BACKGROUND: Acute pancreatitis is a disease with high morbidity and mortality, despite all the advances in technology. The overall mortality rate of acute pancreatitis is 10%, whereas the mortality rate in infected necrotizing pancreatitis is approximately 35%. In this study, we aimed to establish acute pancreatitis in rats in order to try out the alpha-tocopherol treatment protocol and to reveal the results biochemically and histopathologically.
METHODS: Twenty-four male male Sprague–Dawley rats weighing between 300 and 350 g were used in the study. In Group 1, 80 µg/kg of normal saline was subcutaneously injected into eight rats; in Group 2, 80 µg/kg of cerulein was subcutaneously injected into eight rats; and in Group 3, 80 µg/kg of cerulein was subcutaneously injected into eight rats. In addition, 30 mg/kg of alpha-tocopherol was intraperitoneally injected into eight rats.
RESULTS: The mean Schoenberg score, serum amylase, and lipase and Neutrophil Gelatinase-Associated Lipocalin (NGAL) levels were statistically significantly higher in Group 2 than in Group 1. The mean Schoenberg score and serum amylase and lipase levels were statistically significantly lower in Group 3 than in Group 2.
CONCLUSION: In this experimental study rat model of cerulein-induced acute pancreatitis, 30 mg/kg of alpha-tocopherol was injected intraperitoneally to examine its effect on pancreatitis. The improvement was observed in the histopathological examination of pancreatic tissues. We think that alpha-tocopherol may have a therapeutic effect on pancreatic tissue.

BACKGROUND: The aim of the present study was to investigate the effects of curcumin on lung damage following ischemia/reperfusion (I/R) injury after hind limb ligation.
METHODS: Forty Wistar rats were divided into four groups: sham (G1), I/R (G2), curcumin plus sham (G3), and curcumin plus I/R (G4). Curcumin was administered (200 mg/kg) daily for 2 weeks before the study. I/R was induced by placement of rubber tourniquets at the greater trochanters for 2 h, followed by reperfusion for 4 h.
RESULTS: Curcumin pretreatment had significantly lower level of malondialdehydes and higher level of superoxide dismutase in the lung tissues (p<0.05) than the I/R group. Glutathione peroxidase activity was not significantly different among the groups (p>0.05). I/R caused severe histopathological injury (p<0.05), including inflammatory cell infiltration and intra-alveolar hemorrhage.
CONCLUSION: These results suggest that curcumin pretreatment has protective effects against lung injury induced by muscle I/R.

BACKGROUND: Clinical scoring systems have been used to reduce negative appendectomy rate for several decades. However, the use of these systems has been questioned due to differences in their diagnostic accuracies. The aim of this prospective study was to develop a new clinical scoring system using a combination of all previously described variables for the diagnosis of acute appendicitis (AA).
METHODS: Consecutive patients who underwent emergency appendectomy for AA between December 2016 and April 2017 were prospectively included in the study. During admission, a prepared questionnaire including variables obtained from the previously used clinical scoring systems was administered. Histopathological analysis was regarded as the main outcome. Patients with no histopathological evidence of AA were defined as negative appendectomy. All variables were analyzed separately to assess their association with AA. A receiver operating characteristic curve with area under curve analysis was performed to obtain the cut-off values for numerical variables.
RESULTS: There were 200 patients with a mean age of 30.8±12.8 years with a negative appendectomy rate of 5.5%. There was no significant association between the variables and the detection of histologically proven AA except increased white blood cell count >11.05/mm3 and proportion of the polymorphonuclear leukocytes >71.2% (p=0.003 and p=0.015, respectively).
CONCLUSION: The present study shows that the development and/or use of scoring systems does not significantly improve the diagnostic accuracy of AA.

