Introduction
Pilonidal sinus disease (PSD) is a common condition,
with an incidence rate of 26/100,000, typically affecting young men
(1,2). PSD manifests in the sacrococcygeal
region as either an acute abscess or chronic inflammation of the
sinus tract (3-5).
Multiple factors have been associated with PSD, including obesity,
poor hygiene, prolonged sitting, hairiness, and deep natal cleft
(5,6). Treatment options range from minimally
invasive procedures, such as laser treatment and phenolization, to
surgical excision combined with midline closure or flap
reconstruction (5-7).
While surgical methods have traditionally been the primary choice,
recent studies have shown promising results for minimally invasive
approaches, providing faster recovery and low post-operative
complication rates (8-11).
Pilonidal disease is a frequently recurring
condition, with a recurrence rate of up to 40% within a 5-year
follow-up, and significant variation across different treatment
modalities (12,13). In the literature, higher recurrence
rates have been associated with surgical excision combined with
midline closure, whereas off-midline techniques, such as Limberg
flap and Bascom cleft, lift have been linked to lower recurrence
rates (4,12-16).
However, patient-related factors (13,16)
and follow-up times (6,12) should also be considered when
evaluating the recurrence rates. Recurrent PSD can be managed using
primary case treatment modalities (16-18).
The most effective approach remains debated despite the various
treatment options available (15,16,18-20).
Additionally, there is a shortage of published literature
addressing the management of recurrent disease. This study aims to
present the results of re-operations in our patient cohort and
discuss the factors contributing to the recurrence of pilonidal
disease to inform future decisions based on previous experiences
and knowledge.
Materials and methods
Participants
This article presents a case series analysis of 63
patients with recurrent PSD, treated in the plastic surgery
department of a teaching hospital between 2010 and 2021. A total of
319 patients with pilonidal sinus underwent surgery during this
period. Both primary and recurrent cases of PSD were operated on
using laser treatment, surgical excision with direct closure, or
flap reconstruction. Over the years, we have developed treatments
for PSD patients. Initially, we used direct closure, then a flap,
and now we utilize laser. We have discussed these techniques in our
previously published articles (21,22).
A majority (84.1%) of the patients in this study were men; 27
(84.4%) in the direct closure group, 15 (83.3%) in the flap
reconstruction group, and 11 (84.6%) patients in the laser group.
The median age in the laser group was 25.5 years (range 14-51),
28.5 years (range 7-70) in the direct closure group, and 30.5 years
(range 14-65) in the flap group.
Study protocol
All patients underwent preoperative clinical
evaluation and were selected for re-operation if they presented
recurrence or residual disease, or complications such as infection,
hematoma, or dehiscence, with some patients displaying multiple
complications. The research material was gathered retrospectively
from the medical records. Basic variables, including age, gender,
BMI, and smoking habits, were collected preoperatively and
postoperatively. The patients had routine follow-ups in the
outpatient clinics one to three months after the surgery. This
study has received approval from the regional institutional review
board (ID164/2021).
Statistical analysis
Statistical analyses were performed using IBM SPSS
Statistics, version 27. Categorical variables were presented as
absolute numbers and percentages, and continuous variables as the
mean ± standard deviation (SD). Fisher's exact test compared
nominal data and the Mann-Whitney U test for nonparametric data.
P-values <0.05 were considered statistically significant.
Results
Basic characteristics
Out of 319 pilonidal sinus patients, 69 (21.6%)
underwent laser treatment, 156 (48.9%) excision with direct
closure, and 94 (29.5%) excision with flap reconstruction. Within
the study group of 63 re-operated patients, there were 13 in the
laser treatment group, 32 in the direct closure group, and 18 in
the flap reconstruction group. Approximately one in five patients
required re-operation: 18.8% after laser treatment, 20.5% after
direct closure, and 19.2% after flap reconstruction, with no
statistical significance found between the treatment methods.
