Does application of honey improve surgical outcome in pilonidal cyst excision with secondary intention healing? A prospective randomized placebo-controlled clinical trial

Background Pilonidal sinus disease (PSD) is a common chronic inflammatory debilitating illness caused by ingrowth of hair into the skin. Excision and healing by secondary intention is one of the acceptable managements. The post-operative wound care needs frequent and time-consuming follow-ups. Honey is considered to be a traditional remedy for wound healing. The current study aimed at finding if application of honey could improve surgical outcome in pilonidal cyst excision with secondary intention healing. Methods This study was designed as a randomized placebo-controlled parallel assignment interventional (clinical trial) study conducted at the surgical ward of Shahid Beheshti Hospital affiliated to the Yasuj University of Medical sciences, Yasuj, Iran, and was consisted of the 48 patients who underwent surgical resection for PSD with secondary intention healing (24 patients in intervention and placebo-controlled groups). The main element of honey medicinal gel was the unheated natural honey of Dena Biosphere Reserve within the Zagros Mountains. Patients' wounds were visited by a surgeon and a nurse on the days 7, 15, 30, 45, 60, and 90 post-operation. The surgical outcomes including the time to complete wound healing, pain intensity, odor, discharge at the site of surgery, use of analgesics, the time of to return to the daily activities, and occurring of any side effects including infection, erythema, and bleeding were all recorded. Results In intervention group, there was significantly lower wound healing time, the lower time to return to the daily activities, lower mean wound volume at the days of 30, 45, 60, and 90 of the follow-up, higher mean post-operative pain level at the days of 15, 30, 45, 60, and 90 of the follow-up, and more usage of analgesics at the days of 15, 30, 45, and 60 of the follow-up. There was no significant difference between intervention and placebo-controlled groups according to the foul smell and fluid discharge at the site of the operation. There were no side effects and complications in both groups of the study. Conclusions Application of honey after resection surgery with secondary wound healing is associated with a better surgical outcome and could eventually decrease healing time and reduce duration of return to normal activities, but could increase post-operation pain and analgesic consumption, and no effect on foul smell and discharge. Trial registration The project was found to be in accordance to the ethical principles and the national norms and standards for conducting research in Iran with the approval ID and date of IR.YUMS.REC.1399.088 and 2020.05.30 respectively, and is the result of a residency dissertation to get the specialty in general surgery, which has been registered with the research project number 960508 in the Vice Chancellor for Research and Technology Development of Yasuj University of Medical Sciences, Yasuj, Iran, URL: https://ethics.research.ac.ir/EthicsProposalViewEn.php?id=144742

Surgery Management of Pancreatitis with Complication: A Review Article

Introduction: Acute pancreatitis is an inflammatory disease of the pancreas with clinical manifestations that vary from mild to severe manifestations to death. The incidence of pancreatitis varies in various countries in the world and depends on the cause such as alcohol, gallstones, and metabolic factors. The clinical picture and the main symptom in patients with acute pancreatitis is abdominal pain. Abdominal pain varies from mild to severe and excruciating. Abdominal pain that is felt is constant and dull, and is usually felt in the epigastrium and periumbilicus and often spreads to the back, chest, waist, and lower abdomen. Discussion: The onset of acute pancreatitis, the patient should be evaluated for hemodynamic status immediately and receive the necessary resuscitation measures. Patients with acute pancreatitis should receive aggressive intravenous rehydration (250 - 500 ml/hour with isotonic crystalloid fluid) as early as possible with close monitoring, unless contraindicated with cardiovascular and/or renal comorbidities. It is most effective within the first 12-24 hours, but after that the benefits may diminish. Debridement (necrosectomy) is the gold standard in infected acute necrotizing pancreatitis and peripancreatic necrosis. Indications for intervention either through radiological, endoscopic or surgical procedures in necrotizing pancreatitis are suspected or proven infected necrotizing pancreatitis with clinical deterioration, especially after the necrotic tissue has been encapsulated with thick walls (walled-off necrosis). Sterile necrotizing pancreatitis with persistent organ failure several weeks after the onset of acute pancreatitis, particularly after the necrotic tissue has been encapsulated with thick walls (walled-off necrosis). Conclusion: Surgical management is often used in pancreatitis associated with gallstones. Cholecystectomy within 48 hours of the complaint can increase healing time. In addition, cholecystectomy performed early may not increase the risk of complications secondary to surgery. Surgery is not performed in acute necrotizing pancreatitis until the inflammation is reduced and the fluid accumulation no longer increases in size.

