Single-dose metronidazole versus 5-day multi-drug antibiotic regimen in excision of pilonidal sinuses with primary closure: a prospective randomised controlled double-blinded study

BACKGROUND AND AIMS: This pilot study examines whether single-dose intravenous metronidazole preoperatively is at least as effective as a broad-spectrum multi-drug regimen in preventing infection-related wound complications following excision of pilonidal sinuses with primary closure. PATIENTS AND METHODS: A double-blinded study with 50 patients randomised to receiving either a single drug (intravenous metronidazole 500 mg) prophylaxis preoperatively or multi-drug cover (intravenous cefuroxime 1.5 g and metronidazole 0.5 g preoperatively, and oral co-amoxiclav 375 mg 8-hourly postoperatively). They will be reviewed 1, 2 and 4 weeks postoperatively. The wound will be graded as: I, healthy; II, redness and swelling of edges; III, abscess related to a suture; IV, spreading wound infection; V, wound breakdown. Other factors considered are the distance from the lowest wound margin to the anal verge, and previous pilonidal sinus surgery. RESULTS: Results awaited. CONCLUSION: Single-dose metronidazole seems an appropriate and low-cost antibiotic to consider for prophylaxis in pilonidal sinus surgery. This study will form the base for a trial to be conducted in larger numbers as a randomised controlled trial in order to have statistical power.     

Selective treatment of rectal cancer with single-stage coloanal or ultralow colorectal anastomosis does not adversely affect morbidity and mortality

Background and aims The surgical treatment of low rectal cancer commonly includes low pelvic anastomoses with coloanal or ultralow colorectal anastomoses. Anastomotic leak rates in low pelvic anastomoses range from 4 to 26%. Many surgeons opt to routinely create a diverting ostomy to reduce the extent of morbidity should an anastomotic leak occur. The intent of our study was to determine if our policy of selected diversion is safe. Materials and methods A retrospective chart review of 66 rectal cancer patients who underwent proctectomy and low pelvic anastomoses—less than 6 cm from anal verge, with or without a diverting ostomy—was undertaken. Temporary diverting stomas were utilized at the discretion of the attending surgeon primarily based on subjective criteria. The main outcome was postoperative complications. Results/findings Forty-nine patients (78% preoperatively irradiated) were treated with a one-stage operation, whereas 17 (53% preoperatively irradiated) underwent reconstruction with proximal diversion. The mean anastomotic height for patients with a single stage procedure was 3.8 cm above the anal verge versus 2.6 for patients with a two-stage procedure (p = 0.076). Complication rates were lower in patients who did not undergo diversion (29% vs 47%, p = 16). With regard to anastomotic-associated complications for single stage versus two stage, complication rates were 8% versus 18%, respectively (p = 0.27). Interpretation/conclusion Low pelvic anastomoses in rectal cancer patients can be safely performed as a single-stage procedure, reserving the use of diversion for select cases.     

The use of unilateral gluteus maximus muscle for the management of fecal incontinence following anorectal surgery

A dynamic unilateral gluteoplasty sutured as a U-shaped sling around the anal canal was carried out in 9 patients with fecal incontinence, including 8 males and one female ranging in age from 6 to 46 years (mean, 13.9 years). All had previous anorectal surgery: in four cases a Swenson's operation for congenital megacolon, in 2 cases a pull-through procedure for high anorectal anomalies, in 2 cases for a failed sphincteric repair, and in one case to correct rectal prolapse. Morbidity was limited to minor wound infection and postoperative dermatitis (4 cases). Seven patients achieved an improvement in their continence score. Overall continence score was 5–6 (mean, 4.0; SD = 1.4) preoperatively and 2–6 (mean, 4.0; SD = 1.4) postoperatively, a difference which was statistically significant (p = 0.006). Maximum resting pressure and maximum squeeze pressure were improved. None of the patients could retain 200 ml saline in their rectum preoperatively, while 6 patients could do so postoperatively. Rectoanal inhibitory reflex was positive in 2 patients preoperatively and in 6 postoperatively. In conclusion, unilateral dynamic gluteoplasty is an effective option for improving continence with no mortality and minimal morbidity in patients who previously had anorectal surgery, reserving the other gluteus muscle for use in a second attempt if first operation fails. Received: 22 September 1999 / Accepted in revised form: 10 October 1999     

