AMAÇ: Travmatik diyafragma rüptürleri sýkça gözden kaçmasý nedeniyle tanýsý güç olan ve eþlik eden organ yaralanmalarý nedeniyle tedavisinde sorunlarla karþýlaþýlabilen bir patolojidir. Bu çalýþmada 1997-2003 tarihleri arasýnda kliniðimizde tedavi edilen diyafragma yaralanmalý hastalarýn demografik özellikleri, yaralanma þekilleri, eþlik eden organ patolojileri, tedavi þekilleri ile mortalite neden ve oranlarý deðerlendirildi. Ameliyat edilen 45 hastanýn (41 erkek; ort. yaþ 26.35±8.07) 12’sinde künt, 33’ünde penetran (14’ü ateþli silah yaralanmasý, 19’u kesici-delici alet yaralanmasý) yaralanma vardý. Hastalarda karaciðer (n=18, %40) ve dalak (n=16, %35.5) en sýk eþlik eden yaralanmalardý. Sadece 4 olguda (%8.9) ise izole diyafragma yaralanmasý vardý. Hastalarda taný genellikle yandaþ organ patolojileri nedeniyle yapýlan laparotomiler sýrasýnda konuldu (n=37, %82.2). Ameliyat öncesi taný hastalarda, bilgisayarlý tomografi (n=3, %6.7), diyagnostik peritoneal lavaj (n=3, %6.7) ve akciðer grafisi (n=2, %4.4) ile konuldu. Yaralanmalar Moore sýnýflamasýna göre grade 2 (n=10, %22.2), grade 3 (n=26, %57.7) ve grade 4 (n=9,%20) olarak sýnýflanmaktaydý. Tüm hastalarda onarýmlar transabdominal yolla primer sütürlerle yapýldý. Üç hastada (%6.7) eþlik eden akciðer yaralanmasýnýn onarýmý için ayrýca torakotomi uygulanmasý gerekti. Dört hastada (%8.9) mortalite izlendi. Travmatik diyafragma rüptürleri genellikle yandaþ organ yaralanmalarýyla seyreden, taný ve tedavisinde sorunlar olabilen, seyrek olmayarak mortalite ile sonuçlanan patolojilerdir. Acil hastalarda transabdominal yaklaþým uygun bir tedavi seçeneðidir. Diyafragmalarýn bütünlüðü travma nedeniyle yapýlan tüm laparotomilerde mutlaka araþtýrýlmalýdýr.
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OBJECTIVE: Traumatic diaphragm rupture is a pathology causing diagnostic problem since it is often missed at the time of evaluation and treatment of traumatic diaphragm rupture may result in difficulties due to the concomitant organ injuries. In this retrospective study, the patients with traumatic diaphragm injuries admitted and treated in our clinic between 1997 and 2003 were analyzed for demographics, types of the traumas, concomitant injuries, treatment modalities and the rate and causes of the mortality. Diaphragm repair was performed in 45 patients (41 males; median age 26.35±8.07 years). Blunt and penetrating injuries were determined in 12 and 33 patients (14 gunshot injury and 19 penetrating injury), respectively. Liver (n=18, 40%) and spleen (n=16, 35.5%) were the most commonly injured organs concomitantly. Isolated diaphragm injuries were seen in only 4 cases (8.9%). The injuries were generally diagnosed at the time of laparotomy due to neighbor organ injuries (n=37, 82.2%). The diaphragm ruptures were preoperatively diagnosed with computerized tomography (n=3, 6.7%), diagnostic peritoneal lavage (n=3, 6.7%) and chest X-ray (n=2, 4.4%). The injuries were classified as grade 2 (n=10, 22.2%), 3 (n=26, 57.7%) or 4 (n=9, 20%) according to Moore organ injury scaling. The repairs of the diaphragm were performed with primary sutures and via transabdominal approach in all patients. However, thoracotomy was required in 3 cases (6.7%) in order to correct pulmonary injuries. Mortality was seen in 4 patients (8.9%). Traumatic diaphragm ruptures are pathologies generally accompanied by neighbor organ injuries, possibly causing diagnostic and treatment problems and resulting mortalities not infrequently. In our opinion, transabdominal approach is a convenient management option for the emergent cases. The continuity of the diaphragm should be checked in every laparotomy performed due to trauma.
