Kanama sadece yol açtýðý volüm defisitine baðlý olarak ölüme neden olan bir sorun deðildir. Neden olduðu düzeltilemeyen hipotermi, metabolik asidoz ve koagülasyon bozukluklarýyla da hastaneye yetiþtirebilmiþ olsa bile yaralýnýn kaybýna neden olabilir. Travmaya baðlý olarak boyun, koltuk altý ve kasýk bölgeleri gibi turnikeye uygun olmayan lokalizasyonlarda ve ekstremitelerde görülen dýþa kanamalarýn saha þartlarýnda etkin bir þekilde kontrol altýna alýnmasý amacýyla geliþtirilen birçok topikal hemostatik ajan mevcuttur. Bu yazýda, farklý etki mekanizmalarý ve etkinlikleri olan bu ajanlarýn saha kullanýmýna uygun olanlarý ve konu üzerindeki son öneriler irdelenmiþtir.

Massive hemorrhage causes instant and early deaths because of hypovolemia. However, even if the victim makes it to the hospital, hypothermia, metabolic acidosis, and coagulation impairments caused by bleeding pose a great risk for survival. Many topical hemostatic agents are developed for neck, armpit, or groin injuries that are not amenable to tourniquet application and for extremity wounds to be used in conjunction with tourniquets. This paper focuses on those hemostatics that differ based on the action mechanism and are suitable for pre-hospital setting and summarizes the latest recommendations regarding their usage.

AMAÇ: Kombine travmanýn neden olduðu akciðer yaralanmasýnda farklý tedavi rejimlerinin etkinliðini deðerlendirmeyi amaçlamaktadýr.
GEREÇ VE YÖNTEM: Tavþanlar ölümcül olmayan iki taraflý kapalý göðüs kontüzyonu ardýndan tüm vücut alanýnýn %30’unu tutan haþlanma yanýðýna maruz býrakýldý. Tavþanlar minimum ortalama arter kan basýncý 70 mmHg’nin üç yöntemle baþka bir deyiþle 1: 1, 1: 2 veya 1: 3 oranýnda normal salin/poligelin enjeksiyonlarý ile idame ettirilen resüsitasyon gruplarýndan birine randomize edildi (sýrasýyla, 1: 1G, 1: 2 G ve 1: 3 G). Travmadan sonra akciðer yaralanmasý ýslak/kuru (I/K) akciðer aðýrlýðý oraný, ELISA ve gerçek zamanlý PCR analiziyle deðerlendirildi.
BULGULAR: 1: 1 veya 1: 2 sývý resüsitasyon grubuna göre 1: 3 sývý resüsitasyon grubunda tavþanlarda azalmýþ akciðer I/K oraný, alveoler kanama, MPO aktivitesi ve serumda düþük IL-8 ve TNF-α düzeyleri saptandý. Ayrýca 1: 3 sývý resüsitasyonu uygulanan tavþanlarda kombine yaralanmadan 24 saat sonra ultrastrüktürel deðiþiklikler de azaldý.
TARTIÞMA: Bu çalýþma kombine yaralanmaya maruz kalan akciðerde sývý resüsitasyonunun etkisini göstermiþtir. Akciðer yaralanmasýnýn erken evresinde kombine akciðer kontüzyonu ve yanýk yaralanmasýndan sonra 1: 3 sývý resüsitasyonuyla tedavi daha efektiftir.

BACKGROUND: This study aims to evaluate the effectiveness of different treatment regimens on combined injury-induced lung injury.
METHODS: Rabbits were subjected to non-lethal closed-chest bilateral lung contusion followed by a 30% total body surface area scald burn. The rabbits were randomly assigned to resuscitation groups that maintained a minimum mean arterial blood pressure of 70 mmHg using one of the following three methods: normal saline plus polygeline injection in a ratio of 1: 1 (1: 1G), normal saline plus polygeline injection in a ratio of 1: 2 (1: 2G), and normal saline plus polygeline injection in a ratio of 1: 3 (1: 3G), After injury, lung injury was assessed using lung wet-to-dry (W/D) weight ratio, enzyme-linked immunosorbent assay, and real-time PCR.
RESULTS: In the 1: 3 fluid resuscitation group, rabbits exhibited significantly reduced lung W/D ratio, alveolar hemorrhage, myeloperoxidase activity, and IL-8 and TNF-α levels in the serum compared with the 1: 1 or 1: 2 fluid resuscitation groups. The 1: 3 fluid resuscitation-treated rabbits also attenuated ultrastructural changes in the lung 24 h after the combined injury.
CONCLUSION: This study demonstrated the impact of fluid resuscitation on combined injury-induced lung injury. Further, 1: 3 fluid resuscitation treatment at the early stage of lung injury after combined lung contusion and burn injury was found to be more effective.

