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Cai Z, Zhao Z, Ma Q, Shen C, Jiang Z, Liu C, Liu C, Zhang B. Midline and off-midline wound closure methods after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev 2024; 1:CD015213. [PMID: 38226663 PMCID: PMC10790338 DOI: 10.1002/14651858.cd015213.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
BACKGROUND Pilonidal sinus disease is a common and debilitating condition. Surgical treatment remains the mainstay for managing chronic disease, with options including midline and off-midline wound closure methods. However, the optimal approach remains uncertain. Recent developments in tension-free midline techniques require further exploration. OBJECTIVES To assess the effects of midline and off-midline wound closure methods for pilonidal sinus, and to determine the optimal off-midline flap procedures. SEARCH METHODS In June 2022, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus EBSCO, and clinical trials registries. We also scanned the reference lists of included studies, as well as reviews, meta-analyses, and health technology reports. We applied no language, publication date, or study setting restrictions. SELECTION CRITERIA We included parallel RCTs involving participants undergoing midline closure without flap techniques and off-midline closure for pilonidal sinus treatment. We excluded quasi-experimental studies and studies that enroled participants presenting with an abscess. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. The critical outcomes included wound healing (time to wound healing, proportion of wounds healed), recurrence rate, wound infection, wound dehiscence, time to return to work, and quality of life. We assessed biases in these outcomes utilising the Cochrane risk of bias 2 tool and appraised evidence certainty via the GRADE approach. MAIN RESULTS We included 33 studies with 3667 analysed participants. The median or average age of the participants across the included studies ranged from 21.0 to 34.2 years, with a predominant male representation. Geographically, the trials were primarily conducted in the Middle East. We identified nine intervention comparisons. In this abstract, we focus on and present the summarised findings for the three primary comparisons. Off-midline closure versus conventional midline closure Off-midline closure probably reduces the time to wound healing (mean difference (MD) -5.23 days, 95% confidence interval (CI) -7.55 to -2.92 days; 3 studies, 300 participants; moderate-certainty evidence). However, there may be little to no difference between the two methods in the proportion of wounds healed (100% versus 88.5%, risk ratio (RR) 1.13, 95% CI 0.92 to 1.39; 2 studies, 207 participants; very low-certainty evidence). Off-midline closure probably results in lower rates of recurrence (1.5% versus 6.8%, RR 0.22, 95% CI 0.11 to 0.45; 13 studies, 1492 participants; moderate-certainty evidence) and wound infection (3.8% versus 11.7%, RR 0.32, 95% CI 0.22 to 0.49; 13 studies, 1568 participants; moderate-certainty evidence), and may lower rates of wound dehiscence (3.9% versus 8.9%, RR 0.44, 95% CI 0.27 to 0.71; 11 studies, 1389 participants; low-certainty evidence). Furthermore, off-midline closure may result in a reduced time to return to work (MD -3.72 days, 95% CI -6.11 to -1.33 days; 6 studies, 820 participants; low-certainty evidence). There were no data available for quality of life. Off-midline closure versus tension-free midline closure Off-midline closure may reduce the time to wound healing (median 14 days in off-midline closure versus 51 days in tension-free midline closure; 1 study, 116 participants; low-certainty evidence) and increase wound healing rates at three months (94.7% versus 76.4%, RR 1.24, 95% CI 1.06 to 1.46; 1 study, 115 participants; low-certainty evidence), but may result in little to no difference in rates of recurrence (5.4% versus 7.8%, RR 0.69, 95% CI 0.30 to 1.61; 6 studies, 551 participants; very low-certainty evidence), wound infection (2.8% versus 6.4%, RR 0.44, 95% CI 0.16 to 1.17; 6 studies, 559 participants; very low-certainty evidence), and wound dehiscence (2.5% versus 3.0%, RR 0.82, 95% CI 0.17 to 3.84; 3 studies, 250 participants; very low-certainty evidence) compared to tension-free midline closure. Furthermore, off-midline closure may result in longer time to return to work compared to tension-free midline closure (MD 3.00 days, 95% CI 1.52 to 4.48 days; 1 study, 60 participants; low-certainty evidence). There were no data available for quality of life. Karydakis flap versus Limberg flap Karydakis flap probably results in little to no difference in time to wound healing compared to Limberg flap (MD 0.36 days, 95% CI -1.49 to 2.22; 6 studies, 526 participants; moderate-certainty evidence). Compared to Limberg flap, Karydakis flap may result in little to no difference in the proportion of wounds healed (80.0% versus 66.7%, RR 1.20, 95% CI 0.77 to 1.86; 1 study, 30 participants; low-certainty evidence), recurrence rate (5.1% versus 4.5%, RR 1.14, 95% CI 0.61 to 2.14; 9 studies, 890 participants; low-certainty evidence), wound infection (7.9% versus 5.1%, RR 1.55, 95% CI 0.90 to 2.68; 8 studies, 869 participants; low-certainty evidence), wound dehiscence (7.4% versus 6.2%, RR 1.20, 95% CI 0.41 to 3.50; 7 studies, 776 participants; low-certainty evidence), and time to return to work (MD -0.23 days, 95% CI -5.53 to 5.08 days; 6 studies, 541 participants; low-certainty evidence). There were no data available for quality of life. AUTHORS' CONCLUSIONS This Cochrane review examines the midline and off-midline wound closure options for pilonidal sinus, predominantly based on young adult studies. Off-midline flap procedures demonstrate there may be benefits over conventional midline closure for pilonidal sinus, with various off-midline flap techniques. When off-midline flap closures were compared to tension-free midline closure, low-certainty evidence indicated there may be improved wound healing and increased time to return to work for off-midline closure, whilst very low-certainty evidence indicated there may be no evidence of a difference in other outcomes. There may be no evidence of an advantage found amongst the off-midline techniques evaluated. The choice of either procedure is likely to be based on a clinician's preference, experience, patient characteristics, and the patients' preferences. To more accurately determine the benefits and potential harms of these closure techniques, further large-scale and meticulously-designed trials are essential. Specifically, there is a pressing need for more studies addressing the paediatric population, in addition to adult studies.
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Affiliation(s)
- Zhaolun Cai
- Department of General Surgery, Gastric Cancer Center, Research Laboratory of Tumor Epigenetics and Genomics for General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhou Zhao
- Department of Gastrointestinal Cancer Center, Chongqing University Cancer Hospital, Chongqing, China
| | - Qin Ma
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chaoyong Shen
- Department of General Surgery, Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyuan Jiang
- Department of Plastic Surgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Chunyu Liu
- Department of Pharmacy, Evidence-based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chunjuan Liu
- Department of General Surgery, Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Zhang
- Department of General Surgery, Gastric Cancer Center, Research Laboratory of Tumor Epigenetics and Genomics for General Surgery, West China Hospital, Sichuan University, Chengdu, China
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Minneci PC, Gil LA, Cooper JN, Asti L, Nishimura L, Lutz CM, Deans KJ. Laser Epilation as an Adjunct to Standard Care in Reducing Pilonidal Disease Recurrence in Adolescents and Young Adults: A Randomized Clinical Trial. JAMA Surg 2024; 159:19-27. [PMID: 37938854 PMCID: PMC10633416 DOI: 10.1001/jamasurg.2023.5526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/07/2023] [Indexed: 11/10/2023]
Abstract
Importance Recurrence continues to be a significant challenge in the treatment and management of pilonidal disease. Objective To compare the effectiveness of laser epilation (LE) as an adjunct to standard care vs standard care alone in preventing recurrence of pilonidal disease in adolescents and young adults. Design, Setting, and Participants This was a single-institution, randomized clinical trial with 1-year follow-up conducted from September 2017 to September 2022. Patients aged 11 to 21 years with pilonidal disease were recruited from a single tertiary children's hospital. Intervention LE and standard care (improved hygiene and mechanical or chemical depilation) or standard care alone. Main Outcomes and Measures The primary outcome was the rate of recurrence of pilonidal disease at 1 year. Secondary outcomes assessed during the 1-year follow-up included disability days, health-related quality of life (HRQOL), health care satisfaction, disease-related attitudes and perceived stigma, and rates of procedures, surgical excisions, and postoperative complications. Results A total of 302 participants (median [IQR] age, 17 [15-18] years; 157 male [56.1%]) with pilonidal disease were enrolled; 151 participants were randomly assigned to each intervention group. One-year follow-up was available for 96 patients (63.6%) in the LE group and 134 (88.7%) in the standard care group. The proportion of patients who experienced a recurrence within 1 year was significantly lower in the LE treatment arm than in the standard care arm (-23.2%; 95% CI, -33.2 to -13.1; P < .001). Over 1 year, there were no differences between groups in either patient or caregiver disability days, or patient- or caregiver-reported HRQOL, health care satisfaction, or perceived stigma at any time point. The LE group had significantly higher Child Attitude Toward Illness Scores (CATIS) at 6 months (median [IQR], 3.8 [3.4-4.2] vs 3.6 [3.2-4.1]; P = .01). There were no differences between groups in disease-related health care utilization, disease-related procedures, or postoperative complications. Conclusions and Relevance LE as an adjunct to standard care significantly reduced 1-year recurrence rates of pilonidal disease compared with standard care alone. These results provide further evidence that LE is safe and well tolerated in patients with pilonidal disease. LE should be considered a standard treatment modality for patients with pilonidal disease and should be available as an initial treatment option or adjunct treatment modality for all eligible patients. Trial Registration ClinicalTrials.gov Identifier: NCT03276065.
