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4. Kaiser AM, Ortega AE. Anorectal anatomy. Surg Clin N Am. 2002;82:1125–1138.
5. Billingham RP, Isler JT, Kimmins MH, Nelson JM, Schweitzer J, Murphy MM. The diagnosis and man-
agement of common anorectal disorders. Curr Probl Surg. 2004;41:586–645.
6. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976;63:1–12.
7. Sahnan K, Askari A, Adegbola SO, et al. Natural history of anorectal sepsis. BJS. 2017;104:1857–1865.
8. Zubaidi AM. Anal fistula: past and present. Saudi Med J. 2014;35:937–944.
9. Wang D, Yang G, Qiu J, et al. Risk factors for anal fistula: a case-control study. Tech Coloproctol.
2014;18:635–639.
10. Panes J, Rimola J. Perianal fistulizing Crohn’s disease: pathogenesis, diagnosis and therapy. Nat Rev
Gastroenterol Hepatol. 2017;14:652 – 664.
11. Cash DJ, Sadat MM, Abu-Own AS. Anorectal abscess and fistula caused by an ingested chicken bone.
Am J Gastroenterol. 2004;99:1617–1618.
12. Delikoukos S, Zacharoulis D, Hatzitherogilou C. Perianal abscesses due to ingested foreign bodies. Int
J Clin Pract. 2005;59:856–857.
13. Wright WF. Infectious diseases perspective of anorectal abscess and fistula-in-ano disease. Am J Med
Sci. 2016;351:427–434.
14. Hanley PH, Ray JE, Pennington EE, Grablowsky OM. Fistula-in-ano: a ten-year follow-up study of
horseshoe-abscess fistula-in-ano. Dis Colon Rectum. 1976;19:507–515.
15. Sun MR, Smith MP, Kane RA. Current techniques in imaging of fistula in ano: three-dimensional
endoanal ultrasound and magnetic resonance imaging. Semin Ultrasound CT MRI. 2008;29:454–471.
16. Michalopoulos A, Papadopoulos V, Tziris N, Apostolidis S. Perianal fistulas. Tech Coloproctol. 2010;14
(suppl 1):S15–S17.
17. Amato A, Bottini C, De Nardi P, et al. Evaluation and management of perianal abscess and anal fistula:
a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR). Tech Coloproc-
tol. 2015;19:595–606.
18. Seow-Choen F, Hay AJ, Heard S, Phillips RK. Bacteriology of anal fistulae. Br J Surg. 1992;79:27–28.
19. Eykyn SJ. Use of bacteriology in anorectal sepsis as an indicator of anal fistula: experience in a district
general hospital. J
R Soc Med. 1991;84:319.
20. Nelson R. Anorectal abscess fistula: what do we know? Surg Clin N Am. 2002;82:1139–1151.
21. Faria SN, Helman A. Deep tissue infection of the perineum: case report and literature review of Four-
nier gangrene. Can Fam Physician. 2016;62:405–407.
22. Wroblewska M, Kuzaka B, Borkowski T, Kuzaka P, Kawecki D, Radziszewski P. Fournier’s gangrene-
current concepts. Pol J Microbiol. 2014;63:267–73.3.
23. Schubert MC, Sridhar S, Schade RR, Wexner SD. What every gastroenterologist needs to know about
common anorectal disorders. World J Gastroenterol. 2009;15:3201–3209.
24. Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD. Practice parameters for the management of
perianal abscess and fistula-in-ano. Dis Colon Rectum. 2011;54:1465–1474.
25. Willams JG, Farrands PA, Williams AB, et al. The treatment of anal fistula: ACPGBI position statement.
Colorectal Dis. 2007;9(suppl 4):18–50.
26. Ommer A, Herold A, Berg E, Furst A, Sailer M, Schiedeck T. German S3 guideline: anal abscess. Int
J Colorectal Dis. 2012;27:831–837.