Background: Trauma is an important health problem in children, and improvement in national trauma care is only possible through the knowledge gathered from trauma registry systems. This information is not available in our country, because there is no current trauma registry system at the hospitals. Our aim is to explain the trauma registry system we have developed and present the first year's data.
Methods: The planned trauma registry system was integrated into the emergency department registry system of 14 hospitals in Izmir province. The data of pediatric multiple trauma patients have been recorded automatically through the registry system. Demographics, vital signs, mechanism, type of trauma, anatomical region, ISS, PTS, GCS, length of hospital stay and need for blood transfusion/endotracheal intubation/surgery/hospitalization were evaluated by patient transfer status and outcome.
Results: At the end of one year, a total of 356 pediatric major trauma patients were included in the study. The most common type of trauma was blunt trauma (91.9%) and the mechanism was vehicle-related traffic accidents (28.1%). In the group with the worse outcome than the Glasgow outcome score, age was greater, ISS was higher and PTS was lower. Motorcycle accidents, sports injuries, and penetrating injuries were more frequent in this group. All the scales were significantly different between direct and transferred patients. The referral time to the hospital of the transferred patients were longer than directly admitted patients, but the results were not different.
Conclusion: Pediatric major trauma is an important cause of mortality and morbidity, and our trauma registry system, which is a successful example abroad, is not enough in the country. We hope that the trauma registry system we planned and started the pilot application will be expanded to include other hospitals throughout the country with the aim of developing a national registry system.
Key words: Pediatric trauma, major trauma, trauma registry, trauma system

BACKGROUND: This study aimed to assess the demographics, clinical features, and treatment costs of maxillofacial trauma cases referred to our hospital during the Syrian civil war.
METHODS: The study included 80 cases of maxillofacial trauma. Patients with additional pathologies were excluded from the study. The patients were examined with respect to their demographics and clinical characteristics, Injury Severity Score (ISS), Glasgow Coma Score (GCS), treatments applied, costs, and outcomes.
RESULTS: A total of 80 patients included 76 (95%) males and 4 (5%) females, with the mean age of 29.05±9.97 years (range, 13–56 years), and 72 (90%) of them were Syrians injured in the war. The most common mechanism of trauma was the firearms injury in 72 (90%) cases, and the most frequently seen lesion was the mandible fracture (n=48, 60%). The ISS of all the patients was <16, as a severe trauma score. The GCS value was 8–12 in 4 (5%) patients, and 15 in 76 (95%). The most common treatment applied were the reduction and fixation, and graft-flap following fracture (n=12, 15%). The mean duration of hospitalization was 15.27±13.0 days (range, 2–60 days). All patients were discharged from hospital. The mean cost per case was calculated as 5,581.55±56.3 Turkish Lira (range, 772–18,697 TL) or 1,251.24±14.2 US Dollars (US$173–4,192). There was a significant correlation between the costs and the length of hospitalization (p<0.001, r=+0.729) and trauma scores (p=0.004, r=−0.616).
CONCLUSION: Firearms-injured young males with mandible fractures were the most common group of maxillofacial trauma cases seen during the Syrian war. The intensity of patients and the cost of the hospital stay have significantly increased because of the ongoing conflict in the neighboring country of Syria.

BACKGROUND: Stump closure is the most important part of a laparoscopic appendectomy (LA). Closing the appendix base with knot tying is the most cost-effective method. The defined risk factor for surgical site infection (SSI) after LA is the contamination of trocar entry area by inflamed appendicitis. This study aims to compare the single and double knot technique for stump control and specimen removal methods in LA.
METHODS: The data of patients who underwent LA between January 2015 and January 2017 were obtained from prospectively collected database. Single and double knot technique, specimen removal method, operation duration, hospital stay, and perioperative–postoperative complications were compared.
RESULTS: Extracorporeal double knot was used in 134 patients (63%), and single knot was used in 79 patients (37%). There was no difference between operation duration in the two groups (p=0.97). No stump leakage was observed in any patient. Intraabdominal abscess developed in three patients (1.4%). Appendix was removed from the abdomen directly in 101 patients (47%) and using specimen retrieval bag in 112 (53%). SSI developed in five patients (2.3%), and appendices of all of these five patients were removed from abdomen without using specimen retrieval bag. No SSI was detected in the group that used the specimen retrieval bag (p=0.02).
CONCLUSION: Single or double knot(s) tying can be defined as safe and cost-effective stump closure method. The risk of developing SSI can be reduced using specimen retrieval bag.

