Integration of functional capacity to medically necessary, time-sensitive scoring system: A prospective observational study.

OBJECTIVES: To evaluate 2 new modifications to medically necessary, time-sensitive (MeNTS) scoring systems integrating functional capacity assessment in estimating intensive care unit (ICU) requirements. METHODS: This prospective observational study included patients undergoing elective surgeries between July 2021 and January 2022. The MeNTS scores and our 2 modified scores: MeNTS-METs (integrated Duke activity status index [DASI] as metabolic equivalents [METs]) and MeNTS-DASI-5Q (integrated modified DASI [M-DASI] as 5 questions) were calculated. The patients' ICU requirements (group ICU+ and group ICU-), DASIs, patient-surgery-anesthesia characteristics, hospital stay lengths, rehospitalizations, postoperative complications, and mortality were recorded. RESULTS: This study analyzed 718 patients. The MeNTS, MeNTS-METs, and MeNTS-DASI-5Q scores were higher in group ICU+ than in group ICU- (p<0.001). Group ICU+ had longer operation durations and hospital stay lengths (p<0.001), lower DASI scores (p<0.001), and greater hospital readmissions, postoperative complications, and mortality (p<0.001). The MeNTS-METs and MeNTS-DASI-5Q scores better predicted ICU requirement with areas under the receiver operating characteristic curve (AUC) of 0.806 and 0.804, than the original MeNTS (AUC=0.782). CONCLUSION: The 5-questionnaire M-DASI is easy to calculate and, when added to a triage score, is as reliable as the original DASI for predicting postoperative ICU requirements.

Can invasive diagnostic methods be reduced by magnetic resonance imaging in the diagnosis of diaphragmatic injuries in left thoracoabdominal penetrating injuries?

Aim: In this study, we aimed to investigate the effect of magnetic resonance imaging (MRI) in detecting diaphragmatic injury by comparing preoperative computed tomography (CT) and MRI imaging results with diagnostic laparoscopy/thoracoscopy results in patients with left thoracoabdominal penetrating injury. We investigated whether MRI reduces the rate of unnecessary surgery by examining its sensitivity and specificity. Materials and Methods: Patients with left thoracoabdominal penetrating injuries who applied to the Emergency Surgery Unit of Istanbul University Istanbul Faculty of Medicine between November 2017 and December 2020 were evaluated. Patients who underwent emergency surgery, who could not undergo MRI or CT for any reason or who could not be operated on were excluded from the study. Preoperative MRI and CT images of patients who underwent diagnostic laparoscopy/thoracoscopy due to left thoracoabdominal injury in our clinic were evaluated retrospectively by a radiologist who did not know the surgical results. MRI results of the cases were compared with surgical findings and CT images. Results: A total of 43 (41 males, mean age: 31, range: 15-57) patients were included in the study. The most common physical examination finding was lateral injury. The diaphragmatic injury was detected in 13 (30%) cases during surgical interventions. Laparoscopic repair was performed in 11 (84%) cases and thoracoscopic repair was performed in 2 (15%) cases with diaphragmatic injuries. MRI images of 14 (32%) cases were found to be compatible with diaphragmatic injury, in 1 of them no injury was observed during surgical intervention. According to these data, the sensitivity of MRI was calculated as 100%, specificity 94%, positive predictive value 86%, and negative predictive value 100%. The mean hospital stay was 6 days (1-30) in all cases. Conclusion: In our study, MRI was found to have high specificity and sensitivity in detecting diaphragmatic injuries. The number of negative laparoscopy/thoracoscopy can be reduced by performing surgical intervention only in cases with positive or suspected diaphragmatic injury on MRI. Results should be supported by conducting new studies with larger case series with normal MRI findings and long follow-ups.

Is emergency gastrointestinal system tumor surgery safe under treatment of antitrombotics?

