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The effect of obesity on the results of Karydakis technique for the management of chronic pilonidal sinus

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Abstract Background and aims. Body mass index (BMI) was assessed as an objective indicator of obesity to determine whether it has an effect on the results of the Karydakis technique for managing chronic pilonidal sinus. Patients and methods. The
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  International Journal of Colorectal Disease  DOI 10.1007/s00384-002-0407-6 Original Article The effect of obesity on the results of Karydakistechnique for the management of chronic pilonidal sinus Mahmoud Sakr( ) · Habashi El-Hammadi · Mohamed Moussa · Sobhi Arafa · Mohamed Rasheed M. Sakr · H. El-Hammadi · M. Moussa · S. Arafa · M. RasheedDepartment of Surgery, Faculty of Medicine, University of Alexandria, Ramleh Station, Alexandria, EgyptE-mail: mah_sakr@yahoo.comPhone: +20-3-5423145Fax: +20-3-4841189 Accepted: 16 April 2002 / Published online: Abstract Background and aims. Body mass index (BMI) was assessed as an objective indicator of obesity todetermine whether it has an effect on the results of the Karydakis technique for managing chronicpilonidal sinus. Patients and methods. The prospective study included 41 consecutive patients with chronic pilonidalsinus categorized according to their BMI as obese (BMI 26.5, n =32) or nonobese (BMI <26.5, n =9). Patient data included demographics, symptoms, duration of disease, previous management,postoperative course, morbidity, and recurrence. All patients were treated by the Karydakis flap andwere discharged on the 2nd-4th day postoperatively. Patients were followed-up for a mean of 25.7 months (range 3-38). Results. The mean operating time was significantly longer in obese patients, and there was a trend tomean hospital stay being longer in them than in nonobese patients. Minor postoperative complicationswere encountered in four patients: two in the obese group had a seroma that resolved in 2 weeks withconservative measures, and two others, one in each group, suffered from wound infection that resultedin partial wound dehiscence in the obese patient but healed with secondary intention after 20 dayswithout prolonging hospital stay. In the obese group the mean BMI of patients with complications(excluding recurrence) was significantly higher than that in patients without complications. - 1 -  Recurrence, at 13 months postoperatively, was observed in only one patient (3.1%) who had a BMI of 32.2. Conclusion. These findings show that (a) the Karydakis procedure for managing chronic pilonidalsinus in obese patients is easy to perform, has a fast healing time, short hospital stay, rapid return towork, and a low recurrence rate, (b) the results are similar between nonobese and obese patients, withno recurrence seen in these patients, and (c) complications occur in patients with a BMI greater than30; in such patients a dietary regimen before operation is advisable, and inserting a suction drainduring operation is recommended to avoid seroma formation. Keywords. Karydakis - Pilonidal - Sinus - Obesity Introduction Many procedures have been described for the management of pilonidal sinus, none of which is perfect, judged by the yardsticks of primary healing and disease recurrence [ 1 ]. The ideal treatment would beone involving only minimal surgery and minimal absence of the patient from work. An operation thatresults in rapid healing of the wound, abolition of sepsis, and no recurrence is therefore the ultimateaim. Karydakis [ 2 , 3 ] has described a technique of asymmetric natal cleft wound closure for thetreatment of pilonidal sinus that has a success rate greater than 90%.Obesity has long been suspected of being a relative contraindication to the performance of somesurgical procedures. There is some justification for this since increased morbidity and mortality havebeen documented in obese patients undergoing general surgical procedures [ 4 , 5 , 6  , 7  ]. The presentstudy assessed the use of the body mass index (BMI) as an objective indicator of obesity to determinewhether it has an the effect on the results of Karydakis technique for the management of chronicpilonidal sinus regarding wound healing, hospital stay, postoperative morbidity, and recurrence of the disease. Patients and methods This study included 41 consecutive patients with chronic pilonidal sinus admitted to the Department of Surgery at Alexandria University between 1998 and 2001. Patient data were collected prospectivelyand included demographics, symptoms, duration of disease, previous management, postoperativecourse, morbidity and recurrence. Written consent was obtained from patients, and the study protocolwas approved by the ethics committee of the Faculty of Medicine, Alexandria University.Patients