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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 1  |  Page : 102-107

Prospective randomized comparative study of a Karydakis flap versus ordinary midline closure for the treatment of primary pilonidal sinus


Department of Surgery, Faulty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission05-Nov-2014
Date of Acceptance02-Dec-2014
Date of Web Publication14-Jun-2018

Correspondence Address:
Sameh M Zahran
Shakia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.234228

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  Abstract 


Background
There is a high incidence of sacrococcygeal pilonidal disease (SPD) among young males. Despite increasing data on the treatment of SPD, no standard treatment has been established as yet. Karydakis pioneered a procedure that involved raising a flap to overlap the midline with the scar sited to one side to reduce recurrence.
Objective
This study evaluated the outcomes of the Karydakis flap method versus the ordinary midline closure (OMC) method for the treatment of pilonidal sinus.
Patients and methods
This was a prospective study that included 40 patients with SPD. They were divided into two groups according to the surgical technique used. Group I was treated by excision and closure using the transposition Karydakis flap technique at one side of the midline and group II was treated by excision and simple closure at the midline. Both groups were compared.
Results
The duration of the surgery was 12 min longer in the Karydakis group (P < 0.001). Complications were 50% in the OMC group compared with 25% in the Karydakis group. The recurrence rate was 5% for the Karydakis group and 20% for the OMC group. Of the patients who underwent the Karydakis operation, 70.8% were completely satisfied with the procedure, whereas only 32.6% of patients who underwent the OMC reported excellent satisfaction. A significantly higher number of patients in the Karydakis group recommended the same procedure to other patients with SPD.
Conclusion
The Karydakis method may be a preferable option in the treatment of SPD because of the low rate of recurrence and the excellent satisfaction rates.

Keywords: flap, Karydakis, ordinary midline closure, pilonidal, sacrococcygeal pilonidal disease


How to cite this article:
Badr ML, Mohammed MA, Zahran SM. Prospective randomized comparative study of a Karydakis flap versus ordinary midline closure for the treatment of primary pilonidal sinus. Menoufia Med J 2018;31:102-7

How to cite this URL:
Badr ML, Mohammed MA, Zahran SM. Prospective randomized comparative study of a Karydakis flap versus ordinary midline closure for the treatment of primary pilonidal sinus. Menoufia Med J [serial online] 2018 [cited 2018 Nov 17];31:102-7. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/102/234228


  Introduction Top


Pilonidal disease was first described by Hodges in 1880 and is diagnosed by the finding of a characteristic epithelial track (the sinus) situated in the skin of the natal cleft, a short distance behind the anus, and generally containing hair, hence the name pilonidal taken from Latin, meaning literally 'nest of hairs'. There are various theories for the etiology of pilonidal sinus. The exact etiology is not clear [1]; the acquired theory is more accepted by most surgeons instead of the congenital one [2]. Irrespective of the cause, once the hair fragments become 'stuck' in the skin, they cause irritation and inflammation. Inflamed skin quickly becomes infected; thus, a recurring or a persistent infection tends to develop in the affected area. The infection causes the sinus to develop [3]. Pilonidal disease occurs more commonly in young adult males after puberty at the age of 15–30 years, especially males with dark, dense, and strong hair when sex hormones are known to affect pilosebaceous glands. It is rare in children and in adults older than 40 years of age [4]. Pilonidal sinus is an asymptomatic disease until it becomes infected; the majority of patients only present with the onset of symptoms and signs that can vary from a small painless pit or dimple at the base of the spine to a large painful abscess. Once the sinus becomes infected, it becomes symptomatic and the pit begins to swell and the patient may experience symptoms such as pain, redness, swelling, fever, malaise, or nausea. It appears as a small hole or holes draining fluid that may be clear, cloudy, or bloody. If infected, the draining pus may have a foul odor. In chronic or recurrent disease [5], it appears as visible or lumpy tracts. With the uncertainty in terms of the etiology and the complexities often encountered in its treatment, a pilonidal sinus has been considered a difficult disease [6]. A wide varieties of approaches are used in the management of this ailment, ranging from a conservative treatment to an extensive surgical excision or repair [7], with no single procedure fulfilling the requirements of an ideal treatment that can result in a cure for the patient, prevent recurrence, and enable rapid resumption of normal activities by reducing pain and disability [4]. It is universally agreed that the most effective emergency management of a pilonidal abscess is simple incision and drainage [7]. However, surgical management of chronic and recurrent disease is more controversial [6]. The surgical options for the management of a noncomplicated chronic pilonidal sinus, among others, include excision with primary closure [8], excision and laying open of the tract [9], wide and deep excision to the sacrum, incision and marsupialization, and phenol injection [10]. Skin flaps (reconstructive flap technique) have also been described to cover a sacral defect after wide excision [11]. Excision and primary closure is the most common procedure in the treatment of pilonidal sinus [7]. To eliminate the natal cleft and wound tension, various plastic reconstructive techniques, such as a Karydakis flap, can be used. The Karydakis procedure involves raising a flap to overlap the midline with the scar sited to one side; this procedure reduces postoperative hair entry, which enables wound healing and lower the rate of complications, recurrence, and early mobilisation [11].