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AMAÇ: Bu çalýþmada katarakt cerrahisi uygulanan tek gözlü hastalarda ameliyat sonrasý görme prognozu ve cerrahi komplikasyonlarý araþtýrýldý. Fakoemülsifikasyon (FAKO) veya ekstrakapsüler katarakt ekstraksiyonu (EKKE) ve arka kamara göz içi lens implantasyonu (AK GÝL) uygulanan tek gözlü 29 hastanýn kayýtlarý geriye dönük olarak incelendi. Yaþlarý ortalama 76.8 olan 4 kadýn, 25 erkek toplam 29 hasta ortalama 21 ay boyunca takip edildi. Ameliyat sonrasý görme keskinliði 17 hastada 2 sýra ve altýnda, 10 hastada 3 sýra ve üstünde artarken, 2 hastada ayný kaldý. Tek gözlü hastanýn ameliyat öncesi ayrýntýlý öyküsü ve görmeyen gözün sorunlarý göz önünde bulundurulup, cerrahi sýrasýnda gerekli önlemler alýndýðý takdirde katarakt cerrahisinde komplikasyon oraný azalacak, cerrahi ve görme sonuçlarý hasta ve doktor açýsýndan oldukça tatmin edici olacaktýr.
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OBJECTIVE: In this study, the change in visual acuity and complications occurred after cataract surgery in monocular patients were assessed. The records of 29 monocular patients who underwent phacoemulsification or extracapsular cataract surgery (ECCE) with posterior chamber intraocular lens (PC IOL) implantation were reviewed retrospectively. Total 29 patients (4 female, 25 male) with a mean age of 76.8 were followed up for mean 21 months. Postoperative visual acuity (VA) improved 2 lines or under in 17 patients and 3 lines and over in 10 patients but VA did not change in 2 patients. When the preoperative history of the monocular patient and the reasons for the negative light perception of the unoperated eye were taken into consideration and necessary measures were taken during careful surgery, the complication rate of extracapsular cataract surgery (ECCE) will decrease and the results of the surgery and the final visual acuity will be satisfactory both for the patient and the doctor.
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AMAÇ: Subaraknoid blok transüretral prostat rezeksiyonu ameliyatlarýnda sýk kullanýlan bir anestezi tekniðidir. Subaraknoid blok kalitesi kullanýlan lokal anestezik ilaçlara opioidlerin eklenmesi ile artýrýlabilir. Bu çalýþmada transüretral prostat rezeksiyonu ameliyatý geçirecek olgularda, intratekal yolla hiperbarik bupivakaine 2.5 mg sufentanil veya 25 mg fentanil eklenmesinin spinal anestezi kalitesi ve hemodinamik parametreler üzerine etkilerini araþtýrmayý amaçladýk. Bu ileriye dönük, randomize çalýþma, elektif olarak, subaraknoid blok yapýlarak transüretral prostat rezeksiyonu uygulanacak, “American Society of Anesthesiologists” (ASA) I-III grubundan 60 olgu üzerinde gerçekleþtirildi. Olgular rastlantýsal olarak üç gruba ayrýldýlar: Opioid kullanýlmayan grup (Grup K), 2.5 mg sufentanil kullanýlan grup (Grup S), 25 mg fentanil kullanýlan grup (Grup F). Tüm gruplarda, lokal anestezik olarak %0.5 hiperbarik bupivakain (12.5 mg) kullanýldý ve toplam ilaç solüsyon hacmi 4 ml’ye tamamlandý. Bloðun baþlama zamaný, duyusal bloðun ulaþtýðý en üst seviye, motor blok seviyesi, analjezi süresi ve geliþen yan etkiler deðerlendirildi. Kontrol grubu ile kýyaslandýðýnda, opioid kullanýlan gruplarda bloðun baþlama zamaný belirgin olarak kýsa bulundu. Analjezi süresi Grup S ve F’de belirgin olarak uzun bulundu. Kardiyovasküler ve solunum sistemi etkileri deðerlendirildiðinde, gruplar arasýnda farklýlýk gözlenmedi. Opioid kullanan gruplarda, sýk görülen yan etki olan kaþýntý, özellikle 2.5 mg sufentanil kullanýlan grupta sýk görülmüþtür. Sonuç olarak; hiperbarik bupivakaine 2.5 mg sufentanil veya 25 mg fentanil eklenmesi, transüretral prostat rezeksiyonu için yeterli anestezi ve ameliyat sonrasý dönemde yeterli sürede analjezi saðlamaktadýr.
