Renal autotransplantation due to iatrogenic ureter injury: A case report.

Hardy and colleagues carried out 'Renal autotransplantation' for the first time in 1963 to treat severe ureter injury and it has evolved as a method used for complex treatment of trauma, renal artery diseases or ureteral stenosis. In case of proximal ureter injury, approximately 2/3 of which is iatrogenic, if the end-to-end anastomosis is not possible, renal autotransplantation, ileal ureter interposition or nephrectomy are alternative treatments. As technology advances, the use of ureterorenoscopy (URS) increases and in parallel with this iatrogenic injuries that occur during the process have increased as well. These types of injuries are generally in form of simple perforations (2-6%), but from time to time ureter avulsions are also observed (0.3%). In this article, a case is presented where renal autotransplantation is made following development of ureter avulsion during ureterorenoscopy process carried out due to right ureteral calculi and treatment options are discussed in the light of literatures.

The analysis and shooting reconstruction of the ricocheted shotgun pellet wounds.

BACKGROUND: In this study, a 35 years old man was killed with the ricocheted shotgun pellets wounds from the asphalt road surface. The Public Prosecutor to define the ricochet point requested the ricocheted pellet pattern examination in two different ricochet distances. METHODS: The ten ricochet tests were performed for at 2 meters (point A) and 1 meter (point B) from the target, and the pellet distribution and pattern area were calculated using the gauss method. Then, the test and autopsy results were compared in the pellet number, calculated pellet pattern area and ricocheted angle. Furthermore, the similarity of the pellet number and the pellet pattern areas were examined using the two-tailed Mann-Whitney U test. RESULTS: In this study, 81 pellets recovered from the victim's body and the distribution pattern of pellets area was 2134 cm2. At the ricochet point A, the average number of pellets on the target was 82.1 and the distribution pattern of pellets area was 2700 cm2. At the ricochet point B, the average number of pellets on the target was 132.6 and the distribution pattern of pellets area was 4928 cm2. According to the two-tailed Mann-Whitney U test, there was low-level similarity (p<0.05 level Sig. 0.023; z=-2.424) on the pellet pattern area between autopsy and the ricochet point A. However, as regards the pellet number on the target, there was a similarity (p<0.05 level Sig. 0.481; z=-0.808) between autopsy and the ricochet point A. CONCLUSION: Test results showed that the pellet ricochet occurred two meters from the victim.

Negative pressure wound closure system for giant thoracic defect closure in a patient with completely visible pericardium: A case report.

Negative pressure wound closure system facilitates wound closure via wound contraction. In this article, we report a successful application of thoracic negative pressure wound closure system to fill the thoracic defect, control infection, and expand the lung in a 35-year-old male patient with threerib defect, lung parenchyma injury, empyema, left complete pneumothorax, and visible pericardium after gunshot injury. The excellent result obtained in our patient demonstrates that negative pressure wound closure system is a good choice for treating high-energy thoracic injuries by reducing wound infection and enabling early wound closure.

Can Human Recombinant Epidermal Growth Factor Improve Ischemia and Induce Healing of Anastomosis in an Experimental Study in a Rabbit Model?

PURPOSE: Anastomotic leaks following intestinal operations may cause devastating effects on patients. Ischemia may also occur at the intestinal walls in the presence of strangulations. In this study, we examined the effects of human recombinant (Hr)-epidermal growth factor (EGF) given at a single intramural dose into the intestinal walls and daily intraperitoneal cavity on ischemia and the healing process of anastomosis. MATERIALS AND METHODS: Sixteen male New Zeland white rabbits were randomly divided into four groups (n = 4 in each group). In Group 1, two different segments of ileum were identified and, then, transected and the free ends were sutured each other. In the other groups, ischemia was induced by ligating the mesenteric vascular arcade. After the ischemic induction, Group 2 received intramural injections of %0.9 saline, Group 3 received intramural injections of a single dose of EGF, and Group 4 received intramural and intraperitoneal injections of EGF. Bursting pressures and tissue hydroxyproline levels were analyzed. Necrosis, fibroblastic activity, collagen deposition and neovascularization were also studied. RESULTS: The mean levels of bursting pressures in Group 4 (148.6 ± 25.3 mmHg) were higher than Group 2 (70 ± 21.5 mmHg) (p = 0.001). The mean level of bursting pressures was not statistically significant between Group 1 (170.1 ± 35 mmHg) and Group 4 (p = 0.073). Hydroxyproline levels in Group 2 were lower than Groups 3 and 4. There was a statistically significant difference in the mucosal ischemia, mucosal healing and degree of adhesion, but not in the mural anastomotic healing among the groups. CONCLUSIONS: Intramural injection with daily intraperitoneal administration of low-dose EGF enhances the bursting pressure and collagen accumulation in ischemic anastomosis, improving many histological variables associated with ischemic intestinal anastomosis.

