Recurrent Pilonidal Disease

Why does it happen?

Unfortunately, recurrence of pilonidal disease after surgery is a common problem. This article discusses the reasons why this happens, and presents a good solution.

In order to understand why pilonidal disease recurs, it helps to understand why it happens in the first place. Pilonidal disease is caused by the shape and depth of the gluteal fold. In some patients it is so deep and tight that during most of the day, it is tightly folded and no air can get in. Because of this pressure builds up in the cleft and anaerobic bacteria grow. The reaction of the skin to this situation is to create enlarged midline pores, which we call “pits”. Loose hairs that all off the body (mostly from the back of the head) get caught in these pores, work their way under the skin, and cause a “pilonidal cyst”.

Pilonidal disease manifests itself in several common ways:

  • a slightly painful lump that may get intermittently inflamed
  • a more severe infection, which we then call a pilonidal abscess
  • enlargement of the pits to the point that they cause open, draining and/or bleeding wounds
  • tunneling or sinus tract formation, where the midline pits connect to secondary openings off to the side of the crease

The best operations re-configure the gluteal crease so it is not so deep. The cleft-lift operation does this, and has a very low recurrence rate. However the operations that just remove the “cyst” do not flatten the crease, and have an extremely high failure rate.

So, why does pilonidal disease recur?

In almost all situations, when pilonidal disease recurs it is because the cleft was not flattened, and the incision for the surgery was placed in the midline of the cleft. It is NOT BECAUSE THE SURGEON DID AN INADEQUATE JOB OF REMOVING ALL THE CYSTS AND TRACTS! This is not “a cancer which has to be completely removed”; this is a benign disease caused by the shape of the cleft. Removal of the disease is of secondary importance to re-configuring the cleft. Radiologic studies such as ultrasound, MRI or CT scans do not give any useful information beyond what can be seen by a physical exam, and add no value.

So, how should recurrences NOT be treated?

  • More diligent personal hygiene will NOT solve the problem.
  • Greater efforts at hair removal is NOT the solution.
  • Another attempt at removal because “we didn’t get it all” or “you developed a new cyst” is NOT going to solve the problem
  • A MRI so we can find some elusive, missed tunnel or tract is NOT the answer
  • Re-operation with methylene blue dye injected to find elusive sinus tracts will NOT magically uncover the problem

The Cleft-Lift is the answer

The best solution is an operation which flattens the cleft, brings the incision off the midline, and removes whatever current wounds or tracts exist. The cleft-lift is the best operation to achieve this. The Karydakis Procedure is also a good option, if done properly.

A lot of time and effort is spent pursuing operations with very high failure rates. If you have had a failure, and are looking for a solution – find a surgeon with expertise in performing the cleft-lift operation for failed surgery. The odds are very great that it will be successful if done properly.

Suction Drains after a Cleft-Lift

Are they really that important?

After a cleft-lift procedure many surgeons place a drain. There are two different basic kinds in popular use.

  • One type is a “passive drain” and consists of a flat rubber strip that enters one area and exits another, and allows any fluid buildup to find a way out along the rubber drain and onto the dressing. It requires some occasional rolling pressure along the flap to push fluid out the drain site, and does not allow measurement of the output very precisely.
  • The other type is an “active drain”, which is referred to as a “closed suction drain”, or Blake Drain or JP (Jackson Pratt) Drain. It has a clear plastic tube that is placed under the flap, and connects to a clear plastic reservoir, which is emptied once or twice a day and the amount precisely recorded.

I prefer the Blake Drain type because it has been working well for me for many years, but either type is acceptable. However, the bigger questions are whether a drain is really needed at all? And, can failures be attributed to the lack of a drain in cases where one wasn’t used?

The logic of using a closed suction drain is that it:

  • prevents any fluid from accumulating under the flap, which could cause a chronic fluid collection (seroma) or infection
  • prevents fluid from leaking through the incision, which will weaken the incision and possibly sabotage the success of the operation
  • is an indicator of bleeding (the drainage will be red), or infection (the drainage will be creamy) and allows us to respond to the situation more quickly and appropriately.
  • pulls the tissues together with negative pressure so they will heal in the position the surgeon intended.

So, what happens if you don’t use a drain? There are no specific studies that compare patients with and without a drain after a cleft-lift, but there are studies that do this with the Karydakis procedure, which is very similar. One study, done in Turkey in 2005, showed that when a drain was not used, 32% of the patients had problems with fluid collections, as compared to 8% in the patients with drains. Another article, from Ireland in 2010 this time, compared using a drain with putting fibrin glue under the flap instead. In this series, there was a 24% complication rate when the drain was not used, vs 6% when it was used.

So, if one can extrapolate the Karydakis data to the cleft-lift, it seems that a drain is useful. But, can you get away without it? Sure: 70-80% of patients would probably do OK without it. The problem is knowing which patients are the ones who are going to have problems. At present, we have no way of prediction this. Afterwards, in patients with low drain output, we might be able to say they could have gotten away without a drain. In those with a large amount of output, that lasts over a week, we can certainly say they benefited from the drain. I use a drain in all patients, because I don’t think a 25-30% rate of problems from fluid is acceptable.

