Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES最新文献

Uncontrolled hemorrhagic shock due to trauma is a life-threatening condition requiring rapid intervention. Every minute in the man-agement of these patients is valuable. In recent years, resuscitative endovascular aortic balloon occlusion (REBOA) has emerged as a valuable tool in emergency and trauma practice, providing additional time for the patient, particularly in cases where surgical hemosta-sis is delayed. A 62-year-old male patient with no known comorbidities was transported to our tertiary trauma center after receiving five minutes of cardiopulmonary resuscitation (CPR) and intubation at an external facility following a high-energy traffic accident. Upon presentation, the patient's blood pressure was 50/20 mmHg and pulse rate was 128 beats/min. He had extensive pelvic trauma, lower extremity trauma, major soft tissue loss, and vascular and bone injuries. He underwent hemostatic resuscitation along with whole-body computed tomography (CT) imaging; however, cardiac arrest recurred after imaging. During CPR, simultaneous imaging studies revealed no trauma or bleeding in the brain or thorax. REBOA was planned for the patient. Temporary return of spontaneous circula-tion (ROSC) was achieved 38 minutes after REBOA. During this period, the patient received a total of six units of packed red blood cells, three units of fresh frozen plasma, two units of cryoprecipitate, and calcium replacement. The REBOA procedure was performed by emergency physicians and cardiovascular surgeons who had received hands-on training using a REBOA simulation model developed by our team. However, despite achieving a temporary hemodynamic response, the patient could not be stabilized for surgical interven-tion and was pronounced deceased. In this case, we share the first REBOA experience of emergency department physicians trained with a locally produced simulation model. We believe that simulation-based training will contribute to physician experience and direct field application in rare or rapidly evolving emergencies.

Background: Ischemia-reperfusion (IR) injury significantly reduces erythrocyte deformability, leading to increased oxidative stress, inflammation, and impaired microvascular perfusion. This study aimed to examine the protective effects of hydroxytyrosol (HT), a powerful antioxidant derived from olives, on erythrocyte deformability and related oxidative stress markers in a rat model of hind limb ischemia-reperfusion injury.

Methods: Twenty-four rats were randomly divided into four groups: Sham, HT-Sham, ischemia-reperfusion (IR), and IR treated with HT (IR-HT). HT was administered intraperitoneally at a dose of 10 mg/kg prior to ischemia induction. Following reperfusion, biochemical parameters, including malondialdehyde (MDA), superoxide dismutase (SOD), endothelial nitric oxide synthase (eNOS), erythrocyte deformability, and morphology, were evaluated.

Results: HT administration significantly improved erythrocyte deformability, decreased MDA levels, increased SOD activity, and moderated eNOS expression in the IR-HT group compared to the untreated IR group (p<0.001). Morphological analysis demonstrated substantial preservation of erythrocyte integrity, with fewer pathological changes such as echinocytes and dacrocytes.

Conclusion: This study provides preliminary insights into the protective mechanisms of HT, highlighting its therapeutic potential in reducing erythrocyte dysfunction and oxidative damage during ischemia-reperfusion events. Further research exploring comprehensive signaling pathways and long-term clinical outcomes is advisable..

Background: The aim of this study was to present our institutional experience with periprocedural management of emergency cesarean section (CS) operations and maternal and fetal cardiac complications in pregnant women with pulmonary hypertension (PH).

Methods: Thirteen patients who were diagnosed with PH during pregnancy and/or prior to pregnancy according to European Society of Cardiology (ESC) criteria, and who were referred to our hospital with a decision for emergency CS from an external center, were included in the study. For patients who underwent urgent surgery, the following data were recorded: demographic characteristics, time of diagnosis, treatments for pulmonary hypertension used before pregnancy, during pregnancy, and/or after CS, arterial blood gas values, pulmonary and systemic pressure values after induction and at the 12th postoperative hour, extracorporeal membrane oxygenation (ECMO) requirements, time to extubation, length of intensive care stay, and mortality rates.

Results: Eight of the 13 patients were diagnosed with idiopathic pulmonary arterial hypertension (IPAH). The mean systolic systemic arterial pressure (BPs), systolic pulmonary arterial pressure (PAPs), and mean pulmonary arterial pressure were 130+-14.2 mmHg, 93+-28 mmHg, and 52+-17 mmHg, respectively. Six of the 13 patients required ECMO support. The one-month mortality rate was 46%.

