Elsey and Lund describe a novel technique for the treatment of pilonidal disease [1]. The authors point out that the ideal treatment for such disease should be simple, effective, relatively pain free and lead to rapid recovery with early return to normal activity. The last two criteria are especially pertinent given the population that suffer from this problem. They are usually young and active with minimal comorbidity.

Although many surgical treatments for pilonidal disease have been described, in some cases, the intervention can be worse than the disease, at least in the short to medium term.

This technique meets the majority of these criteria. It is simple. Given the description of the technique (pending the degree of track curettage), it should be relatively pain free compared with other techniques involving various degrees of skin incision and excision. Indeed, the lack of extensive surgical ‘invasion’ makes me wonder why the procedure requires a general rather than a local anaesthetic. If only local anaesthesia were required, it would meet a further ‘ideal’ objective not mentioned by the authors. It follows that, if effective, the procedure is likely to result in rapid recovery and return to normality and subsequent high patient satisfaction as shown.

The question is efficacy. With a questionnaire response of only 61 %, it is difficult to draw conclusions. It is, however, not unreasonable to assume that most of the 39 % that did not reply were likely to be ‘cured’. They did not re-attend the treating hospital and such a young mobile group is notoriously bad at replying to follow-up interrogation. Assuming the group that replied is representative of the group as a whole, we could extrapolate a 26 % failure/recurrence rate. This is substantially higher than that quoted for most other surgical techniques and even for equivalent minimally invasive options such as phenol injection [2]. A Cochrane review on open and closed methods of treatment suggests an overall recurrence rate of 6.9 % [3]. However, such a high rate of failure with gluing may well be acceptable to this population given the minimal surgical invasion and potential for harm.

The procedure is not for everyone. The authors are vague about who is suitable and perhaps a formal grading system is necessary to accurately identify candidates for the procedure. This would be required if any form of comparison is to be carried out, in order to standardise the study population. If such a trial is attempted, and it needs to be, it would have to involve other centres to ensure the results are transferrable. Given the myriad of alternative procedures including midline or asymmetric excision with or without primary closure and/or flap transposition and the lack of a gold standard, the authors would have to think carefully about what to compare the procedure to. Assuming failure of therapy is due partly to missed tracks perhaps the use of methylene blue would help improve efficacy and should be considered [4].

Given these caveats, I am persuaded that this technique should form part of the armamentarium of options available to the surgeon who wishes to treat what can be a difficult and depressing condition for both patient and surgeon.