The American Society of Colon and Rectal Surgeons’ Clinical Practice Guidelines for the Management of Pilonidal Disease

Abstract

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made rather than to dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM Pilonidal disease is a potentially debilitating condition affecting ~70,000 patients annually in the United States alone.2 Although there are conflicting etiological theories, the current consensus holds that pilonidal disease is an acquired condition intimately related to the presence of hair in the gluteal cleft.3 Loose hairs trapped in the natal cleft traumatize and penetrate the skin, creating a foreign body reaction that may ultimately lead to formation of midline pits and, in some cases, secondary infection.4 The spectrum of pilonidal disease presentation varies from a chronic cyst and/or sinus with persistent drainage and/or extensive subcutaneous tracts to the more acute presentation of an associated abscess. Numerous treatment options are available that include but are not limited to gluteal cleft hair removal, tract ablation, simple excision, and wide excision with flap reconstruction. This clinical practice guideline will focus on the evaluation and management of pilonidal disease. METHODOLOGY PubMed was used to search MEDLINE for all of the entries included between November 1945 and November 2017 and limited to humans and English language. Search terms included the MEDLINE subject heading pilonidal sinus and the subheadings anatomy/histology, diagnosis, diagnostic imaging, surgery, and therapy, which provided 1022 titles. The PubMed search term pilonidal abscess, also with limitations to humans and English language, provided an additional 174 titles. One additional article was added after the initial search was completed. These 1197 titles (including Cochrane Systemic Database Reviews) were reviewed, duplicate references were resolved, and 1075 titles remained for initial review. Of these 1075 titles, 191 were excluded because of incorrect publication type (n = 27 titles) or subject matter (n = 164). This resulted in 885 unique references that were presented to the authors for additional review. Additional review resulted in exclusion of 548 titles because of ≥1 of the following reasons: wrong study design, wrong publication type, outdated data, wrong study population, or background article. The remaining 337 references were directly reviewed, ultimately yielding 115 references for inclusion (Fig. 1). Prospective, randomized controlled trials and meta-analyses were given preference in developing these guidelines. Directed searches of the embedded references from the primary articles were also performed in certain circumstances. The final source material used was evaluated for the methodologic quality, the evidence base was examined, and a treatment guideline was formulated by the subcommittee for this guideline. The final grade of recommendation was performed using the Grade of Recommendation, Assessment, Development, and Evaluation system1 (Table 1). Members of the ASCRS Clinical Practice Guidelines Committee worked in joint production of these guidelines from inception to final publication. Recommendations formulated by the subcommittee were then reviewed by the entire Clinical Practice Guidelines Committee for edits and recommendations. Final recommendations were approved by the ASCRS Clinical Guidelines Committee and ASCRS Executive Committee. In general, each ASCRS Clinical Practice Guideline is updated every 3 to 5 years.FIGURE 1.: A flow chart illustrating the search strategy for pilonidal disease. CPG, clinical practice guidelines.TABLE 1.: The GRADE system: grading recommendationsINITIAL EVALUATION 1. A disease-specific history and physical examination should be performed, emphasizing symptoms, risk factors, and presence of secondary infection. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C. The diagnosis of pilonidal disease is most often a clinical one, based on patient history and physical findings in the gluteal cleft, especially in patients with chronic or recurrent disease. However, it is important to distinguish pilonidal disease from alternative diagnoses, such as hidradenitis suppurativa, infected skin furuncles, Crohn’s disease, perianal fistula, and infectious processes, including tuberculosis, syphilis, and actinomycosis.5 On examination, those with pilonidal disease will almost always have characteristic midline pits in the gluteal cleft. In addition, although in the acute setting patients may present with cellulitis or a painful, fluctuant mass indicating the presence of an abscess, the chronic state is most often associated with chronic draining sinus disease in the intergluteal fold. Midline pits are often associated with subcutaneous tracts, most of which course cephalad, although some may course in a caudal direction and may be confused with anorectal fistulas. Special attention should be directed toward identification of concomitant cellulitis or an acute abscess to direct additional therapy. It is also important to perform a thorough anorectal examination to evaluate for concomitant fistulous disease, Crohn’s disease, or other anorectal pathology.5 Although malignant degeneration of chronic pilonidal disease has been described, it is extremely rare but may be slightly more common in the immunosuppressed.6,7 If skin lesions have a suspicious appearance, biopsy should be performed. Also, although not constituting a direct cause-and-effect relationship, risk factors associated with pilonidal disease include obesity, a sedentary lifestyle, repetitive trauma or irritation to the gluteal cleft skin, familial history of pilonidal disease, and a hirsute body habitus.2,3,8,9 Identification of these traits may direct counseling or aid in promoting lifestyle modifications. A positive family history of pilonidal disease