Comparison of Curettage Plus Platelet-Rich Plasma Gel and Curettage Plus Phenol Application in Treatment of Pilonidal Sinus Disease: A Randomized Trial.

BACKGROUND: As a chronic condition, pilonidal disease affects a young population, and recovery after the surgical procedures performed to treat this condition require time off from work. Therefore, the search for an ideal treatment is still ongoing. OBJECTIVE: The aim of this study was to compare early and late results of 2 minimally invasive treatment options used to treat pilonidal disease. DESIGN: This study was designed as a parallel group randomized clinical trial. SETTINGS: This study took place at an outpatient clinic in Turkey. PATIENTS: Patients with pilonidal disease were evaluated for the study and were enrolled if they met the inclusion criteria and gave informed consent. INTERVENTIONS: Patients in the platelet-rich plasma group were treated using curettage + platelet-rich plasma gel. Patients in the phenol group were treated by using curettage + crystallized phenol. MAIN OUTCOME MEASURES: The primary study end point was the time to achieve healing; the secondary outcome was recurrence rate. RESULTS: In the platelet-rich plasma group, 96% of patients achieved healing after 1 application. In the phenol group, only 53% patients achieved healing after 1 application. The median healing time was shorter in the platelet-rich plasma group: 6 (4-14) vs 10 (5-42) days (p < 0.001). The mean difference in healing was 5.8 days (95% CI, 4.27-7.38). After a mean follow-up of 43.1 months, there was a 4% recurrence rate in the platelet-rich plasma group in comparison with a 12% recurrence rate in the phenol group (95% CI, 0.024-0.251). LIMITATIONS: Despite the randomized prospective nature of the study, neither the patients nor the investigators were blinded. CONCLUSIONS: The curettage + platelet-rich plasma method can be safely applied with an improved healing time, low recurrence rate, and minimal time off work. See Video Abstract at http://links.lww.com/DCR/B722.Clinical Trial Registration: NCT03070028. COMPARACIN DE CURETAJE MS GEL DE PLASMA RICO EN PLAQUETAS Y LA APLICACIN DE CURETAJE MS FENOL EN EL TRATAMIENTO DE LA ENFERMEDAD DEL SENO PILONIDAL ENSAYO ALEATORIZADO: ANTECEDENTES:Como condición crónica, la enfermedad pilonidal afecta a una población joven y los procedimientos quirúrgicos que se realizan para tratar esta condición requieren un tiempo de recuperación con baja laboral. Por lo tanto, la búsqueda del tratamiento ideal aún está en curso.OBJETIVO:El objetivo de este estudio es comparar los resultados tempranos y tardíos de dos opciones de tratamiento mínimamente invasivos utilizados para tratar la enfermedad pilonidal.DISEÑO:Este estudio está diseñado como un ensayo clínico aleatorizado de dos grupos paralelos.ENTORNO CLÍNICO:El estudio consta de dos grupos: curetaje + plasma rico en plaquetas y curetaje + fenol.PACIENTES:Los pacientes con enfermedad pilonidal fueron evaluados para el estudio y se inscribieron si cumplían con los criterios de inclusión y dieron su consentimiento informado.INTERVENCIONES:Los pacientes del grupo de plasma rico en plaquetas fueron tratados con curetaje + gel de plasma rico en plaquetas. En el grupo de fenol, los pacientes fueron tratados con curetaje + fenol cristalizado.PRINCIPALES MEDIDAS DE RESULTADO: El principal criterio de valoración del estudio fue el tiempo para lograr la curación; el resultado secundario fue la tasa de recurrencia.RESULTADOS:En el grupo de plasma rico en plaquetas, el 96% de los casos logró la curación después de una aplicación. En el grupo de fenol, solo el 53% de los casos lograron la curación después de una aplicación. La mediana del tiempo de curación fue más corta en el grupo de plasma rico en plaquetas; 6 (4-14) vs 10 (5-42) días (p < 0,001). La diferencia media en la curación fue de 5,8 días (IC del 95%: 4,27-7,38). Después de un seguimiento medio de 43,1 meses, hubo una tasa de recurrencia del 4% en el grupo de plasma rico en plaquetas en comparación con una tasa de recurrencia del 12% en el grupo de fenol (IC del 95%: 0.024-0.251).LIMITACIONES:A pesar de la naturaleza prospectiva aleatorizada del estudio, ni los pacientes ni los investigadores fueron cegados.CONCLUSIONES:El método de legrado + plasma rico en plaquetas se puede aplicar de forma segura con un mejor tiempo de curación, una tasa de recurrencia baja y un tiempo de baja laboral mínimo. Consulte Video Resumen en http://links.lww.com/DCR/B722 (Traducción-Dr. Yazmin Berrones-Medina).Este ensayo se registró para ensayos clínicos con ID: NCT03070028. El protocolo completo se puede encontrar en https://clinicaltrials.gov/ct2/show/NCT03070028.

