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November 2014, Volume 64, Issue 11

Original Article

Modified Limberg’s flap versus primary closure for treatment of pilonidal sinus disease: A comparative study

Faisal Shabbir  ( Mayo Hospital, Lahore. )
Mahmood Ayyaz  ( Services Institute of Medical Sciences, Lahore. )
Muhammad Waris Farooka  ( Services Institute of Medical Sciences, Lahore. )
Asad Ali Toor  ( National Hospital & Medical Centre, Lahore. )
Hassan Sarwar  ( Services Institute of Medical Sciences, Lahore. )
Awais Amjad Malik  ( Services Institute of Medical Sciences, Lahore. )

Abstract

Objectives: To compare the outcome of Rhomboid excision and Modified Limberg\'s flap closure with excision and primary closure for the treatment of Sacrococcygeal Pilonidal sinus.
Methods: The study was conducted at the Surgical Department of Mayo Hospital, Lahore, from 2009 to 2012. A total of 60 patients of pilonidal sinus were randomly divided into two equal groups. The patients were operated under general anaesthesia in prone position by Rhomboid excision and Modified Limberg\'s flap closure with a closed suction drain in group 1, and excision and primary closure over a drain in group 2. Patients were followed up for 12 months for surgical complications of the treatment. SPSS 17 was used for statistical analysis.
Results: In group 1 there were 27(90%) males and 3(10%) females, while group 2 had 28(93.3%) males and 2(6.7%) females. The infection rates were observed to be 2(7%) in group 1 and 8(26.6%) (p<0.038) in group 2. The recurrence rate was only 1(3.3%) in group1 compared to 4(13.3%) in group 2. Average hospital stay was 1.63±0.67 days group 1 and 2.8±1.24 days in group 2.
Conclusion: Modified Limberg\'s flap closure is an effective treatment modality for pilonidal sinus disease with 1.5 times less infection rate, 4 times less recurrence rate and 40% in-hospital time.
Keywords: Pilonidal sinus, Rhomboid excision, Modified Limberg\'s flap. (JPMA 64: 1270; 2014).


Introduction

Pilonidal sinus disease affects young adults commonly between age range of 17-38 years.1 It causes discomfort that may interfere with daily life or employment, sometimes for prolonged periods. Aetiology of this disease is uncertain but relates to the implantation of loose hair in to the depth of the natal cleft. Factors that influence the condition are the nature of hairs, force of implantation and vulnerability of the skin. Obese individuals having deeper inter-gluteal grooves and excessive hair are found to be more commonly affected.2,3 It appears most frequently in Sacrococcygeal (natal cleft) region. However, rarely it may be located in the axilla, umbilicus, pubis, inter-mammary region, scalp, ear, amputation stumps, genital tracts of both men and women, inter-digital webs of hairdressers, and hands of farmers who shear sheep.4
Common presenting complaints include pain, swelling and discharge when these sinuses become infected.5 Despite surgical therapy, dating back more than a century, management remains controversial. The management of pilonidal sinus is frequently unsatisfactory. No current method satisfies all the necessary requirements for the ideal treatment, namely rapid healing, minimal hospital admission, minimal patient inconvenience, and low recurrence. Conservative non-operative management, closed methods, laying open of the track, wide excision and open drainage, wide excision and primary closure and limited excision are the methods currently used.6 Studies have shown that Rhomboid excision and Modified Limberg\'s flap closure can be performed for managing primary or recurrent pilonidal sinus with a low complication rate, short hospital stay, short time to return to normal activity, and good long-term results.7
We hypothesised that there is no difference between excision with direct primary closure and local transpositional Modified Limberg\'s flap closure in the treatment of sacrococcygeal pilonidal disease as regards to post-operative complications.
The objective of the study was to compare the outcome of Rhomboid excision and Modified Limberg\'s flap closure with that of excision and direct primary closure for the treatment of sacrococcygeal pilonidal sinus.


Patients and Methods

The study was conducted at the Surgical Department of Mayo Hospital, Lahore, from 2009 to 2012. A total of 60 patients were randomly divided into two equal groups using the lottery method to prevent selection bias. Outcome measurements were complication rates, including infection and recurrence, hospital stay, and time to return to normal activity. Patients over 13 years of age with sacrococcygeal pilonidal sinus were included. Patients with recurrent pilonidal sinus were excluded.
Patients were admitted through outpatient department (OPD) and detailed data was noted, including demographic information, socioeconomic status and profession. The patients were asked about the symptoms, duration and severity, and examined for the severity of the problem and any previous surgical treatment for pilonidal sinus. Informed consent was obtained from the patients and approval was granted by the institutional ethics review committee. Patients were then operated by Rhomboid excision and Modified Limberg\'s Flap technique with a closed suction drain and were allocated as group 1. The other ones were operated by excision and primary closure over a drain and were placed in group 2 (Figure).

