Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches

Understanding the Mechanical Forces on the Sacrum Can Help Optimize Flap-based Pilonidal Sinus Reconstruction

Background

Pilonidal sinus can be treated with excision and flap reconstruction, but treatment is often complicated by wound dehiscence, infection, and recurrence. Understanding the mechanical forces on the sacrococcygeal area during posture change could help guide optimal flap choice.

Methods

Sixteen volunteers underwent measurements of skin-stretching, pressure, and shear stress on the sacrum when sitting relative to standing. Skin-stretching was measured by drawing a 4 × 4 cm square on the sacrum and measuring the vertical, horizontal, and diagonal axes. Pressure and shear stress was measured at six sacral points with a device. The data analysis highlighted the potential of the superior gluteal artery perforator (SGAP) flap for dissipating mechanical forces. Ten pilonidal sinus cases treated with SGAP flaps were retrospectively reviewed for 6-month outcomes.

Results

Sitting is associated with high stretching tension in the horizontal direction [estimated marginal mean (95% confidence intervals) = 17.3% (15.4%-22.6%)]. The lower sacrum experienced the highest pressure [106.6 (96.6-116.5) mm Hg] and shear stress [11.6 (9.7-13.5) N] during sitting. The transposed SGAP flap was deemed to be optimal for releasing the horizontal tension and providing sufficient subcutaneous tissue for ameliorating pressure/shear stress during sitting. It also has high blood flow and can therefore be used with large lesions. Moreover, its donor site is above the high-pressure/stress lower sacrum. Retrospective analysis showed that no patients experienced complications.

Conclusions

Sitting is associated with high mechanical forces on the sacrococcygeal skin. The transposed SGAP flap may ameliorate these forces and thereby reduce the risk of complications of pilonidal sinus reconstruction for large defects.

Evaluation of the efficacy of the Z-plasty surgical technique vs. secondary wound healing mechanism in the treatment of the pilonidal sinus: a clinical trial

Background

The most important step in treating a pilonidal sinus is eradication by surgical excision. Over the years, various surgical techniques have been reported for wound closure, yet their management still poses a challenge. The current study compares the results of two different methods of wound management: secondary wound healing versus the Z-plasty surgical technique.

Material and method

The current clinical trial recruited 84 uncomplicated pilonidal sinus patients who were to undergo complete surgical excision of the pilonidal sinus. For wound healing, the 84 subjects were equally divided into two groups of 42 patients each. One group was selected for Z-plasty surgical wound closure and the other for the secondary healing mechanism. Outcomes measured consisted of demographic data, length of operation, complications, severity of pain, number of dressings, recurrence, and complete healing time.

Result

Age or sex distribution and the median BMI (kg/m²) did not significantly differ between the two groups. The length of the operation for Z-plasty subjects was significantly longer (P <0.0001). The median number of dressing changes for secondary wound healing patients was 38.69, which was significantly higher than the 4.95 dressing changes for the Z-plasty group. The total time recorded for complete wound healing was 21.61±4.27 days in the Z-plasty group and 41.23±24.28 days for secondary wound healing subjects, which was statistically significant. Twenty-four hours postoperation, patients in the secondary wound healing group had significantly more pain, and the Visual Analogue Scale scores of the Z-plasty and secondary wound healing groups were 3.42±0.76 and 6.09±1.2, respectively. Concerning the recurrence rate, there were no significant differences between the two groups. SPSS version 22 performed the analyses, and the independent t-test compared the continuous variables. A P value less than 0.05 was considered statistically significant.

Conclusion

Z-plasty is a safe and effective procedure in terms of wound complications and recurrence rate. This method is also cost-effective and better received by patients.

Bascom II combined with VSD treatment involving the preservation of tissue bridges for recurrent complex pilonidal sinuses with a literature review

INTRODUCTION

For patients with large and deep-seated recurrent complex pilonidal sinuses, the use of traditional open excision or flap reconstruction surgery may lead to high surgical difficulty, significant local damage, numerous complications, slow healing, and a high risk of recurrence. This article reports a case of recurrent complex pilonidal sinus and discusses the advantages of Bascom II combined with VSD treatment involving the preservation of tissue bridges.

CASE PRESENTATION

The patient, a 31-year-old male, presented with recurrent swelling, pain, and purulent discharge from the sacrococcygeal region for over a year. Upon physical examination, extensive lumps and sinus tracts were observed in the lumbosacral tail area, with the lesion extending from L4 to the tip of the coccyx. Under general anesthesia, a segmental resection was performed, and the lumbosacral mass lesion was excised, preserving normal tissue bridges. The mature sinus tract at the upper part of the coccyx was removed, and Bascom II reconstruction surgery was performed. In the late stage at the site of lumbar sacral lesion excision, VSD was applied to promote wound healing.

DISCUSSION

The combination of Bascom II with lesion tunnel-like removal can reduce the damage, elevate gluteal cleft, and lower the recurrence rate. Subsequently, with the addition of VSD, it can accelerate the elimination of necrotic tissue, reduce infection risk, and expedite wound healing.

CONCLUSION

This case explores the advantages and characteristics of combining various techniques in the treatment of recurrent complex pilonidal sinuses, emphasizes the utility of VSD as an adjunctive therapy for large lesions.

Surgical Practice Parameters for the Definitive Management of Sacrococcygeal Pilonidal Sinus Disease: Surgeons' Perspective

Background Sacrococcygeal pilonidal sinus disease (SPD) is a common general surgical condition encountered in practice and predominantly affects young males. Surgical practice parameters for the management of SPD are variable. This study aimed to review current surgical practice parameters for SPD management in Western Australia. Methodology This study conducted a de-identified 30-item multiple-response ranking, dichotomous, quantitative, and qualitative survey of self-reported surgeon practice preferences and outcomes. The survey was sent to 115 Royal Australian College of Surgeons - Western Australia general/colorectal surgical fellows. Data were analyzed using SPSS version 27 (IBM Corp., Armonk, NY, USA). Results The survey response rate was 66% (N = 77). The cohort comprised mostly senior collegiate (n = 50, 74.6%), and most were low-volume practitioners (n = 49, 73.1%). For local disease control, most surgeons perform a complete wide local excision (n = 63, 94%). The preferred wound closure method was an off-midline primary closure (n = 47, 70.1%). Self-reported SPD recurrence, wound infection, and wound dehiscence rates were 10%, 10%, and 15%, respectively. The three high-ranked closure techniques were the Karydakis flap, Limberg's flap (LF), and Z-Plasty flap. Each surgeon's median annual SPD procedures were 10 (interquartile range = 15). The surgeons could utilize their preferred SPD closure technique (mean = 83.5%, standard deviation = ±15.6). Univariate analysis showed significant associations between years of experience and SPD flap techniques utilized, with senior surgeons significantly less likely to use either the LF (p = 0.009) or the Bascom procedure (BP) (p = 0.034). Instead, there was a preference for using healing by secondary-intention technique (SIT) compared to younger fellows (p = 0.017). A significant negative correlation existed between practice volume and SPD flap technique utilization, with low-volume surgeons less likely to prefer the gluteal fascia-cutaneous rotational flap (p = 0.049) or the BP (p = 0.010). However, low-volume practice surgeons were significantly more likely to use SITs (p = 0.023). The three most important patient factors in choosing SPD techniques were comorbidities, likely patient compliance, and attitude toward the disease. Meanwhile, factors influencing local conditions included the proximity of the disease to the anus, the number and location of pits and sinuses, and previous definitive SPD surgery. Key informants for technique preference were perceived low recurrence rate, familiarity, and overall good patient outcomes. Conclusions Surgical practice parameters for managing SPD remain highly variable. Most surgeons perform midline excision with off-midline primary closure as the gold standard. There is a clear and present need for clear, concise, and yet comprehensive guidelines on managing this chronic and often disabling condition to ensure the delivery of consistent, evidence-based care.

