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This white paper documents the consensus opinion of the expert members of the Editorial Board of Artificial Intelligence Surgery regarding the definitions of artificial intelligence and autonomy in regards to surgery and how the digital evolution of surgery is interrelated with the various forms of robotic-assisted surgery. It was derived from a series of video conference discussions, and the survey and results were subsequently revised and approved by all authors.

Objectives: Obesity has become one of the most serious and ever increasing health problems of our times. Diet, exercise and medical treatment have proven to be insufficient. Operations such as laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) have gained popularity. The purpose of this study is to conduct a retrospective comparative analysis of the clinical results gained from patients treated with LSG and LAGB due to morbid obesity. Methods: The patients included in the study were selected among those who were diagnosed with morbid obesity and were operated with LAGB (n = 55) and LSG (n = 52) from May 2007 to December 2012. Both groups were compared in terms of the demographic characteristics, preoperative and postoperative conditions. Results: The groups were similar in terms of age, sex and BMI. In the 6th month, there was a notable loss of appetite in the LSG group patients compared to the LAGB patients (69.2% vs. 23.6%, p < 0.001). The rate of excess weight loss in the LAGB group was 23.93% ± 7.98% and 31.7% ± 7.49% in the LSG group in the postoperative 6th months (p = 0.002). The rate of excess weight loss was 45.36% ± 10.92% in the LAGB group and 60.3% ± 9.81% in the LSG group in the postoperative 12th months (p ˂ 0.001). Conclusions: When the two surgical operations for morbid obesity are compared LSG is found to be a more successful method in terms of body weight loss. Nevertheless, longer hospitalization can be associated with the technically more complicated nature of the operation and the fact that it requires resection.

Objective: In this paper, it was tried to determine the incidence of COVID-19, course of the disease, and mortality rate in liver transplant patients by evaluating all patients operated on in our center. In addition, the results of liver transplantation performed in our center during the pandemic period were also presented. Material and Methods: All patients who had undergone liver transplantation in our liver transplant center were questioned about their history of COVID-19 either at their routine controls in the clinic or by phone interview. Results: Our liver transplant unit had 195 registered liver transplantation patients (2002-2020), and 142 of these were still alive and under follow-up. During the pandemic period, 80 patients referred to our outpatient clinic for follow-up, and their records were evaluated retrospectively in January 2021. Among 142 liver transplant patients, a total of 18 (12.6%) COVID-19 patients were identified. While 13 of these patients were males, mean age of the patients at the time of interviews was 48.8 years (22-65 years). Nine of the patients had living donor liver transplant, and the rest had cadaveric liver transplant. The most common COVID-19 associated symptom in the patients was fever. During the pandemic period, 12 liver transplant operations were performed in our center. Nine of them were living donor liver transplantation and the remainder were cadaveric liver transplantations. Two of our patients got COVID-19 positive during this period. One of them who was transplanted after COVID treatment was followed-up in intesive care for a long time and was lost not related to COVID-19. Conclusion: The incidence of COVID-19 is higher in liver transplant patients than in the general population. Nonetheless, mortality rates are low. During the pandemic period, liver transplantation can be continued by following general precautions.

Objective: During the COVID-19 pandemic, most of the elective surgeries had to be postponed. However, it is not possible to delay the surgical treat- ment of cancer patients for a long time. The aim of this study was to present how gastrointestinal system surgery operations are managed without delay and how employee safety is ensured , together with the results of the last five months. For this purpose, a preclinical and clinical screening system was created. Material and Methods: Data of the patients who presented to our outpatient clinic between April 1st 2020 and August 31st 2020 were retrospectively reviewed. Results: During the last five months of the pandemic, a total of 387 patients were hospitalized and 309 of these patients underwent surgical procedures. 165 of the patients who underwent surgery were newly diagnosed malignancy patients. All patients who were hospitalized were subjected to a screening for COVID-19 during the preclinical, clinical and surgical period. In the preclinical period, five patients were found positive and were directed to COVID-19 treatment without hospitalization. In the clinical period, six patients were isolated by showing symptoms during the hospitalization period. Only one of these patients received surgical treatment. The remaining five patients underwent endoscopic and interventional procedures. In this process, COVID-19 positivity was detected in a total of five healthcare workers. Conclusion: With this preclinical and clinical screening method, it is shown that a COVID-19 sterile environment can be provided by early detection of positive cases in both patients and healthcare workers. In this way, the possibility of surgical continuity was demonstrated.

