Surg Today DOI 10.1007/s00595-013-0764-5
ORIGINAL ARTICLE
Comparison of the Limberg flap and bilateral gluteus maximus advancing flap following oblique excision for the treatment of pilonidal sinus disease Murat Yildar • Faruk Cavdar
Received: 11 June 2013 / Accepted: 22 August 2013 Ó Springer Japan 2013
Abstract Purpose This study was performed to compare the use of a bilateral gluteus maximus advancing flap (BGMAF) following oblique incision, which was recently described for the surgical treatment of sacrococcygeal pilonidal sinus (SPS) disease, with the widely used Limberg flap (LF) technique following a rhomboid incision. Methods A total of 105 patients treated for SPS were evaluated retrospectively. The patients were evaluated in terms of their age, body mass index, symptoms, length of the operation, complications, postoperative hospital stay, time to return to work, postoperative cosmetic satisfaction and recurrence rate. Results Fifty-six of the patients were treated with BGMAF, while 49 were treated with LF. The mean followup was 20.5 ± 5.4 months. The mean length of the operation, hospital stay and time to return to work were shorter, while the cosmetic satisfaction score was higher in the BGMAF group compared to the LF group. There was no statistically significant difference between the groups for the other criteria. Conclusion The BGMAF appears to be superior to the LF in terms of the length of the operation, time to return to work and degree of cosmetic satisfaction. It is preferable for sinuses not to require wide excision, while the LF is more appropriate for sinuses with a large post-excision defect. M. Yildar (&) Department of General Surgery, Balıkesir University Medical School, Balıkesir, Turkey e-mail: [email protected] F. Cavdar Department of General Surgery, Yalova State Hospital, Yalova, Turkey
Keywords Pilonidal sinus Limberg flap Oblique excision Advancing flap Socioeconomic level
Introduction Pilonidal sinus disease is most common in the sacrococcygeal region and has an incidence of 26/100000. It is twice as common in males as in females [1]. A foreign body reaction developing as a result of hair follicles penetrating the skin following trauma is implicated in the pathogenesis of the disease [1–3]. The disease is generally asymptomatic. However, when it becomes symptomatic, it has a negative impact on the patient’s quality of life. Due to their high rates of recurrence, conservative methods of treating symptomatic sacrococcygeal pilonidal sinus (SPS), such as shaving [4], phenol administration [5] and cryosurgery [6], have gradually declined in popularity. Although surgical techniques such as excision, marsupialization and primary closure have lower recurrence rates than conservative methods, they have gradually given way to advancement flap techniques, for reasons such as the need for dressings, prolonged wound healing and wound infection. The Limberg flap (LF) technique has the lowest recurrence rate among the flap techniques currently used to treat SPS. However, recent reports have suggested that this technique does not achieve good results in terms of the cosmetic appearance and wound healing [7]. The oblique excision and bilateral gluteus maximus advancing flap (BGMAF) technique was recently described for the treatment of SPS, and provides results similar to the LF in terms of recurrence [8]. However, to date, there have been no studies comparing this method with other techniques in terms of the length of the operation and the length of the hospital stay.
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Therefore, the present study was performed to compare the results of the LF, which is widely used for the surgical treatment of pilonidal sinus disease, and the recently described BMGAF after oblique excision.
Methods The data for 117 patients surgically treated for SPS at the Mus and Erzincan State Hospitals in Turkey between February 2009 and July 2011 were evaluated retrospectively. Twelve patients were excluded due to a lack of data. The data for the remaining 105 patients who did not have massive gluteal involvement (diseased area more than 5 cm from the intergluteal sulcus) were included. The infected sinuses were treated with antibiotics, while abscesses were treated with surgical drainage and antibiotics. Surgery was performed 2–4 weeks after the regression of the infection. Patients were informed about the operations to be performed, and signed consent was obtained. The operations were performed by the authors. Postoperatively, the patients were examined clinically at 3, 5 and 10 days and 6 months after BGMAF and at 5 and 10 days and 6 months after LF. The final condition of the patients was determined by a telephone interview. The cosmetic satisfaction with the surgical results was scored 6 months postoperatively as follows: 1 = poor, 2 = acceptable, 3 = good or 4 = perfect. Patients were compared in terms of age, body mass index (BMI), symptoms, length of the operation, complications, postoperative hospital stay, time to return to work, the postoperative cosmetic satisfaction score and recurrence. Statistical analysis The data are presented as the means and standard deviations, medians and percentages (range). t test was used to compare normally distributed numerical data between the groups, and the Mann–Whitney U test was used for nonnormally distributed data. In all analyses, a value of P \ 0.05 was considered to indicate statistical significance. Surgical techniques and postoperative care Following the rectal lavage and shaving of the operation area on the morning of surgery, all operations were performed under spinal anesthesia in the prone-jackknife position. One gram of prophylactic cefazolin sodium was administered 20–60 min before the skin incision. The Limberg flap was made following the administration of methylene blue through the sinus opening, in the classic manner, using a vacuum drainage (Fig. 1). In BGMAF, an S-type oblique skin incision was made
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Fig. 1 The final view of the Limberg flap procedure
following the administration of methylene blue through the sinus opening (Fig. 2a). Diseased tissue, including the sinus tract, was excised as far as the postsacral fascia (Fig. 2b). The fascia of both gluteus maximus muscles was incised vertically from the point of adhesion to the sacrum and freed 1.5–2 cm from the muscle with hemostasis established with electrocautery (Fig. 2c). The fascia of each gluteus maximus was sutured individually to the postsacral fascia with no. 0 polyglactin sutures (Fig. 2d). The subcuticular plane was closed with subcutaneous 3-0 polyglactin sutures, and the cutaneous tissue was closed with 3-0 polypropylene sutures (Fig. 3). No drain was used in any patient in the BGMAF group. Postoperative pain was relieved with nonsteroidal anti-inflammatory drugs as needed. Patients in both groups were mobilized on the first postoperative day and told not to sit for the first 7 days. Drains were removed when the drainage level reached \20 mL/day. Patients were discharged with appropriate instructions for wound care and advised to use oral antibiotics (co-amoxicillin 1000 mg, once every 12 h) for 5 days. The skin sutures were removed 10–12 days postoperatively.
