Efficacy of Hyperbaric Oxygen Therapy in Diabetic Foot Ulcers Based on Wagner Classification.

Diabetic foot ulcer is a common chronic complication of diabetes mellitus. In addition to conventional primary therapy, there are adjuvant therapy methods such as hyperbaric oxygen therapy for the healing of diabetic foot ulcer wounds. The present study aimed to determine the efficacy of hyperbaric oxygen therapy in diabetic foot ulcers based on Wagner classification. It was performed retrospectively from prospectively collected data. One hundred thirty patients with diabetic foot ulcers were assessed in 2 groups: 1 group received hyperbaric oxygen therapy; the other group did not. Patients were examined according to age, sex, ulcer grade based on Wagner classification; ulcer healing status; whether hyperbaric oxygen therapy was received; duration of diabetes in years; HbA1C, sedimentation, C-reactive protein levels; and presence of accompanying diseases, including peripheral arterial disease, chronic obstructive pulmonary disease, hypertension, chronic kidney disease, neuropathy, and retinopathy. The mean follow-up period was 19.5 ±â€¯4.45 months (range 12 to 28 months). Seventy-one (54.6%) patients received hyperbaric oxygen therapy, and 59 (45.4%) patients did not. All patients in Wagner grade 2 healed in both groups. In the group that received hyperbaric oxygen therapy for grade 3 and 4 patients, 35 (87.5%) and 11 (84.6%) healed, respectively. In total, 60 (84.5%) patients in the group that received hyperbaric oxygen therapy healed. The subgroup comparison conducted according to Wagner classification revealed no differences between the 2 groups of grades 2 and 5 patients. It also revealed that treatment had higher levels of efficacy in the healing of ulcers in grade 3 and 4 patients.

Chronic lower extremity wound infection due to Kerstersia gyiorum in a patient with Buerger's disease: a case report.

BACKGROUND: Kerstersia gyiorum is an extremely rare pathogen of human infection. It can cause chronic infection in patients with underlying conditions. It can easily be misdiagnosed if proper diagnostic methods are not used. CASE PRESENTATION: A 47-year-old male patient with a history of Buerger's Disease for 28 years presented to our hospital with an infected chronic wound on foot. The wound was debrided, and the specimen was sent to Microbiology laboratory. Gram staining of the specimen showed abundant polymorphonuclear leukocytes and gram-negative bacilli. Four types of colonies were isolated on blood agar. These were identified as Kerstersia gyiorum, Proteus vulgaris, Enterobacter cloacae, Morganella morganii by Maldi Biotyper (Bruker Daltonics, Germany). The identification of K. gyiorum was confirmed by 16S ribosomal RNA gene sequencing. The patient was successfully recovered with antimicrobial therapy, surgical debridement, and skin grafting. CONCLUSIONS: This is the first case of wound infection due to K. gyiorum in a patient with Buerger's Disease. We made a brief review of K. gyiorum cases up to date. Also, this case is presented to draw attention to the use of new and advanced methods like MALDI-TOF MS and 16S rRNA gene sequencing for identification of rarely isolated species from clinical specimens of patients with chronic infections and with chronic underlying conditions.

External Jugular Vein Thrombosis as a Sign of Metastatic Breast Cancer.

External jugular vein thrombosis is a rare vascular event which may lead fatal complication such as sepsis and pulmonary embolism. Its relation to the visceral solid tumor as an etiologic factor has been established well. Although external jugular vein thrombosis may be seen in malignancy, it is unusual to see as a sign of breast cancer. Most of the external jugular vein thrombosis occurs secondary to compression of the vein. Vascular thrombosis due to hypercoagulability is known as Trousseau syndrome. Herein, we present a case of metastatic breast cancer which presented with external jugular vein thrombosis; Trousseau syndrome.

Validation of COLA score for predicting wound infection in patients undergoing surgery for rectal cancer.

