LAUSR

Dear Editor, Dr. Schein’s Invited Commentary [1] is provocative and over-simplistic. It highlights deficiencies in our understanding and floundering attempts at treating pilonidal sinus disease (PSD). He is not alone in assuming all PSDs are the same. In Gips’ et al. [2] huge series, two-thirds of patients only had a solitary midline sinus with no secondary sinuses. Others report 75% of patients with at least one secondary sinus [3]. There are currently no long-term data to determine whether all PSDs have the same natural history or response to surgery. Surgeons may not be reinventing the wheel by returning to older less invasive operations; they may be ignoring the valuable lessons of history. Cochrane data show excision and off-midline closure work [4]. Day case surgery for PSD is not limited to pit excisions—Karydakis [3, 5] and Limberg flaps [6] are achievable. I urge Dr Schein and your readers attend the International Pilonidal Sinus Disease conference in Berlin [7] and be involved in steering the pilonidal ship possibly away from naval mines! As to the controversy of who got there first—in 1847, Anderson described (but did not name) a small ‘‘fistula’’ nearby the coccyx associated with a ‘‘tender spot ... four inches above and to the left’’ containing pus and hair [8]— typical PSD. However, in 1880 Hodges coined the term ‘‘Pilo-Nidal Sinus’’ for a ‘‘conical dimple ... near the coccyx ... resembling the navel’’ in dimensions and appearance [9]—probably what is now recognised as an incidental sacral dimple [10] and very different to what Patey described as a ‘‘tiny inconspicuous epithelial pit’’ [11]. The term American soldiers used for PSD (jeep disease) [11] is best abandoned as it is inaccurate—PSD was indeed a major problem for American and French soldiers during World War II, but the French did not drive! [12] Not surprisingly both armies were full of young men. PSD is uncommon in patients over the age of 40 but to claim it is ‘‘almost unknown’’ is fanciful: in Gips et al.’s [2] and Anderson et al.’s [5] series, the oldest was 46, Tezel et al.’s [13] was 66, and Solla’s 71 years [14]. Last year I saw a 66-year-old woman (with glabrous buttocks) whose first pilonidal abscess was drained at the age of 53 years. A ‘‘forest of dark hairs on your butt’’ and age under 40 years are not prerequisites! Schein states hair is present within the pilonidal cyst in ‘‘about half the cases’’ but ignores Gips’ series where hair was identified in 93% of patients [2]. Gips et al.’s [2] 5-year recurrence was 13%, and Petersen’s [15] actuarial recurrence rate at 12 months was 18%. Khodakaram et al.’s [16] pit picking resulted in an estimated 5-year recurrence of 32% and a mean of three postoperative clinic reviews (range 1–24). Patient acceptance of recurrence after pit excision remains to be established, but certainly after complete excision, it impacts negatively on satisfaction [17]. ‘‘The bigger is the original operation the more complex becomes the treatment of recurrence’’ is an unreferenced statement and certainly has not been the author’s experience or that of Anderson et al. [5]. Labelling recurrence as not a failure of treatment but a ‘‘simple management issue’’ is playing with definitions. & Arkadiusz Peter Wysocki [email protected]