Completeness of excision as a measure to prevent pilonidal sinus recurrence

Background: There are numerous papers on Pilonidal Sinus (PS) detailing uncertainties regarding its etiology, pathogenesis, diagnosis, pathohistology analysis, and treatment. Methods: Our goal is to use a retrospective and prospective study to determine the necessity of a routine pathohistological (PH) analysis to demonstrate whether Pilonidal Sinus was completely excised, if the wound can be primarily closed and whether recurrence would be prevented. Criteria for radically removed PS: no components of the disease detected at the specimen margins. Each wound was primarily closed with a local fasciocutaneous flap. Results: Clinical characteristics of 71 patients suffering from PS were examined. We performed a pathohistological analysis of Pilonidal Sinus specimens and measured the dimensions of the tissue specimens containing the sinus components: 1) pathological embedded follicles over 4mm deep, 2) hair shafts, 3) cysts, 4) squamous epithelium or 5) pits “sacral dimple”. There was no recurrence during the 2-7 year follow-up period. Conclusions: Surgically excised Pilonidal Sinus specimens should include the skin and subcutaneous tissue with superficial fascia, to the muscle fascia with all pathological tissue. A continuous incision should be made from the tip of the coccyx, including all dimples and navicular region of the sinus.  Complete excision does not affect the recurrence rate

Patient impact of Pilonidal Sinus Disease

Introduction: It is commonly assumed that chronic pilonidal sinus disease (PSD) decreases quality of life (QoL) and fitness for work. However very little evidence exists to support this. The aim of this study was to explore the impact of chronic PSD including impact on QoL using two different questionnaires. Methods: No disease specific questionnaire exists. Patients with chronic PSD filled in one of two questionnaires before undergoing Cleft Lift surgery. The questionnaires’ ability to capture the impact of the condition was evaluated. Results: 256 patients with chronic PSD filled in questionnaires. Ninety-five filled in the Eq-5D-3L QoL. 161 completed a symptom-based questionnaire made in our department. Both groups were comparable by age, gender and onset of symptoms. Using the Eq-5D-L3 we found no difference in any of the five questions compared to the general Danish population. Using the symptom-based score 51 ± 8.9% of patients reported that PSD affected their QoL and 36 ± 7.5% that it affected their fitness to work. Conclusion: The Eq-5D-L3 questionnaire was not able to capture the impact of PSD in patients’ health status. However, the symptom-based questionnaire revealed that patients are indeed impacted by chronic PSD and that a validated disease specific questionnaire is warranted.&nbsp

Karydakis Flap types

Introduction: There are many surgical options for managing sacrococcygeal pilonidal sinus disease. Karydakis first described his flap in 1968. Methods: Literature review of Karydakis Flap was performed to determine the type of flap used. Results: Three key modifications of the original flap have been described. Of 77 series identified, 10 series used the Type 4 flap. Conclusion: Four types of the Karydakis flap have been describe

Gender differences in axial hair strength may explain gender related incidence variation in Pilonidal Sinus patients

Background: Pilonidal sinus disease is a disease of mostly young people with male preponderance and caused by ingrowth of cut head hair. We wondered if the gender difference in Pilonidal Sinus Disease (PSD) incidence of this disease was due to hair characteristics. Objective: To investigate the gender specific hair strength characteristics, linked to standardized PSD incidence. Methods: We analysed the axial strength of human head hair in n=150 females and n=150 males of a northern german healthy population with the methods published recently. Standardised gender different PSD disease incidences were computed with raw data provided from the German Institut of Statistics and Health data. Results: Male axial hair force (1.59g +/- 0.9g) is significantly different from female axial hair force (1.25g +/- 0.76g; p=0.002). Male hair strength exceeds female hair strength by the factor of 1.2. During 2000 and 2017, male standardized PSD incidence exceeds female standardized PSD incidence by a factor of mean 3.1 in Germany. Limitations: During that observational period, PSD incidence rose by 40% in Germany. As age may play a role in axial hair strength, further larger age dependent tests series are planned. Conclusion: A higher pilonidal incidence in males is paralleled with stronger axial hair force in males, as compared to females. Hair strength aka. axial hair force may thus be the major factor in gender specific differences between males and females. Softening the hair can avoid the PSD as a preventive method which is worth testing

Pilonidal Sinus Carcinoma found in a Pilonidal Sinus – a surprise diagnosis from the pathologist

