Pilonidal Sinus Journal (PSJ)
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Recurrent pilonidal disease - individualization and pathogenesis-oriented surgery
No full textINTRODUCTIONRecurrence after pilonidal disease surgery are common and difficult to treat. Many options are proposed including cleft lift procedure, Karydakis flap and advanced flaps. The aim of the study is to present and analyze our experience with individualized pathogenesis-based surgery of recurrent pilonidal disease.
METHODSFor a 10-year period (2009-2019) patients with recurrent pilonidal disease were operated by authors.
RESULTSThe healing time in 60 patients was 14-40 days. 22 patients had concomitant hidradenitis suppurativa in gluteal and/or inguinal regions. In 51 patients modified Karydakis operation was performed. In 9 patients complex advanced flaps were used. General or spinal anesthesia is used. In all patients perioperative antibiotics were administered and closed suction drains were used.
Major complications occurred in 7 patients – 3 postoperative hematoma formation and 4 partial wound dehiscence managed conservatively. All patients are recurrence free.
CONCLUSIONThe main issues in surgery of recurrent pilonidal disease is to avoid repeated procedures, to prevent new recurrence and to have acceptable functional and cosmetic results. Radical surgery with individualization following principles of cleft lift and avoiding of midline suture lines leads to best results and patient satisfaction.
According to our experience and literature, we propose tailored radical surgical treatment of recurrent pilonidal disease:(1) recurrence after primary midline closure or pit piking (Bascom 1), or multiple incisions with midline sinus tract or wound with limited lateral extension – Bascom cleft lift procedure or modified Karydakis flap;
(2) recurrence after lay open techniques – Karydakis or advanced flap;
(3) recurrence with gluteal extension or combination with hidradenitis suppurativa – advanced flap with avoiding of midline suture line - “modified cleft lift”.
 
Sonography for adequate clearance during endoscopic management of pilonidal sinus
No full textINTRODUCTIONRecently endoscopic technique (EPSiT) has been increasingly used for managing pilonidal sinus disease. The challenge in this technique is to establish complete clearance of all hair and tracts to avoid recurrence.The aim is to study the use of sonography for adequate clearance of hair and all tracts during EPSiT.METHODSFrom April 2018 till April 2019, Standard EPSiT was used for managing successive patients seeking management for pilonidal sinus disease (PSD). Upon completion of procedure, intraoperative sonography was done to establish completeness of surgery by ensuring (1) absence of residual hair and (2) dealing of all tracts. All patients were followed in usual way postoperatively by continuing dressing till external pits closed spontaneously. Follow-up was done by monthly outpatient visit and telephonically if they couldn’t come for follow-up.RESULTSTwenty patients took part. Sonography provided additional information of residual hair in 2/20 patients, and additional tract in 1/20 patients. More than 3 months follow-up was available for all patients – all were free of complications and recurrence.CONCLUSIONSonography is an important, easily available modality for establishing complete clearance during pilonidal sinus management by the endoscopic technique. Its role can be further judged by bigger sample size and randomized controlled trials
Immediate cut hair translocation to the intergluteal fold in the hairdressers shop – another link to pilonidal sinus disease
No full textIntroduction: The genesis of pilonidal sinus disease is still disputed, but there is mounting evidence that occipital cut hair may play a major role, with the folliculitis theory losing ground. Translocation of cut hair from the head to the lower back has not been proven so far.
Methods: Eight men were asked to undress their upper body immediately following a dry haircut. A large layer of sticky transparent plastic sheeting was applied to their chest and back, then removed and placed on millimeter scale paper, fixing all hairs in position. Cut hairs were counted and the totals were transferred to Excel matrix datasheets.
Results: Despite protective measures taken during haircuts, all customers had cut hair on their upper body (chest and back) (38-630 hair fragments; median 325), with the majority of hairs (62%) located on the back. Cut fragments were mostly found close to or within the sweat crest, and were also present in the lower back.
