Appendecular actinomycosis: A case series of 14 patients

OBJECTIVE

This study aims to assess the clinical, radiological, and histological characteristics of Actinomyces infection identified in appendectomy specimens.

MATERIAL AND METHODS

Between January 2013 and November 2023, 5834 patients underwent appendectomy in our clinic, and their pathology reports were retrospectively reviewed.

RESULTS

Actinomyces appendicites were reported in 14 specimens (0.23%). It was determined that appendectomy was performed in only 10 patients (71.4%), ileocecal resection was performed in two patients (14.2%) and right hemicolectomy in two patients (14.2%). The operations on five patients were performed by laparoscopy, and the operations on the other nine patients were performed by open surgery. Laparoscopy was started in three patients and converted to open surgery due to suspicion of an ileocecal mass and cecal perforation. It was found that the white blood cell count of three patients was within the normal range of reference (8-9.77mg/dL); leukocytosis was detected in other patients (10.2-18.7mg/dL). C-reactive protein was normal in one patient and high in the rest of the patients. While the first-hour erythrocyte sedimentation rate was normal in five patients, it was found to be high in the other patients. Findings on radiological imaging were reported as acute appendicitis, appendicular plastron, and ileocecal mass. As a result of the pathology findings, the patients were given oral penicillin or semi-synthetic penicillin derivatives during one month.

CONCLUSION

Ileocecal and appendecular actinomycosis are rare, and preoperative diagnosis is difficult. A definitive diagnosis is usually made after a histopathological examination. After surgery, long-term antimicrobial treatment of the patient is possible with penicillin.

Amino acids and fatty acids in patients with beta thalassemia major

BACKGROUND

Oxidative damage and increasing of lipid peroxidation are caused by chronic iron overload in patients with beta thalassemia major. Fatty acids are important structural elements for palmitoylation of membrane proteins which constitute a great part of natural membranes. Oxidative damages caused by reactive oxygen derives in thalassemic erythrocytes can be determined with lipid peroxidation, protein oxidation, and antioxidant system elements. The aim of study was to evaluate the relationship between amino acid and fatty acid levels with iron overload and antioxidant enzymes in beta thalassemia major.

METHODS

A total 40 patients with beta thalassemia major with regular blood transfusion and chelating agents were included in the study. The levels of serum amino acid, fatty acid, ferritin, antioxidant enzymes and malondialdehyde were measured.

RESULTS

Only C16- palmitoyl level was found significantly low in patients, other fatty acids and amino acids were in normal range. There were lower malondialdehyde and ferritin levels in patients with low C-16 palmitoyl level (p<0.05).  Conclusions: The high levels of ferritin and malondialdehyde in the patients with low C16-palmitoyl levels might be caused by this fatty acid's preventative effect on oxidative stress.

The role of co-administration of damage control surgery and vacuum-assisted closure in the treatment of perineal wounds

Perineal wounds caused by high-kinetic-energy shotgun blasts have a high mortality risk because they are often accompanied by injuries of the anus, rectum, genitourinary system, and extremities. Mortality often results from hemorrhage in the early stage and from multiple organ failure caused by sepsis in the late stage. The primary step in the treatment of patients presenting with perineal wound and hemodynamic instability caused by severe hemorrhage is to control hemorrhage and contamination using damage control surgery. After achieving hemodynamic stability, vacuum-assisted closure can be used to reduce the risks of infection and sepsis. In this report, we present a case who had a perineal wound caused by a mine blast and was successfully treated by damage control surgery and vacuum-assisted closure.

Emergency Endoscopy and the Importance of Endoscopy Training in General Surgery Residency: A Survey-Based Study

Background

Emergency endoscopy is a life-saving technique of great significance. The aim of our study was to draw attention to endoscopy training activities of general surgeons and their opinions on this issue.

