Ramazan Eryilmaz

Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap

BACKGROUNDnPilonidal sinus is a common chronic disease of the sacrococcygeal region. Although many surgical methods have been suggested, an ideal method is still lacking because of high recurrence rates.nnnMETHODSnThis prospective study was conducted in 63 patients who were treated with the use of a rhomboid excision and Limberg flap closure for sacrococcygeal pilonidal sinus. The follow-up period ranged from 4 to 52 months (mean, 25 months).nnnRESULTSnThe mean hospital stay was 3 days (range, 2-7 days) and the mean time to return to work was 15 days (range, 12-26 days). Early wound complications and recurrence were encountered in 6% and 3%, respectively. Nineteen percent had numbness at the operation site and 63% were not pleased with cosmetic appearance of the scars.nnnCONCLUSIONSnThe results favor rhomboid excision and Limberg flap closure in the treatment of sacrococcygeal pilonidal sinus, especially in recurrent cases and in patients with extensive involvement. Low recurrence rates, shorter hospital stay, and time off from work may outweigh the disadvantages related to unfavorable cosmetic appearance.

Timing of Cholecystectomy for Acute Biliary Pancreatitis: Outcomes of Cholecystectomy on First Admission and after Recurrent Biliary Pancreatitis

Biliary stones are the leading cause of acute pancreatitis. Although cholecystectomy and selective endoscopic retrograde cholangiography (ERC) comprise the current treatment in patients with acute biliary pancreatitis (ABP), the time of intervention is still controversial. In this study we evaluated the outcomes of cholecystectomy on first admission for ABP and in patients with recurrent biliary pancreatitis. A series of 43 patients with ABP between January 1997 and November 2000 were evaluated retrospectively. Patients were classified into two groups. Group I included 27 patients who underwent cholecystectomy on first admission before discharge from the hospital. Group II comprised 16 patients who had recurrent biliary pancreatitis and then underwent cholecystectomy. The severity of the pancreatitis was determined by Ranson’s criteria. Age, gender, length of hospital stay, severity of pancreatitis, amylase level, and complications of cholecystectomy were evaluated in both groups. Patients in group I underwent cholecystectomy during the original hospital admission and patients in group II during an admission for a recurrence. There were 24 patients with a Ranson’s score ≤ 3 in group I and 12 in group II. The mean hospital stays were 15.29 days (range 4–48 days) and 36.66 days (range 15–123 days) in groups I and II, respectively (p = 0.006). Morbidity was 11% without mortality in group I and 43% with one mortality in group II (p = 0.023). Definitive treatment of ABP can be accomplished effectively and safely by cholecystectomy following clinical improvement, with selective ERC performed during the first admission (delayed cholecystectomy). Waiting to perform cholecystectomy (interval cholecystectomy) may result in recurrent biliary pancreatitis, which may increase morbidity and the length of the hospital stay.

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.

The Effect of Scolicidal Agents on Liver and Biliary Tree (Experimental Study)

Hydatid disease of the liver is a parasitic infection. Surgery still remains as the primary choice of treatment. Caustic sclerosing cholangitis is reported following surgical treatment. Hypertonic saline (20%), povidone iodine (1%), and silver nitrate (0.5%) are extensively used as scolicidal solutions. The effects of these scolicidal agents on liver and biliary tree are investigated by direct injection into the common bile duct of rats. At the end of 15 wk, liver function tests, cholangiography, and histopathological examination of the liver and biliary tree were performed. Liver function tests were within normal limits, except elevation of alkaline phosphatase in 2 and 1 rats of the silver nitrate and povidone iodine groups, respectively. Differences were not statistically significant (p >. 05). Cholangiograms of the rats in all groups were normal. Histopathologic changes comprising low-grade inflammatory changes were induced in all study groups. The intensity of the lesions were more remarkable with silver nitrate and minimal with hypertonic saline. We suggest that direct injection of scolicidal agents into the cyst should be avoided particulary in case of biliary communication. If this is to be practiced, hypertonic saline should be preferred as a scolicidal agent.

Acute Appendicitis during Pregnancy

Background: To analyze the diagnosis and surgical treatment of acute appendicitis during pregnancy. Methods: The records of 24 pregnant patients who underwent surgery with preliminary diagnosis of acute appendicitis between January 1990 and July 2000 were reviewed retrospectively. Results: Between January 1990 and July 2000, there were 31,480 deliveries and the incidence of acute appendicitis was 1/1,312. Twenty patients had pathologically proven acute appendicitis (83.3%). Of the remaining 4 patients, one had hemorrhagic ovarian cyst, one had ovarian cyst rupture and in two cases no surgical pathology was diagnosed. Gestational stage at the diagnosis was first trimester in 7 patients, second trimester in 12 patients and third trimester in 5 patients. Five patients had abortions and premature delivery occurred in 2 patients. Conclusion: Diagnosis of acute appendicitis is difficult in pregnancy. Delay in diagnosis and surgery results in increase in complications. Emergency surgical intervention should be performed when acute appendicitis is suspected during pregnancy.

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.