Conclusion: Pregnancy in women with PH is associated with significant maternal morbidity and mortality. If the underlying etiology is IPAH, the risk of mortality is higher than in other forms of PH. Mechanical circulatory support devices, including ECMO, may serve as a temporary bridge to lung transplantation in selected cases. Therefore, early diagnosis of IPAH, timely referral of patients to specialized centers, and planning of these operations by a multidisciplinary team consisting of cardiologists, gynecologists, and cardiac anesthesiologists are necessary.

Background: Acute calculous cholecystitis (ACC) is one of the most common conditions encountered in emergency medicine and surgical practice. Delayed recognition of severe cases can lead to complications such as empyema, gangrene, or perforation, resulting in high morbidity and mortality. While the Tokyo Guidelines provide standardized diagnostic and severity grading criteria, the availability and reliability of imaging may be limited in certain settings. Therefore, there is growing interest in simple and cost-effective biomarkers. This study aimed to evaluate the diagnostic and prognostic value of complete blood count-derived (CBC-derived) systemic inflammatory indices, including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte × platelet ratio (NLPR), systemic immune-inflammation index (SII), and multiple inflammatory index (MII), in predicting disease severity in patients with ACC.

Methods: A total of 160 patients diagnosed with ACC in the emergency department between January 2020 and May 2024 were retrospectively analyzed. Patients with acalculous cholecystitis, cholangitis, choledocholithiasis, incomplete data, or age younger than 18 years were excluded. Demographic, clinical, and laboratory findings were reviewed. Receiver operating characteristic (ROC) curve analysis was used to determine optimal cut-off values.

Results: The strongest predictive performance was observed for MII (cut-off=250,011; sensitivity 76.9%; specificity 78.9%; area under the curve [AUC]=0.770). NLR (cut-off=8.45) showed 76.9% sensitivity and 68.0% specificity (AUC=0.755). NLPR (cut-off=0.027) had 76.9% sensitivity and 54.4% specificity, while SII (cut-off=2414) achieved 69.2% sensitivity and 72.1% specificity (all p<0.05). All indices were significant predictors of severe ACC.

Conclusion: CBC-derived systemic inflammatory indices, particularly MII and NLR, are effective, accessible, and inexpensive markers for predicting the severity of ACC. These parameters may complement clinical assessment and assist in decision-making, especially in situations where imaging is unavailable or inconclusive.

Background: To evaluate the anatomical and functional outcomes of pars plana vitrectomy (PPV) combined with prophylactic chorioretinectomy (CR) in patients with deadly weapon-related open globe injuries (DWOGIs).

Methods: Medical records of patients who underwent PPV and prophylactic CR for open globe injuries (OGIs) caused by deadly weapons between November 2016 and October 2024 were retrospectively reviewed. Demographic characteristics, injury type, cause of injury, zone of injury, intraocular foreign body (IOFB) exit/impact site, best-corrected visual acuity (BCVA), proliferative vitreoretinopathy (PVR) rates, anatomical success, and globe survival were evaluated.

Results: Of a total of 283 OGIs, 41 eyes from 35 patients who underwent PPV with prophylactic CR for deadly weapon-related trauma were included in the analysis. The mean age was 30.9+-9.4 years, and 88.6% of the patients were male. Perforating injuries were observed in 38 eyes (92.7%), and penetrating injuries associated with an IOFB in 3 eyes (7.3%). The causes of injury included improvised explosive devices in 20 eyes (48.8%), hand grenades in 11 eyes (26.8%), landmines in 8 eyes (19.5%), and rocket-propelled grenades in 2 eyes (4.9%). The IOFB exit/impact site was located in the posterior pole in 38 eyes (92.7%), of which 22 (53.6%) were outside the vascular arcades, 12 (29.3%) within the vascular arcades, and 4 (9.7%) adjacent to the optic disc. The mean initial BCVA was 2.62+-0.98 logMAR, with 90.2% of eyes presenting between light perception and counting fingers. PPV was performed at a mean of 5.9+-2.7 days after primary repair. Of these eyes, 43.9% had retinal detachment. The mean number of PPV procedures was 2.6+-1.1. C3F8 gas endotamponade was used in 51.2% of cases. At a mean follow-up of 32.8+-16.6 months, the final BCVA improved significantly to 1.18+-1.20 logMAR (p<0.001), with 68.3% achieving ≥20/200 vision. At final follow-up, the rates of PVR, anatomical success, and globe survival were 14.6% (6/41), 85.4% (35/41), and 87.8% (36/41), respectively.

Conclusion: Pars plana vitrectomy combined with prophylactic CR appears to be an effective treatment option for DWOGIs, offering prevention of PVR development and achieving high anatomical success, favorable globe survival, and meaningful visual improvement despite severe ocular trauma.

