Results of combat medic junctional tourniquet training: a prospective, single-blind, randomized, cross-over study

BACKGROUND

Bleeding remains the leading cause of potentially preventable deaths both in military and civilian pre-hospital trauma settings. Conventional extremity tourniquets do not control bleeding if an iliac artery or a common femoral artery is injured. Stopping junctional bleeding is particularly challenging and requires the use of specifically designed junctional tourniquets. SAM® Junctional Tourniquet (SJT®, United States of America) and Tactical Abdominal Junctional Tourniquet (T-AJT®, Fora Group Türkiye) have been actively used by Turkish security forces. This study questioned the effect of training on combat medics' successful junctional tourniquet applications and application times (AT).

METHODS

Our research on two different junctional tourniquet models was designed as a prospective randomized, crossover, single-blinded study. All 40 participants in the study were attendees of a 12-week combat medic training course with updated medical approvals, which were used as an eligibility criterion. Randomization was performed by drawing T-AJT®-SJT cards. The study consisted of pretraining and after-training tourniquet application phases. In each study phase, all participants' AT and the presence or absence of arterial flow were recorded for each group. Finally, the combat medics were presented with a 6-question survey.

RESULTS

Although training increased successful T-AJT® application rates, training was not statistically significantly associated with successful applications for any tourniquet types (p>0.05). The pretraining phase ATs for SJT® and T-AJT® were 55±11.8 and 93.8±2.9 seconds, respectively, and the difference was statistically significantly different (p<0.001). Likewise, after-training phase ATs for SJT® and T-AJT® were 49±22.6 and 79.2±17.5 seconds, respectively, and participants' SJT® ATs were significantly shorter (p<0.001). Overall, when participants' applied any of the tourniquet unsuccessfully, the odds of participants' lower Visual Analogue Scale scores were 0.2 (95% CI [0.08, 0.49]. p<0.001).

CONCLUSION

Our study basically investigates the effects of training on effective tourniquet application. Unfortunately, our after-training success rates remained unsatisfactory when compared to other studies. This is also the first study on T-AJT® tourniquet application, and further studies on its efficacy are also required.

Injury mechanisms and injury severity scores as determinants of urban terrorism-related thoracoabdominal injuries

Objective: Improving the care of injuries resulting from terrorist attacks requires understanding injury mechanisms in armed conflicts. The aim of this study was to identify injury characteristics in military personnel with thoracoabdominal combat injuries resulting from terrorist attacks in urban settings.

Material and Methods: A retrospective study of military personnel with thoracoabdominal injuries who were referred to a tertiary center after treating and stabilizing at a primary healthcare organization due to terror-related injuries in various urban regions of Turkey between June 2015 and December 2016 was performed.

Results: A total of 70 patients were included in this study, of whom 87.1% were injured by explosives and 12.9% (n= 9) had gunshot wounds (GSWs). Mean injury severity score (ISS) was 21, blood transfusion amount was 3.7 units, and mortality rate was 8.5%. Patients injured by explosives had most commonly abdominal and extremity injuries (31.1%), whereas isolated abdominal injuries (55.6%) were observed among patients with GSWs. There were no significant differences between the mechanisms of injuries and the ISS, blood transfusion, and mortality (p= 0.635, p= 0.634, and p= 0.770, respectively). A significant correlation was observed between the ISS and transfusion amounts (r= 0.548, p< 0.001). Mortality was significantly higher in those with a high ISS and those undergoing massive blood transfusions (p= 0.004 and p< 0.001, respectively).

Conclusion: Explosive injuries, concomitant vascular injuries, high ISS, and the need for massive transfusions increased the mortality rate in urban combat injuries. To quickly identify high-risk patients and improve the care of injuries, it is essential to use predictive models or scoring systems.

Bringing Packed Red Blood Cells to the Point of Combat Injury: Are We There Yet?

Objective

Hemorrhage is the leading cause of injury-related prehospital mortality. We investigated worst-case scenarios and possible requirements of the Turkish military. As we plan to use blood resources during casualty transport, the impact of transport-related mechanical stress on packed red blood cells (PRBCs) was analyzed.

Materials and Methods

The in vitro experiment was performed in the environmental test laboratories of ASELSAN®. Operational vibrations of potential casualty transport mediums such as Sikorsky helicopters, Kirpi® armored vehicles, and the NATO vibration standard MIL-STD-810G software program were recorded. The most powerful mechanical stress, which was created by the NATO standard, was applied to 15 units of fresh (≤7 days) and 10 units of old (>7 days) PRBCs in a blood cooler box. The vibrations were simulated with a TDS v895 Medium-Force Shaker Device. On-site blood samples were analyzed at 0, 6, and 24 h for biochemical and biomechanical analyses.

