LAUSR

Dear Editor: With interest, we read the article of Caliskan et al. about his study comparing three surgical treatment options for pilonidal sinus disease (PSD) [1]. The authors demonstrate an excellently low combined recurrence rate of below 1% per year. This success is even more remarkable when the specific challenges deriving from local settings are considered [2]. While Caliskan and his team can be congratulated for the impressive patient numbers treated in local anaesthesia, there are some remarks to be made. Some of the epidemiological and pathophysiological details require attention: First, the incidence of 26/100.000 described derives from a publication 3 decades ago. The incidence is globally higher today. Second, short sharp hair fragments from the head have been shown to cause PSD [3], with axial hair strength being key for the occurrence of PSD. [4] Some of the methodological details require attention too: To our understanding, the study is likely underpowered, which can explain that no significant differences can be shown between the plastic treatment groups, where – as a trend—the midline closure has the higher recurrence rate, and the Karydakis approach the lowest. The old dogma ‘‘to stay off the midline’’ once more appears to be still valid, and the off-midline closure methods, whatever technique is used, remain superior. Caliskan et al. report that patients without complaints were discharged home 6 h after surgery. We would have loved to learn how many of their patients were kept longer at the hospital, and what consecutive pain treatment those patients received. General anaesthesia can cause post-operative nausea and vomiting and PSD closure procedures may cause pain due to suture tension effects. Longer pain relief may indeed be achieved by local or regional anaesthesia in PSD patients [5], which facilitates discharge at the same day as well. Finally, a further analysis of gender-specific outcome would be interesting in the authors cohort too.