Patients who underwent flap reconstruction were
statistically significantly older (30.9±8.9 years) than those
treated with laser (P=0.038). The mean BMI in the laser group was
27.3±3.6, 29.3±4.5 in the direct closure group, and 33.1±4.7 in the
flap group, with a statistical difference between laser and flap
procedure (P=0.003). There were significantly fewer smokers in the
laser group (n=2, 15.4%) in comparison to the flap group
(n=11, 61.1%, P=0.039), and the direct closure group
(n=15, 46.9%, P=0.025). The mean follow-up time was 18.1±7.3
months after laser treatment, with a statistically significant
difference compared to direct closure (81.0±34.8 months, P=0.000),
and the flap procedure (101.2±24.5 months, P=0.000) (Table I). There was no statistical
difference when comparing patients' gender and re-operations, in
the preoperative data, there were 70-76% of men and re-operated
data included 83-84% men.
 | Table IBasic characteristics of the
re-operated patients. |
Table I
Basic characteristics of the
re-operated patients.
| Characteristics | Laser (n=13) | Direct closure
(n=32) | P-value (laser vs.
direct closure) | Flap (n=18) | P-value (laser vs.
flap) |
|---|
| Age, years (mean ±
SD) | 24.54±7.23 | 26.84±11.55 | 0.688 | 30.94±8.86 | 0.038 |
| Sex (male), n
(%) | 11 (84.6) | 27 (84.4) | NC | 15 (83.3) | NC |
| Smoking, n (%) | 2 (15.4) | 15 (46.9) | 0.039
(0.078a) | 11 (61.1) | 0.025
(0.050a) |
| BMI, kg/m2
(mean ± SD) | 27.29±3.65 | 29.31±4.50 | 0.199 | 33.05±4.69 | 0.003 |
| Follow-up, months
(mean ± SD) | 18.12±7.32 | 80.98±34.78 | <0.001 | 101.24±24.48 | <0.001 |
Reasons for the re-operations
Infection, hematoma, dehiscence, and recurrence or
residual disease were indications for re-operation. Infection rates
were equal across all groups: 38.5% (n=5) of laser-treated
patients, 40.6% (n=13) of direct closure patients, and 38.9%
(n=7) of flap-reconstructed patients presented signs of
infection post-operatively. Hematoma occurred in 13 (40.6%) direct
closure patients and four (22.2%) flap reconstructed patients, with
no statistical significance. Dehiscence was more frequent after
direct closure (n=15, 46.9%) than flap reconstruction
(n=3, 16.7%), but no statistical significance was found
(P=0.064). There were no reports of hematoma or dehiscence after
laser treatment. Residual disease or recurrence was the most common
reason for re-operation after laser treatment (n=11, 84.6%).
Residual or recurrence was detected in 12 (37.5%) direct closure
patients and seven (38.9%) flap-reconstructed patients. There was
also a statistically significant difference when comparing
recurrence and residual as reasons for re-operation between laser
and direct closure or flap (P=0.003 & P=0.010) (Table II).
| Table IICause of the re-operation. |
Table II
Cause of the re-operation.
| Causes | Laser, n (%)
(n=13) | Direct closure, n (%)
(n=32) | P-value (laser vs.
direct closure) | Flap, n (%)
(n=18) | P-value (laser vs.
flap) |
|---|
|
Infectiona | 5 (38.46) | 13 (40.63) | >0.999
(>0.999b) | 7 (38.89) | >0.999
(>0.999b) |
| Hematomaa | 0 (0.0) | 3 (9.38) | 0.546
(>0.999b) | 4 (22.22) | 0.120
(0.240b) |
|
Dehiscencea | 0 (0.0) | 15 (46.88) | 0.002
(0.004b) | 3
(16.67)c | 0.238
(0.476b) |
| Residual
disease/recurrencea | 11 (84.62) | 12 (37.50) | 0.003
(0.006b) | 7 (38.89) | 0.010
(0.020b) |
Re-operation techniques
The majority of re-operations after laser treatment
were performed using the laser (n=9, 61.5%), two (15.4%) with
direct closure, and three (23.1%) with flap reconstruction. Two
(15.4%) laser-treated patients required two or more re-operations.
