, Volume 41, Issue 2, pp 94–95 | Cite as

Pilonidal sinus disease—186 years since Mayo

Einführung zum Thema

Pilonidalsinuserkrankungen – 186 Jahre seit Mayo

Pilonidal sinus therapy is a hot topic—and thus recently there has been an upsurge in interest in the therapy of pilonidal sinus disease (PSD), as more than 30,000 operations per year are performed in Germany alone [1]. The incidence of PSD seems to be rising [2], with more studies published, mostly from the Mediterranean region, where Turkey leads the field (Fig. 1). This renewed interest also shows a massive shift away from midline closure, as this has proven to be the worst therapeutic option a surgeon can choose for their patient [3]. Without any doubt, Karydakis, Bascom, Limberg, and Dufourmentel are superior in terms of recurrence rate [4, 5], which has been shown to be highly dependent on follow-up time. A low recurrence rate is 1% of recurrence per year of follow-up , and an acceptable recurrence rate is 2% per year of follow-up [6]; thus, 1% recurrence rate per year of follow-up is the new gold standard.
Fig. 1

Number of studies published on surgical methods applied for PSD since 1930. (Courtesy of Nora Peters, Marburg)

Some interesting aspects of the mechanism of PSD have been unraveled: It seems that short hair fragments from the head may play a role in PSD recurrence [7, 8, 9]. Is sweating an important aspect in PSD? An ongoing study will give us results in due time.

The therapeutic spectrum differs worldwide. In Indo-Arab countries, phenol is still popular, which is forbidden in Germany owing to toxicity and teratogenic effects [10, 11]. While other nations advocate the use of primary open treatment less [12]—unless the wound situation dictates its use—it is predominantly applied in Germany, with some inherent disadvantages: high costs for insurance companies, high costs for the employer, and a long healing time. Recently, new methods such as laser and endoscopic treatment have gained attention [13, 14, 15], but their value is still to be determined. Surgeons in Germany are still cautious when performing pilonidal plastic surgery as recommended [16] because they fear potential complications. This may be one reason why so-called minimally invasive methods have increased in popularity during the last few years—therapies like Gips’s tract surgery and pit picking [17, 18]. Although these may be associated with a higher recurrence rate, some surgeons argue that they are considered a good start for uncomplicated pilonidal disease—and a flap procedure may be used later, if there is recurrence [19].

If we want to escalate therapy depending on clinical aspects, how can we judge which sinus needs which therapeutic tool? Staging systems are emerging, and their evidence is still weak: But do they provide the clinicians with useful information? Is this just gathering data, or is it a real benefit for the patients? There is still some common ground to be found before the use of these systems can be recommended.

Seven high-profile authors from Sweden, Switzerland, Turkey, the United Kingdom, Australia, and Germany have agreed to contribute their knowledge to this Pilonidal Sinus Series, which Alois Fürst initiated.

Who are the contributing authors? Peter Wysocki from Australia writes on primary open treatments, and Asha Senapati from St. Marks Hospital in London gives us a comprehensive overview of common flaps in pilonidal sinus surgery. Ekmel Tezel from Ankara, Turkey, describes current staging systems, and Andreas Ommer (Essen, Germany) was so kind as to compile an overview of the new kids on the block—laser and endoscopic treatment—and their results in the literature. Thomas Baur (Bern, Switzerland) presents the recurrence rates in uncommon surgical procedures for PSD, and Roland Andersson from Jönköping (Sweden) outlines less invasive surgical procedures. Nora Peters from Marburg is giving some informations on costs of PSD therapy—quite interesting in an increasingly cost orientated medical environment. Each author stands their own ground, and thus different aspects as well as common approaches can be identified.

The choice of pilonidal sinus therapy is an ongoing field of interest. Certain ways of prevention may emerge, but other important questions remain:
  • Since PSD is related to puberty, there must still be yet undiscovered skin and humoral factors, other than hair strength.

  • Why is there a suspected higher incidence in Turkey and other Mediterranean countries, while this disease is not known in Asia and Africa?

  • Incidence is high in some families, sometimes with three generations in a row affected by PSD. Is there a co-genetic predisposition other than BMI (not proven yet) and hair strength?

  • The incidence of PSD seems to be rising, while recurrence is not. Does this mean we have to think of two different mechanisms between first and recurrent disease?

It seems that 186 years after its first description [20], we are only just beginning to understand the mechanisms of PSD.

