Taylor SA, Halligan S, Bartram CI.
Intestinal Imaging Centre, Level 4V, St Mark's Hospital, Watford Rd, Northwick Park, Harrow, Middlesex HA1 3UJ, England.

PURPOSE: To describe magnetic resonance (MR) imaging features in patients with proved pilonidal sinus disease and to compare these features with those in a matched group of patients with proved fistula in ano to determine the accuracy with which MR imaging can be used to distinguish between the two diseases. MATERIALS AND METHODS: Seven patients with pilonidal sinus disease underwent MR imaging with a body coil. The site and morphology of sepsis were noted, with particular reference to natal cleft sepsis and deep-seated sepsis, including intersphincteric anal canal sepsis and any enteric communication. Comparison was made with 14 age- and sex-matched patients with fistula in ano. Categoric frequencies were compared to calculate differences between the groups and sensitivities, specificities, and predictive values. RESULTS: All patients with pilonidal sinus had natal cleft sepsis, but five (71%) had sepsis at deep-seated sites more characteristic of fistula in ano. Eight patients with fistula in ano (57%) had natal cleft sepsis that was thought characteristic of pilonidal sinus. No patient with pilonidal sinus had intersphincteric sepsis or an enteric communication, in contrast to all patients with fistula in ano having both (P <.001). Natal cleft sepsis reached the subcutaneous tissues overlying the coccyx and sacrum in only one patient with fistula (7%), in contrast to six (86%) with pilonidal sinus (P <.001). MR imaging had a sensitivity of 86% (six of seven), specificity of 100% (14 of 14), positive predictive value of 100% (six of six), and negative predictive value of 93% (14 of 15) for diagnosis of pilonidal sinus disease. CONCLUSION: MR imaging features of perianal and deep-seated sepsis, characteristic of fistula in ano, are also found in patients with pilonidal sinus, but the absence of intersphincteric sepsis or enteric opening allows reliable MR imaging distinction between the two.

McGuinness JG, Winter DC, O'Connell PR.
Department of Surgery, University College Dublin, Mater Misericordiae Hospital, Ireland.

INTRODUCTION: The annual incidence of pilonidal sinus is approximately 26 per 100,000, of which complex pilonidal sinuses are the minority. Many different approaches have been described for managing simple cases. Treatment options for complex pilonidal sinus include excision with healing by secondary intention or plastic surgical procedures to obliterate the defect. Recently, vacuum-assisted closure has been used by plastic surgeons to facilitate healing of chronic or complicated wounds with particular success in treating pressure wounds overlying the sacrum. METHODS: A patient with a complex pilonidal sinus was managed with excision and vacuum-assisted closure. RESULTS: A large tissue defect after radical excision healed relatively quickly when the subatmospheric pressure dressing was applied. The patient was discharged with the vacuum pump and change of dressings for alternate days. CONCLUSION: Vacuum-assisted closure of a complex pilonidal sinus shortened the length of hospital stay and the need for further surgery and provided a cosmetically acceptable result.

Holzer B, Grussner U, Bruckner B, Houf M, Kiffner E, Schildberg FW, Vogel P, Rosen HR; EMD study group.
Bundeswehrkrankenhaus Leipzig, Bahnhofstrasse 86, 04448 Leipzig-Wiederitzsch, Germany.

OBJECTIVE: Pilonidal sinus is common. It causes substantial loss of working hours. The major disadvantage of open wound treatment is the long time required for healing. Primary wound closure is on the other hand often followed by infection. A controlled, multicentre trial was carried out to evaluate the efficacy of a new gentamicin collagen fleece (Septocoll) combined with primary closure. PATIENTS AND METHODS: One hundred and three patients (88 men, 15 women, median age 30 years) were included. Fifty-one were randomised to gentamicin fleece plus primary closure (Genta Group), and 52 patients to open treatment alone (Open Group). RESULTS: The median interval to wound healing was 17 days in the Genta group and 68 days in the Open group (P = 0.0001, log-rank test). Two patients in Group 1 developed infection within the first two weeks, requiring reopening of the wound, with primary wound healing occurring in 73%. Failure of primary healing (27%) was usually due to seroma or spontaneous dehiscence which subsequently healed. CONCLUSION: The combination of gentamicin collagen fleece (Septocoll) with primary closure resulted in a shorter period to healing than the open technique without unwanted effects

Aldemir M, Kara IH, Erten G, Tacyildiz I.
Department of General, Faculty of Medicine, Dicle University, Diyarbakir, Turkey.

