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Management of pilonidal sinus and recurrences in 2025 - 28/01/25

Doi : 10.1016/j.jviscsurg.2024.12.005 
Benjamin Darnis , Louise Tedeschi, Marie-Cécile Blanchet, Vincent Frering, Jessica Crozet, Benoit Gignoux, Christophe Duchamp
 Department of Digestive Surgery, Clinique de La Sauvegarde, avenue Ben-Gourion, 69009 Lyon, France 

Corresponding author.
Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Tuesday 28 January 2025

Highlights

Pilonidal sinus is a granuloma caused by the presence of subcutaneous foreign bodies, most often nests of ingrown hair.
The results of pilonidal sinus surgery can be improved by preparing patients: smoking cessation, managing obesity, elective rather than urgent treatment.
Minimally invasive therapies such as phenol injection, endoscopic treatment, and laser are in active development. They are based on the extraction of foreign bodies and the destruction of the granulating tissue lining. They limit postoperative pain, prolonged inactivity, and the time of postoperative care.
Recurrence after excisional surgery is a common problem affecting 10–30% of patients. It should be considered if the wound has not healed within six months after surgery.
The management of recurrences is complex. Obtaining an expert opinion from an experienced team is appropriate. The treatment does not rely on iterative wider excisions.

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Summary

Pilonidal sinus is a common pathology of the intergluteal cleft that can develop into abscess or suppuration. This lesion corresponds histologically to a granuloma that organizes around foreign bodies, most often hairs, and fistulizes to the skin through partially epithelialized orifices. If suppuration and abscess develop, treatment is based either on medical treatment combining analgesics, local antiseptics and sometimes antibiotics, or on emergency incision and drainage in the operating room. This is performed in more than 10,000 patients per year in France. Outside of emergencies, elective surgery for pilonidal sinus is indicated to treat bothersome symptoms or to avoid the risk of recurrent abscess. The surgical indication must take into account the patient's risk factors, particularly active smoking, that increase the risk of postoperative complications and recurrence. Elective intervention is performed on more than 30,000 patients per year in France. Radical excision followed by secondary healing is the most commonly performed option. This strategy carries a risk of failure or recurrence for at least 10% of patients. Primary closure after excision can reduce the time for healing and convalescence, but at the cost of more frequent infectious complications. Midline closure should be avoided, in favor of paramedian or flap closure. Minimally invasive techniques are being developed that combine the extraction of foreign bodies and mechanical debridement or thermal or chemical cautery of the granulomatous walls. They avoid complex and unpleasant nursing care of secondarily healing wounds, at the cost of a recurrence rate equivalent to that from excision techniques. They have the merit of avoiding difficult situations of failure to heal or recurrence after radical excision that are associated with a clear deterioration in the quality of life. The treatment of surgical failures is complex, and combines comprehensive patient care (smoking cessation, anti-infectious treatments, treatment of excess weight, avoidance of a sedentary lifestyle) and often a repeat operation. Minimally invasive treatments, particularly laser treatments, have their place in these difficult situations.

Le texte complet de cet article est disponible en PDF.

Keywords : Pilonidal sinus, Recurrence, Surgery, Skin flaps, Laser


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