Hernia DOI 10.1007/s10029-016-1567-6

COMMENT

Comment to ‘‘An umbilical surprise: a collective review on umbilical pilonidal sinus’’. J. B. Ponten, J. E. H. Ponten, M. D. P. Luyer, S. W. Nienhuijs M. Kaplan1,3

•

F. C ¸ . Kaplan2

Received: 1 November 2016 / Accepted: 17 December 2016 Ó Springer-Verlag France 2016

Dear Editor, We have read the review article published by Ponten et al. [1] with great interest. This presentation of 3 cases of umbilical pilonidal sinus (UPS) includes perhaps the oldest male and female documented patients (patient B and C) until now. Although we agree with most points, there are some additions we wish to suggest. First, the authors claimed the absence of a prospective randomized study regarding UPS. We find this inaccurate, as we have recently published a prospective, randomized study comparing conservative (CT) and surgical treatments (ST) for UPS, which was first released as a protocol in August 2012 on http://www.clinicaltrials.gov and published online in December 2015 on PubMed [2]. Second, the authors concluded that in a larger study, only 3 of the 134 patients received umbilectomy because of failed CT. The authors created a misperception that all other patients responded well to one or several attempts of

This comment refers to the article available at doi:10.1007/s10029-016-1506-6. & M. Kaplan [email protected] 1

Department of General Surgery, Bahcesehir University (BAU) School of Medicine, Istanbul, Turkey

2

Family Physician, 25-Aralik Family Health Center, Gaziantep, Turkey

3

Department of General Surgery, Medical Park Hospital, Mucahitler mah. 52063 sk., No:2, Sehitkamil, 27090 Gaziantep, Turkey

CT with no recurrences during long-term follow-up ranging from 9 months to 6.5 years. This is incorrect. In the mentioned study, the reported follow-up healing rate was 74% for 1 month, which dramatically fell to 34.32% for long-term patients [3]. The prognosis of the remaining patients (65.68%) is unknown. Unfortunately, in many cited publications, there are similar problems that make the results questionable, as already stated. Third, we doubt the authors’ conclusion that surgery can only be considered when CT fails. We have showed that the initial response could not be achieved in 21.4% of patients with CT. Additionally, 28% of patients recurred after more than one attempt at CT; eventually, 32% of them did not resolve in at least 2 years of follow-up. However, ST (described in detail) had better results, with a 98% recurrence-free rate for the first attempt and 100% cure rate after the second attempt (only 1 patient) during the same follow-up period [2]. Consequently, contrary to the authors’ opinion, we believe that CT can be considered only when patient refuses surgery. Since etiologic factors cannot be eliminated permanently, recurrence seems to be more likely to occur after CT. Finally, because patients are now paying greater attention to their cosmetic appearance, surgeons have also engaged with this trend. Because the navel is a component of beauty for many people, the preference of surgeons towards CT seems reasonable, even when better permanent results could be obtained with ST. We have answered this query by describing an umbilicus preserving surgical technique that protects, in most cases at least, the outer third of the navel and its natural appearance after healing. This improves the cosmetic perception of the patient and the level of satisfaction (Fig. 1). In conclusion, we have more reliable data regarding the treatment options and its consequences. Therefore, we

123

Hernia

Fig. 1 Postoperative appearance of the umbilicus in a young woman. a Overall appearance of the anterior abdominal wall and umbilicus with acceptable cosmetic result. b Lifted umbilical cleft and the scar

after surgical treatment is shown (Reprinted from Kaplan et al. [2], Copyright (2016), with permission from Elsevier)

believe that it is important to inform patients about the most recent available evidence and reach a joint decision with them on treatment options.

Informed consent Written informed consent has been obtained from the patients authorizing the publication of the article.

Acknowledgements The authors wish to thank Zeynep Sude Kaplan for her contribution in the technical artwork of the figure. Compliance with ethical standards Conflict of interest The authors declare no conflict of interest. Ethical approval This study does not require ethics committee approval. Human and animal rights All procedures performed in this study involving human participants were in accordance with the ethical standards of Bahcesehir University and Medical Park Hospital which the study conducted. This article does not contain any studies with animals performed by any of the authors.

123

References 1. Ponten JB, Ponten JEH, Luyer MDP, Nienhuijs SW (2016) An umbilical surprise: a collective review on umbilical pilonidal sinus. Hernia 20:497–504 2. Kaplan M, Ozcan O, Kaplan F, Yalcin H, Salman B (2016) Conservative vs surgical interventions for umbilical pilonidal sinus: a multicenter, double-blind, prospective, randomized clinical trial. J Am Coll Surg 222:878–889 3. Kareem T (2013) Outcomes of conservative treatment of 134 cases of umbilical pilonidal sinus. World J Surg 37:313–317