Abstract
The characteristics of the pilonidal sinus that are associated with recurrence have scarcely been investigated in the literature. This study aims to evaluate the outcomes of patients with sacrococcygeal pilonidal sinus disease who were managed by a non‐operative technique using Salih's preparation. This study also tries to classify the patients according to the features that determine the outcome of the intervention. This is a single‐group cohort study that enrolled consecutive patients that had pilonidal sinus. All the patients were managed using Salih's preparation. The patients were seen at the clinic 6 weeks after the intervention to record data of recurrence. The Statistical Package for the Social Sciences (SPSS) Version 25 was used for coding and analysing the data. Test of significance and odds ratio were calculated for all of the features. The total number of patients receiving Salih's preparation was 12 123 cases, of which only 3529 patients were included in this study. The mean age of the participants was 26.95 years, ranging from 14 to 55 years. The most significant factor related to the recurrence was the presence of an abscess. After summation of all odd ratios, the percentage of each one from the total was calculated, and accordingly, the patients were divided into three classes. Non‐operative methods using a preparation with antimicrobial and sclerosing properties can be an alternative for surgical intervention with a lower risk of recurrence. Classification of patients based on specific criteria can give clinicians and even patients themselves a vision of the chance of recurrence and treatment success.
Keywords: acquired disease, PNS, recurrence, risk factors
1. INTRODUCTION
Pilonidal sinus (PNS) is a suppurative disease that occurs most commonly in the sacrococcygeal region. The disease is more common in developing countries. 1 There are several strategies to treat PNS, but the most effective one is still under discussion. 2 Management is often based on the preferences and training backgrounds of clinicians. It can be managed by either non‐operative methods or surgical intervention. 3 Operative intervention with its different techniques is used as the primary treatment. The most common type is the local excision of the sinus tract. Excision with primary closure is another option with better outcomes in comparison to the first one. 3 , 4 All surgical techniques are associated with significant disadvantages, including long‐term hospital admission, poor wound healing, discomfort, pain, sepsis, and difficult follow‐up. Therefore, ideal conservative management is yet to be invented. 3 , 5 , 6 The ideal approach should provide sinus tract removal, adequate healing, painless outcome, cost‐effectiveness, shorter hospitalisation, and most importantly, prevention of recurrence. 7 , 8 The recurrence rate has been reported to be 16% in the management of PNS by phenol injection after the first trial. 9 The recurrence rates of 22%, 27%, and 53.1% have also been reported using different techniques of management. 5 , 10 , 11 Salih et al proposed a new non‐operative technique with only 6% recurrence rate after the first treatment session. 3 Efforts are ongoing to determine the best management modality. The characteristics of the PNS that are associated with recurrence have scarcely been investigated in the literature. 8
This study aims to evaluate the outcomes of patients with sacrococcygeal PNS disease who were managed by a non‐operative technique using Salih's preparation. 3 This study also tries to classify the patients according to the features that determine the outcome of the intervention.
2. MATERIALS AND METHODS
2.1. Study design
This is a single‐group cohort study that enrolled consecutive patients that had PNS. The study lasted 3 years (from January 2019 to January 2022).
2.2. Inclusion criteria
The study included only patients with sacrococcygeal PNS who had detailed data documented regarding pre‐intervention, post‐intervention, and follow‐up.
2.3. Exclusion criteria
Patients with PNS in other regions of the body (not involving the sacrococcygeal area).
Patients that had missing data regarding pre‐intervention, post‐intervention, and follow‐up were excluded from this study.
Patients with poor compliance to the home advice.
2.4. Intervention
All of the patients were managed using Salih's preparation. 3 The patients were advised to do simple self‐dressing and cleaning at home (shaving at least twice per week, massaging the PNS region, and keeping the area dry). The patients were seen at the clinic 6 weeks after the intervention to record data of recurrence. Recurrence (cure failure) was defined as the patient having symptoms or the presence of at least a single opening. In cases of recurrence after 6 weeks, the intervention was be repeated for a second time. If it failed to cure after the second 6 weeks, it was be repeated for the third time, and so on.
