Cemalettin Ertekin

Fournier’s Gangrene: Risk Factors and Strategies for Management

ObjectiveThe prognosis of Fournier’s gangrene (FG) depends on early diagnosis and management. In this study, our objective was to identify the distinct features of FG that may influence the clinical outcome.MethodsA retrospective chart review was performed in patients with a diagnosis of FG between January 1999 and December 2003. Etiological and predisposing factors, causative microbiological organisms, and clinical outcome were investigated.ResultsTwenty-five men (71%) and 10 women (29%) were included in the study. Mean age was 59.7 ± 10.7 (range: 43–88) years. As a predisposing factor, diabetes mellitus (DM) was found to be in 46% of patients. All patients were treated by immediate debridement and wide-spectrum antibiotics. More than one bacterium was found in 75% of the patients’ tissue cultures, and most frequently E. coli (43%) was identified. Although there were no etiological factors in 25 patients (71%), various etiological factors were found in 10 patients (29%). Multiple debridements were performed in the majority of the cases. The overall mortality rate was 40%. The mortality rates were found to be relatively higher in patients with diabetes mellitus (DM; 50%), with delayed admission to the hospital (45%), and in patients presenting with sepsis at the first admission to the hospital (78%) compared with others. In the logistic regression model, the presence of sepsis was as the only significant independent risk factor for mortality in FG.ConclusionsDespite the use of contemporary effective antibiotic treatment, aggressive debridements, and state-of-the-art intensive care conditions, FG still has high mortality and morbidity rates. In our series mortality rates were found to be higher in patients with delayed admission to the hospital, those with DM, and those who initially presented with sepsis.

Traumatic rupture of hydatid cysts : A 12-year experience from an endemic region

BACKGROUND Trauma as a cause of hydatid cyst rupture leads to various clinical sequelae. However, extensive data in the current literature regarding clinical presentation and management of such patients are lacking. METHODS This article is a retrospective review of 16 patients with traumatic rupture of hydatid cysts treated at a university hospital in an endemic area. RESULTS Falls (44%) were the most common cause of trauma. The ruptured cysts were located in the liver in 13 patients (81%), in the spleen in 2 patients, and in the lung in 1 patient. Computerized tomography had a sensitivity of 100% in demonstrating cyst rupture; whereas, ultrasonography had a sensitivity of 85%. Ten patients (62%) had rupture into the peritoneal cavity and 5 patients (31%) into the biliary tree. Five (31%) of the cysts were infected. Surgical procedures included introflexion (five patients), pericystectomy-choledochoduodenostomy (three patients), external drainage-choledochoduodenostomy (two patients), unroofing-external drainage (two patients), splenectomy (two patients), unroofing (one patient), and right hepatectomy (one patient). Mean length of hospitalization was 15.9 days (range, 5-61 days). One patient (6%) died, and eight patients (50%) developed complications. Nine patients (56%) were followed-up for an average of 30 months (range, 3-72 months), and there was no recurrence. CONCLUSION Computed tomography is currently the most sensitive diagnostic tool for demonstrating hydatid cyst rupture. The surgical options vary depending on intraoperative findings. Allergic reactions and recurrence as a result of intraperitoneal spillage are not as common as once believed. Biliary rupture is associated with an increased rate of wound infection.

Higher prevalence of toxoplasmosis in victims of traffic accidents suggest increased risk of traffic accident in Toxoplasma-infected inhabitants of Istanbul and its suburbs ☆