Results

The mean (±standard deviation) age of fresh and old PRBCs was 4.9±2.2 and 32.8±11.8 days, respectively. Six-hour mechanical damage of fresh PRBCs was demonstrated by increased erythrocyte fragmentation rates (p=0.015), hemolysis rates (p=0.003), and supernatant potassium levels (p=0.003) and decreased hematocrit levels (p=0.015). Old PRBC hemolysis rates (p=0.015), supernatant potassium levels (p=0.015), and supernatant hemoglobin (p=0.015) were increased and hematocrit levels were decreased (p=0.015) within 6 h. Two (13%) units of fresh PRBCs and none of the old PRBCs were eligible for transfusion after 6 h of mechanical stress.

Conclusion

When an austere combat environment was simulated for 24 h, fresh and old PRBC hemolysis rates were above the quality criteria. Currently, the technology to overcome this mechanical damage does not seem to exist. In light of the above data, a new national project is being performed.

High velocity missile-related colorectal injuries: In-theatre application of injury scores and their effects on ostomy rates

BACKGROUND

Treatment of colorectal injuries (CRIs) remains a significant cause of morbidity and mortality. The aim of the present study was to analyze treatment trends of Turkish surgeons and effects of the American Association for the Surgery of Trauma (AAST), Injury Severity (ISS), and Penetrating Abdominal Trauma Index (PATI) scoring systems on decision-making processes and clinical outcomes.

METHODS

Data regarding high velocity missile (HVM)-related CRIs were retrospectively gathered. Four patient groups were included: Group 1 (stoma), Group 2 (no stoma in primary surgery), Group 2a (conversion to stoma in secondary surgery), and Group 2b (remaining Group 2 patients).

RESULTS

Groups 1, 2, 2a, and 2b included 39 (66%), 20 (34%), 6 (30%), and 14 (70%) casualties, respectively. Ostomies were performed in casualties with significantly higher AAST scores (p<0.001). However, PATI and ISS scores were not decisive factors in the performance of ostomy (p=0.61; p=0.28, respectively). Ostomy rates of civilian and military surgeons were 62% and 68%, respectively (p=0.47). Receiver operating characteristic (ROC) analysis showed that AAST score was a more accurate guide for performing ostomy, with sensitivity and specificity rates of 80% and 92.9%, respectively.

CONCLUSION

Clinical significance of diversion in HVM-related CRIs remains. Stomas were associated with lower complication rates and significantly higher AAST colon/rectum injury scores.

Generation of Platelet Microparticles after Cryopreservation of Apheresis Platelet Concentrates Contributes to Hemostatic Activity

OBJECTIVE

In the last decade, substantial evidence has accumulated about the use of cryopreserved platelet concentrates, especially in trauma. However, little reference has been made in these studies to the morphological and functional changes of platelets. Recently platelets have been shown to be activated by cryopreservation processes and to undergo procoagulant membrane changes resulting in the generation of platelet-derived microparticles (PMPs), platelet degranulation, and release of platelet-derived growth factors (PDGFs). We assessed the viabilities and the PMP and PDGF levels of cryopreserved platelets, and their relation with thrombin generation.

MATERIALS AND METHODS

Apheresis platelet concentrates (APCs) from 20 donors were stored for 1 day and cryopreserved with 6% dimethyl sulfoxide. Cryopreserved APCs were kept at -80 °C for 1 day. Thawed APCs (100 mL) were diluted with 20 mL of autologous plasma and specimens were analyzed for viabilities and PMPs by flow cytometry, for thrombin generation by calibrated automated thrombogram, and for PDGFs by enzyme-linked immunosorbent assay testing.

RESULTS

The mean PMP and PDGF levels in freeze-thawed APCs were significantly higher (2763±399.4/µL vs. 319.9±80.5/µL, p<0.001 and 550.9±73.6 pg/mL vs. 96.5±49 pg/mL, p<0.001, respectively), but the viability rates were significantly lower (68.2±13.7% vs. 94±7.5%, p<.001) than those of fresh APCs. The mean endogenous thrombin potential (ETP) of freeze-thawed APCs was significantly higher than that of the fresh APCs (3406.1±430.4 nM.min vs. 2757.6±485.7 nM.min, p<0.001). Moreover, there was a significant positive poor correlation between ETP levels and PMP levels (r=0.192, p=0.014).

