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The comparison between drainage, delayed excision and primary closure with excision and secondary healing in management of pilonidal abscess
International Journal of Surgery (2006) 4, 228e231
www.int-journal-surgery.com
The comparison between drainage, delayed excision and primary closure with excision and secondary healing in management of pilonidal abscess Seyed V. Hosseini a,*, Ali M. Bananzadeh a, Maryam Rivaz a, Babak Sabet a, Mahnaz Mosallae a, Saeedeh Pourahmad b, Hooman Yarmohammadi a a
Department of Surgery, Gastroenterhepatology Research Center, Nemazee Hospital, School of Medicine, Shiraz University of Medical Sciences, Zand Avenue P.O. Box 71345-1744, Shiraz, Fars 71345, Iran b Department of Biostatistics, School of Public Health, Shiraz University of Medical Sciences, Shiraz, Iran
KEYWORDS Pilonidal abscess; Drainage; Secondary closure; Primary delayed closure
Abstract Objective: There are numerous methods of treatment for pilonidal abscess; however the best method in acute pilonidal abscess has remained controversial. The present study was designed to compare drainage, delayed excision and primary closure with excision and secondary healing in this relation. Methods: In a randomized clinical trial study among 102 patients with definite diagnosis of pilonidal abscess referred to the Colorectal Clinic of Nemazee Hospital, 80 patients who fulfilled the criteria of entering the study were selected and divided into two groups of A and B. The exclusion criteria were any history of pilonidal abscess operation, diabetes mellitus, renal failure and immunosuppression. In group A, drainage and delayed excision (3 weeks afterwards) and primary closure were performed while in group B, excision and secondary healing was performed. Patients were followed twice a week for 1 month and then 2, 6 and 12 months after the operation. The two methods were compared in terms of time period for wound healing, postoperative complications and any sign of recurrence. Results: Symptoms were relieved in all patients. All patients returned to work 7e 9 days after the operation. After 6 months, there was no signs of recurrence in both groups. After 12 months in group B, the same results were observed as previous
* Corresponding author. Tel: þ98 711 2294951; fax: þ98 711 2299343. E-mail address: [email protected] (S.V. Hosseini). 1743-9191/$ - see front matter ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2005.12.005
Management of pilonidal abscess
229
months while in group A, 14% developed recurrence of pilonidal abscess. Wound infection was noticed in 5.6% of patients in group A and 2.5% in group B and the difference was not significant (p > 0.05). All patients in group B developed wound healing during 6 weeks except two of them who had a delay in this finding up to 8 weeks. Conclusion: The results of drainage and primary wound closure were comparable to the excision and secondary wound healing except in the rate of recurrence which was more frequent in the primary wound closure. As a result, in spite of much property and comfort of primary wound closure, this method would not be recommended for all cases with acute pilonidal abscess. ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Pilonidal disease is a common chronic disease of the sacrococcygeal region. The cause of pilonidal sinus remains controversial. It occurs more often in overweight people, persons with abundant body hair and occurs more often in men than in women.1,2 Numerous kinds of surgical procedures were described for treating pilonidal disease and abscess, i.e. drainage and curettage,3 cryosurgery,4 Z-plasty procedure,5,6 excision with secondary healing, vacuum assisted closure7 and modified lay-open (incision, curettage, partial lateral wall excision and marsupialization),8 however the best method of treatment is a conflicting subject, up to now. This study was performed to compare primary wound closure with secondary wound healing in this relation.
