Sinus pilonidalis – was ist die beste chirurgische Therapie?

Zusammenfassung

Einleitung Der Sinus pilonidalis ist eine meist chronische punktuelle Infektion der behaarten Haut im Bereich von Hautfalten mit der häufigsten Lokalisation im Bereich der Rima ani. Die Erkrankung hat oft erhebliche Auswirkung auf die Lebensqualität der Betroffenen, die Behandlung kann komplex sein und muss dem Patientenbedarf angepasst werden.

Methoden Im Folgenden wird eine Übersicht über die Entstehung sowie die Behandlungsalternativen und deren Besonderheiten gegeben. Dabei werden jeweils die Aspekte frühe postoperative Ergebnisse, Wundheilungsstörung und Langzeitergebnisse dargestellt.

Ergebnisse Der Pathomechanismus der Pilonidalsinus-Erkrankung ist weiterhin nicht abschließend geklärt, es muss auch weiterhin davon ausgegangen werden, dass die Haare in der Rima ani wesentlich zu Entstehung beitragen. Neuere Erkenntnisse weisen jedoch darauf hin, dass die großen Haarbüschel, die immer wieder in der Wundhöhle gefunden werden, am ehesten von der behaarten Kopfhaut stammen. Es lassen sich im Wesentlichen 3 Gruppen der Behandlungsoptionen unterscheiden: Die Standardbehandlung der Exzision und die folgende offene Wundbehandlung hat eine geringe Rezidivrate, weist jedoch erheblichen Aufwand im Rahmen der Wundbehandlung auf und führt dadurch zu langer Krankheitsdauer. Relativ neu in den Fokus geraten sind die lokal destruierenden Behandlungsverfahren, welche die Haut im Wesentlichen erhalten. Wichtige Vertreter sind das sog. Pit Picking, Fistuloskopie und andere Behandlungsformen wie Phenolinjektion oder Laserbehandlung. Bei diesen Behandlungsmöglichkeiten steht die abschließende Bewertung der Ergebnisse noch aus. Die 3. Behandlungsgruppe umfasst die Exzision und plastisch-rekonstruktive Verfahren. Diese Verfahren sind technisch aufwendig, gehen häufig mit stationärer Behandlung einher und führen langfristig jedoch zu relativ guten Ergebnissen.

Schlussfolgerung Die Pilonidalsinus-Behandlung erfordert eine am Patienten orientierte Therapieplanung. Dabei müssen dem Patienten die unterschiedlichen Behandlungsoptionen vermittelt werden und eine Behandlungsempfehlung muss ausgesprochen werden. Hier dient die Exzision und offene Wundbehandlung weiterhin als Standardverfahren, anhand dessen die Vor- bzw. Nachteile der anderen Behandlungsoptionen vermittelt werden können.

Abstract

Introduction Sinus pilonidalis is a chronic infection of the hairy skin in the area of skin wrinkles, with the most common localization in the natal cleft. The disease often has a significant impact on the quality of life of the affected person; the treatment may be complex and needs to be adapted to the patientʼs needs.

Methods Below is an overview of the origin as well as the treatment alternatives and their peculiarities. The following aspects are presented: early post-operative results, wound healing disorder and long-term results.

Results The pathomechanism of pilonidal sinus disease has still not been conclusively clarified; it must continue to be assumed that the hair in the natal cleft contributes significantly to the formation. However, recent findings indicate that the large tufts of hair that are repeatedly found in the wound cavity are most likely to come from the hairy scalp. Three essential treatment options can be distinguished: The standard treatment of excision and subsequent open wound treatment, has a low recurrence rate, but requires considerable effort in wound treatment and thus leads to protracted time off work. Relatively new treatments include locally destructive treatment that essentially preserves the skin. Important representatives are so-called pit picking, fistuloscopy and other forms of treatment, such as phenol injection and/or laser treatment. In these treatment options, the final evaluation of the results is still pending. The third treatment group is excision and plastic reconstruction. These procedures are technically demanding, often involve inpatient treatment but lead to relatively good results in the long term.

Conclusion Treatment of pilonidal disease requires patient-oriented therapy planning. The patient must be taught the different treatment options and a treatment recommendation must be given to the patient. Excision and open granulation continues to serve as a standard procedure with which other treatment options can be compared.