BACKGROUND: The use of antitrombotic (antiaggregant and anticoagulant) drugs is increasing all over the world and in our coun-try. About 12.6% of patients who underwent gastrointestinal tumor surgery receive antitrombotic therapy for various reasons, and in this study, we aimed to demonstrate the safe feasibility of elective or emergency gastrointestinal tumor surgery with the correct perioperative antitrombotic therapy management. METHODS: The patients who were planned for gastrointestinal tumor surgery under antitrombotic treatment were analyzed in three groups as those whose pre-operative treatment management treatment was discontinued, those who underwent bridging treat-ment, and those whose treatment continued. Anti-embolic stockings or intermittent pneumatic compression devices were applied to all patients preoperatively and postoperatively as mechanical prophylaxis. Post-operative complications, especially post-operative bleeding and thrombosis, were evaluated using the Clavien-Dindo post-operative complication classification. RESULTS: When patients who were under antithrombotic therapy, whose therapy was discontinued, and who underwent surgery under bridging therapy, no significant difference was found between the three groups in terms of bleeding complications. CONCLUSION: In tertiary centers with high clinical experience, elective and emergency gastrointestinal system tumour surgery can be safely performed under antitrombotic therapy without increasing the thromboembolic risk.

Can ionized calcium levels and platelet counts used for estimating the prognosis of pediatric trauma patients admitted to the emergency surgery intensive care?

BACKGROUND: Injury is the leading cause of death for pediatric population older than 1 year of age and 95% of those deaths are from the low- and middle-income countries. Most of those injured pediatric patients are treated in general hospitals. In designated trauma centers, the outcomes of severely injured patients are better. Scoring systems used frequently in intensive care units (ICUs) to make triage easier and to estimate prognosis. However, some of the scores may require additional expensive and sometimes time consuming tests. The purpose of the present study was to compare the usefulness of several scoring systems with initial ionized calcium levels and platelet counts to predict prognosis of pediatric trauma patients admitted to the emergency surgery department. METHODS: This retrospective study was performed at a tertiary university hospital. The patients' ages, genders, trauma etiologies, types of trauma, time of trauma, transport place (primary or secondary), duration of stay in the ICU and in the hospital, mortality rates, initial ionized calcium levels (Ca+2), initial platelet counts, and data of several trauma scores (GCS, RTS, ISS, TRISS, and PTS) were analyzed. RESULTS: One hundred and fourteen pediatric trauma patients were admitted to the ICU. The mean age was 77.8±54 months. Most of them were male, falls were the primary mechanism of injury, and head trauma was the most common pattern of injury. The mortality rate was 15.8%, and the admission values for Ca+2, platelet counts, GCS, RTS, TRISS, and PTS had been found higher for patients who survived, while ISS scores were higher for those who had died. CONCLUSION: It was found that pediatric patients admitted to the ICU were younger than 10 years, of whom most of them were male. Falls were the most common mechanism of injury, and head trauma was present in most of the pediatric patients admitted to the ICU. Initial Ca+2 levels and platelet counts can be used along with the trauma scoring systems in predicting mortality and overall survey regarding pediatric trauma patients.

A rare cause of acute abdominal pain: Actinomyces infection of colon mimicking a malignant neoplasm due to intrauterine device.

Actinomycosis is a rare, chronic granulomatous disease that is challenging to diagnose because the clinical symptoms and signs are nonspecific. Usage of intrauterine device (IUD) or being immunocompromised is facilitating factors. Clinical and radiological findings can mimic malignant neoplasm, inflammatory bowel disorder, or acute diverticulitis. We report a case of actinomyces infection of the colon secondary to IUD, which is a rare cause of acute abdominal pain and can mimic a malignant neoplasm. We also provide a review of the literature. Unnecessary surgery can be avoided with the correct diagnosis of granulomatous infectious diseases that can be treated with antibiotics.

Airway management of major blunt tracheal and esophageal injury: A case report.