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OBJECTIVE: Subarachnoid block is a widely used anaesthesia technique for transurethral resection of prostate. Its quality can be improved with addition of opioids to the local anesthetics. In this study, we aimed to compare effects of 2.5 mg sufentanil or 25 mg fentanyl combined with hyperbaric bupivacaine used via intrathecal route in patients undergoing transurethral resection of the prostate on quality of spinal anesthesia and haemodynamic parameters. This was a prospective, randomized, controlled trial with 60 patients, ASA I-II, who were scheduled for elective transurethral resection of the prostate under subarachnoid block. Patients were allocated into three groups: no opioid (Group K), 2.5 mg sufentanil (Group S) and 25 mg fentanyl (Group F). In all groups, hyperbaric bupivacaine 0.5% (12.5 mg) was used as local anesthetic and the total volume of solution was 4 ml. The onset time of block, maximum level of sensory block, motor block level, duration of analgesia, side effects were evaluated. Onset of the block was significantly shorter in the groups receiving opioids compared with the control group. Analgesia time was significantly prolonged in Groups S and F. There was not any statistical difference between groups on effects of cardiovascular and respiratory systems. The occurrence of pruritus was significantly higher in group receiving sufentanil 2.5 mg than in other groups. The addition of sufentanil 2.5 mg and 25 mg fentanyl to hyperbaric bupivacaine provided adequate anesthesia for transurethral resection of the prostate and good postoperative analgesia.
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AMAÇ: Kliniðimizde genel cerrahi pratiðinde sýkça rastlanýlan stoma uygulamalarýmýzý deðerlendirmeyi amaçladýk. Stoma komplikasyonlarý hastalarda psikolojik sorunlara yol açar. Bu çalýþmada stomalý 102 hasta (54 erkek [%52.9], 48 kadýn [%47.1]) mortalite ve morbiditeye göre analiz edildi. Beslenme jejunostomili iki hasta intraabdominal stoma kaçaðý nedeniyle sepsisden kaybedildi. Dört hastada nekroz görüldü. Retraksiyon hastalarýn 11’inde görüldü. Yara yeri infeksiyonu ve deri irritasyonu sýrasýyla 11 ve 38 hastada gözlendi. Titiz cerrahi teknik ve doðru endikasyon ile stomalarda mortalite ve morbidite azaltýlabilir.
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OBJECTIVE: We aimed to evaluate the stoma practices performed frequently in our clinic. The stoma complications lead to psychological problems in the patients. In this study, 102 patients (54 males [52.9%], 48 females [47.1%]) with stomas were analyzed for mortality and morbidity. Two patients who had jejunostomy for nutritional jejunostomy have died because of sepsis due to intraabdominal leak from the stoma. Necrosis was seen in 4 patients. Retraction was found in 11 patients. Wound infection and skin irritation around stoma were observed in 11 and 38 patients, respectively. Mortality and morbidity of stomas may be decreased with the right indications and meticulous surgical techniques.


