Predisposition and risk factor rates for pilonidal sinus disease

To the Editor,

We read with great interest the recently published paper by Sabuncuoglu et al¹ entitled “Eyedrop-shaped, modified Limberg transposition flap in the treatment of pilonidal sinus disease.” We would like to congratulate the authors and thank them for sharing their experiences with us. We think that the procedure of eyedrop technique will reduce wound tension and increase postoperative patient comfort. It is a very good initiative.

Different surgical treatment procedures for pilonidal disease have been described and tried, with numerous reports comparing these procedures being available in the literature. The results of these studies² are on the same line as Sabuncuoglu et al.¹

However, information on the comparison of the most common surgical procedures, including flap technique and others, with respect to quality of health and patient satisfaction criteria, is scarce.³

A wide intergluteal depth, bathing habituation, sitting time, hairy rate, body mass index, and genetic predisposition have been shown as the predisposition factors of sacrococcygeal pilonidal sinus disease by some authors.⁴ In the light of all the facts mentioned above, we think that the predisposition and risk factor rates of the patients, reported in the study by Sabuncuoglu et al¹, can help us explain the results more explicitly. This study recommends us to make a comparison between eyedrop technique and other surgical procedures. We think that a comparison of the results of these two techniques, with respect to the criteria of quality of life and patient satisfaction, would lead us to the next step in the treatment of this disease.

Reply

Thank you for contributing your ideas to our study.¹ Predisposing factors of pilonidal sinus disease (PSD) is an important issue, which should be emphasized. Karydakis² reported that three factors are important in the process of hair insertion namely: (1) the invader that consists of loose hair, (2) the potency that results in hair insertion, and (3) the vulnerability of the skin to hair placement at the depth of the natal cleft. PSD occurs frequently between the ages of 15 years and 25 years, and is rare both before puberty and after the age of 40 years.³ Additionally, male gender, a high body mass index (BMI), deep natal cleft, professions requiring prolonged sitting, deep natal groove, excessive body hair, excessive sweating, and bad sanitary condition have been described as the risk factors.⁴

In our case series, consistent with the literature, the mean age was 25.8 years. However, only one patient was 45-year old. Male gender was dominant (90.1%). Four patients were associated with professions requiring prolonged sitting. Bad sanitary conditions were the predisposing factors in 62 patients. In addition, fecal contamination was seen in one patient who had wound dehiscence.

No relation was mentioned between family history and PSD in the study of Harlak et al,⁵ who analyzed previously proposed risk factors. However, in our series, three patients had a family history of PSD. Doll et al⁶ demonstrated that a family history of PSD predisposes to an earlier onset of disease and a 50% long-term recurrence rate. In our study, five patients experienced recurrence (4.5%) and one of them had a family history of PSD.

Cubukcu et al⁷ reported that obese patients with a high BMI (mean 29.35) have a higher risk of recurrence of PSD after surgical intervention than those with a lower BMI. In our series, for patients who experienced recurrence, BMI was < 30 kg/m². We observed that the recurrence rate was high in patients with poor wound care and who do not pay attention to warnings. In patients with a high BMI, surgery should be considered after weight loss due to difficulty in maintaining personal hygiene and deep natal cleft.

Conflicts of interest

The authors declare no conflicts of interest.

References

1. 1 M.Z. Sabuncuoglu, A. Sabuncuoglu, O. Dandin, et al.; Eyedrop-shaped, modified Limberg transposition flap in the treatment of pilonidal sinus disease; Asian J Surg, 38 (2015), pp. 161–167
2. 2 G.E. Karydakis; Easy and successful treatment of pilonidal sinus after explanation of its causative process; ANZ J Surg, 62 (1992), pp. 385–389
3. 3 M.R.B. Keighley; Pilonidal sinus; M.R.B. Keighley, N. Williams (Eds.), Surgery of the Anus, Rectum and Colon (2nd ed.), WB Saunders, London (1999), pp. 539–563
4. 4 T.L. Hull, J. Wu; Pilonidal disease; Surg Clin North Am, 82 (2002), pp. 1169–1185
5. 5 A. Harlak, O. Mentes, S. Kilic, K. Coskun, K. Duman, F. Yilmaz; Sacrococcygeal pilonidal disease: analysis of previously proposed risk factors; Clinics, 65 (2010), pp. 125–131
6. 6 D. Doll, E. Matevossian, K. Wietelmann, T. Evers, M. Kriner, S. Petersen; Family history of pilonidal sinus predisposes to earlier onset of disease and a 50% long-term recurrence rate; Dis Colon Rectum, 52 (2009), pp. 1610–1615
7. 7 A. Cubukcu, N.N. Gonullu, M. Paksoy, A. Alponat, M. Kurt, O. Ozbay; The role of obesity on the recurrence of pilonidal sinus disease in patients who were treated by excision and Limberg flap transposition; Int J Colorectal Dis, 15 (2000), pp. 173–175

References

1. 1 M.Z. Sabuncuoglu, A. Sabuncuoglu, O. Dandin, et al.; Eyedrop-shaped, modified Limberg transposition flap in the treatment of pilonidal sinus disease; Asian J Surg, 38 (2015), pp. 161–167
2. 2 T. Ertan, M. Koc, E. Gocmen, A.K. Aslar, M. Keskek, M. Kilic; Does technique alter quality of life after pilonidal sinus surgery?; Am J Surg, 190 (2005), pp. 388–392
3. 3 K. Duman, Y. Ozdemir, E. Yucel, M.L. Akin; Comparison of depression, anxiety and long term quality of health in patients with a history of either primary closure or Limberg flap reconstruction for pilonidal sinus; Clinics, 69 (2014), pp. 384–387
4. 4 A. Harlak, O. Mentes, S. Kiliç, K. Coskun, K. Duman, F. Yilmaz; Sacrococcygeal pilonidal sinus disease: analysis of proposed risk factors; Clinics, 65 (2010), pp. 125–131