A systematic review of classification systems for pilonidal sinus.

BACKGROUND: Pilonidal sinus disease (PSD) is a simple chronic inflammatory condition resulting from loose hairs forcibly inserted into vulnerable tissue in the natal cleft. It is an acquired disease with a slight familial tendency. There is no agreement on optimum treatment and the multitude of therapeutic options cannot be compared due to the lack of a universally adopted classification of the disease. The aim of our study was to perform a systematic review of the literature to determine how presentations of PSD are classified and reported. METHODS: A systematic review of the English language literature was undertaken searching studies published after 1980. RESULTS: Eight classification systems of PSD were identified. Most classification systems were based on anatomical pathology hypotheses. The location and number of sinuses were the main factors defining classification systems. No articles were retrieved that assessed the validity and/or reliability of the classification system employed. Furthermore, there was no evidence to suggest a correlation between prognosis outcome and subgroup. CONCLUSIONS: Based on the evidence available from the literature reviewed we have no recommendations regarding the use of the current classification of PSD. A well-recognised and practical classification system to guide clinical practice is required.

Pain resolution in non-operatively managed ultrasound-only groin hernias: 3-year follow-up.

BACKGROUND: General surgeons frequently see patients with groin lumps and pain. However, in the absence of a lump, an ultrasound scan identified groin hernia is a diagnostic and management challenge. Some surgeons recommend inguinal hernia surgery while others do not. The outcome of non-operative management is uncertain. METHODS: This study represents a minimum 3-year follow-up of all non-operatively managed patients seen in general surgical outpatient clinic over a 12-month period. To be included, patients needed to meet all four criteria: groin pain, no clinical hernia, groin hernia identified on ultrasound scan requested by the general practitioner and non-operative management. Patients were interviewed via a standardised telephone survey. Primary outcome measure was groin pain which was assessed with the Sheffield Pain score. RESULTS: From July 2014 to June 2015, 67 patients met the inclusion criteria. 42 participated (37 men and 5 women). Two-thirds were pain free (68%). Only 2 patients underwent hernia surgery. Women were more likely to describe developing a lump (60% vs 14%; p = 0.013), to see a surgeon (40% vs 8%; p = 0.039) and undergo hernia surgery (20% vs 3% p = 0.088). CONCLUSION: At least in the medium term, non-operative management of men who present with groin pain (with an ultrasound scan reporting a hernia but no lump) is reasonable.

Processes of care in surgical patients who died with hospital-acquired infections in Australian hospitals.

BACKGROUND: Infection may complicate surgical patients' hospital admission. The effect of hospital-acquired infections (HAIs) on processes of care among surgical patients who died is unknown. AIM: To investigate the effect of HAIs on processes of care in surgical patients who died in hospital. METHODS: Surgeon-recorded infection data extracted from a national Australian surgical mortality audit (2012-2016) were grouped into HAIs and no infection. The audit included all-age surgical patients, who died in hospital. Not all patients had surgery. Excluded from analysis were patients with community-acquired infection and those with missing timing of infection. Multivariate logistic regression was used to determine the adjusted effects of HAIs on the processes of care in these patients. Costs associated with HAIs were estimated. FINDINGS: One-fifth of surgical patients who died did so with an HAI (2242 out of 11,681; 19.2%). HAI patients had increased processes of care compared to those who died without infection: postoperative complications [51.0% vs 30.3%; adjusted odds ratio (aOR): 2.20; 95% confidence interval (CI): 1.98-2.45; P < 0.001]; unplanned reoperations (22.6% vs 10.9%; aOR: 2.38; 95% CI: 2.09-2.71; P < 0.001) and unplanned intensive care unit admission (29.3% vs 14.8%; aOR: 2.18; 95% CI: 1.94-2.45; P < 0.001). HAI patients had longer hospital admissions and greater hospital costs than those without infection. CONCLUSION: HAIs were associated with increased processes of care and costs in surgical patients who died; these outcomes need to be investigated in surgical patients who survive.

Analysis of deficiencies in care following cholecystectomy.

INTRODUCTION: Failure To Rescue was first defined in patients who died due to a complication following (open) cholecystectomy but research into the relevant factors has been scarce. This study was designed to determine a chronological sequence of deficiencies in care. METHODS: Adult patients who died under the care of a surgeon following cholecystectomy in Queensland were identified from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. RESULTS: Not unexpectedly, this is a high-risk patient population: median age of the 48 patients was 74.5 years and the median number of comorbidities and American Society of Anesthesiologists class was 4. Death occurred on postoperative day 6. Most deaths occurred at the end of the week. Over 80% of deaths followed emergency cholecystectomy. In almost half the patients, there were no deficiencies in care. Most common deficiency was during postoperative management (i.e. Failure To Rescue), however, significant deficiencies also arose prior to surgical admission; choice and timing of intervention as well as intraoperative decision-making. CONCLUSION: Surgeons who perform cholecystectomy need to be aware of the levels at which deficiencies arise given that many may be preventable.

Does pilonidal abscess heal quicker with off-midline incision and drainage?

BACKGROUND: No clinical trials have been done to guide the surgeon in the optimal technique of draining a pilonidal abscess. The aim of our study was to investigate whether the location of the incision influences wound healing. METHODS: Electronic records from the surgical database at our 200-bed district general hospital were reviewed for operative technique (midline vs. lateral) for patients who underwent incision and drainage for acute pilonidal abscess between January 2003 and February 2010. These patients were admitted from the Emergency Department with a pilonidal abscess, underwent operative drainage, and returned for follow-up. The main outcome measure was wound healing time. RESULTS: Two hundred and forty-three pilonidal abscesses were drained, 134 with a lateral and 74 with a midline incision. All patients underwent simple longitudinal incision. No patient underwent de-roofing, marsupialisation, or closure. Forty-eight patients with midline drainage who returned for follow-up were matched for gender, age, and microbiology culture results with patients who underwent lateral drainage. Almost all were drained under general anesthesia with a median postoperative stay of 1 day. The overall length of follow-up was the same in both groups (P = 0.13). Abscesses that did not heal were followed-up for the same period of time irrespective of incision type (P = 0.48). Abscesses that healed after midline incision took approximately 3 weeks longer than those drained via a lateral incision (P = 0.02). Our study has limitations since it was a retrospective study that did not capture patients whose abscess drained spontaneously or were drained in the emergency department. CONCLUSIONS: Pilonidal abscess should be drained away from the midline.

Outcome of sliding inguinal hernia repair.

PURPOSE: Sliding inguinal hernias represent a small proportion of inguinal hernias but become more common with advancing age. The most recent review is based on a series published over 50 years ago. There are, however, many case reports of unusual presentations in girls. METHODS: We performed a review of a prospectively kept electronic record of all operations performed at Logan Hospital since 2003 in order to document the clinical characteristics of sliding inguinal hernias in the twenty-first century. RESULTS: Thirty-one males underwent predominantly anterior repair of a sliding hernia after a median of 9 months of symptoms (2.9% of all hernia repairs-32/1,092). Approximately two-thirds of hernias were left sided. There were five minor and two technical complications. Follow-up ranged from 3 weeks to 3 years. Two recurrences have been repaired. CONCLUSIONS: Sliding inguinal hernias continue to test the surgeon's understanding of the inguinal canal's anatomy and technical expertise with a significant rate of technical complications and recurrence.