Summary
Purpose
Treatment of pilonidal sinus disease (PSD) requires a tailored approach. A national guideline was published in 2014. The current status of surgical PSD therapy in Germany is unknown. The present study aims at evaluating treatment strategies currently used for PSD in Germany. Additionally, changes in surgical practice over the past 20 years were reviewed.
Methods
A total of 1191 German hospitals treating patients with PSD were surveyed between September 2015 and September 2016 to identify treatment strategies used for asymptomatic, acute, and chronic PSD. Answers could be provided electronically or by mail. Analysis was performed following irreversible anonymization of the dataset.
Results
The return rate of the survey was 38%, with 454 of 1191 hospitals responding. Asymptomatic PSD was treated conservatively by a majority (52%) of participating institutions. Acute PSD was incised, and secondary definitive treatment followed in 42%. Chronic PSD was approached by primary excision and open wound healing in 60% of hospitals, with 33% using a flap technique and 15% an off-midline procedure to close the defect. Over the past 20 years, use of flap procedures and off-midline techniques has increased by 37% and 35%, respectively.
Conclusion
The present study reveals that primary excision and open wound healing is still preferred in Germany, in spite of the availability of better options. While the use of flap procedures and off-midline techniques has increased over the past decades, these minimally invasive approaches remained underused, and compliance with the 2014 national guidelines for treatment of PSD remains poor.
Similar content being viewed by others
References
Mayo H. Observations on injuries and diseases of the rectum. London: Burgess & Hill; 1833.
Søndenaa K, Andersen E, Nesvik I, et al. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis. 1995;10:39–42.
Bundesregierung. 2014. http://www.gbe-bund.de/oowa921-install/servlet/oowa/aw92/dboowasys921.xwdevkit/xwd_init?gbe.isgbetol/xs_start_neu/&p_aid=i&p_aid=90682233&nummer=550&p_sprache=D&p_indsp=-&p_aid=9880488.
Doll D, Orlik A, Maier K, et al. Impact of geography and surgical approach on recurrence in global pilonidal sinus disease. Sci Rep. 2019;9:15111.
Evers T, Doll D, Matevossian E, et al. Trends in incidence and long-term recurrence rate of pilonidal sinus disease and analysis of associated influencing factors. Zhonghua Wai Ke Za Zhi. 2011;49:799–803.
Duman K, Girgin M, Harlak A. Prevalence of sacrococcygeal pilonidal disease in Turkey. Asian J Surg. 2017;40:434–7.
Da Silva JH. Pilonidal cyst: cause and treatment. Dis Colon Rectum. 2000;43:1146–56.
Chijiwa T, Suganuma T, Takigawa T, et al. Pilonidal sinus in Japan maritime self-defense force at Yokosuka. Mil Med. 2006;171:650–2.
Lee HC, Ho YH, Seow CF, et al. Pilonidal disease in Singapore: clinical features and management. Aust N Z J Surg. 2000;70:196–8.
Ardelt M, Dennler U, Fahrner R, et al. Puberty is a major factor in pilonidal sinus disease: gender-specific investigations of case number development in Germany from 2007 until 2015. Chirurg. 2017;88:961–7.
Doll D, Friederichs J, Dettmann H, et al. Time and rate of sinus formation in pilonidal sinus disease. Int J Colorectal Dis. 2008;23:359–64.
Bascom J. Pilonidal disease: origin from follicles of hairs and results of follicle removal as treatment. Surgery. 1980;87:567–72.
Doll D, Matevossian E, Wietelmann K, et al. Family history of pilonidal sinus predisposes to earlier onset of disease and a 50 % long-term recurrence rate. Dis Colon Rectum. 2009;52:1610–5.
Patey DH. A reappraisal of the acquired theory of sacrococcygeal pilonidal sinus and an assessment of its influence on surgical practice. Br J Surg. 1969;56:463–6.
Stelzner F. Die Ursache des Pilonidalsinus und der Pyodermia fistulans sinifica. Langenbecks Arch Chir. 1984;362:105–18.
Doll D, Bosche FD, Stauffer VK, et al. Strength of occipital hair as an explanation for pilonidal sinus disease caused by intruding hair. Dis Colon Rectum. 2017;60:979–86.
Doll D, Bosche FD, Hauser A, et al. The presence of occipital hair in the pilonidal sinus cavity‑a triple approach to proof. Int J Colorectal Dis. 2018;33:567–76.
Bosche F, Luedi MM, van der Zypen D, et al. The hair in the sinus: sharp-ended rootless head hair fragments can be found in large amounts in pilonidal sinus nests. World J Surg. 2018;42:567–73.
Dahl HD, Henrich MH. Light and scanning electron microscopy study of the pathogenesis of pilonidal sinus and anal fistula. Langenbecks Arch Chir. 1992;377:118–24.
Akinci OF, Bozer M, Uzunkoy A, et al. Incidence and aetiological factors in pilonidal sinus among Turkish soldiers. Eur J Surg. 1999;165:339–42.
