Results of combat medic junctional tourniquet training: a prospective, single-blind, randomized, cross-over study.

BACKGROUND: Bleeding remains the leading cause of potentially preventable deaths both in military and civilian pre-hospital trauma settings. Conventional extremity tourniquets do not control bleeding if an iliac artery or a common femoral artery is injured. Stopping junctional bleeding is particularly challenging and requires the use of specifically designed junctional tourniquets. SAM® Junctional Tourniquet (SJT®, United States of America) and Tactical Abdominal Junctional Tourniquet (T-AJT®, Fora Group Türkiye) have been actively used by Turkish security forces. This study questioned the effect of training on combat medics' successful junctional tourniquet applications and application times (AT). METHODS: Our research on two different junctional tourniquet models was designed as a prospective randomized, crossover, single-blinded study. All 40 participants in the study were attendees of a 12-week combat medic training course with updated medical approvals, which were used as an eligibility criterion. Randomization was performed by drawing T-AJT®-SJT cards. The study consisted of pretraining and after-training tourniquet application phases. In each study phase, all participants' AT and the presence or absence of arterial flow were recorded for each group. Finally, the combat medics were presented with a 6-question survey. RESULTS: Although training increased successful T-AJT® application rates, training was not statistically significantly associated with successful applications for any tourniquet types (p>0.05). The pretraining phase ATs for SJT® and T-AJT® were 55±11.8 and 93.8±2.9 seconds, respectively, and the difference was statistically significantly different (p<0.001). Likewise, after-training phase ATs for SJT® and T-AJT® were 49±22.6 and 79.2±17.5 seconds, respectively, and participants' SJT® ATs were significantly shorter (p<0.001). Overall, when participants' applied any of the tourniquet unsuccessfully, the odds of participants' lower Visual Analogue Scale scores were 0.2 (95% CI [0.08, 0.49]. p<0.001). CONCLUSION: Our study basically investigates the effects of training on effective tourniquet application. Unfortunately, our after-training success rates remained unsatisfactory when compared to other studies. This is also the first study on T-AJT® tourniquet application, and further studies on its efficacy are also required.

Investigation of postoperative erectile dysfunction in colorectal surgery patients and comparison of results.

BACKGROUND: Although surgical treatment is curative for colorectal cancers, erectile dysfunction (ED) is one of the complications that affect the patient quality of life. The present study aimed to evaluate sexual dysfunction in patients who underwent anterior resection (AR) and low AR (LAR) surgery secondary to rectosigmoid pathologies in our clinic, to analyze the effective variables, and to compare the results. METHODS: In the retrospectively designed study, male patients who underwent surgery for malignancy or other surgical pathologies in the General Surgery Clinic between January 2017 and December 2022 were examined. Female gender, patients under 18 years of age, and patients who refused to participate in the study were excluded. RESULTS: The high age of the patient increased the risk of severe ED in the postoperative period. However, surgical technique, alcohol use, American Society of Anesthesiologists (ASA) score, and Clavien-Dindo class were not determinants in the presence of severe ED. CONCLUSION: ED is an emerging medical problem that affects patients who undergo colorectal surgery adversely both in social and psychological aspects. Discussions on the issue are still ongoing. Clinicians' concerns can be addressed in the future as the number of prospectively designed studies involving more homogeneous and larger populations increases.

Injury mechanisms and injury severity scores as determinants of urban terrorism-related thoracoabdominal injuries.

Objectives: Improving the care of injuries resulting from terrorist attacks requires understanding injury mechanisms in armed conflicts. The aim of this study was to identify injury characteristics in military personnel with thoracoabdominal combat injuries resulting from terrorist attacks in urban settings. Material and Methods: A retrospective study of military personnel with thoracoabdominal injuries who were referred to a tertiary center after treating and stabilizing at a primary healthcare organization due to terror-related injuries in various urban regions of Turkey between June 2015 and December 2016 was performed. Results: A total of 70 patients were included in this study, of whom 87.1% were injured by explosives and 12.9% (n= 9) had gunshot wounds (GSWs). Mean injury severity score (ISS) was 21, blood transfusion amount was 3.7 units, and mortality rate was 8.5%. Patients injured by explosives had most commonly abdominal and extremity injuries (31.1%), whereas isolated abdominal injuries (55.6%) were observed among patients with GSWs. There were no significant differences between the mechanisms of injuries and the ISS, blood transfusion, and mortality (p= 0.635, p= 0.634, and p= 0.770, respectively). A significant correlation was observed between the ISS and transfusion amounts (r= 0.548, p <0.001). Mortality was significantly higher in those with a high ISS and those undergoing massive blood transfusions (p= 0.004 and p <0.001, respectively). Conclusion: Explosive injuries, concomitant vascular injuries, high ISS, and the need for massive transfusions increased the mortality rate in urban combat injuries. To quickly identify high-risk patients and improve the care of injuries, it is essential to use predictive models or scoring systems.

