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Nd:YAG and CO2 Lasers for the Treatment of Pilonidal Sinuses: Advantages over Traditional Techniques
Med. Laser Appl. 19: 155–159 (2004) Elsevier – Urban & Fischer http://www.elsevier.de/lasermed
Nd:YAG and CO2 Lasers for the Treatment of Pilonidal Sinuses: Advantages over Traditional Techniques SHLOMO WALFISCH1, HAIM MNITENTAG2, ABRAHAM M. BARUCHIN3, and AMIRAM SAGI3 1
Colorectal Unit Laser Center 3 Department for Plastic and Reconstructive Surgery Soroka and Barzilai University Medical Centers, Faculty of Health Sciences, Ben Gurion University of the Negev, Israel 2
Submitted: June 2004 · Accepted: September 2004
Summary Pilonidal disease is a common problem in countries with a hot climate. Prolonged healing time and high recurrence rate are the common problems encountered while treating the disease. We evaluated the outcome of surgery in patients whose pilonidal disease was operated using Nd:YAG or CO2 lasers and compared it to the outcome of conventional (non laser) surgery. During the last 9 years 300 patients were operated on in our institute for pilonidal disease. Except for the first 10 patients all patients were operated on under local anesthesia. The operating methods included: (1) Conventional cystectomy through paramedian incision. (2) Nd:YAG laser cystectomy through paramedian incision. (3) Conventional midline cystostomy and curettage. (4) Nd:YAG laser midline cystostomy and curettage, and (5) CO2 laser cystotomy and curettage through a midline incision. The groups were compared regarding bleeding, healing time, postoperative infection rate and recurrence rate. Operative time was similar. Results: Healing time was considerably shorter in all laser treated groups. The rate of postoperative bleeding, postoperative infections and recurrences was also lower in all these groups. The Nd:YAG laser and the CO2 laser yielded similar results. Healing time and postoperative complications were compared. Laser surgery is advantageous over the equivalent conventional surgery in the treatment of pilonidal disease. The main advantage is the much shorter healing time (wound closure) and simplicity of technique. Complication rate was also lower in the laser treated group. The Nd:YAG and the CO2 laser operative results are comparable. Better cost effectiveness is an advantage of the CO2 laser over the Nd:YAG laser.
Key words Pilonidal disease, Nd:YAG laser, CO2 laser
Introduction The pilonidal disease is a relatively common problem occurring in 0.1–1.0% of the population (1, 4). The common etiology is penetration of hairs or hair remnants into the skin of the natal cleft. These buried hair follicles become at times dilated or infected and sub-
sequently form cysts or discharging sinuses that are responsible for the clinical signs and symptoms (1). Many methods have been advocated for the treatment of the disease, all of which were with a high rate of complications. These include postoperative infections, a relatively long healing time (especially when the wound is left for secondary healing) and a high 1615-1615/04/19/03-155 $ 30.00/0
156
S. WALFISCH et al.
rate of recurrence. The difficulty in estimating the extent of the disease, leading to incomplete irradication of the smaller cysts and sinuses, is the main reason for this high complication rate (1). The operative Nd:YAG laser system emits a light beam with a wavelength of 1064 nm. Its spot size diameter is 600–800 µm. It works in a CW mode with a power density at cutting site of 49.8–88.5 W/mm2 , in a cutting speed of 2 cm/sec. The Nd:YAG laser is poorly absorbed by water but provides good penetration into tissues. This high penetration produces interstitial photocoagulation that may be advantageous in the treatment of the pilonidal disease. CO2 laser emits a light beam with a wavelength of 10,600 nm in a CW mode with a power density at cutting site of 477.7 W/mm2 with cutting speed of 2 cm/sec. The spot size is 0.1 mm. It is better absorbed by water than the Nd:YAG laser. The pilonidal disease can actually be divided into two groups. In the less severe form, a well-defined median cyst exists with no discharging sinuses or infected ulcers. We used to treat this condition by excision of the cyst through a paramedian incision. In the more severe form of the disease, infected ulcers or fistulae are present and these were treated by midline cystostomy and through curettage of all sinuses. This study evaluates and compares the results of our previously conventional operations, for the pilonidal disease, with the same operations, when performed with Nd:YAG- or CO2 lasers.
