Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence

Abstract

We systematically searched available databases. We reviewed 6,143 studies published from 1833 to 2017. Reports in English, French, German, Italian, and Spanish were considered, as were publications in other languages if definitive treatment and recurrence at specific follow-up times were described in an English abstract. We assessed data in the manner of a meta-analysis of RCTs; further we assessed non-RCTs in the manner of a merged data analysis. In the RCT analysis including 11,730 patients, Limberg & Dufourmentel operations were associated with low recurrence of 0.6% (95%CI 0.3-0.9%) 12 months and 1.8% (95%CI 1.1-2.4%) respectively 24 months postoperatively. Analysing 89,583 patients from RCTs and non-RCTs, the Karydakis & Bascom approaches were associated with recurrence of only 0.2% (95%CI 0.1-0.3%) 12 months and 0.6% (95%CI 0.5-0.8%) 24 months postoperatively. Primary midline closure exhibited long-term recurrence up to 67.9% (95%CI 53.3-82.4%) 240 months post-surgery. For most procedures, only a few RCTs without long term follow up data exist, but substitute data from numerous non-RCTs are available. Recurrence in PSD is highly dependent on surgical procedure and by follow-up time; both must be considered when drawing conclusions regarding the efficacy of a procedure.

Figure 1

Flow diagram based on Preferred reporting items for systematic reviews and meta-analysis (PRISMA) illustrating the systematic search for evidence regarding recurrence and long term follow-up data associated with common surgical procedures in PSD.

Figure 2

Procedure specific recurrence rates in PSD [%]* derived from RCTs. *Data of homogeneous recurrence rates (I² < 5%, p > 0.2) are printed in bold, heterogeneous data in italic numbers; **includes Bascom cleft lift; ^***includes Bascom Pit Picking.

Figure 3

Procedure specific recurrence rates in PSD [%]* overall derived from RCTs and non-RCTs. *Data of homogeneous recurrence rates (I² < 5%, p > 0.2) are printed in bold, heterogeneous data in italic numbers; **includes Bascom cleft lift, ***includes Bascom Pit Picking.

Figure 4

Recurrence free outcome as a function of follow-up time irrespective of specific therapeutic procedure. Data presented are for RCTs only and for all available studies. Numbers of patients included in the analysis are indicated at 12, 24, 60, and 120 months. Dashed lines indicate 95% confidence intervals.

Figure 5

Recurrence free outcome as a function of follow-up time of patients receiving primary open treatment. Data presented are for RCTs only and for all available studies. Numbers of patients included in the analysis are indicated at 12, 24, 60, and 120 months. Dashed lines indicate 95% confidence intervals.

Figure 6

Recurrence free outcome as a function of follow-up time of patients treated with primary midline closure (not using advancement or rotation flap techniques). Data presented are for RCTs only and for all available studies. Numbers of patients included in the analysis are indicated at 12, 24, 60, and 120 months. Dashed lines indicate 95% confidence intervals.

Figure 7

Recurrence free outcome as a function of follow-up time of patients treated with primary asymmetric closure. Data presented are for RCTs only and for all available studies. Numbers of patients included in the analysis are indicated at 12, 24, 60, and 120 months. Dashed lines indicate 95% confidence intervals.

Figure 8

Recurrence free outcome as a function of follow-up time of patients treated with Bascom and Karydakis techniques. Data presented are for RCTs only and for all available studies. Numbers of patients included in the analysis are indicated at 12, 24, 60, and 120 months. Dashed lines indicate 95% confidence intervals.

Figure 9

Recurrence free outcome as a function of follow-up time of patients treated with Limberg and Dufourmentel flap technique. Data presented are for RCTs only and for all available studies. Numbers of patients included in the analysis are indicated at 12, 24, 60, and 120 months. Dashed lines indicate 95% confidence intervals.

Figure 10

Recurrence free outcome as a function of follow-up time of patients treated with other flap techniques. Data presented are for RCTs only and for all available studies. Numbers of patients included in the analysis are indicated at 12, 24, 60, and 120 months. Dashed lines indicate 95% confidence intervals.