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Vejdan SA, Danesh HA, Amirian F, Amirian Z. Evaluation of the efficacy of the Z-plasty surgical technique vs. secondary wound healing mechanism in the treatment of the pilonidal sinus: a clinical trial. Ann Med Surg (Lond) 2024; 86:2715-2722. [PMID: 38694311 PMCID: PMC11060272 DOI: 10.1097/ms9.0000000000001866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/07/2024] [Indexed: 05/04/2024] Open
Abstract
Background The most important step in treating a pilonidal sinus is eradication by surgical excision. Over the years, various surgical techniques have been reported for wound closure, yet their management still poses a challenge. The current study compares the results of two different methods of wound management: secondary wound healing versus the Z-plasty surgical technique. Material and method The current clinical trial recruited 84 uncomplicated pilonidal sinus patients who were to undergo complete surgical excision of the pilonidal sinus. For wound healing, the 84 subjects were equally divided into two groups of 42 patients each. One group was selected for Z-plasty surgical wound closure and the other for the secondary healing mechanism. Outcomes measured consisted of demographic data, length of operation, complications, severity of pain, number of dressings, recurrence, and complete healing time. Result Age or sex distribution and the median BMI (kg/m²) did not significantly differ between the two groups. The length of the operation for Z-plasty subjects was significantly longer (P <0.0001). The median number of dressing changes for secondary wound healing patients was 38.69, which was significantly higher than the 4.95 dressing changes for the Z-plasty group. The total time recorded for complete wound healing was 21.61±4.27 days in the Z-plasty group and 41.23±24.28 days for secondary wound healing subjects, which was statistically significant. Twenty-four hours postoperation, patients in the secondary wound healing group had significantly more pain, and the Visual Analogue Scale scores of the Z-plasty and secondary wound healing groups were 3.42±0.76 and 6.09±1.2, respectively. Concerning the recurrence rate, there were no significant differences between the two groups. SPSS version 22 performed the analyses, and the independent t-test compared the continuous variables. A P value less than 0.05 was considered statistically significant. Conclusion Z-plasty is a safe and effective procedure in terms of wound complications and recurrence rate. This method is also cost-effective and better received by patients.
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Affiliation(s)
- SA Vejdan
- University of Medicine, Birjand
- Imam Reza Hospital
| | - HA Danesh
- University of Medicine
- Clinical Immunology Research Center at Zahedan University of Medical Science, Zahedan
| | - F. Amirian
- Faculty of Medicine, Department of Internal Medicine, Mashhad University of Medical Sciences, Mashhad
| | - Z. Amirian
- University of Medicine
- Imam Ali Hospital, Meshginshahr, Iran
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Cai Z, Zhao Z, Ma Q, Shen C, Jiang Z, Liu C, Liu C, Zhang B. Midline and off-midline wound closure methods after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev 2024; 1:CD015213. [PMID: 38226663 PMCID: PMC10790338 DOI: 10.1002/14651858.cd015213.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
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.
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Affiliation(s)
- Zhaolun Cai
- Department of General Surgery, Gastric Cancer Center, Research Laboratory of Tumor Epigenetics and Genomics for General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhou Zhao
- Department of Gastrointestinal Cancer Center, Chongqing University Cancer Hospital, Chongqing, China
| | - Qin Ma
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chaoyong Shen
- Department of General Surgery, Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyuan Jiang
- Department of Plastic Surgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Chunyu Liu
- Department of Pharmacy, Evidence-based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chunjuan Liu
- Department of General Surgery, Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Zhang
- Department of General Surgery, Gastric Cancer Center, Research Laboratory of Tumor Epigenetics and Genomics for General Surgery, West China Hospital, Sichuan University, Chengdu, China
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Regadas FS, Murad-regadas S. Persistent pilonidal disease: What to do when your initial surgery fails? Seminars in Colon and Rectal Surgery 2022. [DOI: 10.1016/j.scrs.2022.100916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chaffin AE, Dowling SG, Kosyk MS, Bosque BA. Surgical reconstruction of pilonidal sinus disease with concomitant extracellular matrix graft placement: a case series. J Wound Care 2021; 30:S28-S34. [PMID: 34256587 DOI: 10.12968/jowc.2021.30.sup7.s28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pilonidal sinus disease (PSD) is a chronic inflammatory disease affecting the soft tissue of the sacrococcygeal region and remains a challenging disease for clinicians to treat. The optimal treatment for PSD remains controversial and recent reports describe several different surgical approaches offering different benefits. Approximately 40% of initial incision and drainage cases require subsequent surgery. Due to high recurrence rates and postoperative complications, a more complex revision surgery involving a flap reconstruction may be required. We hypothesised that the combination of an extracellular matrix (ECM) graft with tissue flap reconstruction may decrease the postoperative complications and recurrence rates for PSD. METHOD We report a retrospective case series using a surgical flap reconstruction with concomitant implantation of an ovine forestomach ECM graft under a fasciocutaneous flap with an off-midline closure for recurrent PSD, where previously surgical intervention had failed due to wound dehiscence and/or recurrent disease. RESULTS The case series included six patients. After three weeks, all patients except one were fully healed, and the sixth was fully healed by week 4; all wounds remained fully healed at 12 weeks. All patients achieved good cosmesis and were able to return to normal function without any residual symptoms. CONCLUSION This pilot case series explored augmenting a flap reconstruction for complex PSD with advanced ECM graft materials, demonstrating that it may improve outcomes and minimise typical complications seen in flap closure, such as inflammation, infection, haematoma/seroma and hypoperfusion. Although the study had a limited number of participants, long-term outcomes were promising and suggest that further studies are warranted.
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Affiliation(s)
- Abigail E Chaffin
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, US
| | | | - Mychajlo S Kosyk
- Division of Plastic and Reconstructive Surgery, Tulane University School of Medicine, New Orleans, US
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Mistry A, Shaikh P, Mohammed A, Bagasrawala S, Chauhan A, Anthony G. Outcome of Surgical Management of Sacrococcygeal Pilonidal Sinus Disease with Rotation Flap in 52 Patients-A Retrospective Study. Indian J Plast Surg 2021; 54:163-167. [PMID: 34239238 PMCID: PMC8257315 DOI: 10.1055/s-0041-1729506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Background Surgical treatment of sacrococcygeal pilonidal sinus disease (SPSD) consists of radical excision of the entire tract and treatment of the resultant raw area. Here, the authors have reviewed the results of the rotation flap for closure of the SPSD. Aim This study aims to evaluate the outcomes following SPSD excision and rotation flap closure. Materials and Methods All patients were treated for SPSD with excision and closure using a rotation flap from January 2010 to September 2018. Cases having a follow-up of at least 6 months post surgery were evaluated. Result A total of 52 patients were included in the study; 42 cases were of primary disease while 10 were of recurrent disease. The patients' follow-up records on the 3rd day, 10th day, 1 month, and 6 months were evaluated. None of the patients showed any signs of recurrence on follow-ups. One patient developed a hematoma on the third day post surgery which was treated conservatively. One patient developed a seroma in the perianal region on the fifth postoperative day which required aspiration. Both these patients healed well subsequently. Conclusion Rotation flap is a (simple and reliable) treatment option for closure of postexcision SPSD defect. It not only takes the tension away from suture line, but also pushes the gluteal fat from the sides into the midline, obliterating the deep crevice of the natal cleft which is believed to be one of the important factors in the causation of SPSD, thus minimizing recurrence.
