Effect of sinus resection combined with vacuum‐assisted closure on sacrococcygeal pilonidal sinus

Abstract

This study was aimed at investigating the effect of sinus removal combined with vacuum‐assisted closure in the treatment of sacrococcygeal pilonidal sinus. From January 2019 to May 2022, 62 patients with sacrococcygeal pilonidal sinus were treated and their information was collected at our hospital. These patients were randomly divided into two groups: an observation group (n = 32) and a control group (n = 30). The control group underwent a simple sinus resection and suture, while the observation group received a sinus resection combined with closed negative pressure drainage of the wound. A retrospective analysis of the data obtained was conducted. Perioperative indicators, clinical efficacy, postoperative pain, complications, aesthetic effects, and satisfaction scores at six months after the operation were compared between the two groups, and the recurrence rate at six months after the operation was recorded. Through this study, we found that the observation group had significantly shorter surgery time, hospital stay, and return time compared with the control group (P < 0.05). Additionally, the observation group had a higher overall recurrence rate (ORR) of 100.00%, which was significantly better than the control group's ORR of 86.67% (P < 0.05). The visual analog scale (VAS) score at 6, 12, and 24 h after the operation was significantly lower in the observation group compared with the control group (P < 0.05). Although the differences were not significant (P > 0.05), the observation group had decreased white blood cell, neutrophil, and C‐reactive protein levels after the operation. Moreover, the total occurrence rate of postoperative complications in the observation group was significantly lower (6.25%) than that of the control group (26.67%; P < 0.05). The observation group also had significantly lower scores on the postoperative scar scale and higher satisfaction scores than the control group (P < 0.05). However, there was no significant difference in the postoperative recurrence rate between the two groups (P > 0.05). Our study demonstrated that sinus resection combined with vacuum‐assisted closure was more effective in treating sacrococcygeal pilonidal sinus compared with simple sinus resection and suture. This approach significantly reduced surgery time, hospital stay, and return time. It also effectively relieved postoperative pain, reduced the occurrence of postoperative complications, resulted in smaller postoperative scars, and yielded better aesthetic outcomes and higher patient satisfaction.

Abbreviations

SPS

sacrococcygeal pilonidal sinus

VAC

vacuum‐assisted closure

1. INTRODUCTION

Pilonidal sinus is a chronic sinus or cyst that causes clinical symptoms such as hair, ulceration and discharge, swelling, and pain in the lesion and is commonly located in the soft tissue of the sacrococcygeal intergluteal fissure. ¹ The disease occurs in young men over the age of 17. ² In China, the incidence of pilonidal sinus is relatively low compared with Europe and the United States, but in recent years, the incidence of the sacrococcygeal pilonidal sinus has been on the rise. Because of the large population base in China, it has drawn more and more attention. The disease is known for its long treatment cycle and high recurrence rate, ³ which seriously affect the quality of patients' life. Some severe cases are even cancerous, which could threaten the patients' life.

At present, the specific pathogenesis of the sacrococcygeal pilonidal sinus is not yet clear. Most studies suggest that the occurrence of the disease is associated with high‐risk factors such as local soft tissue injury, prolonged sitting, hard hair, and long‐term irritation. ⁴ Surgery is currently the main clinical treatment, and the key point is intraoperative manipulation of the surgical lesions. Its surgical procedures are more complex and divided into incision and drainage, pilonidal sinus resection combined with flap transfer, and pilonidal sinus resection combined with negative pressure drainage resection. However, the incidence of complications such as infection, incision dehiscence, and delayed wound healing caused by poor incision drainage after surgical treatment is high. ⁵

Negative pressure drainage techniques have been found to stimulate granulation tissue growth, reduce edema and wound contamination, and accelerate wound healing. ⁶ Currently, there are limited clinical studies on the effectiveness of sinus resection combined with vacuum‐assisted closure in the treatment of sacrococcygeal pilonidal sinus. In this study, we investigated the application value of sinus resection combined with closed negative pressure drainage of the wound surface in 62 patients with sacrococcygeal pilonidal sinus. Our findings provide valuable insights for clinical therapy.