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Affiliation(s)
- Peter C. Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
- Department of Surgery, Nemours Children’s Health, Delaware Valley, Wilmington
| | - Lindsay A. Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | - Leah Nishimura
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | - Carley M. Lutz
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | - Katherine J. Deans
- Department of Surgery, Nemours Children’s Health, Delaware Valley, Wilmington
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Horesh N, Maman R, Zager Y, Anteby R, Weksler Y, Carter D, Nachmany I, Ram E. Surgical outcomes of minimally invasive trephine surgery for pilonidal sinus disease with and without laser therapy: a comparative study. Tech Coloproctol 2023; 28:13. [PMID: 38093161 DOI: 10.1007/s10151-023-02897-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Over the last decades, novel therapeutic options have emerged for the surgical treatment of pilonidal sinus disease (PSD). The aim of this study was to evaluate the outcomes of trephine/pit excision surgery with or without laser therapy in patients with PSD. METHODS A retrospective cohort study was conducted at a large tertiary medical center, including all adult patients with PNS who underwent trephine surgery with/without laser therapy between 2016 and 2021[AUTHORS TO INSERT MONTH]. Propensity score matching was used to address confounding factors, and the primary outcome was the 1-year recurrence rate. RESULTS The study included 221 patients with PSD, with a mean age of 23.73 years (87.7% male). In the unmatched cohort (130 trephine surgery alone, 91 trephine surgery + laser therapy), significant differences were observed in mean age (23 vs. 25 years; p < 0.01)[AUTHROS TO USE MEDIAN PLUS RANGE OR ADD SD] and surgeons' experience (p = 0.014). Propensity score matching was applied to overcome confounding factors, resulting in a matched cohort including 73 patients in each group. The addition of laser therapy demonstrated a significantly lower recurrence rate (8.2% vs. 32.9%; p < 0.001) compared to pit excision without laser therapy. Logistic regression analysis showed that the addition of laser was significantly associated with a lower risk for recurrence (OR 0.23; 95% CI 0.089-0.633; p < 0.01). CONCLUSION The incorporation of laser therapy along with trephine/pit excision surgery significantly reduces the recurrence rate in patients with PNS. Further prospective studies are needed to confirm our findings.
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Affiliation(s)
- N Horesh
- Department of General Surgery and Transplantations, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.
| | - R Maman
- Department of General Surgery and Transplantations, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Zager
- Department of General Surgery and Transplantations, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Anteby
- Department of General Surgery and Transplantations, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Weksler
- Department of General Surgery and Transplantations, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Carter
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - I Nachmany
- Department of General Surgery and Transplantations, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Ram
- Department of General Surgery and Transplantations, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Liu X, Zhao X, Shen G, Fan S, Xu J, Fan Z, Li K. Effect of sinus resection combined with vacuum-assisted closure on sacrococcygeal pilonidal sinus. Int Wound J 2023; 20:3474-3482. [PMID: 37218401 PMCID: PMC10588358 DOI: 10.1111/iwj.14218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
This study was aimed at investigating the effect of sinus removal combined with vacuum-assisted closure in the treatment of sacrococcygeal pilonidal sinus. From January 2019 to May 2022, 62 patients with sacrococcygeal pilonidal sinus were treated and their information was collected at our hospital. These patients were randomly divided into two groups: an observation group (n = 32) and a control group (n = 30). The control group underwent a simple sinus resection and suture, while the observation group received a sinus resection combined with closed negative pressure drainage of the wound. A retrospective analysis of the data obtained was conducted. Perioperative indicators, clinical efficacy, postoperative pain, complications, aesthetic effects, and satisfaction scores at six months after the operation were compared between the two groups, and the recurrence rate at six months after the operation was recorded. Through this study, we found that the observation group had significantly shorter surgery time, hospital stay, and return time compared with the control group (P < 0.05). Additionally, the observation group had a higher overall recurrence rate (ORR) of 100.00%, which was significantly better than the control group's ORR of 86.67% (P < 0.05). The visual analog scale (VAS) score at 6, 12, and 24 h after the operation was significantly lower in the observation group compared with the control group (P < 0.05). Although the differences were not significant (P > 0.05), the observation group had decreased white blood cell, neutrophil, and C-reactive protein levels after the operation. Moreover, the total occurrence rate of postoperative complications in the observation group was significantly lower (6.25%) than that of the control group (26.67%; P < 0.05). The observation group also had significantly lower scores on the postoperative scar scale and higher satisfaction scores than the control group (P < 0.05). However, there was no significant difference in the postoperative recurrence rate between the two groups (P > 0.05). Our study demonstrated that sinus resection combined with vacuum-assisted closure was more effective in treating sacrococcygeal pilonidal sinus compared with simple sinus resection and suture. This approach significantly reduced surgery time, hospital stay, and return time. It also effectively relieved postoperative pain, reduced the occurrence of postoperative complications, resulted in smaller postoperative scars, and yielded better aesthetic outcomes and higher patient satisfaction.
