Pilonidal sinus disease guidelines: a minefield?

Abstract

We have studied the recent Italian guidelines on the management of Pilonidal Sinus Disease (PSD) published in Techniques in Coloproctology [1] with interest. Guidelines serve multiple purposes but predominantly aim to reduce inappropriate variation in practice. Achieving a balance between empirical evidence, interpretation of research and individual biases/preferences can be difficult but is crucial. The guidelines are, in part, provocative. Despite the authors’ certainty, it is still not known whether PSD arises due to lose hair penetrating the skin via a preformed sinus or by creating a new sinus [2]. Segre et al. state PSD incidence in Norway in 1995 was 26/100.000, but what is it in Italy today? In Germany, the incidence has increased between 2000 and 2012 from 51/100.000 to 94/100.000 [3]. While undisputedly the peak age at time of surgery is around 20 years, onset of symptoms over the age of 30 is not rare—this age group represents around 36 % of all new PSD (Fig. 1). To clarify, Buie coined the term ‘‘Jeep disease’’ in 1944 and Hardaway ‘‘Jeep rider’s disease’’ in 1958. Importantly, Favre et al. [4] recalculated Buie’s large numbers and concluded the incidence of PSD is not increased within military driving personnel, but this has gone mostly unnoticed. One needs to remain mindful that military personnel are predominantly young males who happen to be at highest risk of developing PSD. While many aspects of PSD remain to be elucidated, the guidelines could have addressed what converts asymptomatic PSD to symptomatic; why familial PSD behaves differently to sporadic (earlier onset and higher recurrence) as well as the role of personal hygiene. The extremes of age are more likely to have natal cleft contamination but are the least likely to develop PSD [3]— the time has truly come to stop insulting the patient! The guidelines recommend shaving as a ‘‘standard component of post-operative treatment in order to prevent recurrence’’ ignoring data suggesting a higher recurrence rate with shaving [5]. Literature detailing outcomes of PSD treatment with phenol is sparse and clouded by low numbers and short follow-up. It is not clear where phenol fits into the PSD management algorithm. Do the authors suggest phenol treatment be the first line for all symptomatic patients with chronic PSD? Little emphasis was placed on the observation that recurrence rate after (surgical) treatment of PSD is a function of time: 30 % of recurrences occur more than 4 years post-operatively. There is no debate that currently, paramedian closure techniques have the lowest recurrence rate and midline closure the highest. By stating ‘‘no clear & D. Doll ddoll@gmx.de; dolld@gmx.de