Endoscopic Treatment of Pilonidal Sinus Disease: State of Art and Review of the Literature

Background: Pilonidal sinus disease (PSD) is a chronic troublesome pathology of the natal cleft of the sacrococcygeal region, with an estimated incidence of 26 cases in every 100,000 inhabitants. The aim of this review is to give a snapshot of the current literature on the endoscopic approach to PSD.Methods: A search on endoscopic treatment of pilonidal disease was performed according to PRISMA guidelines, adopting the following search terms: (pilonidal OR sacrococcygeal) and (endoscopic OR VAAPS OR EPSiT OR minimally invasive OR video-assisted OR video assisted).Results: Thirty-four articles were included in the final analysis, among which 23 were on adults and 11 were on pediatric population. The endoscopic approach is associated with painless postoperative pain, good aesthetic results, short time off work, and high patient satisfaction.Despite these advantages in short-term outcomes, results on recurrence rate in a long-term follow up are needed to definitively confirm the importance of this technique.Conclusions: The endoscopic approach is associated with significant postoperative advantages over other standard surgical approaches, and it should be included in the surgical portfolio for the treatment of PSD. According to the Italian guidelines, this technique could be considered as the gold standard for limited PSD. However, the favorable short-term-outcomes and lack of reliable data on long-term follow-up must be a stimulus to perform further high-quality studies to give definitive conclusions on this technique.

Minimally Invasive Pilonidal Sinus Treatment: A Brief Review

With a prevalence of 26/100,000, pilonidal sinus disease is a frequent natal cleft condition that primarily affects young males. The disease site is often uncomfortable and the disease can result in problems such as abscess formation and recurrent acute or chronic infections. Minimally invasive treatment aims to form a small elliptical wedge of subcutaneous tissue containing all the inflammatory tissue. The sinus and its lateral tracks are removed while keeping the overlying skin intact. Following the notion of “less is more,” novel least invasive treatments such as sinotomy, sinusectomy, trephining, and video-assisted and endoscopic pilonidal sinus surgery have recently been proposed. We look at minimally invasive treatments to explain how research into modern techniques has revealed a low rate of short-term problems.

Compare outcome of simple excision with primary closure vs rhomboid excision with limberg flap for pilonidal sinus

Background: Sacrococcygeal pilonidal sinus is a common condition usually affecting young-to-middle-aged men. For managing sacrococcygeal pilonidal illness, a variety of lateralizing surgical flap procedures based on this principle have been published, including the Karydakis flap, Limberg flap, modified Limberg flap, Z-plasty, and Y-V advancement flap. Aim: To compare the outcome of simple excision with primary closure versus rhomboid excision with limberg flap for sacrococcygeal pilonidal sinus. Methodology: Randomized control study conducted in Surgery Department, Ghurki Trust Hospital, Lahore. 90 patients fulfilling the inclusion criteria were selected from wards and were randomly divided in two equal groups. In group A, patients underwent rhomboid excision with limberg flap. In group B, patients underwent simple excision with primary closure. The operation was performed under spinal anesthesia. After surgery, patients were evaluated every 24 hours if they are able to move on their own then they were discharged and hospital stay was noted. Then after 10 days, patients will be called in OPD for assessment of wound healing. If wound did heal and patient complained of pain (VAS>4) and cannot sit and have fever (temp>100oF) Results: The average age in group A was 44.37±15.42 years while that in group B was 45.24±14.50 years. In group A there were 23(51.1%) males and 22 (48.9%) females whereas in group B there were 25(55.6%) males and 20(44.4%) females. There was difference significant in the mean stay in hospital in both groups (p-value=0.002). Conclusion: The conclusion of the study, that primary sacrococcygeal pilonidal sinus disease and rhomboid excision with Limberg's flap is an effective treatment. Keywords: Simple Excision with Primary Closure, Rhomboid Excision, Limberg Flap, Sacrococcygeal Pilonidal Sinus

Comparison of two Different Surgical Modalities in the treatment of Pilonidal Sinus (Primary Closure and Open Technique)

