Early postoperative outcomes of sinus laser closure versus crystallized phenol treatment for pilonidal sinus disease: a retrospective comparative study

Abstract

Background

Pilonidal sinus disease (PSD), which predominantly affects young adults, has increasingly been managed with minimally invasive techniques aimed at reducing postoperative pain, accelerating recovery, and minimizing work absenteeism. This study aimed to compare the early term outcomes of patients treated with crystallized phenol treatment (CPT) or sinus laser closure (SiLaC) for PSD.

Methods

We retrospectively analyzed a prospectively maintained cohort at a tertiary center between January 2023 and August 2024. Patients with PSD undergoing SiLaC or CPT with scheduled 1-week and 1-month follow-up assessments were included. The primary outcomes were patient satisfaction, health-related quality of life (SF-36), symptom severity (itching, burning, purulent discharge), pain intensity (Visual Analogue Scale), and time to return to work, all assessed at 1 week and 1 month postoperatively. Secondary outcomes included pit orifice closure rates and perioperative complications.

Results

A total of 230 patients were analyzed (SiLaC n = 93; CPT n = 137), with comparable baseline characteristics. At 1 week, itching (1 [1–1] versus 1 [1–2], p < 0.001), burning (1 [1–1] versus 1 [1–2], p = 0.001), and purulent discharge (1 [1–1] versus 1 [1–3], p < 0.001) were less frequent in the SiLaC group. Pain scores were also lower in the SiLaC group (VAS: 0 [0–1] versus 0 [0–5], p = 0.034). SF-36 scores were significantly higher in the SiLaC group for physical functioning (100 [90–100] versus 95 [85–100], p < 0.001), physical role limitation (100 [100–100] versus 100 [75–100], p = 0.005), social functioning (100 [87.5–100] versus 87.5 [62.5–100], p < 0.001), and pain (100 [67.5–100] versus 90 [67.5–100], p = 0.008). Return to daily activities was shorter in the SiLaC group (0 [0–0] versus 0 [0–1] days, p < 0.001). At 1 month, most outcomes were comparable between groups, although purulent discharge remained higher in the CPT group (1 [1–2] versus 1 [1–1], p = 0.045). Complication rates were low and similar between groups (9.6% versus 12.4%, p = 0.489).

Conclusions

The SiLaC method was associated with more favorable quality of life (QoL) outcomes compared with CPT during the first postoperative week. Subgroup analyses suggested that SiLaC may offer advantages in certain clinical scenarios. Further multicenter randomized controlled trials are warranted to better clarify and validate these findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-026-03345-1.

Introduction

Pilonidal sinus disease (PSD) is a clinical condition characterized by recurrent inflammation, pain, and discharge in the presacral region that predominantly affects the young male population [1]. With the increasing rates of sedentary lifestyles and obesity, the incidence of PSD has reached 39 per 100,000 in Northern Europe today, while its prevalence in Turkey has risen to as high as 7% among young, healthy populations [2, 3]. Although traditional excisional methods have been preferred for the treatment of this disease, the reported high recurrence rates with prolonged follow-up, along with extended healing times, high rates of wound site complications, prolonged treatment durations, and thus increased loss of workforce, have made minimally invasive methods particularly popular after the 2000s [4, 5].

The most widely used among the minimally invasive methods are crystallized phenol treatment (CPT) and sinus laser closure (SiLaC), with SiLaC gaining significant attention in surgical practice over the past decade due to its high success rates [6]. Both approaches allow for same-day treatment, faster recovery times, and fewer complications. However, comparative studies, particularly those assessing quality of life (QoL) between the two, remain scarce [7]. Moreover, PSD is not a single entity, and multiple classification methods have been proposed to categorize the disease [8]. A contemporary disease scoring system that also analyzes the characterization of study groups provides the opportunity to reveal more comprehensive results [9].

In light of these considerations, this study aimed to compare the early term outcomes of patients treated with CPT or SiLaC for PSD, with a particular focus on early postoperative patient satisfaction, health-related QoL, and symptom burden.

