Management of recurrent pilonidal disease
Section snippets
Etiology
It has long been debated whether pilonidal disease has a congenital versus an acquired etiology. The most recent literature seems to support the acquired theory of pathogenesis. The current impression of the acquired nature of pilonidal disease is supported by the absence of hair follicles in the cyst or sinuses, although nests of hair shafts are frequently found. Most studies have shown a preponderance of male patients. It is rare to occur before puberty or after age 40.
Except for the
Signs and symptoms
Although most patients are hirsute, there are still a number of patients that do not have an excessively hairy gluteal region. Most patients tend to be moderately obese in their twenties or thirties. The acute painful swelling, +/− drainage of bloody, purulent material just lateral to the natal cleft, is consistent with pilonidal disease. Since the skin of the gluteal region is relatively thick, an abscess can grow relatively large before “pointing” and usually does not spontaneously rupture.
Treatment of acute pilonidal disease
Incision and drainage alone, incision and drainage with subsequent excision of midline pits, lay-open technique with unroofing of the various sinuses, and en-bloc wide excision of the pilonidal disease are a few of the more common methods of treating acute pilonidal disease. Unfortunately, en-bloc wide excision seems to be popular with most surgeons and yet may actually contribute to the development of recurrent disease.
Recurrent pilonidal disease
Patients with recurrent pilonidal disease will present with swelling or cellulitis in the region of the natal cleft. Pain, although present, is usually markedly less severe than during the acute process. They have had one or more of the previously mentioned treatments during the initial/acute presentation. With recurrences, the patient demonstrates a chronic abscess, multiple midline pits, and one or more internal opening. These openings are usually larger in size compared with the midline pits
Treatment of recurrent pilonidal disease
Recurrent disease can have both an acute and a chronic phase. The goals of treating acute, recurrent pilonidal disease are similar to those of treating its initial active counterpart—alleviate symptoms of pain and drainage while providing a well-healed wound. Achieving these goals should come at a minimal “cost” to the patient—not only in terms of money but in time lost from work and hobbies. Since the goals are essentially the same, the treatments employed can also be the same.
Many colorectal
Recurrent, chronic pilonidal disease
The now widely accepted view that a pilonidal sinus is the penetration of natal cleft skin by hairs that would subsequently promote a foreign body granulomatous reaction, and set up a secondary infection with subsequent abscess formation, was championed by Patey and Scarff in their 1946 Lancet article.6 Since that time, numerous other articles have clearly supported the concept of the acquired origin of pilonidal sinus disease.
Despite this overwhelming acceptance of an acquired theory, surgical
Nonoperative management of recurrent pilonidal disease
Nonoperative management of chronic, recurrent pilonidal disease is reserved for patients with minimal symptoms, minimal distortion of the gluteal region, and scant discharge. To avoid surgery, however, strict hygiene and twice daily washing/irrigating of the wound is necessary. Patients are also required to undergo weekly shaving, preferably over electrolysis or depilatory agents. In select patients daily, application of 1% silver nitrate soaked gauze may be beneficial, for antibiosis,
Operative management of recurrence pilonidal disease
Because of the evidence that pilonidal disease “burns itself out” around age 40, many feel “less is best” when it comes to surgical interventions for pilonidal disease. Many patients, however, are truly debilitated by the pain and drainage. Because of this, we are often left with no other option but to employ operative treatment. First, Lord,12 then Bascom, 5 proposed excision of midline pits and sinuses coupled with meticulous removal of hair and debris from the sinus tract. Bascom emphasizes
Wide local excision without primary closure or marsupialization
Certain findings, alone or in combination, may make successful treatment of complex, previously treated pilonidal disease unsuccessful. Extreme obesity, with a particularly deep natal cleft, favors recurrences after apparent successful primary treatment. Patients who proudly wear the scars of numerous prior surgeries and whose tracks lead to granulation lined cavities on both sides of the buttocks pose a particular challenge. The futility of simpler procedures fraught with exuberant
Wide local excision with marsupialization
Similar to Bascom, this author condemns wide excision, except for the occasional patient with significant gluteal sepsis involving complex pilonidal disease. The unhealed wound created with aggressive excision down the fascia facilitates and perpetuates the very environment which led to the disease in the first place. The subsequent deep furrow, under tension, with granulation tissue allows penetration of loose body hairs and is a setup for persistent disease. When a patient presents status
Excision and primary closure
When previous procedures have left the patient with debilitating residual disease, a more aggressive approach can be justified. A significant amount of fixed and fibrotic scar tissue, along with extensive granulation tissue, needs to be addressed. The deep natal cleft often encountered in recurrent disease fosters continued abscesses and foils most surgical interventions.
Allen-Mersh reviewed literature from 1971 to 1987.15 It was noted that several operative techniques were used to completely
Excision and wound closure using an asymmetric incision
To obviate the pitfalls of most primary closures, the use of asymmetrical skin incisions have been used. The advantages of keeping the incision away from the natal cleft, flattening the natal cleft, and reducing buttock friction translate into improved healing time without compromising recurrence rates. Disadvantages include a relatively high rate of failed primary healing (6 to 20%). It was the published failure rates of up to 60% and case reports of wounds that never healed that prompted
Excision and skin flap coverage
In an attempt to eliminate all the previously mentioned factors contributing to recurrence, the Z-plasty was introduced by Monro and McDermott in 1965.27 Twenty-nine patients healed within 2 weeks. No one failed primary healing and only one patient had a recurrence. Mansoory and coworkers used a modification of the original technique on 120 patients over a 10 year period28 (see Fig 2).
