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Umbilical Pilonidal Sinus Disease: Predisposing Factors and Treatment

Pilonidal sinus disease is a common problem of sacrococcygeal region. However, it is also observed in the periumbilical area. There are only a few reports about umbilical pilonidal sinus in the literature. In this study, 26 patients (24 men (92 %), 2 women (8 %) with a mean age of 22 years) with umbilical pilonidal sinus disease were included. Predisposing factors, patient characteristics, treatment modalities, and their results have been studied. Male sex, young age, hairiness, deep navel, and poor personal hygiene were found to be predisposing factors. Twenty-five patients were treated conservatively. However, two patients failed to respond to conservative treatment. Those patients underwent surgery where umbilectomy was carried out without reconstruction. One patient was also operated on for the preoperative misdiagnosis of irreducible umbilical hernia. Patients were followed for 14–96 months. We recommend conservative treatment in patients with umbilical pilonidal sinus. Surgery should be performed in recurrent cases resistant to conservative treatment. The importance of differential diagnosis of umbilical pilonidal sinus from other umbilical pathologies is also emphasized.

Comparison of Surgical Techniques for Treatment of Benign Toxic Multinodular Goiter

Controversy remains regarding the best surgical approach for toxic multinodular goiter (MNG). The aim of this study was to evaluate the results of various thyroid operations for managing toxic MNG. A group of 100 patients with toxic MNG were divided into three groups and managed with total thyroidectomy (TT; group I, n-17), near-total thyroidectomy (NTT; group II, n = 48), or bilateral subtotal thyroidectomy (BST; group III, n = 35). Patients were compared with regard to age, gender, surgical operations, complications, thyroid hormone status, duration of hospitalization, and the reoperation rate for incidentally found thyroid carcinomas. There were 14 men (14%) and 86 women (86 %) with a mean age of 47.03 ± 13.56 years (range 19–77 years). After the operation two patients had a hematoma, and one patient had a seroma. Four patients had unilateral vocal cord paralysis, and one had permanent paralysis. Moreover, 18 patients had transient and 2 patients permanent hypocalcemia. There was no significant difference between the groups regarding complications (p < 0.05). Permanent hypothyroidism was achieved in all patients in group I and 44 patients (92 %) in group II, whereas in group III only 10 (29%) patients had hypothyroidism. Conversely, hyperthyroidism, both subclinical and clinical, was noted only in group III (12 patients, 34 %) during follow-up. We think that TT and NTT are safe, effective approaches in the treatment of toxic MNG, preventing recurrence of thyrotoxicosis and reoperation for incidentally found thyroid cancers. The complication rates for TT and NTT were similar to that for BST. Hence these operation should be considered for patients referred for surgical treatment of toxic MNG.

Surgical Treatment of Complicated Pilonidal Sinus with a Fasciocutaneous V-Y Advancement Flap

PURPOSE: In this study, we investigated the value of fasciocutaneous V-Y advancement flap reconstruction in the treatment of complicated or recurrent sacrococcygeal pilonidal sinus. METHODS: Patients with complicated pilonidal sinus treated with a V-Y advancement flap from July 2002 through December 2005 were studied. The duration of inpatient stay, early wound complications, time of return to active work, recurrence, and patient satisfaction with the operation were recorded. RESULTS: Forty-three patients were treated for recurrent or complicated sacrococcygeal pilonidal disease. All flaps remained viable without necrosis. However, 4 patients (9.3%) had wound infections, and 3 patients (7%) had hematoma. The mean hospital stay was 3 (range, 2–5) days, and time to return to active life was 17 (range, 13–25) days. The mean duration of follow-up was 48 (range, 27 to 69) months. Recurrence was detected in only one patient in the early period. Seven patients (16.3%), including 4 bilateral repairs, had numbness over the operative site. Thirty-nine patients (90.7%) were not satisfied with scars; 4 reported that the scar was not important. CONCLUSIONS: In selected patients, V-Y advancement flaps provide tension-free repair with minimal recurrence rates and reliable skin coverage while flattening the natal cleft that predisposes to recurrence. Because patient dissatisfaction with cosmetic results is high, potential treatment outcomes should be discussed with patients in detail before the operation.

Risk factors of morbidity and mortality in patients with perforated peptic ulcer.

