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<Provider Id="sundheddkcms"> <Item Id="{7C1AE019-41FA-49F4-AFD7-68D16319FF85}" Name="pilonidalcyste" Type="LHContentPage" ParentProviderId="sundheddkcms" ParentItemId="{BE3417D9-3567-413A-868C-BFF4928F31A5}" SortOrder="800" PublishDate="2011-03-12T15:19:00" DeleteDate="2999-12-31T00:00:00" PotItemType=""> <Content> <HtmlField Name="PageContent"><![CDATA[<h2>Generelt</h2> <ul> <li>Cystis pilonidalis ses forholdsvist hyppigt - og 4-5 gange hyppigere hos mænd end hos kvinder. Cystis pilonidalis ses typisk i 15-40 års alderen</li> <li>Pilonidalcyste findes som akut tilstand eller som akut absces</li> <li>Symptomatisk pilonidalcyste behandles med operation, og prognosen er god med nyere operationsteknikker</li> <li>Nedenstående gennemgang bygger på internationale <a href=" " data-type="journal-reference" data-value="Bi S, Sun K, Chen S, Gu J, Surgical procedures in the pilonidal sinus disease: a systematic review and network meta-analysis. Sci Rep 2020;10: 13720" data-value-piped="Bi S, Sun K, Chen S, Gu J|Surgical procedures in the pilonidal sinus disease: a systematic review and network meta-analysis.|Sci Rep|2020|10|13720|32792519" data-url="reference-link" data-pubmedid="32792519" title="Bi S, Sun K, Chen S, Gu J, Surgical procedures in the pilonidal sinus disease: a systematic review and network meta-analysis. Sci Rep 2020;10: 13720"><sup>1</sup></a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Grabowski J, Oyetunji TA, Goldin AB, Baird R, Gosain A, Lal DR, Kawaguchi A, Downard C, Sola JE, Arthur LG, Shelton J, Diefenbach KA, Kelley-Quon LI, Williams RF, Ricca RL, Dasgupta R, St Peter SD, Sømme S, Guner YS, Jancelewicz T, The management of pilonidal disease: A systematic review. J Pediatr Surg 2019;54: 2210-2221" data-value-piped="Grabowski J, Oyetunji TA, Goldin AB, Baird R, Gosain A, Lal DR, Kawaguchi A, Downard C, Sola JE, Arthur LG, Shelton J, Diefenbach KA, Kelley-Quon LI, Williams RF, Ricca RL, Dasgupta R, St Peter SD, Sømme S, Guner YS, Jancelewicz T|The management of pilonidal disease: A systematic review.|J Pediatr Surg|2019|54|2210-2221|30948198" data-url="reference-link" data-pubmedid="30948198" title="Grabowski J, Oyetunji TA, Goldin AB, Baird R, Gosain A, Lal DR, Kawaguchi A, Downard C, Sola JE, Arthur LG, Shelton J, Diefenbach KA, Kelley-Quon LI, Williams RF, Ricca RL, Dasgupta R, St Peter SD, Sømme S, Guner YS, Jancelewicz T, The management of pilonidal disease: A systematic review. J Pediatr Surg 2019;54: 2210-2221"><sup>2</sup></a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Boshnaq M, Phan YC, Martini I, Harilingam M, Akhtar M, Tsavellas G, Limberg flap in management of pilonidal sinus disease: systematic review and a local experience. Acta Chir Belg 2018;118: 78-84" data-value-piped="Boshnaq M, Phan YC, Martini I, Harilingam M, Akhtar M, Tsavellas G|Limberg flap in management of pilonidal sinus disease: systematic review and a local experience.|Acta Chir Belg|2018|118|78-84|29390948" data-url="reference-link" data-pubmedid="29390948" title="Boshnaq M, Phan YC, Martini I, Harilingam M, Akhtar M, Tsavellas G, Limberg flap in management of pilonidal sinus disease: systematic review and a local experience. Acta Chir Belg 2018;118: 78-84"><sup>3</sup></a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Bascom J, Bascom T, Failed pilonidal surgery: new paradigm and new operation leading to cures. Arch Surg 2002;137: 1146-50; discussion 1151" data-value-piped="Bascom J, Bascom T|Failed pilonidal surgery: new paradigm and new operation leading to cures.