BRAZILIAN AND ARGENTINEAN MULTICENTRIC STUDY IN THE SURGICAL MINIMALLY INVASIVE TREATMENT OF PILONIDAL CYST

Carlos Ramon Silveira MENDES Luciano Santana de Miranda FERREIRA Leonardo SALIM About the authors

ABSTRACT

Background:

The pilonidal cyst is an infection of the skin and the subcutaneous tissue, secondary to a chronic inflammation with a greater frequency in the sacrococcygeal region, and associated to the presence of hair. The treatment is eminently surgical.

Aim:

To demonstrate the endoscopic treatment of pilonidal cyst.

Method:

Prospective study with 67 patients who had as surgical indication the diagnosis of pilonidal cyst. They were submitted to a surgical procedure from June 2014 to March 2018. The equipment used was the Meinero fistuloscope, a shutter, a monopolar electrode, a brush and endoscopic forceps.

Results:

Of the 67 patients, 67% (n=45) were male and 33% (n=22) female, with a mean age of 25 years (17-45). Surgical time in average was 40 min (20-120) and mean healing time of four weeks (3-12). Surgical complications were presented in 7% cases (n=5) and recurrences in 9% (n=6).

Conclusion:

The endoscopic treatment of the pilonidal cyst is feasible and presents good surgical results.

HEADINGS:
Laparoscopy; Pilonidal cyst; Minimally invasive surgical procedures

RESUMO

Racional:

O cisto pilonidal é infecção da pele e do tecido subcutâneo, secundário à inflamação crônica, com maior frequência na região sacrococcígea, e associado à presença de pelos nesta região. O tratamento é eminentemente cirúrgico.

Objetivo:

Demonstrar os resultados do tratamento endoscópico de cisto pilonidal.

Método:

Estudo prospectivo, com 67 pacientes que tiveram como indicação cirúrgica o diagnóstico de cisto pilonidal. Os equipamentos utilizados foram o fistuloscópio Meinero, um obturador, um eletrodo monopolar, uma escova e pinça endoscópica.

Resultados:

Dos 67 pacientes 67% (n=45) eram homens e 33% (n=22) mulheres, com média de idade de 25 anos (17-45). O tempo cirúrgico teve com média 40 min (20-120) e o tempo médio de cicatrização de quatro semanas (3-12). Complicações cirúrgicas ocorreram em 7% da amostra (n=5) e recidivas da doença em 9% (n=6).

Conclusão:

O tratamento endoscópico do cisto pilonidal é viável e apresenta bons resultados cirúrgicos.

DESCRITORES:
Laparoscopia; Cisto pilonidal; Procedimentos cirúrgicos minimamente invasivos

INTRODUCTION

Pilonidal cyst is a well-known skin and subcutaneous tissue disease, occurring predominantly in men with a mean age of 30 years and an incidence of 26 cases per 100,0001818 Tien T, Athem R, Arulampalam T. Outcomes of endoscopic pilonidal sinus treatment (EPSiT): a systematic review. Tech Coloproctol 2018; 22: 325-331.. The disease presents complex symptoms, characterized by asymptomatic conditions and painful lesions located in the sacrococcygeal region66 Chintapatla S, Safrani N, Kumar S, Haboubi N. Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol2003; 7: 3-8.. The cause is not fully elucidated; however, some risk factors such as obesity, inadequate personal hygiene, family history and long sitting periods are associated with a higher occurrence of the disease1919 Tas, Sukru et al. Management of flap dehiscense after Limberg procedure for recurrent pilonidal disease by negative pressure wound therapy (NPWT). ABCD, Arq. Bras. Cir. Dig., Mar 2017;30(1): 73-74..