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Affiliation(s)
- Xiao Liu
- Department of Burn and Plastic Surgerythe First Affiliated Hospital of Soochow UniversitySuzhouPeople's Republic of China
| | - Xiaoyu Zhao
- Department of Burn and Plastic Surgerythe First Affiliated Hospital of Soochow UniversitySuzhouPeople's Republic of China
| | - Guoliang Shen
- Department of Burn and Plastic Surgerythe First Affiliated Hospital of Soochow UniversitySuzhouPeople's Republic of China
| | - Shuwen Fan
- Department of Burn and Plastic Surgerythe First Affiliated Hospital of Soochow UniversitySuzhouPeople's Republic of China
| | - Jun Xu
- Department of Burn and Plastic Surgerythe First Affiliated Hospital of Soochow UniversitySuzhouPeople's Republic of China
| | - Zhaojun Fan
- Department of Burn and Plastic Surgerythe First Affiliated Hospital of Soochow UniversitySuzhouPeople's Republic of China
| | - Ke Li
- Department of Burn and Plastic Surgerythe First Affiliated Hospital of Soochow UniversitySuzhouPeople's Republic of China
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Walker H, Hamid O, Ramirez J, Glancy D. Diagnosis and management of sacrococcygeal pilonidal disease in primary care. BMJ 2023; 382:e071511. [PMID: 37696569 DOI: 10.1136/bmj-2022-071511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Affiliation(s)
- Hamish Walker
- Gloucestershire Royal Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Osama Hamid
- Gloucestershire Royal Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Jozel Ramirez
- Gloucestershire Royal Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Damian Glancy
- Gloucestershire Royal Hospitals NHS Foundation Trust, Gloucestershire, UK
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Maasewerd SKM, Stefanescu MC, König TT, Engels MN, Rohleder S, Schwind M, Heydweiller AC, Oetzmann von Sochaczewski C. Paediatric Pilonidal Sinus Disease: Early Recurrences Irrespective of the Treatment Approaches in a Retrospective Multi-centric Analysis. World J Surg 2023; 47:2296-2303. [PMID: 37204438 PMCID: PMC10387461 DOI: 10.1007/s00268-023-07045-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 05/20/2023]
Abstract
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.
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Affiliation(s)
- Sophie K M Maasewerd
- Klinik für Kinderchirurgie, St. Marien Hospital Bonn, Bonn, Germany
- Sektion Kinderchirurgie der Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Tatjana T König
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Germany
| | - Marie N Engels
- Sektion Kinderchirurgie der Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Germany
| | - Stephan Rohleder
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Germany
| | - Martin Schwind
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Germany
| | - Andreas C Heydweiller
- Klinik für Kinderchirurgie, St. Marien Hospital Bonn, Bonn, Germany
- Sektion Kinderchirurgie der Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Germany
| | - Christina Oetzmann von Sochaczewski
- Sektion Kinderchirurgie der Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Germany.
