The management of penetrating abdominal stab wounds with organ or omentum evisceration: The results of a clinical trial.

OBJECTIVE: The therapeutic approach to abdominal penetrating stab injuries has changed over the years from routine laparotomy to non-operative treatment. In case of organ or omental evisceration, although the laparotomy need is greater, non-operative treatment may be applied in selected cases. The aim of our study was to assess the follow-up and treatment outcomes of patients with organ or omental evisceration due to penetrating abdominal injuries. MATERIAL AND METHODS: Patients with organ or omental evisceration due to penetrating abdominal stab injuries were prospectively evaluated between April 2009 and July 2012. Emergent laparotomy was performed in cases that were hemodynamically unstable or had signs of organ evisceration or peritonitis, while other patients were managed conservatively. Patients' follow-up and treatment outcomes were assessed. RESULTS: A total of 18 patients with organ or omental evisceration were assessed. Six (33.3%) patients underwent emergent laparotomy, and 12 (66.7%) patients underwent conservative follow-up. Three patients in the emergent laparotomy group had signs of organ evisceration, and 3 had signs of peritonitis; five of these 6 patients underwent therapeutic laparotomy and 1 negative laparotomy. In the non-operative follow-up group, therapeutic laparotomy was carried out in a total of 7 patients, 4 being early and 3 late, due to development of peritonitis, whereas 5 (27.8%) patients were managed non-operatively. CONCLUSION: Although organ or omental eviscerations due to penetrating abdominal stab injuries have a high rate of therapeutic laparotomy, selective conservative therapy is a safe method in selected cases.

Hollow viscus injury due to blunt abdominal trauma: a tertiary trauma center experience.

BACKGROUND: Hollow viscus injuries (HVIs) present less frequently than solid organ injuries in patients with blunt abdominal trauma, potentially leading to significantly increased morbidity and mortality rates. Modern imaging equipment, confidently used for diagnosing solid organ injuries, may fail to identify hollow viscus injuries. In this study, we aim to present our tertiary center's experience with this entity. METHODS: Patients treated in our clinic from April 2011 to December 2021 for hollow viscus injury following blunt abdominal trauma were included in this study. We recorded and retrospectively evaluated patients' demographic data, injury site and mechanism, preoperative and perioperative findings, and mortality rates in a prospective database. RESULTS: Of the 607 blunt trauma patients, 35 (5.8%) had hollow viscus injuries, with 88.6% being male. Motor vehicle accidents were the leading cause of injury (80%). The mean duration between admission and surgical exploration was 26±21.2 hours. The mean Injury Severity Score was 21.8±13.6. Rigidity was the most frequent clinical finding (60%). The jejunum and ileum were the most frequently injured organs (54.1%). Mortality and morbidity rates were 11.4% and 17.1%, respectively. CONCLUSION: Nondeclining white blood cell (WBC) counts within 24 hours of admission, alongside any physical or radiological finding indicating an HVI, should prompt immediate surgical exploration.

Is it possible to predict mortality in patients with high-grade blunt liver injury? A single trauma center study.

BACKGROUND: Blunt abdominal trauma constitutes a significant portion of trauma cases and is often associated with liver injury. Given that high-grade liver injuries remain life-threatening, identifying patients who will likely require more vigilant attention and care is crucial. This study aims to determine the parameters that increase mortality in patients with high-grade liver trauma. METHODS: This study enrolled 38 patients with Grade III or higher liver injuries, treated by the general surgery department between 2008 and 2023. Eleven patients who died were categorized into Group 1, and 27 survivors were placed in Group 2. We evaluated their respective mechanisms of injury, imaging results, Glasgow Coma Scale scores, Base Excess, Lactate levels, pH, and Injury Severity Score findings. Receiver Operating Characteristics (ROC) analysis was performed for parameters with significant differences, and certain cutoff values were determined. RESULTS: The grade of liver injury and additional abdominal organ injuries were significantly higher in Group 1 (p<0.05). The difference in extra-abdominal injury sites was statistically insignificant between the groups (p>0.05). Erythrocyte suspension requirements were significantly higher in Group 1 (p<0.05). Average lactate and base deficit values were also significantly higher in Group 1 (p<0.05), while leukocyte counts were significantly lower in Group 1 (p<0.05). CONCLUSION: Base deficit, hemoglobin (Hb), lactate levels, injury severity, liver injury grade, accompanying abdominal injuries at admission, and erythrocyte suspension demands were found to be associated with increased mortality rates. Certain cutoff values for the aforementioned parameters could be established. However, further data are required to confirm these findings.

