International Wound Journal ISSN 1742-4801
CASE REPORT
Suture granuloma mimicking a recurrent sacro-coccygeal pilonidal sinus after Limberg flap Michael Ardelt1 , Yves Dittmar1 , Birte Schulz2 , Falk Rauchfuss1 , Hubert Scheuerlein1 & Utz Settmacher1 1 Department of General, Visceral and Vascular Surgery, University Hospital of Jena, Jena, Germany 2 Department of Pathology, University Hospital of Jena, Jena, Germany
Key words Karydakis; Limberg; Pilonidal sinus disease; Suture granuloma
Ardelt M, Dittmar Y, Schulz B, Rauchfuss F, Scheuerlein H, Settmacher U. Suture granuloma mimicking a recurrent sacro-coccygeal pilonidal sinus after Limberg flap. Int Wound J 2014; 11:583–585
Correspondence to
Abstract
M Ardelt Department of General, Visceral and Vascular Surgery University Hospital of Jena Erlanger Allee 101 07747 Jena Germany E-mail: [email protected]
doi: 10.1111/iwj.12341
Sacro-coccygeal pilonidal sinus disease is classified as an asymptomatic, acutely abscess-forming or chronic subcutaneous inflammation in the sacro-coccygeal region featuring characteristic pits in the bottom cleft. Due to high rates of recurrence, two flap techniques have been established in the course of the past three decades. One of them is the Karydakis operation, the other option is a rotation flap named Limberg procedure. We report about a case of suture granuloma in the area of a Limberg flap after recurrent pilonidal sinus with extrusion of the suture material, thus mimicking recurrence. In case of recurrent pilonidal sinus following plastic coverage or primary closure, respectively, the differential diagnosis of suture granuloma should be considered.
Introduction
Sacro-coccygeal pilonidal sinus disease is classified as asymptomatic, acutely abscess-forming or chronic subcutaneous inflammation in the sacro-coccygeal region (1), featuring characteristic pits in the bottom cleft. Numerous treatment options have been described for this disease. However, no standard therapy has yet been established (2,3). Due to high rates of recurrence of up to 42% (4), two flap techniques have been established in the course of the past three decades. One of them is the Karydakis operation, which is a procedure with asymmetric excision and wound closure off the midline (5). The other option is a rotation flap named Limberg procedure. First, a rhomboid excision is performed. Then, a flap is cut from the gluteal region to fit into the rhomboid excision and is then rotated to cover the excision. Both techniques result in lifting the bottom cleft (6). Numerous alternative treatments of the pilonidal sinus have been described. We report about a case of suture granuloma in the area of a Limberg flap with extrusion of the suture material, thus mimicking a recurrent pilonidal sinus. Case report
A 24-year-old male patient was admitted to our department after 2 weeks of discharging secretions from an orifice in the upper region of the bottom cleft. Two months earlier, minor redness was observed in that region. The patient did not experience any additional clinical symptoms.
Key Messages
• we propose that in case of recurrent pilonidal sinus following plastic coverage or primary closure, a suture granuloma should be considered as a possible differential diagnosis • considering the increasing number of case reports about malignant changes, particularly in chronic and recurring sacro-coccygeal pilonidal sinus disease, a histological examination should always be performed
The patient had initially been treated for infected sacrococcygeal pilonidal sinus 6 years before, with excision of the pilonidal sinus. Due to a recurrence after 3 years, a fascio-cutaneous Limberg flap operation was performed using Vicryl® (Ethicon; Johnson & Johnson, Neuss, Germany) for suturing. Clinical examination showed an orifice measuring 4 × 2 mm without surrounding erythema in the upper area of the rhomboid flap (Figure 1). White blood count and C-reactive protein were within normal range. A recurrence after the Limberg flap surgery was suspected, and another excision with plastic coverage according to Karydakis was performed without complication. The intra-operative wound length was 8⋅5 cm. Once again, Vicryl was used for both the fascial and the subcutaneous sutures, and the patient was discharged on the fourth postoperative day.
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
583
M. Ardelt et al.
Suture granuloma mimicking a recurrent pilonidal sinus
Figure 3 Photograph showing wound dehiscence 4 months after Karydakis operation.
Figure 1 An orifice in the upper area of the Limberg flap (the photo was provided to us by the patient).
