Analysis of postoperative emergency admission and hospitalization of patients who underwent bariatric surgery: A single-center experience.

BACKGROUND: Bariatric surgery is a treatment with a low risk of complications that is becoming common in obesity treatment. OBJECTIVE: The aim of this study is to evaluate postoperative visits to the emergency department by patients who underwent bariatric surgery and to investigate what postoperative conditions are encountered in these patients and what can be done to prevent emergency room admission and hospitalization. SETTING: University Hospital. METHODS: The study included 394 patients aged 18 years underwent bariatric surgery for obesity. Emergency department (ED) admissions and diagnoses of patients who underwent bariatric surgery were analyzed in two groups, surgery-related and surgery-unrelated. RESULTS: It was found that 22% (n: 87) of patients visited the ED at least once; 4.8% (n: 19) of them were hospitalized; and 78.1% (n: 68) of 87 patients did not need to be hospitalized. Low preoperative iron, folic acid, and ferritin levels increase the number of visits to ED with a bariatric surgery-related complaint, urinary tract infection was the most common diagnosis and did not require hospitalization; the most common diagnosis of hospitalized patients was gastrointestinal perforation, pulmonary embolism, intra-abdominal abscess. CONCLUSION: Despite the low risk of complications, bariatric surgery is a surgery associated with a high number of preventable postoperative emergency visits. ED visits can be reduced by calling these patients for more frequent outpatient check-ups, providing intravenous hydration therapy in outpatient clinics and, if necessary, providing prescribed treatment.

Gastric cancer diagnosis and staging in coronavirus disease 2019 (Covid-19) pandemic.

AIM: The aim of the study was to analyze whether COVID-19 cause a delay in the diagnosis of gastric cancer patients particularly in the TNM staging of the tumor, or not. MATERIAL AND METHODS: This retrospective single-center study included the patients diagnosed with gastric cancer from March, 2019 to December 2020. The patients were divided into two groups: baseline and the pandemic groups. The following parameters were compared between the groups; demographic data, numbers of newly diagnosed patients, type of the surgery, location of the tumor, frequency of neoadjuvant treatment, ASA score, length of hospital stay, clinical staging and pathologic TNM staging. RESULTS: The mean monthly number of newly diagnosed gastric cancer patients showed a significant decline from 7.5 to 5.6 (p< .001). There were no statistically significant differences between the groups with regard to the demographic factors, except CA 19-9 levels. Patients in the pandemic group had higher both clinical and pathological T-stages (p < 0.05). CONCLUSIONS: Our study showed a decline in the number of the newly diagnosed patients with gastric cancer during the pandemic and also more patients presented with advanced stage during the pandemic period. This study showed that the pandemic causes a potential delay in the diagnosis of gastric cancer patients. KEY WORDS: Cancer surgery, COVID-19, Gastric cancer, Gastric surgery SARS-COV-2, Pandemic.

Evaluating the feasibility of performing elective gastrointestinal cancer surgery during the COVID-19 pandemic: An observational study with 60 days follow-up results of a tertiary referral pandemic hospital.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has interfered with the treatment algorithm for patients with gastrointestinal (GIS) cancer, resulting in deferral of surgery. We presented the outcomes of our patients to evaluate whether surgery could be safely performed and followed-up without delaying any stage of GIS cancer during the pandemic. METHODS: This was an observational study of 177 consecutive patients who underwent elective GIS cancer surgery between March 11 and November 1, 2020. They were assessed regarding their perioperative and 60 days follow-up results for either surgical or COVID-19 status. Morbidity was determined according to the Clavien-Dindo classification (CDC). Continuous and categorical data were presented as median ± SD and number with percentage (%), respectively. RESULTS: The study included 44 gastric, 33 pancreatic, 40 colon, and 59 rectal cancer patients. All patients underwent surgery and received neo/adjuvant treatments without delay. The overall morbidity (CDC grade II-IV) and mortality rates were 10.1% and 3.9%, respectively. None of the patients or medical staff were infected with COVID-19 during the study period. CONCLUSION: GIS cancer surgery can be safely performed even within a pandemic hospital if proper isolation measures can be achieved for both patients and health workers. Regardless of the tumor stage, surgery should not be deferred, depending on unstandardized algorithms.

