Total excision versus non-resectional methods in the treatment of acute and chronic pilonidal disease

RADICAL VERSUS CONSERVATIVE METHODS IN ONE-STAGE PILONIDAL ABSCESS SURGERY: THE EXPERIENCE OF A TUNISIAN CENTER

BACKGROUND

Surgical treatment for pilonidal abscess is the gold standard, but not yet well codified. Different techniques proposed can be conservative or radical.

AIMS

The aim of our study was to compare postoperative outcomes of both methods in one-stage treatment strategy.

METHODS

This is a comparative study including patients operated on for pilonidal abscess, with a satisfactory postoperative follow-up, over a period of 4 years. We looked for the occurrence of postoperative recurrence in the medical records or by interviewing reachable patients.

RESULTS

We analyzed 57 patients: 33 males and 24 females. The mean age was 26.9±10 years. The type of operation was excision in 46 (81%) cases and incision in 11 (19%) cases associated with curettage in three cases and drainage in 1 case. There was no statistically significant relationship between the type of surgery and the occurrence of postoperative surgical complications (p=1) and hospital stay (p=0.4). Excision of pilonidal abscess was significantly associated with a longer time to return to activity (p=0.04). Conservative surgery was significantly associated with faster healing of the surgical wound (p<0.001). The recurrence rate was 19% in radical surgery and 54% in conservative surgery. Radical surgery was significantly associated with a lower recurrence rate than incision procedure (p=0.02).

CONCLUSIONS

Excision of pilonidal abscess was the common technique in our series, with a significantly lower rate of recurrence of the disease than after incision. However, the long convalescence following excision and the longer operating time, particularly in an emergency context, may sometimes lead to choosing conservative surgery.

The comparison of short-term results of marsupialization method in operated patients with acute pilonidal abscess and chronic pilonidal sinus

Objectives

This study aimed to compare the short term results of the marsupialization method for the treatment of patients with acute pilonidal abscess and chronic pilonidal sinus disease treated in single step and to investigate the feasibility of final pilonidal sinus treatment in single step in patients with pilonidal abscess.

Material and Methods

A total of 58 patients who were operated on using the marsupialization method were included in this study. Patients with acute pilonidal abscess were included in Group 1 (23 patients) and those with chronic pilonidal sinus disease were included in Group 2 (35 patients). Pilonidal sinus was excised as a whole by a vertical elliptic incision, with some surrounding intact tissue. After excision, the wound edges were sutured to the postsacral fascia. Daily dressings were performed by relatives at home. The patients were instructed to visit the hospital for follow-up 1-2 times a week. Student's t-test was used to compare the parameters between the groups.

Results

The mean wound length was 73.4 and 61.7 mm in Group 1 and Group 2, respectively. The mean duration of wound closure was 59.3 and 54.1 days in Group 1 and Group 2, respectively. There was no significant difference between the groups in terms of age, operation time, hospital stay, and duration of wound closure; however, wound length was significantly shorter in Group 2 than in Group 1.

Conclusion

The definitive treatment of acute pilonidal abscess can be achieved in single step by using marsupialization method as well as in patients with chronic pilonidal disease.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of pilonidal disease

Pilonidal disease (PD) is a relatively common, benign but challenging condition of the natal cleft. This consensus statement was drawn up by a panel of surgeons, identified by the Italian Society of Colorectal Surgery (SICCR) as having a “special interest” in PD, with the aim of recommending the best therapeutic options according to currently available scientific evidence. A three-step modified-Delphi process was adopted, implying: (1) choice of the panelists; (2) development of a discussion outline and of target issues; and (3) a detailed systematic review of the current literature. The agreement/disagreement level was scored on a five-point Likert scale as follows: “A + : strongly agree; A–: agree; N: unsure/no opinion; D–: disagree; D + : strongly disagree. Each panelist contributed to the production of this manuscript, and the final recommendations were reviewed by the Clinical Practice Guidelines Committee.

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.

Sacro-coxxygial hygiene, a key factor in the outcome of pilonidal sinus surgical treatment?

BACKGROUND

Surgical wound infection contributes to prolonged recovery time after pilonidal sinus excision. As a standard procedure after surgery, we recommend our patients to perform water irrigations in the intergluteal cleft 4 to 6 times a day during the post-operative period. Our hypothesis is that this should reduce healing time and complication rates. The aim of this study was to measure the importance of sacro coccygeal hygiene in the management of pilonidal sinus disease.