2. MATERIALS AND METHODS

2.1. Clinical data

Statistics of 62 patients with sacrococcygeal pilonidal sinus treated in our hospital from January 2019 to May 2022 were retrospectively analysed. The observation group comprised 27 males and 5 females, with ages ranging from 21 to 49 years and a mean age of (35.89 ± 2.85) years. The disease duration ranged from 13 to 34 months, with a mean of (21.52 ± 1.89) months, and the mean body mass index was (22.39 ± 2.84) kg/m2. The control group comprised 26 males and 4 females, with ages ranging from 25 to 48 years and a mean age of (35.67 ± 2.94) years. The disease duration ranged from 15 to 36 months, with a mean of (21.48 ± 1.93) months, and the mean body mass index was (22.15 ± 2.94) kg/m2. No significant differences were observed in general data between the two groups (P > 0.05).

2.2. Inclusion and exclusion criteria

1. Inclusion criteria: Patients diagnosed with sacrococcygeal pilonidal sinus through physical and imaging examination, with recurrent sacrococcygeal pain accompanied by purulent sinus or mass, meeting the American College of Colorectal Physicians guidelines for the clinical management of pilonidal sinuses ⁷ ; aged between 18 and 70 years; patients who were considered suitable for surgical treatment and could tolerate the surgical procedure.; and patients with complete clinical data.

2. Exclusion criteria: Patients with acute suppurative infection; patients with severe primary systemic diseases such as circulatory system, endocrine system, blood system, and respiratory system; patients without obvious surgical indications and poor compliance; patients with sacrococcygeal and spinal cord diseases; patients who have been taking glucocorticoids for a long time; and patients with incomplete clinical data. A total of 62 patients were divided into two groups based on the surgical methods used: the observation group (n = 32) and the control group (n = 30).

2.3. Materials

Vacuum‐assisted closure (VAC) was from KCI USA, Inc.

2.4. Methods

All patients completed blood routine, urine routine, imaging examination, and other relevant examinations before surgery to identify the extent of surgery. The extent of surgery included complete resection of the lesion tissue including the sinus and midline fovea. On the day of surgery, the patient was asked to defecate and routinely abstain from drinking and fasting, and antibiotics were applied 3 days before the operation.

Subjects in the observation group were treated with sinus resection combined with vacuum‐assisted closure of the wound. After the patient had successful general anaesthesia, the jackknifing position was taken, the anal canal was routinely disinfected, and the sacrococcygeal region and gluteal sulcus were fixed and exposed. Methylene blue solution was injected into the sinus of the lesion, and a longitudinal rhomboid incision was made centered on the stained area. The pilonidal sinus tissue and surrounding normal tissue were then sharply dissected using an electrocautery knife until the deep fascial layer. After the incision, if there was methylene blue exudation, the surgical incision was extended, and after complete resection of all lesions of the sacrococcygeal pilonidal sinus and surrounding inflammatory tissue along the superficial layer of the deep fascia, the pilonidal sinus was completely removed. After adequate haemostasis with electrocautery or suturing, hydrogen peroxide, iodophor, and normal saline were used to irrigate the sacrococcygeal wound in proper order. Then according to the specific defect, we chose proper operative schemes to repair the wound. Actually, if the defect was in moderate size, the direct suture was applied. However, when the defect created by surgical extirpation was too large to close, we next designed a local flap to cover it. Usually, drainage catheters were placed within the cavity. Certainly, reliable haemostasis was confirmed before covering the wound. Under the condition of definite haemostasis, the negative pressure drainage materials in the vacuum‐assisted closure vacuum sealing drainage device (produced by KCI, USA) were used to cover the surgery area according to the wound size. Fix the sucker on the sponge surface, seal the biological semipermeable membrane externally, and use the sterile biological semipermeable membrane to closely fit the material and wound surface. Membrane collapse and material shrinkage were observed after negative pressure was connected, and continuous negative pressure sealing drainage was performed at a pressure of 50 to 100 mmHg. At the end of the surgery, local compression bandaging was performed, and the specimen was sent for pathology. Postoperatively, the patient was placed in the prone position, fasted, and rehydrated, antibiotics were applied for 3 days, and the patient was changed to a dregs‐free diet after defecation. Control the appropriate room temperature to avoid sweating, and closely observe the airtightness of the adhesive film, the amount and character of drainage fluid, and the skin around the adhesive film. The wound drainage tube was detached when the wound drainage volume was <2 mL/d. The negative pressure drainage device was removed 1 week after the operation, and bandage compression was used till removing the suture. The sacrococcygeal region was told to depilate every 2 weeks using a razor or depilatory cream to avoid sedentary and local friction and to refrain from strenuous activity for at least 3 months at the time of discharge.

