Different surgical techniques in management of high fistula in Ano

The major objectives in the management of fistulae are to drain sepsis, to define and eradicate the fistulous tract, and to preserve sphincter integrity and function. For these reasons many surgical techniques are described in medical literature, but their outcomes with respect to recurrence and incontinence rates are still under debate. This study was conducted on 75 patients with high anal fistulae who were admitted to Sohag University Hospital in the period from October 2003 to July 2005.All patients were subjected to the following preoperative evaluation including: full history taking, anorectal examination and preoperative special investigations as fistulogram to all patients, magnetic resonance imaging [MRI] in recurrent cases and preoperative biopsy whenever indicated. Patients were divided into 3 equal groups; each group included 25 patients and treated randomly by certain surgical modality as follows: group A treated by cutting seton, group B treated by core fistulectomy and advancement flap and group C treated by autologous fibrin glue injection after curettage of the fistulous tract and drainage of the external opening. Comparative Evaluation of postoperative outcome was performed as regards recurrence, incontinence and other complications. The mean age was 37.45 years [range from 10-74 years]. There were 65 males [86.67%] and 10 females [13.33%]. Purulent discharge was the most common symptom [69%]. Analysis of the history of our series showed that 23 patients [30.7%] were previously operated upon for anal fistula. Intra-operative assessment of the fistulous tract was accurate in detection of type of fistula in 72 patients [96%], site of internal opening in 71 [94%] and detection of side tracts in 69 [92%]. Our patients were categorized into: high transsphincteric fistulae in 58 [77.3%], supra-sphincteric fistulae in 7 [9.3%], extra-sphincteric fistulae in 2 [2.7%] and high transsphincteric fistula with horse shoe extension in 8 [10.7%]. Our results recorded that; all patients in group [B] and group [C] were satisfied with the degree of continence, while in group [A], 3 patients had minor disturbances of continence. As regards the recurrence rate, the least recurrence was recorded in group B [8%] in comparison with group A and C [16% and 24% respectively, P value < 0.02]. Surgical procedures in treatment of high perianal fistulae such as seton placement, core fistulectomy with advancement flap and injection of fibrin glue, are different in characters and results. The most successful one is the advancement flap technique, but it is difficult and has prolonged postoperative hospital stay. Fibrin glue injection has the highest rate of recurrence but it is easy, least painful and not associated with division of the sphincter muscles. Seton technique carries the highest risk of incontinence rate, and the most painful one, but its results in curing fistulae are considered to be reasonable

Evaluation of different surgical techniques in treatment of cystic hydatid disease of the liver

Several techniques have been described in liver hydatid disease surgery, with most well known conventional and radical procedures. Both are under debate, is evaluation of the results of different surgical procedures for treatment of hydatid cysts of the liver. Between January 1999 and January 2005, 16 patients with cystic hydatid disease of the liver were managed in Sohag University Hospital, South Valley University. Diagnosis was made by both serological tests and imaging studies. Operative procedures included the conventional partial cystectomy with either omentoplaty or tube drainage in 9 cases, partial cystectomy with modified captionage in 4 and radical procedures in 3. Complications were classified as minor or major according to their need of extrahospital stay. Mean follow up was 20.6 months. The mean are was 42 years [range 11-69 years] with female to male ratio [1.7:1]. Seventy five percent [75%] of cases were located in rural areas. Abdominal pain was the most predominant symptoms being present in 50% of patients [P = 0.02]. Right upper quadrant and epigastric tenderness were the remarkable physical finding in 62.5% [P = 0.003]. Concomitant disease was present in 43.75% of patients, with obesity as dominant factor [31.7%]. Diagnostic sensitivity of ultrasonography and computed tomography were 93.7% and 83.3% respectively. Postoperative complication rate was significantly better in patients with partial cystectomy with modified capitonage, than the other techniques [25% versus 58.3% respectively, P < 0.05. The overall mortality rate was 6.2 [1/16]. Five patients [31.7%] had remained elevation of the total levels of serum IgG. Of those, 2 [121.5%] patients sowed radiologically confirmed recurrence. Partial cystectomy with modified capitonage in obliteration of the cyst cavity is easy to perform, quick and safe procedure with satisfactory results provided that the hydatid cyst is in favorable anatomical location. The conventional procedures are associated significantly with an increased treatment failure with respect to the complication and recurrence rate. Radical procedures are effective in complete eradication of the disease but has significantly higher rate of complications. Serological tests, using EISA is considered in both follow-up of patients and preoperative diagnosis of equivocal cases

