laparoscopic Nissen fundoplication, but to treat the group ofpatients who have GERD symptoms that are not severe enoughto warrant a laparoscopic approach. These different techniquesare a start along that path, but they are along way from defininga satisfactory endoluminal therapy. The data are too sparse, thefollow-up is too short, and studies are not tightly controlled toprovide any direction. Hopefully, over the next few years, thewaters will become less muddy and there will be some indica-tion as to the merits of any of these procedures, so that the pathcan be directed to new and improved techniques.

We look forward to further reports of these different proce-dures so that a clear determination can be made of their results,complications, and place for the endoluminal treatment ofGERD, or the part that they can play in the development of aneffective therapy.

doi:10.1016/j.cursur.2004.12.003

QUESTIONS AND ANSWERS

Questions1. Does the Stretta procedure cause a change in lower esoph-

ageal pressure?

a. Yesb. No

2. The technique for treatment of patients using Enteryx is toinject the polymer:

a. In the submucosal space.b. Into the muscularis.

c. Deep to the muscularis and outside the esophagus

3. The proposed method of action of the Stretta procedure isthought to be:

a. Scarring and collagen deposition at the esophago-gas-tric junction.

b. Neurolysis potentially destroying sensory and motornerve endings reducing the sensitivity to noxiousstimuli.

c. Reducing transient relaxations of LES.d. All of the above.

4. The injection of the polymer in the Enteryx treatment isplaced in:

a. The upper stomach just below the LES.b. At the squamo-columnar junction.c. Just above the LES.

5. What percentage of patients treated with the EndoCinchremain off antisecretory mediations?

a. Approximately 100%b. Approximately 75%c. Approximately 50%d. Approximately 25%

Answers1. b2. a3. d4. b5. d

Alimentary Tract

What’s the Flap Over Pilonidal Disease?Guest Reviewers: W. Lynn Weaver, MD, and Kibwe A.T. Weaver, MD, Department of Surgery,Morehouse School of Medicine, Atlanta, Georgia

SURGICAL TREATMENT OF SACROCOCCYGEALPILONIDAL SINUS WITH THE LIMBERGTRANSPOSITION FLAP.Eryilmaz R, Sahin M, Alimoglu O, Dasiran F. Surgery 2003;134:745-749.

Objective: To analyze the Limberg transposition flap in thetreatment of sacrococcygeal pilonidal sinus.

Design: Prospective, single-arm study of patients treated witha rhomboid excision and Limberg Flap for sacrococcygeal pi-lonidal sinus.

Setting: Vakif Gureba Training Hospital, Istanbul, Turkey.

Participants: 63 patients with sacrococcygeal pilonidal sinustreated between July 1998 and July 2002.

Methods: Patients had follow-up exams at the end of the first,sixth, and twelfth month after surgery.

Results: Sixty-three patients who underwent surgery for sacro-coccygeal pilonidal sinus treated with rhomboid excision andLimberg Flap Closure between July 1998 and July 2002 in theDepartment of General Surgery in Vikif Gureba Training Hos-pital, Istanbul, Turkey. Fifty-nine males (94%) and four fe-males (6%) with an average age of 26 Years (range, 17-46 years).

Twenty-nine patients (46%) had undergone abscess drainagebefore the definitive surgical intervention. Mean duration ofhospital stay was three days (range, 2-7 days).

CURRENT SURGERY • Volume 62/Number 4 • July/August 2005 387

Wound infections developed in three patients (5%) and he-matoma in one patient (2%).

Recurrences were observed in two patients (3%). Fifty-sevenpatients who were available at the end of six months post-operative, thirty-six patients (63%) expressed dissatisfactionwith the cosmetic appearance of the scars.

Conclusions: The authors conclude that low recurrence rates,short hospital stay, and time off from work make excision andrepair with the Limberg Transposition Flap one of the mostappropriate methods for the treatment of sacrococcygeal pi-lonidal sinus. Patients should be informed of the undesirablecosmetic outcome before surgery.

REVIEWER COMMENTS

This article addresses only the use of the Limberg TranspositionFlap in the treatment of sacrococcygeal pilonidal sinus. Theauthors evaluated the procedure based on the following criteria:low recurrence rated, short hospital stay, early return to work,and minimal discomfort during the post-operative period.