Abstract Purpose: Peptic ulcer perforation is a serious problem that leads to high complication and mortality rates. The aim of this prospective clinical study was to evaluate complications and possible risk factors for peri-operative morbidity and mortality in patients with perforated peptic ulcer (PPU). Material and methods: Ninety-seven patients hospitalized for PPU at the Department of Surgery, Vakif Gureba Training and Research Hospital, between March 1998 and December 2004 were analysed. Results: The mean age of patients was 38.6 years. Ten patients had 19 co-morbidities. The mean hospitalisation time was 7.1 days. Twenty-one complications in 15 patients occurred. Overall morbidity and mortality rates were 15.5% and 5.2% respectively. Multivariate logistic regression analysis of 97 patients revealed that age (p < 0.006) and late admission (p < 0.001) were linked to morbidity. The mortality rate tended to be associated with advanced age, therapeutic delay and co-morbidities. Conclusions: Increased patients’ age and the therapeutic delay, predicted outcome after surgical treatment of PPU. Morbidity and mortality could be reduced by avoiding delays in diagnosis and treatment, especially in older patients, and by instituting proper treatment of any coexisting medical illness.

Spontaneous biloma managed with endoscopic retrograde cholangiopancreatography and percutaneous drainage: a case report

IntroductionSpontaneous biloma formation is a very rare condition, which mandates immediate treatment.Case presentationAn 80-year-old Caucasian man was referred to our department with a diagnosis of intra-abdominal collection located in his right upper quadrant. Further radiological examination demonstrated multiple calculi in his gallbladder and common bile duct. Our patient underwent endoscopic retrograde cholangiopancreatography and the stones in the common bile duct were extracted. Percutaneous drainage of the abdominal collection revealed a spontaneous biloma formation. Continuous drainage of bile persisted for one week, so endoscopic retrograde cholangiopancreatography was repeated and a 10Fr stent was placed; subsequently the biliary leak ceased and our patient was discharged. A control abdominal computed tomography did not show any residual fluid collection.ConclusionSpontaneous biloma formation is a very rare incidence; awareness is necessary for prompt recognition and treatment.

Interdigital Pilonidal Sinus: A Case Report and Literature Review

Although sacrococcygeal pilonidal disease is a common surgical entity, rarer locations of the disease have been reported as case presentations in the literature. Interdigital localization is one of the rarest forms and is commonly encountered in barbers with male customers as an occupational disease due to contact with short and stiff hairs. Templeton first described the disease in 1940, and its histologic structure has been reported as a foreign body granuloma. Interdigital pilonidal disease has also been reported in dog groomers and cow milkers. These cases were known as “shearer’s disease” and “milker’s granuloma,” and they occurred because of the stiff hairs of dogs and goats, exhibiting the same mechanism. Fewer than 20 cases with barber’s disease have been reported in the literature, and taking into account all occupations, approximately 50 cases have been published. Interdigital pilonidal disease begins with penetration of short, stiff hair fibers into the skin of the interdigital sulcus and proceeds with sinus formation that eventually turns into a cyst. The accumulation of short hairs within the sinus leads to infection and subsequent formation of classic pilonidal disease. It mainly presents with a purulent discharge from the infected cyst containing hair particles. Unlike other forms of the disease, which are found in areas such as the sacrococcyx, umbilicus, chest wall, anal canal, ear, and scalp, interdigital pilonidal sinuses do not contain the patient’s own hairs. Here, we report a case of pilonidal disease in a male barber and its surgical treatment.

Endoscopic stenting for selected cases of biliary fistula after hepatic hydatid surgery

BackgroundBiliary fistula develops in 4%–28% of patients after hepatic hydatid disease (HHD) surgery. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) are helpful in the treatment of this complication, persistent fistulas may occur. We therefore conducted a study to evaluate the efficacy of endoscopic biliary stenting in the treatment of biliary fistulas after HHD.MethodsIn this study, 84 patients who underwent ERCP for postoperative biliary fistula due to HHD were evaluated. Group I included 70 patients treated with only ES, and group II included 14 patients who underwent biliary stenting as their initial treatment. Demographic data, complications, the results of treatment and the reasons for the failure were compared between two groups.ResultsNinety-five ERCPs were performed. In 63 patients, biliary fistulas were successfully treated with only ERCP and ES. However, 7 patients underwent repeat ERCP and stent placement because of persistent fistula. Biliary stenting was initially performed in 14 patients. The average time for closure of the fistula was 14 ± 10 days and 7 ± 3 days in group I (7 patients with repeat ERCP were excluded.) and group II, respectively (p = 0.007). There was no statistically significant difference in the complication rates between the groups.ConclusionsAlthough ES is effective in the treatment of biliary fistula after HHD surgery, endoscopic biliary stenting may be considered as the initial procedure in patients with biliary stricture, incomplete clearance of hydatid material in the bile duct, and persisting biliary fistulas after treatment with ERCP and ES.