Comparison of Raja Isteri Pengiran Anak Saleha Appendicitis and modified Alvarado scoring systems in the diagnosis of acute appendicitis.

BACKGROUND: The diagnosis of acute appendicitis (AA) is mainly dependent on clinical evaluation. There are several scoring systems developed for an accurate and early diagnosis of AA. Modified Alvarado score is one of the most common systems. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system was developed in 2010. The aim of this study is to evaluate and compare the accuracy of modified Alvarado and RIPASA scoring systems for the diagnosis of AA. METHODS: A total of 100 cases with the clinical diagnosis of AA were included in the study. All the cases were treated surgically. For all cases, modified Alvarado and RIPASA scores were calculated and recorded. According to the calculated cut-off values, sensitivity, specificity, negative and positive predictive values and total accuracy were calculated for each scoring systems. RESULTS: According to the receiver operating characteristic curve. the optimal score of modified Alvarado score for AA was found to be 5.5 with a sensitivity of 88% and specificity of 69%. According to the receiver operating characteristic curve, the optimal score of RIPASA score for AA was found to be 8.75 with a sensitivity of 94% and specificity of 88%. With the cut-off value of 8.75, total accuracy of RIPASA scoring was found to be 85.2%. Although there is no significant difference in negative appendicectomy rate, both sensitivity and the specificity of the RIPASA were found to be significantly higher than the modified Alvarado. CONCLUSION: According to the current study, RIPASA scoring system was found to be superior to modified Alvarado in the prediction of cases with AA.

Comparison of early and long term outcomes of open Lichtenstein repair and totally extraperitoneal herniorrhaphy for primary inguinal hernias

Background/aim: Inguinal hernia repair is one of the most common surgical procedures worldwide. There is still controversy over which method has the best postoperative results. The aim of this study was to compare early and late postoperative results of laparoscopic totally extraperitoneal herniorrhaphy (TEP) and open Lichtenstein herniorrhaphy (OLR). Materials and methods: The study was conducted in a randomized prospective manner and it was concluded with 302 patients (147 cases in TEP group and 155 cases in OLR group). All procedures were performed by two experienced surgeons in both open and laparoscopic inguinal hernia repair. Results: The groups were similar in terms of age, sex, and types of inguinal hernia according to Nyhuss classification. The mean operation time was shorter in TEP group with 49.2 ± 15.5 min vs 54.3 ± 14.6 min in OLR group (P = 0.004). The mean length of hospital stay was significantly shorter in TEP group (P = 0.001). The mean postoperative visual analogue scale score was significantly lower in TEP group. With a mean follow-up of 40.95 months, the recurrence rates were similar in both groups with a rate of 4.3%. In terms of chronic pain, TEP group has better results than OLR with 3.4% vs 25.2%, respectively (P = 0.001). Conclusion: In experienced hands, TEP procedure has better early and late postoperative results than OLR, whereas recurrence rates are similar.

Randomized prospective comparison of long-term results of onlay and sublay mesh repair techniques for incisional hernia.

OBJECTIVE: Incisional hernia is a significant problem after laparotomy, and there is still no consensus on an ideal treatment method. The aim of this study was to compare the results of onlay and sublay mesh repair techniques. MATERIAL AND METHODS: In this randomized prospective trial, 100 patients were divided into two groups: onlay and sublay groups. Recurrences were evaluated by performing a physical examination. RESULTS: The median follow-up was 37.1 (26.6 to 46.5) months. In the onlay group, the mean operation time was significantly shorter. However, in terms of postoperative pain and wound complications, the sublay group had significantly better results. The recurrence rates were found to be similar in both groups (6% in the onlay group and 2% in the sublay group). CONCLUSION: In the treatment of incisional hernia, sublay mesh repair is superior to onlay mesh repair in terms of postoperative pain and wound complications. Both techniques have similar recurrence rates.

