Fistula Research Articles

Pediatric endoscopic pilonidal sinus treatment (PEPSiT) for managing pilonidal disease in adolescents

Abstract Purpose The aim was to evaluate the success rate, complications and recurrence following paediatric endoscopic pilonidal sinus treatment (PEPSiT) in the treatment of pilonidal disease (PD). Methods A prospective observational study was performed between 01.06.2019 and 30.06.2022 at the author’s institute in patients under 18 years. The indication for PEPSiT was moderate or severe PD. Length of hospital stay (LOS), complications, recurrence, wound healing time (fistula closing) and postoperative hair removal were observed. Results During the study period, 51 PEPSiTs (4 redo) were performed in 47pts. The average age of the studied patients was 15.92 years at the operation. LOS was a day in all cases. The regular day activity came back on the 1.07 postoperative day (in average). The fistula closing time was 6.5 (1–24) weeks. Complication observed in 9/47 patients. Recurrence (including non-healed cases) was found in 15/51 (29.4%) cases. The postoperative hair removal was inadequate (23) or missed (7) in 30pts and the majority of recurrent cases (11/15) were found in this group. The overall success rate of PEPSiT was 70.4%. Conclusions The main reason of recurrence following PEPSiT could be the insufficient hair removal. The advantage of the procedure is the shorter LOS and faster recovery.

Pathological Examination in Pilonidal Sinus Surgery: Evaluating Necessity and Cost-Effectiveness: A 10-Year Retrospective Analysis.

Malignancy in pilonidal sinus disease (PSD) is rare, with squamous cell carcinoma (SCC) being the most common type. This study aims to assess the incidence of malignancy in PSD and identify risk factors to guide more targeted pathological examination strategies. A retrospective analysis was conducted on 1505 patients who underwent surgical excision of PSD between January 1, 2014, and December 31, 2023. Patients with incomplete or missing histopathological data were excluded, and no imputation methods were used for missing data. All specimens underwent histopathological examination to detect malignancies. Two cases (0.13%) of SCC were identified, both in males aged 50 and 58 years without a history of Crohn's disease, HIV, prior radiation, or other cancers. Significant risk factors for malignancy included age over 40 years (OR 3.2, 95% CI 1.1-9.5) and disease duration over 3 years (OR 2.8, 95% CI 1.0-7.6). Both cases were treated surgically and received adjuvant radiotherapy, with both patients being disease-free at the 2-year follow-up. While malignancy in PSD is rare (0.13%), older age and prolonged disease duration are associated with increased risk. Selective pathological examination based on these risk factors could enhance cost-effectiveness by reducing unnecessary routine examinations.

Effective Ayurvedic Treatment of Pilonidal Sinus using Udumber Ksheer Sutra: A Case Study

ABSTRACT Pilonidal sinus, also known as “jeep bottom,” is common among people who sit a lot, such as cab drivers. It mostly affects men and young adults and is associated with thick hair. Surgical techniques are available for treatment, but the condition has a relatively high recurrence rate. The Kshara Sutra method described in the Sushruta Samhita offers a minimally invasive treatment option. Pilonidal disease is estimated to affect about 26 out of every 100,000 persons, with around 0.7% of people affected. This study focuses on the diagnosis and treatment of patients who have Naadi Vrana (Pilonidal Sinus) using Udumber Ksheer Sutra. The Kshara Sutra is a minimally invasive, cost-effective technique with a low recurrence rate for treating pilonidal sinus. Udumber Ksheer Sutra management has also proven to be beneficial as a curative therapy for the pilonidal sinus.

Modern methods of treatment of complicated forms of pilonidal cyst

There are several theories of the origin of diseases of the epithelial coccygeal tract: empirical, neurogenic, ectodermal and acquired. Most Russian scientists consider this pathology to be congenital, while foreign colleagues believe that it is a consequence of sacrococcygeal area injuries. This pathology is quite common, affecting more than 5 % of the adult population, it also occurs in children and adolescents. This disease decreases the quality of patients` life significantly, affecting all aspects of their life. Conservative methods of treatment do not provide a complete cure, since they do not eliminate the causes of the disease. These include sclerotherapy and obliteration of the cavity with silver nitrate or hydrochloric acid. These methods are not used nowadays. Surgical treatment is the most effective one for this pathology. Surgical intervention, despite its apparent simplicity, turns out to be quite complex, which makes it inaccessible to any general surgeon. Treatment results are often disappointing due to the high incidence of complications after surgery, as well as the long period of activity limitation. Therefore, the resulting rough scar is a cosmetic defect, and the risk of recurrence remains quite high. Studying the literature data, one can see that the authors` opinions concerning surgical tactics for this disease differ. At the moment, there is no single approach and surgical tactic for the treatment of epithelial pilonidal cyst. The problem of creating and introducing new methods of treatment of pilonidal disease remains relevant nowadays.