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AMAÇ: Bu çalýþmada fotokoagülasyona dirençli diyabetik diffüz maküla ödeminde intravitreal kristalize kortizonun (triamsinolon asetonid) anatomik ve görsel prognoza etkisini araþtýrmak amaçlandý. Yaþlarý 52 ile 75 arasýnda deðiþen diyabetli 30 hastanýn diffüz maküla ödemli 39 gözüne intravitreal 4 mg/0.1 ml triamsinolon asetonid enjekte edildi. Olgularýn tümüne daha önce lazer fotokoagülasyonu uygulanmýþtý. Olgular fundus fluoresein anjiyografisi (FFA) ve görme keskinliði yönünden 1., 3. ve 6. aylarda deðerlendirildi. Gözlerin 1., 3. ve 6. aylarda yapýlan düzeltilmiþ görme keskinliði ölçümleri sýrasýyla ortalama 0.35±0.16; 0.38±0.18 ve 0.32±0.16 olarak bulundu. Düzeltilmiþ görme keskinliklerinde 1. ayda ortalama 0.13±0.12; 3. ayda ortalama 0.17±0.12 ve 6. ayda ortalama 0.11±0.11’lük artýþ izlendi. Birinci ayda 25 gözde (%64.1) FFA’da düzelme izlenirken, 14 gözde (%35.9) FFA’da iyileþme gözlenmedi. Tedavi öncesi ortalama 15.38±2.40 mmHg olan göz içi basýnçlarýnda 1. ayda %24.2, 3. ayda %14.1 ve 6. ayda %12.2’lik artýþ saptandý. Göz içi basýncý 12 olguda 21 mmHg’nýn üzerine çýktý ve bu gözlerde göz içi basýncý topikal monoterapi ile kontrol altýna alýndý. Lazer fotokoagülasyona cevap vermeyen diyabetik diffüz maküla ödeminde, intravitreal triamsinolon asetonidin geçici bir süre için de olsa, gerek anatomik, gerekse görsel düzelme saðlayan, tecrübeli hekimler için uygulamasý kolay, maliyeti düþük ve komplikasyonlarý kabul edilebilir düzeyde bir tedavi yöntemi olduðu gözlendi.
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OBJECTIVE: To assess the effect of intravitreally administered triamcinolone acetonide on anatomic and visual prognosis in diffuse diabetic macular edema resistant to photocoagulation was aimed in this study. 4 mg/0.1 ml triamcinolone acetonide was injected intravitreally to thirty-nine eyes of thirty diabetic patients aged between 52 and 75. All eyes had a previous history of at least one session of laser photocoagulation. The fundus fluorescein angiographic and visual results of all cases were recorded in the first, third and sixth months after the injection. The best corrected visual acuities of the eyes were measured 0.35±0.16, 0.38±0.18 and 0.32±0.16 in first, third and sixth months respectively. The mean improvement of the best corrected visual acuities were found to be 0.13±0.12 in the first month, 0.17±0.12 in the third, and 0.11±0.11 in the sixth month. Twenty-five eyes (64.1%) showed marked improvement in fundus fluorescein angiographic findings while fourteen eyes (35.9%) showed no improvement. The mean intraocular pressure which was 15.38±2.40 mmHg before the treatment, was found to be increased 24.2% in the first month, 14.1% in the third and 12.2% in the sixth month after the treatment. Intraocular pressure was measured above 21 mmHg in 12 cases, all who responded well to topical monotherapy. Intravitreally administered triamcinolone acetonide was found to be an easy and low-cost agent with an acceptable rate of complications, which temporarily yields anatomic and visual improvements in diffuse diabetic macular edema cases resistant to photocoagulation.


