Co-occurrence of posterior chest wall pilonidal sinus with melanocytic nevus: a challenging presentation: a case report.

INTRODUCTION: To date, only a limited number of case reports have documented the co-occurrence of PNS and melanocytic nevus in the medical literature. This study aims to report an exceptionally rare case of posterior chest wall PNS in conjunction with a melanocytic nevus. CASE PRESENTATION: A 46-year-old female presented with a long-standing black lesion on her left upper posterior chest wall, that had become painful in the two months prior to presentation. There was a painful, dark blue, non-erythematous, and non-tender nodule on the left upper posterior chest wall. Based on the patient's desire for cosmetic purposes, the lesion was excised totally with primary closure under local anaesthesia. Histopathological examination revealed intradermal melanocytic nevus with inflamed pilonidal sinus. DISCUSSION: The rarity of posterior chest wall PNS associated with nevi poses unique diagnostic and therapeutic challenges for clinicians. The distinct anatomical location, different from the conventional region, and the rare association between the two conditions may delay accurate diagnosis and result in mismanagement or inappropriate interventions. CONCLUSION: The posterior chest wall PNS is another type of atypical PNS that is extremely rare. The association between PNS and blue nevus is a fascinating medical finding that deserves further investigation.

SiLaT: A paradigm shift in the treatment of pilonidal disease?

BACKGROUND: Pilonidal disease (PD) is a common condition for which the global incidence is increasing. Surgery is the currently preferred approach to treatment but there is a growing interest in new minimally invasive techniques, such as sinus laser therapy (SiLaT). AIM: Our primary objective was to assess the efficacy of SiLaT for the treatment of pilonidal disease. The secondary objectives were to evaluate morbidity and patient satisfaction and identify predictive factors of success. METHODS: All adult patients, who underwent SiLaT in our department for a primary or recurrent pilonidal sinus from June 1, 2018, to December 31, 2020, were included in the study. Healing was defined as the closure of cutaneous orifices and the absence of seepage or abscesses. RESULTS: In total, 111 consecutive patients, for whom the male/female sex ratio was 2.1 and the mean age 28.8 (± 9.4) years, were included in this study. Eighteen (16.2%) patients had already undergone prior surgery for PD. The mean follow-up was 339.2 (± 221.4) days. A healing rate of 78.4% was observed, with a median time to healing of 20.0 days (15.0-30.0). The median time to return to usual activities was three days (1-7). The only postoperative complication was bleeding, which occurred for two patients (1.8%). Eighty-two patients (88.2%) reported being "very satisfied" with the treatment. Multivariate analysis showed no predictive factors for healing among the studied variables. CONCLUSION: SiLaT is an efficient and safe procedure for the treatment of PD, with a high level of patient satisfaction. It will now be necessary to position it within the therapeutic algorithm.

Propeller Flap Reconstruction Following Pilonidal Cyst Excision: A Single-Center Experience With Same-Day Discharge.

INTRODUCTION: Reconstruction following pilonidal cyst resection must balance risk of recurrence, healing time, and resumption of functional routine. Propeller flaps provide a reliable and effective reconstructive option. This study highlights our experience with propeller flap reconstruction following pilonidal cyst resection and demonstrates the efficacy of same-day discharge. METHODS: A single-institution retrospective chart review was performed for propeller flap reconstructions completed from March 2018 to July 2022. Patient demographics, pilonidal cyst details, operative details, and postoperative outcomes were collected. Primary outcomes included flap survival, flap complications, and pilonidal disease recurrence. RESULTS: Twenty-eight outpatient propeller flap reconstructions following pilonidal cyst resections were identified in 26 patients, with two patients receiving a second propeller flap due to recurrence. Most patients were male (n = 15, 57.7%) with a mean age at time of index operation of 25.5 ± 5.8 years and mean body mass index of 26.5 ± 4.1 kg/m2. Mean symptom duration prior to index surgery was 39.3 months. Mean skin defect size following resection was 28.3 ± 15.3 cm2, with a mean flap size of 44.7 ± 35.5 cm2. Flap survival was 100% (n = 28), with five flaps (17.9%) experiencing minor wound complications and one patient (3.8%) requiring return to the operating room. Mean time to functional improvement was 24.0 ± 22.8 days. Pilonidal disease recurrence occurred in three patients (11.5%). Mean follow-up was 4.1 ± 5.4 months. CONCLUSIONS: Propeller flaps provide a successful and reliable reconstructive option for pilonidal disease defects. Because patients in our cohort experienced favorable outcomes and functional improvement, we advocate for same-day discharge in order to reduce hospital and patient burden.