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Affiliation(s)
- Abbas Mistry
- Department of Plastic and Reconstructive Surgery, Saifee Hospital, Mumbai, Maharashtra, India
| | - Parvez Shaikh
- Department of General Surgery, Saifee Hospital, Mumbai, Maharashtra, India
| | - Aizaz Mohammed
- Department of Anesthesiology, Saifee Hospital, Mumbai, Maharashtra, India
| | - Samir Bagasrawala
- Department of General Surgery, Saifee Hospital, Mumbai, Maharashtra, India
| | - Ankit Chauhan
- Department of General Surgery, Saifee Hospital, Mumbai, Maharashtra, India
| | - George Anthony
- Department of General Surgery, Saifee Hospital, Mumbai, Maharashtra, India
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Iesalnieks I, Ommer A, Herold A, Doll D. German National Guideline on the management of pilonidal disease: update 2020. Langenbecks Arch Surg 2021; 406:2569-2580. [PMID: 33950407 PMCID: PMC8097120 DOI: 10.1007/s00423-020-02060-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- I Iesalnieks
- Dept. of Surgery, München Klinik Bogenhausen, Englschalkinger Str. 77, 81925, Munich, Germany.
| | - A Ommer
- End- und Dickdarm-Zentrum Essen, Essen, Germany
| | - A Herold
- End- und Dickdarmzentrum Mannheim, Mannheim, Germany
| | - D Doll
- Dept. of Procto-Surgery, St. Marienhospital Vechta, Vechta, Germany
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Ray K, Albendary M, Baig MK, Swaminathan C, Sains P, Sajid MS. 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. MINERVA CHIR 2020; 75:355-364. [PMID: 32975384 DOI: 10.23736/s0026-4733.20.08362-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Kausik Ray
- Department of Digestive Diseases and Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, The Royal Sussex County Hospital, Brighton, UK
| | - Mohammed Albendary
- Department of Digestive Diseases and Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, The Royal Sussex County Hospital, Brighton, UK
| | - Mirza K Baig
- Department of Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - Christie Swaminathan
- Department of Digestive Diseases and Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, The Royal Sussex County Hospital, Brighton, UK
| | - Parv Sains
- Department of Digestive Diseases and Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, The Royal Sussex County Hospital, Brighton, UK
| | - Muhammad S Sajid
- Department of Digestive Diseases and Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, The Royal Sussex County Hospital, Brighton, UK -
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Mahmood F, Hussain A, Akingboye A. Pilonidal sinus disease: Review of current practice and prospects for endoscopic treatment. Ann Med Surg (Lond) 2020; 57:212-7. [PMID: 32793341 DOI: 10.1016/j.amsu.2020.07.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/25/2020] [Accepted: 07/26/2020] [Indexed: 02/08/2023] Open
Abstract
Pilonidal sinus disease is chronic acquired condition leading to significant morbidity and associated healthcare costs. Several techniques have been described to manage this condition with no treatment gaining universal acceptance. With the shift towards minimally invasive surgery, Video Assisted-Ablation of Pilonidal Sinus (VAAPS) and Endoscopic Pilonidal Sinus Treatment (EPiST) have gained prominence. The aim of this review is to analyse current treatment modalities and the evidence for endoscopic pilonidal sinus surgery. Reported surgical techniques range from wide excision with or without primary closure to various flap closures. These aim to eliminate the underlying causes driven by natal cleft hair and reducing recurrence. However, long term (≥5 years) recurrence rates range between 10 and 30% with significant complication rates. Trials with endoscopic treatment which have shown comparable short-term results to established treatments with reduced morbidity. However, the potential higher cost, learning curve, patient selection criteria and need for long term outcomes from randomised trials limit widespread application of this promising method. Endoscopic treatment of pilonidal sinus disease therefore provides a minimally invasive alternative to traditional surgical methods with the potential to reduce morbidity. However long-term outcomes data from further prospective randomised trials is needed to establish its efficacy compared to traditional surgical methods. Multiple treatment modalities for pilonidal sinus disease exist with no universally accepted mode of treatment. Pilonidal sinus disease recurrence is high even after treatment. Endoscopic treatment has comparable short-term results to established treatments with reduced morbidity. Video Assisted-Ablation of Pilonidal Sinus and Endoscopic Pilonidal Sinus Treatment are emerging treatment modalities.
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Rogers P, Platell C, Levitt M. Minimal tissue excision in the treatment of pilonidal sinus disease: results from a single surgical unit. ANZ J Surg 2020; 90:529-532. [DOI: 10.1111/ans.15677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Peter Rogers
- Department of Colorectal Surgery, St John of God Subiaco Hospital Perth Western Australia Australia
| | - Cameron Platell
- Department of Colorectal Surgery, St John of God Subiaco Hospital Perth Western Australia Australia
| | - Michael Levitt
- Department of Colorectal Surgery, St John of God Subiaco Hospital Perth Western Australia Australia
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Hardy EJO, Herrod PJ, Doleman B, Phillips HG, Ranat R, Lund JN. Surgical interventions for the treatment of sacrococcygeal pilonidal sinus disease in children: A systematic review and meta-analysis. J Pediatr Surg 2019; 54:2222-33. [PMID: 30940347 DOI: 10.1016/j.jpedsurg.2019.02.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/01/2019] [Accepted: 02/24/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pilonidal sinus disease (PNS) is not uncommon in children. Controversy remains over the best treatment and there is limited evidence. This systematic review and meta-analysis aims to establish which techniques have the best outcomes in children. METHODS MEDLINE, EMBASE and CENTRAL databases were searched. Studies reporting treatment outcomes for PNS in children were included. RESULTS Open healing has pooled risk of recurrence of 26% (95%CI 15-38%), risk of wound complication of 21% (9-36%) and wound healing ranged from 38-92 days. Midline primary closure has pooled risk of recurrence of 12% (8-18%), risk of wound complication of 30% (19-46%) and wound healing ranged from 8 to 32 days. Off-midline primary closure has pooled risk of recurrence of 6% (1-15%), risk of wound complication of 14% (6-25%) and wound healing was 27 days. VAC therapy has pooled risk of recurrence of 20% (0-65%) and wound healing ranged from 38 to 92 days. Minimally invasive techniques has pooled risk of recurrence of 7% (1-16%) and wound healing ranged from 21-30 days. Marsupialisation has pooled risk of recurrence of 6% (0-22%), and wound healing ranged from 6 to 41 days. CONCLUSION Evidence for management of PNS in children is poor. Off-midline primary closure, minimally invasive techniques, and marsupialisation have the best outcomes. LEVEL OF EVIDENCE RATING IV.
