Sacrococcygeal pilonidal disease: analysis of previously proposed risk factors

PURPOSE

Sacrococcygeal pilonidal disease is a source of one of the most common surgical problems among young adults. While male gender, obesity, occupations requiring sitting, deep natal clefts, excessive body hair, poor body hygiene and excessive sweating are described as the main risk factors for this disease, most of these need to be verified with a clinical trial. The present study aimed to evaluate the value and effect of these factors on pilonidal disease.

METHOD

Previously proposed main risk factors were evaluated in a prospective case control study that included 587 patients with pilonidal disease and 2,780 healthy control patients.

RESULTS

Stiffness of body hair, number of baths and time spent seated per day were the three most predictive risk factors. Adjusted odds ratios were 9.23, 6.33 and 4.03, respectively (p<0.001). With an adjusted odds ratio of 1.3 (p<.001), body mass index was another risk factor. Family history was not statistically different between the groups and there was no specific occupation associated with the disease.

CONCLUSIONS

Hairy people who sit down for more than six hours a day and those who take a bath two or less times per week are at a 219-fold increased risk for sacrococcygeal pilonidal disease than those without these risk factors. For people with a great deal of hair, there is a greater need for them to clean their intergluteal sulcus. People who engage in work that requires sitting in a seat for long periods of time should choose more comfortable seats and should also try to stand whenever possible.

The effects of montelukast on antioxidant enzymes and proinflammatory cytokines on the heart, liver, lungs, and kidneys in a rat model of cecal ligation and puncture-induced sepsis

We investigated the potential protective effects of montelukast (MLK) on cecal ligation and puncture (CLP)-induced tissue injury in vital organs - liver, heart, kidneys, and especially lungs - through inhibition of the proinflammatory cytokine response and the generation of reactive oxygen species (ROS) in rats. The rat groups were (1) a 10-mg/kg MLK-treated CLP group; (2) a 20-mg/kg MLK-treated CLP group; (3) a 20-mg/kg MLK-treated, sham-operated group; (4) a CLP control group; and (5) a sham-operated control group. MLK treatment significantly decreased proinflammatory (tumor necrosis factor-alpha, interleukin-6) cytokine levels following CLP. The lipid peroxide level increased in the lung, heart, liver, and kidney tissues after CLP-induced sepsis, and myeloperoxidase activity increased in the lung, heart, and liver tissues. MLK attenuated this elevation in all tissues except the kidney, dose dependently. The glutathione levels and superoxide dismutase activity were significantly increased in the lung, liver, and kidney tissues after MLK treatment. MLK treatment after CLP also potentially reduced mortality. The lung and kidney tissues were the most protected by MLK under sepsis conditions. We can suggest that MLK reverses the systemic inflammatory reaction to polymicrobial sepsis and thereby reduces multiple organ failure.

Limberg flap procedure for pilonidal sinus disease: results of 353 patients

PURPOSE

Pilonidal sinus disease is common especially in young adult males. Many surgical and nonsurgical methods have been described. Some surgical techniques for the treatment still have high recurrence rate. The aim of this study was to evaluate advantages and long term results of Limberg flap surgical technique.

METHODS

From November 2001 to December 2004, 353 patients [335 male, 18 female; average age = 24.65 +/- 4.2 (range, 15-53) years] with primary or recurrent pilonidal sinus disease were operated on under spinal anesthesia by rhomboid excision and Limberg flap. Follow-up examinations were made at the end of the 4 weeks and 3, 6, 12, 18, and 24 months after surgery.

RESULTS

The mean duration of symptoms was 23.28 +/- 16.09 (range, 2-140) months. The mean duration of hospital stay was 4.51 +/- 2.85 (range, 2-19) days. Thirty nine patients (11%) had recurrent disease. Total wound dehiscence and flap necrosis did not occur in any patient. Recurrences were observed in 11 patients (3.1%) at the end of the follow up period.