A new midline closure technique without skin sutures: Long-term outcomes of primary repair of pilonidal sinus disease.

BACKGROUND: Currently, the focus regarding pilonidal sinus disease is put on the treatment techniques. The aim of the study is to compare postoperative long-term complications and recurrence of two surgical techniques. MATERIAL AND METHODS: From February 2015 to December 2020, male patients with pilonidal sinus disease attended at two general surgery outpatient centers were randomly assigned to either Group 1 (n=80; excision and primary closure) or Group 2 (n=80; excision and midline closure without skin sutures). Patients with recurrent or complicated pilonidal sinus or with prior surgical procedures were excluded from the study. Intergroup postoperative results and recurrence throughout the follow-up period were analyzed. RESULTS: Significant decrease (p<0.001) in the duration of the surgical procedure (35 to 25 minutes), length of hospital stay (one day to the day of the surgery), and of the time required to return to work (15 to 12 days) was seen for Group 2 patients. The complication rate (wound infection and seroma) was lower in Group 2 compared to Group 1 (n = 3; 3.7% vs n = 10; 12.5%; p = 0.014). During the five-year mean follow-up, five patients (6.2%) in Group 1 had recurrence compared to none in Group 2 (p = 0.023). CONCLUSIONS: Midline primary closure method without skin sutures - easy to learn and implement and has no complication or recurrence in the long-term follow-up - may be an ideal method in cases where excision and primary repair is planned, especially in patients with sinus orifices located in the midline.

Minimum energy laser pilonidotomy (MELPi): a multicenter study of a novel method in pilonidal disease.

Laser surgery, a minimally invasive procedure for the definitive approach to pilonidal disease (PD), has been frequently studied in recent years. This study aims to describe a new pilonidotomy method using minimal laser energy and evaluate its initial results. This is a retrospective multicenter study. We included 47 consecutive patients who underwent 50 "minimal energy pilonidotomies (MELPi)" between 2019 and 2023 in four centers in Brazil. Age, BMI, gender, smoking, diabetes, Guner classification, duration of illness, energy, hospitalization time, complications, recurrence, wound closure, pain, and return to activities were analyzed. The median age was 27; 61.7% were men, and 38.3% were women. The median BMI was 25.7. Smoking was evident in 14.9%, and diabetes in 2.1%. The average duration of the disease was 3 years. Most operations (36%) were performed on stage R disease. The median hospitalization time was 6 h, and the median healing time was 15 days. The average energy used in procedures was 433 J. The median postoperative pain was 2. Secretion occurred in 14% on the 60th day. Complications (cellulitis) occurred in 4% of cases. The median time to return to work was 7 days. The average following time was 12 months; recurrence occurred in 5 (10%)-in 3 patients, a second MELPi procedure was performed and was effective. MELPi shows promising initial results: low pain, low complication rates, and a fast activity return. It is a good option in recidivate cases and can be done more than once if necessary.

Efficacy of Laser Treatment in Pilonidal Disease: A Single-Arm Meta-Analysis.

Objective: This study aimed to collate all published studies on laser therapy for pilonidal disease and demonstrate the safety and effectiveness of minimally invasive techniques. Methods: A comprehensive literature search, with no language limitations, was performed using PubMed, Embase, and Web of Science from inception to April 23, 2023. Two reviewers independently screened the literature according to the inclusion and exclusion criteria and evaluated the bias risk of included studies. Meta-analysis was performed using RevMan software (version 5.4). (PROSPERO Registration ID Number CRD42023420803). Results: The analysis included 1214 patients from 13 studies, who fulfilled the pre-defined inclusion criteria. With a median follow-up of 12 (range, 7.8-25) months, 1000 (84.4%) patients achieved healing after primary laser treatment. The mean complication and recurrence rates were 12.7% and 7.6%, respectively. Conclusions: Laser ablation for pilonidal sinus disease is a new minimally invasive technique with good treatment efficacy, low postoperative recovery, and shorter recovery periods following employment.

