Management and Morbidity of Major Pelvic Hemorrhage in Complex Abdominopelvic Surgery.

INTRODUCTION: Hemorrhage is a challenging complication of pelvic surgery. This study aimed to analyze the causes, management, and factors associated with morbidity in patients experiencing major pelvic hemorrhage during complex abdominopelvic surgery. METHODS: Patients who had major intraoperative pelvic hemorrhage during complex abdominopelvic surgery at 11 tertiary referral centers between 1997 and 2017 were included. Patient characteristics, management strategies to control bleeding, short- and long-term postoperative outcomes were evaluated retrospectively. RESULTS: There were 120 patients with a mean age of 56.6 ± 2.4 years and a mean BMI of 28.3 ± 1 kg/m2. While 104 (95%) of the patients were operated for malignancy, 16 (5%) of the patients had surgery for a benign disease. The most common bleeding site was the presacral venous plexus 90 (75%). Major pelvic hemorrhage was managed simultaneously in 114 (95%) patients. Electrocauterization 27 (23%), pelvic packing 26 (22%), suturing 7 (6%), thumbtacks application 7 (6%), muscle welding 4 (4%), use of energy devices 2 (2%), and topical hemostatic agents 2 (2%) were the management tools. Combined techniques were used in 43 (36%) patients. Short-term morbidity and mortality rates were 48 (40%) and 2 (2%), respectively. High preoperative CRP levels (p = 0.04), history of preoperative radiotherapy (p = 0.04), longer bleeding time (p = 0.006), and increased blood transfusion (p = 0.005) were the factors associated with postoperative morbidity. CONCLUSION: Postoperative morbidity related to major pelvic hemorrhage can be reduced by optimizing the risk factors. Prehabilitation prior to surgery to moderate inflammatory status and prompt action with proper technique to control major pelvic hemorrhage can prevent excessive blood loss in complex abdominopelvic surgery.

Surgical treatment of caustic esophageal strictures in adults.

BACKGROUND AND AIMS: Caustic esophageal injury is a rare clinical condition in adult patients. Although dilatation, or the conservative approach, is the primary treatment method, some patients require surgical intervention. Because of the rarity of such cases, standard surgical treatment algorithms cannot be utilized. In this article, we present our surgical experience and discuss the challenges in the surgical management of corrosive injury of the esophagus in adults. METHODS: A retrospective review was conducted of 28 patients who suffered from a corrosive esophageal injury between 1996 and 2011. Patient demographics, history of corrosive material ingestion, preoperative findings, treatment strategy, operative technique, postoperative course, requirements for further treatment, and the current status of the patients were investigated. RESULTS: All patients underwent a transhiatal esophagectomy in addition to a gastric pull-up with a cervical esophagogastrostomy. The mean follow-up time was 62 (12-140) months. One patient developed a deep surgical infection; anastomotic stenosis was noted and treated with dilatation in 13 patients. The mean time period between the operation and the first dilatation for 12 patients was 81 (45-161) days. The mean dilatation count for the patients was 3 (1-10). CONCLUSION: Although it comes with high anastomotic stenosis rates, transhiatal esophagectomy and gastric pull-up with cervical anastomosis is a safe procedure, which can be performed for the treatment of corrosive esophageal stricture.

The use of single port surgery for polyps located in the rectum.

Transanal endoscopic microsurgery is a minimally invasive technique for the treatment of rectal lesions which was introduced by Buess. In this report the first clinical experience of transanal endoscopic surgery was performed by a single incision laparoscopic surgical port adapted through the anal canal. In single port surgery, the single incision laparoscopic surgical port has to be stitched around anal orifice. There is no need to use a fixation apparatus. In transanal endoscopic microsurgery procedure, a rigid rectoscope 40 mm in diameter is introduced into the anus by stretching anal sphincter. A single incision laparoscopic surgical port can be disposed through the anal canal where there is no harmful cause because it is made an elastic. The dissection in the transanal endoscopic microsurgery procedure needs specific equipment to improve the surgery; however we could complete the surgical dissection using standard laparoscopic devices with articulated ones. The other factor makes single port surgery easier than transanal endoscopic microsurgery procedure is insufflation. It is easy and controlled way to be insufflated by a particular pump and cheaper than any insufflators. Furthermore, in the operating room, the patient's position on the table was not a limiting factor. As a conclusion, we report that for selected patients, single port surgery can be performed using a single incision laparoscopic surgical port as an adjusted surgical technique. It gives safe and feasible way to remove benign and malign polyps and tumors up to 20 cm in the rectum.

The effects of amlodipine on the biochemical and histopathological changes in the rabbit ileum subjected to ischemia-reperfusion.

