Ercan Gedik

The evaluation of microbiology and Fournier's gangrene severity index in 27 patients

OBJECTIVES The objectives of this study were to identify the causative microorganisms and factors associated with survival in patients with Fourniers gangrene and to determine the accuracy of the Fourniers gangrene severity index. MATERIALS AND METHODS We retrospectively evaluated 27 patients with Fourniers gangrene who were treated and followed up at our hospital between January 2005 and December 2006. Biochemical, hematologic, and bacteriologic study results at admission and at the final evaluation, etiologic and predisposing factors at admission, physical examination findings, the timing and extent of surgical debridement, and antibiotic therapy used were all recorded. RESULTS The admission laboratory parameters that were significantly correlated with outcome included urea, creatinine, sodium, and potassium; at the final evaluation, in addition to these parameters, hematocrit, albumin, and bicarbonate levels were also significantly associated with outcome. The mean Fourniers gangrene severity index score (FGSIS) at admission for survivors was 5.04+/-2.49 compared with 13.6+/-4.61 for non-survivors. There was a strong correlation between the FGSIS and mortality (p<0.0001). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated microorganisms. CONCLUSIONS Patient metabolic status and predisposing factors are important in the prognosis of Fourniers gangrene. Hence, we believe that the FGSIS should be used clinically to evaluate therapeutic options and assess results.

Iloprost, a prostacyclin (PGI2) analogue, reduces liver injury in hepatic ischemiareperfusion in rats

PURPOSE To evaluate the effects of iloprost a prostacyclin analogue on the hepatic IR injury in rats. METHODS Forty male Sprague-Dawley rats (250-300 g) were divided into four groups each containing 10 rats;(1)--controls: data from unmanipulated animals; (2) sham group: rats subjected to the surgical procedure, except for liver I/R, and given saline; (3) I/R group: rats that underwent liver ischemia for 45 min followed by reperfusion for 45 min; (4) IR/ Iloprost group: rats pretreated with iloprost (10 microg kg-1, i.v). Liver tissues were taken to determine SOD, CAT, GSH, and MDA levels and for biochemical and histological evaluation. RESULTS The plasma ALT and AST levels were increased in group 3 than in group 4. MDA values and the liver injury score decreased, while the SOD, CAT, and GSH values increased in group 4 compared to group 3. In group 3, hepatocytes were swollen with marked vacuolization. In group 4, there were regular sinusoidal structures with normal morphology without any signs of congestion. CONCLUSION We demonstrated hepatoprotective effects of iloprost against severe ischemia and reperfusion injury in rat liver.

Splenic injuries: factors affecting the outcome of non-operative management

PurposeThe aim of this study was to evaluate the outcome of non-operative management (NOM) in patients with splenic injuries and to determine the predictive factors of NOM failure.MethodsTwo hundred and six patients with splenic injury were admitted between January 2005 and April 2011. Of the 206 patients with splenic injury, 47 patients met the inclusion criteria of NOM. The mechanism of injury, grade of splenic injury, other intra- and extra-abdominal injuries, systolic blood pressure on admission, hemoglobin levels, number of transfusions, Injury Severity Score (ISS), Glasgow Coma Scale score, and hospitalization period were recorded. The patients were divided into two groups: those with NOM and those in whom the failure of NOM led to laparotomy. The patients were monitored for vital signs, abdominal findings, and laboratory data. NOM was abandoned in cases of hemodynamic instability, ongoing bleeding, or development of peritonitis. Independent predictive factors of NOM failure were identified. The patients managed non-operatively were compared with the patients for whom NOM failed.ResultsNOM was successful in 40 of 47 patients. There were differences between the two groups for ISS, hemoglobin levels, need for blood transfusion, and the number of associated extra-abdominal injuries. The grade of splenic injury was determined to be an important and significant independent predictive factor for the success of NOM of splenic injuries.ConclusionsThe grade of splenic injury is an important and significant independent predictor factor for the success of NOM. NOM is not recommended in patients with high-grade splenic injury.

Pyogenic liver abscess caused by community-acquired multidrug resistance Pseudomonas aeruginosa.