CONCLUSION

Quick healing time, short hospital stay, early return to daily life, low complication and recurrence rate are the important advantages of the Limberg flap procedure. We think using closed suction drain in Limberg flap operation is not necessary. In the light of this study results, Limberg flap surgical technique may be an ideal operation for pilonidal sinus disease.

Effect of intraoperative magnesium sulphate infusion on pain relief after laparoscopic cholecystectomy

INTRODUCTION

The aim of the study is to evaluate the analgesic efficiency of perioperative magnesium sulphate infusion in patients undergoing laparoscopic cholecystectomy (LC).

METHODS

In a randomized, double-blind trial study, 83 patients were divided into two groups. Group MT received 50 mg/kg i.v. magnesium sulphate in 100 ml of 0.9% normal saline and Group T received the same volume of isotonic saline during the intraoperative period. The cumulative post-operative tramadol consumption was measured to assess the analgesic effect using a patient-controlled analgesia device. Pain intensities at rest and while coughing were evaluated at 0, 2, 4, 8, 12, and 24 h post-operatively.

RESULTS

The pain scores in Group MT were significantly lower than Group T at 0, 4, and 12 h post-operatively. The average of visual analogue scale at rest and during cough during 24 h post-operatively was found to be statistically significant between groups. The total dose of tramadol the 24-h period in Group MT and Group T was found to be 281.34 +/- 90.82 and 317.46 +/- 129.59, respectively.

CONCLUSION

Per-operative 50 mg/kg magnesium sulphate infusion is effective in reducing post-operative pain in patients undergoing LC.

Management of pilonidal sinus disease with oblique excision and primary closure: results of 493 patients

PURPOSE

Pilonidal sinus disease is a common and well-known entity. Many surgical methods have been described for the treatment of pilonidal sinus disease. The aim of this study was to determine the advantages and long-term results of oblique excision and primary closure techniques.

METHOD

Between January 1999 and December 2001, 493 patients (490 male, 3 female; average age = 23.48 +/- 3.90 (range, 15-51) years) were operated on for primary or recurrent pilonidal sinus disease. An oblique fusiform-shaped incision was made and the skin was excised. The operation was completed with primary closure. All patients' follow-up examinations were made at the end of the 6 weeks and 3, 6, 12, and 18 months after surgery.

RESULTS

The mean duration of symptoms was 22.09 +/- 17.12 (range, 1-120) months. The mean duration of hospital stay was 5.51 +/- 2.85 (range, 2-17) days. At the end of the follow-up period, the recurrence rate was 5.6 percent.

CONCLUSION

The ideal operation for pilonidal sinus disease treatment must be simple and effective. The technique of oblique excision and primary closure may be considered an alternative operation for pilonidal sinus resulting in a low recurrence rate.

Ultrasonography accurately evaluates the dimension and shape of the pilonidal sinus

PURPOSE

To study the benefits of ultrasonography for detecting the borders of pilonidal sinus tissue. The correlation between physical and ultrasonographic examination was used for surgical planning.

METHOD

Between April and December 2004, 73 patients were recruited for this study. All patients were examined, and the borders of the sinus tissue were marked on the skin according to palpation before surgery. The surgeon also made a treatment plan considering the diseased tissue and marked a possible incision line. Patients were subsequently examined with ultrasonography. According to the ultrasonographic evaluation, the margins, extensions, and openings of pilonidal sinus tissue were determined and marked on the patient in a different color by a radiologist prior to surgery. The most suitable surgical treatment was decided according to the information obtained by ultrasonography.

RESULTS

The average age was 23.03 +/- 3.05 (range 18-39) years. We found 81 lesions in 73 patients. Ultrasonographic borders of sinus tissue were similar to the borders marked by the surgeon in 56 patients (76.7%). In the remaining 17 patients (23.3%), ultrasonography detected branches or borders that distinctly exceeded the planned incision line. After ultrasonographic examination, the surgeon changed his incision line in 14 patients and the surgical intervention in 3 patients.

