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    PublicationOpen Access
    Does resection of heterotopic ossification of the elbow result in satisfactory functional outcomes?
    (Galenos Yayınevi, 2019) Kapıcıoğlu, Mehmet; Sağlam, Yavuz; Ersen, Ali; Atalar, Ata, Can; Durmaz, Hayati; N/A; Demirhan, Mehmet; Faculty Member; School of Medicine; 9882
    Objective: heterotopic ossification (HO) is a common cause of elbow stiffness following surgical treatment of elbow trauma. In this study, our aim was to evaluate the mid-term functional outcomes of open surgical procedures for HO. Methods: in this retrospective study approved by the institutional review board (IRB), all patients who were diagnosed as having stiff elbow due to HO and underwent surgical resection at a single institution from 2006 to 2013 were included. Intrinsic (inside the joint) pathologies were excluded. Range of motion (ROM) in sagittal and coronal planes, complications, functional scores such as Quick Disabilities of the Arm, Shoulder and Hand Score (Q-DASH), and Mayo Elbow Performance Score (MEPS) were evaluated before and after surgery. Results: there were 19 patients (16 males, 3 females) with a mean age of 38.6 (range 15-69) years. At an average follow-up of 36 +/- 8 months, the mean flexion-extension arc was improved from 27.4 degrees to 99.2 degrees (p<0.001) and mean supination-pronation arc was improved from 48.9 degrees to 102.3 degrees (p<0.001). The mean Q-DASH score was decreased from 68.2 to 17.1 (p<0.001) and mean MEPS was improved from 37.5 to 85.6 (p<0.001). Conclusion: excision of heterotopic bone and releasing contracted tissues around elbow can provide a substantial increase in range of motion and improvement in clinical scores.
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    PublicationOpen Access
    Aberrant methylation profile and microsatellit instability in Turkish sporadic colorectal carcinoma
    (Galenos Yayınevi, 2019) Ekmekçi, Cumhur Gökhan; Güllüoğlu, Mine; Dizdaroglu, Ferhunde; Özbek, Uğur; N/A; Kapran, Yersu; Faculty Member; School of Medicine; 168101
    Objective: genomic DNA obtained from paraffin blocks of the intended colorectal cancer cases was evaluated for promoting colorectal cancer by investigating the promoter methylation of 6 different gene promoter regions and microsatellite instability. Methods: DNA was isolated from the paraffin tissue of 76 sporadic colorectal cancer patients by cross sections from the areas determined to be tumorous. The methylation specific PCR (MS-PCR) method was used for these DNA samples fo rmethlylation studies in promoter region of six different APC, hMLH1, p16INK4A, p15, p73 and DAPK1 genes. In the same samples, the presence of microsatellite instability (MSI). Results: the fequencey of methylation was 24% for hMLH1, 31.5% for APC, 19.6% for DAPK1, 42.8% for p16, 30% for p15, 17% for p73. We calculated a methylation index (MI=ratio between the number of genes methylated and the number of genes analyzed). MI was ranged from 0-0.83, with an average of 0.271 corresponding to 1.6 genes/sample and median was 0.225 and there were 15 samples which doesn't methylated in any loci. We analysed MSI in C-kit (21%), hMSH2 (18%) and APC (15%), microsatellite region. Conclusion: we observed APC methylation was common then the other population for Turkish patient. P16 was the most commenest methylated loci among the 6 of gene and it seems storongly related with female patients. P73 was releated with left colorectal cancer and additionally it was related with the MSI.
