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124 S. Thomas and J. Nordenstam
Fig. 6.6 Unroofing of
pilonidal disease (Photograph
courtesy of Charles O.
Finne MD, Minneapolis)
Fig. 6.7 Marsulpialzation
following unroofing
(Photograph courtesy of
Charles O. Finne MD,
Minneapolis)
6 Pilonidal Cyst 125
In the acute stage inci sion and drainage vs needle aspiration followed by
antibiotic course is recommended for acute pilonidal abscesses [14]. Incision and
drainage results in complete wound healing in 60% of cases [15]. Definitive surgical excision is recommended after inflammation subsides, to add ress the resultant
wound. Disease recurrence occurs in 10–15% of cases despite complete wound
healing, as drainage of a pilonidal abscess does not address the underlying cause of
its pathology [15].
Pit picking is one of the minimally invasive procedures. There are various
methods of performing this type of surgery. A common feature in all these methods
is the excision and removal of midline pits followed by drainage or curetting of the
subcutaneous tissues. The aim of these techniques is to remove minimal amount of
tissues. It is important to note that the sinus tract is not excised with these techniques. The advantage of this method is that it is performed on an outpatient basis,
has short wound healing time and short recovery time. The disadvantage is a
recurrence rate of approximately 20–25% in 5 year follow-up [14].
Sinusectomy first described by Soll et al. is another minimally invasive technique. The sinus tracts are probed and injected with methylene blue. The sinus
tracts are then excised following the methylene blue delineation. The wounds are
left open to close by secondary intent [17 ]. A recurrence rate of 5% was reported in
the study [17]. This technique is recommended for patients with less than three
pilonidal pits [14].
Unroofing and marsupialization (UM) of the sinus tracts is another surgical
option [1]. In this procedure no healthy, normal tissue is removed and only affected
tissue is incised [1]. This technique still results in a 1–2 cm open wound, but the
wound is much smaller than the wound caused by wide local excision (WLE) [14].
Rouch et al. described a low recurr ence rate with UM when compared to WLE in
their retrospective review [1].
The most common procedure offered is wide local excision with or without
closure [1, 2, 12, 14, 17]. In this procedure all of the involved tissue is excised and
the resultant wound is either closed or left to close by secondary intent [1 ]. The
technical approach of WLE is similar to sinusectomy and UM, in that the sinus
tracts are probed and sometimes injected with methylene blue prior to being
excised; however, the extent of excision is larger [14]. The disadvantage of
allowing the wound to close by secondary intention is prolonged wound healing
time, increased recurrence rate, patient effort in wound care and time off work [2,
14].
Midline and off midline closure is used in primary closure following WLE.
Shorter time of wound healing is noted with primary closure. Off midline closure is
shown to have faster healing rates, lower infection as well as lower recurrence rates
compared to midline closure [2]. Three off midline procedures commonly used are
the Karydakis flap, the Limberg flap and the cleft lift procedure (Bascom II). The
advantage of off midline closure is that it first removes the chronically diseased
tissue and second it flattens the natal cleft, thereby minimizing recurrence due to
anatomic and mechanical stress [5]. Disadvantage of the off midline closure is
tension on the suture line, resulting in wound dehiscence, and esthetic of ultimate
126 S. Thomas and J. Nordenstam
Table 6.1 Flap closure techniques following WLE and their complications
Flap procedure Technique Complication
Karydakis flap Asymmetrical excision of pilonidal sinus and lateral
Limberg flap Rhomboid excision of pilonidal tissue using closure
Cleft lift
procedure
closure of flap secured to sacrococcygeal fascia
with a rotational fasciocutaneous flap
Excision of midline pits with mobilization of
healthy skin adjacent to the midline. Skin and
subcutaneous tissue is apposed for off midline
closure
Wound separation and
delayed wound healing
Surgical site infections
and wound separation
Seroma, hematoma and
wound separation
scar [18]. The most common complications following off midline flap closure is
hematoma, seroma and wound separation [5, 11]. The use of d rains
intra-operatively may prevent the formation of seromas and hematomas. If wound
hematoma or seroma develop, fluid aspiration with large bore needle is suggested.
Wound separation is treated with wet to dry dress ing applied to the region
(Table 6.1).