ASPECTS OF LIVER ECHINOCOCCOSIS SURGERY

According to the WHO, «…at any given time, more than 1 million people worldwide are aff ected by echinococcosis…». Due to the lack of tendency to decrease the number of patients and the existence of endemic regions where the incidence rate varies from 1.2 to 9.0 per 100,000 population, this parasitic disease continues to be a serious medical and social problem. At the present stage, the diagnosis of echinococcosis does not present signifi cant diffi culties, mainly due to the emergence of non-invasive imaging methods, the informative value of the complex application of which reaches 95-100 %.Aim of the study. Improving the treatment results of patients with liver echinococcosis.Research materials. The study included 328 patients with liver echinococcosis admitted to the surgery department of the multidisciplinary clinic of the Samarkand State Medical University in the period from 2005 to 2023. Depending on the choice of treatment, the patients were divided into two groups: the comparison group consisted of 154 (46.9 %) patients treated from 2005 to 2012 and the main group included 174 (53.0 %) patients operated on from 2013 to 2023.Research results. Compared with the comparison group, in the main group of patients, intraoperative complications decreased from 6.5 to 2.3 %, and complications in the early postoperative period from 18.2 to 5.2 %. In the late postoperative period, the recurrence of the disease decreased from 16.2 % to 3.6 %.Conclusions. The introduction of improved surgical instruments into practice – a modifi ed puncture needle, a «basket clamp» allowed to level the risk of seeding of surrounding tissues with embryonic elements. The introduction of a device for the purpose of identifying hidden biliary fi stulas in the residual cavity after echinococcectomy from the liver reduced the number of bile leaks. With the introduction of a modifi ed method for eliminating the residual cavity after echinococcectomy from the liver, the number of complications during surgery and in the early postoperative period was minimized.

Time trends in incidence of pilonidal sinus disease from 1996 to 2021: A Danish population-based cohort study.

Pilonidal sinus disease (PSD) is a common condition, but no data on disease occurrence exist outside highly selected settings. The aim of this study was to assess time trends in the incidence of PSD in a nationwide setting. Using data from nationwide Danish registries, we identified 48 247 patients recorded with diagnostic or surgical procedure codes representing PSD between 1996 and 2021. We stratified by sex and computed the age-adjusted and age-specific incidence rate, comparing 5-year intervals with the incidence rate ratio (IRR). The overall incidence of PSD increased from 26.1 to 39.6/100 000 person-years (PY) from the period 1996-2000 to the period 2016-2021 (IRR 1.52, 95% CI 0.78-2.94). The incidence increased from 35.8 to 56.9/100 000 PY (IRR 1.59, 95% CI 0.52-4.89) in male patients and from 16.4 to 22.5/100 000 PY (IRR 1.37, 95% CI 0.68-2.76) in female patients. The peak of age-specific incidence was 215.7/100 000 PY (95% CI 206.1-245.4) among 20-year-old men and 107.9/100.000 PY (95% CI 100.0-114.0) among 18-year-old women. Over the study period, the median age at first hospital contact decreased from 27 years [interquartile range (IQR) 22-34 years) to 25 years (IQR 20-34 years) in men but remained stable around 23 years (IQR 18-32 years) in women. However, for both sexes, the highest increase in incidence was seen in early adolescence. The incidence of PSD has increased significantly over the last decades. The increase is driven primarily by men and boys, with the highest increase in incidence seen in early adolescence. The increased burden of disease is not reflected in the literature, and more studies are warranted to understand the drivers of this development.

Comparison of outcome of Simple Excision vs Limberg Flap of pilonidal sinus in terms of post operative pain, operative time, wound infection and hospital stay.

