Ali Bekraki

Background: Fournier’s gangrene (FG) is a rapidly progressive polymicrobial necrotizing fasciitis of the perineal, perianal, and genital regions associated with high mortality rates. While aggressive surgical debridement and broad-spectrum antibiotics are the cornerstones of treatment, managing severe perianal wounds with extensive abdominal or retroperitoneal spread presents a significant therapeutic challenge. Fecal diversion is often required to prevent wound contamination, but definitive stoma formation can increase patient morbidity. Case Presentation: A 62-year-old obese, diabetic, and hypertensive male presented in septic shock following a blunt abdominal trauma two weeks prior. Computed tomography (CT) revealed extensive gas tracking from the left abdominal wall into the retroperitoneal and pelvic cavities. Urgent surgical debridement confirmed FG originating from a perirectal source. To protect the wound from fecal contamination and facilitate simultaneous negative-pressure wound therapy (NPWT), a low-profile 12 mm silicone Penrose catheter was inserted into the rectum as a temporary, minimally invasive fecal diversion device. Over a 50-day period, the patient underwent serial debridements and NPWT dressing changes. Following the subsequent development of a rectus abdominis abscess and fecal incontinence, a definitive diverting loop ileostomy was performed. The wound successfully granulated, the stoma was reversed at six months, and the patient achieved a favorable recovery. Conclusion: In extensive cases of Fournier’s gangrene tracking into the abdominal wall and retroperitoneum without causing acute peritonitis, combining NPWT with a temporary Penrose catheter fecal diversion system offers a simple, cost-effective, and effective bridging strategy before definitive stoma formation is required.

Background:Acute appendicitis remains a common surgical emergency, and diagnostic uncertainty persists despite the use of clinical scores and imaging. We examined whether an interpretable decision tree could support classification of appendicitis using routinely available clinical, laboratory, and imaging variables.Methods:This retrospective single-center study included 281 patients who presented to El-Youssef Hospital with suspected appendicitis between June 2015 and May 2020. A J48 decision tree was developed in WEKA using age, fever, white blood cell count, neutrophil percentage, C-reactive protein, ultrasound findings, and computed tomography findings. Model performance was estimated with 10-fold cross-validation and reported using the confusion matrix.Results:The decision tree achieved an overall accuracy of 84.3%, with a sensitivity of 89.8%, a specificity of 76.3%, a positive predictive value of 84.8%, and a negative predictive value of 83.7%. Ultrasound, computed tomography, white blood cell count, and neutrophil percentage were the most informative predictors. Misclassifications were most common in patients with atypical presentations or borderline laboratory values.Conclusion:In this single-center retrospective cohort, a decision tree classifier showed good internal performance for distinguishing appendicitis from non-appendicitis. The findings support the feasibility of an interpretable decision-support model, but they do not establish clinical effectiveness. External multicenter validation and comparison with alternative algorithms and existing scoring systems are needed before clinical implementation.Keywords:Acute appendicitis; data mining; decision tree; machine learning; diagnostic classification; clinical decision support.

Objective: Short bowel syndrome (SBS) is a severe malabsorptive condition often resulting from extensive resection due to mesenteric ischemia. This study aimed to evaluate the clinical characteristics, intraoperative findings, and outcomes of patients with acute SBS secondary to mesenteric vascular pathology. Methods: This retrospective study analyzed adult patients treated at a tertiary referral center between September 2020 and September 2025. Inclusion criteria were defined as intestinal resection due to ischemic vascular causes resulting in a residual small bowel length of ≤200 cm. Demographics, comorbidities, surgical details (ileocecal valve status, colon continuity), and total parenteral nutrition (TPN) dependence were evaluated. Results: Twenty-eight patients were included (mean age: 61.61 ± 16.24 years; 60.71% male). Most patients (78.57%) were referred from other centers. Common comorbidities included hypertension (57.14%) and diabetes mellitus (35.71%). The predominant etiology was superior mesenteric artery embolism (67.86%). The median remaining small bowel length was 150 (IQR: 112.5-180) cm in all patients. The in-hospital mortality rate was 32.14%. Comparative analysis revealed no significant differences between mortality and discharge groups regarding age, ileocecal valve preservation, or colon continuity. However, patients independent of TPN at discharge had a significantly greater residual small bowel length compared to TPN-dependent patients (P < .05). Conclusion: Acute SBS secondary to mesenteric ischemia is associated with high mortality. While anatomical factors such as valve preservation did not predict short-term survival in this cohort, residual small bowel length was a significant determinant for TPN independence at discharge. Early diagnosis, timely revascularization, and careful perioperative management remain crucial to improving survival rates in this high-risk population. Cite this article as: Demir M, Aladağli I, Ekçi B, et al. Management and outcomes of adult short bowel syndrome: A single-center experience. Cerrahpaşa Med J. 2026, 50, 0025, doi: 10.5152/cjm.2026.26025.