Renal autotransplantation due to iatrogenic ureter injury: A case report.

Hardy and colleagues carried out 'Renal autotransplantation' for the first time in 1963 to treat severe ureter injury and it has evolved as a method used for complex treatment of trauma, renal artery diseases or ureteral stenosis. In case of proximal ureter injury, approximately 2/3 of which is iatrogenic, if the end-to-end anastomosis is not possible, renal autotransplantation, ileal ureter interposition or nephrectomy are alternative treatments. As technology advances, the use of ureterorenoscopy (URS) increases and in parallel with this iatrogenic injuries that occur during the process have increased as well. These types of injuries are generally in form of simple perforations (2-6%), but from time to time ureter avulsions are also observed (0.3%). In this article, a case is presented where renal autotransplantation is made following development of ureter avulsion during ureterorenoscopy process carried out due to right ureteral calculi and treatment options are discussed in the light of literatures.

Diagnostic accuracy of ultrasonography and scoring systems: The effects on the negative appendectomy rate and gender.

BACKGROUND: Despite the development of clinical, laboratory, and imaging methods, the diagnosis of acute appendicitis is not always easy, and negative appendectomy rates are still high. This study aims to reveal the effects of different scoring systems on the diagnostic accuracy of acute appendicitis and negative appendectomy rates, alone or when evaluated together with ultrasonography. METHODS: In this study, 202 consecutive patients who underwent emergency appendectomy for acute appendicitis were included. Clinical scores of all patients were preoperatively calculated using Ohmann, Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), Lintula, Eskelinen, and Alvarado scoring systems. Abdominal ultrasonography (USG) was performed randomly in all cases. The sensitivity and specificity of scoring systems were calculated according to the threshold values. The area under the curve (AUC) was calculated using ROC analysis. In the regression model, histological diagnosis of appendicitis was used as the dependent variable, while scoring systems and USG were preferred as independent variables. RESULTS: The negative appendectomy rate was 15.8%. In the diagnosis of acute appendicitis, Ohmann was the most predictive for both genders (DOR=24.2, 95% CI 6.98-84.44). Similarly, the lowest negative appendectomy rates were obtained with the Ohmann score as 6.9% in females and 3.4% in males. When the scores were combined with USG, the rate of diagnostic accuracy for acute appendicitis was not increased. However, when Ohmann and USG were combined, negative appendectomy rates were further reduced for women from 6.9% to 4%. CONCLUSION: In addition to being a good diagnostic predictor of acute appendicitis in male and female patients, Ohmann score provides the best negative appendectomy rates. The combination of USG and scoring systems does not increase the diagnostic accuracy of acute appendicitis. However, negative appendectomy rates are significantly reduced when the USG and Ohmann scale are used together in females, while this reduction is minimal in men.

Perioperative outcomes of the patients treated using laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography for bile duct stones: Does timing matter?

BACKGROUND: There is no consensus on the optimal timing for laparoscopic cholecystectomy (LC) after emergent endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis. Although certain data suggest that an early interval or single-stage treatment by LC, together with laparoscopic bile duct exploration, has more favorable outcomes, delayed LC is most often preferred as the standard treatment of patients with gallstones and choledocholithiasis following ERCP due to lack of experience, necessary instrumentation, or organizational restrictions. This study aims to compare the effects of different time intervals between ERCP and LC on perioperative outcomes. METHODS: In this paper, preoperative and postoperative data from consecutive patients who were treated for common bile duct stones with emergent ERCP and then underwent LC were reviewed retrospectively. To evaluate the impacts of different time intervals on outcomes, patients were classified into three groups according to the duration from the last ERCP to LC: within two weeks (Group 1), between 2-6 weeks (Group 2), and over six weeks (Group 3). RESULTS: This study involved an analysis of 67 patients with a mean age of 52.8 years. Overall conversion rate was 20.0% in Group 1, 25.0% in Group 2, and 13.6% in Group 3 (p=0.646). The rate of conversion to open surgery was 25.0% in male patients and 14.2% in females. In addition, no significant difference was found between the groups concerning gender, comorbidities, laboratory and gallbladder features, operation time, and length of the hospital stay. The perioperative complication rate was found to be 17.9%; however, there was no significant difference between the three groups. CONCLUSION: Our results support that LC after ERCP is more complex and has higher conversion rates than LC for uncomplicated cholelithiasis. Although no significant effect of different time intervals between ERCP and LC on perioperative outcomes was demonstrated in patients with common bile duct stones concomitant with cholelithiasis, the 2-6 weeks after ERCP is a critical period for conversion to open surgery. It is recommended that LC after ERCP should be performed in the early period, considering that serious complications may occur in the late period and recurrent biliary attacks may occur.

