Outcome Following Surgical Treatment for Chronic Pilonidal Sinus Disease: A Systematic Review of Common Surgical Techniques.

Background: The choice of operation for chronic pilonidal sinus disease remains controversial.

Objective: To compare the outcomes of common operations for chronic pilonidal disease.

Data sources: We searched PubMed, Embase, and Cochrane Library.

Study selection: We included randomized trials in English or Danish language, published 2002-2024 comparing operations treating chronic pilonidal disease in adults and teenagers.

Interventions: We compared the outcomes of secondary healing, primary midline closure, Bascom's-, Limberg's- and Karydakis' flap operations.

Main outcome measures: The primary outcome was recurrence; secondary outcomes were infection, healing time, and length-of-stay. We compared recurrence and infection rates in meta-analyses for all techniques. We assessed the risk-of-bias and the quality of all trials.

Results: Fifty trials included a total of 5762 participants. In a meta-analysis, the flap-operations had fewer recurrences than primary midline closure (OR 0.31 (95% CI, 0.19 to 0.51, p < 0.01). The trials comparing Flap-operations with secondary healing were heterogeneous and did not reach significance (OR 0.38 (95% CI, 0.13 to 1.13, p = 0.08). Recurrence was similar between Limberg's- and Karydakis' operations. Infection rates were lower for the flap-operations compared with primary closure (OR 0.33 (95% CI, 0.23 to 0.48, p < 0.01) and with secondary healing (OR 0.48 (95% CI, 0.30 to 0.77, p < 0.01). Two trials tested Bascom's procedure against Limberg's operation without significant differences. All trials found secondary healing to have significantly longer healing times than any other operation.

Limitations: Most studies had a high or medium risk-of-bias, resulting in very-low to low certainty of evidence. The trials generally had small numbers, short follow-ups, and no reported primary outcomes or power calculations.

Conclusions: Primary closure and secondary healing performed poorly compared with the flap techniques. Most trials tested Limberg's operation; only 2 tested Bascom's operation. The literature suggests the surgeon's expertise determines the choice of flap technique.