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67
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_5, © Springer-Verlag London Limited 2012
5.1 Etiology
Pilonidal sinus disease was fi rst described in the nineteenth century [ 1 ] . Although a
minor condition for most patients, it can result in pain and sepsis with long periods
off work and education. It has caused severe disruption to the armed forces over the
years. In one army center in the USA in the 1990s, over a 2-year period, 229 patients
required 4,760 occupied-bed days, an average of 21 days per patient [ 2 ] . It is an
acquired condition and is seldom seen before puberty. It is rarely seen in older
patients. Risk factors include young age, male gender, hairiness, obesity, deep natal
cleft, and poor hygiene [ 3, 4 ] . Pilonidal sinus disease is commoner in people from
Mediterranean countries. It is thought to be caused by tethering of the midline raphe
in the natal cleft to the underlying sacrum. Enlargement of hair follicles or skin
crypts occurs resulting in sinuses, possibly as a result of changes to these follicles
during puberty with blockage and subsequent sepsis within the follicles. Hair enters
these sinuses and secondarily exacerbating the infection. This is facilitated by the
movement of the buttocks and the barbed nature of the hairs [ 5, 6 ] . Although pilo-
nidal pits occur elsewhere in the body due to direct puncture of the skin due to hairs,
it is not thought to be the etiology in pilonidal sinus disease in the natal cleft [ 7 ] .
5.2 Treatment
Wide en bloc excision of pilonidal sinus disease is still practiced in many centers,
although for the last 70 years it has been becoming increasingly recognized that
debilitating complications often result if this approach fails. In 2001 in England
A. Senapati , Ph.D., FRCS
Department of Surgery , Queen Alexandria Hospital ,
Southwick Hill Rd., Cosham , Portsmouth , PO6 3LY , Hampshire , UK
e-mail: asha.senapati@porthosp.nhs.uk
Chapter 5
The Management of Pilonidal Sinus Disease
Asha Senapati
68
A. Senapati
and Wales, 11,534 patients stayed in hospital for a mean of 4.3 days (49,596 bed
days) [ 8 ] . However, pilonidal sinus disease can be treated entirely as a day case
when appropriately managed. Surgical treatment of pilonidal disease should now
infrequently require hospital admission. Although treatments may have improved,
for some patients, the complications of surgery remain worse than the primary
disease [
9, 10 ] .
Wound healing, recurrent disease and rates of postoperative wound complica-
tions, and time to complete healing are the factors that need to be measured when
comparing different modalities of treatment. Very few studies have included all
these parameters [ 9 ] . Long periods of follow-up are needed; in small studies with
short follow-up, there is a risk of underreporting the most signifi cant and debilitat-
ing complications of pilonidal disease surgery [ 11 ] . It is diffi cult to draw fi rm con-
clusions about different modalities of surgical treatment without this information,
often absent, even within randomized trials [ 9, 10 ] .
5.3 Methods of Treatment ( Box 5.1 )
5.3.1 Nonsurgical Treatment
Treatment is not required in asymptomatic patients. Shaving and attention to per-
sonal hygiene can reduce symptoms from this disease although they do not cure the
condition. Injection with sclerosants and phenol injections without resort to exci-
sional surgery have been used with reported cure rates of 70% [ 12 ] .
5.3.2 Simple Surgical Procedures Without Wide Excision
of the Abscess Cavity
Complete healing rates in patients presenting with an acute pilonidal abscess treated
by simple incision and drainage are 50%.
Box 5.1: Management of Pilonidal Sinus Disease
Asymptomatic – do not treat
Simple disease – simple surgery, e.g., Bascom’s operation or trephine
Complex disease, recurrent disease, and complications – cleft closure,
Karydakis
Failures of above treatments – Limberg fl aps, rhomboid fl ap, etc.
No midline closures
69
5 The Management of Pilonidal Sinus Disease
In the elective setting, a simple, midline pilonidal sinus can be treated by laying open
the track and marsupialization of the wound edges, with reasonable expectation of cure
and rapid wound healing by secondary intention (Table 5.1 ). In one series, only 7 of 125
(6%) patients experienced recurrence when treated in this manner [ 19 ] . Another simple
approach with a high rate of success is Bascom’s operation, the aim of which is to “pick
the pits” and “stay out of the ditch.” The midline pits are removed through small inci-
sions and the abscess drained through a lateral drainage incision (Fig. 5.1 ), In Bascom’s
series of 161 patients, the cumulative 5-year recurrence rate was 17% [ 15 ] . The opera-
tion is simple to perform and can be done under local anesthetic. Patients are self-caring
postoperatively, and the lateral wound does not delay return to work.
