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Healing by primary versus secondary intention after surgical treatment for pilonidal sinus

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Abstract

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Background

Pilonidal sinus arises in the hair follicles in the buttock cleft at the bottom of the backbone. The estimated incidence is 26 per 100,000, people, affecting men twice as often as women. The mean age of presentation is 21 years (men) and 19 years (women) respectively.

Pilonidal sinus results in chronic discharging wounds that cause pain and impact upon quality of life and social function. These sinuses may become infected and present as acute abscesses. Management of these abscesses is uncontroversial and revolves around incision and drainage, however, the mode of surgical management of the chronic discharging sinus is debatable.

Surgical strategies traditionally centre on excision of the sinus tracts followed by primary closure and healing by primary intention or leaving the wound open to heal by secondary intention. There is uncertainty as to whether open or closed surgical management is more effective.

Objectives

To determine the relative effects of open compared with closed surgical treatment for pilonidal sinus on the outcomes of time to healing, infection and recurrence rate.

Search methods

We sought relevant trials from the Wounds Group Specialised Register (Searched 13/6/07); The Cochrane Central Register of Controlled Trials (CENTRAL) (2007, Issue 2); Ovid MEDLINE (1950 ‐ May Week 5 2007); Ovid EMBASE (1980 ‐ 2007 Week 23); Ovid CINAHL (1982 ‐ June Week 2 2007). We checked the bibliographies of review and primary articles for relevant studies and contacted authors of all included studies.

Selection criteria

All randomised controlled trials (RCTs) evaluating open with closed surgical treatment for pilonidal sinus. Exclusion criteria were: non‐RCTs; children aged younger than 14 years and studies of pilonidal abscess.

Data collection and analysis

Screening of eligible studies, data extraction and methodological quality assessment of trials were conducted independently by two review authors. Data from eligible studies were recorded using data extraction forms and any disagreements were referred to a third review author. Results were presented using mean differences for continuous outcomes and relative risk with 95% confidence intervals for dichotomous outcomes.

Main results

Eighteen studies were included (1573 patients). Twelve RCTs compared open healing with primary closure, 10 of which used midline closure and 2 trials used off‐midline closure. Six studies compared midline and off‐midline closure.

Open compared with closed techniques: Evidence suggested more rapid healing after primary closure although there was no difference in the infection rate after wound closure. Recurrence was less likely to occur after open healing (RR 0.42; 95% CI 0.26 to 0.66) suggesting a 58% lower risk of recurrence after open wound healing compared with primary closure. Patients returned to work earlier after primary closure (WMD 10.48 days 95% CI 5.75 to 15.21 days). There was no difference between the two groups for other complications and length of stay. There were few useable data on cost, patient satisfaction and pain.

Closed midline compared with closed off‐midline: there was good evidence of slower healing, higher rates of infection (RR 4.70; 95% CI 1.93 to 11.45), higher rates of recurrence (Peto OR 4.95; 95% CI 2.18 to 11.24) and other complications (RR 8.94; 95% CI 2.10 to 38.02) after midline primary closure compared with off‐midline closure techniques.

Authors' conclusions

No clear benefit was shown for surgical management by primary closure or open healing by secondary intention. A clear benefit was shown for off‐midline closure rather than midline closure after pilonidal sinus surgery. Off‐midline closure should be the standard management when primary closure is the desired surgical option.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Plain language summary

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Healing by primary versus secondary intention after surgical treatment for pilonidal sinus

Pilonidal sinus is a problematic condition probably caused by in‐grown hairs between the buttocks. Sufferers tend to be young men and they usually experience a wound that discharges pus‐like material and does not heal. Usually these are treated by operation, which aims to remove the infected area. However, surgeons frequently disagree about whether the resulting wound should be stitched closed or left to heal without stitches. We found that wounds that are left to heal without stitches take longer to heal and have fewer complications; however, people with this type of wound take longer to return to normal activity. Closed wounds are prone to more complications such as infection, although this can be minimised by using techniques where the stitch line is moved away from between the buttocks.