Trans-sectional injuries of trachea are quite rare and can be extremely challenging for anesthesiologists to deal with. About 25% of post-traumatic deaths are due to thoracic traumas in which blunt injuries take a rather small place within and the resultant damage of respiratory tract is quite rare with an incidence of 0.5-2%. A recent review from a single trauma center revealed an incidence of 0.4% for tracheobronchial injury (TBI) due to blunt thoracic injuries. Most of the patients having tracheal transection lose their lives on the field due to loss of airway. Patients mostly present with a large spectrum of clinical features varying from hoarseness to respiratory collapse; though subcutaneous emphysema is the most common presenting sign which should remind possible TBI. Emergent surgery is preferred seldomly; such in cases of partial damage or because of late diagnosis, due to favorable outcome of conservative approach. Herein, we report the management of a case on TBI due to blunt thoracic trauma, experiencing difficult ventilation despite tracheal intubation. Fiber-optic bronchoscope (FOB) seems obligatory to visualize site and severity of injury and to ensure safe airway during procedures such as the neck exploration, primary end-to-end anastomosis of the trachea, tracheostomy, diversion pharyngostomy, and feeding jejunostomy.

Evaluation of Postoperative Complication with Medically Necessary, Time-Sensitive Scoring System During Acute COVID-19 Pandemic: A Prospective Observational Study.

BACKGROUND: High scores in the Medically Necessary, Time-Sensitive (MeNTS) scoring system, used for elective surgical prioritization during the coronavirus disease 2019 pandemic, are assumed to be associated with worse outcomes. We aimed to evaluate the MeNTS scoring system in patients undergoing elective surgery during restricted capacity of our institution, with or without moderate or severe postoperative complications. STUDY DESIGN: In this prospective observational study, MeNTS scores of patients undergoing elective operations during May and June 2020 were calculated. Postoperative complication severity (classified as Group Clavien-Dindo < II or Group Clavien-Dindo ≥ II), as well as Duke Activity Index, American Society of Anesthesiologists (ASA) physical status, presence of smoking, leukocytosis, lymphopenia, elevated C-reactive protein (CRP), operation and anesthesia characteristics, intensive care requirement and duration, length of hospital stay, rehospitalization, and mortality were noted. RESULTS: There were 223 patients analyzed. MeNTS score was higher in the Clavien-Dindo ≥ II Group compared with the Clavien-Dindo < II Group (50.98 ± 8.98 vs 44.27 ± 8.90 respectively, p < 0.001). Duke activity status index (DASI) scores were lower, and American Society of Anesthesiologists physical status class, presence of smoking, leukocytosis, lymphopenia, elevated CRP, and intensive care requirement were higher in the Clavien-Dindo ≥ II Group (p < 0.01). Length of hospital stay was longer in the Clavien-Dindo ≥ II Group (15 [range 2-90] vs 4 [1-30] days; p < 0.001). Mortality was observed in 8 patients. Area under the receiver operating characteristic curve of MeNTS and DASI were 0.69 and 0.71, respectively, for predicting moderate/severe complications. CONCLUSIONS: Although significant, MeNTS score had low discriminating power in distinguishing patients with moderate/severe complications. Incorporation of a cardiovascular functional capacity measure could improve the scoring system.

The value of potassium, pH and D-dimer levels in early diagnosis of acute mesenteric ischemia: an experimental study on rats.

INTRODUCTION: The aim of this randomized controlled experimental study was to evaluate the efficacy of potassium, pH and D-dimer levels in blood, as well as potassium and pH levels in peritoneal lavage fluid, in the early diagnosis of acute mesenteric ischemia. MATERIAL AND METHODS: This study was conducted at the Istanbul University Center of Experimental Medicine after having received approval from the Istanbul University animal testing ethics committee. Male albino Wistar rats (n = 24; 250 to 350 g) were divided into two control groups and two ischemic groups. Levels of potassium, pH, and D-dimer in blood and levels of potassium and pH in peritoneal lavage fluid were analyzed for 1 h and 2 h after the induced acute mesenteric ischemia procedure. The degree of ischemic injury was determined using the histopathological damage score in tissue samples taken from the terminal ileum. RESULTS: Ischemic groups had statistically significant differences in potassium and pH in blood and peritoneal lavage fluid compared to non-ischemic groups (p < 0.05). There was no significant difference between control and ischemic groups in terms of D-dimer and histologic grading results after 1 h (p = 0.132, p = 0.475 respectively), while there was a significant difference between control and ischemic groups after 2 h (p < 0.05). CONCLUSIONS: The levels of potassium, pH, and D-dimer could be useful in daily practice for the early diagnosis of acute mesenteric ischemia.