Background: As the advantages of minimally invasive techniques in general surgery have been shown, we prefer laparoscopic total extraperitoneal (LTEP) inguinal hernia repair or robotic transabdominal preperitoneal (RTAPP) inguinal hernia repair in patients diagnosed especially with a bilateral inguinal hernia in our practice. The present study aims to evaluate the early/midterm outcomes and complications in patients who underwent LTEP and RTAPP because of bilateral inguinal hernia. Materials and methods: In total, 189 patients underwent inguinal hernia repair between June 2016 and June 2019 in our department. Data of 49 (2F) patients (33 LTEP/16 RTAPP) who had undergone bilateral inguinal hernia repair were evaluated retrospectively. Univariate analysis was performed to identify the relations between the techniques (LTEP vs. RTAPP), outcomes, and complications. Results: Patient demographics and comorbidities were similar in both groups. There was no difference between the groups in terms of American Society of Anesthesiologists (ASA) scores (P=0.09). Operative time was longer in the RTAPP group (P=0.001). Length of hospital stay was similar in both groups (P=0.11). No recurrence was observed in both groups. Mean pain scores were significantly less for the RTAPP group (P=0.05). When general complications were compared, it was found that the RTAPP group had a statistically significant lower complication rate (P=0.02). Mean follow-up was longer in the LTEP group (P=0.04). Total hospital costs for RTAPP and LTEP were 3968$ and 2506$, respectively. Conclusions: We conclude that RTAPP seems to have better results in terms of general complications and postoperative pain score when compared with LTAPP. Robotic surgery might be safely recommended for bilateral inguinal hernia repair. WOS:000685228300011 33347086 Q3

Introduction: After bariatric surgery (BS), patients might suffer from nutrient maldigestion, malabsorption, and vitamin deficiencies. In this study, our aim was to assess pancreatic functions after BS using fecal elastase-1 assay (FE-1). Material and Methods: Sixty patients (21M) undergoing BS and 20 (6M) healthy controls were included into the study. Stool samples were collected 1 year after surgery. Ten patients from one anastomosis gastric bypass (OAGB) and single anastomosis duodenal switch (SADS) groups with the lowest value of FE-1 and GIQLI scores were given pancreatic enzyme replacement therapy (PERT). After PERT, FE-1, excess weight loss (EWL), BMI, GIQLI scores, and vitamin D levels were measured. Results: Vitamin D levels were detected as 19.04 (9–46.5) pg/ml, 15.1 (8.4–23.6) pg/ml, 17.8 (5–30) pg/ml, and 21.79 (11–40.3) pg/ml after sleeve gastrectomy (SG), OAGB, SADS, and control groups, respectively (p = 0.04). GIQLI scores in the first year were found to have increased in all patients (p = 0.02). FE-1 levels were found as 642.35 (566.3–711.4) μg/g, 378.52 (183.5–561.1) μg/g, 458.88 (252.5–593, 5) μg/g, and 518.2 (351.6–691) μg/g for the SG, OAGB, SADS, and control groups, respectively. There was a strong inverse correlation between EWL and FE-1 levels at the end of the first year (Spearman’s rho = − 0.688, p = 0.003). After having performed PERT for patients with the lowest FE-1 levels, the levels increased to 683.39 (615.5–720) μg/g in the OAGB and 691.5 (643.1–720) μg/g in the SADS groups (p = 0.011). Conclusion: FE-1 measurements demonstrated that many patients suffer from malabsorption after OAGB or SADS, whereas functions remain normal after SG. PERT corrects pancreatic functions without affecting weight loss and also contributes to the normal serum level of vitamin D. 32885359

The world has been struggling with the COVID-19 virus since December 2019. Turkey has also been battling with the virus since March 2019. While struggling with this unknown virus, we have postponed our new bariatric surgeries like most elective surgery. However, curfew and quarantine period (increase in food intake and decreased physical activity) increases risks for morbidity and mortality because of obesity and diabetes. When the pandemic decreases and disappears, many obesity patients will seek treatment for obesity and the workload of surgeons will increase. Before bariatric and metabolic surgery operations, which is the most effective treatment of obesity and related comorbidities, necessary precautions must be determined and implemented to protect patients and healthcare workers before and during surgery. In this review, it was aimed to determine the pre-peri and postoperative periods of bariatric surgical requirements. This review has been written on behalf of the Turkish Society for Metabolic and Bariatric Surgery as an initiative in order to answer some questions about bariatric and metabolic surgery during the COVID-19 pandemic.

Objective: Gastric cancer is a common malignancy worldwide. Effective treatment by interdisciplinary cooperation is important, and surgery still plays an important role. Material and Methods: In a ten-year period, 355 patients were diagnosed to have gastric cancer. One hundred and sixty-two patients with a median (range) age of 58 (23-83) years were eligible for the study. There were 107 patients in D2 and 55 patients in D2 lymphadenectomy plus para-aortic lymph node (PALN) dissection group. The two groups were compared in terms of complications, morbidity, mortality and long-term survival. Results: Length of stay was 12 (8-34) days for D2 and 14 (8-42) days for D2 plus PALND. Total number of operative mortality was 8/162 (5%), and it was not different between the groups. Twenty patients (18%) had complications in D2 group and 9 (17%) patients in D2 plus PALND group. Overall survival was also similar between the groups, but patients with T3-T4 tumors, patients with stage IIIA and IIIB disease had better survival with D2 plus PALN dissection. We found that the depth of invasion, PLN, ratio (PLN/TLN), stage and LND were all prognostic variables. Conclusion: This study showed that D2 plus PALN dissection for advanced gastric cancer can be performed as safely as a standard D2 dissection by experienced surgeons without increasing postoperative morbidity and mortality. D2 plus PALN dissection should be preferred in the advanced stage of the disease (IIIA-IIIB) as it increases the rate of survival.

