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SHORT COMMUNICATION
Year : 2016  |  Volume : 1  |  Issue : 1  |  Page : 14-17

Minimally invasive treatment of pilonidal sinus disease using platelet-rich plasma


1 Department of General Surgery, Meram Medical School, Necmettin Erbakan University, Konya, Turkey
2 Department of General Surgery, Sarıkaya State Hospital, Yozgat, Turkey
3 Department of General Surgery, Konya Training and Research Hospital, Konya, Turkey

Date of Submission19-Jan-2016
Date of Acceptance14-Feb-2016
Date of Web Publication1-Apr-2016

Correspondence Address:
Barış Sevinç
Department of General Surgery, Sarıkaya State Hospital, Sarıkaya, Yozgat, 66650
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-5585.179563

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  Abstract 

Aim: Pilonidal disease is an inflammatory disorder, mainly affecting young adults. Platelet-rich plasma (PRP) is shown to have a positive impact on the wound healing process. Herein, the study aims to define the application of PRP and report early results. Methods: The study data were collected prospectively. PRP was prepared from the patients' own blood samples, transformed into gel form, and applied to the sinus tract under local anesthesia. Furthermore, the healing rate and recurrence rate of the disease were evaluated. Results: There were 50 cases included in the study, with 48 cases were cured at the end of the 1st month. At this stage, with a median follow-up of 15 months, there have been no documented recurrences. Conclusion: Minimally invasive treatment of pilonidal disease with PRP application has promising results. Treatment of pilonidal disease by PRP can be applied in outpatient clinic and provides total cure in a short time. The method is simple, painless, with no hospital stay required, less wound care, shorter time to return daily activity, and the cost is effective. However, long-term outcomes are unknown, and additional follow-up is required.

Keywords: Minimally invasive, pilonidal disease, platelet-rich plasma


How to cite this article:
Karahan ÷, Sevinç B, Şimşek G, Demirgül R. Minimally invasive treatment of pilonidal sinus disease using platelet-rich plasma. Transl Surg 2016;1:14-7

How to cite this URL:
Karahan ÷, Sevinç B, Şimşek G, Demirgül R. Minimally invasive treatment of pilonidal sinus disease using platelet-rich plasma. Transl Surg [serial online] 2016 [cited 2019 Mar 22];1:14-7. Available from: http://www.translsurg.com/text.asp?2016/1/1/14/179563


  Introduction Top


Pilonidal disease can be seen in many regions of the body, such as the umbilical and interdigital areas, but is primarily observed in the sacrococcygeal region. The incidence of disease is reported as 8.8% in Turkish soldiers.[1] According to Karydakis [2], the incidence of pilonidal disease increases with time. The basic principle in the surgical treatment of pilonidal disease is excision of the sinus tract. There are several methods to close the defect after the sinus excision. The only nonoperative method proven to be effective is the application of phenol. The ideal treatment of pilonidal disease should fulfill the following criteria: Ease of application, simplicity of wound care, low recurrence rate, minimal pain, early return to activity, and low cost. However, there is no consensus on the best method for the treatment of pilonidal disease. The search for the ideal treatment modality is ongoing.

Platelet-rich plasma (PRP) is produced by the centrifugation of whole blood and contains a higher proportion of platelets than the blood itself.[3] The important role of platelets is to promote and regulate wound healing by cytokines and growth factors.[4] The accelerator effect of PRP on wounds involving muscle, tendon, cartilage, and ligaments is proved by animal studies.[5] The healing mechanism of PRP is thought to include an increase in angiogenesis, cell proliferation, and collagen synthesis.[6],[7]

PRP is used in medicine and dentistry. Recently, there has been an increase in the number of studies related to PRP. This is the first study reporting the use of PRP in the treatment of pilonidal disease. The aim of this report is to define a new minimally invasive treatment modality for pilonidal sinus disease.


  Methods Top


The study was conducted in Konya Training and Research Hospital after obtaining approval from the Ethical Committee of Selçuklu Medical Faculty, Selçuk University. Patients with complaints of pilonidal disease, pain, suppuration, and clinically evident pilonidal sinus disease were considered for inclusion into the study. Patients were informed of the nonoperative intervention using PRP versus conventional surgery. A written informed consent form was obtained from all patients who agreed to participate in the study. Recurrent cases after other treatment methods, those with abscess formation and patients with comorbidities that influence wound healing, such as diabetes mellitus and collagen disorders, were excluded from the study.

