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Original Research (Original Article) 


Abdullah Abed Alghuraybi et al, 2019;3(10):034–039.

International Journal of Medicine in Developing Countries

Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia

Abdullah Abed Alghuraybi1, Mazen Abdulmohsen Almalki1, Abdulaziz Hameed Althumali1, Abdulaziz Mohammed Alshalawi1, Rayan Ibrahim Maghrabi1, Faisal Alotaibi2, Tamer Mohammed Abdelrahman3,4*

Correspondence to: Tamer Abdelrahman

*Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia; Consultant of General Surgery, General Organization for Teaching Hospitals and Institutes, Cairo, Egypt.

Email: drtamer17 [at] gmail.com

Full list of author information is available at the end of the article.

Received: 25 June 2019 | Accepted: 22 July 2019


ABSTRACT

Background:

A pilonidal sinus disease (PNSD) is a chronic inflammatory disease, which mainly affects the young and active people of working age group. Since its high rate and recurrence, the aim of this study was to identify surgeon's attitude and current practices among surgeons, in relation to the most effective technical aspects and surgical procedures for elective management of PNSD.


Methodology:

A cross-sectional study was designed to assess the attitudes and practices of surgeons of Taif city, Saudi Arabia, during the period from 1 January to 31 January 2019. Data were collected by distributing a pre-designed structured questionnaire.


Results:

From 100 surveys, 79 surgeons responded. About half of respondent surgeons (N = 42) performed off-midline flap procedures; karydakis (N = 22), limberg (N = 18), cleft lift (N = 2), and duformental (N = 0). 20.3% of surgeons performed excision and open wound healing, 15.2% performed primary midline closure, and 11.4% performed pit procedures.


Conclusion:

There is no agreement among surgical consultants about the best management of PNSD. It is accepted that evidence-based medicine dictates that a firm conclusion regarding the superiority of one form of management over another requires a prospective double blind controlled study involving randomly selected patients.


Keywords:

Pilonidal sinus disease, PNSD, off-midline flap, open wound healing, surgeon.


Introduction

A pilonidal sinus disease (PNSD) comes from the Latin word pilus (hair) and nidus (nest), and it is a chronic inflammation with a pilonidal cyst containing hair bundles and a sinus tract opening to the surface of the skin. Usually, it affects the sacrococcygeal area [1].

PNSD mainly affects young and active people. It affects approximately 1% of people, at 15–30 years. The disease is acquired and caused by the implantation of hair into the natal cleft, resulting in a chronic foreign body reaction and the formation of epithelialized tracts and midline pits [2].

Patients with PNSD are at risk of infection and abscess formation, with or without complex tracts and fistulas. It is believed to be with a high recurrence rate. There are multiple risk factors of PNSD, including youth age, being fatty, a lot of hair in sacrococcygeal region, sitting for long time, and bad sanitary measures [3].

PNSD burdens the patient's life as it results in loss of time from work or school and frequent hospital visits. It also burdens the health care workers with wound care and follow up [4]. The aim of treatment is the cure of disease that allows the patient to return to his normal life, to prevent complications and to reduce the recurrence rate [5].

The three important principles of management of chronic PNSD are: removal of the tract, complete cure of the overlying skin, and avoiding recurrence [6].

Surgeons have suggested a variety of solutions to treat this disease: non-surgical treatment; minimal surgical procedures; limited excision with or without marsupialization; major excisions with or without primary closure; variants of the former with incisions/scar off midline without or with local flap reconstructions [7].

Iesalnieks et al. [8] concluded that treatment is not required for an asymptomatic pilonidal disease. The surgeons should incise the pilonidal abscess, and when acute inflammation has regressed, then apply the definitive treatment. The standard method for treating chronic PNSD is excision. A low postoperative morbidity rate is associated with open wound healing, but the associated complication is prolonged healing time. Excision and midline wound closure has a recurrence rate with more wound complications, and therefore should be avoided. The primary treatment option for chronic pilonidal disease is off-midline procedures.

Despite many publications in the last 80 years, the conflicts in the management of PNSD still exist all around the planet. In addition to the development of new management (e.g., depilation by laser, surgery assisted by video, huge less invasive operations) further complicates the choice of clinical management [8]. The recent national guidelines which are published by groups in Germany, Italy, and America intent to provide recommendations for surgeons in the management of PNSD with the purpose of lowering the variability [9].

