Excision and marsupialization versus sinus excision for the treatment of limited chronic pilonidal disease: a prospective, randomized trial

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.

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.

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.

Assessment of the effect of platelet rich plasma on the healing of operated sacrococcygeal pilonidal sinus by lay-open technique: a randomized clinical trial

Background

Sacrococcygeal pilonidal sinus disease (PSD) is an infection of the skin and subcutaneous tissue at the upper part of the natal cleft of the buttocks. Excision and healing by granulation “lay-open” method is still more preferable than other methods of midline closure or using flaps but the healing time is lengthy. The present study was performed to assess the healing promotion effect of platelet-rich plasma (PRP) on the pilonidal sinus wounds treated by the lay-open method.

Methods

One hundred patients suffering from PSD were randomly divided into two groups, they were treated by the lay-open method, at General surgery department, Kafr El-Sheik University hospital, Egypt, during the period from December 2018 to December 2019. Group (A) was adopted the regular dressing postoperatively, while group (B) was treated with PRP injection into the wound at 4 and 12 postoperative days.

Results

Accelerated rate of wound healing was detected in group (B) in day 10, with a significant difference detected in days 15, 20, 25 and 30 postoperative, with a mean time of complete healing 45 ± 2.6 days in group B, while it was 57 ± 2.4 days in group A with a p-value of 0.001 which indicates considerable effect in the treated group.

Conclusions

PRP injection is an effective new technique in accelerating the healing of pilonidal wound after surgery, with a significant decrease in post-operative pain, complications and an early return to work.

Trial registration

retrospectively registered. Trial registration number: 12/35/1016 issued on December 2018 from the Institution Review Board at Kafr El Sheikh University. ClinicalTrials.gov identifier: NCT04430413

Conservative Sinusectomy vs. excision and primary off-midline closure for pilonidal disease: a randomized controlled trial

PURPOSE

Pilonidal sinus disease (PD) is a common acquired disease, responsible for discomfort and time off work. There is currently no consensus on the best surgical therapy. We aimed at comparing conservative sinusectomy (S) to excision and paramedian primary closure (PC).

METHODS

This is a randomized controlled trial compatible with the CONSORT statement standards. We included all patients with chronic PD between 2012 and 2017. We excluded patients with acute abscesses, recurrent PD after surgery with a curative intent and patients needing complex reconstructions with rotation flaps. Patients with chronic symptomatic PD were randomized to S or PC. Primary end-point was the rate of patients healed at 3 weeks, secondary outcomes were total healing time, pain, time off work, patient satisfaction and recurrence at 1 year. Patients were seen at a wound clinic until healed and contacted at 3, 6, and 12 months for follow-up.

RESULTS

After inclusion of 58 patients the study was stopped prematurely due to discrepancy between expected and observed outcomes. Only 4/30 (13.3%) patients in the S group had healed completely at 3 weeks compared with 14/28 (50%) in the PC group (p = 0.01). Median time to complete healing was 54 (23-328) days in the S group compared to 34 (13-141) in the PC group (p = 0.025). Number of outpatient visits, time off work, analgesia requirement, and recurrence rates at 12 months 4 (16%) in the S group and 3 (11.1%) in the PC group (p = 0.548) were similar.

CONCLUSIONS

PC leads to faster healing compared to S, with similar healthcare burden.

TRIAL REGISTRATION

The study was approved by the local ethics committee and registered in www.clinicaltrials.gov (REF: NCT03271996). The study was carried out at the Regional Hospital of Lugano, Switzerland.

Excision and tension-free primary closure of pilonidal disease

Objectives

This study aimed to estimate simple excision and tension free primary closure and to study its effectiveness in terms of operating and healing time, duration of hospital stay, degree of post operation complications, and rate of recurrence.

Material and Methods

This is study included 78 patients, of whom 71 were (91%) males and 7 (9%) females, who underwent excision and tension free closure. The procedure was based on bilateral side flaps, which were released and dissected 2-3 cm from the edge of the wound. Patient's age, gender, body mass index, wound healing, operation, drain removal, length of hospital stay, and complications and recurrence were analysed.