2.5. Data collection and analysis
The data were extracted from the database of the centre. Microsoft Excel 2019 was used for the arrangement of the data. The Statistical Package for the Social Sciences (SPSS) Version 25 was used for coding and analysing the data. Test of significance and odds ratio were calculated for all of the features. The patients were classified according to three‐range scores (less than 20: in class 1, 20–40: in class 2, and more than 40 in class 3). The scores were extracted using different features. Each character was given a special value according to the odds ratio and level of significance.
3. RESULTS
The total number of patients receiving Salih's preparation was 12 123 cases. Of which only 3529 patients were included in this study. The mean age of the participants was 26.95 years, ranging from 14 to 55 years. Among the patients, 4213 (68.4%) were male, and 1116 (31.6%) were female (Table 1). One hundred and fifty‐one patients (4.3%) experienced recurrence. The most significant factor related to the recurrence was the presence of abscesses (P‐value: less than .001, odd ratio: 3.057) (Table 2). Seventeen patients (%0.5) failed to be cured by the second trial. Being hairy was the most important predictor for the indication of more than two interventions (odd ratio: 3.670) (Table 3). After summation of all odd ratios, the percentage of each one from the total was calculated (Table 4), and accordingly, the patients were divided into three classes (class I: less than 20, class II 20–40, class III: more than 40) (Table 5).
TABLE 1.
Variables with their frequency and percentages.
| Variable | Frequency | Percentage |
|---|---|---|
| Age (mean ± SD) | 26.95 ± 7.75 | |
| Sex | ||
| Male | 2413 | 68.4 |
| Female | 1116 | 31.6 |
| BMI | ||
| <18.5 | 67 | 1.9 |
| 18.5–24.9 | 1155 | 32.7 |
| 25–30 | 1470 | 41.7 |
| >30 | 837 | 23.7 |
| Occupation | ||
| Doctor | 2 | 0.1 |
| Driver | 102 | 2.9 |
| Housewife | 334 | 9.5 |
| Nurse | 3 | 0.1 |
| Officer | 540 | 15.3 |
| Student | 1041 | 29.5 |
| Teacher | 110 | 3.1 |
| Unemployed | 1242 | 35.2 |
| Engineer | 114 | 3.2 |
| Other | 41 | 1.2 |
| Previous operation | ||
| Yes | 284 | 8 |
| No | 3245 | 92 |
| Deep natal cleft | ||
| Yes | 1635 | 46.4 |
| No | 1893 | 53.6 |
| FHX | ||
| Yes | 1475 | 41.8 |
| No | 2054 | 58.2 |
| Swelling | ||
| Yes | 689 | 19.5 |
| No | 2840 | 80.5 |
| Sinus | ||
| No | 617 | 17.5 |
| 1–5 sinus | 2777 | 78.6 |
| 6–10 sinus | 122 | 3.5 |
| >10 sinus | 13 | 0.4 |
| Discharge | ||
| Yes | 944 | 26.7 |
| No | 2585 | 73.3 |
| Hair | ||
| No | 971 | 27.5 |
| Huge | 700 | 19.8 |
| Little | 1071 | 30.3 |
| Medium | 787 | 22.3 |
| Granuloma | ||
| No | 3000 | 85 |
| 1 | 441 | 12.5 |
| 2 | 71 | 2 |
| 3 | 14 | 0.4 |
| 4 | 0 | 0 |
| 5 | 3 | 0.1 |
| Itching | ||
| Yes | 2284 | 64.7 |
| No | 1245 | 35.3 |
| Diabetic | ||
| Yes | 1 | 0.3 |
| No | 3528 | 99.7 |
| Wound infection | ||
| Yes | 0 | 0 |
| No | 3529 | 100 |
| Recurrence | ||
| Yes | 151 | 4.3 |
| No | 3378 | 95.7 |
| Recurrence rate | ||
| Once | 134 | 88.7 |
| Twice | 14 | 9.3 |
| Thrice | 2 | 1.3 |
| Four times | 1 | 0.7 |
| Neglected patient | ||
| Yes | 37 | 1 |
| No | 3492 | 99 |
TABLE 2.