Mean hospital stay of three days, mean time off work of 15 days,recurrence in two patients (3%), are acceptable outcomes; how-ever, a 63% expressed dissatisfaction with the cosmetic appear-ance of the scars relegate this procedure too the most compli-cated cases.

MODIFIED BASCOM’S ASYMMETRIC MIDGLUTEALCLEFT CLOSURE TECHNIQUE FOR RECURRENTPILONIDAL DISEASE: EARLY EXPERIENCE IN AMILITARY HOSPITAL.Theodoropoulos GE, Vlahos K, Lazaris AC, Tahteris E,Panoussopoulos D. Dis Colon Rectum. 2003; 46:1286–1291.

Objective: Describe the technical details, analyze the advantages,and present the early results of a Modified Bascom’s AsymmetricMidgluteal Cleft Closure Technique applied in patients with re-current pilonidal disease in a military hospital setting.

Design: Male military service patients with recurrent pilonidaldisease treated with a Modified Bascom’s Asymmetric Midglu-teal Cleft Closure Technique.

Setting: Samos Military Hospital, Samos Island, Greece.

Participants: Twenty-four male patients with recurrent pi-lonidal disease treated from August 2001 to August 2002.

Methods: Twenty-four male patients (median age 22; range,19-25years)withrecurrentpilonidaldiseaseeightmonthstofouryearsafter operation performed elsewhere, prior to military enrollment.

Results: During the study period, twenty-four patients whereoperated on for recurrent pilonidal disease using the ModifiedBascom’s Asymmetric Midgluteal Cleft Closure Technique.Post-operative pain control was satisfactory; no dysethesia orloss of skin sensibility and full return to military duty for allpatients three weeks after surgery. One-year follow-up wasavailable for only nine patients (37.5%).

Conclusions: The Modified Bascom’s Technique is an attractive,safe, easily performed operation with minimal morbidity and can beused as a second-line surgical option for recurrent pilonidal disease.

REVIEWER’S COMMENTS

This article describes the technical details of the modification ofBascom’s Technique of Midgluteal Cleft Closure, in the treat-ment of recurrent pilonidal sinus disease. The lack of long termfollow-up is puzzling since all patients were in the military. The

authors conclude that this procedure is a good second-line sur-gical treatment, but admit the concern over small study size,follow-up, and lack of a control group.

REVIEWER’S SUMMARY

Pilonidal disease also known as pilonidal cyst and pilonidalsinus is an entity that most general surgeons will encounter.Although it has probably been with us since antiquity, the firstmodern description is thought to be by Mayo1 in 1833. Thecoinage of the term pilonidal was by Hodgas2 from the Latinpilus (hair) and nidus (nest). During World War II, the condi-tion took on the very familiarly moniqur “Jeep Drivers Dis-ease”, a term that still exist in today’s military.

The entity was felt to have three basic causative factors;1 Hairmigration,2 a force that causes hair insertion,3 lack of hygiene.3

It is also a disease of youth with burnout at 35-40 years of age.4

It is seen in men more than women by 3-4 to 1, and has a higherincidence in Caucasians than African-Americans and Asians.Pilonidal disease can have recurrent rates as high as 40-50%depending on the treatment, although not life-threatening canbe very debilitating and costly. The military has long had aconcern of this problem, and has been eager to find the idealoperation. One that would be simple, require short or no hos-pitalization, have a low recurrence rate, minimal pain andwound care, and rapid return too normal activity. Soldiers fit all

388 CURRENT SURGERY • Volume 62/Number 4 • July/August 2005

the criteria for developing pilonidal disease, they are young,drive vehicles over rough terrain (Hummers have replacedJeeps), and have difficulty maintaining hygiene while in thefield. A solider that is a casualty by enemy fire or disease isunable to carry out his/her mission.5 To date, the ideal opera-tion has not been found even though less invasive procedureshave gained acceptance.

Initial management of pilonidal sinus infection is usually byER physician who prescribes antibiotics and sitz baths. Patientspresent to a surgeon when the above evolves into an abscess orfails to resolve. The treatment options are multiple, but mostagree that avoidance of excision of the midline is desirable.

