yaralanmalarýnda yaralanmaya neden olan silah ve silahýn özelliklerinin bilinmesi tedavi öncesi yaralanmanýn þiddet ve boyutlarýnýn tahmin edilmesini ve farklý tedavi seçeneklerinin uygulanmasýný saðlayacaktýr. Bu nedenle deneysel çalýþmalarda uygun modellerin kullanýlmasý gerekir.

BACKGROUND
Effects of various types and diameters of guns and related treatment principles are different. Our study was performed to experimentally demonstrate the effects of different gunshots in body tissues.
METHODS
9x19 mm hand-gun and 7.62x51 mm G-3 infantry rifle were used in the study. Injury models were created through hand-gun and rifle shootings at isolated soft tissue, lower extremity, liver and intestine tissue simulants made of ballistic candle. High-speed cameras were used to capture 1000 frames per second. Images were examined and wound mechanisms were evaluated.
RESULTS
It was observed that the colon content distributed more within the surrounding tissues by the rifle shootings comparing with hand-gun shootings and could be an infection source due to the large size of the cavity in the colon. Especially when the bullets hitting the bone were investigated, it was seen that much more tissue injury occurs with high speed bullets due to bullet deformation and fragmentation. However, no significant difference was found between the effect of hand-gun and rifle bullets passing through the extremity without hitting the bone.
CONCLUSION
To know the type of the gun that caused the injury and its characteristics will allow to estimate severity and size of the injury before the treatment and to focus on different alternatives of treatment. Therefore, use of appropriate models is required in experimental studies.

AMAÇ
Ülkemizdeki Acil Týp Anabilim Dallarý’na (ATAD) baðlý acil servislerinin iç ve dýþ mimari yapýlarý araþtýrýldý.
GEREÇ VE YÖNTEM
Tanýmlayýcý tipteki bu araþtýrmada, çalýþmanýn yapýldýðý tarihte mevcut olan 26 ATAD’ye anket formlarý gönderildi. Bu anketle acil servislerin iç ve dýþ mimari yapýlarý ve fonksiyonel hizmet durumlarý sorgulandý. Anketi yanýtlayan 22 ATAD’nin verileri deðerlendirmeye alýndý. Henüz kurulma aþamasýnda olan ve hizmet vermeyen iki Anabilim Dalý çalýþmaya dahil edilmedi.
BULGULAR
Geri bildirimlerin deðerlendirilmesinde ATAD’den ancak %59’unun (n=13) hizmet verdikleri alanýn acil servis alaný olarak planlandýðý izlendi. Acil servislerin ambulans giriþlerinin %77 oranýnda uygun olmadýðý, %54,5 ATAD’de (n=12) acil servis giriþinde ambulanslarýn hasta býraktýðý alanýn hava koþullarýndan korumalý olmadýðý görüldü. Gelen yanýtlara bakýldýðýnda ancak %59 ATAD’de (n=13) acil serviste triyaj ünitesinin bulunduðu, yine sadece bir ATAD’de (%4,5) acil serviste temizlenme (dekontaminasyon) odasý bulunduðu bildirildi. Halen hizmet vermekte olan ATAD’lerine baðlý acil servislerin ancak %32’sinde (n=8) mevcut lokal risk faktörleri doðrultusunda geniþleyebilme düzeyinin yeterli olabileceði belirlendi. ATAD’lerin sadece %18’inde (n=4) özürlü tuvaletinin var olmasý ülke genelinde özürlülere yönelik mimari deðiþikliklerin eksikliðinin acil servislerde de olduðunun göstergesidir. Acil týbbýn ülkemizde 12 yýllýk geçmiþi olduðu düþünüldüðünde ATAD’lerin ancak %68’inde (n=15) seminer odalarýnýn var olmasý, akademik yapýlanmaya fiziksel alt yapý yetersizliði olan yerlerde baþlandýðýnýn göstergesidir.
SONUÇ
Ülkemizdeki acil týp yapýlanmasý içerisinde acil servis mimarisine gereken önemin verilmediðini, verilen hizmetteki bilimselliðin mimari yetersizliklerle gölgelendiðini göstermiþtir. Acil servis mimari tasarýmý, bilimsel veri ve kurallar çerçevesinde saðlanmalýdýr. Bunun için hastane ve özellikle acil servis mimarisi hakkýnda bilgi ve tecrübesi olan mimar veya mimarlar yetkili kiþiler ile hedefler üzerinde bir anlaþmaya varmalýdýrlar.

