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Extensive pilonidal cyst
EXTENSIVE PILONIDAL CYST* CASE REPORT CAPTAIN R.
W.
POSTLETHWAIT
MEDICAL CORPS, ARMY OF THE UNITED STATES ECENTLY a Iarge number of papers have appeared concerning the treatment of pilonida1 sinus and cyst.‘v3-
R
4,8.6,7,8.11,12,13,11,16.17The
metho&
of
treat_
ment vary, although most authors discuss different means of obIiterating the dead space after excision, others present radica1 departures from the usua1 therapy.2sg At this hospita1, the premise is foIIowed that each case is a probIem within itseIf and so the prdcedure for each patient is individuaIized as the characteristics of the Iesion indicate. The case reported here was a patient with a Iarge piIonida1 cyst with extensive ramifications of the secondary tracts requiring radica1 excision to obtain a satisfactory resuIt. CASE
REPORT
The patient was a thirty-eight year old white man who entered the hospita1 because of pain and discharge about the anus. One year before, the patient had an ana abscess which required incision and drainage by his physician. HeaIing took pIace after about three months and the patient had no further diffrcuIty unti1 two months before his admission here. At this time he had noted severe aching pain about the anus. For two weeks before admission there had been a discharge of puruIent materia1 without decrease in pain. The famiIy and past histories were non-contributory. The genera1 physica examination showed no abnormaIities. To the Ieft of the anus was a trianguIar scar in which there were three smaI1 openings, with another opening just posterior to the scar. Moderate redness, sweIIing and tenderness were present about the anterior Iimb of the scar. In the midline posteriorly was a fifth opening, and to the right of the anus was a sixth opening. Pressure on the swoIIen area produced a puruIent discharge from the openings posteriorIy and on the right. A slit-
Iike opening, in which hair couId be seen, was present just beIow the tip of the coccyx and ten more openings were scattered over the sacrococcygea1 area. By Iimited gentIe probing, the tracts were a11 found to communicate with one another. CIinicaI Iaboratory finding showed a red blood ceI1 count of 3,940,000, hemogIobin 70 per cent (TaIquist), white blood ceI1 count 8,850 with 76 per cent poIymorphonucIear forms. The urinaIysis was negative; Kahn test was negative. CuIture of the puruIent discharge showed BaciIIus ,aerobacter aerogenes. The patient was given sitz baths twice daily and minera oi1 each evening. The infiammatory reaction rapidly subsided and the discharge decreased. Operation was done under spinal anesthesia on the seventh hospita1 day. A careful search was made for an interna (or primary) anorecta1 opening but none couId be found. The IistuIous tracts about the anus, incIuding a cystic area posteriorIy, were first excised. The end of the strand of hair was found protruding into this posterior cyst. The cyst and tracts over the sacrococcygea1 region were then excised, which necessitated dissection down to the sacrococcygea1 fascia. The pIan had been to Ieave a bridge of intact skin in the region of the coccyx by tunneIing subcutaneousIy, but this was found impracticabIe because of the superficial tract in this area. The connecting tract containing the strand of hair was therefore excised compIeteIy. Because of the anticipated difI?cuIty in heaIing, an attempt was made to reconstruct a bridge of skin and subcutaneous tissue at the IeveI of the coccyx. Two sutures of siIkworm gut were pIaced through the skin and through the fascia over the coccyx. The skin for a distance of about 3 cm. was approximated with interrupted fine silk. The remaining open areas Iying above and beIow the coccyx were IooseIy packed with gauze moistened with azochIoramid. Pathologic study showed foci of infIammatory ceI1 infiItration, especiaIIy of round ceIIs,
* From the Surgical Service of the Station Hospital, Fort Myer, Virginia, CoIoneI M. F. DuFrenne, Commanding. 416
/OL. LXV,
No .3
PostIethwait-PiIonidaI
thrc3ughou It. There
were a number of tracts Jersing the subcu taneous tissue, which were line d with squamou: ; epithelium and contained
Cyst
American I Journal
of Surgery
417
thirds heaIed. EIeven da ys later heahng was complete and the patient was discharged from the hospita1. He has rema lined we11 to datl e.