Results A total of 88 of the 105 patients were male while 17 of them were female; 56 patients were treated with BGMAF and 49 with LF. Their median age was 25 (range 15–49) years. There were no significant differences between the groups in terms of age or gender. The mean follow-up was 20.5 ± 5.4 months. The mean BMI was 25.4 ± 1.9 in the BGMAF group and 24.5 ± 1.6 in the LF group. Although there was a significant difference (P = 0.02) between the groups, this was unlikely to have affected the treatment results. The patients’ preoperative symptoms were similar in both groups. The patients’ characteristics and symptoms are summarized in Table 1. The mean length of the operation was significantly shorter in the BGMAF group compared to the LF group
Surg Today Fig. 2 The BGMAF procedure. a An S-shaped oblique skin incision was made; b the sinus area was obliquely excised; c the advancing flap was prepared; d the fascia of bilateral gluteus maximus muscles was sutured individually to the postsacral area
Table 1 Patient characteristics Characteristics
BGMAF (n = 56)
LF (n = 49)
P*
Age (years)
26.7 ± 7.9
24.1 ± 5.1
0.217
Sex (M/F)
47/9
41/8
0.944
Mean body mass index (kg/m2)
25.4 ± 1.9
24.5 ± 1.6
0.020
Patients with recurrent PS (n)
–
1 (2 %)
0.283
Pain
19 (33.9 %)
15 (30.6 %)
0.717
Discharge
33 (58.9 %)
30 (61.2 %)
0.811
Pain ? discharge
4 (7.1 %)
4 (8.2)
0.844
Preoperative symptoms
Data are expressed as the mean ± SEM or numbers (percentage) * P values \0.05 were considered to be statistically significant
Fig. 3 The final view of the BGMAF procedure
(31.1 ± 3.9 vs. 48.3 ± 5.0, P \ 0.001). Wound dehiscence was seen in seven (12.5 %) patients in the BGMAF group and three (6.1 %) patients in the LF group in the early postoperative period; there were no significant differences between the groups in terms of dehiscence (P = 0.267) or in the total complication (P = 0.154) rates. Wound dehiscence was treated conservatively. Seromas developed in two (3.6 %) patients in the BGMAF group and hematomas developed in two (4.1 %) patients in the LF group. The seromas were aspirated, while the hematomas were drained under local anesthesia. The mean hospital stay and time to return to work were shorter in the BGMAF group (2.1 ± 0.3 and
12.6 ± 2.6 days, respectively) compared to the LF group (2.5 ± 0.6 and 14.0 ± 2.1 days, respectively) (P \ 0.001 and P = 0.003, respectively), and the cosmetic satisfaction score was higher in the BGMAF group than in the LF group (3.2 ± 0.5 vs. 2.9 ± 0.5, respectively, P \ 0.001). Drainage was not used in the group treated with BGMAF. In the LF group, the drainage time was the same as the hospital stay (2.5 ± 0.6 days). Recurrence was seen in four (7.1 %) patients in the BGMAF group and three (6.1 %) in the LF group (P = 0.834). The effects of the treatment modality on the clinical results are shown in Table 2.
Discussion The first surgical techniques used to treat pilonidal sinus included laying open the sinus, marsupialization, excision
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The technique must also be simple, require brief hospitalization, increase the postoperative patient comfort, have an efficient wound healing time and provide cosmetic satisfaction. Techniques such as the Limberg and Dufourmentel flaps were reported to have lower recurrence rates among the flaps used to treat SPS that flatten the natal cleft and remove the incision line and scar tissue from the central line. The reported long-term recurrence and total early complication rates are 1.6–6.9 and 4.7–25.7 %, respectively, for the LF technique, which was first described for the surgical treatment of pilonidal sinus disease by Azab et al. [9–13]. Mentes et al. [14] modified the LF by lateralizing the margin close to the anus, and reported even lower rates of recurrence and complications with this modification. The LF technique has not been previously investigated in terms of parameters such as the length of the operation, length of hospital stay and cosmetic satisfaction. Various techniques used for the surgical treatment of SPS and their outcomes are shown in Table 3. The search for perfect patient satisfaction, while minimizing the rates of recurrence and complications, in the treatment of pilonidal sinus disease continues. Recent studies have shown that the excision techniques used in primary closure management, which involve a shorter hospital stay and less surgical scarring, also reduce the recurrence rates [3, 15, 16]. It was recently hypothesized that the depth of the intergluteal sulcus, the vacuum effect developing between the buttocks and the incision scar in
Table 2 Clinical outcomes of the treatment modalities Outcomes
BGMAF (n = 56)
LF (n = 49)
P*
Length of operation (min)
31.1 ± 3.9
48.3 ± 5.0
\0.001
Duration of drainage (days)
–
2.5 ± 0.6
NA
Length of hospital stay (days) Complications
2.1 ± 0.3
2.5 ± 0.6
\0.001
9 (16.1 %)
5 (10.2 %)
0.154
Seroma
2 (3.6 %)
–
Hematoma
–
2 (4.1 %)
Wound dehiscence
7 (12.5 %)
3 (6.1 %)
Return to work (days)
12.6 ± 2.6
14.0 ± 2.1
0.003
Cosmetic satisfaction
3.2 ± 0.5
2.9 ± 0.5
\0.001
Follow-up period (months)
19.6 ± 5.2
21.6 ± 5.5
0.064
Recurrence
4 (7.1 %)
3 (6.1 %)
0.834
Data are expressed as the mean ± SEM or numbers (percentage) * P values \ 0.05 were considered to be statistically significant
and primary closure techniques. The high recurrence rates associated with these techniques led to the development of new treatment modalities, such as advancement flap techniques. The ideal treatment of pilonidal sinus disease consists of flattening the natal cleft and lateralization, while reducing wound tension will reduce the morbidity by preventing wound dehiscence and scar formation [3, 8]. The ideal method for treating SPS must have a low recurrence rate.
