Medical Abstracts Page 1

Medical Abstracts Page 1

Patient characteristics and symptoms in chronic pilonidal sinus disease
International Journal of Colorectal Disease, 1995

Sondenaa K, Andersen E, Nesvik I, Soreide JA.
Department of Surgery, Rogaland Central Hospital, Stavanger, Norway.

Three hundred and twenty two patients with pilonidal sinus disease were studied to determine factors for the development and maintenance of the disease. A calculated incidence of the disease of 26 per 100,000 inhabitants was found. It occurred 2.2 times more often in men than in women. Age at presentation was 21 years for men and 19 for women. Patients had two years (median) disease history before being referred for treatment. A family history could be found in 38% of the patients. 50% had normal body weight, and 37% were overweight. Local trauma or irritation preceded the condition in 34%, and a sedentary occupation was reported by 44%. Male sex, adolescence or youth, and a familial disposition seem to be associated with the development of pilonidal sinus. Local trauma and overweight are the most important conditioning factors for development of symptomatic pilonidal sinus disease.

Histology of chronic pilonidal sinus
APMIS : acta pathologica, microbiologica, et immunologica
Scandinavica. 1995

Sondenaa K, Pollard ML.
Department of Surgery, Rogaland Central Hospital, Stavanger, Norway.

Many theories concerning the development of chronic pilonidal sinus have been proposed. A histologic study of primary pilonidal sinus in 53 patients is presented. Subcutaneous tissue contained sinuses surrounded by chronic inflammation. Hair in sinuses was found in three quarters of the specimens examined. Examination showed that hair entered via one of the sinus openings created. Pits (defined as darker spots of varying width in the midline of the internatal cleft) were found to be indentations of the skin containing keratin plugs and debris. They may be isolated or connected with hair follicles. Pilonidal sinuses are chronic inflammatory processes of the skin caused by keratin plugs and debris clinically observed as pits, having penetrated the dermis.

Coccygeal pits
Pediatrics, May 2000

Weprin BE, Oakes WJ.
Children's Medical Center of Dallas, Dallas, Texas, USA.

BACKGROUND: Congenital dermal sinuses represent cutaneous depressions or tracts that are lined by stratified squamous epithelium. They communicate between the surface of the skin and deeper structures and may occur anywhere along the craniospinal axis. These sinuses are thought to result from abnormal separation of the cutaneous and neural ectoderm between the third and fifth week of intrauterine life. They may be often accompanied by other cutaneous stigmata, various dysraphic abnormalities, or intraspinal tumors. In the sacrococcygeal area, cutaneous congenital abnormalities are relatively common. It is estimated that 2% to 4% of children harbor intergluteal dorsal dermal sinuses. These intergluteal sinuses in the perianal region are frequently referred to as pits or dimples. Their cause is considered similar to other congenital dermal sinuses and appears unrelated to acquired pilonidal conditions observed in adults. They may become susceptible to local recurrent infection from trauma or hirsutism. Controversy regarding the evaluation and management of cutaneous defects in the coccygeal region exists. METHODS: Both a literature review and a career review of clinical material were performed. Databases for articles published in English were surveyed for key words relating to coccygeal sinuses using standard computerized search techniques. The medical records of children presenting to our neurosurgical clinic for evaluation of dorsal dermal sinuses were reviewed to identify those with intergluteal sinuses. RESULTS: In the evaluation of reported cases and of our own, we were unable to identify any children with coccygeal sinuses without other cutaneous markers other than hair with findings suggestive of intraspinal communication. CONCLUSIONS: Intergluteal dorsal dermal sinuses are relatively common lesions that frequently come to neurosurgical attention. They do not seem to be associated with significant risk of spinal cord and intraspinal anomalies. Simple intergluteal dorsal dermal sinuses without other cutaneous findings do not require radiographic or surgical evaluation and treatment. If other markers or neurologic symptoms are present, however, radiographic evaluation may be indicated.

Early sonographic findings suggestive of the human fetal tail
Prenatal diagnosis, April 1996

Zimmer EZ, Bronshtein M.
Department of Obstetrics and Gynecology, Rambam Medical Center, Technion-Faculty of Medicine, Haifa, Israel.

The prenatal diagnosis of a human tail was suggested in six fetuses with ultrasound findings of an echogenic protrusion in the lumbo-sacral region. All fetuses were at 14-16 weeks' gestation. The ultrasound findings disappeared in all cases at 22-23 weeks. Dermal abnormalities such as pilonidal sinus, deep dimples, and scarred tissue were found in all six newborns. It is possible that the late regression of the embryonic human tail was the cause of these dermal findings.

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Pilonidal sinus: management objectives
The Australian and New Zealand Journal of Surgery, August 1995

Stephens FO, Stephens RB.
Department of Surgery, University of Sydney, New South Wales, Australia.