Objective: To compare post operative pain, wound infection, intraoperative time and length of hospital stay in both groups of simple excision and Limberg flap. Study Design: Comparative Prospective study. Setting: CMA Teaching and Research Hospital/Azra Naheed Medical and Dental College, Lahore, Pakistan. Period: 1st September 2021 to 1st September 2023. Methods: After approval from the Institutional review board of Azra Naheed Medical & Dental College/CMA Hospital, the sample was 120 patients was raised using non-convenience probability sampling divided into 2 groups. Group A patients underwent simple excision while Group B patients underwent Limberg flap Inclusion criteria include all the patients with age more than 13 years and diagnosed as case of pilonidal sinus. All the data was entered and processed by using SPSS 26. Comparison of two groups was done by apply independent sample t-test. A p-value of ≤ 0.05 was considered significant. Results: The average age of the patients was 45.88 ± 9.78 years with minimum and maximum ages were 15 & 59 year respectively. Mean post operative pain was 2.6 ± 1.9 in group A while 3.9 ± 2.7 in group B (p value = <0.05). Similarly wound infection, duration of surgery and length of hospital stay were also less in group A patients as compared to group B patients. Conclusion: Simple excision of pilonidal sinus is better from Limberg flap in terms of post operative pain, wound infection, duration of surgery and length of hospital stay.

An Observational Study On Surgical Procedures Of The Pilonidal Sinus Disease: Primary Closure, Healing By Secondary Intention And Limberg Flap Reconstruction

An Observational Study On Surgical Procedures Of The Pilonidal Sinus Disease: Primary Closure, Healing By Secondary Intention And Limberg Flap Reconstruction

Phenolization of the sinus tract in recurrent sacrococcygeal pilonidal sinus disease: long-term results of a prospective cohort study

AimIn recent years, the paradigm for the treatment of sacrococcygeal pilonidal sinus disease (SPSD) has shifted from surgical excision toward more minimally invasive techniques. Although extensive research has been conducted on the minimal invasive phenolization technique for primary SPSD, literature in recurrent SPSD is lacking. The purpose of this study was to report the long-term outcomes of the phenolization technique for recurrent SPSD.MethodThis study included all 57 patients who were initially prospectively included in this study for short-term follow-up after phenolization for recurrent SPSD. A questionnaire was sent out to all patients to obtain long-term outcome. The primary endpoint was recurrence. Secondary endpoints included quality of life and symptoms related to SPSD.ResultsA total of 47 patients (82.5%) were available for long-term follow-up. Recurrence needing further surgery developed in 7 patients (14.9%) after a mean follow-up of 76 (SD 21.7) months. At follow-up, there was improvement in the quality of life compared to preoperative levels (82.0, IQR 75.0–90.0 versus 74.0 IQR 52.5–80.0, p = 0.024). Additionally, symptoms associated with SPSD, including pain, fluid discharge, and itching sensation, also showed significant improvement. A total of 42 patients (89.4%) would undergo the same treatment again. No significant association was found between known risk factors and recurrence.ConclusionPhenolization for recurrent SPSD showed a recurrence rate of 14.9% with significant improvement of natal cleft symptoms and quality of life at long-term follow-up. Therefore, phenolization should be considered as a feasible option for patients with recurrent SPSD.

A Comparative Analysis of Pain Assessment Methods in the Initial Postoperative Phase Following Different Pilonidal Cyst Surgeries.