Materials and methods Three hundred patients suffering from various degrees of pilonidal disease had been operated on in our proctology unit during the last 9 years. Their files were reviewed and the data collected included age and sex distribution, type of anesthesia, hospitalization time, postoperative follow up time (routine follow up was done 2 days, 1 week, 1 month, 3 months and 1 year following the operation), healing time and postoperative complications. According to the operative procedure the patients were divided into 5 groups: Group 1: Conventional subcutaneous cystectomy through a paramedian incision. Group 2: Same as above using the Nd:YAG laser. (Fig. 1–2) Group 3: Conventional midline cystostomy and curettage. Group 4: Nd:YAG laser midline cystostomy and curettage. Group 5: CO2 laser midline cystostomy and curettage. Except for the first ten patients in Group 1, all patients were operated on in the outpatients’ operating room under local anesthesia. All wounds were left open for healing by secondary intention. During surgery, regardless of the method that was used, utmost care was taken to identify and completely excise all sideways sinuses. Dressing changes were done by
Fig. 1. The pilonidal sinus.
Nd:YAG and CO2 Lasers for the Treatment of Pilonidal Sinuses: Advantages over Traditional Techniques
ambulatory day care service or by the patients themselves every 12 hours until the operative wound was completely closed. The local anesthetic solution contained 5cc adrenaline 1:200000, 5cc mercain 0.5% and 10cc lidocaine 1%. Additional anesthesia was injected when needed. We used a Nd:YAG laser system, model 3000 (Lumenis, Yoknean, Israel), which emit a light beam with a wavelength of 1064 nm at an average power of 25 watts. The delivery system is an optical fiber with a flat cut tip and a core diameter of 600–800 µm. The Nd:YAG laser beam is applied with the optical fiber in contact with the tissue. After each operation the distal tip of the fiber is cut and the delivery system is sterilized. We used a CO2 surgical laser system, model 1030, (Lumenis, Yoknean, Israel), which emit a wavelength of 10,600 nm, in a CW mode, equipped with an articulated arm. We used a focused beam with a 125 mm handpiece at an average power of 15 watts.
Results Twenty-five patients were included in Group 1. Ten of them were operated on under general anesthesia and hence were hospitalized for one day. The other 4 groups included 20, 55, 70 and 130 patients respec-
157
Fig. 2. Laser resection of the pilonidal sinus (a 50 mm surgical straight insert is mounted on the laser conventional handpiece).
tively. They were all operated on under local anesthesia and discharged 2 hours following surgery. Most of the patients (95%) were males with a similar age distribution. The operating time, 15–20 minutes was also similar for all the groups. Table 1 provides a comparison of the healing time, postoperative complications and follow up period for all the groups.
Table 1. The outcome of the different groups. Group No.
1
2
3
4
5
Incision
Paramedian
Paramedian
Midline
Midline
Midline
Procedure
Conven. excision
Laser excision.
Conven. cystostomy and curettage
Laser Nd:YAG cystostomy and curettage
CO2 laser cystostomy and curettage
No. of patients
25
20
55
70
130
Average follow up (months)
36
24
36
18
36
Average healing time (days)
28 (20–38)
14 (10–17)
24 (20–32)
14 (10–17)
12 (10–15)
Post-op. bleeding
1 (4%)
1 (5%)
2 (3.6%)
2 (2.8%)
4 (3.0%)
Infections
2 (8%)
0
4 (7.3%)
4 (5.7%)
3 (2.3%)
Recurrence
1 (4%)
0
5 (9.1%)
4 (5.7%)
7 (5.4%)
