|Year : 2020 | Volume
| Issue : 3 | Page : 433-438
Evaluating the use of fibrin glue in the treatment of pilonidal sinus disease
Mohamed O Alfy1, Sawsan S Mohamed2
1 Department of General Surgery, Al Zahraa University Hospital, Egypt
2 Department of General Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt
|Date of Submission||10-Jun-2020|
|Date of Decision||18-Jun-2020|
|Date of Acceptance||23-Jun-2020|
|Date of Web Publication||2-Oct-2020|
MD Mohamed O Alfy
Department of General Surgery, Al Zahraa University Hospital, Shoubra, Cairo
Source of Support: None, Conflict of Interest: None
Background Pilonidal sinus disease (PSD) is frequently encountered in clinical practice affecting the natal clefts of the buttocks and is associated with high morbidity and discomfort. There are various surgical and nonsurgical methods for its treatment. The use of fibrin glue in PSD is relatively new and encouraging results have been reported. This study aimed to evaluate fibrin glue as a primary treatment for PSD.
Patients and methods This was a prospective observational study on 54 patients with PSD, who were admitted to our hospital during the period from September 2017 to September 2019. Patients with signs of acute abscess and complicated cases were excluded from this study. Patients had curettage of the sinus with a small Volkmann’s spoon; fibrin glue was then injected through the sinus opening to the sinus bed to obliterate the dead space.
Results In all, 54 patients were identified, 42 (77.7%) men and 12 (22.3%) women. The mean duration of operative time was 20 min. Thirty-six (66.6%) had returned to normal activities within a week. There were six (11.1%) recurrences after one glue application and had subsequent excision and lateral closure.
Conclusion Fibrin glue treatment for pilonidal sinus can be used as a first-line treatment. It is associated with patient satisfaction and rapid return to normal activities.
Keywords: fibrin glue, pilonidal disease, pilonidal sinus
|How to cite this article:|
Alfy MO, Mohamed SS. Evaluating the use of fibrin glue in the treatment of pilonidal sinus disease. Sci J Al-Azhar Med Fac Girls 2020;4:433-8
|How to cite this URL:|
Alfy MO, Mohamed SS. Evaluating the use of fibrin glue in the treatment of pilonidal sinus disease. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 28];4:433-8. Available from: http://www.sjamf.eg.net/text.asp?2020/4/3/433/296953
| Introduction|| |
Pilonidal sinus disease (PSD) is frequently encountered in clinical practice and causes serious chronic complaints . It is defined as a chronic inflammatory condition with hairs found in the midline natal pits and associated secondary track extensions. The presentation of the disease varies from acute abscess formation to chronic nonhealing pits .
Although PSD can be diagnosed in the axilla, umbilicus, and between fingers, most of them are detected in the intergluteal sulcus at the presacral area. Hodges first described the pilonidal disease in 1880 using the words ‘pilus (hair)’ and ‘nidus (nest)’ of Latin origin, meaning ‘nest of hairs’ .
Its etiology has not been well established, but implantation of the loose hair into the depth of the natal cleft, which is increased between the buttocks, can cause PSD. The deep natal clefts are favorable environments for sweating, maceration, bacterial contamination, and hair insertion. The causative factors of the pilonidal sinus are the nature of the hair itself, the force that cusses the hair insertion at the depth of the natal cleft, and the vulnerability of skin .
This disease has a high incidence in young people. The incidence rate of the pilonidal sinus is 26 per 100 000 population and it affects men 2.5 times more than women .
This disease is associated with high morbidity and discomfort; it is also a cause of isolation from job and society, which can result in many social and economic problems .
There are various surgical and nonsurgical methods for its treatment. Approximately, 15 different surgical techniques have been defined .
None of these surgical techniques are defined as ‘gold standard.’ Despite improvements in the surgical treatment of the disease, the delay to return to work due to the prolonged length of hospital stay and healing time increases the cost . As a result, operated patients might be unsatisfied.
The ideal management strategy should be simple with minimal tissue loss and a low recurrence rate. Furthermore, both shorter hospital stay and postoperative disability from active life should be minimal, with low cost and high cosmoses. Therefore, simple methods such as pit excision and the mechanical clearance of the sinus, as well as chemical treatments, have gained greater acceptance in the management of PSD.