27. Jayarajah U, Samarasekera DN. Predictive accuracy of Goodsall’s rule for fistula-in-ano. Ceylon Med J.
2017;62:97–99.
28. Toyonaga T, Tanaka Y, Song JF, et al. Comparison of accuracy of physical examination and endoanal
ultrasonography for preoperative assessment in patients with acute and chronic anal fistula. Tech
Coloproctol. 2008;12:217–223.
98 ANORECTAL DISORDERS
29. Brillantino A, Iacobellis F, Di Sarno G, et al. Role of tridimensional endoanal ultrasound (3D-EAUS) in
the preoperative assessment of perianal sepsis. Int J Colorectal Dis. 2015;30:535–542.
30. Navarro-Luna A, Garcia-Domingo MI, Rius-Macias J, Margco-Molina C. Ultrasound study of anal fis-
tulas with hydrogen peroxide enhancement. Dis Colon Rectum. 2004;47:108–114.
31. Ratto, Grillo E, Parello A, Costamagna G, Doglietto GB. Endoanal ultrasound-guided surgery for anal
fistula. Endoscopy. 2005;37:722–728.
32. Sudol-Szopinska I, Kolodziejczak M, Szopinski TR. The accuracy of a postprocessing technique-
volume render mode—in three-dimensional endoanal sonography of anal abscesses and fistulas.
Dis Colon Rectum. 2011;54:238–244.
33. Khati NG, Lewis NS, Frazier AA, Obias V, Zeman RK, Hill MC. CT of acute perianal abscesses and
infected fistulae: a pictorial essay. Emerg Radiol. 2015;22:329–335.
34. Liang C, Lu Y, Zhao B, Du Y, Wang C, Jiang W. Imaging of anal fistulas: comparison of computed tomo-
graphic fistulography and magnetic resonance imaging. Korean J Radiol. 2014;15:712–723.
35. Vogel JD, Johnson EK, Morris AM, et al. Clinical practice guideline for the management of anorectal
abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum. 2016;59:1117–1133.
36. Lohsiriwat V. Anorectal emergencies. World J Gastroenterol. 2016;14:5867–5878.
37. Quah HM, Tang CL, Eu KW, Chan SY, Samuel M. Meta-analysis of randomized clinical trials comparing
drainage alone vs. primary sphincter-cutting procedures for anorectal abscess-fistula. Int J Colorectal
Dis. 2006;21:602–609.
38. Hamalainen K-PJ, Sainio AP. Incidence of fistulas after drainage of acute anorectal abscesses. Dis
Colon Rectum. 1998;41:1357–1362.
39. Aluwihar A. Finding the source of a fistula. Colorectal Dis. 2005;7:528–529.
40. Sahakitrungruang C, Pattana-Arun J, Khomvilai S, Tantiphlachiva K, Atittharnsakul P, Rojanasakul A.
Marsupialization for simple fistula in ano: a randomized controlled trial. J Med Assoc Thai.
2011;94:699–703.
41. Malik AI, Nelson RL. Surgical management of anal fistulae: a systematic review. Colorectal Dis.
2008;10:420–430.
42. Boenicke L, Karsten E, Zirngibl H, Ambe P. Advancement flap for treatment of complex cryptogland-
ular anal fistula: prediction of therapy success or failure using anamnestic and clinical parameters.
World J Surg. 2017;41:2395–2400.
43. Balciscueta Z, Uribe N, Balciscueta I, Andreu-Ballester JC, Garcia-Granero E. Rectal advancement flap
for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis. Int
J Colorectal Dis.
2017;32:599–609.
44. P
ommaret E, Benfredi P, Soudan D, de Parades V. Sphincter-sparing techniques for fistulas-in-ano.
J Visc Surg. 2015;152:S31–S36.
45. Tan KK, Kaur G, Byrne CM, Young J, Wright C, Solomon MJ. Long-term outcome of the anal fistula plug
for anal fistula of cryptoglandular origin. Colorectal Dis. 2013;15:1510–1514.
