Magnetic resonance imaging of pilonidal sinus disease: interobserver agreement and practical MRI reporting tips.

OBJECTIVE: To evaluate the interobserver agreement for the features of natal cleft pilonidal sinus disease (PSD) on magnetic resonance imaging (MRI) and propose a standardized checklist for reporting PSD on MRI. MATERIALS AND METHODS: Forty MRI studies of 39 discrete patients with PSD were retrospectively evaluated by five independent radiologists using a standardized checklist. Fleiss' Kappa (k) coefficients of agreement were used to test the agreement between categorical variables. The MRI features of the natal cleft sepsis associated with PSD were classified into four main categories: morphology, branching and extensions, external skin openings, and the relationship of the PSD to the coccyx. A survey was created and disseminated online among general surgeons who treat patients with PSD to assess the relevance of the MRI features proposed in the standardized checklist. RESULTS: The overall agreement regarding the identification of morphology of the natal cleft sepsis was moderate (k = 0.59). Lateral and caudal extensions interobserver agreement was substantial (k = 0.64 and 0.71, respectively). However, the overall agreement regarding the individual parts of anal sphincter involved was moderate (k = 0.47). Substantial interobserver agreement was found in assessing the proximity of the PSD to the coccyx (k = 0.62). CONCLUSION: Preoperative MRI can delineate the extensions and branching of PSD with substantial agreement. MRI is superior in describing the deep extensions of PSD with better reliability than assessing the number and locations of the external openings. Expert consensus agreement is needed to establish the MRI features necessary for optimal reporting of PSD. CLINICAL RELEVANCE STATEMENT: MRI can offer valuable information about the extent of sepsis associated with pilonidal sinus disease, particularly in cases with involvement of critical anatomical structures such as the coccyx and anal triangle. MRI can potentially contribute to more accurate patient stratification and surgical planning. KEY POINTS: • The interobserver agreement for assessing PSD's lateral and caudal extension on MRI is substantial. • MRI can describe deep extensions and branching of PSD with superior reliability than assessing the number and site of external openings. • Reporting the relationship between natal cleft sepsis in PSD and the anal region may influence the surgical approach and postoperative healing.

Anal fistula and pilonidal sinus disease coexisting simultaneously: An audit in a cohort of 1284 patients.

Fistula-in-ano and pilonidal disease are not known to occur together. In a retrospective study, all patients having fistula-pilonidal disease coexisting simultaneously were included. Out of 1284 patients, 933 were operated (fistula-in-ano, 849; pilonidal disease, 77; and coexisting fistula-pilonidal, 7). A total of 351 patients did not undergo any surgery (two patients had coexisting fistula-pilonidal). Thus, a total of nine patients having coexisting fistula-pilonidal sinus were included in the study (mean age 35.8 ± 19.9 years, M/F 7/2). pIn 6/9 patients, the pilonidal tract was communicating with fistula-in-ano, and in 3/9 patients, they were not communicating/connected. The connection could be established preoperatively with the help of MRI. In all patients with communicating fistula-pilonidal sinus (n=6), the fistula was posterior. 6/9 patients had recurrent fistula and all (9/9) had multiple tracts. The fistula was high and complex in 8/9 patients (grade IV-7, grade V-1). 4/9 patients tested positive for tuberculosis while one patient was suffering from hidradenitis suppurativa. The latter improved on medical treatment. One patient did not agree for surgery and seven were operated. The disease healed in four patients, the disease did not heal in one patient, and two patients were in the convalescent stage. Anal fistula and pilonidal disease can coexist in a same patient and can even be connected. Such diseases are more complex and have a higher incidence of associated diseases like tuberculosis. Magnetic resonance imaging plays a pivotal role in diagnosis. If the connection is missed, the disease treatment becomes difficult.

Sonographic Comparison of Morphologic Characteristics Between Pilonidal Cysts and Hidradenitis Suppurativa.