is a risk factor for disease and may be associated with a higher recurrence rate after surgery.10 Adjunctive laboratory or radiological examinations are not routinely necessary. TREATMENT Nonoperative Therapy/ Nonoperative Adjuncts 1. Elimination of hair from the gluteal cleft and surrounding skin, by shaving or laser epilation, may be used for both acute and chronic pilonidal disease in the absence of abscess as a primary or adjunct treatment measure. Grade of Recommendation: Weak recommendation based on low-quality evidence, 1C. The rationale to support elimination of hair in the gluteal cleft relates to the significance of cleft hair in the development of pilonidal disease. Although it remains unclear whether the development of pilonidal disease is secondary to local pressure on the tissues, ruptured hair follicles, hypoxic tissue beds, or a congenital vulnerability of the natal skin, this central role of cleft hair in the pathogenesis has led to the expanded use of local shaving.4,11,12 Shaving or laser epilation can serve as an adjunct treatment in active disease, as the sole agent of therapy, or as a preventative tool in the setting of chronic sinus disease to avoid recurrent flares and abscess formation. Primary treatment of acute pilonidal disease, with limited lateral incision and drainage (I&D) or cyst excision, combined with surgeon-performed shaving along the intergluteal fold and surrounding region, promotes healing and prevents disease recurrence. Shaving should be repeated every 1 to 2 weeks until healing occurs and in combination with hygiene enforcement.13 After excisional procedures for chronic pilonidal disease, surgeon-performed hair shaving every 1 to 2 weeks until healing occurs and subsequent patient-performed shaving after healing occurs have also proven beneficial in preventing disease recurrence.14,15 However, patient-performed shaving in the immediate postexcision period has been associated with an increase in pilonidal disease recurrence.16 Although this limits the ability to determine its exact contribution to overall healing, shaving is safe with, at most, minimal additional morbidity. While the most effective frequency and extent of shaving have yet to be clarified, we suggest at least weekly. When an abscess is present, this should be addressed surgically, although shaving can play an adjunctive role postoperatively, especially given the relative simplicity, potentially beneficial role, and limited downside to its use. As an adjunct to surgical treatment, neodymium-doped yttrium aluminum garnet or alexandrite laser epilation has resulted in minimal (≤13%) recurrence of pilonidal disease.17–20 When used as the primary treatment for initial or recurrent presentations of pilonidal disease, laser epilation has resulted in durable healing in 44% to 100% of patients who were treated in small, nonrandomized studies.21,22 Laser epilation may require local anesthetic and often requires multiple treatments. The level and quality of evidence regarding this modality are insufficient to date to assess the significance or provide a general recommendation for this technique. 2. In patients with acute or chronic pilonidal disease without abscess, phenol application is an effective treatment that may result in rapid and durable healing. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B. In addition to depilatory measures, other nonoperative techniques have been described for chronic pilonidal disease. The application of crystalized phenol to the cyst and tracts that are present in acute or chronic pilonidal disease has been performed in the outpatient setting, with local anesthesia, and has resulted in minor complications (infection and skin burns) in <15% of patients, resolution of disease in 67% to 100% of patients, and elimination of recurrence in ≥80% of patients.23–28 In general, the treatment procedure involves hair removal and curettage of the cyst and the application of 1 to 3 mL of crystallized phenol into the cyst and associated tracts. One to 4 procedures are most often to healing. In 1 laser epilation performed phenol application resulted in 100% healing of pilonidal In a randomized of phenol treatment or surgical excision, with healing or healing in 100% of patients in each treatment but more rapid healing, and to in patients who phenol treatment. In this pilonidal disease recurrence was in and of the phenol and = in the setting of recurrent chronic sinus disease, phenol and local depilatory application on a have subsequent recurrence at In patients with chronic pilonidal disease without abscess, may be effective as a primary or adjunctive treatment of pilonidal disease. Grade of Recommendation: Weak recommendation based on moderate-quality evidence, to its role in perianal has also been used in the setting of both chronic and recurrent pilonidal sinus disease. In multiple or has been used to the and sinus tracts after pilonidal cyst excision and skin flap to the by sinus excision without or to the after curettage of pilonidal These each included to patients with pilonidal disease and described healing at 2 to weeks with minor complications and rare disease recurrence. with the procedure is and the are to to 2 weeks of the A that included patients with primary pilonidal disease, the flap with or without the demonstrated that all of the patients in the without evidence of recurrence at and drainage and randomized of patients with primary pilonidal disease treated with a flap with a flap with the flap demonstrated treatment with healing in all of the patients but 4 in the these a 2017 Cochrane review that the evidence for of in the treatment of pilonidal disease is of the the of the nonoperative treatment strategy remains to all of the hair and that potentially to a chronic the After removal of the the phenol or application tissue and additional sinus On the of local hair removal