The efficacy of hemogram parameters in the differential diagnosis of renal colic and acute appendicitis in the emergency department.

BACKGROUND: To investigate the efficacy of WBC, PLR and NLR for use in the differential diagnosis of acute appendicitis and renal colic in the emergency department. METHODS: This study was conducted after consent was received from the Cukurova University Medicine Faculty Noninvasive Clinical Research Ethics Committee. In this study, 440 patients for whom file data could be accessed in the hospital automation and archive system who were admitted to the hospital with abdominal pain were included. RESULTS: Of the 440 patients included in this study, 59.5% were male and 40.5% were female. The average age of the patients was 37.74±13.39 years. According to the pathological diagnosis, 207 patients were diagnosed with acute appendicitis. When the efficacy of differential diagnosis using hematological parameters was examined with ROC analysis, the neutrophil/lymphocyte ratio (NLR) value had the strongest predictive ability (AUC, 0.716, SS=0.024, 95% GA 0.668-0.764). After NLR, the platelet/lymphocyte ratio (PLR) value was the second-best concerning predictive ability for differential diagnosis (AUC, 0.608 SS=0.027, 95%, GA 0.555-0.661). CONCLUSION: Patients with acute appendicitis and renal colic often present to the emergency department with abdominal pain. While patients with acute appendicitis are usually treated with surgical methods, medical treatment is used for renal colic in the acute period. The differential diagnosis of these two patient groups is important. We believe that the PLR and NLR values can be used when an exact differential diagnosis cannot be made.

Frequency of postoperative atrial fibrillation and related parameters in patients who underwent sleeve gastrectomy for obesity.

BACKGROUND: In this study, we planned to determine the frequency of postoperative AF and its related parameters in morbidly obese patients who underwent bariatric surgery. METHODS: The study included 300 patients with morbidly obese who had no history of AF and underwent successful bariatric surgery. Routine anamnesis, physical examination and laboratory parameters of the patients were recorded. Patients with postoperative AF were detected. The participants were grouped as patients with and without AF. RESULTS: Postoperative AF occurred in 19 (6.3%) patients. Age, BMI and LAd diameter parameters independently determined the presence of AF. When the ROC curve was performed to identify patients with AF, the area under the ROC curve was found to be 0.841, 0.785 and 0.902 for age, BMI and LAd diameter, respectively. According to this analysis, 50 years for age, 43 kg/m2 for BMI and 40 mm for LAd were used to determine patients with AF with acceptable sensitivity and specificity (>70% each). CONCLUSIONS: The most important determinants of postoperative AF are age, LAd and basal BMI. Therefore, morbidly obese patients with LAd >40 mm, BMI >43 kg/m2 and >50 years of age should be followed up more closely for postoperative AF development and preoperative precautions should be taken to prevent AF development.

Relationship With Calcium, Nutrition Risk, QTc Interval, Tp-e Interval, and Tp-e/QTc Ratio of Critical Care Patients.

BACKGROUND: To our knowledge, there are studies related to QTc interval in critical care patients whose nutrition scores are evaluated but no studies evaluating T-wave peak and end interval (Tp-e interval), Tp-e/QT ratio, and Tp-e/QTc ratio, used to evaluate cardiac arrhythmia risk and ventricular repolarization change rates. Therefore, we aimed to investigate whether there is a change in Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio in patients whose nutrition scores are evaluated. METHODS: This study was planned as a retrospective cross-sectional study. Forty-four patients with a risk score of ≤3 were defined as low-risk group, and 45 patients with a score of ≥4 were defined as high-risk group. Forty-five healthy patients of similar age and gender were included in the control group. All patients underwent 12-lead electrocardiography (ECG). The Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were measured on ECG. The study data were grouped as patients with high Nutritional Risk Screening 2002 (NRS-2002) risk score, low NRS-2002 risk score, and healthy control. RESULTS: QTc interval, Tp-e interval, and Tp-e/QTc ratios were significantly higher in patients with high nutrition risk. In a correlation analysis, Tp-e interval and Tp-e/QTc ratio were found to be independently associated with calcium, corrected calcium, and serum albumin level. CONCLUSION: QTc interval, Tp-e interval, and Tp-e/QTc ratios are significantly increased in patients with high nutrition risk score compared with healthy people and are independently associated with calcium and serum albumin levels; thus, they can be used more effectively in the follow-up of cardiac fatal arrhythmias.