|Arch Surg|2002|137|1146-50; discussion 1151|12361421" data-url="reference-link" data-pubmedid="12361421" title="Bascom J, Bascom T, Failed pilonidal surgery: new paradigm and new operation leading to cures. Arch Surg 2002;137: 1146-50; discussion 1151"><sup>4</sup></a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Steele SR, Perry WB, Mills S, Buie WD, Standards Practice Task Force of the American Society of Colon and Rectal Surgeons, Practice parameters for the management of pilonidal disease. Dis Colon Rectum 2013;56: 1021-7" data-value-piped="Steele SR, Perry WB, Mills S, Buie WD, Standards Practice Task Force of the American Society of Colon and Rectal Surgeons|Practice parameters for the management of pilonidal disease.|Dis Colon Rectum|2013|56|1021-7|23929010" data-url="reference-link" data-pubmedid="23929010" title="Steele SR, Perry WB, Mills S, Buie WD, Standards Practice Task Force of the American Society of Colon and Rectal Surgeons, Practice parameters for the management of pilonidal disease. Dis Colon Rectum 2013;56: 1021-7"><sup>5</sup></a> og danske referencer<a href=" " data-type="journal-reference" data-value="Poulsen IM, Bisgaard T, [Treatment of pilonidal sinus]. Ugeskr Laeger 2008;170: 2963-8" data-value-piped="Poulsen IM, Bisgaard T|[Treatment of pilonidal sinus].|Ugeskr Laeger|2008|170|2963-8|18808749" data-url="reference-link" data-pubmedid="18808749" title="Poulsen IM, Bisgaard T, [Treatment of pilonidal sinus]. Ugeskr Laeger 2008;170: 2963-8"><sup>6</sup></a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Bertelsen CA, Jørgensen LN, [Bascom's operation for pilonidal fistula]. Ugeskr Laeger 2008;170: 2313-7" data-value-piped="Bertelsen CA, Jørgensen LN|[Bascom's operation for pilonidal fistula].|Ugeskr Laeger|2008|170|2313-7|18570761" data-url="reference-link" data-pubmedid="18570761" title="Bertelsen CA, Jørgensen LN, [Bascom's operation for pilonidal fistula]. Ugeskr Laeger 2008;170: 2313-7"><sup>7</sup></a></li> </ul> <h2>Diagnose</h2> <h3>Diagnostiske kriterier</h3> <ul> <li>Typisk sygehistorie og kliniske fund med påvisning af ”pit” og/eller sinus (fistel) åbning(er), sekretion, og eventuelt tegn til absces med rødme, smerter, varme og hævelse mellem balderne. Ofte ses åbning/sinusgang med hår. Der kan være ledsagende ”pits” eller sinus i crena ani</li> </ul> <h3>Sygehistorie</h3> <ul> <li>Tilstanden kan præsentere sig som en absces ved crena ani eller som en kronisk tilstand</li> <li>En pilonidalfistel har ofte skiftevis værre og mildere perioder - og kan udvikle sig til en kronisk tilstand</li> <li>Meget sjældent ses perianal pilonidalfistel</li> <li>Tilstanden vil som regel recidivere, hvis ikke den behandles adækvat (fjernelse af fistelkanalen)</li> <li>En pilonidalcyste kan også være asymptomatisk</li> <li>Yderst sjældent kan en pilonidalcyste ses i interstitiet mellem fingrene og mellem tæerne</li> </ul> <h3>Akut pilonidal absces</h3> <ul> <li>Oftest ses en smertefuld, fluktuerende udbuling i sakrococcygeale region</li> <li>Der kan tømmes pus fra abscessen</li> <li>Tidligt i udviklingen foreligger en cellulitis eller et hår, som har bevæget sig ind under huden</li> </ul> <h3>Kronisk pilonidal fistel</h3> <ul> <li>Oftest ses en fistelgang i den sakrococcygeale region</li> <li>Der kan eventuelt tømmes pus fra fistlen, men der er ingen akut absces dannelse</li> <li>Tidligt i udviklingen ses en lille sort prik (kaldet pit) beliggende midt i crena ani</li> <li>Fra den pit, som er nærmest anus, har hår bevæget sig ind under huden og dannet en hår-rede</li> <li>Den dannede rede af hår i underhuden kan blive inficeret og vil udtømme sig via en fistelgang til huden - og dermed danne en sekundær åbning og kronisk fistel</li> <li>Typisk er, at infektionen kommer og går, med forværring og forbedring af symptomerne</li> </ul> <h3>Kliniske fund</h3> <ul> <li>Afhænger af, hvilket stadium tilstanden har ved undersøgelsen: <br> <ul> <li>”Pits”</li> <li>Sinus</li> <li>Sekundær åbning</li> <li><a href="~/link.aspx?