Primary Closure of Pilonidal Sinus With Slide-Swing Skin Flap Compared With the Secondary Closure: A Single-Blinded Randomized Controlled Trial

INTRODUCTION

There are many surgical approaches for sacrococcygeal pilonidal sinus disease (PSD) therapy, ranging from wide excision repair to less morbid excisions with primary/flap closure. The off-midline flaps, which shift the incision line away from the midline natal cleft, have been associated with lower recurrence rates than the conventional mid-line closure techniques. This single-blinded randomized controlled trial aims to compare the short/long-term efficacy and outcome of the slide-swing flap technique with the conventional secondary wound closure.

METHOD AND MATERIALS

This study was a prospective randomized controlled trial conducted on patients with PSD. Patients were assigned into two groups: secondary closure (control) and slide-swing flap (trial). Patients were advised to visit the surgical clinic two times weekly for the two weeks after the operation for at least six months.

RESULTS

In this study, 100 patients were enrolled. They were assigned into two groups of control, and trial. The mean age of all participants was 29.15 ± 8.36 years old (age range: 18-62 years old). The mean operation time was 39.65 ± 12.63 for both groups, with the control group being 29.70 ± 7.71 and the swing flap group 46.90 ± 7.81. Patient visual analog scale (VAS) scores in both groups revealed that the trial group was associated with lower VAS scores compared with patients who underwent secondary closure (p-value = 0.006). Also, the trial group demonstrated a higher rate of healing, better cosmetic outcomes, and quicker recovery time compared with the controls.

CONCLUSION

Compared with secondary closure, the slide-swing flap was associated with excellent cosmetic outcomes, disease recurrence, and recovery time. Also, the post-operative complications were significantly lower compared with the traditional method.

Unroofing Curettage Versus Modified Limberg Flap in Pilonidal Disease: A Retrospective Cohort Study

BACKGROUND

Sacrococcygeal pilonidal disease (estimated incidence, 25/100,000) is a chronic inflammatory condition that commonly affects young adults. However, the ideal surgical treatment for this disease remains undetermined.

OBJECTIVE

This study aimed to compare the results of the unroofing curettage and those of the modified Limberg flap surgical technique.

DESIGN

This is a retrospective cohort study.

SETTINGS

Procedures were performed by 2 surgeons between January 2013 and January 2017.

PATIENTS

The data of 278 patients who underwent surgery for the treatment of pilonidal disease were analyzed.

INTERVENTIONS

Unroofing curettage was performed under local or spinal anesthesia, whereas spinal anesthesia was used for the modified Limberg flap procedure.

MAIN OUTCOME MEASURES

The primary outcome was recurrence rate. Secondary outcomes included adverse events, limitation of daily activities, and healing time.

RESULTS

Between the 2 groups (unroofing curettage, n = 135; modified Limberg flap, n = 143), recurrence was lower in the unroofing curettage group after a 60-month median follow-up period, but the difference was not statistically significant (1.5% vs 4.2%, p = 0.45). The duration of surgery and length of hospital stay were shorter in the unroofing curettage group (11.44 ± 3.56 minutes vs 52.47 ± 7.92 minutes and 0.27 ± 0.45 days vs 1.07 ± 0.26 days, p < 0.001). Postoperative complications were significantly higher in the modified Limberg flap group (9.8% vs 2.2%, p = 0.009). The time required to return to work or school was shorter in the unroofing curettage group (8.6 ± 7.8 days vs 25.01 ± 6.3 days, p < 0.001). The complete healing time was longer in the unroofing curettage group (35.3 ± 9.2 days vs 23.2 ± 5.4 days, p < 0.001).

LIMITATIONS

The retrospective study design was a limitation of this study.

CONCLUSIONS

Unroofing curettage provided more clinical benefits than the modified Limberg flap approach. Unroofing curettage should be considered as the first choice of surgical treatment for pilonidal disease. See Video Abstract at http://links.lww.com/DCR/B824 .

DESTECHAMIENTO Y CURETAJE VERSUS COLGAJO DE LIMBERG MODIFICADO EN LA ENFERMEDAD PILONIDAL UN ESTUDIO DE COHORTE RETROSPECTIVE

ANTECEDENTES:La enfermedad pilonidal sacrococcígea (incidencia estimada, 25 / 100.000) es una enfermedad inflamatoria crónica que comúnmente afecta a adultos jóvenes. Sin embargo, el tratamiento quirúrgico ideal para esta enfermedad permanece indeterminado.OBJETIVO:Comparar los resultados del destechamiento y curetaje y los de la técnica quirúrgica con colgajo de Limberg modificado.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Los procedimientos fueron realizados por dos cirujanos, entre enero del 2013 y enero del 2017.PACIENTES:Se analizaron datos de 278 pacientes intervenidos quirúrgicamente para el tratamiento de la enfermedad pilonidal.INTERVENCIONES:Se realizó destechamiento y curetaje con anestesia local o raquídea, mientras que para el procedimiento de colgajo de Limberg modificado se utilizó anestesia raquídea.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue la tasa de recurrencia. Los resultados secundarios incluyeron eventos adversos, limitación de las actividades diarias y tiempo de curación.RESULTADOS:Entre los dos grupos (destechamiento y curetaje, n = 135; colgajo de Limberg modificado, n = 143), la recurrencia fue menor en el grupo con destechamiento y curetaje después de un período de seguimiento medio de 60 meses, pero la diferencia no fue estadísticamente significativa (1,5% vs 4,2%, p = 0,45). La duración de la cirugía y la estancia hospitalaria fueron más cortas en el grupo de destechamiento y curetaje (11,44 ± 3,56 min vs a 52,47 ± 7,92 min y 0,27 ± 0,45 días vs 1,07 ± 0,26 días, p < 0,001). Las complicaciones posoperatorias fueron significativamente mayores en el grupo de colgajo de Limberg modificado (9,8% vs 2,2%, p = 0,009). El tiempo necesario para regresar al trabajo o la escuela fue menor en el grupo de destechamiento y curetaje (8,6 ± 7,8 días vs 25,01 ± 6,3 días, p < 0,001). El tiempo de cicatrización completo fue mayor en el grupo de destechamiento y curetaje (35,3 ± 9,2 días vs 23,2 ± 5,4 días, p < 0,001).LIMITACIONES:El diseño del estudio retrospectivo.CONCLUSIONES:El destechamiento y curetaje proporcionó más beneficios clínicos que el abordaje con colgajo de Limberg modificado. El destechamiento y curetaje debe considerarse como la primera opción de tratamiento quirúrgico para la enfermedad pilonidal. Consulte Video Resumen en http://links.lww.com/DCR/B824 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Pit picking vs. Limberg flap vs. primary open method to treat pilonidal sinus disease – A cohort of 327 consecutive patients

Background

Minimally invasive methods in pilonidal sinus disease (PSD) surgery are becoming standard. Although long-term results are available for some techniques, long-term outcome data of patients after pit picking is lacking. We aimed at investigating perioperative and long-term outcomes of patients undergoing pit picking, Limberg flap or primary open surgery to treat PSD.