OBJECTIVE: The aim of this study was to determine the potential, protective effects of amlodipine in an experimental, ischemia-reperfusion (I/R) model in the rabbit small intestine. MATERIALS AND METHODS: The rabbits were divided into four groups: sham-operated, amlodipine (10 mg/kg) + sham-operated, I/R, and I/R + amlodipine (10 mg/kg) groups. An intestinal I/R model was applied to the rabbits. The superior mesenteric artery was occluded for 1 h with an atraumatic vascular clamp and then was reperfused for 2 h. Animals in the amlodipine and I/R + amlodipine groups received the amlodipine by oral gavage. At the end of the 2-h-reperfusion period, the animals were sacrificed. RESULTS: Pretreatment with amlodipine significantly increased SOD activity and GSH levels to values close to those found in the serum from the I/R group. Rabbits in the I/R group showed high levels of serum MDA. Amlodipine pretreatment significantly reduced the serum MDA levels compared to the I/R group, although the MDA levels in the I/R + amlodipine group were still higher than in the sham-operated group. The I/R damage was ameliorated by amlodipine pretreatment, as evidenced by histopathological analysis. CONCLUSION: The present study is the first to report an attenuation of I/R-induced intestinal injury by the systemic administration of amlodipine.

Comparison of permissive hypotensive resuscitation, low-volume fluid resuscitation, and aggressive fluid resuscitation therapy approaches in an experimental uncontrolled hemorrhagic shock model.

BACKGROUND: In this study, we aimed to compare the efficacy of aggressive fluid resuscitation, low-volume fluid resuscitation and permissive hypotensive resuscitation in an experimental uncontrolled hemorrhagic shock model. METHODS: Forty-four male Guinea pigs were used in the study in an experimental uncontrolled shock model. Guinea pigs were split into six groups including normovolemic-normotensive fluid treatment group, normovolemic-permissive hypotensive fluid treatment group, low-volume normotensive fluid treatment group, low-volume permissive hypotensive fluid treatment group, no treatment (n=6), and sham-operated groups (n=6). Resuscitation was initiated when mean arterial pressure (MAP) reached 30 mmHg. In the permissive hypotensive resuscitation group, fluid treatment continued until MAP reached 45+/-5 mmHg and in the aggressive fluid groups until MAP reached 60+/-5 mmHg. Resuscitation fluid was hetastarch 6% (hydroxyethyl starch) in the low-volume fluid groups and Ringer's lactate in the normovolemic fluid groups. RESULTS: Mean survival time was 122.75+/-4.83 min in the normovolemic-normotensive fluid group, 130.87+/-16.31 min in the normovolemic-permissive hypotensive group, 122.12+/-11.53 min in the low-volume-normotensive fluid group, and 152.25+/-9.10 min in the low-volume-permissive hypotensive fluid group. Survival time was found significantly higher in the group in which low-volume-permissive hypotensive fluid treatment was applied than in the other groups. CONCLUSION: When pressure effect was compared during treatment, permissive-hypotensive resuscitation was found more effective in both groups that received colloid and crystalloid treatment.

Can D-dimer become a new diagnostic parameter for acute appendicitis?

INTRODUCTION: In this study, we investigated D-dimer serum level as a diagnostic parameter for acute appendicitis. MATERIALS AND METHODS: Forty-nine patients were enrolled in the study. Patients were classified according to age; sex; duration between the beginning of pain and referral to a hospital or clinic; Alvarado scores; and in physical examination, presence of muscular defense, the number of leukocytes, preoperative ultrasonography, and D-dimer levels of histopathologic study groups were analyzed. RESULTS: Of the patients enrolled in the study, 26.5% were females and 73.5% males. The average age was 21 years (range, 16-38 years) and 81.7% acute appendicitis (AA). According the duration of pain, 63.2% of the patients were referred to the hospital within the first 24 hours, 26.5% of the patients were referred to the hospital within 24 to 48 hours, and 10.3% were referred to the hospital within a period of more than 48 hours. No statistically significant difference was determined regarding D-dimer levels between the histopathologic study groups (P > .05). Alvarado scores lower than 7 were found in 36.7% and 7 or higher in 63.3% of the patients. There was no statistically significant difference related with D-dimer levels between histopathologic study groups (P > .05). The ratio of cases with a number of leukocytes below the upper limit were determined respectively as 32.7% and 67.3%, and no statistically significant difference was found regarding d-dimer levels between histopathologic study groups (P > .05). CONCLUSION: Increased D-dimer levels should not be considered as a diagnostic parameter in diagnosis of acute appendicitis.

Is the zeolite hemostatic agent beneficial in reducing blood loss during arterial injury?

