Comparison of modified Limberg flap transposition and lateral advancement flap transposition with Burow’s triangle in the treatment of pilonidal sinus disease

Treatment options for patients with pilonidal sinus disease: PITSTOP, a mixed-methods evaluation

Background

There is no consensus on optimal management of pilonidal disease. Surgical practice is varied, and existing literature is mainly single-centre cohort studies of varied disease severity, interventions and outcome assessments.

Objectives

A prospective cohort study to determine: • disease severity and intervention relationship • most valued outcomes and treatment preference by patients • recommendations for policy and future research.

Design

Observational cohort study with nested mixed-methods case study. Discrete choice experiment. Clinician survey. Three-stage Delphi survey for patients and clinicians. Inter-rater reliability of classification system.

Setting

Thirty-one National Health Service trusts.

Participants

Patients aged > 16 years referred for elective surgical treatment of pilonidal disease.

Interventions

Surgery.

Main outcome measures

Pain postoperative days 1 and 7, time to healing and return to normal activities, complications, recurrence. Outcomes compared between major and minor procedures using regression modelling, propensity score-based approaches and augmented inverse probability weighting to account for measured potential confounding features.

Results

Clinician survey: There was significant heterogeneity in surgeon practice preference. Limited training opportunities may impede efforts to improve practice. Cohort study: Over half of patients (60%; N = 667) had a major procedure. For these procedures, pain was greater on day 1 and day 7 (mean difference day 1 pain 1.58 points, 95% confidence interval 1.14 to 2.01 points, n = 536; mean difference day 7 pain 1.53 points, 95% confidence interval 1.12 to 1.95 points, n = 512). There were higher complication rates (adjusted risk difference 17.5%, 95% confidence interval 9.1 to 25.9%, n = 579), lower recurrence (adjusted risk difference -10.1%, 95% confidence interval -18.1 to -2.1%, n = 575), and longer time to healing (>34 days estimated difference) and time to return to normal activities (difference 25.9 days, 95% confidence interval 18.4 to 33.4 days). Mixed-methods analysis: Patient decision-making was influenced by prior experience of disease and anticipated recovery time. The burden involved in wound care and the gap between expected and actual time for recovery were the principal reasons given for decision regret. Discrete choice experiment: The strongest predictors of patient treatment choice were risk of infection/persistence (attribute importance 70%), and shorter recovery time (attribute importance 30%). Patients were willing to trade off these attributes. Those aged over 30 years had a higher risk tolerance (22.35-34.67%) for treatment failure if they could experience rapid recovery. There was no strong evidence that younger patients were willing to accept higher risk of treatment failure in exchange for a faster recovery. Patients were uniform in rejecting excision-and-leave-open because of the protracted nursing care it entailed. Wysocki classification analysis: There was acceptable inter-rater agreement (κ = 0.52, 95% confidence interval 0.42 to 0.61). Consensus exercise: Five research and practice priorities were identified. The top research priority was that a comparative trial should broadly group interventions. The top practice priority was that any interventions should be less disruptive than the disease itself.

Limitations

Incomplete recruitment and follow-up data were an issue, particularly given the multiple interventions. Assumptions were made regarding risk adjustment.

Conclusions and future work

Results suggest the burden of pilonidal surgery is greater than reported previously. This can be mitigated with better selection of intervention according to disease type and patient desired goals. Results indicate a framework for future higher-quality trials that stratify disease and utilise broad groupings of common interventions with development of a patient-centred core outcome set.

Trial registration

This trial is registered as ISRCTN95551898.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/17/02) and is published in full in Health Technology Assessment; Vol. 28, No. 33. See the NIHR Funding and Awards website for further award information.

Midline and off-midline wound closure methods after surgical treatment for pilonidal sinus

BACKGROUND

Pilonidal sinus disease is a common and debilitating condition. Surgical treatment remains the mainstay for managing chronic disease, with options including midline and off-midline wound closure methods. However, the optimal approach remains uncertain. Recent developments in tension-free midline techniques require further exploration.

OBJECTIVES

To assess the effects of midline and off-midline wound closure methods for pilonidal sinus, and to determine the optimal off-midline flap procedures.

SEARCH METHODS

In June 2022, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus EBSCO, and clinical trials registries. We also scanned the reference lists of included studies, as well as reviews, meta-analyses, and health technology reports. We applied no language, publication date, or study setting restrictions.

SELECTION CRITERIA

We included parallel RCTs involving participants undergoing midline closure without flap techniques and off-midline closure for pilonidal sinus treatment. We excluded quasi-experimental studies and studies that enroled participants presenting with an abscess.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. The critical outcomes included wound healing (time to wound healing, proportion of wounds healed), recurrence rate, wound infection, wound dehiscence, time to return to work, and quality of life. We assessed biases in these outcomes utilising the Cochrane risk of bias 2 tool and appraised evidence certainty via the GRADE approach.

