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1. Pilonidal Disease Jibran Mohsin Resident, Surgical Unit I SIMS/Services Hospital, Lahore

2. Outline Background Introduction Definition Etymology Classification Epidemiology Pathophysiology Etiology Clinical Manifestation Differential Diagnosis Workup Treatment Complications Prognosis

3. BACKGROUND - Journey from historical congenital theories to new acquired theories D escribed back as far as 1833, when Herbert Mayo described a hair-containing cyst located just below the coccyx R.M.Hodge coined the term "pilonidal" from its Latin origins in 1880 In the 19 th and early 20 th centuries studied on an embryologic basis by many authors, considering it to be of congenital origin. congenital remnant of an epithelial-lined tract from postcoccygeal epidermal cell rests or vestigial scent cells Excision of the lesion was thought to be fundamental to removing all embryologic remnants

4. BACKGROUND- Journey from historical congenital theories to new acquired theories Gained prominence and practical importance amongst World War II soldiers with a high incidence of the disease, so much so it came to be known as J eep seat/ Jeep(riders‘) disease (Jeep/driver’s bottom)* nearly 80,000 US soldiers were admitted and treated at US Army Hospitals between the years 1941-1945 with average hospital stay time of 55 days Prompt return of soldiers to the field was important, leading to a variety of proposed surgical treatments aimed at this goal ____________________________________________________ *large portion of people who were being hospitalized for it rode in Jeeps, and prolonged rides in the bumpy vehicles were believed to have caused the condition due to irritation and pressure on the coccyx

5. BACKGROUND- Journey from historical congenital theories to new acquired theories After the war, Patey and Scarf hypothesized the acquired origin of pilonidal disease penetration of hair into the subcutaneous tissue with consequent granulomatous reaction basing this theory on the high incidence of recurrence, as well as occurrence of disease in other areas of the body, such as the hands of a barber or sheep shearer ___________________________________________________ an acquired etiology of the disease is now the prevailing theory in the medical world

6. BACKGROUND- Journey from historical congenital theories to new acquired theories EVIDENCE IN FAVOR OF ACQUIRED THEORY OF ORIGIN Interdigital pilonidal sinus is an occupational disease of hairdresser Hair within interidigital cleft(s) being from costumers Pilonidal sinus of axilla and umbilicus also reported Age incidence of appearance of pilonidal sinus(82 % occur between 20-29 year) is at variance with age of onset of congenital lesions Hair follicles have almost never been demonstrated in walls of sinus and are lined with cuboidal epithelium

7. BACKGROUND- Journey from historical congenital theories to new acquired theories EVIDENCE IN FAVOR OF ACQUIRED THEORY OF ORIGIN Hairs projecting from sinus are dead hairs, with their pointed ends directed towards the blind end of the sinus Disease mostly affects men, in particularly hairy men Recurrence is common, even though adequate excision of track is carried out

8. Definition PILONIDAL DISEASE S pectrum of clinical presentations, ranging from asymptomatic hair-containing cysts and sinuses to large symptomatic abscesses of the sacrococcygeal region that have some tendency to recur (includes pilonidal abscess, sinus, cyst and fistula)

9. Definition PILONIDAL SINUS Condition found in the natal cleft overlying the coccyx, consisting of 1 or more, usually non-infected, midline openings, which communicate with a fibrous track lined by granulation tissue and containing hair lying loosely within the lumen

10. Etymology Pilonidal means “nest of hair” derived from the Latin words for hair ( pilus ) and nest ( nidus )

11. Classification 3 categories that represent different stages of the clinical course ( 1) acute pilonidal abscess, ( 2) chronic pilonidal disease, and ( 3) complex or recurrent pilonidal disease. Ideal treatment varies according to the clinical presentation/category of the disease

12. Epidemiology WORLDWIDE INCIDENCE 7 per 10000 population Gender Predisposition Adult  M:F ( 3-4 : 1) Children  M:F (1 : 4) RACE predominantly in white/Caucasians

13. Epidemiology AGE* typically in the late teens to early twenties, decreasing after age 25 and rarely occurs after age 40 average age of presentation  21 years(male) and 19 years(female) ** __________________________________________________ *it occurs after puberty, when sex hormones are known to affect the pilosebaceous gland and change healthy body hair growth ** due to the fact that puberty occurs earlier in females