BACKGROUND
In our study which was based upon a questionnaire, the inner and outer architectural designs of emergency services of Emergency Medicine Departments were investigated.
METHODS
In this descriptive study, a standard questionnaire was sent to 26 Emergency Medicine Departments which were operating at that time. In the questionnnaire, the internal, external architectural and functional features were questioned. Answers of 22 Emergency Medicine Departments were analysed.Two Emergency Medicine Departments that were not operating at that time were not included in the study.
RESULTS
The analysis of the replies revealed that only 59% (n=13) of the Emergency Medicine Departments were designed as an emergency service prior to the construction. The ambulance parking areas were not suitable in 77% of the emergency units while only 54.5% (n=12) had protection against adverse weather conditions. In only 59% (n=13) of the emergency units, a triage unit was present and in only one of the in only one (4.5%), a decontamination room was available. It was understood that only 32% (n=8) of the emergency units were appropriate in enlarging their capacity taking the local risk factors into consideration. There was a toilette for disabled patients in only 18% (n=4) of the units as well. Considering a 12-year of history of the Emergency Medicine in Turkey, the presence of a lecture room is still 68% (n=15) in emergency departments which reflects that academical efforts in this field is emerging in challenging physical conditions.
CONCLUSION
The results of our study revelaed that emergency service architecture was neglected in Turkey and medical care given was precluded by the insufficient architecture. The design of emergency services has to be accomplished under guidance of scientific data and rules taking advices of architects who have knowledge and experience on this field.

AMAÇ
Okült diyafragma yaralanmalarý tanýda gecikildiði takdirde yüksek mortaliteye neden olurlar. Bu yazýda, torakoabdominal bölgenin delici ve kesici alet yaralanmalarýnda tanýsal ve terapötik torakoskopi uygulanan hasta grubuna ait deneyimler sunuldu.
GEREÇ VE YÖNTEM
Haziran 2001-Aralýk 2005 tarihleri arasýnda kliniðimizde torakoabdominal bölgenin delici ve kesici alet yaralanmasý nedeniyle torakoskopik yaklaþým uygulanan hastalar bu çalýþmaya alýndý. Veriler geriye dönük olarak analiz edildi.
BULGULAR
Abdominal ve torakoabdominal delici, kesici alet yaralanmasý nedeniyle 93 hastaya videoendoskopik giriþim uygulandý. Bunlarýn içinde torakoabdominal bölgenin delici ve kesici alet yaralanmasý nedeniyle seçilmiþ 11 hastaya tanýsal ve terapötik torakoskopi uygulandý. Ameliyatlar genel (n=10) ve lokal (n=1) anestezi altýnda uygulandý. Diyafragma yaralanmasý üç hastada saptandý ve intrakorporeal dikiþlerle onarýldý. Ýki hastada kanama kontrolü elektrokoterle saðlandý. Geriye kalan altý hastada torakoskopi yalnýzca tanýsal bir iþlem olarak gerçekleþti ve sonlandý. Ortalama ameliyat süresi ve hastanede yatýþ süresi sýrasýyla 35 dakika ve 3.5 gün idi. Perioperatif veya erken postoperatif dönemde komplikasyonla ya da mortaliteyle karþýlaþýlmadý.
SONUÇ
Torakoskopi diyafragma yaralanmalarýnýn taný ve tedavisinde etkili ve güvenilir bir yöntemdir.

BACKGROUND
Occult diaphragmatic injuries are associated with significant mortality, if the diagnosis is delayed. We report our experience in diagnostic and therapeutic thoracoscopy in a selected group of patients with stab wounds of thoracoabdominal region.
METHODS
The patients who underwent thoracoscopic management of thoracoabdominal stab injuries between June 2001-December 2005 were included into the study. The data were retrospectively analyzed.
RESULTS
Ninety-three patients with abdominal and thoracoabdominal stab wounds underwent videoendoscopic management. Among them, eleven selected patients with thoracoabdominal stab injuries were managed by thoracoscopy. The procedures were performed under general (n=10) or local anesthesia (n=1). Diaphragmatic injuries were repaired by intracorporeal sutures in three cases and bleeding was controlled in another two cases by electrocautery coagulation. The procedures were simply diagnostic in six patients. The mean operating time and hospital stay were 35 minutes and 3.5 days respectively. There was neither intraoperative or early postoperative complication, nor mortality.
CONCLUSION
Thoracoscopy is a safe and efficient tool in the diagnosis and treatment of diaphragmatic stab injuries.

