Evaluation on Different Treatment Methods of Pilonidal disease: A Teaching Hospital Based Study

Background: 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. Subjects and Methods: The study was conducted in the department of general surgery, Nimra Institute of Medical sciences (NIMS), Vijayawada, on 100 patients who were admitted with pain and swelling over the sacro coccygeal region, who were selected for surgical excision. The follow up of these patients were over a period of 4yrs. Results: The Results were amazingly good as expected with wide excision of the pilonidal sinus without immediate closure of the wound. Some patients were subjected for secondary suturing, some patients were not sutured at all, the wound was left open to heal on its own. But the results are equal in both the conditions unlike in primary closure where the recurrence is more. Conclusion: In apparently large, inflamed and recurrent situations, we should prefer the Open Excision, where the healing time is longer but the percentage of success is greater.


Introduction
The term pilonidal is derived from the Latin word Pilus (hair) and Nidus (nest) and this term was coined and described by Hodges in 1880. It is diagnosed by the finding of a characteristic epithelial tract (the sinus) located in the natal cleft, a short distance behind the anal verge and generally containing hair. [1] 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. [2,3] Numerous kinds of surgical procedures were described for treating pilonidal disease and abscess, i.e. drainage and curettage, [4] cryosurgery, [5] Z-plasty procedure, [6,7] lancing under local anesthesia, vacuum assisted closure, [8] excision with secondary healing, excision with primary closure local fl ap surgery and Bascom procedure, [9][10][11][12][13][14][15] have been described by various authors. Pilonidal disease can appear as an acute abscess along with sinus tract formation. A more complex manifestation can be characterized by chronic or recurrent abscesses with extensive, branching sinus tracts. [16] The common form is an acute abscess characterized by the existence of a midline pit in the natal cleft typically identified 4 to 8 cm from the anus. The skin enters the sinus giving the opening a smooth edge. This primary tract leads into a subcutaneous cavity, which contains granulation tissue and usually a nest of hairs that are present in two thirds of cases in men and in one third of those in women and may be seen projecting from the skin opening. Many patients have secondary lateral openings 2 to 5 cm above the midline pit. The skin opening and the superficial portion of the tract are lined with squamous cell epithelium, but the deep cavity and its extensions are not. Today pilonidal sinuses are widely accepted to be acquired abnormalities as a result of the drainage of a hair follicle that ruptured in the subcutaneous fat, [17][18][19][20] producing acute or chronic inflammation resulting in an abscess or a tract. [19,21] The invasion of the follicle occurs through the expandable orifice of the vestigial scent gland and is a result of inflammation and rupture in the subcutaneous fat of the follicle. [22,23] Aim of the present study was to be compare the different methods used by clinicians and to determine the outcomes in relation to healing, hospitalization time and recurrence rate.

Subjects and Methods
This present study was conducted in the Department of Surgery, Nimra institute of medical sciences, Vijayawada during the period from 2015 to 2019. Out of 100 patients, 62 were males and 38 were females. Ages ranged from 16

