A Comparative Study on flap necrosis following Karydakis Flap Reconstruction and Z-Plasty in Patients with Sacrococcygeal Pilonidal Disease – Our experience

Aim: The purpose of this study was to evaluate patients with sacrococcygeal pilonidal sinus disease(SPSD) who underwent the Karydakis procedure and Z plasty at our centre concerning theperioperative findings, late postoperative results and recurrence. Patients and Methods: A total of30 patients presenting with SPSD at our centre underwent Karydakis flap repair and Z plasty fromMay 2019 to June 2021. These patients were then followed up and evaluated concerning operativetime, drain use, hospital stay, suture removal, complications, and recurrence. The adipocutaneousflap of Karydakis was devised to shift the natal cleft, while Z-plasty involves a fasciocutaneous flap.Results: The mean operative time was 60 min with a median hospital stay of 4 days. Drains wereremoved at a median of 5 days and sutures at a median of 15 days. The duration of hospitalisationfor the Karydakis procedure was found significantly lesser than that for Z-plasty Patients who werefollowed up for a median of 12 months. The overall complications were more in Z-plasty. Flapnecrosis developed in 30 % of the cases in the Z-plasty group, comparable to no recurrence seen inthe Karydakis procedure. Conclusion: Karydakis flap was found superior to Z-plasty, having lessseroma formation, no flap necrosis and no local hematoma Karydakis flap procedure is a relativelysimple procedure for SPSD and has advantages over Z-plasty technique like keeping scar away fromthe midline and flattening of the natal cleft, thus reducing local recurrence rates.

Pilonidal disease

Pilonidal disease presents with a range of signs and symptoms: asymptomatic pits in the natal cleft, acute abscesses, chronic disease with persistent, discharging sinuses, or recurrent disease following previous attempts at treatment. It primarily affects the sacrococcygeal region and is a disease of young adults, generally male, and leads to pain, disability, and time lost from work. The treatment for an acute pilonidal abscess is widely accepted to be incision and drainage with the incision placed out of the natal cleft. The treatment of chronic and recurrent disease is contentious with excision and then either healing by secondary intention, primary closure, or flap closure all being suggested alongside other less aggressive approaches aimed at conserving tissue. Currently none of these treatments is ideal, although primary closure in the midline has been shown to be inferior and should not be performed.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of pilonidal disease

Pilonidal disease (PD) is a relatively common, benign but challenging condition of the natal cleft. This consensus statement was drawn up by a panel of surgeons, identified by the Italian Society of Colorectal Surgery (SICCR) as having a “special interest” in PD, with the aim of recommending the best therapeutic options according to currently available scientific evidence. A three-step modified-Delphi process was adopted, implying: (1) choice of the panelists; (2) development of a discussion outline and of target issues; and (3) a detailed systematic review of the current literature. The agreement/disagreement level was scored on a five-point Likert scale as follows: “A + : strongly agree; A–: agree; N: unsure/no opinion; D–: disagree; D + : strongly disagree. Each panelist contributed to the production of this manuscript, and the final recommendations were reviewed by the Clinical Practice Guidelines Committee.

THE OUTCOME OF LIMBERG FLAP RECONSTRUCTION PROCEDURE FOR PRIMARY NATAL CLEFT PILONIDAL SINUS DISEASE: FOUR YEARS’ EXPERIENCE AT A TEACHING HOSPITAL IN PAKISTAN

