High Body Mass Index as a Possible Risk Factor for Pilonidal Sinus Disease in Adolescents

Comorbidities are not associated with pain symptom or recurrence in patients with pilonidal disease

BACKGROUND

Comorbidities can potentially impact the presentation or outcome of patients with pilonidal disease (PD) due to poor wound healing or increased inflammatory response. We hypothesized that certain comorbidities could lead to worse pain or higher recurrence rate.

METHODS

A retrospective study was performed on all PD patients treated with standardized minimally invasive protocol at our clinic 2019-2022. Patients' demographics, comorbidities, initial/follow-up pain score, pain duration, and recurrence were recorded. Data were analyzed by t test and Chi-square test.

RESULTS

Of 207 total PD patients (108 male, 99 female), 61 had comorbidities. Mean age was 18.2 years. The recurrence rate was 7%, and patients with recurrence were significantly younger. Associated comorbidities included mood/psychiatric disorders (31%), asthma/respiratory illness (30%), obesity-related illness (15%), gastrointestinal disorders (13%), diabetes (10%), thyroid disease (8%), cardiac disease (8%), musculoskeletal/connective tissue disorders (7%), immunologic disease (7%), inflammatory bowel disease (5%), and chest wall disorders (3%). The presence of comorbidities was not associated with PD recurrence. By dividing patients into adolescents (< 18 years) and adults (≥ 18 years), we found no association between comorbidity and recurrence in either group. 55% of patients had pain as an initial symptom. The initial pain score, pain duration, and pain score at follow-up were not associated with comorbidities. The comorbidities and recurrence were not associated with patient age or sex.

CONCLUSIONS

Having comorbidities was not associated with pain symptoms or recurrence in PD patients. Even though patients with recurrence were younger, there was no association between comorbidity and recurrence in either adolescents or adults.

Non-operative management of pilonidal sinus disease; classification and outcome

The characteristics of the pilonidal sinus that are associated with recurrence have scarcely been investigated in the literature. This study aims to evaluate the outcomes of patients with sacrococcygeal pilonidal sinus disease who were managed by a non-operative technique using Salih's preparation. This study also tries to classify the patients according to the features that determine the outcome of the intervention. This is a single-group cohort study that enrolled consecutive patients that had pilonidal sinus. All the patients were managed using Salih's preparation. The patients were seen at the clinic 6 weeks after the intervention to record data of recurrence. The Statistical Package for the Social Sciences (SPSS) Version 25 was used for coding and analysing the data. Test of significance and odds ratio were calculated for all of the features. The total number of patients receiving Salih's preparation was 12 123 cases, of which only 3529 patients were included in this study. The mean age of the participants was 26.95 years, ranging from 14 to 55 years. The most significant factor related to the recurrence was the presence of an abscess. After summation of all odd ratios, the percentage of each one from the total was calculated, and accordingly, the patients were divided into three classes. Non-operative methods using a preparation with antimicrobial and sclerosing properties can be an alternative for surgical intervention with a lower risk of recurrence. Classification of patients based on specific criteria can give clinicians and even patients themselves a vision of the chance of recurrence and treatment success.

Paediatric Pilonidal Sinus Disease: Early Recurrences Irrespective of the Treatment Approaches in a Retrospective Multi-centric Analysis

BACKGROUND

Incidences of pilonidal sinus disease are rising. Guidelines rarely consider children and adolescents and evidence for their treatment is rare. The literature is divided on the choice of the preferable surgical procedure. Therefore, we aimed to assess recurrences and complications following different treatment approaches in our multi-centric cohort.

METHODS

We retrospectively assessed all patients treated for pilonidal sinus disease in the paediatric surgical departments of Bonn and Mainz between 01/01/2009 and 31/12/2020. Recurrences were defined according to the German national guidelines. The pre-specified analysis via logistic regression included the operative approach, age, sex, use of methylene blue, and obesity as independent predictors.

RESULTS

We included 213 patients, of which 13.6% experienced complications and 16% a recurrence. Median time to recurrence was 5.8 months (95% confidence interval: 4.2-10.3), which was slightly higher in children than adolescents (10.3 months, 95% confidence interval: 5.3-16.2 vs. 5.5 months, 95% confidence interval: 3.7-9.7). None of the investigated procedures, excision and primary closure, excision and open wound treatment, pit picking, and flap procedures had a decisive advantage in terms of complications or recurrence. Of the independent predictors, only obesity was associated to complications (adjusted odds ratio: 2.86, 95% confidence interval: 1.05-7.79, P = 0.04).

CONCLUSIONS

We did not find a difference between the investigated procedures, but our analysis is limited by the small sample size in some subgroups. Our data corroborates that recurrences in paediatric pilonidal sinus disease occur early. Factors linked to these differences remain unknown.

Assessment of Surgical Strategies for Pilonidal Sinus Disease in the Netherlands

Purpose

Pilonidal sinus disease (PSD) is a subcutaneous infection of the sacrococcygeal region due to entrapment of hair and/or debris. International guidelines recommend minimally invasive techniques and flap techniques. A Dutch guideline for the treatment of PSD is not available and this may lead to practice variation. The aim of this study was to perform a national survey on the surgical treatment of PSD in the Netherlands.

Method

An online survey was sent by e-mail to all surgeons and surgical residents of the Dutch Association for Surgeons. Respondents were asked to reflect on their preferences in the treatment of PSD, their perceived satisfaction with this treatment, and the need for national guidelines.

Results

A total of 819 (48.6%) of 1684 invitees responded to the survey, of whom 615 (37%) met the inclusion criteria. Traditional excision techniques were most frequently performed for all types of PSD (50.7%) followed by flap techniques (22.6%) and minimally invasive techniques (22%). Only 22.6% of the participants were satisfied with the current treatment and 82% supported the development of a national guideline.

Conclusion

Traditional excision techniques are most frequently performed for PSD in the Netherlands but the majority of surgeons and surgical residents are not satisfied with the current treatment. There is a demand for a national guideline.

