PILONIDAL SINUS DISEASE

Pilonidal disease is an ailment that occurs in the lower part of the back region. It usually affects young, hairy, plumpy (overweight) males who sweat a lot and have to sit for long hours. It is most common in the 15-30 age group and rarely has the onset after 40. About 1 per cent of the population is affected by this disease and males are afflicted about 3 times more than females.

In this disease, a painful wound forms in the midline about 5-8 cms from the anus in the back region from which pus keeps oozing out. The wound doesn’t heal spontaneously because almost always there is a tuft of hair present at the base of the wound. This happens as the loose hair over the lower back are drilled, propelled, and sucked into the pilonidal sinus. This sucking is caused by friction and the movement of the buttocks whenever the patient stands or sits.

Pilonidal Sinus with hairs protruding from the Sinus
The wound has the tendency to spread upwards, lower side or sidewards, thereby extending the disease to the new area. When pus keeps on forming and somehow is unable to drain, an abscess might form leading to an acute swelling and severe pain.

Pilonidal disease is notorious for its recurrent nature after treatment. However, if properly managed its recurrence is not very common.

The treatment of pilonidal disease is almost always surgical. Of the non-surgical techniques, injections of Phenol or Fibrin Glue may be tried but are usually not widely used. The goals of the ideal procedure for the treatment of this disease should be reliable wound healing with a low risk of recurrence, a short period of hospitalisation, minimal inconvenience to the patient, and minimum wound-management problems. Also, treatment should allow the patient to resume normal daily activities as quickly as possible.

Surgical therapy

1. Incision & drainage: This is done in acute cases when there is an abscess formation. A small cut is made and the pus collected is drained out. The cavity is thoroughly cleaned. The rest of the management of sinus is done at a later date.

2. Excision of the sinus and leaving the wound open: Excision of a pilonidal sinus means removing all the affected tissues with at least 5 mm margin of normal skin. All the tissue right up to the backbone (prescaral fascia) is removed.

The wound is cleaned by rubbing with a blunt instrument to remove the hair, granulation tissue and skin debris. A bunch of hair is usually found at the base of the wound, which is responsible for non-healing of the wound. The resulting wound is left open which gets healed slowly over four-six weeks.

Advantages- Lower recurrence rate as any missed branch/tract would be see during the dressing period

Disadvantages- A large open wound which takes much longer time to heal from upto 6 to 24 weeks depending on the size of the wound. Admission for 2-3 days and bed rest in prone position from 10-14 days.

A patient with Pilonidal Sinus

Wide Excision of Pilonidal Sinus done

Resulting Final Wound left open to heal

3. Excision with primary closure: In this method, the diseased part is totally removed as described above. However, the wound is closed so that it heals much faster. However, a small disadvantage of this method is that the recurrence could be potentially slightly higher. This is so because any infection left behind would not be known as the wound has been closed.

Primary Midline Closure (Stitches in 2 layers)

Final wound after Midline Closure

Different methods have been used to close the wound. It can be a primary closure (simply closing the wound with stitches) or making a flap such as Z flap, rhomboid, limberg, bascom or karydakis flap.

Advantages- The wound heals in shorter time as it is closed (14 to 20 days)

Disadvantages- It’s a bigger operation, hospital admission required for 2-3 days, technically more demanding operation, Big wound and scar, slightly higher risk of recureence

4. Laying Open with Curettage under Local Anesthesia (LOCULA) operation: In this method, the pilonidal is incised/ deroofed (simply cut open and cleaned of all the pus, hair and debris) rather than excised (removing the sinus with a wide margin). The benefit is that the resulting wound is much smaller and healing time and pain is much less than when the wound is widely excised. This procedure can even be done under local anaesthesia, it does not require any hospitalization and the person can resume work with-in two-three hours of operation.

It has distinct advantages-

1. High success rate

2. Low complication rate

3. Possible under to do this under operation under local anesthesia as an outpatient procedure

4. No admission/ hospitalization required

5. Easy to learn and reproduce

6. Less operating time

7. Minimal hospital stay

8. Less pain

9. Early/ Immediate return to normal routine and work

10. Small wound and minimal scar

11. Easy postoperative care

12. Preservation of the body contours

13. Low cost

14. Can be easily done again in case of a failure.

As it has so many advantages, LOCULA procedure has the potential to become the first line procedure for all kinds of Pilonidal sinus disease.

“LOCULA” term has been coined by Dr Pankaj Garg. Dr Garg was invited to Boston on 1st June, 2015 by the AMERICAN Society of Colon Rectum Surgeons (ASCRS), the biggest society of Colon & Rectal Surgeons in the world to give presentation on LOCULA procedure.

Pankaj Garg, Paryush Lakhtaria, Vikas Gupta. Lay open (deroofing) plus curettage (LOCULA) vs excision with primary closure as the treatment of Pilonidal sinus disease: A metaanalysis of randomized controlled trails and a systematic review of lay open (deroofing) plus curettage procedure for Pilonidal sinus disease. Presented at the annual conference of AMERICAN Society of Colon Rectum Surgeons (ASCRS), on 1st June 2015 at Boston, MA, USA.

Pilonidal Sinus- Before Operation

After LOCULA Operation ( The resulting wound is quite small)

Postoperation Care

In spite of all these methods, there is always a small risk of recurrence of the disease after the operation. Therefore, certain precautions need to be taken so that the chances of recurrence are minimised. These are:

a. Regular shaving/cleaning of hair 5 cms around the disease site. This shall be required for at least five years after the operation.

b. Keep the area dry. Apply powder regularly in the buttock folds two-three times a day.

c. In case the body weight is on the higher side, then keeping the weight in check helps.

d. In case of any problem, immediately consult your surgeon.

Artcile published in The Tribune on Pilonidal Sinus Disease
http://www.tribuneindia.com/2011/20111123/health.htm#1