Management of pilonidal sinus using fibrin glue: a new concept and preliminary experience

Sinus laser therapy versus sinus lay open in the management of sacrococcygeal pilonidal disease

AIM

There is no standard method for the management of sacrococcygeal pilonidal disease (SPND); however, surgery remains the gold standard treatment. Wide surgical excision of the sinus is the traditional surgical treatment of SPND, yet it is associated with extended healing time and delayed recovery. This study aimed to compare the outcomes of sinus laser therapy (SiLaT) and sinus lay open in the management of SPND.

METHODS

Patients with SPND who were treated with SiLaT or lay open were retrospectively reviewed. The main outcome measures were the success of surgery in terms of complete healing at 12 months postoperatively, time to complete healing, complications, operation time and quality of life (QoL).

RESULTS

A total of 139 patients with a mean age of 25 years were included to the study. Sixty-two patients underwent SiLaT and 77 underwent lay open. Six patients experienced recurrence after SiLaT while there was no recorded recurrence after the lay open technique (P = 0.007). Sinus lay open had a shorter operation time than SiLaT (P < 0.0001). On the other hand, SiLaT was followed by a shorter healing time, lower incidence of delayed wound healing, better cosmetic outcome, and higher QoL scores compared to the lay open group. The complication rates were comparable between the two groups.

CONCLUSION

Sinus lay open was associated with better success than SiLaT. On the other hand, SiLaT was associated with quicker healing, better cosmesis, better QoL and longer operation time. The complication rate of the two procedures was comparable.

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.

Outcomes of Two Treatments for Uncomplicated Pilonidal Sinus Disease: Karydakis Flap Procedure and Sinus Tract Ablation Procedure Using a 1,470 nm Diode Laser Combined With Pit Excision

BACKGROUND AND OBJECTIVES

An ideal treatment for pilonidal disease should feature a low recurrence rate, minimal incision, and rapid return to daily activities. We compared the outcomes of the well-defined Karydakis technique (KT) and a combination of pit excision (PE) and sinus tract ablation using 1,470-nm diode laser.

STUDY DESIGN/MATERIALS AND METHODS

In this study, from January 2016 to January 2018, patients diagnosed with uncomplicated early-stage pilonidal sinus disease were enrolled and were treated randomly, using KT (n = 28) or a PE/laser ablation technique (PE + LAT; n = 30).

RESULTS

The mean operative times were 36.4 (25-45) minutes in the KT group and 15.1 (12-20) minutes in the PE + LAT group. Postoperative Visual Analog Scale pain scores were 4.4 in the KT group and 2.1 in the PE + LAT group. The time periods to return to normal daily activities were 2.6 (1-5) days in the PE + LAT group and 12.8 (10-20) days in the KT group. The mean Likert satisfaction scores were 3.8 in the KT group and 4.8 in the PE + LAT group. The groups did not differ in terms of recurrence.

CONCLUSIONS

Compared with the KT, the PE + LAT was associated with a shorter operative time, a more rapid return to normal activities, less pain, and a higher level of subjective satisfaction. We found that the PE + LAT was better than the KT for patients with early-stage disease. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

A Comparison of Three Dressing Methods for Pilonidal Sinus Surgery Wound Healing

OBJECTIVE

To evaluate the effect of different dressing methods on the wound healing process after pilonidal sinus surgery.

METHODS

In this clinical trial, 60 patients undergoing pilonidal sinus surgery were randomly assigned to one of three groups. In the first group, hydrogel or alginate and hydrocolloid compounds were used as a standard occlusive dressing method. A modified dressing method was used for the second group, in which transparent hydrocolloid films were replaced by Vaseline gauze. The third group was treated using gauze swabs soaked in normal saline. The length and depth of the studied wounds were recorded once a week for a month. During dressing changes, patient pain was recorded using an 11-point numeric rating scale. The collected data were analyzed by descriptive and inferential statistical methods.

RESULTS

There was a significant reduction in wound length after 2 weeks in all three groups (P < .05), and the pain experienced by the first and second groups was significantly lower than the third group. However, the modified method used for the second group was associated with a lower cost.

CONCLUSIONS

Considering the beneficial results of using modern dressings for wound healing and reducing the severity of associated pain, providers may want to consider using modified wound dressings after pilonidal sinus surgery. Study authors recommend that providers receive training on how to use these products.

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.

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.

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.

Fibrin glue for pilonidal sinus disease

BACKGROUND

Pilonidal sinus disease is a common condition that mainly affects young adults. This condition can cause significant pain and impairment of normal activities. No consensus currently exists on the optimum treatment for pilonidal sinus and current therapies have various advantages and disadvantages. Fibrin glue has emerged as a potential treatment as both monotherapy and an adjunct to surgery.

OBJECTIVES

To assess the effects of fibrin glue alone or in combination with surgery compared with surgery alone in the treatment of pilonidal sinus disease.

SEARCH METHODS

In December 2016 we searched: the Cochrane Wounds Specialised Register; CENTRAL; MEDLINE; Embase and CINAHL Plus. We also searched clinical trials registries and conference proceedings for ongoing and unpublished studies and scanned reference lists to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only. We included studies involving participants of all ages and studies conducted in any setting. We considered studies involving people with both new and recurrent pilonidal sinus. We included studies which evaluated fibrin glue monotherapy or as an adjunct to surgery.