Background: Natal cleft pilonidal sinus disease is known for its high recurrence rate after surgery. Different surgical procedures are being used for its treatment and these vary from wide excision followed by healing with secondary intention to excision followed by reconstruction with a flap. Limberg flap reconstruction procedure has been used by many surgeons as their primary choice owing to its low recurrence rate and less postoperative complications. Objective: The objective of this study was to assess the outcome of Limberg flap reconstruction procedure in patients with primary natal cleft pilonidal sinus disease. Methods: This descriptive case series was conducted at Ghurki trust teaching hospital, Lahore, Pakistan, between January 2015 to December 2018. 110 consecutive patients with primary natal cleft pilonidal sinus disease were included in this study. Informed consent was taken from these patients and all patients underwent Limberg flap reconstruction procedure. The evaluated outcomes of this procedure included duration of hospital stay, postoperative pain, primary healing, surgical site Infection, seroma formation, flap necrosis and, recurrence. Results: The patients age ranged between 18 years to 60 years. The mean age was 26.6 ±8.6 years. 73 patients (66.36 %) were males and 23 patients (33.63%) were females. The duration of disease ranged between 1 month to 6 months with a mean of 3.7±1.7 months. The mean operating time was 47.50±5.14 minutes. The mean duration of hospital stay was 1.87±0.80 days. The mean postoperative pain score calculated by the visual analogue scale (VAS) twenty-four hours after the surgery was 3.45. 95 patients (86.36%) had complete primary healing without any complication. 9 patients (8.18%) had a surgical site infection and 6 patients (5.45 %) had seroma formation. No patient suffered from flap necrosis. 2 patients (1.81%) who had complete primary healing presented with recurrence of the disease within six months of the procedure with a period of one year of follow-up designated for every patient. Conclusion: Limberg flap reconstruction procedure is a safe and efficacious treatment option for primary natal cleft pilonidal sinus disease because it provides early complete primary healing in most patients, and shortens the duration of hospital stay thus reducing the cost of treatment. The pain scores fall in the moderate post-operative pain score category and the complication rates and the recurrence rates are very low.

Outcome of Surgical Management of Sacrococcygeal Pilonidal Sinus Disease with Rotation Flap in 52 Patients—A Retrospective Study

Background Surgical treatment of sacrococcygeal pilonidal sinus disease (SPSD) consists of radical excision of the entire tract and treatment of the resultant raw area. Here, the authors have reviewed the results of the rotation flap for closure of the SPSD. Aim This study aims to evaluate the outcomes following SPSD excision and rotation flap closure. Materials and Methods All patients were treated for SPSD with excision and closure using a rotation flap from January 2010 to September 2018. Cases having a follow-up of at least 6 months post surgery were evaluated. Result A total of 52 patients were included in the study; 42 cases were of primary disease while 10 were of recurrent disease. The patients’ follow-up records on the 3rd day, 10th day, 1 month, and 6 months were evaluated.None of the patients showed any signs of recurrence on follow-ups. One patient developed a hematoma on the third day post surgery which was treated conservatively. One patient developed a seroma in the perianal region on the fifth postoperative day which required aspiration. Both these patients healed well subsequently. Conclusion Rotation flap is a (simple and reliable) treatment option for closure of postexcision SPSD defect. It not only takes the tension away from suture line, but also pushes the gluteal fat from the sides into the midline, obliterating the deep crevice of the natal cleft which is believed to be one of the important factors in the causation of SPSD, thus minimizing recurrence.

Rare presentation of rectal duplication cyst as perineal hernia in an adult

Rectal duplication cysts are rare congenital anomalies of the gastrointestinal tract. They can present with pain, gastrointestinal bleeding, infection or compressive symptoms on the rectum and urinary bladder. A 79-year-old man presented with a 8×5 cm swelling in the sacral region above the natal cleft with a positive cough impulse. During surgical exploration, there were two cysts with the posterior one presenting as the hernia. The cyst was excised and histopathological examination confirmed a diagnosis of rectal duplication cyst. Rectal duplications can lie anterior or more commonly posterior to the rectum. Differential diagnoses include dermoid cyst, diverticular cyst, sacrococcygeal teratoma or meningocele and endoscopic ultrasound is imaging of choice for diagnosis. Surgical excision is the treatment of choice. This is a rare presentation of a rectal duplication cyst as a perineal hernia with only a handful of cases in literature.