As with the majority of surgical problems pilonidal sinusinfections run the gamut from simple to complex, therefore thesurgical treatment can be as simple as I &D to the more com-plex procedures described in these papers.

Patients who present within an initial pilonidal sinus infec-tion should be treated as conservatively as possible i.e. incisionand drainage. The incision should be made lateral to the mid-line pits until pus is encountered. All hairs should be removed.After irrigating the wound it is packed with iodorform gauze. Amidline incision should be avoided due to associated prolongedhealing. The patient is instructed to remove the packing inshower and repack twice a day until the wound has closed.Antibiotics are not normally given unless there is wide spreadcellulitis. This usually can be accomplished on an outpatientbasis. Simple pilonidal sinus infections normally heal withoutrecurrence when attention is paid to hygiene and hair control ofthe sacrococcygeal area. Although, some authors site high re-currence rates for chronic pilonidal diseases there is little followup on simple pilonidal disease which suggest a low recurrencerate and justify a conservative approach.

For those patients who present with extensive disease and/orrecurrence, a more aggressive surgical approach is appropriate,and there are proponents of each of the following techniques:

Excision with or without marsupialization: this involves ex-cising the midline sinus track with the wound edges sutured tothe fibrous portion of the track or left open for healing bysecondary intention.

Excision with primary closure: as stated this involves excisionof all involved tissue with primary closure. The obvious concernof closure is the infected wound and tension in the area regu-lates this procedure to very small chronic non infected sinuses.

Z-plasty: is used to move the natal crease to decrease recur-rence rates. It is used with excision of the midline pits and isonly recommended for the most difficult recurrent wounds.

Lateral incision with excision of midline pits: this is similar tothe technique described above for simple pilonidal infection withthe addition of excising the midline pits and curetting all hair andgranulation tissue. This procedure is preferred by the reviewers.

The first paper reported the use of the Limberg flap for treat-ment of chronic pilonidal sinus infections. The Limberg flap isa transposition flap, commonly known as the rhomboid flapwhich includes skin subcutaneous tissue and fascia of the gluteal

muscle.7,8,9 This is transposed to fill the cleft defect after pi-lonidal sinus excision.

The most common uses of the Limberg Flap and other ad-vancement flaps are in the treatment of sacral decubitus ulcersin the paralyzed and nursing home patient.

The second paper discussed the use of the Modified Bascom’sAsymmetric Midgluteal Cleft Closure Technique more com-monly known as “Bascom’s cleft closure”. This procedure re-quires excising the midline pilonidal sinus with a large ellipticalincision and creations of a flap that moves the wound closureline laterally. The authors modification of the Bascom’s’ origi-nal are minor and modify only the amount of fat mobilize andthe depth of the skin flap.

Many authors have advocated the use of flaps in recurrentpilonidal sinus infection, however new therapies continue to betried for chronic pilonidal sinus infection including closing thewound after packing with gentamicin impregnated collagenfleece.11 The reviewers believe that based on our successful useof vacuum assisted closure (VAC) of some difficult abdominalwounds, that the use of VAC for difficult pilonidal sinuses isalso worthy of consideration.10

The two papers reviewed focus on procedures used in recur-rent pilonidal disease. The first paper had acceptable recurrencerates with a mean 25-month follow-up rate, but it is inappro-priate to ignore the very high dissatisfaction rate with the cos-metic outcome. The extent of the procedure fails to meet thecriteria of simple. The second paper although from a militaryhospital is lacking in quantity, follow-up, and control. There-fore, whether this modification is better than Bascom’s6 originalis unknown.

In conclusion, recurrent pilonidal sinus continues to searchfor its ideal operation but there is little evidence to recommendthe procedures reviewed.

doi:10.1016/j.cursur.2004.11.023

REFERENCES

1. Mayo OH. Observations on injuries and disease of therectum. London: Burgess and Hill; 1833:45-46.

2. Hodges M. Pilonidal sinus. Boston Med Surg J. 1880;103:485-486.

3. Karydakis GE. Easy and successful treatment of pilonidalsinus after explanation of its causative process. Aus & NZJ Surg. 1992;(2):385-389.

