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Effect of Hydrocolloid Dressings on Healing by Second Intention after Excision of Pilonidal Sinus
´ E. Castera, Jose ´ Medrano, Javier Aguilo ´, Jose ´ Torro, Miguel G. Botella and Vicente Viciano, Jose ´ Nieves Toldra
`tiva (Valencia), Spain ´s Alcanyı ´s, Xa From the Department of Surgery, Hospital Lluı

Eur J Surg 2000; 166: 229–232 ABSTRACT Objective: To assess the efficacy of hydrocolloid dressings in wound management after excision of pilonidal sinus. Design: Prospective randomised trial. Setting: District hospital, Spain. Patients: 38 patients with chronic pilonidal sinus. Interventions: Open excision with healing by second intention. Divided into three groups: conventional gauze dressing (control, n = 15), Comfeel1 (n = 12) and Varihesive1 (n = 11) Main outcome measures: Median healing time, infection rate, intolerance, pain, comfort, ease of management, leakage, and recurrence. Results: Median healing time was 68 days (range 33–168) in the control group, compared with 65 days (range 40–137) in the two hydrocolloid groups combined. There were no differences between the hydrocolloid groups. There were no recurrences during the 74 months of follow-up. A third of the postoperative cultures in the control group grew pathogens compared with 1/ 23 of the patients treated with hydrocolloid dressings (p = 0.03). This was of no clinical relevance. 14/23 in the hydrocolloid group developed leaks. Pain was significantly less in the first four postoperative weeks among the patients in the hydrocolloid group than in the control group (p ` 0.05). Conclusions: Hydrocolloid dressings lessen pain and increase comfort for patients after excision of pilonidal sinus, though time to healing is no shorten than when a conventional gauze dressing is used. Key words: pilonidal sinus, wound healing, hydrocolloid dressing.

INTRODUCTION The surgical management of pilonidal sinus remains controversial, and this is reflected by the many surgical techniques proposed. The main problems are the recurrence rate and unsatisfactory wound healing. Recurrence rates as high as 43% have been reported in some series, though healing by second intention and the adoption of plastic reconstructive techniques seem to reduce the risk (1, 4). Primary closure after excision of the sinus poses problems in the form of wound abscesses (in 3.6%–13% of cases), wound breakdown (0–20%) and intense local postoperative pain in up to 24% of patients (3–5, 9). Wounds do not become infected or break down when they are left open to heal by second intention, though this approach involves more postoperative pain and prolonged healing (3, 7, 8, 11). Hydrocolloid dressings have become widely accepted in recent years. By maintaining a humid wound environment they seems to favour the healing of open wounds by shortening healing time and improving patients’ comfort (2). We conducted a prospective randomised study of
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open wounds that were allowed to heal by second intention after excision of pilonidal sinus, with the aim of evaluating the possible benefits (quicker healing and increased comfort) of these dressings.

MATERIAL AND METHODS Thirty-eight patients (31 men and seven women, mean age 24 years; range 16–48) with chronic pilonidal disease were studied. All patients gave verbal consent to participate in the study, and none presented with associated diseases. The trial was approved by the hospital clinical trials committee. Those patients with pilonidal abscesses were excluded. All were operated on under local anaesthesia with 5% mepivacaine. An elliptic incision was made to remove the cyst en bloc to the presacral fascia, leaving the wound open to heal by second intention. The size of the wound was measured to calculate the area of tissue excised. There were no operative or postoperative complications, and the median postoperatively hospital stay was one day (range 1–3). The patients were randomly assigned to three groups
Eur J Surg 166

The bacteriological contamination had no clinical effect on the wound healing. Three in the control group and one in the hydrocolloid group developed dermal folliculitis at the wound margins. the median times to healing were 68 days (range 33–168) Eur J Surg 166 in the control group and 65 days (range 40–137) in the hydrocolloid group. adherence. and probabilities of less than 0. as appropiate. or size of the resected area of tissue. Healing was complete after a median of 67 days (range 33–168) with no differences between groups. Other possible problems were also recorded. had a characteristic smell. The microbiological analyses of specimens collected from wound during the operation all failed to grow pathogens. The hydrocolloid dressings were easy to apply and remove. Table I shows the main variables of interest.8 93. There no significant differences among the three groups in terms of scar quality.03. age. ease of handling of the different dressings and patients’ comfort. which resolved with topical treatment. There were no recurrences after a median follow-up of 74 months (range 59–77). 1. and if there were clinical signs of infection (purulent secretion). of dressings used Range no. Follow-up and postoperative care took place in the outpatient department. 3 5 68 33–168 68 33–168 1. Table I. to find out if the infection influenced healing. .03) (digestive tract and Pseudomonas spp). including intolerance. Care after resection consisted of washing the wound with saline and replacement of the corresponding dressing. or smell. Grouped measures of pain during healing period.1 97. smell. Viciano et al.2 Not evaluable Hydrocolloid dressing group (n = 23) 1 1* 65 40–137 23 13–36 4. The results were analysed by comparing the three groups and contrasting the control group (conventional dressing) with the two hydrocolloid groups combined. A median of 23 hydrocolloid dressings (range 13–36) were used/patient. Bacteriological cultures were made of the bed of the wound during surgery and on cure.3 101.230 V. Costs as at July 1999. leak from the hydrocolloid dressing.3 1. and 14 of them Fig. Comfeel (Coloplast) (n = 12) and Varihesive (Convatec) (n = 11). of dressings used Unit dressing cost: Euro US $ Cost per patient: Euro US $ Leaks * p = 0.0 3. Fisher’s exact test and Mann-Whitney test were used. Postoperative results according to the type of dressings applied Control group (n = 15) Local intolerance Postoperative culture grew pathogen Median healing time (days) Range healing time (days) Median no. RESULTS There were no differences between the groups in sex.05 were accepted as significant.6 90.0 14 at the time of operation to decide the type of dressing that was to be applied postoperatively: conventional gauze with povidone iodine (n = 15). tolerance of the dressing used. but during the period of cure five positive cultures grew pathogens from the control group compared with only one in the combined hydrocolloid group (p = 0. On comparing the conventional gauze group with the two hydrocolloid groups combined. Pain during and between care sessions was rated on a visual analogue scale (VAS).