  Patients and Methods Top


This study was carried out in the General Surgery Department, Menoufia University, and Shebeen Elkom Teaching Hospitals from January 2013 to December 2013. It included 40 patients who had 1year sacrococcygeal pilonidal sinus.

The patients were divided equally into two groups according to the surgical technique used for the treatment of the pilonidal sinus disease. A simple randomized method without any specific criteria was used in the selection of any technique. Each group included 20 patients.

  1. Group I (Karydakis flap group): 20 patients were treated by excision and closure using the transposition Karydakis flap technique at one side of the midline (Karydakis flap).
  2. Group II [ordinary midline closure (OMC)]: 20 patients were treated by excision and simple closure in the midline (closed primary direct closure technique).


Preoperative preparation

Patients were admitted the day before surgery, except for diabetic patients, who were admitted 2 days before the operation (to adjust and control the blood glucose level). The buttocks and natal cleft were completely cleaned of hair and debris (hair epilation). The site of operation was sterilized and covered by sterile dressing. A single dose of broad-spectrum antibiotic may be administered with induction of anesthesia.

Anesthesia

General anesthesia

General anesthesia was administered in cases where a more extensive surgical process was required (Karydakis closure) and there were contraindications to spinal anesthesia.

Spinal anesthesia

Spinal anesthesia was administered in the case of a simple procedure such as direct closure and where there were contraindications to general anesthesia.

Position of the patient

The patient was placed in the prone Jack-knife position with the hips slightly flexed. Strips of adhesive tape 7.5 cm wide were used to separate the buttocks. The site of attachments of these strips to the skin of the buttocks was reinforced by a short length of adhesive tape applied at a right angle to the underlying layer, forming a T-shaped pattern with exposure of the natal cleft and anal verge. The presacral area was examined under bright light to identify the primary and lateral pits and the lateral indurated tracks. Sometimes, the patient had to undergo further shaving deep in the natal cleft.

Sterilization

The operative field in all patients was sterilized by povidone-iodine.

Technique

A set of fistula probes was used to estimate the level and direction of the sinuses, followed by an injection of methylene blue into the sinus track.

Group I (excision and closure by a transposition Karydakis flap)

Excision: A biconcave (elliptical) incision was made. The ellipse was based on the side of any secondary opening or induration. If the sinus is found to be entirely central, either side may be chosen. The incision made was at least 5 cm long, with gentle curvature. The end of the incision was 2 cm to one side of the midline. The medial end of the excision crosses the midline sufficiently to encompass the primary pit. Probing and insertion of povidone-iodine or methylene blue helps to ascertain the extent of the sinus so that the entire sinus and its ramification can be fully excised without inadvertent contamination of the wound by opening the track. The lateral edge of the excised ellipse must be symmetrical with the wall beyond the sinus so that the final suture line can be vertical or its central part can be encroached toward the midline. The scalpel was inserted down to muscle and sacral fascia to remove a boat-shaped wedge of tissue including the entire sinus. Diathermy was not used until the tissue had been excised to avoid confusion of burn marks with methylene blue from divided sinus branches. The medial side of the wound was then undermined at a distance of 2 cm, at a depth of about 1 cm, to produce a flap extending the full length of the wound. The flap should be uniform in thickness. Cutting the flap may expose the deep fascia and muscle in a thin patient, but not in obese patients.