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Doll D, Orlik A, Maier K, Kauf P, Schmid M, Diekmann M, Vogt AP, Stauffer VK, Luedi MM. Impact of geography and surgical approach on recurrence in global pilonidal sinus disease. Sci Rep 2019; 9:15111. [PMID: 31641150 DOI: 10.1038/s41598-019-51159-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/20/2019] [Indexed: 12/18/2022] Open
Abstract
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.
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Hardy E, Herrod P, Sian T, Boyd-Carson H, Blackwell J, Lund JN, Quarmby JW. Fibrin glue obliteration is safe, effective and minimally invasive as first line treatment for pilonidal sinus disease in children. J Pediatr Surg 2019; 54:1668-1670. [PMID: 30268489 DOI: 10.1016/j.jpedsurg.2018.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/31/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND / PURPOSE Sacrococcygeal pilonidal sinus disease (PSD) has an incidence of 1.2-2.5/1000 in children. Onset is around puberty. Symptoms of recurrent abscess and chronic suppuration may interfere with education and social integration. Treatments should cause minimal disruption while having good cure and recurrence rates. Curettage and Fibrin glue obliteration (FGO) show promising results in adults. We present our experience of its use in children. METHODS Review of all pediatric patients receiving FGO of pilonidal sinus performed by a single surgeon from September 2014 to February 2018. RESULTS Eighteen patients were identified. Median age was 16 (range 15-17), 55.6% were male. All procedures were completed as day cases. Median operative duration was 14 .1 (6-29) min. Twelve patients required only 1 procedure, 4 required 2 procedures, 1 required 5 procedures and 1 elected for formal excision after 2 FGO treatments. Median return to normal activities was 3 days, with 1 day school absence. Two patients developed minor surgical site infections. Median follow-up was 52 weeks (17-102), during which time there was 1 recurrence (5.6%). CONCLUSION This study demonstrates FGO is a safe, effective procedure for pediatric PNS, with results comparable to off-midline flap techniques and without the need for extensive tissue excision and the associated morbidity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ejo Hardy
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT.
| | - Pjj Herrod
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - T Sian
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - H Boyd-Carson
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - Jem Blackwell
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - J N Lund
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2; Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby, DE22 2DT
| | - J W Quarmby
- Department of General Surgery, Royal Derby Hospital, Derby, UK DE22 3NE2
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Berthier C, Bérard E, Meresse T, Grolleau JL, Herlin C, Chaput B. A comparison of flap reconstruction vs the laying open technique or excision and direct suture for pilonidal sinus disease: A meta-analysis of randomised studies. Int Wound J 2019; 16:1119-1135. [PMID: 31230414 DOI: 10.1111/iwj.13163] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/22/2019] [Accepted: 05/28/2019] [Indexed: 12/14/2022] Open
Abstract
Many treatments have been described for pilonidal disease, but recurrence cannot be completely eliminated. The aim of this study was to perform a meta-analysis of randomised, controlled trials comparing flap repair vs the laying open technique and/or excision and direct closure techniques in the treatment of chronic pilonidal sinus disease. The primary outcome measure was the recurrence rate. Secondary outcomes were complete wound-healing time, duration of the incapacity to work, quality of life and patient satisfaction, postoperative pain, wound infection, bleeding or haematoma, skin wound complications, and duration of hospital stay. Seventeen studies were included. The meta-analysis demonstrated a lower risk of recurrence, a shorter duration of incapacity to work, a lower risk of wound infections, a lower risk of skin wound complications, and a shorter duration of hospitalisation in favour of flap vs direct closure. A shorter time to complete wound healing and a shorter duration of incapacity to work for flap vs the laying open technique were observed. Superiority of flap repair vs direct closure in pilonidal sinus treatment was demonstrated in this meta-analysis. These results suggest avoiding primary direct closure in clinical practice. Compared with the laying open technique, flaps result in faster healing and a shorter time to return to activities.
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Affiliation(s)
- Charline Berthier
- Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
| | - Emilie Bérard
- Department of Epidemiology, Health Economics and Public Health, University Hospital of Toulouse, Toulouse, France
| | - Thomas Meresse
- Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
| | - Jean-Louis Grolleau
- Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
| | - Christian Herlin
- Department of Plastic Reconstructive Surgery and Burns, Lapeyronie University Hospital, Montpellier, France
| | - Benoit Chaput
- Department of Plastic Reconstructive Surgery and Burns, Rangueil University Hospital, Toulouse, France
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Sinnott CJ, Glickman LT. Limberg flap reconstruction for sacrococcygeal pilonidal sinus disease with and without acute abscess: Our experience and a review of the literature. Arch Plast Surg 2019; 46:235-40. [PMID: 31006184 DOI: 10.5999/aps.2018.01312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/09/2019] [Indexed: 11/16/2022] Open
Abstract
Background The efficacy of Limberg flap reconstruction for pilonidal sinus with acute abscess remains unclear. This study aimed to compare outcomes after Limberg flap reconstruction for pilonidal sinus disease with and without acute abscess. A secondary objective was to perform a review of the literature on the topic. Methods A retrospective chart review was conducted of all patients who underwent excision and Limberg flap reconstruction for pilonidal sinus from 2009 to 2018. Patient demographics, wound characteristics, and complication rates were reviewed and analyzed. Results Group 1 comprised 19 patients who underwent Limberg flap reconstruction for pilonidal sinus disease without acute abscess and group 2 comprised four patients who underwent reconstruction for pilonidal sinus disease with acute abscess. The average defect size after excision was larger in group 2 than group 1 (107.7±60.3 cm2 vs. 61.4±33.8 cm2, respectively). There were no recurrences, seromas or cases of flap necrosis postoperatively. There was only one revision surgery needed for evacuation of a postoperative hematoma in group 1. There were comparable rates of partial wound dehiscence treated by local wound care, hematoma, need for revision surgery and minor infection between group 1 and group 2. Conclusions Limberg flap reconstruction for pilonidal sinus in the setting of acute abscess is a viable option with outcomes comparable to that for disease without acute abscess. This practice will avoid the pain and cost associated with a prolonged local wound care regimen involved in drainage of the abscess prior to flap reconstruction.