BACKGROUND: Uncontrolled hemorrhage is the leading cause of fatality. The aim of this study was to evaluate the effect of zeolite mineral (QuikClot - Advanced Clotting Sponge [QC-ACS]) on blood loss and physiological variables in a swine extremity arterial injury model. METHODS: Sixteen swine were used. Oblique groin incision was created and a 5 mm incision was made. The animals were allocated to: control group (n: 6): Pressure dressing was applied with manual pressure over gauze sponge; or QC group (n: 10): QC was directly applied over lacerated femoral artery. Mean arterial pressure, blood loss and physiological parameters were measured during the study period. RESULTS: Application of QC led to a slower drop in blood pressure. The control group had a significantly higher increase in lactate within 60 minutes. The mean prothrombin time in the control group was significantly increased at 60 minutes. The application of QC led to decreased total blood loss. The QC group had significantly higher hematocrit levels. QC application generated a significant heat production. There were mild edematous and vacuolar changes in nerve samples. CONCLUSION: According to the physiological parameters, we observed that zeolite tends to reduce blood loss, however could not stop bleeding completely. We believe that further clinical trials are needed to conclude that zeolite could be used in the routine practice.

Increased damage from rifle wounds of the chest caused by bullets striking commonly carried military equipment.

BACKGROUND: The purpose of this study was to investigate the fragmentation effect of the bullet that passes through the radio or ammunition magazine, which are essential pieces of equipment for a soldier, in thoracic gunshot injuries. METHODS: Twelve adult pigs were used. The pigs were separated into three groups (each group contained four pigs). The first group was shot without any obstacle between muzzle and subject. The second group was shot through a cartridge magazine placed in front of the subject's thoracic cage. The third group was shot with a radio in front of the subject's thoracic cage. RESULTS: It was observed that there was a large bullet entrance and fragmentation in the pigs that were shot with a radio or magazine placed over them, and there was no fragmentation in those that were shot without any obstacle. CONCLUSION: Metal equipment that soldiers carry causes bullet fragmentation. Fragmented bullets may cause excessive tissue disruption of intrathoracic vital organs.

[Comparison of soft tissue and bone injuries caused by handgun or rifle bullets: an experimental study]. / Tabanca ve piyade tüfegi mermileri ile olusturulan yumusak doku ve kemik yaralanmalarinin karsilastirilmasi: deneysel çalisma.

OBJECTIVES: The aim of this study was to investigate the factors that influence the severity of soft tissue and bone injuries occurring in gunshot traumas and to compare the effects of handgun and rifle bullets on these injuries. METHODS: Sixteen tissue simulants which were made of transparent gel candle blocks and calibrated to muscle tissue were targetted by pistol (9 mm parabellum) or military rifle (G-3) bullets. Half of the blocks contained fresh calf humerus bone. The effects of the bullets in tissue simulants were monitored by using high velocity cameras capable of taking 1,000 views per second. RESULTS: On a millisecond time scale, handgun bullets produced a small-sized temporary cavity while rifle bullets produced a wide temporary cavity in isolated soft tissue simulants. It was shown that the differences in the size of temporary cavities resulting from the blast effect correlated highly with the severity of injury occurring in soft tissues. In samples at which calf humerus bone was targetted, we observed that fragmentation and cavity effects correlated highly with the velocity of the bullet and determined the severity of injury. CONCLUSION: Experimental demonstration of differences in the size and severity of injuries caused by handgun or rifle bullets may have significant implications in the planning of treatment.

A new ballistic simulant "transparent gel candle" (experimental study).

BACKGROUND: Inanimate tissue stimulants have been used to show the bullet effects in ballistic studies. Gelatin has been being used as a ballistic stimulant for the last 20 years. It was considered that transparent gel candle (kraton in white paraffin oil) might be used as a soft tissue stimulant that can be an alternative for gelatin. METHODS: For calibration of transplant gel candle, firstly it was shot at the 10% ordinance gelatin at 4 o C, and several concentrations of the transparent gel candle at 4 o C, by later on, by using a competition air gun. It was seen that 15% kraton in 85% white paraffin oil is the most suitable concentration. This kind of transparent gel candle blocks tested by using 9 mm parabellum and 7.62 mm x 51 (NATO 7.62) infantry rifle bullets and high-speed camera. RESULTS: Because of its transparency and elasticity, the penetration, permanent and temporary cavities of bullets were observed clearly in transparent gel candle. CONCLUSIONS: As a result, transparent gel candle is a good soft tissue stimulant that it can be used in wound ballistic studies.

The magazine: a major cause of bullet fragmentation.

The fragmentation impact of high-velocity bullets penetrating the body after piercing through the magazines carried by soldiers was investigated experimentally. In this study, 16 pigs and 7.62x51-mm full metal jacket bullets were used. Pigs were assigned into two groups, and within 5 minutes of their being sacrificed with overdose anesthesia, bullets were fired into the first group on which magazines were placed and into the second group on which magazines were not placed, targeting abdominal left lower quadrant. It was found that in pigs not carrying magazines, all bullets pierced through the pig; bullets were not fragmented. However, in pigs with magazines, common fragmentation in bullets and multiple organ perforations occurred. It was concluded that magazines caused the bullets to be fragmented, increasing tissue and organ damage.