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    PublicationOpen Access
    Clinicopathologic and prognostic features in gallbladder malignancies: retrospective analysis of 5206 cases
    (Galenos Yayınevi, 2019) Ferhatoglu, Murat Ferhat; Kıvılcım, Taner; Kartal, Abdulcabbar; Gürkan, Alp; N/A; Şenol, Kazım; Doctor; School of Medicine
    Aim: Gallbladder cancer is the sixth most common cancer of the gastrointestinal system. Clinical presentation may not be distinguished from cholelithiasis or cholecystitis and most patients are diagnosed intraoperatively or in the postoperative histologic examination. In this study, we aimed to investigate the association of incidentally detected gallbladder cancer with gallbladder premalignant lesions, age, gender, ultrasonography features and gallbladder stones. Methods: demographic and clinical characteristics and pathology results of 5206 patients who underwent cholecystectomy between January 2012 and December 2015 were evaluated retrospectively. Results: three thousand eight hundred and eighty four (74.6%) patients were female. Pathologic reports showed pre-malignant and malignant lesions in 102 (1.95%) cases. Metaplasia was significantly more common in females, while no significant difference was found in development of dysplasia and cancer between genders. Gallbladder stone was found to be a risk factor for the development of metaplasia. Gallbladder wall thickening and advanced age are the most important risk factors for gallbladder cancer. Conclusion: female gender and gallstone are important risk factors for the development of metaplasia. Advanced age, gallstone and gallbladder wall thickening on ultrasonography are the most important factors in the development cancer. Cholecystectomy should be kept in mind as the most effective method to prevent cancer development in elderly patients with gallbladder stones. / Amaç: safra kesesi kanseri, gastrointestinal sistemin en yaygın altıncı kanseridir. Klinik prezentasyon safra kesesi taşı veya kolesistitden ayırt edilemez ve çoğu hasta intraoperatif veya postoperatif histolojik incelemede tanı alır. Bu çalışmada, insidental olarak tespit edilmiş safra kesesi kanserli olguların safra kesesi pre-malign lezyonları, yaş, cinsiyet, ultrasonografi özellikleri ve safra kesesi taşı ile ilişkisi araştırılmıştır. Yöntemler: Ocak 2012-Aralık 2015 tarihleri arasında kolesistektomi uygulanan 5206 hastanın demografik ve klinik özellikleri, patoloji sonuçları retrospektif olarak değerlendirildi. Bulgular: hastaların 3884’ü (%74,6) kadındı. Patoloji raporlarında 102 (%1,95) olguda pre-malign ve malign lezyonlar olduğu tespit edildi. Metaplazi kadınlarda anlamlı olarak daha fazla iken, displazi ve kanser gelişimi arasında cinsiyete göre anlamlı bir fark bulunamadı. Safra kesesi taşı metaplazi gelişiminde bir risk faktörü olarak bulundu. Safra kesesi duvar kalınlaşmasının ve ileri yaşın safra kesesi kanseri gelişimi için en önemli risk faktörleri olduğu tespit edildi. Sonuç: metaplazi gelişiminde kadın cinsiyet ve taş varlığı önemli faktörlerdir. Ultrasonografide safra kesesi duvar kalınlaşması, ileri yaş, safra kesesinde taşı varlığı kanser gelişiminde en önemli faktörlerdir. Kolesistektomi, ileri yaşta safra kesesi taşı olan hastalarda kanser gelişimini önlemek için en etkili yöntem olarak akılda tutulmalıdır.
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    PublicationOpen Access
    The crime of failure by medical professionals to report an offence (TCC Art. 280)
    (İstanbul Üniversitesi Yayınevi, 2019) N/A; Özgüç, Levent Emre; Researcher; Law School; 265199
    The topic of analysis of this paper is the crime of "Failure by Medical Professionals to Report an Offence", found in article 280 of the Turkish Criminal Code numbered 5237. The crime is situated in the second part, titled "Crimes against the Judiciary", under the fourth section, titled "Crimes against the Nation and the State", under the second book of the Code, and is the equivalent of Article 530 of the annulled Turkish Criminal Code numbered 765. Pursuant to Art. 280, medical professionals who encounter an indication pointing towards a crime in the course of their duties, and do not notify the authorities of that fact or show delay in their notifications, are punishable by imprisonment. The lack of any limitation concerning