Seminars in Colon and Rectal Surgery最新文献

Rectal Intussusception (RI) occurs when the rectal wall telescopes distally without prolapse past the anal verge during defecation and occurs as the result of abnormal rectal wall biomechanics. Symptoms are variable though ¾ of patients with high grade intussusception report straining, incomplete emptying and the need for manual assistance during evacuation. The diagnosis of RI requires a comprehensive clinical history, physical exam and dynamic imaging of evacuation with MR or fluoroscopic defecography. Phenotypic grading is important as low-grade, non-obstructing RI may not significantly contribute to symptoms and outcomes following surgery in this group is poor. Initial management should focus on improving stool form and evacuatory dynamics in conjunction with biofeedback if there associated dyssynergia. Surgery should only be considered in those patients with high-grade intussusception and symptoms resistant to medical therapies after appropriate counselling regarding the risks and benefits of intervention.

Introduction

The Cleft Lift procedure originally named by Bascom is a derivative of the Karydakis flap procedure for pilonidal sinus disease. The terminology and variations of the name have long confused surgeons and have limited its wide adoption.

Technique

This technical paper deconstructs the confusing terminology, suggests simple steps for success, and proposes a more descriptive name for the asymmetric flap procedure which has the lowest reported recurrences for all surgical options for pilonidal disease.

Results

The author has successfully performed the Cleft Lift procedure for pilonidal disease since 2000. In the last consecutive 757 patients treated over 12 years, only 6 patients have required a second operation. This cohort included 287 patients referred with recurrent disease or open wounds from prior pilonidal surgery. A new naming scheme is proposed that more accurately describes the operation. The proposed name is the pilonidal RAF procedure for rotation (around the anus) and advancement (across the natal cleft midline) flap .

Conclusions

The pilonidal RAF procedure is highly successful in treating pilonidal sinus disease with a very low need for additional surgery even in complex recurrent disease.

Sacrococcygeal pilonidal disease is common in the pediatric population and its incidence is increasing. Psychological stigmatization is common. Adolescent patients have unique challenges in body image, communication with family members and caregivers, and hygienic practices. Acute infection requires antibiotics and abscess require drainage. Chronic disease is managed with noninvasive therapies or minimally invasive surgical debridement procedures, which may be repeated for simple recurrences. Larger excision and off-midline flap reconstructions are reserved for complex and extensive disease or multiple recurrences that are refractory to less invasive excisional techniques. Common presentation of pediatric pilonidal disease, available therapies, anticipated outcomes, and a suggested treatment algorithm are presented in this article.

Pilonidal disease (PD) is a common suppurative condition located beneath the skin of the sacrococcygeal region. Diagnosis is clinical and usually doesn't require any instrumental examination or imaging. To date, there is still no gold standard treatment for symptomatic PD, although most clinicians advocate surgical excision as a definitive treatment. Recently, several comparative studies between traditional excision and minimally invasive techniques have been published. However, there are still methodological limitations and selection biases that prevent the achievement of an adequate level of scientific evidence. The main advantages of the minimally invasive procedures include fewer wound infections, less pain, quicker return to work, and higher patient satisfaction. However, the success rate is still unclear and further studies are needed. This article briefly highlights the different minimally invasive approaches introduced in the last years, including both the endoscopic treatment and the laser surgery.

Pilonidal disease is a chronic inflammatory disease which has significant negative impact on quality of life. Numerous treatment methods have been described for pilonidal sinus disease. However recurrence is a major concern for both patients and healthcare providers. More aggressive surgical methods such as flap-based off-midline procedures are the most common surgical treatment methods for complex or recurrent pilonidal disease. The Limberg flap is one of the best described flap-based surgical methods. In this review, we highlight the technical details and postoperative short and long-term outcomes of the Limberg flap procedure which is our preferred surgical technique, with low rates of complications and recurrence.

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.