Excision with or without primary closure for pilonidal sinus disease.

OBJECTIVE: To evaluate the outcome of excision with or without primary closure in the management of chronic pilonidal sinus (PNS) disease. METHODS: Between July 2002 and November 2006, a randomized trial was conducted in the Department of General Surgery, Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia. All the patients who presented with chronic natal cleft PNS disease were included in the study. They underwent either excision with midline closure (EMC group), or excision without closure (EWC group). Patients, who came with an acute pilonidal abscess (complicated) were excluded from the study. The principle outcome measures recorded were wound infection, healing time, time off work and the recurrence rate. RESULTS: A total of 380 patients of chronic PNS were divided into EMC group, (188 patients) and EWC group (192 patients). Majority of the patients were male in both the groups (93%). The hospital stay ranged from 2 to 5 days (mean = 3.6 +/- 1.4 days) for EMC group, while it was 3-5 days (mean = 4 +/- 1.1 days) for EWC group (p < 0.002). wound infection was 4.2% in EMC group, compared to 3.12% of EWC group (MS). The mean healing time and time off work in EMC group was significantly shorter than the patients in EWC group. Median follow up of EMC group was 36.3 months (range 10-52 months) while it was 35.2 months (range 13-51 months) for EWC group. Statistically there was no significant difference in the recurrence rate of both the groups (3.7% vs. 3%). CONCLUSIONS: Excision and primary closure is recommended, as a preferred procedure in the management of chronic PNS disease. It has the advantages of early wound healing, rapid return to work and comparable recurrence rate with excision and open wound.

Value of water-soluble contrast (meglumine amidotrizoate) in the diagnosis and management of small bowel obstruction.

INTRODUCTION: The object of the present study was to determine the effectiveness of a water-soluble contrast follow-through study for differentiating complete from incomplete small bowel obstruction (SBO) and for predicting the need for surgery. METHODS: This prospective study was conducted at Riyadh Medical Complex, Saudi Arabia and spanned 2 years. All adult patients admitted with SBO were included, except those with obstructed hernias, peritonitis, or postabdominal irradiation. The initial resuscitation meglumine amidotrizoate (Gastrografin) follow-though was performed and was considered positive for complete obstruction if the contrast failed to reach the colon as shown on the 24-hour film. Patients were operated on only if they developed signs of strangulation or failed to improve within 48 hours. RESULTS: Our study group consisted of 73 patients, 48 (65.7%) of whom were male. The mean age was 35.70+/-12.65 years. In 60 (82.2%) patients, contrast reached the ascending colon within 24 hours, giving a definitive diagnosis of incomplete obstruction; among these 60 cases, 49 (81.7%) resolved on conservative management. The other 13 (17.8%) patients were diagnosed as having a complete obstruction; 4 (30.8%) of them were treated conservatively, and 9 (69.2%) underwent surgery. Therefore the sensitivity, specificity, positive predictive value, and negative predictive value for meglumine amidotrizoate follow-through as an indicator for operative treatment of SBO were 45.0, 92.5, 81.7, and 69.2, respectively. The P value using Fisher's exact test was 0.0006. CONCLUSIONS: We can confidently diagnose complete and incomplete SBO and differentiate one from the other. This accurate diagnosis indicates a high chance of success with conservative management for incomplete obstruction but does not always correlate with the need for surgical intervention.

Wandering spleen.

Wandering spleen is a rare clinical entity, characterized by splenic hypermobility that results from elongation or maldevelopment of its suspensary ligaments. The wandering spleen is in constant danger of torsion and infarction. This condition poses a great diagnostic challenge due to lack of awareness and paucity of symptoms. Among adults, it usually occurs in females of childbearing age, the children below ten years of age are other sufferers. The clinical presentation may be acute or chronic; such as asymptomatic abdominal mass, an acute abdomen, or, most commonly, a mass associated with vague abdominal symptoms. Computed tomography and duplex ultrasonography are best diagnostic modalities. The traditional conservative approach carries high risk of infarction leading to splenectomy and postsplenectomy sepsis. Splenopexy is the treatment of choice for all noninfarcted wandering spleens. Splenectomy should only be performed when there is no evidence of splenic blood flow after detorsion of the spleen. The present study, reviews the presentation, course, diagnostic modalities and management options of wandering spleen.