the encountered crime which would create the obligation to report caused the medical professionals to face an obligation of substantial extent. Throughout the analysis of the crime, the doctrinal discussions concerning the crime are evaluated. In this context, the topics such as the norm's protected legal value, the scope of the term medical professional, the status of medical professionals in the public sector, the definition of the term indication in relation to the crime and whether documents and statements are included, whether the crime is committable by probable intent, whether the patient-doctor privilege, the right to be excused from testifying or the obligation to give treatment are justifications for the crime, and the rules of aggregation between TCC Art. 280 and similar crimes are explained. / Bu çalışmada, 5237 sayılı Türk Ceza Kanunu’nun 280. maddesinde düzenlenen “Sağlık Mesleği Mensuplarının Suçu Bildirmemesi” suçu ele alınmaktadır. Suç kanunun ikinci kitabının “Millete ve Devlete Karşı Suçlar” başlıklı dördüncü kısmının “Adliyeye Karşı Suçlar” başlıklı ikinci bölümünde yer almaktadır ve 765 sayılı mülga Türk Ceza Kanunu’nun “Cürmü Haber Vermekte Zühul” başlıklı 530. maddesinin karşılığıdır. 5237 sayılı TCK m 280 uyarınca, görevi sırasında belirtisiyle karşılaştığı bir suçu yetkili makamlara bildirmeyen veya bildirimde gecikme gösteren sağlık mesleği mensubu hapis cezasıyla cezalandırılmaktadır. Suç tanımında bildirim yükümlülüğünün doğmasına neden olacak suçlara ilişkin herhangi bir sınırlama yapılmamış olması sağlık mesleği mensuplarının oldukça geniş bir yükümlülükle karşı karşıya kalmasına sebep olmuştur. Suçun incelenmesi sırasında düzenlemeye ilişkin tartışmalar hakkında bilgi verilmiştir. Bu kapsamda suçla korunan hukuki değerin ne olduğu, failin sahip olması gereken sağlık mesleği mensubu kavramının kimleri kapsadığı, aynı zamanda kamu görevlisi olan sağlık mesleği mensuplarının suç bakımından durumları, suç işlendiğini gösteren belirti kavramının anlamı, belge ve beyanların bu kapsamda olup olmayacağı, suçun olası kastla işlenip işlenemeyeceği, sağlık mesleği mensubunun sır saklama yükümlülüğü, tanıklıktan çekinme hakkı veya tedavi yükümlülüğünün suçta hukuka aykırılığı kaldıran neden sayılıp sayılmayacağı, TCK m 280 ile benzer yükümlülükleri düzenleyen suçlar arasındaki içtima ilişkisi gibi hususlar çözülmeye çalışılmıştır.
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    PublicationOpen Access
    Endovascular treatment of iliofemoral deep vein thrombosis in pregnancy using US-guided percutaneous aspiration thrombectomy
    (Aves, 2017) Gedikoğlu, Murat; N/A; Oğuzkurt, Levent; Faculty Member; School of Medicine
    PURPOSE: We aimed to describe ultrasonography (US)-guided percutaneous aspiration thrombectomy in pregnant women with iliofemoral deep vein thrombosis. METHODS: This study included nine pregnant women with acute and subacute iliofemoral deep vein thrombosis, who were severe symptomatic cases with massive swelling and pain of the leg. Patients were excluded from the study if they had only femoropopliteal deep vein thrombosis or mild symptoms of deep vein thrombosis. US-guided percutaneous aspiration thrombectomy was applied to achieve thrombus removal and uninterrupted venous flow. The treatment was considered successful if there was adequate venous patency and symptomatic relief. RESULTS: Complete or significant thrombus removal and uninterrupted venous flow from the puncture site up to the iliac veins were achieved in all patients at first intervention. Complete relief of leg pain was achieved immediately in seven patients (77.8%). Two patients (22.2%) had a recurrence of thrombosis in the first week postintervention. One of them underwent a second intervention, where percutaneous aspiration thrombectomy was performed again with successful removal of thrombus and establishment of in line flow. Two patients were lost to follow-up after birth. None of the remaining seven patients had rethrombosis throughout the postpartum period. Symptomatic relief was detected clinically in these patients. CONCLUSION: Endovascular treatment with US-guided percutaneous aspiration thrombectomy can be considered as a safe and effective way to remove thrombus from the deep veins in pregnant women with acute and subacute iliofemoral deep vein thrombosis.
