4. Discussion
PSD is a widespread disease and usually affects young population[3]. Although lots of surgical methods have been
defined for treatment of PSD, golden standard surgical technic is not
available yet [14]. The main problem of all
techniques is recurrence rate after the applied procedure. There are a
few surgical procedures report the long term recurrence rate is less
than 10% in the literature [2, 25, 27-32], and
these rates are defined as low recurrence. If the long term recurrence
rates are more than 10% and less than 20%, these rates are defined as
acceptable, reasonable or allowable [23, 33, 34].
Lastly, if the long term recurrence rates are above the 20%, it is
generally defined as unsatisfactory or unacceptable and these procedures
are slowly being abandoned over time [13, 35-37].
Sinusectomy is one of the techniques in the pilonidal sinus surgery have
the low recurrence rate, Soll et al. reported the long term recurrence
rate as 7% [25]. In the present study, the
recurrence rates were found as %18.7 and %5.5 in patients underwent to
EPC and SPC, respectively.
The number of midline or peripheral orifices, previous surgical
treatment, wound infection after surgery and chronic disease have been
found risk factors to increase the recurrence rate after the surgery[34, 38]. Though sinusectomy was recommended in
uncomplicated patients with one to three midline pits in German national
guideline [13], the number of orifices and
recurrent case are significantly higher in the SPC group than the EPC
group in present study. Even so, the recurrence rate was lower in SPC
procedure, and a lower risk of recurrence was found in all multivariate
analysis models. These all findings suggest our hypothesis that
sinusectomy procedure could be performed in all patients with
uncomplicated and also complicated cases have higher number of orifices,
sinus tracts and recurrent condition.
In addition to low recurrence rate, the ideal surgical approach have low
risk of local complication, low cosmetic concern, short inpatient
duration, short wound healing time and fast return time to school or
work [12, 28, 34, 39]. The sophisticated surgical
procedures in the treatment of PSD such as excision and primary closure
have increased risk of wound dehiscence, wound infection and abscess
formation [28]; off-midline closure have increased
hospital stay and wound healing time [12]. Similar
to the findings of previous studies, the patients were treated with the
EPC have higher wound infection and abscess formation than the patients
were treated with SPC in our study. It was reported that seroma or
hematoma can occur as an early complication of the sinusectomy procedure[7, 25], but it can usually be successfully
treated by local and simple intervention. Seroma was significantly
higher in SPC procedure, but all patients with seroma were treated with
the simple drainage, and the development of wound infection or abscess
formation were not observed during the follow-up in these patients.
Short hospitalization and short wound healing time were observed in
patients treated with sinusectomy in our study and that were compatible
with the reported outcomes in previous studies [32,
40]. All these satisfying secondary gains were observed in patients
treated with sinusectomy encourage the widespread use of this technique
in patients with PSD.
The economic effects of the sophisticated surgical techniques, they
could be performed inpatients healthcare setting and required several
days’ hospitalization, to the insurance system or to the patient’s own
economic status should also be considered [4, 5].
Minimally invasive procedure could be applied as an outpatient
intervention or if it is performed as an inpatient intervention, it
commonly requires short-term hospitalization of the patients[32]. Therefore these procedures result in lower
workload on healthcare system and lower medical cost[4, 32]. In addition to the better patient
outcomes, this point of view also leads the minimally invasive
procedures become more popular than the sophisticated surgery[32, 40]. The development of new sinusectomy
techniques, video assisted ablation and endoscopic pilonidal sinus
treatment are modern variations of this technique[31, 39, 41-43], supports this perspective
mentioned.
There are a few limitations in the present study. Firstly, BMI of
patients and its effects on results were not evaluated, though BMI was
found as a risk factor for the development of both symptoms and
complications [44]. Secondly, several studies have
evaluated the pleasure of patients using by subjective scale or
intervention. We have not performed any patient’s visual scale, the
authors concluded that the low recurrence-free survival should be the
main goal of the applied surgery. Another limitation of the study is the
retrospective design of the study not allowing us to perform
case-matching. We performed a multivariate analysis to compensate this
limitation. Nevertheless, due to the lack of data, we could not include
some variables (comorbidities, amount of body hair, obesity,
occupational factors, prolonged sitting, poor hygiene etc.) that may
affect the recurrence risk in the multivariate models.