Evaluation of Nutrition Risk in Patients Over 65 Years of Age With Nontraumatic Acute Abdominal Syndrome.

BACKGROUND: The objective of this study is to investigate the power of CRP/Albumin ratio, NRS-2002, mNUTRIC scores to predict nutritional needs and mortality in patients over 65 years of age diagnosed with acute abdominal syndrome in the emergency department and then transferred to the surgical intensive care unit. MATERIAL AND METHOD: CRP/Albumin ratio, APACHE II, SOFA, NRS-2002 and mNUTRIC scores were calculated. The analysis of the data was conducted in IBM SPSS Statistics Base 22.0 package program. RESULTS: In the analytical evaluation made for nutritional needs, AUC value for mNUTRIC was found to be: 0,683, 95% CI 0,611-0,755, p < 0.001. It was found out that mortality of patients had a statistically significant and moderate correlation with mNUTRIC score (r = 0.537; p < 0.001). In the analytical evaluation made for mortality, mNUTRIC's AUC value (AUC: 0.808, 95% CI 0.736-0.880, p < 0.001) was found to be the highest. When the cut-off value determined to predict mortality was taken as 3.5 for mNUTRIC score, sensitivity was 75.9% and specificity was 69.4%. CONCLUSION: The evaluation of the risk of malnutrition through nutritional risk tools in intensive care patients over 65 years of age with acute abdominal syndrome can also predict nutritional needs in the early period besides mortality. Based on our data, the fact that mNUTRIC score cut-off value in older patients hospitalized in intensive care is 3.5 and higher may be a predictor for ICU mortality.

Monocyte High Density Lipoprotein Cholesterol Ratio as a New Prognostic Factor for Mesenteric Embolism.

OBJECTIVE: To determine the effectiveness of the ratio of monocyte count to high density lipoprotein cholesterol in predicting in-hospital mortality. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Intensive Care Unite, Adana Numune Research and Training Hospital, Turkey, from January 2018 to December 2019. METHODOLOGY: Patients admitted to the intensive care unit with the diagnosis of mesenteric embolism were included in the study. Monocyte count and high-density lipoprotein cholesterol (HDL) values were determined. Monocyte HDL Ratio (MHR) values of the patients were calculated. SPSS 26 package programme was used to investigate the effectiveness of MHR in predicting mortality. RESULTS: The mean age of the 81 patients was 69.9 ±10.6 years. In the group with mortality, the number of monocytes and MHR were significantly higher than the group without mortality (p<0.05). In the mortality group, HDL value was significantly lower (p<0.05) than the non-mortality group. Sensitivity of the MHR cutoff value of 19 was 81.8%, positive predictive value was 96.4%, specificity value was 97.9%, negative predictive value was 88.7%. CONCLUSION: For patients diagnosed with acute mesenteric embolism, the use of predictors in terms of mortality estimation is very important for the faster implementation of treatment modalities. MHR value can be used as a strong predictor. Key Words: Mesenteric embolism, Monocyte, HDL cholesterol, MHR, Mortality.

Spontaneous subarachnoidal hemorrhage in patients with Covid-19: case report.

In this article, subarachnoidal hemorrhage developing in a case with Covid-19-related pneumonia was evaluated. In the presence of respiratory system infection signs such as cough and weakness in patient who present with sudden loss of consciousness, performing lung imaging as well as performing brain computerized tomography scan can allow the detection of an underlying Covid-19 infection.

A Novel Oxidative Stress Mediator in Acute Appendicitis: Thiol/Disulphide Homeostasis.