Materials and methods In a randomized clinical trial study from January 2003 through March 2004, among 102 patients with a diagnosis of pilonidal abscess referred to the Colorectal Clinic, of Namazi Hospital affiliated to Shiraz University of Medical Science, 80 patients who fulfilled the criteria of entering the study were selected and divided randomly into two groups of A (primary) and B (secondary). Randomization was done by the registering nurse, who was blind to the study, and patients with odd numbers were classified in group A and those with even numbers were placed in group B. Shiraz University of Medical Sciences Ethical Committee approved the study and an informed written consent was taken from each of the patients. The exclusion criteria were diabetes mellitus, renal failure, immunosuppression and any history of previous pilonidal surgery. A single surgeon handled the operation in all the patients. The patients were evaluated for any signs and symptoms of infection, mass formation, discharge and cellulites before the operation, also, for the
depth and length of surgical procedure. Under local anesthesia (10 ml of 2% xylocaine, 3 ml of 0.5% marcaine and 2 ml of 1100000 epinephrine). In group A, initially, incision and drainage of the abscess was done. Afterwards, oral antibiotic (cephalexin 500 mg orally every 6 h, analgesic (acetaminophen codeine) was given to the patients for 1 week. The patients were advised to take a bath daily and avoid excessive physical strain. Patients were visited weekly and after 3 weeks, excision of the cyst and primary closure was done. None of the wounds were infected at this time. After homeostasis was achieved, simple sutures (Nylon 2/0) were applied to the skin down to the presacral fascia. The skin was approximated with nylon 4/0 and tied dressing using sterile gauze. In group B, excision of the infected cyst was performed at the time of referral and the wound was left open for secondary healing. The patients were advised on daily irrigation and dressing of the wound. The same medication with the same duration was administered for this group. All patients in groups A and B were followed for 1 year in the intervals of twice a week for 1 month and also 2, 6 and 12 months after the operation for any signs and symptoms of recurrence, infection and time period of wound healing. An independent observer (a resident of general surgery) who was blind to the study and was previously trained for diagnosing recurrence and healing evaluated the healing and recurrence rate. All data were analyzed with SPSS software. Chisquared test and t-test were used for comparison. Fisher’s exact test was used for comparing recurrence of abscess formation between the two study groups. A p value less than 0.05 was considered significant.
Results From 80 patients entering the study, 76 patients continued to be followed for 1 year. In the primary
230
S.V. Hosseini et al.
group, there were 36 patients with a mean age of 24.2 7 years and in the secondary group, there were 40 patients with a mean age of 24.7 7.5 years (Table 1). The demographic characteristics of the patients in primary healing and secondary are shown in Table 1. The duration of symptoms, length and depth of abscess in primary vs secondary groups are also shown in Table 1. During follow up, 5.6% of patients (n ¼ 2) in group A and 2.5% in group B (n ¼ 1) developed infection (wound infection) (p > 0.05). Patients in the secondary group used significantly less pain relievers compared to the primary group (p > 0.05). There were no statistically significant differences between the primary and secondary groups in relation to gender, age, duration of symptoms and main chief complaints including discharge, infection, pain and the length and depth of abscess. The symptoms relieved in all patients receiving either of the treatments and all of the patients returned to work 7e9 days after the operation. After 6 months, there was no signs of recurrence in either group. However, the recurrence of abscess formation was detected in 14% (n ¼ 5) of patients in the primary group. In other words, the difference in the rate of abscess formation in the primary and secondary group patients after 1 year was significant (p < 0.05). Table 1 Comparison of symptoms and clinical findings in patients of groups A and B Method A Number of patients 36 (100) (n, %) Male (n, %) 33 (91.6) Female (n, %) 3 (8.4) Mean age (years) 24.2 7 Mean duration of 13.03 19 symptom (months) Length of abscess 2.9 1.6 (cm) Depth of abscess 2.5 1.4 (cm) Pre operation findings Pain 35 (97.2) Swelling 28 (77.8) Infection 29 (80.6) Discharge 26 (72.2) Findings during operation Inflammation 16 (44.4) Sinus formation 29 (80.6) Recurrence 30 (83.3) Mass 29 (80.6) NS, not significant.
