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Pilonidal
sinus disease needs definitive surgical treatment. There are many surgical
procedures ranging from simple shaving to excision and complex flap
repairs.1 Bascom’s repair is popular in the West (Great Britain)
but takes longer time and recurrence rate is around 10%.2
We report our series of 56 patients who underwent excision and
primary closure. |
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INTRODUCTION |
 |
All
the patients underwent complete physical examination. All routine
investigations were done. Diabetes and hypertension were controlled
when present. All the patients had shaving on the day of the
operation and received 1 gm of velocef IV 1 hr. before surgery.
Standardised operative procedure was performed. Patients were
intubated on the trolley and shifted on the operating table
in prone position. Buttocks were strapped wide by an elastoplast.
Part was prepared by painting with povidone three times and
cleaned with spirit prior to draping. |
Sinuses were probed and methylene blue was injected into the sinuses.
An elliptical incision about 0.5 cm. all round the sinuses was made.
Dissection was done with cutting cautery till the entire tract was excised
in toto. Haemostasis was achieved. Suction drain was left in the wound
brought out through a separate incision
.
Tension suture were laid and wound was closed in layers. Tension sutures
were tied over a gauze.
All these patients had IV antibiotics for 48 hours then changed to oral
capsules. Drains were removed between 3-5 days depending upon the amount
of drainage. Tension sutures were removed on the 5th day and the patients
were discharged. Follow-up was on the 10th day in OPD for removal of
skin sutures
.
We had in our series 2 minor wound infections and 3 major wound infection
needed laying open the wound and dressing for a period of 10 to 15 days.
51 out of 56 had successful primary closure. Only two patients had recurrence
which needed culture/sensitivity and appropriate antibiotics. |
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| Complications |
DISCUSSION |
Hodges
first used the name ‘Pilonidal’ in describing the condition
in 1880.3
The origins of pilonidal disease had been debated well over a century.
Before mid 1940 most practitioners believed that the cause of pilonidal
sinus was congenital.
Patey and Scarff proposed the now generally accepted theory that pilonidal
disease is acquired.4
Bascom demonstrated multiple stages in the development of pilonidal
disease through microscopic studies.5 |
| |
Two
theories |
Congenital
Theory |
It
is very rare occurrence. Even when present it is a sinus connected with
post anal dermoid or persistent remnant of original neural canal usually
seen in coccyxeal region. This is prone to meningitis and extradural
abscess. |
| |
Acquired
Theory |
| 1 |
Inter
digital pilonidal sinus is an occupational disease of hair dressers.
Hair being of the customer. |
| 2 |
Pilonidal
sinus is also seen in axilla and umbilicus. |
| 3 |
Age
incidence - 82% occur 20-30 years age group |
| 4 |
Hair
follicles have never been demonstrated in the walls of the sinus. |
| 5 |
Hairs
projecting from the sinus are dead hairs, pointed ends are directed
towards the blind end of sinus. |
| 6 |
Disease
affects hairy men most frequently. |
| 7 |
Recurrence
is common even after adequate excision |
|
Aetio-Pathogenesis : While sitting the buttocks take the weight
of the body and move independently or together. Hairs broken off by
friction of clothes from nape to buttock fall into the natal cleft.
When toilet paper is used it rubs against the cleft causing micro injury
facilitating the entry of hair.
Pilonidal sinus is extremely rare in people who use ablution after defaecation.
Shearing action of the buttocks and rolling along with the natal cleft
causing foreign body reaction and infection commonly termed as jeep
bottoms of World War II.
Pathology : Pilonidal sinus extends into the subcutaneous plane
as an infected tract lined by stratified Squamous epithelium. Hair shafts
are found in cluster or loosely scattered in the sinus with granulation
tissue.
|
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Clinical
features |
Pilonidal
sinus disease affects young adults after puberty up to 40 yrs. of age.
This condition is painful unpleasant, typically affecting overweight,
hairy individuals with poor personal hygiene.
It is common in the western world, and some parts of Arab World. Rare
in Asia and Africa who use ablution after defaecation. Age incidence
20-30 years Male-Female 4:1. Female patients are usually much younger.
There is a chronic or recurring sinus in the natal cleft at the level
of first piece of coccyx. Tuft of hair is seen projecting with foul
discharge or blood stained discharge. There may be 2-3 small openings
in the midline sometimes secondary openings are seen on either sides.6
On examination usually there is cellulitis in sacrococcygeal area. Tenderness
and drainage are frequently noted from one or multiple sinus tracts,
most of which run cephalad (93%).7 |
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Classification
| 1 |
Simple
Pilonidal Sinus : This is a central sinus with small cavity,
having minimal secondary tracts, closer to midline. |
| 2 |
Complex
Pilonidal Sinus : This has branching tracts away from the
midline, frequently it is a large tract and infected. |
| 3 |
Pilonidal
Abscess : Formation takes place whenever sinus opening gets
blocked with infected contents.8 |
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| MANAGEMENT
|
 |
Many
surgical procedures that are available for the symptomatic pilonidal
sinus are well reviewed by Allen-Mersh in 1990.9
Ambulatory surgical treatment although effective but procedures
which offer early recovery and early return to normal activity
are the choice over complex procedures.10,11
The most difficult complication after the surgery for pilonidal
sinus is persistently unhealed midline wound following laying
open or excision of the primary disease.12
Although Karydakis has described a technique of asymmetrical
closure with excellent results, this method is not popular.13 |
Many others including Mann and Springall have also described an asymmetrical
excision and primary closure with good results using GA with a mean
hospital stay of 16 days.14
Bascoms technique is popular method in West (Great Britain). It is done
as a day care under local anaesthesia and sedation. Excision of midline
pits and the abscess cavity is drained laterally 2-3 cm away from the
midline and curetted.15
Buie first described an excision of pilonidal sinus and marsupilization
in 1937 and published in 1944.16
It was further advocated by Culp in 1967.17
Wide local excision and primary closure has been advocated by some researchers
because of its shorter healing time.18
For more complicated or recurrent diseases and non-healing midline wounds
more aggressive treatment such as Split-thickness, Skingraft and Z-plasty
or gluteal myocutaneous flaps.