Most re-operations after direct closure surgery were also performed
using the same method (n=18, 56.3%). The flap procedure was
used in 31.3% (n=10), and laser in 18.8% (n=6) of the
re-operations after primary direct closure. Twelve (37.5%) patients
in this group needed multiple re-operations. Most re-operations
after flap reconstruction were direct closure surgeries
(n=10, 55.6%), 38.9% (n=7) were flap procedures, and
11.1% (n=2) were laser operations. Only one
flap-reconstructed patient (5.6%) required two or more
re-operations (Table III).
| Table IIITechnique of re-operation. |
Table III
Technique of re-operation.
| | Primary
operation |
|---|
| Re-operation | Laser
(n=13)a | Direct closure
(n=32)a | Flap
(n=18)a |
|---|
| Laser, n (%) | 9 (61.54) | 6 (18.75) | 2 (11.11) |
| Direct closure, n
(%) | 2 (15.38) | 18 (56.25) | 10 (55.56) |
| Flap, n (%) | 3 (23.08) | 10 (31.25) | 7 (38.89) |
| Two or more
re-operations, n (%) | 2 (15.38) | 12 (37.50) | 1 (5.56) |
Discussion
Our observations indicate that factors leading to
recurrence and re-operation vary depending on the selected
treatment method. Patients who underwent laser treatment as their
primary operation exhibited more residual and recurrence when
compared to those treated with other surgical techniques, and there
was also a statistical difference between the groups. In our
experience, laser treatment provides favorable results for
relatively superficial pilonidal sinus. However, residual disease
is more common when it affects deeper tissues of the sacrococcyx
area. To address this, we perform a magnetic resonance imaging
(MRI) scan to assess the extent of pilonidal sinuses if residuals
are detected after the second laser treatment. While laser
treatment has yielded promising results with fewer complications
than open surgical methods (12,15,23),
some studies have reported high recurrence rates over extended
follow-up periods (11,12). Nevertheless, comprehensive
long-term data on laser treatment are still limited.
Differentiating recurrence from residual disease may also be
challenging without close post-operative monitoring, thus
potentially influencing the accuracy of recurrence rates.
The most common complication after direct closure
was dehiscence, likely due to this technique resulting in tension
and traction of the suture lines (2,5,16).
Technical factors in suturing can also influence dehiscence.
Factors leading to re-operation seemed more varied after primary
flap reconstruction. Patients in the flap group experienced less
dehiscence than those in the direct closure group, but hematoma was
more prevalent. Flap techniques aim to reduce tension and traction
by flattening the natal cleft and placing sutures away from the
midline, decreasing the risk of dehiscence (2,5,16).
However, flap reconstruction techniques require detaching the soft
tissue from a wider area, resulting in a higher risk of
postoperative hematoma, which may explain our findings.
Infection rates were similar between the groups,
possibly affected by the location of the pilonidal sinus, which can
increase the risk of bacterial contamination. Additionally, PSD
often appears as an infected sinus before surgery (2,5,17).
However, factors like poor hygiene and inadequate wound care may
also influence infection rates (24). Other studies have shown significant
differences in postoperative infection rates, with the highest risk
usually linked to the direct closure method (6,10).
The re-operation method was individually selected
for each patient, considering the primary operation. In most cases,
patients were re-operated using the same treatment modality as in
their initial procedure, apart from flap reconstruction, which was
typically followed by direct closure. By mobilizing the flap during
re-operative surgery, direct closure can be performed without
causing tension on the suture lines, eliminating the need for new
reconstruction. Re-operation with laser treatment was rare after
direct closure or flap reconstruction, as most of these surgeries
were conducted before the introduction of laser treatment to our
clinic. Multiple re-operations were frequently required after
primary direct closure, suggesting that this method may not be
optimal for treating pilonidal disease, a conclusion also reached
by other studies (2,4,7,12).