PURPOSE: Sacrococcygeal pilonidal sinus disease (SPSD) is a disease affecting young patients, which results in a long-term loss of productive power, and also tends to have high rates of morbidity since it has no ideal treatment. The main purpose of this study was to investigate the effectiveness of topical collagenase in the treatment of SPSD. METHODS: In the present study, 40 patients admitted to our department were separated into two groups. Excision and marsupialization with dressing by bacterial collagenase was performed in the first group, while the treatment was excision and marsupialization without dressing by bacterial collagenase in the second group. RESULTS: We determined that the healing in terms of the width and depth of the wound in the first week and in depth of wound in the second week was better in group 1 than in group 2 ( P = 0.040, P = 0.020, P = 0.048, respectively). The duration of wound healing was 21.9 +/- 1.3 days in group 1, and 28.1 +/- 1.3 days in group 2 ( P = 0.0001). The recurrence rate in the intergluteal area, which heals by granulation and has no hair follicles, tends to decrease when a partial closure is obtained. CONCLUSION: We therefore recommend an excision, marsupialization, and dressing with bacterial collagenase, in cases with noncomplicated SPSD.

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Sungurtekin H, Sungurtekin U, Erdem E.
Department of Anesthesiology and Department of General Surgery, Pamukkale University School of Medicine, Denizli, Turkey

To evaluate two anesthetic techniques, namely, local anesthesia with sedation, and spinal anesthesia, with respect to recovery times, postoperative side effects, pain scores, patient satisfaction, and hospital costs for ambulatory pilonidal disease surgery. Prospective, randomized study. University Hospital of Pamukkale.60 consenting patients scheduled for pilonidal disease operation with Limberg flap technique. PATIENTS WERE RANDOMLY ALLOCATED INTO TWO GROUPS: Group 1 (n = 30) received spinal anesthesia with hyperbaric bupivacaine 1.5 mL 0.5%, and Group 2 (n = 30) received local infiltration with a 50-mL mixture containing 10 mL bupivacaine 0.5%, 10 mL prilocaine HCl 2%, and 30 mL isotonic solution with 1:200 000 epinephrine in combination with intravenous (IV) midazolam sedation. Perioperative and postoperative side effects, patient satisfaction, preoperative visual analog scale (VAS) pain scores, and VAS scores from the fourth hour postoperatively until the seventh day were assessed. Anesthesia, operation, surgery, and total hospital time, and costs (drug, resources, and labor) were recorded. No difference was found between groups in the frequency of side effects. Urinary retention was diagnosed in two patients in the spinal anesthesia group. There was no statistical significant difference seen in satisfaction scores between groups. No statistical significance in VAS pain scores between groups was noted except for the fourth postoperative hour values. The average time spent in the operating room (OR) was greater in the spinal anesthesia group. All Group 2 patients achieved fast-tracking criteria in the OR and were able to bypass the post anesthesia care unit (PACU). Total hospital time and total cost were significantly higher in the spinal anesthesia group than local anesthesia-sedation group (p < 0.05).The use of local anesthesia-sedation for ambulatory anorectal surgery resulted in a shorter hospital time, lower hospital costs, and no side effects compared with spinal anesthesia.

Sondenaa K, Diab R, Nesvik I, Gullaksen FP, Kristiansen RM, Saebo A, Komer H.Department of Surgery, Rogaland Central Hospital, Stavanger, Norway. kasoende@online.no