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Wu P, Zhang Y, Zhang Y, Wang S, Fan Z. Progress in the surgical treatment of sacrococcygeal pilonidal sinus: a review. Int J Surg 2023; 109:2388-2403. [PMID: 37158142 PMCID: PMC10442091 DOI: 10.1097/js9.0000000000000447] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND A pilonidal sinus (PS) is an acquired disease resulting from recurrent infections and chronic inflammation. A PS involving the sacrococcyx is referred to as a sacrococcygeal PS (SPS). An SPS is a rare chronic infectious disease for which surgery is a good choice. The incidence of SPS has gradually increased worldwide in recent years. However, surgeons have not reached a consensus on the preferred surgical approach for SPS. The authors performed a systematic review and meta-analysis to analyze differences in the efficacy of different surgical approaches for the treatment of SPS. METHODS A systematic search was conducted in the PubMed database covering the period from 1 January 2003, to 28 February 2023. The primary outcome parameters were recurrence and infection. Finally, statistical analysis (meta-analysis) was carried out using RevMan 5.4.1 software. In addition, we systematically reviewed the latest progress in the surgical treatment of SPS over the past 20 years, especially as reported in the past 3 years. RESULTS Twenty-seven articles, 54 studies, and 3612 participants were included in this meta-analysis. The recurrence rate following the midline closure (MC) technique was much higher than that of other techniques. Among the techniques analyzed, the differences between MC and Limberg flap (LF), and between MC and marsupialization were statistically significant [ P =0.0002, risk ratio (RR)=6.15, 95% CI 2.40, 15.80; P =0.01, RR=12.70, 95% CI 1.70, 95.06]. The recurrence rate of open healing was higher than that of the Karydakis flap (KF) technique, and the difference was statistically significant ( P =0.02, RR=6.04, 95% CI 1.37, 26.55). Most of the results comparing MC with other techniques suggested that the former had a higher infection rate, and the difference between MC and LF was statistically significant ( P =0.0005, RR=4.14, 95% CI 1.86, 9.23). Comparison between KF and LF, modified LF and KF showed that the differences were not statistically significant in terms of recurrence and infection ( P ≥0.05). CONCLUSIONS There are various surgical treatment options for SPS, including incision and drainage, excision of diseased tissue with primary closure and secondary healing, and minimally invasive surgery. It is still not possible to determine which surgical technique should be considered the gold standard for treatment, as even the results of different researchers using the same operation method are conflicting. But what is certain is that the midline closure technique has a much higher incidence of postoperative recurrence and infection than other techniques. Therefore, the anorectal surgeon should formulate the most suitable individualized plan for the patient based on a comprehensive evaluation of the patient's wishes, appearance of the SPS, and the professional ability of the surgeon.
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Affiliation(s)
| | | | - Yewei Zhang
- Hepatopancreatobiliary Center, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuang Wang
- Department of Endocrinology, Second Affiliated Hospital of Dalian Medical University, Dalian
| | - Zhe Fan
- Department of General Surgery
- Liaoning Province Key Laboratory of Corneal and Ocular Surface Diseases Research, The Third People’s Hospital of Daliana
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Gil LA, Deans KJ, Minneci PC. Management of Pilonidal Disease: A Review. JAMA Surg 2023; 158:875-883. [PMID: 37256592 DOI: 10.1001/jamasurg.2023.0373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Importance The management of pilonidal disease continues to be a challenge due to high rates of recurrence and treatment-associated morbidity. Observations There is a heterogeneous repertoire of treatment modalities used in the management of pilonidal disease and wide practice variation among clinicians. Available treatment options vary considerably in their level of invasiveness, associated morbidity and disability, risks of complications, and effectiveness at preventing disease recurrence. Conservative nonoperative management strategies, including persistent improved hygiene, depilation, and lifestyle modification, focus on disease prevention and minimization of disease activity. Epilation techniques using both laser and intense pulse light therapy are also used as primary and adjunct treatment modalities. Other nonoperative treatment modalities include phenol and fibrin injection to promote closure of pilonidal sinuses. The traditional operative management strategy for pilonidal disease involves excision of affected tissue paired with a variety of closure types including primary midline closure, primary off-midline closure techniques (ie, Karydakis flap, Limberg flap, Bascom cleft lift), and healing by secondary intention. There has been a recent shift toward more minimally invasive operative approaches including sinusectomy (ie, trephination or Gips procedure) and endoscopic approaches. Overall, the current evidence supporting the different treatment options is limited by study quality with inconsistent characterization of disease severity and use of variable definitions and reporting of treatment-associated outcomes across studies. Conclusions and Relevance Pilonidal disease is associated with significant physical and psychosocial morbidity. Optimal treatments will minimize disease and treatment-associated morbidity. There is a need for standardization of definitions used to characterize pilonidal disease and its outcomes to develop evidence-based treatment algorithms.
