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.