AMAÇ
Ateþli silah yaralanmasý cerrahisi sonrasýnda gözden kaçan arteryel yaralanmalar ve ihmal edilen ven tamirlerinin klinik gidiþ ve önemini ortaya koymaktýr.
GEREÇ VE YÖNTEM
Bu retrospektif çalýþma Ocak 1992-Aralýk 2004 tarihleri arasýnda ateþli silaha baðlý vasküler yaralanma sonucu kliniðimize müracaat eden 275 hastanýn (269 erkek, 6 kadýn; ort. yaþ 23±5) ameliyat sonuçlarý üzerinden gerçekleþtirildi. Hastalar ameliyat notlarý ve dosya kayýt sistemi üzerinden araþtýrýldýlar. Gözden kaçan arteryel yaralanma, ihmal edilen ven tamirlerinin sýklýðý, vasküler komplikasyonlarýn tip ve lokalizasyonlarý, ekstremite kaybý ve mortalite sonuçlarý ortaya konuldu.
BULGULAR
Hastalarýn 75’i (%27,27) gözden kaçmýþ arteryel yaralanma, 91’i (%33,09) ihmal edilen ven tamiri dolayýsýyla tedavi edildi. Gözden kaçan vasküler yaralanma komplikasyonlarý, yalancý anevrizma (n=43, %57,33), arteriyovenöz fistül (n=20, %26,66) ve týkanýklýk (n=12, %16) olarak belirlendi. Gözden kaçan vasküler yaralanma en sýk süperfisyel femoral arterde idi (n=20). Venöz yaralanma 167 hastada mevcuttu. Venöz komplikasyonlar, venöz ödem ve derin ven trombozu olarak saptandý.
SONUÇ
Ateþli silahla oluþan vasküler yaralanmalarda ilk tanýda veya ameliyat anýnda gözden kaçan arteryel yaralanmalar, ihmal edilen ven tamirleri mortalite ve morbiditeyi etkilemektedir. Ateþli silah yaralanmalý hasta hemodinamik stabilizasyonun ardýndan vasküler yaralanmasýnýn anatomik lokalizasyonunun belirlenmesi için arteriyografi ve venografi ile deðerlendirilmelidir. Tüm vasküler devamlýlýklar primer veya otolog greft ile yeniden saðlanmalýdýr. Popliteal ve femoral bölgedeki tüm venöz yaralanmalar tamir edilmelidir.

BACKGROUND
The aim of this study was to establish the clinical course and importance of missed arterial injuries and disregarded venous repair after surgery for gunshot injuries.
METHODS
This retrospective study was performed on the operative results of 275 shotgun vascular injury patients’ presented to our clinic between January 1992 and December 2004. All patients were analyzed from their medical files and operative notes. The incidence of missed arterial injuries and ignored venous repair, localization and type of vascular complications, limb loss and mortality outcomes were documented.
RESULTS
Seventy-five patients (27.27%) for a delayed diagnosis of a missed arterial injury and 91 patients (33.09%) for an ignored venous repair were treated. Complications of missed arterial injuries were determined as followings: false aneurysm n=43 (57.33%), arteriovenous fistula n=20 (26.66%), occlusion n=12 (16%). The missed vascular injury was most commonly observed in superficial femoral artery (n=20). The venous injury was present in 167 patients. Complications of disregarded venous repair were determined as venous edema and deep vein thrombosis.
CONCLUSION
Missed arterial injuries and disregarded venous repairs during initial diagnosis or operation affect the morbidity and mortality in gunshot injury patients. After haemodynamic stabilization, gunshot patients should be evaluated by arteriography and venography to determine the anatomic localization of vascular injuries. All vascular continuity should be restored either by primary repair or by an autolog graft. All venous injuries located in popliteal and femoral area should be repaired.