techniques to of hair in the natal cleft a of overall and high-quality it to determine the exact that these options will ultimately have in the management of this disease. The of and in pilonidal disease is not of use is Grade of Recommendation: Weak recommendation based on moderate-quality evidence, The use of for pilonidal disease has been evaluated in 3 treatment, and use. In the role, patients who pilonidal excision and primary were to a of excision and primary there were with in terms of or healing 4 weeks In a study of patients that a of was associated with a surgical rate after excision and primary for pilonidal of may be In a small, study of patients primary a of or both and and 5 of The demonstrated in the at 4 weeks of in healing was in a of and of and after excision and primary In the setting, of have although are As an adjunct to primary in chronic pilonidal disease those to by secondary there were in healing or recurrence was given Of the 3 secondary was associated with On the other the addition of for or with after excision and secondary healing of a chronic pilonidal sinus tract a slightly healing in the with those without Additional using of a of and have to any In patients flap for pilonidal disease, a randomized of and in terms of surgical of or disease recurrence as with and conflicting on the use of in the treatment of pilonidal disease. One demonstrated higher after excision of chronic disease or acute pilonidal abscess and with an with primary than those without the the of the not be from the role of the material A more study primary a secondary healing healing and overall in the primary study the of the that there was to the without In a review and the use of a resulted in a toward and on healing or disease Adjunctive use should be in the setting of or concomitant limited evidence in this specific 1. with acute pilonidal disease by the presence of an abscess should be treated with of whether it is a primary or Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B. pilonidal disease is as the presence of a pilonidal abscess with or without associated Although patients with chronic disease may present with pilonidal sinus disease, an abscess in this setting with and with an of and local As with any abscess, the of treatment is surgical which involves creating an incision the of without the midline healing simple for acute pilonidal the remaining patients a procedure to initial healing, simple is associated with an to recurrence to to the and sinus tracts that to to have a on recurrence after surgical excision at its use in acute disease. The that and tissue play on recurrence and healing are The and curettage procedure is a for pilonidal abscess that potentially the for a In a randomized of acute with or without curettage of the abscess and removal of the curettage was associated with healing at weeks = and of recurrence This was in a of the and curettage which demonstrated a recurrence rate of with a rate of and was in both acute and chronic pilonidal The presence of active acute abscess, in the setting of pilonidal excision is to healing and recurrence However, although the are the use of local excision of both the abscess and the midline pits the treatment of the acute pilonidal abscess, which healing by secondary as a of all for disease, has not been to recurrence of or overall of is limited evidence to suggest that patients treated with local excision of tissue a toward = In an additional to the to healing, primary has been used after excision in the acute abscess. In a of excision of the acute pilonidal and pits with healing by secondary of the abscess by cyst excision and primary at 3 there was in disease recurrence between the 2 after although demonstrated the primary with a higher recurrence was in or healing 2. who require for chronic pilonidal disease may excision and primary for excision with healing by secondary or excision with based on and patient use should be Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B. excision is the treatment for chronic pilonidal cyst and sinus disease and is into 2 excision of tissue with primary (including flap excision with healing by secondary (including excision with primary midline excision with healing by secondary there is a toward healing after primary in multiple randomized In addition, patients excision with healing by secondary a from with those excision with primary of This is a result of not healing but also a of and a for care with these primary has certain Although using primary have demonstrated recurrence of this is not the as the Cochrane review primary midline is associated with a higher recurrence rate than after healing by secondary with a recurrence rate of after primary with secondary they that healing by secondary recurrence by with primary individual including that directly midline primary with healing, demonstrated an in the risk of recurrent disease after healing by secondary with primary after the surgical between primary and those by secondary are and of a primary incision not to are available directly the of excision with primary Primary was to have healing disease recurrence were One demonstrated in each the in the in after primary the recurrence with at the of slightly to primary were in primary midline healing by secondary and Additional with wide local excision that was associated with to healing by a of with and a randomized of healing by secondary healing with demonstrated in to healing, in a study The that to provide a is to the rather than direct midline primary This has demonstrated healing of and recurrence However, recurrence varies based on the primary procedure performed, with a a higher recurrence rate in those with primary midline of with and flap with the recurrence rate at any this most often requires and with we that it should to the of the and the patient to determine the and with each on a