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Johnson EK, Vogel JD, Cowan ML, Feingold DL, Steele SR; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons' Clinical Practice Guidelines for the Management of Pilonidal Disease. Dis Colon Rectum 2019; 62:146-57. [PMID: 30640830 DOI: 10.1097/DCR.0000000000001237] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
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.
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Stauffer VK, Luedi MM, Kauf P, Schmid M, Diekmann M, Wieferich K, Schnüriger B, Doll D. Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep 2018; 8:3058. [PMID: 29449548 PMCID: PMC5814421 DOI: 10.1038/s41598-018-20143-4] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 01/15/2018] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- V K Stauffer
- Lindenhofspital, Lindenhofgruppe, 3010, Bern, (VS), Switzerland
| | - M M Luedi
- Department of Anaesthesiology, Bern University Hospital Inselspital, University of Bern, 3010, Bern, (MML), Switzerland
| | - P Kauf
- Biomedical Statistics PROGNOSIX AG, 8001, Zurich, (PK, MS), Switzerland
| | - M Schmid
- Biomedical Statistics PROGNOSIX AG, 8001, Zurich, (PK, MS), Switzerland
| | - M Diekmann
- Department of Procto-Surgery, St. Marien-Krankenhaus Vechta, Teaching Hospital of the Hannover University, 49377, Vechta, (KW, DD), Germany
| | - K Wieferich
- Department of Procto-Surgery, St. Marien-Krankenhaus Vechta, Teaching Hospital of the Hannover University, 49377, Vechta, (KW, DD), Germany
| | - B Schnüriger
- Department of Visceral Surgery and Medicine, Bern University Hospital Inselspital, University of Bern, 3010, Bern, (BS), Switzerland
| | - D Doll
- Department of Procto-Surgery, St. Marien-Krankenhaus Vechta, Teaching Hospital of the Hannover University, 49377, Vechta, (KW, DD), Germany.
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Iesalnieks I, Ommer A, Petersen S, Doll D, Herold A. German national guideline on the management of pilonidal disease. Langenbecks Arch Surg 2016; 401:599-609. [DOI: 10.1007/s00423-016-1463-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 06/08/2016] [Indexed: 01/30/2023]
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Saydam M, Ozturk B, Sinan H, Balta AZ, Demir P, Ozer MT, Demirbas S. Comparison of modified Limberg flap transposition and lateral advancement flap transposition with Burow’s triangle in the treatment of pilonidal sinus disease. Am J Surg 2015; 210:772-7. [DOI: 10.1016/j.amjsurg.2015.03.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 03/20/2015] [Accepted: 03/30/2015] [Indexed: 11/19/2022]
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Affiliation(s)
- Alicia Mackowski
- Colorectal Surgical Unit; St John of God Subiaco Hospital; Perth Western Australia Australia
| | - Michael Levitt
- Colorectal Surgical Unit; St John of God Subiaco Hospital; Perth Western Australia Australia
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Yucel E, Tezcan L, Yilmaz OC, Akin ML. "Flag Excision and Flap" Procedure: a Novel Modification for Off-Midline Closure After Pilonidal Sinus Excision. Indian J Surg 2015; 77:1191-5. [PMID: 27011534 DOI: 10.1007/s12262-015-1241-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/23/2015] [Indexed: 10/24/2022] Open
Abstract
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.
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Emir S, Topuz O, Kanat BH, Bali I. Sinotomy technique versus surgical excision with primary closure technique in pilonidal sinus disease. Bosn J Basic Med Sci 2014; 14:263-7. [PMID: 25428682 DOI: 10.17305/bjbms.2014.4.139] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 10/16/2014] [Accepted: 10/19/2014] [Indexed: 12/27/2022] Open
Abstract
Pilonidal disease is a common chronic disorder mainly seen in the sacrococcygeal region, especially in young males. Many surgical treatment modalities have been suggested, but an ideal and widely accepted treatment has yet to be established. The aim of this study was to compare quality of life of patients treated with the sinotomy technique with quality of life of patients treated with surgical excision plus primary closure technique by means of quality of life questionnaire. The data of patients who had been treated for pilonidal sinus in our clinic from September 2010 to June 2012 were analyzed retrospectively. Forty patients were treated with sinotomy technique and 40 patients were treated with surgical excision plus primary closure technique. Time to return to work and to time to complete wound healing were evaluated. All patients were asked to fill the questionnaire after complete healing occurred. Postoperative complications were bleeding in 2.5%, infection in 3.75% and fever in 2.5% patients. There were no significant differences between the two groups in terms of complete healing (p=0.1) and sport times (p=0.1). There were significant differences between the groups in terms of length of hospital stay (p ≤ 0.001), time off work (p ≤ 0.001),times to sitting on toilet and walking without pain (p=0.002 and p ≤ 0.001,respectively). The mean postoperative VAS scores were 5.2 ± 3.2 and 2.8 ± 2.2, respectively (p=0.02). The technique of sinotomy with good wound and surrounding skin care seems to be an ideal approach with high chance of cure. The patients returned to their routine in a short period of time.
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Affiliation(s)
- Seyfi Emir
- General Surgery Department, Namık Kemal University, Faculty of Medicine, Tekirdağ, Turkey..