AMAÇ
Ýki farklý cerrahi yaklaþým kullanýlarak, açýk redüksiyon ve internal fiksasyonla tedavi edilen çocukluk çaðý suprakondiler humerus kýrýklarýnýn sonuçlarý araþtýrýldý.
GEREÇ VE YÖNTEM
Lateral yaklaþým uygulanan 17 çocuðun sonuçlarý ve triseps adelesi kesilmeden yapýlan posterior yaklaþým uygulanan 10 çocuðun sonuçlarý Flynn’ýn kriterlerine göre deðerlendirildi. Bütün kýrýklar Gartland’a göre tip II-III ve ekstansiyon tipi kýrýk idi. Hastalarýn on dokuzunun sol kolu, sekizinin sað kolu kýrýk idi. Hastalarýn ortalama yaþý 8,5 (3-13 yaþ), ortalama takip süresi 19,4 ay (8-50 ay) idi.
BULGULAR
Lateral yaklaþým uygulanan on yedi hastanýn dördünün (%23,52), posterior yaklaþým uygulanan on hastanýn ikisinin (%20) dirsek hareket açýklýðýnda on dereceden fazla kayýp meydana geldi. Ortalama ameliyat süresi lateral yaklaþým uygulanan olgularda 53,14±18,11 dk, posterior yaklaþým kullanýlan olgularda 68,54±17,67 dk idi. Flynn kriterlerine göre, lateral yaklaþým kullanýlan gruptaki on yedi hastanýn on üçünde (%76,47), posterior yaklaþým kullanýlan gruptaki on hastanýn sekizinde (%80) tatminkâr sonuç elde edildi.
SONUÇ
Çocuk suprakondiler humerus kýrýklarýnda, lateral yaklaþým ile triseps adelesini kesmeden yapýlan posterior yaklaþýmýn dirsek hareket açýklýðýný eþit oranda etkilediði kanaatine varýldý. Posterior yaklaþým ulnar sinirin Kirschner teliyle doðrudan yaralanma ihtimalini azaltmakta ancak ameliyat süresini uzatmaktadýr.

BACKGROUND
The clinic outcomes of supracondylar humerus fractures in children treated with open reduction and internal fixation by using two different surgical exposures were studied.
METHODS
The clinic outcomes of seventeen and ten patients to whom lateral (LA) and posterior (PA) approaches were used respectively, were evaluated according to the Flynn’s criteria. All fractures were extension type and classified as type II and III according to Gartland’s classification. Left arm was broken in nineteen children and right arm in eight. The mean age was 8.5 years (range 3-13 years) and mean follow up was 19.4 months (range 8-50).
RESULTS
Four (23.52%) of the seventeen patients with LA and two (20%) of the ten patients with PA suffered from a loss in the range of motion (ROM) of the elbow more than 10° (p>0.05). Mean operation time was 53.14±18.11 minutes in the patients used LA and 68.54±17.67 minutes in the patients with PA. Satisfactory results were obtained in thirteen of the seventeen patients (76.47%) in the group with LA and in eight of the ten patients (80%) in the group with PA.
CONCLUSION
It is concluded that in the open reduction of childhood supracondylar fractures of the humerus, LA and PA approaches without dividing triceps muscle do equally affect the ROM of the elbow. Although PA decreases the risk of ulnar nerve injury with Kirschner wire, it prolongs the operation time.

AMAÇ
Rektus kýlýf hematomu (RKH) akut karýn aðrýsýnýn nadir görülen nedenlerinden birisidir. Sýklýkla gözden kaçar ve gereksiz cerrahi giriþimlere neden olur. Bunun önlenmesi amacýyla taný ve tedavide dikkat edilmesi gerekli noktalar incelendi.
GEREÇ VE YÖNTEM
Aralýk 2000-Temmuz 2005 yýllarý arasýnda acil cerrahi polikliniðinde RKH tanýsý alan beþ hasta (5 kadýn; ort. yaþ 67,4; daðýlým 53-74 yaþ) retrospektif olarak incelendi. Olgularýn demografik özellikleri, özgeçmiþleri ve yakýnmalarý, tanýya götüren fiziksel inceleme, laboratuvar ve görüntüleme yöntemlerindeki bulgular ve tedavi yöntemleri araþtýrýldý.
BULGULAR
Tüm olgularýn yakýnmasý karýnda kitle ve karýn aðrýsý idi. Dört olgu antikoagülan tedavisi almaktaydý. Fiziksel incelemede palpabl aðrýlý kitle bulundu. Anemi saptanan olgularda taný, birinde yalnýzca bilgisayarlý tomografi (BT), üçünde ultrasonografi (USG) ve BT yardýmýyla ve bir olgudaysa akut karýn düþünülerek yapýlan cerrahi eksplorasyon sýrasýnda konuldu. Tedavi olarak olgularýn tümünde tam kan ve dört olguda antikoagülan tedavisi kesilip, K vitamini ve taze donmuþ plazma verildi. Bir olguda kanama kontrolü ameliyat sýrasýnda yapýldý. Hastalarýn üçü ortalama 13,6 gün yatýþ süresi sonrasý þifa ile taburcu edilirken, iki olgu ameliyat sonrasý iki olgu beþinci ve yedinci günlerde kaybedildi.
SONUÇ
Akut karýn aðrýsý, göbek altý kitlesi ve anemisi olup antikoagülan kullanan ileri yaþlý hastalarda RKH’den þüphe edilmelidir. Klinik þüphe halinde USG veya BT yapýlmalýdýr. Erken ve doðru taný konservatif tedavinin baþarýlý olmasýný ve gereksiz cerrahi giriþimi önler.

