Outcome After Surgical Treatment for Chronic Pilonidal Sinus Disease: A Systematic Review of Common Surgical Techniques

BACKGROUND: The choice of operation for chronic pilonidal sinus disease remains controversial.

OBJECTIVE: To compare the outcomes of common operations for chronic pilonidal disease.

DATA SOURCES: We searched PubMed, Embase, and the Cochrane Library.

STUDY SELECTION: We included randomized trials in English or Danish language, published 2002 to 2024 that compared outcomes of operations to treat chronic pilonidal disease in adults and teenagers.

INTERVENTIONS: We compared the outcomes of secondary healing, primary midline closure, Bascom, Limberg, and Karydakis flap operations.

MAIN OUTCOME MEASURES: The primary outcome was recurrence; secondary outcomes were infection, healing time, and length of stay. We compared recurrence and infection rates in meta-analyses for all techniques. We assessed the risk of bias and the quality of all trials.

RESULTS: Fifty trials included a total of 5762 participants. In a meta-analysis, the flap operations had fewer recurrences than primary midline closure (OR 0.31; 95% CI, 0.19-0.51; p < 0.01). The trials comparing flap operations with secondary healing were heterogeneous and did not reach significance (OR 0.38; 95% CI, 0.13-1.13; p = 0.08). Recurrence was similar between Limberg and Karydakis operations. Infection rates were lower for the flap operations compared with primary closure (OR 0.33; 95% CI, 0.23-0.48; p < 0.01) and with secondary healing (OR 0.48; 95% CI, 0.30-0.77; p < 0.01). Two trials tested Bascom procedure against Limberg operation without significant differences. All trials found secondary healing to have significantly longer healing times than any other operation.

LIMITATIONS: Most studies had a high or medium risk of bias, resulting in very low to low certainty of evidence. The trials generally had small numbers, short follow-ups, and no reported primary outcomes or power calculations.

CONCLUSIONS: Primary closure and secondary healing performed poorly compared with the flap techniques. Most trials tested Limberg operation; only 2 tested Bascom operation. The literature suggests the surgeon's expertise determines the choice of flap technique.