Outcomes and cost of medical and surgical treatments of pilonidal disease: A single Institution's ten-year review

Background

Pilonidal disease is a chronic inflammatory skin disorder typically located in the gluteal cleft. Treatment varies from antibiotic therapy to extensive surgical resection and reconstruction; however, complications and recurrence are common. To understand risk factors, outcomes, and costs associated with various treatments, we performed a retrospective chart review of all patients treated for pilonidal disease at a single health care system from 2008 to 2018.

Methods

Patients with an ICD diagnosis code associated with pilonidal disease were identified. Charts were reviewed for demographic, clinical, and cost information related to pilonidal disease encounters. Data were analyzed for risk of recurrence by Cox proportional hazards regression and economic burden by Wilcoxon signed-rank test.

Results

During the study time frame, 513 patients were diagnosed with pilonidal disease. Primary treatment included 108 patients (21%) with wide excision, 167 (32%) with antibiotics alone, 79 (15%) with incision and drainage, and 109 (21%) with incision and drainage plus antibiotics. The rate of recurrence following antibiotic therapy, incision and drainage, or wide excision was 36.7%, 35.9%, and 21.3%, respectively. Sex, body mass index, obesity, or hidradenitis suppurativa was not associated with recurrence; however, smokers who underwent incision and drainage had a higher risk of recurrence (P < .0001). The median cost of each primary treatment was $3,093 for excision, $607 for incision and drainage, $281 antibiotics alone, and $686 for incision and drainage plus antibiotics.

Conclusion

Pilonidal disease presents with a high degree of heterogeneity and is often managed primarily with antibiotics, incision and drainage, or surgical excision. Risk of recurrence was less in patients who underwent wide excision; however, these patients had higher overall cost compared to patients that had nonoperative management.

Level of evidence

Level III.

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Ten-year review of outcomes for pilonidal treatments at a tertiary institution

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In-depth characterization of the likelihood, timing, and risk factors for recurrence

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Cost analysis of primary treatments

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Smoking identified as a risk factor for recurrence in patients with abscesses

Pili Multigemini Is a Possible Risk Factor for Pilonidal Sinus Disease

The aim of this study is to analyze both previously proposed and new risk factors for the development of pilonidal sinus. This is a prospective case-control study consisting of 145 patients with pilonidal sinus disease (n = 45) and a control group (n = 100). All patients were admitted to the department of general surgery between January 2013 and May 2015. The patients' age, family history, medical history, sitting time in a day, sitting posture, body mass index (BMI), Garn hairiness score, and hair type were evaluated. There were significant differences between the groups in the following characteristics: age (P = 0.01); positive family history (P = 0.01); medical history (P = 0.01); sitting time in a day (P = 0.01); sitting posture (P = 0.01); BMI (P = 0.01); Garn score (P = 0.01); and hair type. Multivariate logistic regression analysis indicated that positive family history (P = 0.03); Garn score (P = 0.05); medical history (P = 0.01); and sitting posture (P = 0.02) were independent risk factors for the development of pilonidal sinus disease.

Endoscopic pilonidal sinus treatment: A minimally invasive surgical technique

INTRODUCTION

Pilonidal sinus disease (PSD) is a common skin and subcutaneous disease that is mainly seen in men (mean age, 30 years); its incidence rate is 26 cases per 100 000. PSD greatly affects quality of life. Ideally, a surgical procedure to treat PSD should involve a minimal hospital stay and require minimal time off work, discomfort, operative time, and cost; it should also limit recurrence. In this study, we present a new minimally invasive technique for pilonidal sinus surgery known as endoscopic pilonidal sinus treatment (EPSiT).

METHODS

From February 2017 to April 2019, 100 patients diagnosed with PSD were treated with the EPSiT method at the Department of General Surgery, Imam Reza Hospital. Patient information was recorded prospectively. During the operation, the fistula cavity and tracts were ablated by an electrode that was introduced through the operative channel. All the epithelial and granulation tissues were removed by a brush inserted into the operative channel or by a Volkmann spoon.

RESULTS

None of the patients had postoperative complications, such as hematoma, seroma, or wound infection, during the follow-up period. Recurrence was seen four patients (4%). At 1 week postoperatively, the visual analog scale score was 3 for 37 patients (37%) and 2 for 28 patients (28%). The maximal cosmetic satisfaction rate was reported in 85 patients (85%).

CONCLUSION

As a minimally invasive procedure, EPSiT is effective for treating PSD. Compared with excision and primary closure techniques, EPSiT has a very low recurrence rate after the procedure and a short hospital stay.

Pilonidal sinus disease recurrence at a tertiary care center in Riyadh

BACKGROUND

Pilonidal sinus disease (PSD) is a chronic inflammatory disease of the sacrococcygeal area. Pilonidal sinus recurrence is a matter of concern to both patients and healthcare providers.

OBJECTIVES

Estimate the rate of PSD recurrence in our center and identify any risk factors contributing to disease recurrence.

DESIGN

Retrospective.

SETTING

Tertiary care center in Riyadh.

PATIENTS AND METHODS

All patients who underwent surgery for primary or recurrent pilonidal sinus between 1 January 2016 to 30 June 2019 were included to allow for at least 1-year of follow-up at the time of data collection.

MAIN OUTCOME MEASURE

Recurrence rate of PSD and risk factors for recurrence.

SAMPLE SIZE AND CHARACTERISTICS

369 patients: 329 males (89.2%) and 40 (10.8%) females. Median (interquartile range) age was 21 (18-26) years.

RESULTS

Of the 369 included patients, recurrence was identified in 84 (22.8%) cases [95% confidence interval (CI) 18.6-27.4], and the mean timing of recurrence was 1.8 (1.6) years after the primary surgery. In a multivariate logistic regression analysis, increased age and post-operative seroma fluid discharge were independent risk factors for recurrence. In contrast, preoperative antibiotic prophylaxis and postoperative hair removal were effective in reducing recurrence. Type of surgery closure had no effect on recurrence, yet primary closure was associated with early onset of recurrence compared to secondary closure (P=.02).

CONCLUSION

Our findings on the factors associated with recurrence of PSD are consistent with many reports in the literature. Reported prevalence estimates vary widely.

