Rhomboid excision and Limberg flap for managing pilonidal sinus: long-term results in 411 patients.

OBJECTIVE: To investigate the results of rhomboid excision and the Limberg flap procedure to treat pilonidal sinus disease. METHOD: The records of 411 patients with pilonidal sinus disease, who underwent rhomboid excision and Limberg flap procedure, were analysed. All sinus tracks were resected en bloc, and a Limberg flap was prepared from left or right gluteal region. A suction drain was routinely used. RESULTS: The mean follow-up period was 109.2 +/- 4.5 months (range: 12-183 months). Recurrence occurred in 12 (2.91%) patients who were all male. In 42 (10.21%) patients, anaesthesia or hypoaesthesia of the upper portion of the flap occurred; this was temporary in 25 patients. Twelve (2.91%) patients developed a seroma and 15 (3.64%) a wound infection. The average hospital stay was 3.2 days (range: 1-10 days), and the average time of return to work was 12.4 days (range: 7-18 days). The average time to walk without pain was 13.4 days (range: 10-28 days) and the average time to sitting on the toilet without pain was 16.1 days (range: 12-28 days). CONCLUSION: The Limberg flap procedure is effective and has a low complication rate, short time for returning to normal activity and short hospitalization.

Comparison of free jejunal graft with gastric pull-up reconstruction after resection of hypopharyngeal and cervical esophageal carcinoma.

The purpose of this study is to evaluate the operative outcomes of a gastric pull-up and free jejunal graft reconstruction after resection of hypopharyngeal and cervical esophageal carcinoma. Records of all patients who underwent esophageal resection for carcinoma of the hypopharynx and cervical esophagus were reviewed. Reconstruction after esophagectomy was performed using the gastric pull-up (n = 38) or free jejunal graft (n = 14) techniques. The hypopharynx was the most common primary tumor site for the free jejunal graft group, whereas the gastric pull-up group had lesions more frequently in the cervical esophagus (P < 0.05). Both operative time and blood loss in the gastric pull-up group were significantly longer and excessive than those of the free jejunal graft group (P < 0.05). The graft survival rate was 95% (32/34) in the gastric pull-up group and 93% (13/14) for the free jejunal transfer group. The overall leakage rate was 1.9% (1/52). Three patients died (6%) in the postoperative period. There was no significant difference with regard to operative morbidity and mortality between the gastric pull-up group and free jejunal graft group. In conclusion, both free jejunal graft and gastric pull-up are safe and effective methods for the immediate restoration of alimentary continuity.

Gastrointestinal quality of life in patients with symptomatic or asymptomatic cholelithiasis before and after laparoscopic cholecystectomy.

BACKGROUND: There is an ongoing need, from both the medical and the economic perspective, for a more accurate definition of the influence of symptomatic or asymptomatic gallstone disease on gastrointestinal symptomatology, as well as on the health of the individual in general. METHODS: Using the Gastrointestinal Quality of Life Index (GIQLI), 37 symptomatic and 30 asymptomatic gallstone patients were evaluated at admission to the hospital and again 4 months after undergoing an uneventful laparoscopic cholecystectomy (LC). RESULTS: Postoperatively, significant increases in the total GIQLI score were noted in both the symptomatic group (113.42 +/- 21.9 vs 80.32 +/- 19.1 preoperatively; p < 0.05) and the asymptomatic group (96.37 +/- 14.26 vs 113.30 +/- 15.22; p < 0.05). For the subgroups of items, the core symptoms and the physical, psychological, and disease-specific items improved significantly in both groups in the postoperative period (p < 0.05 for all comparisons), but only the symptomatic group achieved a significant improvement in the subgroup of social items (p < 0.05). Negative correlations were found in both the symptomatic and asymptomatic groups between the preoperative GIQLI scores and the improvement seen after LC (r = -0.70 and r = -0.49, respectively). CONCLUSION: Gallstone disease has a profoundly negative impact on quality of life, especially in symptomatic patients with a history of biliary colic attacks and/or the complications of the disease. Although the condition is not equally distressing for the asymptomatic group of patients without such a history, uncomplicated LC improves the quality of life significantly in both groups. Gallstone patients with lower GIQLI scores are more likely to benefit from LC.

Liver glutathione contents in patients with gastric adenocarcinomas.

Many antineoplastic agents alter the reduced glutathione (GSH) status of liver and tumor tissue by inhibiting cellular GSH-linked enzymes. Thus, intracellular GSH plays an important role in a wide variety of antineoplastic interventions regarding therapeutic efficacy and toxicity. Mean GSH values were 0.791 +/- 0.072 mg/m wet weight (ww) and 0.719 +/- 0.047 mg/g ww in gastric cancer tissue and nontumorous glandular mucosa, respectively. Whereas, the average GSH level of normal gastric mucosa was 1.709 +/- 0.135 mg/g, the mean GSH level of normal liver biopsies was 2.378 +/- 0.260 mg/g. The GSH values of normal liver tissue were higher than the hepatocellular GSH concentrations of patients with gastric adenocarcinoma and of another group of tumor-bearing patients who had received chemotherapy preoperatively. These results suggest that the GSH levels of tumor and liver may influence the efficacy and/or toxicity of chemotherapeutic agents.