CONCLUSION

Our results showed that, after cryopreservation, while levels of PMPs were increasing, significantly higher and earlier thrombin formation was occurring in the samples analyzed despite the significant decrease in viability. Considering the damage caused by the freezing process and the scarcity of evidence for their in vivo superiority, frozen platelets should be considered for use in austere environments, reserving fresh platelets for prophylactic use in blood banks.

A simple novel technique for enteroatmospheric fistulae: silicone fistula plug

Enteroatmospheric fistulae (EAFs), a rare condition that develops in patients treated with an open abdomen, present serious problems for the surgeon. There are no fixed algorithms for treatment of EAF, and treatment options are determined based on the experience of the surgeon and status of the patient. We developed a 'suspended silicone fistula plug' for treating a patient who developed an EAF after undergoing multiple operations in a short period of time. Used in conjunction with negative pressure wound therapy, application of this novel therapy resulted in EAF closure and patient discharge.

Biliary fistula after treatment for hydatid disease of the liver: When to intervene

AIM: To determine the outcome of patients with biliary fistula (BF) after treatment for hydatid disease of the liver.

METHODS: Between January 2000 and December 2010, out of 301 patients with a diagnosis of hydatid cyst of the liver, 282 patients who underwent treatment [either surgery or puncture, aspiration, injection and reaspiration (PAIR) procedure] were analysed. Patients were grouped according to the presence or absence of postoperative biliary fistula (PBF) (PBF vs no-PBF groups, respectively). Preoperative clinical, radiological and laboratory characteristics, operative characteristics including type of surgery, peroperative detection of BF, postoperative drain output, morbidity, mortality and length of hospital stays of patients were compared amongst groups. Multivariate analysis was performed to detect factors predictive of PBF. Receiver operative characteristics (ROC) curve analysis were used to determine ideal cutoff values for those variables found to be significant. A comparison was also made between patients whose fistula closed spontaneously (CS) and those with intervention in order to find predictive factors associated with spontaneous closure.

RESULTS: Among 282 patients [median (range) age, 23 (16-78) years; 77.0% male]; 210 (74.5%) were treated with conservative surgery, 33 (11.7%) radical surgery and 39 (13.8%) underwent percutaneous drainage with PAIR procedure A PBF developed in 46 (16.3%) patients, all within 5 d after operation. The maximum cyst diameter and preoperative alkaline phosphatase levels (U/L) were significantly higher in the PBF group than in the no-PBF group [10.5 ± 3.7 U/L vs 8.4 ± 3.5 U/L (P < 0.001) and 40.0 ± 235.1 U/L vs 190.0 ± 167.3 U/L (P = 0.02), respectively]. Hospitalization time was also significantly longer in the PBF group than in the no-PBF group [37.4 ± 18.0 d vs 22.4 ± 17.9 d (P < 0.001)]. A preoperative high alanine aminotransferase level (> 40 U/L) and a peroperative attempt for fistula closure were significant predictors of PBF development (P = 0.02, 95%CI: -0.03-0.5 and P = 0.001, 95%CI: 0.1-0.4), respectively. Comparison of patients whose PBF CS or with biliary intervention (BI) revealed that the mean diameter of the cyst was not significantly different between CS and BI groups however maximum drain output was significantly higher in the BI group (81.6 ± 118.1 cm vs 423.9 ± 298.4 cm, P < 0.001). Time for fistula closure was significantly higher in the BI group (10.1 ± 3.7 d vs 30.7 ± 15.1 d, P < 0.001). The ROC curve analysis revealed cut-off values of a maximum bilious drainage < 102 mL and a waiting period of 5.5 postoperative days for spontaneous closure with the sensitivity and specificity values of (83.3%-91.1%, AUC: 0.90) and (97%-91%, AUC: 0.95), respectively. The multivariate analysis demonstrated a PBF drainage volume < 102 mL to be the only statistically significant predictor of spontaneous closure (P < 0.001, 95%CI: 0.5-1.0).

CONCLUSION: Patients with PBF after hydatid surgery often have complicated postoperative course with serious morbidity. Patients who develop PBF with an output < 102 mL might be managed expectantly.

The handmade endoloop technique. A simple and cheap technique for laparoscopic appendectomy

OBJECTIVE

To compare 2 laparoscopic appendectomy techniques.