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Ommer A, Berg E, Breitkopf C, Bussen D, Doll D, Fürst A, Herold A, Hetzer F, Jacobi T, Krammer H, Lenhard B, Osterholzer G, Petersen S, Ruppert R, Schwandner O, Sailer M, Schiedeck T, Schmidt-Lauber M, Stoll M, Strittmatter B, Iesalnieks I. S3-Leitlinie: Sinus pilonidalis. coloproctology 2014. [DOI: 10.1007/s00053-014-0467-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Brusciano L, Limongelli P, del Genio G, Tolone S, Amoroso V, Docimo G, Docimo L. D-Shape Asymmetric Excision of Sacrococcygeal Pilonidal Sinus With Primary Closure, Suction Drain, and Subcuticular Skin Closure. Surg Innov 2014; 22:143-8. [DOI: 10.1177/1553350614535856] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Few studies have reported long-term recurrence rates after asymmetric excision with primary closure in the treatment of sacrococcygeal pilonidal disease. Methods. A retrospective analysis of a prospectively maintained database of 550 surgical excisions performed for sacrococcygeal pilonidal disease between 1988 and 2005 was performed. Results. A total of 550 patients with a diagnosis of pilonidal sinus underwent surgical excision over a period of 17 years. Thirty-eight out of the 550 patients (3.5%) were lost at follow-up. At a mean follow up of 11.2 ± 5.3 years, median 11 years (range = 3-22), the recurrence rate was 8.9%. Actuarial 1-, 5-, 10-, and 20-year disease-free survival rates were 98%, 94%, 92%, and 83%, respectively, with a median overall disease-free survival of 10 years (95% confidence interval [CI] = 3-15). When patients were stratified according to several variables known to influence recurrence, an age of less or ≥22 years (odds ratio [OR] = 1.5, 95% CI = 0.3-7.5, P = .001), a family history of sinus (OR = 5.9, 95% CI = 2.7-12, P = .0001), and intraoperative methylene blue use (OR = 6.3, 95% CI = 1.2-31, P = .024) were indicated as independent predictors of disease-free survival rates. Conclusions. D-shape asymmetric excision and scar lateralization, with primary multilayer subcuticular closure, suction drain insertion, and skin closure in patients with sacrococcygeal pilonidal disease is a safe and adequate surgical treatment offering an effective healing rate as well as low recurrence. Several features are likely to predict a better or a worse long-term recurrence rate in patients undergoing surgery for sinus pilonidalis.
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Enriquez-Navascues JM, Emparanza JI, Alkorta M, Placer C. Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus. Tech Coloproctol 2014; 18:863-72. [DOI: 10.1007/s10151-014-1149-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/12/2014] [Indexed: 12/18/2022]
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Steele SR, Perry WB, Mills S, Buie WD; Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of pilonidal disease. Dis Colon Rectum 2013; 56:1021-7. [PMID: 23929010 DOI: 10.1097/DCR.0b013e31829d2616] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Dass TA, Zaz M, Rather A, Bari S. Elliptical excision with midline primary closure versus rhomboid excision with limberg flap reconstruction in sacrococcygeal pilonidal disease: a prospective, randomized study. Indian J Surg 2012; 74:305-8. [PMID: 23904719 PMCID: PMC3444612 DOI: 10.1007/s12262-011-0400-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 12/21/2011] [Indexed: 02/07/2023] Open
Abstract
To compare elliptical excision with primary midline closure and rhomboid excision with limberg flap reconstruction techniques for the sacrococcygeal pilonidal sinus. This prospective randomized study of 80 patients of sacrococcygeal pilonidal sinus was performed in SKIMS medical college from 2004 to 2007. After assigning patients randomly to either of the surgical groups, group A patients (40/80) were operated by using rhomboid excision with limberg flap reconstruction whereas group B patients (40/80) were operated by using elliptical excision with primary midline closure. Data was compiled in terms of operative period required, immediate post operative complications, post operative pain (VAS scores), work-off period, hospital stay and recurrences over a follow up of 3 years for the two study groups. Data thereby collected was analyzed by using Microsoft excel. The parameters in which the two techniques were found to differ significantly were work-off period, immediate post operative complications profiles and recurrence rates. Rhomboid excision with limberg flap reconstruction technique surely outscores elliptical excision with primary midline closure in certain important parameters. While facing a patient with uncomplicated sacrococcygeal pilonidal sinus, instead of, which procedure for the patient? Surgeons should pose the question why not rhomboid excision with limberg flaps reconstruction?
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Affiliation(s)
- Tufale A. Dass
- Registrar, General Surgery Department Sheri-Kashmir Institute of Medical Sciences (SKIMS) Medical College, Srinagar, Jammu and Kashmir, India 190001
| | - Muneer Zaz
- Registrar, General Surgery Department Sheri-Kashmir Institute of Medical Sciences (SKIMS) Medical College, Srinagar, Jammu and Kashmir, India 190001
| | - Ajaz Rather
- Consultant, General Surgery Department Sheri-Kashmir Institute of Medical Sciences (SKIMS) Medical College, Srinagar, Jammu and Kashmir, India
| | - Shamsul Bari
- Consultant, General Surgery Department Sheri-Kashmir Institute of Medical Sciences (SKIMS) Medical College, Srinagar, Jammu and Kashmir, India
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Abstract
INTRODUCTION The ideal treatment for pilonidal sinus disease has yet to be defined. There are many approaches described in the literature. METHODS Thirty-five consecutive patients who underwent wide excision of pilonidal sinus disease had the wound repaired using a parasacral perforator flap. Outcomes were assessed by case notes analysis and follow-up telephone and postal questionnaires. RESULTS There were ten minor complications including six minor wound edge dehiscences. There were two ischaemic complications, with one flap loss. There were 3 recurrences of pilonidal disease at a mean follow-up of 33 months, giving a 5-year recurrence free rate of 86%. Of the patients questioned, all would recommend the procedure to someone else despite 69% being dissatisfied with the cosmetic outcome. CONCLUSIONS This series indicates that the parasacral perforator flap technique is able to repair pilonidal sinus excision wounds successfully with minimal morbidity and a low recurrence rate at a mean of follow-up of 33 months. The study suggests that it may be a technique best reserved for recurrent cases of pilonidal sinus disease. Patients feel the procedure is successful despite reservations regarding the cosmetic outcome.
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Affiliation(s)
- M R Venus
- University Hospitals Birmingham NHS Foundation Trust, UK.
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Horwood J, Hanratty D, Chandran P, Billings P. Primary closure or rhomboid excision and Limberg flap for the management of primary sacrococcygeal pilonidal disease? A meta-analysis of randomized controlled trials. Colorectal Dis 2012; 14:143-51. [PMID: 20969718 DOI: 10.1111/j.1463-1318.2010.02473.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Sacrococcygeal pilonidal disease is a common condition afflicting the young male working and student population, resulting in considerable pain, embarrassment and loss of work days. Controversy surrounds the most appropriate surgical approach to achieve low recurrence rates whilst minimizing morbidity and permitting an early return to work. This study aims to review the published literature comparing excision followed by either primary suture or rhomboid flap repair. METHODS PubMed, EMBASE, MEDLINE and The Cochrane Library were systematically reviewed, by two independent investigators, for relevant randomized controlled trials. Keywords and MeSH terms included 'pilonidal disease', 'primary suture/repair', 'rhomboid flap' and 'limberg/modified Limberg flap'. 'Related study' function and manuscript bibliographies were searched for further relevant studies. Study quality was assessed using the Jadad score. Meta-analysis was performed on pooled data, utilizing a random effects model when heterogeneity was high and a fixed effects model when heterogeneity was low. The primary end-point assessed was disease recurrence. Secondary end-points included wound dehiscence, pain scores, hospital stay and return to work. RESULTS Six studies were eventually included for pooled analysis following exclusion of randomized controlled trials with poor methodology. Two studies compared 'off-midline' (Karydakis) primary suture with the Limberg flap repair. Six hundred and forty-one patients were included (331 flap repairs). Rhomboid flap excision demonstrated a trend towards less disease recurrence (P = 0.07), lower wound infection (P = 0.001) and dehiscence (P = 0.01). However, no significant difference was found for pain scores, hospital stay or return to work. CONCLUSION The current published literature supports the use of the rhomboid flap excision and the Limberg flap-repair procedures over primary midline suture techniques for the elective management of primary pilonidal disease. Further high-quality studies are necessary to compare flap with off-midline repairs.