0 (25–100) 13. Eur J Surg 166 . controversy persists about whether primary closure or healing by secondary intention is preferable. However.0 (0–8) Hydrocolloid dressing group (n = 23) 25 (9–55) 16. 8. such reactions may also develop with gauze dressings (n = 3). nevertheless advocate primary closure because the patients’ time off work is shorter–despite the greater morbidity involved (abscesses. In comparison. However. the humid environment created by these dressings is thought to protect the nerve endings and limit wound surface damage during healing (2). 9). The poor adherence may have been a result of continuous weight-bearing and friction in the sacral region.0 (0–6) 0. and pain) (1. This could be accounted for by the great depth of the wounds involved. because they were so comfortable. Leaks were a consequence of poor adherence—a problem not observed in other types of wounds—and made it necessary to change dressings more frequently than expected. until the size of the wound decreased. There were no significant differences between the groups in cost. other authors (7.38 0.05). and there were no significant differences between the two types used.0 (0–2) 231 p value 0. The main problem posed by hydrocolloid dressings was leakage during the first weeks postoperatively. 12). showed that the main cause of infection of such wounds is late secondary contamination rather than contamination during the operation (10). DISCUSSION Excision of a pilonidal sinus to the presacral fascia has a low recurrence rate (4). 9). Changing dressings was also less painful in the hydrocolloid groups.0 (2–11) 2. 3. However. However.05 0. though contamination had no clinical relevance in our series.5 (0–15) 1. haematomas. The application and removal of hydrocolloid dressings were easier than those of conventional gauze dressings. conventional gauze dressings must be changed more frequently. in the present study we found no significant differences in healing time from that of conventional gauze dressings. Pain was significantly less in the combined hydrocolloid group during the first four weeks postoperatively than among the controls (p = 0. patients’ comfort was good or excellent.0 (2–76) 4. and are possibly favoured by the degree of exudate that characterises these wounds. when differences in pain were no longer recorded between groups. Despite the leaks patients’ comfort was greater with hydrocolloid than with conventional gauze dressings. which in turn contributes to healing. A number of authors.0 (0–10) 0. Like other authors (2. wound breakdown. who have found no significant differences in recurrence between the open and closed approach (4. 5. 11) have reported higher recurrence rates with primary closure. which were located in high-tension support areas.18 leaked as a result of poor adherence or detachment of the edges of the dressing.0 (1–40) 2.0 (1–20) 5.) for postoperative pain Weeks 1 2 3 4 5 6 Control group (n = 15) 50. and so prefer open techniques that offer less morbidity. Median (Percentile 25th–75th) visual analogue scores (mm. The advantages of hydrocolloid dressings in wound management have been well documented. for unlike the latter they did not tend to stick to the wound (12). prevents infection. The lower incidence of contamination of the wound bed during healing in the combined hydrocolloid group confirms the observations of Lawrence (6). 1). They were generally well tolerated. The difference appeared in the first dressing and it persisted until the fifteenth dressing (Fig.Hydrocolloid dressings and pilonidal sinus Table II. In this sense. with only one dermal reaction being recorded (erythema and folliculitis of the skin to which the dressing had stuck).55 0. for although hydrocolloid dressings are more expensive. the patients refused changes in the type of dressing. Many studies have shown that hydrocolloid dressings effectively shorten the healing time of partial or full-thickness wounds (2).0 (0–13) 0. Sondenaa et al.56 0.86 0. However. we found that the decrease in postoperative pain was the main benefit of these dressings. They provide a humid environment that favours angiogenesis and fibrinolysis. and lessens pain (2). There were no differences in cost between the controls and hydrocolloid groups. the median weekly difference in pain perceived between groups was not significant during the second to fourth weeks because of the small sample size (Table II). After the first four postoperative weeks.

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