Una complicación muy poco frecuente de la cirugía colorrectal y su tratamiento: fuga quilosa

Chylous leakage is a rare complication after major abdominal operations and is characterized by the collection of chylous fluid in the peritoneal cavity. Postoperative chylous leakage mainly develops as a result of surgical trauma to lymphatic channels such as lacteals, tributaries or the main lymphatic duct itself and cysterna chyli. It could be either a localized chylous leakage or diffused chylous peritoneum. The surgical procedures reported to be associated with chylous leakage are mainly the ones involving retroperitoneal dissection such as testicular cancer, pancreatic resection, abdominal aortic surgery, and gastric cancer with D3 dissection. Since it is an unusual complication, the true incidence, natural history and the proper treatment algorithms remain to be defined. The delay in treatment or mismanagement may lead to dire consequences such as loss of fluid, proteins, fats, lymphocytes and subsequent cachexia. Although a few number of cases with chylous leakage after colorectal resection have been reported, neither the incidence nor the associated factors have been stated. Here we present the management of our four cases with chylous leakage after colorectal resection. Between June 2004 and April 2010, all patients who underwent colorectal resection for cancer in Vakif Gureba Training and Research Hospital were prospectively collected in a database approved by our hospital institutional board. Informed consents were obtained from all patients. A postoperative early recovery protocol was adopted from 2006, and oral feeding was started from postoperative day 1 with clear liquids. By the third day, colorectal cancer patients received normal diet with minimal fiber content. Like colorectal cancer patients, oral feeding for gastric cancer patients was started from postoperative day 1 with clear liquids. Chylous leakage was suspected postoperatively when a milky-appearing drain effluent was observed. The diagnosis of chylous leakage was confirmed by the triglyceride level of >110 mg/dl in drain fluid. All patients underwent total parenteral nutrition immediately after the diagnosis. With the cessation of fluid drainage, patients started oral feeding with a low-fat containing diet. Before hospital discharge they resumed normal oral feeding including fats. The demographic data, clinical presentation, primary diagnosis, type and extent of surgery, tumor characteristics and stage, number of harvested lymph nodes, the drain fluid characteristics, the duration of effusion, management and complications were all noted. During the specified period, 273 colorectal resections were performed in our unit. Both open and laparoscopic resections and rarely combined other-organ resections (especially gastric) were performed. Three female and one male patient with chyloperitoneum were identified. The incidence of chyloperitoneum after colorectal resections was 1.46% (4/273). Of four patients, three underwent colorectal resection for malignant causes. In one patient, the chylous leakage was noticed after colostomy takedown where the colostomy had been fashioned earlier for obstructing rectosigmoid cancer. At follow-up period (before takedown operation) CT scan did not identify any abdominal collection and no chylous fluid was present at operation. Two patients had synchronous tumors resulting in multivisceral resections and two patients had radiotherapy before the operation. The only patient without tumor was a female patient with delayed perforated appendicitis. On exploration, both appendix and cecum were found to be perforated due to massive intraabdominal inflammation and necrosis. One patient (patient no 1) underwent percutaneous catheter placement under ultrasonographic guidance for an intraabdominal collection due to premature drain removal. The drain fluid was contaminated with gramnegative bacteria and the patient treated with appropriate antibiotics. Two patients (patient no. 1–4) had wound c i r e s p . 2 0 1 5 ; 9 3 ( 2 ) : 1 1 8 – 1 3 1

The Role of Pain Catastrophizing Score in the Prediction of Venipuncture Pain Severity

In addition to the influence of tissue damage, the intensity of pain is also related to individual cognitive factors. The Pain Catastrophizing Scale (PCS) is used to measure individual tendency toward pain by inquiring about a subjects cognitive characteristics. Building on the knowledge that the venipuncture process causes severe pain and anxiety in some patients, the objective of this study was to investigate the relationship between the PCS score and venipuncture pain.

Diagnostic value of MRCP in biliary pancreatitis: result of long-term follow-up.

Abstract Aim : Magnetic resonance cholangiopancreatography (MRCP) has increasingly been used to evaluate the common bile duct. This study was to determine the role of MRCP instead of endoscopic retrograde cholangiopancreatography (ERCP) in the management of patients with acute biliary pancreatitis. Methods : A total of 81 patients with mild or moderate biliary pancreatitis who underwent MRCP and were treated in our department with selective ERCP between May 2001 and July 2007 were entered into a prospective database. Results : MRCP was considered abnormal in 13 patients. Ten patients underwent ERCP. Three patients did not undergo ERCP due to protocol violations. In nine patients, stone extraction was performed. The remaining patient who had dilatation of the CBD underwent ES. The false positive rate of MRCP was 10%. The median follow-up of overall patients was 36 months (range 23–99 months). The patients with normal MRCP had a median follow-up of 39.5 months (range 23–99 months). During the follow-up period in the normal MRCP group, five patients were diagnosed with recurrent biliary pancreatitis, of which three underwent ERCP (7.4%). There was no disease-related mortality during this period. Conclusion : In conclusion, the use of MRCP in acute biliary pancreatitis is safe and may be recommended as a tool to aid in the selective use of ERCP.