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

Surgical treatment of pilonidal disease - Short-term follow up results of minimally invasive pit-picking surgery versus radical excision without suturing: A prospective randomised trial

Background

In this study we compared the potential benefits of surgical treatments for chronic symptomatic pilonidal disease (PD) - minimally invasive pit-picking surgery and radical excision without wound suturing.

Materials and methods

A total of 100 adult patients with chronic symptomatic PD were enrolled in this study at the Kaunas Hospital of the Lithuanian University of Health Sciences. They were randomly divided into two groups: pit-picking surgery (n = 50) and radical excision with open healing (n = 50). Recurrent PD patients were not excluded. The comparison of the techniques was based on pain within the first postoperative week, failed surgery rates, and wound healing time. Additionally, pain levels at different time intervals following the treatment, analgesic consumption, and time off work, were assessed and compared.

Results

A total of 89 patients (89 %) were available for follow-up after 6 months. Pain levels the first postoperative week were significantly lower in the pit-picking group compared to the radical excision group, with median scores of 10.0 and 20.0, respectively (p = 0.002). The complete wound healing time was longer in the radical excision group (60 days) versus the pit-picking group (17 days), with a significant difference noted (p = 0.00). No significant difference was observed between the type of surgery and the rate of failed surgery, with 5 (11.9 %) cases in the pit-picking group and 4 (8.5 %) in the radical excision group.

Conclusion

Based on our short-term findings, minimally invasive pit-picking surgery is a better option regarding pain, wound healing time and failed surgery rate. In cases where this approach is not suitable, other alternatives should be contemplated, as radical surgery without wound suturing should not be employed as a treatment method for PD. Additionally, the relationship between PD and recurrence rates should be investigated further.

Surgery for pilonidal sinus disease in Norway: training, attitudes and preferences-a survey among Norwegian surgeons

BACKGROUND

Pilonidal sinus disease (PSD) is frequently observed in young adults. There is no wide consensus on optimal treatment in the literature, and various procedures are used in clinical practice. The objective of this study was to assess current practice, experience, training, and attitudes towards PSD surgery among Norwegian surgeons.

METHODS

An online survey on PSD surgery was created and sent to all members of the Norwegian Surgical Association. Categorical data were reported as frequencies and percentages.

RESULTS

Most currently practicing Norwegian surgeons used the Bascom's cleft lift (93.2%) or minimally invasive procedures (55.4%). Midline excisions with primary closure (19.7%) or secondary healing (22.4%) were still used by some surgeons, though. Most surgeons had received training in PSD surgery supervised by a specialist, but only about half of them felt sufficiently trained. The surgeons generally performed few PSD operations per year. Many considered PSD as a condition of low surgical status and this patient group as underprioritized.

CONCLUSIONS

Our findings suggest that PSD surgery in Norway has been moving away from midline excisions and towards off-midline flap procedures and minimally invasive techniques. PSD and its treatment have a low status among many Norwegian surgeons. This study calls for attention to this underprioritized group of patients and shows the need for consensus in PSD treatment such as development of national guidelines in Norway. Further investigation on training in PSD and the role of supervision is needed.

Benign Anorectal Disorder Management in Low-Resource Settings

There are many benign anorectal disorders, which can make patients seek care. In low-resource settings, the incidence of those pathologies is not different from the industrialized and western world. However, an interesting difference colorectal surgeons and gastroenterologists can face is the fact that many patients do not seek help or are not aware and have little opportunities to be helped. Latin America population is estimated to be around 8% of the world population, with Brazil having the largest percentage. Infectious diseases, which were previously under control or were steadily declining, have emerged. For example, we have seen resurgence of dengue, malaria, and syphilis in pregnancy, as well as other sexually transmitted diseases that can affect the anorectal region. In this article, we will address the most common benign anorectal disorders.

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.

Pilonidal sinus disease on the rise: a one-third incidence increase in inpatients in 13 years with substantial regional variation in Germany

PURPOSE

Collective evidence from single-centre studies suggests an increasing incidence of pilonidal sinus disease in the last decades, but population-based data is scarce.

METHODS

We analysed administrative case-based principal diagnoses of pilonidal sinus disease and its surgical therapy between 2005 and 2017 in inpatients. Changes were addressed via linear regression.