Patients and methods

Patients with PSD who visited the proctology outpatient clinic of the General Surgery Department at the University of Health Sciences Ümraniye Training and Research Hospital from January 2023 to August 2024 were retrospectively analyzed. Patients with PSD who completed regular follow-up outpatient clinic visits at the end of the first week and first month and accepted CPT or SiLaC treatment were included in the study. All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki. This study was approved by the Institutional Ethics Committee of Tekirdağ Namık Kemal University (approval number: 2025.148.07.18) and was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Patients with a diagnosis of hidradenitis suppurativa, inflammatory bowel disease, suspected malignancy, those who did not attend follow-ups within the specified time interval, and those under 17 years of age were excluded from the study. In cases presenting with acute infection or abscess formation, initial debridement and antibiotic therapy were administered. Definitive treatment with either CPT or SiLaC was performed only after clinical resolution of the acute inflammatory process, typically at the end of the second week. Treatment allocation was not based on disease characteristics, including sinus size, number, or extent. The choice between SiLaC and CPT was determined solely by the availability of the laser device at the time of intervention. When the laser device was available, SiLaC was performed; when unavailable, CPT was applied. No additional clinical or anatomical criteria were used to guide treatment selection. Consequently, disease extent or size did not influence treatment allocation, and any observed differences between groups reflected real-world practice rather than intentional selection bias.

The study was conducted following an intention-to-treat protocol. Accordingly, patients were treated by colorectal surgeons, other specialist general surgeons, and surgical residents under supervision, reflecting routine clinical practice. Not all procedures were performed by expert colorectal surgeons, and operator experience varied, which was considered an inherent and intentional aspect of the study design. Follow-ups were carried out in the proctology outpatient clinic.

Data collection

Demographic data including age, sex, and body mass index (BMI) were recorded for all patients. The total symptom score (TSS), which consists of itching, burning, and purulent discharge scores; the Visual Analogue Scale (VAS) scores for pain; Short Form-36 (SF-36) scores; time to return to work; rates of complete recovery (CR); rates of pit orifice closure (PoC); and complications were recorded. Patients were stratified using a novel pilonidal sinus scoring system recently developed by Awad et al. [9], which evaluates sex, degree of hirsutism, overweight status (BMI > 25), number and location of sinuses, sinus width, recurrence status, and duration of preoperative symptoms. By scoring each element, a Total Preoperative Score (TPS) was calculated to assess baseline disease severity and group comparability. Subgroup analyses were performed on the basis of these stratifications to reevaluate both preoperative and postoperative TSS components. Data were collected in the prospective database of the relevant clinic and analyzed retrospectively.

Surgical technique

Hair removal using a depilatory cream was a prerequisite for surgery, and all patients underwent standardized preoperative local hygiene of the lumbosacral and intergluteal regions before being positioned prone on the procedure table in the outpatient clinic. Following local anesthesia, a 0.5-cm incision was made to access the sinus tract, with hair follicles and debris extracted using a curette and a clamp. The cavity and tracts were redebrided with a povidone-iodine-soaked gauze, followed by irrigation with sterile saline solution.

In the SiLaC group, the NeoV V1470 Diode Laser (neoLaser Ltd, Caesarea, Israel) with a 2-mm probe was then applied at a withdrawal rate of 1 mm per second inside the cavity. For the CPT group, nitrofurantoin ointment (Furacin, Eczacıbaşı Pharmaceutical Co., Istanbul, Turkey) was applied topically before introducing crystallized phenol into the cavity, which was then compressed for 8 min.

Post-procedure dressings were applied, and patients were discharged with analgesics. Dressings were removed after 24 h, after which patients were permitted to shower. No additional recommendations were provided beyond maintaining local hygiene and covering the wound with sterile gauzes.