Discussing treatment strategies for acute mechanical intestinal obstruction caused by phytobezoar: A single-center retrospective study.

BACKGROUND: This study aims to discuss management strategies regarding phytobezoar induced ileus based upon clinical results. METHODS: In the present study, between December 2012 and December 2018, a total of 25 patients who were diagnosed with phytobezoar were evaluated retrospectively. Patients who had acute mechanical intestinal obstruction due to phytobezoars at different segments of gastrointestinal (GI) tract were included in this study. The clinical data (such as clinical findings, laboratory results, radiological evaluations, treatment methods) of the patients were examined. RESULTS: Twenty five patients were included in this study. Of the 25 patients, 13 were women (52%). The median age was 60 (31-84) years, and the overall median length of the stay was 7 (2-28) days. Previous abdominal surgery had been recorded for 13 patients (72%). Two patients (8%) were followed up conservatively, whereas 20 (80%) patients had needed surgical intervention. One (4%) patient underwent surgery for distal ileal obstruction due to the pieces of bezoar that crumbled with previous endoscopic intervention. Three of the patients had complications, such as surgical site infection, wound dehiscence and paralytic ileus in the postoperative period. There were no differences between milking and gastrotomy/enterotomy groups according to the length of stay and postoperative complications. One patient died on the 13th postoperative day due to multi-organ failure. The mortality rate was 4%. CONCLUSION: Phytobezoars, which are common with many other different surgical entities, can be located at any segment of the gastrointestinal tract and may cause obstruction, strangulation and/or even perforation. Contrast-enhanced CT scan must be performed in case of suspicion and to rule out any other causes of acute mechanical intestinal obstruction. Conservative and endoscopic procedures may be useful for selected patients, but the surgical treatment may be needed for the vast majority of the patients with phytobezoar. The surgery is safe for phytobezoar if the enterotomy site is chosen wisely.

Post-Transplant Immune Tolerance in Rats Following Lymphocyte Injection Into the Anterior Chamber of the Eye.

OBJECTIVE: We aimed to compare the clinical and histopathological results of skin graft transplants between rats that had been injected with lymphocytes into the anterior chamber of the eye with those that had not. METHODS: A total of 16 Wistar albino, male rats were included in the study. Subjects were divided into 2 groups, namely a test group and a control group. Lymphocyte suspensions derived from the subjects of the control group were injected into the anterior chamber of the eye of each opposing subject of the test group. Also, an identical volume of physiological saline was injected into the anterior chamber of each subject in the control group to prevent bias. One week after this procedure, circular skin grafts of 1 cm in diameter were transplanted within the opposing groups. After a period of 1 week, transplanted graft tissues were excised to compare tissue healing. RESULTS: The occurence of granulation and reepithelialization was more evident in the test group (96% and 33%, respectively, vs 80% and 17% for the control group, respectively). On the other hand, it was determined that acute inflammation was more intense in the control group (77% vs 50% for the test group). CONCLUSION: We had created immune tolerance in rats through anterior chamber lymphocyte injection, which slowed down the rejection process. If this can be successfully implemented in practice, survival for transplant patients without long-term rejection will move closer to becoming a reality.

Laparoscopic versus open appendectomy in pregnancy: A single center experience.

BACKGROUND: The aim of this study was to compare the obstetric and surgical outcomes of laparoscopic appendectomy (LA) and open appendectomy (OA) performed for pregnant women at a single center. It was the hypothesis of this study that there would be no significant difference in the results. METHODS: The medical records of 57 consecutive pregnant women who underwent an appendectomy between January 2009 and September 2018 were reviewed retrospectively. The patients were divided into 2 groups: OA and LA. The collected data included age, gestational age, diagnostic modalities used, duration of surgery, length of hospital stay, morbidity, and mortality. RESULTS: Eighteen (31%) patients underwent LA and 39 (69%) patients underwent OA. There were no significant differences in the demographic data. The duration of surgery was significantly less in the laparoscopic group (37 vs 57 minutes; p=0.005). There were no statistically significant differences in the outcomes of deep or superficial surgical site infection, length of hospital stay, pre-term delivery, or loss of the fetus. There was no mortality in either group. CONCLUSION: The results of this study suggest that LA can be a safe option for both the pregnant patient and the child. Further prospective, randomized studies with a larger group of pregnant patients with appendicitis are needed to fully determine the effects of laparoscopy in these circumstances.