BACKGROUND
Rectus sheath hematoma (RSH) is one of the rare causes of acute abdominal pain. This clinical entity is frequently misdiagnosed and leads to unnecessary surgical intervention. We investigated the critical points of the diagnosis and therapy in preventing these mistakes.
METHODS
Five patients (5 females; mean age 67.4; range 53 to 74 years) admitted to the emergency surgery unit and diagnosed as RSH between December 2000 and July 2005 were reviewed retrospectively. Demographic characteristics, medical history complaints and physical examination, laboratory and imaging studies findings were investigated.
RESULTS
Four patients had been receiving anticoagulant therapy. All of the cases were complaining of abdominal mass and abdominal pain. In the physical examination painful mass was palpated. In cases anemia determined, the diagnosis was done only by computed tomography (CT) in one case, by ultrasonography (USG) and CT in three cases, and during surgical exploration for acute abdomen in one case. Blood transfusion was administered in all of the cases. In four patients anticoagulant therapies were discontinued and intravenous vitamin K and fresh frozen plasma were administered. In one case bleeding control was done during the operation. While three cases were discharged uneventfully following mean hospital stay of 13.6 days, two cases died on the fifth and seventh days.
CONCLUSION
In elderly patients with acute abdominal pain, infraumblical mass, anemia and history of anticoagulation therapy, RSH should be taken into consideration and USG and CT should be performed. Early and accurate diagnosis helps for a successful medical treatment and prevents unnecessary surgical intervention.

Süperfisyel temporal arter (STA) anevrizmasý nadir görülür ve genellikle travma kaynaklýdýr. Bu yazýda travmaya sekonder olarak STA psödoanevrizmasý geliþen 23 yaþýnda erkek hasta ve cerrahi tedavisi sunuldu. Sol temporal bölgede yaklaþýk bir ay önce düþme sonrasý meydana gelen þiþlik ve baþ aðrýsý yakýnmasý ile kliniðimize baþvuran hastanýn fiziksel incelemesinde ayný bölgede 1,5 x 1,5 cm boyutlarýnda pulsatil kitle saptandý. Nörolojik muayenesinde bir özellik yoktu. Anjiyografide sol STA’dan kaynaklanan psödoanevrizma saptandý. Lokal anestezi altýnda temporal arter ligasyonu ve anevrizmektomi uygulandý. Hastanýn ameliyat sonrasý klinik seyri sorunsuz seyretti.

Superficial temporal artery (STA) aneurysm is rare and usually caused by trauma. In this report, a 23-year-old man who had a left STA pseudoaneurysm which was secondary to blunt trauma and its surgical treatment was presented. A patient was admitted to our clinic with the complaints of a bulge in the left temporal location that had developed almost a month ago subsequent to a fall and headache. We discovered a pulsatile mass, with 1.5 x 1.5 cm in size, at the left temporal region, on the physical examination. Neurological examination was normal. Angiography revealed pseudoaneurysm originating from superficial temporal artery. Under local anesthesia, temporal artery ligation and aneurysmectomy were performed. Postoperative course was uneventful.