METHODS

We describe a modified technique, the handmade endoloop technique, for closing the base of the appendix. This prospective study was carried out at Harran University Medical Faculty, Sanliurfa, and Gulhane Military Medical Academy, Ankara, Turkey from September 2006 to February 2008. We evaluated the safety and efficacy of the procedure in 98 acute appendicitis cases: 57 patients handmade endoloop patients, and 41 endoloop technique patients. Operative time, postoperative complications, need for analgesics, and procedure cost were measured for both groups. The endoloops and sutures used to manage appendectomy were listed at current prices, summarized as number consumed per case, and compared. Data were analyzed by appropriate test.

RESULTS

The average price of material used for closing the base of appendix was 81 American Dollars (USD) for laparoscopic appendectomy with endoloop, and 8 USD for the technique described by this article. Overall, postoperative complications, operative time, and the need for analgesia did not show a statistical difference in comparing both groups.

CONCLUSION

This procedure is simple, safe, and cheap.

Ultrasonography accurately evaluates the dimension and shape of the pilonidal sinus

PURPOSE

To study the benefits of ultrasonography for detecting the borders of pilonidal sinus tissue. The correlation between physical and ultrasonographic examination was used for surgical planning.

METHOD

Between April and December 2004, 73 patients were recruited for this study. All patients were examined, and the borders of the sinus tissue were marked on the skin according to palpation before surgery. The surgeon also made a treatment plan considering the diseased tissue and marked a possible incision line. Patients were subsequently examined with ultrasonography. According to the ultrasonographic evaluation, the margins, extensions, and openings of pilonidal sinus tissue were determined and marked on the patient in a different color by a radiologist prior to surgery. The most suitable surgical treatment was decided according to the information obtained by ultrasonography.

RESULTS

The average age was 23.03 +/- 3.05 (range 18-39) years. We found 81 lesions in 73 patients. Ultrasonographic borders of sinus tissue were similar to the borders marked by the surgeon in 56 patients (76.7%). In the remaining 17 patients (23.3%), ultrasonography detected branches or borders that distinctly exceeded the planned incision line. After ultrasonographic examination, the surgeon changed his incision line in 14 patients and the surgical intervention in 3 patients.

CONCLUSION

Palpation and methylene blue injection do not provide appropriate information in many patients. Our study revealed that pre-operative ultrasonography can improve the identification of the sinus tract and its branches when compared to palpation and methylene blue injection.

Stump appendicitis, rare complication after appendectomy: report of a case

Appendectomy is one of the most common procedures in surgical practice. Stump appendicitis is an acute inflammation of the residual part of the appendix and a rare complication of incomplete appendectomy. It may present clinically as acute abdomen. We report a case of stump appendicitis 12 years after open appendectomy. After the diagnosis of acute appendicitis, the patient was operated and discharged from the hospital four days after operation without any complications. Stump appendicitis is a rare cause of acute abdomen and should be taken into consideration in the differential diagnosis.

Can SAPS II predict operative mortality more accurately than POSSUM and P-POSSUM in patients with colorectal carcinoma undergoing resection?

BACKGROUND

This study assessed the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score-II), POSSUM (Physiologic and Operative Severity Score for Enumeration of Morbidity and Mortality), and P-POSSUM (Portsmouth-POSSUM) in patients with colorectal cancer undergoing curative or palliative resection.

METHODS

Predicted mortality rates and the observed/expected mortality ratio were computed by means of each scoring system. The results were compared between survivors and nonsurvivors and between elective and emergency operations. Each model was assessed for its accuracy to predict the risk of death using receiver operator characteristic (ROC) curve analysis, and risk stratification was generated as well.

RESULTS

Some 224 patients were enrolled in the study. The overall 30-day mortality rate was 3.6% (n = 8). Predicted mortality rates generated by APACHE II, SAPS II, POSSUM, and P-POSSUM were 9.1%, 3.7%, 13.4%, and 5.2%, respectively. All the scoring systems assigned higher scores to those patients who died than to those who survived. Areas under the curve calculated by ROC curve analysis for APACHE II, SAPS II, POSSUM, and P-POSSUM were 0.786, 0.854, 0.793, and 0.831, respectively. Best stratification was achieved by the SAPS II score.

CONCLUSIONS

SAPS II and P-POSSUM were determined to be better predictors for patients with colorectal cancer undergoing resection. SAPS II also was found to have a higher degree of discriminatory power in colorectal resection for carcinoma. The predictive value of this useful severity score in several surgical subgroups must be examined to evaluate its routine use in risk-adjusted audit.

D-dimer levels in the prediction of the degree of intestinal necrosis of etrangulated hernias in rats

PURPOSE

The aim of this study was to investigate the time-dependent relation between plasma D-dimer levels and the degree of intestinal necrosis and to compare these parameters with leukocyte counts in an experimental etrangulated hernia model in rats.