CONCLUSION

Palpation and methylene blue injection do not provide appropriate information in many patients. Our study revealed that pre-operative ultrasonography can improve the identification of the sinus tract and its branches when compared to palpation and methylene blue injection.

Surgical treatment of caustic esophageal strictures in adults

BACKGROUND AND AIMS

Caustic esophageal injury is a rare clinical condition in adult patients. Although dilatation, or the conservative approach, is the primary treatment method, some patients require surgical intervention. Because of the rarity of such cases, standard surgical treatment algorithms cannot be utilized. In this article, we present our surgical experience and discuss the challenges in the surgical management of corrosive injury of the esophagus in adults.

METHODS

A retrospective review was conducted of 28 patients who suffered from a corrosive esophageal injury between 1996 and 2011. Patient demographics, history of corrosive material ingestion, preoperative findings, treatment strategy, operative technique, postoperative course, requirements for further treatment, and the current status of the patients were investigated.

RESULTS

All patients underwent a transhiatal esophagectomy in addition to a gastric pull-up with a cervical esophagogastrostomy. The mean follow-up time was 62 (12-140) months. One patient developed a deep surgical infection; anastomotic stenosis was noted and treated with dilatation in 13 patients. The mean time period between the operation and the first dilatation for 12 patients was 81 (45-161) days. The mean dilatation count for the patients was 3 (1-10).

CONCLUSION

Although it comes with high anastomotic stenosis rates, transhiatal esophagectomy and gastric pull-up with cervical anastomosis is a safe procedure, which can be performed for the treatment of corrosive esophageal stricture.

The value of serum fibrinogen level in the diagnosis of acute appendicitis

BACKGROUND

The aim of this study was to investigate the importance of serum fibrinogen level in the diagnosis of acute appendicitis.

METHODS

This study was performed on 201 patients who admitted to our clinic. Symptoms, signs, duration of symptoms, and laboratory indicators of appendicitis were recorded, in keeping with the Alvarado score for acute appendicitis. The ultimate diagnosis was based on histopathological results. Serum fibrinogen levels were detected before surgery. The sensitivity, specificity, and predictive values of single test and test combinations were calculated at different cut-off levels.

RESULTS

During the study period, 201 patients underwent surgery for suspected acute appendicitis. Appendicitis was confirmed in 179 (89%) patients. The mean age was 24.8±7.7 (range, 20-57) years, and 154 (76.6%) patients were male and 47 (23.4%) female. The best diagnostic cut-off point for fibrinogen was found at 245.5 mg/dl, for white blood cells (WBC) at 11,900x109/L and for Alvarado score at 7.

CONCLUSION

The use of fibrinogen blood level may be a new diagnostic acute-phase reactant in the diagnosis of acute appendicitis. The formulation of a triple test is recommended as criteria in deciding emergency surgery or observation.

Atopy is a risk factor for acute appendicitis? A prospective clinical study

PURPOSE

The purpose of the study was to assess the role of atopy on the development of appendicitis. Acute appendicitis is the most common indication for emergent laparotomy especially in the late teens and early 20s. The pathogenesis generally begins with luminal obstruction caused by fecal mass, seeds, stricture, and bacterial, parasitic, or viral infections. The present study was designed to evaluate whether allergic reaction is indeed an undefined leading factor for luminal obstruction.

MATERIAL AND METHODS

Mix inhalant and food prick tests were performed in 111 patients who underwent appendectomy for acute appendicitis and in 100 control patients. The material of appendectomy was examined, acute appendicitis was verified and graded according to the severity of inflammation and eosinophilic infiltration rate in the wall of appendix by a pathologist. Demographic data were recorded, and peripheral eosinophil count was also performed.

RESULTS

Mix prick test of 33 patients (29.7%) and food prick test of 14 patients (12.6%) were positive in study group when compared with 7 patients (7%) and 1 patient (1%) in control group (p < 0.001). A total of 38 patients (34.2%) in the study group were reactive with mix or food prick test when compared with 8 patients (8%) in control group. There was no significant difference between eosinophilic infiltration rate, peripheral eosinophil count, severity of inflammation, and Alvarado score of mix prick test positive and negative patients in study group.