Duodenal intramural hematoma due to early postoperative anticoagulant treatment after a renal transplant: A case report.

A spontaneous intramural duodenal hematoma is a rare complication in patients receiving anticoagulation therapy. Presently described is a case of intramural duodenal hematoma in a patient with a cadaveric renal transplant who was under oral anticoagulant treatment due to paroxysmal atrial fibrillation. The patient was admitted with intense abdominal pain, nausea, vomiting, and a total obstruction of duodenum. After a diagnosis of intramural hematoma, a good prognosis was achieved with conservative care.

Drain amylase monitoring for early diagnosis of anastomotic leakage in sleeve gastrectomy An animal study.

BACKGROUND: Sleeve gastrectomy(SG) is a popular bariatric surgery procedure with rare but dreaded complications. Although drain amylase levels are a reliable early predictor of anastomosis leakage in oesophagectomy and pancreaticoduodenectomy, for SG have not yet been studied. We aimed to monitor drain amylase levels to ascertain their applicability for early diagnosis of gastric leakage in SG. METHODS: Twenty-four rats were randomly divided into three groups: Group A: only laparotomy and abdominal drain; Group B: laparotomy, SG, and drain; Group C: laparotomy, SG with fistula,and drain. On postoperative days 0,1,2,3, and 4, drain lavage samples were collected to measure amylase. RESULTS: Groups were compared in pairs. Preoperative weights were not significantly different in any comparison. On postoperative days 0,1,2,3, and 4, drain amylase levels were found to be significantly lower in Group A than in Group B as well as in Group A than in Group C but were significantly higher in Group C than in Group B. For postoperative day 1, a receiver operating characteristic curve was done. Drain amylase levels over 1514 IU were statistically significant for leakage. CONCLUSIONS: Drain amylase levels were significantly high in sleeve gastrectomy with fistula. This indicates that drain amylase level monitoring might be an easy and cheap alternative for determining staple-line leakage for high risk patients with Body Mass Index(BMI)>50kg/m2 in whom we cannot use radiological imaging. KEY WORDS: Animal Experimental Study, Bariatric Surgery, Drain amylase, Sleeve gastrectomy, Staple-line leakage.

Protective effects of pentoxifylline in small intestine after ischemia-reperfusion.

Objective This study was performed to determine the healing effects of pentoxifylline on molecular responses and protection against severe ischemic damage in the small intestine. Methods Thirty-six Wistar albino rats were divided into six groups. The superior mesenteric artery was clamped for 120 minutes, and reperfusion was performed for 60 minutes. Saline (0.4 mL), pentoxifylline (1 mg/kg), and pentoxifylline (10 mg/kg) were intraperitoneally administered to the rats in the C1, P1, and P3 groups, respectively, 60 minutes before ischemia and to the rats in the C2, P2, and P4 groups, respectively, during reperfusion onset. Malondialdehyde, myeloperoxidase, tumor necrosis factor alpha, interleukin-1 beta, and interleukin-6 in serum and tissue were measured by enzyme-linked immunosorbent assay. Intestinal ischemic injury was histopathologically evaluated by the Chiu score and immunohistochemical staining. Results All serum and tissue molecular responses were significantly blunted in the pentoxifylline-treated groups compared with the controls. Significant improvement in ischemic damage was demonstrated in the pentoxifylline-treated groups by histological grading and immunohistochemical scoring. Conclusions The protective effects of pentoxifylline were confirmed by molecular responses and histopathological examination.

Is nighttime laparoscopic general surgery under general anesthesia safe?