Effects of Selective Alveolar Decortication on the Periodontal Complex

Background Modification of bone turnover has been reported following selective alveolar decortication but the molecular signals in the periodontal ligament space (PDL) remain unanswered. The objective of this study was to understand how selective alveolar decortication affects the biological reactions in the periodontal ligament. Methods Selective alveolar decortication in wild-type mice (n=25) was performed on mandibular right buccal cortical plate adjacent to the mandibular right third molar and euthanized at 3, 7, 14 and 28 days. We also performed selective alveolar decortication in Lrp5ACT (n=5) mice and Ad-Dkk1 treated mice (n=5), and euthanized at 7 days. The periodontium around the mandibular third molars were examined using histology, immunohistochemical analyses for osteogenic markers, TGF-β, RANKL, TRAP and alkaline phosphatase activity. Results The expression of osteogenic markers in the wild-type PDL was maintained during healing time period after selective alveolar decortication. Increased osteoclast activity in the wild-type mice was observed at 3 and 7 days after selective alveolar decortication. The PDL in Lrp5G171V (Lrp5ACT) mice and adenovirus Dkk1 (Ad-Dkk1) treated mice also showed insignificant changes in the expression of osteogenic markers following selective alveolar decortication. In Lrp5ACT mice where there was a reduction of bone resorption, selective alveolar decortication caused a dramatic increase in osteoclast activity. Conclusions Selective alveolar decortication affects only bone turnover, but not the expression of osteogenic markers in the PDL.

Clinical Effect of Suture Anchor and Double-Pulley Technique in the Treatment of Inferior Patellar Fracture

Objective. To evaluate the efficacy of suture anchor combined with double-pulley technique for subpatellar comminuted fractures compared with wire vertical suture and Krachow in the treatment of subpatellar fractures. Methods. Retrospectively selected 48 patients with subpatellar pole comminuted fracture admitted in our hospital from February 2013 to July 2019, 25 patients with double-pulley technique (group A), and 23 patients with vertical wire suture with Krachow suture. Patient age, gender, AT/OTA typing, injury mechanism, follow-up time, surgical time, bleeding volume, mean fracture healing time, and postoperative complications were recorded. The Insall-Salvati index immediately and 6 weeks after surgery. Bostman scores and knee activity were recorded at each follow-up, and month 12 was taken as the final result. Results. Time of surgery in group A (46.52 min) was significantly shorter than in group B (76.30 min). Intraoperative bleeding in group 15.1 ml, B, group 15.9 ml. Both incisions healed in stage I, averaging clinical healing of patella fracture within 10 weeks. There was no significant difference in mean Bostman score and knee activity at month 12 (group A: 28.4, 124.8°; group B: 28.1, 125.7°). There was no significant statistical difference in the Insall-Salvati index immediately or 6 weeks between the two groups. Group B patients had two wire fractures, fracture healing and the wire removed one year after surgery, and the remaining patients had no complications such as internal fixation loosening, fracture, delayed healing, or nonhealing of fracture. Conclusion. Compared with the treatment of subpatellar fracture with wire vertical suture and Krachow method, suture anchor with double-pulley technique has short operation time, reliable fixation, and less complications. Patients can have early functional exercise and good knee function recovery without secondary surgery. It can be considered as an alternative therapy for this fracture and deserves clinical adoption and promotion.