RESULTS

When the duration of intestinal ischemia was prolonged, serum D-dimer levels increased relative to the control group, with the difference being statistically significant at hour 2 (P = 0.027). In contrast, leukocyte counts in the 2- and 4-h strangulation group were higher that those of the control group, but the difference was not statistically significant (P = 0.625 and P = 0.846, respectively). However, in the 6-h strangulation group the levels of leukocytes were significantly higher that those of the control group (P = 0.015).

CONCLUSION

Serum D-dimer measurements may be used as a more valuable diagnostic parameter than leukocyte count in the early diagnosis of intestinal ischemia, including strangulated hernia.

Extrahepatic abdominal hydatid disease caused by Echinococcus granulosus: imaging findings

OBJECTIVE

The classical findings in hydatid disease caused by Echinococcus granulosus with liver or lung involvement are well known. However, diagnosing hydatid disease at unusual locations may be challenging because of variable imaging appearances depending on the host reaction. The purpose of this pictorial essay is to review the sonographic, CT, and MRI features of extrahepatic abdominal hydatid disease including intraperitoneum, retroperitoneum, diaphragma, bone, and soft tissue of the abdomen.

CONCLUSION

Extrahepatic abdominal hydatid lesions have nearly identical imaging features, including the presence of cyst wall calcification, daughter cysts, and membrane detachment. The combinations of radiologic and serologic tests especially in patients living in the endemic areas contribute to the diagnosis. Despite their rarity, being familiar with the spectrum of radiologic findings in these unusual sites is helpful to improve diagnostic accuracy.

Appropriate approach to bronchobiliary fistulas: a case series with hydatid disease and algorithm of case-based management

Bronchobiliary fistula caused by liver echinococcosis is a relatively unusual but severe complication of hydatid disease. Optimal management of cases is crucially important in establishing rapid recovery and avoiding additional complications. The use of an algorithmic guide is essential because of an ongoing dilemma that involves a large variety of therapeutic options. We present four patients with bronchobiliary fistulas caused by liver hydatid disease to discuss the management of therapeutic options through a case-based approach and an extent review to finally generate an algorithm. In this series, two patients were treated surgically, and the remaining were treated with conservative methods. To date, they have developed neither recurrence nor need for additional intervention. Although treatment of bronchobiliary fistulas is traditionally thought to be surgical, most of the less severe cases can be treated nonoperatively. Making an accurate selection among less invasive methods and/or open surgical interventions seems to be a key component of management.

Isolated torsion of fallopian tube in a premenarcheal 12-year-old girl

Isolated torsion of fallopian tubes should be considered even at premenarcheal ages in cases of acute pelvic pain, and prompt surgery can preserve the tube and thus fertility. It is an uncommon emergency event and a difficult condition to evaluate clinically. This report focuses on a 12-year-old premenarcheal girl who presented with acute pelvic pain of 2 days. Pelvic ultrasound showed an adnexal mass on the left side. Laparoscopy was performed and an isolated tubal torsion was discovered. The tube was necrotic and salpingectomy was performed. The appendix appeared to be hyperemic and erectile. Appendectomy was also performed to rule out appendicitis. It's our recommendation that in the differential diagnosis of acute lower abdominal pain of girls, isolated torsion of the fallopian tubes should be considered. Also, preservation of the tube and fertility should be possible with prompt surgical intervention.

Comparison of Ileal Conduit and Transureteroureterostomy with Ureterocutaneostomy Urinary Diversion

INTRODUCTION

We compare the postoperative early and late complications of patients who had undergone ileal conduit (IC) urinary diversion and transureteroureterostomy (TUU) with ureterocutaneostomy (UC) urinary diversion during the same interval and by the same surgeons.

MATERIALS AND METHODS

Between 1992 and 2004, we performed TUU with UC urinary diversion in 27 men and 7 women (group I) and ileal conduit urinary diversion in 57 men and 10 women (group II). The mean age of the TUU with UC diversion and the ileal conduit patients was 57+/-11.2 (range 51-76) and 64+/-12.6 (range 54-76) years, and the mean follow-up was 37 (range 14-52) and 56 (range 14-72) months, respectively. The 6F or 8F stents were used routinely.