The national guidelines of Germany in the treatment of PNSD (2016) suggested that first standard treatment should be excision and open wound healing. Second, marsupialization should be avoided because of postoperative pain and cosmetic outcomes. Midline closure should also be avoided because of increased rate of wound complication and recurrence rate. The lower recurrence rate is associated with off-midline procedures, faster wound healing, and return to normal activity and work [8].

A study by Segre et al. [10] on the treatment of pilonidal disease showed that there is no clear benefit of open healing than closure. The standard management when closure is the surgical desire, is off-midline closure. Incision and drainage should be the treatment of abscess, whether it is primary or recurrent.

Considering the high rate and recurrence rate of PNSD, the aim of this study was to identify surgeon’s attitude and current practices among surgeons in Taif city, Saudi Arabia, in relation to the most effective technical aspects and surgical procedures for elective management of PNSD.


Methodology

A cross-sectional study was designed to assess the attitudes and practices of surgeons of Taif city regarding management of PNDS, during the period from 1 January to 1 March 2019. Inclusion criteria included male and female surgeons working in Taif hospitals. Exclusion criteria included Physicians.

The data were collected through pre-designed structured which was based on former studies and modification was done to be applied in the desired locality [9]. The questionnaire included 16 questions, which consisted of demographic about surgeon’s position and years of experience; the attitude of surgeons in dealing with PNSD, and the practice of surgeons in dealing with PNSD.

Data entered on a Microsoft Office Excel sheet 2010. Then data entry and Statistical analysis had done by using statistical package for the social science (SPSS) program for Windows version 21.


Result

From a 100 surveys distributed to surgeons at governmental and private hospitals in Taif City, 79 surgeons responded. All were general surgeons: 25 (31.6%) were consultants, 27 (34.2%) were specialists, and 27 (34.2 %) were residents. 40.5% of participants had an experience of more than 10 years.

80% of the respondent surgeons had operated approximately more than 50 patients with PNSD per year. 75% of the surgeons performed the operation as a day case, and 25% performed it as in-patient procedure.

63.2% of surgeons preferred to do elective operation after incision and drainage (Table 1).

65.8% of the respondent surgeons individualized the type of operation per patient, while 34.2% performed one procedure which was their preferred method (Table 2).

Table 1. Response of the surgeons on how to manage a pilonidal abscess.

Question Response N (%)
How do you manage a pilonidal abscess Wait and see after incision and drainage 8 (10.2%)
Wait and see after incision and drainage plus curettage 21 (26.6%)
Elective operation after one of the above options 50 (63.2%)
Total 79 (100%)

53.2% of the respondent surgeons performed off-midline flap procedures, 20.3% of the surgeons performed excision and open wound healing, and 15.2% performed primary midline closure (Table 3).

44.3% of the surgeons stated the number of midline openings was not important in choosing the procedure (Table 4). Some respondents commented that the number of opening is more than one, and others reported more than two openings.

Half of the surgeons changed the type of surgery based on whether the secondary sinus is on the left or right of the midline. Nearly, half of surgeons liked to excise/treat all secondary openings, if possible, and the other half said that all secondary sinuses need to be excised (Table 5).

Response of surgeons regarding to the site of the secondary opening if it is close to anal verge on infection and recurrence rate shown in (Table 6).

70.9% of respondents always chose a different technique if there had been previous abscess incision and drainage, while 57% of surgeons would not change the type of operation if the pilonidal sinus was recurrent (Table 7).

46.8% of the respondent surgeons stated that 3 months was acceptable time for a pilonidal wound to heal (Table 8).


Discussion

PNSD usually disappears by the age of 30 years. Controlling the risk factors is a preferable goal than urgent cure [7]. Maintaining a good perineal hygiene and proper hair control is important to prevent recurrence and to manage PNDS with avoiding the need for any operation [11].

In the present study, 80% of the respondent surgeons had operated approximately more than 50 patients with pilonidal sinus disease per year, 23% performed from 20 to 50 procedures per year, and 38% of the respondents performed less than 20 procedures per year. Interestingly, in a survey study by Shabbir et al. [6], 44% of surgeons performed less than 10 pilonidal surgery procedures per year. 63.2% did an elective operation after incision and drainage plus curettage of pilonidal abscess (26.6%), while the others like to wait and see (10.2%).

Table 2. Response of the surgeons to the type of procedure for PNSD.