Method B
p value
40 (100)
NS
35 (87.5) 5 (12.5) 24.7 7.5 15.7 18
NS NS NS NS
2.7 1.5
NS
2.6 1.5
NS
39 24 33 31
(97.5) (60) (82.5) (77.5)
NS 0.09 NS NS
20 33 35 28
(50) (82.5) (87.5) (70)
NS NS NS NS
Discussion Pilonidal abscess is one of the most common complications of pilonidal disease.3 Similar to the pilonidal sinus, the treatment of pilonidal abscess has still remained a challenge. Some authors believe that the incision and drainage method is an effective procedure. However, this method would treat only the acute infection and produce the necessity of re-operation for definite therapy. The alternative method is drainage and excision in which the patients will receive definite therapy in a single staged operation.8 Carman9 recommended either treatment according to the possibility and situation. Hanley10 preferred open drainage of the abscess followed by definite excision. Goodall11 in a study on 41 patients with acute pilonidal abscess who were treated with incision and drainage reported that 85% needed further surgical treatment within a year. Overall, excision and primary closure to have a potency to produce early wound infection did not develop, but this method made restriction in activity and resulted in a high rate of recurrence. The rate of recurrence with drainage and primary wound closure was reported to be approximately 38% by previous researchers. In our study the recurrence rate was 14%. On the other hand, Shiptz et al.12 recommended a single stage treatment which was secondary healing by granulation tissue. In a review of 126 patients treated by this method, the recurrence rate of 20.9% was reported. However, the length of time to gain acceptable wound healing decreases its effectiveness to some extent. In the present study, the rate of recurrence was considerably lower in patients receiving this procedure in comparison to primary wound closure. Even, the patients’ wellbeing, return to work and rate of infection were comparable in both procedures. One the most important limitation of our study was that 90% of our patients were male. Although, sex has not been proved in previous studies to have an effect on the outcome of the two methods of operation and additionally since sex distribution between the two studied groups (group A and B) was the same, statistical bias need not be considered. However, if a more equally distributed group of patients was studied, the results would seem more realistic. The results of drainage and primary wound closure were comparable to drainage and secondary wound healing except in the rate of recurrence which was more frequent in primary wound closure. As a result, in spite of much comfort of primary wound closure, this method would not be
Management of pilonidal abscess recommended for all cases with acute pilonidal abscess; however, other studies on a larger number of patients and longer duration of follow up are desirable to document the property of secondary wound healing in this relation.
231
4. 5. 6.
Acknowledgments The author would like to thank the Center for Development Clinical Research of Namazee Hospital, and Dr Davood Mehrabani for his editorial assistance.
References 1. Chintapatla S, Safarani N, Kumar S, Haboubi N. Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol 2003;7(1):3e8. 2. Isbister WH, Prasad J. Pilonidal disease. Aust N Z J Surg 1995;65(8):561e3. 3. Vahedian J, Nabavizadeh F, Nakhaee N, Vahedian M, Sadeghpour A. Comparison between drainage and curettage
7.
8.
9. 10. 11. 12.
in the treatment of acute pilonidal abscess. Saudi Med J 2005;26(4):553e5. Gage AA, Dutta P. Cryosurgery for pilonidal disease. Am J Surg 1977;133(2):249e54. Toubanakis G. Treatment of pilonidal sinus disease with the Z-plasty procedure (modified). Am Surg 1986;52(11):611e2. Mansoory A, Dickson D. Z-plasty for treatment of disease of the pilonidal sinus. Surg Gynecol Obstet 1982;155(3): 409e11. McGuinnes JG, Winter DC, O’Connell PR. Vacuum-assisted closure of a complex pilonidal sinus. Dis Colon Rectum 2003;46(2):274e6. Gencosmanoglu R, Inceoglu R. Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus A prospective, randomized clinical trial with a complete two-year follow-up. Int J Colorectal Dis 2005 [Epub ahead of print]. Carman ML. Dermatologic anal conditions. Colon and rectal surgery. Philadelphia: Lippincott; 1984. p. 177e225. Hanley PH. Acute pilonidal abscess. Surg Gynecol Obst 1980;150:9e11. Goodall P. Management of pilonidal sinus. Proc R Soc Med 1975;88(11):675. Shpits B, Kaufman Z, Kantorovsky A, Reina A, Dinbar A. Definitive management of acute pilonidal abscess by loop diathermy excision. Dis Colon Rectum 1990;33:441e2.