An intra-operative swab sample featured no growth of bacteria. The histological examination showed non-absorbed suture material surrounded by polynuclear giant cells with lymphohistiocytic infiltrates (Figure 2). The sutures were removed on the 14th postoperative day, and the wound was completely unremarkable. After a 4-month uneventful postoperative course, there was a recurrent wound dehiscence of the caudal wound area with secretion of serous fluid (see Figure 3). The edges of the wound were unremarkable and not irritated. The wound extended to the right section of the sacral fascia where the fascia suture from the Karydakis operation was applied. Gentle probing reached 2 cm into the cranial direction. Initially, the wound was irrigated daily with physiological saline, and a Suprasorb® sponge (Lohmann & Rauscher GmbH & Co. KG, Neuwied,
Germany) was inserted. Surprisingly, under this treatment the wound spreads further cranially. However, the irrigation procedures recovered non-absorbed suture material from the wound. This observation confirmed the suspicion of a new suture granuloma. Thus, no excision was performed and no secondary suture was applied. After approximately 2 weeks, the wound cavity measured 7 cm cranially, that is, slightly less than the wound after the Karydakis operation. From this time onwards, no more suture material was recovered by the irrigation procedures and the wound size decreased. After a week, the irrigation procedures were performed every 2 or 3 days. After a total of 8 weeks, the wound cavity had almost reached skin level. In a telephone interview 6 months later, the patient reported no new symptoms, such as wound dehiscence, recurrent pilonidal sinus, redness or pain. Discussion
Retrospectively, the orifice in the upper area of the Limberg flap was not a typical pilonidal sinus pit, but rather a wound dehiscence. A foreign body reaction had probably led to an
Figure 2 Microscopic image of the subcutis with not absorbed suture material surrounding polynuclear giant cells and lymphohistiocystary infiltrates (400× microscopic enlargement); left: haematoxilin/eosin staining image; right: haematoxilin/eosin staining polarisation image.
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© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
M. Ardelt et al.
extrusion of suture material that was initially perceived as mere secretion. Suture granulomas are persistent foreign body reactions to suture material with possible extrusion thereof (7). According to the manufacturer, the suture material should be absorbed after a maximum of 70 days. However, there have been reports of suture granulomas, that had developed after up to 51 years postoperatively. (8). In this case, accurate diagnosis was possible only after histological examination. Considering the increasing number of case reports about degenerations, particularly in chronic and recurring sacrococcygeal pilonidal sinus disease, a histological examination should always be performed (9). Also, a microbiological examination should be performed to optimise the treatment (10). Suture granulomas should not be treated by repeatedly applying the same suture material. One should either aim for secondary healing or use alternative absorbable materials. Nevertheless, the risk of a foreign body reaction cannot be completely eliminated. Conclusion
In summary, we propose that in case of recurrent pilonidal sinus following plastic coverage or primary closure, respectively, the differential diagnosis of suture granuloma should be considered.
Suture granuloma mimicking a recurrent pilonidal sinus
References 1. Dahl HD, Henrich MH. Light and scanning electron microscopy study of the pathogenesis of pilonidal sinus and anal fistula. Langenbecks Arch Chir 1992;377:118–24. 2. Harris CL, Holloway S. Development of an evidence-based protocol for care of pilonidal sinus wounds healing by secondary intent using a modified Reactive Delphi procedure. Part 2: methodology, analysis and results. Int Wound J 2012;9:173–88. 3. Harris CL, Holloway S. Development of an evidence-based protocol for care of pilonidal sinus wounds healing by secondary intent using a modified reactive Delphi procedure. Part one: the literature review*. Int Wound J 2012;9:156–72. 4. Iesalnieks I, Furst A, Rentsch M, Jauch KW. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate. Chirurg 2003;74:461–8. 5. Karydakis GE. New approach to the problem of pilonidal sinus. Lancet 1973;2:1414–5. 6. Limberg AA. Design of local flaps. Mod Trends Plast Surg 1966;2:38–61. 7. Levin JM, Brauer JA, Draft K, Junkins-Hopkins JM, James WD. Suture granuloma following surgical neck rejuvenation procedure. Dermatol Surg 2006;32:768–9. 8. Rettenbacher T, Macheiner P, Hollerweger A, Gritzmann N, Weismann C, Todoroff B. Suture granulomas: sonography enables a correct preoperative diagnosis. Ultrasound Med Biol 2001;27:343–50. 9. Pandey MK, Gupta P, Khanna AK. Squamous cell carcinoma arising from pilonidal sinus. Int Wound J 2012. doi: 10.1111/j.1742-481X.2012.01096.x. 10. Ardelt M, Dittmar Y, Kocijan R, Rodel J, Schulz B, Scheuerlein H, Settmacher U. Microbiology of the infected recurrent sacrococcygeal pilonidal sinus. Int Wound J 2014. doi: 10.1111/iwj.12274.
Acknowledgement
There is no conflict of interest or funding in relation to this report.