158
S. WALFISCH et al.
Discussion The operative principles for the treatment of the pilonidal disease are numerous (1). The most popular method is incision drainage and lay open for secondary healing. Complete excision with lay open technique may leave large wounds and is associated with prolonged healing time; this can be overcome by the use of skin graft. Excision with primary closure is relevant only for small sinuses without purulent secretion. Local flaps, like in Z plasty or other possibilities (4), have been used to obliterate the intergluteal cleft and may also provide better blood supply for the healing process. The Nd:YAG laser is characterized by its good interstitial photocoagulation. As soon as the tissue coagulates, optical penetration coefficient decreases and the tissue absorption coefficient increases. High temperature is produced in a short time and the laser beam vaporizes tissue in a high speed producing the cutting effect. The laser inherent characteristics, like the cuttingcoagulation, together with the accuracy in use, should be advantageous in surgery for the pilonidal disease. Minimal bleeding and less pains and swelling contribute to better and faster wound healing. This in turn will reduce the post-operative morbidity and lead to faster return to regular daily activities. The CO2 laser is cheaper, portable and safer. It cuts easier and photocoagulates superficial tissue as well. In evaluating the results it should be noted that Groups 1 and 2 and Groups 3, 4 and 5 respectively underwent the same procedure except for the mode of operating tools which is therefore the only determinant. (Conventional surgery in Groups 1 and 3 and laser surgery in Groups 2, 4 and 5) The patients in the first two groups had a preserved midline and an obvious palpable mass, a less severe degree of the disease. The patients in Groups 3, 4 and 5 suffered from discharging sinuses or infected ulcers, reflected in the lower complication rate in the first two groups when compared to the last three. In judging the efficiency of each mode of treatment for pilonidal disease, the most important factor is the recurrence rate. From our results we conclude that with the use of laser the recurrence rate is lower, for both forms of the disease, compared to the results achieved by conventional surgery (0% vs. 4% in the
less severe form of the disease and 5.7% vs. 9.1% and 5.4% in the more severe form of the disease). In an extensive review article (1) the overall recurrence rate was 13% when laying-open method was used in comparison with 15% for primary closure. The best results were achieved when the wound was closed primarily following an asymmetric incision (10% vs. 17% with the midline incision). Our recurrence rate following conventional surgery (9.1%) is better than the reported results in the literature for the same technique and is comparable with the method that demonstrated the lowest recurrence rate (Primary closure with asymmetric incision). This technique however, is suitable only for cases in which the midline is preserved. In such cases, there were no recurrences with the laying-open technique following laser cystectomy through a paramedian incision. The results of laser surgery were significantly better than those achieved with conventional surgery by the same operating staff and even more significant when compared to the available literature. This is amplified by the fact that our follow up time for both methods is longer than what appears in the literature: 24 months for conventional surgery and 18 months for laser surgery versus 12 months in the literature (1). The reasons for the better results following layingopen methods are: (1) Midline scars are more susceptible to subsequent hair perforation than after healing by granulation; (2) The broader scar after healing by granulation reduces local hair growth; (3) There are fewer hair follicles near the midline to produce folliculitis; and (4) The broader scar following secondary healing flattens the natal cleft and reduces buttock friction (1). It is difficult to assess from the literature the mean healing time for the different methods, as the results are not always given in absolute numbers. However, the time to return to work after surgery can give us a clue as to achievement of healing. The average time to return to work was 6 weeks for the primary closure method and 7 weeks for the laying open method (2,7). In a motivated air-force personnel the return to work time was shorter for the two groups – 21.7 and 29.1 days respectively (3, 6, 9). Our results are comparable to this last group for the conventionally laying-open
Nd:YAG and CO2 Lasers for the Treatment of Pilonidal Sinuses: Advantages over Traditional Techniques
method – 24 days- but the group treated with laser are significantly better with a result of an average of 14 days. The aims of the ideal treatment for pilonidal sinus as were categorized by Allen-Mersh (1) in his review article are: reliable healing with low risk of recurrence, avoidance of hospital admission and general anesthesia and minimal patient inconvenience and time off work. During the last 7 years all our patients were operated on an outpatient basis under local anesthesia. Healing time for the laying-open laser surgery group is much shorter than for the same conventional surgery. It is also comparable to the faster healing time achieved by primary closure with an asymmetric incision (Table 1). The recurrence rate is significantly lower than that achieved with most other popular methods. The only other method reported to give similar results is the asymmetric incision with primary closure that is technically more demanding (9). In view of our results, we regard the laser surgery as the method of choice in all pilonidal sinus surgery (8). Well-defined median cysts are excised through a paramedian incision, while the more complicated (infected) cases are treated by median cystostomy and curettage. All the operations are performed in the outpatient operating theater under local anesthesia. The surgical technique is simple. Healing time is much shorter than that achieved with the more popular methods and the recurrence rate is significantly lower. CO2 laser surgery has a better cost-effectiveness.