RESULTS

Of 34 TUU with UC cases 8 (23.52%) had early postoperative complications and 2 (5.88%) had early reoperation rates, whereas 11 (16.42%) of 67 ileal conduit cases had early postoperative complications and 4 (5.97%) had early reoperation. The mean hospital stay was 7 (range 5-25 day) and 11 (range 7-34 day) days for each group, respectively. Of the TUU and UC cases, 6 (17.64%) had late complications and 3 had (8.82%) late reoperation, whereas 14 conduit cases (20.89%) had late complications and 6 had (8.9%) late reoperation. Early postoperative complications were defined as those that occurred before hospital discharge or within 30 days from the date of surgery and late complications were defined as those occurring greater than 30 days from the date of surgery as previously described. In group I, the mean operative time was 170 min (range 120-325) compared with 260 min (range 170-473) in group II. The mean blood loss in group I was 474 ml (range 250-1,400) and 589 ml (range 300-1,700) in group II (p>0.05).

CONCLUSIONS

Our results suggest that patients undergoing a TUU and UC diversion have no additional risk of reoperation and the TUU with UC urinary diversion is a safe procedure with postoperative early and late complications.

Enteric and rectal duplications and duplication cysts in the adult

Alimentary tract duplication and duplication cysts are rare congenital malformations. The ileum is the most frequently affected site. However, alimentary tract duplication and duplication cysts can occur at any point along the gastrointestinal tract. Early diagnosis and prompt surgical treatment is the best way to prevent associated morbidity. This article presents the cases of three patients admitted to Gulhane Military Medical Academy with signs of acute abdomen, intra-abdominal mass and chronic abdominal pain. These patients were found to have enteric duplication, duplication cyst and/or retro-rectal cyst. The literature on alimentary tract duplications is reviewed.

Increased intra-abdominal pressure causes bacterial translocation in rabbits

BACKGROUND

Abdominal compartment syndrome (ACS) is defined as intra-abdominal hypertension associated with organ dysfunction. Subsequently, increased intra-abdominal pressure (IAP) adversely affects the pulmonary, cardiovascular, renal, musculoskeletal/integumentary and central nervous systems. Bacterial translocation (BT), which is defined as the movement of viable enteric bacteria to the mesenteric lymph nodes, liver and spleen, occurs after various types of stress and results in splanchnic ischemia. In this experimental study, we aimed to investigate the effects of various levels of increased IAP on BT in rabbits; IAP was increased by the intra-abdominal balloon-insufflation method, thus simulating noncompliant abdominal-wall closure under tension.

METHODS

Fifty rabbits were randomly assigned to 1 of 5 groups, with each group comprising 10 animals. In group I (control group), an intra-abdominal balloon was placed without inflation. In groups II, III, IV and V, IAPs of 10, 15, 20 and 25 mmHg, respectively, were established via inflation of the intra-abdominal balloon. All groups underwent laparotomy after 12 hours. Multiple biopsies were taken from ileocecal lymph nodes, the spleen and liver.

RESULTS

BT was observed to some degree in all 4 experimental groups. A gradual increase in the phenomenon was noted as IAP increased from 10 to 15 mmHg; and BT was overt at 20 mmHg, and significant at 25 mmHg. Klebsiella pneumoniae, Serratia marcescens, and Escherichia coil were the predominant pathogens identified by culture.

CONCLUSION

We propose that an intravesical pressure (IVP) of 15 mmHg is the critical point for BT in patients with increased IAP. In this experimental study, BT occurred when IVP reached 20 mmHg. We suggest that IVP monitoring is desirable in the management of patients with ACS, and that decompressive laparotomy should be performed in patients with IVP >20 mmHg.

Surgical therapy for acute superior mesenteric artery embolism

BACKGROUND

Acute mesenteric artery embolism has a high rate of morbidity and mortality. Early diagnosis and appropriate treatment are the most important factors associated with morbidity and mortality.

METHODS

During the period between 1997 and 2002, 24 patients underwent superior mesenteric artery embolectomy. The patients were divided into three groups according to the onset of symptoms and operation time. Group I (n = 12) patients were operated on in the first 6 hours after onset of symptoms; group II (n = 9) patients were operated on between 6 and 12 hours after onset; and group III (n = 3) patients underwent embolectomy after 12 hours. Low-dose (5 to 10 mg) local tissue-type plasminogen activator (t-PA) administration directly into the superior mesenteric artery was an additional procedure with the embolectomy in all patients.

RESULTS

The macroscopic view of the intestine was normal in 15 patients (12 patients in group I and 3 patients in group II) 30 minutes after the administration of local t-PA. Segmental resection was necessary in 4 patients in group II. Extended resection was necessary in 2 patients in group II and 3 patients in group III, and all of the patients died during the early postoperative period.

