Surgical Treatment of Anal Stenosis with Diamond Flap Anoplasty Performed in a Calibrated Fashion.

BACKGROUND: Regarding anoplasty for anal stenosis, it is not clear to what extent the final anal caliber should be targeted. OBJECTIVE: The aim of this study was to investigate the results of diamond-flap anoplasty performed in a calibrated manner for the treatment of severe anal stenosis due to a previous hemorrhoidectomy. DESIGN AND SETTING: Prospectively prepared standard forms were evaluated retrospectively. PATIENTS AND INTERVENTIONS: Anoplasty with unilateral or bilateral diamond flaps was performed for moderate or severe anal stenosis, targeting a final anal caliber of 25 to 26 mm. The demographic characteristics, causes of anal stenosis, number of previous surgeries, anal stenosis staging (Milsom and Mazier), anal calibers (millimeter), the Cleveland Clinic Incontinence Score, and the modified obstructed defecation syndrome Longo score were recorded on pre-prepared standard forms, as well as postoperative complications and the time of return to work. RESULTS: From January 2011 to July 2013, 18 patients (12 males, 67%) with a median age of 39 years (range, 27-70) were treated. All of the patients had a history of previous hemorrhoidectomy. The number of previous corrective interventions was 2.1 ± 1.8 (range, 0-4), and 2 patients had a history of failed anoplasty. Five patients (28%) had moderate anal stenosis and 13 (72%) had severe anal stenosis. Preoperative, intraoperative, and 12-month postoperative anal calibration values were 9 ± 3 mm (range, 5-15), 25 ± 0.75 mm (range, 24-26), and 25 ± 1 mm (range, 23-27) (p < 0.0001, for immediate postoperative and 12-month postoperative anal calibers compared with the intraoperative). Preoperative and 12-month postoperative Cleveland Clinic Incontinence Scores were 0.83 ± 1.15 (range, 0-4) and 0.39 ± 0.70 (range, 0-2) (p = 1.0). The clinical success rate was 88.9%. No severe postoperative complications were observed. LIMITATIONS: This study was limited because it was a single-armed, retrospective analysis of prospectively designed data. CONCLUSION: Diamond-flap anoplasty performed in a standardized and calibrated manner is a highly successful method for the treatment of anal stenosis caused by previous hemorrhoidectomy.

Comparison of the classic Limberg flap and modified Limberg flap in the treatment of pilonidal sinus disease: a retrospective analysis of 416 patients.

PURPOSE: Pilonidal sinus disease (PSD) is usually seen on the sacrococcygeal region in adolescent patients. The current study analyzed the outcome of the rhomboid excision and the Limberg flap procedure (cLF) in comparison to the modified Limberg flap procedure (mlF) for PSD. METHODS: Four hundred and sixteen patients with PSD were operated on under spinal or general anesthesia by cLF and mlF. The patients were divided into two groups. In Group 1, cLF was performed on 211 patients. In Group 2, mlF was performed on 205 patients. RESULTS: No significant difference was detected between Groups 1 and 2 in terms of sex, age, preoperative disease period, follow-up time, the mean hospital stay, and hypoesthesia. The mlF group had better clinical results than the cLF group. The recurrence rate was statistically higher in the cLF group 1 than in the mlF group (P = 0.036). The time to return to work, time to walk without pain, and time to be able to sit on the toilet without pain were longer in the cLF group (P = 0.001). The maceration and wound infection rate were statistically higher in the cLF group than in the mlF group (P = 0.020 and P = 0.019, respectively). CONCLUSION: The mlF is a more effective treatment than cLF for the surgical management of PSD.

Anal abscess due to leech therapy of hemorrhoids: mumbo jumbo is still in vogue.

Anorectal sepsis usually presents with anal abscesses, which may evolve to become anorectal fistulas. Most of these cases are either of cryptoglandular origin, or they develop secondary to inflammatory bowel diseases. A 32-year-old male patient applied to our Proctology Unit with severe anal pain and swelling. Three days before admission, leeches were applied to the hemorrhoidal swellings in a medical center. The abscess was drained with appropriate unroofing and search for any compartments. The patient recovered rapidly. The abscess culture and microscopy revealed mix flora with predominant Escherichia coli. After 6 months, he has been symptom-free with perfect healing of the surgical site. We need to check up on possible handicaps in our modern patient care policies that divert people to such methods. Nevertheless, such alternative methods should be regarded as nonscientific and out of context unless their efficacy and safety are documented.