OBJECTIVES: To compare the sonographic characteristics of pilonidal cysts and hidradenitis suppurativa. METHODS: A retrospective study of sonographic examinations was performed on 2 groups: 1 with pilonidal cysts and the other with hidradenitis suppurativa. The sonographic characteristics of the pilonidal cyst and hidradenitis suppurativa groups were analyzed, compared, and correlated, including an analysis of the histologic findings. For the pilonidal cyst group, the distribution, morphologic characteristics, location, shape, diameter, axis, vascularity, and scarring were also described. Statistical analyses included Spearman, Wilcoxon, Kruskall-Wallis, χ2 , and Fisher tests. RESULTS: The sonographic examinations of 84 patients were reviewed: 43 with pilonidal cysts and 41 with hidradenitis suppurativa. The comparison of the morphologic characteristics of the key lesions between the pilonidal cyst and hidradenitis suppurativa groups showed no statistically significant differences (P < .05). Both groups had similar dermal and hypodermal saclike and bandlike structures that communicated with the widened base of the hair follicles. Retained fragments of hair tracts within the lesions were sonographically detected in both pilonidal cysts (100%) and hidradenitis suppurativa (83%) and also found on histologic specimens; however, the density of hair tracts per structure was higher in pilonidal cysts. Sonographic signs of scarring were absent in 63% of pilonidal cysts. Only 2% of pilonidal cysts showed communicating bandlike structures. CONCLUSIONS: Key lesions of pilonidal cysts and hidradenitis suppurativa have similar sonographic morphologic characteristics, which suggests that a pilonidal cyst may be a variant or localized form of hidradenitis suppurativa. The retained fragments of hair tracts frequently detected in both entities may be caused by ectopic production of hair and not by embedding. Common therapeutic strategies and research can be designed for both entities.

Sequential, ultrasound-guided, minimally invasive pit-picking procedure with Nd:YAG laser epilation treatment for pilonidal disease.

<b><br>Aim:</b> The aim of this retrospective study was to evaluate our treatment for pilonidal disease in adolescent patients, which uses ultrasonography, minimally invasive pit-picking, and Nd:YAG laser therapy.</br> <b><br>Material and methods:</b> We included 52 of 147 patients treated between June 2017 and December 2020. The patients underwent pit-picking procedures and 6-10 Nd:YAG treatments. The remnants of the cysts were removed by laser therapy, which provided easy epilation. Each patient underwent multiple ultrasound examinations during the therapy to uncover any potential newly formed asymptomatic sinuses. When such issues were identified, the pit-picking procedure was repeated on those sinuses.</br> <b><br>Results:</b> A total of 52 patients were included in this study with a 1-year follow-up following the procedure. There were 49 symptom-free patients (96%). One patient underwent surgery in another hospital because of a recurrence and 1 had a pilonidal disease relapse (4%). In the follow-up period, asymptomatic cysts were found in 2 other patients by ultrasound examination. They were all treated with a pit-picking procedure in the outpatient department with good results.</br> <b><br>Conclusions:</b> Combining sequentially repeated pit-picking procedures and Nd:YAG laser therapy is an effective treatment method for adolescent pilonidal disease. Simultaneous Nd:YAG laser therapy enables efficacious epilation of the intergluteal cleft. Repeatable ultrasonography examinations allow for early diagnosis of possible pilonidal sinus relapse.</br>.

Preoperative advantages of HF sonography of pilonidal sinus.

AIM AND METHODS: Pilonidal sinus is a not infrequent disease, probably due to a disontogenetic origin. Histologically, there is a pseudocystic formation in the subcutaneous adipose tissue, containing some hair bulbs. It usually presents a recurring inflammatory course. The pathologic formation does not normally have thick wall, being made up of thin epidermal epithelium, without internal vascularisation and with frequent subcutaneous fistulae. Even though the clinical diagnosis is rather easy, surgery may prove, on the contrary, a demanding task, with a high incidence of recurrence and complications. An adequate knowledge of the condition and its development, with a precise definition of the margins of the lesions, may simplify the surgery, reducing the chance of recurrence or complications. The use of echography in the diagnosis of this disease, in our cohort of 72 patients, has always provided valuable information. In particular, 13 and 18 MHz linear probes and 20 MHz mechanical array have been used, and the latter in particular for the evaluation of fistolous cavities/passageways under the skin. Results. In all our cases, echography has demonstrated pseudocystic formations, without real walls, with fairly high levels of internal echoes, compared to the hair follicles, or, more rarely, true macrocalcifications with one or more cavities/passageways near the skin, without internal vascularisation, according to the histological findings. Echographic data are rapidly obtained, and can prove useful for surgeons for a a better management of patients. Conclusion. We consider diagnostic echography, using high frequency probes, useful for the anatomical definition of this disease, as well as to enable better surgical management.

Prognostic factors of flap techniques for pilonidal disease based on magnetic resonance imaging and clinical parameters.

