Endoscopic pilonidal sinus treatment: a prospective multicentre trial

Management of Pilonidal Disease and Hidradenitis Suppurativa

Pilonidal disease and hidradenitis suppurativa affect healthy young adults, causing discomfort and pain that leads to loss of work productivity and should be approached in a personalized manner. Patients with pilonidal disease should engage in hair removal to the sacrococcygeal region and surgical options considered. Hidradenitis suppurativa can be a morbid and challenging disease process. Medical management with topical agents, antibiotics, and biologics should be used initially but wide local excision should be considered in severe or refractory cases of the disease.

Pilonidal sinus: an overview of historical and current management modalities

Pilonidal disease is a common condition that commonly affects the younger adult population and is often seen in both the general practice and the hospital setting. Multiple treatment methods have gained and lost popularity over the last several decades, but more recent intervention principles show promising results. This article details the different methods of managing acute and chronic pilonidal disease ranging from treatments in the primary care setting to those in hospital theatres, with special attention to newer modalities of minimally invasive interventions. As a chronic illness that often affects those of working age, pilonidal disease can confer significant morbidity especially, but not limited to, a substantial amount of time off work. Treatment of chronic disease in particular, has evolved from midline techniques to off-midline techniques, with more recent developments offering promising solutions to reduce acute flare ups and hasten recovery time.

Efficacy of laser obliteration with limited excision of pilonidal sinus

OBJECTIVE

This study was performed to compare the effectiveness of laser obliteration with limited excision (LOLE) versus wide excision (WE) of the pilonidal sinus.

METHODS

A prospective, cross-sectional observational study of 152 patients with chronic pilonidal sinus disease was performed from September 2019 to September 2022. Of the 152 patients, 76 underwent LOLE and 76 underwent WE. The main evaluation criteria were complete wound healing, recurrence, and the complication rate.

RESULTS

Complete healing was achieved in 74 (97.4%) patients in the LOLE group and 76 (100%) patients in the WE group. The duration of wound healing was significantly shorter in the LOLE group than in the WE group (6.5 ± 2.4 vs. 14.5 ± 2.6 weeks, respectively). Recurrence developed in six (7.9%) patients in the LOLE group and one (1.3%) patient in the WE group, with no significant difference.

CONCLUSION

According to our study and the data available in the literature, laser surgery should be included in the guidelines for the treatment and management of pilonidal disease.

Minimally Invasive Pilonidal Sinus Treatment: EPSIT Versus PEBAI Method

PURPOSE

We aimed to compare endoscopic pilonidal sinus treatment (EPSIT) and pit/sinus punch needle excision, brushing, ablation and irrigation (PEBAI) method that was performed with principles similar to EPSIT but without fistuloscope and vision in the treatment of pilonidal sinus disease (PSD).

METHODS

Patients who underwent EPSIT and PEBAI methods for PSD in a single center between January 2020 and October 2021 were retrospectively analyzed. The primary endpoint was healing, the secondary endpoints were operative time, pain, wound closure, quality of life, cosmetic results, and cost.

RESULTS

One hundred 4 patients who underwent EPSIT and 184 patients who underwent PEBAI were included in the study. Age ( P =0.871), sex ( P =0.669), BMI ( P =0.176), number of pits ( P =0.99) were similar in both groups. The operative time for PEBAI [20 min (18 to 32)] was shorter than EPSIT [32 min (24 to 44)] ( P <0.0000, u value=3096, z-score=-9.459). Postoperative first ( P =0.147) and 14th day( P =0.382) pain scores, postoperative analgesic requirements ( P =0.609), time to return to daily activities ( P =0.747), time to return to work ( P =0.345), and wound complications ( P =0.816) were similar, whereas the wound closure time was earlier after EPSIT [32 d (24 to 41)] than after PEBAI [37 d (26 to 58)] ( P <0.00001, u value=5344, z-score=6.22141). The median follow-up was 24 (12 to 34) months. Complete wound healing ( P =0.382), recurrence rate ( P =0.533), quality of life at first month and (Wound evaluation scale score at first year ( P =0.252) were similar in both groups. However, the cost of PEBAI [54.8 € (50.13 to 64.96)] was significantly lower than cost of EPSIT [147.36 € (132.53 to 169.60)] ( P <0.00001, u value=0, z-score=7.210).

CONCLUSIONS

PEBAI method is a cheaper alternative to EPSIT with similar surgical principles and clinical outcomes.

Non-excisional techniques for the treatment of intergluteal pilonidal sinus disease: a systematic review

Non-excisional techniques for pilonidal sinus disease (PSD) have gained popularity over the last years. The aim of this study was to review short and long-term outcomes for non-excisional techniques with special focus on the additive effect of treatment of the inner lining of the sinus cavity and the difference between primary and recurrent PSD. A systematic search was conducted in Embase, Medline, Web of Science Core Collection, Cochrane and Google Scholar databases for studies on non-excisional techniques for PSD including pit picking techniques with or without additional laser or phenol treatment, unroofing, endoscopic techniques and thrombin gelatin matrix application. Outcomes were recurrence rates, healing rates, complication rates, wound healing times and time taken to return to daily activities. In total, 31 studies comprising 8100 patients were included. Non-excisional techniques had overall healing rates ranging from 67 to 100%. Recurrence rates for pit picking, unroofing and gelatin matrix application varied from 0 to 16% depending on the follow-up time. Recurrence rates after additional laser, phenol and endoscopic techniques varied from 0 to 29%. Complication rates ranged from 0 to 16%, and the wound healing time was between three and forty-seven days. The return to daily activities varied from one to nine days. Non-excisional techniques are associated with fast recovery and low morbidity but recurrence rates are high. Techniques that attempt to additionally treat the inner lining of the sinus have worse recurrence rates than pit picking alone. Recurrence rates do not differ between primary and recurrent disease.

Platelet-rich plasma for pilonidal disease: a systematic review

OBJECTIVE

To examine the use of platelet-rich plasma (PRP) for treatment of pilonidal disease (PD) and thus provide a reference for clinical application.

METHODS

A systematic review of PubMed and the Cochrane Library was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We considered all studies that reported the use of PRP for treatment of PD. Extracted data included the first author's name, year of publication, study type, number of included patients, inclusion and exclusion criteria, interventions, anesthesia, application of PRP (source, preparation, dose, and operation), antibiotics, follow-up time, therapeutic outcomes, and adverse events.

RESULTS

In total, eight randomized controlled trials and one prospective cohort study involving 809 patients were included. PRP reduced pain, accelerated healing, and reduced adverse events. The application of combined minimally invasive surgery achieved better results. However, overfilling of the wound with PRP in minimally invasive surgeries was shown to potentially increase the risk of adverse events.

CONCLUSION

PRP can be used as an adjuvant treatment in PD surgery to improve the therapeutic effect and reduce adverse events. The optimal combination of PRP and various factors is an important direction of future research.INPLASY registration number: INPLASY2023100070.