The treatment is essentially surgical, with a wide variety of techniques including removal of the cyst by means of flap procedures, as seen in the modified Karydakis and Limberg1414 Milone M, Fernandez LM, Musella M, Milone F. Safety and efficacy of minamally invasive video-assisted ablation of pilonidal sinus: a randomized clinical trial. JAMA Surg. 2016; 151: 547-53. methods. In addition, other less invasive techniques such as curettage of the cavity with application of phenol44 Calikoglu I, Gulpinar K, Oztuna D, Elhan A, Dogru O, Akyol C, et al. Phenol injection versus excision with open healing in pilonidal disease: a prospective randomized trial. Dis Colon Rectum 2017; 60: 161-169. or even the use of laser are commonly used22 Benedetto A, Lewis A. Pilonidal sinus disease treated by depilation using an 800nm diode laser and review of the literature. Dermatol Surg 2006; 31: 587-591.,88 Dragoni F, Moretti S, Cannarozzo G, Campolini P. Treatment of recurrent pilonidal cyst with nd-YAG laser: report of our experience. J Dermtolog Treat 2018; 29: 65-67.,1616 Pappas A, Christodoulou D. A new minimally invasive treatment of pilonidal sinus disease with the use of a diode laser: a prospective large series of patients. Colorectal Dis2018; 587-591.. Less invasive techniques are an alternative to methods of surgical excision, presenting advantages such as less postoperative pain, early return of the patient to his activities and reduced scarring1313 Mendes CRS, Ferreira LSM, Sapucaia RA, Lima MA. Endoscopic pilonidal sinus treatment (E.P.Si.T): a minimally invasive approach. J. Coloproctol 2015; 35: 72-75..

The minimally invasive endoscopic treatment of pilonidal cyst (EPSiT) proposed by Meinero et al1111 Meinero P, Mori L, Gasloli G. Endoscopic pilonidal sinus treatment (EPSiT). Tech Coloproctol. 2014; 18: 389-392. is based on the treatment of anal fistula by means of video, using a fistuloscope, a shutter, a monopolar electrode, brush and forceps. The technique is subdivided into two stages characterized by the diagnosis phase and the operative phase. Diagnosis is designed to identify and characterize the cyst as well as to identify secondary cavities containing abscesses1111 Meinero P, Mori L, Gasloli G. Endoscopic pilonidal sinus treatment (EPSiT). Tech Coloproctol. 2014; 18: 389-392.,1818 Tien T, Athem R, Arulampalam T. Outcomes of endoscopic pilonidal sinus treatment (EPSiT): a systematic review. Tech Coloproctol 2018; 22: 325-331.. Alternatively Milone (2014)1515 Milone M, Musella M, Sardo A, Bifulco G, Salvatore G, Fernandez L, et al. Video-assisted ablation of pilonidal sinus: a new minimally invasive treatment - a pilot study. Surgery2014; 155: 562-566. modified the technique using hysteroscope and saline.

The objective of this study was to demonstrate the effectiveness of minimally invasive endoscopic treatment.

METHODS

This study was approved by the research ethics committees in the Argentinian and Brazilian institutions, and the patients provided the informed consent form before the surgical procedure.

Characteristics of the study

This is a prospective study, carried out from June 2014 to March 2018, comprising patients with symptomatic pilonidal cyst who were admitted to Rosario Provincial Hospital in Santa Fe, Argentina, and Santa Izabel Hospital in Salvador, Brazil.

Surgical technique

The endoscopic technique was performed according to the method idealized by Meinero et al. (2014)1111 Meinero P, Mori L, Gasloli G. Endoscopic pilonidal sinus treatment (EPSiT). Tech Coloproctol. 2014; 18: 389-392., using the Meinero fistuloscope (Karl Storz GmbH - Tuttlingen, Germany, Figure 1A). The patients underwent spinal anesthesia and the procedure was started in the pronated position, with the buttocks separated with the aid of adhesives, and the surgeon positioned between the patient’s legs.

FIGURE 1
A) Karl-Storz fistuloscope; B) exploration of the cyst; C) final surgical aspect of the procedure; D) postoperative after 15 days

The procedure begins with the identification and characterization of cyst extension, as well as secondary cavities by insertion of the fistuloscope with infusion of glycine or mannitol into the spontaneous opening of the cyst (Figure 1B). The cyst is then opened with the aid of jet of these liquids in order to identify hairs and eliminate damaged tissues. The hairs present in the tract are removed with the aid of the forceps and the granular tissue is treated by means of the monopolar electrode1313 Mendes CRS, Ferreira LSM, Sapucaia RA, Lima MA. Endoscopic pilonidal sinus treatment (E.P.Si.T): a minimally invasive approach. J. Coloproctol 2015; 35: 72-75.. All granular tissue is destroyed and removed, the hairs removed, and then the tract is cleaned and left open cavity to facilitate drainage (Figures 1C and 1D).

RESULTS

The characteristics of the patients and the results obtained are shown in Table 1.