Material/Methods

We asked general surgery specialists where they received their general surgery training, the institution where they currently worked, how many years they had been practicing, if they had endoscopy training during or after residency, if a gastroenterologist was available in their hospital, and whether they used endoscopy. We also asked some questions, including ‘Should general surgeons perform emergency or elective endoscopy?’, ‘Is endoscopy training required in general surgery’, and ‘What is your opinion regarding this issue?’, and we assessed the answers.

Results

Of the 138 general surgeons undertaking surveys, 63% of participants received their general surgery training in university hospitals and 37% in training and research hospitals. The duration of practicing as a general surgeon was 5 years for 23.9%, 5–15 years for 38.4%, 15–20 years for 20.3%, and over 20 years for 17.4% of participants. The rate of receiving endoscopy training at residency was 51.4%, 25.4% did not have endoscopy training, and 23.2% had postgraduate training. All participants replied affirmatively to the question ‘Should general surgeons perform emergency or elective endoscopy?’.

Conclusions

Although endoscopy has been widely used recently, gastroenterologists are not available in every hospital. Consequently, it is evident that endoscopy should be part of general surgery training.

Where should the damage control surgery be performed, at the nearest health center or at a fully equipped hospital?

BACKGROUND

Transport of casualties from a combat area to a fully equipped hospital where all techniques of damage control surgery (DCS) can be performed requires a great deal of time. Therefore, prior to transport, prompt control of hemorrhage and contamination should be achieved, and resuscitative procedures should be performed at the nearest health center. The aim of the present study was to investigate the effect of the location at which DCS was performed on rates of mortality.

METHODS

The present retrospective study included 51 combat casualties who underwent DCS at the present clinic or at hospitals nearest the combat area due to high kinetic energy gunshot injuries to the abdomen between 2010 and 2015. Patients were evaluated in terms of acidosis, hypothermia, coagulopathy, and mortality.

RESULTS

Patients were divided into 2 groups depending on the location where the first step of DCS was performed: (1) at the present hospital or (2) at other hospitals. Group 1 comprised 26 patients (51%), and Group 2 comprised 25 (49%). Total mortality occurred in 23 (45.1%) patients, including 15 (57.7%) patients in Group 1 and 8 (32%) in Group 2. In Group 1, mean time from injury to hospital admission was longer, and deep acidosis, hypothermia, and coagulopathy were more marked.

CONCLUSION

Initial surgical control of hemorrhage and contamination in patients injured by high kinetic gunshots should be promptly achieved at the nearest health center. In this way, acidosis, hypothermia, and coagulopathy can be prevented, and the risk of mortality can be reduced.

A swallowed metal nail entrapped in the right psoas muscle

Foreign body ingestion can be caused by many factors, including hallucination in patients with mental retardation. Most ingested foreign bodies are naturally discharged, though surgical intervention is necessary in some cases. Endoscopic intervention often leads to successful outcome, though open surgery may be required in certain instances. A 29-year-old mentally retarded woman presented to emergency services with a 2-day history of right lumbar pain that increased with movement. Physical examination revealed no specific sign beyond palpable tenderness in the right lumbar region. Radiological examination revealed a metal nail in the upper right quadrant, stretching obliquely toward the retroperitoneum. Endoscopy failed, and the nail was extracted via laparotomy. Foreign body ingestion may occur in patients of any age, but is more common in the pediatric population and in patients with mental retardation. Commonly ingested foreign bodies include daily objects, toys, and dentures, though they may differ in patients with mental retardation. The treatment of such cases requires a diversity of methods and experience. Foreign body ingestion should be kept in mind when a patient presents with pain in the right lumbar region, particularly in patients with mental retardation.

Effects of saline lavage temperature on peritoneal fibrinolysis and adhesion formation

BACKGROUND

Peritoneal lavage with saline at room temperature causes peritoneal hypothermia, vasoconstriction, hypoxia, and acidosis, which are effects that are known to reduce fibrinolysis. Decreased fibrinolysis causes permanent adhesions. Normothermic lavage may prevent this deleterious process and reduce peritoneal adhesions.