EFFICACY OF NEGATIVE PRESSURE WOUND THERAPY IN EARLY DIABETIC FOOT ULCER MANAGEMENT IN COMPARISON WITH ADVANCED MOIST WOUND THERAPY

Objective: To compare negative pressure wound therapy with advanced moist wound therapy in managing early diabetic foot ulcer. Study Design: Quasi-experimental study. Place and Duration of Study: Surgical Department, Combined Military Hospital Rawalpindi, from Jul 2016 to Jun 2018. Methodology: A total of 100 patients of diabetic foot ulcer were randomly allocated into two equal groups for the treatment with negative pressure wound therapy (NPWT) and advanced moist wound therapy (AMWT). Ulcers were reassessed after 4 weeks for presence of granulation tissue covering entire ulcer base and reduction of 3 cm in largest diameter of ulcer. Results: Mean age of the study participants was 57.08 ± 9.99 years. 33 patients had Wagner grade-I ulcer, while remaining had Wagner grade-II ulcer. Mean ulcer size at presentation was 6.46 ± 1.71 cm. Both study groups were comparable in terms of mean age (p=0.968), wound size at presentation (p=1.000), age (p=0.695), gender (p=1.000) and Wagner ulcer grade (p=0.288). Mean ulcer size was found smaller with negative pressure wound therapy (3.46cm, p=0.061) at follow-up visits. Reduction in ulcer size ≥3cm was achieved frequently with negative pressure wound therapy technique (72.0% vs. 38.0%; p>0.01). Mean healing time was 4.11 ± 1.65 weeks which was lower with negative pressure wound therapy (3.66 weeks vs. 4.56 weeks; p>0.05). Treatment efficacy (healing in ≤4 weeks and ≥3cm reduction in ulcer) was significantly higher with negative pressurewound therapy (72.0% vs. 38.0%; p<0.01) as well. Conclusion: This study demonstrates superiority of negative pressure wound therapy over advanced moist...............

COMPREHENSIVE PREOPERATIVE APPROACH AND ENDOVENOUS ELECTRIC WELDING IN THE TREATMENT OF CHRONIC VENOUS INSUFFICIENCY C6 CLINICAL CLASS

The evaluation was done in the sphere of preoperative preparation trophic ulcer in patients with CVI using the proposed tactics of mechanochemical debridement and elimination of vertical venous reflux EVEZ method, in comparison with standard preoperative management tactics and EVLT of saphenous veins. It is established that the proposed tactics of preoperative preparation are more effective than classical approaches. Purpose. The use of the EVEZ method in combination with the proposed preoperative preparation of trophic ulcers in the treatment of CVI was determined to be effective. Materials and methods. An analysis of the treatment of 68 patients with CVI C6 clinical class was performed. The patient of the main group received the EVEZ treatment tributaries and perforating veins with preoperative trophic preparation ulcers, which includes: active mechanochemical debridement and control moisture balance in the wound, installation of negative pressure wound therapy system, platelet rich plasma therapy, application drugs based on diosmin and hesperidin. The proposed scheme of preoperative preparation has the following algorithm: Taking a smear from the sore to determine the bacterial spectrum and subsequent rational antibacterial therapy following the results of the antibioticogram; Active mechanochemical debridement with solutions of 0.1% polyaminopropyl biguanide + 0.1% surfactant, povidone-iodine + ethanol + glycerin + laureate 9 and control of moisture balance in the wound with modern hydrogel sore dressings; Installation of VAC system with a constant negative pressure of 120 mm Hg for 3 days for the first 3 performances of the system. Subsequently, VAC therapy was performed in a constant mode with a pressure of 80-120 mm Hg. in patients with insufficient wound cleanliness; After active cleaning, PRP therapy was performed, which involves the introduction of platelet-enriched plasma along the edge of the wound to a depth of 3 to 5 mm. The amount of PRP used depended on the size of the defect and ranged from 1 to 2 ml. All patients of the main group underwent correction of concomitant pathology with systemic use of capillary stabilizing drugs based on diosmin / hesperidin. Patients in the comparison group received standard preoperative preparation and EVLT. Patients of both groups were outpatient for 6 months. 39 of them (57.35%) were women and 29 (42.65%) were men aged 36 to 78 years. The duration of ulcers ranged from 3 months to 7 years. The following localization of venous trophic ulcers was observed: in the area of the medial bone - in 49 (72%) patients, 10 (14.7%) - on the anterior surface, 9 (13.3%) - on the lateral, posterior, anterior medial or anterolateral surface of the tibia. Results. Tactics of preoperative preparation that is offered allowed to achieve: reduction of redness and swelling in the main group on 7.3 ± 0.8 days (comparison group 10.2 ± 0.7 days); complete cleaning of the wound from fibrin and necrotic tissues at 9.1 ± 0.5 days (15.0 ± 1.1); the appearance of granulation tissues at day 12.6 ± 0.9 (18 ± 0.7); the appearance of marginal epithelialization at 15.3 ±0.7 days (20 ± 1.1). Conclusions. The proposed tactics can reduce the term by 1.7 times the preparation of the ulcer for surgery and 1.6 times the healing time of ulcers. The EVEZ method allows performing ablation efficiently and safely trunk great saphenous vein. The use of phlebotonic drugs, which is called Normoven, allows you to accelerate the healing of ulcers and prevent their recurrence.