Management of Pilonidal Disease and Hidradenitis Suppurativa.

Pilonidal disease and hidradenitis suppurativa affect healthy young adults, causing discomfort and pain that leads to loss of work productivity and should be approached in a personalized manner. Patients with pilonidal disease should engage in hair removal to the sacrococcygeal region and surgical options considered. Hidradenitis suppurativa can be a morbid and challenging disease process. Medical management with topical agents, antibiotics, and biologics should be used initially but wide local excision should be considered in severe or refractory cases of the disease.

Recurrence rates of pilonidal sinus disease in the pediatric population following trephine surgery.

BACKGROUND: Pilonidal sinus disease (PSD) is a common surgical disease. Multiple surgical methods exist in the literature, without clear consensus regarding which should be the first-line treatment. Minimally invasive methods such as the Gips procedure are gaining popularity in recent years. The aim of our study was to assess recurrence rates following the Gips procedure and to determine whether using the same surgical approach during re-operation is efficient and successful. METHODS: This is a single-center retrospective observational study of pediatric patients that underwent Gips procedure due to PSD between the years 2012-2022. RESULTS: 565 pediatric patients underwent an elective surgery for PSD in the study period. Recurrence rate was 8.1% (n = 46). In all the patients with recurrence, re-operation took place on average 9 months following the first surgery and using the same surgical method. Following the second surgery, only 8 patients (1%) had multiple recurrences. CONCLUSIONS: We found a relatively low recurrence rate in the pediatric population using the Gips method, and nearly 100% success rate following the second operation. Our findings set a new benchmark for pediatric recurrence following PSD operation, with clear recommendation to use the same method of surgery upon further recurrences as well.

Pilonidal sinus: an overview of historical and current management modalities.

Pilonidal disease is a common condition that commonly affects the younger adult population and is often seen in both the general practice and the hospital setting. Multiple treatment methods have gained and lost popularity over the last several decades, but more recent intervention principles show promising results. This article details the different methods of managing acute and chronic pilonidal disease ranging from treatments in the primary care setting to those in hospital theatres, with special attention to newer modalities of minimally invasive interventions. As a chronic illness that often affects those of working age, pilonidal disease can confer significant morbidity especially, but not limited to, a substantial amount of time off work. Treatment of chronic disease in particular, has evolved from midline techniques to off-midline techniques, with more recent developments offering promising solutions to reduce acute flare ups and hasten recovery time.

Pit excision with fibrin glue closure versus lateralizing flap procedures in the management of pilonidal sinus disease in adolescents: a 14-year cohort study.

INTRODUCTION: Pilonidal sinus disease (PSD) arises in the hair follicles of the gluteal cleft with many cases occurring during adolescence. Early studies of pit excision with fibrin glue closure (PEF), a minimally invasive procedure for the management of chronic PSD, suggest it is safe and effective with similar results to traditional lateralizing flap procedures (LFP), without the need for extensive tissue excision and associated complications. However, these studies lack large sample sizes and prolonged follow-up. METHODOLOGY: All children undergoing primary operative procedures for chronic PSD from May 2009 to February 2022 received either a PEF or a LFP. Recurrence and complications rates alongside their demographic and disease severity data were compared using statistical and Kaplan-Meier analyses. RESULTS: Seventy-eight children had 33 primary PEF and 45 primary LFP procedures with a median follow-up of 2.21 and 2.52 years, respectively. Demographic and disease severity indicators were similar between groups (p > 0.05). The overall recurrence rate in each cohort was 3% for PEF and 11% for LFP, respectively (p = 0.2346). The all-cause repeat intervention rate was 12% and 49% in the PEF and LFP cohorts, respectively (p = 0.0007). Kaplan-Meier analysis showed a reduction in the requirement of re-operation in the PEF cohort (p = 0.0340). Operative time was significantly decreased in the PEF cohort compared to the LFP cohort (p < 0.0001). Wound dehiscence was significantly decreased in the PEF cohort compared to the LFP cohort (3% vs 31%; p = 0.0026). CONCLUSION: This 14-year study is the largest pediatric-focused cohort utilizing PEF to manage PSD and demonstrated clinically relevant decreases in symptom recurrence alongside significantly decreased rates of complications and further surgical intervention compared to traditional LFP techniques. We conclude that PEF is a viable minimally invasive technique in the management of pediatric PSD.

