Short and long-term results of the Karydakis flap versus the Limberg flap for treating pilonidal sinus disease: a prospective randomized study

Postoperative results of modified Karydakis flap method for primary sacrococcygeal pilonidal sinus disease: short and long-term analysis

BACKGROUND

Sacrococcygeal pilonidal sinus is a common surgical condition that requires various treatment options. This study aims to investigate the short and long-term outcomes of the modified Karydakis flap method in patients with sacrococcygeal pilonidal sinus.

METHODS

A retrospective analysis was conducted on 175 patients who underwent the modified Karydakis flap method for sacrococcygeal pilonidal sinus by a single surgeon between September 2015 and February 2021. The patients' demographics, operative time, hospitalization time and complications were recorded.

RESULTS

Of the 175 patients, 125 (71.43%) were male and 50 (28.57%) were female, with a mean age of 24.93 ± 10.27 years. The mean operative time was 55.05 ± 12.33 min, the follow-up time was 39.21 ± 17.58 months, and the mean hospitalization time was 3.4 ± 1.65 days. Complications were observed in 12 (6.85%) patients, including seroma (5.14%) and wound infection (1.71%), with no observed cases of flap necrosis or recurrence.

CONCLUSION

The modified Karydakis flap method appears to be a safe and effective treatment option for sacrococcygeal pilonidal sinus, with an acceptable complication rate and no observed cases of recurrence.

Midline and off-midline wound closure methods after surgical treatment for pilonidal sinus

BACKGROUND

Pilonidal sinus disease is a common and debilitating condition. Surgical treatment remains the mainstay for managing chronic disease, with options including midline and off-midline wound closure methods. However, the optimal approach remains uncertain. Recent developments in tension-free midline techniques require further exploration.

OBJECTIVES

To assess the effects of midline and off-midline wound closure methods for pilonidal sinus, and to determine the optimal off-midline flap procedures.

SEARCH METHODS

In June 2022, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus EBSCO, and clinical trials registries. We also scanned the reference lists of included studies, as well as reviews, meta-analyses, and health technology reports. We applied no language, publication date, or study setting restrictions.

SELECTION CRITERIA

We included parallel RCTs involving participants undergoing midline closure without flap techniques and off-midline closure for pilonidal sinus treatment. We excluded quasi-experimental studies and studies that enroled participants presenting with an abscess.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. The critical outcomes included wound healing (time to wound healing, proportion of wounds healed), recurrence rate, wound infection, wound dehiscence, time to return to work, and quality of life. We assessed biases in these outcomes utilising the Cochrane risk of bias 2 tool and appraised evidence certainty via the GRADE approach.

MAIN RESULTS

We included 33 studies with 3667 analysed participants. The median or average age of the participants across the included studies ranged from 21.0 to 34.2 years, with a predominant male representation. Geographically, the trials were primarily conducted in the Middle East. We identified nine intervention comparisons. In this abstract, we focus on and present the summarised findings for the three primary comparisons. Off-midline closure versus conventional midline closure Off-midline closure probably reduces the time to wound healing (mean difference (MD) -5.23 days, 95% confidence interval (CI) -7.55 to -2.92 days; 3 studies, 300 participants; moderate-certainty evidence). However, there may be little to no difference between the two methods in the proportion of wounds healed (100% versus 88.5%, risk ratio (RR) 1.13, 95% CI 0.92 to 1.39; 2 studies, 207 participants; very low-certainty evidence). Off-midline closure probably results in lower rates of recurrence (1.5% versus 6.8%, RR 0.22, 95% CI 0.11 to 0.45; 13 studies, 1492 participants; moderate-certainty evidence) and wound infection (3.8% versus 11.7%, RR 0.32, 95% CI 0.22 to 0.49; 13 studies, 1568 participants; moderate-certainty evidence), and may lower rates of wound dehiscence (3.9% versus 8.9%, RR 0.44, 95% CI 0.27 to 0.71; 11 studies, 1389 participants; low-certainty evidence). Furthermore, off-midline closure may result in a reduced time to return to work (MD -3.72 days, 95% CI -6.11 to -1.33 days; 6 studies, 820 participants; low-certainty evidence). There were no data available for quality of life. Off-midline closure versus tension-free midline closure Off-midline closure may reduce the time to wound healing (median 14 days in off-midline closure versus 51 days in tension-free midline closure; 1 study, 116 participants; low-certainty evidence) and increase wound healing rates at three months (94.7% versus 76.4%, RR 1.24, 95% CI 1.06 to 1.46; 1 study, 115 participants; low-certainty evidence), but may result in little to no difference in rates of recurrence (5.4% versus 7.8%, RR 0.69, 95% CI 0.30 to 1.61; 6 studies, 551 participants; very low-certainty evidence), wound infection (2.8% versus 6.4%, RR 0.44, 95% CI 0.16 to 1.17; 6 studies, 559 participants; very low-certainty evidence), and wound dehiscence (2.5% versus 3.0%, RR 0.82, 95% CI 0.17 to 3.84; 3 studies, 250 participants; very low-certainty evidence) compared to tension-free midline closure. Furthermore, off-midline closure may result in longer time to return to work compared to tension-free midline closure (MD 3.00 days, 95% CI 1.52 to 4.48 days; 1 study, 60 participants; low-certainty evidence). There were no data available for quality of life. Karydakis flap versus Limberg flap Karydakis flap probably results in little to no difference in time to wound healing compared to Limberg flap (MD 0.36 days, 95% CI -1.49 to 2.22; 6 studies, 526 participants; moderate-certainty evidence). Compared to Limberg flap, Karydakis flap may result in little to no difference in the proportion of wounds healed (80.0% versus 66.7%, RR 1.20, 95% CI 0.77 to 1.86; 1 study, 30 participants; low-certainty evidence), recurrence rate (5.1% versus 4.5%, RR 1.14, 95% CI 0.61 to 2.14; 9 studies, 890 participants; low-certainty evidence), wound infection (7.9% versus 5.1%, RR 1.55, 95% CI 0.90 to 2.68; 8 studies, 869 participants; low-certainty evidence), wound dehiscence (7.4% versus 6.2%, RR 1.20, 95% CI 0.41 to 3.50; 7 studies, 776 participants; low-certainty evidence), and time to return to work (MD -0.23 days, 95% CI -5.53 to 5.08 days; 6 studies, 541 participants; low-certainty evidence). There were no data available for quality of life.