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
585
CASE REPORT
Suture granuloma mimicking a recurrent sacro-coccygeal pilonidal sinus after Limberg flap Michael Ardelt1 , Yves Dittmar1 , Birte Schulz2 , Falk Rauchfuss1 , Hubert Scheuerlein1 & Utz Settmacher1 1 Department of General, Visceral and Vascular Surgery, University Hospital of Jena, Jena, Germany 2 Department of Pathology, University Hospital of Jena, Jena, Germany
Key words Karydakis; Limberg; Pilonidal sinus disease; Suture granuloma
Ardelt M, Dittmar Y, Schulz B, Rauchfuss F, Scheuerlein H, Settmacher U. Suture granuloma mimicking a recurrent sacro-coccygeal pilonidal sinus after Limberg flap. Int Wound J 2014; 11:583–585
Correspondence to
Abstract
M Ardelt Department of General, Visceral and Vascular Surgery University Hospital of Jena Erlanger Allee 101 07747 Jena Germany E-mail: [email protected]
doi: 10.1111/iwj.12341
Sacro-coccygeal pilonidal sinus disease is classified as an asymptomatic, acutely abscess-forming or chronic subcutaneous inflammation in the sacro-coccygeal region featuring characteristic pits in the bottom cleft. Due to high rates of recurrence, two flap techniques have been established in the course of the past three decades. One of them is the Karydakis operation, the other option is a rotation flap named Limberg procedure. We report about a case of suture granuloma in the area of a Limberg flap after recurrent pilonidal sinus with extrusion of the suture material, thus mimicking recurrence. In case of recurrent pilonidal sinus following plastic coverage or primary closure, respectively, the differential diagnosis of suture granuloma should be considered.
Introduction
Sacro-coccygeal pilonidal sinus disease is classified as asymptomatic, acutely abscess-forming or chronic subcutaneous inflammation in the sacro-coccygeal region (1), featuring characteristic pits in the bottom cleft. Numerous treatment options have been described for this disease. However, no standard therapy has yet been established (2,3). Due to high rates of recurrence of up to 42% (4), two flap techniques have been established in the course of the past three decades. One of them is the Karydakis operation, which is a procedure with asymmetric excision and wound closure off the midline (5). The other option is a rotation flap named Limberg procedure. First, a rhomboid excision is performed. Then, a flap is cut from the gluteal region to fit into the rhomboid excision and is then rotated to cover the excision. Both techniques result in lifting the bottom cleft (6). Numerous alternative treatments of the pilonidal sinus have been described. We report about a case of suture granuloma in the area of a Limberg flap with extrusion of the suture material, thus mimicking a recurrent pilonidal sinus. Case report
A 24-year-old male patient was admitted to our department after 2 weeks of discharging secretions from an orifice in the upper region of the bottom cleft. Two months earlier, minor redness was observed in that region. The patient did not experience any additional clinical symptoms.
Key Messages
• we propose that in case of recurrent pilonidal sinus following plastic coverage or primary closure, a suture granuloma should be considered as a possible differential diagnosis • considering the increasing number of case reports about malignant changes, particularly in chronic and recurring sacro-coccygeal pilonidal sinus disease, a histological examination should always be performed
The patient had initially been treated for infected sacrococcygeal pilonidal sinus 6 years before, with excision of the pilonidal sinus. Due to a recurrence after 3 years, a fascio-cutaneous Limberg flap operation was performed using Vicryl® (Ethicon; Johnson & Johnson, Neuss, Germany) for suturing. Clinical examination showed an orifice measuring 4 × 2 mm without surrounding erythema in the upper area of the rhomboid flap (Figure 1). White blood count and C-reactive protein were within normal range. A recurrence after the Limberg flap surgery was suspected, and another excision with plastic coverage according to Karydakis was performed without complication. The intra-operative wound length was 8⋅5 cm. Once again, Vicryl was used for both the fascial and the subcutaneous sutures, and the patient was discharged on the fourth postoperative day.
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
583
M. Ardelt et al.
Suture granuloma mimicking a recurrent pilonidal sinus
Figure 3 Photograph showing wound dehiscence 4 months after Karydakis operation.
Figure 1 An orifice in the upper area of the Limberg flap (the photo was provided to us by the patient).