Results

The study involved 78 patients, 71 (91%) males and 7 (9%) females. Median age of the patients was 28.5 years. Mean operation time was 44.6 minutes . Sixty-one patients (78.2%) had full primary healing without any complication. No one had hematoma or seroma, but five (6.4%) cases had a minor wound infection and three (3.8%) obese patients developed recurrence. Mean length of hospital stay was 2.5 days , most patients went back to their work within 3 weeks. Median follow-up period was in a 26.2 weak range (1-51.4 weak). Five (6.41%) cases had wound infection and three (3.85%) developed recurrence.

Conclusion

Excision and tension free primary closure were found to be simple procedures associated with lower rates of wound infection, shorter hospital stay, lower recurrence, early wound recovery and short period of being absent from work. Surgery can be easily performed and preferred for cases of non-recurrent pilonidal sinus and cyst.

The management of pilonidal disease: A systematic review

OBJECTIVE

The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to derive recommendations from the medical literature regarding the management of pilonidal disease.

METHODS

The PubMed, Cochrane, Embase, Web of Science, and Scopus databases from 1965 through June 2017 were queried for any papers addressing operative or non-operative management of pilonidal disease. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived for three questions based on the best available evidence, and a clinical practice guideline was constructed.

RESULTS

A total of 193 articles were fully analyzed. Some non-operative and minimally invasive techniques have outcomes at least equivalent to operative management. Minimal surgical procedures (Gips procedure, sinusectomy) may be more appropriate as first-line treatment than radical excision due to faster recovery and patient preference, with acceptable recurrence rates. Excision with midline closure should be avoided. For recurrent or persistent disease, any type of flap repair is acceptable and preferred by patients over healing by secondary intention. There is a lack of literature dedicated to the pediatric patient.

CONCLUSIONS

There is a definitive trend towards less invasive procedures for the treatment of pilonidal disease, with equivalent or better outcomes compared with classic excision. Midline closure should no longer be the standard surgical approach.

TYPE OF STUDY

Systematic review of level 1-4 studies.

LEVEL OF EVIDENCE

Level 1-4 (mainly level 3-4).

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.

Comparison of Limberg Flap and Karydakis Flap Surgery for the Treatment of Patients With Pilonidal Sinus Disease: A Single-Blinded Parallel Randomized Study

Purpose

Pilonidal sinus disease is a common condition, which mostly affects young men. While various surgical techniques have been introduced for treating intergluteal pilonidal disease (IPD), controversies still exist regarding the best surgical approach. The purpose of this study was to compare the efficiency and the short-term outcomes of Limberg flap and Karydakis flap surgeries for the treatments of patients with IPD.

Methods

A total of 80 patients with IPD who had underwent either Karydakis flap (KF group: n = 37) or Limberg flap (LF group: n = 27) surgery between January 2015 and January 2016 at Imam Khomeini Hospital of Sari in the North of Iran were recruited for inclusion in this randomized, single-blind study.

Results

Compared to the KF group, the LF group showed faster complete wound healing, longer duration of surgery and hospital stay, larger wound size, and shorter period of incapacity for work. The overall patient satisfaction in the LF group was significantly higher than that in the KF group. The visual analogue scale score of pain was lower in the LF group than in the KF group. Also, the overall frequency of postoperative complications was higher in the KF group than in the LF group. Recurrence was reported in one patient from the KF group.

Conclusion

Given the lower rate of postoperative complications and greater cosmetic satisfaction of patients, the Limberg flap procedure should be selected, instead of the Karydakis flap procedure, as the standard technique for treating patients with IPD.