AMAÇ: Künt toraks travmasý sýkýlýkla pulmoner kontüzyona yol açar, lokal ve sistemik enflamatuvar durumlardan kaynaklanan yüksek morbidite ve mortalite riski taþýyan akut solunum sýkýntýsý sendromunun geliþmesine neden olur. Bu çalýþmanýn amacý sýçanlarda künt göðüs travma modelinde levosimendanýn lokal ve sistemik antienflamatuvar etkilerini araþtýrmaktýr.
GEREÇ VE YÖNTEM: Otuz iki Wistar Albino sýçan dört gruba ayrýldý: Kontrol, Sham, düþük doz levosimendan (LDL) (5 µg/kg 10 dakika yükleme doz, 0.05 µg/kg/dk intravenöz infüzyon) ve yüksek doz levosimendan (YDL) (10 µg/kg 10 dakika yükleme doz, 0.1 µg/kg/dk intravenöz infüzyon) grubu olarak belirlendi. Künt göðüs travmasýndan altý saat sonra histopatolojik ve immünohistokimyasal deðerlendirme için kontüze pulmoner dokular çýkarýlmýþtýr ve serumda TNF-α, IL-1β, IL-6, NO düzeyleri biyokimyasal olarak deðerlendirildi.
BULGULAR: Düþük doz levosimendan ve YDL grubunda ortalama arter basýnçlarý deney boyunca düþük seyretti ve aralarýnda istatistiksel olarak anlamlý fark saptanmadý. Levosimendanýn travma sonrasý oluþan alveolar konjesyonu ve hemorajiyi azaltmadýðý saptandý. Ancak levosimendanýn düþük ve yüksek dozlarda hasarlý akciðer dokusuna nötrofil infiltrasyonunu azalttýðý tespit edildi. PC oluþturulan sýçanlarda akciðer dokusunda NF-κB’nin aktivasyonunun arttýðý ancak levosimendanýn bu aktivasyonu azaltamadýðý gözlendi. Öte yandan levosimendanýn düþük ve yüksek dozlarda verildiðinde serum IL-1β seviyesini azalttýðý; yüksek dozlarda uygulandýðýnda da IL-6 ve NO oranlarýný azalttýðý tespit edildi. Ancak serum TNF-α seviyelerini azaltamadýðý saptandý.
TARTIÞMA: Sonuç olarak levosimendan isimli deneysel ajanýn sýçanlarda oluþturulan pulmoner kontüzyon modelinde hasarlý akciðer dokusuna nötrofil hücre infiltrasyonunu ve bunlardan salýnacak bazý sitokinlerin (IL-1β, IL-6, NO) sistemik salýnýmýný azaltabileceði ve böylece pulmoner hasarý kýsmen azaltabileceði ve/ veya düzeltebileceði; travma sonrasý ortaya çýkan sistemik enflamatuvar yanýtý da azaltabileceði düþünülmüþtür.

BACKGROUND: Blunt thoracic injury often leads to pulmonary contusion and the development of acute respiratory distress syndrome, which carries a high risk of morbidity and mortality, originating from the local and systemic inflammatory states. This study aimed to investigate the local and systemic antiinflammatory effects of levosimendan in rat models of blunt chest trauma.
METHODS: A total of 32 Wistar albino rats were randomly assigned to one of the following four groups: control, sham, low-dose levosimendan (LDL) (5 µg/kg loading dose for 10 min and 0.05 µg/kg/min intravenous infusion), and high-dose levosimendan (HDL) (10 µg/kg loading dose for 10 min and 0.1 µg/kg/min intravenous infusion). Blunt chest trauma was induced, and after 6 h, the contused pulmonary tissues were histopathologically and immunohistopathologically evaluated, serum TNF-α, IL-1β, IL-6, and NO levels were biochemically evaluated.
RESULTS: The mean arterial pressure was low throughout the experiment in the LDL and HDL groups, with no statistically difference between the groups. Levosimendan reduced the alveolar congestion and hemorrhage, which developed after inducing trauma. Neutrophil infiltration to the damaged pulmonary tissue was also reduced in both the LDL and HDL groups. In rats in which pulmonary contusion (PC) was observed, increased activation of nuclear factor kappa B was observed in the pulmonary tissue, and levosimendan did not reduce this activation. Both high and low doses of levosimendan reduced serum IL-1β levels, and high doses of levosimendan reduced IL-6 and NO levels. TNF-α levels were not reduced.
CONCLUSION: In conclusion, the results showed that in a rat model of PC, the experimental agent levosimendan could reduce neutrophil cell infiltration to damaged pulmonary tissues and the systemic expressions of some cytokines (IL-1β, IL-6, and NO), thereby partially reducing and/or correcting pulmonary damage. Systemic inflammatory response that occurs after trauma could also be reduced.

AMAÇ: Çalýþmamýzda fibrin oluþumunu engelleyen ajan olan taurolidin ve fibrin kümelenmesini engelleyen icodextrin’in ayrý ayrý ve birlikte uygulanmasýnýn karýniçi yapýþýklýðýn önlenmesine olan etkisini deðerlendirmeyi amaçladýk.
GEREÇ VE YÖNTEM: Kýrk adet 30–35 gram aðýrlýðýnda, 11–12 haftalýk erkek BALB/c fare, 4 gruba ayýrýldý. Grup 1: Kontrol grubu, Grup 2: Taurolidin grubu, Grup 3: Ýsodekstrin grubu ve Grup 4: Taurolidin ve isodekstrin grubu olarak adlandýrýldý. Deney hayvanlarý 14. gün servikal dislokasyonla sakrifiye edildiler. Yapýþýklýklar iki kör araþtýrmacý tarafýndan Nair’in makroskobik yapýþýklýk skorlama sistemiyle sýnýflandýrýldý. Mikroskobik deðerlendirme için Zühlke’nin sýnýflandýrmasý kullanýldý.
BULGULAR: Grup 2’de skor 4 olan fare olmadý. Grup 3’te skor 3 ve 4 olan fare yoktu. Skor 2, 3 ve 4 Grup 4’teki farelerde saptanmadý. Grup 1’den 4’e doðru yapýþýklýk skor ortalamalarýnýn azaldýðý görüldü. Kontrol grubuyla tüm çalýþma gruplarý arasýnda istatistiksel açýdan anlamlý farklýlýk saptandý. Makroskobik deðerlendirmede çalýþma gruplarý arasýnda farklýlýk saptanmazken histopatolojik incelemede Grup 4 ve diðer çalýþma gruplarý arasýnda istatistiksel açýdan anlamlý farklýlýk saptandý.
TARTIÞMA: Taurolidin ve isodekstrin ayrý ayrý veya beraber kullanýldýðýnda karýniçi yapýþýklýk oluþumunu azaltmaktadýr. Makroskobik görünüm taurolidin ve isodekstrin grubuyla diðerlerinin istatistiksel açýdan farklýlýðýný desteklememektedir ancak mikroskobik deðerlendirme beraber kullanýldýklarýnda farklýlýk yaratmasý nedeniyle gelecek çalýþmalara yol göstermektedir. Doz ayarlamasý için ilave deneysel çalýþmalar gereklidir.

