Bilateral gluteal advancement flap for treatment of recurrent sacrococcygeal pilonidal disease: A prospective cohort study

Bilateral Gluteal Fasciocutaneous Advancement Flaps With and Without Tie-Over Sutures in Treatment of Chronic Pilonidal Disease: A Prospective Case Series

PURPOSE

Flap procedures following pilonidal excision have high recurrence and dehiscence rates. We present a cosmetic, outpatient technique to reconstruction via bilateral gluteal fasciocutaneous advancement flaps with and without tie-over sutures.

METHODS

This is a prospective case series of 51 patients (40 males and 11 females). Following elliptical excision of pilonidal disease, gluteal fasciocutaneous advancement flaps were elevated circumferentially using blunt, discontinuous dissection, and a multilayered closure was performed. The resulting scar was midline. Thirty-five patients (68.6%) also had two full-thickness, compressing sutures tied over rolled up gauze.

RESULTS

Patients had a mean age of 28.2 and body mass index of 26.8. Eight (15.9%) were smokers and 11 (21.6%) were obese. At a mean follow-up of 38.7 months, there were no recurrences and 19 (37.3%) patients had wound dehiscence. There was no significant difference in dehiscence between patients with and without tie-over sutures (31.4% vs 50%, P = 0.20). There was no significant difference in dehiscence between smokers and non-smokers, (62.5% vs 41.9%, P = 0.47), or between obese and non-obese patients (36.4% vs 46.3%, P = 0.51). Obese patients with tie-over sutures had significantly less dehiscence compared to obese patients without tie-over sutures (14% vs 75%, P = 0.03).

CONCLUSION

Bilateral gluteal fasciocutaneous advancement flap with consideration of tie-over sutures is an outpatient treatment for chronic pilonidal disease with resultant midline scar and with no recurrence in our series.

Pilonidal Cyst Excision: Primary Midline Closure with versus without Closed Incision Negative Pressure Therapy

Background

Pilonidal cysts are a painful condition that primarily affect young adult men. In the literature, numerous operative techniques for resolving pilonidal cysts are described, with variable outcomes. The objective of this study was to compare primarily closed midline incisions managed with or without the use of closed incision negative pressure therapy after pilonidal cyst excision.

Methods

Twenty-one patients underwent excision and midline primary closure. Postoperative care composed of closed incisional negative pressure therapy (study group; n = 10) or gauze dressings (control group; n = 11). In both groups, the sutures were partially removed on day 14 and completely removed on day 21. Compared outcomes included the duration of hospitalization, pain on the day of surgical procedure, and on postoperative day 7, and time-to-healing.

Results

The median hospital stay was about 9 hours and 23 hours in the study and control groups, respectively (P < 0.05). The median pain scores on the day of operation were 1.20/10 in the study group and 3.36/10 in the control group (P < 0.05). On day 7, study group showed median pain score 0.9/10 and control group showed 2.63/10 (P < 0.05). The mean healing time was 23.8 and 57.9 days in the ciNPT group and gauze group, respectively (P < 0.05).

Conclusion

These outcomes supported the incorporation of closed incision negative pressure therapy into our surgical treatment protocol for pilonidal cysts.

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.

Sinusectomy and primary closure versus excision and primary closure in pilonidal sinus disease: a retrospective cohort study

BACKGROUND

Various surgical procedures are available for the treatment of pilonidal sinus diseases (PSD), but the best surgical approach remains controversial. Minimally invasive surgical procedures are more popular than surgery. This study aimed to evaluate the efficacy of sinusectomy with primary closure (SPC) in comparison with excision and primary closure (EPC) in primary or recurrent cases.

MATERIALS AND METHODS

This single-center retrospective cohort study was conducted with two cohort groups in which 351 patients with PSD underwent either SPC or EPC. The two procedures were compared according to the presence of short-term complications and recurrence of PSD.

RESULTS

Of the patients, 134 underwent EPC and 217 underwent SPC. The length of stay and the wound healing time were significantly longer in the EPC group than in the SPC group. The occurrence rates of wound site infection and abscess were significantly higher in the EPC group than in the SPC group; however, seroma was statistically significantly more common in the SPC group than in the EPC group. The recurrence rates were 18.7% and 5.5% in the EPC and SPC groups, respectively.

CONCLUSION

SPC is an efficient procedure for the treatment of patients with PSD showing simple and complicated disease patterns.

Complete natal cleft removal with kite incision in the treatment of extensive sacrococcygeal pilonidal sinus

BACKGROUND

Pilonidal sinus (PS) is a benign disease for which different treatment modalities are used, varying from non-surgical treatments to surgical treatments with flap use for big defects. High recurrence is the main problem in complicated cases. We presented complete natal cleft excision with kite incision and fasciocutaneous flap (CNCEF with kite incision) in extensive sacrococcygeal PS.