RESULTS

The mean rate of inpatient episodes of pilonidal sinus disease per 100,000 men increased from 43 in 2005 to 56 in 2017. In females, the mean rate of inpatient episodes per 100,000 women rose from 14 in 2005 to 18 in 2017. In the whole population, for every case per 100,000 females, there were 3.1 cases per 100,000 males, but the numbers were highly variable between the age groups. There was considerable regional variation within Germany. Rates of inpatient episodes of pilonidal sinus disease were increasing in almost all age groups and both sexes by almost a third. Surgery was dominated by excision of pilonidal sinus without reconstructive procedures, such as flaps, whose share was around 13% of all procedures, despite recommendations of the national guidelines to prefer flap procedures.

CONCLUSION

Rates of inpatient episodes of pilonidal sinus disease in Germany rose across almost all age groups and both sexes with relevant regional variation. The underlying causative factors are unknown. Thus, patient-centred research is necessary to explore them. This should also take cases into account that are solely treated office-based in order to obtain a full-spectrum view of pilonidal sinus disease incidence rates.

Pilonidal sinus disease: Review of current practice and prospects for endoscopic treatment

Pilonidal sinus disease is chronic acquired condition leading to significant morbidity and associated healthcare costs. Several techniques have been described to manage this condition with no treatment gaining universal acceptance. With the shift towards minimally invasive surgery, Video Assisted-Ablation of Pilonidal Sinus (VAAPS) and Endoscopic Pilonidal Sinus Treatment (EPiST) have gained prominence. The aim of this review is to analyse current treatment modalities and the evidence for endoscopic pilonidal sinus surgery.

Reported surgical techniques range from wide excision with or without primary closure to various flap closures. These aim to eliminate the underlying causes driven by natal cleft hair and reducing recurrence. However, long term (≥5 years) recurrence rates range between 10 and 30% with significant complication rates. Trials with endoscopic treatment which have shown comparable short-term results to established treatments with reduced morbidity. However, the potential higher cost, learning curve, patient selection criteria and need for long term outcomes from randomised trials limit widespread application of this promising method.

Endoscopic treatment of pilonidal sinus disease therefore provides a minimally invasive alternative to traditional surgical methods with the potential to reduce morbidity. However long-term outcomes data from further prospective randomised trials is needed to establish its efficacy compared to traditional surgical methods.

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Multiple treatment modalities for pilonidal sinus disease exist with no universally accepted mode of treatment.

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Pilonidal sinus disease recurrence is high even after treatment.

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Endoscopic treatment has comparable short-term results to established treatments with reduced morbidity.

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Video Assisted-Ablation of Pilonidal Sinus and Endoscopic Pilonidal Sinus Treatment are emerging treatment modalities.

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 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.

Improving Resource Utilization and Outcomes Using a Minimally Invasive Pilonidal Protocol

PURPOSE

The purpose of this study was to evaluate the resource utilization and outcome of a minimally invasive pilonidal protocol (MIPP) versus surgical excision (SE) in adolescents with pilonidal disease.

METHODS

Improved hygiene, laser epilation (LE), and sinusectomy were implemented as a minimally invasive pilonidal protocol (MIPP) in March 2016. Following IRB approval, 34 consecutive MIPP patients with moderate and severe disease were compared with a random sample of 17 SE patients treated prior to MIPP implementation. Number of visits, laser epilation (LE) treatments, care duration, operations, operating room (OR) time, charges, and condition at last visit were analyzed. Charges were standardized for 2018.

RESULTS

No differences were found in age or body mass index between groups. SE patients underwent an average 1.6 excisions/patient (cumulative 2598 OR minutes) and no LE. MIPP patients underwent an average 1.4 sinusectomies and 3.5 LEs/patient. Six sinusectomies (0.17/patient) were performed in OR (cumulative 258 OR minutes). No differences in number of visits or care duration were found between groups. At last follow-up, 82% of MIPP and 18% of SE patients were healed or asymptomatic (p < 0.01). Average charges were $29,098 for SE versus $8440 for MIPP (p < 0.01).

CONCLUSION

A minimally invasive pilonidal protocol reduces charges and improves outcome compared with surgical excision in adolescents.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective comparative study.

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.

Prevention of Surgical Site Infections: A Systematic Review of Cost Analyses in the Use of Prophylactic Antibiotics

Introduction: The preoperative phase is an important period in which to prevent surgical site infections (SSIs). Prophylactic antibiotic use helps to reduce SSI rates, leading to reductions in hospitalization time and cost. In clinical practice, besides effectiveness and safety, the selection of prophylactic antibiotic agents should also consider the evidence with regard to costs and microbiological results. This review assessed the current research related to the use of antibiotics for SSI prophylaxis from an economic perspective and the underlying epidemiology of microbiological findings.