46. Thekkinkattil DK, Botterill I, Ambrose NS, et al. Efficacy of the anal fistula plug in complex anorectal
fistulae. Colorectal Dis. 2009;11:584–587.
47. Narang SK, Jones C, Alam NN, Daniels IR, Smart NJ. Delayed absorbable synthetic plug (GORE
®
BIO-A®) for the treatment of fistula-in-ano: a systematic review. Colorectal Dis. 2015;18:37–44.
48. Xu Y, Tang W. Comparison of an anal fistula plug and mucosa advancement flap for complex anal fis-
tulas: a meta-analysis. ANZ J Surg. 2016;86:978–982.
49. Bondi J, Avdagic J, Karlbom U, et al. Randomized clinical trial comparing collagen plug and advance-
ment flap for trans-sphincteric anal fistula. GJS. 2017;104:1160–1166.
50. Ozturk E. Treatment of recurrent anal fistula using an autologous cartilage plug: a pilot study. Tech
Coloproctol. 2015;19:301–307.
Chapter 7 • Anorectal Abscess and Fistula 99
51. Ratto C, Litta F, Donisi L, Parello A. Prospective evaluation of a new device for the treatment of anal
fistulas. World J Gastroenterol. 2016;22:6936–6943.
52. Rojanasakul A, Pattanaarun J, Sahakitrungruand C, Tantiphlachiva K. Total anal sphincter saving
technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai.
2007;90:581–586.
53. Vergara-Fernandez O, Espino-Urbina LA. Ligation of intersphincteric fistula tract: what is the evidence
in a review? World J Gastroenterol. 2013;19:6805–6813.
54. Limura E, Giordano P. Modern management of anal fistula. World J Gastroenterol. 2015;21:12–20.
55. Hong KD, Kang S, Kalaskar S, Wexner SD. Ligation of intersphincteric fistula tract (LIFT) to treat anal
fistula: systematic review and meta-analysis. Tech Coloproctol. 2014;18:685–691.
56. Xu Y, TangW. Ligation of intersphincteric fistula tract is suitable for recurrent anal fistulas from followup to 16 months. Biomed Res Int. 2017;2017.3152424.
https://doi.org/10.1155/2017/3152424 [Epub
2017 Feb 8].
57.
Kaminsk JP, Zaghiyan K, Fleshner P. Increasing experience of ligation of the intersphincteric fistula
tract for patients with Crohn’s disease: what have we learned? Colorectal Dis. 2017;19:750–755.
58. Emile SH, Elfeki H, Shalaby M, Sakr A. A systematic review and meta-analysis of the efficacy and safety
of video-assisted anal fistula treatment (VAAFT). Surg Endosc. 2018;32:2084–2093.
59. Garcia-Olmo D, Guadalajara H, Rubio-Perez I, Herreros MD, de-la-Quintana P, Garcia-Arranz M.
Recurrent anal fistulae: limited surgery supported by stem cells. World J Gastroenterol.
2015;21:3330–3336.
60. Borowski DW, Gill TS, Agarwal AK, Tabaqchali MA, Garg DK, Bhaska P. Adipose tissue-derived regen-
erative cell-enhanced lipofilling for treatment of cryptoglandular fistulae-in-ano: the ALFA technique.
Surg Innov. 2015;22:593–600.
61. Voswinkel J, Francois S, Simon JM, et al. Use of mesenchymal stem cells (MSC) in chronic inflamma-
tory fistulizing and fibrotic diseases: a comprehensive review. Clin Rev Allergy Immunol.
2013;45:180–192.
62. Lightner AL, Wang Z, Zubair AC, Dozois EJ. A systematic review and meta-analysis of mesenchymal
stem cell injections for the treatment of perianal Crohn’s disease: progress made and future direction.
Dis Colon Rectum. 2018;61:629–640.
