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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 71-76

Pilonidal sinus in South India: A retrospective review


Department of General Surgery, Apollo BGS Hospitals, Mysore, Karnataka, India

Date of Submission03-Jun-2020
Date of Decision20-Jul-2020
Date of Acceptance04-Jul-2020
Date of Web Publication22-Sep-2020

Correspondence Address:
Dr. Dilip Rajasekharan
Department of General Surgery, Apollo BGS Hospitals, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_1_20

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  Abstract 

Introduction: Pilonidal sinus means a cavity or sinus in the subcutaneous tissue with a tuft of hair embedded in granulation tissue which communicates with the skin surface by a track lined usually by squamous epithelium which is continuous with the epidermis. We aim to identify the demographic and clinical characteristics and treatment modalities in patients with pilonidal sinus (PS). Materials and Methods: This was a retrospective analysis involving records of patients diagnosed with pilonidal sinus in Apollo BGS Hospitals, Mysore, from January 2007 to January 2019. Results: One hundred patients were identified with maximum cases in the age group of 16–25 years (61%). The male-to-female ratio was 2.98:1, with an increase in prevalence in those with sedentary occupations. The most common location was the natal cleft (94%), and risk factors included hirsutism. The maximum duration of hospital stay was 2 days (65%), and the most common presenting symptoms were discharge (77%), pain (74%), and swelling (52%). The average duration of symptoms was 7.82 days. Obesity (19%) was not found to be a significant risk factor. Maximum cases (73%) underwent excision and laying open technique. The recurrence rate of the study was 19%. Conclusion: Despite advances in medicine, pilonidal sinus still remains a bane. While numerous treatment modalities exist, there is no one ideal method for management, and the choice of surgery relies largely on the treating surgeon.

Keywords: Clinical risk profile, pilonidal sinus, recurrence rate, retrospective analysis


How to cite this article:
Rajasekharan D, Nagaraja JB, Subbarayappa S. Pilonidal sinus in South India: A retrospective review. Indian J Colo-Rectal Surg 2019;2:71-6

How to cite this URL:
Rajasekharan D, Nagaraja JB, Subbarayappa S. Pilonidal sinus in South India: A retrospective review. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2022 Sep 26];2:71-6. Available from: https://www.ijcrsonweb.org/text.asp?2019/2/3/71/295860


  Introduction Top


Pilonidal sinus (Latin: pilus = hair; nidus = nest) means a cavity or sinus in the subcutaneous tissue with a tuft of hair embedded in granulation tissue which communicates with the skin surface by a track lined usually by squamous epithelium which is continuous with the epidermis.[1] Herbert mayo was the first to describe a disease that involved a hair-filled cyst at the base of the coccyx in 1833.[2]

The first “official” description was made by Abraham Wendell Anderson (1804–1876) in 1847 in the form of a letter written to the editor of the Boston Medical and Surgical Journal.[1] It was Richard Manning Hodges (1827–1896) in 1880, who first used this term “pilonidal” from the Latin word pilus, which means hair, and nidus, which means nest, when he appeared before the Boston society for medical improvement.[3]

The presentation may vary from asymptomatic pits to painful draining lesions in the intergluteal region. It has a male preponderance and usually affects patients from mid-teens into the early 30s. During World War II, over 80,000 soldiers in the United States Army were hospitalized with the condition. Louis Buie, a Mayo Clinic proctologist, recognized the association and described it in 1944 as “Jeep riders' disease.” As a large number of soldiers who were being hospitalized rode in jeeps for long journeys through rough terrain, it was thought that pressure on and irritation of the coccyx led to the condition.[4]

The pathology of pilonidal sinus is an established one. There are one or more pits in the midline of the natal cleft. These pits lead to a cavity lined by granulation tissue that usually contains hair. From this cavity, one or more tracks run cranially or caudally and open either on the right or left of the midline. The secondary sinus is always laterally placed, whereas the primary sinus is in the midline.[1],[5]

Numerous surgical techniques are employed for the treatment of sacrococcygeal pilonidal sinus. The exact procedure is determined by the nature of the disease presentation and the surgeon's choice. However, there are very few studies documenting the prevalence, profile, and comparison of outcomes of the various surgical procedures in Asian populations. The available data suggest the average incidence of the disease to be about 26/100,000, with a ratio of 4:1 favoring men. The average age at admission is 25 years, with women presenting earlier than men. It is noted to occur more in hairy individuals. Some common etiological factors noted were hirsutism, obesity, sedentary lifestyle, and family predisposition.[5],[6],[7],[8]

Hence, in this study, I would like to profile the cases of pilonidal sinus in our population and study the outcomes of various surgical procedures employed at our hospital.