Background: Despite several studies indicating the efficacy of different molecules in preventing ischemia/reperfusion (I/R) damage, the most effective treatment remains unknown.

Methods: This study included 28 male Sprague rats, which were randomly assigned to four equal groups, with seven rats in each group: Group S (Sham), Group C (Control), Group E (Ethanol), and Group T (Triazole). The superior mesenteric arteries of rats in all groups except Group S were exposed and closed with a vascular clamp, and ischemia was induced for one hour. Oxidative stress parameters, ischemia markers, and biochemical tests indicating organ function were examined.

Results: The mean total antioxidant status (TAS) value of Group T was significantly higher than those of Groups C and E, while being significantly lower than that of Group S (p=0.001). The mean total oxidant status (TOS) value of Group T was significantly lower than those of Groups C and E and significantly higher than that of Group S (p<0.001). Although the mean oxidative stress index (OSI) value of Group T was markedly lower than those of Groups C and E, no statistically significant difference was observed compared to Group S (p=0.002, p<0.001, and p=0.721, respectively). The mean ischemia-modified albumin (IMA) value of Group T was significantly lower than those of Groups C and E and significantly higher than that of Group S (p<0.001). The mean malondialdehyde (MDA) value of Group T was significantly lower than those of Groups C and E and significantly higher than that of Group S (p<0.001).

Conclusion: This study represents the first investigation into the effect of a 1,2,3-triazole compound derived from salicylalde-hyde on ischemia/reperfusion injury. The findings provide strong evidence that the 1,2,3-triazole compound significantly enhances the prevention or treatment of experimental I/R injury. We conclude that this triazole derivative may represent a viable therapeutic option for the treatment and prevention of I/R injury, supported by further experimental and clinical research. The triazole is expected to exhibit enhanced protective properties, particularly when solubilized using alternative methods.

Intradural migration of a bullet within the spinal canal represents an exceptionally uncommon clinical scenario and carries the potential for progressive or delayed neurological decline. Although such fragments may initially remain silent, their subsequent movement within the spinal canal can create significant diagnostic and therapeutic challenges. In this report, we present an unusual and instructive case of cauda equina syndrome that developed secondary to the delayed caudal migration of an intradural bullet fragment. We further provide a detailed discussion of the diagnostic evaluation, surgical management, and clinical decision-making considerations associated with this condition. A 32-year-old male patient sustained a gunshot injury in 2022. Initial imaging demonstrated that the bullet had penetrated the spinal canal and become lodged intradurally at the L1-L2 level, although the patient exhibited no neurological deficits at that time. He was, therefore, managed conservatively with routine follow-up. Approximately 2.5 years later, the patient presented with the sudden onset of bilateral lower extremity weakness, progressive gait impairment, and new-onset urinary incontinence. Computed tomography revealed that the intradural bullet fragment had migrated caudally to the S2 vertebral level, resulting in significant compres-sion of the cauda equina nerve roots. Urgent surgical intervention was undertaken, consisting of a partial bilateral laminectomy at the S1-S2 level and microsurgical extraction of the bullet. Postoperative neurological recovery was substantial, with marked improvement in motor function and complete resolution of urinary symptoms. Although intradural bullet fragments may initially appear clinically insignificant in patients who present without neurological deficits, delayed migration poses a serious risk for the development of cauda equina syndrome and other potentially irreversible complications. This case highlights the importance of maintaining a high index of suspicion and considering early prophylactic surgical extraction when intradural localization is identified, even in neurologically intact individuals. Early intervention may prevent severe late complications such as neurological deterioration, infectious sequelae arising from contaminated missile tracts, and possible lead toxicity related to chronic intradural exposure.

Background: To investigate the prevalence and anatomical distribution of radiologically detected arterial calcification in the abdominal, iliac, and femoral arteries among patients aged ≥65 years undergoing surgical treatment for hip fracture, and to assess the impact of both the presence and localization of arterial calcification on patient survival.

Methods: A retrospective analysis was performed on 270 patients who underwent surgical treatment for hip fractures between 2015 and 2024. The presence of arterial calcifications in the abdominal aorta, iliac arteries, and femoral arteries was assessed on plain radiographs, and their association with patient survival outcomes was investigated. In addition, demographic characteristics, fracture type, treatment modality, and intensive care unit admissions were systematically evaluated.

