Is diagnostic laparoscopy necessary in the management of left thoracoabdominal stab wounds?

BACKGROUND: The diagnosis of a diaphragmatic rupture and the identification of patients for surgical repair is challenging despite current diagnostic algorithms and imaging technologies. Unless treated on time, acute traumatic diaphragmatic injury due to stab wounds has a high mortality and morbidity rate, with an increasing trend in the presence of organ herniation. In this study, we aimed to investigate the efficacy of diagnostic laparoscopy in patients with an anterior thoracoabdominal stab wound and to compare the follow-up outcomes of cases. METHODS: We retrospectively reviewed our institutional database of patients who were admitted with stab wounds between Oc-tober 2012 and 2022. Patients who underwent diagnostic laparoscopy were divided into two groups depending on the presence of a diaphragmatic injury. We analyzed demographics, the success of computed tomography (CT) imaging in the diagnosis, the presence of hemomediastinum, pneumomediastinum, tube thoracostomy application, associated organ injury, type of surgery, duration of surgery, complications, and the length of stay between the groups. RESULTS: Of the 39 patients with penetrating left thoracoabdominal injury underwent diagnostic laparoscopy, CT had a diagnostic sensitivity of 63.16% (95% Confidence interval [CI] 38.36-83.71%), and a specificity of 100% (95% CI 82.35-100.00%). We could not find a statistically significant difference between the groups in terms of studied variables, while operation time was significantly higher in the diaphragmatic injury group (P<0.01). Fourteen patients had accompanied visceral injuries. CONCLUSION: Diagnostic laparoscopy is still the gold standard particularly in the ER setting, particularly in the absence of an experienced radiologist for 24 h and when the close monitoring of the patient by the same team cannot be provided.

The role of tissue inhibitor of metalloproteinases in the aetiology of inguinal and incisional hernias.

Inguinal and incisional hernias are the two most common types of hernias caused by abdominal wall weakness and defects in connective tissue. The structure of the extracellular matrix, mainly collagen and metalloproteinases (MMPs), and their regulators have been studied extensively and found to play a significant role in the pathophysiology of hernias. One of the regulators of MMPs, tissue inhibitor metalloproteinases (TIMPs), bind to MMPs and inhibit its activity significantly shifting the balance towards collagen synthesis rather than degradation. Due to their importance in collagen metabolism, their metabolism might be significant in the aetiology of hernias. Our study used immunohistochemical techniques to investigate the possible effects of TIMP 1 and 2 on the samples taken from the abdominal walls of patients with inguinal and incisional hernias, compared them with control patients, and reviewed the literature. In this study, samples of 90 patients (30 patients from control, inguinal hernia, and incisional hernia groups) were taken and analysed. These samples were stained with TIMP-1 Ab-2 and TIMP2 Ab-5 (Clone 3A4) antibodies and evaluated under ×100 magnification. The degree of staining was classified as (a): No staining (0), (b): Staining less than 10% (I), (c): Staining between 10% and 50% (II), (d): Staining more than 50% (III). Statistical analyses were done. No significant difference was found between groups in terms of patient demographics. Smoking and family history of hernia was not found to be associated with TIMP expression. TIMP1 expression was significantly higher in the incisional and inguinal hernia group than in the control group (P < .05), while the level of TIMP2 was higher in the control group. (P < .05). TIMP1 and TIMP2 levels did not significantly differ between incisional and inguinal hernia groups. We found significantly increased TIMP-1 levels in tissue samples from patients with hernia supporting its suggested role in hernia pathophysiology. Local alterations in MMP and TIMP levels might play a role in the pathogenesis of hernias. Thus detection of TIMP in tissues can be important for clinical use after further validation studies. In the era of molecular medicine, detecting TIMP levels in hernia patients can impact clinical practice.

Factors predicting severity level, progression and recurrence risk of acute left colonic diverticulitis in Turkey: A multicenter study.