Results & Discussion
Among these 100 patients, 62 (62%) were males and 38 (38%) were females. Ages ranged from 16 to 45 years with an average age of about 30.5 years. In OPD, we practice the Open or Primary Suture Excision and marsupialization techniques. There was no inflammation in any of the 100 treated patients. If there was prior inflammation, it was treated first with incision and drainage followed by administration of medication, including antibiotics and nonsteroid anti-inflammatory drugs. Of the 100 patients, 55 were treated with marsupializationand the remaining 45 were treated by excision (in 27 of them open excision was preferred, while the remaining 18 received the primary suture technique). From the total number of patients, 92 (92%) were discharged from the hospital after the surgical procedure, while in the remaining 8 cases, hospitalization for 24 hours was deemed necessary. The results are depicted in the table below for better understanding [   Figure  1].  The pilonidal disease is not a very common problem but it needs a proper evaluation and deep thinking regarding the management aspects. My experience and techniques mainly focused to decrease the recurrence rate of the disease by following the best techniques. We did a comparative study in 100 patients of which half of the patients were subjected for primary suturing of the wound and sent the patient immediately to home with oral antibiotics and analgesics.
Rest of the patients were subjected for delayed suturing of the wound ,with regular dressings, oral antibiotics and some patients were sutured after 4wks, some patients took very long time almost 3 months. Some wounds were left open to heal on its own. Pilonidal disease affects men between 16-25 years of age most often. [24] Usually it is associated with obese and hirsute individuals who experience profuse sweating and have a sedentary lifestyle. [25,26] The treatment of pilonidal disease is mostly surgical. The most commonly used procedures today are: simple incision, excision, plastic surgery techniques, marsupialization and fistulotomy. Simple incision implies a midline incision through the mouths of the pits and is effective in those cases of so-called raphe cannulization where infection spreads from pit to pit. [27] After unroofing the tract it is cleaned and drained. The final cure is done after the end of inflammation. [28] This is usually reserved for acute infective swelling. Recurrence is frequent and is mostly used in acute situations where relief of pain is urgent. Excision is used for chronic and recurrent pilonidal sinuses. Excision of all involved skin and subcutaneous tissue may be necessary for definitive treatment. These wounds may then be managed openly, with healing by secondary intention, allowing the wound to granulate, or is closed by primary suture. [29] Laying the sinus open permits adequate drainage. The healing requires more time, but has lower recurrence. [30] In the primary suture the pilonidal sinus is excised and the wound sutured by using deep tension sutures tied over a gauze dressing. The advantages are quicker healing and an early return to work, albeit with higher recurrence when compared to the open technique. [31] Plastic surgery techniques that include these procedures do not only cover the wound but also, in theory, fatten the natal cleft, reduce hair accumulation, mechanical irritation and risk Chaitanya: Surgical Evaluation on Different Treatment Methods of Pilonidal disease of recurrence. [32] Various kinds of flaps have been used: 1-2 skin flaps, fasciocutaneous flaps like the V-Y flap (for recurrent and complicated sinus disease) and rhomboid excision and the Limberg flap. [33] Moreover, the Karydakis flap achieves asymmetric closure of the pilonidal wounds by avoiding to place the wound in the midline at the depth of the natal cleft and also flattens the cleft reducing hair accumulation and mechanical irritation in order to decrease recurrence. [34] Marsupialization involves milossis and opening up of the cavity. [35] After excision of the sinus front and lateral tracts the cavity is scrubbed to remove hair and granulation tissue. Then, the skin flaps are sutured to the presacral fascia and the wound healing is done by secondary intention. [36] It is vital to have a strong front tract in order to succeed. Fistulotomy involves milossis of the cavernous resource, opening up, removal of hair and scrubbing of granulation tissue and healing by secondary intention. [37] For my cases, we used incision and drainage of the abscessed bladders followed by excision (Open or with Primary Closure) and marsupialization. [37] Clear criteria for selecting the treatment method do not exist. Nevertheless, it is emphasized that Primary Closure should be used in small, uncomplicated bladders and the open excision in larger bladders. After incision and drainage of the bladder has been performed, and after inflammation has subsided, a permanent treatment can be applied. Based on my 100 observed surgical cases, marsupialization is the surgical method of choice as it had a low percentage of recurrence and an acceptably short healing period. It should be noted that selecting marsupialization as a treatment method presupposes the absence of inflammation and that the case is not a recurrence. [38] In apparently large, inflamed and recurrent situations, we should prefer the Open Excision, where the healing time is longer but the percentage of success is greater. We observed the patients almost 4yrs.some patients were reluctant or forgot to com for follow up; we personally telephoned them to visit the surgical OPD. We were surprised to see around 5 young girls affected with this disese, we treated them with seconadary suturing without any possible recurrence over a period of years.

Conclusion
These findings suggest that the absence of inflammation and/or recurrence, marsupialization is the surgical method of choice as it has a low percentage of recurrence and an acceptably short healing period.In apparently large, inflamed and recurrent situations, open excision is preferred. Based on our observed surgical cases, marsupialization is the surgical method of choice as it had a low percentage of recurrence and an acceptably short healing period. It should be noted that selecting marsupialization as a treatment method presupposes the absence of inflammation and that the case is not a recurrence. In apparently large, inflamed and recurrent situations, we should prefer the Open Excision, where the healing time is longer but the percentage of success is greater.