The relationship between lymphopenia and development of late complications in severe acute pancreatitis.

BACKGROUND: In this study we aimed to predict patients who would develop late stage acute pancreatitis related complications. So we would be able to ease the decision making process about the timing of cholecycstectomy. On the other hand we also suggest a possible insight into the mechanisms which lead development of lyphopenia in severe acute pancreatitis and its possible effects on prognosis. METHODS: In this study, 163 severe acute pancreatitis case who has been treated as inpatient between January 2013 and January 2018 has been involved. Patients charts and all documented data has been analysed retrospectively. According to the existence or absence of late complications of severe acute pancreatitis, patients have been divided into two groups; Group 1 had no late complication, Group 2 had either pseudocyst or WON (Walled of Necrosis) at 1st month CT. RESULTS: The difference between two groups in terms of 48th hour lymphocyte percentage was significant (p=0.000; p<0.05). Group 2 had remarkably longer duration of hospital stay (p=0.000; p<0.05). 48th hour CRP level of group 2 was significantly higher than of group 1 (p<0.000). CONCLUSION: There is a statistically significant relation between the presence of lymphopenia, at 48th hour of presentation in severe biliary pancreatitis patients and development of delayed complications. We can strongly say that there would be no late term pancreatitis related complications if there was no lymphopenia at 48 hour and an early cholecystectomi can be performed in such cases. Lymphopenia seen around 48. hr of admission is highly related to development of late complications in severe acute pancreatitis.

Blunt splenic trauma: Analysis of predictors and risk factors affecting the non-operative management failure rate.

BACKGROUND: Non-operative management (NOM) has become a standard treatment in hemodynamically stable patients with blunt splenic trauma. Studies have identified numerous predictors and risk factors for NOM. However, these factors' role in NOM failure continues to be debated. This study aimed to reveal the role of these factors in NOM failure through retrospective analysis of data from patients who underwent non-operative treatment. METHODS: After the initial evaluation of 189 patients brought to the emergency department between March 2009 and June 2021 and diagnosed with blunt splenic trauma, 13 patients underwent emergency surgery due to hemodynamic instability (immediate splenectomy), and 18 patients who died were excluded from the study. NOM was planned for the remaining 158 patients (stable or stabilized). Patients scheduled for NOM were grouped as either successful NOM (s-NOM; n=139) or failure NOM (f-NOM; n=19) and analyzed the results, retrospectively. RESULTS: Of the 158 patients scheduled for the NOM, 115 were male. The mean age in s-NOM and f-NOM was 32.2±14.5 versus 36.1±16.1. The mean hospital stay was 8 (4-21) days. The mean follow-up period was 12 (6-18) months. Used USG for 60 (43.2%) patients and CT for 137 (98.6%) in the NOM. The number of Grades I-V in the NOM planned patients (n=158) was 20 (12.6%), 54 (34.1%) 56 (35.4%), 26 (16.4%), and 2 (1.3%), respectively. The success rates according to the Grades I-V were 20 (100%), 52 (96.3%), 52 (92.8%), 15 (57.7%), and 0 (0.0%), respectively. There were 102 units of red cell transfusions administered (mean, 2.46 units) to 41 patients in the s-NOM group, while 81 units (mean, 4.26 units) were administered to 19 patients in the f-NOM group (p=0.001). ISS score >15 was 57.5% (mean score, 22.8) and those in the f-NOM group were 78.9% (mean score, 34.8), respectively (p<0.001). Overall NOM success was 88.0%, total complications were 10.1%, and mortality was 1.2% in this study. CONCLUSION: Grades I-III blunt splenic trauma patients were successfully treated using the NOM protocol in this study. However, more than half of Grade IV (57.7%) splenic injuries were successfully treated using NOM. Identifying predictors and risk factors based on a standardized plan will likely increase this success.

Efficacy of PET-CT in the prediction of metastatic adrenal masses that are detected on follow-up of the patients with prior nonadrenal malignancy: A nationwide multicenter case-control study.