Pilonidal disease can recur up to 20 years after surgery, but 60% will recur
within 5 years [12]. Early recurrence in midline closures is thought to be secondary
to the surgical site infection and occur in up to 24% of case that undergo WLE with
primary closure [2, 3]. The administration of systemic antibiotics has been reviewed
in several randomized controlled trials, showing no significant benefit[2, 14, 15].
Postoperative antibiotics can be used as an adjunct following surgical excision;
however studies have shown mixed results in term of wound healing and recurrence
rate [15]. Nyugen et al. suggested the use of gentamycin collagen sponge to reduce
the local infection rates; however, the study did not reach statistical significance [2].
Other studies failed to show that the use of gentamycin improved wound healing
and prevented disease recurrence [2, 15].
Complications
Regardless of whether conservative or surgical treatment strategies are utilized,
pilonidal disease often leads to post-therapeutic complications, including poor
wound heali ng and disease recurrence. Male gender, obesity, hirsutism, smoking,
family history, poor hygiene, sinus size, and the surgical procedures are risk factors
for complications and recurrence [7, 10–12, 15, 19]. One study, done by Lesalnieks,
showed that smokers had increased postoperative wound complications following
both minor surgical procedures as well as larger procedures with off mid line closures [19]. Pilonidal disease recurrence was also reported to be increased in
smokers when compared to nonsmokers [19]. Surgeon experience was also considered in disease recurrence. Pilonidal disease recurred in 44% of patients when
the Karydakis flap was performed by an inexperienced surgeo n, while the recurrence rate was 9% when performed by an experienced surgeon [19]. A correlation
6 Pilonidal Cyst 127
also exists between sinus pit size and number of pits and disease recurrence [20].
Incomplete sinus tract excision results in disease recurrence [20]. Method of
anesthesia also affected disease recurrence. Smal ler and inadequate surgical excision with local anesthesia use had higher recurrence rates compared to either spinal
or general anesthesia [20].
Wide local excision with primary closure minimizes wound healing time and has
shorter recovery time prior to patients returning to work [2]. Off midline flap
closures are preferred as these procedures have lower recurr ence rate compared to
midline closures [20]. Onder et al. suggested that primary midline closures had
higher recurrence rates while flap closure had higher postoperative complications
[20].
Minor postoperative complications, such as seroma, hematoma, local wound
infections, and wound dehiscence is reported to between 16 and 17% following
WLE and primary closure [21]. Should a seroma or hematoma develop, fluid
aspiration is recommended. Intra-operative wound drain placement is used to
prevent fluid accumulation. Antibiotics, be it systemic vs local, is used to address
the complication of local wound infection. Wound separation is treated with local
dressing (Figs. 6.8, 6.9, 6.10 and 6.11).
Irrespective of surgical technique chosen, hair removal and maintaining strict
hygiene have been shown to prevent disease recurrence [16].
Fig. 6.8 Unroofing of
extensive pilonidal disease
128 S. Thomas and J. Nordenstam
Fig. 6.9 Marsupialization
Malignant transformation is a rare complication of chronic recurrent pilonidal
disease. Carcinoma developing in the pilonidal sinus tract is rare and occurs in less
than 0.1% of cases of chronic, untreated, recurr ent pilonidal disease [16, 22].
Chronic pilonidal disease is present for approximately 20 years prior to malignant
degeneration [22, 23]. Squamous cell carcinoma is the most common carcinoma,
occurring in 90% of cases. The rema ining 10% is made up of basal cell, mixed
squamous and basal cell, and adenocarcinoma [ 22 ]. The disease presents as an
aggressive, rapidly progressing fungating ulcer [16]. The carcinoma is locally
invasive but rarely has distant metastasis. Treatment of choice is en-bloc surgical
excision with closure of the resultant defect with skin grafting or flaps [22]. The
disease has a poor prognosis and high recurrence rate of 50% despite intervention
[16]. Adjuvant chemotherapy and radiotherapy is used to reduce disease recurrence
[23].
Misdiagnosis
Differential diagnosis for pilonidal disease includes hidradenitis suppurativa, congenital dermal tract, myelomeningocele, meningocele, dermoid cyst, tailgut cyst,
teratoma, or lipoma to mention a few misdiagnoses.