www.int-journal-surgery.com
The comparison between drainage, delayed excision and primary closure with excision and secondary healing in management of pilonidal abscess Seyed V. Hosseini a,*, Ali M. Bananzadeh a, Maryam Rivaz a, Babak Sabet a, Mahnaz Mosallae a, Saeedeh Pourahmad b, Hooman Yarmohammadi a a
Department of Surgery, Gastroenterhepatology Research Center, Nemazee Hospital, School of Medicine, Shiraz University of Medical Sciences, Zand Avenue P.O. Box 71345-1744, Shiraz, Fars 71345, Iran b Department of Biostatistics, School of Public Health, Shiraz University of Medical Sciences, Shiraz, Iran
KEYWORDS Pilonidal abscess; Drainage; Secondary closure; Primary delayed closure
Abstract Objective: There are numerous methods of treatment for pilonidal abscess; however the best method in acute pilonidal abscess has remained controversial. The present study was designed to compare drainage, delayed excision and primary closure with excision and secondary healing in this relation. Methods: In a randomized clinical trial study among 102 patients with definite diagnosis of pilonidal abscess referred to the Colorectal Clinic of Nemazee Hospital, 80 patients who fulfilled the criteria of entering the study were selected and divided into two groups of A and B. The exclusion criteria were any history of pilonidal abscess operation, diabetes mellitus, renal failure and immunosuppression. In group A, drainage and delayed excision (3 weeks afterwards) and primary closure were performed while in group B, excision and secondary healing was performed. Patients were followed twice a week for 1 month and then 2, 6 and 12 months after the operation. The two methods were compared in terms of time period for wound healing, postoperative complications and any sign of recurrence. Results: Symptoms were relieved in all patients. All patients returned to work 7e 9 days after the operation. After 6 months, there was no signs of recurrence in both groups. After 12 months in group B, the same results were observed as previous
* Corresponding author. Tel: þ98 711 2294951; fax: þ98 711 2299343. E-mail address: [email protected] (S.V. Hosseini). 1743-9191/$ - see front matter ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2005.12.005
Management of pilonidal abscess
229
months while in group A, 14% developed recurrence of pilonidal abscess. Wound infection was noticed in 5.6% of patients in group A and 2.5% in group B and the difference was not significant (p > 0.05). All patients in group B developed wound healing during 6 weeks except two of them who had a delay in this finding up to 8 weeks. Conclusion: The results of drainage and primary wound closure were comparable to the excision and secondary wound healing except in the rate of recurrence which was more frequent in the primary wound closure. As a result, in spite of much property and comfort of primary wound closure, this method would not be recommended for all cases with acute pilonidal abscess. ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Introduction Pilonidal disease is a common chronic disease of the sacrococcygeal region. The cause of pilonidal sinus remains controversial. It occurs more often in overweight people, persons with abundant body hair and occurs more often in men than in women.1,2 Numerous kinds of surgical procedures were described for treating pilonidal disease and abscess, i.e. drainage and curettage,3 cryosurgery,4 Z-plasty procedure,5,6 excision with secondary healing, vacuum assisted closure7 and modified lay-open (incision, curettage, partial lateral wall excision and marsupialization),8 however the best method of treatment is a conflicting subject, up to now. This study was performed to compare primary wound closure with secondary wound healing in this relation.