Subjects in the control group were administrated with simple resection and suture of the sinus. Following successful general anaesthesia, the jackknife position was taken and then all external orifices were included and a longitudinal fusiform incision centered on this. Methylene blue solution was injected into the external orifice of the sinus before surgery, and the depth and direction of the sinus were observed using a probe to roughly assess the extent of surgical resection. A longitudinal incision was made centered on the lesion, and the skin and subcutaneous tissue were incised and freed to the sacral fascia. After complete resection of the lesion tissue, the wound was carefully examined for oozing, and repeated irrigation was performed using iodophor and normal saline. Intermittent suture of subcutaneous tissue, skin, skin mattress suture, try not to leave dead space, incision gauze compression bandaging fixation. Postoperative diet, anti‐infection, dressing change, suture removal, and other treatment measures were the same as the observation group. Patients in both groups came to our clinic for follow‐up at 1, 3, and 6 months after discharge, and relevant parameters were assessed.

2.5. Outcome measures

1. Perioperative‐related indexes: The operation time, hospital stay, and return time were documented and contrasted between the two groups.

2. Clinical efficacy: According to the relevant literatures, ⁸ the clinical efficacy evaluation criteria were established, and the patients were cured: the local edema disappeared after the operation, no subcutaneous thrombosis occurred, no wound infection occurred, and the sacrococcygeal distension and pain sensation disappeared; Effective: the patient had significantly reduced local edema, subcutaneous dark purple decreased, a small amount of wound secretion, no infection, and the patient's sacrococcygeal distension and pain were significantly relieved; Ineffective: the patient had no significant improvement in clinical symptoms and signs after the operation, and still needed to receive corresponding treatment. Clinical total effective rate = (recovered cases + effective cases)/total cases >100%.

3. Postoperative pain: Visual analogue scale (VAS) was used to evaluate the pain at 6, 12, and 24 h after the operation in both groups. The score ranges from 0 to 10, with higher scores indicating more significant pain.

4. Laboratory parameters: Peripheral venous blood samples were collected before and after the operation to detect white blood cell count (WBC), neutrophil percentage (NEUT%), and C‐reactive protein (CRP) levels.

5. Postoperative complications: The incidence of complications such as postoperative bleeding, infection, and dehiscence was recorded in the two groups.

6. Cosmetic effect and satisfaction: Vancouver Scar Scale and the self‐made satisfaction scale of our hospital were used to evaluate the cosmetic effect and patient satisfaction at 6 months after operation in the two groups, respectively. The score on the Vancouver Scar Scale ranged from 0 to 15 points, and the higher the score, the more severe the scar; the score on the self‐made satisfaction scale in our hospital ranged from 0 to 10 points, and the higher the score, the more satisfactory the patient.

7. Recurrence rate: The recurrence rate at 6 months after the operation was recorded in both groups.

2.6. Statistical analysis

SPSS 25.0 was used to evaluate and process the obtained data. The measurement data with the normal distribution were stated as $\overline{x}\pm s$ and compared with the t‐test; the enumeration data were expressed as n(%) and the chi‐square test was used for the comparison between the two groups. P < 0.05 was recognised as statistically significant.

3. RESULTS

3.1. Comparison of perioperative‐related indicators

As shown in Table 1, the operation time, hospital stay, and return time in the observation group were noticeably diminished compared with the control group (P < 0.05).

TABLE 1.

Comparison of perioperative‐related markers $\left(\overline{x}\pm s\right)$ between the two groups.

Group	n	Operation time(min)	Hospital stay(d)	Return time(d)
Observation group	32	46.89 ± 6.52	19.25 ± 2.33	21.25 ± 2.28
Control group	30	58.71 ± 7.64	21.89 ± 2.57	23.81 ± 2.46
t		6.566	2.242	4.253
P		0.000	0.000	0.000

3.2. Comparison of clinical efficiency

As shown in Table 2, the efficiency ratio in the observation group was drastically increased compared with that in the control group (86.67%, P < 0.05).

