Treatment of natal cleft sinus

Healing by primary versus secondary intention after surgical treatment for pilonidal sinus

BACKGROUND

Pilonidal sinus arises in the hair follicles in the buttock cleft. The estimated incidence is 26 per 100,000, people, affecting men twice as often as women. These chronic discharging wounds cause pain and impact upon quality of life. Surgical strategies centre on excision of the sinus tracts followed by primary closure and healing by primary intention or leaving the wound open to heal by secondary intention. There is uncertainty as to whether open or closed surgical management is more effective.

OBJECTIVES

To determine the relative effects of open compared with closed surgical treatment for pilonidal sinus on the outcomes of time to healing, infection and recurrence rate.

SEARCH STRATEGY

For this first update we searched the Wounds Group Specialised Register (24/9/09); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 3 2009; Ovid MEDLINE (1950 - September Week 3, 2009); Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations (September 24, 2009); Ovid EMBASE (1980 - 2009 Week 38); EBSCO CINAHL (1982 - September Week 3, 2009).

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing open with closed surgical treatment for pilonidal sinus. Exclusion criteria were: non-RCTs; children aged younger than 14 years and studies of pilonidal abscess.

DATA COLLECTION AND ANALYSIS

Data extraction and risk of bias assessment were conducted independently by three review authors (AA/IM/JB). Mean differences were used for continuous outcomes and relative risks with 95% confidence intervals for dichotomous outcomes.

MAIN RESULTS

For this update, 8 additional trials were identified giving a total of 26 included studies (n=2530). 17 studies compared open wound healing with surgical closure. Healing times were faster after surgical closure compared with open healing. Surgical site infection (SSI) rates did not differ between treatments; recurrence rates were lower in open healing than with primary closure (RR 0.60, 95% CI 0.42 to 0.87). Six studies compared surgical midline with off-midline closure. Healing times were faster after off-midline closure (MD 5.4 days, 95% CI 2.3 to 8.5). SSI rates were higher after midline closure (RR 3.72, 95% CI 1.86 to 7.42) and recurrence rates were higher after midline closure (Peto OR 4.54, 95% CI 2.30 to 8.96).

AUTHORS' CONCLUSIONS

No clear benefit was shown for open healing over surgical closure. A clear benefit was shown in favour of off-midline rather than midline wound closure. When closure of pilonidal sinuses is the desired surgical option, off-midline closure should be the standard management.

Healing by primary versus secondary intention after surgical treatment for pilonidal sinus

BACKGROUND

Pilonidal sinus arises in the hair follicles in the buttock cleft at the bottom of the backbone. The estimated incidence is 26 per 100,000, people, affecting men twice as often as women. The mean age of presentation is 21 years (men) and 19 years (women) respectively.Pilonidal sinus results in chronic discharging wounds that cause pain and impact upon quality of life and social function. These sinuses may become infected and present as acute abscesses. Management of these abscesses is uncontroversial and revolves around incision and drainage, however, the mode of surgical management of the chronic discharging sinus is debatable. Surgical strategies traditionally centre on excision of the sinus tracts followed by primary closure and healing by primary intention or leaving the wound open to heal by secondary intention. There is uncertainty as to whether open or closed surgical management is more effective.

OBJECTIVES

To determine the relative effects of open compared with closed surgical treatment for pilonidal sinus on the outcomes of time to healing, infection and recurrence rate.

SEARCH STRATEGY

We sought relevant trials from the Wounds Group Specialised Register (Searched 13/6/07); The Cochrane Central Register of Controlled Trials (CENTRAL) (2007, Issue 2); Ovid MEDLINE (1950 - May Week 5 200& ); Ovid EMBASE (1980 - 2007 Week 23); Ovid CINAHL (1982 - June Week 2 2007). We checked the bibliographies of review and primary articles for relevant studies and contacted authors of all included studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) evaluating open with closed surgical treatment for pilonidal sinus. Exclusion criteria were: non-RCTs; children aged younger than 14 years and studies of pilonidal abscess.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, data extraction and methodological quality assessment of trials were conducted independently by two review authors. Data from eligible studies were recorded using data extraction forms and any disagreements were referred to a third review author. Results were presented using mean differences for continuous outcomes and relative risk with 95% confidence intervals for dichotomous outcomes.

MAIN RESULTS

Eighteen studies were included (1573 patients). Twelve RCTs compared open healing with primary closure, 10 of which used midline closure and 2 trials used off-midline closure. Six studies compared midline and off-midline closure. Open compared with closed techniques: Evidence suggested more rapid healing after primary closure although there was no difference in the infection rate after wound closure. Recurrence was less likely to occur after open healing (RR 0.42; 95% CI 0.26 to 0.66) suggesting a 58% lower risk of recurrence after open wound healing compared with primary closure. Patients returned to work earlier after primary closure (WMD 10.48 days 95% CI 5.75 to 15.21 days). There was no difference between the two groups for other complications and length of stay. There were few useable data on cost, patient satisfaction and pain. Closed midline compared with closed off-midline: there was good evidence of slower healing, higher rates of infection (RR 4.70; 95% CI 1.93 to 11.45), higher rates of recurrence (Peto OR 4.95; 95% CI 2.18 to 11.24) and other complications (RR 8.94; 95% CI 2.10 to 38.02) after midline primary closure compared with off-midline closure techniques.

AUTHORS' CONCLUSIONS

No clear benefit was shown for surgical management by primary closure or open healing by secondary intention. A clear benefit was shown for off-midline closure rather than midline closure after pilonidal sinus surgery. Off-midline closure should be the standard management when primary closure is the desired surgical option.

Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches

PURPOSE

Pilonidal sinus is a common disease and surgical removal and subsequent wound closure is crucial for lasting cure. To evaluate the outcome of different primary closure techniques we performed a pooled analysis of data published in the past 35 years.

METHODS

We identified reports on wound infection, early failure, and late recurrence status in relation to treatment modality. Surgical techniques were classified into five groups: simple closure technique in the midline, asymmetric or oblique closure techniques, and full-thickness flap techniques like rhomboid flaps, vy-plasty, and z-plasty. Estimations of the incidences resulted from the quotient of number of responses and the number of patients for each study, and these quotients were summarized over all studies.

RESULTS

The MEDLINE search identified 74 publications including 10,090 patients. Pooled data analysis revealed an inhomogeneous effect of the surgical techniques on the infection rate. In contrast, there was a significantly lower early failure rate and late recurrence rate of both the asymmetric-oblique closure techniques and the full-thickness flap techniques when compared with the midline repair technique. No difference was found between the asymmetric repairs and the full-thickness flap techniques.

CONCLUSION

Beside the various statistical considerations when using a pooled data analysis combining results from the literature, this overview suggests a significant benefit of asymmetric-oblique closure techniques or flap techniques in comparison with simple closure in the midline. Thus, we recommend an asymmetric closure technique for primary closure of a chronic pilonidal sinus. These asymmetric procedures provide better results than the simple closure in the natal midline. Furthermore, they are not as sophisticated as the full-thickness plasty techniques.