Metastasis is the second most common type of adrenal gland mass. In patients undergoing follow-up for nonadrenal malignancy, adrenalectomy is performed when metastasis to adrenal gland is suspected on the basis of positron emission tomography-computed tomography (PET-CT) imaging. This study investigated the efficacy of PET-CT in the discrimination of metastatic lesions from nonmetastatic lesions in the adrenal glands. In this multicentric study, data was collected from enrolled centers. Forty-one patients who underwent surgery for suspected adrenal metastases were evaluated retrospectively. The following data types were collected: demographic, primary tumor, maximum standardized uptake value of adrenal mass (a-SUVx) and detectability in computed tomography and/or magnetic resonance imaging, and specimen size and histopathology. Six patients were excluded due to unavailability of PET-CT reports and 4 for being primary adrenal malignancy. The rest were divided into 2 groups (metastatic: n = 17, 55% and nonmetastatic: n = 14, 45%) according to histopathology reports. There was no statistical difference between the analyzed values, except the a-SUVx (P < .05). The a-SUVx cutoff value was defined as 5.50 by receiver operating characteristic curves and compared with literature. There was no statistical difference when each group was divided as low and high (P > .05). It was found that PET-CT was able to discriminate metastatic lesions from primary benign lesions (P = .022). PET-CT can discriminate primary benign lesions and metastatic lesions by cutoff 5.5 value for a-SUVx.

Number of cells in parathyroid tissue in primary hyperparathyroidism cases and its relationship with serum calcium value.

BACKGROUND: The relationship between serum calcium (Ca) level to serum parathyroid hormone (PTH), phosphorus (P) levels and tissue properties of the parathyroid gland is unknown in primary hyperparathyroidism cases. Revealing this relationship may be useful for understanding the etiopathogenesis of primary hyperparathyroidism and determining the time of treatment. METHODS: Ninety patients (71 females, 19 males, age range; 27-73 years, average age; 46) who underwent single gland excision with the diagnosis of primary hyperparathyroidism were studied. The patients were divided into 2 groups as serum Ca level <12 and serum Ca level ≥12. Age and sex of the patients, mean cell number of the gland, mean volume of the gland, serum levels of PTH, P, and histopathologic type of hyperplasia were evaluated. RESULTS: The mean cell number per cubic centimeter is 22.9 (10-220 range) million in all glands. Serum Ca level was <12 in 82 (91.1%) of the patients, and ≥12 in 8 (8.9%) cases. Mean cell number of the gland, mean volume of the gland, existence of cystic hyperplasia of the gland, serum levels of PTH and P were statistically significant between the 2 groups (P < .001, P < .001, P < .05, P < .001, P < .05 respectively). CONCLUSION: In primary hyperparathyroidism cases serum Ca level is not related to age and sex but directly related to proportionals to the cell number and volume of the gland and serum levels of PTH, inversely related to cystic hyperplasia and serum levels of P. Early surgical intervention should be planned since the serum Ca level will be high in large adenomas with a noncystic radiological appearance.

Factors predicting severity level, progression and recurrence risk of acute left colonic diverticulitis in Turkey: A multicenter study.

BACKGROUND: Acute left colonic diverticulitis (ALCD) ranges from localized diverticulitis to perforation and fecal peritonitis, and treatment varies from conservative management to emergency surgery. The risk factors for recurrence following nonoperative management of ALCD is still controversial. We aimed to define the factors predicting severity level, progression and recurrence risk of ALCD to timely select patients requiring surgery. METHODS: This is a multicenter study where patients were included on accrual. Patients in our clinic between December 2017 and June 2019 with ALCD above 18 years of age were included (n=144) in this study, while 18 years and younger, pregnant or nursing mothers, those with Crohn's disease, ulcerative colitis, colorectal and/or anal cancer were excluded from this study. Laboratory parameters, Modified Hinchey Scores, clinical features, demographics, diet, smoking, alcohol consumption, body mass index, previous diverticulitis episodes, chronic diseases of patients with ALCD, as well as recurrences within 18 months after discharge were evaluated. RESULTS: The findings showed that smoking was more common in patients with previous episodes (p=0.04) and patients who underwent emergency surgery (p=0.04). Recurrence was higher in Modified Hinchey 1b and 2 (p=0.03) than 0 and 1a. Patients who were older than 50y had a higher propensity to undergo emergency surgery than the patients younger than 50y (p=0.049). Nausea, fever, respiratory rate, procalcitonin, total bilirubin and direct bilirubin levels were higher in patients with Modified Hinchey 4 (p=0.03, 0.049, 0.02, 0.001, 0.002, 0.001, respectively). Recurrence was higher in patients with a smoking history, previous ALCD episodes, lower body mass index and pandiverticulitis. CONCLUSION: Laboratory parameters, body mass index, age, clinical features, previous episodes of diverticulitis and smoking may predict the severity and progression of ALCD. Smoking and having low BMI seem to be precursors of ALCD recurrence, especially when the patient with MHS 1b or 2 had at least one previous episode of ALCD. Control colonoscopy results are predictive of recurrence.