63. Narang SK, Keogh K, Alam NN, Pathak S, Daniels IR, Smart NJ. A systematic review of new treatments
for cryptoglandular fistula in ano. Surgeon. 2017;15:30–39.
64. Prosst RL, Joos AK. Short-term outcomes of a novel endoscopic clipping device for closure of the inter-
nal opening in 100 anorectal fistulas. Tech Coloproctol. 2016;20:753–758.
65. Dango S, Antonakis F, Schrader D, Radzikhovskiy A, Ghadimi MB, Hesterberg R. Long-term efficacy
and safety of a nitinol closure clip system for anal fistula. Minim Invasive Ther Allied Technol.
2017;26:227–231.
66. Ozturk
E,
Gulcu B. Laser blation of fistula tract: a sphincter-preserving method for treating fistula-in-
ano. Dis Colon Rectum. 2014;57:360–364.
67. Giamundo P, Esercizio L, Geraci M, Tibaldi L, Valente M. Fistula-tract Laser Closure (FiLaC™): long-
term results and new operative strategies. Tech Coloproctol. 2015;19:449–453.
68. Arroyo A, Moya P, Rodriguez-Prieto MA, et al. Photodynamic therapy for the treatment of complex anal
fistula. Tech Coloproctol. 2017;21:149–153.
69. Sica GS, Di Carlo S, Tema G, et al. Treatment of peri-anal fistula in Crohn’s disease. World
J Gastroenterol. 2014;20:13205–13210. https://doi.org/10.3748/wjg. v20.i37.13205.
70.
Bouchard D, Abramowitz L, Bouguen G, et al. Anoperineal lesions in Crohn’s disease: French recommendations for clinical practice. Tech Coloproctol. 2017;21:683–691.
100 ANORECTAL DISORDERS
8
Pilonidal Disease
Luis Charu´a Guindic
HO S P I T AL A N G E L E S L O M A S , M EX I C O CI T Y , M EX I C O
8.1 Introduction
Pilonidal disease is a chronic and intermittent infectious process, forming a blind-ended
or sinus tract with walls made up of epithelial tissue. The presence of one or more hairs in
the tract causes a foreign-body reaction leading to infection that is usually located at the
midline of the sacrococcygeal region.
1
The first description of pilonidal disease is attributed to Herbert Mayo in 1833.2In 1847,
Abraham Wendell Anderson sent a letter to the editor of the Boston Medical Surgical Jour-
nal in which he described having extracted a hair from an ulcer in the sacral region of a
young 21-year-old man who was cured within 3 weeks.
3
In 1880 , Richard Manning Hodges
coined the term “pilonidal sinus” from the Latin pilus, “hair” and nidus, “nest,” or literally,
nest of hair.
4
In 1944, Louis A. Buie pointed out its prevalence in men and named it “jeep
disease,” given that an estimated 80,000 soldiers presented with the pathology during
World War II, losing significant active service time. It was attributed to the constant
trauma to the sacral region from prolonged riding in jeeps on difficult terrain.
5
8.2 Incidence
The disease is relatively frequent, with an increased incidence in young adult men, particularly hirsute individuals, at a ratio of 3–4:1. Its greatest manifestation occurs between
16 and 25years of age. It is more frequent in the white populati on, rarely presenting in
the black population, and practically absent in the Asian population.
6
The incidence
has been reported at 26 per 100,000 inhabitants, 38% of the cases have a family history
of the disease, and more than half of the patients have normal body weight.
7
8.3 Etiology
Pilonidal disease etiology has been a source of discussion and debate for many years. At
present there are two theories on the origin of the disease: congenital and acquired. The
congenital origin is considered to be embryonic, produced by a defect in the invagination
of the skin that covers the sacrococcygeal region. Another theory is that it is caused by a
remnant of the medullary canal left during embryonic development.
1
Anorectal Disorders. https://doi.org/10.1016/B978-0-12-815346-8.00008-4
© 2019 Elsevier Inc. All rights reserved.