Patient care and outcome measures

Patients were evaluated at 1-week and 1-month follow-up appointments. The primary outcomes of the study were patient satisfaction, health-related QoL, symptom severity, pain intensity, and time to return to work. Secondary outcomes included PoC rates and perioperative complications. Health-related QoL was assessed using the SF-36 questionnaire [10], which evaluates eight health domains with scores ranging from 0 (worst health status) to 100 (best health status). Symptom severity was measured using the TSS, which consists of three patient-reported domains—itching, burning, and purulent discharge—each scored from 1 (never) to 5 (always), yielding a total score ranging from 3 to 15. Pain intensity was assessed using the VAS [11], ranging from 0 (no pain) to 10 (worst imaginable pain). Patient satisfaction was evaluated at the 1-month follow-up by asking whether patients would recommend the procedure to others and whether they would choose to undergo the same treatment again if necessary. Time to return to work or normal daily activities was recorded in days. CR was defined as complete cessation of symptoms with epithelialization of sinus openings. PoC was defined as macroscopic closure of external sinus openings on clinical examination. Perioperative complications were categorized as wound site infection, abscess formation, or seroma accumulation. Wound site infection was defined as superficial inflammatory changes at the surgical site (e.g., erythema, tenderness, or exfoliation) managed with local wound care and antibiotics. Abscess formation was defined as a localized purulent fluid collection requiring drainage followed by antibiotic treatment.

Statistical analysis

Categorical variables were expressed as frequencies and percentages and were compared using the Pearson chi-squared test. Continuous variables were first assessed for normality using the Shapiro–Wilk test. As none of the continuous variables followed a normal distribution, they were expressed as median (25th–75th percentiles) and compared between groups using the Mann–Whitney U test. Statistical analyses were performed using SPSS version 29 (IBM Corp., Armonk, NY, USA). All tests were two-sided, and a p value of < 0.05 was considered statistically significant. Missing data were handled as follows. Patients who did not attend the predefined 1-week or 1-month follow-up visits, or who did not fully complete the patient-reported outcome measures (SF-36, VAS, and TSS), were considered lost to follow-up and excluded from the outcome analyses, as illustrated in the study flowchart (Fig. 1). Baseline demographic and clinical variables were complete for all included patients. No imputation methods were applied. All analyses were therefore conducted using complete-case data for each outcome.

Fig. 1.

Flow chart

Results

Basic characteristics of patients

During the study period, 320 patients with PSD were assessed for eligibility; 38 patients were excluded according to predefined criteria, and of the remaining patients, 111 were assigned to the SiLaC group and 171 to the CPT group. Overall, 52 patients were lost to follow-up (Fig. 1). The final analysis included 230 patients, comprising 93 in the SiLaC group and 137 in the CPT group. The median age was 28 years (24–32 years), and 77.8% of patients were male. More than half of the cohort (51.7%) had multiple sinus openings, while 67.4% had midline disease. A total of 140 patients (60.9%) reported symptoms lasting at least 6 months, and 59.6% of cases were recurrent. The median TPS was 12 (11–14), and the median preoperative TSS was 6 (3–8). Baseline demographic and clinical characteristics were largely comparable between groups (Table 1). Although a higher proportion of patients in the CPT group had sinus widths greater than 5 mm compared with the SiLaC group (94.9% versus 87.1%, p = 0.035), overall disease severity, as reflected by the TPS, was similar between groups.

Table. 1.