159
Cystectomie durch paramediane Inzision, 3) Konventionelle Cystostomie und Kurettage, 4) Nd:YAG Laser Cystostomie und Kurettage in der Mitte, 5) CO2 Laser Cystotomie und Kurettage durch eine mediane Inzision. Die Gruppen wurden mittels Blutungen, Heilungszeit, postoperativer Infektion und Rezidiven verglichen. Resultat: Die Heilungszeit nach Laserbehandlung war deutlich kürzer, sowie auch postoperative Blutung und Infektionsraten. Nd:YAG Laser und CO2 Laser ergaben gleiche Resultate. Heilung und postoperative Komplikationen erwiesen sich ebenfalls vorteilhaft.
Schlüsselwörter Pilonidal Sinuses, Nd:YAG Laser, CO2 Laser
References
Nd:YAG- und CO2-Laser zur Behandlung des Pilonidalsinus: Vorteile gegenüber traditionellen Techniken
1. ALLEN-MERSH TG: Pilonidal disease: finding the right track for treatment, Br J Surg 77(2): 123–132 (1990) 2. BISSETT IP, ISBISTER WH: The management of patients with pilonidal disease – a comparative study. Aust NZ J Surg 57: 939–942 (1987) 3. CHERRY K: Primary closure of pilonidal sinus. Surg Gynecol Obstet 126: 1263-1267 (1968) 4. DWIGHT RW, MALOY JK: Pilonidal sinus – experience with 449 cases. N Engl J Med 249: 926–930 (1953) 5. KHATRI VP, EPINOSA MH, AMIR AR: Management of recurrent Pilonidal sinus by simple V–Y Fasciocutaneous Flap.Dis Colon Rectum 37(12): 1232–1235 ( 1994) 6. KODNER JK, FRY RD, FLESHMAN JW AND BIRNBAUM EH: Colon rectum and anus. In Swartz S. Principles of Surgery. 6th edition 1234. Mcgraw-Hill Book comp. (1994) 7. NOTARAS MJ: A review of three popular methods of treatment of postnatal pilonidal sinus disease. Br J Surg 57: 886–890 (1970) 8. PALESTY JA, ZAHIR KS, DUDRICK SJ, FERRI S, TRIPODI G: Nd:YAG laser surgery for the excision of pilonidal cysts: a comparison with traditional techniques. Lasers Surg Med 26(4): 380–385(2000) 9. SPIVAK H, BROOKS VL, NUSSBAUM M, FRIEDMAN I: Treatment of chronic Pilonidal disease. Dis Colon Rectum 39(10): 1136–1139 (1996)
Das Krankheitsbild des Pilonidalsinus tritt häufiger in Regionen mit warmem Klima auf. Chirurgische Maßnahmen mittels Nd:YAG oder CO2 Laser wurden mit den konventionellen Methoden verglichen. In den letzten 9 Jahren wurden 300 Patienten unter lokaler Anaesthesie operiert. Methoden: 1) Konventionelle Exzision der Cyste durch paramedianen Schnitt, 2) Nd:YAG Laser
Correspondence address: Prof. S. Walfisch, Colorectal Unit, Soroka University Medical Center, P.O.B. 151, Beer Sheva 84101, Israel; Fax: ++972-8-6403273; e-mail: [email protected]
Nd:YAG and CO2 Lasers for the Treatment of Pilonidal Sinuses: Advantages over Traditional Techniques SHLOMO WALFISCH1, HAIM MNITENTAG2, ABRAHAM M. BARUCHIN3, and AMIRAM SAGI3 1
Colorectal Unit Laser Center 3 Department for Plastic and Reconstructive Surgery Soroka and Barzilai University Medical Centers, Faculty of Health Sciences, Ben Gurion University of the Negev, Israel 2
Submitted: June 2004 · Accepted: September 2004
Summary Pilonidal disease is a common problem in countries with a hot climate. Prolonged healing time and high recurrence rate are the common problems encountered while treating the disease. We evaluated the outcome of surgery in patients whose pilonidal disease was operated using Nd:YAG or CO2 lasers and compared it to the outcome of conventional (non laser) surgery. During the last 9 years 300 patients were operated on in our institute for pilonidal disease. Except for the first 10 patients all patients were operated on under