There are many recommendations for the treatment of pilonidal cysts and tailbone fistulas, which can be divided into two large groups. The classification is based on the controversial views regarding the development of fistulas of the coccyx.
From the consideration that pilonidal disease is a chronic inflammatory disease of the skin and subcutaneous fatty tissue results the excision of the entire area with subsequent open wound healing or plastic procedures of the large soft tissue defects, which has been practised in many places for over 70 years.
The other consideration sees in the chronic pilonidal disease a problem of the hair in healthy skin, why procedures are used whose goal is the removal of the hair or hair roots. These include minimally invasive procedures such as pit picking, which is performed under local anaesthesia without major soft tissue defects.
Although minimally invasive procedures are not standard in Germany, it is remarkable that the less traumatic procedures are often used in many countries as a first measure for symptomatic tailbone fistula. The results of these procedures are promising.
Overview of the different treatment procedures
Minimally invasive procedures
- Phenol injection according to Maurice and Greenwood
- Lord and Millar procedure
- Pit picking according to Bascom (Bascom I)
- Moshe Gips procedure
- Sinusectomy
Traditional procedures
- Excision with open wound treatment
- Excision, marsupialization and open wound treatment
- Excision with primary midline suture (gluteal fold)
Plastic procedures
- Plastic closure with Z-plastic
- Plastic closure according to Karydakis
- Plastic closure according to Limberg
- Cleft-lift procedure (Bascom II)
Laser application
How is the quality of results measured?
A surgical method is measured, among other things, by how successful it is, i.e. whether the health problem is permanently eliminated by the procedure. Thus, disease recurrence, which here means the recurrence of fistulas and inflammation is an important quality criterion for the surgical method.
As fistulas of the tailbone occur frequently, there are correspondingly many studies on the various treatment methods. The problem is that no uniform definition is used for the criterion "fistula recurrence" - renewed fistula formation after surgery - and this is also missing in many studies. Many second surgical procedures are also not performed because of a fistula recurrence, but because the wound causes problems after the first procedure or does not want to heal. From the patient's point of view, it is irrelevant if a second surgical procedure is performed due to new fistula formation or chronic wound healing disorder - it always represents a burden.
Literature sources:
Bascom J (1980) Pilonidal disease: origin from follicles of hairs and results of follicle removal as treatment. Surgery 87(5):567–572
Iesalnieks I, Deimel S, Kienle K et al (2011) Pit-picking surgery for pilonidal disease. Chirurg 82(10):927–931
Gips M, Melki Y, Salem L et al (2008) Minimal surgery for pilonidal disease using trephines: description of a new technique and long-term outcomes in 1,358 patients. Dis Colon Rectum 51(11):1656–1662 (discussion 1662– 1653)
Rao MM, Zawislak W et al (2009) A prospective randomised study comparing two treatment modalities for chronic pilonidal sinus with a 5-year follow-up. Int J Colorectal Dis
Sondenaa K, Anderson E et al (1992) Morbidity and short term results in a randomised trial of open compared with closed treatment of chronic pilonidal sinus. Eur J Surg 158:351–355
Sondenaa K, Nesvik I et al (1996) Recurrent pilonidal sinus after excision with closed or open treatment: final result of a randomised trial. Eur J Surg 162:237–240
Gencosmanoglu R, Inceoglu R (2005) 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 20:415–422
Othman I (2010) Skin glue improves outcome after excision and primary closure of sacrococcygeal pilonidal disease. Indian J Surg 72:470–474
Can MF, Sevinc MM et al (2009) Comparison of Karydakis flap reconstruction versus primary midline closure in sacrococcygeal pilonidal disease: results of 200 military service members. Surg Today 39:580–586
Guner A, Boz A et al (2013) Limberg flap versus bascom cleft lift techniques for sacrococcygeal pilonidal sinus: prospective, randomized trial. World J Surg 37:2074–2080
Iesalnieks I, Deimel S et al (2013) Karydakis flap for recurrent pilonidal disease. World J Surg 37:1115–1120
Iesalnieks I, Fürst A et al (2003) Erhöhtes Rezidivrisiko nach primärem medianen Wundverschluss bei Patienten mit Pilonidalsinus. Chirurg 74:461– 468
Doll D, Krueger CM et al (2007) Timeline of recurrence after primary and secondary pilonidal sinus surgery. Dis Colon Rectum 50:1928–1934