BACKGROUND: In our present study, we aimed to evaluate the effects of taurolidine, a blocking agent of fibrin deposition, and icodextrin, a colloid osmotic material that also inhibits fibrin accumulation, and the effect of their application separately and concomittantly in intra-abdominal adhesion prevention.
METHODS: Forty BALB/c male mice, weighing 30–35 g and 11–12 weeks old were divided into four groups as follows: group 1: control group, group 2: taurolidine group, group 3: icodextrin group, and group 4: taurolidine and icodextrin group. Animals were sacrificed by cervical dislocation after 14 days. The adhesions were classified and scored by two blinded researchers according to Nair’s macroscopic adhesion staging system and microscopically evaluated using Zuhlke classification system.
RESULTS: In group 2 there was no mice with score 4. In group 3, scores 3 and 4 were absent. Scores 2, 3, and 4 were not detected in group 4. The mean value of adhesion scores decreased from groups 1 to 4. There was a significant statistical difference between all the groups and group 1. There was no change between the study groups on macroscopic examination, whereas histopathological examination revealed statistically significance between group 4 and other groups.
CONCLUSION: Taurolidine and icodextrin, when used alone or together, decrease postoperative intra-abdominal adhesion formation. Macroscopic appearence was not supportive of statistical difference between group 4 and other groups. Microscopic evaluation paves the road for future studies for determining significance when taurolidine and icodextrin are applied concomittantly. Additional experimental studies are required for dose adjustment.

AMAÇ: Bu araþtýrmada dört skorlama sisteminin (APACHE II, SOFA, SAPS II, MEDS) nekrotizan fasiitisli hastalarýn prognozlarýný doðru tahmin etme yetenekleri karþýlaþtýrýldý.
GEREÇ VE YÖNTEM: Nekrotizan fasiitis tanýsý konulan yetmiþdört hasta geriye dönük olarak deðerlendirildi. Bu skorlama sistemlerinin mortalite tahmin yetenekleri, mortalite gruplarýnda (saðkalanlar ve ölenler) tahmin edilen mortalite oranlarý karþýlaþtýrýlarak ve ayrýca saðkalanlar ile ölen hastalar arasýnda mortalite oranlarý sýrasýyla %10, %30 ve %50’nin üzerinde tahmin edilenlerde gerçek mortalite oranlarý ikili gruplar halinde karþýlaþtýrýlarak deðerlendirildi.
BULGULAR: Saðkalanlar ile ölen hastalar arasýnda tüm skorlama sistemlerinde tahmin edilen mortalite oranlarý farklýydý. APACHE II ve SAPS II’nin tahmini mortalite oranlarý gerçek mortalite oranlarýna diðer skorlama sistemlerinkinden daha yakýndý. Tahmini mortalite oranlarý mortalite riski için limit deðer olarak analiz edildiðinde ise, APACHE II’nin mortalite tahmin yeteneði SAPS II’ninkinden daha üstündü.
TARTIÞMA: Deðerlendirilmeye alýnan bu skorlama sistemlerinin hepsinde tahmin edilen mortalite oranlarý, ölenlerde saðkalanlara kýyasla daha yüksekti ancak hepsi de gerçek oranlarýn altýnda mortalite tahmininde bulundu. Ancak, göreceli olarak APACHE II ve SAPS II nekrotizan fasiitisli hastalarda mortalite tahmininde diðerlerine kýyasla daha üstündü. Mevcut skorlama sistemleri arasýnda APACHE II’nin kullanýlmasý daha uygun görünmektedir.

BACKGROUND: This study compared the predictive accuracy of four scoring systems, namely Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score II (SAPS II), and Mortality in Emergency Department (MEDS), for estimating prognosis in patients with necrotizing fasciitis.
METHODS: Seventy-four patients who presented with necrotizing fasciitis were retrospectively examined. The ability of the scoring systems to predict mortality was assessed by comparing the estimated mortality rates in mortality groups (survivors/non-survivors), and mortality rates among survivors and non-survivors with an estimated mortality of >10%, 30%, and 50% in the scoring systems were compared in pairs.
RESULTS: Estimated mortality rates in the survivor and non-survivor groups were different for all the scoring systems. The estimated mortality rates of APACHE II and SAPS II were much closer to the actual mortality rates than the other two scoring systems. When the predicted mortality rates were analyzed as limits for a mortality risk, the predicted mortality rate by APACHE II was superior to that by SAPS II.
CONCLUSION: The studied scoring systems had significantly higher predicted mortality rates in non-survivors than in survivors; however, they all underestimated the mortality rate. APACHE II and SAPS II were relatively superior for estimating mortality in patients with necrotizing fasciitis. APACHE II rather than the other scoring systems should be currently used.

AMAÇ: Fournier gangreni (FG) hastalýðýnýn mortalite tayininde Fournier gangreni skorlama indeksi (FGSÝ) ve Uludað FGSÝ’lerinin (UFGSÝ) prediktivitesini araþtýrmak amaçlandý.
GEREÇ VE YÖNTEM: Ýki eðitim ve araþtýrma hastanesi genel cerrahi kliniðinde Ocak 2012 ile Aralýk 2015 tarihleri arasýnda FG nedeniyle takip ve tedavi edilen olgular mortalite ile iliþkili faktörler yönünden deðerlendirildi. Mortalite iliþkili faktörler ve hastalýk prognozunun tayini için FGSÝ ve UFGSÝ skorlama sistemlerinin duyarlýlýklarýna bakýldý. Olgular yaþayan (Grup I) ve mortalite görülen (GrupII) olarak gruplandýrýldý.
BULGULAR: Toplam 29 olgu çalýþmaya dahil edildi. Yaþ ortalamasý 51.52±13.36 idi. Mortalite oranýmýz %20.6 (6 olgu) idi. Olgularýn 17’sinde (%58.6) yara kültüründe üreme saptandý. Üreme olan olgularýn 11’i (%47.8) Grup I, 6’sý (%100) Grup II’de idi. Bakteri üreme varlýðý mortalite açýsýndan istatistiksel olarak anlamlý bulundu (p=0.028). On dört (%48.3) olguda ek hastalýk varlýðý mevcuttu. Ek hastalýk sayýsý mortalite ile iliþkili bulundu (p=0.049). Fournier gangreni skorlama indeksi ve UFGSÝ puanlarý Grup II olgularda istatistiksel olarak anlamlý yüksek bulundu (sýrasýyla p=0.002 ve 0.001). Uludað Fournier gangreni skorlama indeksi skorlama parametrelerinden Grup II olgularda yaralanan alan, vücut ýsýsý, nabýz sayýsý ve HCO3 puanlarý Grup I olgularýn puanlarýndan istatistiksel olarak anlamlý yüksek bulundu (p<0.05). Fournier gangreni skorlama indeksi ve UFGSÝ’nin mortalite tahminindeki sensitivitesi %100 iken, spesitifite oranlarý sýrasýyla %78.2 ve 73.9 idi.
TARTIÞMA: Fournier gangreni mortalitesinin öngörüsünde FGSÝ ve UFGSÝ oldukça etkindir. Çalýþmamýzda hastalýðýn yayýlýmý prognozda önemli bir parametre olarak görüldü. Hangi skorlama sistemi kullanýlýrsa kullanýlsýn UFGSÝ’deki hastalýðýn yayýlým parametresi mutlaka her olguda kullanýlmalýdýr.