CONCLUSIONS

We suggest that explorative laparotomy should be done in patients with sudden abdominal pain, nausea, vomiting, mild leukocytosis, and metabolic acidosis who have previous valvular heart disease or atrial fibrillation. Ultimately, selective low dose t-PA (5 to 10 mg) administration reduces the length of intestinal portion to be resected.

Beneficial effects of N-acetylcysteine on sodium taurocholate-induced pancreatitis in rats

BACKGROUND

Acute pancreatitis (AP) is a complex disease associated with significant complications and a high rate of mortality. Although several mechanisms are put forward, oxidative stress seems the most important early event in the pathophysiology of AP. Therefore, we evaluated the beneficial effects of N-acetylcysteine (NAC), a strong antioxidant, in experimental AP.

METHODS

Forty-nine Sprague-Dawley rats were used. Acute pancreatitis (AP) was induced by the intraductal infusion of sodium taurocholate. Rats were divided into seven groups (each containing seven rats): control, sham-operated (saline-treated, 3.5 and 12 h), non-treated AP (3.5 and 12 h) and NAC-treated AP (3.5 and 12 h). Treated rats received intraperitoneal (i.p.) NAC 1000 mg/kg 24 h before and just before the induction of pancreatitis.

RESULTS

Rats with AP had extensive parenchymal and fat necrosis and NAC treatment at 12 h reduced tissue necrosis significantly (P < 0.05). NAC treatment at 12 h reduced leukocytic infiltration significantly (P < 0.05). Edema and hemorrhage were significantly increased in the AP groups when compared to controls (P < 0.001). NAC treatment reduced edema and hemorrhage at both 3.5 and 12 h slightly but not significantly. The total pathological mean score was significantly increased in the AP groups (P < 0.05) and it was reduced by NAC treatment (P < 0.05). NAC treatment decreased plasma amylase and lipase levels significantly (P < 0.05). While glutathione peroxidase (GPx) activity of pancreatic tissue was similar in the NAC-treated and AP groups, hepatic tissue GPx activity was lower in the AP groups, and NAC treatment restored it (P < 0.05). NAC had no effect on pancreatic superoxide dismutase level. In the NAC-treated rats, the serum NO(2)/NO(3) (nitrite/nitrate) level was significantly increased in the 3.5-h group when compared to the respective AP group (P < 0.05). NAC treatment also significantly reduced the serum concentration of the lipid peroxidation product, malondialdehyde, at 12 h (P < 0.05).

CONCLUSIONS

NAC treatment had beneficial effects in sodium taurocholate-induced AP in rats. It reduced pancreatic tissue necrosis and lipid peroxidation. In our study, the mechanism underlying the beneficial effects of NAC seemed to be its antioxidant activity, either by increasing hepatic GPx activity, or by a direct scavenging effect on free radicals, thus enhancing the production of and/or inhibiting the degradation of nitric oxide.

The effects of gingko biloba extract (EGb 761) on experimental acute pancreatitis

BACKGROUND AND OBJECTIVE

Acute pancreatitis is an important and fatal disease with high mortality and morbidity. Although the pathogenesis of acute pancreatitis is poorly understood, there are many studies that suggest the role for oxygen free radicals (OFRs) in the development of pancreatitis and its complications and show beneficial effects of scavenger treatment. In the present study, we aimed to investigate whether Egb761, the standardized extract of gingko biloba, restrains the generation of OFRs and ameliorates the histopathologic findings of acute pancreatitis.

MATERIALS AND METHODS

Sixty male Sprague Dawley rats were randomly assigned to one of the following experimental groups. In early and late pancreatitis and treatment groups, acute pancreatitis was induced by retrograde infusion of 3% sodium taurocholate. In treatment groups, 100 mg/kg Egb 761 was given intraperitoneally (IP) 24 h and immediately before induction of pancreatitis. Sham-operated rats received isotonic saline instead of sodium taurocholate. After observation times of 3.5 and 12 h, the pancreas was removed for light microscopy and determination of malondialdehyde (MDA) levels as a marker for OFRs-induced lipid peroxidation. Serum samples also were obtained for amylase and lipase levels.

RESULTS

There was no significant difference in control and sham-operated groups in terms of histopathologic findings and serum enzyme levels. The tissue concentrations of MDA and serum enzyme levels were significantly elevated in early and late treatment groups as compared with the control group. The treatment with Egb 761 caused significant decrease in serum amylase and lipase levels and histopathologic scores as compared with early and late pancreatitis groups.