AUTHORS' CONCLUSIONS

This Cochrane review examines the midline and off-midline wound closure options for pilonidal sinus, predominantly based on young adult studies. Off-midline flap procedures demonstrate there may be benefits over conventional midline closure for pilonidal sinus, with various off-midline flap techniques. When off-midline flap closures were compared to tension-free midline closure, low-certainty evidence indicated there may be improved wound healing and increased time to return to work for off-midline closure, whilst very low-certainty evidence indicated there may be no evidence of a difference in other outcomes. There may be no evidence of an advantage found amongst the off-midline techniques evaluated. The choice of either procedure is likely to be based on a clinician's preference, experience, patient characteristics, and the patients' preferences. To more accurately determine the benefits and potential harms of these closure techniques, further large-scale and meticulously-designed trials are essential. Specifically, there is a pressing need for more studies addressing the paediatric population, in addition to adult studies.

Pilonidal Disease: To Flap or Not to Flap

Pilonidal disease is an acquired disease caused by infected hair follicles imbedded in the midline gluteal area. The diagnosis is made based on clinic examination. Treatment is based on disease severity with minimal invasive techniques like the Bascom I procedure, Moshe Gibs procedure, or video-assisted pilonidal sinus ablation best suited for less complicated cases. However, for recalcitrant diseases, more advanced techniques are needed such as the Karydakis, Limberg, or V-Y advancement flaps.

Cleft closure (the Bascom cleft lift) for 714 patients-treatment of choice for complex and recurrent pilonidal disease (a cohort study)

AIM

Pilonidal disease is a benign condition that affects mainly the young. In existing literature, there is no consensus for best treatment, with multiple operative techniques described, some complex, resulting in a high proportion of failure and/or morbidity. The cleft closure (or cleft lift) described by Bascom and Bascom (Arch Surg, 137, 2002, 1146-50), by comparison, is a simple operation, resulting in healing in the majority and good cosmesis.

METHOD

This is a single surgeon series, with the aim of evaluating outcomes for consecutive patients who underwent cleft closure surgery at two centres (St Mark's Hospital, London, and Queen Alexandra Hospital, Portsmouth) between 1995 and 2021 for either extensive, complex or recurrent pilonidal disease. Primary study outcomes that were measured included rate of primary healing, time to complete healing and rate of recurrence.

RESULTS

Some 714 patients had a cleft closure of whom 656 had documented follow-up. Primary healing occurred in 60.7% (n = 398) rising to 88.5% by 12 weeks (n = 562) and 91.8% by 16 weeks. The remaining patients healed over the following weeks with only 19 wounds failing to heal completely (3%), requiring further surgery to achieve healing. After complete healing 5.3% of patients developed recurrent disease at a median of 12 months.

CONCLUSION

Cleft closure is an effective operation for pilonidal disease. Overall, 97% of patients healed without further surgery. A 3% failure rate and 5.3% recurrence rate were observed. This technique could be considered as an alternative procedure to complex flaps or midline excision, in extensive, recurrent and unhealed pilonidal disease.

Progress in the surgical treatment of sacrococcygeal pilonidal sinus: a review

BACKGROUND

A pilonidal sinus (PS) is an acquired disease resulting from recurrent infections and chronic inflammation. A PS involving the sacrococcyx is referred to as a sacrococcygeal PS (SPS). An SPS is a rare chronic infectious disease for which surgery is a good choice. The incidence of SPS has gradually increased worldwide in recent years. However, surgeons have not reached a consensus on the preferred surgical approach for SPS. The authors performed a systematic review and meta-analysis to analyze differences in the efficacy of different surgical approaches for the treatment of SPS.

METHODS

A systematic search was conducted in the PubMed database covering the period from 1 January 2003, to 28 February 2023. The primary outcome parameters were recurrence and infection. Finally, statistical analysis (meta-analysis) was carried out using RevMan 5.4.1 software. In addition, we systematically reviewed the latest progress in the surgical treatment of SPS over the past 20 years, especially as reported in the past 3 years.

RESULTS

Twenty-seven articles, 54 studies, and 3612 participants were included in this meta-analysis. The recurrence rate following the midline closure (MC) technique was much higher than that of other techniques. Among the techniques analyzed, the differences between MC and Limberg flap (LF), and between MC and marsupialization were statistically significant [ P =0.0002, risk ratio (RR)=6.15, 95% CI 2.40, 15.80; P =0.01, RR=12.70, 95% CI 1.70, 95.06]. The recurrence rate of open healing was higher than that of the Karydakis flap (KF) technique, and the difference was statistically significant ( P =0.02, RR=6.04, 95% CI 1.37, 26.55). Most of the results comparing MC with other techniques suggested that the former had a higher infection rate, and the difference between MC and LF was statistically significant ( P =0.0005, RR=4.14, 95% CI 1.86, 9.23). Comparison between KF and LF, modified LF and KF showed that the differences were not statistically significant in terms of recurrence and infection ( P ≥0.05).

