Table of Content - Volume 19 Issue 1 - July 2021
Study of laser treatment in primary pilonidal disease at a tertiary hospital
Nitish Jhawar1, Manish Pendse2*, Monika Joshi3
1Consultant Surgeon, 3DNB, Department of Surgery, Apollo Hospital Navi Mumbai, Maharashtra, INDIA. 2Associate Professor, Department of Medicine, Dypatil Medical College Nerul Navi Mumbai, Maharashtra, INDIA Email: drmanishpendse@gmail.com
Abstract Background: Pilonidal sinus is a pathology that occurs with acute or chronic infection in the natal cleft, especially in young men. In order to decrease complications and recurrence rates after pilonidal sinus excision, it is desirable to use a less invasive technique that allows patients to recover more quickly and permanently. Present study was aimed to evaluate laser Pilonidotomy, a new technique for the treatment of pilonidal sinus. Material and Methods: Present study was a prospective, observational study conducted in ppatients diagnosed as cases of pilonidal sinus disease, attending surgical OPD, underwent laser pilonidotomy. Results: Total 32 patients were evaluated. Male patients (90.63%) were far more than female patients (9.38%). Mean duration of procedure was 30.34 ± 8.24 minutes, mean duration of hospital stay was 14.65 ± 7.13 hours. Most of patients resumed normal activity in 1.96 ± 0.81 days while complete wound healing by secondary intention was noted after 4.5 ± 1.2 weeks. Successful primary treatment was done in 90.63 %. Recurrence was noted in 3 patients (9.38 %). Infection (6.25 %) was noted in 2 patients, less common complications were bleeding (3.13 %), severe postoperative pain (3.13 %), hypertrophic scar (3.13 %). VAS score analysis was done and a significant change in VAS score was noted between day 1 and day 7. Conclusion: Laser treatment in primary pilonidal disease is minimal invasive surgery, is easy to perform with major advantages such as shorter hospital stay, less post-operative pain and care and the final aesthetic aspect. Keywords: Laser treatment, primary pilonidal disease, minimal invasive surgery, shorter hospital stay
INTRODUCTION Pilonidal sinus is a pathology that occurs with acute or chronic infection in the natal cleft, especially in young men. Pilonidal sinus is a result of a foreign body reaction stimulated due to penetration of surrounding bristles into natal cleft. It is more common in the end of the second decade. The underlying pathophysiologic feature is enlarged hair follicles due to midline vacuum and pulling forces; when plugged with hair or keratin, the follicles rupture, leading to a foreign-body reaction within the presacral subcutaneous tissue and subsequent acute and chronic abscess.1 The familial tendency and genetic predisposition have also been reported. The condition is usually seen associated with obesity, hirsute individuals, profuse sweating and sedentary lifestyle. Local irritation or trauma has been reported as contributing factor.2 The diagnosis of pilonidal sinus is by finding a characteristic sinus lined by epithelialized tract present in the natal cleft a short distance from anus and having hairs as its constituents. A deep abscess cavity with surrounding moist conditions and abundant bacteria, hair, debris and friction cause recurrent infection, associated with chronic pain and discharge.3 In order to decrease complications and recurrence rates after pilonidal sinus excision, it is desirable to use a less invasive technique that allows patients to recover more quickly and permanently.4Present study was aimed to evaluate laser Pilonidotomy, a new technique for the treatment of pilonidal sinus.
MATERIAL AND METHODS Present study was a prospective, observational study conducted at Department of Surgery, Apollo Hospital Navi Mumbai. Study was conducted in department of general surgery, from June 2019 to December 2020 (18 months). An approval from institutional ethical committee was obtained to conduct this study. Inclusion criteria Patients diagnosed as cases of pilonidal sinus disease, attending surgical OPD, underwent laser pilonidotomy, willing to participate and follow up. Exclusion criteria Recurrent pilonidal sinus Pilonidal Sinus abscess with; Human immunodeficiency virus positive patients; Patients on cancer chemotherapeutic drugs; on immunosuppressant therapy. Furthermore, uncooperative or mentally ill patients. Patients lost to follow up. All patients were evaluated by history taking and clinical examination including digital rectal examination. Baseline investigations CBC, blood urea, blood sugar, LFT, coagulation profile were done in each patient. If required ECG, X ray chest were done. Preoperatively shaving of the back was done. Laser pilonidotomy was the procedure planned for all patients. The procedure was explained to patients in local language and an informed consent was taken before surgery. All cases were performed under local anaesthesia, in Jackknife position. All the pits and associated abscess cavities were identified. Crisscross incision was taken over the abscess cavity and debridement done. (At 8 W with 1470 nm diode laser, 100 J of energy per centimeter), till the entire length is debrided. Cavity was flushed with normal saline and hydrogen peroxide. A crisscross incision at natal cleft was taken for drainage through the pit. If the Pilonidal Sinus is more than 4 cm long, additional crisscross incision in the centre of the sinus tract was taken to prevent collection in the recovery period. Wound was kept open for drainage. Follow up was planned at 1 week, 2 weeks and 4-6 weeks. Study outcomes evaluated were operation time, healing time, and the duration of hospitalization, the degree of postoperative complications and rate of recurrence. VAS score was used to evaluate pain on day 1 and day 7. All study subjects were followed for 12 months. The data collected was analyzed using statistical package SPSS (version 25). Statistical analysis was done using descriptive statistics. Chi-square test was used as test of significance for qualitative data. P value of <0.05 was considered as statistically significant
RESULTS Total 35 patients underwent laser pilonidotomy at our hospital. 3 patients were lost to follow-up, so 32 patients were evaluated. Male patients (90.63%) were far more than female patients (9.38%). Mean duration of procedure was 30.34 ± 8.24 minutes, mean duration of hospital stay was 14.65 ± 7.13 hours. Most of patients resumed normal activity in 1.96 ± 0.81 days while complete wound healing by secondary intention was noted after 4.5 ± 1.2 weeks. Successful primary treatment was done in 90.63 %. Recurrence was noted in 3 patients (9.38 %). Infection (6.25 %) was noted in 2 patients, less common complications were bleeding (3.13 %), severe postoperative pain (3.13 %), hypertrophic scar (3.13 %). No dehiscence, tip necrosis was noted in study cases.
