RADICAL VERSUS CONSERVATIVE METHODS IN ONE-STAGE PILONIDAL ABSCESS SURGERY: THE EXPERIENCE OF A TUNISIAN CENTER

ABSTRACT BACKGROUND: Surgical treatment for pilonidal abscess is the gold standard, but not yet well codified. Different techniques proposed can be conservative or radical. AIMS: The aim of our study was to compare postoperative outcomes of both methods in one-stage treatment strategy. METHODS: This is a comparative study including patients operated on for pilonidal abscess, with a satisfactory postoperative follow-up, over a period of 4 years. We looked for the occurrence of postoperative recurrence in the medical records or by interviewing reachable patients. RESULTS: We analyzed 57 patients: 33 males and 24 females. The mean age was 26.9±10 years. The type of operation was excision in 46 (81%) cases and incision in 11 (19%) cases associated with curettage in three cases and drainage in 1 case. There was no statistically significant relationship between the type of surgery and the occurrence of postoperative surgical complications (p=1) and hospital stay (p=0.4). Excision of pilonidal abscess was significantly associated with a longer time to return to activity (p=0.04). Conservative surgery was significantly associated with faster healing of the surgical wound (p<0.001). The recurrence rate was 19% in radical surgery and 54% in conservative surgery. Radical surgery was significantly associated with a lower recurrence rate than incision procedure (p=0.02). CONCLUSIONS: Excision of pilonidal abscess was the common technique in our series, with a significantly lower rate of recurrence of the disease than after incision. However, the long convalescence following excision and the longer operating time, particularly in an emergency context, may sometimes lead to choosing conservative surgery.


Perspectives
Excision of pilonidal abscess was the most commonly used technique in our series, with a significantly lower rate of recurrence of the disease than after incision. We recommend complete excision as a reference treatment for pilonidal abscesses, except in the case of large abscesses for which an incision is preferable to get through the acute phase and secondarily adapt the therapeutic strategy.

Central Message
Pilonidal abscess is a common condition in young people. It represents an acute suppurative form of pilonidal disease. It is true that pilonidal disease has been extensively treated in the literature, but the management of its abscessed form has not received enough attention. A two-stage surgical treatment is often proposed. Different surgical techniques proposed can be grouped into conservative and radical techniques.
with curettage in 3 cases and drainage in 1 case. The average operation time was 14.3±5.9 min, with extremes of 5 and 30 min.

Postoperative outcomes
A postoperative antibiotic therapy was prescribed in seven cases, based on amoxicillin-clavulanic acid, for a mean duration of 5.9±2.3 days. The average hospital stay was 1.1±0.4 days, with extremes of 1 and 4 days.
Only one patient presented a postoperative hemorrhage occurring after the excision procedure. There was no reported case of wound infection. The average time to return to normal activities was 21±13 days, with extremes of 2 and 90 days. The average healing time was 63.4±32.2 days, with extremes of 10 and 150 days.
Recurrence of pilonidal disease was noted in 26% (15 cases) of patients. The mean time of recurrence was 9.7±6.1 months, with extremes of 2 and 24 months.

Analytic study
The analytic study findings are summarized in Table 1. There was no relationship between the type of surgery and the occurrence of postoperative surgical complications (p=1). The mean postoperative length of stay was 1 day for patients who had incision and 1.11 days for those who had excision. The type of procedure and the length of hospital stay were not statistically associated (p=0.4).
The mean time to return to activity was 10.5±5.1 days for patients who had an incision procedure and 23.4±13.4 days for patients who had an excision procedure. Excision of pilonidal abscess was significantly associated with a longer time to return to activity compared to incision (p=0.04). The mean time to wound healing was 28.4±14.9 days for patients who had conservative surgery and 70.9±29.9 days for patients who had radical surgery. Conservative surgery was significantly associated with faster healing of the surgical wound (p<0.001).
The recurrence rate was 19% in radical surgery group and 54% in conservative surgery group. Complete excision of pilonidal abscess was significantly associated with a lower recurrence rate than the incision procedure (p=0.02).

DISCUSSION
Our study involved the following main findings: the comparison of conservative and radical surgical methods did not find any differences in terms of complications and postoperative hospital stay. Wound healing time and time to return to normal activities were shorter after conservative surgery. In contrast, radical surgery resulted in less recurrence of pilonidal disease.
Intervention type in pilonidal abscess is still a matter of controversy. Some authors currently recommend the incision of the abscessed pilonidal sinus, whether it is the first episode of abscess or a recurrence 12,19 . Hanley recommends an urgent

INTRODUCTION
Pilonidal abscess is a common condition in young people. Its prevalence can reach up to 0.7% of the population 18 . It is the acute suppurative form of pilonidal disease 13 . It is true that pilonidal disease has been extensively treated in the literature, but the management of its abscessed form has not received sufficient attention. Moreover, surgical treatment, although being the gold standard, is not yet well codified 1 . A twostage surgical treatment is often proposed. Different surgical techniques proposed can be grouped into conservative and radical techniques.
The aim of our study was to compare the two surgical methods used in one-stage treatment strategy, in terms of postoperative complications, hospital stay, time to return to normal activities, wound healing time, and recurrence of pilonidal disease.

METHODS
This was a comparative study conducted in the Department of Surgery A of "Charles Nicolle" Hospital in Tunis over a period of 4 years, from January 2015 to December 2018, including all patients operated on for pilonidal abscess with a satisfactory postoperative follow-up. Patients treated with a two-stage treatment strategy were not included. Patients with missing data on medical records, patients lost to follow-up, and patients unable to reach through phone were excluded from the study.
We have defined any procedure of wide or limited excision of the abscess and infected tissues as radical surgery. We have defined any incision with pus evacuation, with or without curettage or drainage, as conservative surgery.
Clinical, paraclinical, and operative data were extracted from medical records and from operative reports. Some missing data were recovered by reaching patients by phone. Data entry and analysis were performed using the Statistical Package for Social Sciences (SPSS) software version 23.0. The p-value of <0.05 was considered statistically significant.
Our locally appointed Ethics Committee has approved the research protocol and informed consent has been obtained from the subjects.

Descriptive study
Preoperative data A total of 57 patients were included in the study. There were 33 (58%) men and 24 (42%) women. The mean age was 26.9±10 years, with extremes of 15 and 60 years. Two patients were diabetic. About 61% of patients had a body mass index of >25 kg/m². Twelve patients were operated before for pilonidal disease. The average duration of clinical signs was 5.6±3.2 days. The average abscess size was about 3.6±1.1 cm. According to biological findings, hyperleukocytosis was noted in 60% of patients and the C-reactive protein was increased in 61% of cases.

Operative findings
All patients were operated on: 55 patients under general anesthesia, 70% in lateral position and 30% in supine position. A total of 53 patients were operated on by a resident doctor. The type of operation was an excision procedure in 46 (81%) cases and an incision procedure in 11 (19%) cases associated