Materials and methods In a randomized clinical trial study from January 2003 through March 2004, among 102 patients with a diagnosis of pilonidal abscess referred to the Colorectal Clinic, of Namazi Hospital affiliated to Shiraz University of Medical Science, 80 patients who fulfilled the criteria of entering the study were selected and divided randomly into two groups of A (primary) and B (secondary). Randomization was done by the registering nurse, who was blind to the study, and patients with odd numbers were classified in group A and those with even numbers were placed in group B. Shiraz University of Medical Sciences Ethical Committee approved the study and an informed written consent was taken from each of the patients. The exclusion criteria were diabetes mellitus, renal failure, immunosuppression and any history of previous pilonidal surgery. A single surgeon handled the operation in all the patients. The patients were evaluated for any signs and symptoms of infection, mass formation, discharge and cellulites before the operation, also, for the
depth and length of surgical procedure. Under local anesthesia (10 ml of 2% xylocaine, 3 ml of 0.5% marcaine and 2 ml of 1100000 epinephrine). In group A, initially, incision and drainage of the abscess was done. Afterwards, oral antibiotic (cephalexin 500 mg orally every 6 h, analgesic (acetaminophen codeine) was given to the patients for 1 week. The patients were advised to take a bath daily and avoid excessive physical strain. Patients were visited weekly and after 3 weeks, excision of the cyst and primary closure was done. None of the wounds were infected at this time. After homeostasis was achieved, simple sutures (Nylon 2/0) were applied to the skin down to the presacral fascia. The skin was approximated with nylon 4/0 and tied dressing using sterile gauze. In group B, excision of the infected cyst was performed at the time of referral and the wound was left open for secondary healing. The patients were advised on daily irrigation and dressing of the wound. The same medication with the same duration was administered for this group. All patients in groups A and B were followed for 1 year in the intervals of twice a week for 1 month and also 2, 6 and 12 months after the operation for any signs and symptoms of recurrence, infection and time period of wound healing. An independent observer (a resident of general surgery) who was blind to the study and was previously trained for diagnosing recurrence and healing evaluated the healing and recurrence rate. All data were analyzed with SPSS software. Chisquared test and t-test were used for comparison. Fisher’s exact test was used for comparing recurrence of abscess formation between the two study groups. A p value less than 0.05 was considered significant.
Results From 80 patients entering the study, 76 patients continued to be followed for 1 year. In the primary
230
S.V. Hosseini et al.
group, there were 36 patients with a mean age of 24.2 7 years and in the secondary group, there were 40 patients with a mean age of 24.7 7.5 years (Table 1). The demographic characteristics of the patients in primary healing and secondary are shown in Table 1. The duration of symptoms, length and depth of abscess in primary vs secondary groups are also shown in Table 1. During follow up, 5.6% of patients (n ¼ 2) in group A and 2.5% in group B (n ¼ 1) developed infection (wound infection) (p > 0.05). Patients in the secondary group used significantly less pain relievers compared to the primary group (p > 0.05). There were no statistically significant differences between the primary and secondary groups in relation to gender, age, duration of symptoms and main chief complaints including discharge, infection, pain and the length and depth of abscess. The symptoms relieved in all patients receiving either of the treatments and all of the patients returned to work 7e9 days after the operation. After 6 months, there was no signs of recurrence in either group. However, the recurrence of abscess formation was detected in 14% (n ¼ 5) of patients in the primary group. In other words, the difference in the rate of abscess formation in the primary and secondary group patients after 1 year was significant (p < 0.05). Table 1 Comparison of symptoms and clinical findings in patients of groups A and B Method A Number of patients 36 (100) (n, %) Male (n, %) 33 (91.6) Female (n, %) 3 (8.4) Mean age (years) 24.2 7 Mean duration of 13.03 19 symptom (months) Length of abscess 2.9 1.6 (cm) Depth of abscess 2.5 1.4 (cm) Pre operation findings Pain 35 (97.2) Swelling 28 (77.8) Infection 29 (80.6) Discharge 26 (72.2) Findings during operation Inflammation 16 (44.4) Sinus formation 29 (80.6) Recurrence 30 (83.3) Mass 29 (80.6) NS, not significant.
