Sadullah Girgin

Predicting factors for mortality in the penetrating abdominal trauma.

Abstract Purpose: penetrating abdominal trauma (PAT) is still a serious problem all over the world. This study was made to define and discuss the factors that could affect mortality in the PAT. Methods: the records of 1048 patients hospitalized and operated for PAT at Dicle University Hospital (DUH) between January 1990 and December 2001 were retrospectively reviewed. Patients (n = 1048) were divided into two groups: “Healthy Group” (HG) (n = 942) and “Deathly Group” (DG) (n = 106). The epidemiological and clinical features were evaluated as probable risk factors for mortality. The risk factors for mortality were revealed using univariate and multi-variate analyses. Results: a total of 1048 patients [937 (89.4%) male, 111(10.6%) female] with PAT were included in this study. The mortality rate (22.5%) of female patients was significantly higher than (8.6%) that of male patients (p = 0.000). The mean age was 30.01 ± 63.9 (14–74) years and 30 ± 12.5(15–71) years in the HG and DG consecutively (p = 0.85). The average interval between injury and operation (IBIO) was 2.09 ±1.3 (0.5–3) and 6.9 ±11.4 (1–6.1) hours in the HG and DG respectively (p = 0.000). Presence of shock on admission (PSDA) was determined in 87 patients and in 96 patients in the HG and DG respectively (p = 0.000). The mortality rate (14.9%) in patients presenting gunshot wounds (GSW) was significantly higher than (2.7%) that of patients with stab wounds (SW) (p = 0.000). The average number of injured intraabdominal organs (NIAOI) was 1.98 ±1.08 (1–7) and 4.67 ±1.99 (1-13) in the HG and DG respectively (p = 0.000). Mortality rates were 72.7% in cardiac injury, 30% in great vessels injuries, 32.6% in cranial injury, and 21.5% in major extremity and pelvic injury (p = 0.000). The average penetrating abdominal trauma index (PATI) was 11.78 ± 9.44 (158) and 46.24 ± 22.18 (15-119) in the HG and DG respectively (p = 0.000). In multivariate analyses, female gender [Odds Ratio (OR) = 10.74, 95% Confidence Interval (CI) = 3.03–38.12, P = 0.000], the long IBIO (OR = 1.82, CI = 1.39–2.40, P = 0.000), PSDA (OR = 94.45, CI = 28.32–314.95, P = 0.000), presence of cranial injury (OR = 0.03, CI = 0.002–0.363, P = 0.006) and high PATI (OR = 1.14, CI = 1.09–1.19, P = 0.000), were found significantly important for mortality. Conclusion: we determined that conditions such as, female gender, long interval between injury and operation, presence of shock on admission, presence of cranial injury and high PATI were predicting factors for mortality in PAT.

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.

Pilonidal sinus disease: risk factors for postoperative complications and recurrence.

The aim of this study is to analyze the risk factors for complications and recurrence in pilonidal sinus disease. The prospective study consisted of 144 patients with pilonidal sinus disease who were operated on at Dicle University Medical Faculty, Department of General Surgery, between February 2008 and December 2010. Patients receiving the Limberg flap totaled 106 (73.6%), while 38 (26.4%) had primary closure. Postoperative complications developed in 42 subjects (29.2%), and recurrence occurred in 19 (13.2%). The Limberg flap method was statistically considered as a risk factor for postoperative complications (P  =  0.039). Regarding recurrence, family tendency (P  =  0.011), sinus number (P  =  0.005), cavity diameter (P  =  0.002), and primary closure (P  =  0.001) were found to be risk factors. Postoperative complication rate is higher in the Limberg flap method than primary closure method. The risk of recurrence is related to family tendency, sinus number, cavity diameter and anesthesia type and is also higher in primary closure.

Unusual Noncommunicating Isolated Enteric Duplication Cyst in Adults

Duplication cysts are rare gastrointestinal congenital abnormalities and can occur anywhere within the gastrointestinal tract. Duplication cysts are firmly attached to or share the wall of the alimentary tract and have a common blood supply with the adjacent segment of the bowel. Completely isolated duplication cysts are an extremely rare variety of gastrointestinal duplications with their own exclusive blood supply, and they do not communicate with the intestine. These cysts are usually diagnosed during early childhood, and very rarely detected in adults, mostly incidentally, due to a lack of symptoms. A 28-year-old male was admitted to our hospital with a chief complaint of lower abdominal pain and distention and a palpable mass for 1 month. Based upon computed tomography and sonographic findings, a small bowel duplication cyst was tentatively diagnosed. The cyst had no connection to the gastrointestinal tract. Herein we report the case of a noncommunicating isolated ileal duplication cyst in an adult. Resection of the cyst was performed safely without requiring bowel resection.

