Endoscopic sinusectomy: 'a rose by any other name'. A systematic review of different endoscopic procedures to treat pilonidal disease

Management of pilonidal sinus and recurrences in 2025

Pilonidal sinus is a common pathology of the intergluteal cleft that can develop into abscess or suppuration. This lesion corresponds histologically to a granuloma that organizes around foreign bodies, most often hairs, and fistulizes to the skin through partially epithelialized orifices. If suppuration and abscess develop, treatment is based either on medical treatment combining analgesics, local antiseptics and sometimes antibiotics, or on emergency incision and drainage in the operating room. This is performed in more than 10,000 patients per year in France. Outside of emergencies, elective surgery for pilonidal sinus is indicated to treat bothersome symptoms or to avoid the risk of recurrent abscess. The surgical indication must take into account the patient's risk factors, particularly active smoking, that increase the risk of postoperative complications and recurrence. Elective intervention is performed on more than 30,000 patients per year in France. Radical excision followed by secondary healing is the most commonly performed option. This strategy carries a risk of failure or recurrence for at least 10% of patients. Primary closure after excision can reduce the time for healing and convalescence, but at the cost of more frequent infectious complications. Midline closure should be avoided, in favor of paramedian or flap closure. Minimally invasive techniques are being developed that combine the extraction of foreign bodies and mechanical debridement or thermal or chemical cautery of the granulomatous walls. They avoid complex and unpleasant nursing care of secondarily healing wounds, at the cost of a recurrence rate equivalent to that from excision techniques. They have the merit of avoiding difficult situations of failure to heal or recurrence after radical excision that are associated with a clear deterioration in the quality of life. The treatment of surgical failures is complex, and combines comprehensive patient care (smoking cessation, anti-infectious treatments, treatment of excess weight, avoidance of a sedentary lifestyle) and often a repeat operation. Minimally invasive treatments, particularly laser treatments, have their place in these difficult situations.

Laparoscopic versus open repair of perforated peptic ulcer: systematic scoping review and in-depth evaluation of existing evidence

BACKGROUND

Perforated peptic ulcer remains a common contributor to morbidity and mortality rates worldwide. In common with other emergency surgery conditions, there is a trend towards minimally invasive surgery. This review aims to describe current evidence comparing open and laparoscopic management strategies for perforated peptic ulcers, by summarizing patients, intervention, comparator, outcomes, describing intervention components and delivery, outcomes reported and assessing study pragmatism (applicability) using PRagmatic Explanatory Continuum Indicator Summary-2.

METHODS

Systematic searches of published literature were performed using Ovid MEDLINE and Embase online databases, as well as clinical trial databases. Randomized trials comparing laparoscopic and open repair of peptic ulcer were included. Data extracted included study metadata, patients, intervention, comparator, outcomes elements, technical aspects of interventions and use of co-interventions, and surgeon learning curves/experience. Applicability was assessed using the PRagmatic Explanatory Continuum Indicator Summary-2 tool, to explore whether trials were predominantly pragmatic or explanatory, and study validity assessed using the Cochrane Risk-of-Bias 2 tool.

RESULTS

A total of 408 studies were screened for eligibility, with nine finally included (880 patients). Incision, ulcer closure details and lavage were the most frequently reported aspects of laparoscopic repair. Co-interventions such as antibiotic use and analgesia were reported in most articles, whilst nutrition and Helicobacter pylori eradication were not reported. Interventions were generally delivered by high-volume laparoscopic surgeons. Studies were considered at high Risk-of-Bias. PRagmatic Explanatory Continuum Indicator Summary-2 assessment found studies were neither fully pragmatic nor explanatory.

CONCLUSION

Laparoscopic repair of perforated peptic ulcer is a variably defined intervention. Consideration of how intervention components and co-interventions should be optimally delivered is required to facilitate a well designed randomized trial.

The validation of a simple and instrument-free technique to measure the depth of the natal cleft (a cohort study)

AIM

Pilonidal disease is a benign condition mainly affecting the young population. In recent literature, the depth of the natal cleft is thought to impact postoperative outcomes including wound complications and rate of recurrence. Currently there is no agreed method for measuring the depth of the natal cleft; this study proposes a novel and instrument-free technique that can be used as a research tool to measure the depth.

METHOD

This is a single centre study performed at St Mark's Hospital in London, with 63 participants volunteering to take part. Blinded repeated measurements of the natal cleft were taken by two separate clinicians to assess for inter-observer and intra-observer variation.

RESULTS

Agreement was measured and assessed by the Bland-Altman limits of agreement method and intra-class correlation (ICC). The mean difference between repeat measurements for both inter-observer and intra-observer were close to zero (-0.06 and -0.11 respectively). ICC analysis suggested a value of 0.91 for inter-observer agreement, signifying very good agreement between clinicians. Moderate intra-observer agreement was observed, with an ICC value of 0.74.

CONCLUSION

This study offers an alternative simple validated technique to measure the depth of the natal cleft, with good observer agreement. We propose that future studies aiming to analyse the depth of the natal cleft and its relationship with severity and postoperative outcomes use this technique.