Hemostasis: If bleeding points were encountered close to the bone, these were managed by diathermy coagulation.

Closure:Suction drain was inserted into the depth of the wound taken out through the upper pole of the wound away from the midline. Then, a series of deep sutures of polyglactin (Vicryl) 3/0 or 2/0 on a circle needle were passed through the deep presacral fascia and subcutaneous layer to be tied on inverted simple or vertical mattress.

The actual skin edges were united by a close series of vertical mattress or simple sutures of no. 3/0 of 4/0 polypropylene.

Group II (excision and primary direct closure technique)

Excision:The incision was an elliptical one to prove that it included all sinus openings; if a secondary sinus lay unusually far laterally, the incision was extended to incorporate it either as a special offshoot or as an enlargement of the entire ellipse. The incision was deepened at right angles to the skin through healthy fat to reach the fascia covering the coccyx and sacrum. While traction was applied to the isolated ellipse of skin and fat, it was separated from the fascia by scalpel, scissor, or diathermy dissection, commencing at the anal end and proceeding cranial-wards.

Hemostasis:If bleeding points were encountered close to the bone, these were managed by diathermy coagulation.

Closure:Suction drain was inserted into the depth of the wound taken out through the upper pole of the wound from a separate stab away from the midline. Then, a series of deep sutures of polyglactin (Vicryl) 3/0 or 2/0 on a circle needle were passed through the deep presacral fascia and subcutaneous layer to be tied on inverted simple or vertical mattress. The actual skin edges were united by a close series of vertical mattress or simple sutures of no. 3/0 of 4/0 polypropylene.

Follow-up: Analgesia was administered as required. Antibiotics in the form of broad-spectrum were administered for about 1 week parentally. The wound was exposed on the second postoperative day in both groups. Suction drain was removed when it was draining less than 20 ml (usually on the third to fifth postoperative day). The patient was discharged home after replacing the dressing on removal of the drain. On the 10th postoperative day, all patients were seen for wound inspection, assessment of the wound, and removal of stitches. Patients were reviewed in the outpatient surgical clinic at 3, 6, and 12 weeks and then every 3 months for 1 year. They were instructed to shave the natal cleft monthly for 12 months after the operation and to keep it clean.


  Results Top


Patients' demographics (age–sex)

Group I: 16 (80%) men and four (20%) women ranging in age from 19 to 32 years (25.55 ± 3.87 years) were treated by excision and closure using a transposition Karydakis flap [Table 1].
Table 1: Comparison between sociodemographic characteristics of the groups studied

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Group II: 16 (80%) men and four (20%) women ranging in age from 18 to 25 years (24.05 ± 1.79 years) were treated by excision and simple closure (primary direct closure technique) [Table 1].

Patient's hair-body distribution

Group I: 13 (65%) patients were not hairy and seven (35%) patients were hirsute [Table 2].
Table 2: Comparison between the presence of hair in the groups studied

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Group II: 15 (75%) patients were not hairy and five (25%) patients were hirsute [Table 2].

Postoperative complications in both groups

Group I: 15 (75%) patients showed complete healing, early complications developed in four (20%) patients involving wound breakdown (infection, seroma, hematoma), and a late complication of recurrence was encountered in one (5%) patient within 2 months postoperatively [Table 3].
Table 3: Comparison between postoperative complications in the groups studied

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Group II: 10 (50%) patients showed complete healing, early complications developed in six (30%) patients involving wound breakdown (infection, seroma, hematoma), and a late complication of recurrence developed in four (20%) patients within 2 months postoperatively [Table 3].

Duration of surgery in both groups (min)

Group I: the duration of surgery in group I ranged from 40 to 55 min (49.00 ± 4.97 min) [Table 4].
Table 4: Comparison between duration of surgery (min) in the studied groups

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Group II: the duration of surgery in group II ranged from 25 to 45 min (37.50 ± 4.73 min) [Table 4].