LIMITATION

Single center, small sample size, retrospective.

CONFLICT OF INTEREST

None.

Primary Transverse Closure Compared to Open Wound Treatment for Primary Pilonidal Sinus Disease in Children

We aimed to compare the outcome of two different operative methods to correct pilonidal sinus disease (PSD) in children, i.e., excision and open wound care (OW) versus excision and primary transverse closure (PC) of the wound. In this retrospective, observational study, we extracted data from the medical records of 56 patients who underwent surgery for PSD at our institution between 1 January 2006 and 31 December 2016. To test whether the primary variable, i.e., rate of PSD recurrence, differed between the two surgical groups, a logistic regression model was fitted. Secondary explanatory variables were total length of stay (LOS) at the hospital, complications, sex and age of patients, seniority of the surgeon in charge, and volume of excised specimen. Overall, 32 (57%) children and young adults underwent OW, while 24 (43%) patients were treated by PC. Mean age at operation was 15.5 years in either group. PSD recurred in 12 of 32 (37.5%) children in the OW group and in 3 of 24 (12.5%) children in the PC group (ratio: 0.19, 95% confidence interval [95% CI] 0.03–1.07). Thus, treatment of primary PSD by PC proved superior with respect to PSD recurrence. Moreover, our study did not bring to light any high-grade complications in the PC group, and postoperative pain was minimal. Less invasive treatment approaches for chronic PSD are typically performed in an outpatient setting and offer reduced morbidity, low rates of PSD recurrence, and shortened periods of time to return to work or social activities. More radical operations of PSD should be reserved for recurrent PSD where less invasive approaches have failed several times.

Risk factors of pilonidal sinus disease in preparatory school students; a case control study

Background

Pilonidal sinus disease (PNS) is a disorder of the young population. The aim of this study is to analyze the risk factors associated with development of PNS in the secondary school students.

Methods

This case control study enrolled 189 participants, (Control group: 95 cases, case group: 94 cases). The inclusion criterion for the trial group was those secondary school students with PNS and age ranged between 16 and 20 years without the known risk factors of PNS.

Result

About 80 (42.3%) patients were male and 109 (57.7%) were female. Each group included 95 patients. There was no significant difference in both groups regarding basic features. Among the control group 36 (37.9%) participants were used to study while sitting on a hard place whereas among the case group 62 (66%) cases were used to study while sitting on a hard place, the difference was statistically significant (<0.001).

Conclusion

Sitting on the hard places could be regarded as a risk factor of developing PNS among secondary school students.

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Pilonidal sinus disease is a disorder of the young population.

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Several risk factors have been recognized like job, being hairy …. etc.

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Studying for prolonged time has never being studied to cause PNS.

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In this study, factors have been assessed to cause PNS in preparatory students.

Conservative Sinusectomy vs. excision and primary off-midline closure for pilonidal disease: a randomized controlled trial

PURPOSE

Pilonidal sinus disease (PD) is a common acquired disease, responsible for discomfort and time off work. There is currently no consensus on the best surgical therapy. We aimed at comparing conservative sinusectomy (S) to excision and paramedian primary closure (PC).

METHODS

This is a randomized controlled trial compatible with the CONSORT statement standards. We included all patients with chronic PD between 2012 and 2017. We excluded patients with acute abscesses, recurrent PD after surgery with a curative intent and patients needing complex reconstructions with rotation flaps. Patients with chronic symptomatic PD were randomized to S or PC. Primary end-point was the rate of patients healed at 3 weeks, secondary outcomes were total healing time, pain, time off work, patient satisfaction and recurrence at 1 year. Patients were seen at a wound clinic until healed and contacted at 3, 6, and 12 months for follow-up.

RESULTS

After inclusion of 58 patients the study was stopped prematurely due to discrepancy between expected and observed outcomes. Only 4/30 (13.3%) patients in the S group had healed completely at 3 weeks compared with 14/28 (50%) in the PC group (p = 0.01). Median time to complete healing was 54 (23-328) days in the S group compared to 34 (13-141) in the PC group (p = 0.025). Number of outpatient visits, time off work, analgesia requirement, and recurrence rates at 12 months 4 (16%) in the S group and 3 (11.1%) in the PC group (p = 0.548) were similar.

CONCLUSIONS

PC leads to faster healing compared to S, with similar healthcare burden.

TRIAL REGISTRATION

The study was approved by the local ethics committee and registered in www.clinicaltrials.gov (REF: NCT03271996). The study was carried out at the Regional Hospital of Lugano, Switzerland.

Sinusectomy and primary closure versus excision and primary closure in pilonidal sinus disease: a retrospective cohort study

BACKGROUND

Various surgical procedures are available for the treatment of pilonidal sinus diseases (PSD), but the best surgical approach remains controversial. Minimally invasive surgical procedures are more popular than surgery. This study aimed to evaluate the efficacy of sinusectomy with primary closure (SPC) in comparison with excision and primary closure (EPC) in primary or recurrent cases.

MATERIALS AND METHODS

This single-center retrospective cohort study was conducted with two cohort groups in which 351 patients with PSD underwent either SPC or EPC. The two procedures were compared according to the presence of short-term complications and recurrence of PSD.

RESULTS

Of the patients, 134 underwent EPC and 217 underwent SPC. The length of stay and the wound healing time were significantly longer in the EPC group than in the SPC group. The occurrence rates of wound site infection and abscess were significantly higher in the EPC group than in the SPC group; however, seroma was statistically significantly more common in the SPC group than in the EPC group. The recurrence rates were 18.7% and 5.5% in the EPC and SPC groups, respectively.

CONCLUSION

SPC is an efficient procedure for the treatment of patients with PSD showing simple and complicated disease patterns.

Coexistance of Gynecomastia and Poland Syndrome: Case Report

Coexistence of the Poland syndrome and gynecomastia is a rare condition. Poland syndrome requires soft tissue augmentation of the affected side, whereas gynecomastia necessitates reduction of the breast tissue. To provide symmetry, breast reduction and fat grafting techniques should be combined.