Variables with their impacts on recurrence.
| Recurrence N (%) | |||||
|---|---|---|---|---|---|
| Variable | No | Yes | Odd ratio | 95% confidence interval (lower‐upper) | P value |
| Age | |||||
| ≤25 | 1718 (50.9) | 95 (62.9) | .004 | ||
| >25 | 1660 (49.1) | 56 (37.1) | 0.610 | 0.436–0.855 | |
| Sex | |||||
| Male | 2325 (68.8) | 88 (58.3) | .006 | ||
| Female | 1053 (31.2) | 63 (41.7) | |||
| Odds ratio for sex (Female/male) | 0.633 | 0.454–0.881 | |||
| BMI | |||||
| Normal weight | 1469 (43.5) | 67 (44.4) | .830 | ||
| Overweight | 1909 (56.5) | 84 (55.6) | |||
| Odds ratio for BMI (normal weight/overweight) | 0.965 | 0.695–1.339 | |||
| Occupation style | |||||
| Sitting | 1088 (32.2) | 55 (36.4) | .328 | ||
| No sitting | 2290 (67.8) | 96 (63.6) | |||
| Odds ratio for occupation style (sitting/no sitting) | 0.829 | 0.591–1.164 | |||
| Previous operation | |||||
| Yes | 275 (8.1) | 9 (6) | .335 | ||
| No | 3103 (91.9) | 142 (94) | |||
| Odds ratio for previous operation (No/Yes) | 0.715 | 0.361–1.419 | |||
| Deep natal cleft | |||||
| Yes | 1553 (46) | 83 (55) | .030 | ||
| No | 1825 (54) | 68 (45) | |||
| Odds ratio for deep natal cleft (No/Yes) | 1.434 | 1.034–1990 | |||
| FHX | |||||
| Yes | 1412 (41.8) | 63 (41.7) | .985 | ||
| No | 1966 (58.2) | 88 (58.3) | |||
| Odds ratio for FHX (No/Yes) | 1.003 | 0.721–1.396 | |||
| Swelling (abscess) | |||||
| Yes | 627 (18.6) | 62 (41.1) | <.001 | ||
| No | 2751 (81.4) | 89 (58.9) | |||
| Odds ratio for swelling (Yes/No) | 3.057 | 2.185–4.275 | |||
| Sinus | |||||
| ≤3 sinus | 2950 (87.3) | 124 (82.1) | .062 | ||
| >3 sinus | 428 (12.7) | 27 (17.9) | |||
| Odds ratio for sinus (No/Yes) | 1.501 | 0.978–2.303 | |||
| Discharge | |||||
| Yes | 888 (26.3) | 56 (37.1) | .003 | ||
| No | 2490 (73.7) | 95 (62.9) | |||
| Odds ratio for discharge (No/Yes) | 1.653 | 1.178–2.320 | |||
| Hairy status | |||||
| Not hairy | 945 (28) | 26 (17.2) | .004 | ||
| Hairy | 2433 (72) | 125 (82.8) | |||
| Odds ratio for hairy status (No/Yes) | 1.867 | 1.216–2.868 | |||
| Granuloma | |||||
| ≤3 | 3361 (99.5) | 151 (100) | NA | NA | .382 |
| >3 | 17 (0.5) | 0 (0) | |||
| Itching | |||||
| Yes | 2190 (64.8) | 94 (62.3) | .516 | ||
| No | 1188 (35.2) | 57 (37.7) | |||
| Odds ratio for itching (No/Yes) | 0.895 | 0.639–1.252 | |||
| Diabetic | |||||
| Yes | 1 (0.03) | 0 (0) | NA | NA | N/A |
| No | 3377 (99.97) | 151 (100) | |||
TABLE 3.