All PRPs were prepared through the method described below and developed by the researchers. A total of 40 mL of blood was taken from the patients. The blood was collected in tubes with citrate. After centrifugation for 10 min at 1000 rpm, plasma was re-collected into tubes with citrate and centrifuged again for 12 min at 1500 rpm. The precipitate containing PRP was collected in a glass bottle, and 2 mL of 10% CaCl2(SIEMENS ® CaCl2 of0.025 mol/L) was added. The mixture was allowed to gel at body temperature for 1 h.

The treatment was performed under local anesthesia at an outpatient clinic. The patients were placed in the prone position and the intergluteal cleft was shaved. The opening of the sinus was enlarged and the contents of the sinus were removed. The epithelial lining of the sinus was curetted [Figure 1]. Approximately, 1 mm of skin around the opening of the sinus was excised to accelerate the wound healing. The sinus tracts within the intergluteal region are shown after skin debridement in [Figure 2]. The cavity was washed with 0.9% NaCl solution [Figure 3], and the prepared PRP was placed into the cavity [Figure 4]. The sinus tract was covered with a dressing. Paracetamol, 500 mg, was prescribed for pain and used on an as-needed basis. No antibiotics were administered. The patients were contacted for follow-up visit at 1st, 2nd, 4th, 12th, and 16th weeks, and the 6th month, then yearly. Resolution of the patients' complaints and the closure of the cavity and the sinus opening were evaluated at all visits. Cure was defined as complete resolution of patient complaints and no visible evidence of a cavity or sinus opening. The cases with a reduced cavity size and a residual open sinus tract were recorded as incomplete healing. Cases with a residual cavity were defined as nonhealed.
Figure 1. Removal of the epithelial lining of the sinus cavity

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Figure 2. Intergluteal region after the excision of skin around the sinus tracts

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Figure 3. Cleansing the sinus tract with sterile saline solution

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Figure 4. Platelet-rich plasma gel ready for placement into the cavity

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For patients who were in either the incomplete or the nonhealing group, by the end of the 2nd week, the procedure was repeated.


  Results Top


There were 50 cases between June 2013 and June 2014. A total of 42 cases were male (84%) and 8 cases were female (16%). The mean age was 25.1 and the median follow-up time was 15 (12–19) months.

No patient required hospitalization or analgesic use after the 1st day. No adverse events were reported including allergic reactions. A case controlled at the 2nd week was demonstrated in [Figure 5].
Figure 5. The closed sinus openings at 14 days

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At the end of the 1st week, 48% (n = 24) of the cases achieved cure. At the end of the 2nd week, the closure rate was 70% (n = 35). Moreover, 30% (n = 15) patients did not achieve closure by 14 days, and then these 15 cases achieved complete closure by the end of the 2nd week following the second application of PRP. At 30 days, 96% of the cases with PRP application demonstrated a complete closure. The results are presented in [Table 1]. The median healing time with PRP application was found to be 14 (7–30) days. No recurrences were seen with a median follow-up of 15 months.
Table 1: Patient numbers at timed visits with treatment results

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  Discussion Top


Pilonidal sinus disease mainly affects the young population and causes a significant morbidity. The most common method in the treatment of the pilonidal disease remains excision of the sinus tract. The defect after the excision is closed primarily or by a variety of flap options.

The first description of nonoperative treatment of pilonidal disease with phenol was from Maurice and Greenwood.[8] This method aimed to chemically irritate the cavity and trigger the inflammatory process. The cavity subsequently heals by secondary intention. In our study, the PRP injected into the cavity provides large amounts of cytokines and growth factors. These factors promote the formation of granulation tissue. PRP was prepared from the patients' own blood cells and nonirritating feature of the PRP, which is a new method. Advantages of this new method include preparation from the patients' own blood and absence of tissue irritation.

Maurice and Greenwood [8] described 41 cases of phenol treatment with a median follow-up time of 24 months. And 70% cases required 2 or 3 applications of phenol. The mean healing time was presented as 42.7 days, and the success of the treatment was reported as 95.1%.[9] Compared to Maurice and Greenwood [8], our study, using PRP, showed a single application to be successful in 70% of cases, with 30% requiring second application. No patient required a third application. The treatment success was 96% at the end of the 1st month.