We report a 29-year-old male patient with left gynecomastia and right sided Poland syndrome. In order to correct his asymmetry on the anterior chest wall, left breast tissue resection and fat grafting to the right breast were performed.

Having these two opposite conditions at the same time and on the same patient makes the deformities look more dramatic than they are separately. Accurate planning and selection of proper techniques enable to provide symmetry in such cases.

Obesity, Hypertrichosis and Sex Steroids: Are these Factors Related to the Pilonidal Sinus Disease?

Objectives

Pilonidal sinus disease causes chronic inflammation of the skin and subcutaneous fatty tissue, and it commonly localises in the sacrococcygeal region. This study evaluated the effects of hypertrichosis, family history, obesity and sex steroids in 298 patients with pilonidal sinus disease.

Methods

The medical records of 618 patients treated at the General Surgery Clinic of Malatya State Hospital for primary pilonidal sinus disease between January 2014 and December 2017 were evaluated retrospectively.

Results

Female sex and family histories of pilonidal sinus disease and hypertrichosis were significantly higher in patients with than without hypertrichosis (p=0.030, p=0.035, p<0.001). The mean progesterone level was significantly lower in female patients with hypertrichosis than female patients without hypertrichosis (p=0.003).

Conclusion

Being overweight or obese, having an occupation that requires long-time sitting and having a family history predisposed to developing pilonidal sinus disease.

Surgical interventions for the treatment of sacrococcygeal pilonidal sinus disease in children: A systematic review and meta-analysis

BACKGROUND

Pilonidal sinus disease (PNS) is not uncommon in children. Controversy remains over the best treatment and there is limited evidence. This systematic review and meta-analysis aims to establish which techniques have the best outcomes in children.

METHODS

MEDLINE, EMBASE and CENTRAL databases were searched. Studies reporting treatment outcomes for PNS in children were included.

RESULTS

Open healing has pooled risk of recurrence of 26% (95%CI 15-38%), risk of wound complication of 21% (9-36%) and wound healing ranged from 38-92 days. Midline primary closure has pooled risk of recurrence of 12% (8-18%), risk of wound complication of 30% (19-46%) and wound healing ranged from 8 to 32 days. Off-midline primary closure has pooled risk of recurrence of 6% (1-15%), risk of wound complication of 14% (6-25%) and wound healing was 27 days. VAC therapy has pooled risk of recurrence of 20% (0-65%) and wound healing ranged from 38 to 92 days. Minimally invasive techniques has pooled risk of recurrence of 7% (1-16%) and wound healing ranged from 21-30 days. Marsupialisation has pooled risk of recurrence of 6% (0-22%), and wound healing ranged from 6 to 41 days.

CONCLUSION

Evidence for management of PNS in children is poor. Off-midline primary closure, minimally invasive techniques, and marsupialisation have the best outcomes.

LEVEL OF EVIDENCE RATING

IV.

Impact of geography and surgical approach on recurrence in global pilonidal sinus disease

Pilonidal sinus disease (PSD) is increasing globally. A recent meta-analysis and merged-data analysis showed that recurrence rates in PSD depend essentially on follow-up time and specific surgical procedures. However, the global distribution of surgical approaches and respective recurrence rates have never been studied in PSD. We aimed at studying the impact of geographic distribution of surgical approaches to treat PSD and subsequent geography-specific recurrence rates. We searched relevant databases as described previously. Recurrence rates were then associated with reported follow-up times and geographic origin. We simulated individual patients to enable analogy across data. Globally, recurrence rates range from 0.3% for Limberg/Dufourmentel approaches (95% CI 0.2–0.4) and flaps (95% CI 0.1–0.5) and up to 6.3% for incision (95% CI 3.2–9.3) at 12 months. Recurrence rates range from 0.3% for Karydakis/Bascom approaches (95% CI 0.0–0.8) up to 67.2% for incision (95% CI 7.5–100) in the USA, and 0.0% for primary asymmetric closure in Germany (95% CI 0.0–0.0). Our analysis shows that recurrence rates in PSD not only depend on therapeutic approaches and follow-up time but also on geography. Primary asymmetric closure and various flap techniques remain superior regardless of the geographical region. Some approaches have extraordinarily good outcomes in specific countries.

Is conservative treatment an effective option for pilonidal sinus disease in children?

Pilonidal sinus disease (PSD) is associated with a complex disease process in children, and its management remains controversial. There are a few published studies on PSD in the paediatric literature; therefore, we present our experience of conservatively treating PSD in children. This study involved a retrospective review with telephone follow up. All children diagnosed with PSD in 2012 to 2017 were identified at the outpatient clinic of the Department of Paediatric Surgery. All patients initially underwent conservative treatment (meticulous hair removal, improved perianal hygiene, warm sitz baths, and drainage for abscess). Data collection included demographics, type of management, recurrence, presence of infection, and total healing time. In the study period, 29 children were identified. Their mean age was 14.94 ± 1.09 (range: 12-16) years, and 51.7% were girls. The mean length of follow up was 8.34 ± 6.36 (range: 1-25) months. Complete healing occurred in 79.3% of patients. Recurrence was evident in 12% of patients. Four patients underwent surgery. PSD is being seen in children more frequently in recent years. Conservative treatment may be the recommended initial approach for PSD in children.

Preliminary report on endoscopic pilonidal sinus treatment in children: results of a multicentric series

BACKGROUND

Pilonidal disease is a troublesome acquired condition for whom various surgical treatments have been proposed with relatively high recurrence and complication rates. Since EPSiT technique has been described in 2013, it became an alternative treatment in adult practice. Our study reports the results of a multicentre series of pediatric patients who underwent EPSiT procedure over a 21-month period.

METHODS

Between July 2015 and March 2017, all consecutive patients undergoing EPSiT in four different pediatric surgical units have been enrolled. Details regarding demographic data, detailed surgical procedure, outcome and complications have been recorded.