Reflexes of drivers who have toxoplasmosis have been shown to deteriorate from the actions of the parasitic cysts. The cysts can change the level of the neurotransmitters such as dopamine in the brain and by doing so extend the muscle response time and change personality profiles. In this study, we aimed to determine the frequency of the latent toxoplasmosis (LT) in the driver population who were either injured or died in traffic accidents reported in Istanbul and its suburbs. We compared the results with a control group and discussed the relationship between the LT and the traffic accidents. We included 218 (89.7%) non-fatal, 25 (10.3%) fatal cases in our study as study groups. A total 243 subjects, 234 (96%) male, 9 (4%) female (who were alcohol negative) compared with 191 (95.5%) male and 9 (4.5%) female subjects (control group) who had a traffic accident before but no history of toxoplasmosis were studied. Serologic tests, enzyme immunoassay (EIA) for IgG and IgM, and microimmunoflorescence (MIF) for IgG were used as the reference test, the Sabin-Feldman Dye test (SFDT) was used. According to serologic test results, LT seroprevalence in the study groups was 130 (53.5%) and in the control group 56 (28%) (p<0.0001). A LT was present in 126 out of 234 (53.8%) males in the study groups, and 54 out of 191 (28.3%) males in the control group (p<0.0001). In the 31-44 year age group, there was a significant difference with regard to toxoplasmosis between the study subjects and control groups (p<0.0001). This difference was statistically very significant in (recent and former) cases with middle-aged men (31-44 years old). The results of this retrospective study suggest that LT in drivers, especially those who are between 31 and 44 years might increase the risk for getting involved in a car accident. In a prospective study, Toxoplasma positive and negative subjects can be monitored before they are involved in a traffic accident to clarify the cause and result relationship.

Abdominal stab wounds: the role of selective management.

OBJECTIVE To investigate the role of a selective approach to the operative treatment of abdominal stab wounds. DESIGN Retrospective study. SETTING University hospital, Turkey. SUBJECTS 387 patients with stab wounds of the abdomen, who presented between January 1992 and January 1995. INTERVENTIONS After local exploration of the wound, 200 patients in whom the wound had penetrated the peritoneum, underwent diagnostic peritoneal lavage. The lavage fluid was examined for white cells, red cells, and amylase and alkaline phosphatase activity. The severity of the injury was evaluated with the penetrating abdominal trauma index (PATI). MAIN OUTCOME MEASURES Morbidity and mortality. RESULTS The main complications were wound infection (n=15), wound dehiscence (n=5), pneumonia (n=3) and renal failure (n=1). Five patients died. The median hospital stay was 6.1 days when patients were operated on, and 1.5 days when they were not. CONCLUSIONS We managed to minimise the number of negative and unnecessary laparotomies. We emphasise that the selective approach may easily be applied in teaching hospitals.

Traumatic injuries to the subclavian and axillary arteries : A 13-year review

PurposeBy reviewing our experience, we evaluated the presentation, management, and long-term outcome of patients with subclavian and axillary artery injuries resulting from trauma.MethodsWe retrospectively reviewed the data of 38 patients who received treatment for subclavian or axillary artery injuries in the Emergency and Trauma Department of Medical Faculty of Istanbul, Istanbul University between January 1989 and July 2002.ResultsArterial injuries were repaired with an end-to-end anastomosis in 10 (26.3%) patients, primary repair in 6 (15.7%), autologous vein graft interposition in 16 (42%), ligation in 5 (13.1%), and a proximal subclavian-brachial artery bypass in 1 (2.6%). One (2.6%) of the arterial reconstructions failed in the perioperative period. Fourteen (36%) patients presented with a neurological deficit, which recovered after the intervention in 2 (5.2%) patients. A wound infection developed in 8 (21%) patients and 2 (5.2%) patients died of concomitant injuries. Thirteen (36.1%) of the remaining 36 patients were followed up for a mean period of 7 months.ConclusionSuccessful management of subclavian and axillary artery injuries requires prompt diagnosis because the occult nature of these injuries necessitates a high index of suspicion. Although revascularization procedures are often successful, it is the associated neurological, orthopedic, and soft tissue injuries that affect the functional outcome of the limb.