BACKGROUND: Acute left colonic diverticulitis (ALCD) ranges from localized diverticulitis to perforation and fecal peritonitis, and treatment varies from conservative management to emergency surgery. The risk factors for recurrence following nonoperative management of ALCD is still controversial. We aimed to define the factors predicting severity level, progression and recurrence risk of ALCD to timely select patients requiring surgery. METHODS: This is a multicenter study where patients were included on accrual. Patients in our clinic between December 2017 and June 2019 with ALCD above 18 years of age were included (n=144) in this study, while 18 years and younger, pregnant or nursing mothers, those with Crohn's disease, ulcerative colitis, colorectal and/or anal cancer were excluded from this study. Laboratory parameters, Modified Hinchey Scores, clinical features, demographics, diet, smoking, alcohol consumption, body mass index, previous diverticulitis episodes, chronic diseases of patients with ALCD, as well as recurrences within 18 months after discharge were evaluated. RESULTS: The findings showed that smoking was more common in patients with previous episodes (p=0.04) and patients who underwent emergency surgery (p=0.04). Recurrence was higher in Modified Hinchey 1b and 2 (p=0.03) than 0 and 1a. Patients who were older than 50y had a higher propensity to undergo emergency surgery than the patients younger than 50y (p=0.049). Nausea, fever, respiratory rate, procalcitonin, total bilirubin and direct bilirubin levels were higher in patients with Modified Hinchey 4 (p=0.03, 0.049, 0.02, 0.001, 0.002, 0.001, respectively). Recurrence was higher in patients with a smoking history, previous ALCD episodes, lower body mass index and pandiverticulitis. CONCLUSION: Laboratory parameters, body mass index, age, clinical features, previous episodes of diverticulitis and smoking may predict the severity and progression of ALCD. Smoking and having low BMI seem to be precursors of ALCD recurrence, especially when the patient with MHS 1b or 2 had at least one previous episode of ALCD. Control colonoscopy results are predictive of recurrence.

Importance of knowledge of the management of traumatic dental injuries in emergency departments.

BACKGROUND: Hospital emergency departments (EDs) are confronted with managing dental emergencies of both traumatic and non-traumatic origin. However, the literature suggests inadequate knowledge of the management of traumatic dental injuries (TDIs) among medical professionals. The aim of this study was to investigate the knowledge and attitudes regarding management of TDIs among Istanbul ED physicians. METHODS: Surveys were distributed to emergency departments (ED) directors and their physicians. The survey contained questions about their characteristics and tested their knowledge of managing dental trauma. RESULTS: A total of 126 surveys (13 ED directors and 113 physicians) were returned and included in the analysis. ED physician's knowledge of the appropriate management of crown fractures and avulsion was generally good (p=0.221), but poor for luxation injuries (p=0.0001). Physicians were more likely to have a better knowledge about permanent teeth than about primary teeth (p=0.027). CONCLUSION: Education, monitoring, improved availability of resources, and disciplinary measures in cases of poor compliance are necessary to improve TDI management in hospitals, especially among physicians.

Diagnostic value of basic laboratory parameters for simple and perforated acute appendicitis: an analysis of 3392 cases.

BACKGROUND: The aim of the present study was to examine the efficacy of simple laboratory parameters including neutrophil-to-lymphocyte ratio (NLR), platelet count (PLT), mean platelet volume (MPV), and serum bilirubin level in the diagnosis of acute appendicitis and recognition of perforated appendicitis. METHODS: Records of 3392 patients who underwent appendectomy in a 10-year period were reviewed retrospectively. Patients were divided into 2 groups according to histopathological examination results: Group 1 had normal appendix, Group 2 had acute appendicitis. Patients with acute appendicitis were divided into subgroups: Group 2A had simple acute appendicitis, while Group 2B had perforated appendicitis. Efficacy of the aforementioned laboratory parameters was evaluated in the diagnosis of acute appendicitis and recognition of perforated appendicitis. Independent variables were determined by univariate analysis and multivariate analysis was performed. Receiver operating characteristic (ROC) curve analysis was used to identify significant parameters in multivariate analysis. Cut-off values, sensitivity, specificity, and accuracy calculations performed for parameters with area under curve (AUC) >0.600 were accepted as "significant parameters." RESULTS: White cell count (WCC), bilirubin, and NLR were significant parameters for the diagnosis of acute appendicitis. Cut-off values were 11900/mm3 for WCC (sensitivity: 71.2%; specificity: 67.2%; OR: 5.13), 1.0 mg/dl for bilirubin (sensitivity: 19.1%; specificity: 92.4%; OR: 2.96), and 3.0 for NLR (sensitivity: 81.2%; specificity: 53.1%; OR: 4.27). Serum bilirubin and NLR were independent variables for the diagnosis of perforated appendicitis. Cut-off values were 1.0 mg/dl for bilirubin (sensitivity: 78.4%; specificity: 41.7%; OR: 2.6) and 4.8 for NLR (sensitivity: 81.2%; specificity: 53.1%; OR: 2.6). CONCLUSION: Presence of at least 1 of the following findings in a patient suspected of having acute appendicitis was significantly associated with a definite diagnosis: WCC >11.900 mm3, serum bilirubin >1.0 mg/dl, NLR >3.0. In patients with acute appendicitis, serum bilirubin >1.0 mg/dl or NLR >4.8 were significantly associated with the presence of perforation. While WCC is a significant parameter for diagnosis of acute appendicitis, no significant association with perforated appendicitis was found. PLT and MPV were not useful parameters when diagnosing acute appendicitis.