4. Cintron JR. Pilonidal disease. Current Surgical Therapy.7ed; 316-322.

5. US Army. (2002, August). The medical company tactics,techniques, and procedures. Field Manual No. 4-02.6 (8-10-1). Department of the Army.

6. Bascom’s J. Repeat pilonidal operations. Am J Surg. 1989;154:118-121.

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7. Arumajua PJ, et al. The rhomboid flap for pilonidal dis-ease. Colorectal Div. 2003;5:218-221.

8. Toyqul K, et al. Long term results of Lumber Flap proce-dures for treatment of pilonidal sinus. Dus Clon Rectum.2003 Nov;46(11):1545-1548.

9. Ay A, Aytekin O, Aytekin A. Interdigitating fasciocutane-ous gluteal V-Y advancement flaps for reconstruction ofsacral defects. Ann Plast Surg. 2003 Jun;50(6):636-8

10. Duybury MS, et al. Use of a vacuum assisted closure devicesin pilonidal disease. J Wound Care. 2003 Oct;12(9):355.

11. Holzer B, et al. Efficacy and tolerance of a new geatamicincollagen fleece (septocoll) after surgical treatment of pi-lonidal sinus. Colorectal Dis. 2003 May;5(3):222-227.

QUESTIONS AND ANSWERSQuestions

1. Contributing factors to pilonidal disease include all but:

a. Hurtismb. Trauma

c. Military Serviced. Race

2. T or F: Recurrence rates after simple I & D of pilonidal sizescan approach 50%.

3. What is the concern for patients after Limberg Flap?

a. Painb. Recurrent sinusc. Persistent Drainaged. Scar

Answers

1. c. Although sometimes called Jeep Drivers disease, beingin the military is not a contributing factor. Hygiene isclosely associated. Trauma (Force) drives hair into thegluteal cleft, and the disease has a higher incidence inCaucasians.

2. T3. d. Sixty-three percent of patients were dissatisfied with the

cosmetic appearance of the incision after Limberg Flap pro-cedure.

Pediatrics

Living on the Edge: Current Concepts in the Management ofCongenital Diaphragmatic HerniaGuest Reviewers: CPT Rebecca McGuigan, MC, USA, and COL Kenneth S. Azarow, MC, USA,Department of Surgery, Madigan Army Medical Center, Tacoma, Washington

CONGENITAL DIAPHRAGMATIC HERNIA IN 120INFANTS TREATED CONSECUTIVELY WITHPERMISSIVE HYPERCAPNEA/SPONTANEOUSRESPIRATION/ELECTIVE REPAIR.Boloker J, Bateman DA, Wung JT, Stolar CJ. J Pediatr Surg.2002;37:357-366.

Objective: To evaluate outcome in a single institution’s experi-ence with permissive hypercapnea/spontaneous respiration/elec-tive repair in infants with congenital diaphragmatic hernia (CDH).

Design: Retrospective review of a single institution’s experi-ence with this management strategy.

Setting: Children’s Hospital of New York.

Participants: From August 1992 through February 2000, allinfants with CDH and (1) respiratory distress requiring me-chanical ventilation, (2) in-born, or (3) transferred preopera-tively within hours of birth are reported. The surgeons used arespiratory care strategy that involved permissive hypercapnea/spontaneous respiration and nitric oxide (NO) or high-fre-quency oscillatory ventilation (HFOV), as appropriate, com-bined with elective repair. Pre-repair extracorporeal membraneoxygenation (ECMO) was used by the surgeons selectively, thatonly included patients without lethal anomalies and with evi-dence of adequate lung parenchyma (ability to maintain pre-ductal oxygen saturation �85% for 1 hour). Arterial blood gasvalues and concomitant ventilator support were recorded. Sur-gical repair was delayed until ventilator requirements and pre-ductal–postductal gradients had decreased and echocardiogramdemonstrated minimal pulmonary hypertension. Outcome

The opinions and assertions contained herein are the private views of the authors and arenot to be construed as the official policy or position of the United States Government, theDepartment of Defense, or the Department of the Army.

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