Background and Objectives: In this study, we aimed to evaluate pain intensity in patients after pilonidal disease surgeries of varying extent using pressure algometry and the visual analog scale and to explore potential correlations between these methods. Materials and Methods: A total of 78 adult patients with symptomatic pilonidal cysts were enrolled in this study. The patients were divided into two groups based on the type of surgery assigned to each patient at the pre-hospital consultation: pit-picking surgery (n = 39) and radical excision (n = 39). The pain levels at the surgical site were assessed and compared using the visual analog scale (VAS) and pressure algometry the morning before surgery and the day after the operation. Results: There was no statistically significant difference (p > 0.05) in VAS measurement results between surgical groups when comparing pain intensity experienced by patients before, during, and after surgery. Notably, specific pressure algometry variables (pressure pain tolerance left 2.05 ± 1.46 compared to 1.42 ± 0.73 kg/cm2, p = 0.02; maximum pressure pain tolerance left 2.91 ± 1.33 compared to 2.32 ± 1.14 kg/cm2, p = 0.04; maximum pressure pain tolerance center 2.51 ± 1.07 compared to 1.91 ± 0.91 kg/cm2, p = 0.01; interval of pressure pain tolerance center 0.98 ± 0.62 compared to 0.59 ± 0.39 kg/cm2, p = 0.00) on the first postoperative day were significantly lower in the "pit-picking" group compared to the excision group. Furthermore, no statistically significant correlation was found between VAS and pressure algometry measurements either before surgery or on the first postoperative day. Conclusions: In the early postoperative period following pilonidal disease surgery of varying extents, pain measured with the VAS does not differ. In contrast, the pressure algometry method showed greater pain in the minimally invasive surgery cohort on the first postoperative day. However, further larger studies are needed to compare these pain assessment methods in reporting pain intensity experienced during patient movement.

Short-term results of unroofing and marsupialization compared to the Karydakis technique in the treatment of pilonidal sinus. A randomized prospective study

IntroductionThe treatment of pilonidal sinus (PS) is usually surgical, but no procedure is considered the gold standard. The Karydakis (K) technique is widely used, and unroofing and marsupialization (UM) is a simple surgery with good results. Primary objectiveTo evaluate early postoperative complications (EPC) 30 days after UM surgery compared to the K technique. Secondary objectivesTo evaluate surgical time, postoperative pain, patient satisfaction, return to daily activity and early recurrence within 3 months. MethodProspective, single-center, randomized study in patients who underwent surgery for primary PS with no abscess between June 2016 and November 2017. They were randomized using a computer-generated block method. To analyze the main objective, a non-inferiority analysis was performed. Results122 patients with symptomatic primary PS were randomized: 60 in the K group and 62 in the UM group. Both groups were homogeneous.There were statistically significant differences between surgery and postoperative complications at 15 and 30 days in favor of UM. There were also differences in favor of UM in surgical time and return to daily activity. During the 90-day follow-up, there were 3 recurrences in the UM group and 0 in the K group. ConclusionsUM is a simple, minimally invasive, easily reproducible technique that has a lower rate of early complications, with a shorter operative time and an earlier return to daily activity.

Long Term Follow Up of Limberg's Flap Repair for Pilonidal Sinus Disease

Long Term Follow Up of Limberg's Flap Repair for Pilonidal Sinus Disease

Therapeutic burden in hidradenitis suppurativa: a cross-sectional study of 557 patients.

Therapeutic burden (TB) has been identified as a potential predictor of response to biologic therapy in hidradenitis suppurativa (HS). We aim to analyze the determinants of TB in real-world clinical settings among HS patients to explain this concept and its utility as an additional tool for guiding therapeutic decision-making. We conducted a cross-sectional study including all consecutive HS patients attending a specialized HS clinic between 2017 and 2024. The primary variable was TB, defined as the cumulative sum of prior systemic treatment cycles and surgical interventions for HS. We analyzed whether sociodemographic or clinical factors were associated with a higher TB. We included 557 HS patients. Of these, 50.81% were women, and the mean age was 41.87 (14.19) years. Most patients (62.30%) were referred from general dermatology consultations. The mean disease duration was 17.52 (11.51) years. Regarding disease severity, 46.50% presented with Hurley II, and 42.19% had an IHS-4 score between 4 and 10. Before their baseline visit, 9.70% of patients had received biological therapy, mostly adalimumab (88.89%). The mean TB was 2.42 (2.25) systemic medical and/or surgical interventions. Referral from general dermatology or other hospital departments, older age, longer disease duration, greater HS severity, presence of pilonidal sinus, and prior biological therapy were significantly associated with higher TB. Our findings suggest that TB comprehensively captures HS severity and progression factors. This metric could prove valuable in aiding decision-making for HS patients by indicating when a change in therapy might be necessary.

