Experimental inhalation of chlorine gas produced with a different method; effects of N-acetyl cysteine on acute pulmonary damage.

ABSTRACT The two most common gas inhalation injuries encountered in emergency departments are carbon monoxide and chlorine inhalations. In this study, chlorine was produced through a method different to the previous experimental models. Rats were subjected to inhale chlorine, after which the effects of N-acetylcysteine on pulmonary damage were evaluated. A total of 50 rats were equally divided into five groups. Group 1 received nothing. Groups 2 and 3 were taken as 6 h, groups 4 and 5 as 24 h control and N-acetylcysteine groups, respectively. Firstly, 200 ppm chlorine gas was given for 20 min. Then, 40 mg/kg N-acetylcysteine was given intraperitoneally. The same procedure with the same dose was repeated 3 h later. The same procedures were applied to the control group but this time saline was used. Tissue samples of lungs were taken. Glutathione levels of the rats in the N-acetylcysteine group sacrificed at 24 h were significantly higher than those of the control group. Histopathological evaluation of the pulmonary tissues of the rats sacrificed at 6 and 24 h revealed mild-to-moderate degrees of tissue damage. The degree of tissue damage at 6 h and 24 h N-acetylcysteine group rats was lower than that in the control group. As a result, tissue damage resulting from experimental chlorine inhalation can be alleviated by N-acetylcysteine. This is mainly the result of the antioxidant effects of the N-acetylcysteine.

[The effects of rapid and slow infusion of fluid on coagulation factors in hemorrhagic shock: an experimental dogs model]. / Hemorajik sokta hizli ve yavas sivi infüzyonunun koagülasyon faktörleri üzerine etkisi: köpekte deneysel çalisma.

BACKGROUND: The diagnosis of hemorrhagic shock in a patient with tachycardia and hypotension is generally straightforward. The difficulty lies in the selection of optimal approach for the patient. In this study on a canine model of deep hemorrhagic shock induced by bleeding, we used various amounts of fluid infusion to determine the most appropriate amount of fluid resuscitation. METHODS: The study included 30 mongrel dogs. Mongrel dogs were randomized to three equal groups of 10. The control group received no treatment. The rapid infusion group received 60 mL/kg of lactated Ringer's solution in half an hour whereas the third group received 30 mL/kg during the same time period. RESULTS: The lactate decreased in the two treatment groups. The platelet and fibrinogen levels did not vary in the slow infusion group but decreased markedly in the rapid infusion group. CONCLUSION: In conclusion, fluid resuscitation should not be unnecessarily aggressive. The coagulation parameters are diluted in proportion with the amount of fluid given. Blood lactate level can be used as a guiding marker in evaluation of treatment effectiveness of hemorrhagic shock patients.

Large animal-related abdominal injuries.

BACKGROUND: This study investigated injuries to the abdominal area of the body caused by large animals, as well as the management of this problem. METHODS: All the patients with large animal-related abdominal injuries over a 10-year period were identified retrospectively through the general surgery registrations. RESULTS: Overall, 113 patients were hospitalized after large animal encounters during the 10-year study period, 33 (30%) of which had large animal-related abdominal injuries. These patients comprised 10 women (30%) and 23 men (70%) with a mean age of 56 +/- 14 years. Of the 33 patients, 31 (93.9%) sustained blunt injuries and 2 (6.1%) experienced penetrating abdominal trauma. The mean Injury Severity Score was 12.7 +/- 4.0, and the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 10.6 +/- 3.2. The mean intensive care unit stay was 0.8 +/- 2.2 days, and the total hospital length of stay was 7.3 +/- 5.6 days. Whereas 12 patients (36.4%) were managed nonoperatively, 21 patients (63.6%) required surgery. Laparotomy showed injuries to the jejunum in three patients (9.1%), to the ileum in 13 patients (39.4%), to the ileal mesenterium in 1 patient (3%), to the liver in 4 patients (12.1%), and to the spleen in 2 patients (6.1%). One patient died of myocardial infarction on the second day after admission. CONCLUSIONS: Large animal-related injuries to the abdominal area can be serious. Immediate transportation and early diagnosis of abdominal insults are important because of the frequencies of small bowel and mesenteric injuries, which are difficult to diagnose using currently available diagnostic tools.

Comparison of the results of early, delayed and elective surgery in biliary pancreatitis.

