Daria Marcinkowska, *Sławomir Glinkowski
The place of the Suchorski method in the contemporary treatment of extensive pilonidal sinus disease – a literature review
Miejsce operacji sposobem Suchorskiego we współczesnym leczeniu rozległych torbieli włosowych – przegląd piśmiennictwa
Department of General and Oncologic Surgery in Tomaszów Mazowiecki Health Center
Streszczenie
Zatoka włosowa jest schorzeniem, którego istotę stanowi przewlekły stan zapalny okolicy krzyżowo-ogonowej. Częściej dotyczy mężczyzn, głównie w 2. i 3. dekadzie życia. W wielu przypadkach pierwszą oznaką choroby jest powstanie ropnia tej okolicy. W takich sytuacjach konieczne są nacięcie i drenaż ropnia. Jedynym sposobem skutecznego leczenia torbieli pilonidalnej jest postępowanie operacyjne. Istnieje wiele metod operacji, z których każda ma określone wskazania. Niezależnie od metody operacji istotą każdej z nich powinno być przesunięcie i wypłaszczenie szpary międzypośladkowej, aby zapobiec nawrotowi dolegliwości.
Metoda Suchorskiego, w piśmiennictwie określana również jako wycięcie skośne, jest metodą o udowodnionej wysokiej skuteczności i małym odsetku nawrotów. Szczególnym wskazaniem do jej zastosowania są przypadki, w których ujście zewnętrzne znajduje się blisko kanału odbytu. W takich przypadkach pozwala ona na wycięcie całości torbieli z zachowaniem ciągłości mięśni zwieraczy odbytu.
W artykule przedstawiamy prace na temat skuteczności metody Suchorskiego na tle innych metod. Ze względu na bardzo dobre wyniki leczenia pacjentów operacja sposobem Suchorskiego wydaje się być wciąż metodą niedocenianą.
Summary
Pilonidal sinus disease (PSD) is a chronic inflammation of the sacrococcygeal area. It is more prevalent among men, mainly those in their 20s and 30s. Many patients develop an abscess in this region as the first sign of the disease. In such cases, abscess incision and drainage are necessary. Surgery is the only effective treatment for pilonidal cyst. Many surgical techniques have been developed, with each of them having specific indications. Regardless of the surgical strategy, the essence of each method should be to lift and flatten the gluteal cleft to prevent recurrence.
The Suchorski method, which is also referred to as oblique excision in the literature, is a method with proven high efficiency and low recurrence rates. Cases where the external opening remains in close proximity to the anal canal are a particular indication for this technique. In such cases, it allows for the total excision of the cyst, while maintaining sphincter continuity.
In this paper, we review papers on the efficacy of the Suchorski method compared to other techniques. Despite excellent treatment outcomes, the Suchorski technique still seems to be an underestimated method.
Introduction
Pilonidal sinus disease (PSD), also known as pilonidal cyst, is a chronic inflammatory condition that develops in the sacrococcygeal region. In older scientific papers, it was also referred to as a supracoccygeal pilonidal cyst or fistula (1, 2). Due to its high prevalence among American soldiers during World War II, it was also nicknamed the ‘jeep driver’s disease’ or ‘jeep disease’. At that time, it was the third most common disease after inguinal hernia and acute appendicitis.
There are many theories accounting for PSD aetiology. The most common aetiological factors include a sedentary lifestyle, obesity, inadequate hygiene, excessive hair in this area, and excessive sweating. The disease is more common in men, especially those in their 20s and 30s. It is currently believed that the etiopathogenesis of the disease is associated with the position and structure of the intergluteal cleft. During movement, especially when sitting down, the gluteal muscles change their position in relation to each other, with deepening of the intergluteal cleft, during which hair can be sucked into open skin pores. The presence of bacteria contributes to inflammation, which over time can develop into an abscess in the course of PSD or a cutaneous fistula as a result of encapsulation of the hair in this region (3).
Red and excessively warm skin in the region of forming fluid reservoir (an abscess) may be the first sign of the disease (4). At a later stage, fever develops and a fluctuant mass is palpable during examination. Treatment in such cases usually involves abscess incision and drainage, with supportive antibiotic therapy in patients with comorbidities, such as diabetes or obesity. It is estimated that approximately 50% of all pilonidal cysts initially present as an abscess (5, 6).