Aim. To investigate the role of a novel oxidative stress marker, thiol/disulphide homeostasis, in patients diagnosed with acute appendicitis (AA). Methods. In this study, seventy-one (43 male and 28 female) patients diagnosed with AA and 71 (30 male and 41 female) healthy volunteers were included. Age, gender, body mass index (BMI), haemoglobin (Hb), white blood cell (WBC), c-reactive protein (CRP), and thiol/disulphide homeostasis parameters (native thiol, total thiol, disulphide, disulphide/native thiol, native thiol/total thiol, and disulphide/total thiol ratios) were compared between the groups. Thiol/disulphide homeostasis was determined by a newly developed method by Erel and Neselioglu. Results. The native thiol, total thiol, and the native thiol/total thiol ratio levels were statistically significantly decreased in the AA compared with the control group (p < 0.001). Disulphide level and the ratios of disulphide/native thiol and disulphide/total thiol were higher in the AA group than in the control group (p < 0.001). There was a negative correlation of CRP with native thiol, total thiol, and native thiol/total thiol ratio while there was a positive correlation of CRP with disulphide/native thiol and disulphide/total thiol in the AA group. In the stepwise regression model, risk factors as disulphide/native thiol (OR = 1.368; p = 0.018) and CRP (OR = 1.635; p = 0.003) were determined as predictors of perforated appendicitis compared to the nonperforated group. Conclusion. This is the first study examining the thiol/disulphide homeostasis as a diagnostic aid in AA and establishing thiol/disulphide homeostatis balance shifted towards the disulphide formation due to thiol oxidation. Further studies are needed to optimize the use of this novel oxidative stress marker in AA.

The predictive value of red cell distribution width levels on mortality in intensive care patients with community-acquired intra-abdominal sepsis.

BACKGROUND: Red cell distribution width (RDW) is a part of the complete blood count (CBC) panel reflecting quantitative measure of variability in the size of circulating red blood cells. It has been known that higher RDW is associated with increased mortality in several diseases. The aim of this study was to investigate the association between RDW and hospital mortality in intensive care unit (ICU) patients with community-acquired intra-abdominal sepsis (C-IAS). METHODS: A retrospective analysis of the patients with C-IAS was performed between January 1, 2010 and March 31, 2013. Patients' demographics, co-morbidities, laboratory measures including RDW on admission to the ICU, and Acute Physiologic and Chronic Health Evaluation II (APACHE II) score were analyzed. RESULTS: A total of one hundred and three patients with C-IAS were included into the study with a mean age of 64±14 years. Overall mortality was 50.5%. RDW day 1 (RDW1) values and APACHE II scores were significantly higher in non-survivors than in survivors. In multivariate analysis, only RDW1 and APACHE II predicted mortality. The area under the receiver operating curves (AUC) of RDW1 and APACHE II were 0.867 (95% CI, 0.791-0.942) and 0.943 (95% CI, 0.902-0.984), respectively. CONCLUSION: This study suggests that increased RDW is associated with mortality in ICU patients with C-IAS.

Comparison of intracorporeal knotting and endoloop for stump closure in laparoscopic appendectomy.

BACKGROUND: Several appendiceal stump closure tecniques such as intracorporoeal-knotting, endoloop, stapler and clips are used during laparoscopic appendectomy. This study aimed to compare intracorporoeal-knotting and endoloop tecniques used to close appendiceal stump in laparoscopic appendectomy. METHODS: This study included patients who underwent laparoscopic appendectomy with preliminary diagnosis of acute appendicitis in General Surgery Department of Adana Numune Training and Research Hospital between June 2009 and July 2013. The demographics, appendiceal stump closure tecniques, operation time, complications, and length of hospital stays of the patients were compared. RESULTS: A total of one hundred and twenty-six patients underwent laparoscopic appendectomy (Female: 81, Male: 45). Intracorporeal-knotting (Group 1) was performed in sixty-five patients; whereas, endoloop (Group 2) was performed in sixty-one patients in order to close appendiceal stump. The operation time was longer in Group 1 compared to Group 2 (62.0±10.67 min., 56.80±11.94 min., p=0.01). The length of hospital stays were nonsignificant between the groups. Four patients were complicated by superficial surgical site infection in both groups. CONCLUSION: In the present study, the operation time was found to be longer for intracorporeal knotting tecnique compared to endoloop tecnique; however, there was no significant difference regarding the length of hospital stay and complications. Performing intracorporeal-knotting technique is suggested since it is cheaper than endoloops and it may also improve hand manipulations of the surgeons who intend to advanced laparoscopy.

Rhomboid Flap Technique in Breast-conserving Surgery: An Alternative Method for the Reconstruction of Lumpectomy Defects.