If someone’s cleft-lift failed, and they didn’t have a drain – can we blame it on that omission? It’s hard to say. Often, a poorly constructed cleft-lift goes hand in hand with the omission of a drain. But, without knowing all the details, it is hard to completely blame it on that one issue.

So, I wouldn’t choose your surgeon solely on whether they use a drain, or not. Instead, I would look at how much experience they have, what their interest level is with pilonidal disease, and what their success rates have been. BTW: if you’ve managed to read through this article, you now know more than most surgeons about this topic! Congratulations!

More About “Minimally Invasive” Pilonidal Surgery

Fibrin Glue. Kshar Sutra, Phenol, RFA, and Seton Treatment of Pilonidal Disease

In a previous post I discussed several “minimally invasive” pilonidal treatments, and you can read about them here. However, there are a few other kinds of minimally invasive therapies that are worth discussion. They are:

  • Fibrin Glue
  • Kshar Sutra
  • Phenol Injection
  • RFA (Radio Frequency Ablation)
  • Seton treatment
  • Cryosurgery

These are all addressing the pilonidal sinus tract, which is one of the more common presentations of pilonidal disease. These treatments would have no place in the treatment of a large, non-healing wound. I’ll describe each of these separately:

Fibrin Glue Treatment of Pilonidal Sinus

The sinus tract is cleaned out of hair and debris. Fibrin glue is then injected into the sinus tract to obliterate any space in the sinus tract. (Fibrin glue is a biological adhesive which consists of concentrated human fibrinogen which is activated by the addition of bovine thrombin and calcium chloride.)

Kshar Sutra Treatment of Pilonidal Sinus

The sinus tract is cleaned out, the midline pits are removed, and a medicated thread is put in the sinus tract origin, and out the sinus tract exit, and tied in a circle. It is left in place until it causes the tract to scar down and heal.

Phenol Injection for Pilonidal Sinus

This is a technique that is more popular in Europe than the United States. The sinus tract is cleaned out and some form of phenol is instilled into the tract. There are several forms of phenol such as cream-gel, liquid and crystals. Phenol is a caustic, antiseptic, germicide, and has a local anesthetic effect. (It has been used as an embalming fluid!)

RFA (Radio Frequency Ablation) of Pilonidal Sinus

In this technique the sinus is surgically removed, and an electrocautery unit is used to destroy the residual sinus tissue. As surgeons, we use electrocautery in almost every operation. It is a machine that turns electrical energy into heat energy. (often termed a “Bovie” after the inventor). In this instance, certain kinds of tips are used on the machine to facilitate the procedure.

Seton Treatment of Pilonidal Sinus

This is similar to kshar sutra, in that a thread is placed through the two ends of the sinus and tied. Patients come in weekly for the thread to be tightened, until it cuts through the tissues. The inflammation from the thread obliterates the sinus.

Cryosurgery for Pilonidal Sinus

This is very similar to using RFA or Laser – where energy is used to destroy the sinus, but in this case liquid nitrogen is used to destroy the tissues by freezing.

You may be noticing a theme here:

  • They all of these put something in the sinus tract to obliterate it (chemicals, heat energy, freezing, foreign body, glue).
  • They are not very different than EPSiT, SiLaC (laser surgery), pit picking, or Gips Procedure.
  • They may or may not be able to be done in an office setting.
  • They all require multiple post op visits.
  • They do not re-shape the gluteal crease.

The literature regarding the success rates of these procedures is not the most robust. However, when the literature is evaluated the recurrence rate is reported as 15% – 40%. Many studies contain small numbers of patients and short follow up times. Of course, only surgeons with good results report their outcomes, and many surgeons don’t write papers about this at all!

My take on all of these minimally invasive procedures is:

  • They are are a reasonable first step in a specific group of patients with a SHALLOW CLEFT who present with ONLY a sinus or two.
  • They are NOT an option when dealing with open wounds and non-healing surgery.
  • The patient has to accept that there is a significant failure rate. At best one out of five patients will fail, and more likely one out of three.
  • None of these procedures has been shown to be significantly better than the others.
  • Although they may cause some minor scarring and distortion, they do maintain the original shape of the gluteal cleft, if that is of cosmetic importance to the patient.
  • They are not widely accepted by surgeons, and it may be difficult to find one to perform the procedure.
  • In almost all situations, if they fail, a cleft-lift is still a future option.

I do not perform any of these operations, because I do not feel that the success rate is worth the time, expense and discomfort for a procedure with a low success rate. Especially, if it requires travel across the country to see me. If you are interested in these minimally invasive procedure, I suggest you try to find someone local to evaluate and treat you. If the minimally invasive therapy fails, then come see me for a cleft-lift.