METHODS

We retrospectively collected data after surgical management of pilonidal sinus (sinusectomy procedures) in our division over a 10-year period. Patients were divided into three groups according to their local hygiene during postoperative follow-up and scored one (G1: good hygiene) to three (G3: poor hygiene). Primary outcome was complication rates. Secondary endpoints were, healing time, follow-up, time off work, and recurrence rate.

RESULTS

In G1 (N = 112), complication rate was 3.6%. In G2 (N = 109), it was 5.5%, whereas in G3 (N = 71), it reached 7.03%. However, there were no statistically significant differences between hygiene groups regarding complication rates in both univariate and multivariable analysis. Regarding secondary outcomes, there were significant differences between hygiene groups concerning median follow-up (p = 0.0001) and median time off work (p = 0.0127).

CONCLUSION

Good hygiene of wound is essential for optimal, rapid healing without complications. The importance of this report is to show that thanks to our hygiene follow-up strategy with frequent perineal irrigations and regular follow-up checks, patients with at a first glance "unclean local conditions", reached similar complications, median healing time and recurrences rates to patients with medium and good wound hygiene level.

Laying Open and Curettage under Local Anesthesia to Treat Pilonidal Sinus: Long-Term Follow-Up in 111 Consecutively Operated Patients

(1) Background: Several techniques for the treatment of pilonidal sinus disease (PSD) are in vogue, though none have emerged as the gold standard. Laying open (deroofing) and curettage under local anesthesia is one of the most straightforward procedures to treat PSD. In this study, the long-term follow-up in a large series was analyzed. (2) Methods: The laying open approach was performed for all types of consecutive PSD patients-simple, complicated, and abscess. The primary outcome parameter of the study was the healing rate. The secondary outcome parameters were operating time, hospital stay, time to resumption of normal work, and healing time. (3) Results: 111 (M/F-92/19, mean age-22.9 ± 5.7 years) consecutive patients were operated on and followed for 38 months (6-111 months). Of these, 24 had pilonidal abscesses, 87 had chronic pilonidal disease, while 22 had recurrent disease. Operating time and hospital stay were 24 ± 7 min and 66 ± 23 min, respectively. On average, patients could resume normal work in 3.6 ± 2.9 days and the healing time was 43.8 ± 7.4 days. Three patients were lost to follow-up. Complete resolution of the disease occurred in 104/108 (96.3%) patients, while 4 (3.7%) had a recurrence. One recurrence was due to a missed tract, while three recurrences presented after complete healing had occurred. Two patients with recurrence were operated on again with the same procedure, and both healed completely. Thus, the overall success rate of this procedure was 98.1% (106/108) with a recurrence rate after first surgery of 3.7% over a median follow-up of 38 months. (4) Conclusions: Pilonidal disease managed by laying open (deroofing) with curettage under local anesthesia is associated with a high cure rate. This procedure is effective in treating all kinds of pilonidal disease (simple, complicated, and abscess).

Practical Management of Pilonidal Disease

Pilonidal disease is a common problem across the globe, with a wide variety of options for management, ranging from healing by secondary intention to flap closure. As new techniques have been introduced, the ideal method to reduce complications and limit recurrence has become unclear. In this review, we highlight the most common methods used to treat pilonidal disease, as well as the senior author's preferred technique for management. Ideally, surgeons are able to choose the optimal procedure for each patient and maximize outcomes with minimal patient care burden and morbidity.

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.

Management of sacrococcygeal pilonidal sinus disease

The ideal treatment for patients who suffer from pilonidal sinus disease should lead to a cure with a rapid recovery period allowing a return to normal daily activities, with a low level of associated morbidity. A variety of different surgical techniques have been described for the primary treatment of pilonidal sinus disease and current practice remains variable and contentious. Whilst some management options have improved outcomes for some patients, the complications of surgery, particularly related to wound healing, often remain worse than the primary disease. This clinical review aims to provide an update on the management options to guide clinicians involved in the care of patients who suffer from sacrococcygeal pilonidal sinus disease.

Laser Hair Depilation in the Treatment of Pilonidal Disease: A Systematic Review

BACKGROUND

Laser hair depilation has shown promise in small series of patients with pilonidal sinus disease. The purpose of this study was to review the published literature on laser hair depilation in pilonidal disease to determine its effect on disease recurrence.