Short- and mid-term results of diode laser treatment in pilonidal sinus disease and the role of endoscopic camera use on outcomes

PURPOSE

Nowadays, surgical treatment of pilonidal sinus disease (PSD) with novel techniques is a topic of interest since conventional methods are associated with longer return to daily life and higher complication and recurrence rates. Recently, use of laser as a minimally invasive approach has become popular in the surgical treatment of PSD. In this study, we analyze the short- and mid-term results after laser treatment and the effect of endoscopic camera use on outcomes.

METHODS

A total of 106 patients with PSD who underwent laser treatment between November 2017 and September 2021 were included in this study. All patients were treated with a 1470-nm diode laser. Endoscopic camera was used in 73 patients and results of these were compared with those in whom camera was not used. Follow-up period was determined as a minimum of 1 year. Data were analyzed retrospectively.

RESULTS

There were 80 (75%) male and 26 female patients. The median age was 26 (range 13-50) years. On the first postoperative day, 26 (26.5%) patients did not have any pain and 42(42.8%) patients reported low-grade pain. The mean time to return to daily life was 4.5 ± 5.5 (median 2, range 1-30) days. The complication rate was 10.4%. Eighty-six (87.8%) patients completely recovered and the mean complete recovery time was 27.4 ± 15.9 days. The patient satisfaction rate was 99.0%. The recurrence rate was 11.0%. Neither history of previous surgery nor abscess was associated with recurrence. Use of an endoscopic camera had no effect on postoperative pain, complete recovery, complications, patient satisfaction, and recurrence (p < 0.05).

CONCLUSION

Laser treatment for PSD is a promising approach with the advantages of less postoperative pain, early return to daily life, high patient satisfaction, and acceptable complication and recurrence rates. Nevertheless, further studies are needed to investigate the role of endoscopic camera use in this procedure since its possible advantages could not be clarified.

Five-year recurrence after endoscopic approach to pilonidal sinus disease: A multicentre experience

PURPOSE

The aim of this study was to evaluate the 5-year recurrence rate of pilonidal sinus disease (PSD) after endoscopic sinusectomy and identify risk factors for recurrence.

METHODS

All consecutive patients from September 2011 through December 2017 who underwent endoscopic sinusectomy at seven referral centres for pilonidal sinus treatment were retrospectively analysed from a prospectively maintained database.

RESULTS

Out of 290 patients (185 males versus 105 female, with a mean age of 25.5±6.9), 73 presented recurrence at 5-year follow-up with a recurrence rate of 25.2%. The number of pilonidal sinus with pits off the midline (p = 0.001) and the mean (SD) distance from the most lateral orifice to the midline (p = 0.001) were higher in the group of patients with recurrence at 5-year follow-up. Multivariate analysis demonstrated that the position of the pits off the midline (p = 0.001) and the distance of the most lateral orifice from the midline (p = 0.001) were independent risk factors for recurrence at 5-year follow-up. Receiver operating characteristic (ROC) curve analysis showed that the distance of lateral orifice from midline predicted an 82.2% possibility of recurrence at 5-year follow-up and Youden's test identified the best cut-off as 2 cm for this variable. Out of 195 cases with the most lateral orifice less than 2 cm from the midline, 13 presented recurrence at 5-year follow-up with a recurrence rate of 6.7%. Out of 95 cases with the most lateral orifice more than 2 cm from midline, 60 showed recurrence at 5-year follow-up with a recurrence rate of 63.2%.

CONCLUSIONS

This data may help guide which disease characteristics predict the optimal use of an endoscopic pilonidal sinus technique.

Endoscopic Pilonidal Sinus Treatment: Preliminary Results, Learning Curve and Comparison with Standard Open Approach

Background: Pilonidal sinus (PNS) is a common disease which can lead to complications including infection and abscess formation. Different surgical approaches have been suggested, based on primary or secondary wound closure intention healing or endoscopic treatment (EPSiT). The aim of this study is to verify the superior outcomes of EPSiT, especially in comparison with the traditional open approach, and discuss the operators' learning curve. Methods: A retrospective study was conducted identifying all the patients who underwent surgical treatment for PNS with EPSiT technique between 2019 and 2022 and with open technique between 2002 and 2022. We divided patients in two groups: open procedure (group 1) and EPSiT (group 2). We considered a p value < 0.05 as statistically significant. Results: The mean operative time was 58.6 ± 23.7 min for group 1 and 42.8 ± 17.4 min for group 2 (p < 0.01). The mean hospital stay was 2.6 ± 1.7 days for group 1 patients and of 0.8 ± 0.4 days for group 2 (p < 0.01). Complete healing was obtained in 18.7 ± 5.6 days for group 1 and 38.3 ± 23.5 days for group 2 (p < 0.01). Recurrences were of 23.4% for group 1 and 5.4% for group 2 (p = 0.03). Conclusions: EPSiT is a minimally invasive and effective approach for the treatment of pilonidal cyst that can be safely performed in pediatric patients with promising results concerning aesthetic outcome and pain control, and with a rapid and less complicated recovery compared to traditional open procedures.

Endoscopic approach to complex or recurrent pilonidal sinus: A retrospective analysis

Pilonidal Sinus is a benign, chronic disease that affects the hair follicles of the natal cleft of the sacrococcygeal area. Its ideal treatment is controversial, especially in complex or recurrent cases. The aim of this study is to evaluate the use of minimally invasive endoscopic approach in this setting. We enrolled patients affected by complex or recurrent sacrococcygeal pilonidal sinus from January 2015 through December 2020 who underwent Video-Assisted Ablation of Pilonidal Sinus. All patients enrolled were re-evaluated once a year with a standard physical examination. The patients included were 38. Recurrence rate at 1-, 3- and 5-years follow-ups were 28.9%, 22.2% and 38.1% respectively. Of interest, the mean (SD) distance from the most lateral orifice to the midline was higher in group of patients with recurrence and the multivariate analysis demonstrated that it was the limiting factor, which influences the recurrence rate. In complex or recurrent pilonidal sinus disease with pits off the midline the endoscopic approach should not be the first choice. This makes us think that these cases should have their own classification to be identified and guide surgeons in choosing the appropriate approach.

An effective and considerable treatment of pilonidal sinus disease by laser ablation

The treatment of sacrococcygeal pilonidal disease (SPD) is still challenging. Although many non-surgical and surgical methods exist, no consensus has been reached on the best treatment. This study aimed to evaluate the efficacy of laser ablation using 1470-nm radial diode laser fiber in treating SPD. We retrospectively studied the data of our 48 patients who operated on this technique between March 2019 and July 2022. All patients were treated with laser ablation using 1470-nm radial diode laser fiber. The healing rate and recurrence rate, demographic and surgical data, postoperative pain, complications (wound infection, wound bleeding), the time of returning to regular work and life, and the time of wound healing were recorded. Postoperative pain was measured based on the visual analog scale (VAS) score. Postoperative follow-up was performed in the outpatient clinic every 1 week for 1 month. Among the 48 patients, 41 males and 7 females, with a mean age of 27.7 years (range 14-42), the healing rate was 100%, and the average healing time was 28.3 ± 5.5 days. Mean operative time was 15.5 ± 3.3 min. The recurrence rate was 2.1%. One patient relapsed 3 months after the operation. The patient underwent laser ablation again, and the sinus tract was closed. The median visual analog scale (VAS) score on the day of operation was 0(0,2). The median VAS score on the first, third, seventh, and fourteenth day after operation was 0(0,2), 0(0,1), 0(0,1), and 0(0,0), respectively. There was no wound infection or bleeding after the operation. The mean time to normal work/life was 7.1 ± 3.2 days. Almost all the patients felt very satisfied with the operation. Laser ablation using 1470-nm radial diode laser fiber is effective in SPD treatment. It is associated with minor wounds and mild postoperative pain. It is a simple, safe, and minimally invasive technique and its clinical application for acute and chronic SPD in the absence of abscess is promising.