Variables with their impacts on more than one recurrence.
| Recurrence time N (%) | |||||
|---|---|---|---|---|---|
| Variable | 1 time | More than 1 time | Odd ratio | 95% confidence interval (lower‐upper) | P value |
| Age | |||||
| ≤25 | 84 (62.7) | 11 (64.7) | .871 | ||
| >25 | 50 (37.3) | 6 (35.3) | 0.916 | 0.319—2.631 | |
| Sex | |||||
| Male | 77 (57.5) | 11 (64.7) | .568 | ||
| Female | 57 (42.5) | 6 (35.3) | |||
| Odds ratio for sex (Female/male) | 1.357 | 0.474–3.886 | |||
| BMI | |||||
| Normal weight | 59 (44) | 8 (47.1) | .813 | ||
| Overweight | 75 (56) | 9 (52.9) | |||
| Odds ratio for BMI (normal weight/overweight) | 0.885 | 0.322–2.434 | |||
| Occupation style | |||||
| Sitting | 50 (37.3) | 5 (29.4) | .524 | ||
| No sitting | 84 (62.7) | 12 (70.6) | |||
| Odds ratio for occupation style (sitting/no sitting) | 1.429 | 0.475–4.294 | |||
| Previous operation | |||||
| Yes | 7 (5.2) | 2 (11.8) | .283 | ||
| No | 127 (94.8) | 15 (88.2) | |||
| Odds ratio for previous operation (No/Yes) | 2.419 | 0.460–12.723 | |||
| Deep natal cleft | |||||
| Yes | 72 (53.7) | 11 (64.7) | .392 | ||
| No | 62 (46.3) | 6 (35.2) | |||
| Odds ratio for deep natal cleft (No/Yes) | 1.579 | 0.552–4.516 | |||
| Severe pain | |||||
| Yes | 68 (50.7) | 5 (29.4) | .097 | ||
| No | 66 (49.3) | 12 (70.6) | |||
| Odds ratio for severe pain (No/Yes) | 0.404 | 0.135–1.211 | |||
| Swelling | |||||
| Yes | 61 (45.5) | 1 (5.9) | .002 | ||
| No | 73 (54.5) | 16 (94.1) | |||
| Odds ratio for swelling (Yes/No) | 1.175 | 0.010–0.580 | |||
| Sinus | |||||
| ≤3 sinus | 109 (81.3) | 15 (88.2) | .485 | ||
| >3 sinus | 25 (18.7) | 2 (11.8) | |||
| Odds ratio for sinus (No/Yes) | 0.581 | 0.125–2.707 | |||
| Discharge | |||||
| Yes | 52 (38.8) | 4 (23.5) | .219 | ||
| No | 82 (61.2) | 13 (76.5) | |||
| Odds ratio for discharge (No/Yes) | 0.485 | 0.150–1.568 | |||
| Hairy status | |||||
| Not hairy | 25 (18.7) | 1 (5.9) | .189 | ||
| Hairy | 109 (81.3) | 16 (94.1) | |||
| Odds ratio for hairy status (Yes/No) | 3.670 | 0.465–28.98 | |||
| Granuloma | |||||
| ≤3.0 | 134 (100) | 17 (100) | NA | NA | NA |
| >3.0 | 0 (0) | 0 (0) | |||
| Itching | |||||
| Yes | 82 (61.2) | 12 (70.6) | .452 | ||
| No | 52 (38.8) | 5 (29.4) | |||
| Odds ratio for itching (No/Yes) | 1.522 | 0.507–4.570 | |||
| Diabetic | |||||
| Yes | 0 (0) | 0 (0) | NA | NA | NA |
| No | 134 (100) | 17 (100) |
TABLE 4.