Methods

In a single-centre observational study, we evaluated the outcomes of 327 consecutive patients undergoing PSD surgery between 2011 and 2020.

Results

PSD had recurred in 22% of Limberg flap patients and 62% of pit picking patients at 5 years (p=0.0078; log rank test). Previous pilonidal surgeries, smoking, body mass index, immunodeficiency, and diabetes did not significantly influence the long-term recurrence rate. Primary open treatment was performed for 72% of female patients presenting with primary disease.

Conclusions

Due to its especially dismal long-term results, pit picking should be abandoned, and Limberg flap should be promoted instead, even for primary disease and in females.

Risk factors in the prognosis of flap techniques for pilonidal sinus disease based on magnetic resonance imaging and clinical parameters

BACKGROUND

Postoperative complications and recurrence are major diffficulties in the flap techniques for the treatment of pilonidal sinus (PS), however, the risk factors remain unclear. While magnetic resonance imaging (MRI) offers the highest soft tissue resolution, few studies have applied MRI to investigate the basic parameters of PS.

METHODS

A total of 100 patients receiving Limberg flap (LF) or Karydakis flap (KF) surgery at the Sixth Affiliated Hospital of Sun Yat-Sen University were retrospectively analyzed, and the median follow-up period was 42 (range, 20-90) months. We performed a multivariate logistic analysis on the clinicopathological parameters and MRI data to identify risk factors for complications and recurrence.

RESULTS

The basic parameters of PS were obtained by MRI analysis. The multivariate analysis revealed a large longitudinal sinus diameter (OR = 1.020, 95%CI = 1.000-1.041) and sacrococcygeal dermal thickness (OR = 1.680, 95%CI = 1.142-2.472) to be independent risk factors for early complications. Meanwhile, a small sacrococcygeal fat thickness (OR = 0.923, 95%CI = 0.864-0.987) and a high BMI (OR = 1.291, 95%CI = 1.067-1.563) are independent risk factors for late complications and recurrence, respectively.

CONCLUSION

We used MRI to measure the basic parameters of PS accurately, including size, volume, location and some key points of the surrounding tissues, and identified, besides the selection of surgical approach, some specific basic parameters of PS might be the risk factors for complications and recurrence after flap techniques.

[Wound Healing Disorders after Excision and Open Treatment for Pilonidal Sinus]

INTRODUCTION

Pilonidalis sinus disease is a mostly chronic selective infection of the hairy skin in the area of skin wrinkles, mainly in the area of the natal cleft. Open treatment is still the most common recommended therapy. Nevertheless, there may be healing disorders within the framework of open wound treatment, which can significantly complicate the course.

METHODS

The following is an overview of wound healing disorders after excision of pilonidalis sinus. Healing time and frequency are determined on the basis of current data and the causes of the healing disorder are evaluated. In addition, possible treatment options are presented and treatment recommendations are made.

RESULTS

The evaluation of published data on wound healing period showed that the wound usually heals after a mean of two months. The results of the German forces cohort study show by way of example that almost all wounds have healed in the period up to three months. However, a small percentage of non-healing wounds remain. The frequency of significantly delayed wound healing is given in the literature as 2 - 5%. The influencing factors for wound healing after sinus pilonidalis excision are not only the size and symmetry of the excision wound but also other details of open wound treatment. In addition to intensification of the previous open wound treatment, the new excision and refreshment of the wound are mentioned as treatment options in the event of a lack of wound healing. Furthermore, changes in strategy for plastic-reconstructive procedures or other surface treatment are also recommended.

CONCLUSION

The excision wound of pilonidalis sinus should be healed after three to four months at the latest, after which the wound can be regarded as a wound with significantly delayed healing or as a wound healing disorder. Around this time, the findings should be re-evaluated and, if necessary, a change in the treatment concept should be made.

Pilonidal Sinus Management; Bascom Flap Versus Pilonidal Pits Excision: A Single-Center Experience

Purpose

This study aimed to evaluate the outcomes of the Bascom cleft lift (flap) and the pilonidal pits excision (Gips procedure).

Methods

The records of all the patients who underwent pilonidal sinus excision between November 2013 and August 2017 were reviewed. Inclusion criteria included either pilonidal pits excision or the Bascom cleft lift procedure. All procedures were performed by a single surgeon. Perioperative complications and recurrence rates were reviewed.

Results

Fifty-three patients met the inclusion criteria. Male/female ratio was 36/17, with a mean age of 23.4 ± 7 years. In this study, 21 patients underwent the Bascom cleft lift (skin flap) procedure and 32 underwent the Gips-style operation. The mean follow-up was 3.5 months. Twenty-eight patients (52.8%) underwent prior drainage of pilonidal abscess. Eleven patients had a previous wide local excision with recurrent disease. A higher rate of recurrence was observed among patients who underwent pits picking following failure of a previous wide local excision (80% vs. 0%, P = 0.02). Minor wound dehiscence developed in 8 patients; all of which were in the Bascom flap group (40% vs. 0%, P < 0.005). All of these wounds healed completely between 3 and 6 weeks.

Conclusion

The Gips procedure is the recommended treatment for simple pilonidal disease. For recurrent pilonidal disease, the Bascom cleft lift (flap) procedure is an excellent option since it demonstrates a short wound healing time and a good success rate. This calls into question the continued use of the wide excision technique used by most surgeons in this country and abroad.

Fasciocutaneous Elliptical Rotation Flap for Pilonidal Sinus Disease and Its Outcomes

Objectives

Sacrococcygeal pilonidal sinus is a common disease especially in the Caucasians of the Middle East. It has been reported in the incidence of 12-26 in a 100.000 population. Previously thought to be due to etiological reasons of congenital origin, it is now widely accepted as an acquired disease. The optimal treatment for pilonidal sinus disease still has no consensus. The elliptical rotation flap was first described by Nessar in the surgery of pilonidal sinus and reported successful results, but it has weak points. The purpose of this study was to share the findings of the fasciocutaneous elliptic rotation flap technique retrospectively.

Material and Methods

One hundred and eighty-six patients (149 were males and 37 were females) operated for pilonidal disease with fasciocutaneous elliptic rotation flap between 2013 and 2018 were included into this study. Data of the patients including operation time, wound issues (infection, seroma, wound separation), time required to return to daily activities, complete healing time and recurrence rates were recorded retrospectively.

Results

The patients' complete healing time was 13 ± 3 days and mean follow-up was 19 (6-37) months. Mean operative time was 43 ± 13 minutes. Mean time of drain removal was 2.20 ± 1.18 days. There were no flap necrosis or ischemia. Postoperative infection developed in two patients (1%). Seroma developed in 7 (3.8%) patients. Partial wound dehiscence occurred in 5 (3.2%) patients. None of the cases developed hematoma or complete dehiscence. No recurrence was observed in postoperative follow-ups.

Conclusion

Fasciocutaneous elliptical rotation flap is a method that has follow-up results similar to both the elliptical rotation flap technique and its modification and can be safely preferred in the treatment of pilonidal sinus with its other advantages.