BACKGROUND: Fatigue and sleep deprivation can affect rational decision-making and motor skills, which can decrease medical performance and quality of patient care. The aim of the present study was to investigate the association between times of the day when laparoscopic general surgery under general anesthesia was performed and their adverse outcomes. METHODS: All laparoscopic cholecystectomies and appendectomies performed at the emergency surgery department of a tertiary university hospital from 01. 01. 2016 to 12. 31. 2016 were included. Operation times were divided into three groups: 08.01-17.00 (G1: daytime), 17.01-23.00 (G2: early after-hours), and 23.01-08.00 (G3: nighttime). The files of the included patients were evaluated for intraoperative and postoperative surgery and anesthesia-related complications. RESULTS: We used multiple regression analyses of variance with the occurrence of intraoperative complications as a dependent variable and comorbidities, age, gender, body mass index (BMI), ASA score, and operation time group as independent variables. This revealed that nighttime operation (p<0.001; OR, 6.7; CI, 2.6-16.9) and older age (p=0.004; OR, 1.04; CI, 1.01-1.08) were the risk factor for intraoperative complications. The same analysis was performed for determining a risk factor for postoperative complications, and none of the dependent variables were found to be associated with the occurrence of postoperative complications. CONCLUSION: Nighttime surgery and older patient age increased the risk of intraoperative complications without serious morbidity or mortality, but no association was observed between the independent variables and the occurrence of postoperative complications.

Drain amylase monitoring for early diagnosis of anastomotic leakage in sleeve gastrectomy An animal study.

BACKGROUND: Sleeve gastrectomy(SG) is a popular bariatric surgery procedure with rare but dreaded complications. Although drain amylase levels are a reliable early predictor of anastomosis leakage in oesophagectomy and pancreaticoduodenectomy, for SG have not yet been studied. We aimed to monitor drain amylase levels to ascertain their applicability for early diagnosis of gastric leakage in SG. METHODS: Twenty-four rats were randomly divided into three groups: Group A: only laparotomy and abdominal drain; Group B: laparotomy, SG, and drain; Group C: laparotomy, SG with fistula,and drain. On postoperative days 0,1,2,3, and 4, drain lavage samples were collected to measure amylase. RESULTS: Groups were compared in pairs. Preoperative weights were not significantly different in any comparison. On postoperative days 0,1,2,3, and 4, drain amylase levels were found to be significantly lower in Group A than in Group B as well as in Group A than in Group C but were significantly higher in Group C than in Group B. For postoperative day 1, a receiver operating characteristic curve was done. Drain amylase levels over 1514 IU were statistically significant for leakage. CONCLUSIONS: Drain amylase levels were significantly high in sleeve gastrectomy with fistula. This indicates that drain amylase level monitoring might be an easy and cheap alternative for determining staple-line leakage for high risk patients with Body Mass Index(BMI)>50kg/m2 in whom we cannot use radiological imaging. KEY WORDS: Animal Experimental Study, Bariatric Surgery, Drain amylase, Sleeve gastrectomy, Staple-line leakage.

Comparison of contrast-enhanced CT with diffusion -weighted MRI in the Evaluation of patients with acute biliary pancreatitis.

OBJECTIVE: The aim of this study was to compare contrast-enhanced computed tomography with diffusion-weighted magnetic resonance imaging in the evaluation of patients with acute biliary pancreatitis. MATERIAL AND METHODS: Fifty-three patients diagnosed with acute biliary pancreatitis, between February 2012 and July 2015, were evaluated using diffusion-weighted magnetic resonance imaging and magnetic resonance cholangiopancreatography to explain the elevation of cholestasis enzymes and bilirubin levels at "stanbul University. Contrast-enhanced computed tomography imaging was applied within 8 h following first evaluation. Demographic data, severity of pancreatitis, pancreatic apparent diffusion coefficient, and computed tomography severity index were compared. The significance of the results was evaluated using Statistical Package for the Social Sciences 21.0 program. RESULTS: Median age was 53.39 (22-90) years in these 53 patients (26 were males and 27 were females). The mean Ranson criterion was 0.96 (0-4) and mean hospitalization duration was 16.02 (3-100) days. Twenty-eight patients were evaluated to have mild acute pancreatitis, whereas 16 were moderately severe and nine were severe based on the Revised Atlanta Classification. Mild pancreatitis score was 0.89, moderately severe pancreatitis score was 3.50, and severe pancreatitis score was 5.78 using the Balthazar score. Elevated C-reactive protein levels were not correlated with necrosis and the clinical severity score (p>0.05). There was no significant difference among the Balthazar score, magnetic resonance cholangiopancreatography-apparent diffusion coefficient score, and Revised Atlanta score in the evaluation of the severity of pancreatitis when the two techniques were compared. A statistically insignificant difference was found between the Balthazar score and magnetic resonance imaging results of clinically confirmed necrosis and non-necrosis patients. CONCLUSION: It can be concluded that diffusion-weighted magnetic resonance imaging might be better than contrast-enhanced computed tomography in the diagnosis of acute pancreatitis as it avoids radiation exposure as well as the development of renal failure and pancreatitis aggravation due to the use of contrast for computed tomography. These results need to be confirmed with randomized prospective controlled studies.

