Founrnier's gangrene: review of thirteen cases

Founrnier's gangrene is a synergistic necrotizing fascitis of the perineum and external genitalia. The process was belived to be idiopathic in initial descriptions. Thirteen patients were treated from Fournier's gangrene between 2000 and 2006 in the departments of surgery in El Helal and General Transport Organization hospitals. The common predisposing factors in all our cases were uncontrolled diabetes and sever anaemia. Escherichia coli and Sterptococcus aureus were identified most commonly in cultures of necrotic tissues. Our strategy in management of these cases was simultaneous control of the bad general condition of the patients with serial depridment of the necrotic tissues. Reconstructive operations to cover the raw areas were delayed till complete improvement of the medical status of the patients and till the affected areas were covered by healthy granulation tissues. There was no mortality among our cases

Magnetic resonance cholangio pancreatography in pancreaticobiliary surgical problems

Until recently, the non-invasive evaluation of patients suspected of having biliary tract lesions was limited to ultrasonognaphy [US] and computed tomography [CT], and inspite of their sensitivity in the detection of obstruction, we were in-need for direct cholangiography; especially endoscopic retrograde cholangiopancreatography [ERCP]; as standard of reference for visualizing the biliary tracts and pancreatic ducts for defining the cause and level of lesion. This study is constructed to evaluate Magnetic Resonance Cholangio-Pancreatography [MRCP] abilities in diagnosis of biliary tracts and pancreatic ducts lesions in comparison to the standard ERCP and surgery results. This study was held in MRJ Unit of Radiology Department, Tanta University; and Surgical Gastroenteniology Department of Al-Azhen University and Liven Research Center; during the period from January 2003 to June 2009. It included 37 patients; 29 [78.4%] male and 8 [21.6%] female; their age ranged from 23 to 78 years with median 48 +/- 3.1 years. U/S and MRCP examinations were performed for all patients in the study; while ERCP was done after two days in 32 patients. Surgery was done for 27 patients. MRCP was performed for all 37 patients in our study who were complaining of obstructive jaundice from different pathological causes with success nate [35 from 37] i.e. 94.6% ; ERCP was performed 48 hours after MRCP; in 32 patients only of our study cases; with success rate [29 from 32] i.e. 90.6% . Neoplastic cases were the majority in our study: Thirteen cases carcinoma of head of pancrease, five cases cholangiocarcinoma two cases of gall bladder adenocarcinoma and one case of ampullary carcinoma We have one case of ductal papjllomatosis, seven cases of common bile duct [CBD] stones; five of them secondary to gall bladder stones, the other two cases followed cholecystectomy; five cases of postoperative iatrogenic common hepatic duct [CHD] ligation; two of them after open surgery and three after laparoscopic cholecystectomy; and lastly we had three cases of post-traumatic bile duct injuries. MRCP is an accurate means of diagnostic imaging of the biliary and pancreatic ducts safely and non-invasively, however it lacks therapeutic potential of ERCP which must be tooled as a necessary intenventional procedure after MRCP despite its drawbacks and high cost-effectiveness

Primary pilonidal sinus repair: the outcome of 5 different techniques. can a modification be near ideal or provide a benefit?

Although various surgical treatment procedures for pilonidal sinus disease have been evaluated, no clear agreement has been reached as to which one is optimal for the lower incidence of wound infection, wound dehiscence and recurrence rate, almost certainly because there is none. This study was intended to investigate the outcome among five different selected primary closure techniques and to investigate the possibility of decreasing the operation costs by omitting the subcutaneous suture usage in some primary techniques. Prospective study considering morbidity and recurrence as the main outcome measures. This study included 94 patients: 84 male and 10 females with chronic pilonidal sinus disease who were operated on. All underwent excision and primary closure under spinal [64- 61 males, 3 females] or general anaesthesia [30 patients 23 males, 7 females] between May 2004 and February 2007. Patients were prescribed IV prophylactic antibiotic. 5 different techniques were done. They were simple closure technique in the midline, full-thickness z-plasty flap, semi-open, semi-closed closure techniques, musculofascial flap, and the modified musculofascial flap. Early wound complications with delayed wound healing had occurred in seven patients. Two patients had wound dehiscence [one due to haematoma in the modified group and the 2nd due to wound deep infection in the group of musculofascial flap]. A case of seroma occurred in the modified group. Four cases [4.25%] had minor wound breakdown due to superficial wound infections. They were one case in the simple closure method, one in the musculofascial flap, the third in the full thickness z-plasty and the fourth in the modified musculofascial flap procedure. Late postoperative complications: One patient suffered from late wound dehiscence in of the modified group due to infected haematoma. Two cases of recurrence had occurred. One of the superficial wound infections in the simple closure technique. The 2[nd] case was that of the deep wound infection in the musculofascial flap no recurrence has occurred in either the full-thickness z-plasty flap, the semi-open, semi-closed closure, or in the modified group.No significant difference in operation time, time of wound healing, time to return work, patient's or surgeon's satisfaction and cost effectiveness. Best treatment is still unclear. A perfect operation for pilonidal sinus disease should be simple with short hospital stay and low recurrence and complication rate associated with minimal pain, cost effective and have short off work time. Judging the results of the different procedures is difficult because there are no enough significant differences to prefer one to other procedures. Further investigations into the whole medical, financial and social aspects of these procedures for the treatment and management of pilonidal disease are still required

Recurrent varicose veins. Reflection of reflux pattern on the line of management

The aim of this study is to determine whether specific patterns of recurrent varicose veins are associated with the distribution of reflux sites detected clinically and proved by Doppler scanning; also to detect possible causes and evaluate different methods of management. Thirty nine patients with 64 affected limbs with recurrent varicose veins undergoing Doppler scanning and 3 methods of management [2 limbs for conservative therapy; 17 limbs for sclerotherapy; and 45 limbs for surgery]. The main outcome measures of this study is the type and time of previous surgery, sites and causes of reflux, type and sites of new interventions [conservative, sclerotherapy, and surgery], results-and complications. Recurrent varicose veins presented in both legs in 25 patients [64.1%], in left leg only in 9 patient [23.1%], and in right leg only in 5 patients. [12.8%]; ulceration was in 29 patients. [45.2%. Reflux was detected in 19 patients with residual problems in the groin of 28 / 64 affected limbs [43.8%]; 9 limbs [14.1%] with reflux came from epigastric and pudendal veins. Ulceration was associated with higher rates of deep reflux [45.2% versus 54.7% non-ulcerated limbs]. Groin re-dissection was done in 28 / 45 limbs [62.2%]; thigh communicators ligation in 1/64 limbs [2.2%]; and leg perforators sub-facial ligation in 16 / 64 limbs [35.6%]. Complications rate after surgery was encountered in 13 / 45 limbs [28.9%]. The saphenofemoral junction and long saphenous vein remains the key to varicose veins recurrence and Doppler scanning provides a valuable methodology not only to identify multiple sites of reflux hut also to evaluate the adequacy of previous surgery. Because of the efficacy of surgery in treating and preventing recurrence and ulceration, surgical procedures must be selected carefully and by appropriate expertise