OBJECTIVE: To find out whether failure of primary wound healing after excision and primary suture for chronic pilonidal sinus predicts recurrence. DESIGN: Follow-up of one prospective study and one subsequent randomised, multicentre study. SETTING: Three teaching hospitals in WesternNorway. SUBJECTS: A total of 197 consecutive patients operated on for chronic pilonidal sinus. INTERVENTIONS: Fifty two patients in the prospective group were given cloxacillin perioperatively. In the randomised study, 145 patients were randomised to have either a single preoperative dose of cefoxitin 2 g intravenously (n = 73) or no prophylaxis (n = 72). Patients were followed up for a median of 7 years. MAIN OUTCOME MEASURES: Recurrence of pilonidal sinus. RESULTS: In the prospective group there were 10 recurrences (19%). In the randomised study 6 patients (8%) who had been given antibiotic prophylaxis had a recurrence compared with 14 patients (19%) who had not been given prophylaxis (p = 0.09). In both groups, failure of primary normal healing was significantly associated with early recurrence (p = 0.0002). Neither the use of antibiotics nor sex had any significant influence on the incidence of recurrences. Most recurrences occurred within the first year. CONCLUSION: Wound complications significantly influenced the recurrence rate whereas antibiotics did not. Most recurrences were seen early.

Tritapepe R, Di Padova C.
Institute of General and Oncological Surgery, School of Medicine, University of Milan, Via San Calimero 7, 20122 Milano, Italy.

BACKGROUND: In the case of pilonidus sinus treated with primary intention surgery the uneventful healing is still difficult to obtain, as indirectly proven by the number of different procedures that have been suggested, such as cyst excision with or without primary closure, excision followed by marsupialisation, and excision followed by skin flap transposition. The procedure described here involves excision and primary closure, with a drain being used to flush the operative cavity with an antiseptic solution. METHODS: Two hundred and forty-three patients (173 men and 70 women) were treated by excising the pilonidal sinus and placing a 12F suction drain at the base of the wound, with its tip being brought out in the left gluteal region at least 5 cm laterally to the lower end of the suture. Suction was stopped on the first postoperative day and the drain was cut just above the skin. On day 2, a 5F catheter was inserted through the drain and the cavity was flushed with an antiseptic solution followed by sterile saline solution; the same treatment was repeated on days 4 and 6. The drain was removed on day 8 or 9, some of the stitches on day 8 or 9 and the rest on day 9 or 10. The surgery was performed on a day hospital basis in 207 cases; the remaining 36 were hospitalized overnight and discharged on the following day. RESULTS: Healing was always by first intention, with none of the 243 patients experiencing any complications. The postoperative follow-up now ranges from 5 to 15 years, and there have not been any recurrences. CONCLUSIONS: The drainage of blood from the bottom of the wound and the use of antiseptic/saline flushing are essential for primary intention healing and the avoidance of recurrences.

Serour F, Somekh E, Krutman B, Gorenstein A.
Department of Pediatric Surgery, The Edith Wolfson Medical Center, P.O. Box 5, Holon 58100, Israel.

Controversy persists regarding the treatment of pilonidal sinus (PS). To evaluate the efficacy of excision with primary closure and closed-suction drainage in adolescent patients, between 1990 and 1999, 34 consecutive patients aged 13-18 years (mean 16.4) underwent PS excision with primary closure and suction drainage. Anesthesia was general in 16 (47%) and spinal in 18 (53%) with a statistical age difference ( P< 0.001) (15.5 vs 17.2 years, respectively). No complications due to the anesthetic were observed. Twenty-one patients (61.8%) had day-case surgery while the others were hospitalized for 2 to 4 days (average 2.3 days). The drain was removed on postoperative day 2 to 6 (average 2.2). Primary healing with no postoperative complications occurred in 30 patients (88.2%); 1 underwent partial opening of the wound because of rupture of the drainage tube during its removal. Postoperative infections requiring incision, drainage, and lay-open occurred in 3 cases (9.1%). No recurrence was found at 12-month follow-up. One recurrence (2.9%) was noted 3 years after surgery. Excision with primary closure and closed-suction drainage as an ambulatory procedure is thus a simple and effective method of treatment of uncomplicated PS in adolescents.

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Bascom J, Bascom T.