Three-field lymph node dissection in the treatment of thoracic esophageal carcinoma: the Turkish experience.

The role of extended lymphatic dissection on the prognosis and outcome of thoracic esophageal carcinoma is still controversial. The aim of this study was to determine the impact of three-field lymphatic dissection on the survival and recurrence rates of patients with thoracic carcinoma of the esophagus. Forty-six patients with primary squamous cell carcinoma of the thoracic esophagus underwent esophagectomy with three-field lymphatic dissection between 1992 and 2003. Recurrence and survival rates were examined as well as complications. Overall survival for the patients was 45.6 months and 5-year survival rate was 56%. Five-year survival rates for patients with Stage 2A, 2B, 3 and 4 were 68%, 0%, 53% and 33%, respectively. There was no Stage 1 patient. Mean disease-free survival was 41.4 months. Sixty three percent of patients had node-negative disease (5-year survival rate, 68.9%) and 37% had nodal metastases (5-year survival rate, 33.7%) (P = 0.002). Surgical morbidity was seen in 35 patients (76.1%). Conclusively, lymph node involvement in patients with thoracic esophageal carcinoma is the major determinant of prognosis and survival. Extended lymphatic dissection provides higher disease-free and overall survival rates and our study revealed the highest survival rate for thoracic esophageal carcinoma, to best of our knowledge.

Effect of systemic gastric acid stimulation and intragastric pH changes on synchronous antral gastrin and somatostatin release in anesthetized, nonatropinized duodenal ulcer patients and controls.

The synchronous changes in antral gastrin and somatostatin release in anesthetized, nonatropinized duodenal ulcer patients and control subjects were investigated by serial intraoperative blood sampling from the right gastroepiploic vein. The mean basal antral plasma gastrin and somatostatin concentrations of the two groups did not differ significantly. The significantly greater gastric acid secretory response to systemic gastric acid stimulation (pentagastrin stimulation) in duodenal ulcer patients compared with that of control subjects was not linked to any difference in antral somatostatin release pattern. The decrease in antral plasma gastrin release was significantly lower after acid instillation and the increase was significantly higher after alkali instillation in duodenal ulcer patients compared with those of controls, indicating an abnormal gastrin response to intragastric pH changes in duodenal ulcer patients, which was again not found to be coupled to any significant difference in antral somatostatin release. The results suggest that an abnormal somatostatin-mediated inhibition of gastrin release and/or gastric acid secretion does not exist in duodenal ulcer patients.

Liver glycogen in gangrenous intestinal obstruction.

Considerable drops in liver glycogen contents of guinea pigs suffering from gangrenous intestinal obstruction were recorded in regard to control values (P less than 0.001). An additional experiment was conducted by using carbontetrachloride (CT) to determine whether or not the shortening of survival related to liver glycogen content in animals with strangulation obstruction. The mean tissue glycogen content in the sham-operated group was 816.2 +/- 13.3 micrograms/g, w. wt., whereas in the CT-treated group it was 73.5 +/- 11.0 micrograms/g w. wt. This difference is highly significant (P less than 0.001). The mean survival was 54.4 +/- 5.8 h and 21.9 +/- 5.5 h in animals with gangrenous intestinal obstruction before and after CT treatment, respectively. These results suggested that the liver glycogen depletion was a significant factor in decreasing the survival time of guinea pigs with strangulation obstruction.

Fournier's gangrene after hemorrhoidectomy: association with drug-induced agranulocytosis. Report of a case.

An unusual case of Fournier's gangrene after hemorrhoidectomy and drug-induced agranulocytosis, as the predisposing condition, is described. The patient had severe granulocytopenia that was attributed to the recent use of dipyrone. Together with hemodynamic resuscitation, broad-spectrum antibiotic and recombinant human granulocyte colony-stimulating factor were started. Wide surgical excision of all the gangrenous tissues, in addition to laparoscopic formation of a defunctioning sigmoid loop colostomy, was performed. The white blood cell count rose steadily and the patient experienced a rapid recovery. We emphasize that radical surgery must be accompanied by pharmacologic interventions for a successful outcome in such cases.

Intestinal endotoxins as co-factors of liver injury in obstructive jaundice.

The concept of endotoxin-mediated rather than direct liver injury in biliary obstruction was investigated using the experimental rat model of bile duct ligation (BDL) and small bowel bacterial overgrowth (SBBO). Small identical doses of intravenous endotoxin (bacterial LPS) caused a significantly more severe liver injury in rats with BDL, compared with sham-operated rats, suggesting the possible contribution of LPS in this type of liver damage. BDL was then combined with surgically created jejunal self-filling blind loops, which resulted in SBBO. Plasma LPS level increased significantly, and once again a more severe liver injury, determined by liver histology and serum gamma-glutamyl transpeptidase levels, was observed compared with the control group of rats with BDL+self-emptying blind loops. The data presented suggest that small amounts of exogenous LPS and/or the ordinarily innocous amounts of LPS constantly absorbed from the intestinal tract may be critical in the hepatic damage caused by obstruction of the biliary tract.