use has been described after primary both for and the One nonrandomized study in chronic pilonidal disease that after primary was associated with of and of healing, although recurrence were Additional using for 2 to after primary demonstrated with directly to the and a rate of When used in with flap are associated with a in but in use on a procedures may be performed, especially in the setting of and recurrent chronic pilonidal disease other techniques have Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B. In the setting of chronic pilonidal disease, often with surgical treatment have the of the disease tissue for the from wide with the of the of the natal cleft as a to additional disease recurrence has been in both the primary and recurrent Numerous flap techniques have been described, although of each in the of this guideline. The or in which all of the skin and are to with of a flap and that in of the gluteal cleft, has been used in the treatment of pilonidal disease. are with to disease recurrence and patient of this surgical procedure include a of tissue risk of and Although from randomized trials overall of surgical a randomized controlled a rate of associated with this type of Although of these were and the on to without they require are randomized trials that between flap methods or an of flap in terms of disease as as such as quality of and patient The flap is an additional based on excision of tissue from the midline with tissue in the form of a flap to the with lateral to recurrence in the reviewed of patients treated with this in with a recurrence rate and complications in nonrandomized complications in and recurrence in findings have been in using this local with additional both and to be of In randomized controlled the procedure with healing, the resulted in a to recurrence rate and to at a of 3 to 4 These were to the alternative of healing by secondary to the the to all with minimal removal of tissue by creating a the or the natal cleft. and healing in all patients in a of recurrent pilonidal The study of patients with pilonidal disease in a healing Additional have these findings with healing of to in both the primary and recurrent Additional have demonstrated the in the primary setting as with of healing and of recurrence as other of lateral with midline excision and A randomized study quality of the was with the other have been used for pilonidal disease, including the and which are surgical that have been used to provide tissue for of the healing, and disease recurrence have been in of patients with although these are not The has been described in but with higher of complications and disease recurrence than the other flap Prospective, randomized with excision with or without demonstrated a for additional surgical treatment after with healing by secondary Additional randomized the with excision and secondary healing, of surgical recurrence and overall of which procedure is we on these should additional to the expertise and to is body of evidence that the overall of flap Surgeons must use judgment as to which best in any given and that must be with and in any to acute and chronic pilonidal disease that use or may be used but require and Grade of Recommendation: Weak recommendation based on moderate-quality evidence, In 2 methods of treatment of pilonidal disease, pilonidal sinus treatment and of pilonidal sinus were These initial a recurrence rate of to at to of and a rapid to or The procedures are based on removal of hair and from all of the tracts with of the tracts. This is the pits in minimal incision with minimal to initial study with A study of pilonidal sinus treatment patients with chronic disease and a healing rate by with a recurrence were whether the procedure was performed as a primary or secondary A randomized controlled with the procedure in patients with of a to to as as and patient in the the authors not any rate or recurrence rate for that a was from which to A a study on use of the combined with the use of a 100% rate at of in techniques may to be effective the term but require and on which to recommendations regarding the of these techniques any of Pilonidal 1. for recurrent pilonidal disease should distinguish between the presence of an acute abscess and chronic disease the and expertise of the Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C. and pilonidal disease to be a for both the patient and and should be to this this disease a wide rate of recurrence after initial as as described surgical procedures for treatment of disease, it may to there is a of a treatment strategy for primary pilonidal disease. after secondary and procedures are as effective treatment for the management of recurrent disease. However, because recurrent presentations may a the to to of chronic to include and In general, the and of the patient and and expertise of the will Although recurrence remains a common as by the recurrence for surgical procedures in these there remains a relative of evidence to directly the treatment of recurrent disease. this for the patient with recurrence in is to the to include a of may a in the outpatient management of recurrent disease. In addition, recurrent should be as they were In the of recurrence or pilonidal sinus disease, the should be a treatment strategy that the patient to a lifestyle as as procedures may be local or multiple drainage procedures have been performed or a may be with evidence for that included recurrent patients a flap with a flap demonstrated a rate recurrence and to using the randomized including both and recurrent patients that is using excision with primary and excision with secondary for these we that patients be based on both the presentation acute abscess, or subcutaneous and the and expertise of the Although we specific evidence in the setting of pilonidal disease it is that risk factors for surgical such as and obesity, be on