Table 3 Various flap techniques and outcomes Operation
Flap type
Year
N
Drain
MOT (min)
LOH (days)
Follow-up (years)
CS (S/TS)
Asymmetric incision
Advancement
Karydakis [3]
1992
6545
N
–
3
2–20
–
Ates et al. [13]
2011
135
Y
42.3
3.43
26.2 (months)
2.2/10
11.1
3.1
1984
30
Y
–
10
0.5–3
–
20
0
2002
85
Y
–
5.3
69.3 (months)
–
4.7
3.5
2003
200
Y
–
3.1
5.1
–
6
2.5
Limberg flap Azab et al. [9]
Morbidity %
8.5
Recurrence %
\1
Transposition
Kapan et al. [11] Topgu¨l et al. [10] Mentes. et al. [17]
2008
353
N
–
4.5
24
–
10.4
3.1
Akin et al. [12]
2010
411
Y
–
3.2
109.2 (months)
–
10.2
2.9
Muzi et al. [20] Mu¨ller et al. [7]
2010
130
Y
60.6
4.9
45.7 (months)
–
13.1
0
2011
70
Y
57.4
–
1.4
16.4/24
25.7
1.6
Ates et al. [13]
2011
134
Y
50.1
3.80
26.6 (months)
3.2/10
20.8
6.9
Current
2013
49
Y
48.3
2.5
21.6 (months)
2.9/4
10.2
6.1
Krand et al. [8]
2009
278
N
42.8
–
66 (months)
–
7.2
0.7
Current
2013
56
N
31.1
2.1
19.6 (months)
3.2/4
16.1
7.1
Gluteus Maximus flap
Advancement
N number of patients, MOT mean operation time, LOH length of hospitalization, CS cosmetic satisfaction, Y yes; N no, s score, TS total score
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the midline affect recurrence [17]. The recurrence rates associated with primary midline closure after excision are 20–42 % [18, 19], while the rate is reduced to 0.9–5.6 % with primary closure after oblique excision [8, 15]. In a series of 278 patients, Krand et al. [8] reconstructed the oblique excision with BGMAF and reported total complication (seroma, infection and wound dehiscence) and recurrence rates of 7.2 and 0.7 %, respectively. Mentes et al. [17] reported complication and recurrence rates of 10.4 and 3.1 %, respectively, in a study of 353 patients treated using the LF technique, while Ates et al. [13] reported rates of 20.8 and 6.9 % in a 134-patient study using the same technique. Muzi et al. [20] compared modified tension-free primary closure with the LF technique in a study of 260 patients, and reported complication and recurrence rates of 25.4 vs. 13.1 and 3.8 vs. 0 %, respectively. They did not perform a statistical analysis of the total complication rate, but found no significant differences between the groups in terms of wound infection or wound dehiscence. The total complication rates in our series were 16.1 % in the BGMAF group and 10.2 % in the LF group, while the recurrence rates were 7.1 and 6.1 %, respectively; the differences between the groups were not significant. Although the differences were not significant, we attribute the increased complication rate in the BGMAF group, particularly in wound dehiscence, to the flap technique being unable to sufficiently reduce the wound tension, thus leading to a delay of wound healing. The recurrence and complication rates in our patients treated with the BGMAF technique were higher than those reported by Krand et al. [8] using the same technique. We ascribe this difference more to the socioeconomic level of our subjects, rather than surgical factors, because Krand et al. [8] studied patients living in the top province in terms of socioeconomic development, according to the State Planning Authority’s classification of Turkey’s 81 provinces (SEGE 2011), while our patients lived in the 45th and 81st provinces. Our recurrence and complication rates in the LF group were similar to those cited in some reports, but were higher than the values in others [13, 17, 20]. Our literature review did not reveal any comprehensive research on the effects of socioeconomic development on recurrence and morbidity. Anderson et al. [21] postulated that the outcomes of pilonidal surgery may be affected by patientassociated factors, and reported that cigarette use increased morbidity. However, as their patients were from relatively high socioeconomic levels, the effects of various factors in patients with a low socioeconomic status on the surgical outcomes could not be determined. Krand et al. [8] reported a mean operation time for BGMAF of 42.8 ± 4.2 min; Kirkil et al. [22] reported mean operation times for LF of 79.5 and 65.5 min in
groups without and with drains, respectively. Ates et al. [13] reported a mean operation time of 50.1 min for LF using drainage and Muzi et al. [20] reported mean operation times of 28 min for modified primary closure and 60.6 min for LF with drainage. The mean lengths of the operations in our study were 31.1 ± 3.9 min in the BGMAF group and 48.3 ± 5.0 min in the LF group. Thus, the operation was significantly shorter in the BGMAF group, which was attributed to the preparation of the advancement flap being easier than that of the full-thickness flap, which is used in LF. Drainage was not used in the BGMAF group. The mean hospital stay was 2.1 ± 0.3 days. In the LF group, the mean drainage and hospital stay were both 2.5 ± 0.6 days. There was a significant difference between the groups in terms of the hospital stay time. The most important reason for the longer duration in the LF group was drainage monitoring. However, in a study of 353 patients in whom drainage was not used during LF, Mentes et al. [17] reported a mean hospital stay of 4.5 days. Kirkil et al. [22] reported a mean hospital stay of 3.3 days in a non-drainage patient group and 3.1 days in a group in which drains were used. Although a lack of drain usage seems to have increased the length of the hospital stay in previous studies, our results demonstrated that there is a positive relationship between using a drain in the LF procedure and a prolonged hospital stay. We believe that this difference between our study and the previous studies depended on the variations in the surgical techniques. Krand et al. [8] reported a mean return-to-work time after BGMAF of 12 ± 2 days, Unalp et al. [23] reported a period of 15.2 days after LF, Ertan et al. [24] reported 15.8 days after LF and Mentes et al. [17] reported a mean return-to-work time of 17.2 days after LF. The time to return to work in our study was 12.6 ± 2.6 days in the BGMAF group and 14.0 ± 2.1 days in the LF group (P = 0.003). Our findings suggest that the shorter hospitalization contributes to shortening of the time to return to work, and the BGMAF procedure was associated with a shorter hospitalization and a shorter time to return to work than LF. Krand et al. [8] did not score the cosmetic satisfaction after BGMAF. Mu¨ller et al. [7] evaluated the cosmetic results in a study using the LF technique, and performed a comparison with the scores in studies involving laparoscopic procedures and medial laparotomy; they concluded that the score for the LF technique was intermediate between those for laparoscopic procedures and median laparotomy. We found a higher cosmetic satisfaction score in the BGMAF group compared to the LF group in the present study (3.2 ± 0.5 vs. 2.9 ± 0.5, P \ 0.001). The better cosmetic score was likely associated with the shorter incision scar in the BGMAF group.