Treatment Strategies for Pilonidal Sinus Disease in Switzerland and Austria

Background and objective: No current nationwide consensus exists on pilonidal disease (PD) treatment in Switzerland and Austria. The objective of this study was to assess and compare the spectrum of PD treatment strategies in Switzerland and Austria. Materials and Methods: A survey including 196 certified institutions (Switzerland, N = 99 and Austria, N = 97) was performed. Treatment strategies for both chronic and acute pilonidal disease were investigated, as well as evolution of treatment over the last 20 years. Results: In total, 92 of 196 (47%) hospitals participated in the survey. Recurrence rate (20%) was similar between the two countries. In acute pilonidal disease, a two-stage approach with incision and drainage as the first step was preferred over a one-stage procedure in both countries. In Austria, all patients with chronic pilonidal disease were treated as inpatients, whereas 28% of patients in Switzerland were treated on an outpatient basis (p = 0.0019). Median length of hospital stay was double in Austria (four days) compared to Switzerland (two days; p < 0.001). Primary resection and off-midline closure (p = 0.017) and the use of tissue flaps (p = 0.023) were performed more commonly in Austria than in Switzerland. Minimally invasive techniques were performed more often in Switzerland than in Austria (52% vs. 4%, p < 0.001). Overall, wide excision with secondary wound healing or midline closures declined over the last 20 years. Conclusion: Treatment strategies for chronic PD differ between Austria and Switzerland with more and longer inpatient care in Austria, increasingly minimally invasive approaches in Switzerland, and outdated procedures still being performed in both countries. Overall, heterogeneity of practice dominates in both countries.

Excision and tension-free primary closure of pilonidal disease

Objectives

This study aimed to estimate simple excision and tension free primary closure and to study its effectiveness in terms of operating and healing time, duration of hospital stay, degree of post operation complications, and rate of recurrence.

Material and Methods

This is study included 78 patients, of whom 71 were (91%) males and 7 (9%) females, who underwent excision and tension free closure. The procedure was based on bilateral side flaps, which were released and dissected 2-3 cm from the edge of the wound. Patient's age, gender, body mass index, wound healing, operation, drain removal, length of hospital stay, and complications and recurrence were analysed.

Results

The study involved 78 patients, 71 (91%) males and 7 (9%) females. Median age of the patients was 28.5 years. Mean operation time was 44.6 minutes . Sixty-one patients (78.2%) had full primary healing without any complication. No one had hematoma or seroma, but five (6.4%) cases had a minor wound infection and three (3.8%) obese patients developed recurrence. Mean length of hospital stay was 2.5 days , most patients went back to their work within 3 weeks. Median follow-up period was in a 26.2 weak range (1-51.4 weak). Five (6.41%) cases had wound infection and three (3.85%) developed recurrence.

Conclusion

Excision and tension free primary closure were found to be simple procedures associated with lower rates of wound infection, shorter hospital stay, lower recurrence, early wound recovery and short period of being absent from work. Surgery can be easily performed and preferred for cases of non-recurrent pilonidal sinus and cyst.

Comparison of the Three Surgical Flap Techniques in Pilonidal Sinus Surgery

We aimed to study the efficacy of three surgical flap techniques in pilonidal surgery. Pilonidal disease is characterized by chronic inflammation and infection in the sacrococcygeal region. Complications and recurrence are common after treatment and optimal treatment for the disease has not been established yet. We enrolled a total of 401 patients in this study. Patients have been treated with Karydakis (n = 113), modified Limberg (n = 179), or Limberg (n = 109) flap techniques. Mean off-work period, time to walk without pain, time to sit on the toilet, time to take the drainage catheter off, maceration rates, recurrence, and hypoesthesia rates were significantly better in the modified Limberg group. In conclusion, we showed the modified Limberg technique is superior than both Limberg and Karydakis techniques.

Comparison of Primary Closure, Secondary Closure, and Limberg Flap in the Surgical Treatment of Pilonidal Cysts

There are few studies comparing methods for pilonidal cyst closure. This study was conducted to compare simple surgical closure, secondary healing, and closure using a Limberg flap in the treatment of patients affected with pilonidal cysts. In total, 150 patients with pilonidal cysts were selected and randomized into 3 groups, with 50 participants in each group. Group A underwent primary closure, Group B underwent secondary closure, and Group C underwent closure with a Limberg flap. Operating time, amount of pain after surgery, time to mobilization, time until return to work, time for complete healing, time until being able to sit on the toilet without pain, postoperative complications including infection and recurrence, and seroma and edema after surgery were compared among the 3 groups. Duration of surgery in the Limberg flap group was significantly longer than the duration of surgery in Group A or Group B (p < .001). The time to patient mobilization, the time when the patient returned to work, the time to complete healing, and the time to being able to sit on the toilet without pain were significantly shorter in Group C than in Group A or Group B (p < .001). Although the procedure takes longer when using a Limberg flap, it appears to be a more effective method in the surgical treatment of patients with pilonidal cyst because of the reduced healing time and improved functional status after the procedure.

Limberg flap versus Karydakis flap for treating pilonidal sinus disease: a systematic review and meta-analysis

Background

The Limberg flap reconstruction and the Karydakis flap reconstruction are the 2 most used off-midline closure techniques in pilonidal sinus surgery. The current evidence is inconclusive as to which is the optimal technique. The aim of this systematic review and meta-analysis was to compare differences in outcomes between these 2 flap-based techniques.

Methods

We identified studies by a systematic literature search of the Embase, MEDLINE (PubMed), Cochrane Library and Google Scholar databases and studies selected as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Only randomized controlled trials (RCTs) that compared the Limberg flap (standard or modified) and the Karydakis flap were included in this review.

Results

Operative time was shorter by 7 minutes in the Karydakis group than in the Limberg group (mean difference 7.00 min, 95% confidence interval [CI] 0.53 to 13.48). The seroma formation rate was significantly higher in the Karydakis cohort (odds ratio [OR] 0.36, 95% CI 0.24 to 0.56); however, after excluding studies with a high risk of bias, the sensitivity analysis showed no significant differences in seroma formation rate between the 2 techniques (OR 0.76, 95% CI 0.31 to 1.85). Other outcomes of interest showed no significant differences between the Limberg and Karydakis techniques.

Conclusion

There were no significant differences between the Limberg and Karydakis techniques. Future RCTs with strict adherence to CONSORT guidelines will further elucidate the efficacy of these surgical procedures.

[Selection of the method for surgical treatment of pilonidal disease without abscess formation]

The problem of the treatment of pilonidal disease, affecting 5% of the adult working-age population and occupying the fourth place in the structure of coloproctological diseases after hemorrhoids, paraproctitis and anal fissure, is extremely relevant today. The history of the choice of approaches to surgical treatment has almost 2 centuries. Based on different theories of etiopathogenesis, various methods of surgical treatment have been proposed. However, the results of treatment leave much to be desired. To date, there is no 'gold standard' of surgical treatment of pilonidal disease, nor any standardization in this matter. The aim of the investigation is to compare the two, in our opinion, the most versatile methods of surgical treatment of the nosology under consideration, which allow to achieve a good cosmetic result in cases of any complexity without long-term disability - Limberg flap and Bascom II plastics. Indicators such as the duration of the intervention, the level of postoperative pain, postoperative complications, the duration of disability, patient satisfaction with the cosmetic result, relapses were evaluated. As a result, patients after performing Bascom II noted less postoperative pain and were more satisfied with the cosmetic result. A significantly lower percentage of relapses was noted in the group with Limberg flap. The percentage of complications and terms of disability was not significantly different.