A Holistic Review of Therapeutic Potential of Palasha Kshara Sutra in Shalyaja nadivrana vis-a-vis Pilonidal Sinus

Pilonidal sinus (PNS) is characterized by the presence of a sinus tract in the sacrococcygeal region, typically containing hair and debris, which can lead to recurrent infections and abscess formation. Shalyaja Nadivrana is a type of Nadivrana explained in Sushrutha samhitha. Clinically it can be correlated with Pilonidal sinus. Conventional treatments include surgical excision, which may result in prolonged healing and high recurrence rates. Ayurveda offers Kshara Sutra chikitsa. This para surgical technique has shown promising treat conditions like fistula-in-ano and now holds potential in managing pilonidal sinus.Ksharasutra ligation is regarded as the best method in pilonidal sinus as it is safe, effective, economical and simple OPD procedure with recurrence rate of 5.88%. Kharasutra ligation its gradual and sustainable chemical action not only removes the deberis from the site of track but also helps in encouraging new healthy grannulation tissue formationThe present study aims to explore the effect of palasha kshara sutra in the management of shalyaj nadivrana.As Palasha having katu, tikta, Kashaya rasa, katu vipaka, ushna virya, is vatakaphahara, vranahara, krimihara and shothahara properties. Palasha kshara sutra has anti-inflammatory, anti-oxidant, anti-microbial, anti-fungal and analgesic properties.

Closed-incision negative-pressure wound therapy after Bascom's cleft lift surgery for pilonidal sinus disease: A randomized study comparing healing.

Despite favourable outcomes in recurrence after off-midline closure techniques in pilonidal surgery, between 18% and 40% of patients suffer from prolonged postoperative wound healing. The aim of this work was to investigate if closed-incision negative-pressure wound therapy (NPWT) promotes wound healing after Bascom's cleft lift (BCL) surgery for complicated pilonidal sinus disease compared with conventional drainage and dressing. Patients were randomized to either NPWT for 4-7 days or loop-vessel drain for 24 h and a dry dressing postoperatively. Healing was evaluated by a wound care nurse blinded for randomization at 2 and 12 weeks postoperatively (primary endpoint). Healing was defined as one or no closing defects of ≤5 mm and with no undermining. Although we had wanted to recruit 200 patients, the study was terminated at 118 patients (NPWT group, n = 60; control group, n = 58) after interim analysis. Patients were comparable by age, sex, body mass index, previous smoking status and indication for BCL surgery. At 2 weeks 12% of patients were healed in both the NPWT and control groups [risk difference = 0.00(95% CI -0.12 to 0.11), p = 1.00]. After 12 weeks, 68% of patients were healed in the NPWT group and 72% in the control group [risk difference = -0.03 (95% CI 0.19 to 0.13), p = 0.82]. There was no significant difference in pain experienced postsurgery. In a symptom-based questionnaire, the control group reported self-esteem to be less affected (p = 0.015). Closed-incision negative-pressure wound therapy did not significantly improve healing after BCL surgery for complicated pilonidal sinus disease.

Precise treatment of pelvic fracture urethral injury associated with urethrorectal fistula.

To evaluate the effect of a new strategy of transperineal anastomotic urethroplasty (TAU) with proximal transection in treating pelvic fracture urethral injury (PFUI) associated with urethrorectal fistula (URF). A retrospective review of all patients treated by TAU with proximal transection and fistula repair for PFUI associated with URF was performed between August 2013 and July 2022. Information on demographics, peri-operative variables, and postoperative follow-up outcomes was collected. Successful surgery was defined as restoration of a uniform urethral calibre using flexible cystoscopy (third postoperative month) without strictures or leakage, with no further interventions required. Functional outcomes, including erectile function (assessed using the five-item International Index of Erectile Function) and urinary continence, were assessed. Forty patients diagnosed with PFUI associated with URF and treated by TAU with proximal transection and rectal fistula repair were enrolled. Six patients (15.0%) had a history of failed urethral reconstruction. The mean stenosis length and fistula diameter were 2.9 cm and 1.2 cm, respectively. All patients underwent faecal diversion before urethroplasty. After a median (range) follow-up of 45 (3-115) months, the final success rate was 90.0% (36/40). Postoperative complications included haematoma in three patients, epididymo-orchitis in three, wound infection in one, wound bleeding in one, delayed wound healing in three, and wound numbness in three. The overall incidence of postoperative erectile dysfunction reached 75.0%, with a median (range) score of 9 (0-19). Normal continence was achieved in 31 patients (77.5%). Occasional incontinence without the need for urinal pads occurred in eight patients, whereas one patient required urinal pads. Transperineal anastomotic urethroplasty with proximal transection is a precise and effective surgical strategy for treating PFUI associated with URF. This strategy ensures a high success rate and improves surgical efficiency.

