Short- and Long-term Results of Unroofing and Marsupialization for Adolescent Pilonidal Disease

Pilonidal disease is a benign and often chronic condition of the skin/soft tissue in the sacrococcygeal region. For failed response to nonoperative management, there is currently no consensus among a variety of different operative techniques.^1,2 Currently, wide local excision (WLE) with or without closure is advocated by many.^3,4 This technique is characterized by wide excision of all involved tissue. This is followed by operative closure or is allowed to heal by secondary intention. These therapies can result in significant morbidity, long healing times, and high risk for recurrence. Flap techniques are durable but difficult to learn and require drains and/or prolonged immobilization.⁵

Previously, we reported outcomes following unroofing and marsupialization (UM).⁶ This simple technique involves incision of the sinus tract and marsupialization of the skin edges using absorbable suture. No normal skin tissue is excised in this technique. The purpose of this study is to report our current experience with UM vs WLE as surgical therapy for pilonidal disease and provide, to our knowledge, the first report of long-term follow-up data for UM.

We performed a multicenter retrospective medical record review of adolescent patients undergoing UM and WLE for pilonidal disease at university, community, and county hospitals between December 2009 and March 2015. All surgeons were pediatric surgeons who performed each technique. To evaluate the long-term durability of UM, we also reviewed medical records on a prior cohort of patients who had undergone UM between 2002 and 2007. All patients were given a strict protocol to keep the area completely shaved and clean after the operation.⁶ The primary outcome measures were median time to final healing, recurrence of disease, and need for reoperation. Patient consent was waived as this study was a retrospective review and exempted by the institutional review board at Harbor–University of California–Los Angeles. Data were analyzed using Wilcoxon rank-sum test and χ² analyses.

Fifty-six adolescent patients were included in this study (current series, n = 39 and initial series, n = 17). Of the 39 patients in the current series, 23 had UM and 16 underwent WLE (Table). The 2 groups had similar age and sex distribution, as well as preoperative obesity and abscess rates. Compared with WLE, UM was associated with faster time to complete healing by 3 months (median [interquartile range (IQR)]: 5.9 weeks [IQR, 5.1-9.1] vs 23 weeks [IQR, 21-113]), a 7-fold relative risk reduction for recurrence (1 [4%] vs 5 [31%]), and no need for reoperation (0 [0%] vs 4 [25%]).

Long-term follow-up (median, 6.3 years; IQR, 3.1-10.1) of a prior cohort of 17 patients who had undergone UM revealed only 1 recurrence managed nonoperatively 1.5 years following surgery.

The ideal therapy for pilonidal disease should completely treat the disease, have little to no recurrence, and impose limited morbidity or change in quality of life.² Despite its frequency of 26 of 100 000 in the population, individual pediatric surgeons treat few patients per year with this problem, and thus pursue the familiar surgical technique of WLE with primary or secondary closure despite the associated morbidity.⁴

This study confirms the low rate of short-term recurrence and is, to our knowledge, the first study to evaluate long-term recurrence rates for UM, a simple and effective surgical therapy for pilonidal disease. It involves limited tissue manipulation, small wounds, and no need for technical creation of flaps.⁶ Our prior study identified it as a superior technique to WLE, with decreased time to final healing (6 vs 32 weeks) and decreased need for reoperation (0% vs 56%).⁶ Our current series involves a more diverse group of patients treated in a variety of hospital settings and confirms both faster time to healing (UM: 5.9 weeks vs WLE: 23 weeks) and no need for reoperation (0% vs 25%).

For treatment of adolescent subacute or chronic pilonidal disease, UM is associated with minimal morbidity compared with traditional WLE. The UM technique has low rates of short- and long-term recurrence and should be considered for any adolescent with pilonidal disease.

Corresponding Author: Steven L. Lee, MD, Division of Pediatric Surgery, Harbor–University of California–Los Angeles Medical Center, 1000 W Carson St, PO Box 461, Torrance, CA 90509 (slleemd@yahoo.com).

Published Online: May 25, 2016. doi:10.1001/jamasurg.2016.0850.

Author Contributions: Dr Lee had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Rouch, Lee.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Rouch, Lee.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Rouch, Scott.

Administrative, technical, or material support: Scott, Sydorak, Lee.

Study supervision: DeUgarte, Lee.

Conflict of Interest Disclosures: None reported.