Keyhole deformity: a case series.

OBJECTIVE: Keyhole deformity is frequently encountered after posterior internal sphincterotomy but may be observed after lateral internal sphincterotomy or in patients without any history of previous anal surgery. The aim of the present study is to emphasize the surgical significance of this entity and discuss the possible strategies in the treatment of the deformity. MATERIAL AND METHODS: Patients in whom keyhole deformity developed after surgical or conservative treatment applied for chronic anal fissure in our clinic and patients referred from other centers were recruited. RESULTS: Nine-hundred twenty-six patients were treated for chronic anal fissure. A hundred of these patients directly underwent lateral internal sphincterotomy. The remaining 826 patients initially received conservative management, and 676 of them eventually underwent lateral internal sphincterotomy. In total, 15 patients were diagnosed to have significant keyhole deformity. Initially, all patients received conservative treatment for keyhole deformity, which was successful in two patients. Of the 13 patients in whom conservative management failed, nine underwent advancement flap reconstruction and the remaining four diamond flap reconstruction. CONCLUSION: Keyhole deformity is occasionally seen as a late complication of chronic anal fissure and may be well tolerated by the patients without any well-defined symptoms. The treatment strategy is directed toward the degree of functional alteration.

Effect of oophorectomy and exogenous estrogen replacement on liver injury in experimental obstructive jaundice.

AIM: To investigate the role of estrogen on liver injury in an experimental obstructive jaundice model. METHODS: Three groups of female rats were constituted; group 1 was oophorectomized and given E2 (n = 14), group 2 was oophorectomized and given placebo (n = 14), and group 3 was sham operated (n = 14). Fourteen days following constitution of bile duct ligation, all groups were compared in terms of serum tests, histopathologic parameters, and tissue levels of IFN-gamma and IL-6. RESULTS: The parameters representing both the injury and/or the reactive response and healing were more pronounced in groups 1 and 2 (c2 = 17.2, c2 = 10.20; c2 = 12.4, P < 0.05). In the sham operated or E2 administered groups significantly lower tissue levels of IFN-gamma and higher IL-6 levels were found. In contrast, high IFN-gamma and low IL-6 tissue levels were found in the oophorectomized and placebo group (P < 0.001). Kupffer cell alterations were observed to be more pronounced in the groups 1 and 3 (c2 = 6.13, P < 0.05). CONCLUSION: Our study indicates that E2 impaired liver functions, accelerated both the liver damage and healing. In the conditions of bile duct obstruction, estrogen significantly changed the cytokine milieu in the liver.

Importance of sentinel lymph nodes in colorectal cancer: a pilot study.

Accurate identification of lymph nodes involved in metastases is vitally important for predicting survival, and it facilitates decision making with regard to adjuvant therapy. The study described here, which was undertaken to evaluate the role of sentinel lymph node mapping in refining the staging of colorectal cancer, was performed prospectively in 19 patients with colorectal cancer who underwent surgery from January to July 2005. Sentinel lymph node sampling was performed during each operation with isosulfan blue dye. Additional immunohistochemical staining was performed only if the sentinel nodes were negative for metastasis. In 18 of 19 patients, at least 1 sentinel node was identified. In 5 of 18 patients, sentinel nodes were positive for metastasis, and in 3 of 5, the sentinel node was the only node containing metastasis that was detected by immunohistochemical staining. In 3 patients, metastases in nonsentinel lymph nodes were detected by hematoxylin and eosin staining; these were determined to be false-negative results. Upstaging associated with sentinel lymph node mapping may reveal disease that might otherwise remain undetected by conventional methods. Patients who are upstaged may benefit from adjuvant therapies that have been shown to improve survival.

Torsion of the greater omentum: preoperative computed tomographic diagnosis and therapeutic laparoscopy.