Transcatheter Arterial Embolization for Controlling Severe Bleeding From Recurrent Locally-Advanced Breast Cancer.

One of the rare but most challenging issues in the management of the locally-advanced breast cancer (LABC) is life-threatening bleeding from the fungating and/or ulcerating focus (foci) of these tumors. Breast surgeons may need the assistance of interventional radiologists to solve this urgent condition if surgery cannot provide sufficient benefit. Herein, we report a case of recurrent locally-advanced breast cancer that presented with sudden severe bleeding, which was stopped by an interventional radiologist via transcatheter arterial embolization (TAE). In addition, we evaluate the role of interventional radiology in patients with breast cancer who present with bleeding from the breast by reviewing the relevant literature.

Predominant causes and types of orofacial injury in children seen in the emergency department.

BACKGROUND: The aim of this study is to determine the type and cause of traumatic orofacial injuries in children up to 18 years of age. METHODS: This retrospective study involved data collected from 12055 patients that came to Istanbul University, Medical Faculty, Department of Emergency in 2011. The patients' data were evaluated with regard to age, gender, etiologic factor of the trauma, type and localization of the injury, and time interval between injury and treatment. RESULTS: A total of 1296 children in 12055 patients with orofacial trauma were evaluated. Trauma incidence was higher in boys (65%). The major etiologic factor of injury was falls (56%) and primary localization was in the frontal region (41%). The most frequent types of injury were laceration (30.1%) and hematoma (18.6%). 4% of the injuries were found in the orodental region including lips, teeth, tongue and oral mucosa of the mouth. 38% of the patients came to the emergency department within 30-60 minutes after the injury and 68% were sent home with symptomatic treatment. CONCLUSION: Considering the high percentage of orofacial traumas, effective education is necessary regarding the appropriate diagnostic approach, emergency management and prevention of traumatic dental injuries.

[Reliability of ultrasonography for diagnosing acute appendicitis]. / Akut apandisitte ultrasonografinin güvenilirligi.

BACKGROUND: Abdominal ultrasonography (US) is the most commonly used diagnostic tool for diagnosing acute appendicitis, which is one of the most common causes of acute surgical abdomen. In this study, we examined the reliability of US for diagnosing acute appendicitis. METHODS: In this prospective study, we performed abdominal US on 235 patients admitted to our surgical emergency department during 2007 and diagnosed as acute surgical abdomen according to the physical examination and laboratory findings. These patients were surgically treated by appendectomy, and the materials were pathologically examined. RESULTS: Two hundred thirty-five patients were admitted to this study. One hundred ninety-three of these patients (82.1%) were diagnosed as acute appendicitis, and 42 (17.9%) were diagnosed differently. One hundred thirty-three (88.67%) of 150 patients diagnosed as acute appendicitis on US examinations were also reported as acute appendicitis on histopathological examination. Sixty of 85 patients diagnosed differently on US examination were reported as acute appendicitis on histopathological examination. CONCLUSION: The sensitivity of abdominal US for diagnosing acute appendicitis was determined as 69%. The specificity was calculated as 60%, positive predictive value as 0.89, negative predictive value as 0.30, and accuracy as 0.67. Abdominal US is a helpful diagnostic tool for diagnosing acute appendicitis. However, it should not be seen as superior to anamnesis and physical examination findings.

A prospective, randomized, controlled trial of primary wound closure after lateral internal sphincterotomy.

BACKGROUND: Much of the lateral internal sphincterotomy (LIS) complications is related to LIS incision. In this study, incisions sutured primarily or left to secondary healing after open LIS procedure are compared regarding the wound healing and complications associated with wounds. METHODS: Planning a prospective, randomized clinical study, 39 patients were separated into two groups. Open LIS was performed on both of the groups. While the incisions of the patients in group 1 (n = 22) were closed with two interrupted sutures using 3-0 chromic catgut, the incisions of the patients in group 2 (n = 17) were left open. The patients were followed up for 90 days postoperatively. RESULTS: Hematoma in 1 (4.5%), ecchymosis in 7 (31.8%), and wound infection in 1 (4.5%) developed in patients of group 1. In this group no significant external bleeding was seen. Wound healing duration was 15.05 +/- 5.60 days. In group 2 no hematoma developed (P = 0.98), but 2 (11.7%) ecchymoses (P = 0.25), 4 (23.5%), wound infections (P = 0.14), and 3 (17.6%) postoperative significant external bleedings (P = 0.07) were seen. Wound healing duration was 33.94 +/- 6.67 days (P <0.001). CONCLUSIONS: To achieve early wound healing, primary closure of open LIS incision is useful, but this technique has no significant effect on wound-related complications in comparison with secondary healing.