Dietrich Doll


Conflict of interest

D. Doll declares that he has no competing interests.


  1. 1.
    Destatis (2017) Operationen und Prozeduren in Krankenhäusern. In. Interactive Online Database des Statistischen Bundesamt der Bundesrepublik Deutschland, Wiesbaden. Accessed 31 Aug 2018Google Scholar
  2. 2.
    Karahan Ö, Eryilmaz MA, Torun V et al (2010) Is the increase in the number of pilonidal sinus surgery normal? Turk J Surg 26:207–211CrossRefGoogle Scholar
  3. 3.
    Al-Khamis A, McCallum I, King PM et al (2010) Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev. CrossRefPubMedGoogle Scholar
  4. 4.
    Petersen S, Koch R, Stelzner S et al (2002) Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Dis Colon Rectum 45:1458–1467CrossRefPubMedGoogle Scholar
  5. 5.
    Allen-Mersh TG (1990) Pilonidal sinus: finding the right track for treatment. Br J Surg 77:123–132CrossRefPubMedGoogle Scholar
  6. 6.
    Stauffer VK, Luedi MM, Kauf P et al (2018) Common surgical procedures in pilonidal sinus disease: a meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep 8:1–27CrossRefGoogle Scholar
  7. 7.
    Bosche F, Luedi MM, van der Zypen D et al (2018) The hair in the sinus: sharp-ended rootless head hair fragments can be found in large amounts in pilonidal sinus nests. World J Surg 42:567–573CrossRefPubMedGoogle Scholar
  8. 8.
    Doll D, Bosche F, Hauser A et al (2018) The presence of occipital hair in the pilonidal sinus cavity-a triple approach to proof. Int J Colorectal Dis 33:567–576CrossRefPubMedGoogle Scholar
  9. 9.
    Doll D, Bosche FD, Stauffer VK et al (2017) Strength of occipital hair as an explanation for pilonidal sinus disease caused by intruding hair. Dis Colon Rectum 60:979–986CrossRefPubMedGoogle Scholar
  10. 10.
    Bundesministerium der Justiz (1991) Bundesgesetzblatt vom 02.10.1991 mit Anlagen. Bundesanzeiger, KölnGoogle Scholar
  11. 11.
    Bruce RM, Santodonato J, Neal MW (1987) Summary review of the health effects associated with phenol. Toxicol Ind Health 3:535–568CrossRefPubMedGoogle Scholar
  12. 12.
    Fabricius R, Petersen LW, Bertelsen CA (2010) Treatment of pilonidal sinuses in Denmark is not optimal. Dan Med Bull 57:1–5Google Scholar
  13. 13.
    Pronk AA, Eppink L, Smakman N et al (2018) The effect of hair removal after surgery for sacrococcygeal pilonidal sinus disease: a systematic review of the literature. Tech Coloproctol 22:7–14CrossRefPubMedGoogle Scholar
  14. 14.
    Meinero P, Stazi A, Carbone A et al (2016) Endoscopic pilonidal sinus treatment (EPSiT): a prospective multicentre trial. Colorectal Dis. CrossRefPubMedGoogle Scholar
  15. 15.
    Milone M, Velotti N, Manigrasso M et al (2018) Long-term follow-up for pilonidal sinus surgery: a review of literature with metanalysis. Surgeon 16:315–320CrossRefPubMedGoogle Scholar
  16. 16.
    Ommer A, Berg E, Breitkopf C et al (2014) S3-Leitlinie: Sinus pilonidalis. Coloproctology 36:272–322CrossRefGoogle Scholar
  17. 17.
    Di Castro A, Guerra F, Sandri GB et al (2016) Minimally invasive surgery for the treatment of pilonidal disease. The Gips procedure on 2347 patients. Int J Surg 36:201–205CrossRefPubMedGoogle Scholar
  18. 18.
    Gips M, Melki Y, Salem L et al (2008) Minimal surgery for pilonidal disease using trephines: description of a new technique and long-term outcomes in 1,358 patients. Dis Colon Rectum 51:1656–1662 (discussion 1662–1653)CrossRefPubMedGoogle Scholar
  19. 19.
    Iesalnieks I, Deimel S, Schlitt HJ (2015) “Pit picking” surgery for patients with pilonidal disease : mid-term results and risk factors. Chirurg 86:482–485CrossRefPubMedGoogle Scholar
  20. 20.
    Mayo H (1833) Observations on injuries and diseases of the rectum. Burgess & Hill, LondonGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Procto-Surgery, St. Marienhospital VechtaAcademic Teaching Hospital of the Hannover UniversityVechtaGermany

Personalised recommendations