Primary or idiopathic segmental infarction of the greater omentum is a rare surgical condition. We describe a case of omental torsion in an adult patient who was diagnosed preoperatively by contrast-enhanced computed tomography and managed by laparoscopy.

Fine-tuning of the extent of lateral internal sphincterotomy: spasm-controlled vs. up to the fissure apex.

PURPOSE: This study was designed to compare the results of controlled lateral internal sphincterotomy by using anal calibrators with those of sphincterotomy up to the fissure apex in a randomized, prospective fashion. METHODS: In the fissure apex group, sphincterotomy was extended to the level of the fissure apex, and in the spasm-controlled group, serial small sphincterotomies and anal caliber measurements followed until an anal caliber of 30 mm was obtained. RESULTS: The preoperative anal caliber was 24 +/- 1.9 (range, 20-28) mm and 24.9 +/- 2.44 (range, 19-28) mm in the spasm-controlled and fissure apex groups, respectively (P = 0.127). Postoperatively, the spasm-controlled group had a mean anal caliber of 31.5 +/- 1.28 (range, 30-32) mm, and the fissure apex group had 32.5 +/- 2.33 (range, 25-37) mm (P = 0.035). In the fissure apex group, a significant negative correlation was determined between the postoperative anal caliber and time of relief of pain (r = -0.568, P = 0.001). The early (7 and 28 days) postoperative anal incontinence scores were significantly higher in the fissure apex group (P = 0.002, P < 0.0001, respectively). A significant positive correlation between the anal caliber measurements and anal incontinence scores at 28 days and 2 months also was noted in the fissure apex group (r = 0.406, P = 0.023; and r = 0.364, P = 0.044). CONCLUSIONS: Controlled sphincterotomy provided a faster relief of pain, and it was associated with a lower rate of early postoperative disturbance of continence and an insignificantly lower rate of treatment failure compared with sphincterotomy up to the fissure apex.

Haemorrhoidectomy with electrocautery or ultrashears and stapled haemorrhoidopexy.

BACKGROUND: This study evaluated in a randomized, prospective manner the possible differences in operative time, postoperative pain and analgesic requirement, early complications, time off-work and patient satisfaction between patients undergoing haemorrhoidectomy using the electrocautery (ECH), UltraShears (ultrasonically activated scalpel; USH) or stapled haemorrhoidopexy (SH). METHODS: Patients with symptomatic third-degree or fourth-degree haemorrhoids were randomized into one of the three groups: ECH, SH (PPH stapler; Ethicon Endo-Surgery, Cincinnati, OH, USA) or USH groups. The operative times and complications, if any, were recorded. An identical anaesthetic technique was used for all patients, and postoperative analgesia was also standardized according to the pain scores. Pain was evaluated preoperatively and at 8 and 24 h and 2, 7, 14 and 28 days, postoperatively, by means of a visual analogue scale. The numbers of narcotic and non-narcotic analgesics used, the time required for full return to daily activities and the incontinence scores at 4 months postoperatively were evaluated, as well as patient satisfaction. RESULTS: No significant differences with respect to age or sex existed between the three groups, each consisting of 20 patients. USH was significantly faster than both ECH and SH (P < 0.0001 for both comparisons) in operation time, and SH was faster than ECH (P < 0.0001). Comparing any two groups, the mean pain scores in the ECH group were significantly higher than in the SH and USH groups at postoperative 8 and 24 h, and day 2, but the groups reached comparable pain scores at day 7, 14 and 28. The numbers of narcotic and non-narcotic analgesics used in the ECH group were significantly higher than in the SH and USH groups (P < 0.0001 for all comparisons). The early postoperative complication rate was higher in the ECH group (25%), compared with the SH (P = 0.017) and USH (P < 0.0001) groups. Only 12 patients (60%) in the ECH group could be discharged within the first postoperative 24 h, whereas all of the patients (100%) in the SH and 17 patients (85%) in the USH groups could be treated as day cases. The time required for full return to daily activities was similar in the SH and USH groups (P = 0.841), but it was significantly longer in the ECH group (P < 0.0001 for both comparisons). The 70% patient satisfaction rate in the ECH group was significantly lower than in the SH (95%; P = 0.008) and the USH (100%, P = 0.002) groups. CONCLUSION: Our short-term results have shown that SH and ultrasonic dissector haemorrhoidectomies were superior to ECH haemorrhoidectomy, in terms of surgical utility, postoperative pain, analgesic intake, time off-work and patient satisfaction. Some advantages of USH over SH also appeared.