Results: Arterial calcification was identified in 211 patients (78.1%). The mean survival time was significantly shorter in patients with arterial calcification (47.3 months, 95% CI: 40.7-53.8) compared with those without (76.9 months, 95% CI: 67.1-86.7) (Log-rank χ²=17.23, p<0.001). Log-rank analysis further demonstrated statistically significant differences in survival between patients with and without calcification of the abdominal aorta (χ²=21.39, p<0.001), iliac arteries (χ²=18.21, p<0.001), and femoral arteries (χ²=10.91, p=0.001). Cox regression analysis identified abdominal aortic calcification as an independent predictor of mortality in geriatric hip fracture patients (HR=3.43, 95% CI: 1.31-8.96, p=0.013), whereas iliac artery calcification (HR=1.53, p=0.284) and femoral artery calcification (HR=1.05, p=0.859) were not independently associated with survival after adjustment.

Conclusion: Iliac and femoral artery calcifications should not be regarded as independent predictors of mortality in geriatric patients with hip fractures. In contrast, abdominal aortic calcification has been identified as an independent prognostic determinant of mortality within this patient population.

Although laparoscopic cholecystectomy (LC) is considered the gold standard treatment for symptomatic gallstone disease, iatrogenic bile duct injury remains a rare but serious complication. We present a case of a Strasberg type D bile duct injury that was diagnosed intraoperatively and successfully managed with endoscopic retrograde cholangiopancreatography (ERCP) during the same session, and we discuss it in light of the current literature. A 46-year-old female patient underwent LC for a hydropic and edematous gallbladder. During difficult dissection, a bile leak was observed from the posterior wall of the common hepatic duct, consistent with a Strasberg type D injury. The endoscopy team was consulted intraoperatively, and ERCP was performed. Cholangiography confirmed the leak, and a plastic stent was placed from the common hepatic duct to the ampulla. The operation was completed with drainage of the subhe-patic area. Postoperatively, the patient remained clinically stable. At the sixth postoperative week, follow-up ERCP revealed complete healing with no evidence of leakage, and the stent was removed. The patient had an uneventful recovery, with normal biochemical parameters on follow-up. Early recognition of iatrogenic bile duct injury is the most critical factor influencing prognosis. The literature reports intraoperative detection rates between 25% and 32%, whereas delayed diagnosis is associated with higher morbidity, additional surgical interventions, and prolonged hospital stay. Endoscopic management, particularly in Strasberg type C and type D injuries where ductal continuity is preserved, has shown high success rates (89-96%) and represents a reliable alternative to surgery. This case high-lights that multidisciplinary collaboration and intraoperative endoscopic intervention provide a minimally invasive and effective option for the management of bile duct injuries during LC.

Background: This study evaluates the clinical and functional outcomes of intramedullary nailing without grafting for the treatment of aseptic humeral shaft nonunion.

Methods: Between January 2017 and January 2024, 14 patients treated at a single center for humeral shaft fractures diagnosed with nonunion and managed with intramedullary nailing without grafting were retrospectively analyzed. Demographic and clinical characteristics, union status, and preoperative and postoperative range of motion, Visual Analog Scale (VAS), QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand), and Constant-Murley scores were recorded.

Results: The study included 14 patients (nine women, five men) with a mean age of 49.2+-17.5 years (range: 26-80). Nonunion types were oligotrophic in 64.3% (n=9), atrophic in 28.6% (n=4), and hypertrophic in 7.1% (n=1) of cases. The union rate after intramedullary nailing without grafting was 78.5% (11/14). Two patients who did not achieve union underwent nail exchange with iliac autografting, resulting in a total union rate of 92.9% (13/14). The mean time to union was 4.3+-2.8 months (range: 2-12). The mean preoperative and postoperative QuickDASH scores were 89.4+-6.2 and 17.5+-13.3, respectively, while the Visual Analog Scale scores were 7.7+-1.1 and 1.7+-1.1, respectively (p<0.001). Of the three patients who failed to achieve union after initial treatment, two had atrophic nonunion and one had oligotrophic nonunion. A statistically significant association was observed between nonunion type and the need for revision surgery (p<0.01), with atrophic nonunions being significantly more frequent in patients requiring revision. One patient developed adhesive capsulitis, and another patient who underwent revision experienced transient radial nerve palsy with complete functional recovery. Proximal screw loosening was observed in two patients and was recorded as a minor complication.

Conclusion: Intramedullary nailing without grafting is an effective and safe treatment option for aseptic humeral shaft nonunion in selected patients, particularly those previously treated conservatively. However, omission of grafting in cases of atrophic nonunion or during nail exchange procedures may negatively affect healing.