METHODS

A rat model of cecal abrasion was used. Control animals received no medication while hypothermic or normothermic saline lavage were administered intraperitoneally to the experimental groups (n=24 for each group). Cardinal parameters of peritoneal fibrinolysis (tissue plasminogen activator [tPA] and plasminogen activator inhibitor type 1 [PAI-1]) were determined in peritoneal tissue samples on postoperative day 1, 3, and 10. On postoperative day 10, adhesions were graded. In the sham group (n=8), following laparotomy, peritoneal samples were taken to determine basal values of tPA and PAI-1 in healthy peritoneum.

RESULTS

Cecal abrasion increased PAI-1 levels about tenfold on postoperative day 1 and caused adhesions. Normothermic saline lavage prevented this traumatic PAI-1 increase and stabilized it to baseline values throughout the experiment and reduced peritoneal adhesion formation. Hypothermic lavage also caused an inhibition of PAI-1 rise but adhesion, prevention was not significant.

CONCLUSION

Our results suggest that normothermic saline lavage reduces adhesions by improving peritoneal fibrinolysis.

A tumoral mass (local recurrence of renal cell carcinoma) causing massive intraabdominal bleeding after blunt abdominal trauma

BACKGROUND

Solid organ injury after abdominal trauma is a common condition, however, injury of the local recurrent tumoral masses following abdominal trauma is rare. The injuries and bleeding in recurrent tumors tend to be highly serious since they are more fragile. The bleedings caused by renal cell carcinomas and by the traumatic laceration of their recurrence commonly occur in the retroperitoneum. In this report, we present a 55-year-old female patient who underwent emergency surgery due to intraabdominal bleeding and bleeding was from the recurrence of a renal cell carcinomas.

PRESENTATION OF CASE

The 55-year-old female patient was admitted to the emergency service with intraabdominal bleeding. Physical examination revealed tenderness in the right lower quadrant, particularly in the traumatic area. Ultrasonography and computed tomography revealed diffuse intraabdominal fluid and a ruptured bleeding mass was excised. Pathological analysis indicated that the mass was isolated local recurrence of renal cell carcinoma.

DISCUSSION

Solid organ injury caused by blunt abdominal trauma may be accompanied by tumoral laceration; however, minor bleeding may occur in cases with blunt trauma, coexistence of blunt abdominal trauma with local recurrence and massive bleeding is extremely rare. Control of bleeding is more challenging in tumoral tissues compared to normal tissues. The bleeding intraabdominal area rather than the retroperitoneal area, and this condition was attributed to the peritoneal tear caused by the trauma.

CONCLUSION

Local recurrent tumoral masses may be the source of the intraabdominal massive bleeding after blunt trauma.

The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis

BACKGROUND

We investigated the effects of methylene blue (MB) on the early and late phases of adhesion and abscess formation in a standard colonic wall injury and fecal peritonitis model in rats.

METHODS

There were four groups: Group I (only laparotomy, n=10), Group II (peritonitis + MB, n=15), Group III (peritonitis + saline, n=15), and Group IV (colon incision + saline, n=15). Mortality, morbidity, adhesion scores, histopathologic analyses, serum tumor necrosis factor-alpha (TNF-?) levels, and tissue hydroxyproline (5-HP) levels were evaluated in all animals. Descriptive statistical methods were used with Kruskal-Wallis test. When a statistical difference was obtained between groups, Mann-Whitney U test was used to confirm the difference between two groups.

RESULTS

Adhesion scores of Groups I, III and IV were significantly higher than in Group II. TNF-? levels were significantly higher in Groups I, III and IV. 5-HP levels were significantly lower in Groups I and II compared to Groups III and IV.

CONCLUSION

Based on these results, it appears that MB may prevent peritoneal adhesions in a peritonitis model, but wound healing could be impaired. MB should be further evaluated because of its dual effect.