Gastric cancer (GC) remains one of the most important malignant diseases with significant geographical, ethnic, and socioeconomic differences in distribution. Sentinel lymph node (SLN) mapping is an accepted way to assess lymphatic spread in several solid tumors; however, the complexity of gastric lymphatic drainage may discourage use of this procedure, and the estimated accuracy rate is, in general, reasonably good. This study aimed at reviewing the current status of SLN mapping and navigation surgery in GC. SLN mapping should be limited to tumors clinically T1 and less than 4 cm in diameter. Combination SLN mapping with radioactive colloid and blue dye is used as the standard. Despite its notable limitations, SLN mapping and SLN navigation surgery present a novelty individualizing the extent of lymphadenectomy.

Amac: Glikoz metabolizmasinda eser elementlerin cinko Zn , krom Cr , selenyum Se , demir Fe , bakir Cu ve vanadyum Va etkileri oldugu bilinmektedir. Bu calismanin amaci acil servise basvuran hastalarda eser element duzeyleri ile akut diabetes mellitus DM komplikasyonlari arasindaki iliskiyi tespit etmektir. Yontemler: Bir universitesi hastanesi ucuncu basamak acil servisine 01 Ocak 2012 – 29 Subat 2012 tarihleri arasinda basvuran 18 yas ve uzeri yeni DM tanisi konulan veya daha onceden DM tanisi olan hastalar aydinlatilmis onam alinarak calismaya dâhil edildi. Kontrol Grubu ise bilinen herhangi bir hastaligi ve ilac kullanimi olmayan 18 yas ustu saglikli bireylerden secildi. Eser element duzeyleri ise atomik absorpsiyon spektrofotometrik yontemle TQ X5 marka ICP-MS cihazi kullanilarak elde edildi. Eser element duzeyleri, hem DM ile saglikli kontrol grubu arasinda hem de DM komplikasyonlari olan hastalar ile saglikli kontrol grubu arasinda karsilastirildi. Bulgular: Calismaya toplamda 249 124 kadin kisi alindi. 151 84 kadin kisi calisma grubunu DM olustururken 98’i 40 kadin kontrol grubunu olusturdu. Acil servise basvuran diyabet hastalarinin olculen eser element duzeyleri ile kontrol grubu karsilastirildiginda ortalama degerlerde belirgin bir fark olmadigi tespit edildi p>0,05 . Akut diyabetik komplikasyonlari olan diyabetik ketoasidoz, diyabetik ketoz ve hiperglisemi hastalar n=11 ile kontrol grubu karsilastirildiginda da yine her iki grup arasinda anlamli fark bulunamadi p>0,05 . Sonuc: Yapilan arastirmalar eser elementlerin molekuler duzeyde glikoz metabolizmasindaki etkilerini gostermekle birlikte, calismamizda acil servise basvuran akut diyabetik komplikasyonlari olan hastalarda bakilan eser element duzeylerinin Zn, Cr, Se, Fe, Cu ve Va saglikli bireylerle karsilastirilmasi sonucunda aralarinda anlamli bir fark bulunamamistir.

Since December 2019, the world has been battling the COVID-19 pandemic, and health workers are at the forefront of the fight. Surgeons also fulfill their duty; however, elective cases had to be postponed in order to use resources appropriately in the fight against coronavirus. Although benign elective surgical procedures can be postponed to a distant time during this pandemic, surgical interventions for urgent and life-threatening situations are mandatory to perform but the main uncertainty among surgeons is about cancer patients. In this paper, we aimed to present a suggestion to the surgeon about how to manage digestive system cancers during pandemic in the light of the published articles and guidelines.

The virus COVID-19, which emerged in China in December 2019, was announced by the World Health Organization as a pandemic in January 2020. It is known that infection is not severe and may even progress without symptoms in patients who have come into contact with COVID-19. Although various organizations have been informed about how to take measures to protect the patient and the surgeon in case of diseases requiring urgent or elective surgery in people infected with COVID-19 or in cases with high suspicion, there is still no definite judgment between patients, physicians and health authorities. In this study, which was prepared with the initiative of the Turkish Surgical Association, we tried to shed light on what should be done and how surgeons should act in patients whose operation is mandatory in light of the available data.

Objective: The clinical results of obese patients who have undergone open or laparoscopic appendectomy, whether one technique is superior to the other is still not clearly known.In our study, we compared the clinical results of obese patients operated with laparoscopic or open technique for acute appendicitis. Material and Methods: We performed retrospective analyses of patients operated for acute appendicitis between the dates of July 2016 and July 2019 at Istinye University Faculty of Medicine Bahcesehir Liv Training and Research Hospital and Liv Hospital Ankara. Of the 241 patients whose height and weight information was accessible, 57 had a body mass index of 30 kg/m2 or higher. Eighteen of these patients underwent open surgery while the other 39 underwent laparoscopic surgery. The primary result criterion was complication ratio. Secondary criteria were operation time and length of hospital stay. Results: Upon comparison of laparoscopic and open techniques in terms of intraoperative-postoperative complications (p= 0.01), operation time (p= 0.02) statistically significant differences were found between the groups. However the mean length of hospital stay (p= 0.181) was similar in both groups. Conclusion: In obese appendicitis patients, the laparoscopic technique proved to be superior to the open technique in criteria such as perioperativepostoperative complications, operation time, and etc. Length of hospital stay was determined to be similar between the groups. © Copyright 2020 by Turkish Surgical Society. WOS:000596036500018 32637882