BACKGROUND/AIMS: To evaluate the results of the patients who underwent surgery for biliary pancreatitis, with respect to timing of operation. METHODS: 192 Patients underwent surgery for biliary pancreatitis between January 1990 and December 1999. The patients were retrospectively separated into three groups: early surgery (within 72 hours after admission), delayed surgery (between 3 and 15 days after admission) and elective surgery (after 15 days). RESULTS: There were 98 patients in the early surgery group, 46 in the delayed surgery group and 48 in the elective surgery group. The number of Ranson's criteria present was between 3 and 5 in 58.2% of the cases in the early surgery group and in 54.3% of the cases in the delayed surgery group, whereas 62.5% of the cases in the elective surgery group had 0-2. APACHE II score was in the 6-10 range in 43.9% of the cases in the early surgery group and in 39.1% of the cases in the delayed surgery group, whereas 66.7% of the cases in the elective surgery group had between 0 and 5. The most frequent operations in the early and delayed surgery groups was cholecystectomy, common bile duct exploration, and T-tube placement (60.2% and 69.6%, respectively), whereas it were laparoscopic cholecystectomy in the elective surgery group (66.7%). Pancreatitis-related complication rates in the early, delayed and elective surgery groups were 20.4%, 17.4% and 8.3%, respectively. Mortality rates were 5.1% and 4.3% in the early and delayed surgery groups, respectively. There was no deaths in the elective surgery group. CONCLUSION: In biliary pancreatitis, surgery should not be considered as a primary option until the resolution of the pancreatic inflammation and its systemic effects. It should be employed only when the clinical picture does not ameliorate in spite of conservative treatment.

[Surgical alternatives in complex pancreatic injuries]. / Kompleks pankreas yaralanmalarinda cerrahi yaklasimlar.

BACKGROUND: Objective of this study is to analyze the treatment outcomes of patients undergoing surgery for complex pancreatic injuries in our center over a 20-year period. METHODS: Between January 1980 and December 2001, medical records of 11 patients who underwent surgical intervention for complex pancreatic trauma were investigated retrospectively. RESULTS: The study group consisted of nine males and two female patients with a mean age of 36 years. Six patients had stab wounds, three had motor vehicle accidents and two had gunshot wounds. The mean value of Injury Severity Score (ISS) was 32. Among six patients with Grade III injury, five were managed by distal pancreatectomy and one by external drainage. In three patients with Grade IV injury each underwent distal pancreatectomy, subtotal pancreatectomy and pancreaticoduodenectomy. The remaining two patients with Grade V injury were managed by pancreaticoduodenectomy. In the postoperative course, pancreatic fistula was observed in two patients and peripancreatic abscess and pancreatitis in one patient each. Endocrine insufficiency occurred in one patient who underwent subtotal pancreatectomy. Operative mortality was 18.2%. CONCLUSION: Owing to the retroperitoneal location of the pancreas and its proximity to major vascular structures, associated organ injuries play a significant role in morbidity and mortality.

Effects of recombinant platelet activating factor acetylhydrolase in obstructive jaundice.

BACKGROUND/AIMS: The aim of this study was to investigate effects of recombinant PAH (platelet activating factor acetylhydrolase), on tissue damage and on antioxidant response. METHODOLOGY: A total of 30 Wistar-Albino type rats were used in this PAH treatment, and the subjects were divided into 3 groups namely sham, ligation and PAH treatment groups, each containing 10 rats. In PAH treatment and ligation groups, laparotomy was made; common bile duct was ligated and incised. Following ligation, blood and liver tissue were taken. In the sham group, the common bile duct was turned but no other procedure was applied. The subjects in the ligation group were given intraperitoneal placebo on the 2nd to 6th days; and those in the PAH treatment group were applied PAH at a 5-mg/kg dose. Blood and liver tissue were taken on postoperative day 7. The parameters examined in the blood sample included, liver function tests, superoxide dismutase, glutathione peroxidase, tumor necrosis factor-alpha and interleukin-6. In liver tissue, histopathologic examination was made. RESULTS: Levels of AST, ALT, GGT, ALP, tumor necrosis factor-alpha and interleukin-6 were significantly higher than the levels in the sham group. These parameters, measured on the 7th day in the PAH treatment group were found to be significantly lower than the ligation group. Portal inflammation in the PAH given group was significantly lower than the ligation group. CONCLUSIONS: Administration of PAH in experimental jaundice has produced improvement in liver functions, significant reductions in serum GGT and ALP, tumor necrosis factor-alpha and interleukin-6, and in liver damage whereas it has brought about an increase in the levels of antioxidant enzymes.

Grasper-assisted versus traditional laparoscopic splenectomy in the management of hematologic disorders.

OBJECTIVE: To compare the technical benefits of grasper-assisted laparoscopic splenectomy (LS) with traditional LS. METHODS: The study comprised 27 consecutive patients who were admitted to our hospital from 1998 to 2002 and underwent LS: 13 patients underwent traditional LS (group 1), and 14 had grasper-assisted LS (group 2). RESULTS: In both groups, the most common indication for LS was idiopathic thrombocytopenic purpura. There was no difference between the groups in the demographic characteristics of patients. All splenectomies were performed in the right semidecubitus position, using four or five trocars. Conversion to open surgery was required in one patient (7.7%) in group 1 and in one patient (7.1%) in group 2. Both conversions occurred during the initial 16 operations and no conversion occurred during the subsequent 11 operations. The mean operating time was significantly shorter for group 2 (132 minutes) than for group 1 (154 minutes) (P <.005). Mean estimated blood loss (201 vs. 282 mL) was also lower in group 2 than in group 1 (P <.05). The mean length of hospital stay was 3.3 days in group 1 and 2.4 days in group 2 (P >.05). CONCLUSION: Grasper-assisted LS is both safe and feasible in patients with hematologic diseases. This technique can be preferred in order to grasp and position the spleen during the surgery.