The Role Safety Steps in Success and Complication Rate of Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for treatment of biliary disorders. There are several studies to increase the success rate and decrease the complication rate of ERCP. In this study we aimed to evaluate the affect of safety steps in success and complication rate of ERCP. MATERIALS AND METHODS: In this cohort study patients were evaluated under 2 groups divided as before the introduction of safety steps and after. Successful cannulation rate, difficult cannulations, and complications of the procedure were recorded. RESULT: Failed ampullary cannulation rates were 8.2% in group 1 and 4% in group 2. In terms of postprocedural complications; in group 2 complication rates significantly decreased from 10.7% to 4.3%. Moreover, post-ERCP pancreatitis rate decreased from 9.1% in group 1 to 4% in group 2. CONCLUSIONS: Introduction of safety steps, significantly increase the cannulation rate and decrease both overall complication rate and pancreatitis risk.

Parathyroidectomy Decreases Insulin Resistance Index in Patients with Primary Hyperparathyroidism.

Primary hyperparathyroidism (PHPT) has been considered a cause of insulin resistance (IR) and impaired glucose metabolism. However, there are conflicting results related with the recovery of insulin resistance in patients with PHPT following curative parathyroidectomy. Our aim is to evaluate the effects of curative parathyroidectomy on IR in patients with PHPT. This is a prospective interventional study. Twenty-one consecutive patients with symptomatic PHPT were included into the study. All patients underwent parathyroidectomy. Fasting serum glucose, calcium, phosphorous, parathormone, plasma insulin, and vitamin D levels were measured both at baseline and 2 months after parathyroidectomy. Insulin resistance was calculated by homeostasis of model assessment-insulin resistance (HOMA-IR). Two months after curative parathyroidectomy, serum levels of calcium (p = 0.001), PTH (p < 0.001), insulin (p = 0.003), and HOMA-IR (p = 0.003) decreased, while phosphorous levels increased (p = 0.001). During this period, no changes were observed at vitamin D and glucose levels. We concluded that curative parathyroidectomy decreases HOMA-IR index in patients with PHPT. Studies with larger population and longer follow-up period are required to confirm our results.

Role of Different Treatment Modalities in Cavity Volume during the Treatment of Cystic Ecchinococcosis.

OBJECTIVE: Surgery and percutaneous aspiration-injection-re-aspiration (PAIR) are widely accepted treatment modalities for hepatic hydatid cysts. Endoscopic retrograde cholangiopancreaticography (ERCP) acts as a minimally invasive rescue method for the biliary complications of both the hydatid cysts and treatment modalities. The aim of this study was to identify the role of different treatment modalities in the obliteration of hydatid cysts. METHODS: Patients treated for hydatid cysts between January 2009 and December 2013 were evaluated in the study. Data were collected from hospital records. All cyst cavities were evaluated by ultrasonography or computed tomography. RESULTS: Ninety-five (40.4%) males and 140 (59.5%) females were included in the study. Before the procedures, the mean cyst diameter was 89.7±33.5 mm. At follow-up, the mean cyst diameter decreased to 53.2±30.1 mm. In the ERCP group, the mean diameter of the residual hydatid cyst cavity was significantly lower than that of the other groups (p=0.003). CONCLUSION: ERCP provides faster cyst shrinkage and even disappearance of the residual cavity in 50% of cases. Moreover, in hydatid cysts with biliary communication, ERCP+ES can be safely used for primary treatment.

Effect of medical treatment on histological findings in rabbits with acute appendicitis.

BACKGROUND: Acute appendicitis (AA) is the most common reason for abdominal surgery in the world. The aim of this study was to evaluate the effect of medical treatment on histological findings in rabbits with AA. METHODS: Twenty-one male New Zealand rabbits were divided into 3 groups: appendix ligation and medical treatment, appendix ligation and no treatment, and control group, which underwent only laparotomy. RESULTS: In appendix ligation without treatment group, AA findings were much more severe. CONCLUSION: Medical treatment reduced inflammation of AA.

Randomized prospective comparison of midline and off-midline closure techniques in pilonidal sinus surgery.