BACKGROUND: Postoperative complications and recurrence are major diffficulties in the flap techniques for the treatment of pilonidal sinus (PS), however, the risk factors remain unclear. While magnetic resonance imaging (MRI) offers the highest soft tissue resolution, few studies have applied MRI to investigate the basic parameters of PS. METHODS: A total of 100 patients receiving Limberg flap (LF) or Karydakis flap (KF) surgery at the Sixth Affiliated Hospital of Sun Yat-Sen University were retrospectively analyzed, and the median follow-up period was 42 (range, 20-90) months. We performed a multivariate logistic analysis on the clinicopathological parameters and MRI data to identify risk factors for complications and recurrence. RESULTS: The basic parameters of PS were obtained by MRI analysis. The multivariate analysis revealed a large longitudinal sinus diameter (OR = 1.020, 95%CI = 1.000-1.041) and sacrococcygeal dermal thickness (OR = 1.680, 95%CI = 1.142-2.472) to be independent risk factors for early complications. Meanwhile, a small sacrococcygeal fat thickness (OR = 0.923, 95%CI = 0.864-0.987) and a high BMI (OR = 1.291, 95%CI = 1.067-1.563) are independent risk factors for late complications and recurrence, respectively. CONCLUSION: We used MRI to measure the basic parameters of PS accurately, including size, volume, location and some key points of the surrounding tissues, and identified, besides the selection of surgical approach, some specific basic parameters of PS might be the risk factors for complications and recurrence after flap techniques.

US Guided Si.La.D. A new technique for minimally invasive pilonidal disease treatment, using ultrasound guided laser ablation.

Background: The destruction of the pilonidal sinus with a radial laser probe has been suggested as a safe procedure with good results and low morbidity. Nevertheless, the drawbacks of this technique are: a blind technique, if the sinus has some ramifications or a non-linear development, we cannot be sure for their destruction.Methods: 17 patients (12 men, 5 women) were operated with US guided laser destruction - US guided Si.La.D. Laser destruction of the pathological tissue (cavity, sinus) was performed using a 400 µ radial optical fiber, connected and locked to a radiopaque biopsy needle 14 G, using a 12 MHz linear probe, to introduce and real-time echo guide the fiber in order to achieve laser ablation with 120-140 J /cm of pathological tissueResults: No significant complications were recorded.Conclusion: Real-time echo guided laser ablation of pilonidal sinus and cavities proved to be safe and efficient, providing controlled emission of laser energy only to the pathological tissue, increasing the accuracy of identify the right track to deliver energy, decreasing the risk of traumatic progression of surgical instrument into healthy subcutaneous tissue, accidental progression of the disease and missing in the same time tracts that need to be ablate.

Pilonidal sinus involving the breast in a man: A case report and literature review.

RATIONALE: Pilonidal sinus disease (PSD) involving the breast is extremely rare and has not been described in man. PATIENT CONCERNS: This current case report presents a case of a pilonidal cyst in a 46-year-old man which was surgically treated. He had intermittent pain in his left breast for 2 months and came for local rupture and discharge for 1 week. DIAGNOSIS: The initial diagnosis is male mastitis, on the basis of the histological features of H&E-stained specimens and immunohistochemistry of the resected lump, this case was diagnosed as PSD. INTERVENTIONS: The patient underwent "enlarged resection of the left breast lesion" under local anesthesia. OUTCOMES: The patient's surgical area healed well, without any signs of recurrence. CONCLUSION: PSD involving the breast is extremely rare in man, with no typically clinical manifestations, and could be easily ignored. This disease requires great attentions from clinicians.

Clinical usefulness of variable-frequency ultrasound in localized lesions of the skin.

BACKGROUND: High variable-frequency ultrasound is a recently available technique capable of clearly defining skin layers and deeper structures that also provides local perfusion patterns obtained in real time. OBJECTIVES: The aim of the study was to assess the performance of variable-frequency ultrasound in the evaluation of skin lesions. METHODS: We performed a retrospective study of 4338 skin ultrasound examinations in predominantly localized skin lesions, and in a group of 130 healthy controls. We determined ultrasound sensitivity, specificity, and statistical level of certainty, and compared ultrasound diagnoses with clinical diagnoses. RESULTS: Referring diagnosis was correct in 73% of the lesions, and addition of ultrasound increased correctness to 97% (P < .001 for the difference). Ultrasound overall sensitivity was 99%, specificity was 100%, and statistical diagnostic certainty was 99% LIMITATIONS: Ultrasound in its current version cannot detect lesions that are epidermal only or that measure less than 0.1 mm in depth. CONCLUSIONS: Ultrasound is a reliable adjuvant for the accurate and precise diagnosis of skin lesions.