TABLE 1
Patient characteristics and results obtained

Between June 2014 and March 2018, 67 patients were selected, of which 67% were men and with a mean age of 31 years (17-45). The surgical procedure lasted on average 40 min; the patients were discharged on the same day after the procedure and the mean healing time was four weeks (3-12).

Major complications were not observed; however, five cases had minor complications such as prolonged bleeding and pain. The cure rate was 91%, and five patients had recurrence, and no other case of treatment failure or cyst persistence.

DISCUSSION

Although pilonidal cyst was described more than 150 years ago55 Chia CLK, Tay VWY, Mantoo SK. Endoscopic pilonidal sinus treatment in the Asian population. Surg. Laparosc. Endosc Percutan Techn 2015; 25: e95-e97., and although the treatment is mostly surgical, there are several surgical techniques described in the literature that include excision of the cyst, flap techniques and more recently minimally invasive techniques99 Emile SH, Elfeki H, Shalaby M, Sakr A, Giaccaglia V, Sileri P, et al. Endoscopic pilonidal sinus treatment: a systematic review and meta-analysis. Surg Endosc. 2018; 1-9.. Stauffer and colleagues (2018)1717 Stauffer VK, Luedi MM, Kauf P, Schmid M, Dieckmann M, Weiferich K, et al. Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep. 2018; 15: 3058. through a systematic review identified at least 14 therapeutic strategies for the treatment of cyst and its recurrence.

In this scenario, Meinero et al1111 Meinero P, Mori L, Gasloli G. Endoscopic pilonidal sinus treatment (EPSiT). Tech Coloproctol. 2014; 18: 389-392. employed the technique of video-assisted anal fistula treatment for the treatment of pilonidal disease, in order to avoid one of the major drawbacks of the procedures that aim to remove the infected area by excision, which is the healing of the surgical wound, open or closed. In both cases, the postoperative period necessitates dressing, which increases the time required for healing, in addition to causing pain1010 Giarratano G, Toscana C, Shalaby M, Buonomo O, Petrella G, Sileri P. Endoscopic pilonidal sinus treatment: Long-term results of a prospective series. J. Soc. Laparendosc. Surgeons. 2017; 21: e2017.0043.,1111 Meinero P, Mori L, Gasloli G. Endoscopic pilonidal sinus treatment (EPSiT). Tech Coloproctol. 2014; 18: 389-392..

The endoscopic technique for the treatment of pilonidal cyst causes less postoperative pain, faster healing and less time to return to daily activities. In addition, it is highly efficient in cases of cyst recurrence.

Endoscopic treatment requires shorter operative time compared to excision methods; Limberg’s flap technique takes an average of 54 min, while that of Karydakis11 Bali I, Aziret M, Sozem S, Emir S, Erdem H, Çetinkunar S, et al. Effectiveness of Limberg and Karydakis flap in recurrent pilonidal sinus disease. Clinics. 2015; 70(5): 350-355. 48 min (Table 2). The use of the laser demonstrated even shorter surgical time1616 Pappas A, Christodoulou D. A new minimally invasive treatment of pilonidal sinus disease with the use of a diode laser: a prospective large series of patients. Colorectal Dis2018; 587-591.; however, there is greater relapse and treatment failure compared to other techniques.

TABLE 2
Therapeutic approaches for the treatment of pilonidal cyst

The endoscopic technique has advantages over the less invasive ones that are performed blindly, which explains the greater occurrence of relapses. Endoscopic treatment is favored by the observation of the interior of the cyst, allowing the surgeon to identify the location of the hairs, as well as damaged tissues, contributing to the higher success rate99 Emile SH, Elfeki H, Shalaby M, Sakr A, Giaccaglia V, Sileri P, et al. Endoscopic pilonidal sinus treatment: a systematic review and meta-analysis. Surg Endosc. 2018; 1-9..

The time required for healing after the EPSiT technique was lower than other surgical approaches, presenting even fewer complications. According to Bernier et al. (2015)33 Bernier GV, Johnson EK, Maykel JA, Steele SR. Reoperative surgery for pilonidal disease. Sem. Colon Rectal Surgery. 2015; 26: 211-217. about 10-30% of patients undergoing more than one surgical treatment may progress to chronicity. Endoscopic treatment is associated with a low occurrence of recurrence1515 Milone M, Musella M, Sardo A, Bifulco G, Salvatore G, Fernandez L, et al. Video-assisted ablation of pilonidal sinus: a new minimally invasive treatment - a pilot study. Surgery2014; 155: 562-566., especially when compared to less invasive techniques77 Dodaro CA, Renda A. Comment on: »,» ®,® §,§ ­,­ ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ Video-assisted ablation of pilonidal sinus: a new minimally invasive treatment - A pilot study »,» ®,® §,§ ­,­ ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ . Surgery. 2014; 155: 1097..