Fibrin glue is a tissue sealant that uses the activation of fibrinogen to form a fibrin clot; it has been used for three decades in many fistular diseases with varying success. It has been applied in enterocutaneous fistulas, repairing dura tears, bronchial fistulas, and for achieving hemostasis after spleen and liver trauma 
The use of fibrin glue in PSD is relatively new and encouraging results have been reported. The glue promotes healing with an excellent cosmesis and minimal tissue loss, without excision of large amounts of tissue .
| Patients and methods|| |
Our institutional review board reviewed and approved this a prospective observational study by the Helsinki Declaration (approved number: 201912326). Fifty-four patients with PSD were admitted to the general surgery department at Al Zahraa University during the period from September 2017 to September 2019.
Written informed consent was obtained from all patients who were scheduled for fibrin glue treatment (informing about the procedure, its complications).
Patients were selected for fibrin glue treatment on a case-by-case basis. Exclusion criteria were as follows: patients who refused to participate in the study, patients with signs of an acute abscess, but patients with chronic low-grade suppuration, as frequently seen in pilonidal sinus were included, while patients with very scarred natal clefts, after repeated episodes of sepsis and surgery were more likely to be offered alternative treatments (such as a lateral closure technique or a rhomboid flap).
Antibiotic prophylaxis was given before the procedure. The procedure is performed under spinal anesthesia with the patient in the prone position. After skin shaving, preparation and draping, the pilonidal sinus complex is thoroughly curetted with a small Volkmann’s spoon to remove hair, debris, and granulation tissue. Secondary tracts are also curetted. Care was taken to extract all debris from the sinus to avoid remaining hair and granulation tissue after the glue is injected, which could potentially lead to further acute infection.
Fibrin glue (2–4 ml, Dr.M.AL-Shabrawishi Hospital Blood Bank) was then injected through the sinus opening to the sinus bed to obliterate the dead space ([Figure 1]). The product is supplied in two separate syringes, one containing human fibrinogen and the second human thrombin prepared from single-donor plasma in sterile disposables under aseptic precautions.
- A syringe containing human fibrinogen (1–3 ml).
- A syringe containing human thrombin (1–3 ml).
- Applicator Y-shaped cannula.
- Holder and plunger ([Figure 2]).
The skin was then pressed gently onto the sacrococcygeal fascia and pressure was maintained for 2 min, until the glue was dry. One or two stitches were done to close the sinus opening; then a compressive dressing was applied to the area for 24 h, and thereafter a small gauze was used to keep the wound covered. The patients were kept in observation for 1 h after the procedure before being discharged with oral analgesics that were prescribed for the first few postoperative days. Hygienic advice for the gluteal region was given to all patients at the discharge time. They were instructed to return to normal daily activities as soon as they felt comfortable ([Figure 3],[Figure 4],[Figure 5]).
All patients were invited to the clinic for a follow-up visit at postoperative weeks 1, 2, and 4, as well as 6 and 12 months after the procedure. The duration between the operation and the last visit (clinic visit with close examination) was noted as the follow-up time. Recurrence was defined as the presence of any persistent purulent/blood-stained discharge from the previously operated or nearby area during the follow-up time.
Data were collected, coded, revised, and entered into the Statistical Package for the Social Sciences (IBM SPSS) version 20 (IBM Corp., Armonk, New York, USA). The data were presented as numbers and percentages for the qualitative data, mean, SD, and ranges for the quantitative data with parametric distribution and median with interquartile range for the quantitative data with nonparametric distribution.
The confidence interval was set to 95% and the margin of error accepted was set to 5%. So, the P value was considered significant as the follows:
P>0.05: nonsignificant (NS), P<0.05: significant (S), P<0.01: highly significant (HS).
| Results|| |
Fifty-four patients with PSD, 42 (77.7%) men and 12 (22.3%) women were treated by this technique. The age range was 16–50 years) ([Table 1]). Forty (74%) of these patients had a hairy body structure. Twenty-eight (51.8%) of the patients had a family history of PSD. The mean duration of operative time was 20 min. Thirty-six (66.6%) had returned to normal activities within a week. A further 12 (22.2%) patients were back to normal activities within 2 weeks. The small group of patients with a recovery time of more than 4 weeks were those that had an early breakdown of their wound and a failed glue procedure ([Table 2]). The median follow-up time for all patients was 18 months (range: 12–36 months). The recurrence of disease was noted in six (11.1%) male patients and had subsequent excision and lateral closure following recurrence after gluing. There were no other complications. Forty-eight (88.9%) patients were satisfied with the result of their procedure. Those who were dissatisfied were patients who required further treatment with an alternative surgical technique.
| Discussion|| |
PSD has long been studied on an embryologic basis by many authors, who considered a congenital origin . Patey and Scarff , soon after the end of World War II, hypothesized that the disease was acquired by the penetration of hair into the subcutaneous tissue, with consequent granulomatous reaction. They introduced this concept based on the high incidence of recurrence after complete excision of all tissue overlying the sacrum and on the occurrence of the disease in other locations of the body. On the basis of this theory, incision and curettage have been proposed as the method of choice for PSD treatment .