Background: Pilonidal sinus is disease of young age andits prevalence is higher in men compared to women (almost twice).It is a disease that arises from hair follicles particularly present in the natal cleft. It occurs commonly in Jeep Drivers and hence gets the name from there “Jeep Drivers Disease” and also commonly occurs in Barbers. It leads to formation of abscesses and chronic wounds with discharge and pain. Disease can have huge impact on social life and quality of life. In most cases the treatment is incision and drainage. Study design: It is a case series study. Place and duration of study: Department of General Surgery at Shaikh Zayed Hospital Lahore from January 2019 to January 2021. Aim: To compare the relative effects of open and closed surgical techniques on the recurrence rate, rate of infection and time of healing for pilonidal sinus. Methodology: Patients with pilonidal sinus disease from January 2019 to January 2021 received surgical treatment either excision followed by primary closure as in closed technique (group A) or excision followed by leaving the wound open for healing by secondary intention as in open technique (group B). Surgical management is widely based upon two techniques open and closed. In open technique wound is left open and heals by secondary intention while in closed technique it is closed primarily and heals by primary intention. The better choice between these two techniques is still a topic of debate. Results: The most common age group for pilonidal sinus was between 16-25 years of age. The mean age came out to be 26.7 years. The mean healing time was 15 days in group A and 42 days in group B. The duration of hospital stay ranged between 2-8 days for group A and 5-16 days for group B. Early postoperative complications seen was infection in 1 patient (7.69%) in group A and 5 patients (35.71%) in group B and these cases were managed conservatively.1 (7.69%) case of aseptic gaping of wound after stitch removal was seen in group A and was managed with closed technique. Recurrences reported in group A was 1 case (7.69%) at 6 months and was surgically managed by open technique. There were a total of 4 (28.57%) recurrences which were left open to heal by granulation. Conclusion: It is concluded that better management option for pilonidal sinus disease is primary closure of defect. So it is suggested that management of pilonidal sinus disease should be individualized but preference must be given to closure of wound after excision. Keywords: Pilonidal sinus, Primary Closure, Open Technique.

Colorectal surgery

This chapter studies colorectal surgery. It begins with ulcerative colitis, Crohn’s disease, and other forms of colitis, before looking at colorectal polyps and colorectal cancer. Ulcerative colitis is an acute and chronic inflammatory disease originating in the co-lonic columnar mucosa; it is often precipitated by an apparent acute GI infection. Meanwhile, Crohn’s disease is a chronic inflammatory non-caseating, granulomatous disease affecting any part of the GI tract; it is associated with several extraintestinal disorders. The chapter then explains restorative pelvic surgery and minimally-invasive colorectal surgery. It also discusses diverticular disease of the colon; rectal prolapse; pilonidal sinus disease; fistula-in-ano; haemorrhoids; acute anorectal pain; acute rectal bleeding; acute severe colitis; and post-operative anastomotic leakage.

SP7.1.12 Could surgery under local anaesthetic be the default for Pilonidal Sinus Disease? A systematic review

Aims Pilonidal sinus disease (PSD) is a significant cause of morbidity. The purpose of this systematic review and meta-analysis is to determine the totality of evidence regarding the effectiveness of Local Anaesthesia (LA) when compared to spinal or general anaesthesia in individuals undergoing definitive surgery for PSD. Methods A systematic review of literature was conducted. Studies included randomized controlled trials comparing LA with other anesthetics and non-randomized studies focusing on ambulatory procedure of excising pilonidal sinus aiming wound closure, all performed under local anesthetics. We used Cochrane risk of bias tool. The statistical analysis was done using Revman and Excel. Results Four original RCTs and 10 observational studies were included, with a total of 1801 patients. There was no significant difference in operative time between the groups Patients in the local anaesthetic group experienced less pain than those in other group, lower rates of anaesthetic related complications, early return to work and increased satisfaction. However, the mode of anaesthesia used had no relation with recurrence. Conclusion Our findings support the use of LA in adult patients undergoing definitive surgical treatment for PSD. We aggregate the published evidence to demonstrate clear benefits clinically, patients’ preference, and economic benefits. Patient selection, and adequate dose of local anaesthetic, is the key. In the context of the current COVID—19 pandemic, novel care pathways need to be developed in all medical fields, and we would propose that surgery for Pilonidal Sinus Disease under local anaesthesia should now be the default.

Modified Sinotomy with Marsuplization versus Excision with Lay Open in Treatment of Pilonidal Sinus Disease

Pilonidal sinus disease (PSD) is a common infection of the skin in the gluteal cleft, with a prevalence of 0.7% in the general population. Pilonidal sinus can occur in many different areas of the body but most are found in the sacrococcygeal area, in the natal cleft, approximately 5 cm from the anus. This is a prospective comparative randomized study conducted at Department of General Surgery, Imbaba General Hospital to compare the modified sinotomy with marsupialization versus excision with lay open in treatment of pilonidal sinus disease. Pre-study power analysis revealed that a sample size of 30 patients in each group would be sufficient with 80% power and a P value of 0.05. The perfect approach for the management of PNS should be simple, cause minimal pain, have best chance for success and least recurrence rate with low risk for complications, avoid general anesthesia, require minimal wound care, and ensure minimal inconvenience for the patient with rapid return to normal activity. Number of Patients participated in this study were n = 60 77% of the participants were males aged from 17-52 and 26.3 works as drivers. Operative time in modified sinotomy group ranged from 20-40 minutes and in lay open group ranged from 20-35 min (P-value: 0.07). Presence of hair in the back in the modified sinotomy group in 83.3% while in the lay open group 76.6% (P-value: 0.004). In conclusion, we believe that execution of a minimally invasive surgical technique for PSD can be among the most important methods for treating not only primary PSD but also complicated and recurrent PSD cases.