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    PublicationOpen Access
    Screening for hepatic fibrosis and steatosis in Turkish patients with type 2 diabetes mellitus: a transient elastography study
    (Aves, 2019) Demir, Meryem; Yılmaz, Yusuf; N/A; Deyneli, Oğuzhan; Faculty Member; School of Medicine
    Background/aims: non-alcoholic fatty liver disease is highly prevalent in patients with type 2 diabetes mellitus (T2DM). The aim of the present study was to investigate the potential usefulness of transient elastography (TE), which is a technique that allows measuring both fibrosis and liver fat content simultaneously, as a screening tool for hepatic involvement in Turkish patients with T2DM. Materials and methods: we obtained liver stiffness measurements (LSMs, as a measure of fibrosis) and controlled attenuation parameter (CAP, as a marker of steatosis) in 124 (46 males and 78 females; mean body mass index (BMI): 33.2 +/- 6.6 kg/m(2)) Turkish patients with T2DM. The prevalence rates of overweight, obesity, and metabolic syndrome in our sample were 28.2%, 64.5%, and 77.4%, respectively. Probe-specific LSM cut-off values were used to define advanced fibrosis (>= F3) and cirrhosis (F4) (M probe: F3=9.6-11.4 kPa, F4 >= 11.5 kPa and XL probe: F3=9.3-10.9 kPa, F4 >= 11.0 kPa). Mild, moderate, and severe steatosis were defined as CAP 222-232 dB/m, CAP 233-289 dB/m, and CAP >= 290 dB/m, respectively. Results: advanced fibrosis and cirrhosis were identified in 21 (16.9%) and 10 (8.0%) patients, respectively. TE-defined hepatic steatosis (CAP>222 dB/m) was detected in 117 (94.3%) patients. Mild, moderate, and severe steatosis were identified in 0, 29, and 88 patients, respectively. Conclusion: TE is a useful non-invasive imaging modality to screen for liver involvement in Turkish patients with T2DM. High rates of TE-defined fibrosis and steatosis in our sample reflect the presence of an elevated mean BMI.
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    PublicationOpen Access
    Legal position of third party in transfer of indirect possession by an agreement between transferor and transferee compared to lessee in case of transfer of leased property
    (İstanbul Üniversitesi Yayınevi, 2021) N/A; Karaşahin, Yasin Alperen; Law School; 257378
    In Turkish and Swiss law, if a bailee (third party) is in possession based on a legal relationship with the bailor, the bailor (transferor) can transfer the indirect (constructive) possession by an agreement with the transferee without the consent of the third-party bailee. The Turkish Civil Code (CC) - like the Swiss Civil Code - contains some provisions intended to prevent any negative effect from such an agreement on the interests of the third party. First, the transfer of indirect possession by agreement between transferor and transferee has no legal effect on the third party until that party is notified by the transferor (Article 979/11 of Turkish Civil Code [CC]). This period of ineffectiveness ends upon notice to the third party. However, the third party can refuse delivery to the transferee based on the same defenses that could be invoked against the transferor (Article 979/III CC). Contrary to the prevailing view in Turkish and Swiss literatures, this study argues that the above-referenced provision allows the third party to invoke defenses based on personal rights besides those based on property rights. However, this provision is only applicable to the transfer of indirect possession of chattel. In contrast to a recent opinion in Swiss literature, notice of the transfer does not cause the transferee to become a new party to the legal relationship between the original third-party bailee and transferor. Turkish and Swiss law includes only a provision about lease contracts to that effect. This provision is applicable with regard to the lease of personal and real property. However, in contracts for the lease of chattels, Article 979/III CC, as interpreted in this study, would have been sufficient to protect the lessee's interests without a disproportionate interference in the freedom of contract. / Türk ve İsviçre hukuklarında, zilyetliğin havalesi, özel bir hukukî ilişkiye dayanarak eşyaya zilyet olan üçüncü kişinin rızası aranmaksızın, devreden ile devralan arasında yapılan bir sözleşme ile devralana dolaylı zilyetlik kazandırılması imkânını yaratmaktadır. Üçüncü kişinin rızası olmaksızın yapılan bu işlemin onun menfaatlerini ihlâl etmemesi için kanunda bazı düzenlemeler yer almaktadır. Türk Medenî Kanunu’nun 979. maddesinin 2. fıkrasına göre, zilyetliğin havalesi, üçüncü kişiye devreden tarafından bildirilmesinden önce üçüncü kişi açısından hüküm ve sonuç doğurmamaktadır. Bu hüküm ile öngörülen nisbî etkisizlik, üçüncü kişiye yapılan bildirim ile sona ermektedir; dolayısıyla üçüncü kişiye geçici bir koruma sağlamaktadır. Türk Medenî Kanunu’nun 979. maddesinin 3. fıkrasına göre, üçüncü kişi devredene karşı ileri sürebildiği savunmalara dayanarak eşyayı devralana