Endoscopic sinusectomy: 'a rose by any other name'. A systematic review of different endoscopic procedures to treat pilonidal disease

AIM

Pilonidal sinus or Pilonidal Disease (PD) is a relatively common, benign but challenging condition. Although commonly encountered in practice, its ideal treatment is controversial. One of the most validated treatments is video-assisted surgery. In this context, very similar endoscopic techniques have been published under different names. The aim of this systematic review is to assess the differences among these proposed techniques and their outcomes.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during all stages of this systematic review. A systematic search of the English literature was performed on multiple databases from 1 January 2014 to 3 April 2022. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measures were the adherence to the IDEAL reporting guidelines, the Blencowe framework and the core outcome set (COS) for studies evaluating the introduction and evaluation of novel surgical techniques, the qualitative assessment using appropriate tools, the procedural variations and outcomes of each technique.

RESULTS

A total of 38 articles were included reporting a very similar technique under eight different acronyms. The number of patients varied from 9 to 250. Mean follow-up ranged from 1 to 60 months. There was only one published study of IDEAL 3. The majority (58%) were IDEAL 2a studies. Reporting of domains in the IDEAL reporting guidelines and Blencowe framework was poor, with most studies not reporting the component steps of procedures or efforts to standardize them. Half of COS domains were markedly underreported. The quality of the evidence was categorized as having a risk of bias from moderate to critical level in all nine comparative non-randomized series. Postoperative complications occurred in 0%-6% of cases, including surgical site infection, poor or failed wound healing bleeding, granuloma, haematoma, and pain requiring intervention. The recurrence rate varied from 0% to 22%.

CONCLUSION

The study demonstrates that reporting on technical aspects of interventions for PD is poor, thus warranting a better-quality control of surgical techniques. It is advisable to group all endoscopic procedures under the umbrella term of 'endoscopic sinusectomy', thus embracing the two main principles of this technique, that is, video assistance and PD ablation.

Pilonidal sinus laser-assisted closure (PiLAC) - a low-morbidity alternative to excision with excellent long-term outcomes

INTRODUCTION

Recurrence after surgery for pilonidal sinus disease is a recognised problem and patients often re-present months after discharge. We routinely treat primary and recurrent pilonidal sinus disease with Pilonidal sinus Laser-Assisted Closure (PiLAC). Long-term outcomes following PiLAC surgery was examined following clinical and telephone review.

METHODS

All patients undergoing PiLAC as a day-case between April 2016 and July 2019 were included. Patients were followed up in a nurse-led clinic until complete healing or recurrence. A prospective database and retrospective audit of notes combined with longer-term follow-up by telephone were used.

RESULTS

A total of 35 patients underwent PiLAC, median age 28 (18-53 years), 28 males:7 females. A total of 28 patients had long-term (>60 days) follow-up, mean 407 days (range 67-887 days); 25/28 patients (89.3%) had healed with no recurrence on long-term follow-up. Of these 28 patients, 11 were first presentation of pilonidal disease and underwent PiLAC as their first treatment, with a 91% heal rate long term. A total of 15 patients had seton drainage prior to PiLAC, with a 93% heal rate versus no seton (83%). Fisher's exact test showed no significant difference between sex, new/recurrent pilonidal disease and seton placement (p>0.05).

CONCLUSIONS

Healing after PiLAC for the treatment of primary and recurrent pilonidal sinus disease is preserved with excellent long-term outcomes. We recommend it as an alternative to surgical excision.

Long-term Outcome of Radical Excision Versus Phenolization of the Sinus Tract in Primary Sacrococcygeal Pilonidal Sinus Disease: A Randomized Controlled Trial

BACKGROUND

Phenolization of pilonidal sinus disease has been shown to have advantages over radical excision with regard to short-term outcome; however, long-term outcomes are essentially lacking.

OBJECTIVE

The aim of this randomized controlled trial was to compare the long-term outcome of pit excision and phenolization of the sinus tracts vs radical excision with primary wound closure in pilonidal sinus disease.

DESIGN

Single-center, randomized controlled trial.

SETTINGS

A primary teaching hospital in the Netherlands.

PATIENTS

The study population included patients with primary pilonidal sinus disease presented between 2013 and 2017.

INTERVENTIONS

Patients were randomly assigned to either pit excision with phenolization of the sinus tract(s) or excision with primary off-midline wound closure.

MAIN OUTCOME MEASURES

The main outcomes included recurrence, quality of life (Short-Form 36), and patient's satisfaction.

RESULTS

A total of 100 patients were randomized. Seventy-four patients (77.1%) were available for long-term follow-up. The mean (±SD) time to follow-up was 48.4 (±12.8) months for the phenolization group and 47.8 (±13.5) months for the excision group. No significant difference was found between both groups regarding quality of life. Two patients in the phenolization group (5.6%) and 1 in the excision group (2.6%) developed a recurrence ( p = 0.604). The impact of the whole treatment was significantly less after phenolization ( p = 0.010).

LIMITATIONS

The response rate was almost 80% in this young patient population, patients and assessors were not blinded for the type of surgery, and the results are only applicable to primary pilonidal sinus disease.

CONCLUSIONS

Because of the previously shown favorable short-term results and the currently reported comparable long-term recurrence rate and quality of life between phenolization and excision, phenolization should be considered the primary treatment option in patients with pilonidal sinus disease. See Video Abstract at http://links.lww.com/DCR/C27 .

DUTCH TRIAL REGISTER ID

NTR4043.

RESULTADO A LARGO PLAZO DE LA ESCISIN RADICAL FRENTE AL TRATAMIENTO CON FENOL DEL TRACTO SINUSAL EN LA ENFERMEDAD DEL SENO PILONIDAL SACRO COCCGEO PRIMARIO UN ENSAYO ALEATORIO CONTROLADO

