Comparing the effect of tissue adhesive and suturing material on collagen I/III ratio in abdominal skin wounds: an experimental study.

Background: The skin closure procedure should be technically simple, acceptable, quick, and cost-effective. Sutures remain the technique's mainstay, however tissue adhesive is becoming more used in clinical practice. Collagen ratios of types I and III play a significant role as postoperative wound healing parameters. Here, the authors aim to examine the collagen I/III ratio of tissue adhesive vs. non-absorbable sutures for abdominal skin closure in Wistar albino rats. Material and methods: The authors allocated 20 rats into four experimental groups. Wounds in groups 1 and 3 were sealed with tissue adhesive (cyanoacrylate), while those in groups 2 and 4 were closed using suture material (monofilament non-absorbable nylon). Groups 1 and 2 were sacrificed on postoperative day (POD) 4, while those in groups 3 and 4 were euthanized on POD 7. Skin samples (1×0.5 cm) were collected for analysis, and the collagen I/III ratios were determined using immunohistochemistry staining techniques. Results: The levels of collagen I and III expression did not exhibit statistically significant differences between tissue adhesive and nylon suture groups at either POD 4 (P=0.052, P=0.513) or POD 7 (P=0.125, P=0.80). Similarly, the collagen I/III ratio did not significantly differ between the two groups at POD 4 (1.23±2.26 vs. 0.70±0.24; P=0.47) or POD 7 (0.68±0.96 vs. 0.77±1.22; P=0.857). Conclusions: There were no statistical significance difference in collagen I/III ratio between the tissue adhesive and suture material groups, suggesting that the choice of wound closure material may not influence the abdominal skin closure.

Rapid Malignant Transformation of Tubulovillous Adenoma, Initially Presenting as McKittrick-Wheelock Syndrome: A Case Report.

Most cases of colorectal cancer develop from adenomatous polyps, slowly progressing within an average period of 8-10 years. McKittrick-Wheelock syndrome (MKWS) is a rare manifestation of tubulovillous adenoma. It generally presents as hypersecretory diarrhea with severe electrolyte and fluid depletion. Roughly, 5% of the published cases have reported malignant histopathology associated with MKWS, with little to no data regarding the malignant transformation process of those patients. Our patient was a 53-year-old Asian woman suffering from chronic secretory diarrhea, resulting in severe volume, electrolyte depletion, and prerenal azotemia, consistent for MKWS. Her symptoms initially improved with sulfasalazine but eventually worsened. She demonstrated signs of systemic (elevated leukocyte, CRP, and LDH) and local inflammation (dense lymphocyte infiltration in colorectal tissue) throughout the course of her disease. Serial pathological results showed rapid neoplastic progression of adenomatous polyp to adenocarcinoma within 1 year period. Surgical resection resulted in complete symptom resolution. Molecular examination showed a favorable profile of exon 4 Kirsten rat sarcoma viral oncogene homolog mutation, normal NRAS, BRAF, CDX2, and CK20 expressions. Her molecular pattern did not reflect the profile of an aggressive disease, suggesting the possibility of oncogenic processes outside the major pathways of adenoma to carcinoma progression. Chronic inflammation is a well-established risk factor for colorectal cancer, and prostaglandin E2 (PGE2) has been observed as one of the key regulators of tumor initiation and growth. PGE2 is also responsible for hypersecretory diarrhea associated with MKWS.

Comparison of anal dilatation versus no dilatation with a standardized dilator in reducing pain after hemorrhoidectomy: a randomized control trial.