CONCLUSION

Atopy incidence in patients with acute appendicitis was significantly higher when compared with control group. However, eosinophilic infiltration rate, inflammation grade, and peripheral eosinophil count were not able to explain the relationship between the two conditions. Atopy is a risk factor for acute appendicitis.

Verrucous carcinoma (Buschke–Lowenstein) arising in a sacrococcygeal pilonidal sinus tract: report of a case

PURPOSE

Pilonidal sinus disease is usually located in the sacrococcygeal region. Verrucous carcinoma (Buschke-Lowenstein) is a rare variant of squamous cell carcinoma with distinct clinical and histopathologic features, with a favorable prognosis. Malignant degeneration is an infrequent complication, which is associated with a high recurrence rate and poor prognosis.

MATERIALS AND METHODS

A case report is presented.

RESULTS

We report a 48-year-old man with a 10-year history of recurrent pilonidal sinus disease presented with a sacrococcygeal verrucous carcinoma arising in the pilonidal sinus tract and associated with good prognosis. After operation, a 5-year disease-free follow-up was observed.

CONCLUSION

Careful inspection of the pilonidal area in all chronic and long-standing inflammatory processes is important and should be evaluated for malignant transformation.

Efficacy of wound infiltration with lornoxicam for postoperative analgesia following thyroidectomy: a prospective, randomized, double-blind study

BACKGROUND/AIM

Postoperative pain control constitutes a major problem and studies have focused on reducing opioid requirements using regional techniques. We aimed to investigate the efficacy of wound infiltration with lornoxicam on postoperative pain control following thyroidectomy.

MATERIALS AND METHODS

In this prospective, randomized-controlled study, 80 patients scheduled for thyroidectomy were randomly assigned to 2 groups. After the thyroidectomy was performed, patients in group I underwent wound infiltration with 4 mg of lornoxicam and patients in group II received the same amount of saline. Rescue analgesia was provided with additional doses oflornoxicam delivered by an on-demand patient-controlled analgesia device. Total analgesic consumption during the postoperative 24 h, and pain intensities assessed using a visual analog scale score at 0, 2, 4, 8, 12 and 24 h postoperatively were recorded.

RESULTS

Pain scores during the postoperative 24 h were slightly lower in group I than in group II, but the difference was not significant (P > 0.05). The mean analgesic consumption was 8.87 ± 1.87 mg and 10.33 ± 1.25 mg in groups I and II, respectively (P > 0.05).

CONCLUSION

Wound infiltration with lornoxicam neither improved postoperative pain control nor decreased total analgesic consumption.

Comparison of five different popular scoring systems to predict nonsentinel lymph node status in patients with metastatic sentinel lymph nodes: a tertiary care center experience

Sentinel lymph node biopsy (SLNB) is the current standard of care for breast cancers with no clinically palpable axillary lymph nodes. Almost 50 % of sentinel lymph node positive patients have negative non-sentinel nodes and undergo non-therapeutic axillary dissection. Five different scoring systems, reported in the literature, were compared for their predictive ability of non-SLN involvement in patients with SLN positive breast cancer. 242 patients who underwent breast surgery and SLNB were included in the study. Of these, 70 who were confirmed to have SLN metastasis and received complementary ALND and constituted the final study population. The nomograms (MSKCC, M.D. Anderson Cancer Center, Tenon model, Stanford and Turkish) were statistically compared for their prediction of non-SLN metastasis (95 % confidence interval). We have determined only two clinicopathologic (multifocality and size of the primary tumor) situations which have a statistically significant association between SLN metastasis with using a multivariate logistic regression analysis. Multifocality (P = 0.001) and size of the primary tumor (P = 0.001) were associated with a higher probability of-SLN metastasis. No predictive model was constructed that showed good area under the curve (AUC) discrimination in the validation series. Currently published predictive models lack accuracy when applied to a different population. Multi-institutional heterogenic population studies are important to determine the exact combination of scoring systems and/or nomograms.