ANTECEDENTES:El tratamiento con fenol de la enfermedad del seno pilonidal ha demostrado tener ventajas sobre la escisión radical con respecto al resultado a corto plazo; sin embargo, los resultados a largo plazo aún se encuentran escasos.OBJETIVO:El objetivo de este ensayo aleatorio controlado fue comparar el resultado a largo plazo de la escisión de la fosa del quiste y el tratamiento con fenol de los trayectos sinusales frente a la escisión radical con cierre primario de la herida en la enfermedad del seno pilonidal.DISEÑO:Ensayo aleatorio controlado de un solo centro.AJUSTES:Hospital de enseñanza primaria en los Países Bajos.PACIENTES:Pacientes con enfermedad primaria del seno pilonidal presentados entre 2013 y 2017.INTERVENCIONES:Los pacientes fueron asignados de manera aleatoria a la escisión de la fosa del quiste y posterior administración de fenol de los tractos sinusales o a la escisión con cierre primario de la herida fuera de la línea media.PRINCIPALES MEDIDAS DE RESULTADO:Recurrencia, calidad de vida (Short-Form 36) y satisfacción del paciente.RESULTADOS:Un total de 100 pacientes con enfermedad primaria del seno pilonidal fueron aleatorizados; 50 pacientes fueron sometidos al tratamiento con fenol y 50 a la escisión radical. Eventualmente, 74 pacientes (77,1%) estuvieron disponibles para seguimiento a largo plazo; 36 pacientes después del uso del fenol y 38 después de la escisión. El tiempo medio (± desviación estándar) de seguimiento fue de 48,4 (± 12,8) y 47,8 (± 13,5) meses, respectivamente. No hubo diferencia significativa entre ambos grupos con respecto a la calidad de vida. En el grupo tratado con fenal, dos pacientes (5,6%) desarrollaron recurrencia y un paciente (2,6%) en el grupo de escisión ( p = 0,604). El impacto de todo el tratamiento fue significativamente menor después del uso del fenol (p = 0,010).LIMITACIONES:La tasa de respuesta fue de casi el 80% en esta población de pacientes jóvenes, los pacientes y los evaluadores no estaban cegados por el tipo de cirugía, los resultados son solo aplicables a la enfermedad primaria del seno pilonidal.CONCLUSIONES:Debido a los resultados favorables a corto plazo descritos y a la tasa de recurrencia a largo plazo y la calidad de vida comparables actualmente informadas entre la administración de fenol y la escisión con cierre primario de la herida para la enfermedad primaria del seno pilonidal, la administración de fenol del tracto sinusal debe considerarse como opción de tratamiento primario en pacientes con enfermedad del seno pilonidal. Consulte Video Resumen en http://links.lww.com/DCR/C27 . (Traducción-Dr. Osvaldo Gauto )Registro de prueba holandés-ID:NTR4043.

Comparative analysis on the effect of the endoscopic versus conventional treatment for pilonidal sinus: A meta-analysis of controlled clinical trials

BACKGROUND

Pilonidal sinus is a common disease in the sacrococcygeal region. Although many treatments have been described in recent years, the recurrence of each method remains high. Surgeons did not reach a consensus on the preferred approach for pilonidal sinus. We carried out a meta-analysis of controlled clinical trials comparing the outcomes of endoscopic treatment versus conventional treatment for pilonidal sinus disease in this study.

METHODS

We performed a systematic literature search, and we used electronic databases such as PubMed/Medline, Embase, and the Cochrane library to search for the relevant literature comparing endoscopic management to other conventional treatments for pilonidal sinus disease. The primary outcome parameters were operative time, recurrence, postoperative complications and pain, and total healing time.

RESULTS

Six studies were included in the review. Endoscopic pilonidal sinus treatment had a lower overall complication rate than the conventional surgery group (risk ratio = 0.33 [0.19-0.58], P = .0001) and lower pain score with a weighted mean difference of -2.44 (95% confidence interval: (-3.96) to (-0.92), I2 = 99%, P = .002). There was no significant difference in recurrence (risk ratio = 0.75, 95% confidence interval [0.30-1.90],P = .55). Compared to the excision followed by the primary closure technique, the operation time, time to complete wound healing, and satisfaction were similar.

CONCLUSIONS

Endoscopic pilonidal sinus treatment is a unique and potential method of sacrococcygeal pilonidal disease treatment. The foremost benefits of this technique are mild postoperative pain, lower complications rate, and return to routine for a shorter time. However, due to the limited number of articles, we need to conduct more rigorous large-sample prospective randomized controlled trials to clarify the efficiency of endoscopic treatment for pilonidal cysts.

Evaluation of the Early Outcomes of Laser-Endoscopic Pilonidal Sinus Treatment Combination and Comparison With the Combination of Cautery-Phenol-Endoscopic Pilonidal Sinus Treatment

Introduction

Although there are several methods used in the treatment of pilonidal sinus, research is still ongoing for the most effective method. Minimally invasive surgical methods, alone or in combination, are currently considered the closest treatment modalities to the ideal. The purpose of this study was to evaluate the early outcomes of laser-endoscopic pilonidal sinus treatment combination and compare it with the combination of phenol-cautery-endoscopic pilonidal sinus treatment.

Materials and methods

This is a retrospective study of 42 patients with pilonidal sinus disease treated between September 2020 and April 2022. A total of 26 participants in group one were treated with the laser-endoscopic pilonidal sinus treatment combination, and the remaining 16 in group two were treated with the cautery-phenol-endoscopic pilonidal sinus treatment combination. Both primary and recurrent patients over 16 years of age without active infection were included. In the postoperative period, each patient was followed up at the outpatient clinic. Perioperative and follow-up data were recorded.

Results

Patients were predominantly male. There was no significant difference between the two groups with regards to the time to return to daily life, pain-free walking, recovery time, and recurrence. However, in group one, the operation time was statistically shorter (p = 0.02), and the rate of sitting on the toilet without pain on the day of surgery was significantly higher (p = 0.029). In addition, none of the patients in this group needed painkillers and all returned to work earlier.

Conclusion

The combination of laser-endoscopic pilonidal sinus treatment is a feasible procedure with a 92.3% complete recovery rate according to the early results. However, studies with a larger sample size and longer follow-up period are required to confirm the validity of our results.

Minimally invasive pilonidal sinus disease (PSD) treatment in pediatric patients: A narrative review

Pilonidal sinus is a common disease of the natal cleft, which can lead to complications including infection and abscess formation. Various operative techniques are available options for the treatment of this pathology, but the ideal technique is still debatable. Analyzing the literature we found out that more recently minimally invasive approaches have been described. In particular, the mechanism of an endoscopic approach relies on the use of the endoscope without cutaneous tissue damage. Advantages include shorter operative time and time to discharge, which impact resource management in both primary and secondary care: patients undergoing endoscopic technique have a high satisfaction rate, probably due to the low level of postoperative pain and early return to daily activities. Published results of studies of newer approaches have demonstrated a lower short and long-term complication rate compared to open surgery. However, very poor reports are available in literature about pediatric population.

Endoscopic pilonidal sinus treatment vs. laser-assisted endoscopic pilonidal sinus treatment: short-term results from a retrospective case-matched study

BACKGROUND

The aim of this study was to investigate whether the addition of laser to the endoscopic pilonidal sinus treatment (EPSIT), laser-assisted EPSIT (LEPSIT) has an effect on the method and clinical results in the treatment of pilonidal sinus disease (PSD).

METHODS

Between September 2019 and September 2020, patients who underwent LEPSIT and EPSIT procedures for PSD at Bursa Medicana Hospital, Turkey, were matched for age, pit location and number, body mass index (BMI), and sex. The primary endpoint was complete wound healing and the secondary endpoints were quality of life, cosmetic results, and cost.