Short-term results of Karydakis flap for pilonidal sinus disease

Background Because of the higher quality of life that the Karydakis flap provides compared to excision-only treatment, it became a recommended closure technique for pilonidal sinus disease. This study aimed to evaluate whether Karydakis flap technique can be performed in potentially infected tissue if the surrounding cellulitis allows wound closure. Methods 188 patients with pilonidal sinus who underwent excision only (n=91, 48%) or the Karydakis-flap technique (n=97, 52%) were evaluated. The results were reviewed according to the degree of wound contamination, and the effects of closure technique were studied in terms of early wound complications and the duration of hospital stay. Results In the excision-only group, one patient developed a hematoma (1%) and one patient had cellulitis of the surrounding tissue (1%), which resulted in a 2% complication rate this group. In the Karydakis flap group, wound abscesses were observed in 12 patients (12%). Additionally, four patients (4%) had hematomas, two patients had seromas (2%) and three had other complications. For the Karydakis group, the overall complication rate was 21%, significantly higher than that for the excision-only group (p<0.01). In the Karydakis group, no association was found between complications and the degree of contamination (p=0.36). Conclusions These data provide evidence that the Karydakis flap technique might be performed even in potentially infected tissue. Although a considerable number of wound-related complications was observed in the Karydakis flap group, the majority of patients had primary healing. Thus, from our viewpoint, the Karydakis flap seems to be a potential alternative to simple excision in infected pilonidal sinus disease.     

Surgical Treatment of the Pilonidal Disease: Primary Closure or Flap Reconstruction After Excision

Purpose  Controversy still exists regarding the best surgical technique for the treatment of pilonidal disease in terms of minimizing disease recurrence and patient discomfort. The present study analyzes the results of excision with primary closure and excision with flap reconstruction in the surgical treatment of sacrococcygeal pilonidal disease. Methods  From January 2003 to January 2006, 60 consecutive patients with primary pilonidal sinus disease received surgical treatment in the form of either excision and primary closure (group I, n = 20 patients) or excision and flap reconstruction (group II, n = 40 patients; modified Limberg flap n = 20, classic Limberg flap n = 10 and adipo-fasciocutaneous flap n = 10). Times for complete healing and return to work were recorded. To evaluate patient comfort, all patients were asked to complete a questionnaire including visual analog scale, time to sitting on toilet without pain, and time to walking without pain 3 months after surgery. Results  Mean follow-up was 21 months. A significant difference was observed between the two groups in terms of length of hospital stay (P < 0.003), time to complete healing (P < 0.001), time off work (P < 0.001), wound infection (P < 0.01), recurrence rates (P < 0.01), times to sitting on toilet without pain (P < 0.002), and walking without pain (P < 0.001). The mean (standard deviation) postoperative visual analog scale scores were 6.1 (1.2) in the primary closure group vs. 7.4 (1.3) in the flaps groups (P < 0.001). In the modified Limberg flap, no wound infection, wound breakdown, or recurrence of the disease occurred. Conclusions  Flap reconstructions were superior to primary closure after excision of pilonidal sinus and that modified Limberg flap was superior with regard to wound infection and recurrence.     

The role of obesity on the recurrence of pilonidal sinus disease in patients, who were treated by excision and Limberg flap transposition

Recurrence of pilonidal sinus disease after surgical intervention is not a very rare problem although sophisticated reconstruction procedures have been developed. Recurrence is thought to be related to the anatomical status of the patients, i.e., depth of the intergluteal groove. Obese patients have deeper intergluteal grooves. The aim of this study was to use body mass index (BMI) as an objective indicator of obesity to determine whether there is a relationship between BMI and recurrence of pilonidal sinus disease. BMI was calculated preoperatively in 114 patients with pilonidal sinus disease who were treated by excision and Limberg flap transposition between 1996–1999 in general surgery departments of two university hospital clinics. Fifteen patients were referred to our clinics after surgical intervention carried out at other institutions. Their average BMI was calculated by using their hospital records. The mean follow-up period was 24 months (range 10–36). Six of the 114 patients (5%) had recurrence. The mean BMI of patients with and without recurrence was 29.35 and 27.415, respectively (P<0.05). The mean BMI of 15 patients referred to us because of recurrent disease was 29.41; however, that of patients with primary pilonidal sinus disease was 27.212 (P<0.05). Their BMI before their first operation was 29.30. This was also significantly higher than patients with primary disease (P<0.05). We conclude that obese patients with high BMI have a higher risk of recurrence of pilonidal sinus disease after surgical intervention. Accepted: 1 February 2000     