CONCLUSIONS

There are various surgical treatment options for SPS, including incision and drainage, excision of diseased tissue with primary closure and secondary healing, and minimally invasive surgery. It is still not possible to determine which surgical technique should be considered the gold standard for treatment, as even the results of different researchers using the same operation method are conflicting. But what is certain is that the midline closure technique has a much higher incidence of postoperative recurrence and infection than other techniques. Therefore, the anorectal surgeon should formulate the most suitable individualized plan for the patient based on a comprehensive evaluation of the patient's wishes, appearance of the SPS, and the professional ability of the surgeon.

Bilaterally parallel elliptic flap versus Karydakis flap in primary pilonidal sinus disease: a randomized controlled trial

PURPOSE

Pilonidal sinus disease is a disease that especially affects the young population and causes loss of workforce. Although many treatment methods have been defined, there is still no "gold standard" treatment method. Our objective was to evaluate the postoperative results of bilateral parallel elliptical flap and Karydakis flap in the surgical treatment of pilonidal sinus.

METHODS

This study was conducted at the Colorectal Surgery Department of Ankara Numune Training and Research Hospital. It designed a prospective randomized controlled study. Patients that underwent surgery due to pilonidal sinus were included in the study. The patients were randomly divided into two groups. Surgery was performed with the bilateral parallel elliptical flap (BPEF) technique in one group and the Karydakis flap (KF) technique in the other group. Postoperative pain, length of hospital stay, wound complications, time taken to return to work/school, and recurrence incidence were evaluated.

RESULTS

A total of 102 patients were included in the study, 49 in the BPEF group and 53 in the KF group. The length of hospital stay was similar in the BPEF and KF groups (1.41 ± 0.81 and 1.45 ± 0.84, respectively; p > 0.05). There was less postoperative pain in the BPEF group (2.47 ± 1.02 vs 3.57 ± 1.10, p < 0.05). Wound complications were observed in nine patients in the BPEF group (18.2%) and 14 patients in the KF group (26.2%). The time to return to work/school was shorter in the BPEF group (21.06 ± 6.37 vs 27.04 ± 7.45; p < 0.05). Recurrence developed in two (4%) patients in the BPEF group and three (5.6%) patients in the KF group (p > 0.05).

CONCLUSIONS

The patients who underwent surgery with the bilateral parallel elliptical flap technique had less pain and a shorter time to return to work/school after the operation. The postoperative complication and recurrence rates were similar in both groups.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT05851690. (5/11/2023) (retrospectively registered).

Unroofing Curettage Versus Modified Limberg Flap in Pilonidal Disease: A Retrospective Cohort Study

BACKGROUND

Sacrococcygeal pilonidal disease (estimated incidence, 25/100,000) is a chronic inflammatory condition that commonly affects young adults. However, the ideal surgical treatment for this disease remains undetermined.

OBJECTIVE

This study aimed to compare the results of the unroofing curettage and those of the modified Limberg flap surgical technique.

DESIGN

This is a retrospective cohort study.

SETTINGS

Procedures were performed by 2 surgeons between January 2013 and January 2017.

PATIENTS

The data of 278 patients who underwent surgery for the treatment of pilonidal disease were analyzed.

INTERVENTIONS

Unroofing curettage was performed under local or spinal anesthesia, whereas spinal anesthesia was used for the modified Limberg flap procedure.

MAIN OUTCOME MEASURES

The primary outcome was recurrence rate. Secondary outcomes included adverse events, limitation of daily activities, and healing time.

RESULTS

Between the 2 groups (unroofing curettage, n = 135; modified Limberg flap, n = 143), recurrence was lower in the unroofing curettage group after a 60-month median follow-up period, but the difference was not statistically significant (1.5% vs 4.2%, p = 0.45). The duration of surgery and length of hospital stay were shorter in the unroofing curettage group (11.44 ± 3.56 minutes vs 52.47 ± 7.92 minutes and 0.27 ± 0.45 days vs 1.07 ± 0.26 days, p < 0.001). Postoperative complications were significantly higher in the modified Limberg flap group (9.8% vs 2.2%, p = 0.009). The time required to return to work or school was shorter in the unroofing curettage group (8.6 ± 7.8 days vs 25.01 ± 6.3 days, p < 0.001). The complete healing time was longer in the unroofing curettage group (35.3 ± 9.2 days vs 23.2 ± 5.4 days, p < 0.001).

LIMITATIONS

The retrospective study design was a limitation of this study.

CONCLUSIONS

Unroofing curettage provided more clinical benefits than the modified Limberg flap approach. Unroofing curettage should be considered as the first choice of surgical treatment for pilonidal disease. See Video Abstract at http://links.lww.com/DCR/B824 .

DESTECHAMIENTO Y CURETAJE VERSUS COLGAJO DE LIMBERG MODIFICADO EN LA ENFERMEDAD PILONIDAL UN ESTUDIO DE COHORTE RETROSPECTIVE

