The long-term recurrence rate of minimally invasive methods in pilonidal sinus disease therapy is still unclear

Abstract

We have studied the Italian consensus statement on the management of pilonidal sinus disease (PSD) with pleasure and relief [1]. It has markedly improved on prior Italian and American guidelines, and while the latter have been updated but still contain inaccuracies, this document of the Italian Colorectal society is much more precise. Marco Milone et al. can be congratulated to their work, especially in their equivocal statements about the benefits of off-midline closure, and the critical remarks on the all too frequently used primary open approach. It is refreshing to see that intergluteal depilation is gaining momentum, as reduction of this “catching zone” may be beneficial to reduce recurrence rate. Primary open treatment is a fallback option for a few pilonidal cases, while most of them can be treated by tissue sparing methods or flap techniques. This has been outlined in the article, but unfortunately has not been followed through. Hence, there are some scientific soft spots in the consensus statement of panelists, which need to be commented on. First, the incidence described by Søndenaa et al. should be addressed, this now more than 26-years old and does not reflect the current state of science. Recent work has shown that the incidence of PSD has increased in recent years. [2] Minimally invasive techniques should be considered, as they “...may be safe and effective in the treatment of chronic pilonidal sinus”. There is no doubt that the time of “big surgeons, big incisions” should be over, and it is one of the major faults in PSD surgery to unnecessarily reduce healthy soft tissue cover needed for a potential wound closure. Wounds unnecessarily extended to the anus do heal exceptionally slowly (if at all), even using tricks as metronidazole 10% ointment, alginate fibres or other tactile wound therapies. Is small always beautiful? Tract or hair remnants left in place are one of the main reasons for recurrence, and here the endoscopic approach promoted by Milone and Meinero should be able to identify and debride more thoroughly than other minimal invasive techniques. But Gips et al. [3] who were able prove a 16% recurrence rate after 10 years, which is excellent—and very cost effective—and without endoscopy. So, the question still to be answered is what minimally invasive technique(s) should be used, if at all. While minimally invasive techniques are being validated, the litmus test of every technique is the long-term follow up showing a low recurrence rate, to be reproducible in hospitals all around the world. A closer look at the meta-analysis cited as proof of validation is more than sobering. Emile et al. report on n = 9 studies with n = 497 patients and Tien et al. on n = 8 studies with n = 546 patients; Both studies are from 2018. Both studies have nearly identical sources; 5/9 [4] and 5/8 [5] sources cited are from the endoscopic pioneers Meinero and Milone themselves, and follow-up times are between 6 and 26 months [4]. A larger long-term meta-analysis on the minimally invasive techniques is still pending, and until it is completed we are allowed to be cautious. Nevertheless, if the next large meta-analysis contains several thousand patients, and its Kaplan–Meier 5and 10-year follow-up shows a recurrence rate of 1–2% per year of follow-up or even less, then minimally invasive methods may be a powerful future tool in our surgical portfolio even for recurrent disease. * D. Doll [email protected]