Acute Care Surgery (ACS) is an evolving specialty. The components, as defined by the American Association for the Surgery of Trauma are trauma, surgical critical care and emergency surgery. As documented by the recent reports from the Institute of Medicine, the shortage of surgical specialists who make themselves available for emergency care in the United States, the overcrowding of emergency departments and lack of surge capacity are reaching crisis conditions. The Institute of Medicine has recommended the development of regional centers of surgical specialists, analogous to trauma systems. The training of surgeons in ACS will address the manpower issue to some degree.

Currently, there is great variation in the way trauma and non-trauma emergency surgery is organized in Europe. Trauma system development based on orthopedic trauma surgery seems to be more advanced in the central European countries and less developed in Scandinavia, The Baltic States, United Kingdom and the Mediterranean countries. Specific training for trauma surgery correlates with higher level of trauma system development. Multiple common features in the management of a surgical emergency, whether caused by injury or acute disease process, would favor the integration of these two disciplines into a single organizational and educational entity based on regionalization of emergency surgical services and general surgery-based education aiming for multidisciplinary team leadership and decision making skills, and surgical competence in acute life- and limb-saving surgery.

The number of trauma victims in Turkey is expected to increase as a consequence of the increasing vehicular traffic, potential for earthquakes, and risk of terrorist attacks. The Turkish Association for Trauma and Emergency Surgery monitors trauma cases, publishes a quarterly journal, organizes trauma courses and seminars for various health personnel nationwide. It is also extending efforts to improve in-hospital care by establishing trauma and emergency surgery fellowships and trauma and emergency surgery centers nationwide, which is run by General Surgeons currently. Turkey faces the same dilemma as the rest of the developed world regarding the future of trauma surgeons in the current era of nonoperative trauma management. We suggest that the field of trauma and emergency surgery be redefined to include emergency general surgery and cavitary trauma.

BACKGROUND: It was investigated the effect of using normobaric oxygen (NO) in addition to antibiotherapy in experimental peritonitis and the changes of rectal fever (RF), WBC, CRP and procalcitonin levels were evaluated. METHODS: After the preliminary research of the normal values, rats were infected by E. coli intraperitoneally. Four groups were assigned into “no therapy”, “given NO”, “given antibiotic”, “given antibiotic + NO” groups.
RESULTS: The decline of RF and WBC levels on 3rd and 5th days was recorded in antibiotic + NO group versus the other groups. It was observed that group 4 was superior to the others. The positivity of periton cultures and the inflammation in the muscle were found to be less in antibiotic + NO group. No correlation was found between pathological and microbiological recovery and blood CRP level in all groups. But a significant decrease in blood procalcitonin level was determined in group 4 compared to the other groups. On day 3, procalcitonin and CRP levels increased with increasing WBC levels. On day 5, procalcitonin levels also decreased in groups with decreased WBC levels, but no significant correlation was found between CRP and WBC levels. CONCLUSION: It was concluded that using of NO in addition to antibiotherapy could increase the success rate of experimental intraabdominal sepsis therapy and blood procalcitonin and WBC levels could be more beneficial than CRP levels in monitoring of the severity of the sepsis.

BACKGROUND: Phytoestrogens are plant-derived natural molecules having some bone forming and bone substituting effects. In the present study, the role of phytoestrogens on bone healing was investigated in a rabbit fracture model. METHODS: Twenty-two New Zealand white rabbits with right tibia fracture were divided into two groups randomly. The plant derived extract of Vitex agnus-castus L. (Verbenaceae) prepared before the study was administered intramuscularly in group 1 and group 2 was chosen as control. Fracture healing was monitored in weekly basis with blood alkaline phosphatase level, radiographs of extremities and 99m-Tc MDP bone scintigraphy. The study was finished at the end of the 3rd week. The extremities including tibial fractures were collected for histological examination. RESULTS: Radiographic evidence of fracture healing obtained on postoperative day seven was superior in group 1 than control group (p<0.01). The 99m-Tc MDP bone scintigraphy uptake ratios on postoperative seventh day showed higher uptake in group 1 than in group 2 (p<0.05). The differences of scintigraphic uptakes in fractured tibias calculated on postoperative seventh day and postoperative 14th in group 1 were higher than group 2 (p=0.04). The histopathologic evaluation performed after sacrification of all rabbits on postoperative 25th day showed no significant difference between both groups. No statistical difference was determined related to the other variables. CONCLUSION: Flavonoids affected positively the early periods of fracture healing mechanism in New Zealand white rabbits. We suggest further studies with phytoestrogens to determine the effects of various dosages and administration ways.

