Comparison of Drainage, Delayed Pits Excision, and Closure With Excision and Secondary Healing in Pilonidal Sinus Abscess Cases

A pilonidal sinus (PNS) is a common condition that affects young to middle-aged adult men. The pathogenesis remains uncertain, with arguments suggesting both congenital and acquired bases for the etiology of this condition.¹ PNS disease is caused by the penetration of hairs into the skin of the gluteal cleft, which, due to foreign body reaction, leads to cyst and sinus formation followed by secondary infections and abscesses.²

A pilonidal abscess is one of the most common complications associated with pilonidal disease.^3,4 Pilonidal abscesses may lead to large tissue damage and sepsis unless treated. Pilonidal sinus, which is associated with abscess exacerbations, may spread to the anal canal or perianal region.^5,6 Despite the variety of surgical techniques proposed for the treatment of PSA, the “best method” to use is still a matter of debate.⁷ Conventional treatment of a pilonidal abscess is incision and simple drainage whereby large tissue damage is prevented and the patient is relieved of pain. However, chronic PNS develops in 16% to 92.5% of patients following a simple drainage. In these cases, surgical treatment is required.^8–10 The ideal approach for treating pilonidal disease should be simple, inflict minimal pain, have the best chance for cure and least local recurrence rate, avoid admission to the hospital, not require general anesthesia, require minimal wound care, pose minimal inconvenience, and require the least amount of time off work for the patient.^1,11 This study was performed to compare incision and draining (I&D) of PSA and healing by secondary intention with I&D and delayed pits excision and closure (PE/PC).

Materials and Methods

Surgical technique

Both methods were applied under local anesthesia. The operative field was shaved and cleaned with povidon-iodine. An adequate amount of lidocaine HCl 40 mg/2 mL + epinephrine 0.025 mg/2 mL infiltration was administered to the fluctuating field and surrounding areas when the patient was in prone position. In the patients who received a skin incision and curettage, a skin incision averaging 3 × 2 cm was performed in the fluctuating field. After evacuating the abscess, the whole cavity was curetted and washed with hydrogen peroxide, and then the remaining material was removed. Dressing was done with saline solution twice daily during the first 3 days and daily thereafter. Patients in group 1 were left to heal by secondary intention. In group 2, the cavity was left open for drainage after being washed with hydrogen peroxide first and saline thereafter, following simple drainage (simple drainage was applied from a parallel vertical incision of 2 cm in lateral if the abscess cavity was in midline and with a vertical incision directly over the abscess cavity if it was outside of the midline). After an average of 5 days, midline pilonidal pits were excised with small diamond-shaped incisions. Midline wounds were closed with a subcuticular suture, and lateral wounds were permitted to heal by granulation (Figs. 1 and 2).¹¹ Microbiologic samples were obtained for culture, and empirical antibiotic treatment was started in both groups. Daily wound dressings were recommended for the first week, followed by three dressings the second week and then two dressings a week thereafter. Patients were instructed to adhere to hygiene measures by taking showers and using a towel to rub away loose hairs and to undertake hair depilation to prevent small hairs from making their way into the cavity or overlooked small pits.

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The patients were followed up for a mean of 24 months (12–36 months). Demographic characteristics of the patients, abscess depth and location, duration and healing times of the symptoms, time required to return to work, and ratio of chronic pilonidal sinus development were recorded, and the two methods were compared.

Results

A total of 62 patients who were treated for PSA in our clinic were included in the study. No patients had a previous pilonidal abscess surgery. Associated cellulitis was present in the majority of patients in each group (90.9% in group 1 versus 93.1% in group 2), and abscesses were located in the midline in nearly half of the patients in either group (57.5% versus 51.7%, respectively). The length and depth of abscess in primary and secondary groups are shown in Table 1. There were no statistically significant differences between the groups in relation to sex, age, and preoperative findings, including discharge, infection, pain, and the length and depth of the abscess. During follow-up, 3.03% of patients (n = 1) in group 1 and 3.44% in group 2 (n = 1) developed an infection (wound infection). Table 2 shows that the two groups did not differ significantly from each other regarding hospital stay and time required to return to work or resume normal physical activity. Complications were observed in 6 of the 62 patients (9.6%): 3 patients (9.09%) in group 1 and 3 (10.3%) in group 2. There was no statistically significant difference between the groups in terms of complication rate (P = 0.298). Recurrence was detected in four patients (6.45%). No statistically significant differences were found between the groups in relation to recurrence and development of chronic PNS. The difference in the recurrence rate of a pilonidal abscess, however, was statistically significant (P = 0.033) between the two groups (9.09% in group 1 versus 3.44% in group 2). Lastly, a statistically significant difference was observed between the groups in terms of development of chronic PNS (P = 0.020).