Background: Bariatric surgery plays a major role in ameliorating metabolic abnormalities of type 2 diabetes (T2DM). The aim of this study was to evaluate the early effects of “Single Anastomosis Duodenal Switch-proximal approach” (SADS-p) and “One Anastomosis Gastric Bypass-Mini Gastric Bypass (OAGB-MGB) on the “homeostasis model assessment of insulin resistance” (HOMA-IR) index levels in morbidly obese patients with T2DM. Methods: In this retrospective 3-year trial, outcomes of SADS-p and OAGB-MGB patients were compared considering the changes in HOMA-IR index levels. All bariatric procedures were performed by a single primary surgeon recognized as a surgeon of excellence by IFSO-EC with the assistance of one or two additional attending surgeons. SADS-p was performed on 60(10 males) patients, and 200(27 males) patients underwent OAGB-MGB. Forty-six patients (78%) in the SADS-p group and 125 (63%) in the OAGB-MGB group had T2DM. Patients were evaluated before surgery and 1,3,9,12 months after surgery. Results: In both groups, the HOMA-IR index levels decreased significantly after surgery (p < 0.05), and both procedures markedly improved glycemic control. In the SADS-p group the HOMA-IR index levels significantly decreased from 6.2 to 1.4 after the 12th month of surgery (p < 0.05), in OAGB-MGB group HOMA-IR index levels significantly decreased from 5,9 to 1.7 after the 12th month of surgery (p < 0.05). Conclusion: Both procedures are promising operations which offer excellent control on weight, HOMA-IR index and diabetes. © 2020 IJS Publishing Group Ltd WOS:000539259900016 32305534 Q1

Objective: The whole world is dealing with the COVID-19 pandemic, and healthcare professionals are the most affected group. The aim of this study was to evaluate the knowledge of general surgeons about COVID-19 and understand the attitude and current situation of our colleagues. Material and Methods: This descriptive study comprised general surgeons working in different parts of Turkey. A survey with 23 questions was prepared to determine the demographic characteristics of the participants, workplace characteristics, change in daily work practices and their attitudes in the pandemic process. Results: A total of 332 forms were evaluated. Survey results show that the majority of surgeons have changed their daily surgical practices. Many surgeons take part in the treatment of COVID-19. While most benign cases are delayed, the managemet of malignant cases differs. There are also differences in the evaluation of patients preoperatively and the type of operation. Personal protective measures are followed. While the rate of infected surgeons is low, the majority of surgeons have concerns about infection. Conclusion: Turkish surgeons have managed to get a quick reaction from the start of the pandemic. However, there are still differences in preoperative patient evaluation and operation selection and precautions during the operation. Surgeons also should be informed about the management of malignant patients. WOS:000596036900004 33015559

COVID-19 is a new disease, based on currently available limited information, older adults and people of any age who have severe underlying medical conditions may be at higher risk for severe illness from COVID-19. People of all age groups are also at risk. Healthcare providers have always been the professionals most exposed to the risk of contracting to any kind of infection due to the nature of their profession. Elective interventions have been postponed to give care of patients with COVID-19. However, some interventions cannot be delayed, such as trauma surgery, acute abdomen, and emergency endoscopies. To maintain the sustainability of the healthcare system, the protection of healthcare providers should be the top priority. On the other hand, patients, who need emergency healthcare, should also be provided with appropriate treatment. Healthcare professionals should choose a treatment method appropriately in the circumstances to protect themselves and their patients as much as possible. This paper aims to summarize how a surgeon may act appropriately when an intervention is inevitable during the COVID-19 pandemic.

I am pleased to introduce this special series on “Bariatric and Metabolic Surgery”. Present series includes all recognised available standard techniques and their modifications in bariatric surgery starting from gastric anding to more complex procedures like duodenal switch. WOS:000674391500007

After the introduction of biliopancreatic diversion (BPD), it is modified by adding duodenal switch (DS) to BPD-DS. Although its technical difficulty and high complication rates, it is accepted as one of the most effective procedure for the treatment of obesity. Many modifications have been developed in order to ease the technique and to overcome the complications. Present paper explains our modified technique of single anastomosis duodenal switch (SADS) and results in 2 years follow-up. WOS:000547503000005

BACKGROUND Doctors have an important role in increasing the number of organ donors. This study aimed to investigate the changing attitudes of medical students regarding organ donation, from first-year medical students (FYMS) to sixth-year medical students (SYMS) at a university medical school in Turkey. MATERIAL AND METHODS One hundred first-year medical students and 100 sixth-year medical students participated in the study. A four-part questionnaire was designed for the study, with a response rate of 66.8%. RESULTS Completed study questionnaires showed that organ donation was considered by 46% of first-year medical students and 60% of sixth-year medical students, but an organ donor card was signed by only 8% and 10%, respectively. Information about organ donation had been sought, mainly from social media, by 72% of first-year medical students, and 55% of sixth-year medical students. Regarding their views on organ donation of their relatives, 78% of first-year medical students and 86% of sixth-year medical students were influenced by the opinions of their families and community. When asked about brain death, 50% of first-year medical students and 12% of sixth-year medical students believed it to be a potentially reversible condition, or were uncertain of the definition. CONCLUSIONS During six years of training in a university medical school in Turkey, there was only a slight increase in the number of students who were willing to become organ donors and there was a lack of formal education regarding organ donation. Therefore, urgent improvements are required in the education of doctors and society regarding organ donation.

