Karydakis flap repair for sacrococcygeal pilonidal sinus disease: how important is technique?

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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.

Karydakis procedure can be effectively performed in the lateral position

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes of endoscopic pilonidal sinus treatment (EPSiT): a systematic review

BACKGROUND

Pilonidal sinus is a common disease of the natal cleft, which can lead to complications including infection and abscess formation. Various operative management options are available, but the ideal technique is still debatable. More recently minimally invasive approaches have been described. Our aim was to review the current literature on endoscopic pilonidal sinus treatment (EPSiT) and its outcomes.

METHODS

A systematic literature review was conducted and reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of EMBASE, MEDLINE and Cochrane Library was conducted in November 2017. Full-text studies on the use of endoscopy for the treatment of pilonidal sinus were included in the review.

RESULTS

Initial search results returned 52 articles. Eight studies (eight case series and one randomised control trial) were included in the final qualitative synthesis. These studies demonstrated that EPSiT has good complete healing rates and low recurrence rates. There was also a high level of patient satisfaction and little time taken off work. Two studies reported modifications to the original technique. The main limitation was the lack of comparative studies.

CONCLUSIONS

Initial studies on EPSiT have shown promising results. However, there is a need for a standardised technique and more comparative studies to validate this novel procedure.

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.

Karydakis Flap With Compressing Tie-over Interrupted Sutures Without Drain versus Standard Karydakis for Treatment of Sacrococcygeal Pilonidal Sinus Disease

BACKGROUND

Sacroccygeal pilonidal sinus disease is a worldwide health problem, affecting young adults, mainly males, with a tendency for recurrence. Various modalities have been used for treating this condition. The Karydakis procedure is one of most commonly used asymmetric flaps for treating this condition.

OBJECTIVE

The study aimed to evaluate the Karydakis procedure with tie-over compressing sutures instead of the routine use of a drain in the treatment pilonidal sinus.

DESIGN

This prospective randomized controlled clinical study was conducted between January 2010 and January 2015.

SETTINGS

The study was conducted at Minia University Hospital.

PATIENTS

The study included 154 patients. Patients were randomly assigned into 2 equal groups.

INTERVENTIONS

The patients in group 1 were operated on by the standard Karydakis procedure, and the patients in group 2 were operated on by the Karydakis procedure with tie-over compressing sutures without a drain.

MAIN OUTCOMES AND MEASURES

The primary outcomes measured were the incidence of seroma formation, wound complications, length of hospital stay, off-work time, and recurrence rate.

RESULTS

All patients were discharged on the same day of surgery in group 2 compared with a mean hospital stay of 4.9 ± 2.4 days in group 1. No patients developed seroma in group 2 compared with 7.8% in group 1. In group 2, 1.3% of patients developed wound infection compared with 9.1% in group 1. The average time for return to work in group 2 was 10.2 ± 1.4 days compared with 12.6 ± 4 days in group 1. No recurrences were noted in group 2 compared with 2.6% in group 1.

LIMITATIONS

The feedback about postoperative pain and patient satisfaction about the scar were not investigated. The extent of the disease in both groups was not investigated. The duration of follow-up too short to accurately weight recurrence rate.

CONCLUSION

Karydakis flap with tie-over compressing interrupted sutures without a drain is safe, 1-day surgery with the lowest complications rate.

Investigating the effect of autologous platelet-rich plasma on pain in patients with pilonidal abscess treated with surgical removal of extensive tissue

Background

Pilonidal is a painful disease which occurs mainly in the sacrococcygeal area. In 1833 Herbert Mayo first reported a case of a young woman with a hair-containing sinus in the sacrococcygeal area. In 1880, Hodge suggested the term “pilonidal” from the Latin “pilus” for hair and “nidus” meaning nest.

Objectives

Effect of using autologous platelet-rich plasma (PRP) on pain reduction in patients with pilonidal abscess, subjected to extensive surgical removal tissue, was investigated through a clinical trial.

Patients and Methods

The trial was conducted on two groups from the Center for Surgical Research at Mashhad University of Medical Sciences located at Ghaem hospital in Mashhad city in 2011. Purposive sampling was conducted and the samples were randomly assigned to two groups including test and control. All of the patients referred to the surgical unit of Imam-Reza hospital with acute pilonidal abscess (sacrococcygeal abscess) were considered and randomly assigned to two groups. Patients’ dressing was not removed for two days. To avoid systematic errors (Bias), the resident who checked the wound for the first time was completely unaware of the patient’s treatment plan. Recovery process and wound healing were monitored for the two groups and compared with each other (every other day for 10 days, and then once a week until complete healing). Data analysis was performed using SPSS19 software with Chi-square, independent t, and Mann-Whitney tests.

