Pilonidal sinus and endoscopic surgery—myth or reality?

Introduction

Pilonidal Sinus is a disease frequently encountered in clinical practice, nevertheless its treatment has remained controversial, since it was first described by Mayo in 1833 (1). In 1990 Allen-Mersh published an extensive review of over 90 papers about the treatment of pilonidal sinus (2). The conclusion was that: “the choice of a particular surgical approach is dependent on the surgeon’s familiarity with the procedure and perceived results in terms of low recurrence of the sinus and of quick healing of the resulting cavity or surgical wound”. Twenty years later, this statement is still true; the management of chronic pilonidal sinus is not standardized and it is subject to an open debate (3).

A minimally invasive procedure aimed to the treatment of pilonidal sinus is recently started to spread. Thus, in the era of minimally invasive surgery, could endoscopic approach be a new way to treat pilonidal sinus?

State of art of pilonidal sinus treatment

To treat pilonidal sinus, during the years, many surgical methods have been introduced. Nevertheless, in literature no consensus on the optimal treatment can be found.

No high level of evidential data about treatment choice can be found in current literature (3-7). Several data were based on low- or moderate-quality trials. In our opinion, one of the major limitations of current literature is that the most of the published studies had a short follow-up. Basing on the short-term follow-up (1 year), it is impossible to draw definitive conclusions about the recurrence rate of the minimally invasive technique. According to Doll (8), at least a 5-year follow-up should be considered the gold standard in pilonidal sinus surgery study. Considering this, definitive conclusion about the best choice in pilonidal sinus treatment. However, some of the questions about the best surgical technique for chronic pilonidal disease have now been answered:

• “Less is more” is a worldwide corroborated concept. It is the time to abandon the open radical excision;
• Open healing showed no clinical benefit over surgical closure;
• Sinusotomy/sinusectomy or en bloc resection with primary closure could be considered the preferred approaches;
• Wounds heal more quickly after primary closure, but risk of recurrence is higher;
• “To flat” is the gold standard of primary closure. When surgical closure is the chosen treatment option, off-midline should be considered standard management for pilonidal sinus. Midline closure should be abandoned, since associated with an increased recurrence rate and higher incidence of wound complications;
• Drain use should be individualized. Drainage could not be associated with a better outcome (9,10);
• Fibrin sealant seems to be useless (11).

Update on minimally invasive treatment of pilonidal sinus (Table 1)

The idea of a less radical treatment of pilonidal sinus goes back to World War II. During the world conflict in fact, Phillips (12) suggested a less invasive treatment of infected pilonidal sinuses ‘‘to keep the fighting man in a fit condition for combat”. Again later, in 1970, Patey (13) stated: “Don’t take a hammer to swat a fly!”. In the late 60s Lord and Millar (14,15) introduced the debridement of the sinus using a rounded brush. In 1983 Bascom (16,17) developed a surgical procedure based on the excision of the pilonidal orifices combined with a parallel lateral incision aimed to obtain the debridement of the cavity.

In the last decade, supported by the statement “less is more” many surgeons developed minimally invasive treatment of pilonidal sinus (18-20). Minimally invasive techniques for pilonidal sinus consist of sinusectomy, it means the circumferential incision of the pilonidal orifices avoiding cutaneous margins and a selective subcutaneous extirpation of the sinus without closure of the wound. Satisfactory preliminary results, in terms of time off work and recurrence rates have been achieved by both sinusectomy (19) and sinusectomy by trephines (20).

A new endoscopic treatment for pilonidal sinus has been recently proposed (21-25): the Video Assisted Ablation of Pilonidal Sinus (VAAPS) technique. Its rationale is based on the concept of complete removal by ablation of the sinus though a small surgical access. The conventional surgical technique consists in creating an elliptical wedge of skin and subcutaneous tissue to remove the cavity and its lateral tracks. In contrast, this new technique creates a small elliptical wedge of the subcutaneous tissue, including the inflamed tissue and organic debris, leaving the overlying skin intact.

In our preliminary experience is based on 27 patients (21). Of these all of them immediately returned to normal activities and work and recurrence rates registered were low.

Of interest, a similar minimally invasive technique for pilonidal sinus treatment was designed by Meinero et al. (22): the Endoscopic Pilonidal Sinus Treatment (E.P.Si.T.). Their experience was based on 11 consecutive patients and obtained good preliminary results.