Methods: A literature search was carried out through PubMed and Embase databases from 1 January 2006 to 31 August 2017. The relevant studies which reported the use of prophylactic antibiotics, SSI rates, and costs were included for analysis. The causing pathogens for SSIs were categorized by sites of the surgery. The quality of reporting on each included study was assessed with the “Consensus on Health Economic Criteria” (CHEC).

Results: We identified 20 eligible full-text studies that met our inclusion criteria, which were subsequently assessed, studies had in a reporting quality scored on the CHEC list averaging 13.03 (8–18.5). Of the included studies, 14 were trial-based studies, and the others were model-based studies. The SSI rates ranged from 0 to 71.1% with costs amounting to US$480-22,130. Twenty-four bacteria were identified as causative agents of SSIs. Gram negatives were the dominant causes of SSIs especially in general surgery, neurosurgery, cardiothoracic surgery, and obstetric cesarean sections.

Conclusions: Varying results were reported in the studies reviewed. Yet, information from both trial-based and model-based costing studies could be considered in the clinical implementation of proper and efficient use of prophylactic antibiotics to prevent SSIs and antimicrobial resistance.

The Surgical Management of Pilonidal Disease is Uncertain Because of High Recurrence Rates

Background Pilonidal disease is a common condition with no consensus for the best management of chronic disease or current practice in Australia and New Zealand. Methods A survey was distributed among 190 colorectal and 592 general surgeons in Australia and New Zealand. Data was obtained regarding pilonidal surgery volume, procedures performed, non-operative management and recurrence rates. Three clinical scenarios were also presented. Results The response rate was 58% among colorectal surgeons, 18% among general surgeons. Nineteen percent of surgeons were high-volume (>23 operations per year), 47% low-volume (<12 operations per year). The commonest procedure was the Karydakis procedure (77%), with many others performed including rhomboid flaps (36%), Bascom cleft lift (13%), Z-plasty (7%), and gluteal rotation flaps (5%). Fifty-five percent of high-volume surgeons offered more than one operation while only 16% of low-volume surgeons did. Nineteen percent operated on all patients with pilonidal disease, 89% believing off-midline closure to be superior to midline. Disease extent was the main driver for non-operative management; patient factors such as cosmesis and time-off work being the least important. Sixty-four percent reported recurrence rates above 5%, and 37% recurrence rates >10%. Six percent reported no recurrences ever. Five percent reported recurrence rates over 20%, but 24% stated that over one-fifth of their practice consists of recurrent disease. Conclusions This study reports higher recurrence rates than in published series, suggesting many surgeons do not see their own recurrences, with current treatment not as successful as previously thought. Combined with the widespread variation in practice, optimal management of this disease remains unclear.

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.

Outcomes of Unroofing with Limited Excision and Structured Postoperative Care for Pilonidal Disease

Despite a wide variety of surgical techniques to treat chronic pilonidal disease, high rates of recurrence are common. The current study analyzes the outcome of unroofing with limited excision combined with structured postoperative wound care for pilonidal disease. We performed a retrospective review of all patients who were treated with this technique over a seven year period. Ninety-four patients aged 11 to 63 (mean age 26) received this treatment for pilonidal disease. Eighty-nine patients were treated for primary pilonidal disease and five were treated for recurrent disease after procedures such as flaps. There were 66 males (70%) and 28 females (30%). The operation was performed by unroofing the entire pilonidal sinus along with its pits and area of chronic abscess cavity. All granulation tissue was removed and the base of the sinus was completely cauterized. No wide local excisions were performed. The cavity was packed with dry gauze and the dressing was changed twice daily. Patients were seen postoperatively on a weekly basis in clinic. The area was shaved; the cavity was cleaned and often treated with silver nitrate. In the event of premature skin closure starting to form, unroofing was easily performed in the office. The median time to achieve complete healing was 53 days requiring, on average, seven visits. With a mean follow-up of 40 months, there were two recurrences (2.1%) and reoperation for two (2.1%) inappropriately healing wounds. This study demonstrates that unroofing with limited excision and structured postoperative care for pilonidal disease is a safe and effective treatment approach with a very low recurrence and complication rate.