BACKGROUND: This study aimed to evaluate the usefulness of Fournier’s gangrene scoring index (FGSI) and Uludag FGSI (UFGSI) for predicting mortality in patients with FG.
METHODS: Patients who underwent treatment and follow-up in the A division department of general surgery at two education and research hospitals between January 2012 and December 2015 were evaluated for mortality-related factors. The sensitivities of FGSI and UFGSI scoring systems for predicting mortality-related factors and disease prognosis were evaluated. Patients were grouped as survivors (Group I) or non-survivors (Group II).
RESULTS: In total, 29 patients were included in the study. The mean age (±SD) was 51.52±13.36 years. The mortality rate was 20.6% (six patients). Bacterial growth was observed in wound cultures of 17 patients (58.6%). Of the patients with bacterial growth, 11 (47.8%) were in Group I and six (100%) were in Group II. The presence of bacterial growth was significantly associated with mortality (p=0.028). Fourteen patients (48.3%) had comorbid conditions. The number of comorbid conditions was related (p=0.049). FGSI and UFGSI scores were significantly higher in Group II than in Group I (p=0.002 and p=0.001, respectively). Among UFGSI parameters, extent of disease, body temperature, pulse rate, and HCO3 values were significantly higher in Group II than in Group I (p<0.05). The FGSI and UFGSI scoring systems had 100% sensitivity and 78.2% and 73.9% specificity, respectively, for predicting mortality.
CONCLUSION: The FGSI and UFGSI scoring systems are valuable for predicting mortality in patients with FG. The extent of the disease was an important prognostic parameter in this study. Whichever scoring system is used, we suggest the use of the extent of disease score in UFGSI.

AMAÇ: Bu çalýþmanýn amacý farklý endoskopi merkezleri tarafýndan kliniðimize yönlendirilen endoskopik retrograd kolanjiyopankreatografi (ERCP) komplikasyonlarý ile ilgili deneyimimizi aktarmaktýr.
GEREÇ VE YÖNTEM: ERCP komplikasyonu nedeniyle Ekim 2005–Ocak 2014 tarihleri arasýnda acil cerrahi kliniðimize yönlendirilen 54 hastanýn kayýtlarý geriye dönük incelendi.
BULGULAR: Çalýþmada 25 kadýn, 29 erkek hasta yer aldý. Pankreatit en sýk görülen komplikasyon (%38.8) idi. Perforasyon (%27.7), enfeksiyon
(%20.3) ve kanama (%12.9) diðer sýk görülen komplikasyonlardý. En yüksek oran perforasyonlu hastalarda (%40) olmak üzere olgularýn %22.2’si ölüm ile sonuçlandý. Ölen olgularýn ortalama yaþý 75.9 idi (daðýlým, 47–94). Ölümlerin %41.6’sý ERCP sonrasý ilk hafta, %33.3’ü ikinci hafta içerisinde gerçekleþti. Ölen hastalarýn %50’sinde malign bir hastalýk mevcuttu (birisinde metastatik meme kanseri, birisinde safra kesesi tümörü, birisinde duedonum tümörü, üçünde periampuller tümör). Ölen hastalarýn %50’sinde kardiyopulmoner ve/veya serebrovasküler hastalýklar da mevcuttu.
TARTIÞMA: Risk faktörlerini bilerek uygun yönetimin saðlanmasý komplikasyon oranýný en aza indirse de tamamen ortadan kaldýramaz. Orta ve ciddi dereceli komplikasyonlar özellikle yüksek riskli hastalarda mortaliteyi artýrabilir.

BACKGROUND: The goal of this study was to present our experience in the management of endoscopic retrograde cholangiopan- creatography-related complications in patients referred to our surgical emergency unit by various endoscopy centers.
METHODS: A retrospective investigation was conducted on the records of the 54 patients who were referred to our surgical emer- gency unit between October 2005 and January 2014 due to endoscopic retrograde cholangiopancreatography-related complications.
RESULTS: There were 25 and 29 female and male patients, respectively. Pancreatitis was the most common complication (38.8%). Perforation (27.7%), infection (20.3%), and bleeding (12.9%) were the other complications. In 22.2% of cases, patients were died. The mortality rate was the highest in patients with perforation (40%). The mean age of the patients who were died due to complications was 75.9 years (range, 47–94 years). In total, 41.6% of the patients were died within the first week and 33.3% were died within the second week following ERCP. Nearly half of these patients had a cancerous disease (one had metastatic breast cancer, one had a gallbladder cancer, one had a duodenal cancer, and the other three had periampullary cancers) and 50% of the patients who died also had cardiopulmonary and/or cerebrovascular disorders.
CONCLUSION: Comprehending and managing the main risk factors can minimize complications; however, they would not be elimi- nated. Moderate and severe complications may increase the mortality rates, particularly in high-risk patients.