  Materials and Methods Top


Study site

This study was conducted at Apollo BGS Hospitals, Mysore.

Study population

A total number of eligible patients admitted in Apollo BGS Hospitals, Mysore, during the study period of 12 years (January 2007–January 2019) were included in the study.

Sample size

The sample size of the study was 100 patients.

Rationale for sample size

The prevalence of pilonidal sinus in Asia is 6.6%[9] in the general population. The sample size is calculated as per the Leslie Kish formula.

Study design

  1. Explorative/descriptive study
  2. Purposive sampling.


Study duration

The study duration from January 2007 to January 2019 was taken. The case files of all retrospective cases were meticulously reviewed.

Inclusion criteria

All the patients admitted in Apollo BGS Hospitals, Mysore, in the study duration and clinically diagnosed with pilonidal sinus were included in the study.

Exclusion criteria

  1. Patients refusing treatment
  2. Patients refusing to be a part of this study were excluded from the study.


Methodology

Retrospective data collection

Data records of pilonidal sinus patients in the Medical Records Department of Apollo BGS Hospitals, Mysore, from January 1, 2007, to January 31, 2019, were examined if they fit the inclusion and exclusion criteria.

Procedure

The data from 107 patients were collected. Data of seven patients were not complete, thus eliminating them from the study. Up to 6-month follow-up data were retrieved from the Medical Records Department of our hospital. After 6-month interval, necessary information was collected over a telephonic conversation and, in case of recurrence of symptoms, was advised for review in the outpatient department.

End points of the study

The end points of the study measured age and sex distributions of the disease, the mode of presentation, location of sinus, predisposing factors, type of procedure performed and recurrence rate of the procedure adopted as well, and recurrence rate in relation to various predisposing factors. Additional variables such as duration of hospital stay and comorbidities were documented and analyzed to yield useful data.

Analysis of data

Collected data were analyzed and presented in the form of tables, figures, graphs, and diagrams wherever necessary. The analyzed data have been discussed and compared with the data of other similar studies conducted elsewhere based on the objective of the present study.

Statistical methods

Descriptive statistics

  1. Mean
  2. Standard deviation
  3. Frequency
  4. Percentage.


Inferential statistics

  1. Chi-square test (nonparametric data)
  2. Cramer's V test (nonparametric data)
  3. One-way ANOVA (parametric data).



  Results Top


This retrospective observational study was carried out in Apollo BGS Hospitals, a tertiary care health center, in Kuvempu Nagara, Mysore, Karnataka. Cases from January 1, 2007, to January 31, 2019, were studied. A total of 107 patients were obtained, but 7 patients had to be dropped due to lack of data.

The cases ranged from 16-66 years in age. Maximum patients presenting with pilonidal sinus were within 16-25 years age group (61%). Seventy-seven patients were male (77%) as to the 23 females (23%), bringing the male-to-female ratio to 2.98:1 [Figure 1]. The most common occupations associated with the disease included students (66%), engineers (14%), and bank employees (11%) [Figure 2]. Most cases were noted in the natal cleft region (94%) as to the umbilical region (6%) [Table 1]. The majority of the patients (70%) were found to be hirsute [Figure 3], and no relation to family history was noted (0%). Only 19% of the patients were obese [Table 2]. Maximum patients had a hospital stay of 2 days (65%) [Table 3], and the majority of the patients presented with complaints of discharge (77%), pain (74%), and swelling (52%) [Table 4]. The average duration of symptoms was 7.82 days, with a standard deviation of 10.01 [Table 5].
Figure 1: Age and sex distribution of the disease

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Figure 2: Distribution in relation to occupation

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Table 1: Distribution in relation to site

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Figure 3: Distribution in relation to hirsuteness

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Table 2: Distribution in relation to obesity

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Table 3: Distribution in relation to number of days of stay in the hospital

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Table 4: Distribution in relation to complaints

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Table 5: Distribution in relation to duration of symptoms