AIM: The purpose of our study was to estimate the incidence of SSI (Surgical site infection) and the effect of COLA (contamination, obesity, laparotomy and ASA grade) score on SSI in patients undergoing rectal surgical procedures for rectal cancer. MATERIAL OF STUDY: A total of 92 patients who underwent operation for rectum cancer were enrolled in this study. Wound surveillance was performed in all patients by a staff surgeon identified infected wounds during the hospital stay, and collected information for up to 30 days after operation. RESULTS: The overall rate of incisional SSI and organ/space SSI was 22.8% and 7.6% respectively. Surgical site infection rates were 14.2%, 20.58%, 40.7%, 57.1% for COLA 1,2,3 and 4 scores respectively. The area under the receiver/ operator characteristic curve for the score was 0,660. CONCLUSION: COLA scoring systems predict, with reasonable accuracy, the risk of SSI in rectal cancer patients undergoing elective rectal surgery. KEY WORDS: COLA score Rectal surgery, Surgical site infection, Risk prediction, Wound infection.

Comparison of Coskun and Lichteinstein hernia repair methods for groin hernia.

PURPOSE: Coskun hernia repair technique has been reported to be an effective new fascia transversalis repair with its short-term follow-up results. Our aim is to determine the results of Coskun hernia repair technique and to compare it with Lichtenstein technique. METHODS: At this comparative retrospective study a total of 493 patients, who had groin hernia repair procedure using Coskun or Lichtenstein technique, between January 1999 and March 2010 were enrolled into the study. Patients were reached by telephone and invited to get a physical examination. RESULTS: Out of 493 groin hernia repairs, 436 (88.5%) were carried out by residents and 57 (11.5%) by attending surgeons. Lichtenstein technique was the choice in 241 patients and 252 patients underwent Coskun hernia repair technique. Groin hernia recurrence was detected in 8 patients (3.1%) in Coskun hernia repair group and 7 patients (2.9%) in Lichtenstein group. Comparison of early complication rates in Coskun group (3.9%) and Lichtenstein group (4.5%) showed no significant difference. Late complication rates were significantly higher in Lichtenstein group (1.2% vs. 4.9%). The operation time was shorter in Coskun group (44 minutes) than in Lichtenstein group (60 minutes). Subgroup of patients, whose hernia repair operations were carried out by attending surgeons, had a recurrence rate of 0% and 3.8%, in Coskun group and Lichtenstein group, respectively. CONCLUSION: This study showed that Coskun hernia repair technique has a similar efficacy with Lichtenstein repair, on follow-up.

D1 versus D2 dissection in gastric carcinoma: Evaluation of postoperative mortality and complications.

OBJECTIVE: Surgery is the only curative treatment for patients with gastric cancer. However, the extent of lymph node dissection is still debated. The aim of the study was to evaluate complications, postoperative length of hospital stay and postoperative mortality after D1 or D2 lymph node dissection for gastric cancer in a non-specialized hospital. MATERIAL AND METHODS: All patients who underwent surgery for pathologically confirmed gastric cancer at our 3rd General Surgery Department, Ankara Numune Training Hospital between January 1999 and 2007 were retrospectively reviewed. A consecutive series of 71 gastric cancer patients was identified. D1 resection (level 1 lymphadenectomy) was compared with D2 resection (levels 1 and 2 lymphadenectomy). RESULTS: The D2 group had higher postoperative mortality (16% vs. 8%; p<0.005) and morbidity (54% vs. 34%; p<0.005), and their postoperative length of stay was longer. Splenectomy did not have an effect on postoperative morbidity and mortality in either the D1 or the D2 group. CONCLUSION: The D2 procedure was associated with significantly higher postoperative mortality, morbidity, and postoperative length of hospital stay.

Primary hydatid cyst of the axilla: report of a case.

OBJECTIVE: The aim of this work was to report a case of hydatid cyst located in the axilla. CLINICAL PRESENTATION AND INTERVENTION: A 36-year-old female presented with a painless right axillar swelling of 6 months duration. We removed the entire cyst surgically, and macroscopic and histopathological examinations confirmed the diagnosis of axillar hydatid disease. Seventeen months after the operation there was no recurrence. CONCLUSION: This case report showed that in cases of a cystic mass in an endemic zone, the diagnosis of hydatid cyst should be considered.

Which surgical procedure offers the best treatment for pilonidal disease?