Baseline characteristics of patients

Variable	Total study population (N = 230) (%), median (25–75% IQR)	SiLaC group (N = 93) (%), median (25–75% IQR)	CPT group (N = 137) (%), median (25–75% IQR)	p-Value
Age	28 (24–32)	28 (24–32)	27 (23–33)	0.804
Sex (male)	179 (77.8%)	76 (81.7%)	103 (75.2%)	0.241
Body mass index (kg/m2)	25.1 (23.7–27.6)	25 (22.9–27.8)	25 (24.3–26.7)	0.678
Preoperative itching	1 (1–2)	1 (1–2)	1 (1–2)	0.697
Preoperative burning	2 (1–3)	2 (1–3)	1 (1–3)	0.332
Preoperative purulent discharge	2 (1–2)	2 (1–2)	2 (1–2)	0.906
Hirsute type
Faint hair with free texture	109 (47.4%)	40 (43%)	69 (50.4%)	0.273
Hairy coarse with hard texture	121 (52.6%)	53 (57%)	68 (49.6%)
Overweight	154 (67%)	58 (62.4%)	96 (70.1%)	0.223
Presence of multiple sinuses	119 (51.7%)	41 (44.1%)	78 (56.9%)	0.056
Site of the sinus (midline)	155 (67.4%)	66 (71%)	89 (65%)	0.340
Width of the sinus (> 5 mm)	211 (91.7%)	81 (87.1%)	130 (94.9%)	0.035
Duration of symptoms (> 6 months)	140 (60.9%)	55 (59.1%)	85 (62%)	0.658
Recurrent cases	137 (59.6%)	55 (59.1%)	82 (59.9%)	0.914
Total preoperative score	12 (11–14)	14 (12–15)	14 (12–15)	0.687
Total preoperative symptom score	6 (3–8)	5 (4–6.5)	6 (3–10)	0.206
Preoperative visual analogue scale scores	1 (1–3)	2 (0–2)	1 (1–4)	0.724

Primary endpoints

At the first postoperative week, symptoms of itching, burning, and purulent discharge were significantly more frequent in the CPT group compared with the SiLaC group (p < 0.001, p = 0.001, and p < 0.001, respectively). Pain intensity assessed by the VAS and overall symptom burden measured by the TSS were significantly higher in the CPT group (p = 0.034 and p < 0.001, respectively) (Figs. 2 and 3). Patients treated with SiLaC demonstrated significantly higher health-related QoL outcomes, with higher SF-36 scores in physical functioning, physical role limitation, social functioning, and pain domains (p < 0.001, p = 0.005, p < 0.001, and p = 0.008, respectively).

Fig. 2.

Pain intensity (VAS) before and after treatment

Fig. 3.

Symptom burden (TSS) before and after treatment

At the 1-month follow-up, most symptom- and QoL-related outcomes were comparable between groups, although purulent discharge remained more frequent in the CPT group (p = 0.045). Overall, patient satisfaction was high in both treatment arms: by the end of the first month, 87 patients (93.5%) in the SiLaC group and 126 patients (91.9%) in the CPT group reported that they would both repeat the procedure if needed and recommend it to others, with no significant difference between groups (p = 0.908). Primary outcome measures are summarized in detail in Table 2.

Table. 2.

Comparison of SiLaC and CPT groups in terms of primary outcome measures

Variable	SiLaC group (N = 93) (%), median (25–75% IQR)	CPT group (N = 137) (%), median (25–75% IQR)	p-Value
First week
Itching	1 (1–1)	1 (1–2)	< 0.001
Burning	1 (1–1)	1 (1–2)	0.001
Purulent discharge	1 (1–1)	1 (1–3)	< 0.001
Total symptom score	3 (3–3)	4 (3–6)	< 0.001
Visual analogue scale scores	0 (0–1)	0 (0–5)	0.034
SF-36 Physical functioning (%)	100 (90–100)	95 (85–100)	< 0.001
SF-36 Physical role limitation (%)	100 (100–100)	100 (75–100)	0.005
SF-36 Emotional role limitation (%)	100 (100–100)	100 (100–100)	0.785
SF-36 Energy/fatigue (%)	50 (40–95)	75 (45–95)	0.778
SF-36 Emotional well-being (%)	80 (56–92)	80 (72–80)	0.364
SF-36 Social functioning (%)	100 (87.5–100)	87.5 (62.5–100)	< 0.001
SF-36 Pain (%)	100 (67.5–100)	90 (67.5–100)	0.008
SF-36 General health (%)	80 (40–95)	80 (45–95)	0.186
Return to work/daily physical activities (day)	0 (0–0)	0 (0–1)	< 0.001
First month
Itching	1 (1–1)	1 (1–1)	0.248
Burning	1 (1–1)	1 (1–1)	0.157
Purulent discharge	1 (1–1)	1 (1–2)	0.045
Total symptom score	3 (3–3)	3 (3–4)	0.079
Visual analogue scale scores	0 (0–0.5)	0 (0–1)	0.141
SF-36 Physical functioning (%)	100 (100–100)	100 (100–100)	0.298
SF-36 Physical role limitation (%)	100 (100–100)	100 (100–100)	0.517
SF-36 Emotional role limitation (%)	100 (100–100)	100 (100–100)	0.051
SF-36 Energy/fatigue (%)	95 (65–100)	100 (50–100)	0.550
SF-36 Emotional well-being (%)	100 (80–100)	100 (72–100)	0.147
SF-36 Social functioning (%)	100 (100–100)	100 (100–100)	0.830
SF-36 Pain (%)	90 (70–100)	90 (70–100)	0.966
SF-36 General health (%)	90 (80–100)	80 (80–90)	0.083

