Wundheilungsstörungen nach Exzision und offener Behandlung eines Sinus pilonidalis

Zusammenfassung

Einleitung Der Sinus pilonidalis ist eine meist chronische punktuelle Infektion der behaarten Haut im Bereich von Hautfalten, überwiegend im Bereich der Rima ani. Die offene Wundbehandlung stellt hierbei nach wie vor die am häufigsten durchgeführte Therapiemaßnahme dar. Dennoch kann es im Rahmen der offenen Wundbehandlung zu Heilungsstörungen kommen, die den Verlauf erheblich komplizieren können.

Methoden Im Folgenden wird eine Übersicht über Wundheilungsstörungen nach Exzision eines Sinus pilonidalis gegeben. Dabei werden die Heilungsdauer und Häufigkeit anhand aktueller Daten ermittelt und die Ursachen der Heilungsstörungen evaluiert. Des Weiteren werden mögliche Behandlungsoptionen dargestellt und Behandlungsempfehlungen abgegeben.

Ergebnisse Die Auswertung publizierter Daten zur Wundheilungsdauer ergab, dass die Wunden nach durchschnittlich 2 Monaten verheilt sind. Die Ergebnisse der Bundeswehrkohortenstudie zeigen exemplarisch, dass im Zeitraum bis zu 3 Monaten nahezu alle Wunden verheilt sind. Es verbleibt jedoch ein geringer Prozentsatz an nicht verheilenden Wunden. Die Häufigkeit von erheblich verzögerter Wundheilung wird in der Literatur mit 2 – 5% angegeben. Die Einflussfaktoren auf die Wundheilung nach Sinus-pilonidalis-Exzision sind neben der Größe und Symmetrie der Exzisionswunde auch weitere Details der offenen Wundbehandlung. Als Therapieoptionen bei ausbleibender Wundheilung werden neben Intensivierung der vormaligen offenen Wundbehandlung die neuerliche Exzision und Anfrischung der Wunde genannt. Des Weiteren werden aber auch Strategiewechsel zur plastisch-rekonstruktiven Versorgung bzw. zu einer anderen Oberflächenbehandlung empfohlen.

Schlussfolgerung Die Exzisionswunde eines Sinus pilonidalis sollte spätestens nach 3 – 4 Monaten verheilt sein, danach kann die Wunde als signifikant verzögert heilende Wunde bzw. als Wundheilungsstörung angesehen werden. Etwa zu diesem Zeitpunkt sollte der Befund erneut evaluiert und ggf. ein Wechsel des Behandlungskonzeptes vorgenommen werden.

Abstract

Introduction Pilonidalis sinus disease is a mostly chronic selective infection of the hairy skin in the area of skin wrinkles, mainly in the area of the natal cleft. Open treatment is still the most common recommended therapy. Nevertheless, there may be healing disorders within the framework of open wound treatment, which can significantly complicate the course.

Methods The following is an overview of wound healing disorders after excision of pilonidalis sinus. Healing time and frequency are determined on the basis of current data and the causes of the healing disorder are evaluated. In addition, possible treatment options are presented and treatment recommendations are made.

Results The evaluation of published data on wound healing period showed that the wound usually heals after a mean of two months. The results of the German forces cohort study show by way of example that almost all wounds have healed in the period up to three months. However, a small percentage of non-healing wounds remain. The frequency of significantly delayed wound healing is given in the literature as 2 – 5%. The influencing factors for wound healing after sinus pilonidalis excision are not only the size and symmetry of the excision wound but also other details of open wound treatment. In addition to intensification of the previous open wound treatment, the new excision and refreshment of the wound are mentioned as treatment options in the event of a lack of wound healing. Furthermore, changes in strategy for plastic-reconstructive procedures or other surface treatment are also recommended.

Conclusion The excision wound of pilonidalis sinus should be healed after three to four months at the latest, after which the wound can be regarded as a wound with significantly delayed healing or as a wound healing disorder. Around this time, the findings should be re-evaluated and, if necessary, a change in the treatment concept should be made.