Gips et al. [ 18 ] treated 1,358 cases by a similar minimally invasive approach,
involving trephine excision of all midline pits and secondary openings. Their series
was followed carefully. The cumulative recurrence rate at 1 year was 6.5% and
13.2% at 5 years. A second operation was performed in 53 patients (4%) for recur-
rent sinus formation, with 38 (70%) healing after surgery.
These simple surgical techniques have the advantage that they are straightfor-
ward operations and do not have debilitating consequences if they fail. Furthermore,
they can often be repeated and result in minimal time off work.
Table 5.1 Results of simple surgical procedures
Name Year No. Anesthetic
Hospital
stay (days)
Mean time
to healing
(weeks)
Recurrence
rate (%)
Lord and Millar [
7 ] 1965 33 LA DC Not stated
3
Edwards [
13 ] 1977 120 LA/GA DC 39 11
Bascom [
14 ] 1980 50 LA DC 3 8
Bascom [
15 ] 1983 161 LA DC 3 17
Mosquera and
Quayle [
16 ]
1995 41 GA 2 <8 7.3
Senapati et al. [
17 ] 2000 218 LA DC 4 10
Gips et al. [
18 ] 2008 1358 LA DC 3.4 16
Fig. 5.1 Bascom’s operation
70
A. Senapati
5.3.3 Wide Excision and Midline Closure
Wide local excision and closure has been found to have a poorer outcome in a
Cochrane review than other surgical techniques [ 9 ] , but it is still used widely.
Although the majority of patients will heal primarily after wide excision and suture,
or heal by secondary intention when the sinus is excised and left open, in some
patients, an unhealed midline wound is debilitating and may cause morbidity for
many years [ 20 ] , requiring multiple operations or reconstructive surgery. It is
believed that unhealed wounds in the midline of the natal cleft fail to heal because
of the anaerobic environment when the patient assumes their normal posture, either
lying, sitting, or standing. Although these long-term unhealed midline wounds may
be uncommon, they are the bête noire of pilonidal surgery. In addition, recurrent
pilonidal sinus can develop in up to 40% of patients [ 11 ] .
5.3.4 Off-Midline Closure with and Without Excision
of the Abscess Cavity
Two systematic reviews which include an analysis of six randomized controlled tri-
als [ 9, 10 ] concluded that off-midline closure should become standard management
and have better results than the midline wound. Karydakis’ operation is the most
well known of these, which was developed “to place new resistant skin to the depth
of the intergluteal fold to prevent hair insertion, and therefore recurrent disease.”
This is achieved by an elliptical, asymmetrical, and wide excision of the disease
mobilizing the skin edge closest to the midline to produce a thick fl ap, which is then
sutured to the side furthest away from the midline (Fig. 5.2 ). The deep surface of the
fl ap is transfi xed to the underlying sacrococcygeal fascia [ 4 ] . Many thousands of
patients were treated by Karydakis with a 1% recurrence rate: the operation was
performed as an inpatient under general anesthetic [ 21 ] .
Line of
excision
Excision taken down to
sarococcygeal fascia
Subcutaneous fat
undermined to
close space
off midline
Fig. 5.2 The principle behind the Karydakis procedure
71
5 The Management of Pilonidal Sinus Disease
Kitchen and Bascom modifi ed the Karydakis technique [ 22, 23 ] . Bascom’s cleft
closure, or cleft lift operation, does not require excision of the abscess cavity and
excision is limited to the skin over the natal cleft. Lateral suture keeps the skin wound
away from the midline and partially fl attens the natal cleft (Fig. 5.3 ) Eradication of
the source of sepsis in the midline will allow healing. Published results of these tech-
niques show primary healing rates of between 74% and 97% (Table 5.2 ). A random-
ized trial comparing Bascom’s two operations for primary pilonidal sinus disease
showed better results with the cleft lift procedure [ 31 ] . Five of 29 patients undergoing
Fig. 5.3 Resultant wound after Bascom’s cleft
closure technique
72
A. Senapati
Table 5.2 Results of off-midline closure
Name Year Operation No.
Wound
complications (%) Anesthesia
Mean length of
hospital stay (days)
Mean time to
complete wound
healing (weeks)
Recurrence
rate
Karydakis [
21 ] 1992 Karydakis 7471 8 GA N/S N/S
1%
Bascom [
20 ] 2002 Cleft closure 27 10 GA/LA D/C 17 months 0
Kitchen [
23 ] 1996 Karydakis 141 9 GA 4 Short 4%
Anyanwu et al.
[
24 ]
1998 Karydakis 28 3 GA 4 Short 0
Patel et al. [
25 ] 1999 Karydakis 50 N/S N/S 7 3 0
Akinci et al. [
26 ] 2000 Asymmetric
closure
112 6 N/S 2.6 2 1%
Morden et al.