Damage-control laparoscopic partial cholecystectomy with an endoscopic linear stapler.

OBJECTIVE: Several damage-control procedures have been described in the literature in case of severe Calot's triangle inflammation and fibrosis. In this report, we describe patients who underwent laparoscopic partial cholecystectomy using an endoscopic linear stapler. MATERIALS AND METHODS: Five patients with acute cholecystitis underwent laparoscopic partial cholecystectomy in our clinic between January - December 2011. All patients had severe fibrosis and inflammation of Calot's triangle. The anterior and posterior walls of the gallbladder were totally resected if possible. The gallbladder was transected at its neck or Hartmann's pouch, leaving a remnant gallbladder pouch behind. RESULTS: Five patients had laparoscopic partial cholecystectomy with an endoscopic linear stapler. The main symptom of all patients on admission to the emergency room was abdominal pain. The mean time for the surgical procedure was 140 minutes (range, 120-180 minutes). Inflammation and fibrosis of Calot's triangle was detected in all patients during surgery and a phlegmonous gallbladder was detected in one patient. Surgical drains were used in all patients and no biliary leakage was detected. Remnant common bile duct calculi were detected in one patient and this patient underwent endoscopic retrograde cholangiopancreatography one month after surgery. CONCLUSIONS: When a reliable view of Calot's triangle cannot be obtained due to severe inflammation and fibrosis during laparoscopy, laparoscopic partial cholecystectomy seems to be a safe and feasible alternative to open surgery with an acceptable morbidity rate.

What is the clinical yield of capsule endoscopy in the management of obscure bleeding in emergency service?

BACKGROUND: The aim of this study was to investigate the efficacy of capsule endoscopy (CE) performed on patients who presented to emergency room with clinically evident gastrointestinal (GI) bleeding from unknown source and were hospitalized for follow-up. METHODS: Total of 38 patients who underwent CE and were followed-up for evaluation of clinically perceptible GI bleeding with no obvious etiology in Istanbul Medical Faculty emergency surgery department were included in the study. Patient data, which were collected between January 1, 2007 and June 1, 2015, were reviewed retrospectively. RESULTS: Of the 38 patients included in this study, 12 (32%) patients were women and 26 (68%) were men. Average age was 55.57 years (range: 20-88 years). Nine patients were using anticoagulants. Ten patients were followed-up in intensive care, and 7 patients underwent angiography. Angioembolization was performed for 1 patient who was diagnosed as having active bleed with CE. Average erythrocyte suspension replacement was 20.7 units. Total of 13 patients underwent surgery for bleeding found with CE. Eleven (34%) patients underwent double-balloon endoscopy, during which 5 patients were treated with cauterization and sclerotherapy was performed on 2. Four (18%) patients died during the study period: 2 died as result of bleeding from unknown source, 1 died of cholangiocarcinoma recurrence, and 1 died of anastomotic leakage. One patient was readmitted to hospital due to recurrence of bleeding. Nineteen (50%) patients were treated successfully based on CE findings. Diagnostic yield of CE was determined to be 78.9%. Average length of hospital stay was 32.68 days (range: 3-153 days). CONCLUSION: CE is an effective tool to detect source of GI bleeding. CE should be first choice of evaluation method for patients admitted to emergency room with obscure overt GI bleeding once radiological imaging determines absence of obstruction.