The odd ratio and score of the characters
| Variables | Odds | ≈Percentage from the total Odds: Smart score |
|---|---|---|
| Abscess | 3.1 | 31%:31 |
| Hairy | 1.9 | 13%: 13 |
| Discharge | 1.6 | 9%: 9 |
| More than 3 sinus opening | 1.5 | 7%: 7 |
| Age less than 25 years | 1.4 | 6%: 6 |
| Male gender | 1.4 | 6%: 6 |
| Deep natal cleft | 1.4 | 6%: 6 |
| Prominently sitting during work | 1.4 | 6%: 6 |
| Previous surgical intervention | 1.3 | 4%: 4 |
| Obesity | 1.1 | 2%: 2 |
| Itching | 1.1 | 2%: 2 |
TABLE 5.
The classes of Smart score.
| Classes | Scores | No. of patients (%) | % Cure | % Recurrence |
|---|---|---|---|---|
| Class 1 | ≤20 | 1155 (32.7%) | 98% | 2% |
| Class 2 | 20–40 | 1447 (41%) | 96% | 4% |
| Class 3 | ≥40 | 927 (26.26%) | 92% | 8% |
4. DISCUSSION
Pilonidal sinus disease (PSD) commonly occurs in the sacrococcygeal area. It is regarded as a distressing disease and a challenge to clinicians owing to; the high morbidity of management methods, high recurrence rates, and several other complications. 8 , 12 This disease is multifactorial, and an abundant number of risk factors have been reported to be associated with its occurrence. 12 , 13 In a study by Cevik et al, it was revealed that most of the affected individuals had spent a minimum of 8 hours a day sitting studying. 7 In accordance with the previous study, students were the second most commonly affected group in the present study.
Finding simple and less complicated techniques has been greatly supported. The alternative options are essential to decrease patient discomfort, limit the chance of recurrence and reduce days off work 5 Surgery is the primary management method, and many techniques have been discussed in the literature. None of them have been reported to be an ideal treatment technique. 8 A Cochrane review was conducted to evaluate the outcomes of open and closed surgical techniques in adults with PSD. Primary closure promoted wound healing more quickly than the open technique, but the recurrence was still high. 14 Surgical site infection following the radical excision can be seen in 24% of the cases. 14 Another study by Braungart et al used excision with primary midline closure and flap to manage PNS in children. They recorded recurrence in 22% of the cases with a high morbidity rate. 11 Wide en‐bloc excision has been proposed to manage PSD, even in those patients that have an acute abscess, but the recurrence rate is up to 20%. 15
Recently, several minimally invasive techniques have been proposed as an alternative to surgical intervention. A number of them are associated with fewer complications, are non‐time consuming, and have low discomfort. The sufficiency of these techniques, especially in decreasing the recurrence rate, is still controversial. 15 , 16 Some studies have reported that the recurrence rate was higher in patients who underwent non‐operative treatment than in those who were managed by surgical techniques. 2 , 8 Cevik et al reported a recurrence rate of 12.9% in conservative treatment of children with PNS. 7 Phenol injection was reported to be associated with 7% to 27% recurrence. 17 Recurrence has been reported to be 12% in Pit‐picking procedures. 6 A radial laser probe has a good outcome, but it needs expensive equipment and may enhance complications, such as abscesses and hematomas. 13 Salih et al performed a non‐operative technique using a sclerosing agent containing henna to manage chronic PNS in 400 patients. The recurrence rate was 0.5% after three trials of mixture injection. 3 In the present study, Salih's preparation was used to treat 3529 patients with sacrococcygeal PNS. The technique was simple and cost‐effective, and it consumed 10 minutes to complete each procedure. The patients could directly return to work after the procedure. These results correlated to the study of Salih et al. 3 In this study, the recurrence rate was generally 4.3%, and most of them (88.7%) occurred after the first injection of the preparation. The recurrence decreased to 0.7% after the fourth trial. This finding was closely related to that of Salih et al, even though the sample size in this study was almost nine times greater than that reported by Salih et al. 3
Multiple factors have been mentioned to enhance recurrence and treatment failure, including the length of the tract, history of drainage, multiple sinuses, swelling, obesity, and family history. 7 , 18 , 19 , 20 , 21 In addition, Onder et al reported that age and gender do not have an impact on recurrence and postoperative complications 22 The current study was contrary to Onder et al, and the chance of recurrence was significantly correlated to age and gender. Other factors like deep natal cleft, swelling, discharge, and being hairy were known to cause recurrence in our study. The swelling had a significant effect on the times of recurrence.