_id=6DC6AB8397B44C03A651666F2BAAB483&_z=z">Abscesser i huden</a></li> </ul> </li> <li>Den kroniske fistel forløber opad fra folliklen i 90 % af tilfældene og kan palperes som en streng under huden</li> <li>Det er ikke usædvanligt at påvise flere åbninger fra fistelen i midtlinjen</li> </ul> <p><img src="8F66B76C9C124810B6387A51E241ABCC-240-190" style="height: 190px; width: 240px;" alt="Tegning der viser pilonidal sinus" title="Tegning der viser pilonidal sinus" height="190" width="240"> </p> <h3>Supplerende undersøgelser i almen praksis</h3> <ul> <li>Klinisk undersøgelse med lokalisering af patologi i crena ani</li> </ul> <h3>Andre undersøgelser hos specialist eller undersøgelse på sygehus</h3> <ul> <li>Sjældent anoskopi (ved fistulering perianalt)</li> <li>Sjældent MR-skannning (ved fistulering perianalt)</li> </ul> <h3>Differentialdiagnoser</h3> <ul> <li>Analfistel</li> <li>Hidrosadenitis</li> <li>Furunkel<span></span></li> <li>Yderst sjældent medfødte - spinale med sivende cerebrospinalvæske (sjældent)</li> <li>Sacrococcygealt teratom (meget sjældent)</li> </ul> <h2>Behandling</h2> <h3>Behandlingsmål</h3> <ul> <li>Ved absces er målet at drænere abscessen</li> <li>Ved kronisk fistel er målet fjernelse af inflammeret væv og fremmedlegemer samt opheling med lav recidivrisiko</li> <li>Reducere patientens ubehag efter indgrebet samt undgå sygehusindlæggelse og sygefravær</li> </ul> <h3>Generelt om behandling</h3> <ul> <li>Kirurgi er standardbehandling</li> <li>Behandlingen afhænger af, hvordan tilstanden præsenterer sig: <br> <ul> <li>Akut pilonidal absces</li> <li>Kronisk pilonidal sygdom med 1-3 høje fistelåbninger</li> <li>Kompleks eller recidiverende sygdom med 4-6 fistelåbninger eller anusnære fistelåbninger</li> </ul> </li> <li>Komplicerede tilfælde bør henvises til center med erfaring i denne type operationer</li> <li>Operation for akut absces:<br> <ul> <li>Abscessen åbnes lateralt for midtlinjen, og lades stå åben til behandling med håndbruser hjemme</li> <li>Helingstiden er individuel, men typisk 2-4 uger, og perioden er ofte relativt smertefuld</li> </ul> </li> <li>Operation for kronisk pilonidal fistel<br> <ul> <li>Hvis der findes få pits eller sinus med kort afstand til den sekundære åbning, kan fjernelse af fistelvævet i lokalbedøvelse være en god operation</li> <li>Hvis fistelsystemet er mere omfattende, foretages kløft-løft operation. Behandlingsresultaterne er på det seneste betydeligt forbedrede. Postoperative smerter er få, risikoen for sårhelingsproblemer er dog fortsat tilstede, med 10-20 % som ikke heler fuldstændigt primært </li> <li>Recidivrisikoen er 30-40 % efter pilonidal absces, 20-40 % efter lokal excision af begrænset fistelsystem og 8-20 % efter operation for kronisk pilonidal cyste med en kløft-løft procedure. Recidiv afhænger af valg af operationsmetode og operatørens erfaring </li> </ul> </li> </ul> <h3>Håndtering i almen praksis</h3> <ul> <li>Klinisk undersøgelse og anamnese, fund af patologi i baldeområde (oftest crena ani)</li> <li>Ved