TABLE 2.

Comparison of clinical efficacy between the two groups (n [%]).

Group	n	Recovered	Effective	Ineffective	Total effective rate
Observation group	32	30(93.75)	2(6.25)	0(0.00)	32(100.00)
Control group	30	23(76.67)	3(10.00)	4(13.33)	26(86.67)
χ2					4.561
P					0.033

3.3. Comparison of VAS scores at a dissimilar time after the operation

As exhibited in Table 3, the VAS at 6, 12, and 24 h after surgery in the observation group was considerably decreased compared with that in the control group (P < 0.05).

TABLE 3.

Comparison of VAS score at diverse times after operation between the two groups (Scores $\overline{x}\pm s$).

Group	n	6 h after surgery	12 h after surgery	24 h after surgery
Observation group	32	4.55 ± 0.88	5.23 ± 0.65	3.65 ± 0.27
Control group	30	5.12 ± 0.74	6.17 ± 0.58	4.29 ± 0.36
t		2.751	5.993	7.952
P		0.008	0.000	0.000

3.4. Comparison of laboratory index pre‐ and post‐surgery

There was no significant difference in WBC, NEUT, and CRP levels before surgery between the two groups (P > 0.05). The WBC, NEUT, and CRP levels in the observation group increased after the operation (P > 0.05). In the control group, the levels of WBC, NEUT, and CRP after the operation were significantly higher than those before surgery (P < 0.05). The WBC, NEUT, and CRP levels in the observation group decreased after the operation, but the difference was not statistically significant (P > 0.05), as shown in Table 4.

TABLE 4.

Comparison of laboratory index levels before and after operation between the two groups ($\overline{x}\pm s$).

Group	n	WBC(×109/L)		NEUT(%)		CRP(mg/L)
		Before	After	Before	After	Before	After
Observation group	32	6.54 ± 0.58	6.68 ± 0.69	59.56 ± 12.58	60.42 ± 10.54	6.33 ± 0.39	6.89 ± 0.48
Control group	30	6.29 ± 0.67	7.01 ± 0.85*	59.23 ± 13.09	63.44 ± 10.79*	6.19 ± 0.42	7.08 ± 0.63*
t		1.574	1.683	0.101	1.115	1.361	3.41
P		0.121	0.098	0.920	0.269	0.179	0.185

Note: Compared with the same group before surgery.

^* P < 0.05.

3.5. Comparison of postoperative complications

As shown in Table 5, the occurrence ratio of postoperative complications in the observation group (6.25%) was drastically lower than that in the control group (P < 0.05), which was 26.67%.

TABLE 5.

Comparison of postoperative complications between the two groups (n [%]).

Group	n	Haemorrhage	Infected	Dehiscence	Total Occurrence
Observation group	32	2(6.25)	0(0.00)	0(0.00)	2(6.25)
Control group	30	3(10.00)	2(6.67)	3(10.00)	8(26.67)
χ2					4.771
P					0.030

3.6. Comparison of postoperative scar scale and patient satisfaction score between the two groups

As shown in Table 6, the score of the postoperative scar scale in the observation group was significantly lower than that in the control group, and the score of patient satisfaction in the observation group was significantly higher than that in the control group (P < 0.05).

TABLE 6.

Comparison of postoperative scar scale and patient satisfaction score between the two groups (Scores $\overline{x}\pm s$).

Group	n	Scar scale score	Satisfaction score
Observation group	32	5.34 ± 1.23	6.94 ± 0.63
Control group	30	6.39 ± 1.08	5.27 ± 0.84
t		3.562	8.892
P		0.001	0.000

3.7. Comparison of recurrence rate between the two groups

No recurrence was observed in the observation group 6 months after surgery, whereas two cases (6.67%) recurred in the control group after 6 months. However, the difference in the postoperative recurrence rate between the two groups was not statistically significant (P > 0.05).