14. Pathophysiology SAME AS FOR ACNE VULGARIS/HIDRADENITIS SUPPURATIVA Sex hormones affect the pilosebaceous glands after onset of puberty H air follicle becomes distended with keratin . Resulting in folliculitis, leading to edema and follicle occlusion . I nfected follicle extends and ruptures into the subcutaneous tissue, forming a pilonidal abscess . resulting in a sinus tract leading to a deep, subcutaneous cavity . Direction of the sinus tract is cephalad (90%), coincides with the directional growth of the hair follicle. P laces the tracking follicle approximately 5-8 cm from the anus. _________________________________________ ACNE/FOLLICULAR OCCLUSION TETRAD = hidradenitis suppurativa , acne conglobata , dissecting cellulitis of the scalp , and pilonidal sinus

15. Pathophysiology In the rarer instance that the sinus is located caudally, it is usually found 4-5 cm from the anus. The laterally communicating sinus overlying the sacrum is created as the pilonidal abscess spontaneously drains to the skin surface. The original sinus tract from the natal ( intergluteal ) cleft becomes an epithelialized tube. The laterally draining tract becomes a granulating sinus tract opening

16. Pathophysiology 1 st MECHANISM

17. Pathophysiology 2 nd MECHANISM

18. Pathophysiology

19. Pathophysiology Microscopically, the sinus tract where the hair enters is lined with stratified squamous epithelium with slight cornification (itself soft) Additional sinuses are frequent. sinus tract openings are actually an extension of the deep cavity Cyst/sinus cavities are lined with chronic granulation tissue and may contain hair, epithelial debris, and young granulation tissue. Cutaneous appendages are not seen in the wall of cysts. Cellular infiltration consists of PMNs, lymphocytes, and plasma cells in varying proportions . Foreign body giant cells in association with dead hairs are a frequent finding . Hair enters tip first, and the barbs on the hair prevent it from being expelled, causing the hair to become entrapped. Physical examination occasionally may reveal a tuft of hair emerging from the midline opening in the natal cleft.

20. Pathophysiology 3 pieces are instrumental in this process : the invader, hair; ( 2) the force, causing hair penetration; and ( 3) the vulnerability of the skin. __________________________________________________________________ This process has been well characterized by Patey and Scarff as well as a number of other authors from the second half of the 20 th century through today

21. Pathophysiology MICROBIOLOGY most commonly reported bacteria cultured from pilonidal abscesses differ by author In one study, anaerobic cocci were present 77% of the time; aerobic, 4%; and mixed aerobic and anaerobic, 17 %. Other studies quote Staphylococcus aureus , an aerobe, as being the most common bacterial pathogen.

22. Pathophysiology Rarely, foreign bodies other than human hair can cause this disease process. Rare case reports exist in which the hair did not come from the patient but instead came from a bird's feather, the type used to stuff feather bedding.

23. Etiology- risk factors Male gender Hirsute individuals Dark (stiff) haired individuals rather than softer blond hair Rare in Negroes Increased sweating/moisture Sitting occupations (or sedentary lifestyle)-friction movements Driver of vehicle(own hair) Barber(customer hair) bird keeper/sheep keeper(Animal hair) folliculitis or a furuncle at another site on the body Deep/narrow natal cleft H air within the natal cleft (local irritation) Family history (38 % areas) Obesity risk factor for recurrent disease Buttock friction Other hair features Kinking(shape), medullation (nature) sharp/coarseness , and growth rate Poor personal hygiene Local trauma(army recruits)

24. Clinical Manifestation Most common presentation in the ER is a intermittent painful (persistent, throbbing), swollen discharging ( serosanguinous / purulent) lesion in the sacrococcygeal region about 4-5 cm posterior to the anal orifice May be asymptomatic At times, spontaneous drainage may have occurred prior to presentation to the clinician Occasionally , a history of trauma is recalled Patient may state that a similar lesion occurred in that area before, for which the patient may have had a primary incision and drainage or other definitive care prior to this presentation .