Dermoid sinus in the perirectal fossa of a Siamese cat with involvement of the vaginal wall.

A 2.5-year-old spayed female Siamese cat was presented with a recurrent exudative wound in the right perirectal fossa. Clinical examination at presentation revealed a 1 cm long open wound with purulent discharge in the right perirectal fossa but was otherwise unremarkable. A computed tomography contrast-enhanced study showed a tracking sinus which could be traced from the right dorsolateral perianal region right up to the level of the vagina. Surgical exploration was performed from the perirectal region. The intermuscular sinus tract, which formed a cystic structure and connected to the vaginal wall, was en bloc excised. Histopathological examination confirmed the diagnosis of a dermoid sinus in the perirectal fossa with vaginal infiltration. To the authors' knowledge, this is the first case report in the veterinary literature of the successful surgical management of a dermoid sinus in the perianal region connected to the vaginal wall in a cat.

MRI evaluation of anal and perianal diseases.

Anal and perianal region is a commonly affected area in the course of several inflammatory, infectious, and neoplastic diseases. Several imaging modalities may be used in imaging evaluation of this area and magnetic resonance imaging (MRI) emerges as the imaging modality of choice due to its superb soft tissue resolution. MRI is not only useful for initial detection of anal/perianal pathologies but also in the follow-up of these disorders. In this article, we aimed to illustrate MRI findings of several diseases affecting this area including perianal fistula as well as anal fissure, hypertrophic myopathy of internal anal sphincter, hidradenitis suppurativa, pilonidal sinus, rectovaginal/anovaginal fistula and anal canal carcinoma. We think that this article will serve to familiarize the imaging specialists to the MRI findings of these diseases.

Treatment of recurrent pilonidal cysts with nd-YAG laser: report of our experience.

PURPOSE: Surgical treatment remains the first-line therapy of pilonidal cyst but is associated with high levels of postoperative pain, adverse events and a recurrence rate of 30%. We report our experience with laser hair removal using the Nd-YAG laser for the treatment of pilonidal cyst. MATERIALS AND METHODS: Ten patients affected by pilonidal cyst were examined and treated from October 2011 to November 2016. Treatments were carried out using the Nd-YAG laser (Deka M.E.L.A, Calenzano, Florence, Italy) at a wavelength of 1064 nm at 30-day interval. RESULTS: Nine patients were asymptomatic after the second treatment, while in one case the symptom disappeared after the fourth session. After 4-8 treatments, the pilonidal cyst had clinically disappeared and patients subjectively felt healed. In all cases, the soft-tissue ultrasounds performed before the first and after the last session showed the disappearance of the pilonidal cyst. In the follow-up, all the patients remained asymptomatic without any disease recurrence. CONCLUSIONS: Nd-YAG laser is an effective treatment for pilonidal cysts, providing excellent results with quick healing and no risk of serious adverse side-effects. It could be a very attractive alternative to open surgery, enabling patients to prevent the frequent and severe postoperative issues associated with surgery.

F-18 FDG imaging of an asymptomatic sacrococcygeal pilonidal sinus in a patient with malignant disease.

This case illustrates a pitfall associated with F-18 FDG imaging. We present the images of a 57-year-old woman with non-Hodgkin's lymphoma that shows intense accumulation of F-18 FDG in a sacrococcygeal pilonidal sinus that could indicate a lymphomatous involvement from a primary disease. MRI showed a well-defined sinus tract from skin to the sacrococcygeal region corresponding to the F-18 FDG uptake. She did not have any symptoms of a sacrococcygeal pilonidal sinus such as discharge, swelling or pain. There was no visible opening of the sinus tract on the skin. Pilonidal sinus is commonly a hair-containing sinus or abscess in the sacrococcygeal area. Hair acts as a foreign body causing an inflammatory reaction.

Pilonidal sinus of the nose.

We report an unusual case of a pilonidal sinus appearing on the nose. From the clinical and pathological findings, we find it difficult to believe that it is an acquired condition. En bloc excision by an external rhinoplasty approach was performed with no evidence of any recurrence.

[Sacrococcygeal teratoma in adults]. / Tératome sacro-coccygien de l'adulte.

This report describes a case of sacrococcygeal teratoma, a rare pathology belonging to the group of presacral tumors. Its clinical presentation is very variable. In this case, the tumor presented as a pilonidal cyst, which is an atypical form. The teratoma was associated with a spinal malformation, described in 25% of all cases. It was treated by "en bloc" resection with sacrectomy.