BACKGROUND: Pilonidal sinus is a chronic inflammatory disorder of the intergluteal sulcus. The disorder often negatively affects patients' quality of life, and there are numerous possible methods of operative treatment for pilonidal sinus. The aim of our study was to compare the results of 3 different operative procedures (tension-free primary closure, Limberg flap, and Karydakis technique) used in the treatment of pilonidal disease. METHODS: The study was conducted via a prospective randomized design. The patients were randomized into 3 groups via a closed envelope method. Patients were included in the study after admission to our clinic with pilonidal sinus disease and operative treatment already were planned. The 2 main outcomes of the study were early complications from the methods used and later recurrences of the disease. RESULTS: A total of 150 patients were included in the study, and the groups were similar in terms of age, sex, and American Society of Anesthesiologists scores. The median follow-up time of the study was 24.2 months (range, 18.5-34.27) postsurgery. The recurrence rates were 6% for both the Limberg and Karydakis groups and 4% for the tension-free primary closure group. Therefore, there was no substantial difference in the recurrence rates. CONCLUSION: The search for an ideal treatment modality for pilonidal sinus disease is still ongoing. The main conclusion of our study is that a tension-free healing side is much more important than a midline suture line. Also, tension-free primary closure is as effective as a flap procedure, and it is also easier to perform.

Early hospital readmission after laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy (LC) now has become the golden standard in the treatment of symptomatic gallstone cholecystitis. AIM: This retrospective analysis was conducted to clarify the reasons of early return to the hospital after discharge following a procedure like LC that has been frequently performed in daily surgical practice. MATERIALS AND METHODS: This study covers 586 patients, who were called to follow-ups and thus evaluated, of 676 patients who had had LCs at Meram Medical School's General Surgery Clinic between January 2010 and May 2011. FINDINGS: The rate of representation to the hospital during the early phase following LC was found to be 2.4% in our study. It was observed that 71% of returning patients had presented to the hospital with complaints of abdominal pain. DISCUSSION: We believe that the rate of 2.4% early return to the hospital in our series is a bit high when all the complications are taken into consideration. This retrospective analysis, however, has shown that this rate can further be decreased by taking simple measures.

Is early detection of colon cancer possible with red blood cell distribution width?

BACKGROUND: Red cell distribution width (RDW) is one of the standard parameters with blood cell counts. Much previous research has indicated that it increases in cases of systemic inflammation or cardiametabolic incident. However, information on the relation of RDW with solid tumors causing systemic inflammation is limited. In the present research, we examined the relation of RDW with malignant and benign lesions of the colon. MATERIALS AND METHODS: 115 patients with colon polyps (group 1), and 30 with colon cancer (group 2) who were diagnosed histopathologically in our clinic between January 2010-January 2013 were scanned retrospectively. Patients with anemia, hematologic diseases and active inflammation were excluded. RDW, mean corpuscular volume (MCV), hemoglobin (Hgb) and platelet (Plt) measurements were recorded and their relations with the malignant and benign lesions of the colon were examined. RESULTS: Both groups were similar in age and gender distribution. RDW values of patients with colon cancer were significantly higher than the patients with colon polyp (p=0,01). No significant differences were detected between the two groups in terms of MCV and Plt values (p>0,05). CONCLUSIONS: RDW can be used as an early warning biomarker for solid colon tumors. Further prospective research is required on the relations of cheap and easily measured RDW parameters with colon malignancies.

Otilonium bromide as spasmolytic during endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used in both the diagnosis and the treatment of biliary and pancreatic disorders. The aim of this study is to evaluate the effects of OB usage during ERCP on duodenal motility, the tolerability of the procedure (by patients) and the difficulty of the procedure (by the endoscopist). METHOD: The study was conducted in Konya Training and Research Hospital General Surgery Endoscopy Unit in randomized prospective pattern. The patients were divided into the two groups as spasmolytic and control groups. The procedure was performed under topical anesthesia and sedation. RESULTS: There were 100 cases included into the study (50 cases in each group). The mean duodenal motility score was found to be 1.9 ± 0.5 in the study group and 3 ± 0.6 in the control group. In the study group, the tolerability of the procedure score by the endoscopist was moderate in 16 % and well/very well in 78 % of the cases. On the other hand, in the control group, the scores were poor in 21 %, moderate in 71 %, and well/very well in 24 % of the cases. In terms of patient satisfaction, in study group 42 % of the cases reported the procedure as moderate and 58 % reported as well/very well. However, in the control group 16 % of the cases reported the procedure as poor, 58 % moderate, and 26 % as well/very well. CONCLUSION: Otilonium bromide is a safe agent with low side effects. It can be used before the ERCP procedure to decrease the duodenal motility. It eases the procedure, moreover, it increases the patients' satisfaction.