teslimden kaçınabilir. Türk ve İsviçre oktrinlerinde hâkim olan görüşün aksine, bu hüküm aynî hakka dayanan savunmaların yanında şahsî (nisbî) hakka dayanan savunmaların da devralana ileri sürülmesine imkân vermektedir. Söz konusu düzenleme, hükmün sözünde açıklık olmasa da, sadece taşınırlar üzerinde devralana aynî hak kazandırılması için zilyetliğin devri gereken hâllerde uygulanmalıdır. İsviçre doktrininde savunulan yeni görüşün aksine, zilyetliğin havalesinin bildirimi üzerine, üçüncü kişi ile devreden arasındaki ilişkide devredenin yerini devralanın alması söz konusu değildir. Türk ve İsviçre hukuklarında, kira sözleşmesinin kurulmasından sonra kiralananın devri durumunda, devreden yerine devralanın kiraya veren olması yönünde açık bir düzenleme yer almaktadır. Bu düzenleme kiralananın taşınır veya taşınmaz olması açısından bir fark getirmemektedir. Bu makalede savunulan görüşe göre, kira sözleşmesine dair özel hüküm olmasaydı bile, kiralanan taşınırın mülkiyetinin zilyetliğin havalesi ile devri durumunda üçüncü kişi (kiracı) kiralananı kira süresinin sonuna kadar teslimden kaçınabilirdi. Bu nedenle, taşınır kiraları açısından kiralananın devrine dair özel düzenleme, kiracının irade serbestîsine ölçüsüz bir müdahale teşkil etmektedir.
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    PublicationOpen Access
    Investigation of laboratory parameters that differentiate complicated appendicitis from simple appendicitis in adults
    (Galenos Yayınevi, 2019) Dikme, Özgür; N/A; Dikme, Özlem; Faculty Member; School of Medicine
    Introduction: acute appendicitis is one of the most common abdominal emergencies. In this study, we aimed to investigate preoperative laboratory parameters in patients with simple and complicated appendicitis. Methods: the medical records of patients over 40 years of age with histopathologically diagnosed acute appendicitis between January and December 2015 were retrospectively reviewed. The patients were divided into two groups as simple and complicated. The relationship between appendicitis subgroups and laboratory parameters including white blood cell count, neutrophil count and percentage, lymphocyte count and percentage, basophil count and percentage, platelet count, mean platelet volume, plateletcrit, platelet distribution width was investigated. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) were also analyzed in these groups. Results: a total of 156 patients were included in the study. Twenty-three patients (14.7%) had simple appendicitis and the mean age of all patients was 50.5 +/- 8.5 years. Male and elderly patients had more complicated appendicitis. In univariate analysis, percentage of neutrophils, lymphocyte count and percentage, lymphocyte count and percentage, basophil percentage, plateletcrit, NLR and PLR values were significantly different between the groups. However, in the multivariate logistic regression analysis comparing simple and complicated appendicitis data, only NLR value was found to be significant. Conclusion: neutrophil percentage, lymphocyte count and percentage, basophil percentage, plateletcrit and NLR were associated with complicated appendicitis in patients over 40 years of age, but only NLR was significant in multivariate analysis. However, these parameters can be used to distinguish complicated appendicitis at presentation. / Amaç: akut apandisit en sık görülen abdominal acillerden birisidir. Bu çalışmada basit ve komplike apandisit hastalarında preoperatif laboratuvar değerlerini incelenmeyi amaçladık. Yöntemler: Ocak-Aralık 2015 tarihleri arasında histopatolojik olarak akut apandisit tanısı konulmuş 40 yaş ve üzeri hastaların tıbbi kayıtları retrospektif olarak incelendi. Hastalar basit ve komplike olarak iki gruba ayrıldı. Beyaz kan hücresi sayımı, nötrofil sayısı ve yüzdesi, lenfosit sayısı ve yüzdesi, bazofil sayısı ve yüzdesi, trombosit sayısı, ortalama trombosit hacmi, plateletkrit, trombosit dağılım genişliği ve apandisit alt grupları arasındaki ilişki araştırıldı. Aynı zamanda nötrofil/ lenfosit oranı (NLR) ve trombosit/lenfosit oranı (PLR) da bu gruplarda analiz edildi. Bulgular: kırk yaş üzeri 156 hasta çalışmaya dahil edildi. Hastaların 23’ü (%14,7) basit apandisitti ve tüm hastaların yaş ortalaması 50,5±8,5 yıl olarak saptandı. Erkek ve yaşlı hastalarda daha fazla komplike apandisit saptandı. Tek değişkenli analizde nötrofil yüzdesi, lenfosit sayı ve yüzdesi, lenfosit sayısı ve yüzdesi, bazofil yüzdesi, plateletkrit, NLR ve PLR değerleri gruplar arasında anlamlı farklı bulundu. Basit ve komplike apandisit verilerinin karşılaştırıldığı çok değişkenli lojistik regresyon analizinde sadece NLR değeri anlamlı bulundu. Sonuç: kırk yaş üstü hastalarda nötrofil yüzdesi, lenfosit sayısı ve yüzdesi, bazofil yüzdesi, plateletkrit ve NLR’nin komplike apandisit ile ilişkili olduğu ancak sadece NLR’nin çok değişkenli analizde anlamlı olduğu saptandı. Buna rağmen bu parametreler başvuruda komplike apandisitin ayırt edilmesinde kullanılabilir.
