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RESEARCH: Iain J D McCallum, Peter M King, and Julie Bruce Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis BMJ 2008; 336: 868-871 [Abstract] [Full text]

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Honey Dressings and Pilonidal Sinus

Mohammed F Hamdan, Sharon Hailes (Vascular Nurse Spcialist), Michael A Walker (Consultant Vascular Surgeon)   (25 April 2008)

Recurrence rate in pilonidal sinus disease is grossly underestimated.

Dietrich Doll, Theo Evers   (22 May 2008)

Honey Dressings and Pilonidal Sinus 25 April 2008
Mohammed F Hamdan, Foundation Year 1 Doctor Department of Surgery, West Cumberland Hospital, Whitehaven, Cumbria CA28 8JG, Sharon Hailes (Vascular Nurse Spcialist), Michael A Walker (Consultant Vascular Surgeon) Send response to journal: Re: Honey Dressings and Pilonidal Sinus	The recent editorial and systematic review on the treatment of pilonidal sinus (PNS) highlights that there is as yet no one gold standard treatment for this condition. Although off-midline incision yields a better outcome than midline incision in primary closure no consideration has been given to the possible importance of the type of dressing used if the sinus is simply “opened and packed”. We support the view of Bascom who suggests that PNS treatment should be based on the principle of “drain abscesses and protect tissue from bacteria” rather than wide excision that treats “pilonidal disease as if it were a malignant condition”. We believe that in those undergoing drainage and packing the type of dressing used may play an important role in affecting rate of healing. We have used Manuka honey dressings now for many years in leg ulcers and other wounds with good effect and have a series of 16 PNS patients who were all initial failures with primary treatment (mean of 1.75 operative interventions range 1-5) who had had symptoms post primary intervention for a mean of 10 months (range 7 days to 42 months) before honey dressings were applied. All patients who complied with the dressing regime (14 out of 16) healed with a mean of 63 days (range 14 to 287 days). There has been one recurrence at 29 months. The other 13 have follow up for a mean of 26 months (1 – 65 months) and remain symptom free. Our experience of honey dressings in this difficult group has encouraged us to offer local excision and packing with honey dressing as one option in patients undergoing elective primary treatment of PNS and in those with an acute pilonidal abscess with excellent early results. We believe that this may be another valuable use for Manuka honey dressings. Competing interests: None declared
Recurrence rate in pilonidal sinus disease is grossly underestimated. 22 May 2008
Dietrich Doll, Senior Consultant Military Surgeon Military Hospital Berlin of The Charité, Berlin, Scharnhorststr. 13, D-10115 Berlin, Germany, Theo Evers Send response to journal: Re: Recurrence rate in pilonidal sinus disease is grossly underestimated.	Dear Editor, with interest we have been studying the BMJ Research article by McCallum et al. „Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis [1]. Following the footsteps of Petersen et al. [2] they completed an impressive task of reviewing 1.367 trials, of which finally 19 were taken into closer account. Nevertheless, some methodological aspects on recurrence in pilonidal sinus disease need to be addressed. Firstly, recurrence rate is a function of time. Most of the studies analysed showed a follow up of 1 year (+), with a maximum follow up time of 37 months. Within 1 years time, only 23.2 % of all primary sinus recurrences occurring are to be expected, and after 37 months 50.0 % are to be expected. Thus missing between 50.0 % and 76.8 % of all recurrences, recurrence rate is not “…underestimated slightly…”, but the majority of recurrences will not be seen. Therefore the concept of long term recurrence rate (after 5 years, 10 years, 15 years and 20 years) was introduced [3]. Furthermore, the intraoperative use of methylene blue halves recurrence rate [4], which has not been taken into account as a potent confounder in the studies cited in this review. Age at start of disease has been proven to correlate with recurrence rate [5]; this issue was not addressed at all as was the 50 % recurrence rate in patients with family history (Doll, in publication). The influence of preoperative single shot antibiotics, which gained wide influence within the supportive therapy of primary closure, was not addressed either. Only 8 out of the 19 studies cited had a patient population of 100 (or above; with a maximum of n=200 patients). Thus while conclusions might be biased to an unknown extent, as discussed in full by the authors, recurrence rates are grossly underestimated. Interestingly, we have come to similar conclusions regarding recurrence rate in primary open treatment versus primary midline closure, using a different approach. Analysing telephone interview data from 498 patients following surgery for primary disease, long term follow up was done 8.5 – 25.4 years (mean 15.3 +- 3.7 SD years) after surgery. Recurrence free survival was 82 % versus 91 % after 5 years, 77 % versus 88 % after 10 years and 64 % versus 78 % 20 years post surgery (primary open treatment versus midline closure; p=0.002). Thus we can conclude that rhomboid excision followed by primary open wound healing is followed by a significant lower long term recurrence rate at 5, 10 and 20 years - compared to excision followed by primary midline closure. In conclusion, working with "the" recurrence rate in pilonidal sinus (using not specified, median or mean follow up interval) is not to be recommended, as it may be grossly incorrect. Further studies on pilonidal sinus should always state a 5-year or 10-year recurrence rate, as can be easily deduced from applied Kaplan Meier analysis. Dietrich Doll & Theo Evers Reference List 1. McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta -analysis. BMJ 2008;336:868-71. 2. Petersen S, Koch R, Stelzner S, Wendlandt TP, Ludwig K. Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Dis.Colon Rectum 2002;45:1458-67. 3. Doll D, Krueger CM, Schrank S, Dettmann H, Petersen S, Duesel W. Timeline of recurrence after primary and secondary pilonidal sinus surgery. Dis.Colon Rectum 2007;50:1928-34. 4. Doll D, Novotny A, Rothe R, Kristiansen JE, Wietelmann K, Boulesteix AL et al. Methylene Blue halves the long-term recurrence rate in acute pilonidal sinus disease. Int.J Colorectal Dis. 2008;23:181-7. 5. Doll D, Friederichs J, Dettmann H, Boulesteix AL, Duesel W, Petersen S. Time and rate of sinus formation in pilonidal sinus disease. Int.J Colorectal Dis. 2007. Competing interests: None declared