Non-operative management of civilian abdominal gunshot wounds.

BACKGROUND: In this study, we aimed to evaluate the results of selective non-operative management in patients with civilian abdominal gunshot wounds. METHODS: Patients hospitalized and monitored in our clinic due to civilian abdominal gunshot wounds between January 2009 and January 2018 were retrospectively examined. Patients were studied concerning age, gender, mechanism of injury, anatomic injury site, Penetrating Abdominal Trauma Index (PATI), Injury Severity Score (ISS), Revised Trauma Score (RTS), treatment method, time to operation, days of hospitalization and mortality. RESULTS: Of the patients, 84 (89.4%) were male, and 10 (10.6%) were female with a mean age of 32.7 (range 4-60). The mean ISS, RTS and PATI values of all patients were 17.05, 7.27 and 9.21, respectively. Immediate laparotomy and/or thoracotomy were performed in 21 (22.3%) of the patients due to hemodynamic instability and in 27 (28.7%) of the patients because of peritonitis findings. The remaining 46 (48.9%) patients were managed non-operatively. Among these patients, early laparotomy was performed in five (5.3%) and late laparotomy in eight (8.5%) patients who developed peritonitis symptoms. The other 33 (35.1%) patients were treated non-operatively. Of these patients, 61.1% of the patients with flank injuries, 50% of the patients with right thoracoabdominal injuries, 44.4% of the patients with posterior abdominal injuries, 42.1% of the patients with pelvic injuries and 27.8% of the patients with left thoracoabdominal injuries were successfully treated non-operatively. Non-therapeutic or negative laparotomy was performed on six (6.4%) patients. Mortality was 10.6% (n=10) in all patients. CONCLUSION: Some patients with a civilian abdominal gunshot wound in certain anatomical localization who are hemodynamically stable and have no peritonitis symptoms can be non-operatively managed just as in patients with abdominal stab wounds. Success rates of selective non-operative management are high, especially in gunshot wounds of flank, posterior abdominal, thoracoabdominal and pelvic regions.

Cytodiagnosis of Primary Thyroid Lymphoma Coincident with Unnoticed Papillary Thyroid Carcinoma: A Case Report and Review of the Literature.

Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer, whereas primary thyroid lymphoma is very rare. Here, we report a case in which a right-sided nodule measuring 4.3 × 2.2 cm was examined using fine-needle aspiration biopsy. This revealed abundant monomorphic non-cohesive large lymphoid cells without thyroid follicular cells, on which basis acytodiagnosis of lymphoma coincident with lymphocytic thyroiditis was made. Subsequent histologic examination revealed CD45-, CD20+, and Bcl-6 + and cytokeratin-, CD3-, CD5-, and CD30-negative tumor cells arranged diffusely in the whole thyroid coexisting with a separate PTC nodule sized 1.3 × 1.0 cm in the right lobe. The key point exemplified by this case is that a cytodiagnosis of this extremely rare coexistence of PTC and lymphoma can be made by adequate sampling of both nodules preoperatively. In our case, only one nodule formation was sampled, and therefore the coexisting PTC was not detected with cytology preoperatively.

Comparison of FNAC and Histopathological Results for 4 cm or Larger Benign Thyroid Nodules.