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Affiliation(s)
- Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus
| | - Katherine J Deans
- Department of Surgery, Nemours Children's Health, Delaware Valley, Wilmington, Delaware
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus
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Parente G, Ruspi F, Thomas E, Di Mitri M, Cravano SM, D'Antonio S, Gargano T, Lima M. Endoscopic Pilonidal Sinus Treatment: Preliminary Results, Learning Curve and Comparison with Standard Open Approach. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1063. [PMID: 37371294 DOI: 10.3390/children10061063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/08/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023]
Abstract
Background: Pilonidal sinus (PNS) is a common disease which can lead to complications including infection and abscess formation. Different surgical approaches have been suggested, based on primary or secondary wound closure intention healing or endoscopic treatment (EPSiT). The aim of this study is to verify the superior outcomes of EPSiT, especially in comparison with the traditional open approach, and discuss the operators' learning curve. Methods: A retrospective study was conducted identifying all the patients who underwent surgical treatment for PNS with EPSiT technique between 2019 and 2022 and with open technique between 2002 and 2022. We divided patients in two groups: open procedure (group 1) and EPSiT (group 2). We considered a p value < 0.05 as statistically significant. Results: The mean operative time was 58.6 ± 23.7 min for group 1 and 42.8 ± 17.4 min for group 2 (p < 0.01). The mean hospital stay was 2.6 ± 1.7 days for group 1 patients and of 0.8 ± 0.4 days for group 2 (p < 0.01). Complete healing was obtained in 18.7 ± 5.6 days for group 1 and 38.3 ± 23.5 days for group 2 (p < 0.01). Recurrences were of 23.4% for group 1 and 5.4% for group 2 (p = 0.03). Conclusions: EPSiT is a minimally invasive and effective approach for the treatment of pilonidal cyst that can be safely performed in pediatric patients with promising results concerning aesthetic outcome and pain control, and with a rapid and less complicated recovery compared to traditional open procedures.
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Affiliation(s)
- Giovanni Parente
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Francesca Ruspi
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Eduje Thomas
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Marco Di Mitri
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Sara Maria Cravano
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Simone D'Antonio
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Tommaso Gargano
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Mario Lima
- Pediatric Surgery Department, IRCCS Sant'Orsola-Malpighi Polyclinic, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
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10
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Koskinen K, Harju J, Hermunen K. Long-term results for pit-picking and flap procedures in primary pilonidal sinus disease. BMC Surg 2023; 23:99. [PMID: 37118772 PMCID: PMC10142197 DOI: 10.1186/s12893-023-02014-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 04/20/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Pilonidal sinus disease (PSD), a common inflammatory condition of the natal cleft causing morbidity especially in young adults, is a heterogeneous disease group with no consensus regarding its best treatment. Our aim was to report long-term results for primary PSD surgery. METHODS We retrospectively studied the medical records of 146 patients who underwent primary PSD surgery between November 2010 and October 2015. Of these, 113 underwent either the mini-invasive pit-picking surgery (PSS) (n = 55) or asymmetrical excision with local flap (AELF) (n = 58); we focused on the outcomes of these two subgroups. RESULTS PSD patients who underwent mini-invasive PPS more often succeeded with day surgery (94.5% vs 32.8%, p < 0.001), had fewer postoperative complications (9.4% vs 36.2%, p = 0.002), and had shorter sick leave (median 14 days vs 21 days, p < 0.001) than did AELF patients. Nevertheless, at the first postoperative follow-up visit, both surgery methods healed similarly (75.0% vs 76.8%, p = 0.83). Our long-term follow-up, at a median of 9.3 years (range 5.4-10.6), revealed, however, that recurrence after PPS was markedly higher than after AELF (50.9% vs 10.3%, HR 6.65, p < 0.001). CONCLUSIONS PPS, which is a mini-invasive surgical technique often performed under local anaesthesia, is suitable for primary PSD, despite the high recurrence rate in our study, bearing in mind that patient selection is an important factor to consider. Primary PSD with simple sinus formations may benefit from PPS. On the other hand, primary PSD with complex sinus formations may benefit from AELF regardless of the initial slow recovery in our study. Because PSD is a very heterogenous disease, and patients have different risk factors, it is mandatory for the surgeon to master several different surgical techniques. A classification system to aid the surgeon in selecting the right surgical technique for each patient is warranted.
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Affiliation(s)
- K Koskinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Abdominal Center, Jorvi Hospital, Turuntie 150, PO Box 800, HUS 00029, Espoo, Finland
| | - J Harju
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Abdominal Center, Jorvi Hospital, Turuntie 150, PO Box 800, HUS 00029, Espoo, Finland
| | - K Hermunen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.
- Helsinki University Hospital, Abdominal Center, Jorvi Hospital, Turuntie 150, PO Box 800, HUS 00029, Espoo, Finland.