local anesthesia. The operating methods included: (1) Conventional cystectomy through paramedian incision. (2) Nd:YAG laser cystectomy through paramedian incision. (3) Conventional midline cystostomy and curettage. (4) Nd:YAG laser midline cystostomy and curettage, and (5) CO2 laser cystotomy and curettage through a midline incision. The groups were compared regarding bleeding, healing time, postoperative infection rate and recurrence rate. Operative time was similar. Results: Healing time was considerably shorter in all laser treated groups. The rate of postoperative bleeding, postoperative infections and recurrences was also lower in all these groups. The Nd:YAG laser and the CO2 laser yielded similar results. Healing time and postoperative complications were compared. Laser surgery is advantageous over the equivalent conventional surgery in the treatment of pilonidal disease. The main advantage is the much shorter healing time (wound closure) and simplicity of technique. Complication rate was also lower in the laser treated group. The Nd:YAG and the CO2 laser operative results are comparable. Better cost effectiveness is an advantage of the CO2 laser over the Nd:YAG laser.
Key words Pilonidal disease, Nd:YAG laser, CO2 laser
Introduction The pilonidal disease is a relatively common problem occurring in 0.1–1.0% of the population (1, 4). The common etiology is penetration of hairs or hair remnants into the skin of the natal cleft. These buried hair follicles become at times dilated or infected and sub-
sequently form cysts or discharging sinuses that are responsible for the clinical signs and symptoms (1). Many methods have been advocated for the treatment of the disease, all of which were with a high rate of complications. These include postoperative infections, a relatively long healing time (especially when the wound is left for secondary healing) and a high 1615-1615/04/19/03-155 $ 30.00/0
156
S. WALFISCH et al.
rate of recurrence. The difficulty in estimating the extent of the disease, leading to incomplete irradication of the smaller cysts and sinuses, is the main reason for this high complication rate (1). The operative Nd:YAG laser system emits a light beam with a wavelength of 1064 nm. Its spot size diameter is 600–800 µm. It works in a CW mode with a power density at cutting site of 49.8–88.5 W/mm2 , in a cutting speed of 2 cm/sec. The Nd:YAG laser is poorly absorbed by water but provides good penetration into tissues. This high penetration produces interstitial photocoagulation that may be advantageous in the treatment of the pilonidal disease. CO2 laser emits a light beam with a wavelength of 10,600 nm in a CW mode with a power density at cutting site of 477.7 W/mm2 with cutting speed of 2 cm/sec. The spot size is 0.1 mm. It is better absorbed by water than the Nd:YAG laser. The pilonidal disease can actually be divided into two groups. In the less severe form, a well-defined median cyst exists with no discharging sinuses or infected ulcers. We used to treat this condition by excision of the cyst through a paramedian incision. In the more severe form of the disease, infected ulcers or fistulae are present and these were treated by midline cystostomy and through curettage of all sinuses. This study evaluates and compares the results of our previously conventional operations, for the pilonidal disease, with the same operations, when performed with Nd:YAG- or CO2 lasers.