Short-Term and Long-Term Outcomes of the Cleft Lift Procedure in the Management of Nonacute Pilonidal Disorders

Purpose  We report the results of the cleft lift procedure in the management of nonacute pilonidal sinus disorders. Methods  Seventy consecutive patients who underwent a cleft lift for nonacute pilonidal sinus were evaluated prospectively. Responses to a postal questionnaire were analyzed for long-term outcome. Results  All patients who fulfilled the criteria for day-case were operated on as such. Sixty-six patients achieved complete wound healing within six weeks. Delayed wound healing occurred in three patients and nonhealing occurred in one. Fourteen patients had one or more complications: wound breakdown, superficial (n = 7) and deep (n = 1); wound infection (n = 5); wound seroma (n = 4); and early recurrence (n = 1). The median time off work and to return to normal activities was two and four weeks, respectively (range, 0.5–12). Forty-seven patients completed the questionnaire at a median follow-up of 24 months: five patients reported minimal tenderness in the sacral region; none reported recurrence of pilonidal symptoms; and all were satisfied. Conclusions  The cleft lift procedure is easy to perform as a day-case procedure. It is associated with high rates of primary healing, durable low recurrence rates, and early functional recovery. This technique may be the procedure of choice in the surgical management of nonacute pilonidal disorders. Presented in part at the meeting of the Association of Coloproctolgy of Great Britain and Ireland, Glasgow, United Kingdom, July 2 to 5, 2007.     

Comparison of Outcomes in Z-Plasty and Delayed Healing by Secondary Intention of the Wound After Excision of the Sacral Pilonidal Sinus: Results of a Randomized, Clinical Trial

Purpose Pilonidal sinus is a common disease, mostly among young males. Although the conventional surgery, secondary repair of the wound after wide excision with or without curettage, is not technically difficult, it takes a long time, weeks or months, for a wound to heal. In this study, we compared outcomes and complications of Z-plasty repair with outcomes and complications of delayed healing by secondary intention (conventional surgery). Methods In a randomized, clinical trial, we recruited 72 patients in each arm. All of the patients were operated on by a general surgeon and were followed up for variable periods. Patients in the Z-plasty arm were followed for a mean period of 22.01 months. Patients conventional surgery arm were followed for a mean period of 22.23 months. The main studied outcomes were healing of the wound and disease recurrence during the follow-up period. The main complications that were taken into account were bleeding, hematoma, infection, and recurrence. Results The two arms were comparable in the age and gender distributions, duration of disease, and history of any types of operations. The duration of hospitalization after the operation was shorter in the conventional surgery group (1.76±0.75 days vs. 2.86±0.73 days, P<0.001). However, wounds healed much faster in the Z-plasty group (15.4 vs. 41 days, P<0.001). Moreover, it took longer for patients in the conventional surgery group to return to normal activity (17.5 vs. 11.9 days, P<0.001). There was no difference in postoperative complications regarding bleeding, hematoma, infection, or recurrence during the follow-up period in two arms. Conclusions Healing was considerably faster in patients who were treated with Z-plasty technique of wound closure. This procedure can be used as a desirable treatment for pilonidal sinus, which is a noncomplex method without increased rate of complications. Nonetheless, it might slightly increase the duration of hospitalization. Reprints are not available.     