ANTECEDENTES:La enfermedad pilonidal sacrococcígea (incidencia estimada, 25 / 100.000) es una enfermedad inflamatoria crónica que comúnmente afecta a adultos jóvenes. Sin embargo, el tratamiento quirúrgico ideal para esta enfermedad permanece indeterminado.OBJETIVO:Comparar los resultados del destechamiento y curetaje y los de la técnica quirúrgica con colgajo de Limberg modificado.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Los procedimientos fueron realizados por dos cirujanos, entre enero del 2013 y enero del 2017.PACIENTES:Se analizaron datos de 278 pacientes intervenidos quirúrgicamente para el tratamiento de la enfermedad pilonidal.INTERVENCIONES:Se realizó destechamiento y curetaje con anestesia local o raquídea, mientras que para el procedimiento de colgajo de Limberg modificado se utilizó anestesia raquídea.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue la tasa de recurrencia. Los resultados secundarios incluyeron eventos adversos, limitación de las actividades diarias y tiempo de curación.RESULTADOS:Entre los dos grupos (destechamiento y curetaje, n = 135; colgajo de Limberg modificado, n = 143), la recurrencia fue menor en el grupo con destechamiento y curetaje después de un período de seguimiento medio de 60 meses, pero la diferencia no fue estadísticamente significativa (1,5% vs 4,2%, p = 0,45). La duración de la cirugía y la estancia hospitalaria fueron más cortas en el grupo de destechamiento y curetaje (11,44 ± 3,56 min vs a 52,47 ± 7,92 min y 0,27 ± 0,45 días vs 1,07 ± 0,26 días, p < 0,001). Las complicaciones posoperatorias fueron significativamente mayores en el grupo de colgajo de Limberg modificado (9,8% vs 2,2%, p = 0,009). El tiempo necesario para regresar al trabajo o la escuela fue menor en el grupo de destechamiento y curetaje (8,6 ± 7,8 días vs 25,01 ± 6,3 días, p < 0,001). El tiempo de cicatrización completo fue mayor en el grupo de destechamiento y curetaje (35,3 ± 9,2 días vs 23,2 ± 5,4 días, p < 0,001).LIMITACIONES:El diseño del estudio retrospectivo.CONCLUSIONES:El destechamiento y curetaje proporcionó más beneficios clínicos que el abordaje con colgajo de Limberg modificado. El destechamiento y curetaje debe considerarse como la primera opción de tratamiento quirúrgico para la enfermedad pilonidal. Consulte Video Resumen en http://links.lww.com/DCR/B824 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Comparison of the Keystone flap and the Limberg flap technique in the surgical treatment of pilonidal sinus disease

Pilonidal sinus (PS) disease is a chronic inflammatory disease of the sacrococcygeal region. Although various methods have been described for surgical treatment, there is no consensus on the best surgical technique. The aim of this study was to present the results of a new advancement flap technique named the "Keystone flap (KSF)" and compared with the Limberg flap (LF) technique in pilonidal sinus surgery. A retrospective review was made of 124 consecutive patients surgically treated for PS disease with KSF and LF procedures. Baseline characteristics, operation time, volume of excised specimen, duration of hospitalization, duration of drainage, duration of healing, time to return to work, local complications and recurrence were evaluated and compared between the two procedures. Operation time, healing time, and time to return to work were significantly shorter in the KSF group. Partial wound dehiscense and prolonged wound healing were more common in the LF group. An additional intervention in the operating room was required by 21.1% of the LF group and was a significantly lower rate in the KSF group at 7.5%. There was no significant difference between the groups in terms of recurrence. The KSF procedure seems promising for treating pilonidal sinus disease, with the advantages of shorter operation, healing, and return to work times. It also provides lower partial wound dehiscence and necrosis rates.

Karydakis procedure versus Limberg flap for treatment of pilonidal sinus: an updated meta-analysis of randomized controlled trials

BACKGROUND

The Karydakis procedure (KP) and Limberg flap (LF) are two commonly performed operations for pilonidal sinus disease (PND). The present meta-analysis aimed to review the outcome of randomized trials that compared KP and LF.

METHODS

Electronic databases were searched in a systematic manner for randomized trials comparing KP and LF through July 2020. This meta-analysis was reported in line with the PRISMA statement. The main outcome measures were failure of healing of PND, complications, time to healing, time to return to work, and cosmetic satisfaction.

RESULTS

Fifteen randomized controlled trials (1943 patients) were included. KP had a significantly shorter operation time than LF with a weighted mean difference (WMD) of -0.788 (95%CI: -11.55 to -4.21, p < 0.0001). Pain scores, hospital stay, and time to healing were similar. There was no significant difference in overall complications (OR= 1.61, 95%CI: 0.9-2.85, p = 0.11) and failure of healing (OR= 1.22, 95%CI: 0.76-1.95, p = 0.41). KP had higher odds of wound infection (OR= 1.87, 95%CI: 1.15-3.04, p = 0.011) and seroma formation (OR= 2.33, 95%CI: 1.39-3.9, p = 0.001). KP was followed by a shorter time to return to work (WMD= -0.182; 95%CI: -3.58 to -0.066, p = 0.04) and a higher satisfaction score than LF (WMD= 2.81, 95%CI: 0.65-3.77, p = 0.01).

CONCLUSIONS

KP and LF were followed by similar rates of complications and failure of healing of PND and comparable stay, pain scores, and time to wound healing. KP was associated with higher rates of seroma and wound infection, shorter time to return to work, and higher cosmetic satisfaction than LF.

[Surgical treatment of pilonidal disease]

This review is devoted to comparison of the most common methods of surgical treatment of pilonidal disease. It was found that «closed» methods of surgical treatment of pilonidal disease are effective and accompanied by favorable wound healing and good cosmetic effect. Long-term outcomes of «closed» techniques significantly depend on the choice of surgical treatment and follow-up period.

Limberg flap for the management of pilonidal sinus reduces disease recurrence compared to Karydakis and Bascom procedure: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The objective of this study is to compare the effectiveness of Limberg flap (LF) versus Karydakis and Bascom procedure to reduce the recurrence of pilonidal sinus disease.

EVIDENCE ACQUISITION

The data retrieved from the published randomized controlled trials (RCT) comparing the effectiveness of LF versus Karydakis and Bascom procedure was analyzed using the principles of meta-analysis. The summated outcome of the dichotomous data was presented in risk ratio (RR).