Results

Based on the obtained results it was found that the pain in the test group was significantly reduced in the first and fourth weeks (P < 0.05), compared to the control group.

Conclusions

Therefore, it has been demonstrated that using PRP can significantly reduce pain in patients subjected to surgical treatment for their pilonidal abscess.

Karydakis flap procedure in patients with sacrococcygeal pilonidal sinus disease: experience of a single centre in Istanbul

BACKGROUND

The aim of this retrospective study was to evaluate the results of patients with sacrococcygeal pilonidal sinus who underwent surgery using the Karydakis technique.

METHODS

Two hundred fifty-seven patients with sacrococcygeal pilonidal sinus disease were treated by the Karydakis flap procedure between December 2003 and June 2011. Patients were evaluated with respect to age, gender, preoperative symptoms, duration of preoperative symptoms, history of pilonidal sinus surgery, early postoperative complications, recurrence rates, and cosmetic satisfaction.

RESULTS

There were 223 (86.8%) male and 34 (13.2%) female patients. The mean age of the patients was 27.15 ± 7.69 years. The most frequent symptom was seropurulent discharge (57.58%). Postoperative morbidity was noted in 24 patients (9.3%). The mean hospital length of stay was 3.34 ± 1.42 days. The cosmetic satisfaction rate was 91.06%. Recurrences were noted in 6 patients (2.3%).

CONCLUSION

The Karydakis flap procedure is a safe treatment alternative for the surgical treatment of sacrococcygeal pilonidal sinus disease owing to the associated low complication rate, short hospital length of stay, rapid healing, and a high patient satisfaction rate.

Prospective analysis of cosmesis, morbidity, and patient satisfaction following Limberg flap for the treatment of sacrococcygeal pilonidal sinus

PURPOSE

Recent studies have reported excellent healing and low recurrence rates for rhomboid flaps for pilonidal sinus disease. The cosmetic outcome has been less investigated and is the focus of this study following Limberg flap reconstruction of recurrent and complex pilonidal disease.

METHODS

From August 2006 to December 2007 patients with a recurrent or complex pilonidal sinus were enrolled consecutively. All underwent excision and closure with a Limberg flap. At 3 weeks, morbidity was assessed in the outpatient clinic. Recurrence rate, self-esteem, cosmetic outcome, body image, and patient satisfaction were analyzed prospectively at 1 year.

RESULTS

Seventy patients (57 males) with a median age of 24.8 years (range, 14.7-46.5) were operated on. Median follow-up was 1.4 years (range, 1.0-2.8). The mean cosmetic score was reduced to 16.4 (± 4.3) of 24, the mean body image score was good with 17.9 (± 2.6) of 20, and the mean overall satisfaction was high at 7.6 (± 2.3) of 10. Self-esteem remained unchanged after surgery; it was 7.8 (± 2.3) preoperatively and 7.8 (± 2.1) postoperatively (P = .818). After 3 weeks 84.3% of the wounds were completely healed. Complications occurred in 18 patients (25.7%), including superficial infection and partial suture dehiscence. Six (8.6%) needed reoperation, and all belonged to the group with acute infection before flap closure (P < .001). There was no incidence of flap necrosis. The recurrence rate was 1.6% at 1-year follow-up.

CONCLUSION

Initial wound closure and low recurrence rates after treatment with Limberg flap in pilonidal sinus disease lead to high patient satisfaction. The cosmetic outcome is acceptable, but an issue for some patients. These results support the use of the Limberg flap in complex pilonidal sinus disease after carefully informing patients about the cosmetic consequences.

Simple day-case surgery for pilonidal sinus disease

BACKGROUND

Pilonidal disease is a common and usually minor disease. Although wide excisional surgery has been common practice, there are more simple alternatives. This review focused on the aetiology and management of pilonidal disease.

METHODS

A comprehensive review of the literature on pilonidal disease was undertaken. MEDLINE searches for all articles listing pilonidal disease (1980-2010) were performed to determine the aetiology and results of surgical and non-surgical treatments. Single papers describing new techniques or minor modifications of established techniques were excluded. Further articles were traced through reference lists.

