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      Pit picking vs. Limberg flap vs. primary open method to treat pilonidal sinus disease – A cohort of 327 consecutive patients

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          Abstract

          Background

          Minimally invasive methods in pilonidal sinus disease (PSD) surgery are becoming standard. Although long-term results are available for some techniques, long-term outcome data of patients after pit picking is lacking. We aimed at investigating perioperative and long-term outcomes of patients undergoing pit picking, Limberg flap or primary open surgery to treat PSD.

          Methods

          In a single-centre observational study, we evaluated the outcomes of 327 consecutive patients undergoing PSD surgery between 2011 and 2020.

          Results

          PSD had recurred in 22% of Limberg flap patients and 62% of pit picking patients at 5 years (p=0.0078; log rank test). Previous pilonidal surgeries, smoking, body mass index, immunodeficiency, and diabetes did not significantly influence the long-term recurrence rate. Primary open treatment was performed for 72% of female patients presenting with primary disease.

          Conclusions

          Due to its especially dismal long-term results, pit picking should be abandoned, and Limberg flap should be promoted instead, even for primary disease and in females.

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          Most cited references34

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          Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence

          We systematically searched available databases. We reviewed 6,143 studies published from 1833 to 2017. Reports in English, French, German, Italian, and Spanish were considered, as were publications in other languages if definitive treatment and recurrence at specific follow-up times were described in an English abstract. We assessed data in the manner of a meta-analysis of RCTs; further we assessed non-RCTs in the manner of a merged data analysis. In the RCT analysis including 11,730 patients, Limberg & Dufourmentel operations were associated with low recurrence of 0.6% (95%CI 0.3–0.9%) 12 months and 1.8% (95%CI 1.1–2.4%) respectively 24 months postoperatively. Analysing 89,583 patients from RCTs and non-RCTs, the Karydakis & Bascom approaches were associated with recurrence of only 0.2% (95%CI 0.1–0.3%) 12 months and 0.6% (95%CI 0.5–0.8%) 24 months postoperatively. Primary midline closure exhibited long-term recurrence up to 67.9% (95%CI 53.3–82.4%) 240 months post-surgery. For most procedures, only a few RCTs without long term follow up data exist, but substitute data from numerous non-RCTs are available. Recurrence in PSD is highly dependent on surgical procedure and by follow-up time; both must be considered when drawing conclusions regarding the efficacy of a procedure.
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            Pilonidal sinus: finding the right track for treatment.

            T Allen (1990)
            Management of pilonidal sinus is frequently unsatisfactory. No method satisfies all requirements for the ideal treatment--quick healing, no hospital admission, minimal patient inconvenience, and low recurrence--but greater awareness of the strengths and weaknesses of existing methods would lead to improved management. Early excision of the pilonidal pit at the time of treatment of pilonidal abscess reduces the high (40 per cent) risk of subsequent sinus. Treatments for pilonidal sinus that flatten the natal cleft halve the risk of recurrence. En block excision of pilonidal sinus with secondary healing should be abandoned and emphasis given to development of treatments, such as primary asymmetric closure, which have more potential. Some treatments are operator-dependent and, to achieve the best results, junior surgeons must be correctly trained and supervised. Future treatment studies must be prospective and randomized, and should compare healing time, recurrence rates beyond 3 years, nurse and hospital visits, patient inconvenience and loss of income.
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              Pilonidal disease: origin from follicles of hairs and results of follicle removal as treatment.

              J Bascom (1980)
              Contrary to current concepts, shafts of hairs apparently are not the source of most pilonidal disease. Instead, follicles of hairs seem to be the source. Pilonidal disease progresses through five stages. Accumulation of hair within a chronic pilonidal abscess is a late and secondary phenomenon. The acute abscess is drained only. Over the chronic abscess the distended hair follicles are removed individually from the gluteal cleft. In addition, the cavity of the chronic abscess is cleaned out through incisions placed parallel to, but to one side of, the cleft. Acute abscesses are similary treated 5 days after drainage. Cavity walls are not excised. They are allowed to fall closed and to heal. An epithelial tube, when found, is dissected out through incisions beside the cleft. Nonhealing wounds are effectively treated with Monsel's Salt. Fifty patients were treated in the author's office under local anesthesia. Disability averaged 1 day. Healing time, without disability, averaged 3 weeks. Recurrences in four patients were healed in an average of 2 weeks.
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                Author and article information

                Contributors
                Journal
                Innov Surg Sci
                Innov Surg Sci
                iss
                iss
                Innovative Surgical Sciences
                De Gruyter
                2364-7485
                27 June 2022
                1 March 2022
                : 7
                : 1
                : 23-29
                Affiliations
                deptDepartment of Procto-Surgery , universitySt. Marienhospital Vechta, Academic Teaching Hospital of the MHH Hannover , Vechta, Germany
                universityPilonidal Research Group , Vechta, Germany
                deptDepartment of General and Visceral Surgery , universityAsklepios Klinikum Hamburg-Altona , Hamburg, Germany
                deptDepartment of Visceral Surgery and Medicine , universityInselspital, Bern University Hospital, University of Bern , Bern, Switzerland
                deptDepartment of Anaesthesiology and Pain Medicine , universityInselspital, Bern University Hospital, University of Bern , Bern, Switzerland
                Author notes
                Corresponding author: Prof. Dr. med. Dr. phil. Dietrich Doll, deptDepartment of Procto-Surgery , universitySt Marienhospital Vechta, Academic Teaching Hospital of the Medical School Hannover , Marienstrasse 6, 49377 Vechta, Germany; and Pilonidal Research Group, Vechta, Germany, Phone: +49 4441 99 1240, Fax: +49 4441 99 1250, Mobile: +49 1723 58 54 54, E-mail: Dietrich.Doll@ 123456kk-om.de
                Author information
                https://orcid.org/0000-0001-9832-4545
                Article
                iss-2021-0041
                10.1515/iss-2021-0041
                9352183
                35974777
                bf73c716-cb4b-41e3-b2e5-63981806a0b2
                © 2022 Dietrich Doll et al., published by De Gruyter, Berlin/Boston

                This work is licensed under the Creative Commons Attribution 4.0 International License.

                History
                : 02 November 2021
                : 16 March 2022
                Page count
                Figures: 03, Tables: 05, References: 35, Pages: 07
                Categories
                Article

                limberg flap,long-term recurrence rate,minimally invasive therapy,pilonidal sinus,pit picking

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