According to Karydakis, three main factors contribute to the hair insertion process: first, the invader, consisting of loose hair; second, some force, which causes hair insertion; and third, the vulnerability of the skin. If these three main factors occur, then hair insertion and PSD results. Thus, for the treatment and prevention of PSD, these causative factors must be eliminated .
Armstrong and Barcia , advocating a conservative treatment with no excision but meticulous hair control by natal cleft shaving, showed that improved perineal hygiene and limited lateral incision produce good results.
Fibrin glue is a biological adhesive that imitates the final stage of coagulation. It is composed of purified, virus-inactivated human fibrinogen and thrombin. It stimulates the normal clotting process and is subsequently resorbed by normal tissue enzyme systems, without causing a foreign-body reaction or extensive fibrosis. It has been used for hemostasis in the fields of plastic, cardiovascular and thoracic surgery, neurosurgery, otorhinolaryngology, orthopedic surgery, and dental care in patients with normal or abnormal hemostasis .
The ideal treatment for PSD should be simple, effective, and relatively pain free, allowing a quick recovery and return to normal activities. Using fibrin glue as monotherapy for pilonidal sinus, the disease appears to offer this. Traditional surgical techniques are frequently complicated by wound breakdown, infection, prolonged pain, and immobility. Reported recurrence rates vary widely between reported studies of midline excision with and without primary closure (either midline or off-midline closure).
Vitale et al.  first reported the use of fibrin glue in PSD after the excision of the sacrococcygeal fistula to fill the cavity.
Greenberg et al.  successfully trialed the use of fibrin glue in the management of PSD, following its use in the management of fistula-in-ano. They proposed that fibrin glue promoted wound healing by mechanisms of hemostasis, angiogenesis, macrophage stimulation, and increased collagen deposition. They showed no recurrence in a series of 33 adults and a wound infection rate of 13% following sinusectomy and application of fibrin glue. Since this paper, management of PSD with pit excision and application of fibrin sealant has been widely adopted in adult practice and early reports seem to show acceptably low recurrence rates. A recent review article of four case series and one RCT showed one recurrence in 85 adults, with a shorter time to return to normal activities .
Seleem and Al-Hashemy  have used fibrin glue after excision of a minimal amount of skin and subcutaneous tissue in 25 patients, while Lund and Leveson  used the glue after excision of the epithelium of the sinus.
Altinli et al.  compared two groups of patients to study the effect of fibrin glue on the elimination of drain use after Limberg flap surgery and found that drains may have been avoided with fibrin sealant.
We hoped to treat PSD without the requirement of surgery through the elimination of dead space by fibrin glue. Without excision, this noninvasive treatment is easy and simple to perform, has minimal postoperative disability, and the operation may be performed by surgeons who are less experienced. It has good aesthetic results without disfiguring scars, saving the natural and deep shape of the anal cleft.
Treatment for PSD with fibrin glue can be performed as a day-case surgery. Young patients can return to normal activities rapidly, and although not measured in this service evaluation, there will likely be significant quality of life and health economic benefits consequently. This would appear to compare favorably with results from traditional surgical techniques.Most patients can be treated successfully with fibrin glue as a primary procedure. Recurrence rates are like other, more invasive treatments, but without the discomfort of an incision in the natal cleft.
If not initially successful, fibrin glue treatment can be repeated after a discussion of the alternatives with the patient. Complicated diseases were treated by excision and Limberg Flap technique.
Guidelines from the American Society of Colon and Rectal Surgeons in Pilonidal Disease Management: Those with chronic disease, but without an abscess, can be treated with fibrin glue alone or in conjunction with surgical excision to prevent recurrence .
The limitations of this study include the small sample size. Also, PSD has a wide spectrum of disease severity ranging from simple pits to multiple deep sinuses with complex cavities, associated with granulation and infection. The applicability and success of fibrin glue procedure for severe forms of PSD are still to be established.
| Conclusion|| |
Fibrin glue treatment for pilonidal sinus can be used as a first-line treatment for patients who have no history of infection and only one sinus. It is associated with high patient satisfaction and rapid return to normal activities.
A prospective, randomized trial of fibrin glue against the best alternative surgical treatment should be conducted to better evaluate the role of fibrin glue application for the treatment of PSD.
The authors express their gratitude and thanks to all participating patients and the clinical staff.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]