FIG. I. Upper left: Extent of lesion prior to operation, with applicators in Iarger openings; upper right: extent of wound jfter excision; lower left: healing fourteen days lower right: twenty-eight days after after operation; operation, healing nearIy complete.
hairs. Some of these showed inflammatory reaction. There was aIso a Iarger tract Iined by granuIation tissue with many poIymorphonucIear and giant ceIIs in addition to the round cells. The wound was dressed every other day and the packs repIaced. At the end of ten days, the bridge of tissue over the coccyx was firmIy heaIed with union to the coccygea1 fascia. There was very Iittle discharge and healthy granulation tissue was present in the open areas. FoIIowing this, an ointment containing 6 per cent suIfaniIamide and IO per cent cod Iiver oil ip Ianolin was applied daily. Progress thereafter was very rapid. Twenty-eight days after operation, the upper haIf of the wound was aImost healed and the Iower half was two-
COMMENT
The recent exceIIent summary by Kooistra1° makes any review of the Iiterature unnecessary here. SeveraI features of the reported case were interesting. The extent of the Iesion was unusua1. When the patient was first seen, a diagnosis of fistuIo-in-ano and piIonida1 cyst was made. This combination has been reported by Warman.15 As no internal opening couId be found at operation, it was apparent that the extension was entirely from the piIonida1 cyst. The advantage of Ieaving a bridge of intact tissue in the region of the coccyx when the tract extends in this direction has been
418
AmericanJournaIof Surgery
PostIethwait-PiIonidaI
noted by others in the treating of f%tuIoin-ano, and a two-stage operation may be preferabIe to opening this entire area because of diffIcuIty in heaIing. FortunateIy, firm union resuIted in the sutured tissue of this case, and this was an important factor in hastening fina heahng. The preparation of suIfaniIamide and cod Iiver oi1 in IanoIin was modified from the formuIa suggested by Brezin.3 This aIso aided greatIy in the heaIing process as evidenced by the smaI1 amount of discharge and the rapid growth of firm heaIthy granuIation tissue. REFERENCES I. ADCOCK, DAVID F. Pilonidal cyst. J. Soutb Carolina M. A., 38: Iog, 1942. 2. BIEGELEISEN, H. I. ScIerotherapy for piIonida1 cyst. Am. J. Surg., 44: 622, 1939. 3. BREZIN, DAVID. Pilonidal cyst. Am. J. Surg., 59: 18, 1943. 4. BREZIN, DAVID; LOVE, CARRUTHERS and LAWRENCE, JOSEPH. PiIonidal cyst. Am. J. Surg., 60: 264, 1943. 5. COHN, ISIDORE. An operation Am. J. Surg., 61: 61, 1943.
for pilonida1 sinus.
Cyst
SEPTEMBER, ,944
6. DEPRIZIO, CARL J. PiIonidaI cyst and a new improved type operation. ML Surg., 91: zgz, 1942. 7. DUNPHY, J. E. and MATSON, D. D. The treatment of pilonidal sinus. Surg., Gynec. IT Oh., 75: 737, 1942. 8. JACOBS, RAYMOND G. Observations of pilonidat cysts. U. S. Naval Med. Bull., 41: 1296, 1943. Q. JACOBSON, PHILIP. A new method for eradicating congenita1 sinuses by eIectrocoagulation and steam, with special reference to pitonidal sinuses. Virginia M. Monthly, 6g: 206, 1942. IO. KOOISTRA, HENRY P. PiIonidal sinuses. Am. J. Surg., 55: 3, 1942. I I. LANE. WARREN Z. PiIonidaI cvsts and sinuses in the na;y. U. S. Naval Med. But%, 4 I : I 284, 1943. 12. MACFEE, WILLIAM F. PiIonidaI cysts and sinuses. Ann. Surg., I 16: 587, 1942. 13. PICKET-~,WILLIAM J. and BEATTY, ARCH J. Pilonida1 cysts in the army. Am. J. Surg., 56: 375, ‘942. 14. SCOTT, JAMES V. PiIonidaI cyst, the IocaI use of buffered SuIfaniIamide m primary cIosure. Ann. Surg., 117: 191, 1943. 15. WARMAN, W. MERLE. A case of fistuIa in ano with piIonida1 sinus. West Virginia M. J., 32: 80, 1936. 16. WEEKS, RICHARD B. and YOUNG, GEORGE G. SacrococcygeaI cysts. Am. J. Surg., 60: 260, 1943. 17. WOLDENBERG, S. C. and SHARPE, W. S. Surgical treatment of piIonida1 (dermoid) cysts. Surg., Gynec. c~ Obst., 76: 164, 1943.
