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S3-Leitlinie: Sinus pilonidalis

AWMF-Registriernummer: 081-009

S3 guidelines: pilonidal sinus

Association of the Scientific Medical Societies in Germany (AWMF) registration number: 081-009

  • Leitlinien
  • Published:
coloproctology Aims and scope

Zusammenfassung

Hintergrund

Der Sinus pilonidalis ist eine erworbene Erkrankung. Haare spielen bei der Pathogenese eine wichtige Rolle. Das Ziel dieser Leitlinie ist, die Vor- und Nachteile verschiedener Behandlungsverfahren aufzuzeigen und eine optimale evidenzbasierte Therapieempfehlung abzugeben.

Methode

Es wurde ein systematisches Review der Literatur vorgenommen. Die Aussagen der Leitlinie wurden auf einer Konsensuskonferenz verabschiedet.

Ergebnisse

Es können 3 Erscheinungsformen des Sinus pilonidalis differenziert werden: der blande Befund ohne stattgehabte Exsudation, der akut abszedierende und der chronische Sinus pilonidalis. Die häufigste Erscheinungsform des Pilonidalsinus ist das chronische Stadium mit intermittierenden Absonderungen. Zurzeit existiert keine Therapieoption, die alle Anforderungen an eine einfache, schmerzfreie Behandlung mit schneller Wundheilung und geringer Rezidivrate erfüllt.

Schlussfolgerung

Ein blander Sinus pilonidalis bedarf keiner Therapie. Bei der akut abszedierenden Form ist eine primäre Exzision möglich, der Vorteil des komplikationsarmen Verfahrens wird durch den Nachteil einer langen Wundheilung und möglicherweise höheren Rezidivrate erkauft. Es gibt Hinweise darauf, dass zunächst eine Abszessexzision und eine sekundäre Versorgung des Sinus pilonidalis durch eine der weiter unten beschriebenen Behandlungsmethoden vorteilhaft sind. Die Ergebnisse einer primären Rekonstruktion bereits im abszedierten Stadium sind aufgrund einer hohen Komplikationsrate nicht zufriedenstellend. Beim chronischen Sinus stellt die Exzision derzeit die Basisbehandlung dar. Die offene Wundbehandlung mit sekundärer Wundheilung ist hinsichtlich der Komplikationsrate ein sicheres Verfahren, das aber mit einer langen Wundheilungsdauer einhergeht. Die minimal-invasive Technik – das sog. Pit-Picking – stellt ebenfalls eine Behandlungsoption für die chronische Erscheinungsform dar, wobei mit einer höheren Rezidivrate im Vergleich zu den Exzisionstechniken gerechnet werden muss. Die Anwendung des Mittellinienverschlusses zur primären Wunddeckung ist in keiner Hinsicht zufriedenstellend und sollte vermieden werden. Alternativ sollten die plastischen (asymmetrischen) Techniken und Verschiebelappen verwendet werden. Ein eindeutiger Vorteil für eine dieser Techniken besteht nicht, wobei Limberg- und Karydakis-Lappen die derzeit am häufigsten angewendeten Verfahren sind.

Abstract

Background

The pilonidal sinus is an acquired disease of hair follicles. The aim of the present guidelines is to compare various treatment methods and to assist physicians with evidence-based recommendations.

Methods

A systemic literature review was carried out. The present guidelines were reviewed and accepted by a consensus conference.

Results

There are three types of disease manifestation: an asymptomatic condition, acute abscess and chronic pilonidal disease. The latter is the most frequent type of presentation. At present, there is no treatment method fulfilling all desired criteria: a simple, painless procedure associated with rapid wound healing and a low recurrence rate.

Conclusion

An asymptomatic pilonidal disease does not necessitate any treatment. A pilonidal abscess should initially be locally incised followed by one of the definitive treatment methods after regression of the acute inflammation. A primary complete excision of the abscess and open wound treatment is associated with a prolonged healing time. An excision of the pilonidal abscess and primary wound closure is associated with increased morbidity and recurrence rate and should be avoided. The basic treatment method of chronic pilonidal disease is surgical excision. Open wound treatment after pilonidal excision is associated with a low postoperative morbidity; however, this method is complicated by a considerably prolonged wound healing. Minimally invasive procedures (e.g. pit picking surgery) represent a treatment option for chronic pilonidal disease; however, the recurrence rate is higher compared to open procedures. Excision followed by a primary midline wound closure bears no advantages to other methods and should be avoided. An off-midline surgical approach can be adopted as a primary treatment option in chronic pilonidal disease. At present, there is no evidence of any outcome differences between various off-midline procedures. The Limberg flap and the Karydakis procedure are the two best described methods.

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    E. Berg, C. Breitkopf, D. Bussen, D. Doll, A. Fürst, A. Herold, F. Hetzer, T.H. Jacobi, H. Krammer, B.H. Lenhard, G. Osterholzer, S. Petersen, R. Ruppert, O. Schwandner, M. Sailer, T.H.K. Schiedeck, M. Schmidt-Lauber, M. Stoll, B. Strittmatter & I. Iesalnieks

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Ommer, A., Berg, E., Breitkopf, C. et al. S3-Leitlinie: Sinus pilonidalis. coloproctology 36, 272–322 (2014). https://doi.org/10.1007/s00053-014-0467-4

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