Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus.

BACKGROUND: There are different open healing and primary closure approaches for chronic pilonidal sinus (CPD) that differ in principles and extension. AIMS: To compare the results of different closure surgical techniques, we performed a meta-analysis of randomized controlled trials (RCT) comparing: (1) open wide excision versus open limited excision (sinusectomy) or unroofing (sinotomy); (2) midline closure (conventional and tension-free) versus off-midline; (3) advancing versus rotation flaps; and (4) sinusectomy/sinotomy versus primary closure. METHODS: Data extraction and risk of bias assessment were conducted independently by the authors using the Cochrane Collaboration's tool. Data were pooled using fixed and random-effects models. Primary outcomes were rate of healing, recurrence, wound infection and dehiscence. Twenty-five trials (2,949 patients) were included. RESULTS: Four trials compared limited versus radical open healing. Although recurrence rate did not differ, all other outcomes favored the limited approach. Ten studies compared midline versus off-midline primary closure; wound infection and dehiscence were significantly higher after midline closure. Six RCT compared Karydakis/Bascom versus Limberg. No difference was found in recurrence or wound complications rate. Six RCT compared sinusectomy/sinotomy versus primary closure. Recurrence rate was significantly lower after sinusectomy/sinotomy; no significant differences were found in other outcomes. CONCLUSION: Our meta-analysis suggest that some of the questions of which is the best surgical technique for CPD have now been answered: open radical excision and primary midline closure should be abandoned. Sinusotomy/sinectomy or en bloc resection with off midline primary closure are the preferred approaches.

Intrapelvic placement of a breast implant to allow deferred ileoanal pouch anastomosis after emergency proctocolectomy.

Restoration of intestinal continuity at a second stage after emergency total proctocolectomy may be difficult or hazardous due to the pelvic cavity being closed off. We present a way of keeping the pelvic cavity open and accessible following total proctocolectomy by insertion of a breast implant that hinders fibrosis and prevents intestinal loops from occupying the space. A 275 ml silicone breast implant was placed in the pelvic cavity after total proctocolectomy and closure of the rectal stump. Three months after the initial surgery, the breast implant had kept the pelvic cavity open, facilitating identification of the rectal stump and creation of an ileoanal J-pouch at this second stage. The use of a breast implant to fill the pelvic cavity may facilitate restoration of intestinal continuity in second-stage surgery and thereby decrease the number of associated complications.

¿Se puede mejorar el postoperatorio de la hemorroidectomía? Estudio comparativo del dispositivo Ligasure® frente a la hemorroidectomía con diatermia / Can posthemorrhoidectomy pain be improved? Ligasure® vs diathermy hemorrhoidectomy

Introducción. La hemorroidectomía es una técnica de uso frecuente y con una importante morbilidad, fundamentalmente en forma de dolor postoperatorio.El presente trabajo tiene el objetivo de comparar, en términos de dolor postoperatorio, un nuevo tipo de hemorroidectomía mediante el empleo del sellador de vasos Ligasure®.Pacientes y métodos. Cincuenta pacientes consecutivos intervenidos de hemorroides grados II, III y IV fueron aleatorizados en 2 grupos: en 24 pacientes se realizó una hemorroidectomía abierta con Ligasure®y en 26, como grupo control, una hemorroidectomía con diatermia. Se valoró el dolor postoperatorio mediante escala analógica visual en el primer, tercer y séptimo días, en la tercera semana y en el tercer mes.Un investigador independiente realizó una encuesta de satisfacción al final del estudio.Resultados. Treinta y tres mujeres (66 por ciento) y 17 varones (34 por ciento) con una edad media de 54 años fueron intervenidos de hemorroides: 24 con el dispositivo Ligasure® y 26 con técnica de diatermia. La distribución por grados fue de 4 pacientes con grado II, 28 con grado III y 18 con grado IV. El número de paquetes intervenidos fue de un paquete en 2 pacientes, dos en 7 pacientes, tres en 39 y cuatro en 2. No se detectaron diferencias entre los grupos en relación con la edad (p = 0,724), el sexo (p = 0,556), el grado hemorroidal (p = 0,39), el número de paquetes (p = 0,25), el tiempo de intervención (p = 0,122), la escala analógica visual al primer, tercer y séptimo días postoperatorios (p = 0,850, 0,595 y 0,969, respectivamente), el tacto rectal a la tercera semana y el tercer mes (p = 0,931) así como el número y el tipo de complicaciones.Conclusiones. En nuestra experiencia, en términos de dolor postoperatorio, no hay diferencias entre la cirugía hemorroidal con diatermia y el empleo del Ligasure® (AU)

Hepatic resections with the Lin liver clamp.

Twenty-three hepatic resections were performed over a period of four years with the use of a Lin liver clamp and an operative mortality rate of 17.3%. Indications for liver resections were: five primary liver malignancies, four metastatic liver tumors and 14 benign liver diseases. All of the 14 patients with benign diseases survived the operation without developing late symptoms or complications. The survival rate of five patients with malign diseases ranged from three to 31 months. The technical details, advantages and precautions involved in the use of the Lin liver clamp are discussed. This approach improved the rate of operative mortality and facilitated partial lobectomy in cirrhotic livers, but the long-term results are dependent on the disease rather than the result of the operation.