Treatment strategies
Total surgical excision of the lesion with advancement flap and flattening of the intergluteal cleft is the only effective strategy for pilonidal cyst. Many different therapeutic approaches have been proposed for PSD. The most important factors to be considered when choosing an appropriate treatment option include the extent of the lesion, the presence of additional tracts, as well as the surgeon’s experience and preferences. In each case, it seems reasonable to apply a dye to the openings in the skin to identify all tracts and branches of the sinus, and thus excise all the inflamed tissues. Leaving any tract will lead to recurrence.
Some surgeons still opt for excision with marsupialization. However, long-term healing process of about 3 months is the largest limitation of this method. Other clinicians decide to close the wound with sutures, but without lifting the intergluteal cleft. In this case, the healing time is shorter, but the risk of recurrence increases, with recurrence rates estimated at up to 1/3 of patients undergoing surgery, as the cause of the disease is not eliminated. Currently, the most commonly performed surgical procedures include (7):
– Bascom II procedure,
– Suchorski method (oblique excision),
– Karydakis procedure,
– Limberg flap procedure,
– Surgery with V-Y, Z-plasty.
Each of these methods has specific indications, with the incision line to be adjusted to the size of the fistula.
All these treatment options share common features such as:
– excision of the entire lesion with healthy tissue margin,
– tight, layered suture closure without generating tension,
– using an advancement flap to lift the gluteal cleft off the midline.
Bascom II procedure if dedicated for less extensive cysts. Its main assumption is to make an incision around the entire lesion, which on the one hand runs parallel to the midline, and on the other takes an oval shape. Both wound apices are off midline, on one side of the gluteal cleft. After healing, this results in flattening of the gluteal cleft and placing it off the midline.
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Piśmiennictwo
1. Tylicki M: Operacje proktologiczne. PZWL, Warszawa 1973: 56-59.
2. Tylicki M: Zarys proktologii klinicznej. PZWL, Warszawa 1984: 72-75.
3. Murphy CD, Merson J: Pilonidal disease. JAAPA 2022; 35(10): 54-55.
4. Mahjoubi MF, Ben Latifa M, Karoui Y et al.: Radical versus conservative methods in one-stage pilonidal abscess surgery: the experience of a Tunisian Center. Arq Bras Cir Dig 2022; 19: 35.
5. Bascom J: Pilonidal disease: long-term results of follicle removal. Dis Colon Rectum 1983; 26: 800-807.
6. Allen-Mersh TG: Pilonidal sinus: finding the right track for treatment. Br J Surg 1990; 77: 123-132.
7. Kołodziejczak M, Ciesielski P: Choroby proktologiczne. Diagnostyka i leczenie. PZWL, Warszawa 2022: 153-163.
8. Karaman K, Ozturk S, Tugmen C et al.: S-shaped wide excision with primary closure for extensive chronic pilonidal sinus disease. Case Rep Surg 2014; 2014: 451869.
9. Dessily M, Charara F, Ralea S et al.: Pilonidal sinus destruction with a radial laser probe: technique and first Belgian experience. Acta Chir Belg 2017; 117(3): 164-168.
10. Georgiou GK: Outpatient Treatment of Pilonidal Disease with a 1470 nm Diode Laser; Initial Experience. Int J Surg Surgical Porced 2016; 1: 103.
11. Liagkos G, Papaioannou Ch, Mpalampou E: Minimally invasive treatment of pilonidal sinus using the new Infinite Ring Fiber. A case series. Ann Ital Chir 2022 Nov 14: S0003469X22037629.
12. Zubaidi AM, Alali MN, Al Shammari SA et al.: Outcomes of Sinus Laser Therapy in Sacrococcygeal Pilonidal Sinus Disease: A Single-Center Experience. Cureus 2022; 21(14): 9.
13. Mentes O, Bagci M, Bilgin T et al.: Management of pilonidal sinus disease with oblique excision and primary closure: results of 493 patients. Dis Colon Rectum 2006; 49(1): 104-108.
14. Krand O, Yalt T, Berber I et al.: Management of pilonidal sinus disease with oblique excision and bilateral gluteus maximus fascia advancing flap: result of 278 patients. Dis Colon Rectum 2009; 52(6): 1172-1177.
15. Ciftci F, Abdurrahman I, Tosun M, Bas G: A new approach: oblique excision and primary closure in the management of acute pilonidal disease. Int J Clin Exp Med 2014; 7(12): 5706-5710.