An intra-operative swab sample featured no growth of bacteria. The histological examination showed non-absorbed suture material surrounded by polynuclear giant cells with lymphohistiocytic infiltrates (Figure 2). The sutures were removed on the 14th postoperative day, and the wound was completely unremarkable. After a 4-month uneventful postoperative course, there was a recurrent wound dehiscence of the caudal wound area with secretion of serous fluid (see Figure 3). The edges of the wound were unremarkable and not irritated. The wound extended to the right section of the sacral fascia where the fascia suture from the Karydakis operation was applied. Gentle probing reached 2 cm into the cranial direction. Initially, the wound was irrigated daily with physiological saline, and a Suprasorb® sponge (Lohmann & Rauscher GmbH & Co. KG, Neuwied,
Germany) was inserted. Surprisingly, under this treatment the wound spreads further cranially. However, the irrigation procedures recovered non-absorbed suture material from the wound. This observation confirmed the suspicion of a new suture granuloma. Thus, no excision was performed and no secondary suture was applied. After approximately 2 weeks, the wound cavity measured 7 cm cranially, that is, slightly less than the wound after the Karydakis operation. From this time onwards, no more suture material was recovered by the irrigation procedures and the wound size decreased. After a week, the irrigation procedures were performed every 2 or 3 days. After a total of 8 weeks, the wound cavity had almost reached skin level. In a telephone interview 6 months later, the patient reported no new symptoms, such as wound dehiscence, recurrent pilonidal sinus, redness or pain. Discussion
Retrospectively, the orifice in the upper area of the Limberg flap was not a typical pilonidal sinus pit, but rather a wound dehiscence. A foreign body reaction had probably led to an
Figure 2 Microscopic image of the subcutis with not absorbed suture material surrounding polynuclear giant cells and lymphohistiocystary infiltrates (400× microscopic enlargement); left: haematoxilin/eosin staining image; right: haematoxilin/eosin staining polarisation image.
584
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
M. Ardelt et al.
extrusion of suture material that was initially perceived as mere secretion. Suture granulomas are persistent foreign body reactions to suture material with possible extrusion thereof (7). According to the manufacturer, the suture material should be absorbed after a maximum of 70 days. However, there have been reports of suture granulomas, that had developed after up to 51 years postoperatively. (8). In this case, accurate diagnosis was possible only after histological examination. Considering the increasing number of case reports about degenerations, particularly in chronic and recurring sacrococcygeal pilonidal sinus disease, a histological examination should always be performed (9). Also, a microbiological examination should be performed to optimise the treatment (10). Suture granulomas should not be treated by repeatedly applying the same suture material. One should either aim for secondary healing or use alternative absorbable materials. Nevertheless, the risk of a foreign body reaction cannot be completely eliminated. Conclusion
In summary, we propose that in case of recurrent pilonidal sinus following plastic coverage or primary closure, respectively, the differential diagnosis of suture granuloma should be considered.
Suture granuloma mimicking a recurrent pilonidal sinus
References 1. Dahl HD, Henrich MH. Light and scanning electron microscopy study of the pathogenesis of pilonidal sinus and anal fistula. Langenbecks Arch Chir 1992;377:118–24. 2. Harris CL, Holloway S. Development of an evidence-based protocol for care of pilonidal sinus wounds healing by secondary intent using a modified Reactive Delphi procedure. Part 2: methodology, analysis and results. Int Wound J 2012;9:173–88. 3. Harris CL, Holloway S. Development of an evidence-based protocol for care of pilonidal sinus wounds healing by secondary intent using a modified reactive Delphi procedure. Part one: the literature review*. Int Wound J 2012;9:156–72. 4. Iesalnieks I, Furst A, Rentsch M, Jauch KW. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate. Chirurg 2003;74:461–8. 5. Karydakis GE. New approach to the problem of pilonidal sinus. Lancet 1973;2:1414–5. 6. Limberg AA. Design of local flaps. Mod Trends Plast Surg 1966;2:38–61. 7. Levin JM, Brauer JA, Draft K, Junkins-Hopkins JM, James WD. Suture granuloma following surgical neck rejuvenation procedure. Dermatol Surg 2006;32:768–9. 8. Rettenbacher T, Macheiner P, Hollerweger A, Gritzmann N, Weismann C, Todoroff B. Suture granulomas: sonography enables a correct preoperative diagnosis. Ultrasound Med Biol 2001;27:343–50. 9. Pandey MK, Gupta P, Khanna AK. Squamous cell carcinoma arising from pilonidal sinus. Int Wound J 2012. doi: 10.1111/j.1742-481X.2012.01096.x. 10. Ardelt M, Dittmar Y, Kocijan R, Rodel J, Schulz B, Scheuerlein H, Settmacher U. Microbiology of the infected recurrent sacrococcygeal pilonidal sinus. Int Wound J 2014. doi: 10.1111/iwj.12274.
Acknowledgement
There is no conflict of interest or funding in relation to this report.
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
585