Kalýcý hemodiyaliz kateteri yerleþtirimi sonrasý vena kava süperior sendromu geliþmesi nadir bir komplikasyon olarak karþýmýza çýkmaktadýr. Bu yazýda diyaliz amacýyla subklavyen vene yerleþtirilmiþ kateter kaynaklý vena kava süperior sendromlu bir olgu sunuldu. Hasta kateter uygulanýmý sonrasý yüz ve boyunda þiþme gibi tipik belirtilerle müracaat etti. Anjiyografide vena kava süperiorun trombüs nedeniyle týkalý olduðu görüldü. Cerrahi tedavide trombektomi, otolog perikart yama ile vena kava’nýn tamiri gerçekleþtirildi. Ameliyattan sonra hastanýn yakýnmalarý ve bulgularý dramatik olarak geriledi. Bu olgu ýþýðýnda gerekli vakalarda diyaliz kateteri kullanýmýnýn en aza indirgenerek erken dönemde arteriyovenöz fistül açýlmasýnýn uygun olacaðý kanaatindeyiz.

The superior vena cava (SVC) syndrome is an uncommon complication due to permanent hemodialysis catheters. Herein we present a case with superior vena cava syndrome resulting from dialysis access catheter placed in the subclavian vein. The patient was admitted with typical signs and symptoms of superior vena cava syndrome. Angiography revealed obstruction of the superior vena cava with thrombosis. Surgical repair consisted of thrombectomy and patch repair of superior vena cava with autologous pericardium. The complaints and symptoms of the patient decreased dramatically following the operation. In view of this case, we do think that creating an early arteriovenous fistula should be kept in mind to minimize the use of dialysis catheter.

Aksesuvar böbrek çok nadir görülen bir üriner sistem anomalisidir. Sað alt kadranda aðrý yakýnmasý ile kliniðimize baþvuran 39 yaþýndaki kadýn hastanýn fiziksel incelemesinde, sað alt kadranda hassasiyet, defans, lökositoz ve idrar incelemesinde enfeksiyon bulgularý saptandý. Karýn ultrasonografisinde pseudokidney görüntüsü bildirildi. Ýleri tetkikte karýn bilgisayarlý tomografisinde bu görüntünün normal yerleþimli iki böbrekten ayrý, sað pelvik yerleþimli üçüncü bir böbreðe ait olduðu belirlendi. Akut karýna benzer tabloyu oluþturan patolojinin pelvik yerleþimli üçüncü böbreðe ait enfeksiyon olduðu düþünülerek antibiyotik ve antienflamatuvar tedavisi baþarýyla uygulandý. Pelvik yerleþimli üçüncü böbrek ve bu böbrekte enfeksiyon varlýðý akut karýna benzer bulgular verebilir. Çok nadir olmasýna raðmen, pelvik aksesuvar böbrek gibi doðuþtan anomaliler ayýrýcý tanýda göz önüne alýnmalýdýr.

Supernumerary kidney is an extremely rare congenital anomaly of the urinary tract. A 39 year-old woman was admitted to the emergency unit with right lower quadrant pain. Physical examination revealed abdominal tenderness and defense on palpation of the right pelvic region. Blood and urine analysis revealed leukocytosis and urinary tract infection. Ultrasound examination demonstrated a suspicious mass which was thought to be a pseudokidney in the pelvis. Native kidneys were found in the normal anatomic position. Further investigation with computed tomography demonstrated a functioning third kidney which has located at the right iliac fossa in addition to normal excreting right and left kidneys. Acute abdomen like symptoms were secondary to the urinary infection of the third kidney and the urinary infection was successfully treated by antimicrobial and anti-inflammatory medication. We conclude that the infection of pelvic supernumerary kidney may create clinical symptoms of acute abdomen. Although extremely rare, congenital anomalies like supernumerary pelvic kidney should be included in the differential diagnosis.

Diyafragma yaralanmalarýna ilk baþvuruda taný konulamamasý sýklýkla geç komplikasyonlara neden olur. Burada ateþli silah yaralanmasýna baðlý atlanmýþ diyafragma yaralanmasýnýn neden olduðu fekal peritonitli 38 yaþýndaki erkek hasta sunulmaktadýr. Laparotomi sýrasýnda sol plöral boþluða fýtýklaþmýþ sol kolon obstrüksiyonuna ikincil diyastatik apendiks perforasyonu saptandý. Fýtýk defekti geniþletilerek, mide ve sol kolon karýna doðru redükte edildi ve diyafragmatik fýtýk polipropilen devamlý dikiþlerle tamir edildi. Mide ve kolonun canlýlýðýndan emin olduktan sonra, apandektomiyi takiben çekal eksteriorizasyon uygulandý. Ameliyat sonrasý dönemde herhangi bir komplikasyonla karþýlaþýlmadý ve hasta ameliyat sonrasý 10. günde taburcu edildi. Torako-abdominal travmalarda diyafragmanýn tümüyle gözden geçirilmesi gereklidir. Yaþamý tehdit edici komplikasyonlarý önlemek amacýyla tüm diyafragma yaralanmalarý onarýlmalýdýr.