were categorized as obese (BMI 26.5) or nonobese (BMI <26.5, n =9). There were 32obese patients, including 27 men and 5 women (84%/16%), with a mean age of 28.5±5.85 years (range19-48) and BMI of 28.2±0.72 (26.6-32.2). In the nonobese group there were 9 patients, including 8men and 1 woman (89%/11%), with a mean age of 26.8±6.94 years (22-43) and BMI of 23.43±0.88(22.5-26.2). There were no statistically significant differences between the two groups in demographicdata or in clinical presentation. Clinical features of the patients are presented in Table 1. The mostfrequent presenting symptom was seropurulent discharge, being present in 17 obese patients (53%)and 5 nonobese patients (56%). Other symptoms included pain, local swelling, and bleeding. Themean duration of the present disease was 31.6 months (range 12-45). In the obese group a singlefistula was identified upon admission in 15 patients (47%), and two or more in 17 patients (53%),compared to 4 (44%) and 5 (56%) patients in the nonobese group, respectively. The treatment receivedby patients before admission included antibiotics for minor discharge or inflammation in 23 (56%), - 2 -  surgical drainage of pus for acute abscess in 9 (22%), and surgery performed at other hospitals in 7 (17%). Table 1.  Clinical characteristics of the obese and nonobese patients ( n.a.  not applicable)Obese (n=32)Nonobese (n=9) n %  n % P  (  2 ) Symptoms Seropurulent discharge1753.13555.56 Pain1237.50333.340.803 Local swelling26.25111.11n.a. Bleeding13.1200.00n.a.Duration of symptoms 1-2 years412.50111.110.643 2-3 years2681.25777.780.807 3 years26.25111.11n.a.Number of openings One1546.87444.450.803 Two618.75333.330.632 Three618.75111.110.971 Four39.38111.11n.a. Five26.2500.00n.a.Previous management Antibiotics alone1959.37444.450.676 Incision and drainage721.88222.220.665 Surgery (open method)412.533.33n.a. None26.2500.00n.a.All patients were treated by the Karydakis flap, described in detail elsewhere [ 2 , 3 ]. Briefly, surgerywas performed under spinal anesthesia with the patient positioned prone and with the buttocksstrapped apart. An ellipse is based on the side of any secondary opening or induration; if the sinus isentirely central, either side may be chosen. Each end of the ellipse is placed 2 cm to one side of themidline. Probing of the sinus and insertion of methylene blue helps to ascertain the extent of the sinusso that the whole sinus, and its ramifications can be fully excised down to the sacral fascia withoutinadvertent contamination of the wound by opening the track. The medial side of the wound is thenundercut a distance of 2 cm at a depth of one cm to produce a flap extending the full length of thewound. A layer of interrupted absorbable sutures (1 vicryl or dexon) is placed before and then tied, the - 3 -  needle being passed into the sacral fascia in the midline and then deeply into the fat at the base of theflap. The wound is then closed without drainage, and a firm dressing is applied to the closed wound.The patient is nursed supine and is kept in bed for 1-2 days to help hemostasis by pressure and toprevent hematoma formation. Patients were usually discharged on the third or fourth daypostoperatively, and sutures were removed after 9-11 days. Patients were followed up for a mean of 25.7 months (range 3-38)Statistical analysis used SPSS/PC version 8 computer software. Data are presented as mean ±SD. Thetwo-tailed Student’s t   test was used to compare means between two groups. The 2  test with Yate’scorrection was used to compare percentages. The 5% level was used as the cutoff level for statistical significance. Results As shown in Table 2, the mean operating time was significantly longer in obese than in nonobesepatients (39.2 vs. 32.3 min; P =0.024). The mean hospital stay was 3.2 days in obese patients and2.9 days in nonobese patients (n.s.). Minor postoperative complications were encountered in fourpatients (9.76%); two in the obese group had a seroma that resolved in 2 weeks with conservativemeasures, and two others suffered from wound infection, one in each group. In the obese patient itresulted in partial wound dehiscence that required frequent clinic visits for dressing, but eventuallyhealed after 20 days without prolonging hospital stay. All other wounds (40/41, 98%) healedprimarily, and stitches were removed on the 9th-11th day after operation. In the obese group the meanBMI of patients with and without complications (excluding recurrence) was 30.4 and 27.1,respectively ( P <0.001). Only one patient (3.1%) suffered recurrence, 13 months postoperatively, whohad a BMI of 32.2. The mean BMI of obese patients with postoperative problems, includingrecurrence, was 30.8±1.0. Patients returned to work within 3-4 weeks of the operation and housewives ( n =4) resumed their unrestricted daily physical activities within a similar period of time. Table 2.  