AMAÇ: Fournier gangreni akut geliþen, hýzlý ve sinsi ilerleyen, taný ve tedavide geç kalýndýðýnda yüksek oranda morbidite ve mortalite ile sonuçlanan acil cerrahi bir hastalýktýr. Bu çalýþma ile kliniðimizde Fournier gangreni tanýsý ile takip ve tedavi edilen hastalarýn sonuçlarýný irdelemeyi amaçladýk.
GEREÇ VE YÖNTEM: Bu çalýþma, 2010–2015 yýllarý arasýnda Fournier gangreni tanýsýyla ameliyat edilen hastalarýn geriye dönük taranmasý ile yapýldý. Hastalarýn tanýsý fizik muayene ile konuldu. Genital, perineal ve perianal bölgede hassasiyet, endurasyon, siyanoz, gangren ve cilt altý krepitasyon saptanan olgular Fournier gangreni olarak kabul edildi. Resussitasyonu takiben agresif cerrahi debritman ve seçilmiþ olgularda debritmana ilave olarak ‘Vacuum Assisted Closure’ (VAC) uygulandý. Gerekli durumlarda mükerrer debritmanlar yapýldý. Hastalarýn takip ve tedavi sonuçlarý analiz edildi.
BULGULAR: Çalýþmaya 25 hasta dahil edildi. Bunlardan 14’ü (%56) kadýn, 11’i (%44) erkek olup yaþ ortalamasý 54.3 (daðýlým, 27–82) idi. Kadýnlarýn yaþ ortalamasý istatistiksel olarak daha yüksekti (p=0.001). Hastanede ortalama yatýþ süresi 21.4 gün, ortalama debritman sayýsý 2.4 kez idi. Hastalarýn 13’ünde (%52) perianal bölgede apse ve 20’sinde (%80) diabetes mellitus tespit edildi. Hastalarýn tümünde geniþ debritman, 16’sýnda (%64) ise debritmana ilave olarak VAC uygulamasý yapýldý. VAC uygulanan hastalarda hastanede ortalama yatýþ süresi ve ortalama debridman sayýsý istatistiksel olarak daha yüksek bulundu (sýrasýyla, p=0.004, p=0.048). Bir hastaya ostomi açýldý ve bir hasta mortal seyretti.
TARTIÞMA: Fournier gangreninde erken taný, etkili resüsitasyon, agresif debritman ve uygun olgularda debritmana ilave olarak VAC uygulanmasý ostomi ihtiyacýný, morbidite ve mortaliteyi azaltabilir.

BACKGROUND: Fournier’s gangrene is a surgical emergency that progresses rapidly and insidiously and results in high morbidity and mortality rates unless it is immediately diagnosed and managed. Here we analyze the outcomes of patients who were followed up and treated for Fournier’s gangrene.
METHODS: We conducted a retrospective analysis of the medical data of 25 patients operated on for Fournier’s gangrene between January 2010 and June 2015. The diagnosis of Fournier’s gangrene was made by performing a physical examination. Patients who had genital, perineal, and perianal tenderness; induration; cyanosis; gangrene; and subcutaneous crepitation were considered as having Fournier’s gangrene. Following resuscitation, aggressive surgical debridement was performed and vacuum-assisted closure (VAC) was conducted in addition to debridement in select patient. Repeat debridements were performed as requirement.
RESULTS: This study included 25 patients. Fourteen patients (56%) were females and 11 (44%) were males. The mean age of the patients was 54.3 years (range: 27–82 years). The mean duration of hospital stay was 21.4 days; the mean number of debridements performed was 2.4. Thirteen patients (52%) had perianal abscesses, and 20 (80%) had diabetes mellitus. All patients underwent extensive debridement; 16 patients (64%) underwent VAC in addition to debridement. Patients undergoing VAC had significantly longer durations of hospital stay and a higher mean number of debridements performed (p=0.004 and p=0.048, respectively). An ostomy was made in one patient, and one patient died.
CONCLUSION: In Fournier’s gangrene, early diagnosis, effective resuscitation, aggressive debridement, and VAC application in suitable cases may reduce the morbidity and mortality rates and the need for an ostomy.

AMAÇ: Kapalý humerus cismi kýrýðýnýn neden olduðu radyal sinir felcinin tedavisi tartýþmalýdýr. Bu çalýþmanýn amacý, kararlý olmayan kapalý humerus cismi kýrýklarý olan hastalarda radiyal sinir felcinin erken evrede tedavisinin sonlanýmýný deðerlendirmek ve bu tip yaralanmasý olan hastalarýn cerrahi yolla eksplore edilip edilmemesi gerektiðini belirlemektir.
GEREÇ VE YÖNTEM: Kararlý olmayan kapalý humerus cismi kýrýklarýnýn tedavisi için açýk redüksiyon ve internal fiksasyon geçirmiþ 15 ardýþýk hastanýn týbbi kayýtlarý gözden geçirildi. Yaralanma mekanizmalarý, radyogramlar, zedelenmiþ sinirin intraoperatif bulgularý ve klinik iyileþmeler irdelendi. On beþ hastanýn ikisi basit düþme, ikisi beyzbol oynarken, biri kayak yaparken biri de iþ sýrasýnda makineye kaptýrmýþtý. Kýrýklar 6 hastada humerusun ortasýnda 8 hastada orta-distalinde ve bir hastada orta-proksimalinde bulunuyordu. Kýrýklar 6 hastada transvers kýrýk, 4 hastada kelebek fragmanlý parçalý kýrýk, 3 hastada oblik segmentli kýrýk ve 2 hastada spiral kýrýk þeklindeydi.
BULGULAR: On bir hastada makroskopik olarak sinirler saðlamdý ve dördünde sinir tamamen enine kesilmiþti. Total sinir kesisi olan dört hasta trafik kazasý geçirmiþti. Bu dört hastanýn birinde humerus cisminin orta-distal kýsmýnda kelebek fragmanlý parçalý kýrýk, diðer üçünde ise yine humerus cisminin orta-distalinde deplase transvers kýrýk mevcuttu. Ýki olguda enine kesili sinirler primer onarýldý. Diðer iki olguda sinir uçlarý ezilmiþ olduðu için humerus boyu kýsaltýldý ve sinir grefti kondu. Saðlam sinirli hastalarýn tümü son izlemde tamamen fonksiyonlarýna kavuþmuþtu.
TARTIÞMA: Kararlý olmayan humerus cismi kýrýðýnýn eþlik ettiði radiyal sinir felcinin tedavisi için tercihen radiyal sinirin primer eksplorasyonu, açýk redüksiyon, kýrýðýn plakayla tespiti düþünülmelidir. Yüksek enerjili travma, orta-distal humerusta lokalize kýrýk ve basit transvers kýrýk veya kelebek fragmanlý parçalý kýrýðýn radiyal sinir transeksiyonu için risk faktörleri olduðu görünmektedir.