Materials and methods Three hundred patients suffering from various degrees of pilonidal disease had been operated on in our proctology unit during the last 9 years. Their files were reviewed and the data collected included age and sex distribution, type of anesthesia, hospitalization time, postoperative follow up time (routine follow up was done 2 days, 1 week, 1 month, 3 months and 1 year following the operation), healing time and postoperative complications. According to the operative procedure the patients were divided into 5 groups: Group 1: Conventional subcutaneous cystectomy through a paramedian incision. Group 2: Same as above using the Nd:YAG laser. (Fig. 1–2) Group 3: Conventional midline cystostomy and curettage. Group 4: Nd:YAG laser midline cystostomy and curettage. Group 5: CO2 laser midline cystostomy and curettage. Except for the first ten patients in Group 1, all patients were operated on in the outpatients’ operating room under local anesthesia. All wounds were left open for healing by secondary intention. During surgery, regardless of the method that was used, utmost care was taken to identify and completely excise all sideways sinuses. Dressing changes were done by
Fig. 1. The pilonidal sinus.
Nd:YAG and CO2 Lasers for the Treatment of Pilonidal Sinuses: Advantages over Traditional Techniques
ambulatory day care service or by the patients themselves every 12 hours until the operative wound was completely closed. The local anesthetic solution contained 5cc adrenaline 1:200000, 5cc mercain 0.5% and 10cc lidocaine 1%. Additional anesthesia was injected when needed. We used a Nd:YAG laser system, model 3000 (Lumenis, Yoknean, Israel), which emit a light beam with a wavelength of 1064 nm at an average power of 25 watts. The delivery system is an optical fiber with a flat cut tip and a core diameter of 600–800 µm. The Nd:YAG laser beam is applied with the optical fiber in contact with the tissue. After each operation the distal tip of the fiber is cut and the delivery system is sterilized. We used a CO2 surgical laser system, model 1030, (Lumenis, Yoknean, Israel), which emit a wavelength of 10,600 nm, in a CW mode, equipped with an articulated arm. We used a focused beam with a 125 mm handpiece at an average power of 15 watts.
Results Twenty-five patients were included in Group 1. Ten of them were operated on under general anesthesia and hence were hospitalized for one day. The other 4 groups included 20, 55, 70 and 130 patients respec-
157
Fig. 2. Laser resection of the pilonidal sinus (a 50 mm surgical straight insert is mounted on the laser conventional handpiece).
tively. They were all operated on under local anesthesia and discharged 2 hours following surgery. Most of the patients (95%) were males with a similar age distribution. The operating time, 15–20 minutes was also similar for all the groups. Table 1 provides a comparison of the healing time, postoperative complications and follow up period for all the groups.
Table 1. The outcome of the different groups. Group No.
1
2
3
4
5
Incision
Paramedian
Paramedian
Midline
Midline
Midline
Procedure
Conven. excision
Laser excision.
Conven. cystostomy and curettage
Laser Nd:YAG cystostomy and curettage
CO2 laser cystostomy and curettage
No. of patients
25
20
55
70
130
Average follow up (months)
36
24
36
18
36
Average healing time (days)
28 (20–38)
14 (10–17)
24 (20–32)
14 (10–17)
12 (10–15)
Post-op. bleeding
1 (4%)
1 (5%)
2 (3.6%)
2 (2.8%)
4 (3.0%)
Infections
2 (8%)
0
4 (7.3%)
4 (5.7%)
3 (2.3%)
Recurrence
1 (4%)
0
5 (9.1%)
4 (5.7%)
7 (5.4%)