Using negative pressure wound therapy following surgery for complex pilonidal disease: a case series

Complex pilonidal disease, an uncommon manifestation of an anorectal condition, is characterized by chronic or recurrent abscesses with extensive, branching sinus tracts. Definitive treatment requires wide excision of all involved tissue followed by secondary intention healing or reconstructive surgery. All treatment options have unique advantages and disadvantages. Following recent reports that negative pressure wound therapy after surgery for complex pilonidal disease may be a useful alternative to moist saline dressing treatments, five patients (three men and two women, median age 21 years [range: 16 to 63 years]) with complex pilonidal disease (symptom duration range 6 months to 30 years) were treated on an outpatient basis. Following wide excision under general anesthesia, a portable negative pressure wound therapy device was applied. Mean wound defect size after excision was 11 cm x 4 cm x 5 cm, or 205 cm(3) (range 90 cm(3) to 410 cm(3)). Negative pressure wound therapy was used for an average of 6 weeks (range 4 to 9 weeks) and mean time to complete epithelialization was 12 weeks (range 9 to 22 weeks), including use of moist saline dressings post negative pressure wound therapy. Treatment was discontinued in one patient due to skin irritation. No other complications were observed. Long-term follow-up is required to assess the risk of recurrent pilonidal disease or wound failure following negative pressure wound therapy. Additional studies of negative pressure wound therapy in the management of pilonidal disease are warranted.     

Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus

Background and aims The best surgical technique for treating pilonidal sinus disease is controversial. The aim of this study is to compare the modified lay-open technique with primary closure following excision with respect to operating time, healing time, time before return to work, morbidity rate, and recurrence rate.Patients and methods After a pre-study power analysis, 142 patients with chronic sacrococcygeal pilonidal sinus were prospectively and randomly allocated, either to the modified lay-open group (Group A, n=73) or the primary closure group (Group B, n=69). In the former, incision, curettage, partial lateral wall excision, and marsupialization were performed. Single doses of cefazoline (1 g) and metronidazole (500 mg) were given intravenously 15 min before surgery to all patients.Results There were no differences with respect to gender, age, body mass index, and mean operating time between the groups. In Group A, healing failure and early bridging occurred in one patient each. In Group B, wound infection occurred in four patients, wound breakdown in three, one healing failure and hematoma in one patient each. Morbidity and recurrence rates were significantly lower in Group A (2.7 vs. 13%, P=0.028 and 1.4 vs. 17.4%, P<0.001 respectively). The median time before return to work in Group A was significantly shorter than in Group B (3 [range 2–8] vs. 21 [range 14–63] days, P<0.001). The median healing time in Group A was significantly longer than in Group B (7 [range 3–16] weeks vs. 2 [range 2–9] weeks; P<0.001).Conclusion The results of the present study suggest that modified lay-open is superior to excision with primary closure for the surgical treatment of chronic sacrococcygeal pilonidal sinus with regard to morbidity and recurrence rates, and time before return to work, although healing time is longer.     

Timeline of Recurrence After Primary and Secondary Pilonidal Sinus Surgery

Purpose This study was designed to evaluate the timeline of recurrence of pilonidal sinus disease after primary vs. multiple surgery. Data of medical military service in Germany were reviewed. Methods Telephone interview of 205 patients after pilonidal sinus disease surgery after median interval of 14.8 (standard deviation ±3.9) years was conducted. A total of 345 patient charts with pilonidal sinus disease recurrence and fully documented previous surgery history were analyzed. Results Pilonidal sinus disease recurred in 41 of 205 patients (20 percent; actuarial survival 22 percent) after first surgery. Median recurrence-free-interval was 1.8 (range, 0.1–16.5) years. Twenty-nine of 41 of all recurrences (71 percent) were observed within four years after primary surgery. Fifteen of 50 patients (30 percent) treated by primary closure had recurrent disease after a median recurrence-free interval of 2.7 (range, 0.2–13.5) years compared with 24 of 144 patients (17 percent), who experienced recurrence after rhomboid excision and open wound treatment after a median of 1.8 (range 0.1–16.5) years (P = 0.081, long-rank-test). Analysis of 345 recurrent disease charts revealed that recurrence time decreased for multiple recurrences compared with first recurrence (R1 vs. R2: P = 0.07; R2 vs. R3: P = 0.03, Mann-Whitney U test). Conclusions Long-term recurrence rate was 22 percent and thus higher than previously reported. This may be attributed to the long follow-up interval. Recurrences up to 20 years after surgery were seen. Our data provide evidence that follow-up after first to the third pilonidal sinus surgery should complete or exceed five years, because the majority of recurrences occur during this postoperative interval. Nevertheless, even a five-year follow-up will still miss 25 percent of recurrences. Reprints are not available.     