In spite of a number of ingenious operative and non-operative techniques in the management of pilonidal sinus no single technique can be relied upon to prevent recurrence of this benign yet troublesome condition. Once thought to be a congenital condition it is now appreciated that pilonidal sinus most often an acquired condition due to accumulation of tough, bristly hair penetrating the skin, or local hair growing into a skin crevice, pit or abnormal follicle. The most common site is the upper natal cleft but the condition may occur in other sites especially where there is a crevice or irregularity of skin surface with pressure or suction applied to that region. Most surgical procedures have been designed to eradicate the existing sinus and the crevice in which hair tends to accumulate. However, without the presence of hair there can be no pilonidal sinus and, in the past, little attention has been given to preventing the re-accumulation of hair in the troublesome site; hence the risk of recurrence. Management objectives should be directed not only at eradicating the obvious lesion present but also to preventing recurrence of aetiological factors; especially the re-accumulation or re-growth of hair.

Pilonidal cyst: cause and treatment
Diseases of the Colon & Rectum August 2000

da Silva JH.
School of Medicine, University of Sao Paulo, Brazil.

PURPOSE: The treatment of sacrococcygeal pilonidal cyst, despite being considered a well-defined clinical entity and opinion as to its acquired origin being almost unanimous, has some controversial aspects. Surgery is the principal method of treatment, and several techniques have been proposed. All of them try to reduce morbidity, to offer conditions of fast cicatrization, to have a low recurrence rate, and to offer cure. This study was undertaken to review the available data in the literature about the cause of the disease and to determine the current optimal method of treatment, evaluating morbidity, healing, recurrence, and cure. METHODS: Data available on the topic of pilonidal cyst in the English-language literature were obtained from Index Medicus and MEDLINE and were reviewed and analyzed. RESULTS: There is nearly a consensus that pilonidal cyst is acquired, hair being the agent that causes the disease. Presently, the most-used surgical procedure is excision of the cyst, with open or closed wound for healing. However, many authors prefer to use the method of incision and curettage. New surgical techniques are being proposed. CONCLUSION: The majority of authors conclude that sacrococcygeal pilonidal cyst is an acquired disease, although a minority believe it is congenital. Although excision is the method of choice for most surgeons, in our experience the incision and curettage procedure is the best surgical treatment with regard to morbidity, healing, recurrence, and cure of the disease.

The role of obesity on the recurrence of pilonidal sinus disease in patients,who were treated by excision and Limberg flap transposition
International Journal of Colorectal Disease June 2000

Cubukcu A, Gonullu NN, Paksoy M, Alponat A, Kuru M, Ozbay O.
Department of General Surgery, Kocaeli University, Medical Faculty, Izmit, Turkey.

Recurrence of pilonidal sinus disease after surgical intervention is not a very rare problem although sophisticated reconstruction procedures have been developed. Recurrence is thought to be related to the anatomical status of the patients, i.e., depth of the intergluteal groove. Obese patients have deeper intergluteal grooves. The aim of this study was to use body mass index (BMI) as an objective indicator of obesity to determine whether there is a relationship between BMI and recurrence of pilonidal sinus disease. BMI was calculated preoperatively in 114 patients with pilonidal sinus disease who were treated by excision and Limberg flap transposition between 1996-1999 in general surgery departments of two university hospital clinics. Fifteen patients were referred to our clinics after surgical intervention carried out at other institutions. Their average BMI was calculated by using their hospital records. The mean follow-up period was 24 months (range 10-36). Six of the 114 patients (5%) had recurrence. The mean BMI of patients with and without recurrence was 29.35 and 27.415, respectively (P<0.05). The mean BMI of 15 patients referred to us because of recurrent disease was 29.41; however, that of patients with primary pilonidal sinus disease was 27.212 (P<0.05). Their BMI before their first operation was 29.30. This was also significantly higher than patients with primary disease (P<0.05). We conclude that obese patients with high BMI have a higher risk of recurrence of pilonidal sinus disease after surgical intervention.

Lack of evidence that obesity is a cause of pilonidal sinus disease
European Journal of Surgery, April 2001

Cubukcu A, Carkman S, Gonullu NN, Alponat A, Kayabasi B, Eyuboglu E.
Kocaeli University, Medical School, Turkey.

OBJECTIVE: To find out whether pilonidal sinus is more common among obese people. DESIGN: Retrospective study from hospital records. SETTING: Two university hospitals, Turkey. SUBJECTS: 419 patients who were operated on for pilonidal sinus disease; and 213 age and sex matched patients with benign diseases other than pilonidal sinus disease and who were not morbidly obese acted as controls. MAIN OUTCOME MEASURES: Comparison of body mass index (BMI) in the two groups. RESULTS: Patients with BMI of 25-30 were classified as overweight (61/419, 15% compared with 28/213, 13%), and those with BMI of 30 or more as obese (7/419 compared with 4/213, 2% in each group). Mean (SD) BMI of patients with pilonidal sinus disease was 26.0 (3.9) compared with 25.6 (3.9) in the control group (p =0.4). CONCLUSION: Obesity alone is not an important factor in the aetiology of pilonidal sinus disease.

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Retrorectal cyst: a rare tumor frequently misdiagnosed
Journal of the American College of Surgeons June 2003

Singer MA, Cintron JR, Martz JE, Schoetz DJ, Abcarian H.
Department of Surgery, The University of Illinois at Chicago, USA.