BACKGROUND: The treatment of radial nerve palsy caused by closed humeral shaft fracture is a matter of debate. The purpose of this study is to evaluate the outcome of early surgical management of radial nerve palsy in patients with unstable closed humeral shaft fractures and to determine whether patients with this injury should be surgically explored.
METHODS: Medical records of 15 consecutive patients who had undergone open reduction and internal fixation for unstable closed humeral shaft fractures were reviewed. Injury mechanisms, radiographs, intraoperative findings of the injured nerve, and clinical improvement were analyzed. Of the 15 patients, two were injured during simple falls, two during baseball pitching, one by a fall from a height, one during skiing, and one by direct machine impaction during work. Fracture locations were middle humerus in six patients, middle-distal in eight patients, and middle-proximal in one patient. Fracture patterns were transverse fracture in six patients, butterfly segment fracture in four patients, oblique segment fracture in three patients, and spiral fracture in two patients.
RESULTS: Eleven patients showed macroscopically intact nerves, and four had total nerve transection. All four patients with total nerve transection were injured in traffic accident. Of these four patients, one showed comminuted fracture with butterfly fragment on the middle-distal shaft and the other three showed displaced transverse fracture on the middle to middle-distal shaft area. Transected nerves were directly repaired in two patients. In the other two patients, humerus shortening and nerve grafting were performed because of mangled nerve endings. All patients who had intact nerves showed fully recovered function at the last follow-up.
CONCLUSION: For radial nerve palsy accompanied by unstable humeral shaft fracture, primary exploration of the radial nerve and open reduction and plate fixation of the fracture should be considered as a treatment of choice. High-energy trauma, fracture location at the middle-distal humerus, and simple transverse fracture or comminuted fracture with butterfly fragment seems to be risk factors for radial nerve transection.

AMAÇ: Bu klinik çalýþmada amaç ön kolda proksimal, orta ve distal seviyelerde ulnar ve median sinirin birlikte kesilerinin erken primer tamiri sonrasý geç dönemde duyu ve motor fonksiyonlarýnýn deðerlendirilmesidir.
GEREÇ VE YÖNTEM: Ulnar ve median kombine kesilerde geç dönem duyu deðerlendirilmesi iki nokta ayrým testi, monoflaman testi ile yapýldý. Motor deðerlendirme ise ulnar sinir için dorsal palmar interosseöz gücü, median sinir için abduktor pollisis brevis kas gücü deðerlendirildi. Soðuk intoleransý, obje tanýma ve aðýrlýk ayýrt etme de deðerlendirildi.
BULGULAR: Çalýþmaya ulnar median kombine kesisi olan 5–59 yaþ arasý 26 hasta dahil edildi. Hastalarýn hiç birinde duyu fonksiyonlarýnda yetersizlik gözlenmezken median duyusal alanda 12 (%46) hastada, ulnar duyusal alanda yedi (%26) hastada dokunma duyusunda azalma saptandý. Motor fonksiyon açýsýndan en anlamlý kayýp oppozisyon pinch gücünde saptandý. Ýki hastada pençeleþme, iki hastada eklem kontraktürü gözlendi.
TARTIÞMA: Periferik sinir yaralanmalarýnda ideal tedavi primer tamir olmalýdýr. Motor fonksiyon dönüþü median sinirde ulnara göre daha iyidir. Duyusal açýdan anlamlý fark yoktur. Distal seviyede median ve ulnar sinirin grup yapýsý oluþturmasý nedeniyle epiperinöral tamir yerine grup fasiküler tamir tercih edilmelidir. Proksimal ulnar kesilerde motor fonksiyon yetersizliði nedeniyle primer tamire alternatif gerekmektedir. Periferik sinir tamiri için yapýlan testlerde standartizasyon yoktur.

BACKGROUND: The objective of this clinical study was to evaluate sensory and motor functions in the later period following primary repair of combined injuries of the ulnar and median nerves in the forearm at proximal, middle, and distal levels.
METHODS: Later period sensory evaluation of ulnar and median combined cuts was performed using two-point discrimination and monofilament tests. On the other hand, motor evaluation was performed by determining dorsal palmar interosseus strength for the ulnar nerve and abductor pollicis brevis muscle strength for the median nerve. Cold intolerance, object recognition, and weight discrimination were also reviewed.
RESULTS: In total, 26 patients with ulnar-median combined cut and aged between 5 and 59 years were included in this study. Although no deficiency was observed in the sensory functions of any of the patients, a decrease in tactile sensation was detected in the median sensory region in 12 (46%) patients and in the ulnar sensory region in 7 (26%) patients. The most significant loss in terms of motor functions was detected in the opposition pinch strength. Two patients developed claw hand and two showed joint contracture.
CONCLUSION: Ideal treatment for peripheral nerve injuries should be primary repair. Restoration of the motor function in the median nerve is relatively easier than that in the ulnar nerve. No significant difference was observed in terms of sensory function. An alternative is needed for primary repair because of lack of motor function in proximal ulnar incisions. There is no standardization of tests performed for peripheral nerve repair.

AMAÇ: Bu çalýþmanýn amacý titanium çivi ya da K-telleri kullanýlarak intramedüller çivileme ile tedavi edilen çocuk önkol kýrýklarýnýn kýsa dönem radyolojik ve klinik sonuçlarýnýn karþýlaþtýrýlmasýdýr.
GEREÇ VE YÖNTEM: Bu çalýþma ileriye yönelik karþýlaþtýrmalýdýr. Ýntramedüller tespit ile cerrahi olarak tedavi edilen açýk ya da kapalý önkol çift kýrýklý 43 hasta randomize olarak iki gruba ayrýldý. Takibi yapýlamayan üç hasta çalýþmadan çýkarýldý. Kýrk hastadan 20’si elastik stabil intramedüller çivi grubuna ve 20’si de K-teli grubuna dahil edildi. Demografik veriler yaralanmanýn tarafý dýþýnda iki grup arasýnda benzerdi. Perioperatif veriler, radyolojik ve klinik sonuçlar deðerlendirildi.
BULGULAR: Kohort yaþ ortalamasý 11.60 (±2.69) olan 5 kýz ve 35 erkek çocuktan oluþuyordu. Ameliyattan önce konservatif olarak takip eilen hastalarýn oraný dýþýnda tüm perioperatif veriler gruplar arasýnda benzerdi. Radyolojik ve klinik sonuçlar da benzer idi. Toplamda iki kaynama gecikmesi, bir tel dibi enfeksiyonu ve bir refraktür gözlendi.
TARTIÞMA: Çocuklarda önkol kýrýklarýnýn titanyum çivi ya da K-teli ile intramedüller tespitinin radyolojik ve klinik sonuçlarý benzerdir. Hem elastik stabil intramedüller çivi hem de K-teli tespiti pediatrik diafizeal önkol kýrýklarýnýn tedavisinde etkindir.