A standardized treatment protocol for pilonidal disease can influence the health mindset of adolescents.

PURPOSE: Pilonidal disease (PD) significantly impacts patients' quality of life and requires regular maintenance behaviors to achieve cure. Health mindset is a psychological construct which can influence health behaviors and outcomes, with a growth mindset being associated with better outcomes than a fixed. We propose that participation in a standardized treatment protocol can affect the health mindset for adolescents with pilonidal disease. METHODS: PD patients' demographics, recurrence, and comorbidities were prospectively collected from 2019 to 2022. We assessed patients' mindset score at initial presentation using the validated Three-Item Mindset Scale (1-6) then reassessed during follow-up. t-test was used to compare baseline and follow-up mindset scores and stratified by recurrence or comorbidities. p ≤ 0.05 was considered significant. RESULTS: A total of 207 PD patients (108 males, 99 females) with mean age 18.2 ± 3.7 years were followed for 351 ± 327 days. Mean baseline mindset score (4.76 ± 1.27) was significantly lower than mean follow-up mindset score (5.03 ± 1.18, p = 0.049). Baseline mindset score was significantly lower among patients with PD recurrence (4.00 ± 0.66) compared to those without recurrence (4.8 ± 1.29, p = 0.05). Among patients with PD recurrence, mean baseline mindset score (4.00 ± 0.66) was significantly lower than mean follow-up mindset score (5.27 ± 0.93, p = 0.0038). Patient comorbidity did not affect the baseline or follow-up mindset score. CONCLUSIONS: Participation in a standardized treatment protocol is associated with the development of a stronger growth mindset over time for patients with PD. Furthermore, a growth mindset was linked to lower recurrence rate than a fixed mindset. Further investigations into how treatment approaches can work in concert with health mindset are proposed.

Efficacy of laser obliteration with limited excision of pilonidal sinus.

OBJECTIVE: This study was performed to compare the effectiveness of laser obliteration with limited excision (LOLE) versus wide excision (WE) of the pilonidal sinus. METHODS: A prospective, cross-sectional observational study of 152 patients with chronic pilonidal sinus disease was performed from September 2019 to September 2022. Of the 152 patients, 76 underwent LOLE and 76 underwent WE. The main evaluation criteria were complete wound healing, recurrence, and the complication rate. RESULTS: Complete healing was achieved in 74 (97.4%) patients in the LOLE group and 76 (100%) patients in the WE group. The duration of wound healing was significantly shorter in the LOLE group than in the WE group (6.5 ± 2.4 vs. 14.5 ± 2.6 weeks, respectively). Recurrence developed in six (7.9%) patients in the LOLE group and one (1.3%) patient in the WE group, with no significant difference. CONCLUSION: According to our study and the data available in the literature, laser surgery should be included in the guidelines for the treatment and management of pilonidal disease.

Commentary on packing vs non-packing of pilonidal sinus cavities after incision and drainage.

Pilonidal sinus disease (PSD) manifests as an inflammatory skin condition typically emerging within the anal cleft. The prevalence of this disease varies in high income countries. This disease is associated with significant physical and psychosocial distress. Surgery is an option for managing PSD; yet, surgical methods vary, and a universally accepted gold standard approach is lacking, leading to current practices that are diverse and subject to ongoing debate. One such point of contention revolves around the decision to use packing or opt for a non-packing approach following surgery. Mohamedahmed et al (2021) conducted a systematic review to evaluate the comparative outcomes of packing versus non-packing of an abscess cavity following incision and drainage of cutaneous abscess on any part of the body. This commentary aims to critically appraise the methods used within the review by Mohamedahmed et al (2021) and expand upon the findings in the context of treatment and management of PSD.