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AMAÇ: Konjenital pes ekinovarusta (PEV) konservatif tedaviyle baþarý elde edilemeyen ve geç baþvuran olgularda cerrahi tedavi uygulanýr. Erken cerrahi tedavi fibrozis, nedbeleþme ve eklem katýlýðýný indüklediðinden cerrahi tedavi için en az üç ay beklemek gereklidir. Kliniðimizde 1997-2001 yýllarý arasýnda konjenital PEV tanýsý ile Kite yöntemi ile ilk basamak tedavileri yapýlýp tam düzelme saðlanamayan 15 hastanýn 24 ayaðýna cerrahi tedavi uygulandý. Hastalarýn ortalama yaþý 11 (6-36) ay idi. Hastalarýn 4’ü kýz, 11’i erkek olup; 10’unda bilateral, 3’ünde sol ve 2’sinde sað PEV mevcuttu. On altý ayaða komplet subtalar gevþetme (CSTR), 4 ayaða aþiloplasti, 4 ayaða posteromedial gevþetme uygulandý. Hastalarýn ortalama takip süreleri 36 (10-84) ay olup; sonuçlar Simons kriterlerine göre deðerlendirildiðinde 19 (%79) ayakta baþarýlý, 5 (%21) ayakta baþarýsýz sonuç alýnmýþtýr. Ýki olguda cilt nekrozu geliþmiþ, yara takibi ile sekonder giriþime gerek kalmadan sorunsuz iyileþmiþtir. Baþarýsýz sonuç aldýðýmýz 5 ayaðýn dördüne CSTR, birine ise posteromedial gevþetme uygulanmýþtý. Komplet subtalar gevþetme yara yeri sorunlarý ve “over” korreksiyon gibi komplikasyonlarý olmasýna karþýn tam bir düzelme saðlayabildiðinden, bizim de çoðu olgumuzda tercih ettiðimiz gibi günümüzde en sýk kullanýlan cerrahi prosedürdür.
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OBJECTIVE: Congenital pes equinovarus (PEV) cases, who are late admitted or conservative treatment was unsuccessful, are surgically treated. Since early surgical treatment induces fibrosis, scar formation and joint stiffness; it is necessary to delay surgery at least for 3 months. Twenty-four feet of 15 patients diagnosed as congenital PEV and treated conservatively by Kite method but not corrected completely were treated surgically in our clinic during 1997-2001. Mean age of the patients was 11 (range, 6-36) months. Four patients were female and 11 patients were male. 10 patients had bilateral PEV while 3 had in left hand side and 2 had in right hand side. 16 feet were treated by complete subtalar release (CSTR), 4 by posteromedial release and 4 by achiloplasty. Mean follow-up period of the patients was 36 (range, 10-84) months. When the results were evaluated according to Simons criteria, there were 19 (79%) successful, 5 (21%) unsuccessful results. There were 2 skin necrosis healed by wound care without no requirement for secondary intervention. Four cases with unsuccessful results were treated by CSTR and 1 case was treated by posteromedial release. Although having some complications such as wound problems, over correction, etc; CSTR is the most favorable surgical procedure as we preferred in our most patients.
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AMAÇ: Kompleks bir ameliyat olan pankreatikoduodenektominin mortalitesi son yýllarda azalmasýna raðmen morbiditesi hala yüksektir. Bu çalýþmada amacýmýz çeþitli nedenlerle pankreatikoduodenektomi yapýlan hastalarý sonuçlarý ile birlikte deðerlendirmektir.
YÖNTEMLER: Kliniðimizde 2002-2005 yýllarý arasýnda 25 hastaya Whipple prosedürü uygulandý.
BULGULAR: Ameliyat mortalitesi olmazken (%0); %36 hastada morbidite saptandý. Pankretikojejunal anastomoz hattýndan oluþan fistül oraný %8 idi. Pankreas baþý ve periampuller bölge malign tümörlerinde medyan saðkalým süresi 17 ay idi.