Effects of weapon types, interventions, and transport times on complications in combat injuries to musculoskeletal system.

OBJECTIVE: To analyze the effects of weapon type, medical interventions, and transportation time on complications due to combat-related injuries of the musculoskeletal and soft tissue (ST). METHODS: A total of 108 patients treated at the emergency department (ED) over a period of 3.5 years were included in this study. The effects of weapon type, type of first intervention team, interventions at the ED, and transport time on complications were compared by retrospectively assessing patients' recorded data. RESULTS: The average age of 108 patients with ST injuries was 24 years. 25 patients developed complications. The ratio of complications in patients with injuries from explosive weapons was 25.42% and was significantly greater (p<0.05) than the rate observed from non-explosive weapons. Regarding the transport time of patients reaching the hospital, the greatest complication rate was 30.77% in patients transported to the hospital in 2-4 h; this rate was significantly (p<0.05) greater than for those transported in other time ranges. Regarding the ED procedures, the complication rate was 37.50% and significantly higher (p<0.05) in the group that received debridement + irrigation + late primary repair. CONCLUSION: Transporting the injured to the ED within the first 2 h, treatment including irrigation and debridement, and secondary healing following explosive injuries containing contamination and dead tissue appear to be good options for reducing complications.

Negative pressure wound closure system for giant thoracic defect closure in a patient with completely visible pericardium: A case report.

Negative pressure wound closure system facilitates wound closure via wound contraction. In this article, we report a successful application of thoracic negative pressure wound closure system to fill the thoracic defect, control infection, and expand the lung in a 35-year-old male patient with threerib defect, lung parenchyma injury, empyema, left complete pneumothorax, and visible pericardium after gunshot injury. The excellent result obtained in our patient demonstrates that negative pressure wound closure system is a good choice for treating high-energy thoracic injuries by reducing wound infection and enabling early wound closure.

Successful conservative treatment of type 3 injury (ductal injury) developing after ERCP.

Although endoscopic retrograde cholangio-pancreatography (ERCP) is considered a safe procedure, it is associated with complications such as pancreatitis, bleeding and perforation of the bile duct, pancreatic duct and duodenum. In recent years, successful conservative treatment in selected patients with complications have increased. We present a case with successful conservative treatment of rare injury (type 3) developing after ERCP.

An uncommon cause of acute abdomen in an acromegalic patient: colonic volvulus.

Acromegaly is a chronic endocrine disease, typically caused by a pituitary adenoma leading to increased circulating GH levels and increased IGF-I secretion by peripheral tissues. Gastrointestinal diseases related acromegaly such as colon cancers, adenomatous polyps, and dolichocolon are much less known. We aimed to present a case of complete colonic volvulus in a patient with acromegaly. A 60-year-old male patient presented with the complaints of inability to pass gas or stool, worsening distension, and pain for one week. The clinical exam showed significant tenderness and distended abdomen as well as a typical appearance of acromegaly. In his past medical history, he underwent an operation of pituitary adenoma with the diagnosis of acromegaly. He also underwent a sigmoid colon resection due to dolichocolon detected by abdominal computerized tomography (CT) and colonoscopy. Upright abdominal X-ray was compatible with volvulus, so endoscopic distortion was tried but failed. At exploration, entire colon was extremely dilated and had a necrotic appearance, and observed to be twisted 360 degrees around its mesenteric axis. The patient underwent total colectomy and end ileostomy. Pathology result was reported as necrotic and hemorrhagic colon with 150 cm in length and 20 cm in width. The patient was discharged on the 14th postoperative day without complications. GH and IGF-1 have an irreversible effect on colonic collagen synthesis in acromegaly and has been proposed to be correlated with the presence of dolichocolon. Dolichocolon often can lead to an abnormal rotation, volvulus, and development of Chilaiditi syndrome. The occurrence of volvulus including the whole colon, although the pituitary adenoma was treated and partial colectomy was done, refers to predisposing factor being the irreversible effect of acromegaly on the colon. KEY WORDS: Acromegaly, Emergency, Volvulus.

Can Human Recombinant Epidermal Growth Factor Improve Ischemia and Induce Healing of Anastomosis in an Experimental Study in a Rabbit Model?