Patients' activities after surgery (days)

Group I: nine patients mobilized for the first time 1 day after surgery (45%), 10 (50%) patients mobilized 2 days after surgery, and one (5%) patient mobilized after 3 days [Table 5]. Leg massages must be performed from the first day to avoid DVT.
Table 5: Comparison between two studied groups regarding patient's activities after surgery (days)

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Group II: eight (40%) patients mobilized for the first time 1 day after surgery, 11 (55%) patients mobilized after 2 days, and one (5%) patient mobilized after 3 days [Table 5]. Leg massages must be preformed from the first day avoid Deep veins thrombosis (DVT).

Postoperative hospital stays (days)

Group I: the length of hospital stay ranged from 2 to 3 days (2.45 ± 0.51 days) [Table 6].
Table 6: Comparison between postoperative hospital stay in the studied groups

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Group II: the length of hospital stay ranged from 2 to 4 days (2.50 ± 0.69 days) [Table 6].

Complete wound healing in both groups

Group I: the time for complete healing ranged from 18 to 60 days (34.50 ± 20.33 days) [Table 7].
Table 7: Comparison between time of complete healing in the studied groups

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Group II: the time for complete healing ranged from 25 to 60 days (39.00 ± 8.05 days) [Table 7].


  Discussion Top


In terms of sex distribution, 32 (80%) men and eight (20%) women, it is found that the Karydakis group included 16 (80%) men and four (20%) women, which is similar to the results reported by Akca et al. [12] [13 (86.6%) men and two (24.4%) women], but were not in agreement with the results reported by Mahdy [13] [10 (66.6%) men and five (33.3%) women]. In the OMC group, there were more men [16 (80%) men and four (20%) women], which was very similar to the results reported by Akca et al. [12] [12 (80%) men and three (20%) women], and this was not in agreement with the results reported by Mahdy [13] [10 (66.6%) men and five (33.3%) women].

For hirsutism, it was found that the Karydakis group included 13 (65%) nonhairy patients and seven (35%) hirsute patients, which is similar to the results reported by the Bannura et al.'s [14] study, in which nine (60%) patients were hirsute and six (40%) patients were not hairy. In the OMC group, 15 (75%) patients were not hairy, which is similar to the results obtained by the Bannura et al.'s [14] study, in which eight (53.3%) patients were hirsute.

In the Karydakis group, mobilization occurred within 1–3 days [nine (45%) patients mobilized for the first time 1 day after surgery, 10 (50%) patients mobilized 2 days after surgery, and one (5%) patient mobilized after 3 days, which is longer in duration than the results reported by Mahdy [13] (1 day after surgery) and also longer in duration than the results reported by Acka et al. [12] (1 day after surgery), but similar to the results reported by Lahooti et al. [15]. In the OMC group, mobilization occurred 1–3 days after surgery [eight (40%) patients mobilized for the first time 1 day after surgery, 11 (55%) patients mobilized 2 days after surgery, and one (5%) patient mobilized after 3 days], which is similar to the results reported by Mahdy [13] (2.6 days after surgery), but longer in duration than the results reported by Akca et al. [12], which was 1–2 days after surgery.

In terms of the mean length of stay at hospital, in the Karydakis group, it was found to be 2–3 days (2.45 ± 0.51 days). This was shorter in duration than the results reported by the Mahdy's [13]study, in which the length of hospital stay was 2–6 days (2.9 days), and the Azab et al.'s [16] study, in which the length of hospital stay was 10 days, but longer in duration than the results reported by the Acka et al.'s [12] study, in which the length of hospital stay was 2 days. In the OMC group, the length of hospital stay was 2–4 days (2.50 ± 0.69 days), which is shorter in duration than the results reported by Akca et al. [12] of 4–6 days, and is shorter in duration than the results reported by Mahdy [13], which is 3–11 days (4.8 days).