RESULTS

Twenty-four LEPSIT patients were matched to 72 EPSIT patients. Eighty-one (84.4%) of the included patients were male, and the median age was 26 years (range 16-52 years). The median follow-up time was 9 months (range 3-15 months).Wound healing rates (LEPSIT; 95.8% vs. EPSIT; 93%; p = 0.99) were similar in both groups. In patients who underwent LEPSIT, the operative time (p = 0.00086) was significantly shorter, time taken to return to work (p = 0.03572) and wound closure (p < 0.00001) were significantly less. However, the time taken to return to daily activities and the percentage of wound complications were similar in both groups. The pain scores on postoperative -days 1 7, and 14 were significantly higher after EPSIT (p = 0.0083, p = 0.00054, and p = 0.0479, respectively). The postoperative analgesic requirement was significantly higher after EPSIT (p = 0.01492). The total hospital cost was significantly less in patients who underwent EPSIT (p < 0.00001). Significantly better cosmetic improvement was observed in LEPSIT procedure (p = 0.00694). First month quality of life (evaluated with the Short Form 36 Health Survey Questionnaire) was similar except for bodily pain (better after LEPSIT).

CONCLUSIONS

The success rates of LEPSIT and EPSIT are similar. LEPSIT results in better wound healing and patient comfort, and a shorter time to return to work.

Endoscopic Treatment of Pilonidal Sinus Disease: State of Art and Review of the Literature

Background: Pilonidal sinus disease (PSD) is a chronic troublesome pathology of the natal cleft of the sacrococcygeal region, with an estimated incidence of 26 cases in every 100,000 inhabitants. The aim of this review is to give a snapshot of the current literature on the endoscopic approach to PSD.

Methods: A search on endoscopic treatment of pilonidal disease was performed according to PRISMA guidelines, adopting the following search terms: (pilonidal OR sacrococcygeal) and (endoscopic OR VAAPS OR EPSiT OR minimally invasive OR video-assisted OR video assisted).

Results: Thirty-four articles were included in the final analysis, among which 23 were on adults and 11 were on pediatric population. The endoscopic approach is associated with painless postoperative pain, good aesthetic results, short time off work, and high patient satisfaction.

Despite these advantages in short-term outcomes, results on recurrence rate in a long-term follow up are needed to definitively confirm the importance of this technique.

Conclusions: The endoscopic approach is associated with significant postoperative advantages over other standard surgical approaches, and it should be included in the surgical portfolio for the treatment of PSD. According to the Italian guidelines, this technique could be considered as the gold standard for limited PSD. However, the favorable short-term-outcomes and lack of reliable data on long-term follow-up must be a stimulus to perform further high-quality studies to give definitive conclusions on this technique.

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.

Endoscopic Pilonidal Sinus Treatment: A Tertiary Care Academic Center Experience

Background: Pilonidal disease (PD) represents one of the most common proctological diseases in young adults. Although several approaches to treating PD have been described, there is still a lack of agreement on which is the best. The aim of this study was to evaluate the long-term efficacy of endoscopic pilonidal sinus treatment (EPSiT) at a tertiary care academic center. Methods: Between June 2017 and January 2021, a total of 32 patients [12 women (37.5%) and 20 men (62.5%)] with a mean age of 29.22 ± 12.98 years were treated with EPSiT. Pre- and post-operative symptoms were assessed with a score of 0-5. Success was defined as the absence of any subjective symptoms, as well as by complete post-operative wound healing. Results: Most of the patients had a midline external opening (17/32; 53.1%), with a mean number of external openings of 2.41 (1-4) ± 1.04. The median post-operative pain score was 0, and the mean follow-up period was 22 (4-42) ± 11.49 months. The time to wound healing was reduced in patients with one opening (28.14 ± 4.06 days) compared to patients with two or more openings (33.64 ± 7.3 days) (p = 0.067). The mean operative time was longer in patients who subsequently had a recurrence (41.75 ± 6.24 vs. 34.18 ± 6.24 min; p = 0.031). The overall success rate was 87.5% (28/32), and the mean time to recurrence was 3.25 (2-5) ± 1.26 months. Conclusions: EPSiT represents a viable option for the treatment of PD. More evidence and a longer follow-up period are needed to validate the results.

Endoscopic Pilonidal Sinus Treatment: Rapid Recovery, Satisfactory Success, and High Quality of Life

PURPOSE

In the treatment of pilonidal sinus disease (PD), endoscopic pilonidal sinus treatment (EPSIT), a skin-sparing minimally invasive technique, has attracted attention as an effective treatment. The aim of this study to evaluate the treatment success, cosmetic outcomes, and the quality of life in the patients who underwent an EPSIT for PD.

MATERIALS AND METHODS

The prospectively maintained data of 86 patients who underwent EPSIT for PD were retrospectively analyzed. The primary end-point of this study was complete wound healing, while the secondary end-points were the quality of life and cosmetic outcomes.

RESULTS

Seventy-two (83.7%) patients were male, and the median age was 28 (16 to 52). The median operative time was 32 (24 to 44) minutes, the median time to return to daily activities was 1 (1 to 4) day, and the median time to return to work was 3 (1 to 11) days. Fifty-two patients (60.4%) required no analgesics. No wound complication was observed. The median follow-up period was 12 (3 to 23) months. The complete wound healing rate was 94.2%, incomplete wound healing rate was 4.6% and the recurrence rate was 1.2%. Treatment failure was observed in 5 of the 6 patients with >3 pits located in the midline. The first-year median Wound evaluation scale score was 0 (0 to 4). The quality of life [physical function, physical role difficulty, pain, general health perception, energy/vitality, social functioning, emotional role, and mental health (P<0.0001)] significantly increased from preoperative levels a month after the EPSIT procedure.

CONCLUSION

EPSIT, a minimally invasive treatment modality for the treatment of sacrococcygeal PD, is an effective treatment that does not hamper the daily life of the patients, presents high success rates, and has satisfactory cosmetic outcomes.

Endoscopic pilonidal sinus treatment: A minimally invasive surgical technique

INTRODUCTION

Pilonidal sinus disease (PSD) is a common skin and subcutaneous disease that is mainly seen in men (mean age, 30 years); its incidence rate is 26 cases per 100 000. PSD greatly affects quality of life. Ideally, a surgical procedure to treat PSD should involve a minimal hospital stay and require minimal time off work, discomfort, operative time, and cost; it should also limit recurrence. In this study, we present a new minimally invasive technique for pilonidal sinus surgery known as endoscopic pilonidal sinus treatment (EPSiT).

METHODS

From February 2017 to April 2019, 100 patients diagnosed with PSD were treated with the EPSiT method at the Department of General Surgery, Imam Reza Hospital. Patient information was recorded prospectively. During the operation, the fistula cavity and tracts were ablated by an electrode that was introduced through the operative channel. All the epithelial and granulation tissues were removed by a brush inserted into the operative channel or by a Volkmann spoon.

RESULTS

None of the patients had postoperative complications, such as hematoma, seroma, or wound infection, during the follow-up period. Recurrence was seen four patients (4%). At 1 week postoperatively, the visual analog scale score was 3 for 37 patients (37%) and 2 for 28 patients (28%). The maximal cosmetic satisfaction rate was reported in 85 patients (85%).