Pilonidal granuloma formation after an incision and drainage procedure is associated with retained hair within the sinus – A case series

Introduction and importancePilonidal disease may present with a draining secondary sinus or granuloma, but the development of these findings is not well-characterized. Case presentationTwo adolescent males presented with pilonidal disease. The first patient had a gluteal cleft abscess, and an incision and drainage procedure was performed. Although the abscess resolved, the incision site formed a granuloma with intermittent draining wound with granulation tissue. He underwent a pit-picking procedure along with excision of the granuloma. A large amount of hair was also removed from within the pilonidal sinus. The second patient underwent an incision and drainage procedure to treat the pilonidal abscess. The incision site evolved into a granuloma with recurring drainage. A pit-picking procedure was performed, and the granuloma was excised. During the excision, a moderate amount of hair was evacuated from the pilonidal sinus. Clinical discussionMany pilonidal patients present with a granuloma or secondary sinus at the gluteal cleft, but there has been no documentation of the natural history of this development. The role of hair is central to pilonidal disease pathophysiology and is a known factor in foreign body granuloma formation – a cutaneous inflammatory response to endogenous or exogenous material in the dermis that is not broken down readily by macrophages. ConclusionEven though the pilonidal abscess was drained with an incision, a granuloma was able to form with recurrent drainage when hair was retained within the pilonidal sinus.

Identification of Associations with Dermatologic Diseases through a Focused GWAS of the UK Biobank

The UK Biobank includes genotype information for about 500,000 patients for over 7,000 phenotypes. However, due to multiple testing correction for approximately 200 billion tests, many clinically and statistically significant associations remain unappreciated. We perform a focused analysis of the UK Biobank for 13 dermatologic conditions, including malignant melanoma, melanoma in situ, squamous cell carcinoma, basal cell carcinoma, actinic keratosis, seborrheic keratosis, psoriasis, lichen planus, systemic lupus erythematosus, hyperhidrosis, pilonidal cyst, sebaceous cyst, and lipoma. We identify 447 sentinel variants, which are enriched for protein-coding variants and an elevated CADD score compared to background variants. Through GO enrichment analysis, we identify known pathways involved in melanoma, actinic keratoses, and squamous cell carcinoma and uncover pathways. We also uncover 5 protein-coding variants, which to our knowledge have not been previously reported, including LRP3 for lipomas, PLCD1 for sebaceous cysts, EIF3CL for lichen planus, TTK for pilonidal cysts, and MAPK15 for systemic lupus erythematosus.

European Society of Coloproctology guidelines for the management of pilonidal disease.

European Society of Coloproctology guidelines for the management of pilonidal disease.

Peri anal region is an overlooked location for pilonidal recurrence after surgical excision and closure – A case series

Introduction and importancePatients with pilonidal disease (PD) often undergo wide excision of pilonidal sinuses and flap-based closures. Patients who failed these procedures can have recurrent perianal wounds obscured by hair and unrecognized even by the treating physicians. In this report, we describe a series of pilonidal patients with recurrent disease and perianal wounds. Case presentationFive pilonidal patients with recurrent disease after surgical excision and flap closure were referred to our Pilonidal Care Clinic. All five were found to have perianal wounds. Each patient was treated with regular manual and laser epilation and only one patient required a Gips procedure. All wounds were successfully healed. Clinical discussionAfter removal of hair at the perianal region, patients with recurrent pilonidal disease can expose a pilonidal sinus that was previously unrecognized. Peri-anal wounds can have poor wound healing due to the close proximity of the wound to the anal verge, risk of contamination, difficulty of consistent observation of the wound, and moist environment of the anus that retains bacteria. Careful consideration of proper wound care post-excision of perianal pilonidal sinuses should be prioritized. ConclusionsPilonidal perianal wounds after previous surgical excision and flap closure can be obscured by hair, resulting in recurrent pain and drainage. The perianal wounds can be successfully healed with regular manual and laser epilation and selectively excised using Gips procedure.