OBJECTIVE: We aimed to present our experience with rhomboid flap reconstruction, which is a simple technique, in breast cancer patients who underwent breast-conserving surgery. METHODS: We reviewed the medical records of 13 patients with breast cancer who underwent rhomboid flap reconstruction. The patients were evaluated for tumor size, safe surgical margin, and other clinical and pathological features. RESULTS: The mean age of the patients was 43.1 years (range: 28-69 years). The mean tumor diameter was 30.8 mm (range: 15-60 mm). The mean of the safe margin of resection was evaluated to be 17.8 mm (range: 5-30 mm). Re-excision was required for one patient in the same session. CONCLUSION: Rhomboid flap reconstruction can facilitate the applicability of breast-conserving surgery in early breast cancer patients with large tumor-to-breast-size ratio or tumors close to the skin.

Laparoscopic rectopexy for solitary rectal ulcer syndrome without overt rectal prolapse. A case report and review of the literature.

Solitary rectal ulcer syndrome is a rare clinical entity. Several treatment options has been described. However, there is no consensus yet on treatment algorithm and standard surgical procedure. Rectopexy is one of the surgical options and it is generally performed in patients with solitary rectal ulcer accompanied with overt prolapse. Various outcomes have been reported for rectopexy in the patients with occult prolapse or rectal intussusception. In the literature; outcomes of laparoscopic non-resection rectopexy procedure have been reported in the limited number of case or case series. No study has emphasized the outcomes of laparoscopic non-resection rectopexy procedure in the patients with solitary rectal ulcer without overt prolapse. In this report we aimed to present clinical outcomes of laparoscopic non-resection posterior suture rectopexy procedure in a 21-year-old female patient with solitary rectal ulcer without overt prolapse.

Laparoscopic rectopexy for solitary rectal ulcer syndrome without overt rectal prolapse: a case report and review of the literature.

Solitary rectal ulcer syndrome is a rare clinical entity. Several treatment options has been described. However, there is no consensus yet on treatment algorithm and standard surgical procedure. Rectopexy is one of the surgical options and it is generally performed in patients with solitary rectal ulcer accompanied with overt prolapse. Various outcomes have been reported for rectopexy in the patients with occult prolapse or rectal intussusception. In the literature; outcomes of laparoscopic non-resection rectopexy procedure have been reported in the limited number of case or case series. No study has emphasized the outcomes of laparoscopic non-resection rectopexy procedure in the patients with solitary rectal ulcer without overt prolapse. In this report we aimed to present clinical outcomes of laparoscopic non-resection posterior suture rectopexy procedure in a 21-year-old female patient with solitary rectal ulcer without overt prolapse.

Effect of preserving the hepatic vagal nerve during laparoscopic Nissen fundoplication on postoperative biliary functions.

BACKGROUND: Cutting the hepatic branch of the anterior vagus nerve (HB-AVn) technically facilitates the laparoscopic Nissen fundoplication. The aim of this study was to investigate the effects of preserving or sacrificing this branch on postoperative gallbladder functions. METHODS: The patients (n = 40) were prospectively randomized into two groups. The HB-AVn was preserved during the dissection of the lesser omentum in the first group. The nerve was cut in the second group. Postoperative fasting gallbladder volumes were calculated by ultrasonography. Postoperative gallbladder ejection fraction (GEF) and gallbladder emptying time (GET) were determined by calculating intestinal transit time scintigraphically. RESULTS: Fasting gallbladder volumes and GEF values were not different between the groups. On the other hand, in patients with HB-AVn preserved, GET measurements were found to be significantly shorter than those with HB-AVn sacrificed. CONCLUSIONS: Sacrificing the hepatic branch causes prolongation in the GET. This change in the motor functions of the gallbladder does not cause any symptomatic effect during the early postoperative period. However, the delay in the GET may increase the risk of gallbladder stone formation in the long term.

Ectopic breast cancer: A case report.

Ectopic breast may be present at any site, from the axilla to the vulva, other than its normal location. Cysts, adenofibromas and rarely carcinomas have been reported in ectopic breasts. In this case report, we present a patient with ectopic breast cancer. The patient had a thickening and enlarging of her ectopic breast tissue, on the left arcus costarium. Tru-cut biopsy revealed "invasive lobular carcinoma". Left ectopic mastectomy and level I-II axillary dissection were performed and then chemotherapy+radiotherapy+endocrine therapy treatment was commenced. During follow up, the patient is doing well; in spite of R1 resection, she has no evidence of local recurrences or distant metastases.