3.8. Representative cases

Here we present two typical cases to demonstrate the effectiveness of sinus resection combined with vacuum‐assisted closure for pilonidal sinus, as shown in Figures 1 and 2 below. We have observed good clinical outcomes with this approach.

FIGURE 1.

A 43‐year‐old male patient who had pilonidal sinus. Because of the wide defect after lesion removal, we performed local skin flap surgery to repair the wound. VAC device was removed five days after the operation, and the patient had a good recovery.

FIGURE 2.

A 22‐year‐old male patient who had pilonidal sinus. Methylene blue was injected into the lacuna during the operation to mark and completely remove the lesion. Because the defect was small in size, direct suturing was used, and the prognosis was good.

4. DISCUSSION

Pilonidal sinus was first described by Mayo in 1833, but its specific pathogenesis of pilonidal sinus is still unknown. ⁹ The main pathogenesis of pilonidal sinus can be divided into two theories: congenital and acquired theory. According to the congenital theory, congenital remnants of the epithelium or congenital depressions of the epidermis are the root causes of the disease. Its internal hair is thought to be caused by the invagination of the epithelial hair follicle, leading to the generation of chronic sinus because of infection and other factors. ¹⁰ Based on the aetiology of SPS explained by the theories above, it has also been concluded that SPS has an acquired aetiology. ¹¹ The acquired theory suggests that the main cause of pilonidal sinus disease is the swing and friction of the gluteal sulcus during movement. Harder hairs in the gluteal fissure are then pricked into the adjacent or contralateral skin and small channels are generated within the skin at the insertion site. At this point, the hair base has not detached from the original skin, and dermoid metaplasia continues to occur in the small channels. As the hair detaches from the root, suction generated within the cuticularized fine channel sucks into the channel, which leads to sinus formation. ¹² , ¹³ In recent years, the acquired theory has been mostly recognised, suggesting that the cause of pilonidal sinus lies in hard hair, skin injury, hair suction by the skin and other factors. ¹⁴ However, factors such as local soft tissue injury, prolonged sitting, hair hardness, and local long‐term irritation are all high‐risk factors for the disease.

There are already lots of studies focusing on SPS, and its ideal treatment is controversial. ¹⁵ Surgery is still the main way to treat pilonidal sinus. ¹⁶ According to relevant diagnosis and treatment guidelines, the surgical methods of pilonidal sinus are mainly divided into incision and drainage, pilonidal sinus resection combined with incision suture, pilonidal sinus resection combined with flap transfer, pilonidal sinus resection combined with negative pressure drainage. ¹⁷ , ¹⁸ With the development of technology, endoscopic approaches have also achieved some amazing results. ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵

Each surgical approach has its own obvious advantages and disadvantages. The optimal surgical approach remains controversial. ²⁶ Traditional incision and drainage are mainly indicated for patients with severe acute infection. Pilonidal sinus resection combined with incision suture has the characteristics of a short healing time and less local scar. ²⁷ However, there is a greater probability of wound dehiscence following surgery. Once incision dehiscence occurs after the operation, it will affect the wound healing time and postoperative recovery of patients, so it is only suitable for patients with a small lesion range, shallow sinus, and cyst, small incision tension after sinus resection, and mild infection. ²⁸ Pilonidal sinus resection combined with flap transfer can remove the diseased tissue of patients to the greatest extent, and then greatly reduce the tension of incision suture through flap transplantation. However, there are high requirements for flap design and operator operation level. If the flap design is not ideal, it may lead to an increased incidence of complications such as postoperative incision dehiscence, infection, and flap necrosis in patients. ²⁹ , ³⁰

As an emerging technology, vacuum drainage plays a unique advantage in promoting wound healing. Previous studies ³¹ , ³² have pointed out that the mechanism of the wound‐closed negative pressure drainage to promote wound healing is mainly divided into (1) Inhibition of bacterial multiplication. The results of animal experiments showed that the number of bacteria, especially gram‐negative bacteria, could be significantly reduced by closed negative pressure drainage； (2) Promote blood circulation. Blood supply and circulation of wound surface are important factors affecting wound healing; The wound‐closed negative pressure drainage can effectively dilate the blood flow velocity of wound microcirculation, and dilate microvessels, thereby increasing wound blood flow and accelerating wound healing; (3) Relieve edema. Tissue edema hinders the exchange of substances between cells and compresses microcirculatory vessels, resulting in insufficient blood supply to the wound and hindering wound healing. The wound closed negative pressure drainage can significantly reduce tissue edema, thereby accelerating wound healing; (4) Traction effect. The negative pressure formed by closed negative pressure drainage can produce mechanical traction force on the wound surface, then promote the reproduction of tissue cells and promote the expression of related cell growth factors, thereby increasing the proliferation of wound repair cells and angiogenesis and accelerating wound repair.