158
S. WALFISCH et al.
Discussion The operative principles for the treatment of the pilonidal disease are numerous (1). The most popular method is incision drainage and lay open for secondary healing. Complete excision with lay open technique may leave large wounds and is associated with prolonged healing time; this can be overcome by the use of skin graft. Excision with primary closure is relevant only for small sinuses without purulent secretion. Local flaps, like in Z plasty or other possibilities (4), have been used to obliterate the intergluteal cleft and may also provide better blood supply for the healing process. The Nd:YAG laser is characterized by its good interstitial photocoagulation. As soon as the tissue coagulates, optical penetration coefficient decreases and the tissue absorption coefficient increases. High temperature is produced in a short time and the laser beam vaporizes tissue in a high speed producing the cutting effect. The laser inherent characteristics, like the cuttingcoagulation, together with the accuracy in use, should be advantageous in surgery for the pilonidal disease. Minimal bleeding and less pains and swelling contribute to better and faster wound healing. This in turn will reduce the post-operative morbidity and lead to faster return to regular daily activities. The CO2 laser is cheaper, portable and safer. It cuts easier and photocoagulates superficial tissue as well. In evaluating the results it should be noted that Groups 1 and 2 and Groups 3, 4 and 5 respectively underwent the same procedure except for the mode of operating tools which is therefore the only determinant. (Conventional surgery in Groups 1 and 3 and laser surgery in Groups 2, 4 and 5) The patients in the first two groups had a preserved midline and an obvious palpable mass, a less severe degree of the disease. The patients in Groups 3, 4 and 5 suffered from discharging sinuses or infected ulcers, reflected in the lower complication rate in the first two groups when compared to the last three. In judging the efficiency of each mode of treatment for pilonidal disease, the most important factor is the recurrence rate. From our results we conclude that with the use of laser the recurrence rate is lower, for both forms of the disease, compared to the results achieved by conventional surgery (0% vs. 4% in the
less severe form of the disease and 5.7% vs. 9.1% and 5.4% in the more severe form of the disease). In an extensive review article (1) the overall recurrence rate was 13% when laying-open method was used in comparison with 15% for primary closure. The best results were achieved when the wound was closed primarily following an asymmetric incision (10% vs. 17% with the midline incision). Our recurrence rate following conventional surgery (9.1%) is better than the reported results in the literature for the same technique and is comparable with the method that demonstrated the lowest recurrence rate (Primary closure with asymmetric incision). This technique however, is suitable only for cases in which the midline is preserved. In such cases, there were no recurrences with the laying-open technique following laser cystectomy through a paramedian incision. The results of laser surgery were significantly better than those achieved with conventional surgery by the same operating staff and even more significant when compared to the available literature. This is amplified by the fact that our follow up time for both methods is longer than what appears in the literature: 24 months for conventional surgery and 18 months for laser surgery versus 12 months in the literature (1). The reasons for the better results following layingopen methods are: (1) Midline scars are more susceptible to subsequent hair perforation than after healing by granulation; (2) The broader scar after healing by granulation reduces local hair growth; (3) There are fewer hair follicles near the midline to produce folliculitis; and (4) The broader scar following secondary healing flattens the natal cleft and reduces buttock friction (1). It is difficult to assess from the literature the mean healing time for the different methods, as the results are not always given in absolute numbers. However, the time to return to work after surgery can give us a clue as to achievement of healing. The average time to return to work was 6 weeks for the primary closure method and 7 weeks for the laying open method (2,7). In a motivated air-force personnel the return to work time was shorter for the two groups – 21.7 and 29.1 days respectively (3, 6, 9). Our results are comparable to this last group for the conventionally laying-open
Nd:YAG and CO2 Lasers for the Treatment of Pilonidal Sinuses: Advantages over Traditional Techniques
method – 24 days- but the group treated with laser are significantly better with a result of an average of 14 days. The aims of the ideal treatment for pilonidal sinus as were categorized by Allen-Mersh (1) in his review article are: reliable healing with low risk of recurrence, avoidance of hospital admission and general anesthesia and minimal patient inconvenience and time off work. During the last 7 years all our patients were operated on an outpatient basis under local anesthesia. Healing time for the laying-open laser surgery group is much shorter than for the same conventional surgery. It is also comparable to the faster healing time achieved by primary closure with an asymmetric incision (Table 1). The recurrence rate is significantly lower than that achieved with most other popular methods. The only other method reported to give similar results is the asymmetric incision with primary closure that is technically more demanding (9). In view of our results, we regard the laser surgery as the method of choice in all pilonidal sinus surgery (8). Well-defined median cysts are excised through a paramedian incision, while the more complicated (infected) cases are treated by median cystostomy and curettage. All the operations are performed in the outpatient operating theater under local anesthesia. The surgical technique is simple. Healing time is much shorter than that achieved with the more popular methods and the recurrence rate is significantly lower. CO2 laser surgery has a better cost-effectiveness.