DATA COLLECTION AND ANALYSIS

Two study authors independently extracted data and assessed risk of bias. We used standard methods expected by Cochrane.

MAIN RESULTS

We included four RCTs with 253 participants, all were at risk of bias. One unpublished study evaluated fibrin glue monotherapy compared with Bascom's procedure, two studies evaluated fibrin glue as an adjunct to Limberg flap and one study evaluated fibrin glue as an adjunct to Karydakis flap.For fibrin glue monotherapy compared with Bascom's procedure, there were no data available for the primary outcomes of time to healing and adverse events. There was low-quality evidence of less pain on day one after the procedure with fibrin glue monotherapy compared with Bascom's procedure (mean difference (MD) -2.50, 95% confidence interval (CI) -4.03 to -0.97) (evidence downgraded twice for risk of performance and detection bias). Fibrin glue may reduce the time taken to return to normal activities compared with Bascom's procedure (mean time 42 days with surgery and 7 days with glue, MD -34.80 days, 95% CI -66.82 days to -2.78 days) (very low-quality evidence, downgraded as above and for imprecision).Fibrin glue as an adjunct to the Limberg flap may reduce the healing time from 22 to 8 days compared with the Limberg flap alone (MD -13.95 days, 95% CI -16.76 days to -11.14 days) (very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and imprecision). It is uncertain whether use of fibrin glue affects the incidence of postoperative seroma (an adverse event) (risk ratio (RR) 0.27, 95% CI 0.05 to 1.61; very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and imprecision). There was low-quality evidence that fibrin glue, as an adjunct to Limberg flap, may reduce postoperative pain (median 2 versus 4; P < 0.001) and time to return to normal activities (median 8 days versus 17 days; P < 0.001). The addition of fibrin glue to the Limberg flap may reduce the length of hospital stay (MD -1.69 days, 95% CI -2.08 days to -1.29 days) (very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and for unexplained heterogeneity).A single RCT evaluating fibrin glue as an adjunct to the Karydakis flap did not report data for the primary outcome of time to healing. It is uncertain whether fibrin glue with the Karydakis flap affects the incidence of postoperative seroma (adverse event) (RR 3.00, 95% CI 0.67 to 13.46) (very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and for imprecision). Fibrin glue as an adjunct to Karydakis flap may reduce length of stay but this is highly uncertain (mean 2 days versus 3.7 days; P < 0.001, low-quality evidence downgraded twice for risk of selection, performance and detection bias).

AUTHORS' CONCLUSIONS

Current evidence is uncertain regarding any benefits associated with fibrin glue either as monotherapy or as an adjunct to surgery for people with pilonidal sinus disease. We identified only four RCTs and each was small and at risk of bias resulting in very low-quality evidence for the primary outcomes of time to healing and adverse events. Future studies should enrol many more participants, ensure adequate randomisation and blinding, whilst measuring clinically relevant outcomes.

Novel Approach of Treatment of Pilonidal Sinus Disease With Thrombin Gelatin Matrix as a Sealant

BACKGROUND

Sacrococcygeal pilonidal sinus disease is a condition caused by insertion of fallen hair shafts into the skin. Different types of operations have been described for the management of pilonidal sinus, yet none of them have proven to be superior to the others. Recently, sealants like fibrin glue have been successfully used.

OBJECTIVE

This study aimed to assess the efficacy of thrombin gelatin matrix as a new sealant for pilonidal sinus treatment.

DESIGN

This was a prospective study conducted from March 2013 to March 2015.

SETTINGS

The study was conducted in private hospitals in Mansoura City.

PATIENTS

The study included 36 male patients (72%) and 14 female patients (28%), with a median age of 22 years.

INTERVENTIONS

Fifty patients with pilonidal sinus were admitted and treated with thrombin gelatin matrix injection.

MAIN OUTCOME MEASURES

Incidence and time of pilonidal sinus recurrence, postoperative pain and complications, duration of hospital stay, healing status, and time to return to work were recorded.

RESULTS

The median duration of symptoms was 13 months, median operative time was 18 minutes, and median hospital stay was 6 hours. All of the procedures were conducted as day-case surgeries. Median follow-up duration was 24 months. Three patients (6%) had a breakdown of the sealant, and the wound was managed with daily dressings. Recurrence at 1 year was observed in 2 patients (4%). A total of 96% of patients were satisfied with the outcome of the procedure, and 92% of patients resumed their daily activities within 3 days.

LIMITATIONS

Follow-up for a longer duration is required to ascertain the efficacy of this new technique. The cost of this treatment might be challenging for resource-limited communities.

CONCLUSIONS

Management of pilonidal sinus using thrombin gelatin matrix, despite being expensive, is an effective, simple treatment that is easy to perform and associated with low recurrence rate, minimal morbidity, and rapid recovery.

Fibrin sealant use in pilonidal sinus: Systematic review

AIM: To review the current data about the success rates of fibrin sealant use in pilonidal disease.