RESULTS

A total of 43 patients underwent EPSiT procedure. Mean age was 15 years. There was a slight female preponderance. Mean weight and height at surgery were 67 kg and 168 cm, respectively. In 14% of cases a previous ineffective procedure was performed. Mean length of procedure was 34 min and median hospital stay was 24 h (12-72 h). Median length of follow-up was 4 months (range 3-18 months). Complications leading to reoperation were reported in 9% of cases with an overall resolution rate of 88%.

DISCUSSION

EPSiT proved to be feasible and safe even in the pediatric population. The effectiveness and safety of the procedure suggest that this technique can represent a valid alternative for the treatment of pilonidal disease in children.

Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence

We systematically searched available databases. We reviewed 6,143 studies published from 1833 to 2017. Reports in English, French, German, Italian, and Spanish were considered, as were publications in other languages if definitive treatment and recurrence at specific follow-up times were described in an English abstract. We assessed data in the manner of a meta-analysis of RCTs; further we assessed non-RCTs in the manner of a merged data analysis. In the RCT analysis including 11,730 patients, Limberg & Dufourmentel operations were associated with low recurrence of 0.6% (95%CI 0.3-0.9%) 12 months and 1.8% (95%CI 1.1-2.4%) respectively 24 months postoperatively. Analysing 89,583 patients from RCTs and non-RCTs, the Karydakis & Bascom approaches were associated with recurrence of only 0.2% (95%CI 0.1-0.3%) 12 months and 0.6% (95%CI 0.5-0.8%) 24 months postoperatively. Primary midline closure exhibited long-term recurrence up to 67.9% (95%CI 53.3-82.4%) 240 months post-surgery. For most procedures, only a few RCTs without long term follow up data exist, but substitute data from numerous non-RCTs are available. Recurrence in PSD is highly dependent on surgical procedure and by follow-up time; both must be considered when drawing conclusions regarding the efficacy of a procedure.

Which treatment modality for pediatric pilonidal sinus: Primary repair or secondary healing?

OBJECTIVE

To evaluate the outcome and characteristics of patients who were operated for sacrococcygeal pilonidal sinus (SPS) treatment using primary repair or secondary healing technique.

METHODS

Forty-seven patients (female: 25, male: 22) diagnosed with pilonidal sinus operated between 2009 and 2015 were retrospectively analyzed. The cases were evaluated for age, gender, body mass index (BMI), surgical technique, hospital stay, recovery time and recurrence. Mainly two types of surgical techniques were applied: primary repair and secondary healing.

RESULTS

Mean age of the patients was 15.6 (±1.2) years. Excision and primary repair was performed in 36, excision and secondary healing was in 11. There was no statistically significant difference between the groups regarding length of hospital stay and duration of postoperative pain (p > 0.05). There was a statistically significant difference between groups regarding recovery time (p < 0.05). Recurrence was detected in a total of 11 (23.4%) patients.

CONCLUSION

We did not find any significant difference concerning length of hospitalization, duration of postoperative pain and recurrence rate. However we determined that the primary repair group recovery time is significantly shorter compared to our secondary healing group. Therefore we recommended primary repair in the treatment of primary repair PS in children.

Strength of Occipital Hair as an Explanation for Pilonidal Sinus Disease Caused by Intruding Hair

BACKGROUND

Pilonidal sinus disease is thought to be caused by intrusion of hair into healthy skin; loose hair in the intergluteal fold is thought to promote disease. However, compelling evidence to support these postulates is lacking; the cause of pilonidal sinus disease remains uncertain.

OBJECTIVE

To determine whether particular properties of hair are associated with susceptibility to pilonidal sinus disease, we compared physical properties of hairs of patients with pilonidal sinus disease with hairs from control subjects who were matched for sex, BMI, and age.

DESIGN

This was an experimental study with establishment of a mechanical strength test for single hairs to quantify the maximum vertical force that a hair could exert, following tests of strength of occipital, lumbar, and intergluteal hair.

SETTINGS

Hair from patients with pilonidal sinus disease and matched control subjects were harvested from patients of the St. Marienhospital Vechta Department of Procto-Surgery.

PATIENTS

A total of 17 adult patients with pilonidal sinus disease and 217 control subjects were included.

MAIN OUTCOME MEASURES

ANOVA and intraclass and interclass variations of data gained from mechanical strength tests of occipital, lumbar, and intergluteal hair were included.

RESULTS

Vertical hair strength was significantly greater in patients with pilonidal sinus disease. Occipital hair exhibited 20% greater, glabella sacralis 1.1 times greater, and intergluteal hair 2 times greater strength in patients with pilonidal sinus disease than in matched control subjects (all p = 0.0001). In addition, patients with pilonidal sinus disease presented with significantly more hair at the glabella sacralis and in the intergluteal fold.

LIMITATIONS

The study was limited by its relatively small number of patients from a specific cohort of European patients.

CONCLUSIONS

Occipital hair exhibited considerable vertical strength. Because occipital hair exerted the greatest force and cut hair fragments were found in the pilonidal nest in large quantities, these data suggest that pilonidal sinus disease is promoted by occipital hair. See Video Abstract at http://links.lww.com/DCR/A435.

Risk Factors for Pilonidal Sinus Disease in Teenagers

OBJECTIVE

To investigate the risk factors for pilonidal sinus in teenagers.

METHODS

Between January 2013 and September 2015, 55 teenage patients who underwent surgery due to pilonidal sinus disease (PSD) in the Department of Pediatric Surgery, Sakarya University Teaching and Research Hospital were included in this study. Age, gender, body mass index (BMI), number of baths taken per week, time spent sitting per day, family history, and skin color were examined as risk factors. The control group comprised of healthy teenagers without pilonidal sinus disease.

RESULTS

Out of the total 42 teenagers, 23 (54.8 %) were girls and 19 (45.2 %) were boys. Patients were classified as obese, overweight, or normal according to their BMI (14.3 %, 31 %, and 54.8 %, respectively). The number of baths taken per week in the PSD group was lower than that in the control group [odds ratio (OR): 3.690; p = 0.004]. The family history of PSD was significantly higher in teenagers with PSD, compared to the control group (OR: 8.652; p = 0.005). No differences were detected between the PSD and control groups with respect to sitting for ≥ 6 h per day (OR: 3.212; p = 0.028). Skin color was not found to be affected by PSD in teenagers (OR: 1.294; p = 0.392).

