Introduction

Pilonidal sinus was first described by Herbert Mayo in 1833 as a hair-containing sinus in the sacrococcygeal region of a female patient. Later, in 1880, Hodges used the word “pilonidal” as a combination of the Latin words “pilus”, meaning hair, and “nidus”, meaning home. The condition is more common in the young adult male population. It can manifest with a wide spectrum of symptoms ranging from abscess, pain, and discharge to an asymptomatic form.^1,2,3

It is clinically classified in four types according to symptoms: 1) asymptomatic, 2) acute pilonidal abscess, 3) chronic fistulizing form, and 4) recurrent types. While the chronic fistulizing form is the most common, cases with acute abscess are also substantial in number. Many clinicians drain these abscesses under local anesthesia in outpatient clinics without conducting follow-up. In fact, when a good medical history is obtained, many patients who present with the chronic fistulizing form are also found to have a history of severe or mild abscess.^4,5

In spite of an established treatment approach for the asymptomatic, chronic fistulizing, and recurrent forms, there is no consensus as to when to perform definitive surgical interventions in patients with abscess. In our previous study, we compared the methods of unroofing-curettage with secondary intention healing and antibiotherapy followed by flap surgery in patients with abscess and reported that antibiotherapy followed by flap surgery may be preferable, especially because of its shorter treatment duration.⁴ The aim of the current study is to present non-powered negative-pressure wound dressing used to accelerate healing in patients after unroofing-curettage. This system involves wound dressing with negative pressure applied by hand pump, without the need for an electrical power source.

Materials and Methods

The data of five patients who presented to our clinic between June and December 2015 with pilonidal abscess and underwent unroofing-curettage and secondary intention healing with non-powered negative-pressure wound dressing were included in the study. The patients were analyzed with regard to age, gender, treatment duration, complications, and recurrence rates.

Obtaining the consent of an ethics committee was not necessary for this retrospective clinical study. However, consent was obtained from the hospital management for processing the data. Patients signed an informed consent form for the surgical procedure and subsequent treatment, and the necessary permission was obtained to use their data in our analyses.

Patients presenting with abscess underwent drainage under local anesthesia followed by unroofing-curettage. The wound was dressed using the Nanova^™ Therapy System every 48 hours for the first 3 applications and every 72 hours for the remaining applications.

Under local anesthesia, a wire probe was inserted into the sinus opening and removed where the abscess fistulized, and the roof of the sinus tract was opened to drain the abscess (Figures 1, 2). The area was thoroughly debrided and hemostasis was achieved. The wound was covered using the Nanova^™ Therapy System (Figures 3, 4). The manual, non-powered vacuum unit was connected and the patient was discharged with follow-up visits scheduled every 48 hours for the first 3 wound dressing applications and every 72 hours for the remaining applications (Figures 5, 6, 7, 8). The patient was considered recovered when they no longer required wound dressing.

Results

As the number of cases was small, patients were reviewed individually. The average age of the patients was 33 years (28-38 years) and all were male. The medical records did not include previous history of pilonidal sinus. Wound dressing was applied 3 times for one patient, 4 times for three patients, and 5 times for one patient. The average number of applications was 4. Only one patient experienced bleeding as a complication, which was controlled by sutures. The mean recovery period was 22.2±6.26 (16-32) days. The mean follow-up time was 20.8±3.34 (16-24) months, during which there was no recurrence (Table 1).