Correspondence to: Mehmet Ulug, MD BSK Anadolu Hospital, Department of Infectious Diseases and Clinic Microbiology, 43100 Kutahya, Turkey Phone (mobile): +90-532-4475756 Fax: +90-274-2244433 E-mail: mehmetulug21@ yahoo.com Pyogenic liver abscess (PLA) is a very uncommon liver disease affecting predominantly young males in the setting of intra-abdominal infection. PLA can be caused by several organisms. An uncommon case of PLA caused by multidrug resistant (MDR) Pseudomonas aeruginosa is described. A previously healthy 28-year-old man was admitted to our clinic with a two weeks history of pain in the right upper abdomen, followed by fever, chills, and vomiting. On admission day, physical examination revealed that he was in pain and feverish (38.6° C), and had hepatomegaly. Laboratory fi ndings included total white blood cell (WBC) count of 14,800/mm, erythrocyte sedimentation rate was 87 mm/h with a C-reactive protein (CRP) measuring 63 mg/dL (range, 0-8 mg/dL), and total bilirubin, alanine aminotransferase, aspartate aminotransferase, gamma glutamyl transpeptidase, alkaline phosphatase were within normal limits. Abdominal ultrasonography (US) showed solid mass at right hepatic lobe, which suggested a liver abscess, according to clinical fi ndings. It was also confi rmed by abdominal computed tomography (CT). The abscess was localized with transverse CT images and percutaneous drainage with 20 Fr gauge was performed. Fluid samples were sent for microbiological cultures. He was initially treated with ceftriaxone 2 g/day plus metronidazole 1 g/day with no improvement. After three days, the aspiration culture grew MDR P. aeruginosa. The bacteriological resistance results led us to change the initial treatment to imipenem 2 g/day plus amikacin 1.5 g/day for four weeks. The patient was discharged 21 days after admission without evidence of any complication. Despite continuous improvement in image modalities, availability of potent antibiotics and advancement in the knowledge and treatment of PLA, morbidity and mortality remains high. Its incidence ranges from 0.008 to 0.0022% in hospitalized patients. The diagnosis of PLA was based on clinical fi ndings and evidence from imaging studies, either abdominal US or CT. Treatment with intravenous antibiotics and application of catheter drainage or aspiration are the primary therapeutic strategies. The most common pathogenic agents, which enter the liver by vascular routes, are Escherichia coli, Klebsiella pneumoniae, Salmonella typhi, Proteus vulgaris, streptococci, and staphylococci, but anaerobes may also be present. Nevertheless, P. aeruginosa has long been regarded as a relatively rare pathogen of PLA, especially in patients without underlying conditions, such as lung and renal disease, malignancies, organ transplantation, immunosuppression. P. aeruginosa was defi ned as being MDR when the organism was resistant to all agents studied (ampicillin, amoxicillin-clavulanate, ceftriaxone, ceftazidime, cefepime, aztreonam, chloramphenicol, ciprofl oxacin, gentamicin, piperacillin, and trimetoprim-sulfamethoxazole), except imipenem, amikacin, and colistina. When searching Pub Med, we fi nd only one case report of PLA caused by P. aeruginosa, but it was not MDR. On the other hand, PLA caused by P. aeruginosa was seen 2-6% in literature, and this is the fi rst case of PLA caused by community-acquired MDR P. aeruginosa in literature. The incidence of MDR P. aeruginosa increased in recent years. For this reason, we attach great importance to the rational use of antibiotics in inpatients and outpatients.