EVIDENCE SYNTHESIS

Eighteen RCTs on 2073 patients comparing the effectiveness of LF versus Karydakis and or Bascom procedure for the surgical excision of pilonidal sinus disease were analyzed. In the random effects model analysis using the statistical software Review Manager 5.3, the LF was associated with the reduced risk (RR, 0.52; 95% CI: 0.29, 0.93; z=2.19; P=0.03) of disease recurrence after pilonidal sinus excision compared to Karydakis and Bascom procedure. On subgroup analysis the LF was still superior to Karidakys procedure (RR, 0.52; 95% CI: 0.23, 1.17; z=1.57; P=0.12) and Bascom procedure (RR, 0.49; 95% CI: 0.19, 1.29; z=1.44; P=0.15) but statistically it was not significant.

CONCLUSIONS

LF seems to have clinical advantage over Karydakis and Bascom procedure in terms of reduced recurrence rate following surgical excision of pilonidal sinus. Although, this advantage was clinically persisted on subgroup analysis but failed to achieve statistical significance.

Surgical procedures in the pilonidal sinus disease: a systematic review and network meta-analysis

The most appropriate surgical treatment for pilonidal sinus disease (PSD) is still in dispute. This study aims to comprehensively compare the outcomes of surgical interventions using network meta-analysis. Randomized controlled trial studies were searched systematically to identify all eligible studies in multiple databases and previous publications and Bayesian network meta-analysis was performed. Our primary outcome was the recurrence rate. Differences in the findings of the studies were explored in meta regressions and sensitivity analyses. The risk of bias of each study was assessed using the Cochrane risk of bias tool. Confidence in evidence was assessed using CINeMA (Confidence in Network Meta-Analysis). A total of 39 studies and 5,061 patients were identified and the most common surgical intervention was the Limberg flap. In network meta-analysis, modified Limberg flap and off-midline closure were associated with the lowest recurrence rate. However, the Karydakis flap was associated with shorter operation time by several minutes compared with other interventions and few significant results were found in other outcomes. Modified Limberg flap and off-midline closure provided relatively low recurrence and complications rates. Therefore, they could be two promising surgical interventions for PSD patients.

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.

Comparison of the Three Surgical Flap Techniques in Pilonidal Sinus Surgery

We aimed to study the efficacy of three surgical flap techniques in pilonidal surgery. Pilonidal disease is characterized by chronic inflammation and infection in the sacrococcygeal region. Complications and recurrence are common after treatment and optimal treatment for the disease has not been established yet. We enrolled a total of 401 patients in this study. Patients have been treated with Karydakis (n = 113), modified Limberg (n = 179), or Limberg (n = 109) flap techniques. Mean off-work period, time to walk without pain, time to sit on the toilet, time to take the drainage catheter off, maceration rates, recurrence, and hypoesthesia rates were significantly better in the modified Limberg group. In conclusion, we showed the modified Limberg technique is superior than both Limberg and Karydakis techniques.

Comparison of postoperative quality of life of Limberg flap and Karydakis flap in pilonidal sinus operations

Objectives

Pilonidal sinus disease (PSD), most commonly seen in young men, is a chronic disease resulting from the pilosebaceous in the sacrococcygeal region. There is still no standardization in surgical treatment. In this study, the effectiveness, follow up outcomes and quality of life level were compared between Karydakis flap (KF) and Limberg flap (LF) operations.

Material and Methods

Among the patients who had undergone PSD surgery in our clinic between 2015 and 2016, those who could be reached and who received KF (n= 53) and LF (n= 51) operations were included into the study. Clinical data of these patients were retrospectively evaluated. Postoperative satisfaction levels of the patients were determined with Cardiff wound healing survey questions and visual analog scale.

Results

Mean operational time was 54 (44-75) minutes in the LF group and 45 (35-60) minutes in the KF group, and it was statistically significant (p= 0.001). Mean time to return to work was 14.3 (9-28) days in the LF group and 17.6 (10-30) days in the CF group and was statistically significant (p= 0.001). The rates of complications and recurrence were lower in the LF group although the difference was not statistically significant between the groups (p> 0.05). Mean psychosocial assessment score was 70.3 (57.5-88.7) in the KF group and 73.4 (53.5-87.5) in the LF group and the difference was statistically significant (p= 0.001).

Conclusion

LF was a more reliable and preferable method compared to KF because of earlier return-to-work, lower rate of recurrence at long term follow up, and higher psychosocial satisfaction.

Long-term results of endoscopic pilonidal sinus treatment vs Limberg flap for treatment of difficult cases of complicated pilonidal disease: a prospective, nonrandomized study

AIM

To present the results of a prospective, nonrandomized comparative study on the treatment of complicated pilonidal sinus by endoscopic pilonidal sinus treatment (EPSiT) compared with Limberg flap surgery, based on experience of a single surgical centre.

METHOD

A prospective, nonrandomized comparative study. Long-term follow-up of 62 patients with complicated pilonidal disease was analysed (36 operated on using the Limberg flap technique and 26 using the EPSiT method). The median follow-up was 27 months (12-44).

RESULTS

The median operating time in the EPSiT group was 60 min (25-80 min) and in the Limberg group 67 min (35-95 min). In the EPSiT group, primary healing was achieved in 22 out of 26 patients (84.6%) in a median of 42 days with a total complication rate of 11.5%. There were seven recurrences after initial healing. The total success rate of the EPSiT procedure with long-term follow-up was 57.7%. In the Limberg flap group, all patients healed (100%) in a median of 21 days. The complication rate in this group was 26.5%, and there were two recurrences in this group. The total success rate of the Limberg flap procedure was 94.1%.

CONCLUSION

For patients with complicated pilonidal sinus, the endoscopic procedure has a significantly lower success rate than the Limberg flap procedure, but a lower risk of complications. Such patients should be offered a choice between a safer, minimally invasive procedure with a higher risk of recurrence or flap surgery, which is more effective, but with a higher risk of complications.