OBJECTIVE: To assess the fine-needle aspiration cytology (FNAC) and histopathological results of thyroid nodules sized 4 cm or larger with benign cytology. STUDY DESIGN: Analytical study. PLACE AND DURATION OF STUDY: Health Science University Umraniye Training and Research Hospital, Istanbul, Turkey. METHODOLOGY: Patients with thyroid nodule size 4 cm. or larger and benign FNAC results were included in the study. All patients' age, gender, size of nodule, results of FNAC, types of surgery and histopathological results of thyroid specimen were extracted from patients' files. RESULTS: Out of 720 patients, who underwent thyroidectomy between January 2009 and January 2018, 310 patients with a benign FNAC results, between the ages of 18 and 78 years, with nodule diameters ranging from 4 to 8.4 cm were included in the study. Of these 310 patients, 243 (78.4%) were females and 67 (21.6%) were males. In the final histopathological examination, thyroid carcinoma was detected in five of the cases (1.6%). CONCLUSION: The risk of malignancy in 4 cm and larger thyroid nodules with benign FNAC was as much as expected in other benign nodules.

Importance of diagnostic laparoscopy in the assessment of the diaphragm after left thoracoabdominal stab wound: A prospective cohort study.

BACKGROUND: Stab wounds in the left thoracoabdominal region may cause diaphragmatic injury. The aim of the present study was to determine incidence of diaphragmatic injury and role of diagnostic laparoscopy in detection of injury in patients with left thoracoabdominal stab wound. METHODS: Total of 81 patients (75 male, 6 female; mean age 27.5±9.8 years; range 14 to 60 years) who presented with left thoracoabdominal stab wound between April 2009 and September 2014 were evaluated. Laparotomy was performed on patients who had hemodynamic instability, signs of peritonitis, or organ evisceration. Remaining patients were followed conservatively. After 48 hours, diagnostic laparoscopy was performed on patients without laparotomy indication to examine the left diaphragm for injury. Follow-up and treatment findings were prospectively evaluated. RESULTS: Thirteen patients underwent laparotomy while diagnostic laparoscopy was performed on remaining 68 patients. Left diaphragmatic injury was observed in 19 patients (23.5%) in the study group. Four injuries were diagnosed by laparotomy and 15 were diagnosed by laparoscopy. Presence of hemopneumothorax did not yield difference in incidence of diaphragmatic injury (p=0.131). No significant difference was detected in terms of diaphragmatic injury with respect to entry site of stab wound in the thoracoabdominal region (p=0.929). CONCLUSION: It is important to evaluate the diaphragm in left thoracoabdominal stab injuries, and diagnostic laparoscopy is still the safest and most feasible method.

Fournier's gangrene: A retrospective analysis of 25 patients.

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

Percutaneous cholecystostomy: A curative treatment modality forelderly and high ASA score acute cholecystitis patients.

BACKGROUND: Acute cholecystitis (AC) is a common emergency seen by general surgeons. Optimal treatment is laparoscopic cholecystectomy (LC); however, in cases where surgery cannot be performed due to high risk of morbidity and mortality, such as in elderly patients with comorbid diseases, other treatment modalities may be used. Percutaneous cholecystostomy (PC) is one alternative method to treat AC. PC can be used to provide drainage of the gall bladder and control infection. Subsequently, interval cholecystectomy can be performed when there are better conditions. Presently described is experience and results with PC in high risk, elderly patients with AC. METHODS: Medical records of all consecutive patients who underwent PC between January 2011 and January 2014 were identified. Tokyo Guidelines were used for definitive diagnosis and severity assessment of AC. Senior surgeon elected to perform PC based on higher risk-benefit ratio due to comorbidity, age, or duration of symptoms. All PC procedures were performed by the same interventional radiologist under local anesthesia with ultrasonographic guidance. RESULTS: Total of 40 PC procedures were performed during the study period. Of those, 22 (55%) were male and 18 were (45%) were female, with median age of 70.5 years (range: 52-87 years). All of the patients had American Society of Anesthesiologists classification of either 3 or 4. Success rate of PC was 100% with complication rate of 2.5% (n=1). One patient was operated on shortly after PC procedure due to bile peritonitis complication. PC drains were kept in place for 6 weeks. Total of 16 patients (40%) had surgery following removal of PC drain. In 3 (18.8%) cases, conversion from LC was required. Remaining 23 (57.5%) patients did not have subsequent operation after drain removal. No disease recurrence was observed in follow-up. CONCLUSION: When elderly patients present in emergency setting with AC and LC cannot be performed due to comorbid disease or poor general condition, PC can be performed safely. After removal of PC drain, LC may be performed with acceptable conversion rate of 18.8%.

Multivariate analysis of patients with blunt trauma and possible factors affecting mortality.