METHODS

The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched to identify all studies published through December 1, 2017 that examined the role of laser hair depilation in the treatment of pilonidal sinus disease. Study characteristics, including design, treatment regimen, number of patients evaluated, rate of recurrence, and duration of follow up were recorded.

RESULTS

Thirty-five published studies were included. Of these, 28 studies were retrospective and seven were prospective. There were five comparative studies: two retrospective, one prospective observational, and two randomized controlled trials. The number of patients included in each study ranged from one to 86 patients and patients received between one and 11 laser treatments. The pilonidal disease recurrence rate after laser depilation ranged from 0% to 28% at a mean follow-up ranging from 6 months to 5 years across studies. Four of the five studies that included a comparative group demonstrated a decreased recurrence rate compared to the non-laser cohort.

CONCLUSION

Laser hair depilation is a promising therapy in the management of pilonidal disease. However, the literature published to date is heterogeneous and has limited generalizability. Additional research is needed to determine the effectiveness of laser hair depilation to prevent pilonidal disease recurrence.

Pilonidal Disease: Classic and Contemporary Concepts for Surgical Management

BACKGROUND

Pilonidal disease (PD) is a recalcitrant condition associated with significant morbidity. It affects 26 in 100,000 individuals; however, there is no consensus on optimal surgical treatment, and up to half of patients struggle with recurrence. This review appraises the current literature on techniques and outcomes of PD surgery, to better guide decision making.

METHODS

A literature review using directed search terms was performed to identify studies addressing PD management, in accordance with the PRISMA guidelines. Data on techniques, outcomes, and complications were collected.

RESULTS

Open healing remains the most widely used treatment method and achieves reliable outcomes at the expense of prolonged wound healing, between 21 and 71 days. Asymmetric closure reduces healing time to 10 to 23 days and produces significantly fewer recurrences relative to midline closure (P < 0.05). Outcomes are similar between various asymmetric techniques; the Bascom cleft lift, Karydakis flap, and Limberg transposition are commonly used approaches which all demonstrate recurrence rates under 6%. Deroofing is associated with a significantly lower rate of complications than any closure procedure at 1.4% (P < 0.05), with recurrence in only 1% to 10% of patients, and represents a favorable treatment alternative.

CONCLUSIONS

Despite the heterogeneous nature of studies on PD, certain techniques have been consistently shown to optimize postoperative outcomes. Deroofing sinuses and allowing secondary healing results in low rates of recurrence with minimal morbidity. When closure is preferred, off-midline flaps provide more effective coverage than midline repair. Treatment recommendations should be guided by individualized patient preferences and be grounded in high-quality data.

High Rate of Major Morbidity after Surgical Excision for Pilonidal Disease

BACKGROUND

Recurrent pilonidal disease has been reported to occur in up to 30% of patients after their initial infection. Surgical resection is often performed to prevent recurrence of disease, however, morbidity after surgical excision from incision complications and disease recurrence is common. The aim of this study was to quantify major morbidity after initial pilonidal excision.

PATIENTS AND METHODS

Patients with pilonidal disease who had initial excision procedures between 2011-2013 at hospitals reporting data to the Pediatric Health Information System (PHIS) were included. Predictors of the composite outcome of major surgical site complication or surgical re-excision within one year were evaluated using multivariable logistic regression models. Kaplan-Meier analysis was used to examine time to surgical re-excision.

RESULTS

Of the 1,932 patients included, 4.7% (n = 138) had a major surgical site complication, 8.0% (n = 154) had a surgical re-excision, and 8.7% experienced either event within one year of their initial excision. The majority of re-excisions for recurrent disease occurred during the first two years after the initial excision. Risk factors associated independently with a greater risk of the composite outcome included older age (odds ratio [OR] 1.04 [95% confidence interval {CI} 1.00-1.07), p = 0.03), male gender (OR 1.49 [95% CI 1.09-2.08), p = 0.01), and the presence of a complex chronic gastrointestinal condition (OR 4.33 [95% CI 1.96-9.59], p < 0.001).

CONCLUSIONS

Surgical excision of pilonidal disease is often complicated by site complications and nearly 1 of 10 patients develop recurrent disease requiring re-excision within two years after their initial excision. Future research into alternative therapies to treat pilonidal disease is warranted.

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.