BACKGROUND: Post-operative pain is the main problem of hemorrhoidectomy. An adequate pain management can promote early mobilization, fast recovery, and reduce hospitalization costs. This study aimed to investigate the role of preoperative anal dilatation using a standardized anal dilator in reducing post-operative pain. METHOD: This study was conducted using randomized prospective trial with a total of 40 subjects, who were divided into 2 groups. The first group received preoperative anal dilatation using a 33 mm anal dilator for 20 min, while the second group did not. The post-operative anal pain, edema, bleeding, and incontinence were observed in the first, second, and seventh day. RESULT: The post-operative pain was significantly lower in the preoperative anal dilatation group for all days of observation (p < 0.05). The difference of post-operative bleeding and edema between groups were not significant. Fecal incontinence was initially significantly higher in the preoperative anal dilatation group, but the difference was insignificant at the seventh day (p = 0.500). CONCLUSION: Preoperative anal dilatation significantly reduced post-operative pain. The side effect of fecal incontinence was only temporary until the seventh day after surgery. Trial Registration This trial was registered on Thai Clinical Trials Registry (TCTR) with TCTR identification number TCTR20220314002, on 14/03/2022 (retrospectively registered).

A new technique for surgical haemorrhoidectomy without post-operative complication: A case series.

Introduction: Hemorrhoids are a common coloproctology problem and among 10% of cases need surgical intervention. However, the established surgical interventions still have many complications. Case presentation: We reported three female patients, who presented with circular 3rd degree internal hemorrhoids. The surgical treatment was performed with pre-operative anal dilatation using a 33 mm dilator for 20 minutes, followed by triangle incision above the dentate line. The hemorrhoid excision was performed, and the wound was sutured with simple interrupted radial sutures using a multifilament absorbable 3-0 thread. There were neither complaints of pain, bleeding, anal incontinence, anal stenosis, wound dehiscence, nor recurrence at the first, second, and fourth weeks of follow-ups in all patients. Discussion: Post-operative bleeding, pain, and anal incontinence are common after an open hemorrhoidectomy, while suture breakage and anal stenosis were reported after the old technique of closed hemorrhoidectomy. Stapled hemorrhoidectomy had less complications but requires a relatively more expensive cost for the device itself. We performed a combination of preoperative anal dilatation, above dentate line triangle incision, and simple interrupted radial sutures to treat the patients with 3rd degree internal hemorrhoids, which resulted in no post-operative complications within the first month of follow-up. Conclusion: A combination of preoperative anal dilatation, above dentate line triangle incision, and radial suture technique is a simple and effective surgical option for treating a 3rd degree hemorrhoid.

Combination of simple advancement flap and fistulectomy to treat complex anal fistula as a complication of hemorrhoidectomy: Case report.

INTRODUCTION: After hemorrhoidectomy, anal stenosis occurs, which is an uncommon but severe consequence. The majority of severe cases require advancement flap anoplasty. PRESENTATION OF CASE: A 50-year-old female patient with a history of hemorrhoidectomy 10 months prior to admission complained of difficulty defecating, pain, and incomplete evacuation sensation, as well as a hole on the right side of the anal canal through which feces unintentionally passed. On the physical examination, we found that the anal lumen was partially obstructed, which did not allow the insertion of a finger. There was an impression of a perineal fistula at 5 and 7 o'clock, which was connected to the anal canal 3 cm from the edge of the anus. The patient was diagnosed with severe anal stenosis with perianal fistula. The patient underwent fistulectomy and advancement flap with perianal skin. In the outpatient follow-up clinic in the first and second weeks, the patient showed no complications, and no recurrence of her complaints was found. DISCUSSION: Several corrective surgical techniques have been applied to restore a healthy lining to the constricted portion of the anal canal. We performed a combination of simple cutaneous advancement flap and fistulectomy to manage the patient with severe anal stenosis following hemorrhoidectomy with concurrent anal fistula. CONCLUSION: A combination of fistulectomy and simple cutaneous advancement flap anoplasty is a simple, safe, and effective surgical option for the management of severe anal stenosis with concomitant anal fistula.

TGF-ß expression on different suturing technique for abdominal skin wound closure in rats.