BACKGROUND: This study aimed to investigate the signs and prognosis of the patients hospitalized due to blunt trauma injuries and identify possible factors that affect mortality. METHODS: Between January 2009 and January 2013, a total of 237 patients admitted with blunt trauma injury were retrospectively analyzed. The age and gender of the patients, type of the trauma, injury site, Injury Severity Scores (ISS), Revised Trauma Scores (RTS), Focused Assessment with Sonography in Trauma (FAST) results, hemodynamic status, need for transfusion, treatment modalities, treatment outcomes, and mortality rates were recorded. RESULTS: Of the patients, 187 (78.9%) were male, 50 (21.1%) were female and mean age was 36.9±16.9 years (3-81 years). Of the patients, 131 (55.3%) suffered thoracic injuries, 110 (46.6%) abdominal injuries, 96 (40.5%) pelvic and limb injuries, 34 (14.3%) head and neck injuries, 26 (11%) maxillofacial injuries, and 24 (10.1%) skin and subcutaneous tissue injuries. Forty-five patients (19%), including 33 patients with hemodynamic instability and 12 patients with peritonitis-related signs, were operated on. Mortality was seen in 26 patients (11%), including 10 (38.5%) with unstable pelvic fractures. Mortality rates; in patients with packing performed was 75%, in patients without any need for packing was 33.3%, in patients with hemodynamic instablity was 60.6%, in hemodynamically stable patients was 8.3% and in FAST (+) patients was 20.5%, in FAST(-) patients was 3.4% (p<0.05). CONCLUSION: Blunt trauma often presents with multi-trauma involving more than one anatomical structure of the body. Thoracic, abdominal, and pelvic injuries usually accompany blunt trauma. The majority of abdominal solid organ injuries are followed non-operatively. Our study results show that ISS, RTS, FAST result, hemodynamic unstability, packing requirment, and need for transfusion are statistically invaluable in identifying the mortality risk.

Evaluation of diaphragm in penetrating left thoracoabdominal stab injuries: The role of multislice computed tomography.

INTRODUCTION: Penetrating left thoracoabdominal stab injuries are accompanied by diaphragmatic injury in 25-30% of cases, about 30% of which later develop into diaphragmatic hernia. This study aimed to determine the role of multislice computed tomography in the evaluation of left diaphragm in patients with penetrating left thoracoabdominal stab wounds. MATERIALS AND METHODS: This study reviewed penetrating left thoracoabdominal stab injuries managed in our clinic between April 2009 and September 2014. The thoracoabdominal region was defined as the region between the sternum, fourth intercostal space, and arcus costa anteriorly and the vertebra, lower tip of scapula, and the curve of the last rib posteriorly. Unstable cases and cases with signs of peritonitis were operated with laparotomy; the remaining patients were closely monitored. Forty-eight hours later, a diagnostic laparoscopy was applied to evaluate the left hemidiaphragma in asymptomatic patients who did not need laparotomy. The preoperatively obtained multislice thoracoabdominal computed tomography images were retrospectively examined for the presence of left diaphragm injury. Then, operative and tomographic findings were compared. RESULTS: This study included a total of 43 patients, 39 (91%) males and 4 (9%) females of mean age 30 years (range 15-61 years). Thirty patients had normal tomography results, whereas 13 had left diaphragmatic injuries. An injury to the left diaphragm was detected during the operation in 9 (1 in laparotomy and 8 in diagnostic laparoscopy) of 13 patients with positive tomography for left diaphragmatic injury and 2 (in diagnostic laparoscopy) of 30 patients with negative tomography. Multislice tomography had a sensitivity of 82% (95% CI: 48-98%), a specificity of 88% (71-96%), a positive predictive value of 69% (39-91%), and a negative predictive value of 93% (78-99%) for detection of diaphragmatic injury in penetrating left thoracoabdominal stab injury. CONCLUSIONS: Although diagnostic laparoscopy is the gold standard for diaphragmatic examination in patients with penetrating left thoracoabdominal stab wounds, multislice computed tomography is also valuable for detecting diaphragmatic injury.

Management of strangulated abdominal wall hernias with mesh; early results.

