Surgical reconstruction of pilonidal sinus disease with concomitant extracellular matrix graft placement: a case series
Pilonidal sinus disease (PSD) is a chronic inflammatory disease affecting the soft tissue of the sacrococcygeal region and remains a challenging disease for clinicians to treat. The optimal treatment for PSD remains controversial and recent reports describe several different surgical approaches offering different benefits. Approximately 40% of initial incision and drainage cases require subsequent surgery. Due to high recurrence rates and postoperative complications, a more complex revision surgery involving a flap reconstruction may be required. We hypothesised that the combination of an extracellular matrix (ECM) graft with tissue flap reconstruction may decrease the postoperative complications and recurrence rates for PSD.
We report a retrospective case series using a surgical flap reconstruction with concomitant implantation of an ovine forestomach ECM graft under a fasciocutaneous flap with an off-midline closure for recurrent PSD, where previously surgical intervention had failed due to wound dehiscence and/or recurrent disease.
The case series included six patients. After three weeks, all patients except one were fully healed, and the sixth was fully healed by week 4; all wounds remained fully healed at 12 weeks. All patients achieved good cosmesis and were able to return to normal function without any residual symptoms.
This pilot case series explored augmenting a flap reconstruction for complex PSD with advanced ECM graft materials, demonstrating that it may improve outcomes and minimise typical complications seen in flap closure, such as inflammation, infection, haematoma/seroma and hypoperfusion. Although the study had a limited number of participants, long-term outcomes were promising and suggest that further studies are warranted.
Pilonidal sinus disease (PSD) is a chronic inflammatory process involving the sacrococcygeal region that is characterised by highly inflamed soft tissue, recurrent infections and significantly reduced patient quality of life. The aetiology of PSD is relatively unknown. It is believed that PSD is an acquired condition relating to the presence of hair in the natal cleft which the body recognises as a foreign object, leading to the formation of midline pits with superseding secondary infection.1 The infected follicle extends and ruptures into the subcutaneous tissue, forming a pilonidal abscess which can form a sinus track extending to deeper subcutaneous cavities. The challenge to clinicians who manage and treat these cases stems from the high risk of recurrence due to frequent pathogenic microbes and chronically inflamed tissue. Although PSD is a benign disorder, it can be very painful for patients, leading to absences from work or school, and may have a dramatic impact on quality of life. It is estimated that PSD has an incidence rate of 26 per 100,0001 and affects roughly 70,000 patients annually in the US alone. Males are affected 4.1–8.1 times more frequently than females2 and PSD commonly presents in the second decade of life. Risk factors include obesity, poor hygiene, familial history, repetitive irritation/trauma to the gluteal cleft and prolonged sitting.3,4,5
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