CONCLUSION

As a minimally invasive procedure, EPSiT is effective for treating PSD. Compared with excision and primary closure techniques, EPSiT has a very low recurrence rate after the procedure and a short hospital stay.

Crystallized phenol for treatment of pilonidal sinus disease in children: a comparative clinical study

BACKGROUND

The aim of this study was to present our experience in the use of crystallized phenol (CP) to treat pediatric patients with 'simple' and complex' Pilonidal sinus disease (PSD).

MATERIALS AND METHODS

Patients who underwent CP treatment in between January 2015 and January 2020 were evaluated retrospectively, using prospectively collected data. The patients were divided into simple and complicated groups. The groups were assigned depending on the number of sinuses and clinical presentation. The groups were compared in terms of age, sex, number of sessions, cost analysis, body mass index (BMI), recurrence, time resolution, cosmetic results, results /improvement, and complications.

RESULTS

This study included 54 patients: 28 (52%) girls and 26 (48%) boys. The mean number of sinuses was 2.4. Symptoms included discharge in 50 (92%) patients, and pain in 42 (78%) patients. Fifty (93%) patients experienced mild pain during the procedure, whereas four (7%) patients had moderate pain. The mean number of CP sessions was 2.9; mean numbers of CP sessions were 2.2 and 4.2 in the Simple and Complicated groups. In total, 5 of 54 patients (9%) had recurrence.At the end of treatment, therapeutic success was achieved in 49 of 54 (91%) patients: 31 of 33 (94%) patients in the Simple group and 18 of 21 patients (86%) in the complicated group. The mean treatment cost for the whole cohort was $17.40. One patient (2%) presented with moderate skin burns. Cosmesis was deemed acceptable by patients, although there was evidence of minor skin burns following the procedure.

CONCLUSIONS

The findings showed that the CP procedure was advantageous for treatment of PSD, because it was minimally invasive, cost-effective, provided good cosmesis, and had a high success rate and low complication rate. Furthermore, it did not require prior examination, and could be performed under local anesthesia. Therefore, the CP procedure may be useful as a first-line treatment option in children with PSD.

Sinus laser closure (SiLaC) versus Limberg flap in management of pilonidal disease: A short term non-randomized comparative prospective study

INTRODUCTION

Fistula Laser Closure (FiLAC) is a method that was originally applied in the treatment of perianal fistulas. Because of promising results, diode lasers were later on used to treat pilonidal sinus disease in a method called sinus Laser Closure (SiLaC). The aim of this study is to compare between SiLaC and Limberg flap in management of pilonidal disease.

METHODS

A prospective, nonrandomized comparative study. A short-term follow-up of 71 patients with pilonidal disease was analyzed (24 operated on using the SiLaC technique and 47 using the Limberg technique). With a primary outcome is healing rate and recurrence and a secondary outcome is other measures i.e. complications, hospital stay and postoperative pain.

RESULTS

The median operative time in the SiLaC group was 26.45 ± 5.41 min (20-35 min) and in the Limberg group 58.63 ± 7.42 min (50-75 min). In the SiLaC group, the primary healing was achieved in 23 out of 24 patients (95.8%) with a total complication rate of 20.83%. There were two cases of recurrence after initial healing in each group.

CONCLUSION

Sinus laser Closure (SiLaC) is comparable to Limberg flap technique in the terms of healing rate and recurrence with better outcome regarding operative time, hospital stay and post-operative pain.

Negative pressure-assisted endoscopic pilonidal sinus treatment

BACKGROUND

Endoscopic pilonidal sinus treatment (EPSiT) is a novel minimally invasive option for the treatment of pilonidal sinus disease (PSD). To optimise the postoperative wound management after EPSiT, an ultraportable negative pressure wound therapy (NPWT) device was used. The aim of this study was to assess the clinical outcomes of negative pressure-assisted (NPA) EPSiT.

METHODS

All patients with PSD treated by EPSIT from November 2017 to October 2019 were managed postoperatively with a commercially available NPTW dressing applied to the wound. All patients were prospectively entered into a dedicated database. Primary outcome measures were healing rate and return to normal activities. Secondary outcomes were postoperative complications and patient satisfaction.

RESULTS

Thirteen male patients underwent NPA EPSiT (mean age 27.8 years, range 16-52 years). Two patients had previous surgery for PSD. The mean follow-up was 14 months (range 4-28 months). In two patients, only partial healing of the tract was achieved. One of these required a further successful NPA EPSiT, while the other one refused any other treatment because of the lack of symptoms. Eight patients were very satisfied and 5 were satisfied with this treatment.

CONCLUSIONS

NPA EPSiT is a simple method for improving postoperative wound management, facilitating a quicker recovery and possibly improving overall patient satisfaction.

The EPIC procedure (Endoscopic-assisted Pilonidal Irrigation and Cleaning): a simple and effective treatment for pilonidal disease

BACKGROUND

Pilonidal disease (PD) is a common condition of the sacrococcygeal region leading to inflammation and abscess formation. PD is a topic of renewed interest due to the lack of satisfactory management options. Minimally invasive techniques have recently been investigated, with promising results in adult and pediatric populations. Our technique, the "EPIC procedure," Endoscopic-assisted Pilonidal Irrigation and Cleaning, involves removal of hair under direct visualization using a small endoscope while flushing saline through the cavity via an angiocatheter. We aim to show that the EPIC procedure is a safe and effective operation for the treatment of pilonidal disease in the pediatric population.

MATERIALS AND METHODS

We performed a retrospective chart review including 20 consecutive patients. All had a primary sacrococcygeal pilonidal sinus; all underwent the EPIC procedure. Post-operative care instructions included daily bathing and weekly depilatory application. We evaluated gender, age, weight, disease severity, operative duration, recurrence of PD, and other complications.

RESULTS

In the 20 patients studied, 22 EPIC procedures were performed. The median follow-up duration was 27.95 (range 0.63-45.27) months. The mean operative duration was 28.8 (SD 10.2) min. There was a 15% recurrence rate (95% CI 0.00%, 30.65%).

CONCLUSIONS

The EPIC procedure is an endoscopic-assisted operation that simplifies previously published techniques in pursuit of reduced operative complexity, cost, and time, with comparable recurrence and complication rates. All three recurrences occurred in patients that did not follow instructions for post-operative depilatory care. Two of these patients underwent repeat EPIC procedure and had no further complications. The third was lost to follow-up. The EPIC procedure provides a simple, effective, and minimally invasive approach to the treatment of pilonidal disease.