BACKGROUND: Esophageal perforation (EP) is a lethal surgical emergency that needs to be diagnosed and treated immediately. Diagnosis and treatment options for EP are limited due to its lower incidence. There are scoring systems proposed for this purpose; however, they cannot be applied to every patient. The recent trend in the treatment of EP is toward the non-operative approach over the surgical treatment methods. The purpose of the present study was to evaluate our treatment methods and outcomes in patients with EP.
METHODS: Thirteen patients with EP treated in our clinic between 2013 and 2017 were retrospectively reviewed. The Pittsburgh Perforation Severity Score (PSS), systemic condition status, and Clavien–Dindo Classification (CDC) score were assessed, and treatment methods were reviewed. Their effects on morbidity and mortality were examined using Fisher’s exact test and biserial correlation test.
RESULTS: A total of 13 patients (six males and seven females; median age 64 years) were included in the study. Ten patients were managed non-operative, and three were treated surgically. Of the 10 patients, two had additional surgery after non-operative management. The PSS, systemic condition status, CDC score, duration of stay in the hospital, time to diagnosis, presence of hypotension, and being in shock were strongly correlated with mortality (p<0.05). The PSS, CDC score, and stay in the intensive care unit were strongly correlated with morbidity (p<0.05). The comparison between the non-operative and operative groups did not yield a statistically significant difference in mortality and morbidity.
CONCLUSION: Even if the scoring systems help to understand the severity of the condition, they are inadequate to determine the treatment option. Early diagnosis and treatment are the most important steps in management. Operative and non-operative treatment options are not superior to each other, but their complementary use will be more beneficial for the patients.

BACKGROUND: Multiple traumas are a leading cause of mortality among young adults worldwide. Thoracic trauma causes approximately 25% of all trauma-associated deaths. This study aims to determine the independent prognostic factors of mortality in cases with thoracic trauma (isolated or with accompanying organ injuries) who were admitted to the intensive care unit (ICU).
METHODS: We retrospectively reviewed data from patients with thoracic trauma who were admitted to our ICU between 2007 and 2016. After excluding pediatric patients (aged <18 years), the study sample included 564 cases. From the records, we collected the patients’ demographical data, comorbid diseases, primary trauma as an indication for ICU admission, other traumas accompanying thoracic trauma, type of thoracic injury, and therapeutic interventions. The study sample was divided into two subsets: survival and non-survival groups. These two groups were compared with regards to first ICU day laboratory results and intensive care scores, mechanical ventilation times, and ICU stay lengths.
RESULTS: Of the 8063 patients admitted to the ICU between 2007 and 2016, 616 (7.6%) had thoracic trauma. The median age (min–max) of the 564 patients eligible for this study was 43 (18–87) years. Mortality occurred in 159 (28.1%) cases, while 405 (71.8%) were discharged from the ICU. Multivariate regression analyses were also performed, in which every increment in age was associated with a 1.025-fold increase in the odds of mortality due to thoracic trauma. Additionally, the presence of central nervous system (CNS) trauma was associated with a 2.147-fold increase, and the presence of pulmonary contusion was associated with a 1.752-fold increase.
CONCLUSION: Results of this study indicate that advanced age, the presence of pulmonary contusion, and accompanying CNS trauma are independent predictors of mortality in patients with thoracic trauma in the ICU. Our non-invasive approach is further supported by the trauma and injury severity score (TRISS) scoring system, which is one of the latest scoring systems used in trauma cases.