Limberg flap versus Karydakis flap for treating pilonidal sinus disease: a systematic review and meta-analysis

Background

The Limberg flap reconstruction and the Karydakis flap reconstruction are the 2 most used off-midline closure techniques in pilonidal sinus surgery. The current evidence is inconclusive as to which is the optimal technique. The aim of this systematic review and meta-analysis was to compare differences in outcomes between these 2 flap-based techniques.

Methods

We identified studies by a systematic literature search of the Embase, MEDLINE (PubMed), Cochrane Library and Google Scholar databases and studies selected as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Only randomized controlled trials (RCTs) that compared the Limberg flap (standard or modified) and the Karydakis flap were included in this review.

Results

Operative time was shorter by 7 minutes in the Karydakis group than in the Limberg group (mean difference 7.00 min, 95% confidence interval [CI] 0.53 to 13.48). The seroma formation rate was significantly higher in the Karydakis cohort (odds ratio [OR] 0.36, 95% CI 0.24 to 0.56); however, after excluding studies with a high risk of bias, the sensitivity analysis showed no significant differences in seroma formation rate between the 2 techniques (OR 0.76, 95% CI 0.31 to 1.85). Other outcomes of interest showed no significant differences between the Limberg and Karydakis techniques.

Conclusion

There were no significant differences between the Limberg and Karydakis techniques. Future RCTs with strict adherence to CONSORT guidelines will further elucidate the efficacy of these surgical procedures.

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.

Pilonidal Sinus—Plenty of Literature yet Lack of Direction: A Pooled Analysis

A systematic analysis was conducted to compare various surgical treatment modalities and evaluate the short- and long-term outcomes in the management of sacrococcygeal pilonidal disease. Pilonidal sinus is a common and debilitating condition often requiring a surgical approach to treatment, of which many are available. Despite numerous treatment methods, no universal decision has been made as to the most efficient and effective surgical treatment. All randomized control trials published between January 1, 2003 and January 8, 2013 were accessed. Interventions included classic and modified Limberg flap, Karydakis flap, primary closure, and healing by secondary intention. Primary outcome measures included rate of surgical site infection, recurrence, and length of hospital stay. Secondary outcome measures were hematoma or seroma, and return to work. The search identified 22 articles suitable for inclusion in this review totaling 3693 patients. Analysis showed a 50% reduction in the rate of infection and recurrence in patients receiving closure with flaps compared with primary midline closure and healing by secondary intention. The Karydakis flap was shown to be more favorable cosmetically; however, it failed to compete with the classic and modified Limberg flap in treatment of complicated disease. No significant difference was noted between the modified Limberg and Limberg flap. These results show that the Karydakis flap, classic, and modified Limberg flap demonstrate significant benefits over healing by secondary intention and primary closure.

Classical Limberg versus classical Karydakis flaps for pilonidal disease- an updated systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Pilonidal disease (PD) is associated with significant disability culminating in time off work/school. Recurrence rates remain high following conventional surgical interventions. Flap-based techniques are postulated to decrease recurrence. We performed a systematic review and meta-analysis to compare the effectiveness of the classical Limberg (LF) and Karydakis (KF) flaps in the treatment of PD.

METHODS

The online databases of Medline, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials as well as Google Scholar were searched for relevant articles from inception until May 2017. All randomized studies that reported direct comparisons of classical LF and KF were included. Two independent reviewers performed data extraction. Random effects models were used to calculate pooled effect size estimates. A sensitivity analysis was also carried out.

RESULTS

Five randomized controlled trials describing 727 patients (367 in LF, 360 in KF) were examined. There was significant heterogeneity among studies. On overall random effects analysis, there was a lower rate of seroma formation associated with LF, and this approached statistical significance (OR = 0.47, 95% CI = 0.22 to 1.03, p = 0.06). However, there were no significant differences in recurrence (OR = 1.03, 95% CI = 0.48 to 2.21, p = 0.939), wound dehiscence (OR = 0.53, 95% CI = 0.09 to 2.85, p = 0.459), wound infection (OR = 0.59, 95% CI = 0.23 to 1.52, p = 0.278) or haematoma formation (OR = 2.08, 95% CI = 0.82 to 5.30, p = 0.124) between LF and KF. On sensitivity analysis, focusing only on primary and excluding recurrent PD, the results remained similar.

CONCLUSIONS

LF and KF appear comparable in efficacy for primary PD, although LF is associated with less seroma formation.

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.

Karydakis flap reconstruction versus Limberg flap transposition for pilonidal sinus disease: a meta-analysis of randomized controlled trials

INTRODUCTION

The definitive treatment of pilonidal sinus disease (PSD) is surgical. There is still no consensus as to the most appropriate off-midline primary closure technique. The aim of this meta-analysis has been to compare Karydakis flap reconstruction (KF) to Limberg flap transposition (LF) with regard to short- and long-term postoperative outcomes.

METHODS

A systematic literature search for randomized controlled trials (RCTs) comparing KF to LF was performed. Data regarding postoperative outcomes were extracted and compared by meta-analysis. The odds ratio and standardized mean differences with 95% confidence intervals (CIs) were calculated.

RESULTS

Eight RCTs were identified comparing KF (n = 554) to LF (n = 567). There was no significant difference noted between KF and LF with regard to the primary outcome variable, recurrence rate (OR = 1.07; 95% CI [0.59-1.92]; p = 0.83; 7 studies; I² = 40%). LF was associated with a lower rate of post-operative seroma (OR = 2.03; 95% CI [1.15, 3.59]; p = 0.01; 7 studies; I² = 0%). No further significant differences were noted in the secondary endpoints between the two study groups.

CONCLUSIONS

Recurrence rates of PSD were found to be similar in both study groups. Post-operative seroma rate was significantly higher in the KF group. The meta-analysis did not indicate any further statistically significant differences between the two surgical procedures.