BACKGROUND Laparoscopic Nissen fundoplication is gold standard treatment for gastroesophageal reflux disease. We examined the results of laparoscopic Nissen fundoplication with or without double-sided polypropylene mesh. PATIENTS AND METHODS Sixty patients were prospectively evaluated. Primer cruroraphy and primer cruroraphy with mesh were performed in 31 and 29 patients, respectively. The Gastrointestinal Quality of Life Index (GIQLI) was used for assessment of the patient satisfaction preoperatively and postoperatively at 12 months. RESULTS Sixty patients were included in the study, with a mean age of 42 years. There was no difference between the 2 groups with respect to age, sex, and duration of symptoms. GIQLI showed an equal improvement, and there were no differences in the quality of life in both the groups. All patients' endoscopic findings were normal at first year. CONCLUSIONS Laparoscopic Nissen fundoplication appears to prevent reflux and its symptoms and create better quality of life. Double-sided polypropylene mesh for repair may result in better quality of life.

High International Normalized Ratio (INR) level resulting from warfarin use increases the risk of gastrointestinal hemorrhages. We aimed to compare the efficacy of prothrombin complex concentrates (PCC) and fresh frozen plasma (FFP) at lowering the INR level, decreasing active hemorrhages visible by endoscopy, and shortening the length of stay at the emergency department (ED).This study is a prospective cohort study of consecutive patents with gastrointestinal hemorrhages that received either PCC or FFP. With strict exclusion criteria, only patients over 18 years of age with a high INR level (2.1) due to warfarin usage were included.A total of 40 patients (18 female) were included in the study, 20 each in the PCC and FFP groups. For the PCC group, the mean INR levels at the second and sixth hours were lower than those for the FFP group (second hour INR: 1.53 vs 4.50, P.01, sixth hour INR: 1.52 vs 2.41, P.01). Seven patients experienced active bleeding (Forrest 1) in the FFP group, whereas no patient experienced active bleeding in the PCC group based on the Forrest classification (35% vs 0%, P.01), and only 3 patients in the FFP group underwent invasive/surgical treatment (15% vs 0%, P.01). The ED length of stay was lower for the PCC group (1.62 days vs 3.46 days, P.01).For patients experiencing a gastrointestinal hemorrhage, INR levels were reversed more quickly, there was less active bleeding on endoscopy, and the ED length of stay was lower in the PCC group than in the FFP group.

Background Liver is the most frequently injured intraabdominal organ following abdominal trauma. Liver injury in polytraumatized patients can vary from minor contusions to major lacerations and is associated with morbidity and mortality. The objective of this study was to evaluate the outcome of liver injury in polytraumatized patients. Methods Only surgically treated 82 patients with liver injury over an eight year period (2005-2013) were included in this study and analyzed retrospectively. Data collected included demographics, laboratory findings, intraoperative findings, operative management, and outcome. The patients were divided into two groups and the mortality and survival data were compared. Results The overall mortality rate was 18.3% (15 of 82 patients). 34 (41.5%) patients had blunt, forty-eight (48.5%) had penetrating trauma. There were multiple traumas in forty-seven (57%) patients. Forty-seven (57%) patients had total of seventy one coexisting intraabdominal injuries. Forty-six (56.1%) patients had stable and thirty-six (43.9%) had unstable hemodynamics on admission. In mortality group AST, ALT, LDH, APTT, PT, INR, and creatinine levels were high, fibrinogen levels and platelet counts were low on admission. Conclusion Hemodynamic instability, coexisting musculoskeletal and chest injury, high APTT, PT, INR, AST, ALT, LDH levels, and low fibrinogen levels and platelet counts on admission should be considered as predictive factors for mortality.

A fistulous tract between the stomach and the spleen is a rare manifestation. Spontaneous gastrosplenic fistula formation resulting from primary gastric lymphoma is extremely rare and should be managed as an emergency. To date, four gastrosplenic fistulas originating from gastric lymphoma have been reported, of which three were spontaneous and one occurred following chemotherapy. We report a case of spontaneous gastrosplenic fistula in a 35 years-old-man with gastric malignant B-cell non-Hodgkin's lymphoma who was diagnosed by computed tomography and endoscopically, followed by successful treatment with total gastrectomy and splenectomy.