25. Clinical Presentation Given most patients are young and healthy, other comorbidities are not common, and review of systems is often negative, including fever and chills. There is no known preponderance of this disease in smokers or alcohol or drug abusers. Although usually found near the coccyx/natal ( intergluteal ) cleft / sacrococcygeal region C ondition can also affect the umbilicus, web spaces of hand, armpit or genital region (though rarer)

26. Sacrococcygeal Pilonidal Disease

27. Clinical Presentation Usually, the patient is afebrile and nontoxic(minimum constitutional symptoms) Local examination may show a relatively unremarkable sinus tract in the sacrococcygeal region Primary sinus having 1 or more openings All strictly in the midline, with tuft of hairs seen in opening of sinus Between level of sacrococcygeal joint and tip of coccyx or may have secondary lateral openings superior to the midline pit. Usually at ER presentation, the patient has typical findings of an abscess, including redness, warmth, local tenderness, and fluctuance with or without induration.

28. Differential Diagnosis Anal Fistulas and Fissures Hidradenitis Suppurativa Perirectal Abscess Syphilis Tuberculosis Osteomyelitis of Coccyx

29. Workup No specific laboratory studies or tests are needed to diagnose pilonidal disease and its sequelae or differentiate it from other disease entities I t is a clinical diagnosis best elicited by history and physical examination findings.

30. Treatment Conservative treatment INDICATION: patients whose symptoms are relatively minor( and without abscess) natural history of condition is usually one of regression Cleaning out the tracks and removal of all hair, with regular shaving of area and strict hygiene

31. Treatment Pilonidal Abscess(acute exacerbation) Conservative Rest, baths, local antiseptic dressings and broad-spectrum antibiotics Surgery Incision and drainage Small longitudinal incision made over the abscess and off the midline Through curettage of granulation tissue and hair May or may not be associated with complete resolution

32. Treatment Chronic P ilonidal Disease Lack of overall superiority of 1 method over others Factors affecting choice of method Time spent off work Perceived recurrence rates Surgeon preference G oals of the ideal procedure should be Reliable wound healing Low risk of recurrence S hort period of hospitalization minimal inconvenience to the patient(low morbidity) few wound-management problems. Resumption to normal daily activities as quickly as possible.

33. Treatment POSITION: Jack Knife*( Kraske position) (prone with buttocks elevated) Anesthesia: General or Local OPTIONS Laying open & curetting of all tracks(demonstrated by methylene blue) +/- marsupialisation Excision of all tracks with OPEN METHOD: wound left open-secondary intention healing over 3-4 weeks (Least recurrence) CLOSED METHOD: primary closure(+/- retention suturing) closure by some other means designed to avoid a midline wound Z- plasty , Karydakis procedure semilateral incision and lateralised suturing of wound away from midline _________________________________________________________________________ *Jackknifing  means the folding of an articulated vehicle (such as one towing a trailer) such that it resembles the acute angle of a folding pocket knife

34. Cleft left procedure

35. Bascom’s procedure Incision(s) 2-4 mm sized lateral to midline to gain access to sinus cavity Pus drained, hairs removed with only minima/NO excision of sinus/cavity wall Most effective for primary pilonidal sinuses

36. Treatment POSTOPERATIVE CARE Daily pack/dressing change after warm shower/ sitz bath elimination of hair (ingrown, local or other) from the wound every 1-3 weeks as effective in preventing recurrence as a secondary surgical procedure FOLLOW UP After 1-2 weeks examine the wound for healing, assess for potential recurrence, arrange for definitive care of the sacrococcygeal region if necessary

37. Treatment RECURRENT PILONIDAL SINUS ETIOLOGY Part of sinus complex overlooked at primary operation New hairs enter the skin or the scar Persistence of a midline wound caused by shearing forces and scarring TREATMENT Revisional surgery including extensive resection /re-excision followed by wound closure and obliteration of natal cleft either by ( Limberg -single/double Rhomboid) myocutaneous rotational buttock flap V-Y gluteal advancement flap

38. Treatment CONTRAINDICATION Although no specific contraindications exist for the treatment of pilonidal disease, consider the patient's overall situation and well-being weigh the complexity of the proposed surgical procedure against the patient's individual comorbidities and long-term prognosis.

39. Complications Recurrence of the abscess most common complication(40-50 %) Wound infection Leading to sacral osteomyelitis, necrotising fascitis and rarely meningitis SCC in chronic pilonidal disease Exceedingly rare requires en bloc surgical resection and appropriate oncologic care with local radiation and possibly chemotherapy

40. Prognosis Excellent long-term prognosis M ortality is practically NIL unless SCC develops, though abscess recurrence is common