BACKGROUND: The method of closing the abdominal wall, as well as, the choice of material for stitching are important aspects of efficient incision closure. Generally, transforming growth factor-beta (TGF-ß) is involved in the wound healing process. Suturing procedures also play a part in the wound dehiscence occurrence. This study aimed to compare TGF-ß expressions in rats after using the large stitch vs. small stitch technique for abdominal skin wound closure. METHODS: A total of twenty Wistar rats (Rattus norvegicus) were used in this experiment. Small tissue bites of 5 mm were obtained by the small stitch group and the large stitch group received large bites of 10 mm. Abdominal skin incisions were closed by running sutures. On days 4 and 7, the animals were euthanized. For TGF-ß expressions, histological parts of the tissue-embedded sutures were analyzed. With significance set at p < 0.05, two-way ANOVA showed that on days 4 and 7, the TGF-ß expressions of the rats in the small stitch group were nearly identical to those in the large stitch groups. RESULTS: After including twenty rats in this study, results showed the TGF-ß expressions on days 4 and 7 in rats in the small stitch group were equivalent to those in the large stitch group. (p = 0.45). CONCLUSIONS: Between the small and the large stitch groups, the TGF-ß expressions are similar, suggesting that the suturing methods do not have any significantly different beneficial impact on the frequency of wound dehiscence.

Differentiating Chilaiditi's Syndrome with hollow viscus perforation: A case report.

INTRODUCTION: Chilaiditi's syndrome is a rare condition accounting for only 0.25%-0.28% of all abdominal imaging worldwide. To rule out Chilaiditi's syndrome from other acute abdominal emergencies is very important to avoid unnecessary treatment or surgical procedure. PRESENTATION OF CASE: A 25-year-old female presented in the emergency room with 1 week history of abdominal discomfort. At time of examination, she had a mild shortness of breath that was not related with rigorous activities. A plain abdominal x-ray was suggested the presence of an air-filled bowel tract within the right subphrenic space (Fig. 1). Abdominal computed tomography suggested colonic loop present between the right hemi-diaphragm and liver. The absence of abdominal free air confirmed an isolated pseudo-pneumoperitoneum due to colonic interposition between the liver and diaphragm. DISCUSSION: Chilaiditi sign is radiolucency in the subdiaphragmatic space as a result of bowel interposition between a diaphragm and the liver. If gastrointestinal symptoms present, the condition is known as Chilaiditi's syndrome. The abdominal symptoms including severe pain, anorexia, diarrhea, nausea, vomiting, bloating and constipation might mislead physicians or surgeons with diaphragmatic hernia, subdiaphragmatic abscess, bowel perforation, infected hydatid cyst and liver tumor. Thorough physical examination, imaging, and timely follow up is very important to avoid unnecessary exploratory laparotomies. CONCLUSION: Chilaiditi's Syndrome is often misdiagnosed with bowel perforation because the presence of pseudopneumoperitoneum in the plain X-Rays. It is important to understand the unique characteristics of the sign, symptoms and findings of Chilaiditi's Syndrome to prevent unnecessary surgical procedures.

The effect of different suturing materials for abdominal fascia wound closure on the collagen I/III expression ratio in rats.

BACKGROUND: Incisional hernia is a frequent complication of abdominal wall incision and has a high rate of recurrence. Most of the studies stated that non-absorbable sutures decreased incisional hernia incidences, but some stated otherwise. We aimed to compare the collagen type I/III ratio between monofilament non-absorbable sutures and multifilament absorbable sutures for abdominal fascia closure in Wistar albino rats. METHODS: Forty rats were divided into four groups. Groups 1 and 3 were sutured with monofilament non-absorbable (polyvinylidene fluoride). Groups 2 and 4 were sutured with multifilament absorbable (polyglycolide). Then, groups 1 and 2 were euthanized on day 4 (POD 4), while groups 3 and 4 were euthanized on day 7 (POD 7). Samples of fascia (1 × 0.5 cm) were taken for analysis. Collagen I/III ratios were measured using immunohistochemistry staining methods. RESULTS: While the expression of collagen I was not significantly different between monofilament non-absorbable and multifilament absorbable at POD 4 and 7 (p = 0.45 and 0.81, respectively), the expression of collagen III reached a significant level with p-values of 0.0003 and 0.0004 for POD 4 and 7, respectively. Moreover, the collagen I/III ratio was also significantly different between the two groups either at POD 4 (0.88 ± 0.23 vs. 0.53 ± 0.08; p = 0.0003) and 7 (1.77 ± 0.65 vs. 1.03 ± 0.28; p = 0.004). CONCLUSIONS: Monofilament non-absorbable sutures show a significantly higher collagen I/III ratio than multifilament absorbable sutures for abdominal fascia closure in rats. Our findings imply that the usage of monofilament non-absorbable sutures might have a beneficial effect on decreasing the incisional hernia occurrence.