Some studies ³³ have found that postoperative drainage was not smooth, and infection caused by dead space left after removal of the drainage tube is an important factor to increase the occurrence of postoperative complications and affect the postoperative recovery of patients. Therefore, how to improve the patency rate of postoperative drainage and reduce the incidence of postoperative infection is of great significance. In this study, sinus resection combined with closed negative pressure drainage of the wound was used in the treatment of patients with sacrococcygeal pilonidal sinus. The results showed that compared with the control group, the overall clinical response rate in the observation group was significantly higher; the operation time, hospital stay, and return time were significantly shorter. This suggests that sinus resection combined with wound‐closed negative pressure drainage is more effective in the treatment of sacrococcygeal pilonidal sinus than simple sinus resection and suture, which can effectively shorten the operation time, hospital stay, and return time of patients. VAS score is an important scale for the clinical evaluation of postoperative pain, which has the characteristics of accuracy, simplicity, and high sensitivity. In the results of this study, the VAS score at 6, 12, and 24 h post‐surgery in the observation group was significantly lower than that in the control group, and the difference had statistical significance. This suggests that sinus resection combined with wound‐closed negative pressure drainage in the treatment of patients with sacrococcygeal pilonidal sinus can effectively relieve postoperative pain. Meanwhile, WBC, NEUT, and CRP levels in the observation group were markedly reduced compared with the control group after surgery.

The comparison of postoperative recurrence rate between the two groups showed no significant difference (P > 0.05), which might be connected to factors such as the small sample size included in our study. In the results of this study, the occurrence ratio of postoperative complications in the observation group was 6.25%, markedly lower than the 26.67% in the control group. This suggests that sinus resection combined with wound‐closed negative pressure drainage in the treatment of sacrococcygeal pilonidal sinus can efficiently decrease the occurrence of postoperative complications compared with simple sinus resection and suture. The score on the postoperative scar scale in the observation group was significantly better than that in the control group, while the score of patient satisfaction was greatly higher (P < 0.05). This suggests that sinus resection combined with wound‐closed negative pressure drainage is more easily accepted by patients with sacrococcygeal pilonidal sinus than simple sinus resection and suture. It is characterised by small postoperative scars, good aesthetic results, and higher patient satisfaction.

In summary, sinus resection combined with closed negative pressure drainage of the wound is more effective in the treatment of sacrococcygeal pilonidal sinus than simple sinus resection and suture. It can effectively shorten the operation time, hospital stay, and return time of patients, relieve postoperative pain, reduce the incidence of postoperative complications, and result in small postoperative scars, good aesthetic effects, and higher patient satisfaction.

AUTHOR CONTRIBUTIONS

All the authors in this research collaborated to complete the work together. Ke Li designed the study and analysed the data. Xiaoyu Zhao, Shuwen Fan, and Guoliang Shen collected related cases and recorded the patients’ information, and carried out statistics processing. Jun Xu and Zhaojun Fan applied follow‐up for patients and dealt with the electronic tables. Xiao Liu wrote the manuscript, reviewed, and edited it. Finally, all the authors read through the manuscript and marked it up with objections, and then approved the final manuscript. All the authors approved the final version of the manuscript for submission.

FUNDING INFORMATION

This study is supported by the Suzhou Science and Technology Plan Projects (SYS2020105).

CONFLICT OF INTEREST STATEMENT

All authors declare that there are no conflicts of interest.

Liu X, Zhao X, Shen G, et al. Effect of sinus resection combined with vacuum‐assisted closure on sacrococcygeal pilonidal sinus. Int Wound J. 2023;20(9):3474‐3482. doi: 10.1111/iwj.14218

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.