The complications associated with EPSiT treatment observed in this study were 7%, with self-limiting bleeding in three patients and two reports of pain for a prolonged period, requiring the use of analgesics. No patient demonstrated complications such as necrosis or seroma during follow-up. Prolonged pain requiring analgesics was described in two (22%) patients by Chia et al (2015)55 Chia CLK, Tay VWY, Mantoo SK. Endoscopic pilonidal sinus treatment in the Asian population. Surg. Laparosc. Endosc Percutan Techn 2015; 25: e95-e97. and by Meinero et al1111 Meinero P, Mori L, Gasloli G. Endoscopic pilonidal sinus treatment (EPSiT). Tech Coloproctol. 2014; 18: 389-392. in 9.7%. In this way the complications observed in this study are comparable or better to the other experiences in the literature1616 Pappas A, Christodoulou D. A new minimally invasive treatment of pilonidal sinus disease with the use of a diode laser: a prospective large series of patients. Colorectal Dis2018; 587-591..

According to Umesh et al (2018)2020 Umesh V, Sussman RH, Smith J, Whyte C. Long term outcome of the Bascom cleft lift procedure for adolescent pilonidal sinus. J Ped Surg 2018; 53: 295-297. excision techniques may compromise the sacral fascia and be associated with increased morbidity and increased healing time; on the other hand, the use of the fistuloscope reduces these circumstances, and it presents smaller scars.

Among the several treatments for the pilonidal cyst, the EPSiT technique presents itself as a safe alternative; however, its use depends on specific equipment, which may limit it1313 Mendes CRS, Ferreira LSM, Sapucaia RA, Lima MA. Endoscopic pilonidal sinus treatment (E.P.Si.T): a minimally invasive approach. J. Coloproctol 2015; 35: 72-75.. Milone et al. (2014)1414 Milone M, Fernandez LM, Musella M, Milone F. Safety and efficacy of minamally invasive video-assisted ablation of pilonidal sinus: a randomized clinical trial. JAMA Surg. 2016; 151: 547-53. described a similar procedure using a hysteroscope for performing the video-assisted operation. This procedure also uses saline solution to aid the distension of the cyst.

Dodaro and Renda (2014)77 Dodaro CA, Renda A. Comment on: »,» ®,® §,§ ­,­ ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ Video-assisted ablation of pilonidal sinus: a new minimally invasive treatment - A pilot study »,» ®,® §,§ ­,­ ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ . Surgery. 2014; 155: 1097. clarify that the Meinero fistuloscope can also be used to treat anal fistulas, in addition to pilonidal cyst, which contributes to reduce the costs and learning curve required to perform the technique.

This technique, pioneered in Brazil and Argentina, represents a safe and reproducible alternative for the treatment of the pilonidal cyst, also allowing the patient to resume his daily activities in a short period of time and in a more aesthetic way, as it results in few scars when compared to other treatments.

CONCLUSION

Endoscopic treatment for pilonidal cyst treatment demonstrated great safety and efficiency. The technique offers benefits such as good results, reduced recovery time, and low rate of complications.