Minimal Excision and Primary Suture is a Cost-Efficient Definitive Treatment for Pilonidal Disease with Low Morbidity: A Population-Based Interventional and a Cross-Sectional Cohort Study

Background

Conventional treatment of pilonidal disease with wide excision is associated with high morbidity. We describe the short- and long-term results and the impact on the health care system of a simple operation performed in the office under local anaesthesia, consisting of minimal excision of pilonidal sinuses with primary suture—the modified Lord–Millar operation (mLM).

Methods

All patients operated with mLM from February 2008 till November 2012 were prospectively followed for recurrence by telephone interviews and examination of symptomatic patients till July 2015. The outcome is compared with that in all patients operated with conventional wide excision from January 2003 till February 2008. The effects on the health care system of a consistent use of mLM is analysed by comparing the management of all patients with pilonidal disease at three hospitals during 2013 and 2014.

Results

Some 129 patients underwent conventional surgical treatment, and 113 had the mLM operation. The mLM operation was more often performed under local anaesthesia, was less often admitted to hospital, had fewer post-operative health care visits (2.4 vs. 14.6, p < 0.001) and a shorter sick leave (1.0 vs. 34.7 days, p < 0.001) indicating faster wound healing. The estimated 5-year recurrence rate was similar (32 vs. 23%, p = 0.091). The cost per operated patient was lower (2231 vs. 6222 EUR, p < 0.001). The hospital consistently applying the mLM operation used less resources for pilonidal diseased patients (34,545 vs. 77,421 EUR per 100,000 inhabitants and year).

Conclusions

The mLM operation is simple, cost-efficient and has low morbidity and good long-term results.

Modified Primary Closure Method for the Treatment of Pilonidal Sinus

OBJECTIVE

Pilonidal sinus (PS) is considered to be the acquired disease of especially in the sacrococcygeal region. Various primary or secondary or flap methods, accompanied by one of local curettage, phenol application, electro-cauterization and total sinus excision methods, are used for the treatment of pilonidal sinus. However, currently there is not a single widely accepted treatment method.

MATERIALS AND METHODS

Ninety-eight patients who had operation for PS in Atatürk University, Department of General Surgery between January 2012 and August 2014 were included in this study. The patients were categorized into two groups: first, the patients undergone total sinus excision with primary closure (Group 1), and second, patients undergone total sinus excision with modified primary closure (MPC) (Group 2). Among all 98 patients participated in this study, age, sex, type of operation, duration of operation, amount of excised skin, duration of postoperative stay at hospital and complications were evaluated.

RESULTS

Forty-four patients (44.9%) underwent primary closure method, while 54 patients (55.1%) underwent MPC method. Mean duration of operation was 39.1 (30-60) minutes, mean diameter of excised material was 9.3 (8-11) cm(2) and mean duration of stay at hospital was 1.4 (1-3) days for the patients in the first group. Meanwhile, duration of operation was 52.2 (35-70) minutes, mean diameter of excised material was 2.6 (2-4) cm(2) and mean duration of stay at hospital was 1.6 (1-3) days for the patients in the second group. There was statistically significant difference between the two groups by means of duration of operation, dehiscence of surgical wound, recurrence and development of general complications (p<0.001, p<0.05, p<0.05 and p<0.005, respectively). According to the multivariate analysis, during surgical treatment of pilonidal sinus, primary closure method increases the rate of complication 6.65 times and MPC method increases the duration of operation 1.2 times.

CONCLUSION

We hereby suggest that MPC method could be a good alternative for surgical treatment of PS, because it causes fewer complications and recurrence.

Comparison of Drainage, Delayed Pits Excision, and Closure With Excision and Secondary Healing in Pilonidal Sinus Abscess Cases

A pilonidal abscess is an emergency situation which requires immediate drainage and is usually seen in young men. We aimed to compare incision and draining (I&D) of acute pilonidal abscess (PSA) and healing by secondary intention with I&D and subsequent delayed pits excision and closure (PE/PC). A total of 62 patients admitted with PSA were randomized to undergo either I&D and healing by secondary intention (group 1, n = 33) or I&D and PE/PC (group 2, n = 29). Demographic characteristics of the patients, abscess depth and location, duration and healing times of the symptoms, time required to return to work, and ratio of chronic pilonidal sinus (PNS) development were recorded, and the two methods were compared. No statistically significant differences were found between the groups in relation to sex, age, and preoperative findings, including discharge, infection, pain, and length and depth of abscess. There was no difference in length of hospital stay between the groups, and no statistically significant difference was found between the groups in terms of complication rate (P = 0.298). A statistically significant difference (P = 0.033) was, however, found between the two groups in the recurrence rate of a pilonidal abscess (9.09% in group 1 versus 3.44% in group 2). A statistically significant difference was also observed between the groups in terms of development of chronic PNS (P = 0.020). According to the results of our study, I&D and PE/PC should be the primary procedure used, as opposed to skin incision, curettage, and secondary healing for the treatment of PSA.