Introduction: Malignancy arising in long standing chronic infection is known in ulcerative colitis and non healing burns scars. It is exquisitely rare in long standing pilonidal sinus infection. We report a male case with the incidental finding of a SCC in a 20 year old untreated pilonidal sinus. Methods: Decription of the diagnostic and therapeutic course till his demise of reported world case #125. Results: A 59 yr. old male presented with extensive fistulous disease in the presacral area with induration and reddening. On surgery, tracts were found to extend into the perianal up to the perineum. Pathology specimen analysis revealed SCC with involvement of the PSD tracts with R1 situation (pT2pN0M0G2R1). Despite consecutive wide excision and tumor board advised radiochemotherapy the patient recurred twice locally, in lymph nodes and in the ischorectal fossa and demised 3 years later. Conclusion: Despite best surgical and oncological practice, the patient demised due to a – if defined by the skin SCC classification – low TNM stage carcinoma. Pilonidal carcinoma is a exquisitely rare disease which most surgeons have not experienced in their professional lifetime. As earlier carcinomas may arise within the pilonidal sinus system, all histopathological specimen should be either opened and meticulously inspected by the surgeon himself, or sent for routine histopathological examination. Despite early diagnosis, aggressive therapy may change the otherwise dismal course of disease

Karydakis Flap in the Management of Pilonidal Sinus Disease: 15 years Single Author Experience

Introduction: Pilonidal Sinus Disease (PSD) is notorious for its ability to recur and presents a significant challenge to surgeons. Many different surgical methods are practiced and each has its own concepts and conclusions. Various flaps have been reported with satisfactory healing and low recurrence rates. Karydakis flap may be considered ideal as it addresses the primary etiological factors. Methods: The present multicenter prospective study was conducted during the period April 2002 to April 2017. All patients were operated on by the author. Patients were divided into groups according their ages and Body Mass Index. Mean operating time, blood loss, complications within 30 days and recurrence were the end points of study. Results: Out of 692 patients, 636 (92%) were male and 56 (8%) were female. 161 (23.2%) had prior PSD surgery. Mean age was 23 years (range 16-49 years). 175 (25.4%) patients had a single midline sinus. Mean operating time was 29 minutes (range 23-70 min), mean blood loss was 26 mL (10-70mL) and mean hospital stay was 3 days (range 2-7 days). Complications were recorded in 80 (11.8%). 26 (3.8%) patients developed a major wound infection requiring opening of the suture and regular dressings. 35 (5.2%) patients developed a minor wound infection, 15 (2.2%) developed seroma and 18 (2.6%) had leakage of serous fluid from drain site. There were only 18 (2.6%) recurrences during the follow up period of 23 months (range 11 months to 4 years). Conclusion: Karydakis flap is a logical approach for PSD as it addresses the etiological factors of the disease. The recurrence rate is low on short and long term follow up. Karydakis flap avoids painful and prolonged dressing regimens and is well accepted by patients

Subcutaneous Unilateral Excision Technique in Treatment of Tezel Type 4 Pilonidal Sinus Disease

Introduction: A large number of methods have been proposed for the treatment of pilonidal sinus disease (PSD). Methods: Patients with Tezel Type 4 PSD underwent subcutaneous ultrasound unilateral excision. Results: 12 patients with Tezel Type 4 PSD are recurrence-free at follow-up from 1 to 3 years. Our technique of low-traumatic subcutaneous ultrasound unilateral excision of PSD (UA Patent 69889) is described. Conclusion: The newly described subcutaneous unilateral excision technique can be a good alternative for traditional surgery (such as Bascom cleft lift procedure, Karydakis or Limberg flaps) in case of Tezel Type 4 pilonidal sinus disease

Another common sharp hair fragment disease – barbers’ anterior disease (BAD)

Introduction: There is suspicion that sharp cut hair fragments cause intergluteal pilonidal sinus disease. Barbers, exposed daily, have not been systematically investigated for risk. Methods: One hundred barbers in Northern Germany were interviewed regarding site and incidence of hair penetration as well as methods/frequency of self-epilation, using a structured questionnaire. Results: Ninety-two percent of barbers experience foreign hair penetration, mostly when cutting short dry hair. Despite daily showering and changes of clothing, 43% need monthly and 25% weekly hair removal using forceps. Left index and middle fingers as well as palms are prone to penetration, followed by feet, anterior chest and elbow groove. While 12 barbers reported intergluteal pilonidal sinus disease within their families, none had it themselves. Self-epilation was not linked to a higher incidence of hairs in the axilla, arms, legs or genital region. Conclusion: The overwhelming majority of barbers need to remove penetrating foreign hair fragments regularly, despite changing clothes and daily showering after work. Fingers, hands, feet and the anterior chest are particularly at risk. The term “Barbers’ Anterior Disease” could be used to describe sharp hair fragments affecting hair care professionals. Anterior hair exposure is not linked to posterior pilonidal hair disease

Sonography for adequate clearance during endoscopic management of pilonidal sinus

INTRODUCTIONRecently 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

Introduction: 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