Re-operation with laser is recommended in cases with minor residual
disease in the operation area. Laser is also a safe and effective
option for recurrent pilonidal disease (25).
The typical characteristics of pilonidal disease
patients (male gender, age, and overweight) were well represented
in our patient cohort. However, significant variation was found
between the groups. Patients who underwent flap reconstruction were
older and had higher BMIs. Additionally, both the flap
reconstruction and direct closure groups had significantly more
smokers compared to the laser group, possibly reflecting the
increased emphasis on smoking cessation in recent years. Smoking
and obesity are associated with a higher risk of complications and
inadequate healing, potentially influencing the complication rates
of the groups. Smoking and high BMI could also contribute to the
need for re-operation rate. Data on poor personal hygiene,
sacrococcygeal hair density, sitting time, tight clothing usage,
and microbiological data were not collected because the information
was unavailable.
Laser treatment is a minimally invasive procedure
performed in an outpatient clinic under local anesthesia, requiring
little post-operative care and minimal sick leave. In contrast,
flap reconstruction and direct closure are more extensive
procedures, requiring postoperative wound care, sitting
limitations, and longer sick leave for optimal healing (9-11).
These differences present a challenge when comparing the
complication rates of the groups. The follow-up time after laser
treatment was significantly shorter after direct closure and flap
reconstruction. Patients in these groups underwent treatment at
different periods, so the follow-up times are not directly
comparable. As laser treatment is a relatively new method in our
clinic, extensive long-term data on its outcomes are yet to be
acquired.
While this study provides valuable insights, its
limitations include a retrospective design and a relatively small
patient cohort. Additionally, comparing laser treatment and
excision, combined with direct closure or flap reconstruction,
presents challenges due to their distinct natures. Furthermore,
variations in patient characteristics between the groups and the
notably shorter follow-up time after laser treatment may impact the
results. Multivariable analysis was not performed due to the small
number of patients in the data. Different techniques used in
various periods may lead to selection bias. The Flap group, for
example, may include more complex cases. Larger studies with longer
follow-up periods are required to determine the optimal treatment
method for PSD. In the study, we did not evaluate the quality of
life assessment, including pain and return to work, which is a
limitation of the operative results. Only pairwise Mann-Whitney U
tests were used, increasing the risk of type I error, therefore
results should be interpreted with caution to avoid
overinterpretation. Despite these limitations, the study benefits
from a lengthy, continuous period during which the treatment of
pilonidal disease has improved and shifted towards a minimally
invasive approach. This improvement is reflected in the
post-operative results, with fewer complications associated with
laser treatment than other modalities. Additionally, the extended
follow-up of patients in the flap and direct closure groups
provides valuable insight into the recurrence rates associated with
these methods.
In conclusion, the risk of recurrent pilonidal sinus
disease remains significant, yet most patients typically require
only one re-operation. Laser treatment emerges as a promising
approach for both primary and recurrent cases. However, long-term
outcomes are necessary to confirm the matter.
Acknowledgements
Not applicable.
Funding
Funding: No funding was received.
Availability of data and materials
The data generated in the present study may be
requested from the corresponding author.
Authors' contributions
JL, HMM and HN contributed to data collection,
writing, data analysis and editing. JL, HMM and HN confirm the
authenticity of all the raw data. All authors have read and
approved the final version of the manuscript.
Ethics approval and consent to
participate
The present study was conducted retrospectively from
data obtained for clinical purposes and has been approved by the
Regional Institutional Review Board of Kuopio University Hospital
(approval no. ID164/2021). Informed consent was not required as
this was a retrospective study.
Patient consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing
interests.
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