Schlüsselwörter

Pilonidalsinus - Exzision - primär offene Wunde - offene Wundbehandlung - Wundheilungsstörung - Wundheilung

Key words

pilonidal sinus - excision - primary open wound - wound healing - open wound care - delayed wound healing

• Literatur

• 1 Iesalnieks I, Ommer A, Petersen S. et al. German national guideline on the management of pilonidal disease. Langenbecks Arch Surg 2016; 401: 599-609 doi:10.1007/s00423-016-1463-7
• 2 Doll D, Krueger CM, Schrank S. et al. Timeline of recurrence after primary and secondary pilonidal sinus surgery. Dis Colon Rectum 2007; 50: 1928-1934 doi:10.1007/s10350-007-9031-4
• 3 Marks J, Harding KG, Hughes LE. et al. Pilonidal sinus excision–healing by open granulation. Br J Surg 1985; 72: 637-640
• 4 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 doi:10.1038/s41598-018-20143-4
• 5 McCallum IJ, King PM, Bruce J. Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis. BMJ 2008; 336: 868-871 doi:10.1136/bmj.39517.808160.BE
• 6 Gaiser MR, Lee SB, Enk A. et al. Surgical intervention of pilonidal sinus: impact on patientsʼ postoperative satisfaction and return to work time. Eur J Dermatol 2013; 23: 487-490 doi:10.1684/ejd.2013.2052
• 7 Olsson M, Jarbrink K, Divakar U. et al. The humanistic and economic burden of chronic wounds: A systematic review. Wound Repair Regen 2019; 27: 114-125 doi:10.1111/wrr.12683
• 8 Doll D, Friederichs J, Dettmann H. et al. Time and rate of sinus formation in pilonidal sinus disease. Int J Colorectal Dis 2008; 23: 359-364 doi:10.1007/s00384-007-0389-5
• 9 Berry DP, Harding KG, Stanton MR. et al. Human wound contraction: collagen organization, fibroblasts, and myofibroblasts. Plast Reconstr Surg 1998; 102: 124-131 discussion 132-124
• 10 Binnebösel M, Junge K, Schwab R. et al. Delayed wound healing in sacrococcygeal pilonidal sinus coincides with an altered collagen composition. World J Surg 2009; 33: 130-136 doi:10.1007/s00268-008-9748-9 discussion 137
• 11 Marks J, Harding KG, Hughes LE. Staphylococcal infection of open granulating wounds. Br J Surg 1987; 74: 95-97
• 12 Agren MS, Ostenfeld U, Kallehave F. et al. A randomized, double-blind, placebo-controlled multicenter trial evaluating topical zinc oxide for acute open wounds following pilonidal disease excision. Wound Repair Regen 2006; 14: 526-535 doi:10.1111/j.1743-6109.2006.00159.x
• 13 Baier PK, Baumgartner U, Furtwängler A. et al. [Therapy of the pilonidal sinus – primary wound closure or open wound after excision]. Zentralbl Chir 2002; 127: 310-314
• 14 Fazeli MS, Adel MG, Lebaschi AH. Comparison of outcomes in Z-plasty and delayed healing by secondary intention of the wound after excision of the sacral pilonidal sinus: results of a randomized, clinical trial. Dis Colon Rectum 2006; 49: 1831-1836 doi:10.1007/s10350-006-0726-8
• 15 Garg P, Garg M, Gupta V. et al. Laying open (deroofing) and curettage under local anesthesia for pilonidal disease: An outpatient procedure. World J Gastrointest Surg 2015; 7: 214-218 doi:10.4240/wjgs.v7.i9.214
• 16 Gencosmanoglu R, Inceoglu R. Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus: a prospective, randomized clinical trial with a complete two-year follow-up. Int J Colorectal Dis 2005; 20: 415-422 doi:10.1007/s00384-004-0710-5