REFERENCES

  • 1
    Bali I, Aziret M, Sozem S, Emir S, Erdem H, Çetinkunar S, et al. Effectiveness of Limberg and Karydakis flap in recurrent pilonidal sinus disease. Clinics. 2015; 70(5): 350-355.
  • 2
    Benedetto A, Lewis A. Pilonidal sinus disease treated by depilation using an 800nm diode laser and review of the literature. Dermatol Surg 2006; 31: 587-591.
  • 3
    Bernier GV, Johnson EK, Maykel JA, Steele SR. Reoperative surgery for pilonidal disease. Sem. Colon Rectal Surgery. 2015; 26: 211-217.
  • 4
    Calikoglu I, Gulpinar K, Oztuna D, Elhan A, Dogru O, Akyol C, et al. Phenol injection versus excision with open healing in pilonidal disease: a prospective randomized trial. Dis Colon Rectum 2017; 60: 161-169.
  • 5
    Chia CLK, Tay VWY, Mantoo SK. Endoscopic pilonidal sinus treatment in the Asian population. Surg. Laparosc. Endosc Percutan Techn 2015; 25: e95-e97.
  • 6
    Chintapatla S, Safrani N, Kumar S, Haboubi N. Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol2003; 7: 3-8.
  • 7
    Dodaro CA, Renda A. Comment on: »,» ®,® §,§ ­,­ ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ Video-assisted ablation of pilonidal sinus: a new minimally invasive treatment - A pilot study »,» ®,® §,§ ­,­ ¹,¹ ²,² ³,³ ß,ß Þ,Þ þ,þ ×,× Ú,Ú ú,ú Û,Û û,û Ù,Ù ù,ù ¨,¨ Ü,Ü ü,ü Ý,Ý ý,ý ¥,¥ ÿ,ÿ ¶,¶ . Surgery. 2014; 155: 1097.
  • 8
    Dragoni F, Moretti S, Cannarozzo G, Campolini P. Treatment of recurrent pilonidal cyst with nd-YAG laser: report of our experience. J Dermtolog Treat 2018; 29: 65-67.
  • 9
    Emile SH, Elfeki H, Shalaby M, Sakr A, Giaccaglia V, Sileri P, et al. Endoscopic pilonidal sinus treatment: a systematic review and meta-analysis. Surg Endosc. 2018; 1-9.
  • 10
    Giarratano G, Toscana C, Shalaby M, Buonomo O, Petrella G, Sileri P. Endoscopic pilonidal sinus treatment: Long-term results of a prospective series. J. Soc. Laparendosc. Surgeons. 2017; 21: e2017.0043.
  • 11
    Meinero P, Mori L, Gasloli G. Endoscopic pilonidal sinus treatment (EPSiT). Tech Coloproctol. 2014; 18: 389-392.
  • 12
    Meinero P, Stazi A, Carbone A, Dasolini F, Regusci L, Torre ML. Endoscopic pilonidal sinus treatment: a prospective multicentre trial. Colorectal Dis 2016; 18 O164-O17
  • 13
    Mendes CRS, Ferreira LSM, Sapucaia RA, Lima MA. Endoscopic pilonidal sinus treatment (E.P.Si.T): a minimally invasive approach. J. Coloproctol 2015; 35: 72-75.
  • 14
    Milone M, Fernandez LM, Musella M, Milone F. Safety and efficacy of minamally invasive video-assisted ablation of pilonidal sinus: a randomized clinical trial. JAMA Surg. 2016; 151: 547-53.
  • 15
    Milone M, Musella M, Sardo A, Bifulco G, Salvatore G, Fernandez L, et al. Video-assisted ablation of pilonidal sinus: a new minimally invasive treatment - a pilot study. Surgery2014; 155: 562-566.
  • 16
    Pappas A, Christodoulou D. A new minimally invasive treatment of pilonidal sinus disease with the use of a diode laser: a prospective large series of patients. Colorectal Dis2018; 587-591.
  • 17
    Stauffer VK, Luedi MM, Kauf P, Schmid M, Dieckmann M, Weiferich K, et al. Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep. 2018; 15: 3058.
  • 18
    Tien T, Athem R, Arulampalam T. Outcomes of endoscopic pilonidal sinus treatment (EPSiT): a systematic review. Tech Coloproctol 2018; 22: 325-331.
  • 19
    Tas, Sukru et al. Management of flap dehiscense after Limberg procedure for recurrent pilonidal disease by negative pressure wound therapy (NPWT). ABCD, Arq. Bras. Cir. Dig., Mar 2017;30(1): 73-74.
  • 20
    Umesh V, Sussman RH, Smith J, Whyte C. Long term outcome of the Bascom cleft lift procedure for adolescent pilonidal sinus. J Ped Surg 2018; 53: 295-297.

  • Financial source:

    none

Publication Dates

  • Publication in this collection
    21 Oct 2019
  • Date of issue
    2019

History

  • Received
    14 Oct 2018
  • Accepted
    16 Jan 2019
Colégio Brasileiro de Cirurgia Digestiva Av. Brigadeiro Luiz Antonio, 278 - 6° - Salas 10 e 11, 01318-901 São Paulo/SP Brasil, Tel.: (11) 3288-8174/3289-0741 - São Paulo - SP - Brazil
E-mail: revistaabcd@gmail.com