343 Bangladesh Journal of Medical Science Vol. 19 No. 02 April’20 Letter to Editor: Response to: Limberg Flap Reconstruction in Treating Sacrococcygeal Pilonidal Sinus Hayati F 1 , Syed Abdul Rahim SS 2 , Che Ani MF 3 , Zakaria AD 4 Correspondence to: Firdaus Hayati, Department of Surgery, Faculty of Medicine and Health Sciences, Uni- versiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia, E-mail : frdaushayati@gmail.com 1. Firdaus Hayati, Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia 2. Syed Sharizman Syed Abdul Rahim, Department of Community and Family Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia 3. Mohd Firdaus Che Ani, Department of Surgery, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia 4. Andee Dzulkarnaen Zakaria, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia Bangladesh Journal of Medical Science Vol. 19 No. 02 April’20. Page : 343-344 DOI: https://doi.org/10.3329/bjms.v19i2.45021 Dear authors, We read with great interest the article by Faruk MO et al 1 which was recently published in your esteemed journal 1 . The authors conducted a prospective study on surgical treatment of sacrococcygeal pilonidal sinus and recommended the choice of Limberg fap reconstruction in our daily practice. It was proven to have a low complication rate, shorter hospital stay, low recurrence rates, earlier healing and reduced of- work period. We believe that the values of this study are lacking in certain areas, which can be improved in the near future. In order to prove the quality and efectiveness of a particular surgical technique, among the highest level of evidence, is to perform a randomized controlled trial (RCT) instead of a mere observation prospective study. With an added randomisation, control group as well as blinding techniques in an RCT, it would provide a higher strength of evidence. Despite so, similar outcomes were achieved by an RCT Conducted by Alvandipour M et al which proved that Limberg fap is superior to Karydakis fap surgery 2 . The sample size of 24 participants is not big enough to achieve a proper analysis. We believe that the authors should have increased the power of the study by enrolling more participants to increase the sample size. We would appreciate if the authors could look again at the descriptive statistics, as a sample size that small might not be normally distributed, thus the use of median and IQR would be more appropriate. Moreover, this study lacked of statistical analysis, which is the main determinant of a certain research. With the absence of a comparator group, the analysis would only be descriptive and does not add adequate evidence to assume what method is better as compared to another. This study did mention other centres were involved, however, it was not specifed where and how many exact centres. Because this involved multiple centres, some ethical issues need to be considered and that is whether this study obtained its approval for other collaborative centres and not only from the surgical department from one hospital. In fact, there should be a proper ethical committee board to approve this study as it is inadequate from the department alone. Going through the results section, the heading ‘expected results’ is an inaccurate term as these were observed results from a prospective study. Furthermore, we feel Table 3 can be further improved and elaborated to include other methods of faps. This would be more benefcial and meaningful rather than comparing with just the similar surgical method.