asymptomatisk pilonidalfistel behøves ikke henvisning til kirurgisk afdeling</li> <li>Ved symptomatisk pilonidalfistel henvises til kirurgisk afdeling</li> </ul> <h3>Råd til patienten</h3> <ul> <li>God hygiejne med daglig vask (bruser) og især fjernelse af løse hår imellem balderne</li> </ul> <h3>Medicinsk behandling</h3> <ul> <li>Behandlingen er kirurgisk</li> <li>Der gives ofte perioperativ antibiotika omend antibiotika ikke er nødvendig ved akut tilstand (absces)</li> </ul> <h3>Andre medicinske behandlinger</h3> <ul> <li>Ingen</li> </ul> <h3>Anden behandling</h3> <ul> <li>Laserbehandling med fjernelse af hår i området er ikke effektiv</li> </ul> <h3>Kirurgi </h3> <h4>Akut pilonidal absces</h4> <ul> <li>Håndteres med incision, drænage, curettage af absceskaviteten for at fjerne hår og hudaffald</li> <li>Indgrebet<br> <ul> <li>Incision og oprensning af abscesområdet anbefales frem for radikal excision en bloc. Gevinsten er kortere rekonvalescenstid</li> </ul> </li> <li>Opfølgende behandling<br> <ul> <li>Såret bør rengøres dagligt med bruser</li> <li>Ved evt. hår i området bør hårene barberes væk for at hindre hår i at komme ind i det helende sår</li> <li>Bør fortsætte i ca. 3 måneder, selv efter at såret er helet</li> </ul> </li> <li>Effekt<br> <ul> <li>90 % opnår fuld opheling i løbet af en måned</li> <li>Incision og drænage uden curettage giver opheling hos ca. 60 % indenfor 10 uger, af disse vil 40 % få recidiv</li> <li>I første periode smerter (især første uge) - men mange har flere ugers generende smerter</li> </ul> </li> <li>Radikal operation?<br> <ul> <li>Skal ikke forsøges udført i den akutte fase </li> </ul> </li> <li>Efter incision af absces skal der ske hyppige sårskift og renligholdelse med telefonbruser etc.</li> </ul> <h4>Kronisk pilonidalsinus</h4> <ul> <li> Indgrebet foregår på dedikerede centre i lokalanæstesi ved minimale forandringer, og i general anæstesi ved længere afstand imellem fistel åbningerne eller mere komplekse eller anusnære fistelsystemer</li> <li>Flere typer indgreb er mulige</li> <li>Simpel excision med eller uden primærlukning anses i dag som obsolet pga. betydeligt dårligere resultater - både i forhold til helingstid, postoperative smerter og recidiv - end ved kløft-løft operationer</li> <li>Mindre udbredte forandringer kan fjernes i lokalanalgesi med fjernelse af sinus og sekundær fistel med eller uden primær sutur</li> <li>Ved den typiske operationsmetode i Danmark benyttes der ”Bascom’s pit pick”. Ved mere omfattende eller anusnære forandringer benyttes lateral lap operation</li> </ul> <p>Der findes tre anerkendte operationsmetoder (og adskillige variationer over samme): Lindberg’s lap operation, Karydakis’ operation og Bascom’s kløft-løft operation. Bascoms operation er let at udføre, og benyttes mest i Danmark.</p> <p>Formålet med alle tre operationer er:</p> <ul> <li>at fjerne fistelvævet</li> <li>at gøre crena ani mindre dyb (hindrer recidiv)</li> <li>at lateralisere cikatricen (væk fra bevægelsen) for bedre heling</li> </ul> <h3>Forebyggende behandling</h3> <ul> <li>God personlig hygiejne</li> <li>Der er ikke evidens for effekt af omhyggelig fjernelse af hår i sakralområdet, evt. regelmæssig barbering uden kirurgi har gavnlig effekt</li> <li>Undersøgelser af hår i pilonidal fistler har afsløret, at 71 % af hårene i fistlen kommer fra hovedet eller ryggen (hovedhår identificeres ved, at de er klippet i begge ender)</li> </ul> <h2>Henvisning</h2> <ul> <li>Manglende kompetence i at håndtere tilstanden</li> <li>Udbredt betændelse</li> <li>Kronisk, recidiverende