Schlüsselwörter

Abszess - Sinus pilonidalis - Chirurgie - Wundheilung - Rezidiv

Key words

abscess - pilonidal sinus - surgery - wound healing - recurrence

• Literatur

• 1 Iesalnieks I, Ommer A, Petersen S. et al. German national guideline on the management of pilonidal disease. Langenbecks Arch Surg 2016; 401: 599-609 doi:10.1007/s00423-016-1463-7
• 2 Bascom J, Bascom T. Prevention of wound healing disorders and recurrence. Am J Surg 2009; 198: 293-294 doi:10.1016/j.amjsurg.2008.05.002
• 3 Bascom J. Pilonidal disease: origin from follicles of hairs and results of follicle removal as treatment. Surgery 1980; 87: 567-572
• 4 Karydakis GE. New approach to the problem of pilonidal sinus. Lancet 1973; 2: 1414-1415
• 5 Doll D, Bosche FD, Stauffer VK. et al. Strength of occipital hair as an explanation for pilonidal sinus disease caused by intruding hair. Dis Colon Rectum 2017; 60: 979-986 doi:10.1097/DCR.0000000000000795
• 6 Doll D, Bosche F, Hauser A. et al. The presence of occipital hair in the pilonidal sinus cavity-a triple approach to proof. Int J Colorectal Dis 2018; 33: 567-576 doi:10.1007/s00384-018-2988-8
• 7 Stelzner F. [Causes of pilonidal sinus and pyoderma fistulans sinifica]. Langenbecks Arch Chir 1984; 362: 105-118
• 8 Tezel E. A new classification according to navicular area concept for sacrococcygeal pilonidal disease. Colorectal Dis 2007; 9: 575-576 doi:10.1111/j.1463-1318.2007.01236.x
• 9 Wysocki AP, Andersson RE, Gips M. et al. Towards a classification for sacrococcygeal pilonidal disease – Berlin 2017. PSJ 2018; 4: 5-10
• 10 Patey DH. The principles of treatment of sacrococcygeal pilonidal sinus. Proc R Soc Med 1970; 63: 939-940
• 11 Doll D, Novotny A, Rothe R. et al. Methylene Blue halves the long-term recurrence rate in acute pilonidal sinus disease. Int J Colorectal Dis 2008; 23: 181-187 doi:10.1007/s00384-007-0393-9
• 12 Testini M, Piccinni G, Miniello S. et al. Treatment of chronic pilonidal sinus with local anaesthesia: a randomized trial of closed compared with open technique. Colorectal Dis 2001; 3: 427-430
• 13 Allen-Mersh TG. Pilonidal sinus: finding the right track for treatment. Br J Surg 1990; 77: 123-132
• 14 Milone M, Velotti N, Manigrasso M. et al. Long-term follow-up for pilonidal sinus surgery: a review of literature with metanalysis. Surgeon 2018; 16: 315-320 doi:10.1016/j.surge.2018.03.009
• 15 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: 868-871 doi:10.1136/bmj.39517.808160.BE
• 16 Sondenaa K, Andersen E, Soreide JA. Morbidity and short term results in a randomised trial of open compared with closed treatment of chronic pilonidal sinus. Eur J Surg 1992; 158: 351-355
• 17 Menzel T, Dorner A, Cramer J. [Excision and open wound treatment of pilonidal sinus. Rate of recurrence and duration of work incapacity]. Dtsch Med Wochenschr 1997; 122: 1447-1451 doi:10.1055/s-2008-1047784
• 18 Ypsilantis E, Carapeti E, Chan S. The use of topical 10 % metronidazole in the treatment of non-healing pilonidal sinus wounds after surgery. Int J Colorectal Dis 2016; 31: 765-767 doi:10.1007/s00384-015-2269-8
• 19 Iesalnieks I, Deimel S, Kienle K. et al. [Pit-picking surgery for pilonidal disease]. Chirurg 2011; 82: 927-931 doi:10.1007/s00104-011-2077-9
• 20 Bascom J. Pilonidal disease: long-term results of follicle removal. Dis Colon Rectum 1983; 26: 800-807
• 21 Iesalnieks I, Deimel S, Schlitt HJ. [“Pit picking” surgery for patients with pilonidal disease: mid-term results and risk factors]. Chirurg 2015; 86: 482-485 doi:10.1007/s00104-014-2776-0
• 22 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: 1656-1662 doi:10.1007/s10350-008-9329-x