METHODS

Seventy-six patients who underwent CNCEF with kite incision because of extensive PS extending through intergluteal sulcus to the anus, with multiple sinus tracts and recurrent PS were retrospectively analysed. A special incision involving natal cleft and all sinus tracts completely and fasciocutaneous flap, lateralizing median line, was used in all cases. Post-operative complications and recurrence was recorded.

RESULTS

Sixteen (21.1%) patients were operated because of recurrence. The mean age and body mass index were 33.04 ± 6.78 and 29.86 ± 5.46, respectively. The mean hospital stay period and mean operation time was 2.95 ± 0.76 days and 64.33 ± 8.64 min, respectively. The mean drain removal time was 2.78 ± 0.7 days and mean follow-up was 13.46 ± 4.31 months. There were flap oedema and seroma in one (1.3%) and four (5.3%) of the patients, respectively. Surgical site infection necessitating antibiotic treatment developed in three (3.9%) patients. The overall post-operative complication rate was 10.5% and there was recurrence in one patient on follow-up period (1.3%).

CONCLUSION

CNCEF with kite incision method, which shifts midline, is a safe and reliable method with acceptable post-operative complication and recurrence rates in extensive sacrococcygeal PS 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.

Contralateral Limberg flap reconstruction for pilonidal disease recurrence

To identify surgical techniques applied in case of recurrence in patients with pilonidal sinus, who have undergone primary treatment with Limberg flap, and to present our cases treated with Limberg flap reconstruction prepared from the contralateral gluteal region. Nine patients with recurrence out of 219 patients who underwent Limberg flap reconstruction between 2009 and 2016 at our clinics, and 6 patients who have been referred to our clinics with total 15 recurrence after primary Limberg flap reconstruction at other institutes were included in the study. Total excision and primary repair was applied in 3 patients while 2 patients underwent excision with lay open procedures. The remaining 10 patients underwent rhomboid excision of the recurrence area and Limberg flap repair from the contralateral gluteal area. All patients who underwent primary repair or excision-lay open procedures recurred again. These two patients also underwent contralateral Limberg flap reconstruction as their second revision surgery. There were no complications or recurrences in the study group. We believe that reconstruction with contralateral Limberg flap is an effective and feasible method in recurrent pilonidal sinus cases who have been initially treated surgically by the Limberg flap.

Excision with primary midline closure compared with Limberg flap in the treatment of sacrococcygeal pilonidal disease: a randomised clinical trial

BACKGROUND

Although several surgical techniques for treatment of sacrococcygeal pilonidal sinus (SPND) have been described, there is no consensus on the optimal surgical procedure. In this study we compared excision with primary closure and Limberg flap in the treatment of SPND.

METHODS

This was a prospective randomised clinical trial in patients with SPND who were randomly allocated to one of two groups: group I (excision and primary closure) and group II (Limberg flap technique). The primary outcome of the trial was recurrence of SPND whereas postoperative complications, return to work and cosmetic results were the secondary outcomes.

RESULTS

Sixty patients were included, with a mean age of 24.1 years and mean body mass index (BMI) of 26.8 kg/m². Group 1 had significantly shorter operation time than group II. Both groups had similar hospital stay and comparable complication rates (43.3% vs 30%; P = 0.4). Group I had significantly higher recurrence rate (20% vs 0; P < 0.02) and significantly better cosmetic satisfaction score than group II. Being hairy (P = 0.04), positive family history (P = 0.03), diabetes mellitus (P = 0.005) and history of previous surgery for SPND (P = 0.01) were the significant predictors for recurrence.

CONCLUSIONS

The Limberg flap is an effective technique for the treatment of SPND with very low recurrence rate and comparable complication rate and hospital stay to excision and primary closure. Excision and primary closure offered the advantages of quicker healing time, earlier resumption of daily activities, better cosmetic results, which may render it more suitable for patients with low risk for recurrence.

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.

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.

A New Surgical Technique for Closure of Pilonidal Sinus Defects: Triangular Closure Technique

Background

We present a clinical experience with a new local flap procedure, namely the triangular closure technique, for reconstruction of sacrococcygeal skin defects resulting from excision of the pilonidal sinus.

Material/Methods

In this technique, the defect is surgically converted to a triangle in shape. Then, the triangular defect is closed by transposition of 2 skin flaps designed in an unequal z-plasty manner. Over 6 years, this technique has been used for closure of defects of chronic pilonidal sinus disease in 27 patients (6 females, 21 males). The size of the defect ranged between 3.5 cm and 12 cm in dimension.

Results

A tension-free defect closure was obtained in all patients. All flaps except one healed with no complications. A mean follow-up of 3.62±1.77 months revealed aesthetically and functionally acceptable results with the obliteration of the natal cleft in all patients. No recurrence was observed in the follow-up period.

Conclusions

The triangular closure technique was found to be a useful technique for the treatment of pilonidal sinus with favorable results regarding the time before return to work.