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Conclusion Although BGMAF achieved similar outcomes to LF in terms of recurrence, it had a higher rate of wound dehiscence; but ultimately, the difference was not significant. We attribute the high level of dehiscence in BGMAF to increased wound tension associated with the greater width of the excision in advancement flaps compared to transposition flaps. BGMAF appears to be superior to LF in terms of the length of the operation, length of hospital stay, time to return to work and the cosmetic satisfaction, and may be preferred for sinuses not requiring wide excision. We believe that the LF technique, which better reduces tension, is preferable for sinuses with a large post-excision defect. Acknowledgments We thank Prof. Said Bodur for the statistical analysis of the data. Conflict of interest
None.
References 1. Al-Khamis A, McCallum I, King PM, Bruce J. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev. 2010;Jan 20;(1):CD006213. 2. Surrel JA. Pilonidal disease. Surg Clin North Am. 1994;74: 1309–15. 3. Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. ANZ J Surg. 1992; 62:385–9. 4. Armstrong JH, Barcia PJ. Pilonidal sinus disease: the conservative approach. Arch Surg. 1994;129:914–9. 5. Schneider IHF, Thaler K, Kockerling TF. Treatment of pilonidal sinus by phenol injection. Int J Colorectal Dis. 1994;9:200–2. 6. Gage AA, Dutta P. Cryosurgery for pilonidal disease. Am J Surg. 1977;133:249–54. 7. Mu¨ller K, Marti L, Tarantino I, Jayne DG, Wolff K, Hetzer FH. Prospective analysis of cosmesis, morbidity, and patient satisfaction following Limberg flap for the treatment of sacrococcygeal pilonidal sinus. Dis Colon Rectum. 2011;54(4):487–94. 8. Krand O, Yaltı T, Berber I, Kara VM, Telliıg˘lu G. Management of pilonidal sinus disease with oblique excision and bilateral gluteus maximus fascia advancing flap: result of 278 patients. Dis Colon Rectum. 2009;52:1172–7. 9. Azab AS, Kamal MS, Saad RA, Abou al Atta KA, Ali NA. Radical cure of pilonidal sinus by a transposition rhomboid flap. Br J Surg. 1984;71(2):154–5.
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10. Topgu¨l K, Ozdemir E, Kilic¸ K, Go¨kbayir H, Ferahko¨s¸ e Z. Longterm results of Limberg flap procedure for treatment of pilonidal sinus: a report of 200 cases. Dis Colon Rectum. 2003;46(11): 1545–8. 11. Kapan M, Kapan S, Pekmezci S, Durgun V. Sacrococcygeal pilonidal sinus disease with Limberg flap repair. Tech Coloproctol. 2002;6(1):27–32. 12. Akin M, Gokbayir H, Kilic K, Topgul K, Ozdemir E, Ferahkose Z. Rhomboid excision and Limberg flap for managing pilonidal sinus: long-term results in 411 patients. Colorectal Dis. 2008; 10(9):945–8. 13. Ates M, Dirican A, Sarac M, Aslan A, Colak C. Short and longterm results of the Karydakis flap versus the Limberg flap for treating pilonidal sinus disease: a prospective randomized study. Am J Surg. 2011;202(5):568–73. 14. Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, Oguz M. Modified Limberg transposition flap for sacrococcygeal pilonidal sinus. Surg Today. 2004;34(5):419–23. 15. Mentes O, Bagci M, Bilgin T, Coskun I, Ozgul O, Ozdemir M. Management of pilonidal sinus disease with oblique excision and primary closure: results of 493 patients. Dis Colon Rectum. 2006; 49(1):104–8. 16. Kim JK, Jeong JC, Lee JB, Jung KH, Bae BK. S-Plasty for pilonidal disease: modified primary closure reducing tension. J Korean Surg Soc. 2012;82:63–9. 17. Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir M. Limberg flap procedure for pilonidal sinus disease: results of 353 patients. Langenbecks Arch Surg. 2008;393(2):185–9. 18. Al-Hassan HK, Francis IM, Negle´n P. Primary closure or secondary granulation after excision of pilonidal sinus? Acta Chir Scand. 1990;156(10):695–9. 19. Iesalnieks I, Fu¨rst A, Rentsch M, Jauch KW. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate. Chirurg. 2003;74(5):461–8. 20. Muzi MG, Milito G, Cadeddu F, Nigro C, Andreoli F, Amabile D, Farinon AM. Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease. Am J Surg. 2010;200(1):9–14. 21. Anderson JH, Yip CO, Nagabhushan JS, Connelly SJ. Day case Karydakis flap for pilonidal sinus. Dis Colon Rectum. 2008; 51(1):134–8. 22. Kirkil C, Bo¨yu¨k A, Bu¨lbu¨ller N, Aygen E, Karabulut K, Cos¸ kun S. The effects of drainage on the rates of early wound complications and recurrences after Limberg flap reconstruction in patients with pilonidal disease. Tech Coloproctol. 2011;15(4): 425–9. 23. Unalp HR, Derici H, Kamer E, Nazli O, Onal MA. Lower recurrence rate for Limberg vs. V-Y flap for pilonidal sinus. Dis Colon Rectum. 2007;50(9):1436–44. 24. Ertan T, Koc M, Gocmen E, Aslar AK, Keskek M, Kilic M. Does technique alter quality of life after pilonidal sinus surgery? Am J Surg. 2005;190(3):388–92.
