Korhan Taviloglu

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.

Fat Embolism Syndrome

Fat embolism syndrome (FES) was first described in 1862, but its frequency today is still unclear. A diagnosis of FES is often missed because of a subclinical illness or coexisting confusing injuries or disease. Fat embolism syndrome develops most commonly after orthopedic injuries, but it has also been reported after other forms of trauma such as severe burns, liver injury, closed-chest cardiac massage, bone marrow transplantation, and liposuction. Although FES usually presents as a multisystem disorder, the most seriously affected organs are the lung, brain, cardiovascular system, and skin. Fat embolism syndrome is a self-limiting disease and treatment should be mainly supportive. Many drugs have been used to treat FES, but the results are inconclusive.

Complicated intra-abdominal infections in Europe: a comprehensive review of the CIAO study

The CIAO Study (“C omplicated Intra-A bdominal infection O bservational” Study) is a multicenter investigation performed in 68 medical institutions throughout Europe over the course of a 6-month observational period (January-June 2012).Patients with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study.2,152 patients with a mean age of 53.8 years (range: 4–98 years) were enrolled in the study. 46.3% of the patients were women and 53.7% were men. Intraperitoneal specimens were collected from 62.2% of the enrolled patients, and from these samples, a variety of microorganisms were collectively identified.The overall mortality rate was 7.5% (163/2.152).According to multivariate analysis of the compiled data, several criteria were found to be independent variables predictive of patient mortality, including patient age, the presence of an intestinal non-appendicular source of infection (colonic non-diverticular perforation, complicated diverticulitis, small bowel perforation), a delayed initial intervention (a delay exceeding 24 hours), sepsis and septic shock in the immediate post-operative period, and ICU admission.Given the sweeping geographical distribution of the participating medical centers, the CIAO Study gives an accurate description of the epidemiological, clinical, microbiological, and treatment profiles of complicated intra-abdominal infections (IAIs) throughout Europe.

Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds.

Background: The modern management of penetrating abdominal trauma has decreased the incidence of unnecessary laparotomy by using selective non-operative management protocols. However, the real benefits of physical examination and different diagnostic methods are still unclear. Methods: From January 2000 to April 2003, we prospectively collected data on 117 patients with penetrating stab wounds to the thoracoabdominal, anterior abdominal, and back regions who had non-operative management. Clinical examination was the primary tool to differentiate those patients requiring operation. Findings of physical examination, ultrasound, computed tomography, endoscopy, echocardiography, diagnostic peritoneal lavage, and diagnostic laparoscopy were reviewed. The number of therapeutic, non-therapeutic, and negative laparotomies were recorded. Results: Non-operative management was successful in 79% of patients. There were 11 early (within 8 hours of admission) and 14 delayed (more than 8 hours after admission) laparotomies performed, depending on the results of various diagnostic procedures. Non-operative management failed in 21% of patients, and the rate of non-therapeutic laparotomy in early and delayed laparatomy groups was 9% and 14% respectively. There was no negative laparatomy. Conclusions: The use of physical examination alone and/or together with different diagnostic methods allows reduction of non-therapeutic laparotomies and elimination of negative laparatomies.

The European experience with vascular injuries

The rich and diverse heritage of the management of vascular injuries in the 45 independent European countries prevents the authors from revealing a uniform picture of the European experience, but some trends are clearly emerging. In countries with a low incidence of penetrating trauma and increasing use of interventional vascular procedures, the proportion of iatrogenic vascular trauma exceeds 40% of all vascular injuries, whereas on other parts of the continent, armed conflicts are still a major cause of vascular trauma. National vascular registries, mostly in the Scandinavian countries, produce useful, nationwide data about vascular trauma and its management but suffer still from inadequate data collection. Despite a relatively low incidence of vascular trauma in most European countries, the results are satisfactory, probably in most cases because of active and early management by surgeons on call, whether with vascular training or not, treating all kinds of vascular surgical emergencies. In some countries, attempts at developing a trauma and emergency surgical specialty, including expertise in the management of vascular injuries, are on their way.

World Society of Emergency Surgery (WSES) guidelines for management of skin and soft tissue infections

Skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions ranging from simple superficial infections to severe necrotizing soft tissue infections. Necrotizing soft tissue infections (NSTIs) are potentially life-threatening infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Successful management of NSTIs involves prompt recognition, timely surgical debridement or drainage, resuscitation and appropriate antibiotic therapy. A worldwide international panel of experts developed evidence-based guidelines for management of soft tissue infections. The multifaceted nature of these infections has led to a collaboration among surgeons, intensive care and infectious diseases specialists, who have shared these guidelines, implementing clinical practice recommendations.

Necrotizing fasciitis: strategies for diagnosis and management

Necrotizing fasciitis (NF) is uncommon and difficult to diagnose, and it cause progressive morbidity until the infectious process is diagnosed and treated medically and surgically. The literature addressed NF contains confusing information, inaccurate bacteriologic data, and antiquated antibiotic therapy. A delay in diagnosis is associated with a grave prognosis and increased mortality. The main goal of the clinician must be to establish the diagnosis and initially treat the patient within the standard of care. This review is planned as a guide for the clinician in making an early diagnosis of NF and initiating effective medical and surgical therapy.

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.

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.