Classification of the PNS is an essential point to consider in management. 8 Beal et al classified the PNS based on presentation, and Irkörücü et al suggested that a classification system should be used for comparing different techniques in the management of PSD. 23 , 24 Recurrence is one of the most common complications of PNS, although there is no classification of patients based on the chances of recurrence. 12 In this study, we classified the patients into three classes (Smart score), and each class was associated with several risk factors of recurrence with different scores. Class I includes those patients that had scores of ≤20, and the chance of recurrence was the lowest. Class III with scores ≥40 was associated with the highest rate of recurrence.
In conclusion, non‐operative methods using a preparation with antimicrobial and sclerosing properties can be an alternative for surgical intervention with a lower risk of recurrence. Classification of patients based on specific criteria can give clinicians and even patients themselves a vision of the chance of recurrence and treatment success.
FUNDING INFORMATION
None.
CONFLICT OF INTEREST STATEMENT
The authors declare that they have no competing interests.
ETHICS STATEMENT
Ethical approval: The study was approved by the Sulaimani University Ethical Committee.
Informed Consent Patients: Written informed consent was obtained from the patient.
ACKNOWLEDGEMENTS
None.
Salih AM, Ahmed MM, Baba HO, et al. Non‐operative management of pilonidal sinus disease; classification and outcome. Int Wound J. 2023;20(9):3639‐3647. doi: 10.1111/iwj.14242
DATA AVAILABILITY STATEMENT
The datasets generated and analyzed during the current study are available from the corresponding author on rea‐sonable request
REFERENCES
- 1. Eid Mond thyo . Barw medical journal, why?! Barw Med J. 2023;1(1):1‐2. doi: 10.58742/bmj.v1i1.10 [DOI] [Google Scholar]
- 2. Foti N, Passannanti D, Libia A, Campanile FC. A minimally invasive approach to pilonidal disease with endoscopic pilonidal sinus treatment (EPSiT): a single‐center case series with long‐term results. Tech Coloproctol. 2021;25(9):1045‐1054. [DOI] [PubMed] [Google Scholar]
- 3. Salih AM, Kakamad FH, Salih RQ, et al. Nonoperative management of pilonidal sinus disease: one more step toward the ideal management therapy—a randomized controlled trial. Surgery. 2018;164(1):66‐70. [DOI] [PubMed] [Google Scholar]
- 4. Arslan S, Karadeniz E, Ozturk G, Aydinli B, Bayraktutan MC, Atamanalp SS. Modified primary closure method for the treatment of pilonidal sinus. Eurasian J Med. 2016;48(2):84‐89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Aksoy HM, Aksoy B, Ozkur E, Calikoglu E. Topical polyphenol treatment of sacrococcygeal pilonidal sinus disease: use of ultrasonography to evaluate response to treatment—clinical case series study. Adv Dermatol Allergol Postȩpy Dermatol Alergol. 2019;36(4):431‐437. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Thompson MR, Senapati A, Kitchen P. Simple day‐case surgery for pilonidal sinus disease. J Br Surg. 2011;98(2):198‐209. [DOI] [PubMed] [Google Scholar]
- 7. Cevik M, Dorterler ME, Abbasoglu L. Is conservative treatment an effective option for pilonidal sinus disease in children? Int Wound J. 2018;15(5):840‐844. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Dag A, Colak T, Turkmenoglu O, Sozutek A, Gundogdu R. Phenol procedure for pilonidal sinus disease and risk factors for treatment failure. Surgery. 2012;151(1):113‐117. [DOI] [PubMed] [Google Scholar]