Akinci OF, Kurt M, Terzi A, et al. Natal cleft deeper in patients with pilonidal sinus: implications for choice of surgical procedure. Dis Colon Rectum. 2009;52:1000–2.
Doll D, Luedi MM, Wieferich K, et al. Stop insulting the patient: neither incidence nor recurrence of pilonidal sinus disease is linked to personal hygiene. Pilonidal Sinus J. 2015;1:11–8.
Sievert H, Evers T, Matevossian E, et al. The influence of lifestyle (smoking and body mass index) on wound healing and long-term recurrence rate in 534 primary pilonidal sinus patients. Int J Colorectal Dis. 2013;28:1555–62.
Balik O, Balik AA, Polat KY, et al. The importance of local subcutaneous fat thickness in pilonidal disease. Dis Colon Rectum. 2006;49:1755–7.
Ommer A, et al. S3-Leitlinie Sinus pilonidalis. 2020. https://www.awmf.org/uploads/tx_szleitlinien/081-009l_S3_Sinus_pilonidalis_2020-07.PSDf.
Doll D, Friederichs J, Dusel W, et al. Surgery for asymptomatic pilonidal sinus disease. Int J Colorectal Dis. 2008;23:839–44.
Jensen SL, Harling H. Prognosis after simple incision and drainage for a first-episode acute pilonidal abscess. Br J Surg. 1988;75:60–1.
Stauffer VK, Luedi MM, Kauf P, et al. Common surgical procedures in pilonidal sinus disease: a meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep. 2018;8:3058.
Doll D, Matevossian E, Hoenemann C, et al. Incision and drainage preceding definite surgery achieves lower 20-year long-term recurrence rate in 583 primary pilonidal sinus surgery patients. J Dtsch Dermatol Ges. 2013;11:60–4.
Hussain ZI, Aghahoseini A, Alexander D. Converting emergency pilonidal abscess into an elective procedure. Dis Colon Rectum. 2012;55:640–5.
De Parades V, Bouchard D, Janier M, Berger A. Pilonidal sinus disease. J Visc Surg. 2013;150:237–47.
Fahrni GT, Vuille-Dit-Bille RN, Leu S, et al. Five-year follow-up and recurrence rates following surgery for acute and chronic pilonidal disease: a survey of 421 cases. Wounds. 2016;28:20–6.
Ommer A, Berg E, Breitkopf C, et al. S3-Leitlinie: Sinus pilonidalis. coloproctology. 2014;36:272–322.
Deutsches Krankenhausverzeichnis. 2015. www.deutsches-krankenhaus-verzeichnis.de.
Lamdark T, Vuille-Dit-Bille RN, Bielicki IN, et al. Treatment strategies for Pilonidal sinus disease in Switzerland and Austria. Medicina. 2020;56:341.
Iesalnieks I, Fuerst A, Rentsch M, et al. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate. Chirurg. 2003;74:461–8.
Doll D, Krueger CM, Schrank S, et al. Timeline of recurrence after primary and secondary pilonidal sinus surgery. Dis Colon Rectum. 2007;50:1928–34.
Doll D, Matevossian E, Luedi MM, et al. Does full wound rupture following median Pilonidal closure Alter long-term recurrence rate? Med Princ Pract. 2015;24:571–7.
Petersen S, Koch R, Stelzner S, et al. Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Dis Colon Rectum. 2002;45:1458–67.
Evers T, Doll D. Pilonidalsinus: Hohe chirurgische Rezidivrate. AmbChir. 2009;6:25–8.
Al-Khamis A, McCallum I, King PM, et al. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev. 2010; https://doi.org/10.1002/14651858.CD006213.pub3.
Allen-Mersh TG. Pilonidal sinus: finding the right track for treatment. Br J Surg. 1990;77:123–32.
Kronborg O, Christensen K, Zimmermann-Nielsen C. Chronic pilonidal disease: a randomized trial with a complete 3‑year follow-up. Br J Surg. 1985;72:p303–p4.
Al-Hassan HKF, Francis IM, Neglén P. Primary closure or secondary granulation after excision of pilonidal sinus. Acta Chir Scand. 1990;156:695–9.
Enriquez-Navascues JM, Emparanza JI, Alkorta M, et al. Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus. Tech Coloproctol. 2014;18:863–72.
Petersen S. Exzision und Marsupialisation im Vergleich zu Rhomboidexzision mit Limberg-Plastik beim Sinus pilonidalis. coloproctology. 2010;32:189–90.
Cihan A, Mentes BB, Tatlicioglu E, et al. Modified Limberg flap reconstruction compares favourably with primary repair for pilonidal sinus surgery. ANZ J Surg. 2004;74:238–42.
Urhan MK, Kücükel F, Topgul K, et al. Rhomboid excision and Limberg flap for managing pilonidal sinus: results of 102 cases. Dis Colon Rectum. 2002;45:656–9.