Retrorectal tumors: a case series.

BACKGROUND/AIMS: Retrorectal masses are rarely encountered in surgical practice, and they arise from congenital remnants, and from osteogenic, neurogenic, inflammatory, or metastatic processes. The majority of these masses are benign but many can be malignant, so they need to be treated with aggressive surgical management. METHODS: In this case series, eight patients with retrorectal masses of various etiologies are described, with particular emphasis on diagnosis and surgical treatment. RESULTS: In our series, we noted one duplication cyst, one tailgut cyst, one epidermoid cyst, one teratoma, one gastrointestinal stromal tumor, one epithelial malignant tumor, one inflammatory mass, and one retrorectal mass of as yet unknown origin. In three patients, complete excision via posterior sagittal approach was performed, one underwent abdominoperineal en-block proctectomy, two were only biopsied for neoadjuvant therapy, and two are waiting for operation. CONCLUSIONS: Surgery is the main treatment of choice, and the surgical strategy should be decided according to the localization and nature of the retrorectal mass.

Gelatinase B expression as a prognostic factor in patients with stage II/III rectal carcinoma treated by postoperative adjuvant therapy.

OBJECTIVE: The matrix-metalloproteinases (MMPs) are thought to be critically involved in tumor invasion and metastasis. This retrospective study was aimed both to examine the gelatinase expression status in patients with rectal cancer and to investigate their prognostic value on survival. METHODS: Sixty patients who underwent postoperative adjuvant chemoradiotherapy for Stage II and III rectal carcinoma were included. Expressions of MMP-2, MMP-9, and tissue inhibitors of MMP (TIMP-1 and TIMP-2) were analyzed by immunohistochemistry in paraffin-embedded primary rectal cancers and graded for the intensity and the percentage of cells stained. The relation between the expression of the markers studied and clinicopathologic features were evaluated for the primary study endpoint. The data were also analyzed using a multivariate Cox proportional hazards model for prognosis as a secondary endpoint. RESULTS: Positive MMP-9 expression was observed in 70% of the tumors. The ratio of tumors with positive MMP-9 expression was increased according to N stage (P = 0.005), AJCC stage (P = 0.005), and tumor differentiation (P = 0.017). Overall survival was reduced in poorly differentiated tumors and tumors with positive MMP-9 expression (P = 0.002). Disease-free survival was lower in patients with positive MMP-9 expression (P = 0.007). Multivariate analysis indicated that positive MMP-9 expression was an independent predictor of reduced overall survival (P = 0.0103) and reduced disease-free survival (P = 0.0360). The other markers studied were associated with neither any clinicopathologic feature nor any survival parameter. CONCLUSION: MMP-9 expression was observed in the tumors of patients with Stage II and III rectal carcinoma in comparable values and was characterized by poor overall survival and disease-free survival.

Transperineal rectocele repair with polyglycolic acid mesh: a case series.

PURPOSE: This study was designed to evaluate the outcome of transperineal rectocele repair using polyglycolic acid mesh. METHODS: Eighty-three consecutive females with predominant, symptomatic Stage II or Stage III rectocele underwent transperineal rectocele repair using polyglycolic acid (Soft PGA Felt(R)) mesh and finished their six-month follow-up. No additional interventions, including levatoroplasty or perineorraphy, were performed. The preoperative and postoperative symptom scores and stages of the posterior vaginal wall prolapse were recorded. The end points were reassessed at six months, postoperatively. RESULTS: Preoperatively, 39 patients had Stage II and 44 patients had Stage III rectocele. The mean total symptom score was 9.87 +/- 1.93, which was reduced to 1.62 +/- 0.59 postoperatively (P < 0.0001). Objective evaluation of anatomic repair revealed that 74 patients (89.2 percent) had anatomic cure. Surgical complications were seen in a total of seven patients (8.4 percent), including hemorrhage (3.6 percent) and wound infection (4.8 percent). Mesh erosion, mesh infection, or worsening of sexual function was not noted. CONCLUSIONS: Transperineal repair of rectocele with the polyglycolic acid mesh is an efficient therapy for patients with rectocele. It is highly successful in eliminating symptoms of obstructed defecation, and it is free of significant complications.