6 Pilonidal Cyst 129
Fig. 6.10 Recurrent pilonidal cyst initially treated with Limberg flap (Photograph courtesy of
Charles O. Finne MD, Minneapolis)
Hidradenitis suppurativa (HS) is a disease that affects skin with high concentration of apocrine glands especially the axilla, inframammary, inguinal, perineal,
and perianal regions. The etiology of HS is thought to be secondary to occlusion of
hair follicles, with resultant dilation, follicle rupture, and coalescing tract formation
[24]. This is similar to the pathogenesis of pilonidal disease. If disease is confined to
the perianal and perineal tissue, patients present with pain and malodorous drainage
similar to that of pilonidal disease. On physical examination subcutaneous
abscesses with multiple draining tracts are seen. Treatment ranges from conservative management to surgical management with wide local excision and woun d
closure by secondary intent [ 24].
130 S. Thomas and J. Nordenstam
Fig. 6.11 Lichen Sclerosis
minimking pilonidal disease
(Photograph courtesy of
Charles O. Finne MD,
Minneapolis)
Congenital sinus tracts may be seen anywhere from the nose to the coccyx,
occurring at the midline or adjacent to the midline [25]. The sinus tracts are lined
with stratified squamous epithelium, like skin, and contain dermal appendages [25].
The tracts can extend as far as the spinal cord and may be complicated by
meningitis or be linked to tracts ending in the subcutaneous tissue.
Tailgut cysts are congenital lesion in the retrorectal space, considered to be
embryological remnants of postnatal intestinal tract [26]. As tailgut cysts are found
in the retrorectal space they present with signs of mechanical obstruction to the
rectal/anal canal or urinary system as the cysts increase in size. Tail gut cysts may
be misdiagnosed as pilonidal disease and they can also incidentally found as a
sacrococcygeal dimpling in the natal cleft [26]. Tailgut cysts may be surgically
excised; however, this is associated with a high morbidity and complication rate
[26].
Myelomeningocele, meningocele, and ependymoma are defects of the central
nervous system that can occur along the central nervous tract in the sacrococcygeal
region [27 ]. As these lesions present as a fluctuant mass in the sacrococcygeal
region they may be misdiagnosed as pilonidal disease. The initial management
would be to aspirate or incise and drain the lesion, which will not result purulent
fluid. Surgical excision and pathological evaluation confirms diagnosis [27].
6 Pilonidal Cyst 131
Understanding the epidemiology and disease presentation is important in
effective diagnosis of pilonidal disease. Sending tissue sample for pathological
evaluation will also aid in confirming diagnosis.
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Hidradenitis Suppurativa
Jacqueline Harrison and Francois Dagbert
Hidradenitis suppurativa is a cutaneous disorder involving apocrine gland bearing
skin regions. Rich in apocrine glands, the perianal region is frequently involved, as
well the gluteal, inguinal, and axillary regions. Women are more frequently affected
than men (3:1), and obesity and cigarette smoking are known risk factors [1]. The
course of the disease is variable, but frequently progresses to a chronic condition
with subcutaneous abscesses, draining sinuses and extensive skin fibrosis. Even
though medical therapy, as well as simple incision and drainage, may be adequate
for the management of early, limited disease and acute infection, their role in the
management of chronic, extensive disease is limited [2]. Recurrence rate of 100%
after simple incision and drainage is common [3].
The treatment of chronic, severe hidradenitis suppurativa is primarily surgical.
For patients with extensive disease, a staged procedure may be required. On
average, patients suffer 10 years of active disease before undergoing radical excision [4]. The resulting wounds can take many weeks, even months, to heal completely and can be associated with significant morbidity and disability. Quality of
life is adversely affected, by the disease and its treatment, and depression and
anxiety are more frequent in patients with hidradenitis suppurativa [5]. There is
extensive debate in the literature regarding the extent of excision of perianal
hidradenitis suppurativa and options for closure of these often massive wounds.
Frequent coexistence of inflammatory bowel disease and hidradenitis suppurativa
can make diagnosis and treatment challenging. Practitioners need to be aware of the
risk of malignancy associated with long-standing hidradenitis suppurativa, especially in the perianal and perineal regions, and appropriate treatment of this devastating complication.
7
J. Harrison (&) F. Dagbert
Division of Colon and Rectal Surgery, John H. Stroger Hospital of Cook County,
1900 W. Polk Street, Chicago, IL 60612, USA
e-mail: Sbhayden@hotmail.com
© Springer International Publishing AG 2017
H. Abcarian et al. (eds.), Complications of Anorectal Surgery,
DOI 10.1007/978-3-319-48406-8_7
133