Secondary endpoints

At the first postoperative week, a statistically significantly higher proportion of patients in the SiLaC group achieved PoC compared with the CPT group (p < 0.001). At the 1-month follow-up, PoC rates remained numerically higher in the SiLaC group; however, this difference was no longer statistically significant. Overall, perioperative complications occurred in 9 patients (9.6%) in the SiLaC group and 17 patients (12.4%) in the CPT group. In the SiLaC group, wound site infection was observed in five patients (5.3%), abscess formation in two patients (2.2%), and seroma secondary to early epithelialization in two patients (2.2%). In the CPT group, 11 patients (8.0%) developed skin exfoliation due to phenol contact, while 6 patients (4.4%) developed abscesses. The overall complication rates did not differ significantly between the SiLaC and CPT groups (9.6% versus 12.4%, p = 0.489). All abscesses were managed by drainage, areas of early epithelialization were excised, and antibiotic therapy was administered. All perioperative complications were managed effectively on an outpatient basis with minimal intervention and did not require hospital readmission. Secondary outcome measures are summarized in detail in Table 3.

Table-3.

Comparison of SiLaC and CPT groups in terms of secondary outcome measures

Variable	SiLaC group (%), median (25–75% IQR)	CPT group (%), median (25–75% IQR)	p-Value
Overall complication rates	9 (9.6%)	17 (12.4%)	0.489
First week
Pit orifice closure	61 (65.6%)	39 (28.5%)	< 0.001
First month
Pit orifice closure	71 (76.3%)	92 (67.2%)	0.132
Complete recovery	70 (75.3%)	89 (65%)	0.097

Subgroup analyses according to sex, body mass index, hair characteristics, sinus number, sinus location, sinus width, symptom duration, and recurrence status are presented in Table 4. At the 1-month follow-up, early postoperative symptom scores favored the SiLaC group in patients with overweight status, coarse hair texture, single sinus presence, and wider sinuses (p = 0.001, p < 0.001, p = 0.005, p = 0.003, respectively). Among patients with faint hair and free texture, symptom scores were lower in the CPT group (p = 0.015).

Table 4.