Although the mechanism of treatment is similar to the sinusectomy (19,20), the video-assisted technique benefits from a magnified view by the endoscope that allows the identification of the sinus borders, its lateral tracks, if present, and the presence of hair and debris inclusions in the cavity. According to this technique, infection and recurrence should be avoided by destroying all sinus cavities, the lateral tracks when present and by removing hair and debris. Furthermore, the small scar (5 mm wide and 2 mm deep) caused by this technique (that heals by secondary intention) fastens the healing, allowing rapid return to work and an optimal aesthetic results. However it is important to highlight that, up to now, there was no any comparative study between sinusectomy and endoscopic treatment. Thus it is not possible to give any conclusion about the superiority/non inferiority of endoscopic sinusectomy,

Thereafter, Chia et al. (23) obtained good results of the endoscopic treatment, on 9 consecutive patients; Meinero et al. (24), in a multicenter experience, on 250 patients, demonstrated that the procedure is a safe and effective technique for treating pilonidal sinus. In fact, compared to other more invasive techniques, it provides better short- and long-term outcomes. Giarratano et al. (26) demonstrated that E.P.Si.T. is an uneventful procedure, with good aesthetic results and a low recurrence rate. Gecim et al. (27) combined a crystalized phenol treatment with E.P.Si.T., with good results and no recurrences, but consisted of a relatively small number of patients.

Minimally invasive technique was performed in acute disease too: Javed et al. (28) compared traditional incision and drainage with endoscopic treatment for pilonidal abscess, concluding that endoscopic approach is associated with reduced post-operative morbidity without compromising the adequacy of abscess drainage. Also Jain et al. (29) reported their experience of minimally invasive endoscopic technique in the acute disease, with encouraging results about postoperative morbidity, recurrance rate and wound healing.

Milone M. et al. (21) published the first randomized clinical trial comparing the minimally invasive treatment with the validated off-midline intervention.

The results demonstrate that the new technique is more effective than the traditional one in terms of rapid return to normal activity (time off work) and in pain management after surgery. Additionally, patients demonstrate high satisfaction levels and aesthetic appearance is satisfactory.

It is worth mentioning that, according to Milone et al., this treatment could be an effective and feasible treatment for pilonidal sinus, being connected to a similar rate of postoperative complications compared with the conventional treatment. Moreover, in the minimally invasive group fewer infections were recorded alongside a similar recurrence rate was registered, providing evidence of the non-inferiority of the minimally invasive treatment compared with traditional off-midline closure.

On the other hand, it is very important to highlight that the recurrence rate, obtained by current literature, deserves further evaluation over a longer term period. In fact, based on the short-term follow-up, used to analyze clinical outcomes, it is impossible to draw definitive conclusions about the recurrence rate of the minimally invasive technique. Furthermore, further RCT comparing endoscopic treatment with sinusotomy or off-midline procedure are needed to confirm superiority/non-inferiority of this endoscopic procedure.

Definition of minimally invasive treatment

This new approach designed simultaneously and independently by Milone (21) and Meinero (22) had many names that should not confounded the clinicians involved in the disease’s management.

VAAPS, EPSiT, video assisted treatment, endoscopic sinusectomy, etc. have to be considered all synonymous of a new technique. There is only one concept; to treat pilonidal sinus by a minimally invasive technique.

Conclusions

The foundation for the birth of a new era of pilonidal sinus treatment has been laid. Our new technique provides outstanding advantages: no surgical wounds on the buttocks, high patients’ compliance due to minimal pain and wound care, and the technique facilitates immediate return to work and to daily activities.