159
Cystectomie durch paramediane Inzision, 3) Konventionelle Cystostomie und Kurettage, 4) Nd:YAG Laser Cystostomie und Kurettage in der Mitte, 5) CO2 Laser Cystotomie und Kurettage durch eine mediane Inzision. Die Gruppen wurden mittels Blutungen, Heilungszeit, postoperativer Infektion und Rezidiven verglichen. Resultat: Die Heilungszeit nach Laserbehandlung war deutlich kürzer, sowie auch postoperative Blutung und Infektionsraten. Nd:YAG Laser und CO2 Laser ergaben gleiche Resultate. Heilung und postoperative Komplikationen erwiesen sich ebenfalls vorteilhaft.
Schlüsselwörter Pilonidal Sinuses, Nd:YAG Laser, CO2 Laser
References
Nd:YAG- und CO2-Laser zur Behandlung des Pilonidalsinus: Vorteile gegenüber traditionellen Techniken
1. ALLEN-MERSH TG: Pilonidal disease: finding the right track for treatment, Br J Surg 77(2): 123–132 (1990) 2. BISSETT IP, ISBISTER WH: The management of patients with pilonidal disease – a comparative study. Aust NZ J Surg 57: 939–942 (1987) 3. CHERRY K: Primary closure of pilonidal sinus. Surg Gynecol Obstet 126: 1263-1267 (1968) 4. DWIGHT RW, MALOY JK: Pilonidal sinus – experience with 449 cases. N Engl J Med 249: 926–930 (1953) 5. KHATRI VP, EPINOSA MH, AMIR AR: Management of recurrent Pilonidal sinus by simple V–Y Fasciocutaneous Flap.Dis Colon Rectum 37(12): 1232–1235 ( 1994) 6. KODNER JK, FRY RD, FLESHMAN JW AND BIRNBAUM EH: Colon rectum and anus. In Swartz S. Principles of Surgery. 6th edition 1234. Mcgraw-Hill Book comp. (1994) 7. NOTARAS MJ: A review of three popular methods of treatment of postnatal pilonidal sinus disease. Br J Surg 57: 886–890 (1970) 8. PALESTY JA, ZAHIR KS, DUDRICK SJ, FERRI S, TRIPODI G: Nd:YAG laser surgery for the excision of pilonidal cysts: a comparison with traditional techniques. Lasers Surg Med 26(4): 380–385(2000) 9. SPIVAK H, BROOKS VL, NUSSBAUM M, FRIEDMAN I: Treatment of chronic Pilonidal disease. Dis Colon Rectum 39(10): 1136–1139 (1996)
Das Krankheitsbild des Pilonidalsinus tritt häufiger in Regionen mit warmem Klima auf. Chirurgische Maßnahmen mittels Nd:YAG oder CO2 Laser wurden mit den konventionellen Methoden verglichen. In den letzten 9 Jahren wurden 300 Patienten unter lokaler Anaesthesie operiert. Methoden: 1) Konventionelle Exzision der Cyste durch paramedianen Schnitt, 2) Nd:YAG Laser
Correspondence address: Prof. S. Walfisch, Colorectal Unit, Soroka University Medical Center, P.O.B. 151, Beer Sheva 84101, Israel; Fax: ++972-8-6403273; e-mail: [email protected]