Comparison of subgroups in terms of first month outcomes

Subgroup	Outcome measure	SiLaC group (%), median (25–75% IQR)	CPT group (%), median (25–75% IQR)	p-Value
Female (N = 51)	Itching	1 (1–1)	1 (1–1)	0.604
	Burning	1 (1–1)	1 (1–1)	0.732
	Purulent discharge	1 (1–1)	1 (1–2)	0.194
	Total symptom score	3 (3–3.5)	3 (3–4)	0.493
Male (N = 179)	Itching	1 (1–1)	1 (1–1)	0.122
	Burning	1 (1–1)	1 (1–1)	0.133
	Purulent discharge	1 (1–1)	1 (1–2)	0.099
	Total symptom score	3 (3–3)	3 (3–4)	0.096
Average or underweight (N = 76)	Itching	1 (1–2)	1 (1–1)	0.547
	Burning	1 (1–1)	1 (1–1)	0.717
	Purulent discharge	1 (1–2)	1 (1–2)	0.599
	Total symptom score	3 (3–5)	3 (3–4)	0.331
Overweight (N = 154)	Itching	1 (1–1)	1 (1–1)	0.015
	Burning	1 (1–1)	1 (1–1)	0.017
	Purulent discharge	1 (1–1)	1 (1–2)	0.001
	Total symptom score	3 (3–3)	3 (3–4)	0.001
Faint hair with free texture (N = 109)	Itching	1 (1–1)	1 (1–1)	0.091
	Burning	1 (1–1)	1 (1–1)	0.166
	Purulent discharge	1 (1–2)	1 (1–1)	0.049
	Total symptom score	3 (3–5)	3 (3–3)	0.015
Hairy coarse with hard texture (N = 121)	Itching	1 (1–1)	1 (1–1.75)	0.002
	Burning	1 (1–1)	1 (1–1.75)	0.002
	Purulent discharge	1 (1–1)	1 (1–2)	< 0.001
	Total symptom score	3 (3–3)	3 (3–6)	< 0.001
Single sinus presence (N = 111)	Itching	1 (1–1)	1 (1–2)	0.018
	Burning	1 (1–1)	1 (1–1)	0.007
	Purulent discharge	1 (1–1)	1 (1–3)	0.002
	Total symptom score	3 (3–3)	3 (3–6)	0.005
Multiple sinus presence (N = 119)	Itching	1 (1–1)	1 (1–1)	0.458
	Burning	1 (1–1)	1 (1–1)	0.458
	Purulent discharge	1 (1–2)	1 (1–2)	0.564
	Total symptom score	3 (3–5)	3 (3–4)	0.562
Midline sinus presence (N = 155)	Itching	1 (1–1)	1 (1–1)	0.265
	Burning	1 (1–1)	1 (1–1)	0.087
	Purulent discharge	1 (1–1)	1 (1–1)	0.116
	Total symptom score	3 (3–3)	3 (3–3)	0.312
Convex side (off-midline) sinus presence (N = 75)	Itching	1 (1–1)	1 (1–2)	0.948
	Burning	1 (1–1)	1 (1–1.75)	0.929
	Purulent discharge	1 (1–3)	2 (1–2)	0.750
	Total symptom score	3 (3–5)	4 (3–6)	0.721
Sinus wider than 5 mm (N = 211)	Itching	1 (1–1)	1 (1–1)	0.022
	Burning	1 (1–1)	1 (1–1)	0.008
	Purulent discharge	1 (1–1)	1 (1–2)	0.001
	Total symptom score	3 (3–3)	3 (3–4)	0.003
Sinus narrower than 5 mm (N = 19)	Itching	1 (1–3)	1 (1–1)	0.053
	Burning	1 (1–3)	1 (1–1)	0.055
	Purulent discharge	2 (1.25–3)	1 (1–5)	0.895
	Total symptom score	5 (3.5–8)	3 (3–7)	0.189
Duration of symptoms less than 6 months (N = 90)	Itching	1 (1–1)	1 (1–1)	0.173
	Burning	1 (1–1)	1 (1–1)	0.810
	Purulent discharge	1 (1–1)	1 (1–1)	0.293
	Total symptom score	3 (3–3)	3 (3–3)	0.846
Duration of symptoms more than 6 months (N = 140)	Itching	1 (1–1)	1 (1–2)	0.098
	Burning	1 (1–1)	1 (1–2)	0.143
	Purulent discharge	1 (1–2)	1 (1–2)	0.122
	Total symptom score	3 (3–5)	3 (3–6)	0.087
Primary cases (N = 93)	Itching	1 (1–1)	1 (1–1)	0.351
	Burning	1 (1–1)	1 (1–1)	0.780
	Purulent discharge	1 (1–1)	1 (1–1)	0.232
	Total symptom score	3 (3–3)	3 (3–3)	0.472
Recurrent cases (N = 137)	Itching	1 (1–1)	1 (1–2)	0.124
	Burning	1 (1–1)	1 (1–2)	0.117
	Purulent discharge	1 (1–2)	1 (1–2)	0.113
	Total symptom score	3 (3–5)	3 (3–6)	0.107