• 17 Gupta PJ. Radiofrequency sinus excision. A simple technique for sacro-coccygeal pilonidal sinus disease. Saudi Med J 2005; 26: 1141-1142
• 18 Holmebakk T, Nesbakken A. Surgery for pilonidal disease. Scand J Surg 2005; 94: 43-46 doi:10.1177/145749690509400111
• 19 Jamal A, Shamim M, Hashmi F. et al. Open excision with secondary healing versus rhomboid excision with Limberg transposition flap in the management of sacrococcygeal pilonidal disease. J Pak Med Assoc 2009; 59: 157-160
• 20 Lorant T, Ribbe I, Mahteme H. et al. Sinus excision and primary closure versus laying open in pilonidal disease: a prospective randomized trial. Dis Colon Rectum 2011; 54: 300-305 doi:10.1007/DCR.0b013e31820246bf
• 21 Mohamadi S, Norooznezhad AH, Mostafaei S. et al. A randomized controlled trial of effectiveness of platelet-rich plasma gel and regular dressing on wound healing time in pilonidal sinus surgery: Role of different affecting factors. Biomed J 2019; 42: 403-410 doi:10.1016/j.bj.2019.05.002
• 22 Perruchoud C, Vuilleumier H, Givel JC. Pilonidal sinus: how to choose between excision and open granulation versus excision and primary closure? Study of a series of 141 patients operated on from 1991 to 1995. Swiss Surg 2002; 8: 255-258
• 23 Prieto JM, Checchi KD, Kling KM. et al. Trephination versus wide excision for the treatment of pediatric pilonidal disease. J Pediatr Surg 2020; 55: 747-751 doi:10.1016/j.jpedsurg.2019.06.014
• 24 Rao MM, Zawislak W, Kennedy R. et al. A prospective randomised study comparing two treatment modalities for chronic pilonidal sinus with a 5-year follow-up. Int J Colorectal Dis 2010; 25: 395-400 doi:10.1007/s00384-009-0804-1
• 25 Testini M, Piccinni G, Miniello S. et al. Treatment of chronic pilonidal sinus with local anaesthesia: a randomized trial of closed compared with open technique. Colorectal Dis 2001; 3: 427-430
• 26 Varnalidis I, Ioannidis O, Paraskevas G. et al. Pilonidal sinus: a comparative study of treatment methods. J Med Life 2014; 7: 27-30
• 27 Viciano V, Castera JE, Medrano J. et al. Effect of hydrocolloid dressings on healing by second intention after excision of pilonidal sinus. Eur J Surg 2000; 166: 229-232 doi:10.1080/110241500750009339
• 28 Allen-Mersh TG. Pilonidal sinus: finding the right track for treatment. Br J Surg 1990; 77: 123-132
• 29 Sievert H, Evers T, Matevossian E. et al. The influence of lifestyle (smoking and body mass index) on wound healing and long-term recurrence rate in 534 primary pilonidal sinus patients. Int J Colorectal Dis 2013; 28: 1555-1562 doi:10.1007/s00384-013-1731-8
• 30 Doll D, Petersen S. Recurrence and wound healing disorders–two pairs of shoes. Am J Surg 2008; 195: 556 doi:10.1016/j.amjsurg.2007.05.039
• 31 Jockenhofer F, Gollnick H, Herberger K. et al. Aetiology, comorbidities and cofactors of chronic leg ulcers: retrospective evaluation of 1 000 patients from 10 specialised dermatological wound care centers in Germany. Int Wound J 2016; 13: 821-828 doi:10.1111/iwj.12387
• 32 Harris C, Sibbald RG, Mufti A. et al. Pilonidal Sinus Disease: 10 Steps to Optimize Care. Adv Skin Wound Care 2016; 29: 469-478 doi:10.1097/01.ASW.0000491324.29246.96