Laying open (deroofing) and curettage under local anesthesia for pilonidal disease: An outpatient procedure

AIM

To test the efficacy of lay open (deroofing, not excision) with curettage under local anesthesia (LOCULA) for pilonidal sinus as an outpatient procedure.

METHODS

LOCULA procedure was done for all types of pilonidal disease. The primary outcome measure was cure rate. The secondary outcome measures were hospital stay, operating time, return to work, healing time and complication rate.

RESULTS

Thirty-three (M/F-30/3, mean age-23.4 ± 5.8 years) consecutive patients were operated and followed for 24 mo (6-46 mo). Eleven were pilonidal abscess and 22 were chronic pilonidal disease. Six had recurrent disease. Operating time and the hospital stay was 22.3 ± 5.6 min and 63.8 ± 22.3 min respectively. The patients could resume normal work in 4.3 ± 3.2 d and the healing time was 42.9 ± 8.1 d. Thirty (93.8%) patients had complete resolution of the disease and two (6.2%) had a recurrence. Both the recurrences happened in patients who had complete healing but ignored the prescribed recommendations. One out of these got cured after getting operated again with the same procedure. Thus the overall success rate of this procedure was 96.9%.

CONCLUSION

Lay open (deroofing) with curettage procedure under local anesthesia is an effective procedure to treat both simple and complicated pilonidal sinus and abscess. It is a simple procedure, has a high cure rate (up to 97%), doesn't require admission and is associated with minimal morbidity and scarring. Considering the distinct advantages, this procedure has the potential to become the first line procedure for treating pilonidal disease.

Use of a double rhomboid transposition flap in the treatment of extensive complex pilonidal sinus disease

OBJECTIVE

Rhomboid transposition flaps are safe and successful in treating recurrent, complex pilonidal disease. There are little data on treatment of very large (> 12 cm) pilonidal sinuses. We describe a new technique using two simultaneous rhomboid flaps to achieve primary closure following extensive wide-excision.

METHOD

With antibiotic prophylaxis, the sinus is excised en-bloc as a parallelogram (two adjacent rhomboids). Two rhomboid fasciocutaneous flaps are transposed to close this defect over suction-drains. Sutures are removed after 14 days.

RESULTS

Eight patients (seven males) were treated with this technique (median age 26 years; range 22-35 years). All had very extensive and recurrent disease, having had multiple previous procedures. Median drain-duration was 2 days (range 1-5 days) and postoperative stay was 2 days (range 0-5 days). One complication arose: a wound infection with partial dehiscence which healed with conservative treatment. No recurrence or further complication arose in a 33-month follow-up (range 8-41 months).

CONCLUSION

This is the first description of the use of two simultaneous rhomboid flaps for very large recurrent pilonidal disease. It is a relatively simple and safe alternative to major plastic reconstruction which is often resorted to in such large-scale disease.

Sacrococcygeal pilonidal disease

BACKGROUND

Sacrococcygeal pilonidal is a common disease in active young adults. Many surgical methods have been proposed, although no clear consensus as to the optimal treatment has been reported. This review looks at the different surgical techniques available and examines the reported results of primary healing, recurrent disease and complications (including delayed healing).

METHOD

A literature search using the Medline database was performed to locate English language articles on surgery for pilonidal disease. Further articles were obtained from the references cited in the literature initially reviewed.

RESULTS

Management should be tailored according to the individual and whether the disease is acute or chronic. Treatment should take into consideration hospital stay and return to work. Simple excision, curettage, partial lateral wall excision, or marsupialisation, are simple techniques with good results. They can be used for the initial surgery but their use is not recommended for recurrent disease. The modified rhomboid flap for recurrent disease has consistently shown positive results in terms of complication rates and recurrence.