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Affiliation(s)
- J Horwood
- Department of General Surgery, Wrexham Maelor Hospital, Wrexham, UK.
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Ates M, Dirican A, Sarac M, Aslan A, Colak C. Short and long-term results of the Karydakis flap versus the Limberg flap for treating pilonidal sinus disease: a prospective randomized study. Am J Surg 2011; 202:568-73. [DOI: 10.1016/j.amjsurg.2010.10.021] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 10/31/2010] [Accepted: 10/31/2010] [Indexed: 11/19/2022]
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Abstract
BACKGROUND Pilonidal disease is a common and usually minor disease. Although wide excisional surgery has been common practice, there are more simple alternatives. This review focused on the aetiology and management of pilonidal disease. METHODS A comprehensive review of the literature on pilonidal disease was undertaken. MEDLINE searches for all articles listing pilonidal disease (1980-2010) were performed to determine the aetiology and results of surgical and non-surgical treatments. Single papers describing new techniques or minor modifications of established techniques were excluded. Further articles were traced through reference lists. RESULTS Patients with minimal symptoms and those having drainage of a single acute abscess can be treated expectantly. Non-surgical treatments may be of value but their long-term results are unknown. There is no rational basis or need for wide excision of the abscess and sinus. Simple removal of midline skin pits, the primary cause of pilonidal disease, with lateral drainage of the abscess and sinus is effective in most instances. Hirsute patients with extensive primary disease and deep natal clefts, or with recurrent disease and unhealed midline wounds, may also require flattening of the natal cleft with off-midline skin closure. These more conservative procedures are usually done as a day case, require minimal care in the community and are associated with a rapid return to work. They also avoid the occasional debilitating complications of surgical treatment. CONCLUSION Simple day-case surgery to eradicate midline skin pits without wide excision of the abscesses and sinus is rational, safe and effective for patients with pilonidal sinus disease.
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Affiliation(s)
- M R Thompson
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth, UK.
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Muzi MG, Milito G, Cadeddu F, Nigro C, Andreoli F, Amabile D, Farinon AM. Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease. Am J Surg 2010; 200:9-14. [PMID: 20637332 DOI: 10.1016/j.amjsurg.2009.05.036] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 05/26/2009] [Accepted: 05/26/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure. METHODS A total of 260 patients with sacrococcygeal pilonidal disease were assigned randomly to undergo Limberg flap procedure or tension-free primary closure. RESULTS Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure (P = .0793). Surgical time for primary closure was shorter. Wound infection was more frequent in the primary closure group (P = .0254), which experienced less postoperative pain (P < .0001). No significant difference was found in time off from work (P = .672) and wound dehiscence. Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group (P = .153). CONCLUSIONS Our results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.
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Affiliation(s)
- Marco Gallinella Muzi
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome, Italy
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Abstract
Objectives Many conservative methods have been applied in the treatment of pilonidal sinus disease (PSD). The most commonly used conservative treatment is 80% phenol solution. Our observations demonstrated that 80% phenol solution caused much destruction in the sacrococcygeal region. Design In this study low concentrations of phenol were used with the aim of reducing the unwanted side-effects of high-concentration phenol without reducing the therapeutic effects. Participants We treated 112 patients (18 women, 94 men) with PSD using phenol solution. Patients were divided into two groups: Group A was treated with a 40% solution of phenol solution, and Group B was treated with an 80% solution of phenol solution. Setting All patients were treated on an outpatient basis. One mL of low (40%) or high (80%) concentration phenol solution was injected into the main sinus orifice. During the check it was observed and noted whether there was skin necrosis, fatty tissue necrosis or abscesses. Main outcome measures The mean age was 27.4 years (6–44). The median length of symptoms was seven months (0.5–132). In the 2.8 years (1–6) of mean follow-up period, the disease recurred in 13 (11.6%) patients. Results This treatment procedure was well-tolerated by all the patients except for those who had unwanted results. No patients in group A had skin necrosis, and only one had abscesses. In group B two patients had abscesses, and three had skin necrosis. Fatty tissue necrosis was seen in one patient in Group A and in five patients in Group B. Recurrence rates were four (7.4%) cases in Group A and nine (15.5%) cases in Group B. Conclusions It is possible to treat patients in a shorter time with a considerably smaller loss of working time, since the destruction of peripilonidal adipose tissue and skin is less. Therefore, the use of low-concentration phenol solution is an option to be considered in the treatment of PSD.
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Affiliation(s)
- Ibrahim Sakçak
- Department of General Surgery, Numune Teaching and Research Hospital , 06100, Ankara , Turkey
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Abstract
BACKGROUND Various surgical techniques are available in the management of pilonidal sinus, but controversy concerning the optimal surgical approach persists. The present study analyzes the outcome of unroofing and curettage as the primary intervention for acute and chronic pilonidal disease. METHODS A total of 297 consecutive patients presenting with chronic disease, acute abscess, or recurrent disease were treated with unroofing and curettage. The wound was left open to heal by secondary intention. Hospitalization, time required to resume daily activities and return to work, healing time, and recurrence rates were recorded. RESULTS All patients were discharged within the first 24 h after operation. The median period before returning to work was 3.2 +/- 1.2 days, and the mean time for wound healing was 5.4 +/- 1.1 weeks. Six patients were readmitted with recurrence of the disease within the first six postoperative months. All recurrences were in patients who did not follow the wound care advice and who did not come to regular weekly appointments. Patients with recurrence underwent repeat surgery by the same technique with good results. CONCLUSIONS Unroofing and curettage for pilonidal sinus disease is an easy and effective technique. The vast majority of the patients, including those with abscess as well as those with chronic disease, will heal with this simple procedure, after which even recurrences can be managed successfully with the same procedure. Relying on these results, we advocate unroofing and curettage as the procedure of choice in the management of pilonidal disease.