Abscess formation as a complication of a ruptured urachal cyst

The urachus is a midline tubular structure that extends upward from the dome of the bladder toward the umbilicus. This tubular structure normally involutes before birth, remaining as a fibrous band with no known function. Persistence of all or any portion of the fetal urachus results in several anomalies, the most common of which is the urachal cyst (Yu JS, Kim KW, Lee HJ, Lee YJ, Yoon CS, Kim MJ, Radiographics, 21:451-4611, 2001; Ohgaki M, Higuchi A, Chou H, Takashina K, Kawakami S, Fujita Y, Hagiwara A, Yamagishi H, Surg Today, 33:75-77, 2003). Although most urachal cysts are asymptomatic, there are a few reports about intraperitoneal rupture of infected urachal cysts, all of which caused peritonitis and sepsis (Ohgaki M, Higuchi A, Chou H, Takashina K, Kawakami S, Fujita Y, Hagiwara A, Yamagishi H, Surg Today, 33:75-77, 2003; Kojima Y, Miyake O, Taniwaki H, Morimoto A, Takahashi S, Fujiwara I, Int J Urol, 10:174-176, 2003; Agatstein EH, Stabile BE, Arch Surg, 119:1269-1273, 1984). We report the imaging and operative findings of a patient, presented with a urachal abscess after a spontaneously ruptured urachal cyst.

The value of combined elevation of D-dimer and neopterin as a predictive parameter for early stage acute mesenteric ischemia: An experimental study

Background The diagnosis of acute mesenteric ischemia is variable. Early diagnosis is important for reducing the mortality and morbidity rates. Aim This experimental study aims to investigate the diagnostic utility of D-dimer and neopterin as a marker for the early stage of acute mesenteric ischemia caused by occlusion of superior mesenteric artery. Methods The levels of D-dimer and neopterin were measured using an animal acute mesenteric ischemia model in 21 male rabbits. Superior mesenteric artery occlusion (Group 1, n = 14) and control (Group 2, n = 7) groups were identified. Blood samples at different times are collected from each rabbits. Blood samples from superior mesenteric artery occlusion group were taken 30 min after anesthesia but before laparotomy, 1, 2, and 3 h after superior mesenteric artery ligation. Blood samples from control group were taken 1 h before, 1 and 3 h after anesthesia and laparotomy. The D-dimer and neopterin levels of each blood sample were measured. Results The probability of acute mesenteric ischemia was found to be 36 times higher when the D-dimer level was over 0.125 ng/L, whereas the probability was 19.2 times higher when the neopterin level was over 1.25 nmol/L. Conclusions In this experimental study, the combined elevation of two significant markers, D-dimer and neopterin, may be helpful for the early diagnosis of acute mesenteric ischemia.

The Effects of Total Colectomy on Bacterial Translocation in a Model of Acute Pancreatitis

Prevention of secondary infection is currently the main goal of treatment for acute necrotizing pancreatitis. Colon was considered as the main origin of secondary infection. Our aim was to investigate whether prophylactic total colectomy would reduce the rate of bacterial translocation and infection of pancreatic necrosis. Forty-two Sprague-Dawley rats were used. Pancreatitis was created by ductal infusion of sodium taurocholate. Rats were divided into four groups: group-1, laparotomy + pancreatic ductal infusion of saline; group-2, laparotomy + pancreatic ductal infusion of sodium taurocholate; group-3, total colectomy + pancreatic ductal infusion of saline; and group-4, total colectomy + pancreatic ductal infusion of sodium taurocholate. Forty-eight hours later, tissue and blood samples were collected for microbiological and histopathological analysis. Total colectomy caused small bowel bacterial overgrowth with gram-negative and gram-positive microorganisms. Bacterial count of gram-negative rods in the small intestine and pancreatic tissue in rats with colectomy and acute pancreatitis were significantly higher than in rats with acute pancreatitis only (group-2 versus group-4; small bowel, p = <0.001; pancreas, p = 0.002). Significant correlation was found between proximal small bowel bacterial overgrowth and pancreatic infection (r = 0,836, p = 0.001). In acute pancreatitis, prophylactic total colectomy (which can mimic colonic cleansing and reduction of colonic flora) induces small bowel bacterial overgrowth, which is associated with increased bacterial translocation to the pancreas.