A rare complication after thyroidectomy: esophageal perforation.

A 67 year-old woman with recurrent multinodular goiter was admitted for bilateral near total thyroidectomy. On the postoperative period, a turbid fluid came from suction drain which was due to an esophageal perforation. Esophagoscopy and contrast computerized tomography revealed a perforation in the upper third part of the esophagus. Following nonoperative treatment by restricting oral intake, parenteral administration of antibiotics, and parenteral nutrition for 10 days, the patient has recovered and was discharged without any sequela. We discussed the cause of perforation according to the possible reasons frequently seen in the literature. Among iatrogenic reasons, unsuccessful intubation trials were more common than neck surgery. Key words: Esophagus, perforation, surgery, intubation, thyroidectomy

The role of intra-peritoneal honey administration in preventing post-operative peritoneal adhesions.

OBJECTIVE(S): The accelerative effect of honey in the wound healing process is known. This effect is related to its specific physical properties of hygroscopicity, hypertonicity, lower pH and complex chemical composition. Because peritoneal healing is a kind of wound healing process we hypothesised that post-operative peritoneal adhesions (PPA) may be reduced with intra-peritoneal honey administration. STUDY DESIGN: The study was conducted with 40, 6-month-old, out-bred female Wistar albino rats with a mean weight of 197 +/- 12 g. The rats were divided into two equal groups. An adhesion model was constituted in the cecum and terminal ileum of all rats in each groups. Later the adhesion areas were washed with 0.9% NaCl solution and 5 ml of the same solution was left in the peritoneal cavity in the control group. The same area in the rats in the other group was covered with honey and 5 ml of honey was left in the peritoneal cavity of each animals. Ten days later the rats were sacrificed and the adhesions were graded according to their degree of severity. Statistical analysis was performed with the non-parametric Mann-Whitney U-test. RESULTS: In the control group, there were no rats with grade-0 or grade-1 adhesions but in the honey administered group there were six rats (30%) with grade-0 and 12 rats (60%) with grade-1 adhesions. In the control group, there were six rats (30%) with grade-2 and 14 rats (70%) with grade-3 adhesions. In the honey administered group while two rats (10%) with grade-2 adhesions were present, no rat with grade-3 adhesions was seen. In the comparison, the difference between the groups was found to be highly significant (P < 0.001). CONCLUSION(S): The wound healing accelerative effect and the mechanical barrier formed by the honey, since, it has a high density and, thus, absorbed slowly from peritoneal cavity, may be the reasons for its inhibitory effect on the PPA. This study indicates that though the mechanism is not clear intra-peritoneal honey administration reduces PPA.

[Not Available]. / KUNT KARIN TRAVMALARINA YAKLASIM(ULUSAL TRAVMA VE ACIL CERRAHI DERNEGI AYLIK HASTANELER ARASI TOPLANTILARI GENEL SONUCLARI 2).

BACKGROUND: In this review we wanted to explane of opinions of The Turkish Association for Trauma and Emergency Surgery monthly inter-hospital meetings results. METHODS: Opinions of meetings participants about blunt abdominal trauma were reviewed. RESULTS: Haemodynamic stability and conscience situation are the main factors to determine the approach to blunt abdominal trauma patients. We generally prefer ultrasonography (USG) to first step diagnostic technique for haemodynamica/ly stable patients. IfUSG is not possible, diagnostic peritoneallavage (DPL) could be perform. We propose that DPL or USGcould be perform when the focus isnot known in the haemodynamica/ly unstable, multi-traumatised patients. But we don 't agree to perform any diagnostic techniques if we know that haemodynamic unstability is caused from intraperitoneal injury. CONCLUTION: We prefer and propose resuscitation and emergency laparotomy for a/l patients of whom focus of the haemodynamica/ly un-stability is i1itra-abdominal damage. But ifthe haemodynamica/ly un-stable patients have pelvic bone fractures we don't propose the emergency laparotomy, because the probablefocus ofthe serious bleeding is pelvic vessels. In our opinion that patients must be resuscitated aggressively and evaluated with C1; because in this situations false positivity of the DPL is often. Surgeons must not take shelter the laparotomy for the name of life rescue, because negative and non- therapeutic laparotomy has high morbidity.