Comparison of Three Surgical Techniques in Pilonidal Sinus Surgery

Our study aims to compare the surgical outcome of Limberg transposition flap, Karydakis flap, and primary closure after excision to treat sacrococcygeal pilonidal sinus disease. A total of 634 patients with pilonidal sinus who underwent surgery were evaluated retrospectively from January 2014 to January 2016. The patients were divided into three groups. Limberg transposition flap (LTF) was performed in 131 patients (group 1), Karydakis flap (KF) was performed in 232 patients (group 2) and primary closure (PC) after excision was performed in 271 patients (group 3). Patient demographics, operative and postoperative outcomes were recorded and analyzed retrospectively. The mean age (p=0.98), sex ratio (p=0.74) and removed sinus volume (p=0.67) were not statistically different between groups. Mean operative time was 54.3 ± 6.4 min for group 1, 46.8 ± 10.5 min for group 2, and 26.9 ± 5.8 min for group 3 respectively (p=0.01). When the length of hospital stay was compared, there was a significant difference in favor of primary closure (p=0.01). Regarding early surgical complication, Karydakis flap technique was superior to other groups (p<0.001). The recurrent rate was higher in the primary closure group (p<0.001). In our study, the primary closure method regarding the duration of surgery and hospitalization; Karydakis method regarding postoperative complications (seroma, hematoma, wound dissociation, infection, recurrence) were superior to the other two methods.

Comparison of Crystallized Phenol Treatment and Simple Primary Closure Methods for Pilonidal Sinus Disease

The objective of the study was to compare the results of the patients treated with crystallized phenol treatment (CPT) or simple primary closure (SPC) for pilonidal sinus disease (PSD). For PSD treatment, both SPC and CPT have the advantages of rapid recovery, minimal pain, and short hospital stay. Even though these two techniques can be used interchangeably in uncomplicated cases, there is not enough evidence about which method is superior. A total of 102 patients who underwent CPT (n = 57) and SPC (n = 45) for uncomplicated PSD were included in the study. In all of the cases, data were recorded and compared between CPT and SPC groups, including age, gender, duration of the symptoms, hospital stay, complications, healing time, and recurrence. The mean age was 25.6 years and the male-to-female ratio was 93:9. The SPC and CPT groups were similar in terms of age, gender, duration of symptoms, complications, and healing time. The CPT group did not require hospitalization or anesthetic procedure in addition to local anesthesia, but the SPC group required a median of 1 day (range, 1–3 days) of hospitalization, and 3 patients (6.7%) needed spinal anesthesia. During a median of 27.5 months' follow-up, the recurrence rate in the CPT group (6 patients; 10.5%) was lower than in the SPC group (13 patients; 28.9%). Both hospital stay and recurrence rates were better in the CPT group. Healing time and complication rates were similar in both methods. Based on these results, we suggest that CPT should be preferred to SPC in uncomplicated cases.

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.

Muzi's Tension Free Primary Closure of Pilonidal Sinus Disease: Updates on Long-Term Results on 514 Patients

BACKGROUND

The aim of this study is to evaluate the long-term results of Muzi's tension free primary closure technique for pilonidal sinus disease (PSD), in terms of patients' discomfort and recurrence rate.

METHODS

This study is a retrospective analysis of prospectively collected data. Five hundred fourteen patients were treated. Postoperative pain (assessed by a visual analog scale, VAS), complications, time needed to return to full-day activities, and recurrence rate were recorded. At 12, 22, and 54 months postoperative, patients' satisfaction was evaluated by a questionnaire scoring from 0 (not satisfied) to 12 (greatly satisfied).

RESULTS

The median operative time was 30 min. The overall postoperative complication rate was 2.52%. Median VAS score was 1. The mean of resumption to normal activity was 8.1 days. At median follow-up of 49 months, recurrence rate was 0.4% (two patients). At 12 months' follow-up, the mean satisfaction score was 10.3 ± 1.7. At 22 and 54 months' follow-up, the score was confirmed.

CONCLUSIONS

Muzi's tension free primary closure technique has proved to be an effective treatment, showing in the long-term follow-up low recurrence rate and high degree of patient satisfaction. Therefore, we strongly recommend this technique for the treatment of PSD.

Pilonidal cyst of the clitoris

A pilonidal cyst is an epithelialized sinus tract or cyst containing hair follicles with a surrounding inflammatory reaction. It usually develops in the sacrococcygeal region with few reports of its development in the genitalia. We present a case of a periclitoral pilonidal cyst in a young woman and its management.