Factors Affecting Morbidity and Mortality in Gangrenous Cholecystitis

Abstract Introduction: Gangrenous cholecystitis is a serious complication of acute cholecystitis. Male gender, older age, leukocytosis, cardio-vascular diseases and diabetes were reported as factors that increase the risk of gangrenous cholecystitis. The aim our study was to determine variables affecting morbidity and mortality as well as to define the independent risk factors in Gangrenous Cholecystitis. Methods: Fifty three patients who had been treated for Gangrenous Cholecystitis were reviewed. The variables are defined as follows: age, gender, systemic diseases, Mannheim Peritonitis index, aspartate aminotransferase, alanine aminotransferase, white blood cell count and type of surgery. In order to determine the independent risk factors that might affect morbidity and mortality in Gangrenous Cholecystitis, we made use of multivariate logistic regression analysis. Results: The independent risk factors affecting on morbidity were age (P = 0.037), existing systemic disease (P = 0.047) and > 29 Mannheim Peritonitis index (P = 0.008), and the independent risk factors affecting on mortality were age (P = 0.046), white blood cell count (P = 0.035). Pre-operative and post-operative third day aspartate aminotransferase and alanine aminotransferase average values were compared, there was a significant difference (P < 0.0001, P < 0.0001 respectively). Conclusions: We found that older age, > 29 Mannheim Peritonitis index and existence of systemic diseases were independent risk factors affecting morbidity. Older age and lower of white blood cell count were independent risk factors affecting mortality. We believe that further comprehensive studies, involving prospective, multi-center and a large number of patients, are needed.

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.

Fasciola hepatica infection at a University Clinic in Turkey

INTRODUCTION We aimed to analyze the approaches to the diagnosis and treatment of patients with fascioliasis in light of current literature. METHODOLOGY Thirty-nine patients with fascioliasis admitted to the Surgery Clinic of Dicle Medical Faculty (Turkey) were included in this study. The demographic, clinical, diagnostic, treatment and outcome data were analyzed retrospectively. RESULTS Abdominal pain (n = 37; 95%) and eosinophilia (n = 31; 79%) were the most common findings. Twenty-seven patients were diagnosed by clinical and radiological findings. Patients were treated with triclabendazole. Thirty-six (92.4%) of the patients improved after medical treatment. CONCLUSIONS The presence of typical clinical, laboratory and radiological findings is sufficient for diagnosis. Triclabendazole administration is often an effective treatment, with improvements occurring over the course of a few months.

The Reliability of Fine-Needle Aspiration Biopsy in Terms of Malignancy in Patients With Hashimoto Thyroiditis

The aim of this study was to analyze the presence of malignancy in patients with Hashimotos thyroiditis and to investigate the reliability of preoperative fine-needle aspiration biopsy (FNAB). The retrospective study included 44 patients who were operated on for nodular goiter between December 2010 and October 2011. The patients underwent thyroidectomy following a cytologic analysis plus FNAB. Hashimotos thyroiditis was confirmed on histopathology in all patients. FNAB results were defined as benign in 14 (31.8%), suspicion for malignancy in 17 (38.6%), malignant in 9 (20.5%), and inadequate in 4 (9.1%). Following the thyroidectomy, presence of papillary thyroid carcinoma and follicular variant of papillary thyroid carcinoma were detected in 10 patients (22.7%) and 1 (2.3%) patient, respectively. The FNAB results were interpreted in terms of malignancy, which revealed the sensitivity as 80%; specificity, 40%; false positives, 69.2%; false negatives, 14.3%; positive predictive value, 31.8%; negative predictive value, 85.7%; and diagnostic accuracy, 50%. The coexistence of Hashimotos thyroiditis with papillary thyroid carcinoma is quite common. The FNAB results for such cases are hard to evaluate, and they are likely to increase the number of false positives.

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.

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.