W.
POSTLETHWAIT
MEDICAL CORPS, ARMY OF THE UNITED STATES ECENTLY a Iarge number of papers have appeared concerning the treatment of pilonida1 sinus and cyst.‘v3-
R
4,8.6,7,8.11,12,13,11,16.17The
metho&
of
treat_
ment vary, although most authors discuss different means of obIiterating the dead space after excision, others present radica1 departures from the usua1 therapy.2sg At this hospita1, the premise is foIIowed that each case is a probIem within itseIf and so the prdcedure for each patient is individuaIized as the characteristics of the Iesion indicate. The case reported here was a patient with a Iarge piIonida1 cyst with extensive ramifications of the secondary tracts requiring radica1 excision to obtain a satisfactory resuIt. CASE
REPORT
The patient was a thirty-eight year old white man who entered the hospita1 because of pain and discharge about the anus. One year before, the patient had an ana abscess which required incision and drainage by his physician. HeaIing took pIace after about three months and the patient had no further diffrcuIty unti1 two months before his admission here. At this time he had noted severe aching pain about the anus. For two weeks before admission there had been a discharge of puruIent materia1 without decrease in pain. The famiIy and past histories were non-contributory. The genera1 physica examination showed no abnormaIities. To the Ieft of the anus was a trianguIar scar in which there were three smaI1 openings, with another opening just posterior to the scar. Moderate redness, sweIIing and tenderness were present about the anterior Iimb of the scar. In the midline posteriorly was a fifth opening, and to the right of the anus was a sixth opening. Pressure on the swoIIen area produced a puruIent discharge from the openings posteriorIy and on the right. A slit-
Iike opening, in which hair couId be seen, was present just beIow the tip of the coccyx and ten more openings were scattered over the sacrococcygea1 area. By Iimited gentIe probing, the tracts were a11 found to communicate with one another. CIinicaI Iaboratory finding showed a red blood ceI1 count of 3,940,000, hemogIobin 70 per cent (TaIquist), white blood ceI1 count 8,850 with 76 per cent poIymorphonucIear forms. The urinaIysis was negative; Kahn test was negative. CuIture of the puruIent discharge showed BaciIIus ,aerobacter aerogenes. The patient was given sitz baths twice daily and minera oi1 each evening. The infiammatory reaction rapidly subsided and the discharge decreased. Operation was done under spinal anesthesia on the seventh hospita1 day. A careful search was made for an interna (or primary) anorecta1 opening but none couId be found. The IistuIous tracts about the anus, incIuding a cystic area posteriorIy, were first excised. The end of the strand of hair was found protruding into this posterior cyst. The cyst and tracts over the sacrococcygea1 region were then excised, which necessitated dissection down to the sacrococcygea1 fascia. The pIan had been to Ieave a bridge of intact skin in the region of the coccyx by tunneIing subcutaneousIy, but this was found impracticabIe because of the superficial tract in this area. The connecting tract containing the strand of hair was therefore excised compIeteIy. Because of the anticipated difI?cuIty in heaIing, an attempt was made to reconstruct a bridge of skin and subcutaneous tissue at the IeveI of the coccyx. Two sutures of siIkworm gut were pIaced through the skin and through the fascia over the coccyx. The skin for a distance of about 3 cm. was approximated with interrupted fine silk. The remaining open areas Iying above and beIow the coccyx were IooseIy packed with gauze moistened with azochIoramid. Pathologic study showed foci of infIammatory ceI1 infiItration, especiaIIy of round ceIIs,
* From the Surgical Service of the Station Hospital, Fort Myer, Virginia, CoIoneI M. F. DuFrenne, Commanding. 416
/OL. LXV,
No .3
PostIethwait-PiIonidaI
thrc3ughou It. There
were a number of tracts Jersing the subcu taneous tissue, which were line d with squamou: ; epithelium and contained
Cyst
American I Journal
of Surgery
417
thirds heaIed. EIeven da ys later heahng was complete and the patient was discharged from the hospita1. He has rema lined we11 to datl e.