101
The theory of acquired origin is widely accepted, despite the numerous mechanisms
proposed. In 1946, David H. Patey and Robert Wilfred Scarff were the first to state that
development of pilonidal disease was due to the penetration of hair into the subcutaneous
tissue, resulting in a granulomatous reaction. That theory was based on the high incidence
of recurrence, as well as the appearance of the disease in other areas of the body.
8
In 1980,
John Bascom proposed an alternative theory in which normal hair follicles become covered with keratin and penetrate into the soft subcutaneous fat; bacteria then colonize and
cause the formation of abscesses.
9
George Karydakis published his hypothesis in 1992 in which a loose hair is inserted into
the intergluteal fold causing an inflammatory response to the foreign body and secondary
infection, resulting in the formation of the primary sinus. The theory is based on three
factors that promote the insertion of the hair into the subdermal tissue. The first is the
invader, which is the loose hair; the second is the force that causes the insertion; and
the third is the vulnerability of the skin.
10
The theories of those two physicians, John Bascom and George Karydakis, provide the best explanations for the pathogenesis of the
disease.
Pilonidal disease is not exclusive to the sacrococcygeal region and its appearance has
been reported at the following sites: scalp, chest, groin, axilla, breast, penis, umbilicus,
anal duct, and interdigital commissure, as well as in facial wounds.
11–22
The microorganisms that have been cultured in the acute disease phase are: Escheri-
chia coli, group D Streptococci, Bacteroides fragilis, Bacteroides melaninogenicus, and species of Proteus, Fusobacterium, and Clostridium. In the chronic phase Staphylococcus
aureus, Streptococcus haemolyticus, Bacteroides sp., and Gram-negative cocci have been
isolated.
23
Anaerobic bacteria have been isolated in 77% of the cultures, whereas aerobic
bacteria have been isolated in only 4%, and the combination of the two in 17%.
24
8.4 Clinical Manifestations
Pilonidal disease can manifest as an abscess, triggering constant pain that increases daily,
accompanied by redness of the skin. Palpation reveals a tense and painful tumor. Fever,
chills, general malaise, and leukocytosis can also present. Once the abscess is drained,
whether spontaneously or surgically, there is immediate pain relief and suppuration gradually decreases until the wound closes. However, secretion has been known to persist
indefinitely.
If the disease is left untreated, the abscess can recur, and the formation of secondary
tracts and pits is not uncommon.
8.5 Differential Diagnosis
The differential diagnosis is made with anal fistula, hidradenitis suppurativa, sebaceous
cyst, pyoderma gangrenosum, osteomyelitis, congenital abnormalities, and actinomycosis.
102 ANORECTAL DISORDERS
8.6 Complications
The possibility of malignant degeneration of pilonidal disease is extremely low. It has been
associated with squamous cell carcinoma and basal cell carcinoma in long-term carriers
of the disease, on aver age for a period of 20 years or more. The Netherlands Cancer Institute identified 59 cases published up to the year 2001 that included 47 men and 12 women
with a mean age of 52 years, the majority of whom were treated with surger y. After mean
follow-up of 28 months, 20% of the patients persisted with disease and 10% had died from
a different cause. The recurrence rate was 39%, with a mean time to recurrence of only
9months. The local recurrence rate was lower when radiotherapy was added to the surgical treatment (30% vs 44%).
25
Other complications, such as osteomyelitis,26necrotizing fasciitis,27meningitis,28, and
septic shock
29
have been reported.