Topgül K, Ozdemir E, Kilic K, et al. Long-term results of limberg flap procedure for treatment of pilonidal sinus: a report of 200 cases. Dis Colon Rectum. 2003;46:1545–8.
Kapan M, Kapan S, Pekmezci S, et al. Sacrococcygeal pilonidal sinus disease with Limberg flap repair. Tech Coloproctol. 2002;6:27–32.
Kaya B, Eris C, Atalay S, et al. Modified Limberg transposition flap in the treatment of pilonidal sinus disease. Tech Coloproctol. 2012;16:55–9.
Bessa SS. Comparison of short-term results between the modified Karydakis flap and the modified Limberg flap in the management of pilonidal sinus disease: a randomized controlled study. Dis Colon Rectum. 2013;56:491–8.
Petersen S, Aumann G, Kramer A. Short-term results of Karydakis flap for pilonidal sinus disease. Tech Coloproctol. 2007;11:235–40.
Guner A, Cekic AB. Pilonidal sinus—challenges and solutions. Open Access Surg. 2015;8:67–71.
Ersoy OF, Karaca S, Kayaoglu HA, et al. Comparison of different surgical options in the treatment of pilonidal disease: retrospective analysis of 175 patients. Kaohsiung J Med Sci. 2007;23:67–70.
Muzi MG, Milito G, Cadeddu F, et al. Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease. Am J Surg. 2010;200:9–14.
Doll D, Luedi MM, Evers T, et al. Recurrence-free survival, but not surgical therapy per se, determines 583 patients’ long-term satisfaction following primary pilonidal sinus surgery. Int J Colorectal Dis. 2015;30:605–11.
Karakayali F, Karagulle E, Karabulut Z, et al. Unroofing and marsupialization vs. rhomboid excision and Limberg flap in pilonidal disease: a prospective, randomized, clinical trial. Dis Colon Rectum. 2009;52:496–502.
Gencosmanoglu R, Inceoglu R. Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus: a prospective, randomized clinical trial with a complete two-year follow-up. Int J Colorectal Dis. 2005;20:415–22.
Kepenekci I, Demirkan A, Celasin H, et al. Unroofing and curettage for the treatment of acute and chronic pilonidal disease. World J Surg. 2010;34:153–7.
Unalp HR, Derici H, Kamer E. Lower recurrence rate for Limberg vs. V‑Y flap for pilonidal sinus. Dis Colon Rectum. 2007;50:1436–44.
Luedi MM, Kauf P, Mulks L, et al. Implications of patient Age and ASA physical status for operating room management decisions. Anesth Analg. 2016;122:1169–77.
Luedi MM, Kauf P, Evers T, et al. Impact of spinal versus general anesthesia on postoperative pain and long term recurrence after surgery for pilonidal disease. J Clin Anesth. 2016;33:236–42.
Fabricius R, Petersen LW, Bertelsen CA. Treatment of pilonidal sinuses in Denmark is not optimal. Dan Med Bull. 2010;57:A4200.
Doll D, Friederichs J, Boulexteix AL, et al. Surgery for asymptomatic pilonidal sinus disease. Int J Colorectal Dis. 2008;23:839–44.
Karip AB, Celik K, Aydin T, et al. Effect of triclosan-coated suture and antibiotic prophylaxis on infection and recurrence after Karydakis flap repair for pilonidal disease: a randomized parallel-arm double-blinded clinical trial. Surg Infect. 2016;17:583–8.
Popeskou S, Christoforidis D, Ruffieux C, et al. Wound infection after excision and primary midline closure for pilonidal disease: risk factor analysis to improve patient selection. World J Surg. 2011;35:206–11.
Kundes MF, Cetin K, Kement M, et al. Does prophylactic antibiotic reduce surgical site infections after rhomboid excision and Limberg flap for pilonidal disease: a prospective randomized double blind study. Int J Colorectal Dis. 2016;31:1089–91.
Petersen S, Wietelmann K, Evers T, et al. Long-term effects of postoperative razor epilation in pilonidal sinus disease. Dis Colon Rectum. 2009;52:131–4.
Doll D, Novtny A, Wietelmann K, et al. Factors influencing surgical decisions in chronic pilonidal sinus disease. Eur Surg. 2009;41:60–5.
Cubukcu A, Gönüllü NN, Paksoy M, et al. The role of obesity on the recurrence of pilonidal sinus disease in patients, who were treated by excision and Limberg flap transposition. Int J Colorectal Dis. 2000;15:173–5.
Acknowledgements
The authors would like to thank Jeannie Wurz, Medical Editor at the Bern University Hospital, for careful reading of the manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
R. Schneider, M. Dettmer, N. Peters, T. Lamdark, M. M. Luedi, M. Adamina, and D. Doll declare that they have no competing interests.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Schneider, R., Dettmer, M., Peters, N. et al. The current status of surgical pilonidal sinus disease therapy in Germany. Eur Surg 54, 117–125 (2022). https://doi.org/10.1007/s10353-021-00715-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10353-021-00715-x