FIG. I. Upper left: Extent of lesion prior to operation, with applicators in Iarger openings; upper right: extent of wound jfter excision; lower left: healing fourteen days lower right: twenty-eight days after after operation; operation, healing nearIy complete.
hairs. Some of these showed inflammatory reaction. There was aIso a Iarger tract Iined by granuIation tissue with many poIymorphonucIear and giant ceIIs in addition to the round cells. The wound was dressed every other day and the packs repIaced. At the end of ten days, the bridge of tissue over the coccyx was firmIy heaIed with union to the coccygea1 fascia. There was very Iittle discharge and healthy granulation tissue was present in the open areas. FoIIowing this, an ointment containing 6 per cent suIfaniIamide and IO per cent cod Iiver oil ip Ianolin was applied daily. Progress thereafter was very rapid. Twenty-eight days after operation, the upper haIf of the wound was aImost healed and the Iower half was two-
COMMENT
The recent exceIIent summary by Kooistra1° makes any review of the Iiterature unnecessary here. SeveraI features of the reported case were interesting. The extent of the Iesion was unusua1. When the patient was first seen, a diagnosis of fistuIo-in-ano and piIonida1 cyst was made. This combination has been reported by Warman.15 As no internal opening couId be found at operation, it was apparent that the extension was entirely from the piIonida1 cyst. The advantage of Ieaving a bridge of intact tissue in the region of the coccyx when the tract extends in this direction has been
418
AmericanJournaIof Surgery
PostIethwait-PiIonidaI
noted by others in the treating of f%tuIoin-ano, and a two-stage operation may be preferabIe to opening this entire area because of diffIcuIty in heaIing. FortunateIy, firm union resuIted in the sutured tissue of this case, and this was an important factor in hastening fina heahng. The preparation of suIfaniIamide and cod Iiver oi1 in IanoIin was modified from the formuIa suggested by Brezin.3 This aIso aided greatIy in the heaIing process as evidenced by the smaI1 amount of discharge and the rapid growth of firm heaIthy granuIation tissue. REFERENCES I. ADCOCK, DAVID F. Pilonidal cyst. J. Soutb Carolina M. A., 38: Iog, 1942. 2. BIEGELEISEN, H. I. ScIerotherapy for piIonida1 cyst. Am. J. Surg., 44: 622, 1939. 3. BREZIN, DAVID. Pilonidal cyst. Am. J. Surg., 59: 18, 1943. 4. BREZIN, DAVID; LOVE, CARRUTHERS and LAWRENCE, JOSEPH. PiIonidal cyst. Am. J. Surg., 60: 264, 1943. 5. COHN, ISIDORE. An operation Am. J. Surg., 61: 61, 1943.
for pilonida1 sinus.
Cyst
SEPTEMBER, ,944
6. DEPRIZIO, CARL J. PiIonidaI cyst and a new improved type operation. ML Surg., 91: zgz, 1942. 7. DUNPHY, J. E. and MATSON, D. D. The treatment of pilonidal sinus. Surg., Gynec. IT Oh., 75: 737, 1942. 8. JACOBS, RAYMOND G. Observations of pilonidat cysts. U. S. Naval Med. Bull., 41: 1296, 1943. Q. JACOBSON, PHILIP. A new method for eradicating congenita1 sinuses by eIectrocoagulation and steam, with special reference to pitonidal sinuses. Virginia M. Monthly, 6g: 206, 1942. IO. KOOISTRA, HENRY P. PiIonidal sinuses. Am. J. Surg., 55: 3, 1942. I I. LANE. WARREN Z. PiIonidaI cvsts and sinuses in the na;y. U. S. Naval Med. But%, 4 I : I 284, 1943. 12. MACFEE, WILLIAM F. PiIonidaI cysts and sinuses. Ann. Surg., I 16: 587, 1942. 13. PICKET-~,WILLIAM J. and BEATTY, ARCH J. Pilonida1 cysts in the army. Am. J. Surg., 56: 375, ‘942. 14. SCOTT, JAMES V. PiIonidaI cyst, the IocaI use of buffered SuIfaniIamide m primary cIosure. Ann. Surg., 117: 191, 1943. 15. WARMAN, W. MERLE. A case of fistuIa in ano with piIonida1 sinus. West Virginia M. J., 32: 80, 1936. 16. WEEKS, RICHARD B. and YOUNG, GEORGE G. SacrococcygeaI cysts. Am. J. Surg., 60: 260, 1943. 17. WOLDENBERG, S. C. and SHARPE, W. S. Surgical treatment of piIonida1 (dermoid) cysts. Surg., Gynec. c~ Obst., 76: 164, 1943.