BACKGROUND: Laparoscopic adhesiolysis became popular in the last decade for the management of postoperative adhesive small bowel obstruction. This paper investigates the feasibility, effectiveness and safety of laparoscopy in this field; the details of a selective adhesolysis were discussed as well. METHODS: The patients who underwent laparoscopic management of acute or chronic recurrent adhesive bowel obstruction were included into the study. The patients were managed according to a specific algorithm. If the conservative management has failed, selective laparoscopic adhesiolysis to the transition zone of distended /collapsed bowel was performed. Patients, who were suffering from chronic recurrent obstruction attacks and those who tolerated oral intake, underwent preoperative enteroclysis studies and selective adhesiolysis was performed according to imaging findings. Computerized tomography was performed in all cases to exclude other diagnoses. RESULTS: Thirty-one patients (22 female, 9 male) underwent laparoscopic adhesiolysis from January 1998 to June 2007. The mean age was 48 (range: 20-80). Enteroclysis - guided laparoscopic adhesiolysis was performed in nineteen patients. Twelve patients underwent laparoscopic adhesiolysis for acute obstruction. Enteroclysis was able to demonstrate the pathological adhesion or band in all of the patents who underwent this imaging technique. Conversion and complication rates were 9.6%. The entire patients tolerated well oral intake postoperatively except one who had underwent enteroclysis-guided adhesiolysis; the patient presented with transient subileus on postoperative day 34 and responded well to conservative management. Mean hospital stay was 4.1 days (range: 2-7). The patients are free of symptoms on their follow-up.
CONCLUSION: Laparoscopy is feasible, safe and effective in postoperative adhesive disease. Laparoscopic adhesiolysis should be performed as selective as possible in acute and chronic cases. Enteroclysis is a helpful imaging modality for performing selective laparoscopic adhesiolysis in chronic obstruction.

BACKGROUND: We investigated exocrine pancreatic insufficiency in severely traumatised patients with enteral nutrition using the fecal elastase-1 concentration. METHODS: The fecal elastase-1 levels of critically ill patients after major trauma (n=18) were determined in a prospective study. Early enteral nutrition was started with a high molecular diet via a naso-duodenal tube, starting 24-36 hours after admission to the intensive care unit. Enteral feeding was administered continuously starting with 20 mL/h (1 kcal/mL) and advanced gradually to 80 mL/h in the next days. Stool samples from the first and second stool after beginning of the enteral nutrition were taken for determination of the fecal elastase-1. For elastase-1 analysis in a sandwich-type enzyme immunoassay (ELISA), a sample of approximately 1 g stool was taken from the first and second stool after beginning of the enteral nutrition. Elastase-1 concentration of >200 mg/g was considered as normal, whereas <100 mg/g elastase-1 was significantly low indicating a severe exocrine pancreas dysfunction. RESULTS: All patients were fed enterally without relevant feeding-associated complications and no diarrhoea occurred in any patient. In the initial stool passage, 55.6% of the patients had moderately or severely decreased elastase-1 concentrations. In the second stool passage, only 38.9% of the patients showed a decrease in the elastase-1 concentration (p<0.01). The average elastase-concentration in the first stool sample was 268.4 mg/g (median: 162.1 mg/g) and in the second sample 333.8 mg/g (median: 520.2 mg/g). CONCLUSION: The data of this study suggests that initial exocrine pancreas insufficiency may occur in severely traumatised and critically ill patients, which improves under early enteral nutrition with polymeric enteral diets. The clinical consequences of exocrine pancreatic dysfunction in the early posttraumatic situation have to be defined.

