Karydakis flap for post-proctectomy perineal sinus: A case series and review.

INTRODUCTION: Persistent perineal sinus (PPS) may occur in up to 38% of patients undergoing proctectomy. The available therapeutic options range from simple but ineffective to relatively successful but complex. The Karydakis procedure is a straightforward day-case operation, commonly performed by general surgeons in the treatment of pilonidal disease, a not dissimilar pathology to PPS. This report is the first in the literature describing the use of Karydakis procedure in patients who developed PPS after proctectomy for Crohn's disease. PRESENTATION OF CASE: Two patients, both of whom suffered from Crohn's disease and a PPS, underwent a Karydakis procedure as first-line treatment for PPS. Case 1 had a relatively superficial PPS while Case 2 had a deeper, more complex and longstanding PPS. Both patients had no post-operative complications and were discharged on the same day. They achieved complete healing in eight weeks and eight months respectively. The follow up range was 8-16 months. DISCUSSION: Various techniques, including complex myocutaneous flap reconstruction, have been described in the literature to treat PPS. In contrast to these complex techniques, Karydakis operation is a simple day case procedure that was successful in treating PPS in our patients. While there is robust data regarding low recurrence rates following a Karydakis flap for pilonidal disease, there is no existing data for the indication outlined in this report. CONCLUSION: While it requires further assessment, the Karydakis operation has potential as a simple, safe and effective first-line treatment in selected patients with PPS while not precluding more complex operative options in the future.

An investigation into the role of waterproofing in a two-stage hypospadias repair.

In our unit a two-stage procedure, using a full thickness preputial graft, has been adopted as the method of choice for the repair of hypospadias proximal to the coronal sulcus. In 1993 an audit was undertaken to establish our complication rate for this procedure. Twenty-two consecutive patients who completed a two-stage repair between January 1988 and December 1993 were studied. An unacceptably high fistula rate was identified (63%, 14/22 cases). Consequently our technique was modified by transposing a vascularised flap of preputial areolar tissue over the urethral suture line, at the time of urethroplasty. A second group of 22 consecutive patients, operated upon between January 1994 and July 1997, were subsequently investigated and a dramatic improvement in the fistula rate was demonstrated (4.5%, 1/22 cases). These cases represent a subgroup of almost 200 cases, which the senior author has managed over the last 10 years. The senior author undertook or supervised the surgery in all 44 cases, which were the focus of this study, and the introduction of a waterproofing layer represents the only change in technique.

Rotation-angulation osteotomy in the hand.

The use of a single osteotomy combining both rotation and angulation is described, with a means of achieving the correct angle and direction of the osteotomy. Patients who have been treated by this method are presented.

Metastatic colonic adenocarcinoma in a pedicled omental flap used for sternal reconstruction: a case report.

Dehiscence of a median sternotomy wound is a fortunately rare but potentially lethal complication of cardiac surgery. If conservative management, including irrigation and secondary closure, fails then osteomyelitis with or without necrosis of the sternum, costochondritis and anterior mediastinitis may result. In the face of such sequelae, radical debidement of the sternum and flap coverage is required. A variety of flaps may be used to cover the defect following debridement of the sternum, in particular pectoralis major or rectus abdominis muscle flaps and the omentum. We report the case of a 65-year-old man, who required an omental flap for sternal dehiscence after coronary artery bypass grafting and who subsequently presented with a metastatic colonic adenocarcinoma within the flap.

Avascular necrosis of the hamate.

Avascular necrosis of the hamate is a rare condition, only one case having been reported in the literature (Van Demark and Parke, 1992). This reflects the relative rarity of fractures of the body of the hamate and the arrangement of the intraosseous vascular anatomy. A case is presented, which was diagnosed by MR Imaging and treated surgically.

Recurrence of intraoral squamous cell carcinoma at the base of nasolabial flaps used for intraoral reconstruction: a report of two cases.

The nasolabial flap has proved useful in facial and intraoral reconstruction. Two cases are presented where nasolabial flaps used for intraoral reconstruction were associated with tumour recurrence in the base of the nasolabial flap.

Comparative study of abdominal incision techniques.

The characteristics of surgical incisions made with an electrosurgical technique were compared with those made using conventional methods in a prospective randomized trial. In particular, the claim that the method of incision may influence postoperative pain was investigated. A total of 101 consecutive patients receiving full-length midline laparotomy incisions for gastrointestinal resection were studied. A record was kept of the time required to make the incision and blood loss as well as postoperative pain (using a linear analogue scale), ventilatory function and requirement for analgesia. There were 50 patients in group 1 (scalpel; 15 men, 35 women) and 51 in group 2 (electrocautery; 26 men, 25 women). The groups were similar in age, body-weight, diagnosis and the type of surgical procedures being performed. Incision time was similar in the two groups but median blood loss during incision was significantly less in group 2 patients than in group 1 (10 versus 25 ml, P < 0.0001). Linear analogue pain scores were not significantly different between the groups at any stage after operation. The same was true of postoperative ventilatory function and requirement for analgesia. A total value for morphine use during the entire postoperative period was derived for each group and the median was 1.55 mg/kg for group 1 compared with 1.49 mg/kg for group 2. The electrosurgical method is associated with less blood loss during incision, although this study has failed to confirm any reduction in postoperative pain or requirement for analgesia in these patients.