The Clinical Outcome of the Reduction of the Patellar Inferior Pole Fracture with Wire Cerclage Through A Generated Bone hole, in Combination with Patellar Concentrator: A Retrospective Comparative Study

Objective: The patellar inferior pole fracture is typically comminuted. Hence, achieving firm fixation and early activity is highly challenging. In this article, we employed the method of wire cerclage through a generated bone hole to reduce the fracture. Our objective was to compare the clinical efficacy of patellar concentrator alone with a combination of cerclage and patellar concentrator in the treatment of patellar inferior pole fracture.Methods: We conducted a retrospective review of patients with patellar inferior pole fractures, who underwent patellar concentrator fixation only (the control group) or cerclage combined with patellar concentrator fixation (the experimental group), performed by a single surgeon, between July 2015 and October 2019. Our analysis included surgical indexes like7 aspects (fracture gap after operation, operation time, intra-operative blood loss,intra-operative number of C-arm fluoroscopies conducted, Insall-Salvati ratio calculated immediately after operation, initial range of motion on the 7th day after operation, and fracture healing time), as well as the Bostman score and complications recorded on 1-, 3-, 6-, and 12-month follow up post operation.Results:A total of 94 patients with patellar inferior pole fracture and a minimum 1-year followup were recruited. Following operation, the control group had 33(71.74%) patients with a fracture gap of 0-2 mm and 13(28.26%)patients with a fracture gapgreater than 2 mm(P=0.002). Conversely,the experimental grouphad46(95.83%)patients with a fracture gap of 0-2 mm and 2(4.17%) patients with a fracture gapgreater than 2 mm(P=0.002). Compared to the control group, the experimental group did not experience enhanced operation time or intra-operative blood loss (P=0.811, P=0.823). The Insall-Salvati ratio and initial range of motion in the experimental group were larger than the control group (P=0.037, P=0.000). Alternately, the number of intra-operative C-arm fluoroscopies conductedand fracture healing time of the experimental group were considerably less than the control group (P=0.003,P=0.000).Moreover, at 1-, 3-, 6-, and 12-month follow ups after operation, the Bostman scores of the experimental group were remarkably higher than the control group (P< 0.05).At 12 months post operation, 23 cases (50%) were classified as excellent, 22 cases (47.83%) were good, and 1 case (2.17%) was poor in the control group(P=0.005). In the meantime, in the experimental group, 38 cases (79.17%) were deemed as excellent and 10 cases (20.83%) were good (P=0.005).Lastly, complications were detected in 3 cases (6.52%;1 case of internal fixation loss,2 cases of hematoma) within the control group, and in 1 case(2.08%; marginal wound necrosis) within the experimental group. There was no wound infection, implant discomfort, or broken fixation in eithergroup.Conclusion: Managingthe patellar inferior pole fracture with wire cerclage through a generated bone hole is both simple and effective. Moreover, an additional step of patellar concentrator fixation facilitates early functional exercise, with satisfactory clinical outcome.