APPROACH TOWARDS SACROCOCCYGEAL FISTULA: A PROSPECTIVE CLINICAL AND COMPETITIVE INTERPRETATION

Background: Sacrococcygeal fistula, also known as Pilonidal sinus is an acute or chronic infection in the subcutaneous fatty tissue, mainly in the natal cleft. The condition, though not life threatening, is socially embarrassing and adversely affects the quality of life of patients. In Ayurvedic literature Sacrococcygeal fistula is better correlated and treated as Nadi Vrana. Acharya Sushruta had explained Para-surgical procedure with the intervention of medicated Seton (Kshara Sutra) as one of the treatment modalities. The ideal method of treatment of Sacrococcygeal fistula should be effective with a low recurrence rate, short hospital stay and economical. Aim: This study is an attempt to evaluate the efficacy of Arka Ksharasutra in the management of Sacrococcygeal fistula. Methodology: A total no. of 10 patients having signs and symptoms of Sacrococcygeal fistula were selected for Arka Ksharasutra ligation under local anesthesia and the Seton was changed every week during the entire treatment period. Results: In this study all the patients i.e.,100% were males with age between 25-35 years. The length of initial track was 3.6 to 5.5 cm and average Unit Cutting Time was 7.23 days/cm in previously non-operated cases and 11.26 days/cm in previously operated cases, average being 8.2days/cm. There was no post-operative complication and recurrence even after 3 months of follow-up. Conclusion: Arka Ksharasutra is laced with anti-bacterial, anti-fungal, bactericidal and anti- inflammatory properties which minimizes the use of antibiotics and also demolished the recurrence of symptoms.

A COMPARATIVE CLINICAL STUDY OF ‘CHEDANA KARMA & KSHARSUTRA (SETON) KARMA’ (GUGGULU BASED) IN THE MANAGEMENT OF SHALYAJ NADI VRANA(SINUS) W.S.R. TO PILONIDAL SINUS (ASSOCIATED WITH ROPAN LEPA)

A Pilonidal Sinus is a common disease of the natal cleft. Pilonidal Sinus is a track which contains hairs. The incidence of the disease is calculated to be 26 per 100,000 people. Pilonidal disease has a male pre-dominance with a ratio of 3:1. There are several methods to treat pilonidal sinus, but the recurrence rate is more in modern surgical interventions. According to Ayurveda it can be correlated to Salyajanya Nadi Vrana (pilonidal sinus), a type of Nadi Vrana (sinus). Whose etiopathology is described in Nidanasthana and treatment aspect in Chikitsasthana of Susrutha Samhita. Susrutha mentioned the ap-plication of Kshara (caustic alkali) and Ksharsutra (Seton) (Seton) in the management of Nadi Vrana (si-nus). Studies show that by Ayurvedic treatment, it helps to reduce recurrence rate, even though Nadi Vrana (sinus) is said to be Kricchrasadhya (difficult to cure). Hence successful management of this disease de-pends on the knowledge of pathogenesis, patient’s presentation and knowledge on treatment aspects. In this Clinical study, effect of Chedana karma & Ksharsutra (Seton) karma’ (Guggulu based) in the management of Salyajanya Nadi Vrana (pilonidal sinus) w.s.r. To pilonidal sinus (associated with ropan lepa) is seen and conclusion in drawn.

Z- Plasty: an Effective Technique for Pilonidal Sinus

Introduction: Pilonidal sinus is a commonly encountered problem with multiple surgical options. With Z- plasty, primary closure ensues faster healing while the alteration of local anatomy reduces recurrence. The extremely low recurrence rate following Z-plasty for pilonidal sinus results from the fact that the operation was planned with the true physiology of the disease in mind. It is the deep natal cleft which predisposes to pilonidal sinuses and this architecture is altered with multiple Z -plasty. Materials and methods: A prospective, observational study was conducted into department of Plastic Surgery and burn, Dhaka Medical College and Hospital. Here 18 patients with pilonidal sinus were treated by Z – plasty between 2013 to 2018. Result: There was only one recurrence during the follow up time. There were no necrosis of flaps and no wound dehiscence. Conclusion: The Z-plasty technique is an effective procedure for treating pilonidal sinus in terms of both faster healing and lower recurrence rate. J Dhaka Medical College, Vol. 28, No.2, October, 2019, Page 164-171