Primary wound closure with a Limberg flap vs. secondary wound healing after excision of a pilonidal sinus: a multicentre randomised controlled study.

PURPOSE: Off-midline procedures seem to be the best method of primary wound closure after excision of a pilonidal sinus. Primary wound closure with a Limberg flap was compared to secondary wound healing. METHODS: From January 2006 to July 2012, 102 patients with given informed consent (mean age 28 years, men 81%) who had excision of a pilonidal sinus in three hospitals in Switzerland were randomised to group L (Limberg flap, n = 51) or to group E (excision only, n = 51). Primary endpoint was duration of incapacity for work. Follow-up was at 3 weeks and at 1 year postoperative (95% follow-up). RESULTS: Both groups were comparable with regard to patient characteristics. The median (range) operation time was 60 (30-80) min in group L vs. 30 (10-75) min in group E (p < 0.001). No significant differences were found in postoperative pain and painkiller intake; pain, percentage of patients at work and overall satisfaction at 3 weeks postoperative; and overall duration of incapacity for work and overall satisfaction at 1-year follow-up. The complication rate was 49% in group L vs. 12% in group E (p < 0.001). Complications in group L were seroma (6%), wound dehiscence (45%), skin necrosis (10%), hematoma (6%), infection (4%) and recurrent disease (13%). Complications in group E were recurrent disease (6%) and wound healing disorder (6%). CONCLUSIONS: After excision of a pilonidal sinus, primary wound closure with a Limberg flap has no advantage over secondary wound healing. The main reason for this conclusion is the relatively high complication rate of primary wound closure with a Limberg flap.

[Cost increase due to incorrect antibiotic prophylaxis in visceral, thoracic and vascular surgery]. / Mehrkosten infolge inkorrekter Antibiotikaprophylaxe in der Viszeral-, Thorax- und Gefässchirurgie.

We analysed retrospectively 460 patients treated between March 1991 and February 1992, in respect to a correct perioperative antibiotic prophylaxis. In our opinion a correct prophylaxis is a single-shot application, with a second dose given only during long operations (over 3 hours) or when blood loss is great. 240 of the 460 patients analysed (52.2%) were given antibiotics prophylactically. In 76.6% of the cases (n = 184) the prophylaxis was performed correctly. In 23.4% (n = 56) antibiotic application was extended indiscriminately into the post-operative phase. This calculated to costs three times higher than those actually necessary, causing us to spend 22,000-Swiss francs unnecessarily, one twelfth of the total cost of antibiotic treatment in our hospital each year. For economic reasons as well as to keep growth of resistant strains in check, an antibiotic prophylaxis should be restricted to the perioperative period in most cases as a single shot only.

[Therapy of choice in complicated diverticulitis?]. / Therapie der Wahl bei komplizierter Divertikulitis?

Between 1988 and 1992 we treated in our hospital 79 patients with a complicated diverticular disease. We analysed and compared two groups (group A 42 cases January 1988 to February 1991/retrospectively, group B 37 cases March 1991 to December 1992/prospectively). We studied our operative procedure in respect to the postoperative morbidity and lethality, the number of performed and persistent stomata and the mean length of stay. The complications of diverticular disease in both groups were similar. Since March 1991 we performed primary resection with primary anastomosis in 89% of the patients, three-stage resection or primary resection with an anastomosis and a proximal colostomy was no more done. The Hartmann procedure was rarely chosen (only in 4 of 37 patients). In spite of forcing the primary resection with a primary anastomosis in group B, the complication rate (local and general) decreased from 35.7% to 29.7%, the lethality rate from 9.5% to 2.7%. The number of performed stomata showed a great difference with 22 in group A against 4 in group B. The mean length of stay was 31 versus 22 days. Therefore we consider primary resection with an anastomosis for the best therapy in complicated diverticular disease.