Conclusion: Any haircut results in large numbers of sharp hair fragments on the upper body despite the use of a protective gown and an elastic paper collar. This sharp hair slides down the posterior sweat crest towards the nates and into the intergluteal fold, where it can inject itself into the healthy skin. Young patients should shower or take a bath following a haircut to reduce their intergluteal hair load. It is highly likely, but not yet proven, that the frequent exposure to a large number of cut hair fragments at a certain age leads to pilonidal sinus disease. If we solve this question, then prevention of pilonidal sinus would be possible
Laser depilation as an adjuvant therapy in prevention of recurrence of pilonidal sinus disease: Initial experience of a district general hospital in the UK
No full textINTRODUCTIONPilonidal sinus disease (PD) is a chronic debilitating illness involving the sacrococcygeal area. It commonly affects economically productive age groups and carries a significant effect on social activities and quality of life. Despite the availability of many surgical options, recurrence continues to be a major issue. Laser depilation therapy (LDT) has been proposed as an adjunct to surgery in PD and shown promising results in minimising recurrence. We present our initial experience in adjuvant LDT in patients with PD in a district general hospital.METHODSProspectively maintained database of patients with PD who have had Laser-induced hair removal after surgical therapy from 01/06/2013 to 01/06/2018 were analysed. Patients were offered a minimum of two sessions of LDT and all Fitzpatrick skin types were enrolled. Follow up data were available until 01/06/2019. Persistent symptoms of PD after 1 year from the date of last surgical intervention were recognised as recurrent disease. Data are presented as median.RESULTSSixty-seven (67) patients underwent LDT, although 60 patients were eligible for final analysis. Fifty-seven of them were males (57:3) and the median age was 23 (16-46) years. 15% of patients were smokers and 13% had their BMI over 30. The majority (64%) of patients received 6 cycles of LDT. There were no complications related to Laser treatments. Overall, our recurrence rate after LDT was 13% at a median follow up of 172 weeks. A subset of patients who had Laser hair removal after EPSiT demonstrated the lowest recurrence rate of 6%.
CONCLUSIONLDT is a safe and effective adjunct to surgery in reducing the recurrence of PD. Patients after EPSiT may have greater benefits of LDT. High quality randomised control trials are required to prove its efficacy and safety further
Which factors are suggestive of hidradenitis suppurativa in patients with pilonidal sinus disease? Results from a 459 cross-sectional prospective study
No full textINTRODUCTIONIn a recent international multicenter study performed on the behalf of the European Hidradenitis Suppurativa Foundation, we reported the high prevalence (27%) of inflammatory lesions in the intergluteal fold (pilonidal sinus disease – PSD – in 77%) in patients with hidradenitis suppurativa (HS). Although the exact underlying mechanisms are not understood, we also showed evidence that HS patients with PSD have a specific phenotype associating smoking, more severe HS and frequent disease occurrence in the breast, the buttocks, and in genital and anal regions. In the present study, we aimed to compare the clinical characteristics of patients operated for HS-free PSD and HS-associated PSD.The next step of our work was to compare the clinical characteristics of patients operated for HS-free PSD and HS-associated PSD.
METHODSWe prospectively included all consecutive patients who 1) underwent surgery in our secondary/tertiary center (Clinique du Val d’Ouest, Lyon, France) for inflammatory lesions in the intergluteal fold, and 2) had a definitive pathological diagnosis of PSD (patients operated for an inflammatory lesion in the intergluteal fold and with an actual pathological diagnosis of HS were excluded). Clinical and pathological data were recorded. Normality of the distributions was checked using a combination of Skewness and Kurtosis tests. Comparisons were performed using Student’s t test for continuous variables and Chi-squared test (gender, smoking, PSD recurrence, family history) and Fisher exact test (inflammatory comorbidities and acne conglobata) for categorical variables.
RESULTS459 patients were included, 118 (26%) with and 341 (74%) patients without associated HS (Table 1). Patients with HS-associated PSD were significantly younger at surgery (25 vs 28 years), more frequently women (51% vs 34%), and smokers (75% vs 47%). They had a higher BMI (26 vs 24 kg/m2) and more frequently a medical history of inflammatory joint diseases (4% vs 1%) and acne conglobata (3% vs 0%). They also had more frequently a family history of HS (25% vs 4%) and a family history of “dermal swelling” (21% vs 4%; as defined by the patient, without any medical indication about the exact nature of the swelling: simple cyst, boil, abscess …).
Age at PSD occurrence was not different between the two groups in this univariate analysis. When associated with HS, PSD had longer dimensions (Table 1) and was more frequently recurred at the time of surgery (44% vs 29%).
Using logistic regression analyses, we identified age at surgery, female gender, BMI, smoking, family history of HS, and family history of dermal swelling as independent positive predictors of an HS-associated PSD (Table 1). Age at PSD occurrence proved to be an independent negative predictor of an HS-associated PSD.