The impact of different suturing techniques for abdominal fascia closure on the Interleukin-6 expressions in Rattus norvegicus.

OBJECTIVE: Incisional hernia is a frequent complication of midline laparotomy. The suturing technique is an important determinant of the risk of developing an incisional hernia. Moreover, IL-6 has crucial roles in the wound-healing process. We aimed to compare the large stitch vs. small stitch technique for abdominal fascial closure on IL-6 expressions in rats. RESULTS: Twenty rats were used. The small stitch group received small tissue bites of 5 mm and the large stitch group received large bites of 10 mm. The incisions of fascia were closed by running sutures. Animals were euthanized on days 4 and 7. Histological sections of the tissue-embedded sutures were analyzed for IL-6 expressions. Two-way ANOVA showed that rats in the small stitch group had similar IL-6 expressions on days 4 and 7 to those in the large stitch group (p = 0.36). In conclusion, the IL-6 expressions are similar between the small and the large stitch groups, implying that different suturing techniques might not have an impact on the incisional hernia occurrence.

Double Pedicle Artery Rotation Sigmoid Vaginoplasty for Vaginal Aplasia Management.

Sigmoid vaginoplasty has been popular for neovagina reconstruction in vaginal aplasia. The most common surgical complication was vaginal stenosis caused by inadequate vascularization and tension because of graft length. Therefore, ischemia ensued and disrupted wound healing. The selection of double pedicle artery rotation sigmoid vaginoplasty is expected to reduce this problem. Five patients from April to December 2016 were diagnosed with vaginal aplasia; 4 had history of neovagina stenosis. These patients underwent sigmoid vaginoplasty with double pedicle artery rotation. No complications occurred during or after the procedure. Assessment postsurgery was conducted at 1 year. These results suggest that double pedicle artery rotation sigmoid vaginoplasty is a safe and acceptable technique for management of vaginal aplasia. The procedure decreased tension inside vascular pedicles as a result of maintaining abundant vascularization supply. Consequently, this procedure could avert graft necrosis, leakage, and severe stenosis. All of the patients exhibited regular menstrual cycle and satisfactory sexual activity. The outcomes were excellent with remarkable anatomical and functional results.

Giant diverticulum of the transverse colon mimicking gastrocolic fistula: A case report.

INTRODUCTION: Giant transverse colonic diverticula are a rare case of giant colonic diverticulum (GCD). Instead of being asymptomatic, bleeding, inflammation, and perforation may result in fistula formation and require surgery. This type of diverticulum is thought to be closely related to the gastrocolic fistula (GCF). PRESENTATION OF CASE: We report a 26-year-old female presenting severe abdominal pain accompanied by nausea and vomiting and a history of constipation since childhood. The patient felt a mass around the epigastric region and extends to the right hypochondrium. Enema contrast examination showed a large diverticulum in the transverse colon. CT scan revealed a 21.4 × 8.4 cm structure with air-filled structures visible from the transverse colon filled with contrast material, suggesting a possible gastrocolic fistula. Resection was performed on the diverticulum and 20 cm in length of the transverse colon, followed by side-to-side anastomosis. Histopathological findings were type III GCD. The patient was discharged without complications 1 week later. DISCUSSION: Giant diverticulum is characterized by a diverticulum with 4 cm or more in length. Our case was a diverticulum from the central portion of the transverse colon with 25 × 9 × 3 cm in length and type III GCD. Resection was performed on the diverticulum and 20 cm in length of the transverse colon, followed by side-to-side anastomosis. CONCLUSION: Differentiating GCD and GCF with similar clinical course may necessitate multiple investigation before establishing the correct diagnosis. We suggest colectomy followed by side-to-side anastomosis is the best option of treatment for GCD.