Comparison of Limberg Flap and Karydakis Flap Surgery for the Treatment of Patients With Pilonidal Sinus Disease: A Single-Blinded Parallel Randomized Study

Purpose

Pilonidal sinus disease is a common condition, which mostly affects young men. While various surgical techniques have been introduced for treating intergluteal pilonidal disease (IPD), controversies still exist regarding the best surgical approach. The purpose of this study was to compare the efficiency and the short-term outcomes of Limberg flap and Karydakis flap surgeries for the treatments of patients with IPD.

Methods

A total of 80 patients with IPD who had underwent either Karydakis flap (KF group: n = 37) or Limberg flap (LF group: n = 27) surgery between January 2015 and January 2016 at Imam Khomeini Hospital of Sari in the North of Iran were recruited for inclusion in this randomized, single-blind study.

Results

Compared to the KF group, the LF group showed faster complete wound healing, longer duration of surgery and hospital stay, larger wound size, and shorter period of incapacity for work. The overall patient satisfaction in the LF group was significantly higher than that in the KF group. The visual analogue scale score of pain was lower in the LF group than in the KF group. Also, the overall frequency of postoperative complications was higher in the KF group than in the LF group. Recurrence was reported in one patient from the KF group.

Conclusion

Given the lower rate of postoperative complications and greater cosmetic satisfaction of patients, the Limberg flap procedure should be selected, instead of the Karydakis flap procedure, as the standard technique for treating patients with IPD.

A systematic review of classification systems for pilonidal sinus

BACKGROUND

Pilonidal sinus disease (PSD) is a simple chronic inflammatory condition resulting from loose hairs forcibly inserted into vulnerable tissue in the natal cleft. It is an acquired disease with a slight familial tendency. There is no agreement on optimum treatment and the multitude of therapeutic options cannot be compared due to the lack of a universally adopted classification of the disease. The aim of our study was to perform a systematic review of the literature to determine how presentations of PSD are classified and reported.

METHODS

A systematic review of the English language literature was undertaken searching studies published after 1980.

RESULTS

Eight classification systems of PSD were identified. Most classification systems were based on anatomical pathology hypotheses. The location and number of sinuses were the main factors defining classification systems. No articles were retrieved that assessed the validity and/or reliability of the classification system employed. Furthermore, there was no evidence to suggest a correlation between prognosis outcome and subgroup.

CONCLUSIONS

Based on the evidence available from the literature reviewed we have no recommendations regarding the use of the current classification of PSD. A well-recognised and practical classification system to guide clinical practice is required.

Comparison of Three Surgical Techniques in Pilonidal Sinus Surgery

Our study aims to compare the surgical outcome of Limberg transposition flap, Karydakis flap, and primary closure after excision to treat sacrococcygeal pilonidal sinus disease. A total of 634 patients with pilonidal sinus who underwent surgery were evaluated retrospectively from January 2014 to January 2016. The patients were divided into three groups. Limberg transposition flap (LTF) was performed in 131 patients (group 1), Karydakis flap (KF) was performed in 232 patients (group 2) and primary closure (PC) after excision was performed in 271 patients (group 3). Patient demographics, operative and postoperative outcomes were recorded and analyzed retrospectively. The mean age (p=0.98), sex ratio (p=0.74) and removed sinus volume (p=0.67) were not statistically different between groups. Mean operative time was 54.3 ± 6.4 min for group 1, 46.8 ± 10.5 min for group 2, and 26.9 ± 5.8 min for group 3 respectively (p=0.01). When the length of hospital stay was compared, there was a significant difference in favor of primary closure (p=0.01). Regarding early surgical complication, Karydakis flap technique was superior to other groups (p&lt;0.001). The recurrent rate was higher in the primary closure group (p&lt;0.001). In our study, the primary closure method regarding the duration of surgery and hospitalization; Karydakis method regarding postoperative complications (seroma, hematoma, wound dissociation, infection, recurrence) were superior to the other two methods.

The Management of Pilonidal Sinus

BACKGROUND

Pilonidal disease is an acute or chronic infection in the subcutaneous fatty tissue, mainly in the natal cleft. Its incidence in Germany in 2012 was 48 cases per 100 000 persons per year.

METHODS

This review is based on pertinent publications retrieved by a selective literature search.

RESULTS

The numerous minimally invasive techniques that are available for the treatment of pilonidal disease have the advantages of being relatively atraumatic and of enabling the patient to continue working almost without interruption. They are suitable for small lesions that have not been previously surgically treated. These techniques are associated with a higher recurrence rate than excisional methods (level of evidence [LoE]: Ib). It is not yet clear whether minimally invasive techniques employing laser or endoscopic technology can reduce the recurrence rate. In systematic meta-analyses, the duration of wound healing was shorter after off-midline techniques (the Karydakis procedure, the Limberg procedure, and others) than after excision with open wound treatment; the off-midline techniques should, therefore, be preferred for patients who have undergone previous surgery and for those with large lesions (LoE: Ia). Excision with midline suturing should not be performed (LoE: Ia). Postoperative permanent shaving cannot be recommended either (LoE: IV).

CONCLUSION

Further randomized trials are needed to clarify the role of newer techniques in the treatment of pilonidal disease.

Effect of triclosan-coated sutures on surgical site infections in pilonidal disease: prospective randomized study

PURPOSE

The aim of this study is to investigate the effect of triclosan-coated sutures on surgical site infections after wide excision and primary closure for pilonidal disease.

METHODS

One hundred seventy-seven patients were randomized into two groups: 91 in control and 86 in triclosan groups. In the control group, 1/0 monofilament polypropylene retention sutures, 3/0 polyglactin subcutaneous sutures, and 3/0 polypropylene skin sutures were used. In the triclosan group, 1/0 triclosan-coated monofilament polydioxanone, 3/0 triclosan-coated polyglactin, and 3/0 triclosan-coated monofilament polydioxanone were used. Postoperative care and follow-up was made by a surgeon according to Centers for Disease Control guideline. Surgical site infection rates between groups were compared. Secondary outcomes were seroma and wound dehiscence.

RESULTS

Seroma was seen in 30 (16.9%) patients: 20 (23.3%) in the triclosan group and 10 (10.9%) in the control group (p = 0.030). Thirteen (7.3%) patients had superficial wound dehiscence: 5 (5.5%) patients in the control group and 10 (11.6%) patients in the triclosan group (p = 0.116). Overall surgical site infection (SSI) rate was 15.8% (n = 28): 19 (20.8%) patients in the control group and 9 (10.5%) patients in the triclosan group (p = 0.044). Healing was observed on mean 17.8 ± 6.7 days. Primary and secondary healing rates and time to healing were similar between groups.

CONCLUSION

Triclosan-coated sutures decreased surgical site infection rate but had no effect on time to healing in pilonidal disease. Seroma and wound dehiscence were more common in triclosan groups. Randomized trials are needed to clear the effect of triclosan-coated sutures on postoperative wound complications.