Discussion

There is still controversy regarding when and how to treat patients with acute pilonidal abscess. While the literature includes articles arguing that some of these cases do not become chronic after drainage and therefore not all require a definitive procedure during drainage, there are also descriptions of methods such as flap following drainage and antibiotherapy or unroofing-curettage followed by secondary intention healing.^4,5,6

The guideline for the management of pilonidal disease issued in 2013 by the American Society of Colon and Rectal Surgeons strongly recommends (level 1B, based on moderate-quality evidence) that cases of acute abscess should be treated with incision and drainage, regardless of being primary or recurring.⁷ The importance of drainage is also emphasized in the guideline published by Italian Society of Colorectal Surgeons, which reports that lateral incision may shorten the recovery period for abscesses.⁸ Given the clear importance of drainage, research is ongoing for more effective drainage methods. In a study using a new endoscopic technique to treat pilonidal abscess, Javed et al.⁹ reported significantly better results in wound healing time and time to return to work when compared with the conventional incision and drainage technique.

Khalil et al.¹⁰ described a technique of draining abscesses with needle aspiration and injection of local anesthetic using low negative pressure in the emergency department, thus presenting a way of treating pilonidal abscess with minimally invasive methods that minimize the patient’s pain without increasing the pressure in the abscess cavity or enlarging the cavity. It can be concluded that applying negative-pressure wound therapy to the abscess cavity ensures a more effective treatment by maintaining low pressure in the abscess cavity, increasing the patient’s comfort, and minimizing the pain felt by the patient.

Negative-pressure wound therapy has been in use for about 50 years. These methods have become more common in daily practice, especially with the technological advances seen in recent years. These methods allow for absorption-drainage (vacuum) of the wound. The vacuum helps effectively drain the fluid accumulated in the wound. Negative-pressure systems use a special wound dressing and a connection tube, generally accompanied by an electrical pump, to apply continuous or intermittently controlled subatmospheric pressure to the wound. These methods are reported to decrease the amount of bacteria in the wound, shorten recovery time, and normalize the immune response. They increase local blood flow, causing contraction from the periphery to the center of the wound.¹¹

In our study, we used wound dressing in which negative pressure is created manually by hand pump, without an electrical power source. A statistical comparison was not possible due to the small number of patients. However, compared to our previous studies, we found that vacuum-assisted wound care shortened the recovery periods in patients allowed to heal via secondary intention. Recovery time improved from 34.7±3.3 days in our previous study to 22.2±6.26 days in the current study.⁴ The mean follow-up time was 20.8±3.34 (16-24) months, during which no recurrence was observed. However, this data is insufficient due to the limited patient number.

A retrospective comparison of daily wound dressing and negative-pressure wound dressing in pilonidal sinus patients left to heal by secondary intention showed that patients with negative-pressure wound dressing had shorter recovery times.¹²

The vacuum-assisted wound dressing we employed in our study is a therapeutic system designed for the treatment of acute and chronic superficial wounds with low or medium exudate, combining the healing power of negative pressure with the easy application of advanced wound dressings. The kit consists of a closure method and vacuum-producing therapy unit. The method allows for effective exudate management, maximum sealing, and minimal maceration. It ensures rapid recovery, is user-friendly, and is portable and silent with no charging, electronic devices, or alarms.

In conclusion, the use of unroofing-curettage and secondary intention healing combined with non-powered negative-pressure wound dressing may not be ideal for all cases, but is particularly suitable for those pilonidal abscess patients who want to undergo definitive surgical treatment during drainage and to get back to work in a relatively shorter period of time.

Ethics

Ethics Committee Approval: Obtaining the consent of an ethics committee was not necessary for this retrospective clinical study. However, consent was obtained from the hospital management for processing the data.

Informed Consent: Patients signed an informed consent form for the surgical procedure and subsequent treatment, and the necessary permission was obtained to use their data in our analyses.

Peer-review: Internally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: B.H.K., A.A., Concept: B.H.K., M.G., Y.S.İ., A.A., Design: B.H.K., M.G., Y.S.İ., A.A., Data Collection or Processing: B.H.K., A.A., Analysis or Interpretation: M.G., Y.S.İ., Literature Search: M.G., A.A., Writing: B.H.K., M.G.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: This study received no financial support from any institution or individual. The non-powered negative-pressure wound dressing used in this study is a consumable supply in our hospital and was provided to each patient.