CONCLUSIONPSD is a frequent clinical condition. The frequent and non-coincidental association of PSD and HS, as well as the fact that PSD can be the first occurring inflammatory skin lesion in HS patients (in up to 36% of the patients), raise the question of an associated HS. The physician facing a PSD should be aware of this possibility and should specifically look for HS through a complete physical examination (gender, age, BMI, other obvious inflammatory skin lesion) and by directly questioning the patient about his/her habits (smoking), his/her medical history (“have you ever experienced any kind of inflammatory lesion elsewhere in your body?”) and his/her family history. The discovery of any factor among those here found to be associated with an increased risk of HS should be accompanied by a specific follow-up or at least specific information delivered to the patient and/or his/her GP
1470 nm-diode laser for pilonidal sinus disease
No full textINTRODUCTIONFor many years in the treatment of the pilonidal sinus (PS) there was a clear discrepancy between the trauma from the surgical access to the size of the pathological process itself. This has lengthened the recovery time for patients. All minimally invasive techniques proposed to solve this problem (endoscopic, chemical, electrosurgical and others) generally solved the problem of preserving the integrity of the skin over the sinus, but were not without their drawbacks. The main drawbacks are technical complexity, lack of visual control of treatment efficacy, long periods of treatment and high level of discomfort for the patient. These factors, according to many authors, led to a higher percentage of disease recurrences than in traditional methods of treatment.
METHODSWe have studied the results of 39 patients with pilonidal sinus treatment by Velas II diode laser with a wavelength of 1470 nm. 32 patients had chronic form of the disease and 7 – an acute one. In the treatment of chronic forms of PS, under intravenous anesthesia, all external sinus passages were opened by scalpel using circular incisions. The dimensions of the access were only 1 mm more than the dimensions of the outer holes of PS. PS was investigated using a probe to detect side branches from the central axis. After this, the cavity was cleared of the contents with a Folkman spoon and a “biopsy brush”. Initially about 200 ml of hydrogen peroxide solution was used for rinsing, then - 40 ml 0.2% solution of chlorhexidine bigluconate. Next stage was introducing of laser into the course and, at a power of 10 W with an exposure time of 1 second, PS was coagulated along the entire course. In the presence of lateral branches, similar coagulation was performed in all directions. The areas of PS excised by the scalpel were not processed by the laser. If necessary, hemostasis was performed by laser or electrocoagulation. Intraoperatively, patients were administered ceftriaxone 1000 mg intravenously. Hospitalization of patients was not necessary. During the postoperative period, the surgical access areas were treated with an antiseptic solution 2 times a day, after which an aseptic dressing was applied. Analgesia was prescribed for 3 days: Dexketoprofen 25mg, tablets, 2 times a day, while about 60% of patients refused to undergo analgesia from the second day after surgery. From the third day after the operation, patients were allowed to take a hygienic shower.Patients with acute PS were treated in the same way. In case of violation of the vitality of the skin a contraperture was performed over the ulcer. Also, additional cuts for the drainage of purulent cavities were performed with the spread of pus in the gluteal region. Wounds from purulent streaks on the buttocks were not treated with a laser. After the operation, a water-soluble antibiotic ointment (Levomecol) was applied into additional wounds.In the postoperative period, the patients were administered antibiotic ceftriaxone 1000 mg, intramuscularly, 2 times a day for 5 days. Pain relief was used depending on the intensity. Bandages of wounds from drainage of purulent cavities were performed 2 times a day. Cavities of the wound were treated with a solution of hydrogen peroxide, chlorhexidine, followed by the introduction of water-soluble antibiotic ointment (Levomecol). Daily dressings were performed until the moment of complete cleaning of the residual cavity from pus, on average, within three days from the moment of surgery. Further wound management was performed according to general surgical principles. Patients started to take a hygienic shower from 3 to 5 days after surgery.
RESULTSThe treatment of patients with chronic PS, according our observations, took 1 day. During the treatment, patients did not lose their ability to work. They were able to return to sports and other types of activity without any restrictions from the 7th - 10th day. Complete epithelization of wounds from surgical access occurred on the 10th day.The disability periods of patients with acute forms of PS depended on the nature of their work, the size of wounds through which the purulent cavities drained, but in all cases did not exceed 7 days.Complications during treatment were not observed. In 1 patient with an acute form of PS on the 16th day after the operation, the residual purulent cavity was opened along the postoperative scar in the area of contraception.In two patients with chronic PS and one with acute for 7–10 days, seromas with a volume of 0.1-0.3 ml were emptied through wounds from excision of the external course of PS.Clinically and according to ultrasound studies (10 days after surgery - 55% of patients and 30 days after surgery - 35% of patients) during period of investigation up to 6 months, no recurrences of PS were observed.
