Trephination versus wide local excision for pilonidal disease: a propensity-matched study

Abstract

Aim: The optimal surgical technique for pilonidal sinus disease (PSD) remains controversial. This propensity score-matched study compared trephination with wide local excision to minimize selection bias.

Methods: We retrospectively analyzed 317 patients undergoing surgical treatment for PSD (2010-2022). Propensity score matching (1:1, caliper 0.05) using age, sex, body mass index (BMI), occupation, smoking, previous surgery, and symptom duration yielded 78 matched pairs. Primary outcome was recurrence; secondary outcomes included pain [Visual Analog Scale (VAS)], healing time, hospital stay, and return to work. Multivariate logistic regression identified recurrence predictors.

Results: After matching, groups were well-balanced [all standardized mean differences (SMDs) < 0.2]. Recurrence occurred in 15.4% of excision versus 7.7% of trephination patients (P = 0.20). Trephination demonstrated significantly lower pain scores at all timepoints: day 1 (5.2 ± 0.6 vs. 6.3 ± 1.7), day 7 (1.5 ± 1.1 vs. 2.8 ± 1.2), and month 1 (0.1 ± 0.2 vs. 0.5 ± 0.5; all P < 0.001). Hospital stay (1.0 ± 0.7 vs. 2.3 ± 1.2 days) and return to work (10.5 ± 2.2 vs. 12.7 ± 6.4 days) were shorter with trephination (both P < 0.001). Multivariate analysis identified younger age [odds ratio (OR) 0.46 per standard deviation (SD) increase of ~ 10-11 years; P = 0.005] and higher BMI (OR 1.60 per 1 kg/m² increase; P = 0.03) as independent predictors of recurrence.

Conclusions: Trephination offers significant advantages in postoperative pain, hospital stay, and return to work compared to wide local excision, with a favorable but non-significant difference in recurrence. These findings support trephination when rapid recovery is prioritized. Larger trials are needed to establish long-term recurrence equivalence.

Keywords

Pilonidal sinus disease / trephination / wide local excision / minimally invasive surgery / propensity score matching

References

[1] Doll D,Luedi MM,Evers T,Kauf P,Matevossian E. Recurrence-free survival, but not surgical therapy per se, determines 583 patients’ long-term satisfaction following primary pilonidal sinus surgery Int J Colorectal Dis. 2015 30 605 11

[2] Stauffer VK,Luedi MM,Kauf P.et al. Common surgical procedures in pilonidal sinus disease: a meta-analysis, merged data analysis, and comprehensive study on recurrence Sci Rep. 2018 8 3058 PMC5814421

[3] Grabowski J,Oyetunji TA,Goldin AB.et al. The management of pilonidal disease: a systematic review J Pediatr Surg. 2019 54 2210 21

[4] Doll D,Orlik A,Maier K.et al. Impact of geography and surgical approach on recurrence in global pilonidal sinus disease Sci Rep. 2019 9 15111 PMC6805955

[5] Doll D,Matevossian E,Luedi MM,Schneider R,van Zypen D,Novotny A. Does full wound rupture following median pilonidal closure alter long-term recurrence rate? Med Princ Pract. 2015;24:571-7 PMC5588279

[6] Sevinç B, Karahan Ö, Okuş A, Ay S, Aksoy N, Şimşek G. Randomized prospective comparison of midline and off-midline closure techniques in pilonidal sinus surgery Surgery. 2016 159 749 54

[7] Enriquez-Navascues JM,Emparanza JI,Alkorta M,Placer C. Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus Tech Coloproctol. 2014 18 863 72

[8] Brown SR,Lund JN. The evidence base for pilonidal sinus surgery is the pits Tech Coloproctol. 2019 23 1173 5 PMC6890656

[9] Iesalnieks I,Ommer A,Herold A,Doll D. German national guideline on the management of pilonidal disease: update 2020 Langenbeck’s Arch Surg. 2021 406 2569 80 PMC8097120

[10] Milone M,Basso L,Manigrasso M.et al. Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of pilonidal disease Tech Coloproctol. 2021 25 1269 80 PMC8580911

[11] Emile SH,Elfeki H,Shalaby M.et al. Endoscopic pilonidal sinus treatment: a systematic review and meta-analysis Surg Endosc. 2018 32 3754 62

[12] Johnson EK,Vogel JD,Cowan ML,Feingold DL,Steele SR. ; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American society of colon and rectal surgeons’ clinical practice guidelines for the management of pilonidal disease Dis Colon Rectum. 2019 62 146 57

[13] Gips M,Melki Y,Salem L,Weil R,Sulkes J. Minimal surgery for pilonidal disease using trephines: description of a new technique and long-term outcomes in 1,358 patients Dis Colon Rectum. 2008 51 1656-62; discussion 1662-3.

[14] Di Castro A,Guerra F,Levi Sandri GB,Ettorre GM. Minimally invasive surgery for the treatment of pilonidal disease. The Gips procedure on 2347 patients Int J Surg. 2016 36 201 5

[15] Amorim M,Estevão-Costa J,Santos C,Fernandes S,Fragoso AC. Minimally invasive surgery for pilonidal disease: outcomes of the Gips technique-A systematic review and meta-analysis Surgery. 2023 174 480 6

[16] Horesh N,Maman R,Zager Y.et al. Surgical outcomes of minimally invasive trephine surgery for pilonidal sinus disease with and without laser therapy: a comparative study Tech Coloproctol. 2023 28 13

[17] Khalilieh S,Horesh N,Cordoba M.et al. Surgical outcomes of minimally invasive trephine surgery for pilonidal sinus disease and risk factors for recurrence J Laparoendosc Adv Surg Tech A. 2022 32 288 92

[18] Bi S,Sun K,Chen S,Gu J. Surgical procedures in the pilonidal sinus disease: a systematic review and network meta-analysis Sci Rep. 2020 10 13720 PMC7426950

[19] McCallum I,King PM,Bruce J. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus Cochrane Database Syst Rev. 2007 CD006213

[20] Milone M,Fernandez LM,Musella M,Milone F. Safety and efficacy of minimally invasive video-assisted ablation of pilonidal sinus: a randomized clinical trial JAMA Surg. 2016 151 547 53

[21] Pronk AA,Smakman N,Furnee EJB. Short-term outcomes of radical excision vs. phenolisation of the sinus tract in primary sacrococcygeal pilonidal sinus disease: a randomized-controlled trial Tech Coloproctol. 2019 23 665 73

[22] Algazar M,Zaitoun MA,Khalil OH,Abdalla WM. Sinus laser closure (SiLaC) versus Limberg flap in management of pilonidal disease: a short-term non-randomized comparative prospective study Asian J Surg. 2022 45 179 83

[23] Romic I,Augustin G,Bogdanic B,Bruketa T,Moric T. Laser treatment of pilonidal disease: a systematic review Lasers Med Sci. 2022 37 723 32

[24] Harlak A,Mentes O,Kilic S,Coskun K,Duman K,Yilmaz F. Sacrococcygeal pilonidal disease: analysis of previously proposed risk factors Clinics (Sao Paulo). 2010 65 125 31 2827697