It is the time to give patients this treatment opportunity in daily practice. It is the time to talk about the endoscopic treatment of pilonidal sinus. It is the time to thoroughly study every fold of this procedure in the effort of identifying indication, contraindications, advantages and disadvantages of a new weapon available against this tricky disease.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ales.2017.12.07). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Mayo OH. Observations on injuries and diseases of the rectum. London: Burgess and Hill, 1833:45-6.
2. Allen-Mersh TG. Pilonidal sinus: finding the right track for treatment. Br J Surg 1990;77:123-32. [Crossref] [PubMed]
3. 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. [Crossref] [PubMed]
4. McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis. BMJ 2008;336:868-71. [Crossref] [PubMed]
5. Brasel KJ, Gottesman L, Vasilevsky CAMembers of the Evidence-Based Reviews in Surgery Group. Meta-analysis comparing healing by primary closure and open healing after surgery for pilonidal sinus. J Am Coll Surg 2010;211:431-4. [Crossref] [PubMed]
6. 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. [Crossref] [PubMed]
7. 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;CD006213 [PubMed]
8. 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. [Crossref] [PubMed]
9. Milone M, Di Minno MN, Musella M, et al. The role of drainage after excision and primary closure of pilonidal sinus: a meta-analysis. Tech Coloproctol 2013;17:625-30. [Crossref] [PubMed]
10. Milone M, Musella M, Salvatore G, et al. Effectiveness of a drain in surgical treatment of sacrococcygeal pilonidal disease. Results of a randomized and controlled clinical trial on 803 consecutive patients. Int J Colorectal Dis 2011;26:1601-7. [Crossref] [PubMed]
11. Kayaalp C, Ertugrul I, Tolan K, et al. Fibrin sealant use in pilonidal sinus: Systematic review. World J Gastrointest Surg 2016;8:266-73. [Crossref] [PubMed]
12. Phillips CW. Pilonidal disease in a military hospital. J Natl Med Assoc 1954;46:329-32. [PubMed]
13. Patey DH. The principles of treatment of sacrococcygeal pilonidal sinus. Proc R Soc Med 1970;63:939-40. [PubMed]
14. LORD PH. MILLAR DM. PILONIDAL SINUS: A SIMPLE TREATMENT. Br J Surg 1965;52:298-300. [Crossref] [PubMed]
15. Millar DM, Lord PH. The treatment of acute postanal pilonidal abscess. Br J Surg 1967;54:598-9. [Crossref] [PubMed]
16. Bascom J. Pilonidal disease: long-term results of follicle removal. Dis Colon Rectum 1983;26:800-7. [Crossref] [PubMed]
17. Bascom J. Pilonidal disease: origin from follicles of hairs and results of follicle removal as treatment. Surgery 1980;87:567-72. [PubMed]
18. Soll C, Hahnloser D, Dindo D, et al. A novel approach for treatment of sacrococcygeal pilonidal sinus: less is more. Int J Colorectal Dis 2008;23:177-80. [Crossref] [PubMed]
19. Soll C, Dindo D, Steinemann D, et al. Sinusectomy for primary pilonidal sinus: less is more. Surgery 2011;150:996-1001. [Crossref] [PubMed]
20. Gips M, Melki Y, Salem L, et al. Minimal surgery for pilonidal disease using trephines: description of a new technique and long-term outcomes in 1,358 patients. Dis Colon Rectum 2008;51:1656-62; discussion 1662-3.
21. Milone M, Musella M, Di Spiezio Sardo A, et al. Video-assisted ablation of pilonidal sinus: a new minimally invasive treatment—a pilot study. Surgery 2014;155:562-6. [Crossref] [PubMed]
22. Meinero P, Mori L, Gasloli G. Endoscopic pilonidal sinus treatment (E.P.Si.T.). Tech Coloproctol 2014;18:389-92. [Crossref] [PubMed]
23. Chia CL, Tay VW, Mantoo SK. Endoscopic pilonidal sinus treatment in the Asian population. Surg Laparosc Endosc Percutan Tech 2015;25:e95-7. [Crossref] [PubMed]
24. Meinero P, Stazi A, Carbone A, et al. Endoscopic pilonidal sinus treatment: a prospective multicentre trial. Colorectal Dis 2016;18:O164-70. [Crossref] [PubMed]
25. Milone M, Fernandez LM, Musella M, et al. Safety and Efficacy of Minimally Invasive Video-Assisted Ablation of Pilonidal Sinus: A Randomized Clinical Trial. JAMA Surg 2016;151:547-53. [Crossref] [PubMed]
26. Giarratano G, Toscana C, Shalaby M, et al. Endoscopic Pilonidal Sinus Treatment: Long-Term Results of a Prospective Series. JSLS 2017;21. pii: e2017.00043.
27. Gecim IE, Goktug UU, Celasin H. Endoscopic Pilonidal Sinus Treatment Combined With Crystalized Phenol Application May Prevent Recurrence. Dis Colon Rectum 2017;60:405-7. [Crossref] [PubMed]
28. Javed MA, Fowler H, Jain Y, et al. Comparison of conventional incision and drainage for pilonidal abscess versus novel endoscopic pilonidal abscess treatment (EPAT). Tech Coloproctol 2016;20:871-3. [Crossref] [PubMed]
29. Jain Y, Javed MA, Singh S, et al. Endoscopic pilonidal abscess treatment: a novel approach for the treatment of pilonidal abscess. Ann R Coll Surg Engl 2017;99:134-6. [Crossref] [PubMed]