CONCLUSIONS

Heredity and the number of baths taken per week were found to significantly affect the incidence of PSD, whereas other variables (gender, age, BMI, skin color, and time spent sitting per day) did not exhibit any significant influence on the rate of incidence.

Excision and Primary Closure May be the Better Option in the Surgical Management of Pilonidal Disease in the Pediatric Population

The optimal management of pilonidal disease in the pediatric population is still debated. We conducted a retrospective review of patients 21 years old and younger who underwent surgical management for pilonidal disease between 2009 and 2013 at a single pediatric institution. Sixty patients (41.7% male) were included in the analysis, with a mean age of 15.0 years (range, 13–20). Twelve (20%) had a prior drainage procedure for pilonidal abscess before the definitive operative treatment. After excision to the presacral fascia, 36 (60%) had primary closure, 17 (28.3%) were left to heal by secondary intention, and 7 (11.7%) had flap closure. Overall recurrence rate was 41.7 per cent with 33.3 per cent in the primary, 58.8 per cent in the secondary, and 42.9 per cent in the flap group, respectively. Ten (16.7%) patients developed postoperative complications, which were similar among surgical groups, gender, and body mass index. The average length of stay was 0.67 (median 0, range, 0–5) days. Primary closure had the shortest length of stay (analysis of variance P = 0.04), and flap closure had no reoperations (analysis of variance P < 0.01). Pilonidal disease remains surgically challenging. Our data suggest that excision and primary closure is a better option in the pediatric population.

Does Sacrococcygeal Angle Play a Role on Pilonidal Sinus Etiology?

The predisposing factors for the development of sacrococcygeal pilonidal disease (SPD) still remain undetermined. Here, we investigate the sacrococcygeal angle as a possible predisposing factor for the development of disease. Consecutive male patients admitted to our clinic with the diagnosis of SPD were included. Sex, age and BMI matched healthy controls without SPD were enrolled to the study. The predefined sacrococcygeal angles of patients and controls were measured on lateral pelvic radiographs by a single experienced radiologist. Thirty patients were included in each group. Sacrococcygeal angles of patients and control group were measured as 37.3±14.5 and 36.81±10.23 in patients and controls, respectively. The difference with respect to sacrococcygeal angle was not statistically significant between two groups. Sacrococcygeal angle which is the main skeletal determinant of intergluteal sulcus is not a predisposing factor for the development of sacrococcygeal pilonidal disease.

Modified Limberg flap technique in the treatment of pilonidal sinus disease in teenagers

BACKGROUND

Pilonidal sinus disease (PSD) is most common in young adults but can also affect teenagers. Although many techniques have been used to treat pilonidal sinus disease in adults, few studies have compared treatment methods for the condition in teenagers. In this study, we aimed to compare the modified Limberg flap technique with the excision and primary closure technique, both of which are used routinely in adults and teenage patients.

MATERIALS AND METHODS

This study was a retrospective review of 40 teenaged patients who underwent surgery in a single pediatric surgery center over ~2 years. The patients' age, gender, body mass index (BMI), number of sinuses, surgery technique and any complications were recorded. The patients underwent excision and primary repair or rhomboid excision and a modified Limberg flap.

RESULTS

Of the 40 patients, 22 (55%) were female, and 18 (45%) were male. The mean age of all the patients was 15.20 ± 1.31 (12-17) years. The average number of sinuses was 3.18 ± 0.90 (1-5). Of the patients, 52.5% (n=21) had a high body mass index. These patients were obese (n=4) and overweight(n=17). Pilonidal sinus excision and primary repair were performed in 8 (20%) of the patients, while the remaining 32 (80%) underwent the modified Limberg flap technique. Complications were observed in 87.5% of the patients undergoing excision and primary repair, and in 15.6% of those who underwent the modified Limberg flap technique. Recurrence was observed with only the primary repair technique (37.5%).

DISCUSSION

When compared with adults, teenage pilonidal sinus disease occurs more frequently in females. In this study, no correlation existed between the number of sinuses, symptoms, BMI and postoperative complications. Based on the results of this study, the modified Limberg flap technique has a low complication rate when used to treat pilonidal sinus disease in teenagers.

Cutaneous manifestations in children with diabetes mellitus and obesity

Obesity and diabetes are chronic diseases that affect people all over the world, and their incidence is increasing in both children and adults. Clinically, they affect a number of organs, including the skin. The cutaneous manifestations caused or aggravated by obesity and diabetes are varied and usually bear some relation to the time that has elapsed since the onset of the disease. They include soft fibromas, acanthosis nigricans, striae, xerosis, keratosis pilaris, plantar hyperkeratosis, fungal and bacterial skin infections, granuloma annulare, necrobiosis lipoidica, psoriasis, and atopic dermatitis. In this review article we present the skin changes found in children with diabetes mellitus and obesity and related syndromes and highlight the importance of the skin as a tool for establishing clinical suspicion and early diagnosis of systemic disease.

Pilonidal sinus disease: risk factors for postoperative complications and recurrence

The aim of this study is to analyze the risk factors for complications and recurrence in pilonidal sinus disease. The prospective study consisted of 144 patients with pilonidal sinus disease who were operated on at Dicle University Medical Faculty, Department of General Surgery, between February 2008 and December 2010. Patients receiving the Limberg flap totaled 106 (73.6%), while 38 (26.4%) had primary closure. Postoperative complications developed in 42 subjects (29.2%), and recurrence occurred in 19 (13.2%). The Limberg flap method was statistically considered as a risk factor for postoperative complications (P  =  0.039). Regarding recurrence, family tendency (P  =  0.011), sinus number (P  =  0.005), cavity diameter (P  =  0.002), and primary closure (P  =  0.001) were found to be risk factors. Postoperative complication rate is higher in the Limberg flap method than primary closure method. The risk of recurrence is related to family tendency, sinus number, cavity diameter and anesthesia type and is also higher in primary closure.