PURPOSE: Our aim was to determine the most effective surgical procedure for treatment of pilonidal disease, by comparing different surgical techniques. METHODS: A total of 354 patients who underwent operation for pilonidal disease were enrolled in this prospective study. The data included patient's demographic characteristics, age, gender, body mass index, occupation, smoking, concomitant diseases, surgeon's experience, wound-healing problems (wound separation and infection), time to return to work, and development of recurrence. RESULTS: Of the 354 patients, total excision + primary closure was performed in 133 (37.6%), D-flap in 101 (28.5%), Karydakis technique in 74 (20.9%), and Limberg flap surgery in 46 (13%). The male/female ratio was 8.5:1, which is a statistically significant difference (p < 0.05). The average follow-up period was 37 months (range, 12-97 months); during this period, wound-healing problems were observed in 70 (19.7%) patients, and 34 (9.6%) patients developed recurrence. There was no difference in the rate of recurrence of pilonidial disease between procedures done by trainees and staff surgeons. Recurrence rates were similar for all four treatment methods (7.5-13.5%). Wound-healing problems were higher for D-flap than for other methods (p = 0.027). The average time to return to work with the D-flap method was longer than that for the other methods (p < 0.01). Recurrence increased 14.44-fold following the development of wound infection. Higher recurrence rates were also noted in obese patients (8.10-fold) and in females (6.72-fold). CONCLUSIONS: Despite the increasing volume of data on the treatment of pilonidal disease, the optimal treatment has yet to be established.

Perforated intestinal leiomyosarcoma as a metastasis of uterine leiomyosarcoma: a case report.

INTRODUCTION: Uterine leiomyosarcomas are relatively uncommon soft tissue neoplasms and rarely metastases to small bowel. In the current case; a patient is suffering from intestinal perforation due to metastatic leiomyosarcoma of the small bowel. CASE PRESENTATION: A 59-year-old woman underwent a modified radical mastectomy for infiltrating ductal cancer of the breast six years ago and a total abdominal hysterectomy for leiomyosarcoma of the uterus two years ago. About 2400 cGy total dose radiotherapy has also been applied after total hysterectomy for bone metastasis of breast cancer. She admitted to our clinic with the complaints of acute abdomen due to perforated small bowel metastasis of leiomyosarcoma during the radiotherapy. Laparotomy was performed and leiomyosarcoma of the ileum was removed totally. Histopathologic examination of the specimen confirmed the presence of the leiomyosarcoma in intestinal tissue samples. CONCLUSION: We aimed to present this unusual case which perforated presentation of the intestinal metastasis of uterine leiomyosarcoma.

Factors influencing mortality in traumatic ruptures of diaphragm.

BACKGROUND: Diaphragmatic injuries are infrequent but severe injuries, associated with high morbidity and mortality. METHODS: The hospital records of 58 patients with traumatic rupture of diaphragm which was diagnosed during surgery in emergency department during last five years were re-evaluated, in order to identify the factors on mortality. RESULTS: The mean age of patients was 33 years. The most common cause of diaphragmatic rupture was penetrating injury (52%). The overall mortality rate was 21%. Preoperative diagnoses were accurately made in only twelve (20%) patients and remaining 46 patients were diagnosed during surgery. Rupture was located on the left side in 42 patients. Intrathoracic herniation was seen in eleven cases. Presence of herniation has no effect on mortality (p=0.155). All cases with mortal course were blunt trauma and the most common cause of death was haemorrhagic shock. Associated injuries were present in 88% of the patients; 92% of the mortal cases had an associated injury. CONCLUSION: The diagnosis of diaphragmatic injury is important due to increased morbidity and mortality in traumatic victims. Blunt trauma, increased grade of injury, presence of shock, blood transfusions over three units and splenic injury are factors influencing mortality in traumatic ruptures of diaphragm.

Effect of hyperbaric oxygen therapy on healing of diabetic foot ulcers.

Hyperbaric oxygen therapy can be used as an adjunct to standard wound care in the treatment of diabetic patients with foot ulcers. We undertook a prospective, randomized investigation of the use of hyperbaric oxygen therapy versus standard therapy for the treatment of foot ulcers in diabetic patients. A number of demographic variables were analyzed in regard to wound healing. We noted that foot ulcers in patients in the hyperbaric oxygen therapy group were more likely to heal, and were more likely to undergo amputation distal to the metatarsophalangeal joint compared with those patients receiving standard therapy without hyperbaric oxygen. We feel that hyperbaric oxygen therapy should be considered a useful adjunct in the management of foot ulcers in diabetic patients.

