Converting emergency pilonidal abscess into an elective procedure

German National Guideline on the management of pilonidal disease: update 2020

BACKGROUND

The present German National Guideline is an updated version of previous Guideline published in 2014. It aims to compare various treatment methods and to assist physicians with evidence-based recommendations.

METHODS

Systemic literature review.

RESULTS

Three types of disease manifestation could be differentiated: asymptomatic disease, an acute abscess, and the chronic pilonidal disease. At present, there is no treatment method fulfilling all desired criteria: simple, painless procedure associated with rapid wound healing, and low recurrence rate. Thus, treatment modality should be tailored to disease manifestation and extent.

CONCLUSION

Asymptomatic pilonidal disease should not be treated. A pilonidal abscess should be unroofed. After resolution of the acute inflammation, the disease should be treated definitely. As for today, sinus excision is the standard treatment of the chronic pilonidal disease. Wide excision and open treatment of chronic disease is a safe procedure which, however, leads to prolonged secondary healing and time off-work, as well as to considerable recurrence rate. The extent of excision should be as limited as possible. Excision and midline wound closure is associated with impaired outcomes. Today, it has become obsolete. Minimally invasive procedures (e.g., pit picking surgery) represent a treatment option for chronic pilonidal disease. However, the recurrence rate is higher compared to excision procedures. Nevertheless, they may be used for small primary disease. Off-midline procedures should be used for disease not suitable for minimally invasive treatments. The Limberg flap and the Karydakis procedure are two best described methods which are associated with similar short- and long-term results.

Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians

BACKGROUND

Abscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses.

OBJECTIVE

This review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department.

DISCUSSION

Ultrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative.

CONCLUSIONS

This review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.

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.

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.

The risk of recurrence of Pilonidal disease after surgical management

Objectives:

To estimate the rate of the Pilonidal disease (PND) recurrence and to evaluate the associated predictors of the recurrence.

Methods:

This is a retrospective study, conducted at King Fahd Hospital of the University in Alkhobar, Kingdom of Saudi Arabia over a period of 10 years from January 2003 until December 2013.

Results:

A study of 366 with PND, 19 of those were identified as secondary cases and excluded. Most involved 347 patients were Saudi (82.1%), single (87%), and men (93.1%). The mean age of the sample was 23 ± 8 years, and the mean body mass index (BMI) was 29.7 ± 6 Kg/m². Overall recurrence rate after the surgical management was found in 25 patients (7.2%). By logistic regression to the recurrence group, young age group, prolong sitting and BMI may increase the likelihood of the disease recurrence.

Conclusion:

Pilonidal disease still has challenges in its management. Treatment should depend on the extent and severity of the disease. The recurrence rate in this study is approximately 7.2%. The most predominate factors associated with recurrence were prolong sitting job, young age group, and high BMI.

Endoscopic pilonidal abscess treatment: a novel approach for the treatment of pilonidal abscess

INTRODUCTION Pilonidal abscess is a common surgical emergency. Conventional treatment with incision and drainage is associated with significant postoperative morbidity. We report our initial experience of using minimally invasive endoscopic technique for the treatment of pilonidal abscesses, referred to as endoscopic pilonidal abscess treatment (EPAT). MATERIALS AND METHODS A prospective database of all patients undergoing EPAT between January 2015 and March 2016 at Whiston Hospital was maintained. Data regarding patient demographics, peroperative variables and postoperative follow-up were recorded. RESULTS Nineteen patients were included, male to female ratio was 53 : 47 and median age of the cohort was 24 years (interquartile range 22-25 years). EPAT was the primary procedure for 10 patients and 9 had EPAT for recurrent pilonidal abscesses. There were no readmissions and none needed further surgery within 6 weeks of having the procedure. In all patients, complete wound healing was achieved within 6 weeks; all reported minimal postoperative pain (median postoperative visual analogue scale score 1) and immediate return to the activities of daily life. Four of the nineteen patients (21%) required definitive intervention for pilonidal disease in the follow-up period. CONCLUSIONS EPAT is a novel, minimally invasive technique for the treatment of acute pilonidal abscesses. It is safe, associated with reduced postoperative morbidity, recurrence rate and quick wound healing. Initial encouraging results require further investigations on a larger group of patients in a multicentre setting.

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).

Microbiology of the infected recurrent sacrococcygeal pilonidal sinus

The aim of the present retrospective single centre study was to define the changes in the microbiological flora of the recurring sacrococcygeal pilonidal sinus (PS). Microbiological findings of swab samples of abscess-forming PS from 2000 to 2010 were evaluated. Within this time span, 73 swab samples were taken from primary sacrococcygeal pilonidal sinus (pPS) and 23 swab samples of patients with recurring sacrococcygeal pilonidal sinus (rPS). Our results show a statistically significant shift of the bacterial flora towards the gram-positive range (P = 0·029) and a shift with tendency towards the aerobic range (P = 0·090). Pathogens of pPS are not always solely anaerobic or gram-negative, and those of rPS not always aerobic or gram-positive. Therefore, antibiosis preceding microbiological examination should cover both the aerobic and anaerobic bacteria as well as the gram-positive and the gram-negative spectrum.