Treatment of adolescent pilonidal disease with a new modification to the Limberg flap: symmetrically rotated rhomboid excision and lateralization of the Limberg flap technique

BACKGROUND/PURPOSE

Pilonidal disease is a common and frustrating problem among adolescents due to its high recurrence rate. The rhomboid excision and Limberg flap techniques promise successful results, but the lower part of the incision left on the intergluteal sulcus is prone to recurrences. Consequently, we have developed a new modification to this technique and have designed a descriptive prospective study to evaluate its efficiency.

METHODS

We conducted this prospective study between March 2011 and March 2012. All of the patients who were operated on for sacrococcygeal pilonidal disease were included in this study. The surgical procedure primarily consisted of symmetrically rotated (clockwise) rhomboid excision and lateralization of the Limberg flap in order to keep the inferior corner of the suture line apart from the intergluteal sulcus.

RESULTS

A total of 15 adolescents (8 boys and 7 girls) were included in the study group. Of the patients, 47% were normal, 13% were overweight, and 40% were obese. Five patients were operated on under general anesthesia, and 10 were operated on under spinal anesthesia. The length of the flap margins ranged from 2.5 to 7 cm (median=4 cm). The median duration of hospitalization was 5 days, and the median duration of suction drainage was 4 days. The median postoperative follow-up period was 4 months (ranging from 1 to 12 months), and we did not encounter any wound infection or recurrent disease during this period. Only one patient had wound hematoma as a result of drain breakdown and was treated with wound care without any additional complications.

CONCLUSION

Although the number of patients in this study was small and the follow-up period was short, we obtained satisfactory results without any recurrence by performing a symmetrically rotated rhomboid excision and lateralized Limberg flap procedure.

Specimen index may be a predictive factor for recurrence after primary closure of pilonidal disease

PURPOSE

The aim of the present study was to evaluate the predictive value of volume of the specimen/body mass index (VS/BMI) ratio for recurrence after surgical therapy of pilonidal disease.

METHODS

Ninety-eight patients with primary pilonidal disease were enrolled in this study. The VS/BMI ratio was calculated for each patient. This ratio was defined as the specimen index (SI). VS, BMI and SI were evaluated to determine whether there is a relationship between these parameters and recurrence of pilonidal disease. In addition, the predictive ability of SI for recurrence was analyzed by receiver operating characteristic (ROC) curve.

RESULTS

VS and SI were found to be higher in patients with recurrence. ROC curve analysis showed that VS and SI are predictive factors for recurrence in patients treated with primary closure, nevertheless our new index had higher sensitivity and specificity than VS (sensitivity 85.7% vs 71.4% and specificity 90.7% vs 85.1%, respectively). The cut-off level for the greatest sensitivity and specificity for SI was 1.29.

CONCLUSION

Recurrence is higher in patients with high VS regardless of the operation method. SI may be a predictive value in patients treated with primary closure.

Is There a Relation Between Natal Cleft Depth and Post-Operative Morbidity After Different Methods of Excision of Sacro-Coccygeal Pilonidal Sinus?

The role of natal cleft depth in postoperative morbidities after pilonidal sinus disease (PSD) surgery is still uncertain. To examine the correlation between natal cleft depth and postoperative morbidities after different methods of excision of PSD. We prospectively examined data of 66 operated patients with PSD at Prince Fahd Ben Sultan hospital, Tabouk, KSA. Of the studied patients, 18 were treated by simple closure (27.3 %), 13 patients by Bascom closure (19.7 %), 21 patients by the open method (31.8 %) and 14 patients by the semiopen method (21.2 %). Postoperative morbidities were recorded. The data were analyzed using appropriate statistical tests. Sixty six patients (62 males, 4 females) underwent surgery for PSD. The mean age of the studied patients was 26.7 ± 6.9 (range 15-51). Nine patients (13.7 %) showed delayed healing with the highest incidence was among patients treated by the open method (6/21 (28.5 %)), and 5 patients (7.5 %) showed recurrence. There have been significant positive correlations between natal cleft depth and delayed healing, which was evident among patients treated by the open method (r = +0.78; p < .0001). The findings suggest that natal cleft depth is a significant factor correlated with postoperative morbidities of PSD after surgical treatment.

Development of an evidence-based protocol for care of pilonidal sinus wounds healing by secondary intent using a modified reactive Delphi procedure. Part one: the literature review*

This article is in two parts. The overall aim of this section was to review the literature in relation to pilonidal sinus wounds (PSW) healing by secondary intent for a Master's of Science in Wound Healing and Tissue Repair thesis. The purpose of the literature review was to determine if an evidence-based guideline or consensus document existed for the care of these wounds, and if not, to determine the topics from which to develop items for the first round of a modified reactive Delphi questionnaire. Part two will describe the iterative process, the analysis and the results. The review found no best practice guidelines concerning PSW, and only one clinical pathway. Seventeen areas of interest were identified that may contribute to optimal healing conditions or to delayed healing. These included microbiology of infected PSW, signs and symptoms of localised or deeper (spreading) chronic wound infection, swab for c&s, role of topical antiseptics or antimicrobials, systemic antibiotics, local wound interventions, optimal positioning, wound cleansing, principles of moist wound healing/dressing selection, topical negative pressure (TNP) therapy, peri-wound skin decontamination and depilation, pain control, physical activities, optimal nutrition and patient education.

Day-Case Limberg Flap for Recurrent Pilonidal Sinus: Does Obesity Complicate the Issue?

The purpose of this study was to analyze the long-term outcome of rhomboid excision with Limberg flap reconstruction (LF) as one-day surgery in treatment of recurrent pilonidal sinus (RPS). The effect of obesity on outcome will be addressed. Forty-nine patients with RPS were treated by rhomboid excision and LF as one-day surgery. Data collected included demographics, body mass index, operative time, flap ischemia, wound infection, length of hospital stay, time of complete healing, and recurrence. Patients’ mean age was 33.4 years and mean number of previous operations was 3.4. Operative time ranged from 40 to 70 minutes. Two patients developed sterile seroma (4.1%) and two patients (4.1%) had wound infections. No wound dehiscence or flap ischemia was reported. All patients returned to normal activity within 7 days. No recurrences were reported after a mean follow-up of 32.1 months. Obesity significantly increased the operative time, however, it affected neither the postoperative outcome nor the long-term recurrence. Rhomboid excision and LF as one-day surgery is a safe and reliable method for treatment of RPS. It guarantees low morbidity, short hospital stay, short time off work, and carries low risk of recurrence, even in obese patients.