CONCLUSIONThe use of a diode laser with a wavelength of 1470 nm for the treatment of PS is an easy-to-use and low-impact method of surgical treatment that does not require hospitalization of the patient, limiting labor and social activity in the postoperative period. The absence of additional skin trauma for surgical access, bleeding, sutures and residual cavities does not require any special wound care in the postoperative period in patients with chronic PS. The terms of treatment in acute forms of PS are determined by the volume of purulent impurities and the size of wounds performed for drainage of abscesses. The healing time of the PS areas treated with a laser in acute PS forms is comparable with similar results in the group of patients with chronic PS. Insufficient time and the number of patients observation in the late postoperative period requires further investigations to assess the PS treatment efficacy by 1470 nm-diode
Minimally Invasive Closed Excision of pilonidal cyst (MICE): Results of a series of 145 consecutive patients
No full textINTRODUCTIONWound healing is the main drawback of pilonidal disease surgery. Many surgical techniques have been reported to challenge the excision and lay-open techniques which remain popular despite long healing times and debilitating condition. Herein is reported the results of a minimally invasive closed excision (MICE) that meets the gold principles of the wide excision lay-open technique without it’s side effects.METHODSMICE consisted of wide excision of postsacral diseased tissue through a minimal access using a thermofusion device. Then hair containing sinuses and pits including dermal abscesses were excised by cold bistoury. Wounds were covered with a pressure-dressing until day 4, then patients wore a pair of compression-shorts (Medical Innovation Care Europe, Avignon, France) until day 10 or until healed. Results were collected prospectively. Phone surveys were carried out among patients having 6 months of follow up at minimum. The first endpoints were healing time and recurrence.RESULTSMICE was carried out in 145 consecutive outpatients. Two patients were converted to lay-open technique and excluded from the survey. 130 patients were followed up for a minimum of 6 months (6 to 68). The recurrence rate was 7% (9/130) over a median follow up of 30 months. A 90% healing rate was achieved by postoperative week 3. The median healing time was 15 days.CONCLUSIONMinimally invasive closed excision of pilonidal disease (MICE) was applied to consecutive patients. It applied well to an extensive disease. This technique achieved complete excision of pilonidal disease, had a median healing time of 15 days and a low recurrence rate of 7%. These results advocate MICE as the gold standard for pilonidal excision
Short term outcomes of Endoscopic Pilonidal Sinus Treatment (EPSiT)
No full textINTRODUCTIONEndoscopic treatment of pilonidal disease (EPSiT) was initially described by Meinero in 2013. This minimally invasive technique has both technical and aesthetic advantages. The diagnostic application helps identify the anatomy of the pilonidal disease and the operative phase ablates and cleans the infected cavity. Our aim was to study the short-term outcomes of EPSiT and evaluate complications and recurrence ratesMETHODSProspectively maintained database of all consecutive patients who underwent EPSiT by a single surgeon in a District General Hospital from 01/11/2014 to 31/03/2018 were analysed. Follow-up was available until 30/09/2018. Data are presented as median (range).RESULTS74 (56 males) patients underwent EPSiT. Median age was 21 (16-62) years. All patients underwent EPSiT as day case procedures of which 7 patients had under local anaesthesia. There were no immediate postoperative complications, return to theatre or re-admissions within 90 days. On a median follow-up of 52 (2-114) weeks, 57 patients healed completely, and 8 patients were lost to follow-up. We achieved primary healing rates of 67% (44/66) and delayed healing rate of 77% (51/66) with EPSiT.CONCLUSIONEPSiT is a safe, effective, minimally invasive technique that should be considered as first-line treatment in selected cases of pilonidal sinus disease, thereby reducing morbidity related to conventional procedures
Patient Reported Outcomes in Pilonidal Disease – results of a patient survey
No full textIntroduction: Pilonidal disease continues to frustrate the patient and surgeon. Choosing between the multitudes of surgical options is hampered by the lack of an accepted classification, paucity of long term follow up and absence of a validated tool for assessing Patient Reported Outcomes.
Methods: Existing colorectal literature was used to develop a novel list of Patient Reported Outcomes. Patients with pilonidal disease were asked to fill in the questionnaire over a 2 week period.
Results: A survey consisting of 12 Patient Reported Outcomes was filled in by 12 patients. 58% (N = 7) patients had Tezel Type 3 pilonidal disease and 17% (N = 2) had recurrent disease. Being recurrence free was ranked as the most important outcome measure. Having no surgical complications and being able to return to work were also important. Scar appearance was important to only one patient.
Conclusion: The surgical treatment of pilonidal disease is hampered by early wound complications and disease recurrence. Patients rank disease recurrence as the most important outcome measure
Recurrent intermammary pilonidal sinus: a rare case with literature review.
No full textIntroduction: the usual area for pilonidal sinus disease is the sacrococcygeal region. The aim of this study is to report an extremely rare condition of recurrent intermammary pilonidal disease with a brief literature review.
Case report:
A 22 -year-old married lady complained of discharge, pain, and redness in the intermammary region for 1 year. On examination, there is a single discharging sinus and an old scar around it. Excisional biopsy confirmed the diagnosis of pilonidal sinus.
Conclusion: However its rare, intermammary pilonidal sinus may recur and require surgical re-intervention