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Meta-Analysis
. 2010 Jan 20;2010(1):CD006213.
doi: 10.1002/14651858.CD006213.pub3.

Healing by primary versus secondary intention after surgical treatment for pilonidal sinus

Ahmed Al-Khamis  1 , Iain McCallum, Peter M King, Julie Bruce
Affiliations
Meta-Analysis

Healing by primary versus secondary intention after surgical treatment for pilonidal sinus

Ahmed Al-Khamis et al. Cochrane Database Syst Rev. .

Abstract

Background: Pilonidal sinus arises in the hair follicles in the buttock cleft. The estimated incidence is 26 per 100,000, people, affecting men twice as often as women. These chronic discharging wounds cause pain and impact upon quality of life. Surgical strategies centre on excision of the sinus tracts followed by primary closure and healing by primary intention or leaving the wound open to heal by secondary intention. There is uncertainty as to whether open or closed surgical management is more effective.

Objectives: To determine the relative effects of open compared with closed surgical treatment for pilonidal sinus on the outcomes of time to healing, infection and recurrence rate.

Search strategy: For this first update we searched the Wounds Group Specialised Register (24/9/09); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 3 2009; Ovid MEDLINE (1950 - September Week 3, 2009); Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations (September 24, 2009); Ovid EMBASE (1980 - 2009 Week 38); EBSCO CINAHL (1982 - September Week 3, 2009).

Selection criteria: All randomised controlled trials (RCTs) comparing open with closed surgical treatment for pilonidal sinus. Exclusion criteria were: non-RCTs; children aged younger than 14 years and studies of pilonidal abscess.

Data collection and analysis: Data extraction and risk of bias assessment were conducted independently by three review authors (AA/IM/JB). Mean differences were used for continuous outcomes and relative risks with 95% confidence intervals for dichotomous outcomes.

Main results: For this update, 8 additional trials were identified giving a total of 26 included studies (n=2530). 17 studies compared open wound healing with surgical closure. Healing times were faster after surgical closure compared with open healing. Surgical site infection (SSI) rates did not differ between treatments; recurrence rates were lower in open healing than with primary closure (RR 0.60, 95% CI 0.42 to 0.87). Six studies compared surgical midline with off-midline closure. Healing times were faster after off-midline closure (MD 5.4 days, 95% CI 2.3 to 8.5). SSI rates were higher after midline closure (RR 3.72, 95% CI 1.86 to 7.42) and recurrence rates were higher after midline closure (Peto OR 4.54, 95% CI 2.30 to 8.96).

Authors' conclusions: No clear benefit was shown for open healing over surgical closure. A clear benefit was shown in favour of off-midline rather than midline wound closure. When closure of pilonidal sinuses is the desired surgical option, off-midline closure should be the standard management.

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Conflict of interest statement

None declared

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Open vs. closed (all), Outcome 1 SSI rate.
1.2
1.2. Analysis
Comparison 1 Open vs. closed (all), Outcome 2 Recurrence rate.
1.3
1.3. Analysis
Comparison 1 Open vs. closed (all), Outcome 3 Other complications & morbidity.
1.4
1.4. Analysis
Comparison 1 Open vs. closed (all), Outcome 4 Patient satisfaction rate.
1.5
1.5. Analysis
Comparison 1 Open vs. closed (all), Outcome 5 Cost.
1.6
1.6. Analysis
Comparison 1 Open vs. closed (all), Outcome 6 Pain.
1.7
1.7. Analysis
Comparison 1 Open vs. closed (all), Outcome 7 Wound healing rate.
2.1
2.1. Analysis
Comparison 2 Closed (midline) vs. closed (other), Outcome 1 Time to wound healing.
2.2
2.2. Analysis
Comparison 2 Closed (midline) vs. closed (other), Outcome 2 SSI rate.
2.3
2.3. Analysis
Comparison 2 Closed (midline) vs. closed (other), Outcome 3 Recurrence rate.
2.4
2.4. Analysis
Comparison 2 Closed (midline) vs. closed (other), Outcome 4 Time to return to work.
2.5
2.5. Analysis
Comparison 2 Closed (midline) vs. closed (other), Outcome 5 Other complications & morbidity.
2.6
2.6. Analysis
Comparison 2 Closed (midline) vs. closed (other), Outcome 6 Patient satisfaction.
2.7
2.7. Analysis
Comparison 2 Closed (midline) vs. closed (other), Outcome 7 Pain.
2.8
2.8. Analysis
Comparison 2 Closed (midline) vs. closed (other), Outcome 8 Wound healing rate.
2.9
2.9. Analysis
Comparison 2 Closed (midline) vs. closed (other), Outcome 9 Operative time.
3.1
3.1. Analysis
Comparison 3 Closed other (classic Limberg) vs. closed other (modified Limberg), Outcome 1 SSI rate.
3.2
3.2. Analysis
Comparison 3 Closed other (classic Limberg) vs. closed other (modified Limberg), Outcome 2 Recurrence rate.
3.3
3.3. Analysis
Comparison 3 Closed other (classic Limberg) vs. closed other (modified Limberg), Outcome 3 Time to return to work.
3.4
3.4. Analysis
Comparison 3 Closed other (classic Limberg) vs. closed other (modified Limberg), Outcome 4 Other complications & morbidity.
3.5
3.5. Analysis
Comparison 3 Closed other (classic Limberg) vs. closed other (modified Limberg), Outcome 5 Length of stay.
4.1
4.1. Analysis
Comparison 4 Closed other (Karydakis) vs. closed other (classic Limberg), Outcome 1 SSI rate.
5.1
5.1. Analysis
Comparison 5 Closed other (simple Bascom) vs closed other (Bascom cleft closure), Outcome 1 Recurrence.
5.2
5.2. Analysis
Comparison 5 Closed other (simple Bascom) vs closed other (Bascom cleft closure), Outcome 2 Wound healing rate.
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