Desmoid tumor arising at the colostomy site after abdominoperineal resection for rectal carcinoma: report of a case.

A 69-year-old male who developed a desmoid tumor at the site of his end colostomy after abdominoperineal resection for rectal carcinoma is reported. The tumor was resected with wide margins. Histopathology revealed desmoid tumor of the anterior abdominal wall with no malignant features. The patient had an uneventful postoperative course. To our knowledge, this is the first case of solitary desmoid tumor of anterior abdominal wall at the colostomy site reported in the literature.

Results of lateral internal sphincterotomy for chronic anal fissure with particular reference to quality of life.

PURPOSE: The aim of this study was to investigate the effects of lateral internal sphincterotomy on quality of life in patients with chronic anal fissure using the Gastrointestinal Quality of Life Index and the Fecal Incontinence Quality of Life Scale. METHODS: Adult patients with chronic anal fissure underwent lateral internal sphincterotomy with the open technique. Two hundred forty-four patients completed the Gastrointestinal Quality of Life Index questionnaire at admission and at 12 months postoperatively. The Fecal Incontinence Severity Index score was calculated preoperatively and at 2 and 12 months postoperatively. The Fecal Incontinence Quality of Life Scale was administered to any patient who had a Fecal Incontinence Severity Index score greater than 0 at 12 months postoperatively. RESULTS: The mean preoperative Gastrointestinal Quality of Life Index score was 118.34 +/- 6.33, which developed to 140.74 +/- 2.38 postoperatively (P< 0.001). At the two-month follow-up, 18 patients (7.38 percent) had a Fecal Incontinence Severity Index score greater than 0. By 12 months, the number of patients with Fecal Incontinence Severity Index score greater than 0 was reduced to seven (2.87 percent). These seven patients had a Gastrointestinal Quality of Life Index score similar to that of the group with postoperative Fecal Incontinence Severity Index score of 0, and only three patients (1.22 percent) had evident deterioration in the Fecal Incontinence Quality of Life Scale. The 12-month total Gastrointestinal Quality of Life Index score of the three patients who developed anal abscess/fistula after sphincterotomy (139.33 +/- 3.21) was similar to the Gastrointestinal Quality of Life Index score of those without complications. However, the Gastrointestinal Quality of Life Index score of the recurrent cases (111.53 +/- 3.53) was apparently low. CONCLUSION: The gastrointestinal quality of life improved significantly following lateral internal sphincterotomy, regardless of the surgical complications or postoperative disturbances of continence. Only 1.2 percent of the patients experienced deterioration in Fecal Incontinence Quality of Life Scale.

Colostomy irrigation: results of 25 cases with particular reference to quality of life.

AIMS AND OBJECTIVES: The aim of this study was to document our results with colostomy irrigation with particular emphasis on the possible contribution of irrigation on quality of life. BACKGROUND: Colostomy irrigation is a useful method of achieving faecal continence in selected conditions, and may improve quality of life. When successful, irrigation offers a regular, predictable elimination pattern and only a small covering is needed for security between irrigations. METHODS: The digestive disease quality of life questionnaire-15 (DDQ-15) and Short Form-36 were used to analyse quality of life before and 12 months after stomatherapy in a series of 25 irrigating patients with permanent end colostomies. During the same time period, 10 similar patients with left-end colostomies who also received counselling but did not consent to colostomy irrigation were also analysed for comparison. RESULTS: Colostomy irrigation was found to be effective for achieving faecal continence in selected patients with end colostomies with no complications or significant side-effects, The digestive disease quality of life questionnaire-15 score improved significantly in both groups after stomatherapy (P < 0.0001 and P = 0.009 in the irrigating and non-irrigating groups respectively). The poststomatherapy digestive disease quality of life questionnaire-15 score of the irrigating group was also significantly higher than that of the non-irrigating group (P = 0.039). Although none of the poststomatherapy item scales of Short Form-36 differed significantly between the two groups, stomatherapy with CI resulted in significant improvements in role limitation due to physical problems, social functioning, role limitation due to emotional problems, general mental health, vitality and bodily pain (P < 0.05 for all comparisons). On the contrary, the non-irrigating patient group showed significant improvements only in social functioning and general mental health. CONCLUSION: Our findings suggest that colostomy irrigation can be a useful method of achieving faecal continence in selected conditions, it is safe, and it may help improve many aspects of quality of life. RELEVANCE TO CLINICAL PRACTICE: Colostomy irrigation is free from complications and significant side-effects, and it may serve as a useful adjunct to conventional stomatherapy. Therefore, the enterostomal therapy nurse should assess the appropriateness of routine irrigation as a method of stoma management for patients with left-end colostomy.