Limberg flap in management of pilonidal sinus disease: systematic review and a local experience

OBJECTIVES

To review published evidence of Limberg flap (LF) use in pilonidal sinus disease (PSD). We also included our local experience of LF.

METHODS

Medline and Embase database were searched for the words 'pilonidal, sinus, Limberg, flap'. Non-English articles and those not-related to our scope of search were omitted. We included a retrospective study of patients underwent LF in our district hospital. Data including length of hospital stay, post-operative complications and recurrence were collected.

RESULTS

Literature review revealed 68 studies (22 case series, 35 comparative studies, nine RCTs and two meta-analyses). Recurrence rate was 0-7.4% in case series. Recurrence rate in comparative studies was 0-8.3%, compared to 4-37.7% for primary closure and 0-11% for Karydakis flap. RCTs showed that LF or its modification is superior to primary closure, with comparable results to Karydakis flap. About 26 patients included in the cohort study (16 male, average age 27 years). Six patients presented with recurrent disease. Post-operative length of hospital stay was four to seven days. Post-operative complication rate was 11.5% - [two partial wound dehiscence, one wound infection]. Recurrence rate was 7.7%. Average follow-up was 18 months.

CONCLUSIONS

Limberg flap presents a safe and effective method that can be offered for patients with primary or recurrent PSD.

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.

Fascio-Adipo-Cutaneous Lateral Advancement Flap for Treatment of Pilonidal Sinus: A Modification of the Karydakis Operation-Cohort Study

BACKGROUND

Pilonidal sinus is a common chronic disease affecting young adults. Many surgical procedures have been developed for its treatment, but an optimal one has still not been achieved. This study presents a modification to the Karydakis operation.

METHODS

A total of 265 patients with chronic pilonidal sinus between May 2008 and May 2015 were included in this study and submitted to fascio-adipo-cutaneous lateral advancement flap as 1-day case surgery. Any Septic complication was treated firstly. Follow-up examinations were conducted during the first three postoperative months at the outpatient clinic at regular intervals and thereafter by phone calls or direct examination to check for recurrences.

RESULTS

Males constituted 93.6% with a mean age of 21.6 ± 7.7 year. The median disease duration was 15 months. Twenty-eight patients had recurrent disease. The mean operative time was 41.4 ± 12.7 min. The mean time out of work was 11.6 ± 4.6 days. Complications occurred in 19 patients (7.1%) in the form of seroma in six patients (2.2%), superficial wound infection occurred in nine patients (3.3%), cuticular wound disruption occurred in four patients (1.5%). All patients completed 3-months follow-up, but 48 patients were lost at variable intervals with the remaining 217 patients completed follow-up throughout the period of the study with a median follow-up of 43 months. No reported recurrence and 96.7% of the patients were satisfied about their wound.

CONCLUSION

This modification is simple with low complication rate, no recurrence, and excellent patient satisfaction.

Treatment Options for Pilonidal Disease

Pilonidal disease can be treated medically; however, surgical excision remains the gold standard. Nonetheless, all current surgical approaches are still associated with potential for tissue loss, wound healing disorders, and high rates of recurrence. Aim of this study is to assess the long-term outcomes of the minimal-invasive pit-picking operation in comparison to the well-established technique of Karydakis flap-closure. Medical records of all patients undergoing either Karydakis flap-closure or the pit-picking operation for pilonidal disease at our department were reviewed retrospectively. A total of 101 patients were treated either by excision and Karydakis flap-closure (n = 62) or by the pit-picking operation (n = 39). Mean follow-up time was 65.5 (range: 38–101) months, including data collection using a standardized questionnaire. Analysis of the outcomes revealed no significant differences between the Karydakis flap-closure- and the pit-picking groups; however, the latter was associated with faster recovery, no need for hospitalization and overall low complication rates. In summary, the main advantages of the pit-picking operation lie in its’ outpatient character, the simplicity of the procedure, low complication rates, short recovery time, and predictably good results.

A Comparison of the Results of the Karydakis Flap Procedure and Primary Closure in the Treatment of Pilonidal Sinus Disease Over the Short and Long Term: A Randomized Clinical Study

In the current prospective study, we compared the results of the Karydakis flap procedure (KFP) and primary closure (PC). This study compared the short and long-term results of the KFP and PC techniques. The sample of this study was a total of 352 patients (302 male: 85.7%; median age: 24 years) who underwent reconstruction after pilonidal sinus excision in our clinic. The reconstruction was performed using the KFP (group 1, n = 176, 50%) or PC (group 2, n = 176, 50%). The following data on the patients was obtained; sex, age, body mass index (BMI), duration of operation and hospital stay, length of time patient could walk without pain, length of time patients could sit on toilet without pain, complications (e.g., infection, recurrence). No significant difference was found between groups 1 and 2 with respect to sex, age, BMI, and duration of operation. Moreover, length of time patients could walk and sit on toilet without pain was similar in both groups. On the other hand, the rate of recurrence was significantly lower in group 1 (n = 4, 2%) compared with group 2 (n = 20, 11%, P &lt; 0.001). KFP is preferable to PC since it is easier to learn and perform and has lower complication and recurrence rates.

