Cleft closure for the treatment of pilonidal sinus disease.

AIM: Treatments for pilonidal sinus disease are numerous and prone to failure. In complex disease, the morbidity is high. In contrast with complex operations, the cleft closure procedure can be done simply and successfully with better cosmetic results. We present the results of a single-centre experience of this procedure. METHOD: One hundred and fifty patients had the operation; most were treated as a day case and many were operated under local anaesthetic. RESULTS: Primary healing occurred in 83 (60%) of 139 patients. Recurrences requiring surgery have been seen in 5.3%. The long-term cosmetic appearance has been noted to approach normality. CONCLUSION: Cleft closure is a simple and highly effective operation to treat recurrent or extensive pilonidal sinus disease.

Restorative proctocolectomy in UK servicemen.

OBJECTIVE: To investigate the outcome of restorative proctocolectomy (RPC) in UK Servicemen and to determine the compatibility of this procedure with Service life. PATIENTS: All Servicemen undergoing restorative proctocolectomy for ulcerative colitis (UC) or familial adenomatous polyposis (FAP) up to December 31st 2000 were identified from Service records. Patients were reviewed by direct or telephone interview. Pouch function, military duties, medical category or reasons for discharge from the Service were recorded. RESULTS: Fifteen Servicemen (6 Royal Navy, 6 Army, 3 RAF), mean age 30 years, underwent RPC for UC (14) or FAP (1) with a median follow-up of 74 months. Eight remain in their Service, five of whom carry out full duties and three restricted duties. Of the seven who have left the Services only one was medically unfit to continue due to poor pouch function whilst six left voluntarily to pursue active civilian careers. Fourteen patients have acceptable pouch function; one pouch has been excised for intractable pouchitis. CONCLUSIONS: Restorative proctocolectomy is compatible with Service life and most individuals are capable of fulfilling active unrestricted military duties.

Bascom's operation in the day-surgical management of symptomatic pilonidal sinus.

BACKGROUND: Many treatments for symptomatic pilonidal sinus disease have been described. Ambulatory treatment with minimal morbidity and a rapid return to normal activity is desirable. Bascom's operation fulfils these requirements. This paper describes the operative technique and results of treatment. METHODS: Some 218 patients of mean age 27 years were treated as day cases. The mean duration of symptoms was 2.4 years. Sixty-eight per cent of patients had complex disease with more than two midline pits and/or a lateral discharging sinus. One hundred and eighty-three patients (84 per cent) were operated on under local anaesthesia. RESULTS: Ninety-five per cent of patients have been followed up for a mean of 12.1 (range 1-60) months. All except one midline wound healed. Lateral wounds healed after a mean of 4.0 (range 1-15) weeks. Postoperative complications were few, including bleeding in 4 per cent and abscess formation treated by reopening the lateral incision in 6 per cent. Twenty-one patients (10 per cent) have had recurrence and have needed reoperation. CONCLUSION: Bascom's operation is simple and results in considerable financial savings with minimal social disruption and an early return to work. Recurrent disease is no more frequent than after other treatments.

Primary blast injury: pathophysiology and implications for treatment. Part III: Injury to the central nervous system and the limbs.

There are some structures in which changes consistent with primary blast may be found despite secondary and tertiary blast being the most frequent sources of injury. The Central Nervous System for example, especially the brain, is well protected yet there are historical and experimental accounts of damage which cannot be attributed to secondary or tertiary blast or even air embolism resulting from pulmonary disruption. Similarly, analysis and experimental simulation of specific skeletal injuries has shown that primary blast alone can fracture bones and that it is likely to be responsible for limb avulsions in victims exposed to stress waves of sufficiently high intensity.

The pathophysiology of primary blast injury and its implications for treatment. Part II: The auditory structures and abdomen.