In the literature, the mean hospital stay was reported to be 1.14 days for primary closure and 3.61 days for flap procedures. The time to return to work was reported to be 7–21 days for patients with major surgery.[10] For the patients with wound complications, return to normal activity may be significantly longer. Pilonidal disease mostly affects the young population and longer duration to return to work causes loss of labor. Therefore, minimally invasive treatment of pilonidal sinus is important to prevent economic loss. In the report by Arık and Borazan,[11] minimally invasive surgery and phenol were used in combination. Although there were no limitations for the patients, the return to work duration was reported as 1–3 days.[11] In our study, none of the patients were hospitalized, and they were free to return to work.

The most important complication of the surgical treatment of pilonidal disease is a wound complication. Local and systemic therapy, including anticipated reopening of the sacrococcygeal wound with secondary healing, is common. Wound complications increase the economic burden.[11]

The most common complications of phenol treatment are localized abscess and dermatitis.[12] In our study, there were no reports of infection or abscess formation, likely due to the nonirritating properties of autologous PRP.

Using the described method, PRP can be inexpensively prepared with hardware common to a surgical clinic. There is no need for special equipment.

Limitations of our study include the absence of randomization and short duration of follow-up. The reported results are early with a median follow-up time of 15 months. A longer follow-up interval will provide more definitive recurrence data. However, early results of our study suggest that nonoperative treatment of pilonidal disease with PRP is promising.

In conclusion, treatment of pilonidal disease with minimal debridement of the wound followed by the application of PRP in an outpatient setting provides a total cure in a short time. The method is simple, painless, with no hospital stay required, minimal wound care could return to daily activity early, and the cost is effective. To determine the absolute outcomes and recurrence rates, randomized studies with longer follow-up intervals are needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Akinci OF, Bozer M, Uzunköy A, Düzgün SA, Coşkun A. Incidence and aetiological factors in pilonidal sinus among Turkish soldiers. Eur J Surg 1999;165(4):339-42.  Back to cited text no. 1
    
2.
Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z J Surg 1992;62(5):385-9.  Back to cited text no. 2
    
3.
Paoloni J, De Vos RJ, Hamilton B, Murrell GA, Orchard J. Platelet-rich plasma treatment for ligament and tendon injuries. Clin J Sport Med 2011;21(1):37-45.  Back to cited text no. 3
    
4.
Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: From basic science to clinical applications. Am J Sports Med 2009;37(11):2259-72.  Back to cited text no. 4
    
5.
Nguyen RT, Borg-Stein J, McInnis K. Applications of platelet-rich plasma in musculoskeletal and sports medicine: An evidence-based approach. PM R 2011;3(3):226-50.  Back to cited text no. 5
    
6.
Yılmaz B, Keskinburun S. Platelet-rich plasma applications. Turk J Phys Med Rehabil 2013;59:338-44.  Back to cited text no. 6
    
7.
Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med 1999;27(6):393-408.  Back to cited text no. 7
    
8.
Maurice BA, Greenwood RK. Conservative treatment of pilonidal sinus. Br J Surg 1964;51:510-2.  Back to cited text no. 8
[PUBMED]    
9.
Dogru O, Camci C, Aygen E, Girgin M, Topuz O. Pilonidal sinus treated with crystalized phenol: An eight-year experience. Dis Colon Rectum 2004;47(11):1934-8.  Back to cited text no. 9
    
10.
Ersoy OF, Karaca S, Kayaoglu HA, Ozkan N, Celik A, Ozum T. Comparison of different surgical options in the treatment of pilonidal disease: Retrospective analysis of 175 patients. Kaohsiung J Med Sci 2007;23(2):67-70.  Back to cited text no. 10
    
11.
Arık MK, Borazan E. Phenol application combined with minimal invasive surgery for pilonidal sinus treatment. Anatol J Clin Invest 2011;5(4):165-8.  Back to cited text no. 11
    
12.
Kayaalp C, Aydin C. Review of phenol treatment in sacrococcygeal pilonidal disease. Tech Coloproctol 2009;13(3):189-93.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]


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