Karydakis procedure can be effectively performed in the lateral position

BACKGROUND

Karydakis published a large pilonidal series in 1992, reporting a recurrence rate of less than 1% and complication rate of 8.5%. The aim of this study was to compare the outcomes of Karydakis procedure (KP) performed in the lateral versus the prone position in a consecutive series.

METHODS

Ninety-seven consecutive patients undergoing a KP between March 2000 and February 2018 were retrospectively assessed. Patients with disease sinuses or fistulas extending from the midline to either left or right sides only were considered for KP in the contralateral side position.

RESULTS

Surgery was carried out for primary pilonidal disease in 71 patients (73%) and for recurrent disease in 26 patients (27%). The majority (62%) of pilonidal tracts veered off from the midline to either the left or right side only. Wound complications, mostly minor skin separation, occurred in 37 patients (38%). Disease recurrence occurred in eight patients (8%). There was no difference between patients who had KP in a lateral position compared with those operated in a prone position regarding wound complications (41% versus 35%, P = 0.675), disease recurrence (9% versus 7%, P = 1.000), mean operating time (64.6 min versus 66.6 min, P = 0.259) and mean length of hospital stay (1 day for both groups).

CONCLUSIONS

Pilonidal surgery in the lateral position has potential benefits for patient safety, patient comfort and theatre efficiency. The clinical results of this series show that the KP can be performed safely and effectively with the patient in the lateral position for most cases of pilonidal disease.

Pilonidal Sinus—Plenty of Literature yet Lack of Direction: A Pooled Analysis

A systematic analysis was conducted to compare various surgical treatment modalities and evaluate the short- and long-term outcomes in the management of sacrococcygeal pilonidal disease. Pilonidal sinus is a common and debilitating condition often requiring a surgical approach to treatment, of which many are available. Despite numerous treatment methods, no universal decision has been made as to the most efficient and effective surgical treatment. All randomized control trials published between January 1, 2003 and January 8, 2013 were accessed. Interventions included classic and modified Limberg flap, Karydakis flap, primary closure, and healing by secondary intention. Primary outcome measures included rate of surgical site infection, recurrence, and length of hospital stay. Secondary outcome measures were hematoma or seroma, and return to work. The search identified 22 articles suitable for inclusion in this review totaling 3693 patients. Analysis showed a 50% reduction in the rate of infection and recurrence in patients receiving closure with flaps compared with primary midline closure and healing by secondary intention. The Karydakis flap was shown to be more favorable cosmetically; however, it failed to compete with the classic and modified Limberg flap in treatment of complicated disease. No significant difference was noted between the modified Limberg and Limberg flap. These results show that the Karydakis flap, classic, and modified Limberg flap demonstrate significant benefits over healing by secondary intention and primary closure.

Pilonidal Disease: Classic and Contemporary Concepts for Surgical Management

BACKGROUND

Pilonidal disease (PD) is a recalcitrant condition associated with significant morbidity. It affects 26 in 100,000 individuals; however, there is no consensus on optimal surgical treatment, and up to half of patients struggle with recurrence. This review appraises the current literature on techniques and outcomes of PD surgery, to better guide decision making.

METHODS

A literature review using directed search terms was performed to identify studies addressing PD management, in accordance with the PRISMA guidelines. Data on techniques, outcomes, and complications were collected.

RESULTS

Open healing remains the most widely used treatment method and achieves reliable outcomes at the expense of prolonged wound healing, between 21 and 71 days. Asymmetric closure reduces healing time to 10 to 23 days and produces significantly fewer recurrences relative to midline closure (P < 0.05). Outcomes are similar between various asymmetric techniques; the Bascom cleft lift, Karydakis flap, and Limberg transposition are commonly used approaches which all demonstrate recurrence rates under 6%. Deroofing is associated with a significantly lower rate of complications than any closure procedure at 1.4% (P < 0.05), with recurrence in only 1% to 10% of patients, and represents a favorable treatment alternative.

CONCLUSIONS

Despite the heterogeneous nature of studies on PD, certain techniques have been consistently shown to optimize postoperative outcomes. Deroofing sinuses and allowing secondary healing results in low rates of recurrence with minimal morbidity. When closure is preferred, off-midline flaps provide more effective coverage than midline repair. Treatment recommendations should be guided by individualized patient preferences and be grounded in high-quality data.

The Surgical Management of Pilonidal Disease is Uncertain Because of High Recurrence Rates

Background Pilonidal disease is a common condition with no consensus for the best management of chronic disease or current practice in Australia and New Zealand. Methods A survey was distributed among 190 colorectal and 592 general surgeons in Australia and New Zealand. Data was obtained regarding pilonidal surgery volume, procedures performed, non-operative management and recurrence rates. Three clinical scenarios were also presented. Results The response rate was 58% among colorectal surgeons, 18% among general surgeons. Nineteen percent of surgeons were high-volume (>23 operations per year), 47% low-volume (<12 operations per year). The commonest procedure was the Karydakis procedure (77%), with many others performed including rhomboid flaps (36%), Bascom cleft lift (13%), Z-plasty (7%), and gluteal rotation flaps (5%). Fifty-five percent of high-volume surgeons offered more than one operation while only 16% of low-volume surgeons did. Nineteen percent operated on all patients with pilonidal disease, 89% believing off-midline closure to be superior to midline. Disease extent was the main driver for non-operative management; patient factors such as cosmesis and time-off work being the least important. Sixty-four percent reported recurrence rates above 5%, and 37% recurrence rates >10%. Six percent reported no recurrences ever. Five percent reported recurrence rates over 20%, but 24% stated that over one-fifth of their practice consists of recurrent disease. Conclusions This study reports higher recurrence rates than in published series, suggesting many surgeons do not see their own recurrences, with current treatment not as successful as previously thought. Combined with the widespread variation in practice, optimal management of this disease remains unclear.

Fascio-Adipo-Cutaneous Lateral Advancement Flap for Treatment of Pilonidal Sinus: A Modification of the Karydakis Operation-Cohort Study

BACKGROUND

Pilonidal sinus is a common chronic disease affecting young adults. Many surgical procedures have been developed for its treatment, but an optimal one has still not been achieved. This study presents a modification to the Karydakis operation.

METHODS

A total of 265 patients with chronic pilonidal sinus between May 2008 and May 2015 were included in this study and submitted to fascio-adipo-cutaneous lateral advancement flap as 1-day case surgery. Any Septic complication was treated firstly. Follow-up examinations were conducted during the first three postoperative months at the outpatient clinic at regular intervals and thereafter by phone calls or direct examination to check for recurrences.

RESULTS

Males constituted 93.6% with a mean age of 21.6 ± 7.7 year. The median disease duration was 15 months. Twenty-eight patients had recurrent disease. The mean operative time was 41.4 ± 12.7 min. The mean time out of work was 11.6 ± 4.6 days. Complications occurred in 19 patients (7.1%) in the form of seroma in six patients (2.2%), superficial wound infection occurred in nine patients (3.3%), cuticular wound disruption occurred in four patients (1.5%). All patients completed 3-months follow-up, but 48 patients were lost at variable intervals with the remaining 217 patients completed follow-up throughout the period of the study with a median follow-up of 43 months. No reported recurrence and 96.7% of the patients were satisfied about their wound.

