Should I Have a Wide Excision for My Pilonidal Cyst

A very common question

Here is the scenario: a patient has a pilonidal cyst and sees a board certified general surgeon in whom the patient has faith in their skills. The surgeon recommends a wide excision, with or without primary closure (sewing it back together) and possibly with a post op wound VAC (wound vacuum device). They are told that it will take a few weeks to heal and has the highest success rate of the various pilonidal operations.  If the patient asks about a cleft lift the surgeon says:

  • The cleft lift is only for “severe cases”.
  • The cleft lift has a high failure rate.
  • The cleft lift has a high infection rate.
  • The procedure I do “is sort of like a cleft lift”.

So - what should the patient do?

The most important thing is that the patient be educated in the facts regarding the treatment of pilonidal disease, and is able to make an intelligent decision. So, let’s look at the accuracy of what this patient is being told.

A wide excision will only take a few weeks to heal.

This is extremely variable, and depends on the size of the excision and the depth of the cleft. The typical healing time in a good situation is about 3 months. But, there are numerous times when it is still not healed at one year. The reason for this is that wounds do not heal well buried in a cleft, and often will develop into new pilonidal disease, rather than healing.

A wound VAC is a good way to get things to heal quickly.

In general, wound VAC devices work very well to get wounds elsewhere on the body to heal faster. However, in the gluteal crease they are hard to get in position, awkward to have in place, and it is not unusual to have the VAC device get the wound almost healed, but never fully healed; or the wound heals but opens up once the VAC is removed.

Open excision has the highest success rate.

This is definitely incorrect. This may have been true long ago, but the newer advancements in treatment of pilonidal disease, especially with the cleft lift have changed this. In general, a reasonable success rate to ascribe to open excision is 50-70%. The success rate of a properly performed cleft lift is in the 95-99% range. This is a huge difference: at best one out of three open excisions fail.

The cleft lift is only for severe cases.

This is not true in our clinic, nor in the clinics of the other cleft lift specialists. Every patient has a different idea regarding how aggressive they want to be with their first operation. Some patients want to start out with a “minimally invasive” operation, and others take a “one and done” approach. The high success rate with the cleft lift makes it the only procedure needed in over 95% of the situations.

The cleft lift has a high failure rate.

The cleft lift has a high infection rate.

This is not true either. In our clinic the infection rate is between 2 and 3% depending on the situation.

The procedure I do is sort of like a cleft lift.

If your surgeon says this, I’d investigate his or her experience with the procedure a bit more thoroughly. Some surgeons feel that an excision with primary closure, where they try to get the closure a bit off the midline is the same as a cleft lift; but it is not. The cleft lift is a very specific procedure with many technical aspects that must be done correctly.

In Conclusion

How you should proceed depends upon how you put all this information together with your own personal situation, and you need to consider geography, finances, and personal needs. But, excision has a high failure rate, and another operation might be needed if it fails. A cleft lift can be done after multiple failed excisions – but it makes the situation more difficult.

The Real Success Rate of Pit Picking

About minimally invasive pilonidal surgery

Pit Picking (also called Bascom’s Operation, or Bascom 1) is one of the minimally invasive procedures used to treat pilonidal disease. This operation removes any midline pits, and destroys any sinus tracts and remaining abscess cavities. All of the minimally invasive procedures are similar in what they accomplish, they just differ in what method is used to accomplish this. The other methods use a laser, cryosurgery, phenol, suture material, or even an endoscope to directly look into the sinus tract.

Although these are all appealing in concept, they do not address the shape and depth of the gluteal cleft. They are “minimal” in the size of the incision, but until now there has not been a study that really looks at the success rate.

The latest data

In an open access article, from Dr Dietrich Doll from Germany, which came out in June of 2022, 327 patients with pilonidal disease were treated with either pit picking, open excision, or a Limberg Flap.

The article also demonstrated a 44% failure rate at 10 years for patients who had open excision – which approximates the 50/50 number that many surgeons equate with this procedure.

The data was statistically analyzed and predicted out to five years for the pit picking patients.

They found that the five year recurrence rate in the pit picking patients was 62%. In other words, approximately 2 out of 3 patients had failure within 5 years – about a 12% failure rate per year. Although this is a lower success rate than some other articles, it confirms what many surgeons intuitively have found, and it is why many of us do not offer pit picking, or any of the minimally invasive operations.

This series also showed a 22% failure rate in the Limberg Flap patients. This is in contrast to the failure rate of the cleft lift procedure, which Dr Immerman demonstrated in his 2021 article, which was 3.4% at 3 years using the same type of statistical analysis. That article can be viewed by following this link. Most likely, dedicated pilonidal surgeons who perform the cleft lift procedure frequently, have similar success rates.

Conclusions

This clinical research really shines a light on the place of pit picking, and probably all minimally invasive operations for pilonidal disease. As surgeons, we will rarely accept an operation with a 20-30% failure rate; one with a 62% failure rate would be completely unacceptable.

The conclusion of Dr Doll and his colleagues is:

"Although the technique is minimally invasive, fast, and cheap, it has a recurrence rate of 60%, without a benefit for the majority of patients."