ORIGINAL ARTICLE
Comparison of the Limberg flap and bilateral gluteus maximus advancing flap following oblique excision for the treatment of pilonidal sinus disease Murat Yildar • Faruk Cavdar
Received: 11 June 2013 / Accepted: 22 August 2013 Ó Springer Japan 2013
Abstract Purpose This study was performed to compare the use of a bilateral gluteus maximus advancing flap (BGMAF) following oblique incision, which was recently described for the surgical treatment of sacrococcygeal pilonidal sinus (SPS) disease, with the widely used Limberg flap (LF) technique following a rhomboid incision. Methods A total of 105 patients treated for SPS were evaluated retrospectively. The patients were evaluated in terms of their age, body mass index, symptoms, length of the operation, complications, postoperative hospital stay, time to return to work, postoperative cosmetic satisfaction and recurrence rate. Results Fifty-six of the patients were treated with BGMAF, while 49 were treated with LF. The mean followup was 20.5 ± 5.4 months. The mean length of the operation, hospital stay and time to return to work were shorter, while the cosmetic satisfaction score was higher in the BGMAF group compared to the LF group. There was no statistically significant difference between the groups for the other criteria. Conclusion The BGMAF appears to be superior to the LF in terms of the length of the operation, time to return to work and degree of cosmetic satisfaction. It is preferable for sinuses not to require wide excision, while the LF is more appropriate for sinuses with a large post-excision defect. M. Yildar (&) Department of General Surgery, Balıkesir University Medical School, Balıkesir, Turkey e-mail: [email protected] F. Cavdar Department of General Surgery, Yalova State Hospital, Yalova, Turkey
Keywords Pilonidal sinus Limberg flap Oblique excision Advancing flap Socioeconomic level
Introduction Pilonidal sinus disease is most common in the sacrococcygeal region and has an incidence of 26/100000. It is twice as common in males as in females [1]. A foreign body reaction developing as a result of hair follicles penetrating the skin following trauma is implicated in the pathogenesis of the disease [1–3]. The disease is generally asymptomatic. However, when it becomes symptomatic, it has a negative impact on the patient’s quality of life. Due to their high rates of recurrence, conservative methods of treating symptomatic sacrococcygeal pilonidal sinus (SPS), such as shaving [4], phenol administration [5] and cryosurgery [6], have gradually declined in popularity. Although surgical techniques such as excision, marsupialization and primary closure have lower recurrence rates than conservative methods, they have gradually given way to advancement flap techniques, for reasons such as the need for dressings, prolonged wound healing and wound infection. The Limberg flap (LF) technique has the lowest recurrence rate among the flap techniques currently used to treat SPS. However, recent reports have suggested that this technique does not achieve good results in terms of the cosmetic appearance and wound healing [7]. The oblique excision and bilateral gluteus maximus advancing flap (BGMAF) technique was recently described for the treatment of SPS, and provides results similar to the LF in terms of recurrence [8]. However, to date, there have been no studies comparing this method with other techniques in terms of the length of the operation and the length of the hospital stay.
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Therefore, the present study was performed to compare the results of the LF, which is widely used for the surgical treatment of pilonidal sinus disease, and the recently described BMGAF after oblique excision.
Methods The data for 117 patients surgically treated for SPS at the Mus and Erzincan State Hospitals in Turkey between February 2009 and July 2011 were evaluated retrospectively. Twelve patients were excluded due to a lack of data. The data for the remaining 105 patients who did not have massive gluteal involvement (diseased area more than 5 cm from the intergluteal sulcus) were included. The infected sinuses were treated with antibiotics, while abscesses were treated with surgical drainage and antibiotics. Surgery was performed 2–4 weeks after the regression of the infection. Patients were informed about the operations to be performed, and signed consent was obtained. The operations were performed by the authors. Postoperatively, the patients were examined clinically at 3, 5 and 10 days and 6 months after BGMAF and at 5 and 10 days and 6 months after LF. The final condition of the patients was determined by a telephone interview. The cosmetic satisfaction with the surgical results was scored 6 months postoperatively as follows: 1 = poor, 2 = acceptable, 3 = good or 4 = perfect. Patients were compared in terms of age, body mass index (BMI), symptoms, length of the operation, complications, postoperative hospital stay, time to return to work, the postoperative cosmetic satisfaction score and recurrence. Statistical analysis The data are presented as the means and standard deviations, medians and percentages (range). t test was used to compare normally distributed numerical data between the groups, and the Mann–Whitney U test was used for nonnormally distributed data. In all analyses, a value of P \ 0.05 was considered to indicate statistical significance. Surgical techniques and postoperative care Following the rectal lavage and shaving of the operation area on the morning of surgery, all operations were performed under spinal anesthesia in the prone-jackknife position. One gram of prophylactic cefazolin sodium was administered 20–60 min before the skin incision. The Limberg flap was made following the administration of methylene blue through the sinus opening, in the classic manner, using a vacuum drainage (Fig. 1). In BGMAF, an S-type oblique skin incision was made
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Fig. 1 The final view of the Limberg flap procedure
following the administration of methylene blue through the sinus opening (Fig. 2a). Diseased tissue, including the sinus tract, was excised as far as the postsacral fascia (Fig. 2b). The fascia of both gluteus maximus muscles was incised vertically from the point of adhesion to the sacrum and freed 1.5–2 cm from the muscle with hemostasis established with electrocautery (Fig. 2c). The fascia of each gluteus maximus was sutured individually to the postsacral fascia with no. 0 polyglactin sutures (Fig. 2d). The subcuticular plane was closed with subcutaneous 3-0 polyglactin sutures, and the cutaneous tissue was closed with 3-0 polypropylene sutures (Fig. 3). No drain was used in any patient in the BGMAF group. Postoperative pain was relieved with nonsteroidal anti-inflammatory drugs as needed. Patients in both groups were mobilized on the first postoperative day and told not to sit for the first 7 days. Drains were removed when the drainage level reached \20 mL/day. Patients were discharged with appropriate instructions for wound care and advised to use oral antibiotics (co-amoxicillin 1000 mg, once every 12 h) for 5 days. The skin sutures were removed 10–12 days postoperatively.