Antioxidant support in composite musculo-adipose-fasciocutaneous flap applications: An experimental study

Abstract Free radicals are chemicals that play roles in the etio-pathogenesis of ischaemia-reperfusion injury. Various antioxidants have been used in an attempt to mitigate the damage induced by these chemicals. In the present study, the antioxidative effects of grape seed extract (proanthocyanidin), tomato extract (lycopene), and vitamin C (ascorbic acid) on a composite re-established-flow inferior epigastric artery based rectus abdominis muscle-skin flap model on which experimental ischaemia was induced were investigated. The rats have been administered antioxidants for 2 weeks prior to the surgery and for 2 more weeks thereafter. Macroscopic, histopathological, and biochemical analyses were carried out at the decision of the experiment. It was found that flap skin island necrosis was significantly reduced in the proanthocyanidin, lycopene, vitamin C groups (p < 0.001). Statistical analyses showed significant decreases in inflammation, oedema, congestion, and granulation tissue in the proanthocyanidin and lycopene groups compared to the vitamin C and control groups (p < 0.001). When the viability rates of fat and muscle tissues were examined, significant improvements were found in the proanthocyanidin and lycopene groups in comparison to the other groups (p < 0.001). Serum antioxidant capacity measurements revealed significant differences in the lycopene group compared to all other groups (p < 0.001). It is concluded that lycopene and proanthocyanidin are protective antioxidants in rat composite muscle-skin flap ischaemia-reperfusion models.

Intraperitoneal octenidindihydro-chloride – phenoxyethanol solution to prevent peritoneal adhesion formation in a rat peritonitis model

Background. Peritoneal adhesion is a common complication following abdominal surgery. Despite recent advances in diagnosis and treatment, it still presents a problem for the patients and surgeons. In the present study, we investigated the effects of octenidindihydro‐chloride – phenoxyethanol (OCP) on peritoneal adhesions. Method. Rats were divided into four groups: Group 1 (saline), Group 2 (peritonitis plus saline), Group 3 (OCP), and Group 4 (peritonitis plus OCP). Peritonitis was induced in the rats of Groups 2 and 4. The abdominal cavities of the rats in Groups 1 and 2 were washed with saline, while those of the rats in Groups 3 and 4 were irrigated with 1:10 OCP solution. Adhesion and fibrotic scores were determined by re‐laparotomy after 21 days. Results. The adhesion scores in Groups 1 (saline), 2 (peritonitis plus saline), 3 (OCP) and 4 (peritonitis plus OCP) were 3.30±0.94, 5.25±1.03, 1.12±0.83 and 0.28±0.48, respectively. Statistical analysis of adhesion scores revealed significant differences between groups, except between Groups 3 and 4 (p = 0.265). Statistical analyses of grades of histopathological signs showed that Group 1 differed from Groups 2 and 4 (p = 0.004, p = 0.003, respectively); Group 2 differed from Groups 3 and 4 (p = 0.001, p = 0.001, respectively). On the other hand, differences between Group 3 and Groups 1 and 4 were not significant (p = 0.06, p = 0.08, respectively). Conclusion. OCP decreased the peritoneal adhesion formation macroscopically and microscopically in the presence or absence of peritonitis. Peritoneal defects due to trauma are to be left open and OCP diluted 1:1 should not be used intraperitoneally.

Relaparotomies: Why is Mortality Higher?

Background:Relaparotomy is sometimes required for complications that develop after abdominal surgery, but it is associated with high mortality. We aimed to investigate the independent risk factors related to mortality in patients that undergo relaparotomies.Materials and Methods:One hundred and fourteen patients who had relaparatomies were evaluated. Risk factors studied were patient characteristics, cause of the first operation, condition of the first operation, systemic diseases, presence of peritonitis, relaparotomy interval, cause of relaparatomy, APACHE II score, transfused blood units, number of relaparatomies, length of hospital stay, and mortality. In order to determine the independent risk factors, we carried out multivariate logistic regression analysis.Results:There were 75 male and 39 female patients with a mean age of 46.06 ± 19.98 (15–84). The most common reasons for relaparotomy were leakage from intestinal primary repair or anastomosis (29.8%). Mortality developed in 55 (48.2%) patients undergoing relaparatomy. Intestinal necrosis (p = 0038) and intraabdominal sepsis (p = 0.027) were found to be risk factors in mortality. In multivariate logistic regression analysis, advanced age (OR 0.966, p = 0. 0.017) and APACHE II score ≥ 20 (OR 0.137, p < 0.0001) were found to be independent risk factors affecting mortality.Conclusion:Advanced age and APACHE II score ≥ 20 were found to be independent risk factors affecting relaparotomy-related mortality.