Real-world practice and outcomes in pilonidal surgery: Pilonidal Sinus Treatment Studying The Options (PITSTOP) cohort.

BACKGROUND: Numerous surgical approaches exist for the treatment of pilonidal disease. Current literature on treatment is of poor quality, limiting the ability to define optimal intervention. The aim of this study was to provide real-world data on current surgical practice and report patient and risk-adjusted outcomes, informing future trial design. METHODS: This UK-wide multicentre prospective cohort study, including patients (aged over 16 years) who had definitive treatment for symptomatic pilonidal disease, was conducted between May 2019 and March 2022. Patient and disease characteristics, and intervention details were analysed. Data on patient-reported outcomes, including pain, complications, treatment failure, wound issues, and quality of life, were gathered at various time points up to 6 months after surgery. Strategies were implemented to adjust for risk influencing different treatment choices and outcomes. RESULTS: Of the 667 participants consenting, 574 (86.1%) were followed up to the study end. Twelve interventions were observed. Broadly, 59.5% underwent major excisional surgery and 40.5% minimally invasive surgery. Complications occurred in 45.1% of the cohort. Those who had minimally invasive procedures had better quality of life and, after risk adjustment, less pain (score on day 1: mean difference 1.58, 95% c.i. 1.14 to 2.01), fewer complications (difference 17.5 (95% c.i. 9.1 to 25.9)%), more rapid return to normal activities (mean difference 25.9 (18.4 to 33.4) days) but a rate of higher treatment failure (difference 9.6 (95% c.i. 17.3 to 1.9)%). At study end, 25% reported an unhealed wound and 10% had not returned to normal activities. CONCLUSION: The burden after surgery for pilonidal disease is high and treatment failure is common. Minimally invasive techniques may improve outcomes at the expense of a 10% higher risk of treatment failure.

Midline and off-midline wound closure methods after surgical treatment for pilonidal sinus.