Missing the diaphragmatic injury on first admission is often associated with late complications. A 38 year-old male patient is presented here as a case of missed diaphragmatic injury due to gunshot injury resulted with fecal peritonitis. Celiotomy revealed a distended appendix perforation due to herniated left colon obstruction through the left pleural cavity. Left colon and stomach were reduced to peritoneal cavity and diaphragm was repaired with interrupted polypropylene sutures. After being sure about the viability of the colon and stomach, appendectomy with cecal exteriorization was performed. Postoperative period was uneventful. The patient was discharged on the 10th postoperative day. A thorough inspection of the diaphragm is essential in thoraco-abdominal trauma. Repair of the diaphragmatic defects should invariably carried out to avoid life-threatening complications.

Mezenterik kistler nadir karþýlaþýlan karýn içi iyi huylu lezyonlardýr. Sýklýkla cinsiyet gözetmeksizin ileum mezenterinde bulunurlar. Mezenterik kistler asemptomatik olabilir ve rutin radyolojik tetkikler sýrasýnda saptanabilirler. Kronik karýn aðrýsý, akut cerrahi karýn bulgularýyla da karþýmýza çýkabilirler. Ultrasonografi, bilgisayarlý tomografi, manyetik görüntüleme yöntemleri tanýda yararlýdýr. Nadiren travma sonrasý rüptürle karþýmýza çýkabilirler. Bu yazýda künt batýn travmasý sonrasý acil laparotomi sýrasýnda taný konulmuþ ileum mezenteri yerleþimli mezenterik kist rüptürü olgusu sunuldu.

Mesenteric cysts are rare intraabdominal benign cystic lesions. These lesions are most commonly located in the ileal mesentery, without any sex predilection. Mesenteric cysts may be totally asymptomatic and discovered incidentally during routine radiologic examinations. Chronic abdominal pain or acute abdomen may be accompanying to these lesions. Ultrasonography, computed tomography and magnetic resonance imaging are valuable in the diagnosis. Rarely, these lesions may be presented with rupture after trauma. We present a patient with a ruptured ileal mesenteric cyst due to a blunt abdominal trauma and diagnosed by emergency laparotomy.

Akut pankreatit taný, tedavi ve takip açýsýndan cerrahinin hala baþ etmekte zorlandýðý önemli konularýndan birisidir. Akut pankreatitli hastalarýn bilgisayarlý tomografi (BT) ile deðerlendirilmesi, hastalýðýn morbidite ve mortalitesini etkileyen en önemli faktörlerden birisi olan pankreatik nekrozu görüntülemedeki baþarýsý nedeniyle popülarite kazanmýþtýr. Son çalýþmalar BT için kullanýlan ajanlarýn pankreas enflamasyonu ve nekrozuna katkýda bulunabileceðine iþaret etmektedir. Ayrýca manyetik rezonans görüntüleme için verilen gadoliniumun ise pankreasý görüntülemede kontrast BT ajanlarýndan daha güvenli olduðu ifade edilmektedir. Bu yazýda gadolinium tarafýndan tetiklenmiþ ve/veya þiddetlenmiþ bir akut pankreatit olgusu irdelendi.

Acute pancreatitis is still one of the challenging issues in general surgical practice in terms of diagnosis, management and follow-up. CT evaluation of the patients with acute pancreatitis gained popularity in order to document necrosis within the pancreatic tissue which is one of the most important factor linked to the morbidity and even mortality of the disease. Recent studies evidenced that agents used for CT evaluation might also contribute to pancreatic inflammation and cause necrosis. Recently, magnetic resonance imaging (MRI) with gadolinium has been speculated as a safer mean of providing optimum imaging of the pancreas than contrast enhanced CT. In this article we report an unusual case of acute pancreatitis which might have been initiated and/or worsened by gadolinium.