Dissociation between Corneal and Cardiometabolic Changes in Response to a Time-Restricted Feeding of a High Fat Diet

Mice fed a high fat diet (HFD) ab libitum show corneal dysregulation, as evidenced by decreased sensitivity and impaired wound healing. Time-restricted (TR) feeding can effectively mitigate the cardiometabolic effects of an HFD. To determine if TR feeding attenuates HFD-induced corneal dysregulation, this study evaluated 6-week-old C57BL/6 mice fed an ad libitum normal diet (ND), an ad libitum HFD, or a time-restricted (TR) HFD for 10 days. Corneal sensitivity was measured using a Cochet-Bonnet aesthesiometer. A corneal epithelial abrasion wound was created, and wound closure was monitored for 30 h. Neutrophil and platelet recruitment were assessed by immunofluorescence microscopy. TR HFD fed mice gained less weight (p < 0.0001), had less visceral fat (p = 0.015), and had reduced numbers of adipose tissue macrophages and T cells (p < 0.05) compared to ad libitum HFD fed mice. Corneal sensitivity was reduced in ad libitum HFD and TR HFD fed mice compared to ad libitum ND fed mice (p < 0.0001). Following epithelial abrasion, corneal wound closure was delayed (~6 h), and neutrophil and platelet recruitment was dysregulated similarly in ad libitum and TR HFD fed mice. TR HFD feeding appears to mitigate adipose tissue inflammation and adiposity, while the cornea remains sensitive to the pathologic effects of HFD feeding.

TYMPANOPLASTY TYPE-1: DIFFERENT APPROACHES AND THEIR SURGICAL OUTCOMES

Objective: To calculate the surgical outcomes of different approaches of tympanoplasty type 1 in terms of air bone gap closure, wound healing, and postoperative pain. Study Design: Prospective cross-sectional study. Place and Duration of Study: Department of ENT, Head and Neck Surgery, Medical Teaching Institute (MTI), Lady Reading Hospital (LRH), Peshawar, Pakistan from Jun 2018 to May 2020. Methodology: Size of sample was 75 patients divided into three groups. Consent was obtained from all the patients included in study. After proper evaluation and relevant investigation pre- and post-operative PTA was performed. Tympanoplasty type-1 was performed by the same surgeon by the three approaches following established otological surgical protocol. Collected data was entered in SPSS-25 for analysis. Results: All 75 patients were divided into three equal groups. Male were 55 (73.3%), females were 20 (26.7%). Male: female ratio was 2.7:1. Majority of patients presented in 2nd and 3rd decades of life 31 (41.33%) and 28 (37.33%) respectively. Preoperative mean ± SD, ABG in groups A, B and C were 37.60 ± 11.28 dB, 37 ± 9.68 dB and 31.80 ± 12.40 dB, respectively. No significant difference was found amongst the three groups regarding pre-operative and post-operative ABG (p=0.85 and p=0.4), respectively. Mean ± SD, wound healing time in Groups A, B and C were 1.00 ± 0.00, 1.80 ± 0.40 and 1.76 ± 0.43 respectively with p=0.0001 and similarly postoperative pain with p=0.001. The wound healing time and post-operative was statistically better (p<0.05) in group A (Transmeatal approach) than other groups........