Evaluation of nutritional risk screening-2002 and subjective global assessment for general surgery patients: a prospective study.

OBJECTIVE: To investigate the reliability of nutritional risk screening (NRS-2002) and Subjective Global Assessment (SGA) tools to predict the length of hospital stay, complications and mortality, and to compare these tools in predicting outcomes of surgical patients. METHODS: The prospective study was conducted at the Surgery Department of Numune Training and Research Hospital, Adana, Turkey, from March 30 to September 30, 2010. The patients were divided into 3 groups. Group 1 included patients requiring major surgical operations for gastrointestinal malignancy; Group 2 and 3 included patients undergoing moderate surgery and minor surgical operations respectively. Discrimination characteristics of the scoring systems were evaluated using receiver operating characteristic curves. RESULTS: Nutritional risk at admission was found to be increased in 132 (22.5%) patients by NRS-2002, and 90 (15.3%) by SGA. The sensitivity and specificity of NRS-2002 for complications were 53.3% and 96.6% respectively. The SGA values were 55% and 98.5% respectively. NRS-2002 and SGA at admission had a reliable power of discrimination (AUC > 0.8) for mortality and to predict complications in major gastrointestinal surgical patients. CONCLUSION: SGA and NRS-2002 methods had positive predictive power in estimating the mortality risk in general surgical patient population. Both scoring tools were also positive in estimating post-operative complication risk in major surgical patients.

Increased nutritional risk in major trauma: correlation with complications and prolonged length of stay.

BACKGROUND: Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Trauma Injury Severity Score (TRISS) are physiological and anatomical severity scores to predict trauma outcome. Nutritional Risk Screening (NRS-2002) is used for the screening of nutritional risk, which can affect outcome adversely. The objective of this study was to determine the reliability of these scales to predict disease severity, complications and mortality, and to compare the reliability of the NRS-2002 in predicting outcome with different scoring systems in trauma-intensive care unit (ICU) patients. METHODS: The study enrolled 100 consecutive patients who were admitted to the ICU in a training hospital due to trauma in the six-month study period (1 July 2008 and 1 January 2009). Discrimination characteristics of the scoring systems were evaluated using receiver operating characteristic (ROC) curves. RESULTS: Overall mortality was 14%, and the complication rate was 22%. Nutritional risk at admission was found to be increased in 58% of the patients. The NRS-2002 score was increased in patients with complication. ISS, TRISS and APACHE II at admission had a reliable power of discrimination (AUC>0.8) for mortality and complication prediction. The NRS-2002 score had moderate discrimination power for complication prediction (AUC=0.708) but showed high correlation with increased length of stay (LOS). CONCLUSION: A significant percent of trauma patients are at nutritional risk. The NRS-2002 score can be useful in predicting complication and prolonged LOS in trauma patients.

Comparison of different operation techniques and suture materials in pyloric exclusion, in an animal model.

PURPOSE: The aim of this study is to compare the results of different operating techniques and suture materials for pyloric exclusion procedures. METHODS: The study was conducted on a sample of 125 rats. Transgastric pyloric exclusions with gastrojejunostomy were performed on the first 50 rats, which were divided into two groups each of 25: a resorbable (polyglactin) suture material was used in the first group and a nonresorbable (silk) material was used in the second group. External pyloric exclusion with a gastrojejunostomy were performed in a subsequent group consisting of 50 rats, again divided into two subgroups of 25 each with an absorbable (polyglactin) suture material used in one and a nonabsorbable (silk) material used in the other. For the last 25 rats external pyloric exclusion with a gastrojejunostomy were performed and a nonresorbable (polypropylene) material was used. RESULTS: The ratio of pyloric reopening was higher in the transgastric group than the external exclusion group on the 14th day (P = 0.01). The external pyloric exclusion group with polypropylene suture material had the lowest ratio of pyloric reopening. CONCLUSION: The external pyloric exclusion technique with nonresorbable (preferably polypropylene) suture material was therefore found to provide a higher pyloric closure incidence on the 14th day, which is the necessary duration period for healing in duodenal injuries.