BACKGROUND: The purpose of this study was to compare short-term radiographic and clinical results of pediatric both-bone diaphyseal forearm fractures treated with intramedullary nail fixation using titanium nails or K-wires.
METHODS: This was a prospective comparative trial. In total, 43 patients with both-bone open or closed forearm fractures who underwent surgical treatment with intramedullary fixation were randomly classified into two groups. Three patients did not return for the follow-up and were excluded from the study. Twenty of the 40 patients were assigned to the elastic stable intramedullary nail group and 20 were assigned to the K-wire group. Demographic data suggested no difference between the two groups except for the side of injury. Perioperative data and radiological and clinical outcomes were evaluated.
RESULTS: The cohort comprised 5 girls and 35 boys whose mean age was 11.60 ± 2.69 years. Except the proportion of patients who were conservatively followed up preoperatively, all perioperative data were similar between the groups. Radiographic and functional results were similar. There were two delayed unions; one pin track infection and one re-fracture.
CONCLUSION: Intramedullary fixation of forearm fractures in children with titanium nail or K-wire does not affect radiological and clinical results. Both elastic stable intramedullary nail and K-wire fixation were effective in stabilizing pediatric diaphyseal forearm fractures.

AMAÇ: Diyafragma rüptürü (DR) seyrek görülen, travma sonucu veya kendiliðinden oluþan yaþamý tehdit edici potansiyeli olan bir olaydýr. Bazen DR yaralanmadan birkaç ay sonra oluþur. Göðüs filmi ve bilgisayarlý tomografi en etkili tanýsal yöntemlerdir. Sýklýkla DR tanýsý gecikir. Bu çalýþmanýn amacý DR etiyoloji, klinik tablosu ve tedavisini incelemek ve daha iyi anlamaktýr.
GEREÇ VE YÖNTEM: Bu çalýþma Ýtalya, Milano I.R.R.C.S. Vakfý Cà Granda Hastanesi Acil ve Genel Cerrahi Bölümü Polikliniði’nde [Emergency and General Surgery Department of Fondazione I.R.R.C.S. Cà Granda, Ospedale Policlinico in Milan (Italy)] gerçekleþtirildi. 2001 ila 2011 yýllarý arasýnda DR tanýsý konup ameliyat geçirmiþ hastalar çalýþmaya dahil edilip geriye dönük olarak hastalarýn verileri toplandý.
BULGULAR: Çoðu sað tarafta DR olan 14 hastaya taný konmuþtur. Baþlýca neden trafik kazalarýydý (%86). Sekiz hastada (%57) ameliyat öncesi DR tanýsý konmuþtu. Göðüs filmi hastalarýn %50’sine taný koydurmuþ, üç olguda (%60) bilgisayarlý tomografi yararlý olmuþtur. On iki hastada diyafragma hernisi mevcuttu. Ýki olguda DR meþ ile onarýlmýþtýr. Ortalama hastanede kalýþ süresi 16.6 gün idi.
TARTIÞMA: Nonspesifik kliniði nedeniyle erken taný koymada zorluk yaþanmaktadýr. Çok kuþkucu olmak gerekir, tedavisi cerrahidir. Ýç organlar içeri itilir ve diyafragma defekti onarýlýr.

BACKGROUND: Diaphragmatic rupture (DR) is a rare and potentially life-threatening event caused by trauma or spontaneously. DR occasionally occurs several months after the injury. Chest X-ray and computed tomography are the most effective diagnostic methods. Delay in DR diagnosis occurs frequently. This study aimed to examine and improve our understanding of the etiology, clinical presentation, and management of DR.
METHODS: This study was performed at the Emergency and General Surgery Department of Fondazione I.R.R.C.S. Cà Granda, Ospedale Policlinico in Milan (Italy). Patients diagnosed with DR between 2001 and 2011 who underwent surgery were included, and their data were retrospectively collected.
RESULTS: Fourteen patients were diagnosed with DR, mainly left-sided DR. Road traffic collisions were the main causes (86%). DR diagnosis was preoperatively established in eight patients (57%). Chest X-ray was diagnostic in 50% of the patients and computed tomography in three patients (60%). Twelve patients had a diaphragmatic hernia. DR was repaired with a mesh in two patients. Mean hospital stay was 16.6 days.
CONCLUSION: Difficulty in achieving early diagnosis of DR is due to its nonspecific presentation. High index of suspicion is needed. Its treatment is using surgery involving reduction of the viscera and repair of the diaphragm defect.

“Klingsor sendromu” veya “kiþinin kendi penisini ampüte etmesi” seyrek görülen bir klinik durum olup psikiyatrik bozukluklar, emir alma varsanýsý, dinsel saplantýlar, madde kötüye kullanýmý, toplumdan izole edilme veya ihmal edilme ile iliþkilidir. Nadiren rastlandýðý gibi seyrek görülen bir cerrahi acildir. Optimal sonuçlarý güvence altýna alma amacýyla uygun ve zamanýnda tedavi açýsýndan yetersiz veri mevcuttur. Yirmi beþ yaþýnda bekâr, günahlarýnýn kefaretini ödeme ve Tanrýnýn affýný kazanma yöntemi olarak penisini yaralamýþtýr. Yaralanmadan 12 saat sonra gerçekleþtirilen mikrovasküler reimplantasyon çabasý yeterli kozmetik ve fonksiyonel sonuçlarýyla baþarýlý olmuþtur. Bu seyrek görülen hastalýkta gecikmeye raðmen optimal kozmetik ve psikososyal yararlar için tek bir reimplantasyon denemesi bile zahmete deðer.