The authors have previously considered the mechanisms by which primary blast injury affects the respiratory and cardiovascular systems and what deductions may be made about management of the resulting injuries. This article considers the somatic effects of primary blast on abdominal and auditory structures. These injuries are usually of less immediate concern but require accurate management in order to avoid late mortality and morbidity and to return the casualty to full function. Recognition of likely injury patterns is vital to the instigation of correct management. The tympanic membrane, for instance, is easily damaged by blast and such an injury may be complicated by ossicular disruption, perilymph fistula or forceful distribution of squamous epithelium around air filled spaces with potential to form cholesteatoma. Abdominal organs can be severely disrupted by primary blast. The treatment of such injuries is not dissimilar to that of any other cause of abdominal trauma. The most challenging aspect is the identification of intestinal intramural haemorrhage and discrimination between those lesions destined for perforation or for spontaneous recovery. In this article the range and mechanism of injury are described for each system, drawing on experience from other modes of injury closely related to blast, followed by suggestions for their management established from literature reviews and experimental work undertaken by the authors during periods of full time research.

Anovestibular fistula to Bartholin's gland.

BACKGROUND: Acquired fistulation from the anal canal to Bartholin's gland has not been reported before. This fistula has been identified in 11 women treated between 1991 and 1995. METHODS: All discharge diagnoses during this period were searched. The clinical records of patients managed for this diagnosis were reviewed. RESULTS: Eleven women aged 24-49 years were identified. Seven of 11 fistulas arose in association with inflammatory bowel disease (five Crohn's disease, two ulcerative colitis). Patients typically presented with the vulval passage of flatus and faeces or acute sepsis of Bartholin's gland. Time to diagnosis of the fistula ranged from 1 to 15 (median 8) months after the onset of symptoms. Anatomically, all fistulas were high trans-sphincteric or suprasphincteric. All eight fistulas for which repair was attempted (five in the presence of inflammatory bowel disease) remain healed at short-term follow-up. Proctocolectomy was undertaken in two patients with severe Crohn's colitis. CONCLUSION: Ano-Bartholin's fistulas, although rare in general surgical practice, present with troublesome symptoms and may be repaired successfully. Gynaecologists and surgeons should be aware of this clinical entity to avoid unnecessary delays in treatment.

The pathophysiology of primary blast injury and its implications for treatment. Part I: The thorax.

There is insufficient evidence to support a definitive approach to the clinical management of primary pulmonary blast injury. Post-blast cardiovascular and pulmonary changes are reviewed in this paper in order to highlight important aspects in the immediate management of the blast injured casualty. Blast profiles and theoretical mechanisms of injury vary widely but all result in mechanical disruption and cause similar pathological, physiological and biochemical responses. Some patients may present acutely, while others appear unharmed and develop respiratory failure 12-24 hours later. Treatment outcome may depend on the judicious use of resuscitative fluids and respiratory support. The roles of supplementary oxygen and assisted ventilation remain controversial although administration of high inspired oxygen concentrations and respiratory support may be unavoidable. The advantage of pharmacological manipulation of reflex mechanisms is as yet unproven. Hyperbaric therapy may improve survival in pulmonary blast injury.

Risk of late perforation in intestinal contusions caused by explosive blast.

BACKGROUND: Despite the predominance of superficial injuries after explosive blast exposure, major morbidity or mortality among immediate survivors is caused by delayed perforation of intestinal mural contusions. Previous studies have suggested that small bowel and colonic contusions larger than 10 mm in diameter are at high risk. This experimental study aimed to identify contusions at high risk of late perforation. METHODS: Histological features of injury were classified in 188 blast-induced intestinal contusions in 16 anaesthetized Large White pigs. RESULTS: Some 16 per cent of small bowel and 12 per cent of colonic contusions were at high risk of late perforation. Small bowel contusions larger than 15 mm in diameter had a worse histological grading than those smaller than 15 mm (chi 2 = 0.09, 2 d.f., P = 0.01). Contusions that extended over more than half the bowel circumference (chi 2 = 14.79, 2 d.f., P = 0.0006) and those affecting the mesenteric border (chi 2 = 7.5, 2 d.f., P = 0.024) were more severe injuries. Colonic contusions larger than 20 mm in diameter had a worse histological grading than smaller ones (chi 2 = 14.95, 2 d.f., P = 0.0006). Confluent, rather than diffuse, colonic contusions were more severe injuries (chi 2 = 6.37, 2 d.f., P = 0.04). CONCLUSION: Once identified at laparotomy, the number of small bowel contusions requiring excision may be reduced from 86 to 60 per cent; similarly, excision of colonic contusions can be reduced from 73 to 27 per cent if small bowel contusions smaller than 15 mm in diameter and colonic contusions of less than 20 mm are managed conservatively.