Surgical outcomes of laparoscopic and open appendectomy in pregnant patients: A single-center retrospective cohort study - Turkish Journal of Surgery

Spontaneous rectus sheath hematoma (RSH) is a rare but potentially life-threatening cause of acute abdominal pain. Prognosis has traditionally been assessed by hematoma size or imaging features, but the influence of systemic comorbidity is poorly defined. This study investigates the predictive value of the Charlson comorbidity index (CCI) on mortality and treatment outcomes in patients with RSH. We retrospectively analyzed 44 adult patients (≥18 years) diagnosed with spontaneous RSH at Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey, between January 2020 and December 2024. Patients with traumatic or postsurgical hematomas were excluded. Hematoma size and volume were measured via computed tomography imaging. Demographics, comorbidities, laboratory parameters, and treatment modalities (conservative, interventional embolization, surgical) were recorded. The primary endpoint was in-hospital mortality. Receiver operating characteristic curve and logistic regression analyses were performed to evaluate the predictive performance of CCI. Systemic comorbidity, as quantified by CCI, is a stronger predictor of mortality and treatment outcomes in RSH than hematoma size or imaging characteristics. Integration of comorbidity assessment into clinical decision-making is recommended for early risk stratification and personalized management. Prospective multicenter studies are warranted to validate these findings and establish comprehensive management algorithms. The mean patient age was 61.5 ± 15.3 years; the mean hematoma volume was 512.9 ± 462.7 mm ³ , and the mean CCI score was 4.84 ± 2.54. Overall survival was 77.3% (n = 34), while 22.7% (n = 10) of patients died. Mortality was not significantly associated with hematoma volume, laboratory parameters, or treatment modality. In contrast, non-survivors had significantly higher CCI scores (6.60 ± 3.24 vs 4.30 ± 2.11; P = .011). Multivariate analysis confirmed CCI as an independent predictor of in-hospital mortality (odds ratio = 1.46 per point increase; P = .022). Receiver operating characteristic analysis demonstrated moderate discriminatory power (area under the curve = 0.732), with a threshold of CCI ≥ 6 optimally predicting mortality. Decision curve analysis showed modest clinical benefit for early risk stratification using CCI.

Background: The optimal timing of percutaneous cholecystostomy (PC) in acute cholecystitis remains unclear, despite its increasing adoption as a treatment option for elderly and critically ill patients. This study aimed to evaluate the impact of PC timing on complications, hospital stay, and mortality in high-risk patients with moderate and severe acute calculous cholecystitis. Materials and Methods: Between 2020 and 2024, 124 consecutive patients who underwent PC were retrospectively reviewed. The time periods from admission to PC were measured. Patients with grade II cholecystitis who had a Charlson Comorbidity Index (CCI) score ≥6 and an American Society of Anesthesiologists Physical Status (ASA-PS) score ≥3, and those with grade III cholecystitis who had a CCI score ≥4 and an ASA-PS score ≥3, were defined as high-risk patients using TG18-aligned thresholds. Among these 82 high-risk patients, the median time from admission to PC was 39 hours (range: 21 to 62 h). Results: Early high-risk group (≤48 h; n=51) had shorter hospital stay [7 (5 to 8) vs. 13 (6 to 20) d; P 48 h; n=31). Delayed PC (OR=4.80, P =0.004) and complications related to PC (OR=4.37, P =0.015) were independent risk factors for longer hospital stay. A higher CCI Score (≥7) (OR=13.68, P =0.047) and delayed PC (OR=8.64, P =0.04) were independent risk factors for in-hospital mortality. Conclusions: While emergency cholecystectomy remains the gold standard for the treatment of acute cholecystitis, PC represents a valuable initial treatment alternative in high-risk patients when performed at an early stage. Early PC provides significant advantages, including fewer complications, shorter hospitalization, and reduced in-hospital mortality.