Current surgical practices and attitudes toward pilonidal sinus disease among Russian surgeons: A national survey

AIM

Pilonidal sinus disease (PSD), also known as pilonidal disease, is a common chronic disorder in coloproctology and general surgery. It predominantly affects young male patients and is typically located in the sacrococcygeal region. Nowadays, various approaches are used to address this condition, but no consensus on a gold standard has been established. The aim of this study was to analyse and assess current PSD practice, diagnostic and surgical approaches, training and attitudes among Russian surgeons.

METHOD

A comprehensive online survey comprising 35 structured questions was developed by the Russian Society of Colorectal Surgeons and distributed to its members. The survey targeted colorectal and general surgeons and collected data on demographics, professional experience, surgical training, PSD management practices and both elective and abscess surgery techniques. Categorical data are reported as frequencies and percentages.

RESULTS

Of the 158 respondents, the vast majority were coloproctologists and general surgeons (n = 152, 96%) with over 10 years of experience (n = 110, 69.6%) and performing 10-50 operations per year. The most popular surgical procedures were excision with midline closure (68%), open healing (62%) and marsupialization (59%). PSD-associated abscesses were managed through incision and drainage by 81 surgeons (51%). About half of surgeons had access to laser therapy for treating PSD, but sinus laser-assisted closure was used by only 16%. Most surgeons had received training in PSD surgery under specialist supervision and felt sufficiently trained.

CONCLUSION

Our findings suggest that PSD surgery in Russia has not yet shifted from midline excisions to off-midline flap procedures and minimally invasive surgery. This study calls for attention to this underprioritized group of patients and underscores the importance of developing national guidelines in Russia.

Pilonidal sinus: an overview of historical and current management modalities

Pilonidal disease is a common condition that commonly affects the younger adult population and is often seen in both the general practice and the hospital setting. Multiple treatment methods have gained and lost popularity over the last several decades, but more recent intervention principles show promising results. This article details the different methods of managing acute and chronic pilonidal disease ranging from treatments in the primary care setting to those in hospital theatres, with special attention to newer modalities of minimally invasive interventions. As a chronic illness that often affects those of working age, pilonidal disease can confer significant morbidity especially, but not limited to, a substantial amount of time off work. Treatment of chronic disease in particular, has evolved from midline techniques to off-midline techniques, with more recent developments offering promising solutions to reduce acute flare ups and hasten recovery time.

An international survey exploring the management of pilonidal disease

AIM

Pilonidal disease (PD) is a common debilitating condition frequently seen in surgical practice. Several available treatments carry different benefit/risk balances. The aim of this study was to snapshot the current management of PD across European countries.

METHOD

Members affiliated to the European Society of Coloproctology were invited to join the survey. An invitation was extended to others via social media. The predictive power of respondents' and hospitals' demographics on the change of therapeutic approach was explored.

RESULTS

Respondents (n = 452) were mostly men (77%), aged 26-60 years, practising in both academic and public hospitals and with fair distribution between colorectal (51%) and general (48%) surgeons. A total of 331 (73%) respondents recommended surgery at first presentation of the disease. Up to 80% of them recommended antibiotic therapy and 95% did not use any classification of PD. A primary closure technique was the preferred procedure (29%), followed by open technique (22%), flap creation (7%), sinusectomy (7%) and marsupialization (7%). Approximately 27% of subjects would choose the same surgical technique even after a failure. Almost half (46%) perform surgery as office based. A conservative approach was negatively associated with acutely presenting PD (p < 0.001). Respondents who were not considering tailored surgery based on patient presentation tended to change their approach in the case of a failed procedure.

CONCLUSION

With the caveat of a heterogeneous number of respondents across countries, the results of our snapshot survey may inform the development of future guidelines.

Five-year recurrence after endoscopic approach to pilonidal sinus disease: A multicentre experience

PURPOSE

The aim of this study was to evaluate the 5-year recurrence rate of pilonidal sinus disease (PSD) after endoscopic sinusectomy and identify risk factors for recurrence.

METHODS

All consecutive patients from September 2011 through December 2017 who underwent endoscopic sinusectomy at seven referral centres for pilonidal sinus treatment were retrospectively analysed from a prospectively maintained database.

RESULTS

Out of 290 patients (185 males versus 105 female, with a mean age of 25.5±6.9), 73 presented recurrence at 5-year follow-up with a recurrence rate of 25.2%. The number of pilonidal sinus with pits off the midline (p = 0.001) and the mean (SD) distance from the most lateral orifice to the midline (p = 0.001) were higher in the group of patients with recurrence at 5-year follow-up. Multivariate analysis demonstrated that the position of the pits off the midline (p = 0.001) and the distance of the most lateral orifice from the midline (p = 0.001) were independent risk factors for recurrence at 5-year follow-up. Receiver operating characteristic (ROC) curve analysis showed that the distance of lateral orifice from midline predicted an 82.2% possibility of recurrence at 5-year follow-up and Youden's test identified the best cut-off as 2 cm for this variable. Out of 195 cases with the most lateral orifice less than 2 cm from the midline, 13 presented recurrence at 5-year follow-up with a recurrence rate of 6.7%. Out of 95 cases with the most lateral orifice more than 2 cm from midline, 60 showed recurrence at 5-year follow-up with a recurrence rate of 63.2%.

CONCLUSIONS

This data may help guide which disease characteristics predict the optimal use of an endoscopic pilonidal sinus technique.