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11
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Jackisch T. Karydakis-Plastik für die Behandlung des Sinus pilonidalis. COLOPROCTOLOGY 2023. [DOI: 10.1007/s00053-023-00688-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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12
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Safadi MF, Dettmer M, Berger M, Degiannis K, Wilhelm D, Doll D. Demographic overview of pilonidal sinus carcinoma: updated insights into the incidence. Int J Colorectal Dis 2023; 38:56. [PMID: 36849571 PMCID: PMC9971075 DOI: 10.1007/s00384-023-04344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE There are only rough estimates of the worldwide incidence of pilonidal sinus carcinoma. The purpose of the study is to explore the demographic characteristics of this disease and to provide more precise information about its incidence. METHODS The study included questioning the surgeons and pathologists in Germany in addition to a literature research. The literature investigation included all published articles about pilonidal carcinoma in all languages. The questionnaire included 1050 pathologists and all 834 hospitals with a surgical division in Germany. The outcome measures included the total number of cases, the language of publication, gender, age, country of origin, interval until the diagnosis of carcinoma, and reported incidence based on local studies. RESULTS From 1900 to 2022, we found 140 cases of pilonidal sinus carcinoma in 103 articles. The investigation revealed two additional unpublished cases from Germany. The male-to-female ratio was 7.75:1. The countries with the most cases were the USA (35 cases, 25.0%), Spain (13 cases, 9.3%), and Turkey (11 cases, 7.6%). The average age was 54.0 ± 11.8 years and the interval between the diagnosis of the disease and the development of carcinoma was 20.1 ± 14.1 years. There was a parallel increase in reported cases of pilonidal sinus disease and pilonidal carcinoma over the last century. The reported incidence varied from 0.03% to 5.56%. The worldwide calculated incidence equaled 0.17%. CONCLUSION Due to underreporting and other causes, the incidence of carcinoma emerging on the background of pilonidal sinus disease is higher than reported.
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Affiliation(s)
- Mhd Firas Safadi
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Germany.
- Vechtaer Institut für Forschungsförderung, VIFF e.V., Vechta, Germany.
| | - Marius Dettmer
- Vechtaer Institut für Forschungsförderung, VIFF e.V., Vechta, Germany
- Department of Trauma Surgery and Orthopedics, Reconstructive and Hand Surgery and Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Matthias Berger
- Department of General and Visceral Surgery and Proctology, Diakoniekrankenhaus Chemnitzer Land, Hartmannsdorf, Germany
| | - Konstantinos Degiannis
- Department of Trauma, Orthopedic and Hand Surgery, St. Marienhospital Vechta, Academic Teaching Hospital of the MHH Hannover, Vechta, Germany
| | - Dirk Wilhelm
- Faculty of Medicine, Clinic and Polyclinic of Surgery, Technical University Munich, Klinikum rechts der Isar, Munich, Germany
| | - Dietrich Doll
- Vechtaer Institut für Forschungsförderung, VIFF e.V., Vechta, Germany
- Department of Procto-Surgery and Pilonidal Sinus, St. Marienhospital Vechta, Academic Teaching Hospital of the MHH Hannover, Vechta, Germany
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13
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The epidemiology of funnel chest repairs in Germany: monitoring the success of Nuss’ procedure. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00079-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
In recent years, the Nuss procedure was gaining ground in pectus excavatum repair, but the scientific focus had been on complications compared to conventional repairs. Despite a substantial prevalence of pectus excavatum in population-based studies, the adoption of minimally invasive funnel chest repair and subsequent replacement of conventional procedures has not been assessed on a population-based level.
Methods
We analysed German administrative case-based data on funnel chest repairs separate by age group and operative procedure: conventional or minimally invasive. Changes over time between 2010 and 2018 were analysed by linear regression.
Results
There were x̅ = 256 operations per year, which did not change throughout the study time, but following the introduction of minimally invasive repairs, their usage increased particularly in males aged 15 to 19 years by 8.7 procedures per year (P = 0.0142) and was accompanied by a concomitant decrease in conventional repairs in all relevant age groups. We observed a shift of operations towards the age group of 15 to 19 years, whose numbers increased by 5.3 yearly procedures (P = 0.0222), whereas they decreased in all other relevant age groups. These shifts could not be observed in females in a similar fashion, but in both males and females, the numbers of minimally invasive per conventional repair increased.
Conclusions
In Germany, the introduction of the Nuss procedure did result in a concentration of funnel chest repairs in adolescence and a replacement of conventional repairs. Data from other healthcare systems are missing but are direly needed to assess the current situation in other healthcare systems.
Level of evidence
III.
