pilonidal sinus
TRANSCRIPT
Pilonidal sinus
Dr. Zeeshan
Definition: Infection of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttocks.
NOT a true cyst
History 1833- hair containing cyst located just below the coccyx Mayo
1880- Hodge coined the term “pilonidal” Nest of hair
In 19th and 20th century – considered to be congenital
In WW II
Patey and Scarf – hypothesised origin of pilonidal sinus acquired by penetration of hair into subcutaneous tissue.
What causes pilonidal sinus??? Midline holes – Hair follicles that have enlarged Pulling forces between sacrum and skin Force concentrate on 1mm2 area where the narrow
gluteal crease comes in close contact with the sharp angle of sacrum
Weakest point of skin gives way first– Skin at the bottom of the follicle.
Primary cause – “Pit” Secondary casue – “ Hair follicles”
Cause of pilonidal sinus (1) Invader hair
(2) Force causing hair penetration
(3) Vulnerability of skin
Anatomy Intergluteal cleft: A groove between the buttocks that
extends from just below the sacrum to the perineum.
Anchoring of the deep layers of skin overlying the coccyx to the anococcygeal raphe
Epidemiology Incidence : 26 per 100,000
Mean age: 19 years for women and 21 years for men
Sex: M/F ratio – 2:1 to 4:1
Equal incidence of acute:chronic
Risk factors Overweight/ obesity
Local trauma or irritation
Sedentary lifestyle/prolonged sitting
Deep natal cleft
Family history
Theory Acquired vs Congenital
Tendency to recur following complete excision.
Tendency to occur in places other than natal cleft.
Pathogenesis Hair and inflammation – inciting factors
On sitting/bending natal cleft stretches- breakage of follicles- opening of a pore/pit- collection of debris - pilonidal sinus - abscess
Proof?? Pilonidal tract extends cephalad. Cavity contains hair, debris or granulation tissue.
Clinical manifestations Patient presentation:- Acute onset mild to severe pain (sitting/bending)
- Intermittent mucoid/purulent/bloody discharge
- Recurrent / persisting pain
- Fever / malaise
Physical examination One/more pits in the natal cleft +/- painless sinus opening
cephalad and lateral to cleft
Tender mass or sinus draining mucoid/bloody or purulent fluid
Diagnosis Clinical - Finding a pore/sinus in the natal cleft- No imaging required
Differential diagnosis Perianal abscess/ fistula
Hidradenitis suppurativa
Perianal complications of Crohn’s disease
Skin abscess/ furuncle/ carbuncle
Folliculitis
Surgical treatment Drainage with/ without excision
Marsupialisation
Excision with primary closure
Excision with grafting
Sinus extraction
Sclerosing injections
ACUTE ABSCESS
-- Incision is performed lateral to midline midline over area of maximum
fluctuance
- Packing of the wound
- Marsupialisation
Problems Recurrence rates are from 20 – 55 %
During a 3 year period, 73 patients treated with I & D for first episode of pilonidal abscess
Healed : 42 patients (58%; 95% CI) within 10 weeks Recurrence : 9 patients (21%;95% CI) Follow up period : median of 60 months
Constant cure rate : 76% (CI 95%) after 18 months Prognosis after simple incision and drainage for a first-episode acute pilonidal abscess. Jensen SL, Harling H Br J Surg. 1988;75(1):60.
Chronic pilonidal sinus
Surgical approaches:- Excision- Wound closure
(1)Primary closure in midline/ off midline > Z plasty > V-Y advancement flap > Rhomboid flap (limberg)
(2) Reconstruction using flaps
Karydakis surgery Karydakis believed that hair insertion is the cause for
pilonidal sinus Low recurrence rates due to:- Wound placed away from midline- Resulting new natal cleft was shallower
Problems- Sutured taken over the presacral fascia causing pain- Patients requiring GA- Prolonged hospital stay
Modified Karydakis/Basscom II/Cleft lip Use of shallow cleft Under LA Causes less pain as presacral fascia not included
Z- plasty
Z-plasty for pilonidal sinus
V-Y Plasty
Limberg flap
Primary versus delayed closure Time to wound healing: - Total of 13 trials done (n= 1421) included data for time
for wound healing (not aggregrated due to high heterogeneity)
- 9 trials reported a faster time to wound healing following primary closure.
- Largest trial (n=380) found that patients undergoing primary repair had a significant faster wound healing rate compared to open wounds(14.5 versus 60 days)
- Excision with or without primary closure for pilonidal sinus disease.- Al-Salamah SM, Hussain MI, Mirza SM; J Pak Med Assoc. 2007 Aug;57(8):388-91.
Time to return to work: - A total of 11 trials done (n=1729)- 9 studies reported a faster return to work following
primary closure- The largest study (n=144) found that patients had a faster
return to work following primary repair compared to delayed closure.(11.9 versus 17.5 days)
Comparison of outcomes in Z-plasty and delayed healing by secondary intention of the wound after excision of the sacral pilonidal sinus: results of a randomized,
clinical trial.Fazeli MS, Adel MG, Lebaschi AH
Dis Colon Rectum. 2006 Dec;49(12):1831-6.
Recurrence rates:- Based on 16 trials including 1666 patients , the overall
recurrence rate was 6.9%.- Primary wound closure was associated with a HIGHER
recurrence rate compared to delayed wound closure. (8.7 versus 5.3 percent, relative risk RR [1.5] CI1.08-2.17
Rate of surgical site infection:- Based on 10 trials including 1231 patients
NO SIGNIFICANT DIFFERENCE between primary and delayed wound closure and risk of SSI
(8 versus 10% , RR 0.76, CI 0.54-1.08)
Off midline versus midline primary sutured closures Sutured off midline wounds – less time to heal (n=100 ,
mean difference 5.4 days, 95% CI 2.3-8.5)
Risk of SSI was significantly lower for off midline wounds (n=541, RR 0.27, CI 0.13-0.54)
Risk of recurrence LOWER for off midline wounds (n=574, RR=0.22, CI 0.11-0.43)
The overall complication rate was LOWER for off midline wounds (n=461, RR=0.23, CI0.08-0.66)
Types of off-midline closure While an off midline approach is superior , optimal off
midline approach has not been identified.
Two trials were perfomed to determine recurrence and complications rates between lateral advancement flaps ( modified Karydakis) and modified Limberg’s flap
N = 120 Karydakis lateral advancment flap
Limberg’s flap
Wound disruption 0 patients 9 patients
Rate of complications
23 % 40 %
Wound infection 3% 5%
Subcutaneous fluid collection
5% 0%
Hypoaesthesia 10% 23%
Recurrence rates 3% 2%
Comparison of short-term results between the modified Karydakis flap and the modified Limberg flap in the management of pilonidal sinus disease: a randomized controlled study.Bessa SSDis Colon Rectum. 2013;56(4):491.
N=295 Karydakis flap Limberg
Seroma formation 19.8% 7.4%
Wound dehiscence 15.4% 3.7%
Flap maceration 11% 3.7%
Which flap method should be preferred for the treatment of pilonidal sinus? A prospective randomized study.Arslan K, Said Kokcam S, Koksal H, Turan E, Atay A, Dogru OTech Coloproctol. 2013 Feb;
In summary Patients with acute pilonidal sinus – I & D
For patients with chronic pilonidal sinus – An excision of the sinus and all tracts
A primary closure is associated with faster wound healing – however a delayed closure is associated with less recurrence
For patients undergoing primary wound closure – off midline closure recommended
Role of Abx Generally limited to clinical setting of cellulitis Indications:- Immunosuppresion- High risk for Endocarditis- MRSA- Concurrent systemic illness