Complete wound healing in the Karydakis group was found to occur within 18–60 days (34.50 ± 20.33 days), which was shorter in duration than the results reported by the Awatef et al.'s [17] study, in which the mean time of wound healing was 18–72 days, but longer in duration than the results reported by the Mahdy's [13] study, in which the mean time of wound healing was 15–20 days (18.3 days). However, in the OMC group, it was found to be 25–60 days (39.00 ± 8.05 days) longer in duration than the results reported by the Mahdy's [13] study, which is 17–31 days (25.1 days), and longer in duration than the results reported by the Hassan et al.'s study [18], which is 10–15 days (20.4 ± 9.51 days, median 18.6 days).

In terms of postoperative complications encountered in the Karydakis group, 15 (75%) patients showed complete healing, early complications developed in four (20%) patients involving wound breakdown (infection, seroma, hematoma) because of sweating and dirty environment, and a late complication of recurrence developed in one (5%) patient within 2 months postoperatively, which was similar to the results reported by the Mahdy's [13] study, in which 11 (73.3%) patients showed complete healing, three (20%) patients developed wound breakdown, and one (6.7%) patient developed recurrence, and similar to the results reported by the Acka et al.'s [12] study, in which 11 (73.3%) patients showed complete healing, three (20%) patients developed wound breakdown, and one (6.7%) patient developed recurrence. In terms of the duration of surgery in patients treated with Karydakis flap closure, it was found to range from 40 to 55min (49.00 ± 4.97 min), which was shorter than that reported by the Akca et al.'s [12] study, in which the duration of surgery ranged from 60 to 73 min (60 min). However, in the OMC group, the duration of surgery was 25–45 min (37.50 ± 4.73 min), which is shorter in duration than that reported by the Akca et al.'s [12] study, in which the duration of surgery was 40–60 min (45 min), and shorter in duration than the results reported by the Hassan et al.'s [18] study, in which the mean operative time was 20–58 min (33.9 ± 10.1 min).

In this study, no statistically significant difference was found between both methods in terms of the following:

  1. Sex, age, and hirsutism.
  2. Length of hospital stay.
  3. Time to achieve complete healing.
  4. Postoperative complications.
  5. Activities after operation.
  6. Percentage of complete healing.
  7. Recurrence.


A significant statistically difference was found between both groups in terms of duration of surgery (longer in the Karydakis flap).

These results were in agreement with those of Acka et al. [12], but not in agreement with those of Mahdy [13], who found a significant difference also in the first time to mobilize, hospital stay, and wound healing. The results were also not in agreement with those of Abu Galala et al. [4], who found a significant difference in wound healing and length of hospital stay.


  Conclusion Top


We conclude that shorter hospital stay, earlier healing, shorter time off work, and lower rates of complications are the main advantages of the Karydakis flap technique in pilonidal sinus surgery. Altogether, these parameters contribute toward patient comfort and satisfaction after surgical treatment. The cosmetic results of flap transposition may not be satisfactory, especially for women. We recommend the use of a Karydakis flap wherever possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Abu Galala KH, Salam IM, Abu Samaan KR, El Ashaal YI, Chandran VP, Sabastian M, Sim AJ. Treatment of pilonidal sinus by primary closure with a transposed rhomboid flap compared with deep suturing: a prospective randomised clinical trial. Eur J Surg 1999; 165:468–472.  Back to cited text no. 4
    
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Zimmerman CE. Outpatient excision and primary closure of pilonidal cysts and sinuses. Am J Surg 1978; 136:640–642.  Back to cited text no. 8
    
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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.  Back to cited text no. 9
    
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Akca T, Colak T, Ustunsoy B. Randomized clinical trial comparing primary closure with the Limberg flap in the treatment of primary sacrococcygeal pilonidal disease. BMJ 2005; 92:1081–1084.  Back to cited text no. 12
    
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Mahdy T, Mahdy T, Gaertner WB, Hagerman GF, Goldberg SM, Finne CO III. Surgical treatment of the pilonidal disease: primary closure or flap reconstruction after excision. Dis Colon Rectum 2008; 51:1816–1822.  Back to cited text no. 13
    
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Bannura G, Barrera A, Melo C. Obesity and hirsutism as risk factors for sacrococcygeal pilonidal sinus disease. R C J surg. 2007; 57:340–344.  Back to cited text no. 14
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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