Discussion

This study focused on early postoperative QoL outcomes following minimally invasive treatment for PSD, assessed using patient-reported measures.

Both groups predominantly comprised mildly overweight young male patients, consistent with the demographic profile of PSD reported in the literature [12, 13]. According to the classification system applied, factors associated with greater disease severity included recurrence, coarse hair texture, multiple sinus tracts, overweight status, symptom duration exceeding 6 months, convex side sinus location, male sex, and narrower tracts [9].

Both groups included a high proportion of complex cases and were otherwise comparable, apart from a single parameter favoring CPT, supporting the reliability of the findings and their comparability with existing literature. Given the high prevalence of PSD, treatment is often delivered by general surgeons rather than specialized colorectal surgeons. Although variability in operator experience may influence outcomes, it reflects routine clinical practice and enhances the external validity of the study. The surgical techniques used in both groups closely align with those described in the majority of published studies, making the comparison of our results with existing literature more meaningful and reliable [13–15].

Kayaalp et al. and Olmez et al. reported a return-to-work time of 2–3 days following CPT [15, 16], whereas two large series evaluating SiLaC reported a broader range of 0–12 days [17, 18]. In our study, all patients were discharged on the same day, and most resumed daily activities immediately. It should be noted that CPT is not routinely practiced in many European Union countries, and that SiLaC studies from these settings are often conducted in higher-income healthcare systems where patients may have greater flexibility regarding time off work. In this context, both techniques generally allowed early return to daily activities; however, SiLaC was associated with a shorter time to return to work compared with CPT.

In the literature, the median VAS scores for SiLaC are reported as 0 in the first week and first month [17, 19, 20]. For CPT, these values are reported as 0–2 in the first week and 0.23 in the first month [16, 21, 22]. The higher VAS scores observed in the immediate postoperative period may be attributable to the caustic effect of phenol on the skin and to whether a protective ointment was applied before CPT as a preventive measure. In our study, median postoperative VAS scores were consistent with published data and did not exceed preoperative values. Although most patients reported minimal pain, first-week pain complaints were significantly more frequent in the CPT group based on both VAS and SF-36 pain scores, indicating superior early pain outcomes with SiLaC.

Since QoL and patient satisfaction are influenced by multiple factors, including symptom relief and recovery speed, both SF-36 and TSS were evaluated in our study. Reported satisfaction rates in the literature range from 79% to 99% for SiLaC and exceed 80% for CPT, although most studies focus on long-term outcomes and lack validated QoL assessments [13, 19, 23–31]. In our study, both groups demonstrated high SF-36 scores and minimal symptoms during the early postoperative period; however, the CPT group had a higher proportion of symptomatic patients and lower scores in physical functioning, social functioning, and physical role limitation at 1 week. These differences largely resolved by 1 month, except for purulent discharge. Overall satisfaction at 1 month was high and comparable between groups. Taken together, these findings suggest that SiLaC provides a faster and more comfortable early recovery, although this advantage diminishes over time, consistent with reports of prolonged discharge following CPT [32].

All perioperative complications in our study were classified as Clavien–Dindo grade I–II and were managed with simple medical interventions. Consequently, this conservative management strategy likely contributed to the comparable return-to-work times and QoL outcomes observed between groups at the 1-month follow-up. Reported complication profiles for both techniques mainly consist of surgical site infections and related skin manifestations, with both their presentation and management consistent with our findings [15, 26].