Results A total of 88 of the 105 patients were male while 17 of them were female; 56 patients were treated with BGMAF and 49 with LF. Their median age was 25 (range 15–49) years. There were no significant differences between the groups in terms of age or gender. The mean follow-up was 20.5 ± 5.4 months. The mean BMI was 25.4 ± 1.9 in the BGMAF group and 24.5 ± 1.6 in the LF group. Although there was a significant difference (P = 0.02) between the groups, this was unlikely to have affected the treatment results. The patients’ preoperative symptoms were similar in both groups. The patients’ characteristics and symptoms are summarized in Table 1. The mean length of the operation was significantly shorter in the BGMAF group compared to the LF group
Surg Today Fig. 2 The BGMAF procedure. a An S-shaped oblique skin incision was made; b the sinus area was obliquely excised; c the advancing flap was prepared; d the fascia of bilateral gluteus maximus muscles was sutured individually to the postsacral area
Table 1 Patient characteristics Characteristics
BGMAF (n = 56)
LF (n = 49)
P*
Age (years)
26.7 ± 7.9
24.1 ± 5.1
0.217
Sex (M/F)
47/9
41/8
0.944
Mean body mass index (kg/m2)
25.4 ± 1.9
24.5 ± 1.6
0.020
Patients with recurrent PS (n)
–
1 (2 %)
0.283
Pain
19 (33.9 %)
15 (30.6 %)
0.717
Discharge
33 (58.9 %)
30 (61.2 %)
0.811
Pain ? discharge
4 (7.1 %)
4 (8.2)
0.844
Preoperative symptoms
Data are expressed as the mean ± SEM or numbers (percentage) * P values \0.05 were considered to be statistically significant
Fig. 3 The final view of the BGMAF procedure
(31.1 ± 3.9 vs. 48.3 ± 5.0, P \ 0.001). Wound dehiscence was seen in seven (12.5 %) patients in the BGMAF group and three (6.1 %) patients in the LF group in the early postoperative period; there were no significant differences between the groups in terms of dehiscence (P = 0.267) or in the total complication (P = 0.154) rates. Wound dehiscence was treated conservatively. Seromas developed in two (3.6 %) patients in the BGMAF group and hematomas developed in two (4.1 %) patients in the LF group. The seromas were aspirated, while the hematomas were drained under local anesthesia. The mean hospital stay and time to return to work were shorter in the BGMAF group (2.1 ± 0.3 and
12.6 ± 2.6 days, respectively) compared to the LF group (2.5 ± 0.6 and 14.0 ± 2.1 days, respectively) (P \ 0.001 and P = 0.003, respectively), and the cosmetic satisfaction score was higher in the BGMAF group than in the LF group (3.2 ± 0.5 vs. 2.9 ± 0.5, respectively, P \ 0.001). Drainage was not used in the group treated with BGMAF. In the LF group, the drainage time was the same as the hospital stay (2.5 ± 0.6 days). Recurrence was seen in four (7.1 %) patients in the BGMAF group and three (6.1 %) in the LF group (P = 0.834). The effects of the treatment modality on the clinical results are shown in Table 2.
Discussion The first surgical techniques used to treat pilonidal sinus included laying open the sinus, marsupialization, excision
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The technique must also be simple, require brief hospitalization, increase the postoperative patient comfort, have an efficient wound healing time and provide cosmetic satisfaction. Techniques such as the Limberg and Dufourmentel flaps were reported to have lower recurrence rates among the flaps used to treat SPS that flatten the natal cleft and remove the incision line and scar tissue from the central line. The reported long-term recurrence and total early complication rates are 1.6–6.9 and 4.7–25.7 %, respectively, for the LF technique, which was first described for the surgical treatment of pilonidal sinus disease by Azab et al. [9–13]. Mentes et al. [14] modified the LF by lateralizing the margin close to the anus, and reported even lower rates of recurrence and complications with this modification. The LF technique has not been previously investigated in terms of parameters such as the length of the operation, length of hospital stay and cosmetic satisfaction. Various techniques used for the surgical treatment of SPS and their outcomes are shown in Table 3. The search for perfect patient satisfaction, while minimizing the rates of recurrence and complications, in the treatment of pilonidal sinus disease continues. Recent studies have shown that the excision techniques used in primary closure management, which involve a shorter hospital stay and less surgical scarring, also reduce the recurrence rates [3, 15, 16]. It was recently hypothesized that the depth of the intergluteal sulcus, the vacuum effect developing between the buttocks and the incision scar in
Table 2 Clinical outcomes of the treatment modalities Outcomes
BGMAF (n = 56)
LF (n = 49)
P*
Length of operation (min)
31.1 ± 3.9
48.3 ± 5.0
\0.001
Duration of drainage (days)
–
2.5 ± 0.6
NA
Length of hospital stay (days) Complications
2.1 ± 0.3
2.5 ± 0.6
\0.001
9 (16.1 %)
5 (10.2 %)
0.154
Seroma
2 (3.6 %)
–
Hematoma
–
2 (4.1 %)
Wound dehiscence
7 (12.5 %)
3 (6.1 %)
Return to work (days)
12.6 ± 2.6
14.0 ± 2.1
0.003
Cosmetic satisfaction
3.2 ± 0.5
2.9 ± 0.5
\0.001
Follow-up period (months)
19.6 ± 5.2
21.6 ± 5.5
0.064
Recurrence
4 (7.1 %)
3 (6.1 %)
0.834
Data are expressed as the mean ± SEM or numbers (percentage) * P values \ 0.05 were considered to be statistically significant
and primary closure techniques. The high recurrence rates associated with these techniques led to the development of new treatment modalities, such as advancement flap techniques. The ideal treatment of pilonidal sinus disease consists of flattening the natal cleft and lateralization, while reducing wound tension will reduce the morbidity by preventing wound dehiscence and scar formation [3, 8]. The ideal method for treating SPS must have a low recurrence rate.