Recurrent pleomorphic adenomas of the parotid glands: approaches, hazards and treatment outcomes

Nerve preserving surgery is widely recommended for recurrent parotid pleomorphic adenoma though the risk of further relapse may be high. Adjuvant radiotherapy may improve control but its exact role requires clarification. Is evaluation of different therapeutic modalities for treatment of recurrent pleomorphic adenoma. A series of 17 patients with first recurrences treated between 1996 and 2003 in Sohag University Hospital, South Valley University, are reviewed. The diagnosis was made by clinical examination aided by ultrasonography. Treatment modality was either surgery alone [SG; n=9] or surgery with radiotherapy [SG + RT; n=8]. Surgical strategies included extra-capsular excision, superficial conservative parotidectomy and total conservative parotidectomy. Results were determined with respect to facial nerve function and tumour control. The incidence of permanent facial nerve injury was 17.6% [3/17]. There was no cases of malignant degeneration. The rate of second recurrence was 23.5% [4/17] with median follow up of 41.1 [range 6-72] months. Among the surgical categories, no procedure was superior to another [P > 0.05]. Multinodular recurrences treated by surgery alone were at particular high risk of second relapse, but tumour control was significantly improved with adjuvant radiotherapy [SG versus SG + RT; 66.6% versus 20% respectively; P = 0.008]. In contrast, no statistically significant difference was demonstrated between surgery alone and surgery plus radiotherapy in the uninodular recurrences [SG versus SG + RT; 16.6% versus zero% respectively; P = 0.1]. December 2003. For the purpose of this study, patients were excluded if they had undergone multiple operations prior to referral or they were referred immediately following primary surgery [categorized as residual]. In an attempt to define patients at high risk of recurrence, our study also compared the demographic data of those patients with the data of another 23 patients having had primary pleomorphic adenomas admitted and treated at the same period. Detailed of previous treatment were available in eleven out of the seventeen patients. Local excision or enucleation was reported in 8 [72.7%] cases, while 2 [18.1%] patients developed recurrence after superficial parotidectomy. One [9%] patient had been treated by local excision and radiotherapy prior to referral. The median time from initial surgery to first recurrence was 12.3 months [range 6 to 32 months]. The diagnosis of recurrent pleomorphic adenoma was made by clinical examination and imaging studies. Ultrasonography was performed in all cases with first recurrence. The main indications for computed tomography [CT] scan and magnetic resonance imaging [MRI] were assessment of the extent of large sized and deep lobe tumours. The distinction between uninodular [solitary] and multiple recurrences was obtained at the time of surgery. Histopathological examination of the all postoperative specimens was performed to confirm the diagnosis and exclude malignant changes

Diverticular disease; is it an underestimated problem in our locality?

Background: Colonic diverticular disease is common in Western countries. It is often asymptomatic; only 10-26% of patients will progress to diverticulitis with symptoms ranging from minor complaints to life threatening sequelae

Objectives: To recognize the pattern of presentation, diagnosis, treatment and. outcome of diverticular disease in our community

Methods: From January 1996 to June 2004, 19 patients with diverticular disease were retrospectively studied

Results: Twelve patients were males and 7 females. Mean age was 5912.9 [range 47.5-71] years. Fifteen patients [90%] presented with left lower quadrant pain, bleeding per rectum in 5 patients [26.3%], tender left lower quadrant mass in 3 patients [15.8%] and acute abdomen in 3 patients [15.8%]. Diagnosis was done using ultrasonography, colonoscopy enema and CT. Conservative treatment was successful in 12 patients [63.2%]. Seven patients [36.8%] required surgery Hartmann’s procedure was done in 5 patients [71.4%], and one-stage colonic resection was done in 2 patients [28.6%]Postoperative complications were encountered in 2 patients [28.6%]. No reported mortality

Conclusion: Diverticular disease is not uncommon in our locality, and requires high index of suspicion and multidisciplinary approach for proper diagnosis and management. The majority of cases are treated conservatively but surgery remains safe in some patients. Resection and primary anastomosis has an acceptable morbidity and mortality. For high-risk patientsr Hartmann's procedure remains a gold standard