Primary Transverse Closure Compared to Open Wound Treatment for Primary Pilonidal Sinus Disease in Children

We aimed to compare the outcome of two different operative methods to correct pilonidal sinus disease (PSD) in children, i.e., excision and open wound care (OW) versus excision and primary transverse closure (PC) of the wound. In this retrospective, observational study, we extracted data from the medical records of 56 patients who underwent surgery for PSD at our institution between 1 January 2006 and 31 December 2016. To test whether the primary variable, i.e., rate of PSD recurrence, differed between the two surgical groups, a logistic regression model was fitted. Secondary explanatory variables were total length of stay (LOS) at the hospital, complications, sex and age of patients, seniority of the surgeon in charge, and volume of excised specimen. Overall, 32 (57%) children and young adults underwent OW, while 24 (43%) patients were treated by PC. Mean age at operation was 15.5 years in either group. PSD recurred in 12 of 32 (37.5%) children in the OW group and in 3 of 24 (12.5%) children in the PC group (ratio: 0.19, 95% confidence interval [95% CI] 0.03–1.07). Thus, treatment of primary PSD by PC proved superior with respect to PSD recurrence. Moreover, our study did not bring to light any high-grade complications in the PC group, and postoperative pain was minimal. Less invasive treatment approaches for chronic PSD are typically performed in an outpatient setting and offer reduced morbidity, low rates of PSD recurrence, and shortened periods of time to return to work or social activities. More radical operations of PSD should be reserved for recurrent PSD where less invasive approaches have failed several times.

Endoscopic Approach to Recurrent Pilonidal Sinus: A Retrospective Analysis

Background: The aim of this study is to report short- and long-term results using video-assisted ablation of pilonidal sinus (PS) technique to treat recurrent PS. Methods: We included all consecutive patients with a recurrent PS disease operated on with endoscopic approach since 1st January 2014 to 31st December 2018. Analyzed outcomes were recurrence rate at 1, 3, and 5 years, time off work, time to sitting on toilet and to walk without pain, time to wound healing, rate of incomplete wound healing and postoperative infection, postoperative pain at 6 hours, 1 day, and 1 week, and patients' satisfaction after 1 month. Demographic and sinuses' data were recorded. To adjust for all the variables, multivariate analyses were performed with outcomes as dependent variables, and with patients' and sinuses' characteristics as independent variables. Results: Sixty-three patients were included in the analysis. Recurrence rate at 1-year follow-up was 4.7% (3 patients on 63), at 3-year follow-up was 11.7% (4 on 34), and at 5-year follow-up was 23.07% (3 on 13). A 3- and 5-year follow-up was completed by 34 and 13 patients, respectively. The mean time off work was 3.5 ± 1.5 days, time to sitting on toilet without pain was 1.5 ± 1.1 days, and time to walk without pain was 1.3 ± 0.9 days. The mean time to wound healing was 27.9 ± 10.3 days, with a rate of incomplete wound healing of 4.7%. Postoperative infection rate was 7.9%. The mean postoperative pain was 1 ± 0.9 at 6 hours after the procedure, 0.6 ± 0.6 at 1 day and 0.1 ± 0.3 at 1 week. Patients' satisfaction was good in 98.5% of patients. After the multivariate analysis, no parameters showed an influence on the postoperative outcomes. Conclusions: Our results encouraged to adopt an endoscopic approach even in case of recurrent PS.

Outcomes of minimally invasive endoscopic pilonidal sinus surgery

INTRODUCTION

Pilonidal disease is a common condition that is often treated with morbid and painful surgeries. A minimally invasive, endoscopic approach has been described as an alternative to traditional open procedures. It allows the full visualization of the sinus tracks, leaves minimal scarring and results in less pain and a quicker recovery.

METHODS

Patients who underwent minimally invasive endoscopic surgery for pilonidal disease at a major metropolitan hospital in Australia were retrospectively identified. Their operative reports and medical records were assessed to determine analgesic requirements, lengths of hospital stay, recurrence rates of pilonidal disease, and wound complications.

RESULTS

Nine patients had endoscopic sinus surgery (six male, three female). All patients received treatment from the same surgeon. No patients required opiate analgesia for pain and only one stayed post-operatively in hospital overnight. There were no recorded wound complications. The median follow-up period was 28 months (range, 8-36 months). Eight patients had satisfactory healing recorded during their post-operative consultations. Three patients suffered recurrent disease.

CONCLUSION

Minimally invasive surgery is safe and well tolerated when employed to treat pilonidal disease. It could be considered as a first-line treatment for the obliteration of symptomatic pilonidal sinuses.

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.

Long-term results of endoscopic pilonidal sinus treatment vs Limberg flap for treatment of difficult cases of complicated pilonidal disease: a prospective, nonrandomized study

AIM

To present the results of a prospective, nonrandomized comparative study on the treatment of complicated pilonidal sinus by endoscopic pilonidal sinus treatment (EPSiT) compared with Limberg flap surgery, based on experience of a single surgical centre.

METHOD

A prospective, nonrandomized comparative study. Long-term follow-up of 62 patients with complicated pilonidal disease was analysed (36 operated on using the Limberg flap technique and 26 using the EPSiT method). The median follow-up was 27 months (12-44).

RESULTS

The median operating time in the EPSiT group was 60 min (25-80 min) and in the Limberg group 67 min (35-95 min). In the EPSiT group, primary healing was achieved in 22 out of 26 patients (84.6%) in a median of 42 days with a total complication rate of 11.5%. There were seven recurrences after initial healing. The total success rate of the EPSiT procedure with long-term follow-up was 57.7%. In the Limberg flap group, all patients healed (100%) in a median of 21 days. The complication rate in this group was 26.5%, and there were two recurrences in this group. The total success rate of the Limberg flap procedure was 94.1%.

CONCLUSION

For patients with complicated pilonidal sinus, the endoscopic procedure has a significantly lower success rate than the Limberg flap procedure, but a lower risk of complications. Such patients should be offered a choice between a safer, minimally invasive procedure with a higher risk of recurrence or flap surgery, which is more effective, but with a higher risk of complications.

Long-term results of a randomized clinical trial comparing endoscopic versus conventional treatment of pilonidal sinus

BACKGROUND

In the new era of minimally invasive surgery, recent studies encouraged the adoption of endoscopic approaches as the most effective way to treat (pilonidal sinus disease) PSD but little is known about long-term results of minimally invasive procedures.

MATERIALS AND METHODS

A total of 145 patients with chronic non recurrent pilonidal sinus were enrolled for this randomized controlled trial. The follow-up rate was 97% at 5 years for a total of 74 patients assigned to the minimally invasive treatment group and 67 patients assigned to the conventional Bascom cleft lift treatment group. We evaluated the following outcomes: long-term recurrence rate, patients' satisfaction, cosmetic outcome and cost-effectiveness results.

RESULTS

Long-term data confirm that the recurrence rate was similar in both groups and, in minimally invasive patients, there were a higher satisfaction and better cosmetic results. Costs analysis revealed improved outcome in favour of VAAPS with a much lower mean global cost.

CONCLUSION

Minimally invasive treatment has all the characteristics of an ideal approach to PSD with advantages including minimal patient inconveniences, high satisfaction and good aesthetics results. It was also more cost effective to carry out the treatment.

Pilonidal sinus disease: Preliminary case-control study on heat-related wound dehiscence

Background

Pilonidal disease is a morbid condition of the young population, that could impair quality of life with a high cost for the health care system. No consensus exists on optimal surgical treatment, even if several techniques have been proposed. In this preliminary case-control study we compared excision by knife and diathermy to investigate if wound dehiscence could be related to heat spreading during excision of the sinus.