Serum D-lactate: a useful diagnostic marker for acute appendicitis.

BACKGROUND/AIMS: Acute appendicitis is the most common acute surgical infection seen in emergency department. The present study aims to evaluate the sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of the serum D-lactate levels as a marker for the diagnosis of acute appendicitis. D-lactate is the stereoisomer of the mammalian L(+)-lactate, and is produced by indigenous bacteria (Escherichia coli, Klebsiella, Bacteroides, Lactobacillus) in the gastrointestinal tract. Once obstruction occurs, appendix is a good medium for bacterial proliferation, and ischemic injury leads to an increase in D-lactate levels. METHODOLOGY: A total of thirty-two consecutive patients with the suspicion of acute appendicitis were prospectively included in the study. Patient characteristics, ultrasonography (US) and laboratory assessment including white blood cell (WBC), C-reactive protein (CRP), D-lactate and intraoperative findings, histology results, clinical outcome were evaluated. RESULTS: WBC level above 10(9)/L had an accuracy of 66%, whereas a CRP level above 5 mg/L had an accuracy of 75%. We observed that when the D-lactate level was greater than 0.25 mmol/L in acute appendicitis, the specificity was 60%, the false negative rate was 25% and the accuracy was 90%. The false negative rate of CRP (67%) was higher than that of D-lactate levels (25%). Ultrasound had a sensitivity of 96%, specificity 40% and accuracy 87% in our study. CONCLUSIONS: We found positive correlations between serum D-lactate levels and acute appendicitis and serum D-lactate had the lowest false negative rate among the other parameters. Therefore, we conclude that D-lactate might be a simple and reliable diagnostic marker for appendicitis.

Internal biliary fistula due to cholelithiasis: a single-centre experience.

AIM: To discuss about the perioperative problems encountered in patients with internal biliary fistula (IBF) caused by cholelithiasis. METHODS: In our hospital, 4,130 cholecystectomies were carried out for symptomatic cholelithiasis from January 2000 to March 2004 and only 12 patients were diagnosed with IBF. The perioperative data of these 12 IBF patients were analyzed retrospectively. RESULTS: The incidence of IBF due to cholelithiasis was nearly 0.3%. The mean age was 57 years. Most of the patients presented with non-specific complaints. Only two patients were considered to have IBF when gallstone ileus was observed during the investigations. Nine patients underwent emergency laparotomy with a pre-operative diagnosis of acute abdomen. In the remaining three patients, elective laparoscopic cholecystectomy was converted to open surgery after identification of IBF. Ten patients had cholecystoduodenal fistula and two patients had cholecystocholedochal fistula. The mean hospital stay was 13 d. Two wound infections, three bile leakages and three mortalities were observed. CONCLUSION: Cholecystectomy has to be performed in early stage in the patients who were diagnosed as cholelithiasis to prevent the complications like IBF which is seen rarely. Suspicion of IBF should be kept in mind, especially in the case of difficult dissection during cholecystectomy and attention should be paid in order to prevent iatrogenic injuries.

The relationship between intestinal hypoperfusion and serum d-lactate levels during experimental intra-abdominal hypertension.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) may result from several clinic situations and carries high morbidity and mortality risk, particularly in intensive care unit patients. The clinical spectrum changes from splanchnic hypoperfusion and intestinal ischemia to multiple organ failure. Previous studies demonstrated that serum D-lactate levels may be an early indicator in intestinal ischemia. This study aimed to investigate the relationship between intestinal ischemia and serum D-lactate levels during experimental IAH. Thirty-two male Wistar Albino rats weighing 250+/-50 g were divided into four groups. Three different intra-abdominal pressure (IAP) levels supplied by placement of an intraperitoneal Peritofix catheter and iso-osmotic polyethylene glycol infusion. Each of the IAP levels (15, 20, and 25 mm Hg groups) was checked with the monitor system and fixed for an hour. Control-group animals were not subjected to increased IAP. One hour later, 5-ml blood samples were taken for measurement of serum D-lactate levels and 2-cm intestinal tissue samples were taken 5 cm proximal to the ileocecal valve for histopathologic examination. Elevated serum D-lactate levels were recorded in animals with higher IAP levels. There was a positive correlation between serum D-lactate levels and IAP levels. Histological examinations of the intestinal tissue samples showed no significant pathologic changes in concordance with intestinal ischemia. Serum D-lactate levels may be an early indicator for increased IAP pressure before intestinal ischemic changes occur.