MAIN RESULTS

We included 33 studies with 3667 analysed participants. The median or average age of the participants across the included studies ranged from 21.0 to 34.2 years, with a predominant male representation. Geographically, the trials were primarily conducted in the Middle East. We identified nine intervention comparisons. In this abstract, we focus on and present the summarised findings for the three primary comparisons. Off-midline closure versus conventional midline closure Off-midline closure probably reduces the time to wound healing (mean difference (MD) -5.23 days, 95% confidence interval (CI) -7.55 to -2.92 days; 3 studies, 300 participants; moderate-certainty evidence). However, there may be little to no difference between the two methods in the proportion of wounds healed (100% versus 88.5%, risk ratio (RR) 1.13, 95% CI 0.92 to 1.39; 2 studies, 207 participants; very low-certainty evidence). Off-midline closure probably results in lower rates of recurrence (1.5% versus 6.8%, RR 0.22, 95% CI 0.11 to 0.45; 13 studies, 1492 participants; moderate-certainty evidence) and wound infection (3.8% versus 11.7%, RR 0.32, 95% CI 0.22 to 0.49; 13 studies, 1568 participants; moderate-certainty evidence), and may lower rates of wound dehiscence (3.9% versus 8.9%, RR 0.44, 95% CI 0.27 to 0.71; 11 studies, 1389 participants; low-certainty evidence). Furthermore, off-midline closure may result in a reduced time to return to work (MD -3.72 days, 95% CI -6.11 to -1.33 days; 6 studies, 820 participants; low-certainty evidence). There were no data available for quality of life. Off-midline closure versus tension-free midline closure Off-midline closure may reduce the time to wound healing (median 14 days in off-midline closure versus 51 days in tension-free midline closure; 1 study, 116 participants; low-certainty evidence) and increase wound healing rates at three months (94.7% versus 76.4%, RR 1.24, 95% CI 1.06 to 1.46; 1 study, 115 participants; low-certainty evidence), but may result in little to no difference in rates of recurrence (5.4% versus 7.8%, RR 0.69, 95% CI 0.30 to 1.61; 6 studies, 551 participants; very low-certainty evidence), wound infection (2.8% versus 6.4%, RR 0.44, 95% CI 0.16 to 1.17; 6 studies, 559 participants; very low-certainty evidence), and wound dehiscence (2.5% versus 3.0%, RR 0.82, 95% CI 0.17 to 3.84; 3 studies, 250 participants; very low-certainty evidence) compared to tension-free midline closure. Furthermore, off-midline closure may result in longer time to return to work compared to tension-free midline closure (MD 3.00 days, 95% CI 1.52 to 4.48 days; 1 study, 60 participants; low-certainty evidence). There were no data available for quality of life. Karydakis flap versus Limberg flap Karydakis flap probably results in little to no difference in time to wound healing compared to Limberg flap (MD 0.36 days, 95% CI -1.49 to 2.22; 6 studies, 526 participants; moderate-certainty evidence). Compared to Limberg flap, Karydakis flap may result in little to no difference in the proportion of wounds healed (80.0% versus 66.7%, RR 1.20, 95% CI 0.77 to 1.86; 1 study, 30 participants; low-certainty evidence), recurrence rate (5.1% versus 4.5%, RR 1.14, 95% CI 0.61 to 2.14; 9 studies, 890 participants; low-certainty evidence), wound infection (7.9% versus 5.1%, RR 1.55, 95% CI 0.90 to 2.68; 8 studies, 869 participants; low-certainty evidence), wound dehiscence (7.4% versus 6.2%, RR 1.20, 95% CI 0.41 to 3.50; 7 studies, 776 participants; low-certainty evidence), and time to return to work (MD -0.23 days, 95% CI -5.53 to 5.08 days; 6 studies, 541 participants; low-certainty evidence). There were no data available for quality of life.

AUTHORS' CONCLUSIONS

This Cochrane review examines the midline and off-midline wound closure options for pilonidal sinus, predominantly based on young adult studies. Off-midline flap procedures demonstrate there may be benefits over conventional midline closure for pilonidal sinus, with various off-midline flap techniques. When off-midline flap closures were compared to tension-free midline closure, low-certainty evidence indicated there may be improved wound healing and increased time to return to work for off-midline closure, whilst very low-certainty evidence indicated there may be no evidence of a difference in other outcomes. There may be no evidence of an advantage found amongst the off-midline techniques evaluated. The choice of either procedure is likely to be based on a clinician's preference, experience, patient characteristics, and the patients' preferences. To more accurately determine the benefits and potential harms of these closure techniques, further large-scale and meticulously-designed trials are essential. Specifically, there is a pressing need for more studies addressing the paediatric population, in addition to adult studies.

