World J. Surg. 29, 469–471 (2005) DOI: 10.1007/s00268-004-7533-y

High Body Mass Index as a Possible Risk Factor for Pilonidal Sinus Disease in Adolescents _ ¨nmez1 Irfan Serdar Arda, M.D.,1 L. Hakan Gu ¨ney,1 Sinasi Sevmis¸,2 Akgu ¨n Hic¸so 1 Department of Pediatiric Surgery, Baskent University Faculty of Medicine, Fevzi C ¸ akmak caddesi 10. Sokak No:45, 06490 Bahc¸elievler Ankara, Turkey 2 Department of General Surgery, Baskent University Faculty of Medicine, Fevzi C ¸akmak caddesi 10. Sokak No:45, 06490 Bahc¸elievler Ankara, Turkey

Published Online: March 22, 2005 Abstract. Pilonidal sinus disease (PSD) is common in adults, but it may also develop in adolescents. The intergluteal groove is a deep moist area in which broken hairs and foreign bodies can collect, often leading to infection. Only a few papers have been published considering PSD in children. For the present study, we retrospectively examined the data of operated patients with PSD. From that review, it appears that high body mass index (BMI) might be a risk factor for the development of PSD and its complications in older children. Fourteen young patients (12 males, 2 females, 12–18 years of age) underwent surgery for PSD. According to the BMI-for-age, eight of these patients (57, 1%) were overweight or obese. Five of them (35.8%) developed mild to moderate postoperative complications. Symptoms recurred in one patient (7.1%) whose BMI was considered as overweight. In patients with normal weight no early or late complications developed. Our findings suggest that high BMI in adolescents is a significant risk factor in the development of both symptoms and complications of PSD after surgical treatment.

The term sacrococcygeal pilonidal sinus describes a midline opening (or series of openings) in the natal cleft. Pilonidal sinus disease (PSD), which is a commonly hair-containing sinus or abscess in the sacrococcygeal area is not complex, but it can be an irritating inconvenience and often leads to complications. Adults are most often affected, but young people may also develop symptoms and related complications [1]. Because the intergluteal groove is deep and moist, and particularly so in overweight individuals, increased weight has been identified as a risk factor for the development of PSD [2, 3]. These features make the skin in the area especially vulnerable to penetration by hair or foreign bodies, which cause irritation and promote local infection [4]. Body mass index percentile (BMIP) is used to assess underweight and overweight. For children, the charts of BMIP for age are used [5]. The English literature contains only a few reports of PSD in childhood [1, 6–8]. Here we present a series of 14 adolescents with PS, and underline the

effect that excessively high BMIP has on the development of symptoms and postoperative complications. Patients and Methods Between January 2000 and January 2003, we operated on 14 young patients (12 to 18 years of age, including 12 males (mean age: 15.7 years) and 2 females (mean age: 13.5 years). The previous history of patients did not indicate any condition related to obesity such as diabetes. The patient complaints at presentation, body weight and postoperative results in each case were retrospectively investigated. Body mass index was assess as an objective indicator to define the patientsÕ status as overweight or obese in our study [5]. A BMI Web calculator was used for this purpose: http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm. Values below 18.5, those between 18.6 and 24.9, those between 25.0 and 29.9, and those that were 30.0 and above were considered as underweight, normal, overweight, and obese, respectively. Second-generation cephalosporins were prescribed in patients with purulent discharge at admission for at least 10 days. The night before the surgery, each case was given antibiotics (cephtriaxone, 2 G, i.v.), and the affected area was cleansed and shaved to provide a clean operative site. The surgical method consisted of en bloc excision of the sinus and surrounding healthy tissue down to the level of the presacral fascia with an elliptical incision, mobilization of the flap to the sacrococcygeal fascia, and primary closure. The excision was done with cauterization without using temporary packing. The wound was drained by a narrow Penrose drain for one day. All patients were hospitalized for 2 days with the area immobilized to promote good initial healing. Oral cefuroxime (500 mg/day) was given for 7 days postoperatively. The patients were advised to perform local cleansing and shaving for 2 months after the surgery. Results

_ Correspondence to: Irfan Serdar Arda, M.D., e-mail: baskent-ank.edu.tr

serdara@

The complaints at presentation for this series of 14 adolescents were as follows: purulent discharge (n = 12), presacral pain

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Table 1. The patientsÕ body mass indices (BMI). Patient No

Age (yr)

Sex

Weight (kg)

Height (cm)

BMI (kg/m2)

Result

1 2 3 4 5 6 7 8 9 10 11 12 13 14 Means

16 16 12 15 15 16 17 18 15 16 14 13 16 17 15.4

M M M M M M M M M M F F M M

77 78 55 90 95 76 71 98 60 77 90 65 61 83 76.9

180 175 140 180 171 170 171 197 172 180 170 162ss 167 182 172.6

23.8 255 28.1 27.8 32.5 26.3 24.3 25.3 20.3 23.8 31.1 24.8 21.9 25.1 25.8

Normal range Overweight Overweight Overweight Obese Overweight Normal range Overweight Normal range Normal range Obese Normal range Normal range Overweight