"Flag Excision and Flap" Procedure: a Novel Modification for Off-Midline Closure After Pilonidal Sinus Excision

Pilonidal sinus surgery has evolved with the novel flap techniques, and off-midline closure became a preferred surgical procedure due to shorter recovery time and low recurrence rates. To obtain a better off-midline closure without maceration and a possible wound problem, we modified a novel excision technique. We aimed to present this novel flag modification of rhomboid excision and flap reconstruction experience. From December 2007 to June 2009, 100 patients were treated with flag excision and flap reconstruction under regional anesthesia and followed with a mean of 42 (range 35-55) months. Competent closure results were obtained successfully in all patients without an overlap between incision line and midline. None of the patients had seroma. Two patients (2 %) had partial wound detachment superiorly. None of the patients had recurrence during follow-up. The flag excision and flap reconstruction procedure is an effective and comfortable technique both for the surgeon and the patient with a quick healing period and low complication rates without maceration.

Day-Case Limberg Flap for Recurrent Pilonidal Sinus: Does Obesity Complicate the Issue?

The purpose of this study was to analyze the long-term outcome of rhomboid excision with Limberg flap reconstruction (LF) as one-day surgery in treatment of recurrent pilonidal sinus (RPS). The effect of obesity on outcome will be addressed. Forty-nine patients with RPS were treated by rhomboid excision and LF as one-day surgery. Data collected included demographics, body mass index, operative time, flap ischemia, wound infection, length of hospital stay, time of complete healing, and recurrence. Patients’ mean age was 33.4 years and mean number of previous operations was 3.4. Operative time ranged from 40 to 70 minutes. Two patients developed sterile seroma (4.1%) and two patients (4.1%) had wound infections. No wound dehiscence or flap ischemia was reported. All patients returned to normal activity within 7 days. No recurrences were reported after a mean follow-up of 32.1 months. Obesity significantly increased the operative time, however, it affected neither the postoperative outcome nor the long-term recurrence. Rhomboid excision and LF as one-day surgery is a safe and reliable method for treatment of RPS. It guarantees low morbidity, short hospital stay, short time off work, and carries low risk of recurrence, even in obese patients.

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.

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.

A novel approach for treatment of sacrococcygeal pilonidal sinus: less is more

BACKGROUND

The surgical management of sacrococcygeal pilonidal sinus (PS) is still a matter of discussion. Therapy ranges from complete wide excision with or without closure of the wound to excochleation of the sinus with a brush. In this paper, we introduce a novel limited excision technique. The aim of this study was to assess the morbidity and recurrence rate of this technique.

MATERIALS AND METHODS

Limited excision consisted of a selective extirpation of the sinus after tagging the tract with methylene blue. Ninety-three consecutive patients, who underwent surgery between 2001 and 2004, were analyzed. The patients' survey was performed by mail questionnaire and telephone interview inquiring recurrence, time off work, and time to wound healing.

RESULTS

Seventy-three percent of the patients were treated in an outpatient setting. With a median follow-up of 2 years, the recurrence rate was 5%. The median time off work was 2 weeks. The median wound healing time was 5 weeks.

CONCLUSION

Limited excision for PS can be done in an outpatient setting with a low recurrence rate and short time off work.

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.

Sinus excision for the treatment of limited chronic pilonidal disease: results after a medium-term follow-up

PURPOSE

We have previously introduced a minimally invasive technique for the treatment of limited pilonidal disease. In this paper, the results for patients who had at least one year of follow-up are provided.

METHODS

All patients operated with the sinus excision technique were studied retrospectively and those who had a follow-up period shorter than 12 months were excluded. Demographics, perioperative and postoperative data, and patient satisfaction scores were obtained from a prospectively designed database. Limited pilonidal disease was defined as disease presenting with less than four visible pits.