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Affiliation(s)
- Ilknur Kepenekci
- Department of General Surgery, Ankara University School of Medicine, Ankara, Turkey.
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Abstract
The ideal elective surgical procedure for pilonidal disease is debated. Simple excision and closure is commonly performed but is associated with a high incidence of wound complications and recurrence. We developed a simple modification of primary closure, which involves the elevation, mobilization, and closure of the gluteal fascia. The purpose of this study is to compare outcomes of this gluteal fascial advancement technique with standard primary closure for the treatment of pilonidal disease. We retrospectively reviewed our surgical database to include all patients who underwent surgery for pilonidal disease from 2004 to 2007. Patients who underwent primary closure (n = 66) were compared with patients who underwent gluteal fascial advancement (n = 17). Demographic data as well as recurrence and the incidence of wound complications were examined. There was a significant difference in incidence of wound breakdown (0 vs 21%), recurrence (0 vs 20%), and early wound drainage (6 vs 32%). Overall there was an 80 per cent reduction in wound complications after gluteal fascial advancement compared with primary closure. Gluteal fascial advancement is a simple modification of standard primary closure and is associated with fewer wound complications and recurrences.
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Affiliation(s)
- Joshua D. Washer
- Greenville Hospital System, University Medical Center, Academic Department of Surgery, Greenville, South Carolina
| | - Dane E. Smith
- Greenville Hospital System, University Medical Center, Academic Department of Surgery, Greenville, South Carolina
| | - Mary E. Carman
- Greenville Hospital System, University Medical Center, Academic Department of Surgery, Greenville, South Carolina
| | - Dawn W. Blackhurst
- Greenville Hospital System, University Medical Center, Academic Department of Surgery, Greenville, South Carolina
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Abstract
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.
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Affiliation(s)
- Ahmed AL‐Khamis
- University of Aberdeenc/o Section of Population HealthPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Iain McCallum
- Queen Elizabeth HospitalGeneral SurgerySheriff HillGatesheadUKNE9 6SX
| | - Peter M King
- Aberdeen Royal InfirmaryWard 31AberdeenUKAB25 2ZN
| | - Julie Bruce
- University of WarwickWarwick Clinical Trials UnitGibbet Hill RdCoventryUKCV4 7AL
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Strittmatter B, Breitkopf C, Furtwängler A, Lenhard B, Meier zu Eissen J, Mlitz H, Osterholzer G, Pommer G, Raulf F, Wienert V. Leitlinie Pilonidalsinus. Coloproctol 2009. [DOI: 10.1007/s00053-009-0043-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
PURPOSE We describe our experience with tumescent local anesthesia for excision and flap procedures in the treatment of pilonidal disease. METHODS Forty consecutive patients with symptomatic pilonidal disease were treated. Tumescent solution was prepared by mixing one volume of a lidocaine (20 mg/ml) and adrenaline (0.0125 mg/ml) combination with 9 volumes of lactated Ringer's solution. The final solution was infiltrated gradually and liberally, first subcutaneously and then into the skin. The end point was swollen and firm skin. After excision, the area was filled with an advancement flap or a rotational flap. RESULTS The study group consisted of 37 men (92.5%) and 3 women (7.5%); mean age, 27 (range, 18-61) years. The amount of injected solution ranged from 60 mL to 140 mL (mean, 100 mL; dose interval, 2-4 mg/kg). No additional anesthesia or sedation was needed, and no complications were observed during the procedure. Half of the patients were discharged on the day of the operation, half on the next day. Follow-up ranged from 13 to 37 months. Patients returned to daily activities after a mean of 10.5 (range, 2-30) days. Primary healing occurred uneventfully in 28 patients (70%); wound healing complications occurred in 12 (30%). No flap necrosis was observed. Thirty-seven (92.5%) patients reported satisfaction with the procedure. Recurrence was observed in 3 patients (7.5%). CONCLUSIONS Excision and flap procedures for sacrococcygeal pilonidal disease can be performed under tumescent local infiltration anesthesia with acceptable results, without requiring regional or general anesthesia.
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Yamout SZ, Caty MG, Lee YH, Lau ST, Escobar MA, Glick PL. Early experience with the use of rhomboid excision and Limberg flap in 16 adolescents with pilonidal disease. J Pediatr Surg 2009; 44:1586-90. [PMID: 19635310 DOI: 10.1016/j.jpedsurg.2008.11.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 11/04/2008] [Accepted: 11/05/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND Rhomboid excision with Limberg flap (RELF) repair has been shown to be effective in the management of pilonidal disease (PD) in adults. Wide excision allows complete removal of diseased tissue, and the rotational flap allows tensionless coverage as well as helps flatten the natal crease, which is believed to contribute to the recurrence of PD. METHODS This study is a retrospective review of all adolescents who underwent excision of pilonidal disease using RELF at a single institution for a period of 18 months. RESULTS Sixteen adolescents with PD were treated with RELF during this period. All procedures were completed with no intraoperative complications. Mean operative time and hospital stay were 92 +/- 30 minutes and 1.8 +/- 0.29 days, respectively. Mean follow-up was 11 +/- 6.0 months. One patient had recurrence of his disease, and one needed prolonged wound care after wound breakdown. Six others had minor complications including 4 patients (25%) who had superficial wound separation that resolved promptly with dressing change. One patient had a superficial wound infection. One patient had residual pain. CONCLUSION Rhomboid excision with Limberg flap is effective in the management of PD in adolescents. The 6% recurrence rate is similar to that reported in the adult literature. Despite the limitations of this study, the low morbidity, hospital stay, and recurrence rate noted with our initial experience are very encouraging.
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Affiliation(s)
- Sani Z Yamout
- Division of Pediatric Surgery, Department of Surgery, University at Buffalo, Women and Children's Hospital of Buffalo, Buffalo, NY 14222, USA.