Question Response N (%)
Do you typically perform one procedure for PNSD or individualize per patient? Perform one procedure 27 (34.2%)
Individualize per patient 52 (65.8%)
Total 79 (100%)

Table 3. Response of the surgeons to the main procedure for PNSD.

Question Response N (%)
Your main procedure for PNSD is: Excision and open wound healing 16 (20.3%)
Excision and primary midline closure 12 (15.2%)
Off-midline procedures (Karydakis, Limberg, cleft lift, Duformental 42 (53.2%)
Pit procedures (Gips, pit picking, phenol ablation 9 (11.4%)
Other procedures 0 (00.0%)
Total 79 (100%)

Table 4. Response of the surgeons to the important of the number of primary midline openings.

Question Response N (%)
When planning surgery, is the number of primary midline openings important? Yes 44 (55.7%)
No 35 (44.3%)
Total 79 (100%)

Table 5. Response of the surgeons to type of procedure according to site of the secondary opening.

Question Response N (%)
Do you change the type of procedure if the secondary opening /sinus are on the left or right of midline? Yes 42 (53.2%)
No 37 (46.8%)
Do you excise/treat secondary openings if these are bilateral? Excise/treat all secondary openings if possible 37 (46.8%)
All secondary sinuses need to be excised 39 (49.4%)
No need to excise all 3 (3.8%)
Total 79 (100%)

Table 6. Response of the surgeons to site of the secondary opening if it is close to anal verge.

Question Response N (%)
If the secondary opening/sinus is close to the anal verge (i.e. caudal to the primary sinuses)? Felt the rate of wound infection and recurrence was increased. 46 (58.2%)
Felt only the rate of infection to be increased. 13 (16.5%)
Uncertain about the impact of sinus-anus-proximity on infection and recurrence rate 20 (25.3%)
Total 79 (100%)

Table 7. Response of the surgeons if there has been a previous incision and drainage/ recurrence.

Question Response N (%)
Do you change your treatment if there has been a previous incision and drainage? Do not change 22 (27.8%)
Sometime change 1 (1.3%)
Always choose a different technique 56 (70.9%)
Do you change your surgical plan in recurrent PNSD patients? Yes 45 (57.0%)
No 34 (43.0%)
Total 79 (100%)

Table 8. Response to time needed for unhealed pilonidal wound to heal.

Question Response N (%)
After what period of time is the unhealed or dehisced or open surgical wound considered as unhealed? 6 weeks 14 (17.7%)
3 months 37 (46.8%)
6 months 26 (32.9%)
12 months 2 (2.5%)
Total 79 (100%)

Only 10.2% of the present study surgeons preferred to wait and see after incision and drainage, 26.6% preferred to wait and see after incision and drainage plus curettage, and the majority of them (63.2%) preferred to do one of the above options plus an elective operation later. While in study by Moshe Schein about incision and drainage; wait and see were preferred by 21.74%, whereas incision and drainage plus curettage; wait and see) 33%) and one of the above options plus an elective operation later (45%). Moshe Schein [7] suggested that such abscesses should be managed with simple incision and drainage and nothing else. More than half of such patients would not suffer any further symptoms [7].

65.8% of the respondent surgeons individualized the type of operation per patient, while 34.2% performed one procedure which was his preferred method. In a survey study by Murphy et al. [9] 84% surgeons individualized the type of operation, while 16% typically performed their preferred method.

The present respondents were commented that the factors determined the types of their procedures which were according to complexity, cavity, number and site of the sinuses, and the majority reported recurrence. Also, presence of abscess, fistula, depth, diabetes mellitus, immunosuppression, body mass index, hair distribution, age, availability of facilities, and healing process after incision and drainage were documented by other studies [7].

About half of the respondent surgeons (N = 42) performed Off-midline flap procedures: Karydakis (N = 22), Limberg (N = 18), cleft lift (N = 2), Duformental (N = 0), while 20.3% of surgeons performed excision and open wound healing, 15.2% performed primary midline closure, and 11.4% performed pit procedures. Which is different from the survey done by Shabbir et al. [6] where the result was as following: excision with midline closure in 27% of the surgeons, Karydakis flap 18% of them, Bascom pit picking 12%, Bascom cleft lift 12%, excision with healing by secondary intention 10%, and rhombic flaps was 5%. Also, 17% of surgeons did a combination of these techniques. Off-midline procedures have a high level of evidence, a strong consensus of strength, and a grade of recommendation associated with lower recurrence rate than others procedures, and faster return to work [10].