SONUÇ: Whipple prosedürü, endikasyonu olan hastalara uygulamada tereddüt edilmemelidir; fakat komplike bir ameliyat olmasý nedeniyle deneyimli merkezlerde uygulanmalý ve bu hastalar multidisipliner yaklaþýmla ele alýnmalýdýr.

OBJECTIVE: Although the mortality rate of pancreaticoduodenectomy, that is a complex operation, has decreased recent years the morbidity rate is still high. The aim of this study is to evaluate the outcome of the patients’ undergone pancreaticoduodenectomy.
METHODS: The number of patients’ undergone Whipple procedure, between 2002 and 2005 was twenty five.
RESULTS: There was no operative mortality (0%). The morbidity rate was 36%. The pancreaticojejunal fistula rate was 8%. The median survival duration was 17 months in patients with malign neoplasm of head and periampullary region of the pancreas.
CONCLUSION: The surgeons should not hesitate to perform pancreaticoduodenectomy whenever indicated. However this operation should be performed in experienced centers because of the complexity of the operation and patients should be evaluated with multidisciplinary pattern.

Yoðun bakým hastalarý strese baðlý mukozal kanamalar açýsýndan oldukça yüksek risk taþýmaktadýr. Bu kanamalar klinik olarak önem taþýyabilir; bu durum mortalite ve morbiditeyi artýrmaktadýr. Bu hastalarda stres ülser profilaksisi yapýlmasýna karþýn saðkalým üzerine etkisi henüz gösterilememiþtir. Bu yazýda, stres ülser profilaksisine raðmen yoðun gastrointestinal kanamadan dolayý kaybedilen iki olguyu tartýþmayý amaçladýk.

Critically ill patients have increased risk for stress-related gastrointestinal hemorrhage. These hemorrhages can be clinically important which are associated with increased mortality and morbidity. Stress ulcer prophylaxis are used in these patients but has not been shown to improve survival. We reported two cases that died due to massive gastrointestinal bleeding in spite of stress ulcer prophylaxis.

Antifosfolipid sendromu; antifosfolipid antikorlarýnýn varlýðýnda tekrarlayan arteryel ve/veya venöz trombozlar ve/veya ölümcül kayýplarla seyreden bir hiperkoagülabilite durumudur. Baþta sistemik lupus eritematozis olmak üzere çeþitli otoimmün hastalýklarda sýk görüldüðü gibi infeksiyonlar, maligniteler ve ilaç kullanýmý sonrasý da görülebilir. Tromboembolik olaylarýn ve gebelerde tekrarlayan abortuslarýn incelenmesi esnasýnda antifosfolipid antikorlarýn gösterilmesiyle taný konulur. Trombozlar, aortadan prekapiller arteriole kadar tüm vasküler sistemde görülmekle birlikte en sýk alt ekstremitelerde ve kranyal damarlarda oluþur. Trombozun yerleþimine baðlý olarak geniþ bir klinik yelpaze gösterebilir. Asitle kliniðimize baþvuran olgunun incelenmesinde primer antifosfolipid sendromu ile uyumlu bulgular saptandý. Nadir görülmesi nedeniyle bu olgu sunuldu.

Antiphospholipid syndrome is a hypercoagulable state characterized by recurrent venous and/or arterial thrombosis and/or pregnancy complications of fetal loss in the presence of antiphospholipid antibodies. Often it is seen in association with autoimmune connective tissue disorders like systemic lupus erythematosus (SLE). It may be seen in presence of infections, malignancies and drugs. Antiphospholipid syndrome (APS) is diagnosed by measuring antiphospholipid antibodies in patients with vascular thrombosis and/or repeated abortions in pregnancy. Thromboses are observed in all of the vascular system from aorta to precapillary arteriole, however mainly in lower extremities and cranial veins. Depending on the localization of the thromboses, it may display a wide range of clinical spectrum. A patient who presented with ascites to our clinic was diagnosed as primary antiphospholipid syndrome. Since it is a rare case, we present this case here.