Comparison of the Keystone flap and the Limberg flap technique in the surgical treatment of pilonidal sinus disease

Pilonidal sinus (PS) disease is a chronic inflammatory disease of the sacrococcygeal region. Although various methods have been described for surgical treatment, there is no consensus on the best surgical technique. The aim of this study was to present the results of a new advancement flap technique named the "Keystone flap (KSF)" and compared with the Limberg flap (LF) technique in pilonidal sinus surgery. A retrospective review was made of 124 consecutive patients surgically treated for PS disease with KSF and LF procedures. Baseline characteristics, operation time, volume of excised specimen, duration of hospitalization, duration of drainage, duration of healing, time to return to work, local complications and recurrence were evaluated and compared between the two procedures. Operation time, healing time, and time to return to work were significantly shorter in the KSF group. Partial wound dehiscense and prolonged wound healing were more common in the LF group. An additional intervention in the operating room was required by 21.1% of the LF group and was a significantly lower rate in the KSF group at 7.5%. There was no significant difference between the groups in terms of recurrence. The KSF procedure seems promising for treating pilonidal sinus disease, with the advantages of shorter operation, healing, and return to work times. It also provides lower partial wound dehiscence and necrosis rates.

Combined Horizontal Split Gluteus Maximus Muscle and Fasciocutaneous Limberg Flaps for Reconstruction of Recurrent Sacrococcygeal Pilonidal Sinus

Pilonidal sinus is a chronic recurrent medical disease. The exact etiology of the disease is still unknown, but the most accepted theory is an acquired condition characterized by infected sinus in the natal cleft area containing a lifeless hair tuft. Multiple techniques were prescribed for its treatment; however, the ideal method is not yet defined.

Methods

The study population includes 58 male patients who underwent excision of their recurrent pilonidal sinus, and the resulting defects were reconstructed using combined horizontal split gluteus maximus flaps and rhomboid flaps. Outcomes were revised from patient case files and followed up in our outpatient clinic and via questionnaires.

Results

The mean hospital stay was 3 days. The mean time to return to work was 16 days. Partial wound dehiscences occurred in 2 patients. Distal end flap necrosis occurred in 1 patient. There were no flap losses, no recurrences, no infections, no loss of function, and no seromas during a mean follow-up period of 24 months. All patients were satisfied with the results.

Conclusions

This technique has an operative time and hospital stays comparable to those of other techniques. It has minimal and acceptable complication rates and no recurrences. We can conclude that this procedure of combined split gluteus maximus muscle flap and rhomboid flap provides an excellent, effective, easy, and feasible method of choice for reconstructing defects of recurrent pilonidal sinus disease.

Surgical procedures in the pilonidal sinus disease: a systematic review and network meta-analysis

The most appropriate surgical treatment for pilonidal sinus disease (PSD) is still in dispute. This study aims to comprehensively compare the outcomes of surgical interventions using network meta-analysis. Randomized controlled trial studies were searched systematically to identify all eligible studies in multiple databases and previous publications and Bayesian network meta-analysis was performed. Our primary outcome was the recurrence rate. Differences in the findings of the studies were explored in meta regressions and sensitivity analyses. The risk of bias of each study was assessed using the Cochrane risk of bias tool. Confidence in evidence was assessed using CINeMA (Confidence in Network Meta-Analysis). A total of 39 studies and 5,061 patients were identified and the most common surgical intervention was the Limberg flap. In network meta-analysis, modified Limberg flap and off-midline closure were associated with the lowest recurrence rate. However, the Karydakis flap was associated with shorter operation time by several minutes compared with other interventions and few significant results were found in other outcomes. Modified Limberg flap and off-midline closure provided relatively low recurrence and complications rates. Therefore, they could be two promising surgical interventions for PSD patients.