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14
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Sinus pilonidalis. COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-022-00657-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Froehlich M, Wagner JP, Lee SL. Pilonidal disease surgery in the pediatric patient: less is more! SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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16
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Doll D, Petersen S, Andreae OA, Matner H, Albrecht H, Brügger LE, Luedi MM, Puhl G. Pit picking vs. Limberg flap vs. primary open method to treat pilonidal sinus disease – A cohort of 327 consecutive patients. Innov Surg Sci 2022; 7:23-29. [PMID: 35974777 PMCID: PMC9352183 DOI: 10.1515/iss-2021-0041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/16/2022] [Indexed: 11/15/2022] Open
Abstract
Background Minimally invasive methods in pilonidal sinus disease (PSD) surgery are becoming standard. Although long-term results are available for some techniques, long-term outcome data of patients after pit picking is lacking. We aimed at investigating perioperative and long-term outcomes of patients undergoing pit picking, Limberg flap or primary open surgery to treat PSD. Methods In a single-centre observational study, we evaluated the outcomes of 327 consecutive patients undergoing PSD surgery between 2011 and 2020. Results PSD had recurred in 22% of Limberg flap patients and 62% of pit picking patients at 5 years (p=0.0078; log rank test). Previous pilonidal surgeries, smoking, body mass index, immunodeficiency, and diabetes did not significantly influence the long-term recurrence rate. Primary open treatment was performed for 72% of female patients presenting with primary disease. Conclusions Due to its especially dismal long-term results, pit picking should be abandoned, and Limberg flap should be promoted instead, even for primary disease and in females.
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Affiliation(s)
- Dietrich Doll
- Department of Procto-Surgery , St. Marienhospital Vechta, Academic Teaching Hospital of the MHH Hannover , Vechta , Germany
- Pilonidal Research Group , Vechta , Germany
| | - Sven Petersen
- Pilonidal Research Group , Vechta , Germany
- Department of General and Visceral Surgery , Asklepios Klinikum Hamburg-Altona , Hamburg , Germany
| | | | - Hanne Matner
- Department of General and Visceral Surgery , Asklepios Klinikum Hamburg-Altona , Hamburg , Germany
| | - Henning Albrecht
- Department of General and Visceral Surgery , Asklepios Klinikum Hamburg-Altona , Hamburg , Germany
| | - Lukas E. Brügger
- Department of Visceral Surgery and Medicine , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Markus M. Luedi
- Pilonidal Research Group , Vechta , Germany
- Department of Anaesthesiology and Pain Medicine , Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
| | - Gero Puhl
- Department of General and Visceral Surgery , Asklepios Klinikum Hamburg-Altona , Hamburg , Germany
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17
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Segre D. What You Should Remember in Managing Pilonidal Disease. Front Surg 2021; 8:792121. [PMID: 34950697 PMCID: PMC8688353 DOI: 10.3389/fsurg.2021.792121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Diego Segre
- Formerly Responsible Colonproctology Unit, S.Croce Hospital, Private Practice, Cuneo, Italy
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18
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Heydweiller A, Kurz R, Schröder A, Oetzmann von Sochaczewski C. Inguinal hernia repair in inpatient children: a nationwide analysis of German administrative data. BMC Surg 2021; 21:372. [PMID: 34670522 PMCID: PMC8529810 DOI: 10.1186/s12893-021-01371-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/11/2021] [Indexed: 02/07/2023] Open
Abstract
Background Contrary to adult inguinal hernia surgery, large-scale investigations using registries or administrative data are missing in paediatric surgery. We aimed to fill this gap by analysing German administrative hospital data to describe the current reality of inpatient hernia surgery in children.
Methods We analysed aggregated data files bought from the German federals statistics office on hospital reimbursement data separately for principal diagnoses of inguinal hernia in children and for herniotomies in inpatients. Developments over time were assessed via regression and differences between groups with nonparametric comparisons.
Results Principal diagnoses of hernias were decreasing over time with the exception of male bilateral and female bilateral incarcerated hernias in the first year of life which increased. The vast majority of operations were conducted via the open approach and laparoscopy was increasingly only used for females older than 1 year of age. Recurrent hernia repair was scarce. Rates of inguinal hernia repair were higher in both sexes the younger the patient was, but were also decreasing in all age groups despite a population growth since 2012. The amount of inguinal hernia repairs by paediatric surgeons compared to adult surgeons increased by 1.5% per year. Conclusions Our results corroborate previous findings of age and sex distribution. It demonstrates that inpatient hernia repair is primarily open surgery with herniorrhaphy and that recurrences seem to be rare. We observed decreasing rates of hernia repairs over time and as this has been described before in England, future studies should try to elucidate this development. Level of evidence III.
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Affiliation(s)
- Andreas Heydweiller
- Sektion Kinderchirurgie, Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Ralf Kurz
- Sektion Kinderchirurgie, Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Arne Schröder
- Klinik für Kinder- und Jugendmedizin, Klinikum Dortmund, Dortmund, Germany
| | - Christina Oetzmann von Sochaczewski
- Sektion Kinderchirurgie, Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Germany. .,Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin Mainz, Mainz, Germany.
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