8.7 Pathologic Anatomy
The main characteristic is the presence of a blind-ended sinus tract with fibrous walls
lined by granulation tissue that often contains hair and is located at the midline of the
intergluteal fold, immediately above the sacrococcygeal ligament or fascia that frequently
becomes infected. The primary subcutaneous tract is usually 2–5 cm long and generally
communicates with a small cavity or sinus with a larger longitudinal diameter, which
in turn communicates with one or several secondary tracts. It should be m entioned that
no hair follicles, arrector pili muscle, sebaceous glands, or sudoriferous glands have been
identified in those lesions. Except for the primary opening that contains squamous epithelium, neither the wall of the sinus nor the secondar y tracts have an epithelial lining,
and therefore the term “pilonidal cyst” is not appropriate.
30
Many surgeons are accustomed to systematically sending the surgical specimen for its
histopathologic examination. In their study, Boulanger et al. analyzed the characteristics of
the surgical specimens of 731 patients. The primary outcome measure was the presence of
malignantdisease in the specimen and the secondary outcome measures were wound healing time and recurrence rate. There were no malignant lesions. The histologic analysis did
not describe resection margins for 323 patients. Resection was confirmed as complete in
285 patients and incomplete in 38. Twenty-four patients had recurrence (7%) and there
was no significant difference between the patients that had complete resection and those
that had incomplete resection. Healing time was 61days. The authors raised the question as
to the value of systematic histologic analysis of the surgical specimen in pilonidal disease.
31
8.8 Treatment
Persons with asymptomatic pits do not require treatment.
24
Incision and drainage of
the pilonidal abscess relieves symptoms, regardless of the size of the infe ctious process.
This procedure is preferred to definitive treatment, due to the presence of infection and
Chapter 8 • Pilonidal Disease 103
severe inflammation of the adjacent tissues. The abscess should be drained as soon as the
diagnosis is made. Pain relief is almost immediate, and the patient can return to his or her
daily activities. A bacterial culture or antimicrobial treatment (topic or systemic) is not
usually necessary, except in patients with orthopedic or cardiac devices and in those that
are immunocompromised.
32
After the cicatrization of the spontaneous drain or the surgical wound made to drain
the abscess, surgery, whose goal is the definitive cure of pilonidal disease, can be performed. A good number of these abscesses cicatrize permanently and most likely will
not require surgery. The need for surgical intervention can be determined 1 or 2 months
after abscess drainage.
8.8.1 Available Methods for the Surgical Treatment of Chronic or
Recurrent Pilonidal Disease
No treatment method for pilonidal disease has been completely satisfactory. Numerous
surgical and no nsurgical techniques for the definitive treatment of the disease have been
described. It should be emphasized that definitive cure is the result used to evaluate and
compare the different alternatives. Upon analyzing the published data, it becomes apparent that there are very few prospective, randomized, and controlled studies, which is a
significant problem.
Ideal surgery should be simple, and not require prolonged hospital stay. It should offer
a low recurrence rate, a minimum of pain, and ease of wound care to reduce the time away
from work, as well as low-cost of care.
The procedures for definitive treatment of pilonidal disease that stand out are outlined
in the following section.
8.8.1.1 Excision With Open Wound
This is a rapid and effective procedure involving excision with an open wound that consists of a wide elliptical incision that includes the disease tract or tracts and all its
branches. Hemostasis is verified and the wound is left open to allow closure by secondary
intention (
Fig. 8.1),
33,34
creating a hair and hair follicle-free cicatrization zone in which the
pathogenetic mechanism cannot occur.
35
The wound cicatrization time varies from 56 to
168 days, with recurrence rates of 2%–13%.
33
A minimal resection technique has been proposed for cases of chronic and limited disease, in which only the affected tissue is excised
and no deep incision to the sacral fascia is carried out, with good short-term and longterm results.
A recent option for managing large or complex pilonidal sinuses is vacuum-assisted
closure ( VAC), which is wound occlusion through subatmospheric pressure. A foam
pad is placed into the wound and plastic fenestrated tubing is inserted into the middle
portion of the pad. An adhesive drape is then placed to perfectly occlude the zone. In theory, this device aids in wound contraction by exerting centripetal force, increasing blood
flow, and by reducing edema and the bacteria count in the tissues. Its disadvantages are
104 ANORECTAL DISORDERS
cost and the relative immobility of the patient. VAC was first described in the management
of pilonidal disease by McGuinness in 2003, and there have been few reports since then in
the international literature.