And, we agree with their conclusion. With the failure rate of open excision being 44% and pit picking 62% – it is difficult to justify these operations. We do not recommend either in our clinic.

How should a patient determine their best options for treatment of pilonidal disease?

Why are patient experiences so different? How do I get good information?

Information from discussion with a local surgeon

In general, having an appointment with a local general or colorectal surgeon would seem to be the best approach – and I recommend that you consider that – but unfortunately it does not always work out as it should and it may not be as helpful as it could be:

  • Many surgeons are not familiar with all the options for treating pilonidal disease, and have misinformation regarding the complication rates, recurrence rates, and recovery period involved with the various procedures. They often have one operation that they have been doing since residency, and have not revisited whether or not it is really the best option for patients.
  • Surgeons often minimize the disruption in lifestyle during the recovery period of these procedures, and often grossly underestimate the amount of time needed for these wounds to heal.
  • When physicians discuss this, they often use incorrect terminology. Even something as simple as “open excision” can encompass many different operations, ranging from a small, ½” wound – to a wound as big around as a grapefruit! Clearly, the recovery from one is going to be different than another. What one surgeon may call a ”cleft lift”, another might call an “excision with midline closure”.
  • Surgeons do things differently, have different degrees of interest in pilonidal disease, and have varying results. So, just because a surgeon says he is going to do one thing, does not mean it is the same as another surgeon saying the same thing.
  • The websites of major academic centers still have outdated and incorrect information when it comes to pilonidal disease (…and, yes. They have been contacted, and they persist in their online misinformation.)
  • Most surgeons do not have accurate data on their own success rates. When their procedure fails, the patients often go elsewhere for treatment, and the original surgeon makes the incorrect assumption that things ultimately healed.
  • So, going to see a surgeon is a good idea, but afterwards, it is a good idea to do some research. As Ronald Reagan said, “Trust…but verify.”

Information from online discussion boards

It is not unusual for online discussions to start with a patient asking for the experiences of others in order to help him or her decide what might be the best kind of treatment for their own pilonidal problem. These discussions usually elicit numerous responses from helpful posters describing the experience that they have had, or a friend, or family member has experienced

The original poster often finds that these answers either provide solace or anxiety regarding their particular situation. Although everyone involved means well – this isn’t the best way to get information.

Reasons why the advice may not be helpful:

  • Every patient has a different situation. The appropriate options available to someone with just a few asymptomatic pits is quite different from a patient with an open perianal wound after previous failed operations.
  • Your degree of disease may be very different than that of the person answering your question, and your baseline anatomy and ability to heal may be very different as well.
  • Patients’ tolerance for pain, disruption in lifestyle, and failure are quite different. For some patients the idea that a second operation might be needed is intolerable; for others a lifelong daily regime of hygiene, topical medications, and lifestyle modification is felt to be acceptable. So, when one poster says that recovery from an operation was “easy” and another “a nightmare”; that might be helpful, but has to be viewed as purely subjective.
  • People have different ideas of how proactive to be about this problem. This web page discusses how to think about pilonidal disease with minimal symptoms.
  • These posters are usually not physicians, and may or may not have the basic knowledge needed to answer your question, and the information that they have received from their surgeons may actually be incorrect (see above).

Information from literature research

As I said above, it is reasonable start with the opinion of a local surgeon, but then do some research to see if they have discussed all the options, and if what they said made sense. You can also call or email one of the pilonidal specialists in your country. The websites of the Pilonidal Alliance and the International Pilonidal Society may be helpful. This is one situation where another opinion is a good idea.

However, even doing your own research is fraught with problems because there are articles extolling the virtues of just about any pilonidal procedure that you can imagine. Fortunately, one of the most useful articles came out in 2018 authored by Stauffer, Luedi, et. al. and published in Scientific Reports and is available to everyone online. They compiled the results of 6,143 studies encompassing 89,583 patients, and describe the recurrence rates of various procedures over time. So far, this is the best we have to compare results of the various operations. If you look at this article and don’t want to read through the minutiae, just take a look at Figure 3 which shows recurrence rates of various operations at 12,24, 60, 120 and 240 months.

What about the cleft lift?

You may have noticed that I have not mentioned the cleft lift procedure in this blog post until now. My personal opinion is that it is the procedure that has the lowest recurrence rate with the easiest recovery if done by a surgeon who has experience in performing the operation, and is appropriate for all presentations of pilonidal disease. In the article mentioned above it has a recurrence rate of 0.2% at 12 months and increases to 2.7% at 120 months. This compares very favorably to the other procedures. In 2021 I published an article consisting of 700 patients who had the cleft lift procedure in our clinic. The recurrence rates varied depending on the severity of the initial presentation and was as low as 1.9% in patients without previous surgery, with an overall success rate of 96.6% (I now have over 1000 patients in this series, and the numbers have not changed.)

Conclusion

It is actually a sad state of affairs when patients have to go through all of this analysis to determine their best treatment. In a perfect world, they should be able to go into any surgeon’s office and get a good discussion of the best options and a firm recommendation for the best treatment. For most diseases treated by board certified general, colorectal, and plastic surgeons that is certainly the case. But, for pilonidal disease it is not, and it does not appear that this is going to change in the near future – so you have to advocate for yourself!

Dr. Immerman