- 9. Kayaalp C, Olmez A, Aydin C, Piskin T, Kahraman L. Investigation of a one‐time phenol application for pilonidal disease. Med Princ Pract. 2010;19(3):212‐215. [DOI] [PubMed] [Google Scholar]
- 10. Aksoy HM, Aksoy B, Egemen D. Effectiveness of topical use of natural polyphenols for the treatment of sacrococcygeal pilonidal sinus disease: a retrospective study including 192 patients. Eur J Dermatol. 2010;20(4):476‐481. [DOI] [PubMed] [Google Scholar]
- 11. Braungart S, Powis M, Sutcliffe JR, Sugarman ID. Improving outcomes in pilonidal sinus disease. J Pediatr Surg. 2016;51(2):282‐284. [DOI] [PubMed] [Google Scholar]
- 12. Chaffin AE, Dowling SG, Kosyk MS, Bosque BA. Surgical reconstruction of pilonidal sinus disease with concomitant extracellular matrix graft placement: a case series. J Wound Care. 2021;30(Sup7):S28‐S34. [DOI] [PubMed] [Google Scholar]
- 13. Dessily M, Charara F, Ralea S, Allé JL. Pilonidal sinus destruction with a radial laser probe: technique and first Belgian experience. Acta Chir Belg. 2017;117(3):164‐168. [DOI] [PubMed] [Google Scholar]
- 14. Ahmed AK, McCallum I, King PM, Bruce J. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev. 2010;1:CD006213. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Harries RL, Alqallaf A, Torkington J, Harding KG. Management of sacrococcygeal pilonidal sinus disease. Int Wound J. 2019;16(2):370‐378. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Emile SH, Elfeki H, Shalaby M, et al. Endoscopic pilonidal sinus treatment: a systematic review and meta‐analysis. Surg Endosc. 2018;32(9):3754‐3762. [DOI] [PubMed] [Google Scholar]
- 17. Topuz Ö, Sözen S, Tükenmez M, Topuz S, Vurdem ÜE. Crystallized phenol treatment of pilonidal disease improves quality of life. Indian J Surg. 2014;76(1):81‐84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Kaymakcioglu N, Yagci G, Simsek A, et al. Treatment of pilonidal sinus by phenol application and factors affecting the recurrence. Tech Coloproctol. 2005;9(1):21‐24. [DOI] [PubMed] [Google Scholar]
- 19. Milone M, Velotti N, Manigrasso M, Anoldo P, Milone F, De Palma GD. Long‐term follow‐up for pilonidal sinus surgery: a review of literature with metanalysis. Surgeon. 2018;16(5):315‐320. [DOI] [PubMed] [Google Scholar]
- 20. Arda İS, Güney LH, Sevmiş Ş, Hiçsönmez A. High body mass index as a possible risk factor for pilonidal sinus disease in adolescents. World J Surg. 2005;29(4):469‐471. [DOI] [PubMed] [Google Scholar]
- 21. Doll D, Matevossian E, Wietelmann K, Evers T, Kriner M, Petersen S. Family history of pilonidal sinus predisposes to earlier onset of disease and a 50% long‐term recurrence rate. Dis Colon Rectum. 2009;52(9):1610‐1615. [DOI] [PubMed] [Google Scholar]
- 22. Onder A, Girgin S, Kapan M, et al. Pilonidal sinus disease: risk factors for postoperative complications and recurrence. Int Surg. 2012;97(3):224‐229. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Beal EM, Lee MJ, Hind D, Wysocki AP, Yang F, Brown SR. A systematic review of classification systems for pilonidal sinus. Tech Coloproctol. 2019;23(5):435‐443. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Irkörücü O. Management for pilonidal disease: before you compare, use a classification system. Asian J Surg. 2017;39(4):260‐261. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed during the current study are available from the corresponding author on rea‐sonable request