Table 1  Patient characteristics and clinical presentation in both groups

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Table 2  Postoperative course and complications in both groups

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Discussion

A pilonidal abscess is one of the most common complications of pilonidal disease.^3,4 However, there is not yet a consensus about the optimal treatment.¹² Some authors believe that the incision and drainage method is an effective procedure. However, this method would treat only the acute infection and lead to the necessity of reoperation for definite therapy.⁷ Bascom proposed that the main etiologic factor was hair follicles and not the hair. He also suggested that the early chronic PNS development rate could be reduced to 15% by excising the epithelized pilonidal sinus mouth with a small incision 5 days after a simple drainage.¹³ Using the Bascom operation technique, sinuses were opened through a 2-cm lateral incision, parallel to the natal cleft. Bacteriology swabs were taken, and sinus cavities were allowed to drain freely through the lateral incision. Excision of the midline pilonidal pits were performed with small diamond-shaped incisions, and a buttress of fat was constructed to support the healing of the midline wound. Midline wounds were closed with a subcuticular suture, and lateral wounds were permitted to heal by granulation. We observed that with this technique chronic PNS developed 3.44% of the time.

The rate of recurrence with drainage of PSA and primary wound closure ranged from 14% to 38%.⁷ McLaren reported that surgical intervention was required in 40% of the patients who received an incision and drainage.¹⁴ Whereas Matter et al reported 16% recurrence with incision and drainage in PSA, they detected 12% recurrence with excision and packing.¹⁵

There is currently no consensus about the curettage of the abscess wall. In relevant studies, the cure rate has been reported to be 76%.¹⁶ In addition, the combination of drainage and curettage is known to provide faster regression in symptoms compared to simple drainage. In our study, the abscess pouch was curetted and cleaned mechanically. Millar and Lord reported a 97% success rate with excision and mechanic cleaning under local anesthesia in PSA and chronic PNS.¹⁷ Incision (lay open) techniques with or without marsupialization have low recurrence rates, averaging approximately 8% over the long term.¹⁸ Isbister and Prasad proposed that lay open could be applied successfully in both conditions by arguing that it was unnecessary to discriminate between PSA and chronic PNS treatment. They reported PSA in 311 of 323 cases and 12% PNS development with lay open technique.¹⁹

A single-step radical treatment of a pilonidal abscess was performed, using drainage, curettage, and marsupialization, in 43 patients in the study conducted by Licheri et al. They reported a failure rate (persistent sinus or recurrence) of 18.7% and complete healing within 4–10 weeks in 95.3%.²⁰ Chronic PNS development was found to be 18.2% in the secondary healing group in our study. Hosseini et al compared drainage, delayed excision and primary closure with excision and secondary healing in the management of 76 patients with a pilonidal abscess and reported a significantly higher 1-year recurrence rate with primary closure.⁷ Sakr et al compared, drainage, delayed excision, and delayed closure with incision, drainage, and secondary healing, and reported speedier healing times and fewer visits required for dressing when I&D and delayed excision/delayed closure (DE/DC) was performed for PSA. However, a significantly higher overall complication rate was seen compared with I&D and secondary healing.³ Chronic PNS developed in 11.29% of the cases during the 24-month period of follow-up in the patients who were fully recovered. Although duration of hospital stay was 1.1 ± 0.7 hours and healing time was 33.7 ± 9.3 days in incision, drainage, and excision, in cases of incision and delayed pits removal, the duration of hospital stay was 1.4 ± 0.3 hours and healing time was 32.5 ± 8.8 days, with no statistically significant difference being found between the procedures. Healing time was significantly shorter in the incision and drainage group. The rate of recurrence was considerably lower in patients receiving this procedure compared with those who underwent secondary healing.

The first intervention is of primary importance in PSA treatment and those methods that pose a lower risk for chronic PNS development should be preferred.

Conclusion

PSA needs definitive treatment after drainage to prevent it from becoming a chronic disease. Incision, drainage, and combined definitive surgery have been shown to be a reliable method of treatment. According to the results of our study, I&D, delayed pits excision, and closure should be the primary procedure used, as opposed to skin incision and curettage, in the treatment of acute pilonidal abscess.