BACKGROUND: The rarity of retrorectal cysts and their nonspecific clinical presentations often lead to misdiagnoses and inappropriate operations. In recent years, several such patients have been referred to our institutions for evaluation and treatment of misdiagnosed retrorectal cysts. A review of these patients is presented. STUDY DESIGN: Medical records of the colorectal surgery divisions at two institutions were reviewed. Patients found to have previously misdiagnosed retrorectal cysts were identified. Preliminary diagnoses, radiologic examinations, operative procedures, and final diagnoses were obtained. RESULTS: Seven patients with retrorectal cysts who had been misdiagnosed before referral were identified. These patients had been treated for fistulae in ano, pilonidal cysts, perianal abscesses; psychogenic, lower back, posttraumatic, or postpartum pain, and proctalgia fugax before the correct diagnosis was made. Patients underwent an average of 4.1 operative procedures. Physical examination in combination with CT scanning made the correct diagnosis in all patients. All patients underwent successful resection through a parasacrococcygeal approach, and six of seven did not require coccygectomy. The resected tumors included four hamartomas, two epidermoid cysts, and one enteric duplication cyst. CONCLUSIONS: Retrorectal cysts are a rare entity that can be difficult to diagnose without a high index of clinical suspicion. A history of multiple unsuccessful procedures should alert the clinician to the diagnosis of retrorectal cyst. Once suspected, the correct diagnosis can be made with physical examination and a CT scan before a definitive surgical procedure.

Perineal pilonidal sinus. Case report

Annali Italiani di Chirurgia. May-June 2002

Testini M, Miniello S, Di Venere B, Lissidini G, Esposito E.Vascolare ed Oncologia Clinica Dipartimento per le Applicazioni in Chirurgia delle Tecnologie Innovative Facolta di Medicina e Chirurgia Universita degli Studi di Bari, Policlinico P.za Giulio Cesare 70124 Bari, Italy.

Pilonidal sinus is a very common disease and its most frequent location is in the presacral area. Other locations are extremely rare. We describe the case of a 28-year-old white man, a baker by profession, with a swelling around the right side of the anus, pain with burning, itching and seropurulent secretion which had been present for 7 months. A physical examination demonstrated the presence of multiple cutaneous fistulas. A fistulography and the endoscopy demonstrated the absence of fistulas-in-ano. Moreover, MRI confirmed the diagnosis of a perianal mass not communicating with the anal canal. Surgical exploration revealed the presence of hair and an excision of the mass with fistulas was performed. Healing was rapid and uncomplicated. Perineal pilonidal sinus with foreign body inflammatory reaction was the histological diagnosis.

Treatment of malignancy arising in pilonidal disease
Annals of Surgical Oncology Jan-Feb 2001

de Bree E, Zoetmulder FA, Christodoulakis M, Aleman BM, Tsiftsis DD.
Department of Surgical Oncology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Huis, Amsterdam.

BACKGROUND: Malignant degeneration is a rare complication of pilonidal disease and is associated with a high recurrence rate and poor prognosis compared with regular non-melanoma skin cancer. Treatment in our departments and in the international literature was evaluated. METHODS: We analyzed the data from three patients with malignant degeneration who were treated in our departments and an additional 56 patients who were found after an extensive literature search. RESULTS: A total of 47 males and 12 females, with a mean age of 52 years, were most frequently primarily treated with surgery. After a mean follow-up time of 28 months, 20% of all patients died with evidence of disease and an additional 10% died of unrelated causes. The overall recurrence rate was 39%, with a median time to recurrence of only 9 months. The local recurrence rate was lower when radiotherapy was added to surgical treatment alone (30% vs. 44%). Re-excision of local recurrence resulted in some long-term survivals. CONCLUSIONS: Early diagnosis and treatment may lead to improvement of the relative poor prognosis. Surgical treatment should be tailored according to the locoregional extent. The high recurrence rate after surgical treatment can be reduced by the addition of radiotherapy. Although repeat surgery for recurrent disease may involve extensive resection and morbidity, this may result in prolonged survival.

A fatal case of carcinoma arising from a pilonidal sinus tract
Ulster Medical Journal May 2001

Velitchklov N, Vezdarova M, Losanoff J, Kjossev K, Katrov E.
Department of Emergency Surgery, Military Medical Academy, Bulgaria.

We report a male patient with carcinoma arising on the basis of neglected sacrococcygeal pilonidal sinus disease. Following initial operation, performed without suspicion of malignancy, histology demonstrated cellular atypia and an increased mitotic rate. A second, wider tissue excision was recommended but the patient declined further surgery. Two years later, he presented with fungating carcinoma involving the rectum but again declined surgery. This rare case demonstrates that the presence of carcinoma should be suspected in long-standing, although innocent-looking, pilonidal sinus disease. In the circumstance of uncertain histologic diagnosis, more generous surgical sampling is required. Every effort must be made to overcome patient's reluctance to accept a second, possibly life-saving procedure.

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