RESULTS

Sixty-two patients (56 males, 90.3 percent; mean age, 25.8 +/- 10.4 years) were included in the study. Patients returned to work in 1.9 +/- 0.7 days, and the mean healing period was 43 +/- 10.4 days. All procedures were performed under local anesthesia, and the mean operation time was 9.7 +/- 3.4 minutes. The number of outpatient procedures was 45 (72.6 percent). One patient suffered from a minor complication (bleeding that was stopped with electrocauterization; n = 1, 1.6 percent) and recurrence was observed in another case (n = 1, 1.6 percent). Patients received a satisfaction questionnaire, which revealed that 34 patients (54.8 percent) were "completely satisfied with the procedure" and 49 (79 percent) would "absolutely recommend the technique to other patients."

CONCLUSIONS

Sinus excision is an advisable technique for the treatment of limited pilonidal disease, because it can be performed under local anesthesia mostly as an outpatient procedure and the operation time is extremely short. Although the healing period is long, the off-work period is short, and patients are generally satisfied with the procedure. After a medium-term follow-up, the complication and recurrence rates are acceptable. We believe that sinus excision technique is a simple and effective method for the treatment of limited pilonidal disease.

Successful treatment of recurrent pilonidal sinus with laser epilation

BACKGROUND

Pilonidal disease is a chronic disease of the natal cleft. Recurrent follicular infection is the causative factor. Surgical treatment has a significant failure rate, and recurrence is common. Laser removal of hair in the natal cleft could be an alternative to surgery.

OBJECTIVE

To determine the effectiveness of laser hair removal in the natal cleft on pilonidal disease.

METHODS

Six young men with recurrent pilonidal disease were treated with laser epilation in our clinic from 2000 to 2003. Most patients had a history of one or more surgical treatments in the area, and all patients had suffered recurrent folliculitis for years. An alexandrite laser was mostly used, although, occasionally, an intense pulsed light device was used. The number of epilation treatments ranged from 3 to 11, performed at 6- to 8-week intervals.

RESULTS

All patients experienced progressive resolution of the folliculitis with the laser epilation treatments. No more surgical treatments have been needed. The treatments were simple and quick, and there were no complications.

CONCLUSION

Laser epilation of the natal cleft should be considered a first choice treatment for recurrent pilonidal disease. Preventive laser epilation of the natal cleft in patients with recurrent folliculitis could avoid future surgery.

Comparison between three therapeutic modalities for non-complicated pilonidal sinus disease

OBJECTIVE

To evaluate the outcome of each of the three methods used to treat pilonidal sinus disease.

STUDY DESIGN

A prospective blind randomised study.

MATERIALS AND METHODS

Between April 2000 and February 2003, 83 patients (68 male and 15 female), aged between 19 and 31 years (mean 26.6), scheduled for elective operations for pilonidal sinus disease. Patients were randomly assigned to receive one of three excisional surgical procedures. Group A consisted of 28 patients (22 males and six females) and underwent wide resection of the skin and subcutaneous tissue of the natal cleft, followed by primary closure of the wound in two layers after insertion of suction drain. Group B consisted of 26 patients (22 males and four females) and underwent wide resection of the skin and subcutaneous tissue and their wounds left opened for secondary intention healing. Group C consisted of 29 patients (24 males and five females) and underwent limited excision of the fistulous tract and their wounds were left opened for secondary intention healing. Patients were followed-up for 15 to 48 months post-operatively. Demographic data, operative time, hospital stay, operative blood loss, post-operative pain, wound healing time and patient's satisfaction were recorded.

RESULTS

The limited excision group of patients had a highly significant shorter operative time than the closed wound group of patients (p<0.001). They also had the shortest hospital stay, operative blood loss and post-operative pain (p<0.001). The closed wound group of patients showed significantly shortest wound healing time, followed by the limited excision group of patients; the wide excision group of patients showed the longest healing time. Apart from the minimal non-significant elevation of the rate of recurrence in the closed wound group of patients, there was no difference between the three groups. All recurrent cases were obese patients and presented within the first six months after operations.

CONCLUSION

Limited excision of a pilonidal sinus represents one of the best therapeutic options. The result of this method is comparable with the more aggressive frequently used excisional method, and it has the advantage of having a shorter convalescence and better patient satisfaction.