Seminars in Colon and Rectal Surgery最新文献

The crude rate of persistent or recurrent disease following surgical interventions for pilonidal disease correlates with the duration of follow-up. Furthermore, patient and disease related factors, body habitus, and the choice of surgical technique impact both short and long-term outcomes. Despite modern advances in surgical care, persistent and recurrent disease remain a challenge to the surgeon and the patient. Currently there is no standard of care or consensus as to the choice of operation for either primary, persistent, or recurrent disease. The selection of an operation for an individual patient is often determined by the surgeon's training background, personal experience, and own biases. A variety of techniques have been described to treat pilonidal disease ranging from simple minimally invasive procedures to operations entailing wide excision with primary closure, flap reconstruction, or wound management by secondary healing. In this article we share our perspective and approach to patients with persistent disease following failed intervention.

There are several proposed etiologies that are thought to contribute to the development of pilonidal disease. Initially, PSD was thought to be a congenital condition arising from a variety of errors in embryogenic development; now it is believed to be an acquired condition. The management of PSD can be challenging. Acute abscess should be treated with incision and drainage. Patient expectations and preferences should be coupled with the surgeon's familiarity with different procedures, balancing time to wound healing and short-term postoperative complications with long term recurrence rates and quality of life.

Pilonidal disease is a very common affliction that affects mainly young, hirsute, obese males during their young adult years of life. Previous etiological theories of this ailment centred on congenital causes. The current understanding is that pilonidal disease is an acquired affliction. Some patients, however, may have confounding hereditary tendencies to form pilonidal disease. There is a myriad of methods of treatment for chronic pilonidal disease. Such treatments vary from the creation of large skin flaps to simple instillation of chemicals into the sinuses. No single technique is favoured by every surgeon and each technique has its ardent supporters. The current favoured treatments however, are toward the use of the less invasive options compared to the large extensive flaps. Favoured options include minimally invasive techniques as well as simple lay open and marsupialisation. No proposed classification system for the assessment of severity of pilonidal disease has correlated disease severity with treatment options. Therefore, no classification system is in widespread use by the surgical community. Post-operative supportive management, especially in the early post-operative period, and laser hair epilation after the initial healing phase, have some usefulness in the overall treatment of pilonidal disease.

Introduction

Pilonidal sinus disease is a chronic inflammatory condition typically found in the sacrococcygeal region. It is caused by loose hair penetrating natal cleft skin. Treatment of symptomatic disease is surgical. There is a lack of consensus on the ideal surgical technique.

Methods

The Karydakis flap involves asymmetric excision of the disease and closing the wound off midline with a lipocutaneous flap to flatten the natal cleft. The procedure has evolved since its description in 1968 and currently entails two layered fat closure, thin flap, displacement of the caudal apex, avoidance of routine drainage and the use of absorbable skin sutures. Its design and execution remain straight forward with a short learning curve.

Results

Out of 1029 type 4 Karydakis flaps reviewed, 16% were complicated by wound dehiscence. Recurrence rate at a mean of 29 months follow-up was 1%.

Discussion

By achieving a scar which is totally away from the midline, the Karydakis flap achieves a low recurrence rate. Minimizing early superficial dehiscence of the caudal wound remains a surgical challenge. The flap is suitable for all types of pilonidal disease.

Chronic pilonidal disease continues to be a therapeutic challenge. Discrepancies in technique, recurrence rates, complications, time to return to work/school, and patient's aesthetic satisfaction between the various treatment options have led to controversy over the best approach. It is undeniable that the best technique should strike a balance between recurrence and surgical morbidity. Despite the plethora of various complex surgical options, it seems that one of the oldest and simplest methods such as incision and curettage can balance the various desirable outcomes without excessive morbidity. In this manuscript, we review the literature and the evidence supporting this surgical procedure. We conclude that incision and curettage should be considered as the initial option for most patients with chronic uncomplicated pilonidal disease, and that more complex surgical options should be reserved for severe and recurrent cases.

In this study, we review the clinical course of patients treated for pilonidal disease in the various colorectal surgery training institutions in the Philippines. As part of this review, we aimed to determine the surgical training practice pattern for this rarely encountered disorder in the Philippines.

Our understanding of the pathophysiology of pilonidal disease continues to evolve. In this manuscript we would like to review the current thinking about plausible causes of pilonidal disease. Based on our current understanding of this benign disorder, we offer seven potential strategies to minimize the development of symptomatic disease and recurrence. Finally, we share some ideas about future research.

Transanal approaches are an important modality for the diagnosis and treatment of rectal neoplasia while allowing for organ preservation. Choosing the appropriate surgical approach based on anatomy, pathology, platform capabilities and surgical skill is paramount to success. In this article we review preoperative considerations, the present options for transanal approach and the relative advantages and disadvantages they each offer. We will focus on advanced transanal options including robotic-assisted approaches and endoscopic submucosal resection.

Transanal excision is an important approach in the management of diseases of the rectum. Most notably, advances in transanal excision technique have evolved with efforts to safely excise rectal tumors. There have been many important advancements over the past several thousand years to reach this frontier. In this article, we review the interesting history behind transanal surgery. We begin with the ancient Egyptians and Greeks who performed transanal surgery with high mortality, and end with contemporary approaches, which minimize patient morbidity. Transanal surgery is now an accepted approach in selected patients as a result of overcoming three obstacles: 1) the ability to perform these operations safely; 2) the importance of performing an oncologically sound resection; and 3) technical advances in surgical exposure. What has resulted is a rapidly evolving new era in transanal surgery.

Transanal minimally invasive surgery (TAMIS) is a technique that allows high quality local excision of benign rectal neoplasms and early-stage rectal cancers. These lesions can be located more proximal that those treated with conventional transanal excision. Operative costs are minimized and access to the technique is expanded with utilization of conventional laparoscopic instruments. Good oncologic outcomes can be achieved for local excision of early rectal cancers, but its role in the surgical treatment of more advanced tumors is still being evaluated. As with all surgical techniques, appropriate training must be ensured and continued assessment of oncologic outcomes maintained.