Day-Case Karydakis Flap for Pilonidal Sinus

Purpose The Karydakis flap for pilonidal sinus is associated with primary wound healing and infrequent recurrence. Previous studies had reported in-patient protocols. This cohort study was designed to assess the feasibility, safety, and practicalities of day-case Karydakis flap surgery. Factors relating to wound healing also were explored. Methods Consecutive patients undergoing day-case Karydakis flap surgery, by one consultant surgeon, for pilonidal sinus were studied prospectively. Patients were assessed at weekly intervals after surgery until healing was complete. Wound healing time was compared with 1) patients’ gender, age, body mass index, deprivation index, occupation and smoking status, 2) pilonidal diseases’ dimensions and proximity to anus, 3) wounds’ dimensions and proximity to anus, and 4) drain volume. Results Day-case Karydakis flap surgery was feasible, safe, and effective. None of the 51 patients in the study required readmission to hospital, sepsis drainage, or surgery for recurrent sinus. Median wound healing time was three weeks. Smokers healed quicker than nonsmokers. No other factors were identified that were associated with delayed healing. Normal activity was resumed within one month of surgery in 95 percent of patients. Conclusions The Karydakis flap can offer the advantage of day-case surgery for pilonidal sinus patients in addition to primary wound healing and low sinus recurrence rates. Presented at The Association of Coloproctology of Great Britain and Ireland, Glasgow, United Kingdom, July 2 to 5, 2007.     

The artificial bowel sphincter for faecal incontinence: a single centre study

Background and aims Faecal incontinence (FI) is a socially devastating problem. The treatment algorithm depends on the aetiology of the problem. Large anal sphincter defects can be treated by sphincter replacement procedures: the dynamic graciloplasty and the artificial bowel sphincter (ABS). Materials and methods Patients were included between 1997 and 2006. A full preoperative workup was mandatory for all patients. During the follow-up, the Williams incontinence score was used to classify the symptoms, and anal manometry was performed. Results Thirty-four patients (25 women) were included, of which, 33 patients received an ABS. The mean follow-up was 17.4 (0.8–106.3) months. The Williams score improved significantly after placement of the ABS (p < 0.0001). The postoperative anal resting pressure with an empty cuff was not altered (p = 0.89). The postoperative ABS pressure was significantly higher then the baseline squeeze pressure (p = 0.003). Seven patients had an infection necessitating explantation. One patient was successfully reimplanted. Conclusion The artificial bowel sphincter is an effective treatment for FI in patients with a large anal sphincter defect. Infectious complications are the largest threat necessitating explantation of the device.     

Laparoscopic abdominoperineal resection revisited: are there any health–related benefits? A comparative study

Background Laparoscopic colectomy is associated with less overall morbidity and improved survival for patients with colonic cancers. There are unfortunately limited clinical reports on laparoscopic abdominoperineal resection. We therefore designed this study to compare laparoscopic abdominoperineal resection with conventional open surgery, with emphasis on health–related issues from the patients’ perspective in order to justify its role in the management of low rectal or anal canal tumours. Methods We carried out a non–randomized, prospective comparative study on a cohort of patients who underwent either laparoscopic or open abdominoperineal resection between March 1994 and December 2003. Patient demographics, tumour characteristics, operative morbidity and mortality, as well as overall survival were considered. The standard endpoints of last follow–up date and deaths were used. Data was analyzed according to intention–to–treat principle. Results A total of 102 patients were recruited: 31 patients underwent conventional open abdominoperineal resection (OAPR) and 71 patients were treated laparoscopically. Patient demographics, median follow–up period, as well as tumour characteristics were similar between groups. The median operating time was similar among groups (145 min in laparoscopic group vs. 156 min in open group; p=0.62). Patients in the laparoscopic group had significantly less blood loss (p=0.01) and fewer requirements for blood transfusion (p=0.01). Despite similar overall morbidity, the laparoscopic group had a reduced incidence of abdominal wound infections (p=0.01) and chest infections (p=0.01). Overall survival was significantly better in the laparoscopic group (p=0.01). Conclusions Laparoscopic abdominoperineal resection confers definite health–related benefits the over open approach in terms of reduced septic complications and fewer requirements for blood transfusion. It should be considered the procedure of choice for patients with low rectal or anal canal tumour in whom sphincter excision proved inevitable.     