Periampullary adenomyoma: report of two cases.

Adenomyoma is a rare nonneoplastic lesion of the biliary tract. We report two cases of adenomyoma; one located in the duodenum, and the other located in the ampulla Vateri. Both patients presented with jaundice, and preoperative endoscopic and radiologic procedures could not show whether the tumor was benign or malignant. Despite intraoperative frozen section in one patient, the diagnosis of adenomyoma was not confirmed until after pancreaticoduodenectomy.

The perforation problem in hydatid disease.

Hydatidosis (echinococcosis) is endemic in the Mediterranean region, including Turkey. We evaluated the problem of perforation in hydatidosis. The clinical data on 21 patients with intra-abdominal hydatid cyst perforation who were treated in the last 10 years were evaluated retrospectively. Twelve patients (57%) were men and nine (43%) were women. Their average age was 40 (range = 20-65). Blunt trauma was the etiologic mechanism in four cases (19%). Except for a case with a cyst in the left inguinal region, most (95%) of the patients had primary hepatic hydatidosis (95%). The procedures used on the 30 cysts found in 21 patients were as follows: partial cystectomy and drainage in 21 (70%), total cystectomy in 5 (17%), partial cystectomy plus omentopexy in 2 (7%), and drainage plus vacuum obliteration in 2 (7%). The average postoperative hospital stay was 12 days (range = 6-30). Two patients (10%) had complications: an incisional hernia developed in one patient, and a gastrocutaneous fistula developed in the other. Albendazole (10 mg/kg/day) was prescribed for two months. The mean follow-up time was 80 months (range = 6-131). Three patients (14%) underwent additional surgery for recurrence at various times. The morbidity and mortality associated with perforated hydatid cysts were higher when compared with that of nonperforated cysts. Hydatidosis is endemic in Turkey and traffic accidents are common. When these factors coexist, hydatid perforation should be considered in trauma patients with stable hemodynamics, but suspicious abdominal findings. The choice of the operative approach should be based on the experience of the surgeon and regional characteristics.

Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts.

PURPOSE: The most common complication of hydatid liver cysts is spontaneous rupture into the biliary tract. This study was conducted to evaluate the surgical management of spontaneous intrabiliary rupture of a hydatid liver cyst in 41 patients. METHODS: The preoperative diagnosis was confirmed by ultrasound in all 41 patients, 37 of whom were jaundiced. RESULTS: According to Gharbi's classification, 39% of the cysts were type III and they ranged from 3 to 18 cm in diameter, with a mean diameter of 9 cm. The mean total bilirubin and alkaline phosphatase values were 6.3 mg/dl and 450 IU, respectively. Partial cystectomy, cholecystectomy, and common bile duct exploration were performed in all patients. In seven patients, the visible biliary duct within the cyst cavity was sutured with 2/0 silk. Intraoperative cholangiography was performed in all patients, and choledochoscopy was performed in 11 patients. A T-tube was inserted after the biliary tract content was thought to have been totally cleaned out in 38 patients (93%), and a choledochoduodenostomy was performed in 3 patients (7%). An external biliary fistula developed in five patients, persisting for 11-25 days. The fistulae healed within a mean period of 5 days after endoscopic sphincterotomy (EST). For patients without a fistula the mean hospitalization time was 8 days and there was no mortality. CONCLUSION: These results suggest that when a hydatid liver cyst ruptures into the biliary tract, common bile duct exploration should be conducted using intraoperative cholangiography and choledochoscopy. If the biliary tract is cleaned of all cystic content, T-tube drainage should be sufficient, but EST is an effective technique for treating persistent extended external biliary fistulae.

The correlation between the TRISS trauma score and plasma levels of NO and TBARS in multiply traumatized patients following traffic accident.

BACKGROUND: There are controversies on determination of trauma severity and on predicting effects of trauma severity on organism in patients with multiple trauma. It is of great importance to rule out these controversies in Turkey where incidence of multiple trauma due to traffic accidents is considerably high. The aim of our study was to investigate whether a correlation exists between trauma severity and plasma levels of nitric oxide and thiobarbituric acid reactive substance in patients with multiple trauma. METHODS: The patients with multiple trauma were divided into two groups as the study group (TRISS score 30 or above) and the control group (TRISS score below 30) and the relationship between plasma NO and TBARS levels was evaluated. In our study, we used the TRISS trauma score (Revised Trauma Score, Injury Severity Score and Age Combination Index) to evaluate trauma severity. RESULTS: There was no effect of trauma severity on plasma NO levels (p > 0.05). There was a positive correlation between TRISS scores and plasma TBARS levels (p < 0.05). CONCLUSIONS: It can be suggested that measurement of plasma NO levels is not useful to indicate trauma severity because change in TRISS is not associated with a correlated change in plasma NO levels. On the other hand, there is a significant correlation between plasma TBARS levels and increase in trauma severity.