Effectiveness of N-butyl cyanoacrylate-based microbial skin sealant on the prevention of surgical site infections.

BACKGROUND: Surgical site infections (SSIs) are a serious concern in health care, and wound contamination by endogenous skin flora is a major factor in the development of SSIs. Despite preventive tactics in pre-operative skin care, antibiotic prophylaxis, surgical technique, and post-operative incision care, complete sterilization of the skin is not possible. Recently developed microbial skin sealant forms a continuous but breathable barrier that prevents migration of endogenous skin flora into the incision. The skin sealant closes dermal microabrasions, preventing re-colonization of potential pathogens at the incision. The purpose of this study was to determine the effect of an N-butyl cyanoacrylate-based microbial skin sealant in reducing the occurrence of SSIs in an experimental rodent model. METHODS: This was a randomized, controlled animal trial. Forty-eight Wistar albino rats were divided into six groups of eight rats each. Three groups received application of sealant against specific bacteria, and three matched control groups received only the bacteria without the sealant. Group one underwent pre-operative hair removal, followed by application of skin sealant, then abdominal incision and closure. Group two (control) simply underwent hair removal, followed by incision and closure, with no skin sealant applied. Group three received an application of cage swabs (containing a mixture of urine, stool and sawdust from the animals' cages) before application of skin sealant, and group four (control) received cage swabs without subsequent skin sealant. Group five received methicillin-resistant Staphylococcus aureus (MRSA) followed by skin sealant, and group six (control) received MRSA without skin sealant. Seven days after surgery, the animals were sacrificed. Samples were taken from the abdomen of each rat and placed in culture medium. Proliferation of the following bacteria were observed: Coagulase-negative staphylococci (CoNS), gram-positive bacilli (GPB), Pseudomonas aeruginosa, and MRSA. RESULTS: There was a statistically significant difference between the median number of GPB in the group that received cage swabs+sealant and the group that received cage swabs without sealant (median, GPB count 29,430 colony-forming units [CFU]/g vs 359,100 colony-forming units [CFU]/g; p<0.05). The study results showed that microbial skin sealant was not as effective in preventing CoNS or MRSA contamination as it was in preventing GPB contamination. CONCLUSIONS: Use of a microbial skin sealant before surgery can lower the rate of SSIs by reducing the migration of some specific bacterial agents. Additional data are needed to validate its use in clinical practice.

[The wounding potential of free-falling bullets]. / Serbest Düsme Hareketi Yapan Mermi Çekirdeklerinin Yaralama Potansiyelleri.

BACKGROUND: It was aimed in this study to clarify the wounding potential of free-falling bullets fired at 90° or close to right angles. MEHTOHDS: In this study, 9x19 mm and 7.65x17 mm bullets, which are commonly used among civilians, were used. The muzzle velocities of these ammunitions were measured. According to the muzzle velocity data, the free-falling motion and strike velocity of the 9x19 mm and 7.65x17 mm bullets were simulated using the EBV4® External Ballistics Software at angles of 65°-90° with firings at 5° intervals. The simulation results were compared with critical velocity of tissues. In addition, the judicial records and press reports on this type of wound were examined and evaluated in light of the literature. RESULTS: The strike velocity and kinetic energy of free-falling bullets, which were fired into the air at 5° intervals between 65°-90°, were measured. The average strike velocity and kinetic energy of 9x19 mm bullets were 92.25 m/sec and 34.05 J and of 7.65x17 mm bullets were 79.66 m/sec and 14.91 J, respectively. As a result of the archives examination, 65 such wounds were detected between 2000 and 2012, and 27 of them resulted in death. DISCUSSION: According to these results, the strike velocity of free-falling 9x19 mm and 7.65x17 mm bullets, which were fired into the air, exceeds the threshold and critical velocity limits of skin and flat bones, and the kinetic energy of the bullets is able to cause significant wounding. Even though the symptoms and features of these types of wounds may not be similar to those of ordinary gunshot wounds in the first medical examination, the first responders should be aware of the possibility of gunshot wounds, and they should take into account the criminal investigation phase during the treatment process; the necessary precautions should be taken in order to preserve the evidence.