OBJECTIVE: Surgery for abdominal wall hernias is a common procedure in general surgery practice. The main causes of delay for the operation are comorbid problems and patient unwillingness, which eventually, means that some patients are admitted to emergency clinics with strangulated hernias. In this report, patients who admitted to the emergency department with strangulated adominal wall hernias are presented together with their clinical management. METHODS: Patients who admitted to our clinic between January 2009 and November 2011 and underwent emergency operation were included in the study retrospectively. Demographic characteristics, hernia type, length of hospital stay, surgical treatment and complications were assessed. RESULTS: A total 81 patients (37 female, 44 male) with a mean age of 52.1±17.64 years were included in the study. Inguinal, femoral, umbilical and incisional hernias were detected in 40, 26, 9 and 6 patients respectively. Polypropylene mesh was used in 75 patients for repair. Primary repair without mesh was used in six patients. Small bowel (n=10; 12.34%), omentum (n=19; 23.45%), appendix (n=1; 1.2%) and Meckel's diverticulum (n=1; 1.2%) were resected. Median length of hospital stay was 2 (1-7) days. Surgical site infection was detected in five (6.2%) patients. No significant difference was detected for length of hospital stay and surgical site infection in patients who had mesh repair (p=0.232 and 0.326 respectively). CONCLUSION: The need for bowel resection is common in strangulated abdominal wall hernias which undergo emergency operation. In the present study, an increase of morbidity was seen in patients who underwent bowel resection. No morbidity was detected related to the usage of prosthetic materials in repair of hernias. Hence, we believe that prosthetic materials can be used safely in emergency cases.

The predictive value of physical examination in the decision of laparotomy in penetrating anterior abdominal stab injury.

A selective conservative treatment for penetrating anterior abdominal stab injuries is an increasingly recognized approach. We analyzed patients who followed-up and treated for penetrating anterior abdominal stab injuries. The anterior region was defined as the area between the arcus costa at the top and the mid-axillary lines at the laterals and the inguinal ligaments and symphysis pubis at the bottom. An emergency laparotomy was performed on patients who were hemodynamically unstable or had symptoms of peritonitis or organ evisceration; the remaining patients were followed-up selectively and conservatively. A total of 175 patients with purely anterior abdominal injuries were included in the study. One hundred and sixty-five of the patients (94.29%) were males and 10 (5.71%) were females; the mean age of the cohort was 30.85 years (range: 14-69 years). While 16 patients (9%) were made an emergency laparotomy due to hemodynamic instability, peritonitis or evisceration, the remaining patients were hospitalized for observation. During the selective conservative follow-up, an early laparotomy was performed in 20 patients (12%), and a late laparotomy was performed in 13 patients (7%); the remaining 126 patients (72%) were discharged after non-operative follow-up. A laparotomy was performed on 49 patients (28%); the laparotomy was therapeutic for 42 patients (86%), non-therapeutic for 4 patients (8%), and negative for 3 patients (6%). A selective conservative approach based on physical examination and clinical follow-up in penetrating anterior abdominal stab injuries is an effective treatment approach.

[Factors affecting mortality in blunt thoracic trauma]. / Künt toraks travmasinda mortaliteye etki eden faktörler.

BACKGROUND: Blunt thoracic trauma is usually associated with extra-thoracic injuries, but the effect of blunt thoracic trauma on mortality is not known. METHODS: Patients with blunt thoracic trauma were evaluated with regard to clinical findings and factors affecting mortality. RESULTS: There were 76 patients (37.2±15 years) in the study group. Traffic accidents (63%) were the most common cause of trauma. Pneumothorax (54%), rib fracture (42%), hemothorax (22%) and lung contusion (22%) were common thoracic injuries. Extra-thoracic injuries were most commonly seen in the extremities (46%) and abdomen (40%). Glasgow Coma, Injury Severity and Revised Trauma Scores were 14±2.6, 19±13 and 7.4±1.5, respectively. Non-operative management was effective in 37 (48.7%) patients, tube thoracotomy and thoracotomy were performed in 37 (48.7%) and 2 (2.6%) patients, respectively. Mortality rate was 10.5%. Systolic blood pressure lower than 90 mmHg and superficial and apneic respiration at the first admission, and values of trauma scoring systems were significantly associated with mortality (p<0.05). CONCLUSION: The effect of thoracic trauma on mortality with regard to thoracic pathology is not shown, although it is usually associated with extra-thoracic injuries. There was a close relationship between the pattern of respiration, values of systolic blood pressure and trauma scoring systems, and mortality. Non-operative management and tube thoracotomy were effective in most of the cases.