BACKGROUND: In this study we aimed to determine the prevalence of sharp injuries (SI) and blood and body fluid (BBF) splashes in health care workers during elective surgery procedures (ESP). This study would help to plan the preventive measures for injuries and BBF splashes. METHODS: All ESP were recorded during three months period and SI and BBF splashes were analyzed in Hospital of Dicle University. Hospital employees who reported SI or BBF splashes were interviewed about the types of devices causing injury and the circumstances of the injury. RESULTS: During three months period, 1988 ESPs were recorded. SIs were reported in 111 procedures (5.6%) and BBF splashes were in 145 (7.3%). Incidence rate of SI was 2.8 per person year in teaching staff, 5.6 in residents, 6.3 in nurses and 1.5 for other health care workers. Incidence rate of BBF splashes was 14.5 per person year in trainers, 6.9 in residents, 8.4 in nurses, respectively. Duration of ESP, start time of ESP and number of employed personnel in the ESP were the factors that significantly influenced SI incidence. Duration of ESP and total person worked in ESP was effective on BBF splashes. SI was occurred in 14.4 of mandibulofacial, 12.2% of general surgery, 10.5% of chest surgery and 8.4% of brain surgery ESP. BBF splashes occurred in 14.4% of general surgery’s, 13.5% of urology’s, 14% of chest surgery’s, 14.7% of cardiovascular surgery’s ESP. The most frequently injured tissue was index finger (33.9%) and the pollex finger (31.4%). CONCLUSION:
SIs and BBFs are important health risks for health professionals who are involved in surgery, as it is in all other medical practices. SI and BBF splashes should be monitored and preventive measures should be planned urgently.

BACKGROUND: This research has been designed to to assess first aid knowledge levels of housewives, determine the attitudes and behaviors of housewives in the prevention of domestic accidents and examine factors related to first aid knowledge levels and attitudes and behaviors in prevention of domestic accidents. METHODS: In this cross-sectional type research, together with a query questioning sociodemographic characteristics, a test prepared to assess their first aid knowledge levels and a Likert-type form to determine their attitudes and behaviors levels in the prevention of domestic accidents have been applied to housewives of 180 household via face-to-face interview technique. RESULTS: First aid knowledge score increased with increasing levels of education of study population. First aid knowledge score of working women was higher than the unemployed ones. Attitude and behavior scores of the study population were increasing with increasing levels of education and economic status and were decreasing with increasing age. Preventative attitude and behavior score of women who had not experienced an accident at home was higher than the remaining. CONCLUSION: In this study, it has been determined that both first aid knowledge level and development of positive accident-preventative attitudes and behaviors were affected by the education levels. Increasing women’s formal education level and raising women’s social status are the keys in solving many social problems.

BACKGROUND: The surgical outcomes of comminuted subtrochanteric fractures result in high incidence of nonunion and malunion due to high energy trauma. Biological fixation offers decrease in these complications while preserving soft tissue vascularity. The aim of this study was to evaluate the results of patients treated with bridge plating for comminuted subtrochanteric femoral fractures retrospectively. METHODS: Ten patients with comminuted subtrochanteric femoral fractures between 1996 and 2002 were included into this study. All patients were male and mean age was 46±15.2 years (range: 29-76 years). Six patients had C-3-1 and four patients had C-3-2 type fractures according to AO/OTA classification. Bridge plating under fluoroscopy control, according to biological fixation principles was carried out on all patients. Pain, walking capacity, functionality, motion, daily activities, radiological assessment for Sander’s criteria and shaft-neck angles of both fractured and the other sides were recorded for statistical analysis, at the last follow-up. RESULTS: Mean follow-up period was 62±20.9 months (range: 37-104 months). Partial and full weight-bearing were recommended at an average period of 3.3±1.1 (range: 1.5-4.5 months) and 4,8±1 months (range: 3-6 months) respectively (range: 3-6 months). There were eight excellent (80%), one good (10%) and one poor (10%) results according to Sanders’ criteria. There was no statistically significant difference between the healthy and fractured sides with respect to femoral shaft-neck angles. CONCLUSION: We have concluded that biological fixation applied with bridge plating offered an alternative method in the treatment of comminuted subtrochanteric femoral fractures.