HYPOTHESIS: Refractory pilonidal disease is due to damage of the epidermis in the deep gluteal cleft by moisture and bacteria, rather than to damage in deep tissues. A new paradigm suggests that a procedure to change the shape of the gluteal cleft will improve results. DESIGN: Before-and-after trial. SETTING: Community private practice with extensive experience in pilonidal disease, providing ambulatory and hospital care. PATIENTS: Thirty-one patients with severe refractory pilonidal disease, with a median follow-up of 20 months in 27 patients (87%). Patients had undergone a total of 141 operations with wounds still open for a combined total of 252 years. INTERVENTION: The deep gluteal cleft was reshaped with a skin flap. Deep tissue was left essentially intact. MAIN OUTCOME MEASURES: Number healed, time to healing, number of operations required. RESULTS: Wounds in all 31 patients healed, 28 after a single procedure. The time to healing was rapid, within 1 week in 22 patients. There were no recurrences. CONCLUSIONS: For refractory pilonidal disease, the cleft lift procedure produced rapid results by drawing intact skin over the cleft and bringing the suture line out to open air. The failures of old methods and success of this new one suggest a need for a paradigm shift in our understanding of pilonidal disease. The source of disease is not the deep tissue but rather the epidermis in the moist, hypoxic, and bacteria-laden gluteal cleft. This also has implications for initial treatment of pilonidal disease, where simple, nonoperative treatments are often effective.

Chintapatla S, Safarani N, Kumar S, Haboubi N.
Hope Hospital Centres, Trafford Healthcare NHS Trust, Manchester, UK.

Sacrococcygeal pilonidal disease is a common and well recognized entity. For many years the cause of sacrococcygeal pilonidal sinus has been matter of debate. When the treatment is considered, there was a frequent lack of succes of the surgical methods of excision regarding morbidity, healing, recurrence and cure. All these factors rendered the acquired thesis of pilonidal sinus disease to be more accepted. In dealing with the pathogenesis of pilonidal sinus disease, Karydakis attributed the hair insertion process to three main factors: the invader, i.e. the loose hair; the force, which causes the insertion; and the vulnerability of the skin to the insertion of hair at the depth of the natal cleft. The sinus is initiated from a small midline opening lined by stratified squamous epithelium. Additional sinuses are frequent and have lateral openings. Malignant transformation is rare but cases of squamous cell carcinoma and verrucous carcinoma have been reported. Pilonidal sinus disease consists in a symptoms complex with presentations ranging from asymptomatic pits to painful draining lesions that are predominantly located in the sacrococcygeal region. Asymptomatic pits do not require treatment. Options for treatment of acute abscess include aspiration, drainage without curettage, and drainage with curettage. The choice of a particular surgical approach depends on the surgeon's familiarity with the procedure and perceived result in terms of low recurrence of sinus and a quick healing of resulting cavity or surgical wound. Conservative nonoperative management, closed methods, laying of track, wide excision and open drainage, wide excision and primary closure, and limited excision are the methods currently used. From the profusion of studies, it is apparent that various methods are being tried and no one method is universally acceptable. Recurrence rates vary with the technique, operator and length of follow-up. Primary closure with a lateral approach appears to give the best results.

A comparative study of partial closure with local anesthetics and open surgical methods in patients with pilonidal sinus
Tehran    Fall 2000

Nasiri, H., Pirmoazzen, N., Javaherzadeh, M. Department of Surgery, Shaheed Modarres Hospital

The clinical trial strategy of this study was performed on 48 patients. They were randomly divided into two control and case groups. For control group, the open method and routine procedures and for control group, an outpatient method and local anesthetics were applied. For the latter, the cyst (sinus) was removed and stitched by silk thread # 0. This method not only prevented hemorrhage, but also produced an operation area of less extent and less supporation and its treating is easier. After 5 days, the granulation tissue was formed and the sutures were removed. This procedure is a modified and converted form of open method and is accompanied with less infection and relapse (a modification to Dives method). Control group (n=24, 20 males and 4 females) consisted of patients at an average age of 27 years (from 18 to 36 years) and case group included 24 patients (22 males and 2 females) at an average age of 31 years (from 16 to 45 years). In both groups, the sinuses were similar regarding type and dimension. The wound extent in control group was from 15 to 25 mm and in the case group was from12 to 18 mm. In addition, both of them did not show hemorrhage, one patient in control group had infection, and wound healing in control and case groups observed after 45 ± 5 and 25 ± 5 days respectively. It is concluded that partial closure method have less complications in the treatment of patients with pilonidal sinus.

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