Chyle Fistula after Neck Dissection for an Unusual Breast Cancer Recurrence

BACKGROUND: Chyle fistula is one of the rare complications of neck dissections. Even though no consented algorithm for the management of this entity has been established yet, conservative treatment options including somatostatin analogues have been suggested as an adequate modality for low output fistulas. CASE REPORT: Here we present a patient with a right-sided neck fistula which was resistant to conventional treatment, and was finally treated by surgery. The neck dissection was performed for a malignant right neck mass that was accepted as the lymph node metastasis of formerly treated papillary thyroid carcinoma. The pathology of the specimen revealed a contralateral neck metastasis of previously treated breast carcinoma. CONCLUSION: We assume that consecutive surgeries on axillary and neck lymph pathways resulted in such a complicated and exceptional case.

Diagnostic efficacy of serum procalcitonin, IL-6, IL-2, and D-dimer levels in an experimental acute appendicitis model

BACKGROUND/AIMS

Acute appendicitis is the most frequent cause of acute abdomen emergency surgery. It continues to be a problem today due to delayed diagnosis and its high perforation rate. For this reason, diagnostic tests continue to be developed. In this experimental study, the diagnostic significance of blood procalcitonin (PCT), interleukin (IL)-6, IL-2, and D-dimer levels in an acute appendicitis model in rabbits was investigated.

MATERIALS AND METHODS

A total of five groups were included: control group, sham group, and three different acute appendicitis groups. In the appendicitis groups, the appendix was ligated by laparotomy, and the blood PCT, IL-6, IL-2, and D-dimer levels were measured at 12 (group 3), 24 (group 4), and 48 h (group 5). Then, an appendectomy was performed.

RESULTS

In the present study, PCT and IL-6 levels increased in parallel with the inflammation of the appendix in all groups and were found to be statistically significant. IL-2 and D-dimer values were higher in the groups diagnosed with appendicitis but were not statistically significant.

CONCLUSION

In our experimental study, PCT and IL-6 levels were determined to be important in the early diagnosis of acute appendicitis, especially IL-6, and that these two parameters are more important markers than IL-2 and D-dimer.

Effects of prevention of oxidative and nitro-oxidative stress on experimental rat colon anastomosis using acetylcysteine, Ebselen and 1400w

Oxygen radicals and radicals derived from nitrogen metabolism are important in wound and anostomotic healing. In particular, nitrous oxide, originating from induced nitrous oxide synthetase, retards the wound healing process by producing peroxynitride. Therefore induced nitric oxide synthase (INOS) inhibitors and peroxynitride cleansing agents seem helpful in promoting healing. The purpose of this study was to investigate the effects of N-acetylcysteine (antioxidant), ebselen (peroxynitride cleansing agent) and 1400w (INOS inhibitor) on experimental colonic anastomotic wound healing.

MATERIAL AND METHODS

45 randomized Sprague-Dawley rats received colonic anastomosis, and all animals were treated for four days with drugs specific for each group except for the sham and control groups. All rats were given a relaparatomy on the fifth day of the study and evaluated for study parameters indicating anastomotic healing, burst pressure, tissue malondialdehit (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPx) and hydroxyproline (OH-proline).

RESULTS

when compared to the control group, increased (p < 0.01) burst pressure, OH-proline and decreased MDA, and SOD levels were noted in the 1400w group. Furthermore, the GPx levels were higher (p < 0.05) in rats given NAC therapy.

CONCLUSIONS

the positive results of selective INOS inhibition using 1400w in this study confirm the adverse effects of the INOS enzyme on anastomotic wound healing. Therefore, we have concluded that 1400w may be helpful in promoting anastomotic healing.