BACKGROUND: Due to a massive increase in capillary permeability during the state of shock caused by burns, albumin and intravascular fluid rapidly move to the extravascular areas. Therefore, hypoalbuminemia is seen as an early and prolonged finding in major burns. Hypoalbuminemia leads to various problems. The aim of this study was to investigate the effect of the preoperative albumin level on perioperative morbidity and mortality in patients with major burns.
METHODS: Demographic data, preoperative albumin levels, surgical records, and clinical follow-up records of a total of 61 patients who underwent surgery for major burns in our hospital for the last 2 years were examined. Intraoperative complications were recorded, such as hypotension, bradycardia, low saturation, metabolic acidosis, reduced urine output, and hyperglycemia. Postoperative complications were recorded as intubation and the use of mechanical ventilator, sepsis, ARDS, acute renal failure, tracheotomy, hemorrhage, arrest, pneumonia, urinary tract infection, tissue infection, congestive heart failure, and pleural effusion.
RESULTS: In patients with albumin levels measured as <2 gr/dL and >2 gr/dL, intraoperative complications were determined at the rates of 31.4% and 20.8%, respectively, postoperative complications at 60.0% and 51.5%, respectively, and mortality rates at 40% and 25.8%, respectively (p=0.148, p=0.251, p=0.85, respectively). The cut-off point for the preoperative albumin level affecting postoperative morbidity was determined as ≥2.3 gr/dL (Area Under Curve=0.587; p<0.001; 95% Confidence Interval, 0.476–0.699; Cut-Off Albumin, ≥2.3).
CONCLUSION: There is as yet no consensus on the time and dosage of the delivery of albumin in patients with major burns. Although there are studies in the literature that have shown increased morbidity and mortality rates in individuals given albumin in the intensive care, there are also reports supporting the finding that it makes a positive contribution. No useful guidelines have been obtained on the subject of hypoalbuminemia in patients with major burns. The results of this study showed that the albumin level above or below 2 gr/dL did not create any change in perioperative morbidity and mortality; however, the preoperative level above 2.3 gr/dL was the cut-off value for morbidity.

BACKGROUND: Marking a stoma site preoperatively decreases the possibility of experiencing later stoma-related problems and improves the quality of life of patients in the postoperative period. Those best equipped to perform this procedure are ostomy nurses and colorectal surgeons, as they receive the stoma therapy education during their training programs. The aim of this study was to compare the rate of stoma problems and quality of life of patients who underwent an operation that included stoma creation (elective or urgent) with and without preoperative stoma siting. The approach and behavior of surgical residents regarding stoma creation was also assessed.

METHODS: Patients who had undergone gastrointestinal surgery between January 2012 and December 2013 were assessed. A total of 116 of those patients who had a stoma created during the initial operation were followed by a stoma therapy nurse in the postoperative period and were enrolled in the current study. In addition, a survey of the residents was conducted to evaluate their knowledge about stoma creation and stoma care.

RESULTS: A total of 67 (58%) of the 116 patients included were male. The median age was 57±16 years (range: 17–87 years). A body mass index above 30 kg/m2 was detected in 16 patients (14%). The reason for surgery was malignant disease in 93 (80%) patients, and 97 cases (84%) were elective operations. Preoperative stoma marking was performed in 72 patients (62%). The stoma type was an ileostomy in 87 patients (75%). Stoma-related complications were observed in 40 patients (35%). Emergency surgery (p=0.02), preoperative stoma marking (p<0.0005), adjuvant therapy (p=0.004), and the stoma caretaker (patient or relatives) (p=0.05) were associated with stoma-related complications. Logistic regression analysis revealed that only the type of surgery (emergency or elective), preoperative stoma marking, and the stoma caretaker increased the rate of stoma-related complications.

CONCLUSION: Marking the stoma location before surgery reduces the risk of stoma-related complications and has a positive effect on the patient’s quality of life. Multivariable analysis indicated that marking the stoma site before the operation was the only factor that affected the rate of stoma-related complications, regardless of emergency or elective surgical conditions. Since surgeons will encounter the need for a stoma procedure during their professional career and they will not always have the opportunity to work with stoma therapy nurse, stoma care education should be provided during their residency (internship) education, and ascertaining a stoma localization before surgery for all potential stoma cases should be encouraged in emergency shifts.