• 33 Harris CL, Laforet K, Sibbald RG. et al. Twelve common mistakes in pilonidal sinus care. Adv Skin Wound Care 2012; 25: 324-332 doi:10.1097/01.ASW.0000416004.70465.8a quiz 333-324
• 34 Buie LA, Curtiss RK. Pilonidal disease. Surg Clin North Am 1952; 32: 1247-1259
• 35 Doll D, Bosche F, Hauser A. et al. The presence of occipital hair in the pilonidal sinus cavity-a triple approach to proof. Int J Colorectal Dis 2018; 33: 567-576 doi:10.1007/s00384-018-2988-8
• 36 Webb PM, Wysocki AP. Does pilonidal abscess heal quicker with off-midline incision and drainage?. Tech Coloproctol 2011; 15: 179-183 doi:10.1007/s10151-011-0684-6
• 37 Chaudhuri A, Bekdash BA, Taylor AL. Single-dose metronidazole vs. 5-day multi-drug antibiotic regimen in excision of pilonidal sinuses with primary closure: a prospective, randomized, double-blinded pilot study. Int J Colorectal Dis 2006; 21: 688-692 doi:10.1007/s00384-005-0064-7
• 38 Ypsilantis E, Carapeti E, Chan S. The use of topical 10 % metronidazole in the treatment of non-healing pilonidal sinus wounds after surgery. Int J Colorectal Dis 2016; 31: 765-767 doi:10.1007/s00384-015-2269-8
• 39 Gordon KJ, Hunt TM. Osteomyelitis as a complication of a pilonidal sinus. Int J Colorectal Dis 2016; 31: 155-156 doi:10.1007/s00384-015-2184-z
• 40 Iesalnieks I, Deimel S, Zulke C. et al. Smoking increases the risk of pre- and postoperative complications in patients with pilonidal disease. J Dtsch Dermatol Ges 2013; 11: 1001-1005 doi:10.1111/ddg.12140
• 41 Al-Khayat H, Al-Khayat H, Sadeq A. et al. Risk factors for wound complication in pilonidal sinus procedures. J Am Coll Surg 2007; 205: 439-444 doi:10.1016/j.jamcollsurg.2007.04.034
• 42 Kasim K, Abdlhamid NM, Badwan BR. et al. Is There a Relation Between Natal Cleft Depth and Post-Operative Morbidity After Different Methods of Excision of Sacro-Coccygeal Pilonidal Sinus?. Indian J Surg 2015; 77: 201-205 doi:10.1007/s12262-012-0762-7
• 43 Martin P, Nunan R. Cellular and molecular mechanisms of repair in acute and chronic wound healing. Br J Dermatol 2015; 173: 370-378 doi:10.1111/bjd.13954
• 44 Biter LU, Beck GM, Mannaerts GH. et al. The use of negative-pressure wound therapy in pilonidal sinus disease: a randomized controlled trial comparing negative-pressure wound therapy versus standard open wound care after surgical excision. Dis Colon Rectum 2014; 57: 1406-1411 doi:10.1097/DCR.0000000000000240
• 45 Jonas J, Blaich S, Bahr R. [The Limberg transposition flap in surgical therapy of chronic pilonidal sinus]. Zentralbl Chir 2000; 125: 976-981 doi:10.1055/s-2000-10076
• 46 Iesalnieks I, Deimel S, Schlitt HJ. Karydakis flap for recurrent pilonidal disease. World J Surg 2013; 37: 1115-1120 doi:10.1007/s00268-013-1950-8
• 47 Prassas D, Rolfs TM, Schumacher FJ. et al. Karydakis flap reconstruction versus Limberg flap transposition for pilonidal sinus disease: a meta-analysis of randomized controlled trials. Langenbecks Arch Surg 2018; 403: 547-554 doi:10.1007/s00423-018-1697-7
• 48 Petersen S, Koch R, Stelzner S. et al. Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Dis Colon Rectum 2002; 45: 1458-1467 doi:10.1097/01.DCR.0000029764.01110.5C
• 49 Bascom J, Bascom T. Utility of the cleft lift procedure in refractory pilonidal disease. Am J Surg 2007; 193: 606-609 doi:10.1016/j.amjsurg.2007.01.008 discussion 609