Indications and results for transduodenal sphincteroplasty in the era of endoscopic sphincterotomy.

BACKGROUND: Transduodenal sphincterotomy (TS) has fallen into disuse since endoscopists developed techniques to treat sphincter problems nonsurgically. However, some patients experience recurrent sphincter strictures after endoscopic sphincterotomy (ES), with the ampulla endoscopically inaccessible, and pancreas divisum (PD); these patients are referred to a surgeon because they are unsuitable for ES. METHODS: The medical records of patients who underwent TS at the First Department of Surgery of the Medical School, University of Rome "La Sapienza," between January 1997 and December 2005 were reviewed. A total of 82 patients, including 47 women and 35 men with a mean age of 47 years (range, 26-67 y), underwent TS in our unit in the aforementioned period. Previous unsuccessful endoscopic retrograde cholangiography and ES were the indications for TS in 44 patients, and previous gastric surgery with duodenal bypass was the indication for TS in 21 patients. Five patients underwent TS because of a PD and 10 because of the intraoperative findings of daughter hydatid cysts in the common bile duct and of a wide communication between the cyst cavity and the intrahepatic biliary tree. Two patients were referred to our institution after a surgical papillotomy performed elsewhere. Symptoms included abdominal pain in 100% of patients, nausea and/or vomiting in 78% of patients, and referred back pain in 56% of patients. Acute pancreatitis was present in the history of 26 patients, including 23 with previous ES. All patients underwent TS. Sphincteroplasty of the accessory papilla was performed in all patients with PD. Cornerstones of a successful TS are depicted. RESULTS: Asymptomatic hyperamylasemia was observed in 37 patients, and cholangitis and pancreatitis, which was resolved with conservative management, occurred in 2 patients. One patient developed an intra-abdominal abscess that was treated with image-guided percutaneous drainage. No perioperative deaths occurred in this series. The mean length of follow-up evaluation was 84.4 months (range, 16-115 mo). Good results were achieved in 53 patients (73.6%), fair results in 17 patients (23.6%), and poor results in 2 patients (2.7%). Both patients with poor results required reoperation because of recurrent pancreatitis and pancreatic pseudocyst. CONCLUSIONS: TS still represents, although undoubtedly with updated indications compared with the past, a surgical procedure that must be up to date, ensuring absolutely satisfactory results.

Outcome of chronic pilonidal disease treatment after ambulatory plain midline excision and primary suture.

BACKGROUND: Pilonidal sinus (PS) is a common chronic disorder of the sacrococcygeal region. The optimal treatment for PS remains controversial, and recent reports have advocated different surgical approaches. METHODS: A prospective study was performed on 103 patients with nonrecurrent quiescent chronic discharging sinus. Excision with primary closure was performed on all patients. Patients were subdivided randomly into 2 groups. In group A, the excision was associated with drainage of the wound; in group B, the wound was not drained. RESULTS: Excision with primary closure and drainage was performed in 53 patients (group A). Drainage was omitted in 50 patients (group B). Minor wound complications occurred in 3 patients in group A and in 36 patients in group B. No complete dehiscence of the wound was observed in patients in group A and in 8 patients in group B. Complete healing was fastest in patients in group A. Sinus recurrence occurred in 1 patient in group A and in 2 patients in group B. CONCLUSION: Short- and long-term results suggest that limited midline excision with primary closure and wound drainage is a simple and effective procedure in the surgical treatment of uncomplicated PS. More demanding flap techniques and plasties should be reserved for complicated PS, which requires a wider excision.