44.3% of the surgeons stated the number of midline openings was not important in choosing the procedure. In a survey study by Murphy et al. [9], 55% of the surgeons stated the number of midline pits/ sinuses do not impact on the procedure chosen. Some commented that if there were too many midline pits (e.g. > five midline pits), a flap procedure would be performed. 53.2% of the present study surgeons changed the type of surgery based on whether the secondary sinus was on the left or right of the midline, while in a survey study by Murphy et al. [9], 75% of surgeons reported that they did not change the type of surgery if the secondary sinus was on the left or right of the midline.

46.8% of the surgeons liked to excise/ treat all secondary openings if possible, 49.4% of them reported that all secondary sinuses are needed to be excised, while 3.8% of them stated that there is no need to excise all.

58.2% of the surgeons felt the rate of wound infection and recurrence increases if the secondary sinus is close to the anal verge, while 16.5% felt only the rate of infection to be increased and 25.3% of surgeons were uncertain about the impact of sinus-anus-proximity on infection and recurrence rate. 27.8% of the respondents did not change the type of technique if there had been previous abscess incision and drainage, 1.3% sometimes changed their technique and 70.9% of them always chose a different technique. This result was different from the result of Murphy and Wysocki survey, where 45% felt the rate of wound infection and recurrence was increased, while 30% felt only the rate of infection was increased and 25% of surgeons were uncertain about the impact of sinus-anus-proximity on infection and recurrence rate. 54% of surgeons did not change the type of procedure if there had been previous abscess incision and drainage, 27% sometimes changed their technique and 20% chose a different technique (e.g. to perform a flap procedure) [9]. 57% of surgeons did not change the type of the operation if the pilonidal sinus was recurrent and 43% changed their technique.

Almost half of the present study surgeons changed their procedures after recurrence of pilonidal abscess. The alternative procedures were fistulectomy, wide excision, or both. Also, flap reconstruction karydakis, excision and open wound healing, excision and marsupilization, wide excision after injection of methyline blue, 17.7% of the respondent surgeons stated that 6 weeks was an acceptable time period for a pilonidal open wound to close while the majority (46.8%) stated 3 months was acceptable time, 32.9% stated 6 months and 2.5% stated 12 months was the needed time for a pilonidal wound to heal. No standardized time frame for PNSD postoperative wound healing has been described in the literature. Significant variability was found in the present study surgeons’ responses. Wound healing after PNSD surgery is defined as a complete epithelialization of the wound. In a study by Al-Khamis et al. [12] considered that successful healing was achieved within 6 months.

It is accepted that evidence-based medicine dictates that a firm conclusion regarding the superiority of one form of management over another requires a prospective double blind controlled study involving randomly selected patients [13]. Although several surgical methods have been defined for PNSD treatment, no definitive method exists until now [14].

Choosing among various treatment options should also be based on patient and surgeon’s preferences. Patients need to be thoroughly informed about all aspects of the operative and postoperative course, including the complication and recurrence rates associated with the technique [10].


Conclusion

The conflicts in the management of PNSD still exist. This study and other previous studies showed that there is no agreed method of managing PNSD, and every surgeon has their own technique to treat PNSD. Hence, the need for a national guideline with the purpose of lowering this variability is mandatory. It is recommended that there is need for more research studies that focus in the procedure causing least recurrence and fastest in healing.


List of Abbreviations

PNSD pilonidal sinus disease

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from the participants.


Ethical approval

The research was approved by Research Ethics Committee of Research and Studies Department, Directorate of Health Affairs Taif (approval letter number 156 and date 23-12-2018).


Author details

Abdullah Abed Alghuraybi1, Mazen Abdulmohsen Almalki1, Abdulaziz Hameed Althumali1, Abdulaziz Mohammed Alshalawi1, Rayan Ibrahim Maghrabi1, Faisal Alotaibi2, Tamer Abdelrahman3,4

  1. College of Medicine, Taif University, Taif, Saudi Arabia
  2. Department of Surgery, King Abdulaziz Specialist Hospital Taif, Taif, Saudi Arabia
  3. Assistant Professor, Department of Surgery, College of Medicine, Taif University, Taif, Saudi Arabia
  4. Consultant of General Surgery, General Organization for Teaching Hospitals and Institutes, Cairo, Egypt