Monitoring C-reactive protein levels during medical management of acute appendicitis to predict the need for surgery.

PURPOSE: To clarify the role of medical treatment in the management of acute appendicitis and the value of C-reactive protein (CRP) for predicting its failure. MATERIALS AND METHODS: Patients with clinically diagnosed acute appendicitis, confirmed by imaging studies, were enrolled in this study. We measured leukocyte counts and CRP levels and recorded success and recurrence rates and the efficiency of medical treatment during follow-up. The efficiency of CRP values to predict failure of medical treatment was evaluated using receiver operating characteristics (ROC) curve analysis. RESULTS: The subjects comprised 193 patients (mean age 30.9 years) who received medical treatment for acute appendicitis. The mean follow-up period was 12.3 (6-24) months and the early success rate of medical treatment was 86.5 % (160/185). Fifteen (9.3 %) patients suffered recurrence during follow-up. The leukocyte and CRP levels in these two groups of patients were not significantly different at the beginning of the treatment, but the increase in the CRP value differed significantly between the two groups during the follow-up period (p < 0.001). ROC curve analysis suggested that the optimum CRP cut-off point for unsuccessful medical treatment was 80.8 mg/L, with 81.82 % sensitivity and 84.34 % specificity (p < 0.001). CONCLUSION: The success rate for treating acute appendicitis medically is high, with antibiotic treatment being effective as the firstline therapy for many unselected patients. An increase in CRP levels to 80.8 mg/L and above seems to be a meaningful parameter for determining a lack of response to medical treatment.

Nitric oxide regulates tissue transglutaminase localization and function in the vasculature.

The multifunctional enzyme tissue transglutaminase (TG2) contributes to the development and progression of several cardiovascular diseases. Extracellular rather than intracellular TG2 is enzymatically active, however, the mechanism by which it is exported out of the cell remains unknown. Nitric oxide (NO) is shown to constrain TG2 externalization in endothelial and fibroblast cells. Here, we examined the role of both exogenous and endogenous (endothelial cell-derived) NO in regulating TG2 localization in vascular cells and tissue. NO synthase inhibition in endothelial cells (ECs) using N-nitro L-arginine methyl ester (L-NAME) led to a time-dependent decrease in S-nitrosation and increase in externalization of TG2. Laminar shear stress led to decreased extracellular TG2 in ECs. S-nitrosoglutathione treatment led to decreased activity and externalization of TG2 in human aortic smooth muscle and fibroblast (IMR90) cells. Co-culture of these cells with ECs resulted in increased S-nitrosation and decreased externalization and activity of TG2, which was reversed by L-NAME. Aged Fischer 344 rats had higher tissue scaffold-associated TG2 compared to young. NO regulates intracellular versus extracellular TG2 localization in vascular cells and tissue, likely via S-nitrosation. This in part, explains increased TG2 externalization and activity in aging aorta.

Conservative management of abdominal injuries.

OBJECTIVE: Non-operative management of abdominal injuries has recently become more common. Especially non-operative treatment of blunt abdominal trauma is gaining wide acceptance. In this study, the efficacy of non-operative treatment in abdominal trauma (blunt penetrating) is discussed. MATERIAL AND METHODS: All patients who received treatment due to abdominal trauma from November 2008 to January 2013 were retrospectively analyzed. The demographic characteristics, type of injury, injured organ, type of treatment (operative vs. nonoperative) and mortality data were evaluated. RESULTS: The study includes 115 patients treated for abdominal trauma in our department. The mechanism of trauma was stab wounds in 60%, blunt abdominal trauma in 23.5% and gunshot wounds in 16.5%. Forty-two patients (36.5%) were operated for hemodynamic instability and/or peritonitis on admission. The remaining 63.5% of patients (n=73) were treated nonoperatively, 10 of whom required laparotomy during follow-up. The remaining 63 patients were treated with non-operative management. The success rate for non-operative treatment was 86.3% and there was no difference in terms of the types of injuries. The mortality rate was 4.3% (n= 5) in the whole series, but there were no deaths among the patients who had received non-operative treatment. In the whole patient group 54.2% (n=63) were treated nonoperatively. CONCLUSION: Nonoperative treatment in abdominal trauma is safe and effective. Patients with clinical stability and normal physical examination findings can be treated nonoperatively with close monitoring.