A 55-year-old man was admitted to the emergency department, with high fever. Physical examination revealed a soft abdomen without any signs of peritoneal irritation and bowel sounds were normal. Laboratory tests revealed elevation of white cell count (11.5×103/mm3) and C reactive protein. Contrast-enhanced CT showed sigmoid colon diverticulosis and increasing stranding of fat tissue adjacent to the sigmoid colon, in keeping with diverticulitis (figure 1). In addition, complete thrombosis of the inferior mesenteric vein …

BACKGROUND: This study aimed to evaluate injury patterns of patients admitted to the emergency department with gunshot wounds, results of imaging studies, treatment modalities, outcomes, mortality ratios, and complications. METHODS: A retrospective descriptive study was carried out including a total number of one hundred and forty-two patients admitted to Hacettepe University Emergency Department with gunshot injuries between January 1, 1999 and December 31, 2013. The Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Injury Severity Score (ISS), and theTrauma and Injury Severity Score (TRISS) probability of survival for penetrating trauma were calculated for all patients. RESULTS: Among the one hundred and forty-two patients in the study, one hundred and twenty-eight (90.1%) were male. Mean age was 36 years. On admission, the average GCS score was 13, mean RTS was 6.64, median ISS was 5 and median TRISS probability for survival was 99.4% for penetrating trauma. Fluid was detected in three (13%) patients in FAST, whereas intra-abdominal solid organ injury and bowel injury were detected in 11 (58%) patients in abdominal CT. The pneumothorax, hemothorax and lung injuries were detected in 10 (40%) patients, whereas hemothorax was detected only in one patient with thoracic injury by chest X-ray. Twenty four (16.9%) patients died; eighteen patients (75%) had isolated severe intracranial injuries, two (8.3%) had thoracic injuries with head and neck injuries, and four (16.7%) patients had intra-abdominal organ injuries (one with concomitant head injury). Ten patients were brought to the ED in cardiopulmonary arrest. In dead patients, GCS, RTS and TRISS were significantly lower, and ISS were significantly higher than in surviving patients. Twenty three (95.8%) patients were in critical injury level (ISS 25-75, actually ISS >50) in the exitus group. CONCLUSION: Mortality rates in gunshot wound patients with cranial injuries are very high. Spontaneous return is not seen in patients brought to the ED in arrest state. Bullets can cause internal organ injuries which can be greater than expected. In thoracoabdominal gunshot wound injuries, conventional X-ray and bedside FAST can be ineffective in detecting the whole extent of intrathoracic and intra-abdominal injuries. Thus, thoracic and abdominal CT should be planned early for hemodynamically stable patients in order to eliminate causes of fatality and make a timely and correct diagnosis. ISS, RTS and GCS are useful in predicting prognosis and mortality. Especially in patients with ISS scores >50, the mortality rate can be as high as 96%. Language: en

Many emergency departments (EDs) have established units capable of providing critical care because of increasing need for critical care, called as ED intensive care unit (EDICU). However, prolonged critical care leads to crowding, resulting in poor quality of care and high mortality rates. We aimed to determine which type of critically ill patients play a main role for crowding in the EDICU, and how to manage these patients.Patients aged older than 18 years who presented to the ED and presented for consultation to the ICU were eligible for inclusion in this study. Patients were classified into 4 priority groups by the Society of Critical Care Medicine.Four hundred medical patients were enrolled in the study. Sixty-one patients were not admitted to hospital (15.2% of all patients) and were treated in the EDICU. These patients were older (mean age, 66.6 years) and had a higher percentage belonging to the priority 3 group (82.0%-unstable with reduced likelihood of recovery due to chronic illness) in comparison with other ICUs patients (mean age, 60.4 years and 11.9%, respectively) (P.05). In priority 3 patients, the length of stay was median 120 hours, and also, length of invasive mechanical ventilations duration was median 19 hours in the EDICU.Emergency department intensive care unit occupancy appears driven by categorized as "reduced benefit" patients, and these units tend to become alternative dumping grounds for palliative care services. Hospitals and health care administrators should take special care to develop policies for improving the management of these patients.

Amantadine is a dopaminergic agent with possible N-methylD-aspartate antagonist effects. Dopaminergic agents have been succesfully used for many purposes, including prophylaxis for influenza, adjunctive therapy for psychiatric diseases, treatment for Parkinson Disease, and treatment for disorders of consciousness. In this case report, amantadine infusion was started in a patient whose unconciousness could not be identified for ten days. A dramatic recovery was detected on the second day following amantadine infusion. The patient was discharged on the twenty-first treatment day with a 15 GCS score. Conclusion: Amantadine may be added to the standard therapy in comatose patients as it accelerates neurological functional recovery.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) can be performed through transvaginal, transgastric, transrectal, transvesical, or transesophageal approaches. As a skin scar-free surgery, it eliminates the complications related to incisions, yet brings new challenges, unseen before in laparoscopic surgery. Although NOTES is felt to represent a logical evolution in minimally invasive surgery and over 2,000 NOTES cases have been performed since the first description, technical, logistical, and other challenges have limited its use and currently many of the procedures are hybrid.

