RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS (in block letters) / Dr. RICHA MISRA
D/o Mr. U.P. MISRA
E-Block, Flat No. 12, Vibgyor Towers, New Town, Rajarhat Kolkata 700059
2. / NAME OF THE INSTITUTION / J.J.M. MEDICAL COLLEGE,
DAVANGERE-577004,
KARNATAKA.
3. / COURSE OF STUDY & SUBJECT / POSTGRADUATE
M.S. IN GENERAL SURGERY
4. / DATE OF ADMISSION TO COURSE / 01-06-2012
5. / TITLE OF THE TOPIC / “PROSPECTIVE STUDY OF THE CLINICAL MANAGEMENT OF PILONIDAL SINUS”
6. / BRIEF RESUME OF THE INTENDED WORK:
6.1 Need for the study:
Pilonidal sinus is a cavity in the subcutaneous tissue which is lined by granulation tissue contains hair and communicates with the surface by a track line usually by squamous epithelium continuous with the epidermis. Pilonidal sinus can be acute chronic and recurrent. It appears to have a higher frequency in males (male/female ratio 3–4: 1).It is associated with indolent discharge, malodorous smell, pain.
Management of pilonidal sinus can be conservative or surgical depending upon site and type of abscess. Conservative nonsurgical management (including phenol application, cryosurgery, and shaving). Simple infections can be treated with antibiotic coverage as well as incision and drainage on opd basis.When the disease is confined to the midline excision and layin with primary closure and suction drainage is treatment of choice. In case of chronic and recurrent various surgical modalities are proposed like unroofing and curettage, Bascom’s procedure, classical limber flap, modified limber flap, Karydakis.
The surgical management of sacrococcygeal pilonidal sinus is still a matter of discussion. Therapy ranges from complete wide excision with or without closure of the wound to excochleation of the sinus with a brush. Except for difficult recurrent pilonidal sinus most widely used methods for treatment are
1. Excision with lay open and secondary healing of wound.
2. Excision with primary suture.
Management of pilonidal sinus is controversial and frequently unsatisfactory with multiple therapeutic approaches described in the literature.no method was found to satisfy all requirements like no need for hospital admission, minimal patient inconvenience, quick healing and low recurrence rate. Excision with closure, injection with scelorosing agent, destruction of tract, irradiation, various flaps and definitive graft treatment has been proposed.
The ideal operation for pilonidal sinus disease should be simple, require short or no hospitalization, and have a low recurrence rate. There should be minimal pain and wound care, rapid return to normal activity, and finally the treatment should be cost effective. The need for the study is to find the approach keeping above mentioned factors in the mind.
6.2 Review of literature :
Ø  Pilonidal sinus was first described in 1833 by MAYO as a hair containing cyst located just below the coccyx1. In 1847 pilonidal sinus was published by ANDERSON in a paper entitled “hair extracted from an ulcer. In 1880 HODGE coined the term pilonidal from its Latin origin Pilus meaning hair Nidus meaning nest2. With the growth of embryological knowledge in early 19th century pilonidal sinus was considered as congenital and theories emerged based on this hypothesis3-4
Ø  “Pilonidal sinus developed from the cystic remnants of medullary canal persisting in the sacro-coccygeal region “– Tourneaux and Herrmann in 1887.5
Ø  “Faulty development of median raphe in sacrococcygeal region leads to dermal inclusion which later become a sinus “- Fe`re (1878) Lanne longue (1882) Bland Sutton` (1922) and Fox (1935)6,7
Ø  “Pilonidal sinus is a vestigial structure homologous with preen gland of the bird “- stone (1931)8
Ø  “Vestigial sex gland” Kallet (1936)9
These theories were postulated based on the site of the pilonidal sinus and management was thought to be fundamental by excising and removing all embryologic remnants.
In early 20th century pilonidal sinus was hypothesized by Patey and Scarf as acquired by penetration of hair into the subcutaneous tissue with constant granulomatous reaction .During World War II pilonidal sinus gained prominence amongst solider with high incidence so much so it came to be known as jeep disease10.
Today pilonidal describes as spectrum of clinical presentation ranging from asymptomatic hair containing cyst and sinus to large asymptomatic abscess. Karydakis states that a 35-year study on thousands of cases of pilonidal disease leaves no doubt as to the true acquired aetiology. He describes three factors that are involved in the hair insertion process: (1) the invader, consisting of loose hair; (2) a force that causes hair insertion; and (3) the vulnerability of the skin to the insertion in the depths of the nadal cleft. Loose hair, leading with the root end, collects in the nadal cleft. Friction forces the hair to insert at the depth of the cleft, not at the sides. With the insertion of one hair, others can more easily follow, provoking the foreign body reaction and infection of pilonidal disease. Karydakis felt that the primary sinuses are the portals of entry of the hair and the secondary fistulas are the portals of hair exit11. Other factors like age, familial history, gender, trauma, poor personal hygiene, may also be involved to explain the occurrence of the disease in hairless people. Although usually seen in the sacrococcygeal region, interdigital pilonidal sinus disease has been described in the hands of hairdressers and barbers sheep shearers (from the wool)12 ,milkers (from the cow’s hair) , dog groomers , and a man who worked in a slaughterhouse .Additionally, the disease has been described in the umbilicus , chest wall, anal canal , ear , and scalp . It is associated with indolent discharge, malodorous smell, pain.
Pilonidal disease occurs predominately in men (80%). The peak incidence is in those 15 to 24 years of age and it decreases after age 25. It is rare after age 45.13 Malignant transformation is rare but cases of squamous cell carcinoma and verrucous carcinoma have been reported Although many surgical and nonsurgical methods have been proposed, no clear consensus as to optimal treatment has been reported so far in the literature.
Conservative nonsurgical management (including phenol application, cryosurgery, and shaving), a limited excision, excision with marsupialization, wide excision and primary closure, and most recently, flap surgery have been utilized in the treatment of this disease.
Despite the availability of a range of surgical techniques, wound healing after pilonidal sinus surgery can be problematic . In a study Binnebo¨sel et al. have shown a clear relationship between disturbances of several components of the extracellular matrix at the excision margins and subsequent wound healing in patients who underwent pilonidal sinus surgery14.
Various conservative and surgical techniques are available in the management of pilonidal sinus, but controversy concerning the optimal surgical approach persists.
6.3. Objectives of the study:
a) To know the incidence of pilonidal sinus in Bapuji and Chigteri Hospital
b) To know the incidence of pilonidal sinus based on occupation.
c) Comparison of incidence of pilonidal sinus among gender.
d) Comparison of conservative versus surgical management
e) Evaluation of different surgical approaches
f) Post-operative stay in hospital
7 / MATERIALS AND METHODS:
7.1  Source of data:
a)  Study subject:
After the institutional ethical committee approval and with informed written consents the study will be conducted on the patient with the complaint of pilonidal sinus in Chigteri hospital and Bapuji hospital between November 2012- September 2014.