PURPOSE: Anastomotic leaks following intestinal operations may cause devastating effects on patients. Ischemia may also occur at the intestinal walls in the presence of strangulations. In this study, we examined the effects of human recombinant (Hr)-epidermal growth factor (EGF) given at a single intramural dose into the intestinal walls and daily intraperitoneal cavity on ischemia and the healing process of anastomosis. MATERIALS AND METHODS: Sixteen male New Zeland white rabbits were randomly divided into four groups (n = 4 in each group). In Group 1, two different segments of ileum were identified and, then, transected and the free ends were sutured each other. In the other groups, ischemia was induced by ligating the mesenteric vascular arcade. After the ischemic induction, Group 2 received intramural injections of %0.9 saline, Group 3 received intramural injections of a single dose of EGF, and Group 4 received intramural and intraperitoneal injections of EGF. Bursting pressures and tissue hydroxyproline levels were analyzed. Necrosis, fibroblastic activity, collagen deposition and neovascularization were also studied. RESULTS: The mean levels of bursting pressures in Group 4 (148.6 ± 25.3 mmHg) were higher than Group 2 (70 ± 21.5 mmHg) (p = 0.001). The mean level of bursting pressures was not statistically significant between Group 1 (170.1 ± 35 mmHg) and Group 4 (p = 0.073). Hydroxyproline levels in Group 2 were lower than Groups 3 and 4. There was a statistically significant difference in the mucosal ischemia, mucosal healing and degree of adhesion, but not in the mural anastomotic healing among the groups. CONCLUSIONS: Intramural injection with daily intraperitoneal administration of low-dose EGF enhances the bursting pressure and collagen accumulation in ischemic anastomosis, improving many histological variables associated with ischemic intestinal anastomosis.

Experiences of Conflict Zone-Related Ballistic Renal Injury.

To analyze our approaches and experiences in patients with renal injuries accompanying penetrating abdominal injuries admitted to the hospital due to high kinetic energy weapons. Patients including renal injuries associated with penetrating abdominal injuries due to gunshot wounds and fragments of shell treated at our institution between February 2002 and May 2013 were retrospectively analyzed. Total 21 patients were included in this study, 20 of whom (86.2 %) were male and 1 (13.8 %) female. Renal injury was scaled in 2 patients as grade 1, 4 patients as grade 2, 4 patients as grade 3, 8 patients as grade 4, and 3 patients as grade 5. While conservative treatment was applied to patients with grade 1 and 2 injuries, 2 patients with grade 3 injury underwent renal repair and the other 13 patients underwent nephrectomy. The amount of blood transfused in all cases was determined to be mean 8.28 (6-16) units for red blood cells (ES) and 9 (6-17) units for fresh frozen plasma. When patients were assessed according to the Penetrating Abdominal Trauma Index (PATI) scores, the median score and average PATI score were 35 and 37.6 (10-70), respectively. A physical examination along with a quick assessment of vital signs should be made, and unnecessary and time-consuming investigations such as abdominal tomography and angiographic intervention should be avoided. Conservative and organ preservation should be considered absolutely for appropriately selected patients, namely in stable patients in whom kinetic energy transfer is less and who have bullet path away from midline. However, the majority of these patients are considered to be hemodynamically unstable condition, possible complications of the procedure to be applied, and selection of patients should be carefully evaluated.

High velocity missile-related colorectal injuries: In-theatre application of injury scores and their effects on ostomy rates.

BACKGROUND: Treatment of colorectal injuries (CRIs) remains a significant cause of morbidity and mortality. The aim of the present study was to analyze treatment trends of Turkish surgeons and effects of the American Association for the Surgery of Trauma (AAST), Injury Severity (ISS), and Penetrating Abdominal Trauma Index (PATI) scoring systems on decision-making processes and clinical outcomes. METHODS: Data regarding high velocity missile (HVM)-related CRIs were retrospectively gathered. Four patient groups were included: Group 1 (stoma), Group 2 (no stoma in primary surgery), Group 2a (conversion to stoma in secondary surgery), and Group 2b (remaining Group 2 patients). RESULTS: Groups 1, 2, 2a, and 2b included 39 (66%), 20 (34%), 6 (30%), and 14 (70%) casualties, respectively. Ostomies were performed in casualties with significantly higher AAST scores (p<0.001). However, PATI and ISS scores were not decisive factors in the performance of ostomy (p=0.61; p=0.28, respectively). Ostomy rates of civilian and military surgeons were 62% and 68%, respectively (p=0.47). Receiver operating characteristic (ROC) analysis showed that AAST score was a more accurate guide for performing ostomy, with sensitivity and specificity rates of 80% and 92.9%, respectively. CONCLUSION: Clinical significance of diversion in HVM-related CRIs remains. Stomas were associated with lower complication rates and significantly higher AAST colon/rectum injury scores.