The reported rate of recurrence of pilonidal sinus varies widely in
the literature from 0% to 43%.19
No treatment for pilonidal sinus is perfect. Bascom procedure is a popular
method which employs local anaesthesia with sedation and done as out
patient.
Excision and primary closure as done in our series gives a good result
in healing and an acceptable recurrence rate. |
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Acknowledgement |
Thanks
to, Dr. Fouad Dagestani, Hospital Director Supervisor General for his
encouragement and permission for publication. |
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REFERENCES |
| 1 |
Armstrong
JH, Barcia PJ. Pilonidal sinus disease. The conservative approach.
Arch Surg 1994; 129 : 914-17.
|
| 2 |
Allen-Mersh
TG. Pilonidal sinus : Finding the right tract for treatment. Br
J Surg 1990; 77 : 123-32. |
| 3 |
Hodges
RM. Pilonidal sinus. Boston Med Surg J 1880; 103 : 485-86. |
| 4 |
Patey
DH, Scarff RW. Pathology of a post anal pilonidal sinus : Its
bearing on treatment. Lancet 1946; 2 : 484-86. |
| 5 |
Bascom
J. Pilonidal disease. Origin from hair follicles and results of
hair follicle removal as treatment surg. 1980; 87 : 567-72. |
| 6 |
Short
TB. Surgery ed by RCG Russel, Norman’s; Williams and Christopher
JK, Bulstore 23rd edition Arnold, London 1121-22. |
| 7 |
Hodgeson
WJB. Pilonidal sinus and cyst. In cameron JL. Ed. Current surgical
therapy 2nd edition Philadelphia, BC Decker 1986; 150-52. |
| 8 |
Oxford TB. Surgery ed by Peter J Morris, Ronald Malt, Oxford University
1994; 1 : 1155. |
| 9 |
Allen-Mersh TG. Pilonidal sinus : finding the right tract for
treatment. Br Surg 1990; 77 : 123-32. |
| 10 |
Thompson Fawcett MW, Cook TA, Baigrie RJ, Mortensen NJMcC. What
patients think of day-surgery proctology. BJ Surg 1998; 85 : 1388. |
| 11 |
Royal
College of Surgeons of England working party. Guidelines for day
care surgery London. Royal College of Surgeons of England, 1992. |
| 12 |
McLaren
CA. Partial closure and other techniques in pilonidal surgery
an assessment of 157 cases. Br J Surg 1984; 71 : 561-2. |
| 13 |
Karydakis
GE. Easy and successful treatment of pilonidal sinus after explanation
of its causative process. Aust NZJ Surg 1992; 62 : 385-9. |
| 14 |
Mann
CV, Springall RD. Excision for sacrococcygeal pilonidal sinus
disease. JR Soc Med 1987; 80 : 292-5. |
| 15 |
Bascom
J. Pilonidal Sinus. In current therapy in colon and rectal surgery.
Toronto : BC Decker, 1990; 32-9. |
| 16 |
Buie
LA. Jeep disease. South Med J 1944; 37 : 103-9. |
| 17 |
Culp
CE. Pilonidal disease and its treatment surg. Clin North America
1967; 47 : 1007-14. |
| 18 |
Kronbag
O, Christiansen K, Zimmermann-Nielson C. Chronic pilonidal sinus
disease : A randomised trial with complete three year follow up.
Br J Surg 1985; 72 : 303-4. |
| 19 |
Allen-Mersch TG. Pilonidal sinus : Finding the right tract for
treatment. Br J Surg 1990; 77 : 123-32. |
|
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SUBTHALAMIC
STIMULATION FOR PARKINSON’S DISEASE - LIVING BETTER ELECTRICALLY?
One of the true miracles of modern medicine was the introduction
of levodopa, the precursor of dopamine, for the treatment of
Parkinson’s disease. However, even in the early trials
of levodopa, unexpected complications were observed. These included
choreoathetotic movements (dyskinesias) and fluctuations from
a state of mobility (the “on” period), often accompanied
by dyskinesias, to a state of severe parkinsonism (“off”
period), sometimes many times a day. These complications become
increasingly common and disabling with longer durations of the
disease and of exposure to levodopa.
Krack et al report on their prospective study of stimulation
of the subthalamic nucleus in 49 patients with Parkinson’s
disease who were followed for five years.
Many patients obtain a prolonged and relatively uncomplicated
benefit from medication, and the risk of surgical mishaps is
unacceptably high in untreated or highly functional patients.
However, stimulation therapy should be considered for relatively
young patients.
Many elderly patients will not be good candidates for stimulation
of the subthalamic nucleus. Postural instability, freezing and
falls, dysarthria, dysphagia, and cognitive dysfunction are
common among elderly patients and appear to progress despite
treatment with stimulation.
Anthony E Lang N Engl J Med 2003; 349 : 1888-1889 |
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