7.2 Method of collection of data (including sampling procedure if any):

Ø  Study design- prospective study
Ø  Sample size- purposive sampling will be done and 50 patients will be selected who are fitting into my inclusion criteria.
Ø  Study design-
ü  The study consists of patient fitting under my inclusion criteria with written consent.
ü  The study will be based on format consisting of clinical features and management of pilonidal sinus.
ü  Patients will be advised same antibiotics, same analgesics same type of dressing of the wound.
ü  The type of management will be decided by the type of pilonidal sinus
ü  On discharge patients will be on similar antibiotics, wound care advice, dietery advice.
ü  The study group will be analysed on factors as; a) type of management of pilonidal sinus
Ø  Post-operative stay in the hospital
Ø  Age
Ø  Pain
7.3. Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly
Yes.
Ø  Hb % TC, DC, ESR, Bleeding time, clotting time
Ø  Blood urea
Ø  Serum Creatinine
Ø  RBS
Ø  Serum Electrolytes
Ø  ECG
Ø  Sinus gram
Ø  HIV and HbsAg
7.4  Has ethical clearance been obtained from your institution in case of 7.3?
Yes
8 / LIST OF REFERENCES:
1.  Mayo.Oh. observation on injuries and diseases of the rectum .London:Burgess and Hill;1833 pp.45-46
2.  Hodges.Rm. pilonidal sinus . poston med surgery journal 1880;103:485-486
3.  Da Silva JH (2000) Pilonidal cyst: cause and treatment. Dis Colon Rectum 43:1146–1156.
4.  Davage ON (1954) The origin of sacrococcygeal pilonidal sinuses: based on an analysis of four hundred sixty-three cases. Am J Pathol 30:1191–1205.
5.  Tomeaux F, Herman G (1887). Sur la persistence de vestiges medularis coccygiens pendant tout le period foetale chezl’homme et sur role de ces vestiges dans la production des tumeurs sacro–coccyginennes congenitales. J Anat 23:498–529.
6.  Fere C (1878) Cloisonement de la cavite pelvienne; uterus et vagina doubles; infunibulum cutane de la region sacroccygienne. Bull Soc Anat Paris 3:309–312
7.  Bland-Sutton J (1903) Tumeurs, innocent and malignant; their clinical features and appropriate treatment, 3rdedn. WT Keener, Chicago, p 556
8.  Stone HB (1931) The origin of pilonidal sinus (coccygeal fistula).Ann Surg 94:317–320
9.  Kallet HI (1936) Pilonidal sinus. The factor of adolescence.Trans Am Proctol Soc 37:163–165
10.  Buie LA (1944) Jeep disease. South Med J 37:103-109
11.  Karydakis GE (1992) Easy and successful treatment of pilonidal sinus after explanation of it’s causative process. Aust N Z J Surg 62:385–389
12.  Phillips PJ (1966) Web space sinus in a shearer. Med J Aust 2:1152–1153.
13.  Chintapatla S, Safarani N, Kumar S, Haboubi N. Sacrococcygeal pilonidal sinus: historical review pathological insight and surgical options. Tech Coloproctol 2003;7:3–8.
14.  Binnebosel.M.Junge.K.Schwab(2008). Delayed Wound healing in sacrococcygeal pilonidal sinus-World.J.Surg DOI 10:1007|S00268-008-9748-9.
9. / SIGNATURE OF THE CANDIDATE
10. / REMARKS OF THE GUIDE / Pilonidal sinus is an uncommon surgical condition presenting with typical and atypical clinical manifestations having an equal controversy in the selection of ideal surgical method for its proper management. This study is undertaken for evaluation of same in our clinical setup.
11. / NAME & DESIGNATION
(in block letters)
11.1 Guide
11.2 Signature
11.3 Co-Guide (If any)
11.4 Signature
11.5 Head of Department
11.6 Signature / Dr SHUBHA .N.RAO M.S..
PROFESSOR,
DEPARTMENT OF SURGERY,
J.J.M. MEDICAL COLLEGE,
DAVANGERE-577004
Dr. R.L. CHANDRASHEKAR M.S.
PROFESSOR AND HEAD,
DEPARTMENT OF SURGERY,
J.J.M. MEDICAL COLLEGE,
DAVANGERE-577004
12. / 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL
12.2 Signature

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