Tuberculosis of the Breast

To the Editor: There has been considerable increase in the prevalence of tuberculosis (TB) as well as an increase in its extrapulmonary manifestations worldwide. This may be due to the increasing number of people with suppression of the immune system, aging, and the development of drugresistant strains of Mycobacterium tuberculosis (1,2). TB of the breast is an extremely rare disease. Although breast tuberculosis may be seen in males, it usually affects young, multiparous, lactating women. In the literature 95.5% of cases occur in women and only 4.5% occur in men. Its incidence in Western countries is less than 0.1%, whereas in developing countries, where TB is endemic (1–3), the incidence is 0.25–4.5%. The breast can be primary site, but tuberculosis more commonly reaches the breast through lymphatic spread from axillary, mediastinal, or cervical nodes, or directly from underlying structures such as the ribs. Breast tuberculosis usually presents as round, slowly growing nodular lumps. The classic presentation is a breast lump with associated sinus in 39% of patients, isolated breast lump in 23%, sinus without lump in 12%, and tender nodularity in 23%. Associated axillary lymphadenopathy may be found in 41% of cases (4). The most common presentation is that of an acute abscess resulting from infection of an area of tuberculosis by pyogenic organisms. The diagnosis of breast tuberculosis is difficult because of nonspecific clinical and radiologic findings. Tuberculosis lesions such as nodular mastitis, disseminated mastitis, and sclerosing lesions clinically mimic fibroadenoma, carcinoma, and fibrocystic change, depending on the mode of presentation. A young, multiparous, lactating woman with a lesion should arouse a suspicion of tuberculous mastitis. Diagnostic modalities include, mammography, fine-needle aspiration cytology, and excision biopsy, with accuracies of 14%, 12%, and 60%, respectively (5). Mammography and ultrasonography are the primary imaging methods in the evaluation of breast lesions. But mammographic findings of breast tuberculosis are nonspecific. A mammographic demonstration of a dense tract connecting an ill-defined breast mass to a localized skin thickening and bulge (skin bulge and sinus tract sign) is strongly suggestive of tuberculous breast abscess. Changes in the shape and outline of the breast mass can be seen in the standard breast views (6). With ultrasonography, the findings of abscesses and sinus tracts and of circumscribed hypoechoic masses with moving internal echoes and posterior enhancement may aid in differential diagnosis (1). Computed tomography may define involvement of the thoracic wall in those cases that present as mammary masses adhering to deep levels, and is also able to evaluate accompanying pulmonary disease, if it is present (7). Fine-needle aspiration biopsy material may demonstrate acute neutrophilic exudate, few isolated aggregates of epithelioid histiocytes, necrosis, epithelioid cell granulomas, giant cells, and lymphocytes (8). Overall acid-fast bacillus (AFB) positivity is 22.7%. AFB positivity is greater in the presence of necrosis when epithelioid cells are absent. Up to 73% of breast TB can be confidently diagnosed when both epithelioid cell granulomas and necrosis are present (9). Differential diagnosis includes breast carcinoma, traumatic fat necrosis, plasma cell mastitis, pyogenic breast abscess, sarcoma, actinomyces, and granulomatous mastitis. Also breast carcinoma and tuberculosis may be seen synchronously (10). Erythrocyte sedimentation rate and purified protein derivative (PPD) tests are not significantly high in some cases. Their positivity support the diagnosis, but negativity does not rule out the disease. Antibacillary drugs are the mainstay of therapy. Surgery is used only in cases that fail to respond to medical treatment and/or involve extensive tissue damage. Although rare, tuberculosis of the breast should be considered as a possible diagnosis, particularly in countries where tuberculosis is endemic (10). Wilson and MacGregor (11) suggest simple mastectomy for treatment. But the regimen composed of necrotic tissue excision and drainage combined with antituberculosis drugs is also effective.

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.

The Role of Dura Mater and Free Peritoneal Graft in the Reinforcement of Colon Anastomosis

Anastomotic leakage is the most important complication leading to morbidity and mortality in colorectal surgery. To prevent anastomotic leakage, a number of drugs with different mechanisms of action were tested, and autogenic grafts and various synthetic materials were used for reinforcement of the anastomotic region. In this experimental study aimed at preventing anastomotic leakage and dehiscence, we used dehydrated, lyophilized human dura mater and free peritoneal graft for reinforcement of anastomotic region after primary repair in rats, and investigated whether they are superior to primary anastomosis. The rats were sacrificed 3 and 7 days postoperatively. The anastomotic region was observed macroscopically for adhesions, bursting pressure of bowel was measured for tensile strength of the anastomosis, and histopathologic evaluation was performed for anastomotic healing. Compared to the control group, dura mater and free peritoneal graft groups displayed a lower bowel bursting pressure (p <. 05), worse anastomotic healing (p <. 05), a higher number of adhesions, and presence of anastomotic stricture. In conclusion, both human dura mater and free peritoneal graft reinforcement groups had worse anastomosis healing. The results could be attributed to avascularity of grafts and to aggravated adhesions between anastomosis and intra-abdominal organs, which created a favorable environment for reproduction and dispersion of bacteria and consequently led to decreased anastomosis healing.