Unroofing and curettage for the treatment of acute and chronic pilonidal disease

BACKGROUND

Various surgical techniques are available in the management of pilonidal sinus, but controversy concerning the optimal surgical approach persists. The present study analyzes the outcome of unroofing and curettage as the primary intervention for acute and chronic pilonidal disease.

METHODS

A total of 297 consecutive patients presenting with chronic disease, acute abscess, or recurrent disease were treated with unroofing and curettage. The wound was left open to heal by secondary intention. Hospitalization, time required to resume daily activities and return to work, healing time, and recurrence rates were recorded.

RESULTS

All patients were discharged within the first 24 h after operation. The median period before returning to work was 3.2 +/- 1.2 days, and the mean time for wound healing was 5.4 +/- 1.1 weeks. Six patients were readmitted with recurrence of the disease within the first six postoperative months. All recurrences were in patients who did not follow the wound care advice and who did not come to regular weekly appointments. Patients with recurrence underwent repeat surgery by the same technique with good results.

CONCLUSIONS

Unroofing and curettage for pilonidal sinus disease is an easy and effective technique. The vast majority of the patients, including those with abscess as well as those with chronic disease, will heal with this simple procedure, after which even recurrences can be managed successfully with the same procedure. Relying on these results, we advocate unroofing and curettage as the procedure of choice in the management of pilonidal disease.

Introducing an asymmetric cleft lift technique as a uniform procedure for pilonidal sinus surgery

BACKGROUND AND AIMS

Asymmetric techniques for surgery in pilonidal sinus disease (PSD) have been reported to provide better results than simple excision and closure in the midline. The aim of this retrospective study was to evaluate the results after introducing the Bascom asymmetric cleft lift procedure in our hospital on a day care basis.

MATERIAL AND METHODS

From a total of 33 patients operated from April 2002 to September 2004 with the Bascom asymmetric cleft lift technique, we were able to contact 29 who were invited to a follow up study. Eighteen (62%) of these patients accepted a consultation in the outpatient clinic while 11 (38%) were interviewed by phone.

RESULTS

At follow up mean 17 (range 10-27) months after the operation 24 (83%) of the wounds were healed while recurrences were present in 5 (17%) of the patients. In two of the patients with recurrences errors in the procedures were identified. Further results related to pre-, per- and postoperative conditions are discussed in this paper.

CONCLUSION

Early results after surgery for PSD with the Bascom asymmetric cleft-lift technique are promising. The technique has now become our standard procedure for treating chronic, symptomatic PSD.

The importance of local subcutaneous fat thickness in pilonidal disease

PURPOSE

This study was designed to investigate the local subcutaneous fat thickness in sacrococcygeal pilonidal disease.

METHODS

Subcutaneous fat thickness was measured by ultrasonography in 125 patients with sacrococcygeal pilonidal disease and 125 age-matched, body mass index-matched and gender-matched controls.

RESULTS

The sacrococcygeal subcutaneous fat thickness was 14.4 +/- 2.9 mm, 18.3 +/- 3.1 mm, and 22 +/- 2.2 mm, respectively, in normal, overweight, and obese patients with sacrococcygeal pilonidal disease and 9.1 +/- 3.1 mm, 11.3 +/- 2.6 mm, and 20 +/- 1.8 mm, respectively, in normal, overweight, and obese controls. Sacrococcygeal fat was significantly thicker in normal and overweight patients with pilonidal disease compared with controls with same body mass index (P< 0.01). There were no significant differences in fat thickness between obese patients and obese controls (P > 0.05).

CONCLUSIONS

Sacrococcygeal fat thickness, as a local factor, is closely associated with pilonidal disease.

Obesity and infection

Obesity increases morbidity and mortality through its multiple effects on nearly every human system. However, the various aspects of the association between obesity and infection have not been reviewed. Thus, we reviewed the relevant literature focusing on clinical aspects of this association. Obesity has a clear but not yet precisely defined effect on the immune response through a variety of immune mediators, which leads to susceptibility to infections. Data on the incidence and outcome of specific infections, especially community-acquired infections, in obese people are so far limited. The available data suggest that obese people are more likely than people of normal weight to develop infections of various types including postoperative infections and other nosocomial infections, as well to develop serious complications of common infections. Large prospective studies are required to further define the burden of infectious morbidity and mortality conferred by obesity.

Treatment of Pilonidal Disease with Laser Epilation

Pilonidal disease is a debilitating, chronic disease of the natal cleft. It mainly involves the sacrococcygeal region and the presentation varies from asymptomatic pits to painful draining abscesses. Treatment options vary from observation to wide excision. Unfortunately, surgical treatment often results in recurrence. The etiologic agent remains in question, as does the optimal treatment. Our objective was to assess the efficacy of laser epilation as an adjunctive therapy to surgical excision of the pilonidal sinus. Eighteen men and five women were treated with laser epilation in our office from 2001 to 2004. All patients had experienced recurrent folliculitis and had undergone some form of drainage procedure or prior excision. After surgical excision of the affected area, a Vasculite™ Plus laser was used for the epilation treatments. Each session involved 9 to 12 treatments and the patients underwent an average of two sessions. All 19 of the patients that remain in follow-up report no recurrence of their folliculitis or need for further surgical procedures. During treatment, six of the men and one of the women experienced a superficial wound dehiscence. All healed with local wound care and continued laser treatments. Laser epilation is an effective adjunctive therapy for the treatment of pilonidal disease. Although not curative in and of itself, the removal of hair allows better healing and decreases the chance of recurrence by removal of a significant etiology of pilonidal disease.