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Karakayali F, Karagulle E, Karabulut Z, Oksuz E, Moray G, Haberal M. Unroofing and marsupialization vs. rhomboid excision and Limberg flap in pilonidal disease: a prospective, randomized, clinical trial. Dis Colon Rectum 2009; 52:496-502. [PMID: 19333052 DOI: 10.1007/DCR.0b013e31819a3ec0] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of the study was to compare clinical outcomes and quality of life in patients undergoing surgery for pilonidal disease with unroofing and marsupialization (UM) or rhomboid excision and Limberg flap (RELP) procedures. METHODS One hundred forty consecutive patients with pilonidal sinus were randomly assigned to receive either UM or RELP procedures. A specifically designed questionnaire was administered at three months to assess time from the operation until the patient was able to walk, return to daily activities, or sit without pain, time to return to work or school, and time to healing. Postoperative pain was assessed with a visual analog scale and the McGill Pain Questionnaire. Patients' quality of life was evaluated with the Cardiff Wound Impact Schedule (CWIS). Questionnaires were administered by a clinician blinded to treatment. RESULTS Compared with RELP, patients receiving UM had significantly shorter duration of operation and hospital stay, shorter time periods to walk, return to daily activities, or sit without pain and to return to work or school, and fewer complications. Time to final healing was significantly shorter and quality of life scores on the CWIS were higher in patients receiving RELP than in those receiving UM. Patients with UM had lower levels of pain one week after surgery. CONCLUSION The unroofing and marsupialization procedure provides more clinical benefits in the treatment of pilonidal disease than rhomboid excision and Limberg flap and should be considered the procedure of choice. However, it may be associated with more inconvenience in wound care and longer healing time than rhomboid excision and Lindberg flap.
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Mahdy T. Surgical treatment of the pilonidal disease: primary closure or flap reconstruction after excision. Dis Colon Rectum 2008; 51:1816-22. [PMID: 18937009 DOI: 10.1007/s10350-008-9436-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 06/30/2008] [Indexed: 02/08/2023]
Abstract
PURPOSE Controversy still exists regarding the best surgical technique for the treatment of pilonidal disease in terms of minimizing disease recurrence and patient discomfort. The present study analyzes the results of excision with primary closure and excision with flap reconstruction in the surgical treatment of sacrococcygeal pilonidal disease. METHODS From January 2003 to January 2006, 60 consecutive patients with primary pilonidal sinus disease received surgical treatment in the form of either excision and primary closure (group I, n = 20 patients) or excision and flap reconstruction (group II, n = 40 patients; modified Limberg flap n = 20, classic Limberg flap n = 10 and adipo-fasciocutaneous flap n = 10). Times for complete healing and return to work were recorded. To evaluate patient comfort, all patients were asked to complete a questionnaire including visual analog scale, time to sitting on toilet without pain, and time to walking without pain 3 months after surgery. RESULTS Mean follow-up was 21 months. A significant difference was observed between the two groups in terms of length of hospital stay (P < 0.003), time to complete healing (P < 0.001), time off work (P < 0.001), wound infection (P < 0.01), recurrence rates (P < 0.01), times to sitting on toilet without pain (P < 0.002), and walking without pain (P < 0.001). The mean (standard deviation) postoperative visual analog scale scores were 6.1 (1.2) in the primary closure group vs. 7.4 (1.3) in the flaps groups (P < 0.001). In the modified Limberg flap, no wound infection, wound breakdown, or recurrence of the disease occurred. CONCLUSIONS Flap reconstructions were superior to primary closure after excision of pilonidal sinus and that modified Limberg flap was superior with regard to wound infection and recurrence.
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Affiliation(s)
- T Mahdy
- Department of Surgery, Mansoura University Hospital, Mansoura, Egypt.
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Affiliation(s)
- A. Stewart
- Community Nursing Southcare, Sutherland Hospital, Sydney, Australia
| | - J. Donoghue
- Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australia
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Marzouk DM, Abou-Zeid AA, Antoniou A, Haji A, Benziger H. Sinus excision, release of coccycutaneous attachments and dermal-subcuticular closure (XRD procedure): a novel technique in flattening the natal cleft in pilonidal sinus treatment. Ann R Coll Surg Engl 2008; 90:371-6. [PMID: 18634729 DOI: 10.1308/003588408x285955] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The objective of this study was to analyse, prospectively, the outcome of a new technique - excision of pilonidal sinus and flattening the natal cleft by division of the coccycutaneous attachments at the lower end of the incision. PATIENTS AND METHODS Sixty-six consecutive patients with chronic pilonidal sinuses were treated between 1995 and 2001. The procedure consisted of an elliptical, wide, local excision, release of the coccycutaneous attachments and primary closure using dermal-subcuticular closure (XRD). Suction drains were used until drainage was minimal. The height of skin level at the lower angle of the wound from the coccyx was measured intra-operatively before and after division of the coccycutaneous attachments. Postoperatively, patients were assessed for hospital stay, return to normal activity, complications and recurrence. RESULTS Sixty-four patients (97%) were males, median age 27 years. The height of skin level rose from a mean of 1.8 cm (95% CI, 1.78-1.85) to a mean of 3.8 cm (95% CI, 3.77-3.88; P < 0.001). Morbidity affected 12 patients (18%), epidermal separation of the lower wound angles (6 patients), seromas (5 patients) and 1 wound dehiscence at 2 weeks. All other wounds healed primarily without dehiscence. There were no recurrences after a median follow-up of 22.5 months (range, 12-38 months). CONCLUSIONS Release of the coccycutaneous attachments is an easy technique to learn, which seems to be an effective way of flattening the natal cleft and may result in lower recurrence rate. This technique should be tried in uncomplicated pilonidal sinus disease before more complex procedures are attempted.
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Affiliation(s)
- Deya M Marzouk
- Department of Colorectal Surgery, Queen Elizabeth the Queen Mother Hospital, Margate, Kent, UK.
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Abstract
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.
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Affiliation(s)
- P J Lee
- Department of Surgery, Colorectal Unit, Christchurch Hospital, Christchurch, New Zealand
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Abstract
BACKGROUND Pilonidal sinus is a common disease that mostly affects young people. Despite numerous treatment modalities, the best technique has not yet been determined and there are many recurrences, causing economic losses and serious discomfort for the patients. METHODS The authors used V-Y rotation flaps for coverage of the defects after excision and debridement of chronic pilonidal sinuses in eight patients. The results were evaluated and compared with previously reported studies regarding the grade of disease at presentation, duration of surgery, blood loss, hospitalization period and active mobilization periods, complications, and loss of sensitivity. RESULTS No major complications occurred; hospitalization and immobilization periods were acceptably convenient. Recurrence was not seen, and sensitivity of the gluteal region did not diminish. The outcome was also satisfactory regarding aesthetics, and all the patients were satisfied with the result. CONCLUSION The authors believe that the V-Y rotation advancement flap is a good alternative method for the treatment of pilonidal sinus.
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Affiliation(s)
- Nezih Sungur
- First Plastic and Reconstructive Surgery Department, Ankara Training and Research Hospital, Ulucanlar, Turkey
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Affiliation(s)
- R Flamein
- Service de chirurgie générale et digestive, Hôtel Dieu, boulevard Leon-Malfreyt, BP 69, 63058 Clermont-Ferrand cedex 01, France
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