(n = 5), itching (n = 5), and bloody discharge (n = 2). One patient had three sinuses, two patients had two sinuses, and 11 patients had only one sinus. The skin surrounding the sinuses contained significant hair coverage in all patients except two females. One patient with an infected sinus was treated preoperatively with simple drainage and antibiotics. Another patient had undergone previous excision and had developed recurrence. The BMIs in the series are listed in Table 1. According to the BMIfor-age six (42.9%), six (42.9%), and two (14.2%) patients were considered normal, overweight, obese, respectively. In four of six normal weight patients (Patients 1, 7, 10, and 12) values were very close to the upper limit. The follow-up period ranged from 6 to 36 months (mean; 19.8 months). Five of the patients (35.8%, Patients 4, 5, 6, 12, and 14) developed mild wound infection and superficial incisional dehiscence postoperatively. The BMI results indicated obesity for one and overweight in the other four of these individuals. These five patients were treated on an outpatient basis with daily wound dressings and antibiotics. All the wounds closed spontaneously. One patient (7.1%, Patient 2) developed recurrence 3 months post-surgery, and the BMI in this case was considered as overweight. Discussion Pilonidal sinus disease was first described by Hodges in 1880 [9]. The pathology is diagnosed by the finding of a characteristic epithelial track situated in the skin of the natal cleft, generally containing hair, hence the name pilonidal, from the Latin, meaning literally ‘‘nest of hairs.’’ Pilonidal sinus is uncommon in childhood, with a reported rate of 2.63 cases per 1000 children [1]. A family history has been found in 38% of these affected [10]. In a recent study by Serour et al., the mean age of the pediatric patients with PSD was 16.3 years, and males were predominant. The affected girls were younger than the boys, likely because of the earlier onset of puberty in females [6]. Sex hormones first produced at puberty are known to affect the pilosebaceous glands, which coincides with the earliest onset of pilonidal disease [11]. Although congenital theories that dominated in the first 70 years of the literature suggest that pilonidal sinuses are vestigial structures, cystic remnants of the medullary canal or the result of dermal inclusions caused by faulty development of the med-

ian coccygeal raphe, it has since been established that PSD is an acquired condition involving midline pits in the natal cleft. Pilonidal sinus is first characterized by visible pits in the midline that may have the microscopic appearance of enlarged hair follicles. The enlargement is considered to occur as a result of stretching of the follicular openings caused by the weight of the buttocks being pulled by gravity, particularly in overweight people. If the force applied reaches a critical level, the base of the follicle ruptures. Additionally, friction between the buttocks is also responsible for sucking keratin and hair into the distended follicles, which leads to infection and the resulting abscess of the follicle. Hair acts as a foreign body causing an inflammatory reaction and may lead to prolonged inflammation and the development of chronic PSD [6, 12, 13]. The source of hair can be either the natal cleft itself in hirsute individuals, or hair from the head or back that falls down inside clothes into the natal cleft. All these factors prevent spontaneous recovery, and after surgical treatment they may delay healing and facilitate recurrence [14]. As noted above, obesity has been suspected as a risk factor for the development of PSD in adults [2, 3]. To our knowledge, no study has investigated the relation between body weight and the development of PSD in adolescent patients. Body mass index is used to assess the status of underweight and overweight. For children, BMI, also referred to as BMI-for-age, is gender and age specific. Thus BMI-for-age is plotted on gender-specific growth charts, which are used for children and teens between 2 and 20 years of age [5]. In the 14 cases we studied, the BMIs of eight patients (57.1%) were considered overweight and obese. In addition, four of six normal weight patientsÕ values were just below the upper limit of normal. Together, these findings are evidence that high BMI is a significant risk factor for the development of PSD in adolescents. Postoperative recurrence of PSD occurs in up to half of the patients, regardless of the surgical technique used [15]. In one study, the operating time, mean length of hospital stay, and complications encountered postoperatively have been reported to be greater in obese patients than in nonobese ones [3]. In our series, there was only one case of PSD recurrence, and this patientÕs BMI was considered as overweight. Five other patients developed wound infection and dehiscence; the BMI was considered obese in one and overweight in the other four patients. These results suggest that high BMI is also a risk factor for the

Arda et al.: Body Mass Index and Pilonidal Sinus

development of early and late postoperative complications in adolescents with PSD. In our experience, we have found that it is difficult to flatten the natal cleft for surgery and that local postoperative skin care in obese adolescents is difficult because of the deep intergluteal groove that results from excess fat tissue. We believe that this was one of the the main factors in recurrence and post-surgical complications in our patients. Because of this condition, we strongly recommend a dietary regimen before the operation in these patients. There are only 14 patients in this series, but the rarity of PSD in children, combined with our findings, suggest that high BMI in adolescents is a significant risk factor in the development of both initial symptoms and complications after surgical treatment of PSD. References 1. Yucesan S, Dindar H, Olcay I, et al. Prevalence of congenital abnormalities in Turkish school children. Eur. J. Epidemiol. 1993;9:373–380 2. C¸ubukc¸u A, Go¨nu¨llu¨ NN, Paksoy M, et al. The role of obesity on the recurrence of pilonidal sinus disease in patients, who were treated by excision. Int. J. Colorectal Dis. 2000;15:173–175 3. Sakr M, El-Hammadi H, Moussa M, et al. The effect of obesity on the results of Karydakis technique for the management of chronic pilonidal sinus. Int. J. Colorectal Dis. 2003;18:36–39

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