Evaluation of Healing and Complications After Lateral Internal Sphincterotomy for Chronic Anal Fissure: Marginal Suture of Incision vs. Open Left Incision: Prospective, Randomized, Controlled Study

Purpose Internal sphincterotomy remains the standard for treatment of anal fissure, but it is associated with risks of infection, bleeding, and incontinence. Recent studies have suggested that the complications after lateral internal sphincterotomy are related to surgical technique. This study was designed to assess the incidence of early and late complications after lateral internal sphincterotomy with marginal sutured incision. Fissure healing, pain, and complications were compared in patients undergoing a procedure involving three interrupted marginal sutures after open lateral internal sphincterotomy procedure. Methods Ninety patients of chronic anal fissure were randomly assigned to two groups. Both groups received open lateral internal sphincterotomy via standardized method. The incisions of the patients in Group 1 (n = 45) were sutured marginally with three interrupted sutures using 2-0 chromic catgut, whereas the incisions of the patients in Group 2 (n = 45) were left open. The patients were assessed at 12 weeks postoperatively by an independent observer. Results The fissure-healing rate was not significantly different in both groups (95 and 93.1 percent, respectively). The pain score was slightly higher in Group 2, and it was statistically significant. Four cases of bleeding and two abscesses were observed in Group 2. These complications were not observed in Group 1. One case of incontinence was observed at the beginning in Group 1 and four in Group 2, but the incontinence was transient in both cases. Conclusions Marginal sutures of incision after lateral internal sphincterotomy may be beneficial to reduce complications related to early wound healing.     

A minimally invasive approach to pilonidal disease with endoscopic pilonidal sinus treatment (EPSiT): a single-center case series with long-term results

Background

Minimally invasive techniques for treating pilonidal disease are safe and effective alternatives to conventional surgery, with improved recovery time, cosmetic results, and pain control. The aim of this study was to evaluate the 5-year surgical outcomes of a single-center case series treated with endoscopic pilonidal sinus treatment (EPSiT).

Methods

We conducted a retrospective single-center analysis of all patients treated with EPSiT, by a single surgical team, from March 2015 to December 2019, for primary or recurrent pilonidal disease. The primary outcomes were recurrence, persistence and treatment failure. The secondary outcomes were postoperative pain, painkiller use, time off work, satisfaction, complications, wound healing time, time to persistence or recurrence.

Results

Forty-two patients underwent 46 EPSiT procedures [34 males, 8 females, median age 25 (IQR 13.75) years] for primary (47.8%) or recurrent pilonidal disease (52.2%). All patients completed the follow-up [median 62 (IQR 43) months]. The single procedure healing rate was 76.1%. The healing rate for the first procedures plus the second EPSiT procedure (performed in 4 cases) was 83.3%. Among the 46 EPSiT procedures, we recorded six cases of persistence (13.0%) and five cases of recurrence (10.9%) The median operative time was 32.5 (IQR 18.75) minutes, the median pain score (visual analog scale) in week 1 was 2 (IQR 2), and the median time off work was 4 (IQR 2) days. Four patients (8.7%) experienced complications: serosanguineous (n?=?2) or seropurulent discharge (n?=?2). The satisfaction rate was 95.7%.

Conclusions

In our experience, EPSiT is safe, well accepted. and associated with a low level of postoperative pain, short hospitalization, short time off work, as well as optimal cosmetic results. Its failure rate is similar to that of excisional surgery.