BACKGROUND: In this study we have discussed the factors that affect our surgical results according to our experience on patients who were admitted to our hospital’s Emergency Surgery Department for civilian craniocerebral gunshot wounds between 1997 and 2006.
METHODS: The clinical and radiological findings of 82 patients (74 males, 8 females) who were treated for civilian craniocerebral gunshot wounds were retrospectively recorded. Neurological and physical examination, cranial computerized tomography (CCT) findings, trauma types, treatment modalities, prognosis, complications, morbidity and mortality rates were analyzed. RESULTS: Seventy-four (90%) of the patients were male, the mean age was 29.2 year. The Glasgow Coma Scores (GCS) during admission were as following respectively: 3-5 in 35 patients, 6-8 in 9 patients, 9-12 in 19 patients and 13-15 in 19 patients. According to their radiological findings, most commonly subdural hematoma, intracerebral hematoma, multiple contusion, depressed fracture and subarachnoidal hematoma were encountered. Operation or debridement was performed in 51 patients totally. Forty-one patients died and the mortality rate of 82 patients was calculated as 50%. CONCLUSION: The mortality rate of craniocerebral gunshot wound is high. The patients with GCS higher than 8 and with unihemispheric lesions during admission have better prognosis. We concluded that all patients must undergo debridement and the patients that have mass effect must be operated as soon as possible.

BACKGROUND: Electrical energy has gained wide acceptance since the middle of 20th century. Rapid progress of industrialization and widespread utilization of electrical appliances lead to many electrical accidents and deaths. Aim of our study was to analyze such injuries with a forensic perspective and to draw conclusions. METHODS: Sixty-three death cases (59 males, 4 females; mean age 32.5±12.7; range 5 to 62 years) due to electrical current injury that underwent forensic autopsy between the years of 1996-2003 in Bursa city of Turkey were included into the study. Demographic features, origin of death, scene of the injury, localization of entry and exit lesions were examined.
RESULTS: The cases were most common in between 30-39 years of age and 93.7% were male. Sixty-three point five percent of the deaths were occupational accidents. Deaths occured usually in summer. Although homicidal and suicidal cases were rare in the literature, all of our cases were accidental in origin. CONCLUSION: The physician who performs autopsy should be thoroughly informed about the place of death due to electrocution. It is necessary to solve infra-structural problems, increase security measures and provide training about prevention of electrical injuries.

A 48-year-old man, on acenocoumarol due to past aortic valve replacement, was referred to our emergency department for left thoracic pain, progressive dyspnea and fatigue gradually worsening over the past 24 hours. Thirty-one days ago he had suffered from left rib fractures due to a fall, while 15 days ago his regular follow-up chest X-ray was negative for hemopneumothorax. On admission, chest X-ray revealed left pleural effusion, while his peripheral blood hematocrit was 28% and the INR 3.57. Following plasma transfusion his INR recovered to two, but five hours later his blood hematocrit dropped to 22.6%. The hemothorax was then drained by a chest tube and followed by blood transfusion. Acenocoumarol might not have been the initiating factor of delayed hemothorax, but could be blamed for the exacerbation of bleeding. It is recommended that all patients with rib fractures, receiving anticoagulants should have a close surveillance until the 4th week post-injury.

We report a patient who was diagnosed as fat embolism syndrome after replantation surgery of left amputated foot. This diagnosis was based on the presence of a long bone fracture with an amputation of a major extremity, supported by the signs of pulmonary and cerebral dysfunction and confirmed by the demonstration of arterial hypoxemia in the absence of other disorders.

Injuries to the spinal accessory nerve are rare and mostly iatrogenic. Pain, impaired ability to raise the ipsilateral shoulder, and scapular winging on abduction of the arm are the most frequently noted clinical manifestations. As a seldom case, a 20 year-old male with spinal accessory nerve palsy after penetrating trauma by gunshot was reported. Three months after the injury, he was complaining about left arm pain in abduction to shoulder level and a decreased range of movement. On physical examination, wasting of the left trapezium with loss of nuchal ridge and drooping of the shoulder were found. On neurological examination of the left trapezius and sternomastoid muscles, motor function were 3/5 and wide dysesthesia on the neck, shoulder and arm was present. The bullet entered just above the clavicle and exited from trapezium. Radiological studies were normal, where electromyography (EMG) showed neuropathic changes. Surgical exploration showed the intact nerve lying on its natural course and we performed external neurolysis for decompression. The postoperative period was uneventful. Dysesthesia has diminished slowly. He was transferred to physical rehabilitation unit. In his clinical control after 3 months he had no dysesthesia and neurological examination of the left trapezius and sternomastoid muscles motor function were 4/5. EMG showed recovery in the left spinal accessory nerve.

Penetrating injuries to the neck have high morbidity and mortality rates because of the multiple vital structures present within this anatomic region. Endovascular treatment of an AV fistula of left common carotid artery and left subclavian vein subsequent to stab injury of the left supraclavicular region is presented in this case report.