The timing of surgery was no sooner than 5 to 6 weeks after initial treatment of suppurative disease. No
Excision and rotation advancement flap
Fishbein and Handelsman described a rotational flap used on 50 patients with pilonidal disease.19 Their 1979 report recommended a technique whereby ostia, draining tracts, and cavity, as well as previous surgical scars were removed en-bloc using a full-thickness elliptical or crescentic bloc of tissue, down to postsacral fascia. The resulting flap has the pliability and elasticity to be advanced into the surgical defect (see Fig 3). Close suction drainage is also used. This procedure can be
Chronic/recurrence pilonidal disease complicated by squamous cell carcinoma
Although rare, any discussion of recurrent, chronic pilonidal disease would be incomplete if degeneration into squamous cell carcinoma was not mentioned. Much like in any chronically inflamed wound (for example, a Marjolin’s ulcer in burns when normal reparative measures are compromised), malignant degeneration can follow. This occurs in an estimated 0.08 to 0.1% of pilonidal sinuses.32 The local form of this complication can be recognized by central ulceration with friable, indurated,
Conclusions
As with acute pilonidal disease, there are many operative options from which to choose when dealing with chronic/recurrent pilonidal disease. At present, it is still this author, and many before me, that believe minimal intervention should be used whenever possible. Curing the disease and minimizing recurrences is important but doing so at minimal morbidity and the least loss of time from work is paramount to a satisfied patient and a happier colorectal surgeon.
Acknowledgements
Illustrations for this article were drawn by Melissa Notaro.
References (35)
- et al.
Pathology of postanal pilonidal sinus
Lancet
(1946) - et al.
Pilonidal cyst, an operative approach
Ann J Surg
(1978) Repeat pilonidal operations
Ann J Surg
(1987)New approach to the problems of pilonidal sinus
Lancet
(1973)- et al.
Recurrent pilonidal disease, in Reoperative Colon and Rectal Surgery
Pilonidal DiseaseLong-term results of follicle removed
Dis Colon Rectum
(1983)Jeep Disease
Southern Med J
(1944)- et al.
Total excision vs. non-resectional methods in the treatment of acute and chronic pilonidal disease
Br Surg
(1995) Pilonidal Diseaseorigin from follicles of hairs and results of follicle removal as treatment
Surgery
(1980)- et al.
A conservative treatment of pilonidal sinus
Br J Surg
(1964)
Treatment of pilonidal sinus by phenol injection
Ulster Med J
Phenol treatment of pilonidal sinuses of the natal cleft
Br J Surg
Conservative management of pilonidal sinus
Surg Gynecol Obstet
The dilemma of pilonidal diseasereverse bandaging for cure of the reluctant pilonidal wound
Dis Colon Rectum
Etiology of pilonidal sinus
Dis Colon Rectum
Pilonidal sinusa simple treatment
Br J Surg
Sacrococcygeal pilonidal sinusis Lords procedure safe and useful
Coloproctology
Cited by (16)
Pilonidal sinus disease: Review of current practice and prospects for endoscopic treatment
2020, Annals of Medicine and SurgeryImproving Resource Utilization and Outcomes Using a Minimally Invasive Pilonidal Protocol
2020, Journal of Pediatric SurgeryPit-picking resolves pilonidal disease in adolescents
2019, Journal of Pediatric SurgeryReoperative surgery for pilonidal disease
2015, Seminars in Colon and Rectal SurgeryCitation Excerpt :Unfortunately, despite multiple treatments with a variety of approaches, some patients׳ disease will again recur. Furthermore, approximately 10–30% of patients undergoing their second or third round of treatment will develop recurrent disease.8 While abscesses may occur anywhere in the area of the cleft, the majority of recurrent sinus disease occurs in the midline.21
Recurrent pilonidal sinus disease: Do lasers have the answer?
2011, Medical Laser ApplicationCitation Excerpt :Patients are usually young with a mean age of presentation of 21 years for males and 19 years for females. Risk factors include hirsutism and obesity although not all patients exhibit these features [6] (Table 1). Acute presentation of the disease is varied and ranges from asymptomatic pits to painful pus discharging abscesses.
Evaluation and Management of Pilonidal Disease
2010, Surgical Clinics of North AmericaCitation Excerpt :Lifestyle changes can be implemented if risk factors are identified.4,9 Because the cause of pilonidal sinus disease is widely attributed to hair follicle ingrowth and subsequent foreign body reaction, local hair control, whether by shaving or laser epilation, has been used as a primary treatment and as an adjunctive strategy.5,6,8,10–14 Compared with various surgical techniques, shaving and improved hygiene have been demonstrated to decrease total hospital admission days and surgical procedures and has resulted in faster return to work or school.15