Dieulafoy's lesion of esophagus

We report a successful spleen-preserving laparoscopic distal pancreatectomy for a large insulinoma with conservation of the splenic artery and vein. The patient was a 48-year-old man with syncope due to hypoglycemia. Abdominal computed tomography (CT) and ultrasonography revealed a large 6-cm mass located in the tail of the pancreas. We adopted the laparoscopic approach to remove the tumor. After careful dissection and an accurate hemostasis between the pancreas and splenic vessels, laparoscopic distal pancreatectomy was carried out using a linear stapler. There were no perioperative complications. The patient was discharged uneventfully. He had no hypoglycemic episodes or abdominal symptoms during 8 months of follow-up. When performed by experienced laparoscopic surgeons in conjunction with intraoperative ultrasonography, spleen-preserving laparoscopic distal pancreatectomy with conservation of the splenic artery and vein is a technically feasible procedure for the treatment of benign lesions of the tail or body of the pancreas.

Percutaneous transcatheter embolization in arterial injuries of the lower limbs.

Purpose: To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries. Material and Methods: From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate. Results: There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67±0.91 days. Conclusion: PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.

Polymorphisms in tumour necrosis factor alpha (TNFα) gene in patients with acute pancreatitis.

Proinflammatory cytokines, such as tumour necrosis factor α (TNFα), play fundamental roles in the pathogenesis of acute pancreatitis (AP). The aim of this study was to determine if polymorphisms in the TNFα gene are associated with AP. Two polymorphisms located in the promoter region (positions −308 and −238) in TNFα gene were determined using polymerase chain reaction- (PCR-) restriction fragment length polymorphism (RFLP) methods in 103 patients with AP and 92 healthy controls. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated using logistic regression analysis adjusted for age, sex, BMI and smoking. The frequencies of TNFα polymorphisms were both similar in patients with mild or severe pancreatitis, so were in pancreatitis patients and in controls. We suggest that both SNPs of TNFα are not genetic risk factor for AP susceptibility (OR = 1.63; 95% CI: 1.13−4.01 for TNFα −308 and OR = 0.86; 95% CI: 0.75−1.77 for TNFα −238).

Endoscopic ligation for patients with active bleeding Mallory-Weiss tears.

Background: Only a few patients with active nonesophageal variceal upper gastrointestinal bleeding have been treated with endoscopic ligation. To further address this issue, four patients with active bleeding Mallory-Weiss tears who underwent endoscopic band ligation are presented. Patients and Methods: Endoscopic ligation was performed in four patients with a median age of 52 years (range, 40-93 years) after a diagnosis of active bleeding Mallory-Weiss tears (MWTs). A 45-year-old man with massive persistent upper gastrointestinal bleeding as a cause of a MWT underwent therapeutical endoscopic band ligation after an unsuccessful endoscopic injection trial. On the contrary, injection therapy should have been performed on a 93-year-old woman with multiple myeloma because of an actively bleeding MWT caused by the fibrotic tissue after an unsuccessful endoscopic ligation trial, although her other actively bleeding MWT lesion had been ligated successfully. Results: After endoscopic ligation, all patients achieved complete hemostasis, and rebleeding did not occur. They were discharged without complications after a control endoscopy. Conclusions: Endoscopic ligation can be performed easily and without any complications such as perforation or delayed hemorrhage in patients with actively bleeding nonfibrotic MWTs.

The case of acute appendicitis and appendiceal duplication.

Abstract Background: Appendiceal anomalies are extremely rare malformations that are usually found in the adult population as an incidental finding during laparotomy performed for other reasons. Abnormal development of the appendix usually takes the form of a double appendix. Accompanying intestinal, genito-urinary or vertebral malformations may be present when appendiceal duplications are detected in childhood. Case Report : Presented herein is a case of perforated double appendix, which causes acute abdomen in a child, without any co-existing pathology. Conclusion : Appendiceal anomalies are of great practical importance and a surgeon must bear them in mind during an operation. If he overlooks them, the patient undergoing surgery may experience grave consequences. They also may be a forensic issue in cases when a second explorative laparotomy reveals ‘previously removed’ vermiform appendix.