Operative time and postoperative course in the obese and nonobese patients ( n.a.  not applicable)Obese ( n =32)Nonobese ( n =9)  P  ( t  ) Operative time (min)39.2±8.2 (30-45)32.2±6.9 (25-40)0.024Hospital stay (days)3.2±0.4 (3-4)2.9±0.6 (2-4)0.084Wound healing Primary (9-11 days)31 (96.88%)9 (100.00%)n.a. Secondary (21 days)1 (3.12%)0n.a.Complications Seroma2 (6.25%)0n.a. Wound infection1 (3.12%)1 (11.11%)n.a.Recurrence1 (3.12%)0n.a. - 4 -  Discussion It is not possible to establish a satisfactory procedure for the treatment of pilonidal disease, particularlyin obese patients who have a deep intergluteal groove [ 8  ]. Surgery should not only eradicate thepresenting sinus but also aim to eliminate factors that predispose to formation of another sinus. This isachieved by reducing the depth of the natal cleft and ensuring that all parts of the wound and all sutureholes are away from the midline [ 9 ]. Although the Z-plasty procedure [ 10 ] reduces the natal cleft,recurrence has been reported when new sinuses occur at the lower end in the midline where the woundmeets the midline and the cleft is not flattened. Excision with an open wound involves prolongedhospitalization or clinic attendance for many painful dressings and takes months to heal. Both thismethod and excision with marsupialization leave a portal in the midline for further hair entry and havea small but significant recurrence rate [ 11 , 12 , 13 , 14 ]. Several series have shown that excision withprimary closure is preferable to excision with an open wound in many respects: less bleeding, lesswound breakdown, lower infection, reduced wound pain, fewer postoperative visits, shorter time off work, and faster healing time [ 12 , 14 , 15 ]. Day surgery with simple lay-open, curettage, brushing, orphenol injection may eliminate the hairs and cure the sinus but the midline wound may take severalweeks to heal, and there is a significant recurrence rate because of the open portal for hair insertion [ 1 ]. Thus the advantages of simple day surgery may be outweighed by the longer time to return to work and the greater likelihood of a further operation with longer hospitalization for recurrence.Asymmetric excision with a Karydakis flap is the only operation that takes the whole wound awayfrom the midline. Karydakis [ 2 , 3 ] reported that wounds heal well, with a recurrence rate of less than1%. Patel et al. [ 16  ], using Karydakis’ method, avoided the situation of unhealed midline wound,albeit with an inpatient stay of 5 days. No recurrence was seen in these cases. Anyanwu et al. [ 17  ]treated 28 patients by this technique and reported no recurrences after a median follow-up of 3 years.Primary healing occurred in 88% of cases, and all wounds eventually healed. Patients stayed inhospital for an average of 4 days. Kitchen [ 9 ] noted a 4% recurrence rate and a slow healing rate of 3%.In the present study we evaluated the results of the Karydakis technique in obese patients. Of these,three patients (9.4%) had minor complications in the form of seroma and wound infection with partialwound dehiscence, as compared to one patient (11.11%) in the nonobese group. The difference wasnot statistically significant. Obese patients with postoperative complications had a BMI greater than 30each (mean 30.367). The rate of complications seems related to the anatomical status of such patients,i.e., depth of the intergluteal groove [ 18  ]. It is conceivable that the insertion of suction drain during theoperation would avoid seroma formation postoperatively and result in a lower rate of complications inthis subgroup of obese patients.Recurrence was observed in only one obese patient (3.13%, 1/32) who had the highest BMI (32.2).This overall low recurrence rate (2.44%, 1/41) was achieved by not only flattening the natal cleft butalso by surgically changing follicle orientation of the presacral skin away from the midline with theKarydakis flap. On the other hand, patients who were referred to us with recurrent disease followingexcision with a central ellipse and open drainage had a lower BMI (mean 27.9±0.43). Cubukcu et al. [ 18  ] reported that obese patients with high BMI (mean 29.35) have a higher risk of recurrence of pilonidal sinus disease after surgical intervention than those with a lower BMI (mean 27.415).Based on the data presented, it may be concluded that (a) the Karydakis procedure for management of chronic pilonidal sinus in obese patients is easy to perform, has a fast healing time, short hospital stay,rapid return to work, and a low recurrence rate, (b) results are similar between nonobese and obesepatients with a BMI less than 30, with no recurrence seen in these patients, and (c) complicationsoccur in patients with a BMI greater than 30; in such patients, a dietary regimen before operation is - 5 -
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