CONCLUSION

This modification is simple with low complication rate, no recurrence, and excellent patient satisfaction.

Rotational gluteal flap versus modified Limberg flap in treatment of sacrococcygeal pilonidal disease

BACKGROUND

Sacrococcygeal pilonidal disease (SPND) is a common surgical condition with a multitude of surgical treatments. The aim of this study was to compare the outcome of modified Limberg flap (MLF) and that of rotational gluteal flap (RGF) in treatment of SPND.

MATERIALS AND METHODS

This was a retrospective case-controlled study involving adult patients of both genders who were treated with either MLF or RGF for SPND. The main outcomes of the study were the recurrence of SPND, complications, operation time, hospital stay, time of healing, time to return to daily activities, and cosmetic outcomes.

RESULTS

A total of 189 (143 males) patients with a mean age of 23.5 y were included. Ninety-five patients were treated with RGF (cases), and 94 were treated with MLF (controls). Both the groups were matched regarding age, gender, body mass index, and disease severity. The operation time of RGF was longer than that of MLF (P < 0.0001). No significant difference in recurrence was noted between RGF and MLF (3.1% versus 7.4%, P = 0.21). RGF had lower complication rate than MLF (17.9% versus 40.4%; P = 0.001). Time to return to work was similar in both the groups. RGF conferred significantly better cosmetic outcomes than MLF.

CONCLUSIONS

Both RGF and MLF achieved comparable, low recurrence rates. Although the operation time of RGF was significantly longer than that of MLF, the RGF had shorter healing time; lower complication rate, particularly seroma formation; and better cosmetic appearance.

Wound closure with Karydakis flap is decreasing the perioperative costs after pilonidal sinus excision as compared to lay-open approach

PURPOSE

To assess the impact of a simple flap closing procedure by Karydakis flap (KF) after pilonidal sinus excision on the costs and healing time as compared to routine lay-open technique.

METHOD

Out of 44 consecutive patients operated on for pilonidal excision (November 2013-March 2015), 17 had a Karydakis flap and 27 a lay-open procedure. For each patient, the length of stay, the operating time (OT), the time needed for complete healing and postoperative care resources were recorded. The global costs included OT, nursing care quantity, and modalities until complete scar healing.

RESULTS

One reoperation in the lay-open group was necessary during the follow-up (8±5months). No recurrence occurred. Postoperative morbidity was similar in both groups. Results showed that KF global cost was inferior as compared to lay-open technique (941±178€ vs. 1601±399€; P=0.0001), KF healed faster (32±17 vs. 59±22days; P=0.0001), whereas OT was longer in KF group (16±7 vs. 25±4min; P=0.001).

CONCLUSION

KF allows a faster healing time and a 41% lower cost than lay-open technique. Preferential use of KF rather than lay-open procedure could allow a significant health cost saving.

Treatment Options for Pilonidal Disease

Pilonidal disease can be treated medically; however, surgical excision remains the gold standard. Nonetheless, all current surgical approaches are still associated with potential for tissue loss, wound healing disorders, and high rates of recurrence. Aim of this study is to assess the long-term outcomes of the minimal-invasive pit-picking operation in comparison to the well-established technique of Karydakis flap-closure. Medical records of all patients undergoing either Karydakis flap-closure or the pit-picking operation for pilonidal disease at our department were reviewed retrospectively. A total of 101 patients were treated either by excision and Karydakis flap-closure (n = 62) or by the pit-picking operation (n = 39). Mean follow-up time was 65.5 (range: 38–101) months, including data collection using a standardized questionnaire. Analysis of the outcomes revealed no significant differences between the Karydakis flap-closure- and the pit-picking groups; however, the latter was associated with faster recovery, no need for hospitalization and overall low complication rates. In summary, the main advantages of the pit-picking operation lie in its’ outpatient character, the simplicity of the procedure, low complication rates, short recovery time, and predictably good results.

Modified Dufourmentel flap with superior pedicle: a useful technique for sacrococcygeal pilonidal sinus

PURPOSE

In order to prevent postoperative infection and recurrence of sacrococcygeal pilonidal sinus, the authors developed a modified Dufourmentel flap, involving the superior pedicles, and designed a descriptive prospective study to evaluate its efficiency.

METHODS

Between July 2007 and March 2014, 16 patients with sacrococcygeal pilonidal sinus were treated with an irregular quadrilateral excision and reconstruction by a modified Dufourmentel flap with superior pedicle. The duration of wound healing, presence of wound complications and permanent hypoesthesia, and recurrence rates were recorded and assessed.

RESULTS

None of the patients developed flap necrosis or wound infection postoperatively. The duration of wound healing was 7.2 ± 2.9 (range = 6-15) days. Wound dehiscence was demonstrated in only one patient (6.3%). The mean follow-up period was 4 years and 2 months (range = 4 months-8 years and 8 months), whereby no permanent hypoesthesia or recurrence was detected.

CONCLUSION

The modified Dufourmentel flap with superior pedicle can be safely used as a treatment of sacrococcygeal pilonidal sinus, with excellent results.

Comparison of modified Limberg flap and Karydakis flap operations in pilonidal sinus surgery: prospective randomized study

The best surgical technique for pilonidal sinus disease (PSD) is still disputed. The objective of this prospective randomized study is to compare the short and long-term results of modified Limberg flap and Karydakis flap surgeries that have been widely used in recent years. Ninety one patients were included in the study. The patients were divided into two groups: modified Limberg flap (MLF; n = 46) and Karydakis flap (KF; n = 45). Preoperative findings of the patients, their surgical findings, and short and long-term postoperative findings were recorded and statistically compared. While no significant difference was discovered between the groups in terms of postoperative analgesic need, hospital stay, postoperative infection rate, drain stay time, painless sitting time, painless toilet-sitting time, and painless walking time, return to work or school time was shorter in the MLF group compared with the KF group (20.61 ± 7.89 days, 23.29 ± 6.42, respectively; P < 0.05). Cosmetically, the visual analog scale (VAS) of the KF group was significantly higher than that of the MLF group (VAS score 7.12 ± 1.28, 5.45 ± 1.77, respectively; P < 0.05). Considering recurrence rates, no statistically significant difference was found between the groups. Our study found out that short and long-term results of the MLF and KF procedures are similar. We believe both methods can be safely used in surgical PSD treatment given that in the MLF procedure, shorter return-to-work time is achieved, while the procedure provides better cosmetic results.

[Pilonidal sinus: Secondary wound closure vs. Limberg flap : Cost and satisfaction analysis]

BACKGROUND

After excision of a pilonidal sinus, several treatment options are possible, but no gold standard has been established. A literature review revealed no study comparing the costs and time off work after either secondary wound closure or treatment with a Limberg transposition flap. The aim of this study was to focus on these aspects by analysing the patients treated at the KlinikumStadtSoest.

METHOD

Sixty patients with pilonidal sinus after excision were treated either by secondary wound closure or Limberg transposition flap at the KlinikumStadtSoest between 2011 and 2012. The authors analysed retrospectively the patients' demographics, cost, and satisfaction with both techniques and compared them.