Extent of lateral internal sphincterotomy: up to the dentate line or up to the fissure apex?

PURPOSE: The aim of this randomized, prospective study was to compare the results of lateral internal sphincterotomy up to the dentate line or up to the fissure apex in the treatment of chronic anal fissure. METHODS: Adult patients with chronic anal fissure were randomly assigned to undergo lateral internal sphincterotomy to the level of the dentate line or to the level of the fissure apex. The patients were reexamined on postoperative Days 1, 7, 14, 28, and then at 2 and 12 months. RESULTS: The time required for relief of pain postoperatively was 2.08 +/- 1.44 days in the dentate line group, which was significantly shorter than that for the fissure apex group (4.72 +/- 4.86 days; P = 0.002). Objective healing was achieved in 23.7 percent and 17.6 percent at 14 days, 97.4 percent and 88.2 percent at 28 days, and 100 percent and 97.7 percent at 2 months in the dentate line and fissure apex groups, respectively (P > 0.05 for all comparisons). Only sphincterotomy up to the dentate line caused a significant change in anal incontinence (P = 0.016). Both groups had significantly lower anal resting pressures at 4 months postoperatively, compared with their corresponding preoperative levels (P = 0.005 and P = 0.007). The postoperative resting pressures did not differ significantly between the two groups (P = 0.273). By 12 months postoperatively, no treatment failures or recurrences were noted in the dentate line group (100 percent healing rate). In the fissure apex group, there was one nonhealing case and four recurrences, resulting in a 13.2 percent rate of treatment failure (P = 0.058). CONCLUSIONS: Sphincterotomy up to the dentate line provided a faster and definitive healing within the time limits of this study, but it was associated with a significant alteration in anal continence. In turn, sphincterotomy up to the fissure apex was free of significant disturbance of continence, but its healing effect was slower and it was prone to an insignificantly higher rate of treatment failure.

Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure.

PURPOSE: Botulinum toxin injection into the internal anal sphincter has been shown to be an effective treatment for chronic anal fissure. A randomized, prospective trial was conducted to compare botulinum toxin with lateral internal anal sphincterotomy as definitive management for chronic anal fissure. METHODS: Patients diagnosed as having chronic anal fissure were randomly assigned to one of the two treatment arms. In the botulinum toxin group (n = 61), 20 to 30 U (approximately 0.3 U/kg) of type A botulinum toxin (Botox) was injected into the internal anal sphincter. The injection was repeated two months later if complete healing was not accomplished. Patients in the sphincterotomy group (n = 50) underwent lateral internal anal sphincterotomy. The same investigators evaluated the patients on postoperative/postinjection days 7 and 28, and then in a blinded manner at 2, 6, and 12 months. RESULTS: In the botulinum group, single injection resulted in complete healing in 45 of the 61 patients (73.8 percent) at the second month. Of the 16 failures, 6 patients refused further treatment, and 10 were treated with a second injection, which resulted in an overall healing rate of 86.9 percent (53/61) at 6 months. In the sphincterotomy group, the success rate was 82 percent (41/50) at day 28 and 98 percent (49/50) at the second month (P = 0.023 and P < 0.0001, respectively, compared with the botulinum group-single injection). At 6 months, 2 patients in the LIS group developed recurrences, and the healing rate was similar to that of the botulinum group (86.9 96.4 percent; P = 0.212). At 12 months, the success rate of the Botox group fell to 75.4 percent (46/61) with 7 recurrences, whereas it remained stable in the sphincterotomy group (94 percent, P = 0.008). Sphincterotomy was associated with a significantly higher complication rate (8 cases of anal incontinence none in the botulinum toxin group; P < 0.001). Full return to daily activities took significantly less time in the botulinum group (1 14.8 +/- 5.7 days; P < 0.0001). CONCLUSION: Although the healing rate of chronic anal fissure is considerably high with botulinum toxin injection with earlier recovery and less complications compared with sphincterotomy, it occasionally requires a repeat injection, and the healing is slower. The early (two months) and late (one year) healing rates are significantly higher in the sphincterotomy group, the two groups reaching similar healing rates only at six months.