Table 3 Various flap techniques and outcomes Operation
Flap type
Year
N
Drain
MOT (min)
LOH (days)
Follow-up (years)
CS (S/TS)
Asymmetric incision
Advancement
Karydakis [3]
1992
6545
N
–
3
2–20
–
Ates et al. [13]
2011
135
Y
42.3
3.43
26.2 (months)
2.2/10
11.1
3.1
1984
30
Y
–
10
0.5–3
–
20
0
2002
85
Y
–
5.3
69.3 (months)
–
4.7
3.5
2003
200
Y
–
3.1
5.1
–
6
2.5
Limberg flap Azab et al. [9]
Morbidity %
8.5
Recurrence %
\1
Transposition
Kapan et al. [11] Topgu¨l et al. [10] Mentes. et al. [17]
2008
353
N
–
4.5
24
–
10.4
3.1
Akin et al. [12]
2010
411
Y
–
3.2
109.2 (months)
–
10.2
2.9
Muzi et al. [20] Mu¨ller et al. [7]
2010
130
Y
60.6
4.9
45.7 (months)
–
13.1
0
2011
70
Y
57.4
–
1.4
16.4/24
25.7
1.6
Ates et al. [13]
2011
134
Y
50.1
3.80
26.6 (months)
3.2/10
20.8
6.9
Current
2013
49
Y
48.3
2.5
21.6 (months)
2.9/4
10.2
6.1
Krand et al. [8]
2009
278
N
42.8
–
66 (months)
–
7.2
0.7
Current
2013
56
N
31.1
2.1
19.6 (months)
3.2/4
16.1
7.1
Gluteus Maximus flap
Advancement
N number of patients, MOT mean operation time, LOH length of hospitalization, CS cosmetic satisfaction, Y yes; N no, s score, TS total score
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Surg Today
the midline affect recurrence [17]. The recurrence rates associated with primary midline closure after excision are 20–42 % [18, 19], while the rate is reduced to 0.9–5.6 % with primary closure after oblique excision [8, 15]. In a series of 278 patients, Krand et al. [8] reconstructed the oblique excision with BGMAF and reported total complication (seroma, infection and wound dehiscence) and recurrence rates of 7.2 and 0.7 %, respectively. Mentes et al. [17] reported complication and recurrence rates of 10.4 and 3.1 %, respectively, in a study of 353 patients treated using the LF technique, while Ates et al. [13] reported rates of 20.8 and 6.9 % in a 134-patient study using the same technique. Muzi et al. [20] compared modified tension-free primary closure with the LF technique in a study of 260 patients, and reported complication and recurrence rates of 25.4 vs. 13.1 and 3.8 vs. 0 %, respectively. They did not perform a statistical analysis of the total complication rate, but found no significant differences between the groups in terms of wound infection or wound dehiscence. The total complication rates in our series were 16.1 % in the BGMAF group and 10.2 % in the LF group, while the recurrence rates were 7.1 and 6.1 %, respectively; the differences between the groups were not significant. Although the differences were not significant, we attribute the increased complication rate in the BGMAF group, particularly in wound dehiscence, to the flap technique being unable to sufficiently reduce the wound tension, thus leading to a delay of wound healing. The recurrence and complication rates in our patients treated with the BGMAF technique were higher than those reported by Krand et al. [8] using the same technique. We ascribe this difference more to the socioeconomic level of our subjects, rather than surgical factors, because Krand et al. [8] studied patients living in the top province in terms of socioeconomic development, according to the State Planning Authority’s classification of Turkey’s 81 provinces (SEGE 2011), while our patients lived in the 45th and 81st provinces. Our recurrence and complication rates in the LF group were similar to those cited in some reports, but were higher than the values in others [13, 17, 20]. Our literature review did not reveal any comprehensive research on the effects of socioeconomic development on recurrence and morbidity. Anderson et al. [21] postulated that the outcomes of pilonidal surgery may be affected by patientassociated factors, and reported that cigarette use increased morbidity. However, as their patients were from relatively high socioeconomic levels, the effects of various factors in patients with a low socioeconomic status on the surgical outcomes could not be determined. Krand et al. [8] reported a mean operation time for BGMAF of 42.8 ± 4.2 min; Kirkil et al. [22] reported mean operation times for LF of 79.5 and 65.5 min in
groups without and with drains, respectively. Ates et al. [13] reported a mean operation time of 50.1 min for LF using drainage and Muzi et al. [20] reported mean operation times of 28 min for modified primary closure and 60.6 min for LF with drainage. The mean lengths of the operations in our study were 31.1 ± 3.9 min in the BGMAF group and 48.3 ± 5.0 min in the LF group. Thus, the operation was significantly shorter in the BGMAF group, which was attributed to the preparation of the advancement flap being easier than that of the full-thickness flap, which is used in LF. Drainage was not used in the BGMAF group. The mean hospital stay was 2.1 ± 0.3 days. In the LF group, the mean drainage and hospital stay were both 2.5 ± 0.6 days. There was a significant difference between the groups in terms of the hospital stay time. The most important reason for the longer duration in the LF group was drainage monitoring. However, in a study of 353 patients in whom drainage was not used during LF, Mentes et al. [17] reported a mean hospital stay of 4.5 days. Kirkil et al. [22] reported a mean hospital stay of 3.3 days in a non-drainage patient group