RESULTS

For secondary wound closure (group 1) 19 out of 31 patients and for Limberg transposition flap (group 2) 21 out of 29 met the inclusion criteria. Time off work following the final surgery (group 1: 69 day vs. group 2: 30 days, p = 0.046) and the number of dressing changes (group 1: 107 times vs. group 2: 16 times, p = 0.000) were significantly lower in the group of Limberg transposition flap (group 2) as well as the associated costs. The surgery-related costs were lower when treated by secondary wound closure.

DISCUSSION

Plastic reconstruction with Limberg transposition flap (group 2) provides a chance to reduce the period of incapacity for work due to a shorter treatment period. With that said, patients should nonetheless be offered both techniques as the current literature does not reveal a clear benefit for either procedure.

Modified Primary Closure Method for the Treatment of Pilonidal Sinus

OBJECTIVE

Pilonidal sinus (PS) is considered to be the acquired disease of especially in the sacrococcygeal region. Various primary or secondary or flap methods, accompanied by one of local curettage, phenol application, electro-cauterization and total sinus excision methods, are used for the treatment of pilonidal sinus. However, currently there is not a single widely accepted treatment method.

MATERIALS AND METHODS

Ninety-eight patients who had operation for PS in Atatürk University, Department of General Surgery between January 2012 and August 2014 were included in this study. The patients were categorized into two groups: first, the patients undergone total sinus excision with primary closure (Group 1), and second, patients undergone total sinus excision with modified primary closure (MPC) (Group 2). Among all 98 patients participated in this study, age, sex, type of operation, duration of operation, amount of excised skin, duration of postoperative stay at hospital and complications were evaluated.

RESULTS

Forty-four patients (44.9%) underwent primary closure method, while 54 patients (55.1%) underwent MPC method. Mean duration of operation was 39.1 (30-60) minutes, mean diameter of excised material was 9.3 (8-11) cm(2) and mean duration of stay at hospital was 1.4 (1-3) days for the patients in the first group. Meanwhile, duration of operation was 52.2 (35-70) minutes, mean diameter of excised material was 2.6 (2-4) cm(2) and mean duration of stay at hospital was 1.6 (1-3) days for the patients in the second group. There was statistically significant difference between the two groups by means of duration of operation, dehiscence of surgical wound, recurrence and development of general complications (p<0.001, p<0.05, p<0.05 and p<0.005, respectively). According to the multivariate analysis, during surgical treatment of pilonidal sinus, primary closure method increases the rate of complication 6.65 times and MPC method increases the duration of operation 1.2 times.

CONCLUSION

We hereby suggest that MPC method could be a good alternative for surgical treatment of PS, because it causes fewer complications and recurrence.

Early results with the Mutaf technique: a novel off-midline approach in pilonidal sinus surgery

Purpose

The objective of the present study was to compare different off-midline techniques in terms of their advantages and disadvantages.

Methods

A total of 81 patients were included in this prospective, controlled, randomized study. Patients in group 1 were treated with the Limberg flap, and patients in group 2 were treated with Mutaf technique. Patients were followed up for 9 months postsurgically and assessed at regular intervals.

Results

A total of 41 and 40 patients received surgical treatment with Limberg or Mutaf techniques, respectively. The 2 groups were similar in terms of age, gender, body mass index, and Tezel pilonidal sinus classification. Also, the 2 groups were comparable with regard to the frequency of preoperative discharge from the wound site, history of abscess formation, and the resultant antibiotic use. Early results showed similar recurrence rates and surgical-site complications between the 2 groups. Although a lower visual analogue scale score was found in group 2 at postoperative day 1, seroma persistence, time to withdrawal of surgical drains, and wound healing were more prolonged.

Conclusion

In this study, Mutaf technique was comparable to Limberg flap in the treatment of pilonidal sinus. Therefore, Mutaf technique may be offered as a viable surgical therapeutic option among off-midline closure approaches.

A proposed staging system for chronic symptomatic pilonidal sinus disease and results in patients treated with stage-based approach

BACKGROUND

Although there are many therapeutic options to manage patients with sacrococcygeal pilonidal sinus disease, there remains controversy over a gold standard method for treating such patients. Most studies regarding sacrococcygeal pilonidal sinus, collected patients in a single pool, and single modality was performed to all patients so far. Staging according to the progressive nature of disease and comparisons of stage-based treatment approaches are yet to be conducted. This study aimed to define a staging system and to evaluate outcomes with the use of stage-based treatment approach.

METHODS

The collected data of patients who underwent surgery for the treatment of pilonidal sinus disease prior to June 2011 were analyzed. Following this analysis, a staging system was defined based on morphological extent of disease (stage I to stage IV for primary disease, and stage R for recurrent disease). Specific surgical technique was used for each stage. Between June 2011 and December 2014, 367 patients were operated based on proposed staging system and treatment algorithm. Demographics, perioperative data, short-term and long-term outcomes were evaluated according to the disease stage.

RESULTS

For all patients, the median length of hospital stay was 1 (range, 0-4) day. Primary healing without any wound complications was achieved in 320 (87.2%) patients. The median time to functional recovery was 10 (range, 2-35) days and for wound healing was 12 (range, 10-55) days. Disease recurrence was identified in six (1.6%) patients within the median follow-up period of 29 (range, 5-47) months. The outcomes of each stage were evaluated separately.

CONCLUSIONS

We believe that the proposed staging system and stage-based treatment approach, which need further validation, will have an efficacy in the treatment of chronic pilonidal sinus disease and will contribute to the development of more appropriate individualized management approaches. Moreover, the use of this staging system will likely facilitate sharing and comparing more specific clinical data from future studies.

TRIAL REGISTRATION

NCT02712970 (ClinicalTrials.gov/09.03.2016).

Recurrence-free survival, but not surgical therapy per se, determines 583 patients' long-term satisfaction following primary pilonidal sinus surgery

PURPOSE

With pilonidal sinus disease (PSD) incidence increasing and patients freely choosing their surgeon, patients' interest issues have been brought forward estimating patient satisfaction following pilonidal sinus surgery. The influence of wound healing time and long-term recurrence rate on patient satisfaction in primary PSD surgery has not been investigated yet.

METHODS

Five hundred eighty-three patients (German military cohort) were interviewed, compiling wound healing time, aesthetic satisfaction, long-term recurrence-free survival and patient satisfaction having undergone primary open (PO) treatment, marsupialization (MARS) or primary midline closure (PMC) treatment. Recurrence rate was determined by Kaplan-Meier calculation following up to 20 years after primary PSD surgery.

RESULTS

Patient satisfaction ranking from 1 to 10 (10 = max. satisfied) showed an average satisfaction of 8.2 (range 0-10; 95% confidence interval (CI) 7891-8250). In-hospital stay time was significantly longer in primary open (PO) and marsupialization (MARS) group as compared to primary midline closure (PMC; p < 0.0001, Kruskal-Wallis test). Satisfaction was comparable between treatment groups, and was neither linked to in-hospital stay time nor to longer outpatient wound care period or total treatment time. Recurrence-free survival, as seen in the PO and PMC treatment group, revealed a highly significant difference for all patients. Improvement in MARS patients with versus without recurrence was low, as satisfaction with primary treatment was lower as the other groups.

CONCLUSIONS

Neither choice of surgical treatment nor treatment duration within hospital or after hospital influences patient satisfaction, as long as recurrence-free survival can be provided. Marsupialization was ranked lower in both groups (with or without recurrence), and should be abandoned, as patients are significantly less satisfied with either results, independent of recurrence.