The Surgical Management of Pilonidal Disease is Uncertain Because of High Recurrence Rates

Background Pilonidal disease is a common condition with no consensus for the best management of chronic disease or current practice in Australia and New Zealand. Methods A survey was distributed among 190 colorectal and 592 general surgeons in Australia and New Zealand. Data was obtained regarding pilonidal surgery volume, procedures performed, non-operative management and recurrence rates. Three clinical scenarios were also presented. Results The response rate was 58% among colorectal surgeons, 18% among general surgeons. Nineteen percent of surgeons were high-volume (>23 operations per year), 47% low-volume (<12 operations per year). The commonest procedure was the Karydakis procedure (77%), with many others performed including rhomboid flaps (36%), Bascom cleft lift (13%), Z-plasty (7%), and gluteal rotation flaps (5%). Fifty-five percent of high-volume surgeons offered more than one operation while only 16% of low-volume surgeons did. Nineteen percent operated on all patients with pilonidal disease, 89% believing off-midline closure to be superior to midline. Disease extent was the main driver for non-operative management; patient factors such as cosmesis and time-off work being the least important. Sixty-four percent reported recurrence rates above 5%, and 37% recurrence rates >10%. Six percent reported no recurrences ever. Five percent reported recurrence rates over 20%, but 24% stated that over one-fifth of their practice consists of recurrent disease. Conclusions This study reports higher recurrence rates than in published series, suggesting many surgeons do not see their own recurrences, with current treatment not as successful as previously thought. Combined with the widespread variation in practice, optimal management of this disease remains unclear.