BACKGROUND: The aim of our study was to determine the efficacy and cost-effectiveness of intraoperative autotransfusion that uses the cell saver system (CSS) in patients undergoing posterior instrumentation and fusion of thoracic and lumbar vertebral fractures.
METHODS: We divided 121 patients who were to undergo posterior instrumentation and fusion due to thoracic and lumbar vertebral fractures into two groups: 59 patients (23 males and 36 females) were in the cell saver group, and 62 patients (22 males and 40 females) were in the control group. Hemoglobin, hematocrit, and red blood cell (RBC) values were recorded for all patients preoperatively, on the postoperative first, second, and third days, and on the hospital discharge day. Transfusion rates and numbers of allogeneic erythrocyte transfusions, as well as the costs of transfused total auto- and allogeneic transfusions were compared.
RESULTS: The numbers of erythrocyte suspensions transfused perioperatively were 0.2±0.6 units in the cell saver group and 0.7±1.4 units in the control group (p=0.01). Statistically significant differences were noted between the two groups on the postoperative first, second, and third days in terms of hemoglobin, hematocrit, and RBC values. These differences had disappeared by the hospital discharge day. The average cost of perioperative blood transfusions was $431±27.4 in the cell saver group and $34.5±66.25 in the control group (p<0.001).
CONCLUSION: The use of the CSS was not cost-effective, but it was particularly successful at reducing the rate and the number of units of postoperative allogenic blood transfusions.

BACKGROUND: Hip fractures in elderly patients are associated with a high mortality rate. Most deaths associated with hip fracture result from complications after surgery. Recent studies suggest that the neutrophil-to-lymphocyte ratio (NLR), which is a laboratory marker used to evaluate systemic inflammation, may be useful to estimate excess mortality. This study aimed to investigate the prognostic value of admission NLR in elderly patients with hip fracture.
METHODS: We evaluated patients admitted to the Orthopaedic Surgery Department of Balikesir-Edremit State Hospital. Inclusion criteria were female gender, age between 65 and 80 years, ASA score of 3, unstable intertrochanteric fracture treated with hemiarthroplasty, and time between fracture and surgery less than 72 h. Patients with multiple fracture, previous same side or other side hip surgery, pathological fracture, such as fracture caused by tumor or metabolic bone disease (e.g., Paget’s disease), and malignancies were excluded from this study (purposive sampling technique). Finally, “case” (group 1) was defined as patients who died within 1 year after surgery, whereas “control” (group 2) was defined as patients who survived. Patients in group 1 and 2 were statistically compared in terms of NLR value on hospital admission. A total of 22 patients (44%) were included in group 1, and 28 (56%) were included in group 2.
RESULTS: We found that the admission NLR values of patients in the mortality group were significantly higher than those of patients in the control group (p<0.001). The cutoff value of NLR was calculated as 4.7 on ROC analysis.
CONCLUSION: We believe that the NLR value at admission could be used for risk stratification of mortality in elderly patients with hip fracture.

BACKGROUND: Lateral malleolar fractures associated with syndesmotic injuries are common. Various surgical implants may be used for the management of syndesmosis injury. One of these is ANK nail. The aim of the present study was to assess the clinical and radiological outcomes of patients treated with ANK nail.
METHODS: Forty-eight patients who were followed up for a minimum of 10 years were reviewed retrospectively using American Orthopedic Foot and Ankle Society (AOFAS) score, radiological evaluation, and development of posttraumatic arthritis. Final data were collected at the last follow-up.
RESULTS: The mean age of the patients was 37.3 (17–69) years. The mean follow-up was 129.9 (123–150) months. Twenty-two patients had Weber type B fracture, and their mean AOFAS score was 93.36 points. The remaining 26 patients had Weber type C fracture, and their mean AOFAS score was 97.66 points. There was no relationship between the type of fracture and the clinical outcome. There was a significant correlation between shortening of the fibula and posttraumatic arthritis.
CONCLUSION: The ANK nail used for the management of ankle fractures may provide both fracture and syndesmosis stabilities in selected cases and is also a cost effective method as cheap as a cortical screw and a Kirschner wire.