CONCLUSION

We would recommend tailored treatment with simple excision for initial presentation and the modified rhomboid flap for recurrent disease.

Tratamento cirúrgico da doença pilonidal: meta-análise dos principais procedimentos adotados mundialmente

OBJETIVO: Analisar e comparar os diversos procedimentos cirúrgicos descritos para o tratamento da doença pilonidal. MÉTODO: Foram selecionados 34 trabalhos publicados em revistas indexadas, totalizando 8698 doentes operados. Realizou-se meta-análise para comparação das sete principais técnicas cirúrgicas descritas na literatura, quanto aos resultados em relação à recidiva e ao tempo de cicatrização no pós-operatório. RESULTADOS: Do total de doentes estudados, houve recidiva em 230 doentes (2,6%). O tempo de cicatrização no pós-operatório foi significantemente maior no grupo de excisão sem sutura. As recidivas foram estatisticamente semelhantes nos métodos: excisão sem sutura, marsupialização, incisão e curetagem, excisão e retalho e técnica de Karidakys. Os métodos que apresentaram maior índice de recidiva (estatisticamente significante - p<0,001) foram: excisão e sutura primária e o método de Bascom. CONCLUSÕES: Conclui-se, por esse estudo, que os resultados em relação à recidiva são estatisticamente semelhantes em todos os métodos, com exceção da excisão e sutura primária e da técnica de Bascom, que apresentaram recidivas mais freqüentes. O tempo de cicatrização foi maior nos indivíduos operados pela técnica de excisão sem sutura primária.

Pilonidal disease

Pilonidal disease is a disease of young people, usually men, which can result in an abscess, draining sinus tracts, and moderate debility for some. It probably results from hair penetration beneath the skin, for reasons that are not totally clear. Therapy should be simple, inflict minimal pain, have a short hospitalization, have a low recurrence rate, require minimal wound care, and allow rapid return to normal activity. No treatment meets all these ideal goals. Therefore, starting with a simple treatment and progressing to other treatments if failure occurs despite meticulous wound care and hair shaving is the logical approach. Table 1 depicts treatments from simple to more complex.

Treatment of external anorectal mucosal prolapse with circular stapler: an easy and effective new surgical technique

PURPOSE

The aim of this study was to demonstrate the feasibility, effectiveness, and reliability of a new technique for treating overt rectal mucosal prolapse using a stapler device.

METHODS

Eighteen consecutive patients with overt rectal mucosal prolapse were selected for the study. Preoperative anal manometry and cinedefecography demonstrated no anal incontinence and the absence of full-thickness rectal prolapse. One or two purse strings were prepared 3 to 4 cm distally to the dentate line and tied on a 33 mm circular stapler introduced through the anus and then fired.

RESULTS

The operation lasted an average of 15 minutes, and no local complications were recorded. Supplementary hemostatic sutures (2 to 6 stitches) were sometimes necessary. Seven patients did not require postoperative analgesia, whereas eight patients received one or two administrations of analgesics. Longer-lasting analgesic treatment (4 days) was necessary in only three patients. Sixteen patients were discharged after 48 hours, and only 1 after four days because of pulmonary infection. Patients resumed normal activities after a median period of three days. Median follow-up was 20 months. The prolapse was eliminated in all cases. No stricture was found at anal exploration, and no episodes of anal incontinence or bleeding were recorded. Postoperative manometry did not show significant changes compared with preoperative findings.

CONCLUSIONS

This new surgical technique is safe, effective, and rapid, causing minimum or no postoperative pain and could be proposed to replace traditional surgery for this common condition.

Pilonidal cyst on the vault. Case report

Pilonidal cysts and sinuses are described as dermoid cysts which contain follicles of hairs and sebaceous glands. They clinically present as a classic case of inflammation which comes with pain, local infection and redness. The origin of pilonidal disease remains controverse. There are many hypothesis as lack of hygiene on the affected area and a penetration and growth of a hair in the subcutaneous tissue caused by constant friction or direct trauma on the damaged area. The option for clinical treatment is very frequent. However, taking into consideration the incidence and the possibility of recidive, surgical treatment is presently recommended. Complications include cellulitis and abscess formation. Pilonidal cysts are mostly found on the sacral region. In the literature is found description of pilonidal cysts on the penis, interdigital region on the hands as well as on the cervical region. We present a case of pilonidal cyst located on the vault biparietal region, without malignant degeneration.