Relation between serology and grow-up time in atypically localized hydatic cysts.

OBJECTIVE: Hydatic cyst is a parasitic disease caused by the larvae of Echinococcus granulosus. In the study, the aim is to evaluate the relation between serology and grow-up time in atypically localized cysts. METHODS: Retrospectively, all the patients with hydatic disease between December 2004 and May 2012 were screened from the hospital database. Hydatic cyst localization other than the liver and lungs were accepted as atypical localization. RESULTS: There were 325 patients with a diagnosis of hydatic disease. Most common localizations of the cysts were the liver (72.8%) and lungs (21%). Atypically localized cyst rate was 6.4% (n: 21). The most common atypical localization was the spleen (2.4%). 80.9% of atypically localized cysts were primary cases. In 3 cases with primary intramuscular hydatic cyst and 2 cases with primary subcutaneous hydatic cysts, serology was negative. CONCLUSION: The relation between the hydatid cyst and the host is the main factor in serological tests and grow-up time. In tissues with a weaker cellular immunity like muscle and subcutaneous tissue, serology tends to be negative and grow-up time to be faster. In atypically localized cysts,hematogenous dissemination cannot explain the pathogenesis fully. Therefore, lymphatic dissemination should be kept in mind.

Comparison of topical zinc oxide and silver sulfadiazine in burn wounds: an experimental study.

BACKGROUND: We aimed to compare the effects of topical zinc oxide and topical silver sulfadiazine in the treatment of partial-thickness burn wounds. METHODS: The study was conducted with 20 New Zealand rabbits, and burn wounds were created by a brass probe. The animals were randomly divided into two groups. The burns were treated with zinc oxide (Group O) or silver sulfadiazine (Group S) with daily application. The wound healing process was followed both clinically and histopathologically. We determined the days at which 50% and 80% re-epithelization was observed. RESULTS: The mean time for 50% and 80% re-epithelization was 21.4 and 25.4 days in Group O and 25.8 and 30.2 days in Group S, respectively (p<0.001). The mean score for wound colonization was lower in Group O. The difference was statistically significant at weeks 2, 3, 4, and 6 (p<0.001). In the histopathological examination, the thicknesses of the epidermis, dermis and scar tissue were 0.12 mm, 3.80 mm and 244 mm in Group O, and 0.16 mm, 4.76 mm and 3.16 mm in Group S, respectively (p<0.001). CONCLUSION: In this experimental burn study, zinc oxide was more effective than silver sulfadiazine in terms of epithelization, dermis maturation and scar formation.

Comparison of Limberg flap and tension-free primary closure during pilonidal sinus surgery.

BACKGROUND: Pilonidal disease is an inflammatory disease seen in the intergluteal region. In this study, our aim was to compare the efficacy of the Limberg flap versus a tension-free primary closure. METHODS: A total of 93 patients were included in this study. The patients were assigned consecutively by the closed-envelope technique to one of two groups: 49 patients in group 1 (excision and Limberg flap) and 44 patients in group 2 (tension-free primary closure). Excision and reconstruction with the Limberg flap was performed in its classic form. For tension-free primary closure after excision of the sinus tract with an elliptical incision, the skin and subcutaneous tissue were released 2-3 cm away from the incision line. The subcutaneous tissue was closed twofold with 2/0 polyglactin sutures. The skin underwent 3/0 polypropylene mattress suturing. RESULTS: The median age was 25 years (17-43 years). The median follow-up period was 29.5 months (8-43 months). There was no significant difference between the groups in terms of age, sex, follow-up time, or anesthesia method. One patient in each group experienced wound infection. During the first 6 months of follow-up there was no recurrence. However, at later visits recurrences were seen in two patients in each group (4.1% in group 1, 4.5% in group 2). CONCLUSIONS: The lower rates of wound infection and recurrence associated with the Limberg flap reported elsewhere may be associated with healing of the tension-free procedure. In this study, tension-free primary closure was found to be as effective as the Limberg flap reconstruction.