Comparison of modified Limberg flap and Karydakis flap operations in pilonidal sinus surgery: prospective randomized study

The best surgical technique for pilonidal sinus disease (PSD) is still disputed. The objective of this prospective randomized study is to compare the short and long-term results of modified Limberg flap and Karydakis flap surgeries that have been widely used in recent years. Ninety one patients were included in the study. The patients were divided into two groups: modified Limberg flap (MLF; n = 46) and Karydakis flap (KF; n = 45). Preoperative findings of the patients, their surgical findings, and short and long-term postoperative findings were recorded and statistically compared. While no significant difference was discovered between the groups in terms of postoperative analgesic need, hospital stay, postoperative infection rate, drain stay time, painless sitting time, painless toilet-sitting time, and painless walking time, return to work or school time was shorter in the MLF group compared with the KF group (20.61 ± 7.89 days, 23.29 ± 6.42, respectively; P < 0.05). Cosmetically, the visual analog scale (VAS) of the KF group was significantly higher than that of the MLF group (VAS score 7.12 ± 1.28, 5.45 ± 1.77, respectively; P < 0.05). Considering recurrence rates, no statistically significant difference was found between the groups. Our study found out that short and long-term results of the MLF and KF procedures are similar. We believe both methods can be safely used in surgical PSD treatment given that in the MLF procedure, shorter return-to-work time is achieved, while the procedure provides better cosmetic results.

Local administration of gentamicin collagen sponge in surgical excision of sacrococcygeal pilonidal sinus disease: a systematic review and meta-analysis of the literature

Surgical site infections occur in up to 24 % of patients after surgical excision of sacrococcygeal pilonidal sinus disease with primary wound closure. Local administration of antibiotics by a gentamicin collagen sponge could reduce this infection rate. The objective of this systematic review and meta-analysis was to evaluate the effect of a gentamicin collagen sponge on outcome after surgical excision in patients with sacrococcygeal pilonidal sinus disease. A structured literature search was performed in the PubMed, Embase, The Cochrane Library, and Scopus databases. Studies comparing surgical excision of sacrococcygeal pilonidal sinus disease with versus without a gentamicin collagen sponge were included. Outcome measures were surgical site infection, wound healing, and recurrence. The search strategy yielded six studies with a total of 669 patients. Three randomized controlled trials, comparing excision of pilonidal sinus disease and primary wound closure with versus without gentamicin collagen sponge, were eligible for inclusion in the meta-analysis (319 patients), demonstrating a trend towards reduced surgical site infections after administration of gentamicin collagen sponge [absolute risk reduction 20 %, 95 %-confidence interval (CI) 1-41 %, p = 0.06]. The wound healing (absolute risk reduction 22 %, 95 % CI 32-77 %, p = 0.42) and recurrence rate (absolute risk reduction 8 %, 95 % CI 7-22 %, p = 0.30) were not significantly different between both groups. Administration of a gentamicin collagen sponge after surgical excision of sacrococcygeal pilonidal sinus disease showed no significant influence on wound healing and recurrence rate, but a trend towards a reduced incidence of surgical site infections. Therefore, additional larger well-designed randomized controlled trials are required.

Effectiveness of Limberg and Karydakis flap in recurrent pilonidal sinus disease

OBJECTIVE

Sacrococcygeal pilonidal sinus is common in young men and may recur over time after surgery. We investigated whether a factor exists that can aid in the determination of the preferred technique between the early Limberg flap and Karydakis flap techniques for treating recurrent pilonidal sinus.

MATERIALS AND METHODS

This prospective and randomized study enrolled 71 patients with recurrent pilonidal sinus in whom the Limberg flap or Karydakis flap techniques were applied for reconstruction after excision. Patients were divided into two groups as follows: 37 patients were treated with the Limberg flap technique and 34 patients were treated with the Karydakis flap technique. Fluid collection, wound infection, flap edema, hematoma, partial wound separation, return to daily activities, pain score, complete healing time, painless seating and patient satisfaction were compared between the groups. ClinicalTrial.gov: NCT02287935.

RESULTS

The development rates of total fluid collection, wound infection, flap edema, hematoma, and partial wound separation were 9.8%, 16%, 7%, 15% and 4.2%, respectively; total flap necrosis was not observed in any patient (p<0.001). During the average follow-up of 28 months, no patients (0%) developed recurrent disease. The two groups differed with respect to early surgical complications (p<0.001).

CONCLUSION

In this study, use of the Limberg flap was associated with lower complication rates, shorter length of hospital stay, early return to work, low pain score, high patient satisfaction and better complete healing duration. Therefore, we recommend the Limberg flap for treatment of recurrent pilonidal sinus.

Retrospective review of pilonidal sinus patients with early discharge after Limberg flap procedure

The aim of this study was to evaluate the results of cases with pilonidal sinus (PS) disease that underwent Limberg flap (LF) transposition and to compare the short and long-term results of early discharge cases with those in the literature. A total of 345 patients who underwent rhomboid excision and LF transposition for PS were evaluated retrospectively. No major anesthetic or surgical complications occurred. Partial wound dehiscence, localized flap necrosis, hematoma, wound infection, and seroma rates were determined as 4.0, 2.1, 1.5, 3.3, and 3.7% respectively. All patients other than those with a hematoma or localized necrosis were discharged with a drain in place 24 hours after the operation. The recurrence rate was 3.9% after a mean 33.1-month follow-up (range, 6-72 months). As a result, we found that short and long-term results of patients who underwent LF and were discharged 24 hours after the operation were similar to those in the literature. We suggest that patients without postoperative complications, such as hematoma or flap necrosis, can be discharged early.

S-shaped wide excision with primary closure for extensive chronic pilonidal sinus disease

Background. The management of complex pilonidal sinus disease (PSD) with multiple pits on and beside the natal cleft is variable, contentious, and problematic. Wide excision of the sinus and reconstruction of the defect using different flap techniques have become more popular in recent years. Case Report. We report a case with a complex chronic PSD to which we applied primary closure after S-shaped wide excision. The patient's postoperative course was uneventful, and at the end of one-year followup he is now disease-free and comes for routine checkups. Conclusion. The simplicity of the technique and the promising results support the applicability of the S-shaped wide excision in chronic bilaterally extended large PSDs. Further studies entailing large patient populations are needed to reach a definite conclusion.