In our study, PoC was one of the CR criteria and SiLaC was found to be superior to CPT in the first week in this regard. However, the definition of healing varies across studies, and cessation of symptoms is widely accepted in the literature as a sufficient criterion for recovery, even in the absence of complete pit orifice closure [16]. Considering that CPT-treated patients may have a longer recovery period, we believe that observing this difference within the first postoperative month is an expected outcome.

The PSD classification used in this study was selected for its practical applicability in the absence of a universally accepted system. Although a detailed evaluation of this classification is beyond the scope of the present analysis, certain cutoff values—such as sinus width < 5 mm and symptom duration ≥ 6 months—warrant further validation. In particular, existing evidence suggests that sinus tracts narrower than 3 mm should be widened preoperatively [17], raising uncertainty regarding the basis on which the 5-mm threshold and symptom duration cutoffs were defined. Despite these limitations, the classification proved useful for subgroup analyses. In this context, SiLaC demonstrated more favorable early QoL outcomes in patients with single sinus tracts > 5 mm and in hairy or overweight patients, whereas CPT appeared more favorable in less hairy individuals. However, given the limited subgroup sizes, these findings should be interpreted cautiously. Overall, SiLaC may offer advantages in cases where hygiene maintenance is challenging and in simpler forms of PSD.

Recent guidelines from the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology emphasize the increasing role of minimally invasive techniques in PSD management, particularly given the persistent recurrence rates observed even after flap-based procedures [33, 34]. These guidelines prioritize recovery-related outcomes, such as postoperative morbidity and return to normal activities, but provide limited emphasis on very early patient-reported outcomes. In this context, our study adds relevant evidence by specifically evaluating early postoperative symptom burden and QoL outcomes.

This study has several limitations. Although data were collected prospectively, the analysis was retrospective, and the absence of randomization may have introduced selection bias. Nevertheless, the inclusion of surgeons with varying levels of experience reflects real-world practice and enhances generalizability. The classification system used for subgroup analyses has not yet been validated, which may have influenced subgroup findings. In addition, follow-up was intentionally limited to 1 week and 1 month to focus on early postoperative recovery and short-term QoL; therefore, no conclusions regarding long-term healing or recurrence can be drawn, which typically require follow-up of at least 6–12 months in PSD. Outcomes were also not analyzed separately for patients presenting with acute infection, which may have provided additional insights. Moreover, although subgroup analyses were prespecified, no formal sample size or effect size calculations were performed specifically for these analyses; therefore, the findings should be interpreted with caution due to the potential risks of both type I and type II errors. Finally, because all procedures were performed within a state-funded healthcare system, a formal cost comparison between SiLaC and CPT was not feasible, and treatment selection should consider local resource availability and reimbursement structures.

In conclusion, the SiLaC method was associated with more favorable QoL outcomes compared with CPT during the first postoperative week. These early QoL benefits may translate into reduced workforce absenteeism, which is a relevant consideration for young, working-age patients. By the end of the first postoperative month, however, no significant differences in QoL outcomes were observed between the two groups. Subgroup analyses suggested that SiLaC may offer advantages in certain clinical scenarios. Further multicenter randomized controlled trials are warranted to better clarify and validate these findings.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Conceptualization: M.K.Y. and M.T.D.; methodology: M.K.Y. and M.T.D.; data curation: M.K.Y. and M.T.D.; formal analysis: M.K.Y. and M.T.D.; investigation: M.K.Y. and M.T.D.; resources: M.K.Y.; writing—original draft: M.K.Y.; writing—review and editing: M.K.Y.; supervision: M.K.Y. and M.T.D.; and project administration: M.K.Y. and M.T.D.

Funding

None.

Data availability

Upon request, the dataset will be shared.

Declarations

Conflict of interest

The authors declare no competing interests.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

This study was retrospective in design and based on analysis of prospectively maintained clinical data. In accordance with the decision of the Institutional Ethics Committee, individual informed consent for participation was waived due to the retrospective nature of the study and anonymized data analysis.