Single-incision laparoscopic cholecystectomy versus laparoscopic cholecystectomy: a prospective randomized study.

This prospective randomized study compared single-incision laparoscopic cholecystectomy (SILC) and laparoscopic cholecystectomy (LC) with respect to estimated blood loss, operative time, postoperative pain levels, and complications. Thirty-four study patients were divided into 2 groups: 17 patients underwent SILC and 17 underwent LC. Operative time was longer for SILC than for LC, and the difference was statistically significant (P<0.001). There was no statistically significant difference in the relationship of body mass index with operative time between SILC and LC (P=0.613, P=0.983, respectively). The 2 groups had no statistically significant differences with respect to visual analog scale scores, estimated blood loss, shoulder pain, or complications (P>0.05). SILC can be the treatment of choice for gallbladder disease. Although the surgeon's first several attempts at SILC require a longer operative time compared with LC, there are no differences in hospital length of stay, blood loss, complication rates, or pain scores between SILC and LC.

Use of vacuum-assisted closure (VAC™) in high-energy complicated perineal injuries: analysis of nine cases.

Our study reviewed nine patients who were treated with the VAC™ Abdominal Dressing System after suffering pelvic fractures and soft tissue loss after high-energy pelvic trauma. Between March 2008 and August 2009, our clinic treated nine patients with complicated perineal injuries from high-energy pelvic trauma with multiple irrigation and debridement procedures and broad-spectrum antibiotics. Protective ostomies were created for all nine patients. Required interventions were made for associated injuries, and VAC™ application was started. All patients were male, with an average age of 24·3 (range 21-32) years, and a mean injury severity score of 36·4 (range 16-59). Wound diameters ranged from 15 to 30 cm, and wound depths ranged from 5 to 25 cm. The injuries included one traumatic bilateral hemipelvectomy, and three unilateral and two bilateral lower extremity amputations. Intensive care unit length of stay averaged 12 (6-19) days, and average hospital length of stay was 44·12 (31-64) days. Beginning at an average of day 17 (±5·9 days) post-injury, wound cultures detected no bacterial colonisation. One patient died on the sixth day after injury from septic complications. Two patients' wounds were closed by primary closure, and six patients' wounds were closed by split thickness grafts after an average of 31·4 (17-50) days. Optimal treatment of high-energy perineal injuries requires early and extensive debridement and rich irrigation. The application of the VAC™ system as temporary coverage of large complex wounds in the pelvic region enhances wound healing and facilitates an early grafting process.

Organ models in wound ballistics: experimental study.

BACKGROUND: Effects of various types and diameters of guns and related treatment principles are different. Our study was performed to experimentally demonstrate the effects of different gunshots in body tissues. METHODS: 9x19 mm hand-gun and 7.62x51 mm G-3 infantry rifle were used in the study. Injury models were created through hand-gun and rifle shootings at isolated soft tissue, lower extremity, liver and intestine tissue simulants made of ballistic candle. High-speed cameras were used to capture 1000 frames per second. Images were examined and wound mechanisms were evaluated. RESULTS: It was observed that the colon content distributed more within the surrounding tissues by the rifle shootings comparing with hand-gun shootings and could be an infection source due to the large size of the cavity in the colon. Especially when the bullets hitting the bone were investigated, it was seen that much more tissue injury occurs with high speed bullets due to bullet deformation and fragmentation. However, no significant difference was found between the effect of hand-gun and rifle bullets passing through the extremity without hitting the bone. CONCLUSION: To know the type of the gun that caused the injury and its characteristics will allow to estimate severity and size of the injury before the treatment and to focus on different alternatives of treatment. Therefore, use of appropriate models is required in experimental studies.