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Of the 100 cases admitted for pilonidal sinus in between January 2007 and January 2019, 73 cases were selected for excision and lay-open technique, 17 cases for excision and marsupialization, 4 cases for Limberg's flap cover, and 6 cases for excision and primary closure (in the case of umbilical pilonidal sinuses) [Figure 4]. It was found in the study that the average number of days of stay for excision and lay-open technique was 2.02 days [Table 6]. It was also noted that there was not much difference between the average days of stay in the hospital with respect to the type of procedure performed.
Figure 4: Distribution in relation to operative procedures

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Table 6: Average number of days of stay in relation to operative procedure

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In the present study, the average time taken for wound healing and return to work was 4.75 days for excision and Limberg's flap cover, 8.1 days for excision and primary closure, 23.7 days for excision and marsupialization, and 46.6 days for excision and lay-open technique [Figure 5] and [Table 7].
Figure 5: Distribution with respect to the time taken for wound healing

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Table 7: Time taken for wound healing with respect to the type of treatment and time to return to work

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Of the 100 cases taken for this study, a recurrence was noted in 19 cases (19%) [Figure 6]. It was noted that of the 7 diabetics who presented with pilonidal sinus, a recurrence was noted in 2 patients (28.5%). In relation to the location of the pilonidal sinus, the cases that presented with an umbilical pilonidal sinus showed a recurrence rate of 0% and those that had a pilonidal sinus at the natal cleft had a recurrence rate of 20.2% [Table 8]. Of the surgical procedures studied, excision and lay-open method had a recurrence rate of 19.2%, excision and marsupialization had a recurrence rate of 29.4%, and no recurrence was noted for excision and primary closure and Limberg's flap technique [Table 9].
Figure 6: Recurrence rate of the study

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Table 8: Recurrence rate in relation to site of pilonidal sinus

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Table 9: Recurrence rate in relation to type of procedure

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  Discussion Top


The present study was conducted to profile the cases of pilonidal sinus attending a tertiary care hospital. All patients who presented to the hospital underwent surgical management. The most common age of presentation was 21–25 years (38%). The results of our study coincide with the findings by Onder et al.[10] According to Onder et al., the disease is more common in the age group of 21–25 years among males with a slightly earlier presentation in females. This is attributed to the earlier achievement of puberty by females.

The male-to-female ratio in our study was 2.98:1. This too is in accordance with the findings by Onder et al.[10] who found the disease to be 4.1–8.1 times more prevalent in males. In our study, the majority of the cases were students, engineers, or bank employees. This shows an increased prevalence of pilonidal sinus among professions that involve the sedentary nature of activities. This is similar to observations made by Søndenaa et al.[11] The findings by Søndenaa et al.[11] show that the presence of hairy body is prevalent in 37%–80% of the cases. Harlak et al.[12] in their study demonstrated that among their cases of pilonidal sinus, 39.5% were hairy and 52.5% were mildly hairy. This is reflected in our study where the prevalence of hairiness is 70% among our cases, indicating that pilonidal sinus is more prevalent among hairy people.

Almost all cases (94%) presented in the natal cleft region (recurrence rate: 20.2%), whereas the prevalence of umbilical pilonidal sinus was 6% (recurrence rate: 0%). This correlates with the findings that umbilical pilonidal sinus is a rare phenomenon.[13] However, the site-specific recurrence rates were not found to be statistically significant.

Of all the cases, none were found to have a familial history and being overweight/obese was found to be associated with 19% of the cases. While Onder et al.[10] in their study attribute to obesity as an important risk factor associated with higher rates of postoperative complications and recurrence, a similar study by Cubukçu et al.[14] did not detect a statistical significance between obesity and pilonidal sinus. Almost all patients complained of pain, discharge, and swelling. Lesser reported complaints include fever and bleeding.

Of the 100 cases operated, 73 cases underwent excision and lay-open technique (recurrence rate: 19.2%), 17 cases underwent excision and marsupialization (recurrence rate: 29.4%), 4 cases underwent excision and Limberg's flap cover (recurrence rate: 0%), and 6 cases underwent excision and primary repair (recurrence rate: 0%). In the case of excision and lay-open technique, our study was found to be higher than the average of other studies, whereas for excision and primary closure technique, our results closely coincide with that obtained by Khawaja et al.[15] who reported a zero recurrence rate. Among the patients with diabetes who presented with pilonidal sinus, the recurrence rate was 28.5%.