METHODS: Fibrin sealant can be used for different purposes in pilonidal sinus treatment, such as filling in the sinus tracts, covering the open wound after excision and lay-open treatment, or obliterating the subcutaneous dead space before skin closure. We searched Pubmed, Google-Scholar, Ebsco-Host, clinicaltrials, and Cochrane databases and found nine studies eligible for analysis; these studies included a total of 217 patients (84% male, mean age 24.2 ± 7.8).

RESULTS: In cases where fibrin sealant was used to obliterate the subcutaneous dead space, there was no reduction in wound complication rates (9.8% vs 14.6%, P = 0.48). In cases where sealant was used to cover the laid-open area, the wound healing time and patient comfort were reported better than in previous studies (mean 17 d, 88% satisfaction). When fibrin sealant was used to fill the sinus tracts, the recurrence rate was around 20%, despite the highly selected grouping of patients.

CONCLUSION: Consequently, using fibrin sealant to decrease the risk of seroma formation was determined to be an ineffective course of action. It was not advisable to fill the sinus tracts with fibrin sealant because it was not superior to other cost-effective and minimally invasive treatments. New comparative studies can be conducted to confirm the results of sealant use in covering the laid-open area.

Early experience of the use of fibrin sealant in the management of children with pilonidal sinus disease

BACKGROUND

The use of fibrin sealant in the management of pilonidal sinus disease has not previously been described in children. We present our experience of primary pit excision and use of fibrin sealant (PEF) and compare outcomes with lateralising flap procedures (LFP).

METHODS

A single centre retrospective case note review of all children who had undergone a definitive procedure for pilonidal sinus from August 2006 to Dec 2013 was performed using data expressed as median (range) and compared using Fisher's exact test. P<0.05 was regarded as significant.

RESULTS

Forty-one children were identified having undergone 49 procedures, with median age 15 (12-16 years) and follow up 32 (8-92) months. Groups were comparable for disease severity. Ten children underwent primary PEF and twenty-six LFP. Two children had recurrence following primary PEF and had repeat PEF which was curative. Overall recurrence rates following PEF procedure were comparable to LFP (17% vs 21%; P=1.0). There were no wound dehiscences in the PEF group and one wound infection. There was one wound dehiscence and one wound infection in the LFP group. Median operative time for PEF was lower than LFP (20 vs 60 min, P=0.001). 83% of PEF procedures were performed as day cases. One child was lost to follow up, and two children progressed to adult services.

CONCLUSIONS

We recommend PEF in children with pilonidal sinus disease as primary treatment and for recurrence. PEF has comparable recurrence and wound infection rates to LFPs, is performed as day case, has shorter anaesthetic times, and the risk of wound dehiscence is avoided.

Crystallized phenol treatment of pilonidal disease improves quality of life

The effects of crystallized phenol treatment of pilonidal sinus on quality of life has not been investigated before. This study aimed to compare the phenol treatment with surgical excision plus primary closure technique in terms of life quality by means of a life quality questionnaire. This is a prospective randomized clinical study. The study was conducted at Training and Teaching Hospital, Kayseri, Turkey. In total, 40 patients with pilonidal disease were randomly assigned into 2 clinically comparable groups between September 2010 and June 2011. Cristallyzed phenol application was done to 20 patients and surgical excision plus primary closure was done to 20 patients for the treatment of pilonidal disease. Data regarding demographic variables were recorded. To evaluate quality of life and patient comfort all patients asked to fill the questionnaire after complete healing occurred. There was no difference between the groups in age, sex and occupation. Two of the 20 patients in the excision and primary closure group had complication of wound dehiscience and needed prolonged wound care. There was significant differences in favor of the phenol group in all terms of life quality except for complete healing time. As a first degree treatment, phenol treatment is better than the other treatment choices of pilonidal disease in terms of time off work perioperative pain, being away from school and social life. Also phenol treatment can be done without any pretreatment laboratory examination. Further studies will be needed about cost-effectivity of phenol treatment.

Sticking to the facts: a systematic review of fibrin glue for pilonidal disease

BACKGROUND

Pilonidal disease occurs when hair invading the natal cleft causes inflammation and abscess formation. Opinions vary on best practice, and most procedures have considerable morbidity and high recurrence rates of 6-40%.

OBJECTIVES

This study systematically reviews the use of fibrin glue in the treatment of pilonidal disease. Outcomes measured were healing time and recurrence rate.

DATA SOURCE

ScienceDirect and PubMed databases were searched for relevant literature, yielding seven papers including five small trials. The total number of patients receiving fibrin glue treatments across all trials was 85. There were no exclusion criteria in this review.

RESULTS

Fibrin glue treatments had equivalent or better reported healing times than conventional therapies at an average of 2-6 weeks, and low recurrence rates between 0 and 17% at follow-up periods between 4 and 28 months. Considerable heterogeneity in study methodologies and surgical techniques prevented statistical significance or aggregate figures from being determined.

CONCLUSIONS

There appears to be early promise for the use of fibrin glue in the treatment of pilonidal disease and an impetus for definitive research.

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.