Impact of geography and surgical approach on recurrence in global pilonidal sinus disease

Pilonidal sinus disease (PSD) is increasing globally. A recent meta-analysis and merged-data analysis showed that recurrence rates in PSD depend essentially on follow-up time and specific surgical procedures. However, the global distribution of surgical approaches and respective recurrence rates have never been studied in PSD. We aimed at studying the impact of geographic distribution of surgical approaches to treat PSD and subsequent geography-specific recurrence rates. We searched relevant databases as described previously. Recurrence rates were then associated with reported follow-up times and geographic origin. We simulated individual patients to enable analogy across data. Globally, recurrence rates range from 0.3% for Limberg/Dufourmentel approaches (95% CI 0.2–0.4) and flaps (95% CI 0.1–0.5) and up to 6.3% for incision (95% CI 3.2–9.3) at 12 months. Recurrence rates range from 0.3% for Karydakis/Bascom approaches (95% CI 0.0–0.8) up to 67.2% for incision (95% CI 7.5–100) in the USA, and 0.0% for primary asymmetric closure in Germany (95% CI 0.0–0.0). Our analysis shows that recurrence rates in PSD not only depend on therapeutic approaches and follow-up time but also on geography. Primary asymmetric closure and various flap techniques remain superior regardless of the geographical region. Some approaches have extraordinarily good outcomes in specific countries.

A New Oval Advancement Flap Design for Reconstruction of Pilonidal Sinus Defect

BACKGROUNDS

Pilonidal sinus is a common chronic disease of the sacrococcygeal region. Although many surgical methods have been described for treating pilonidal sinus disease, controversy still exists as to the best surgical technique. The aim of this study is to present a new modified advancement flap technique named "omega flap" for the treatment of pilonidal sinus disease.

MATERIALS AND METHODS

This study included 18 patients with pilonidal sinus who were treated between March 2012 and August 2014. All cases underwent oval excision and omega advancement flap reconstruction. Defect size, postoperative complications, postoperative pain, painless sitting time, patient satisfaction and recurrence were evaluated retrospectively.

RESULTS

All patients were discharged on the first postoperative day. There was no flap necrosis. No recurrence and no major complication were observed during follow-up period. The outcomes were also satisfactory regarding functionally and aesthetically, and the patients were satisfied with the results.

CONCLUSIONS

Presented method has a different geometry than classical advancement flap methods. Our technique provides two-layered repair with minimal tension and off-midline closure for the reconstruction of pilonidal sinus defect. It is easily performed, reliable, associated with no recurrens and good aesthetic results.

Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence

We systematically searched available databases. We reviewed 6,143 studies published from 1833 to 2017. Reports in English, French, German, Italian, and Spanish were considered, as were publications in other languages if definitive treatment and recurrence at specific follow-up times were described in an English abstract. We assessed data in the manner of a meta-analysis of RCTs; further we assessed non-RCTs in the manner of a merged data analysis. In the RCT analysis including 11,730 patients, Limberg & Dufourmentel operations were associated with low recurrence of 0.6% (95%CI 0.3-0.9%) 12 months and 1.8% (95%CI 1.1-2.4%) respectively 24 months postoperatively. Analysing 89,583 patients from RCTs and non-RCTs, the Karydakis & Bascom approaches were associated with recurrence of only 0.2% (95%CI 0.1-0.3%) 12 months and 0.6% (95%CI 0.5-0.8%) 24 months postoperatively. Primary midline closure exhibited long-term recurrence up to 67.9% (95%CI 53.3-82.4%) 240 months post-surgery. For most procedures, only a few RCTs without long term follow up data exist, but substitute data from numerous non-RCTs are available. Recurrence in PSD is highly dependent on surgical procedure and by follow-up time; both must be considered when drawing conclusions regarding the efficacy of a procedure.

Comparison between primary closure with Limberg Flap versus open procedure in treatment of pilonidal sinus, in terms of frequency of post-operative wound infection

Objective

Pilonidal sinus is a disorder of the sacrococcygeal region affecting younger individuals with a higher hair and weight distribution. Treatment involves the use of various surgical modalities, most of which are associated with a high rate of complications. Open procedure (OP) and Limberg Flap (LF) are two commonly performed surgical procedures for the correction of pilonidal sinus disease in our setup. The objective of our study was to compare the treatment of pilonidal sinus disease by primary closure with Limberg Flap verses Open procedure in terms of frequency of postoperative wound infection.

Methods

The study is a randomized clinical trial (RCT) conducted at the department of surgery, military hospital, Rawalpindi, Pakistan. It was carried out over a period of 8 months from 16 February, 2015 to 16 September, 2015. Using consecutive non-probability sampling, a total of 60 patients were selected, 30 of whom underwent Limberg Flap procedure and the remaining 30 underwent open procedure. Postoperatively, observations for wound infection on date of discharge and then again on the various follow-up visits over the next 3 weeks. The data collected was then compared by applying the chi-square test, with p-value less than 0.05 considered statistically significant.

Results

Our results showed that both primary closure with Limberg flap, and open procedure are comparable options in terms of wound infection. There was no statistical significance in the incidence of post operative infections, between the two surgeries.

Conclusion

In terms of wound infection, both procedures are satisfactory surgical procedures for Pilonidal sinus disease.