36,37
8.8.1.2 Incision and Curettage
This metho d can be employed in all cases, including those with abscess. In incision and
curettage, the tract is identified, the skin is incised, the lesion is curetted, the secondary
tracts are identified, and the wound is examined, packing it with gauzes and compressing
it (
Fig. 8.2). This technique has two essential steps: first, the adjacent skin is resected to
create a flat plane and second, part of the wall of the sinus is resected. Given its relatively
short cicatrization time (27.2–48 days) and low recurrence rate (1.25%–19 .5%), the results
with this method are considered good.
38
8.8.1.3 Marsupialization
Louis Buie first described marsupialization in 1937 and later reported on it as treatment
for “jeep disease.” Cicatrization is faster if the sutures keep the edges together. Unfortunately, the sutures frequently break, and the result is the same as leaving the wound
FIG. 8.2 Incision and curettage technique stages: (A) introduction of a stylet from one opening to the other;
(B) unroofing of the sinus; and (C) curettage and wall exposure.
FIG. 8.1 Open technique. The aim is to remove the entire sinus with a margin of healthy adjacent tissue.
Chapter 8 • Pilonidal Disease 105
completely open and packed. Even without this complication, the wound requires packing, curettage, and dressings. Cicatrization takes a mean 4weeks (20–35 days) and the
recurrence rates are 1.2%–6%. Marsupialization can be re-attempted if the disease recurs
(
Fig. 8.3).
5,33,39
8.8.1.4 Excision and Primary Closure
Closure can be performed at the midline, lateral, or oblique locations.40There is a higher
risk of infection (12.4%), dehiscence (6.9%), and recurrence (9.4%) with closure at the midline (
Fig. 8.4), compared with other primary closure techniques.
41
The procedure
described by Karydakis consists of a lateral incision over the sinus and tracts to the sacral
fascia, mobilizing the edges from the opposite side to approximate the wound with no
tension at the side of the midline (
Fig. 8.5). Infection is reported in 7.9% of the cases,
dehiscence in 3.5%, and recurrence in 1.5%.
41
Sinus extraction was described by Peter Lord and John Bascom as a modification of the
Karydakis technique. These authors have emphasized the importance of not making the
incision at the midline. Bascom detailed two techniques for the treatment of pilonidal disease. In the first (Bascom I,
Fig. 8.6), the author proposes draining the sinus and excising
the pits. The sinus is drained through a longitudinal incision 2.5 cm from the midline,
through which the sinus is approached, and the granulation tissue and hairs are curetted.
All the pits are excised cylindrically and individually, leaving only small wounds 2–4mm in
diameter at the midline. The cavity walls are not resected and are allowed to collapse. The
resection sites of the pits are closed with nonabsorbable 3-0 or 4-0 subcut icular sutures
and the drainage wound is left open. Surgery can be performed as an outpatient procedure
in the office or hospital.
42–44
In the authors’ report of the technique, the incision was smaller than 7 mm, mean dis-
ability time was 1 day, mean healing time was 3 weeks, and there was 8% recurrence.
44
The Bascom II technique involves a full-thickness rotation flap and is described in the
next section.
FIG. 8.3 Marsupialization technique: (A) incision and curettage of the cavity with resection of the edges. (B,C)
suturing of the edges.
106 ANORECTAL DISORDERS
FIG. 8.4 Excision and closure at the midline: (A) delimitation of the cavity through methylene blue staining;
(B) complete tangential excision, without opening the cavity; (C, D) two-layer wound closure.
FIG. 8.5 Karydakis technique. (A–C) lateral incision of the cavity and excision of the sinus; (D, E) lateral wound
approximation by layers.
Chapter 8 • Pilonidal Disease 107
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