Does serum hexosaminidase activity play a role in the diagnosis of strangulated bowel obstruction? An experimental study.

Strangulation is associated with an increased risk of mortality and morbidity in patients with mechanical bowel obstruction. The accurate and early recognition of the presence of strangulation is important to allow safe nonoperative treatment. A number of studies have shown that there was no single and reliable test to detect or exclude the presence of strangulation. The aim of this study was to evaluate the role of serum hexosaminidase (Hex) levels in recognition of strangulation in an experimental model of closed loop small bowel obstruction. Forty-two Wistar albino rats were divided into four groups: I, control (n = 5); II, sham laparotomy (n = 5); III, simple obstruction (n = 16); and IV, strangulation groups (n = 16). Activity levels of total Hex and its fractions (Hex A and B) were assayed in serum samples obtained from rats after 3 and 8 hr. Samples of small bowel were also evaluated histologically. Histological evaluation of bowel sections obtained from the strangulation group after 8 hr, revealed transmural hemorrhagic infarction in all animals with a mean +/- SD total Hex activity of 978.25 +/- 150 nmol/hr/ml, which was significantly higher than that in the other groups (P < 0.001). Although sections of bowel from the strangulation group after 3 hr showed severe ischemic injury, the activities of total Hex, Hex A, and Hex B were not different from those of the control, sham, and simple obstruction groups. Histological examination of these groups did not show any sign of ischemia. Total Hex, Hex A, and Hex B activities in the strangulation group were all significantly greater than the activities seen in the simple obstruction group (P < 0.001, for all). In conclusion, increased serum hex levels indicate irreversible transmural infarction only in the late period of strangulation in the closed loop small bowel obstruction model. It seems unuseful for detecting reversible and/or irreversible ischemia in the early period of strangulation.

[The role of nitric oxide in trauma and infection]. / Travma ve enfeksiyonda nitrik oksidin rolü

Nitric oxide (NO) is a very important molecule for homeostasis. It is involved in several pathological conditions ranging from hypertension to septic shock. It is synthesized from L-arginine, which is catalyzed by nitric oxide synthase (NOS). Both constitutional and inducible NOS are involved in NO synthesis. While NO produced by constitutional NOS is required for normal physiologic processes, excessive production by inducible NOS results in injury and tissue damage. Induced NO may be either protective or damaging in acute inflammatory conditions. As a result of pluripotent activities, NO presents as a paradoxical phenomenon in almost all conditions in which confusing aspects arise concerning the pathophysiology. This article reviews the role of NO in trauma and infections.

The evaluation of the patients admitted to a burn center in Turkey.

BACKGROUND: Burns constitute an important part of the accident-related deaths due to high morbidity and mortality. METHODS: The medical records of 778 (279 female) patients who were treated during last three years period were retrospectively analyzed concerning age, gender, the cause of the burn, the month when the burn occurred, admission date, duration of the hospital stay, area of the burn. The relationship between these parameters and the mortality was analyzed. RESULTS: The average age of the patients was 20 years. The burns were related to accidents in 87% patients, abuse in 8%, co-morbid diseases in 3% and suicidal attempts in 2%. In 48% of the cases there were hot fluid burns and in 37% (284) fire-flames. The burns were due to electrical burns in 13% patients and to other reasons in the remaining 2%. One hundred and seventy - two patients had fatal courses. The mortality rate was 75% in 12 patients who were above 60 years. Average burn area was 24% (10-100) and average hospital stay was 13 days. CONCLUSION: As most of the burns were due to accidents, the number of burns might be reduced by prioritizing preventive measures and better results could be obtained when the quality and the number of the burn centers is increased.