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    PublicationOpen Access
    Impact of fecal carriage of extended-spectrum beta-lactamase producing enterobacteriaceae on the outcomes of transrectal needle biopsies of the prostate
    (Marmara Üniversitesi (MÜ) Yayınları, 2013) Tükenmez-Tigen, Elif; Altinkanat, Gülşen; Özgen, Mahir Bülent; Ertük Şengel, Buket; Odabaşi, Zekaver; Türkerí, Levent N.; Mülazimo?lu, Lütfye; Korten, Volkan; N/A; Ergönül, Önder; Faculty Member; School of Medicine
    Objective: This study aimed to address the prevalence, the risk factors and the results of fecal carriage of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL-PE) in patients who had undergone transrectal needle biopsy of the prostate (TRNBP). Patients and Methods: A total of 143 patients who had undergone TRNBP were included. Of these, 33(23%) had fecal carriage of ESBL-PE. The mean age of the patients was 62 ± 7.5 (43-81) years. Results: A univariate analysis showed that quinolone or other antibiotic use within the last 2 months, prostatitis, and diabetes mellitus (DM) were significantly associated with the presence of ESBL-PE. A multivariate analysis showed that quinolone use within the past 2 months (OR: 4.865; CI: 1.45-16.1), and DM (OR: 4.04; CI: 1.64-10) were found to be significant. Development of dysuria (p<0.001), fever (p=0.046) and chills (p=0.002) after TRNBP were shown to be related to the presence of ESBL-PE. There was no asymptomatic bacteriuria and sepsis, the rate of symptomatic urinary tract infection was 19%. Conclusion: This study showed that pre-biopsy risk factors for the presence of ESBL-PE were quinolone or other antibiotic use within the last 2 months and presence of DM. Changing prophylactic regimens should not be recommended due to the low rate of severe complications
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    PublicationOpen Access
    Rinoplasti operasyonu sonrası yapılan ek lokal anestezinin postoperatif ağrı düzeyine olan etkisi
    (Gazi Üniversitesi, 2016) Tatar, Sedat; Şencan, Ayşe; Şibar, Serhat; Fındıkcıoğlu, Kemal; N/A; Özmen, Selahattin; Faculty Member; School of Medicine
    Objective: We aimed to assess the effect of additional local anesthesia on postoperative pain levels which made at the end of the rhinoplasty operation. Material and Method: Sixty-six patients who had open technique rhinoplasty operation included in this study. Patients were operated under general anesthesia. Additional local anesthesia was applied at the end of the operation. Patient's pain level was evaluated with Visual Analog Scale (VAS) at preoperative intravenous catheterization, recovery room, postoperative 1st 2rsd, 4th, 6th, 12th, 18th, 24th hours and compared with the group who had no additional local anesthesia. Result: The highest pain levels were at the catheterization, 1st and 2rsd hours. There was a significant difference between 1st and 2nd hours pain level between groups. First and 2nd hour pain levels were significantly lower in the additional local anesthesia group. Conclusion: Additional local anesthesia decreases the early postoperative pain levels and this possibly increases the patient satisfaction.