Mesenteric ischemia is a life-threatening vascular emergency with high mortality rates. Mean platelet volume (MPV) has been shown to be closely related to platelet activation. We investigated whether MPV was associated with outcome of acute mesenteric ischemia (AMI). Sixty-one patients who were operated for AMI were retrospectively evaluated. Patients were divided into two groups: survivors and nonsurvivors, according to the outcome, and the two groups were compared in terms of MPV levels and other prognostic factors. Urea, creatinine, alkaline phosphatase, amylase, gamma-glutamyl transferase and MPV levels were significantly higher in nonsurvivors, when compared to that of survivors. In addition, hypertension, atherosclerotic heart diseases and rhythm disorders were statistically significant risk factors for mortality. AMI is an uncommon but highly lethal surgical emergency. Our results indicate that an elevated MPV is associated with a worse outcome in patients with AMI.

AIM: To study a retrospective analysis of patients who presented to the emergency departments (ED) with complaints related to foreign body ingestions. METHODS: Patients older than 16 years of age who presented to the ED between January 1st and December 31st of 2010 with complaints related to swallowed foreign bodies were identified from electronic health records and patient charts. RESULTS: A total of 100 patients presented with a complaint of foreign body ingestion during the study period. Overall, an X-ray was performed on 75 patients, and a fiberoptic evaluation was performed on 45 patients. A foreign body was detected in 46 (46%) patients. The diagnostic yield of the X-ray was 27 (36%) out of 75 patients, while the diagnostic yield of the fiberoptic evaluations was 21 (47%) out of 45 patients. The detected foreign bodies were mostly located in the esophagus (17 out of 46 foreign bodies detected). When the types of ingested foreign bodies were evaluated, 52 (52%) patients reported ingesting food, and 19 (19%) patients reported swallowing pins. An X-ray was performed on 33 patients with accidental food ingestions but yielded a positive result in only two cases. In 12 out of 21 patients with accidental food ingestion who underwent fiberoptic evaluation, the foreign material was detected and removed. CONCLUSION: Plain radiography is helpful in the localization of radiopaque swollen foreign bodies, while fiberoptic methods are useful as both diagnostic and therapeutic tools, regardless of radiopacity. (C) 2013 Baishideng. All rights reserved.

BACKGROUND To compare ESI Five-Level Triage System with 5-Level Hacettepe Emergency Triage System (HETS), which was developed for Overcrowded EDs in our country. METHODS Over a period of six days, patients were assessed by a different ED staff everyday using HETS, then re-evaluated blindly by an emergency physician using HETS. Then patients were evaluated blindly for a third time by an independent, ESI-using emergency physician. RESULTS Of the patients in the study, 133 were men, 175 were women and the average age was 44.41±18.033. Inter-rater agreement was 97.40% (Kappa=0.963) between HETS and HETS-Blind, 74.35% (Kappa=0.646) between HETS and ESI-Blind, 74.67% (Kappa=0.652) between HETS-Blind and ESI-Blind. Inter-observer agreement between the second emergency physician performing HETS-Blind and the first emergency physician, resident, or nurse was very good (Kappa=1.0). Intern doctor, non-medical secretary and paramedic were found to have almost very good agreement (Kappa=0.971; 0.935; 0.864, respectively). An overtriage of 7.25% and undertriage of 1.08% were found in HETS. CONCLUSION Complaint-based HEST developed for overcrowded Eds is a triage system with a very good agreement between observations and observers. Low undertriage and overtriage ratios, and easy application by all staff from a non-medical secretary to the emergency physician.

Background Acute pancreatitis remains a common intraabdominal disease with a complex pathophysiology. The overall outcome has improved, but specific treatment remains elusive. The challenge is the early identification and treatment of patients who will develop severe acute pancreatitis. Therefore, the aim of the present study is to investigate plasma levels of copeptin in the initial phase of predicted severe acute pancreatitis. Methods Between August 2008 and December 2011, 57 patients with acute pancreatitis and 30 healthy individuals were included in the study. Four blood samples, for serum copeptin measurement, were taken from each individual in each group. The first measurement was taken from the admission blood sample. The subsequent 3 samples were taken at 12, 24, and 48 hours after the onset of pain. Results Copeptin plasma concentrations were significantly higher in patients with acute pancreatitis when compared with healthy controls. Copeptin plasma concentrations in severe pancreatitis patients were significantly higher than in mild pancreatitis patients. Conclusions Copeptin plasma concentrations were significantly higher in patients with acute pancreatitis when compared with healthy controls. Copeptin plasma concentrations in severe pancreatitis patients were significantly higher than in mild pancreatitis patients.

Torsion of the extraperitoneally transplanted kidney is rare complication with no clinical data in the literature. The authors present the case of a 44-year-old man with end-stage renal disease who received a kidney transplant from his father. On postoperative day 4, serum urea and creatinine levels increased and urine output decreased. Renal ultrasonography revealed the renal hilum to be rotated to the lateral pelvic border, causing mild pelvocaliectasis, and Doppler ultrasonography, the patients showed a poststenotic flow pattern. After the patient underwent urgent reoperation, all laboratory values and ultrasonography findings returned to normal. To the authors' knowledge, this is the first published case report of torsion of the extraperitoneally transplanted kidney. When posttransplant deterioration in renal function occurs, renal torsion should be considered in the differential diagnosis.