References

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  2. Minneci PC, Halleran DR, Lawrence AE, Fischer BA, Cooper JN, Deans KJ. Laser hair depilation for the prevention of disease recurrence in adolescents and young adults with pilonidal disease: Study protocol for a randomized controlled trial. Trials. 2018;19(1):599. https://doi.org/10.1186/s13063-018-2987-7
  3. Bolandparvaz S, Dizaj PM, Salahi R, Moghadam Dizaj P, Salahi R, Paydar S, et al. Evaluation of the risk factors of pilonidal sinus: a single center experience. Turk J Gastro Enterol. 2012;23:535–7. https://doi.org/10.4318/tjg.2012.0381
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  6. Shabbir J, Chaudhary BN, Britton DC. Management of sacrococcygeal pilonidal sinus disease: a snapshot of current practice. Int J Colorectal Dis. 2011;26:1619–20. https://doi.org/10.1007/s00384-011-1169-9
  7. Schein M. Treating pilonidal disease: you do not need to detonate a naval mine to catch a fish. World J Surg. 2017;41(5):1303–4. https://doi.org/10.1007/s00268-017-3905-y
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How to Cite this Article
Pubmed Style

Alghuraybi AA, MAA, Althumali AH, Alshalawi AM, Maghrabi RI, Alotaibi F, Abdelrahman TM. Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia. IJMDC. 2019; 3(10): 34-39. doi:10.24911/IJMDC.51-1561502305


Web Style

Alghuraybi AA, MAA, Althumali AH, Alshalawi AM, Maghrabi RI, Alotaibi F, Abdelrahman TM. Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia. http://www.ijmdc.com/?mno=54191 [Access: October 18, 2019]. doi:10.24911/IJMDC.51-1561502305


AMA (American Medical Association) Style

Alghuraybi AA, MAA, Althumali AH, Alshalawi AM, Maghrabi RI, Alotaibi F, Abdelrahman TM. Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia. IJMDC. 2019; 3(10): 34-39. doi:10.24911/IJMDC.51-1561502305



Vancouver/ICMJE Style

Alghuraybi AA, MAA, Althumali AH, Alshalawi AM, Maghrabi RI, Alotaibi F, Abdelrahman TM. Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia. IJMDC. (2019), [cited October 18, 2019]; 3(10): 34-39. doi:10.24911/IJMDC.51-1561502305



Harvard Style

Alghuraybi, A. A., , . M. A. A., Althumali, . A. H., Alshalawi, . A. M., Maghrabi, . R. I., Alotaibi, . F. & Abdelrahman, . T. M. (2019) Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia. IJMDC, 3 (10), 34-39. doi:10.24911/IJMDC.51-1561502305



Turabian Style

Alghuraybi, Abdullah Abed, Mazen Abdulmohsen Almalki, Abdulaziz Hameed Althumali, Abdulaziz Mohammed Alshalawi, Rayan Ibrahim Maghrabi, Faisal Alotaibi, and Tamer Mohammed Abdelrahman. 2019. Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia. International Journal of Medicine in Developing Countries, 3 (10), 34-39. doi:10.24911/IJMDC.51-1561502305



Chicago Style

Alghuraybi, Abdullah Abed, Mazen Abdulmohsen Almalki, Abdulaziz Hameed Althumali, Abdulaziz Mohammed Alshalawi, Rayan Ibrahim Maghrabi, Faisal Alotaibi, and Tamer Mohammed Abdelrahman. "Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia." International Journal of Medicine in Developing Countries 3 (2019), 34-39. doi:10.24911/IJMDC.51-1561502305



MLA (The Modern Language Association) Style

Alghuraybi, Abdullah Abed, Mazen Abdulmohsen Almalki, Abdulaziz Hameed Althumali, Abdulaziz Mohammed Alshalawi, Rayan Ibrahim Maghrabi, Faisal Alotaibi, and Tamer Mohammed Abdelrahman. "Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia." International Journal of Medicine in Developing Countries 3.10 (2019), 34-39. Print. doi:10.24911/IJMDC.51-1561502305



APA (American Psychological Association) Style

Alghuraybi, A. A., , . M. A. A., Althumali, . A. H., Alshalawi, . A. M., Maghrabi, . R. I., Alotaibi, . F. & Abdelrahman, . T. M. (2019) Management of sacrococcygeal pilonidal sinus disease: surgeons’ current practice in Taif—Saudi Arabia. International Journal of Medicine in Developing Countries, 3 (10), 34-39. doi:10.24911/IJMDC.51-1561502305