• 23 Petersen S. Skin preserving pit excision, so-called pit picking. PSJ 2017; 3: 1-7
• 24 Meinero P, Mori L, Gasloli G. Endoscopic pilonidal sinus treatment (E.P.Si.T.). Tech Coloproctol 2014; 18: 389-392 doi:10.1007/s10151-013-1016-9
• 25 Tien T, Athem R, Arulampalam T. Outcomes of endoscopic pilonidal sinus treatment (EPSiT): a systematic review. Tech Coloproctol 2018; 22: 325-331 doi:10.1007/s10151-018-1803-4
• 26 Lindholt-Jensen CS, Lindholt JS, Beyer M. et al. Nd-YAG laser treatment of primary and recurrent pilonidal sinus. Lasers Med Sci 2012; 27: 505-508 doi:10.1007/s10103-011-0990-2
• 27 Dessily M, Charara F, Ralea S. et al. Pilonidal sinus destruction with a radial laser probe: technique and first Belgian experience. Acta Chir Belg 2017; 117: 164-168 doi:10.1080/00015458.2016.1272285
• 28 Kayaalp C, Aydin C. Review of phenol treatment in sacrococcygeal pilonidal disease. Tech Coloproctol 2009; 13: 189-193 doi:10.1007/s10151-009-0519-x
• 29 Segre D, Pozzo M, Perinotti R. et al. The treatment of pilonidal disease: guidelines of the Italian Society of Colorectal Surgery (SICCR). Tech Coloproctol 2015; 19: 607-613 doi:10.1007/s10151-015-1369-3
• 30 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;
• 31 Stauffer VK, Luedi MM, Kauf P. et al. Common surgical procedures in pilonidal sinus disease: a meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep 2018; 8: 3058 doi:10.1038/s41598-018-20143-4
• 32 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: 863-872 doi:10.1007/s10151-014-1149-5
• 33 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: 1458-1467 doi:10.1097/01.DCR.0000029764.01110.5C
• 34 Hasse FM, Rademacher C, Bingham K. et al. [The Dufourmentel flap-plasty for treatment of chronic pilonidal sinus]. Chirurg 1998; 69: 663-666
• 35 Prassas D, Rolfs TM, Schumacher FJ. et al. Karydakis flap reconstruction versus Limberg flap transposition for pilonidal sinus disease: a meta-analysis of randomized controlled trials. Langenbecks Arch Surg 2018; 403: 547-554 doi:10.1007/s00423-018-1697-7
• 36 Ersoy E, Devay AO, Aktimur R. et al. Comparison of the short-term results after Limberg and Karydakis procedures for pilonidal disease: randomized prospective analysis of 100 patients. Colorectal Dis 2009; 11: 705-710 doi:10.1111/j.1463-1318.2008.01646.x
• 37 Bascom J, Bascom T. Utility of the cleft lift procedure in refractory pilonidal disease. Am J Surg 2007; 193: 606-609 doi:10.1016/j.amjsurg.2007.01.008
• 38 Senapati A, Cripps NP, Flashman K. et al. Cleft closure for the treatment of pilonidal sinus disease. Colorectal Dis 2011; 13: 333-336 doi:10.1111/j.1463-1318.2009.02148.x
• 39 Biter LU, Beck GM, Mannaerts GH. et al. The use of negative-pressure wound therapy in pilonidal sinus disease: a randomized controlled trial comparing negative-pressure wound therapy versus standard open wound care after surgical excision. Dis Colon Rectum 2014; 57: 1406-1411 doi:10.1097/DCR.0000000000000240
• 40 Ommer A, Pitt C, Albrecht K. et al. [Pilonidal sinus – primary closure also in case of abscess?]. Zentralbl Chir 2004; 129: 216-219 doi:10.1055/s-2004-822742
• 41 Webb PM, Wysocki AP. Does pilonidal abscess heal quicker with off-midline incision and drainage?. Tech Coloproctol 2011; 15: 179-183 doi:10.1007/s10151-011-0684-6
• 42 Lauterbach HH, Konrad U. Zweiphasen-Konzept zur Therapie des infizierten Sinus pilonidalis. chir praxis 1999; 55: 623-628
• 43 Doll D, Matevossian E, Hoenemann C. et al. Incision and drainage preceding definite surgery achieves lower 20-year long-term recurrence rate in 583 primary pilonidal sinus surgery patients. J Dtsch Dermatol Ges 2013; 11: 60-64 doi:10.1111/j.1610-0387.2012.08007.x