[
27 ]
2005 Karydakis 24 8 G/A DC N/S 0
Anderson et al.
[
28 ]
2008 Karydakis 51 20 GA DC 3 0
Rushfeldt et al.
[
29 ]
2008 Cleft closure 33 24 LA DC N/S 17%
Abdelrazeq et al.
[
30 ]
2008 Cleft closure 70 20 N/S N/S N/S 1%
Nordon et al. [
31 ] 2009 Cleft closure 26 19 GA/LA DC 1–5 0
Senapati et al.
[
32 ]
2011 Cleft closure 150 14 GA/LA DC 2–64 5%
Ersoy et al. [
33 ] 2009 Karydakis 50 26 N/S 2 Short N/S
N/S not stated, DC day case
73
5 The Management of Pilonidal Sinus Disease
simple pit excision failed to heal and required further surgery, compared to none of
the 26 patients who underwent the cleft lift procedure. Furthermore, after median
follow-up of 3 years, two patients developed recurrent disease after pit excision com-
pared to none of the patients who underwent cleft lift procedure.
5.3.5 More Complex Skin Flat Procedures After Wide
Excisional Surgery
Good results have been achieved after V-Y plasty or rhomboid or Limberg fl aps
[ 34– 37 ] . However, these operations are complex, require general anesthesia and a
period of time in hospital, and have greater potential complications than simpler
procedures. In particular, they are cosmetically disfi guring because the natal cleft is
completely obliterated and surgery results in horizontal scars across the buttocks
(Fig. 5.4 ).
5.3.6 Treatment of Recurrence, Complications, and Extensive
Pilonidal Sinus Disease
Once a midline wound has become established, simple procedures are unlikely to
result in wound healing. Neither recurrent disease developing after simple proce-
dures nor extensive primary pilonidal sinus disease is suitable for simple opera-
tions. Under these circumstances Karydakis’ or Bascom’s cleft lift procedures
may be performed with good results. The recurrence rate was 5% in a series of
150 patients having a cleft lift operation for failure of healing of a midline wound,
or recurrent or extensive pilonidal sinus [ 32 ] . Although partial breakdown of the
wound occurred in a percentage of patients, they were all healed after a median
of 11 weeks.
Fig. 5.4 Resultant wound
after Limberg fl ap procedure
74
A. Senapati
5.4 Summary of Treatments
Surgery for pilonidal sinus disease should be simple with no long-term morbidity.
Although all treatments have a failure rate, the failures should cause minimal mor-
bidity to the patient and should be correctable. Avoidance of midline wounds with
the use of lateral closure techniques is the preferred surgical treatment.
References
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45P–6.
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of symptomatic pilonidal sinus. Br J Surg. 2000;87(8):1067–70.
Key Points
Pilonidal sinus disease
Symptomatic disease needs surgical treatment •
Simple day-case surgery is best •
Off-midline wounds are best •
Unhealed midline wounds can be avoided •
Unsightly wounds can be avoided •
75
5 The Management of Pilonidal Sinus Disease
18. Gips M, Melki Y, Salem L, Weil R, Sulkes J. Minimal surgery for pilonidal disease using tre-
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Obstet. 1982;155(3):409–11.
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77
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_6, © Springer-Verlag London Limited 2012
6.1 What Is Hidradenitis?
The term hidradenitis comes from the two Greek words: hidros = sweat and
aden = glands. Hidradenitis is a chronic acneiform infection of the cutaneous apo-
crine glands that also involves adjacent subcutaneous tissue and fascia. The hall-
mark of the disease is sinus tracks in the apocrine gland body areas. Typically, the
patient complains of painful, infl amed, discharging sinuses in the axillae, the groins,
the perineum, and occasionally under the breasts – all areas that contain the so-
called apocrine sweat glands (Box 6.1 ) .
6.2 Pathophysiology
The most likely mechanism responsible for the development of hidradenitis is
occlusion of the hair follicle (rather than the apocrine gland) due to a defect in ter-
minal follicular epithelium (Fig. 6.1 ). Therefore, hidradenitis is now described as a
disorder of terminal follicular epithelium within apocrine gland bearing skin [ 2 ] .
N. Scott , M.D., FRCS
Department of Colorectal Surgery , Royal Preston Hospital ,
Sharoe Green Lane, Fulwood, Preston, Lancashire PR2 9HT , UK
e-mail: nigel.scott11@btinternet.com
Chapter 6
Hidradenitis Suppurativa
Nigel Scott
Box 6.1: Hidradenitis: The Facts
Common: involves 1–2% of the population, but the precise incidence and •
prevalence are unknown
Sex prevalence: 4• ♀:1♂
Onset at any age after puberty – peak incidence of onset between 11 and •
30 years; declining rapidly by the fi fth decade [ 1 ]
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