Evaluation of the mesh-bridged posterior partial fundoplication-a new technique in treatment of gastroesophageal reflux disease

Disruption of the wrap and slipping are the most frequent causes of deficient reflux control after anti-reflux surgery. Isolauri et al. [1997], after an experimental study, suggested that if scarring could be induced between the fundal wrap and the esophagus, it could probably help to prevent slippage and disruption of the fundoplication wrap. This study was randomly conducted in the Gastrointestinal Surgery Unit, General Surgery Department, Tanta University Hospital on 60 patients suffering from GERD during the period from May 2003 to June 2005. They were randomly classified into two groups; group I comprised 30 patients for whom posterior partial fundoplication [modified Toupet technique] was performed and group II comprised 30 patients for whom mesh-bridged posterior partial fundoplication was performed. At 24 months postoperatively, 4 out of the 30 patients belonged to group I developed recurrence of GERD while none of the 30 patients belonging to group II developed recurrence. The difference in the recurrence rate between the two groups was found to be statistically significant. [P<0.0412]. The mesh-bridged posterior partial fundoplication proved to be effective in achieving the advantages and avoiding the disadvantages of both total and partial fundoplication in short term and mid-term follow-up; good reflux control and low incidence of mechanical complications. Moreover, did not significantly prolong the operation time and did not add to the patients' morbidity

rhomboid flap for recurrent pilonidal disease

Pilonidal sinus is a common chronic disease of the sacrococcygeal region. The treatment varies according to the clinical presentation of the disease. Although many surgical methods have been suggested, an ideal method is still lacking because of high recurrence rates. Recurrent disease causes significant morbidity particularly with time off work. The aim of this work is to assess the rhomboid flap's role in promoting primary healing in recurrent pilonidal disease and to evaluate the morbidity and recurrence. This prospective study included 40 patients [32 males and 8 females] who were treated with the use of a rhomboid flap closure for recurrent sacrococcygeal pilonidal sinus at Tanta University Hospital from Januray 2000 to October 2006. The follow-up period ranged from 06 months to 07 years. There were 32 males and 8 females with a median age of 18 years [range 16-38 years]. The mean hospital stay was 06 days [range, 05-11 days]. Two patients had to be hospitalized for two weeks due to superficial wound infection that recovered with injectable antibiotics. The mean time to return to work after discharge from the hospital was 15 days [range, 12-26 days]. Post-operative morbidity involved superficial wound infection in 4 patients [10%]. There were four recurrences [10%]. Six patients [15%] had numbness over the flap and four patients [10%] were not pleased with cosmetic appearance of the scars. The results favor rhomboid flap closure in the treatment of recurrent sacrococcygeal pilonidal sinus, especially with multiple recurrences and in patients with extensive involvement. Lower recurrence rates, shorter hospital stay, and time off work may outweigh the disadvantages related to unfavorable cosmetic appearance

Prophylactic prosthetic reinforcement of midline abdominal incisions in high-risk patients

The incisional hernia is one of the major elements of morbidity after abdominal surgery. In the best centers the incidence of post-operative hernia has been at least 10 percent as shown by long follow up. The risk of developing an incisional hernia can be increased due to patients related factors as age, obesity, D.M, cirrhosis, cough, constipation, smoking, glucocorticoid therapy, multiparity, malignancy and previous abdominal operations. It was soon recognized that vertical midline incisions were the most common site of postoperative incisional herniation because of this awareness, more consideration was given to choice of incisions wound closure, and wound healing to protect against incisional hernia. The aim of this work is to reduce the incidence of incisional hernia in high-risk patients after midline abdominal incision by prophylactic prosthetic reinforcement. From October 2002 to September 2003, forty [40] high-risk patients liable to develop postoperative incisional hernia underwent elective abdominal operations through midline incisions were operated upon at Gastroenterology and laparoscopic Unit, Surgery Department, Tanta University Hospital .They were randomly divided into two groups; Group A: Patients for whom the midline abdominal incisions were closed by conventional method and reinforced by subfascial polypropylene mesh, [20 patients]. Group B: Patients for whom the midline abdominal incisions were closed by conventional method only [20 patients].with follow up period up to 3.5 years. This study included 40 patients [18 males and 22 females] divided into two groups [A, B] with most patients around age of 50-60 years [12 patients, 5 in group A and 7 in group B]. In this study, twenty-three patients [57.5%] were presented with more than one risk factor [9 in group A and 14 in group B]. Types of midline abdominal incisions done in this study, upper midline incisions in 19 patients [11 in group A and 8 in group B], extended upper midline in incisions 4 patients [6 in group A and 8 in group B], lower midline incisions in 7 patients.[3 in group A and 4 in group B] Early local postoperative complications, subcutaneous seroma in 7 patients [2 in group A and 4 in group B], surgical site infection. [1 in group A and 2 in group B], partial wound disruption. [4 in group A and 3 in group B] and complete wound disruption. [Complete burst] in only one patients in group B. Late postoperative complications chronic wound pain. Three patients [15%] in group A, ascites three patients in [group A] and one in [group B] all were cirrhotic patients, developed moderate postoperative ascites. None of [group A] patients developed postoperative incisional hernia during follow up, while three patients 15% in [group B] developed postoperative incisional hernia. Prophylactic subfascial non-absorbable mesh reinforcement of midline closure in high-risk patients can be used safely and effectively to provide an extrinsic strength of the wound without relying much on the defective development of its own intrinsic strength and to prevent subsequent incisional hernia. The final statement should await the outcomes of the long term follow up of the studied cases