Postoperative Pain and Recurrence Rates in Pilonidal Sinus Disease: A Systematic Review Comparing Surgical Interventions

Description

Pilonidal sinus disease (PSD) is a chronic inflammatory condition of the sacrococcygeal region with an estimated global incidence of 26 per 100,000 people, predominantly affecting young adult males with a 2:1 male-to-female ratio and typically manifesting during the second and third decades of life. The condition causes significant morbidity, discomfort, and lost productivity during patients' most active years. Its etiology is generally considered acquired rather than congenital, with recognized risk factors including obesity, deep natal cleft anatomy, excessive body hair in the sacrococcygeal region, poor personal hygiene, and prolonged sitting. The underlying pathophysiology involves hair penetration into subcutaneous tissues, triggering a foreign body reaction and inflammatory response that ultimately leads to abscess formation and chronic sinus tract development. Surgical intervention remains the mainstay of definitive treatment; however, considerable controversy persists regarding the optimal surgical approach, as numerous techniques have demonstrated varied outcomes in terms of postoperative pain, wound complications, healing time, and long-term recurrence. The available approaches include excision with open healing by secondary intention, excision with primary midline closure, excision with off-midline closure such as the Karydakis and Limberg rhomboid flaps, minimally invasive techniques including pit-picking, sinusectomy, phenolization, and endoscopic treatment, as well as conservative strategies. While prior systematic reviews have examined either pain or recurrence in isolation or have limited their comparative scope to a narrow set of techniques, this study aims to comprehensively evaluate the relationship between different surgical interventions and both postoperative pain and long-term recurrence rates simultaneously, providing a more integrated and nuanced evidence base to guide individualized clinical decision-making for patients with PSD. Methods A comprehensive systematic literature search will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, querying three major electronic databases from inception to the date of search completion: PubMed, Embase, and the Cochrane Library. The search strategy will incorporate a combination of Medical Subject Heading (MeSH) terms and free-text keywords connected with appropriate Boolean operators, covering terms related to pilonidal sinus disease, its surgical variants, and the outcomes of interest including recurrence and pain. The reference lists of all retrieved articles and previously published systematic reviews will also be manually searched to capture any additional eligible studies, and no language restrictions will be imposed at the initial search stage. All identified citations will then undergo a two-stage independent screening process by two reviewers, beginning with title and abstract evaluation and proceeding to full-text assessment against predefined inclusion and exclusion criteria; disagreements will be resolved through discussion, with a third reviewer consulted when consensus cannot be reached. Studies will be included if they involve patients diagnosed with pilonidal sinus disease, evaluate at least one eligible surgical technique, report postoperative pain or recurrence data, include a minimum of 20 patients, maintain a follow-up period of at least 6 months, and employ a comparative study design such as randomized controlled trials, systematic reviews, meta-analyses, or comparative cohort studies. Studies will be excluded if they are non-comparative, focused exclusively on pediatric populations under 14 years of age, focused exclusively on recurrent or complex disease, lack clear reporting of techniques or outcomes, or represent duplicate publications with overlapping patient populations. Following screening, data will be extracted independently by two reviewers using a standardized form capturing study design, sample size, patient demographics, surgical techniques, operative details, pain scores, recurrence rates, wound healing time, complication data, and patient satisfaction measures. The primary outcomes of interest are postoperative pain, measured using validated instruments such as the Visual Analog Scale or Numeric Rating Scale, and disease recurrence, defined as the reappearance of PSD following complete wound healing. Secondary outcomes include wound complications such as infection, dehiscence, seroma, and hematoma, as well as time to complete healing, time to return to normal activities, and patient satisfaction with cosmetic results. Methodological quality of included randomized controlled trials will be assessed using the Cochrane Risk of Bias Tool, while non-randomized studies will be appraised using the Newcastle-Ottawa Scale, with all assessments conducted independently by two reviewers. Statistical analyses will be performed using R version 4.5.1; pooled odds ratios with 95% confidence intervals will be calculated for dichotomous outcomes, while mean differences or standardized mean differences will be computed for continuous outcomes. Random-effects models will be used throughout given anticipated heterogeneity, which will be formally quantified using the I-squared statistic. Publication bias will be assessed using funnel plots and Egger's test where at least ten studies are available, and subgroup analyses will be performed by surgical technique, follow-up duration, and study design, with sensitivity analyses conducted by excluding high-risk-of-bias studies.