BACKGROUND: Pilonidal sinus disease is a common and debilitating condition. Surgical treatment remains the mainstay for managing chronic disease, with options including midline and off-midline wound closure methods. However, the optimal approach remains uncertain. Recent developments in tension-free midline techniques require further exploration. OBJECTIVES: To assess the effects of midline and off-midline wound closure methods for pilonidal sinus, and to determine the optimal off-midline flap procedures. SEARCH METHODS: In June 2022, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus EBSCO, and clinical trials registries. We also scanned the reference lists of included studies, as well as reviews, meta-analyses, and health technology reports. We applied no language, publication date, or study setting restrictions. SELECTION CRITERIA: We included parallel RCTs involving participants undergoing midline closure without flap techniques and off-midline closure for pilonidal sinus treatment. We excluded quasi-experimental studies and studies that enroled participants presenting with an abscess. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methodology. The critical outcomes included wound healing (time to wound healing, proportion of wounds healed), recurrence rate, wound infection, wound dehiscence, time to return to work, and quality of life. We assessed biases in these outcomes utilising the Cochrane risk of bias 2 tool and appraised evidence certainty via the GRADE approach. MAIN RESULTS: We included 33 studies with 3667 analysed participants. The median or average age of the participants across the included studies ranged from 21.0 to 34.2 years, with a predominant male representation. Geographically, the trials were primarily conducted in the Middle East. We identified nine intervention comparisons. In this abstract, we focus on and present the summarised findings for the three primary comparisons. Off-midline closure versus conventional midline closure Off-midline closure probably reduces the time to wound healing (mean difference (MD) -5.23 days, 95% confidence interval (CI) -7.55 to -2.92 days; 3 studies, 300 participants; moderate-certainty evidence). However, there may be little to no difference between the two methods in the proportion of wounds healed (100% versus 88.5%, risk ratio (RR) 1.13, 95% CI 0.92 to 1.39; 2 studies, 207 participants; very low-certainty evidence). Off-midline closure probably results in lower rates of recurrence (1.5% versus 6.8%, RR 0.22, 95% CI 0.11 to 0.45; 13 studies, 1492 participants; moderate-certainty evidence) and wound infection (3.8% versus 11.7%, RR 0.32, 95% CI 0.22 to 0.49; 13 studies, 1568 participants; moderate-certainty evidence), and may lower rates of wound dehiscence (3.9% versus 8.9%, RR 0.44, 95% CI 0.27 to 0.71; 11 studies, 1389 participants; low-certainty evidence). Furthermore, off-midline closure may result in a reduced time to return to work (MD -3.72 days, 95% CI -6.11 to -1.33 days; 6 studies, 820 participants; low-certainty evidence). There were no data available for quality of life. Off-midline closure versus tension-free midline closure Off-midline closure may reduce the time to wound healing (median 14 days in off-midline closure versus 51 days in tension-free midline closure; 1 study, 116 participants; low-certainty evidence) and increase wound healing rates at three months (94.7% versus 76.4%, RR 1.24, 95% CI 1.06 to 1.46; 1 study, 115 participants; low-certainty evidence), but may result in little to no difference in rates of recurrence (5.4% versus 7.8%, RR 0.69, 95% CI 0.30 to 1.61; 6 studies, 551 participants; very low-certainty evidence), wound infection (2.8% versus 6.4%, RR 0.44, 95% CI 0.16 to 1.17; 6 studies, 559 participants; very low-certainty evidence), and wound dehiscence (2.5% versus 3.0%, RR 0.82, 95% CI 0.17 to 3.84; 3 studies, 250 participants; very low-certainty evidence) compared to tension-free midline closure. Furthermore, off-midline closure may result in longer time to return to work compared to tension-free midline closure (MD 3.00 days, 95% CI 1.52 to 4.48 days; 1 study, 60 participants; low-certainty evidence). There were no data available for quality of life. Karydakis flap versus Limberg flap Karydakis flap probably results in little to no difference in time to wound healing compared to Limberg flap (MD 0.36 days, 95% CI -1.49 to 2.22; 6 studies, 526 participants; moderate-certainty evidence). Compared to Limberg flap, Karydakis flap may result in little to no difference in the proportion of wounds healed (80.0% versus 66.7%, RR 1.20, 95% CI 0.77 to 1.86; 1 study, 30 participants; low-certainty evidence), recurrence rate (5.1% versus 4.5%, RR 1.14, 95% CI 0.61 to 2.14; 9 studies, 890 participants; low-certainty evidence), wound infection (7.9% versus 5.1%, RR 1.55, 95% CI 0.90 to 2.68; 8 studies, 869 participants; low-certainty evidence), wound dehiscence (7.4% versus 6.2%, RR 1.20, 95% CI 0.41 to 3.50; 7 studies, 776 participants; low-certainty evidence), and time to return to work (MD -0.23 days, 95% CI -5.53 to 5.08 days; 6 studies, 541 participants; low-certainty evidence). There were no data available for quality of life. AUTHORS' CONCLUSIONS: This Cochrane review examines the midline and off-midline wound closure options for pilonidal sinus, predominantly based on young adult studies. Off-midline flap procedures demonstrate there may be benefits over conventional midline closure for pilonidal sinus, with various off-midline flap techniques. When off-midline flap closures were compared to tension-free midline closure, low-certainty evidence indicated there may be improved wound healing and increased time to return to work for off-midline closure, whilst very low-certainty evidence indicated there may be no evidence of a difference in other outcomes. There may be no evidence of an advantage found amongst the off-midline techniques evaluated. The choice of either procedure is likely to be based on a clinician's preference, experience, patient characteristics, and the patients' preferences. To more accurately determine the benefits and potential harms of these closure techniques, further large-scale and meticulously-designed trials are essential. Specifically, there is a pressing need for more studies addressing the paediatric population, in addition to adult studies.