Table 1: Patient and operative characteristics
VAS score analysis was done and a significant change in VAS score was noted between day 1 and day 7.
Table 2: VAS score analysis.
DISCUSSION Excessive hair growth has a pivotal pathogenetic role due to the penetration of broken terminal hairs into the subcutaneous tissue with subsequent inflammatory granuloma development and potential secondary infection. Discomfort and pain are common symptoms after debridement without skin closure and marsupialization. This procedure require repeated change of dressing which results in delayed healing.5 Excision of pilonidal sinus and primary midline closure has high rates of recurrence and infection and longer hospitalization.6 There are many surgical methods described, varying from the simple incision, drainage, unroofing, curettage and spontaneous secondary healing to excision-flap sliding, Karydakis, Bascom, and MacFee methods. The standard treating pilonidal sinus (PNS) is surgical intervention with excision of sinus. Although surgical intervention is acutely effective, but the recurrence of pilonidal sinus is high.4 The aim of laser treatment is to use high energy at the tip of the probe to destroy the squamous epithelium of the pilonidal sinus and induce contraction/ obliteration of the tract.7 Laser pilonidoplasty is a simple, reasonable, feasible, minimal invasive, reproducible technique and competitive alternative to other surgical intervention. It is, however, more common in young adult men, a population with an incidence of 1.1%. Affected patients are typically in their middle to late 20s and have had symptoms for 4 to 5 years at initial presentation.8 The onset of disease in adolescent can be correlated with pubertal hormonal effect as well as skin and hair changes.8 Ashwin P9 studied laser pilonidotomy in 228 patients. Mean duration of Procedure was 33 ± 11 min, mean duration of Hospital Stay was 12 ± 3 h, resumption of normal activity within 4 ± 2 days , mean duration for Complete Wound Healing by secondary intention 6 ± 1.25 Weeks. Among complications, infection reported in 1.08%. The difference between the mean pre and post-operative VAS score was statistically highly significant (p < 0.0001). Recurrence rate was 3.24%. Success rate was 96.75% and Overall patient’s satisfaction was 97.84%. Laser Pilonidotomy is effective in destruction of a pilonidal cyst with good success rate, fewer complications and with high patient’s satisfaction. Similar findings were noted in present study. Oram et al.10 reported a 13.3% recurrence rate of pilonidal sinus after a mean number of 2.7 Alexandrite laser treatments. Recurrence rate after excision and primary closure was high (38%) and excision and flap reconstruction provided the best results with a relapse rate of only 7.3%. Therefore, it is attractive to speculate that the choice of surgical technique influences pilonidal sinus recurrence rate.10 Patil AM,11 studied pilonidal sinus destruction with Neo V Laser Probe The success rate was 87.5% (35 patients/40). Recurrence rate was 2.9% (1/35). Alferink M et al.,12 studied 50 patients operated with radial laser probe (Sinus Laser-Assisted Closure, SiLaCTM, Biolitec, Germany). The median follow up duration was 120 days. The initial success rate was 92% (45/50). There were no complications during or after surgery. Mean patient satisfaction was 9.0 (3.0 to 10.0). Thirteen percent of patients did not require any analgesia, 37% used only when needed, of which 32% for less than one week and 10% for one to two weeks. In a retrospective series of 40 patients treated with the FILAC™ radial laser probe and documented an 87.5% success rate with 2.9% recurrence. The mean follow-up period was 234 days. Four patients presented with complications: 2 hematomas (5%) and 2 abscesses (5%), which were all medically treated.7 In a meta-analysis and merged-data analysis13, recurrence after Limberg/Dufourmentel operations was as low as 0.6% at 12 months and 1.8% at 24 months postoperatively. Recurrence after Karydakis/Bascom procedures was 0.2% at 12 months and 0.6% at 24 months postoperatively. Primary midline closure after 240 months was associated with recurrence rates of 67.9%. CO2 laser able to seal lymphatic and blood vessels up to 1mm diameter and can reduce intraoperative bleeding and the occurrence of postoperative swelling. It also offers more comfort to patients by reducing intraoperative bleeding and postoperative edema, facilitating the process of wound healing after surgery.14 Major limitations of present study were small sample, relatively short median follow-up duration. A prospective study with larger sample size and longer median follow-up is required to establish recurrence rates more accurately.
CONCLUSION Laser treatment in primary pilonidal disease is minimal invasive surgery, is easy to perform with major advantages such as shorter hospital stay, less post-operative pain and care and the final aesthetic aspect. It is accompanied by a reduction in pain, early resuming work with decreased rate of recurrence.
REFERENCES
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