and 3.1 days in a group in which drains were used. Although a lack of drain usage seems to have increased the length of the hospital stay in previous studies, our results demonstrated that there is a positive relationship between using a drain in the LF procedure and a prolonged hospital stay. We believe that this difference between our study and the previous studies depended on the variations in the surgical techniques. Krand et al. [8] reported a mean return-to-work time after BGMAF of 12 ± 2 days, Unalp et al. [23] reported a period of 15.2 days after LF, Ertan et al. [24] reported 15.8 days after LF and Mentes et al. [17] reported a mean return-to-work time of 17.2 days after LF. The time to return to work in our study was 12.6 ± 2.6 days in the BGMAF group and 14.0 ± 2.1 days in the LF group (P = 0.003). Our findings suggest that the shorter hospitalization contributes to shortening of the time to return to work, and the BGMAF procedure was associated with a shorter hospitalization and a shorter time to return to work than LF. Krand et al. [8] did not score the cosmetic satisfaction after BGMAF. Mu¨ller et al. [7] evaluated the cosmetic results in a study using the LF technique, and performed a comparison with the scores in studies involving laparoscopic procedures and medial laparotomy; they concluded that the score for the LF technique was intermediate between those for laparoscopic procedures and median laparotomy. We found a higher cosmetic satisfaction score in the BGMAF group compared to the LF group in the present study (3.2 ± 0.5 vs. 2.9 ± 0.5, P \ 0.001). The better cosmetic score was likely associated with the shorter incision scar in the BGMAF group.
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Conclusion Although BGMAF achieved similar outcomes to LF in terms of recurrence, it had a higher rate of wound dehiscence; but ultimately, the difference was not significant. We attribute the high level of dehiscence in BGMAF to increased wound tension associated with the greater width of the excision in advancement flaps compared to transposition flaps. BGMAF appears to be superior to LF in terms of the length of the operation, length of hospital stay, time to return to work and the cosmetic satisfaction, and may be preferred for sinuses not requiring wide excision. We believe that the LF technique, which better reduces tension, is preferable for sinuses with a large post-excision defect. Acknowledgments We thank Prof. Said Bodur for the statistical analysis of the data. Conflict of interest
None.
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10. Topgu¨l K, Ozdemir E, Kilic¸ K, Go¨kbayir H, Ferahko¨s¸ e Z. Longterm results of Limberg flap procedure for treatment of pilonidal sinus: a report of 200 cases. Dis Colon Rectum. 2003;46(11): 1545–8. 11. Kapan M, Kapan S, Pekmezci S, Durgun V. Sacrococcygeal pilonidal sinus disease with Limberg flap repair. Tech Coloproctol. 2002;6(1):27–32. 12. Akin M, Gokbayir H, Kilic K, Topgul K, Ozdemir E, Ferahkose Z. Rhomboid excision and Limberg flap for managing pilonidal sinus: long-term results in 411 patients. Colorectal Dis. 2008; 10(9):945–8. 13. Ates M, Dirican A, Sarac M, Aslan A, Colak C. Short and longterm results of the Karydakis flap versus the Limberg flap for treating pilonidal sinus disease: a prospective randomized study. Am J Surg. 2011;202(5):568–73. 14. Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, Oguz M. Modified Limberg transposition flap for sacrococcygeal pilonidal sinus. Surg Today. 2004;34(5):419–23. 15. Mentes O, Bagci M, Bilgin T, Coskun I, Ozgul O, Ozdemir M. Management of pilonidal sinus disease with oblique excision and primary closure: results of 493 patients. Dis Colon Rectum. 2006; 49(1):104–8. 16. Kim JK, Jeong JC, Lee JB, Jung KH, Bae BK. S-Plasty for pilonidal disease: modified primary closure reducing tension. J Korean Surg Soc. 2012;82:63–9. 17. Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir M. Limberg flap procedure for pilonidal sinus disease: results of 353 patients. Langenbecks Arch Surg. 2008;393(2):185–9. 18. Al-Hassan HK, Francis IM, Negle´n P. Primary closure or secondary granulation after excision of pilonidal sinus? Acta Chir Scand. 1990;156(10):695–9. 19. Iesalnieks I, Fu¨rst A, Rentsch M, Jauch KW. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate. Chirurg. 2003;74(5):461–8. 20. Muzi MG, Milito G, Cadeddu F, Nigro C, Andreoli F, Amabile D, Farinon AM. Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease. Am J Surg. 2010;200(1):9–14. 21. Anderson JH, Yip CO, Nagabhushan JS, Connelly SJ. Day case Karydakis flap for pilonidal sinus. Dis Colon Rectum. 2008; 51(1):134–8. 22. Kirkil C, Bo¨yu¨k A, Bu¨lbu¨ller N, Aygen E, Karabulut K, Cos¸ kun S. The effects of drainage on the rates of early wound complications and recurrences after Limberg flap reconstruction in patients with pilonidal disease. Tech Coloproctol. 2011;15(4): 425–9. 23. Unalp HR, Derici H, Kamer E, Nazli O, Onal MA. Lower recurrence rate for Limberg vs. V-Y flap for pilonidal sinus. Dis Colon Rectum. 2007;50(9):1436–44. 24. Ertan T, Koc M, Gocmen E, Aslar AK, Keskek M, Kilic M. Does technique alter quality of life after pilonidal sinus surgery? Am J Surg. 2005;190(3):388–92.