     

Time and rate of sinus formation in pilonidal sinus disease

Background and aims To elicit mechanisms and timing of sinus development, the role of age at onset of symptoms, symptomatic disease duration, and consecutive number of sinuses were investigated. Materials and methods Analysis of 1,962 medical records of patients admitted for primary surgical pilonidal sinus treatment. Results Sinus number ranged from 1 to 16 (median 2), with chronic pilonidal disease showing more sinuses than acute disease (mean 2.6 vs 2.1 sinuses; p < 0.0001; Kolmogorov–Smirnov). Disease duration in chronic pilonidal disease was not linked to sinus formation (p = 0.98; Spearman). In acute pilonidal disease, duration was linked to the development of six sinuses per 1,000 symptomatic disease years (p = 0.0001; Spearman). A larger sinus number correlated with earlier onset of symptoms (p = 0.009; Spearman). Conclusion Long-standing chronic disease does not produce sinus per se. As sinus does not substantially arise during the course of symptomatic disease, there must be a time before the start of symptomatic disease when the sinus originates. These findings suggest that sinus can only be acquired up to a certain age, even if occupational exposure continues.     

Effect of oral diazepam on anal continence after low anterior resection: a preliminary study

The aim of the present study was to investigate the effect of oral diazepam on anal incontinence after low anterior resection for rectal cancer. Five patients with persistent incontinence after low anterior resection for rectal cancer (median level of anastomosis was 4.0 cm from the anal verge) were treated with oral diazepam (2 mg/day) 9–90 months after surgery. Grade and frequency of anal incontinence, the need for a protective pad and changes of lifestyle were recorded to the Cleveland Clinic's continence grading scale; anorectal manometry was performed before and after 3 months of treatment. All patients improved on treatment although occasional minor soiling persisted in two patients. Continence score improved from 14 (median, range 9–16) to 0 (range 0–12) after taking diazepam. Improvement occurred within a week after administration of diazepam. Although the patients improved symptomatically, anorectal manometry failed to demonstrate any significant changes. In conclusion, oral administration of diazepam may be worthwhile in the attempt to improve anal continence after low anterior resection. Received: 20 September 2001 / Accepted in revised form: 6 December 2001     

Are postoperative drains necessary with the limberg flap for treatment of pilonidal sinus?

PURPOSE: Different methods for managing pilonidal sinus have been described in the literature. Our purpose was to evaluate the influence of postoperative drainage in Limberg flaps. METHODS: Forty patients with pilonidal sinus undergoing radical excision and reconstruction with Limberg flap between 1994 and 1996 were evaluated prospectively. After patients were assigned randomly to the two groups, the effects of drains were studied statistically in terms of wound complications, hospital stay, and recurrence rate. RESULTS: Except for two minor transient wound dehiscences, in all cases primary healing was achieved. Early wound complication rate was 7.5 percent and recurrence rate was 2.5 percent for both groups. There was no significant difference between the groups in early wound complications (P>0.05). The length of hospital stay was significantly longer in the drainage group (P<0.001). CONCLUSION: We conclude that Limberg flaps with no drains in place will result in shorter hospital stays without deleteriously affecting the surgical results of wide excision and primary closure with well-vascularized tissue.     

Lower Recurrence Rate for Limberg <Emphasis Type="Italic">vs</Emphasis>. V-Y Flap for Pilonidal Sinus

Purpose Pilonidal sinus is a disease that does not have a standardized surgical treatment method. This study was designed to compare the outcomes of Limberg fasciocutaneous transposition and V-Y fasciocutaneous advancement flaps in the treatment of patients with pilonidal sinus. Methods A total of 111 patients (98 males; 88.3 percent; mean age, 27.1 years) who received reconstruction after pilonidal sinus excision in our clinics with Limberg flap (Group 1, n = 66, 59.5 percent) or V-Y flaps (Group 2, n = 45, 40.5 percent) between 1997 and 2004 were investigated retrospectively. Results No significant difference was detected between Groups 1 and 2 in terms of gender, history of infection or abscess, mean duration of operation, requirement for analgesics, wound-related complications, such as necrosis, seroma, and infection, and average time off work. Mean follow-up periods were 45.4 vs. 48.8 months in Group 1 and Group 2, respectively (P = 0.337). On the other hand, rate of recurrence was significantly lower in Group 1 (n = 1, 1.5 percent) compared with Group 2 (n = 5, 11.1 percent; P = 0.039). Conclusions We conclude that, if the defect is to be reconstructed with a flap in pilonidal sinus cases, reconstruction with Limberg flap should be preferred over reconstruction with V-Y flap because of its lower rate of recurrence.