Materials and method

Between January 2017 and February 2018, 29 patients underwent to sinus excision.16 patients underwent sinus excision by diathermy (named “Hot” group, case-group) while 13 patients underwent excision by the knife as the control group (named “Cold” group). The temperature data were recorded for both groups. Were considered primary and secondary outcomes.

Results

the cold group has worse outcomes in operative time and blood loss, but better results in post-operative pain at first day and first control, number of weekly and total dressings until healing, time for full wound recovery, days to return to work, patient feeling feedback and scar aspect. Wounds healed within 8–12 days were 84.6% in the Cold group and 18.8% in the Hot one. I° Dindo-Clavien complications were respectively 15.4% and 100.0% for the Cold and Hot group. No differences were recorded for II° Dindo-Clavien complications and in days of hospitalization.

Conclusion

cold excision of the sinus pilonidalis has better results both in terms of precarious healing and quality of life, probably because the tissues are not subjected to diathermocoagulation damage and therefore the healing occurs more quickly. (United States National Institutes of Health, www.clinicaltrial.gov, number NCT 03764657, www.researchregistry.com UIN 5003).

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Pilonidal sinus disease.

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Cold and Hot surgical procedures.

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Wounds healed within 8–12 days were 84.6% in the Cold group and 18.8% in the Hot one. I° Dindo-Clavien complications were 15.4% for the Cold and 100.0% for the Hot group.

The SiLaC procedure for pilonidal sinus disease: long-term outcomes of a single institution prospective study

BACKGROUND

In 2014, we started to treat pilonidal sinus disease in our institution with sinus laser-assisted closure (SiLaC) procedure. The aim of the present study was to evaluate the safety and efficacy of the SiLaC procedure in a single institution prospective study on a large cohort of patients and with a long follow-up period, and try to determine what factors that could influence healing and recurrence.

METHODS

A prospective study was conducted on consecutive patients with primary pilonidal sinus disease operated on with the SiLaC procedure at our institution from March 2015 to August 2017. Demographic and surgical data, outcomes, and complications were prospectively recorded and compared between the healed and not healed/recurrence groups to find factors influencing healing. Postoperative follow-up was performed in the outpatient clinic every 2 weeks for 2 months. In March 2018, patients were questioned by mail or phone to assess long-term recurrences.

RESULTS

There were 200 patients. The healing rate was high (94%) with a mean healing time of 19.5 ± 14.4 days. Mean operative time (9.4 ± 2.6 min) and mean duration of postoperative analgesic therapy (4.72 ± 5.64 days) were short. Postoperative complications (15%) were mainly infection (9.5%). There was a response rate of 77.5% to mail/phone questionnaires about recurrence. The recurrence rate was 14.9%. Mean time until recurrence was 193.5 ± 87.19 days. The incidence of secondary openings, complications, and infection in the healing vs not healed or recurrence groups, was 24.8% vs 56.6%, 19.2% vs 40%, and 8.8% vs 30%, respectively.

CONCLUSIONS

SiLaC is an effective, easy to perform, reproducible, and almost painless procedure. Factors influencing healing seem to be the presence of secondary openings, postoperative complications, and, especially, infection. The SiLaC procedure could become one of the treatments of choice for pilonidal sinus disease.

Surgical interventions for the treatment of sacrococcygeal pilonidal sinus disease in children: A systematic review and meta-analysis

BACKGROUND

Pilonidal sinus disease (PNS) is not uncommon in children. Controversy remains over the best treatment and there is limited evidence. This systematic review and meta-analysis aims to establish which techniques have the best outcomes in children.

METHODS

MEDLINE, EMBASE and CENTRAL databases were searched. Studies reporting treatment outcomes for PNS in children were included.

RESULTS

Open healing has pooled risk of recurrence of 26% (95%CI 15-38%), risk of wound complication of 21% (9-36%) and wound healing ranged from 38-92 days. Midline primary closure has pooled risk of recurrence of 12% (8-18%), risk of wound complication of 30% (19-46%) and wound healing ranged from 8 to 32 days. Off-midline primary closure has pooled risk of recurrence of 6% (1-15%), risk of wound complication of 14% (6-25%) and wound healing was 27 days. VAC therapy has pooled risk of recurrence of 20% (0-65%) and wound healing ranged from 38 to 92 days. Minimally invasive techniques has pooled risk of recurrence of 7% (1-16%) and wound healing ranged from 21-30 days. Marsupialisation has pooled risk of recurrence of 6% (0-22%), and wound healing ranged from 6 to 41 days.

CONCLUSION

Evidence for management of PNS in children is poor. Off-midline primary closure, minimally invasive techniques, and marsupialisation have the best outcomes.

LEVEL OF EVIDENCE RATING

IV.

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.

BRAZILIAN AND ARGENTINEAN MULTICENTRIC STUDY IN THE SURGICAL MINIMALLY INVASIVE TREATMENT OF PILONIDAL CYST

BACKGROUND

The pilonidal cyst is an infection of the skin and the subcutaneous tissue, secondary to a chronic inflammation with a greater frequency in the sacrococcygeal region, and associated to the presence of hair. The treatment is eminently surgical.

AIM

To demonstrate the endoscopic treatment of pilonidal cyst.

METHOD

Prospective study with 67 patients who had as surgical indication the diagnosis of pilonidal cyst. They were submitted to a surgical procedure from June 2014 to March 2018. The equipment used was the Meinero fistuloscope, a shutter, a monopolar electrode, a brush and endoscopic forceps.

RESULTS

Of the 67 patients, 67% (n=45) were male and 33% (n=22) female, with a mean age of 25 years (17-45). Surgical time in average was 40 min (20-120) and mean healing time of four weeks (3-12). Surgical complications were presented in 7% cases (n=5) and recurrences in 9% (n=6).

CONCLUSION

The endoscopic treatment of the pilonidal cyst is feasible and presents good surgical results.

A hairy cavity: endoscopic therapy of a presacral recurrence of a complex pilonidal sinus

BACKGROUND

Recently, minimally invasive techniques to avoid radical excisions of the pilonidal sinus with long-lasting secondary wound healing were developed. We describe a rare case of an intrapelvic, pararectal recurrence of a pilonidal sinus, who was innovatively treated with flexible endoscopy.

CASE PRESENTATION

A 43-year-old Caucasian man presented with an intrapelvic, pararectal recurrence of a primarily wide-stretched pilonidal sinus, originally located in the sacrococcygeal region and spreading laterally to the gluteal region and intrapelvic to the presacral area. No connection to the bowel was evident. Up until presentation in the endoscopic department, a total of five attempts of surgical resection were performed, always confirming the diagnosis of a pilonidal sinus. Endoscopic therapy consisted of a combination of debridement, laser ablation and endoscopic vacuum therapy. After completion of APC and VAC therapy, the patient irrigated the abscess cavity for a further 2 weeks with a rinsing syringe. The resulting deep scar at the gluteal fistula was resected after secondary wound healing was completed. Two years after the end of the therapy, no recurrence was evident.

CONCLUSION

Flexible endoscopy is, with its multiple therapeutic applications, an effective tool even in very complex inflammatory fistula and abscesses. Correctly indicated, it is with its minimally invasive character an excellent alternative to open surgical approaches.

[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.