We aimed to present our method called as new isolation technique with stopper (NITS) to manage enteroatmospheric fistula (EAF) in an open abdomen (OA). The patient was a 71-year-old male with Hartmann colostomy and incisional hernia. A dual mesh was used for incisional hernia repair after colorectal anastomosis. The patient was urgently re-admitted to hospital due to EAF on the postoperative 30th day. The NITS application was performed twice at different times. General anesthesia was not required for the applications, but sterile conditions in operation room were provided. A Penrose drain was sutured with 5/0 polydioxanone onto the mucosa of EAF orifice. A small pool was created to protect enteric content from leakage. The leak test was performed by spilling saline into this pool. The sponge with visceral organ protector around the pool was adhered by adhesive sterile drape, and one opening was performed on drape. Negative pressure therapy was launched with -75 mmHg in continuous form. EAF was isolated from the OA wound and sponge with the help of stopper performed with adaptable and obstacle ring paste. After these two applications, EAF was converted to stoma. The anastomosis of small intestine was performed 45 days later. In our NITS system, control of EAF may be successfully provided besides prevention of loss of enteric fluid and electrolyte. Advantages of NITS: 1) Successful control in all types of EAF is possible with NITS. 2) The required material for NITS system can be found easily. 3) All types of EAF can be converted into stoma in a short time. Consequently, the therapy of EAF in Björck 4 OA patients may be carried out successfully with NITS method.

Gastrointestinal stromal tumors (GISTs) are among the rare tumors of gastrointestinal (GI) tract. GISTs occur respectively in the stomach, small intestines, colon and rectum, omentum and mesentery, esophagus, retroperitoneal space, and abdominal cavity. However, they may occur anywhere along the GI tract. Typically, these tumors generally do not cause symptoms; however symptomatic patients may show stomach pain, GI bleeding, and palpable abdominal masses. These patients usually undergo surgery for obstruction symptoms or some other diagnosis. Our patient was admitted to the emergency department with acute abdomen and hypovolemic shock due to fall. The patient underwent emergency surgery, which revealed active bleeding from a stomach tumor showing an exophytic pattern of growth. This patient was a 32-year-old male, and blood tests revealed a white blood cell count of 23.500/mm³ and a hemoglobin level of 7.9 gr/dL. The heart rate was 110 beats/minute. The chest radiograph showed no subdiaphragmatic free air, and abdominal ultrasound showed impression of a mass that could not be distinguished from the liver, along with closed perforation or hemangioma. During the surgical procedure, 1200 cc of blood was suctioned, and the exophytic tumor was removed completely. Histological analysis of the tumor showed GIST, and it was considered to be a ruptured tumor by the oncology consultant. The patient was applied imatinib for 3 years after the surgery, and the disease did not re-occur during this period. Our goal in this case study is to emphasize that trauma may not be necessarily the cause of acute abdomen for emergency patients but that it also may be caused by hypotension-associated hypovolemic shock or other causes, bleeding from a GIST along with tumor torsion.

Airbags and seatbelts are among the primary means of preventing severe injuries after motor vehicle accidents. Nonetheless, many studies have examined injuries that were related to airbag deployment. To our knowledge, this is the first case report of multiple mandible fractures caused by impact with the airbag cover. Removal of non-viable bone fragments was performed and the resulting hemi-mandible defect was reconstructed with a free iliac crest flap. A radial forearm free flap was used to reconstruct the mucosal defect. Airbags can prevent deadly injuries; however, they can also cause serious harm to the maxillofacial bones at the time of deployment.

A 55-year-old male patient developed a duodenal re-leak, which caused severe peritonitis, on the second postoperative day after surgery to treat an acutely perforated duodenal ulcer. Relaparotomy was performed 2 days after surgery for the re-leak after omentoplasty. The necrotic omentum was dissociated from the bulbus duodeni. Viable omentum for reinsertion of the omental patch was not found. The turned-outward duodenal mucosa was excised and the duodenal perforation was sutured. Two-way vacuum-assisted closure (VAC) was carried out by taking a liquid culture of the abdomen and washing the abdomen. The two-way VAC exchange procedures were continued every 3 days until the re-leak was terminated. The whole treatment process occurred in the intensive care unit. The duodenal leak was completely stopped by 41 days after surgery. The subcutaneous layer was dissected from the fascial layer of the anterior wall of the abdomen; thus, the abdominal skin was closed without tension and the patient was subsequently discharged. In conclusion, since primary source control is often difficult when treating duodenal leaks, the two-way VAC system is a convenient solution for localizing the source of the peritonitis and removing toxic peritoneal material.