In our study, wound infection was found in four cases of excision and lay-open technique. Our results are similar to the low infection rates of other studies and coincide closely with the findings by Hameed[16] who reported a wound infection rate of <5% for excision and lay-open technique and 8.69% for other techniques. The duration of wound healing in our study coincides closely with those obtained by Khawaja et al.[15] (41 days) with respect to the excision and lay-open technique and similar to the results of Kronborg et al.[17] (13 days) with respect to the excision and primary closure technique. The average duration of hospital stay was highest for excision and Limberg's flap technique and lowest for excision and lay-open technique.


  Conclusion Top


Despite gargantuan advances in the field of medical science, pilonidal sinus, a relatively benign and historic disease, still remains a bane. While multiple methods of treatment have been described, there is no one perfect solution. The ideal mode of management must be simple with short hospital stay, early return to work, and no wound infection or recurrence. As the ideal method still remains elusive, the choice of surgery thus depends on the surgeon's preference and the patient's choice. Excision and lay-open technique remains the most commonly practiced technique worldwide.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Gordon P, Nivatvongs S, Barrows S, Gunn C. Principles and Practice of Surgery of Colon, Rectum, and Anus. 3rd ed. New York, NY: Informa Healthcare; 2007.  Back to cited text no. 1
    
2.
Mayo OH. Observations on injuries and diseases of the rectum. Med Chir Rev 1833;19:289-306.  Back to cited text no. 2
    
3.
Hodges RM. Pilonidal sinus. Boston Med Surg J 1880;103:485-6.  Back to cited text no. 3
    
4.
Buie LA. Jeep disease (pilonidal disease of mechanized warfare). South Med J. 1944;37:103-9.  Back to cited text no. 4
    
5.
Hull TL, Wu J. Pilonidal disease. Surg Clin North Am 2002;82:1169-85.  Back to cited text no. 5
    
6.
Clothier PR, Haywood IR. The natural history of the post anal (pilonidal) sinus. Ann R Coll Surg Engl 1984;66:201-3.  Back to cited text no. 6
    
7.
Akinci OF, Bozer M, Uzunköy A, Düzgün SA, Coşkun A. Incidence and aetiological factors in pilonidal sinus among Turkish soldiers. Eur J Surg 1999;165:339-42.  Back to cited text no. 7
    
8.
Goodall P. The aetiology and treatment of pilonidal sinus. A review of 163 patients. Br J Surg 1961;49:212-8.  Back to cited text no. 8
    
9.
Duman K, Gırgın M, Harlak A. Prevalence of sacrococcygeal pilonidal sinus disease in Turkey. Asian J Surg 2017;40:434-7.  Back to cited text no. 9
    
10.
Onder A, Girgin S, Kapan M, Toker M, Arikanoglu Z, Palanci Y, et al. Pilonidal sinus disease: Risk factors for postoperative complications and recurrence. Int Surg 2012;97:224-9.  Back to cited text no. 10
    
11.
Søndenaa K, Andersen E, Nesvik I, Søreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis 1995;10:39-42.  Back to cited text no. 11
    
12.
Harlak A, Mentes O, Kilic S, Coskun K, Duman K, Yilmaz F. Sacrococcygeal pilonidal disease: Analysis of previously proposed risk factors. Clinics (Sao Paulo) 2010;65:125-31.  Back to cited text no. 12
    
13.
Al-Kadi AS. Umbilical pilonidal sinus. Int J Health Sci (Qassim) 2014;8:307-10.  Back to cited text no. 13
    
14.
Cubukçu A, Gönüllü NN, Paksoy M, Alponat A, Kuru M, Ozbay O. 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 2000;15:173-5.  Back to cited text no. 14
    
15.
Khawaja HT, Bryan S, Weaver PC. Treatment of natal cleft sinus: A prospective clinical and economic evaluation. BMJ 1992;304:1282-3.  Back to cited text no. 15
    
16.
Hameed KK. Outcome of surgery for chronic natal cleft pilonidal sinus: A randomized trial of open compared with closed technique. Medical Forums 2001;12:20-3.  Back to cited text no. 16
    
17.
Kronborg O, Christensen K, Zimmermann-Nielsen C. Chronic pilonidal disease: A randomized trial with a complete 3-year follow-up. Br J Surg 1985;72:303-4.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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