Klingsor syndrome or self-Inflicted traumatic penile amputation is a rare clinical entity that is associated with psychiatric disorders, command hallucinations, religious preoccupations, substance abuse, and isolation from or neglect by society. In addition to being infrequently encountered, it is a rare surgical emergency, with paucity of data on appropriate and timely management to ensure optimal functional outcomes. We report the case of a 25-year-old unmarried male who inflicted this injury upon himself in a fit of paranoia as a way to expiate his sins and earn solace from God. An attempt at microvascular re-implantation 12 h after the injury was successful, with adequate cosmetic and functional outcomes obtained. Thus, in this rare disease, despite a delay in presentation, a single attempt at re-implantation may still be worthwhile for obtaining optimal cosmetic and psychosocial benefits.

Çocuklarda künt abdominal travma sonrasý duodenal yaralanma son derece seyrek görülmektedir. Genellikle geç dönemde ortaya çýkar ve mortalite ve morbiditenin artmasýna yol açar. Künt abdominal travma sonrasý çocuklarda oluþan iki izole duodenal yaralanma olgusunu bildiriyoruz.

Duodenal injury following blunt abdominal trauma in children is extremely rare. It commonly has a delayed presentation, thus leading to increased mortality and morbidity. We report two cases of isolated duodenal injury following blunt abdominal trauma in children.

Penetran yaralanmanýn neden olduðu eksternal karotis arter (EKA) psödoanevrizmalarý seyrek görülen bir vasküler anomalidir. Eksternal karotis arter segmentinin eksplorasyonu standart tedavi olmasýna raðmen, cerrahi olarak ulaþýlmasý zor alanda kanamanýn kaynaðýný bulmada zorluk varsa endovasküler tedavi (EVT) düþünülebilir. Burada EKA’nýn ana gövdesinde psödoanevrizmalý III. zon boyun penetran yarasýnýn neden olduðu kanamanýn neden olduðu koagülopatiyle birlikte kanamasý durdurulamayan genç bir hastayý tedavi ettik. Hasta baþarýlý hemostazýn saðlandýðý EVT geçirmiþtir. PubMed verilerine dayanan literatür derlemeleri sonucu EVT ile tedavi edilmiþ penetran EKA yaralanmalarýna ait 155 yayýnlanmýþ olgu raporu saptanmýþtýr. Endovasküler tedavinin, boyunda penetran yaralanma sonrasý oluþan rüptüre EKA psödoanevrizmasýnýn yol açtýðý kanamanýn neden olduðu koagülopati hastalarýnda etkili bir alternatif cerrahi tedavi olduðu kararýna vardýk.

The formation of external carotid artery (ECA) pseudoaneurysms caused by stab wounds is a rare vascular anomaly. Although the surgical exploration of the ECA segment is the standard treatment, endovascular treatment (EVT) can be considered if there is difficulty in identifying the source of bleeding in the injured regions that are difficult to operatively access. Here we treated a young patient who had hemorrhagic instability with hemorrhage-induced coagulopathy caused by a zone III cervical stab wound with a pseudoaneurysm from the main trunk of the ECA; the patient underwent EVT and successful hemostasis. A literature review based on the data available on PubMed was conducted, and 15 published reports of 82 penetrating ECA injuries treated by EVT were identified. We concluded that EVT appears to be an effective surgical alternative for patients with hemorrhage-induced coagulopathy caused by a ruptured ECA pseudoaneurysm after a cervical stab wound.

Yabancý cisim yutulmasý çocukluk çaðýnda sýk görülen bir acil durumudur. Bu cisimlerin çoðu gastrointestinal sistemden herhangi bir sorun olmadan geçer. Karýnda devamlý ayný yerde sebat eden bir yabancý cisim olduðunda ise eksplorasyon yapmadan tanýyý koymak imkansýzdýr. Bu yazýda, kliniðimize baþvuran Meckel divertikülünde para hapsolmuþ bir olgu ve bu olguya laparoskopik yaklaþýmýmýz sunulmuþtur. Sað alt kadranda uzun süre sebat eden bir yabancý cisim varlýðýnda Meckel divertikülü tanýsý ve laparoskopik yaklaþým seçeneði göz önünde bulundurulmalýdýr.

Foreign body ingestion is a common problem in children. Most of these foreign bodies spontaneously pass through the gastrointestinal tract. When there is a persistent foreign body in the abdomen, it is impossible to make a diagnosis without exploration. We herein present the case of a child who was admitted to our hospital with a coin trapped in Meckel’s diverticulum and our laparoscopic approach in this case. The diagnosis of Meckel’s diverticulum should be considered when there is a prolonged lodgment of a foreign body in the right lower quadrant, and the laparoscopic approach is the preferred choice in these cases.

Künt travma sonrasý, çoðunlukla yaralanan karýn içi organ karaciðerdir. Karaciðer masif yaralanma yönetimi kompleks bir durumdur. Karaciðer cerrahisi sonrasý geliþen özellikle proksimal biliyer duktus striktürlerinde perkütanöz transhepatik biliyer drenaj göz önünde bulundurulmasý gereken ilk yaklaþýmdýr. Acil servisimize grade V karaciðer yaralanmasý olan, 27 yaþýnda bir kadýn hasta transfer edildi. Hemodinamik olarak deðiþken olan hastaya sað hepatektomi yapýldý. Cerrahi sonrasý hasta, biliyer duktusda benign striktür ile baþvurdu ve bu durum perkütanöz yaklaþýmla tedavi edildi.

The liver is the most commonly injured intra-abdominal organ after blunt trauma. The management of massive liver injury is complex. Percutaneous transhepatic biliary drainage is the first approach considered, particularly for proximal bile duct strictures after liver surgery. A 27-year-old female patient was transferred to our emergency department with grade V blunt injury. Regarding the patient’s unresponsive hemodynamic instability, right hepatectomy was performed. The patient presented with benign biliary duct stricture after surgery that were treated via the percutaneous approach.