Method B
p value
40 (100)
NS
35 (87.5) 5 (12.5) 24.7 7.5 15.7 18
NS NS NS NS
2.7 1.5
NS
2.6 1.5
NS
39 24 33 31
(97.5) (60) (82.5) (77.5)
NS 0.09 NS NS
20 33 35 28
(50) (82.5) (87.5) (70)
NS NS NS NS
Discussion Pilonidal abscess is one of the most common complications of pilonidal disease.3 Similar to the pilonidal sinus, the treatment of pilonidal abscess has still remained a challenge. Some authors believe that the incision and drainage method is an effective procedure. However, this method would treat only the acute infection and produce the necessity of re-operation for definite therapy. The alternative method is drainage and excision in which the patients will receive definite therapy in a single staged operation.8 Carman9 recommended either treatment according to the possibility and situation. Hanley10 preferred open drainage of the abscess followed by definite excision. Goodall11 in a study on 41 patients with acute pilonidal abscess who were treated with incision and drainage reported that 85% needed further surgical treatment within a year. Overall, excision and primary closure to have a potency to produce early wound infection did not develop, but this method made restriction in activity and resulted in a high rate of recurrence. The rate of recurrence with drainage and primary wound closure was reported to be approximately 38% by previous researchers. In our study the recurrence rate was 14%. On the other hand, Shiptz et al.12 recommended a single stage treatment which was secondary healing by granulation tissue. In a review of 126 patients treated by this method, the recurrence rate of 20.9% was reported. However, the length of time to gain acceptable wound healing decreases its effectiveness to some extent. In the present study, the rate of recurrence was considerably lower in patients receiving this procedure in comparison to primary wound closure. Even, the patients’ wellbeing, return to work and rate of infection were comparable in both procedures. One the most important limitation of our study was that 90% of our patients were male. Although, sex has not been proved in previous studies to have an effect on the outcome of the two methods of operation and additionally since sex distribution between the two studied groups (group A and B) was the same, statistical bias need not be considered. However, if a more equally distributed group of patients was studied, the results would seem more realistic. The results of drainage and primary wound closure were comparable to drainage and secondary wound healing except in the rate of recurrence which was more frequent in primary wound closure. As a result, in spite of much comfort of primary wound closure, this method would not be
Management of pilonidal abscess recommended for all cases with acute pilonidal abscess; however, other studies on a larger number of patients and longer duration of follow up are desirable to document the property of secondary wound healing in this relation.
231
4. 5. 6.
Acknowledgments The author would like to thank the Center for Development Clinical Research of Namazee Hospital, and Dr Davood Mehrabani for his editorial assistance.
References 1. Chintapatla S, Safarani N, Kumar S, Haboubi N. Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol 2003;7(1):3e8. 2. Isbister WH, Prasad J. Pilonidal disease. Aust N Z J Surg 1995;65(8):561e3. 3. Vahedian J, Nabavizadeh F, Nakhaee N, Vahedian M, Sadeghpour A. Comparison between drainage and curettage
7.
8.
9. 10. 11. 12.
in the treatment of acute pilonidal abscess. Saudi Med J 2005;26(4):553e5. Gage AA, Dutta P. Cryosurgery for pilonidal disease. Am J Surg 1977;133(2):249e54. Toubanakis G. Treatment of pilonidal sinus disease with the Z-plasty procedure (modified). Am Surg 1986;52(11):611e2. Mansoory A, Dickson D. Z-plasty for treatment of disease of the pilonidal sinus. Surg Gynecol Obstet 1982;155(3): 409e11. McGuinnes JG, Winter DC, O’Connell PR. Vacuum-assisted closure of a complex pilonidal sinus. Dis Colon Rectum 2003;46(2):274e6. Gencosmanoglu R, Inceoglu R. Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus A prospective, randomized clinical trial with a complete two-year follow-up. Int J Colorectal Dis 2005 [Epub ahead of print]. Carman ML. Dermatologic anal conditions. Colon and rectal surgery. Philadelphia: Lippincott; 1984. p. 177e225. Hanley PH. Acute pilonidal abscess. Surg Gynecol Obst 1980;150:9e11. Goodall P. Management of pilonidal sinus. Proc R Soc Med 1975;88(11):675. Shpits B, Kaufman Z, Kantorovsky A, Reina A, Dinbar A. Definitive management of acute pilonidal abscess by loop diathermy excision. Dis Colon Rectum 1990;33:441e2.