Both groups were followed up for twelve months (after one week, two weeks, six months and twelve months) for surgical complications of the treatment, including post-operative infection, and recurrence, duration of hospital stay and return to work.
Data was analysed using SPSS 17. Descriptive analysis was done for demographic variables. T-test was applied to quantitative variables. Variables analysed were post-operative infection, length of hospital stay, recurrence and return to normal activity.


Results

Each group had 30(50%) patients. In group 1 there were 27(90%) males and 3(10%) females, while group 2 had 28(93.3%) males and 2(6.7%) females.
In group 1, discharging sinuses were reported in 23(76.7%) patients, 3(10%) complained of swelling and 4(13.3%) had pain. In group 2, 20(66.7%) patients presented with discharging sinus, 6(20%) had swelling and 4 (13.3%) had pain (Table-1).


In group 1, 2 (6.6%) patients had infection and 1(3.3%) presented with recurrence. In group 2, 8 (26.6%) patients had infection and 4(13.3%) had recurrence (Table-2).

The mean hospital stay was 1.63±0.67 days in groups 1 and 2.8±1.24 days in group 2. Statistically, the difference between the hospital stay was significant (p<0.04).Patients returned to work within 13.43±1.52 days in group 1 and 15.7±4.09in group 2 (p<0.05) (Table-3).




Discussion

Simple excisional techniques are associated with high morbidity and recurrence owing to the continuing presence of the natal cleft. Recurrence rates of 7-42 percent have been reported following excision and primary closure8,9 which in our study was 13% while 0-5 percent recurrence has been reported in literature after Rhomboid excision and Modified Limberg\'s flap closure3 which was about 3% in our study. Researchers have concluded that flap reconstruction was superior to excision and primary closure for pilonidal disease and Modified Limberg\'s flap was superior with regards to wound infection and recurrence.10-13 In this study, same trend was observed). Post-operative infection rate is 4 times higher after primary closure.
A study reported on 100 consecutive age and gender matched patients, while comparing both techniques, that quality of life improved by shorter hospital stay, earlier healing, shorter time of work, lower rate of complications, lower pain perception and improved general health were the main advantages of Modified Limberg\'s flap in pilonidal surgery.14 All together these parameters added to patient\'s comfort and satisfaction after surgical treatment. Another study showed that morbidity developed in 24 patients treated by primary excision (infection rate was 10, flap oedema 13, wound dehiscence 5), whereas only 3 patients had these morbidities after Modified Limberg\'s flap procedure (infection 2 and flap oedema 1). Eleven patients had recurrence after primary closure and no recurrence for Modified Limberg\'s flap.11
Recurrence and complications are associated with obesity as in our study obese patient with body mass index (BMI) >35 had prolonged drain output and hospital stay as well as complications occurred more frequently than non-obese patients.3,6,15
Hospital stay depends not only on healing time, but also on hospital discharge policy e.g., day-care surgery or specific discharge days. A study noted hospital stay of 1 to 2 days for Modified Limberg\'s flap; qhile another reported that the mean hospital stay was 7.9 days. One study concluded hospital stay of 3.1±0.30 days. The patients in other studies16-19 had hospital stay of 4.1 days. While comparing both procedures, one study found it to be 2.9 days for Modified Limberg\'s flap and 4.8 days for primary closure. In this study the mean hospital stay was 1.6±0.67 days for Modified Limberg\'s flap and 2.8±1.24 days for primary closure which is quite significantly comparable with other studies.16-19


Conclusion

Although the study had a small number of patients and short follow-up period, but it can be safely said that for primary sacroccocygeal pilonidal sinus disease, Rhomboid excision with Modified Limberg\'s transposition flap is an effective treatment in terms of its low complication rate, a short hospital stay, short time to return to normal activity, low recurrence rate, patient comfort and good long-term results.


Acknowledgement

We are grateful to Prof. Muhammad Arshad Cheema for his guidance.

References

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