AIM: To discuss about the perioperative problems encountered in patients with internal biliary fistula (IBF) caused by cholelithiasis. METHODS: In our hospital, 4 130 cholecystectomies were carried out for symptomatic cholelithiasis from January 2000 to March 2004 and only 12 patients were diagnosed with IBF. The perioperative data of these 12 IBF patients were analyzed retrospectively. RESULTS: The incidence of IBF due to cholelithiasis was nearly 0.3%. The mean age was 57 years. Most of the patients presented with non-specific complaints. Only two patients were considered to have IBF when gallstone ileus was observed during the investigations. Nine patients underwent emergency laparotomy with a pre-operative diagnosis of acute abdomen. In the remaining three patients, elective laparoscopic cholecystectomy was converted to open surgery after identification of IBF. Ten patients had cholecystoduodenal fistula and two patients had cholecystocholedochal fistula. The mean hospital stay was 13 d. Two wound infections, three bile leakages and three mortalities were observed. CONCLUSION: Cholecystectomy has to be performed in early stage in the patients who were diagnosed as cholelithiasis to prevent the complications like IBF which is seen rarely. Suspicion of IBF should be kept in mind, especially in the case of difficult dissection during cholecystectomy and attention should be paid in order to prevent iatrogenic injuries.

Summary Background/Objective The study aims to evaluate the alterations in the brain due to oxidative stress and lipid peroxidation resulting from obstructive jaundice. Methods Forty-one Wistar albino rats were used in this study. Simple laparotomy was performed in the sham group ( n = 5). In the remaining 36 rats, the common bile duct (CBD) was found and ligated. They were divided into six groups. Group I, Group II, and Group III were sacrificed at the 3 rd , 7 th , and 14 th day of ligation, respectively. In Group Id, Group IId, and Group IIId ligated bile ducts were decompressed at the 3 rd , 7 th , and 14 th day, respectively. One week after decompression these rats were also sacrificed and samples were taken. Results After the CBD ligation, serum levels of bilirubin and malondialdehyde were found to be increased progressively in parallel to the ligation time of the CBD. After decompression these values decreased. In electron microscopy evaluation, the damage was found to be irreversible depending on the length of the obstruction period. In Group II, the damage was mostly reversible after the internal drainage period of 7 days. However in Group III, the tissue damage was found to be irreversible despite the decreased values of oxidative stress and bilirubin. Conclusion Ultrastructural changes in brain tissue including damage in the glial cells and neurons, were found to be irreversible if the CBD ligation period was >7 days and did not regress even after decompression. It is unreliable to trace these changes using blood levels of bilirubin and free radicals. Therefore, timing is extremely critical for medical therapies and drainage.

Measuring cognitive load is important for surgical education and patient safety. Traditional approaches of measuring cognitive load of surgeons utilise behavioural metrics to measure performance and surveys and questionnaires to collect reports of subjective experience WOS:000711212701036 Q1

Initially sleeve gastrectomy (SG) was performed as an open procedure in 1988, known as Hess and Marceau's technique, which is actually the first stage of the bilio-pancreatic diversion-duodenal switch (BPD-DS). It was proposed in 1993 as a single weight-loss procedure defined by Johnston, later known as operation Magenstrasse and Mill. In 1999 Gagner was the first to describe laparoscopic SG technique. Therefore SG became popular and one of the most common bariatric surgery procedure in the world. The method has many technical differences. Unfortunately, there is still no strict standardization of the method. With the development of technology, robotic surgery has taken its place in bariatric surgery field. A lot of new studies on robotic SG (RSG) have recently been published. Also there are several technical conflict, such as distance from the pylorus, resection of greater curvature, size of the antrum, use of bougie, fundus resection, whether or not reinforce the staple line, identification and repair of the hiatus. There are also some contraindications for SG. Barrett's esophagus is a one of them. These variations in the technique affect the complications and effectiveness of surgery. In this study, we aimed to discuss the development and modifications of SG steps of with the current literature review. WOS:000547503000007

Background: Robotic sleeve gastrectomy (RSG) is a new and popular option for obesity surgery. This study aims to analyze our experience during the transition period from laparoscopic sleeve gastrectomy (LSG) to RSG. Patients and Methods: Sixty patients with sleeve gastrectomy (SG) were enrolled into the study. Last 30 patients in the LSG group and first 30 patients in the RSG group were included in the study. Total operative time (OT), docking time, complications (intraoperative and postoperative), hospital stay, and amount of postoperative drainage were recorded and groups were compared. Results: There were no complications during surgery. There was no mortality or conversions to another approach in any patient. There were no leaks. Hospital stay, complication rates, and excess weight loss rates were similar in both groups. OT was longer in the RSG group. Postoperative drainage was lesser in the RSG group. Conclusion: RSG is safe and feasible and might be considered as an initial procedure for surgeons who plan to move forward to more complex procedures in bariatric surgery. For an experienced surgeon, the learning curve seems shorter for this procedure. WOS:000480127400001 Q4