Purpose Despite medical progress and laparoscopic cholecystectomy being standard for Grade II-III acute calculous cholecystitis in ASA II patients, optimal management, especially the timing of cholecystectomy (early vs. delayed) considering morbidity, risk-benefit, and cost, is still debated. While percutaneous cholecystostomy is definitive for ASA III/IV patients, its role as a bridge to cholecystectomy and the ideal interval in ASA II medically refractory cases remain unclear. Methods This retrospective study assessed the impact of initial percutaneous cholecystostomy on the timing, duration, and type of subsequent elective cholecystectomy in ASA Class II patients with Tokyo Grade II–III acute calculous cholecystitis. Percutaneous cholecystostomy was performed in patients with moderate cholecystitis unresponsive to conservative management and in those with severe cholecystitis presenting with negative predictive factors indicating a high risk of conservative treatment failure and perioperative complications. In both groups, the procedure served as a bridging intervention to stabilize patients before definitive surgery. The primary aim was to evaluate the effects of this strategy on surgical timing, complexity, and overall treatment outcomes. Results Of the 176 patients initially admitted with acute cholecystitis, 97 met the inclusion criteria, comprising those with Tokyo Grade II–III disease and classified as ASA II. Among patients who underwent laparoscopic cholecystectomy more than eight weeks after percutaneous cholecystostomy, 77% experienced prolonged operative durations, defined as procedures exceeding 60 min. Delayed surgical intervention in this specific cohort was consistently associated with a marked increase in both intraoperative complexity and technical difficulty during the laparoscopic cholecystectomy. Conclusions The liberal use of percutaneous cholecystostomy in patients with Tokyo Grade II–III acute calculous cholecystitis is not recommended. When percutaneous cholecystostomy is necessary as a bridging intervention prior to definitive surgical management, early laparoscopic cholecystectomy should remain the preferred approach in the majority of ASA II cases. Percutaneous cholecystostomy should be reserved for patients who are unresponsive to conservative treatment or present with contraindications to immediate surgery.

Background and Objectives: Complicated left-sided colonic diverticulitis is one of the important causes of hospital admissions and emergency surgery in industrialized societies and requires serious clinical decision-making processes for patient management. This study aims to evaluate the predictive role of albumin-based nutritional indices in deciding on surgical strategy (primary anastomosis vs. Hartmann procedure) in patients treated operatively for complicated left-sided colonic diverticulitis. Materials and Methods: This retrospective single-center study included 57 patients who were operatively treated for Hinchey stage III–IV diverticulitis between 2021 and 2024. Patients were divided into two groups according to surgical method: Hartmann procedure (n = 40) and primary anastomosis (n = 17). Prognostic Nutritional Index (PNI), Hemoglobin–Albumin–Lymphocyte–Platelet Score (HALP), CRP–Albumin–Lymphocyte (CALLY) Index, and Modified Glasgow Prognostic Score (mGPS) were evaluated as albumin-based nutritional indices in the preoperative period. Predictive parameters were determined using ROC analysis and multivariate logistic regression. Results: Albumin level, PNI, HALP, and CALLY scores were found to be significantly lower in the Hartmann procedure group. Additionally, the proportion of patients with mGPS score 2 was significantly higher in the Hartmann procedure group (57.5% vs. 5.9%; p < 0.001). In the ROC analysis, the cut-off value for the CALLY index was determined as 0.45 (AUC: 0.826). In multivariate analysis, albumin < 38.5 g/L (OR: 16.53), CALLY index < 0.45 (OR: 6.40), and systemic inflammatory response syndrome (SIRS) detection (OR: 12.98) were determined as independent factors predicting the Hartmann procedure. Conclusions: A low CALLY index was found to be independent predictors for the Hartmann procedure. The CALLY index, which reflects the inflammatory response, immune capacity and nutritional status, can assist surgeons in making objective, and individualized decisions by holistically evaluating the patient’s physiological status. Multicenter prospective studies are required to confirm the clinical validity of the findings.

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Objective: Despite substantial medical advancements in recent decades, the optimal management of Grade II-III acute calculous cholecystitis in patients with an ASA II classification remains a subject of ongoing debate, even with laparoscopic cholecystectomy established as the standard of care. Background: The optimal timing of cholecystectomy (early vs. delayed) remains debated regarding morbidity, risk-benefit balance, and cost. While percutaneous cholecystostomy is supported as definitive management for ASA III/IV patients, its efficacy as a bridge to cholecystectomy in ASA II medically refractory grade II-III acute cholecystitis is unclear. Moreover, the optimal interval between percutaneous cholecystostomy and interval laparoscopic cholecystectomy in this specific group is not well-established. Methods: This retrospective cohort study aimed to elucidate the impact of percutaneous cholecystostomy, performed as an initial intervention, on the subsequent elective cholecystectomy in patients classified as ASA II and diagnosed with Grade II-III acute calculous cholecystitis. Specifically, the study evaluated the influence of prior percutaneous cholecystostomy on the timing, duration, and type of the subsequent elective cholecystectomy procedure. Of the 186 patients managed with percutaneous cholecystostomy for severe acute calculous cholecystitis, 97 patients, classified as ASA II, who subsequently underwent interval elective cholecystectomy at our institution, constituted the study cohort. Results: 77% experienced prolonged laparoscopic cholecystectomy, defined as being longer than 60 minutes, when operated after 8 weeks of cholecystostomy placement. The complexity and the difficulty of surgery were significantly increased in this group. Conclusion: Liberal use of percutaneous cholecystostomy for grade II-III acute calculous cholecystitis is discouraged. Early laparoscopic cholecystectomy is preferred for most ASA II acute cholecystitis cases, reserving percutaneous cholecystostomy for intractable cases or those with contraindications to immediate surgery.