CONCLUSIONS

Prophylactic application of Egb761 exerts highly beneficial influence on the course of acute pancreatitis, and this seems to be related to the oxygen radical scavenger effect of Egb761.

Diagnostic features and treatment modalities in solitary rectal ulcer syndrome

Solitary rectal ulcer syndrome (SRUS) is a traumatic lesion of the anterior or circular rectal wall caused by straining due to functional disorders of defecation. Defecography, transrectal ultrasonography or anorectal manometry are suitable procedures that may be used to detect the causative disorder and should, therefore, be performed in patients with solitary rectal ulcer syndrome. Histopathological features of SRUS are characteristic and pathognomonic, nevertheless the endoscopic and clinical presentations may be confusing. The lesions may mimic other rectal pathologies and lead to wrong diagnosis. We retrospectively evaluated 34 patients with SRUS who had various treatments. Rectosigmoidoscopy, defecography, transrectal ultrasonography and anorectal manometry were performed for evaluation of cases. The operative management was rectopexy in 26 patients, rectal mucosectomy in 4 patients, segmental colonic resection in 2 patients, local excision in 1 patient and colostomy in 1 patient. Total regression and healing of the ulcer occurred in 32 of 34 patients. Partial regression of symptoms in 2 patients, who underwent rectopexy and rectal mucosectomy, occurred, but we could not get complete healing.

Effects of portal triad occlusion on left-sided colonic anastomosis

Anastomotic healing can deteriorate because of different local and systemic effects in cases of concomitant left colon and liver injuries. We evaluated the effects of portal triad occlusion (PTO) on bowel anastomosis after concomitant segmental left colonic resections achieved in rats. There were three separate groups of animals; each consisted of 20 Sprague-Dawley male rats weighing 250 +/- 20 g. In group I, left colonic segmental resection 1 cm in diameter and anastomosis were performed as controls. In group II, the same surgical procedure was done after 15 minutes of PTO followed by 30 minutes of reperfusion. In group III, PTO time was held at 30 minutes. The rats were killed at days 4 and 7 to evaluate anastomotic healing, histological changes, bursting pressures, and serum levels of malondialdehyde (MDA) and hydroxyproline. In group II, the bursting pressures of anastomosis on days 4 and 7 were similar to group I; these pressures were significantly lower in group III (P < 0.001), whereas the hydroxyproline levels in group II were lower than group I and group III levels (P < 0.002). There were histopathological changes that support the data found in groups II and III. Serum MDA levels in groups II and III were significantly higher than in group I (P < 0.001). We observed that serum MDA levels peaked at day 4 and gradually decreased with a statistically significant difference at day 7. In conclusion, there were no negative effects of PTO on colonic anastomosis in group II. But in group III, with longer occlusion times, anastomotic healing was impaired and the mortality rate was higher.

[Gastrointestinal hemorrhage due to traumatic superior mesenteric artery aneurysm (case report)]

We report the case of a 21-year-old male patient with superior mesenteric artery aneurysm due to missed arterial injuries, its complications of enteric fistula and results of surgical treatment. The aneurysm was excised, enteric fistula was closed and aorta-mesenteric bypass using saphenous vein graft was performed. The hemorrhage became masked because of the tamponade in the mesentery during penetrating abdominal injury and initial surgery, and the late complication of false aneurysm came on the scene in follow up. Aorta-mesenteric bypass by a transmesenteric approach provides successful result in surgical treatment of superior mesenteric artery aneurysm.

Augmentation of mucosal adaptation following small-bowel resection by electromagnetic field stimulation in rats

Survival following massive resection of the small intestine is often possible due to substantial hyperplasia of the mucosal surface in the remaining small intestine. While nutrients provide the major stimulus for hyperplasia in the clinical setting, the availability of drugs to augment this process would have obvious therapeutic implications. Electromagnetic field stimulation (EMF) of connective tissue and skin increased the DNA and messenger RNA and protein synthesis in experimental studies. We evaluated the ability of electromagnetic field stimulation to augment mucosal hyperplasia following massive small bowel resection in the rat. Two groups of 10 Wistar rats, 250 gr body weight, were subjected to 70% jejunoileal resection. The first group received EMF stimulation for ten days at a dosage of 43.20 gauss, the second group did not receive any stimulation. After fourteen days, segmental evaluation of mucosal mass in the remaining small intestine was determined by measuring mucosal protein, and disaccharidase levels, as well as intestinal length and circumference. EMF stimulation appears to augment mucosal adaptation following massive small bowel resection in rat, in the proximal and distal small intestine.