Intestinal injury mechanisms after blunt abdominal impact.

Intestinal injury is frequent after non-penetrating abdominal trauma, particularly after modern, high-energy transfer impacts. Under these circumstances, delay in the diagnosis of perforation is a major contributor to morbidity and mortality. This study establishes patterns of intestinal injury after blunt trauma by non-penetrating projectiles and examines relationships between injury distribution and abdominal wall motion. Projectile impacts of variable momentum were produced in 31 anaesthetised pigs to cause abdominal wall motion of varying magnitude and velocity. No small bowel injury was observed at initial impact velocity of less than 40 m/s despite gross abdominal compression. At higher velocity, injury to the small bowel was frequent, irrespective of the degree of abdominal compression (P = 0.00044). Large bowel injury was observed at all impact velocities and at all degrees of abdominal compression. This study confirms the potential for intestinal injury in high velocity, low momentum impacts which do not greatly compress the abdominal cavity and demonstrates apparent differences in injury mechanisms for the small bowel and colon. Familiarity with injury mechanisms may reduce delays in the diagnosis of intestinal perforation in both military and civilian situations.

Family based colorectal cancer screening in a district hospital.

Colorectal cancer (CRC) screening using family history to define a group at increased risk is gaining support. Three hundred and ninety six subjects aged over 25 with at least one first degree affected relative have been screened using a single slide, immunological faecal occult blood test (FOBT), and family history data to select the highest risk group. Compliance was 64.9% but was significantly better if contact was made within one year of diagnosis of the index relative (75% v 62.1%, chi 2 = 5.7, p < 0.05). Twelve subjects (13.2%) of those who had a colonoscopy) bearing adenomas have been detected, three of which were at high risk of malignant transformation. No cancers have been diagnosed. Most subjects undergoing screening were less than 55 years of age (67.8%). These accounted for most colonoscopies (68.1%) but only one large adenoma was diagnosed in this group. The FOBT was particularly useful, enabling the detection of five large adenomas. Family based CRC screening is practical in a district hospital setting. Although labour intensive, it meets a population demand and can detect significant numbers of adenomas. Screening, even in those at moderately increased risk, could be focused on the older age groups, probably those aged over 40.

The influence of personal blast protection on the distribution and severity of primary blast gut injury.

Primary blast injuries have been recognized since World War I when the most significant reported injury was to the lung. The prevalence of injury to tissues containing air was underlined by the frequency of gut blast injury in underwater explosions mostly reported during World War II. Gut injury is the most likely cause of mortality after the more immediate effects of pulmonary primary blast injury. Effective protection has been achieved for lungs exposed to short duration external blast waves by the placement of stress wave decouplers on to the thoracoabdominal wall in a pig model, thus modifying the energy coupled into the body. A combination of two densities of glass-reinforced plastic plate and Plastazote foam (GRP/PZ) effectively eliminated pulmonary injury in 17 protected animals, compared with the production of severe blast lung in nine unprotected animals (p < 0.001). Partial pulmonary protection was achieved using a plasticized lead and plastazote foam decoupling combination (PbPVC/PZ) in a further group of 10 animals. Peak incident overpressures were not significantly different in any group. Small bowel contusions were highly significantly reduced in the GRP/PZ groups when compared with unprotected animals and with PbPVC protected animals (both p < 0.001); no significant reduction was observed in the summed colonic contusion size in any protected group. Intestinal perforations were also highly significantly reduced in both GRP/PZ groups (p < 0.001). Primary pulmonary blast injury and probably small bowel injury are caused by the propagation of coupled stress waves within the body. Elimination of these injuries implies prevention of stress wave propagation. Because colonic injury was not prevented by the same protection, a different mechanism for the injury is suggested: transmission and propagation of shear waves. These findings have important implications for blast protection and the clinical management of primary blast casualties.