RESULTS

Patients with minimal symptoms and those having drainage of a single acute abscess can be treated expectantly. Non-surgical treatments may be of value but their long-term results are unknown. There is no rational basis or need for wide excision of the abscess and sinus. Simple removal of midline skin pits, the primary cause of pilonidal disease, with lateral drainage of the abscess and sinus is effective in most instances. Hirsute patients with extensive primary disease and deep natal clefts, or with recurrent disease and unhealed midline wounds, may also require flattening of the natal cleft with off-midline skin closure. These more conservative procedures are usually done as a day case, require minimal care in the community and are associated with a rapid return to work. They also avoid the occasional debilitating complications of surgical treatment.

CONCLUSION

Simple day-case surgery to eradicate midline skin pits without wide excision of the abscesses and sinus is rational, safe and effective for patients with pilonidal sinus disease.

The role of the platelet-rich plasma in accelerating the wound-healing process and recovery in patients being operated for pilonidal sinus disease: preliminary results

BACKGROUND

Because of the poor quality of life that results from the open technique (open excision and packing) for surgically treating pilonidal cyst disease, several alternatives that accelerate the wound-healing process have been proposed. This study aimed to evaluate the effect of platelet-derived growth factors on the healing process.

METHODS

Fifty-two patients with pilonidal sinus disease who underwent open excision and secondary closure of the surgical wound (n = 22) or additional local postoperative infusion of platelet-derived growth factors (n = 30) were evaluated. Duration of total wound healing and time to return to normal activities were evaluated. Quality of life of patients in each group was assessed via a stabilized questionnaire.

RESULTS

Wound-healing rates were much greater for the platelet group (p < 0.01). Complete healing of the surgical wound required 24 days for the platelet group while the respective time for the control group was more than 30 days (p < 0.01). Patients in the platelet group returned to their normal activities around the postoperative day 17 when mean wound volume was about 10 cc, while control group patients managed to do so around the postoperative day 25.

CONCLUSIONS

These data provide evidence that the use of platelet-derived growth factors directly to the surgical wound enhances the healing process resulting in faster recovery of patients surgically treated for pilonidal sinus disease.

Introducing an asymmetric cleft lift technique as a uniform procedure for pilonidal sinus surgery

BACKGROUND AND AIMS

Asymmetric techniques for surgery in pilonidal sinus disease (PSD) have been reported to provide better results than simple excision and closure in the midline. The aim of this retrospective study was to evaluate the results after introducing the Bascom asymmetric cleft lift procedure in our hospital on a day care basis.

MATERIAL AND METHODS

From a total of 33 patients operated from April 2002 to September 2004 with the Bascom asymmetric cleft lift technique, we were able to contact 29 who were invited to a follow up study. Eighteen (62%) of these patients accepted a consultation in the outpatient clinic while 11 (38%) were interviewed by phone.

RESULTS

At follow up mean 17 (range 10-27) months after the operation 24 (83%) of the wounds were healed while recurrences were present in 5 (17%) of the patients. In two of the patients with recurrences errors in the procedures were identified. Further results related to pre-, per- and postoperative conditions are discussed in this paper.

CONCLUSION

Early results after surgery for PSD with the Bascom asymmetric cleft-lift technique are promising. The technique has now become our standard procedure for treating chronic, symptomatic PSD.

Short-term results of Karydakis flap for pilonidal sinus disease

BACKGROUND

Because of the higher quality of life that the Karydakis flap provides compared to excision-only treatment, it became a recommended closure technique for pilonidal sinus disease. This study aimed to evaluate whether Karydakis flap technique can be performed in potentially infected tissue if the surrounding cellulitis allows wound closure.

METHODS

188 patients with pilonidal sinus who underwent excision only (n=91, 48%) or the Karydakis-flap technique (n=97, 52%) were evaluated. The results were reviewed according to the degree of wound contamination, and the effects of closure technique were studied in terms of early wound complications and the duration of hospital stay.

RESULTS

In the excision-only group, one patient developed a hematoma (1%) and one patient had cellulitis of the surrounding tissue (1%), which resulted in a 2% complication rate this group. In the Karydakis flap group, wound abscesses were observed in 12 patients (12%). Additionally, four patients (4%) had hematomas, two patients had seromas (2%) and three had other complications. For the Karydakis group, the overall complication rate was 21%, significantly higher than that for the excision-only group (p<0.01). In the Karydakis group, no association was found between complications and the degree of contamination (p=0.36).

CONCLUSIONS

These data provide evidence that the Karydakis flap technique might be performed even in potentially infected tissue. Although a considerable number of wound-related complications was observed in the Karydakis flap group, the majority of patients had primary healing. Thus, from our viewpoint, the Karydakis flap seems to be a potential alternative to simple excision in infected pilonidal sinus disease.