Modified Limberg transposition flap for sacrococcygeal pilonidal sinus.

PURPOSE: To investigate the results of wide rhomboid excision with Limberg transposition flap reconstruction to treat pilonidal sinus. METHODS: We analyzed the well-documented records of 238 patients with sacrococcygeal pilonidal sinus who underwent wide excision with a Limberg transposition flap and were followed up for longer than 1 year postoperatively. After the first 40 operations, we modified this flap reconstruction by tailoring the rhomboid excision asymmetrically to place the lower pole of the flap 1-2 cm lateral to the midline. Wound infection rates, hospitalization, time required for free mobilization, and recurrence rates were recorded. RESULTS: Postoperative infection developed in two patients (0.8%), which was easily managed by wound care, antibiotics, removal of skin staples, prolonged drainage, or a combination of these treatments. The mean hospitalization was 2.10 +/- 0.20 days (range 1-3 days), and the mean time required for recovery and return to daily activities was 8.00 +/- 2.50 days (range 4-17 days). There were only three recurrences (1.26%) after a mean follow-up of 29.20 +/- 3.10 months (range 12-38 months). Since we started performing our modification of the technique by lateralization of the inferior apex, no further recurrences have been seen. The recurrence rate differed significantly between the classical Limberg flap group and the modified Limberg flap group ( P = 0.004) CONCLUSION: These results provide further evidence that wide excision with a Limberg transposition flap reconstruction is an effective surgical method for primary or recurrent pilonidal sinus, associated with a low complication rate, short hospitalization and disability, and a low recurrence rate. A modification of the technique was devised to further enhance wound healing and reduce the risk of recurrence.

Impact of stomatherapy on quality of life in patients with permanent colostomies or ileostomies.

BACKGROUND AND AIMS: The impact of a stoma on a patient's life is little discussed and is often underestimated, as well as the contribution of stomatherapy to health-related quality of life (QOL). This present study examined the problems faced by patients with ileostomies or colostomies and the possible contribution of stomatherapy to QOL. PATIENTS AND METHODS: Forty-three selected and well-documented stoma patients who had properly constructed, well functioning end colostomies or ileostomies were analyzed. Further analyses were carried out for the subgroups of patients with irrigating colostomies ( n=16), nonirrigating colostomies ( n=15), and ileostomies ( n=12). The digestive disease QOL questionnaire 15 (DDQ-15) was used to analyze QOL before and 3 months after stomatherapy. A second questionnaire consisting of 11 questions with yes/no answers was also used before and 3 months after stomatherapy to define more specifically the stoma-related problems of each patient as well as the frequency of each issue in a patient group at a given time. RESULTS: Cumulatively the mean QOL score was significantly higher after stomatherapy than before. Before stomatherapy the irrigating colostomy patients had the highest QOL score and the ileostomy group the lowest. QOL scores 3 months after stomatherapy were significantly higher in all groups than before. Again, the irrigating colostomy patients had a significantly higher score than the nonirrigating colostomy and ileostomy patients. Cumulatively all of the items improved significantly after stomatherapy, such as getting dressed, bathing, and participating in sports. CONCLUSION: These findings confirm that colostomy or ileostomy has a profoundly negative impact on QOL. Specialized counseling of these patients by a dedicated team improves QOL significantly.