tilstand</li> <li>Cystisk område uden symptomer behøver ikke henvisning til forebyggende behandling</li> </ul> <h2>Opfølgning</h2> <ul> <li>Opfølgning i almen praksis er som regel ikke nødvendig</li> </ul> <h2>Sygdomsforløb, komplikationer og prognose</h2> <h3>Sygdomsforløb</h3> <ul> <li>Uden behandling bliver tilstanden som regel recidiverende</li> <li>Tilstanden er ofte recidiverende, hvis man har behandlet en absces med incision og drænage uden fjernelse af pilonidalcysten</li> <li>Kløft-løft operationer har i litteraturen en recidiv rate på 6-20 %</li> <li>Tilstanden synes at bedres spontant efter 40-årsalderen</li> </ul> <h3>Komplikationer</h3> <ul> <li>Vedvarende sekretion</li> <li>Dårlig sårheling med langvarig sårbehandling</li> <li>Recidiv efter operation<br> <ul> <li>Væv, som er fjernet i forbindelse med tidligere operation, komplicerer re-operation</li> <li>Midtlinjear øger også risikoen for recidiv og for dårlig opheling af sår</li> </ul> </li> </ul> <h3>Prognose</h3> <ul> <li>Ved lateral lap operation er prognosen god</li> </ul> <h2>Baggrundsoplysninger</h2> <h3>Definition</h3> <ul> <li>Akut eller kronisk inflammation med evt. absces i det sacrococcygeale område</li> <li>Kan medføre abscesdannelse og udvikling af fistler i underhuden</li> </ul> <h4>Klinisk skelnes der mellem</h4> <ul> <li>Akut pilonidal absces</li> <li>Kronisk pilonidal sygdom </li> <li>Kompleks eller recidiverende sygdom</li> <li>Ubehandlet er der risiko for årelange gener med sekretion, smerter, fisteldannelse og abscedering</li> </ul> <h3>Forekomst</h3> <ul> <li>Er en relativt almindelig tilstand blandt yngre voksne, hyppigst i aldersgruppen 15-30 år</li> <li>Tilstanden optræder sjældent efter 40-års alderen</li> <li>Incidens er 25 per 100.000. I Danmark er incidensen formentlig ca. 1.500</li> <li>Mænd afficeres 4-5 gange så ofte som kvinder</li> </ul> <h3>Ætiologi og patogenese</h3> <ul> <li>Tilstand, som optræder oftest efter puberteten, da kønshormoner ændrer kroppens hårvækst</li> <li>Der er øget familiær ophobning på baggrund af livsstil, hårstruktur og kropsform </li> </ul> <h4>Patofysiologi</h4> <p>Diskuteres fortsat. Følgende er nu den mest accepterede forklaring:</p> <ul> <li>Indtrængen af hår igennem huden og efterfølgende dannelse af en subkutan hår-rede. Sjældent ses samme fænomen hos for eksempel frisører (især herrefrisører) imellem 1. og 2. finger eller imellem tæerne, hvis de klipper hår iført åbne sandaler</li> <li>Hår-reden kan blive inficeret med ekspansion af fistelsystemet og dannelse af sekundær åbning, hvorigennem infektionen tømmer sig</li> <li>Sygdommen kan være associeret med hidrosadenitis suppurativa</li> <li>Sinusdannelse med en kanal der forbinder hudoverfladen med ansamlinger af hår, celledebris og keratiniseret epitelial væv</li> <li>En pilonidalsinus kan betragtes som et ar med epitelialiseret kanal</li> <li>Er associeret til <a href="~/link.aspx?_id=162173C006984542B3D679686BF14E3F&_z=z">hidrosadenitis</a> suppurativa og muligvis aknetilstand</li> </ul> <h3>Disponerende faktorer</h3> <ul> <li>Grov og rigelig kropsbehåring </li> <li>Varme og øget svedtendens i forbindelse med stillesidning og friktion mod området<br> <ul> <li>Siddende arbejde, fx chauffør</li> <li>Fra 2. verdenskrig kendt som "Jeep rider´s disease", hvor den gav anledning til hospitalisering af 80.000 amerikanske soldater</li> </ul> </li> <li>Dårlig personlig hygiejne</li> <li>Overvægt (BMI>30)</li> <li>Lokale traumer</li> <li>Familiær disposition</li> </ul> <h3>ICPC-2</h3> <div>[ICPC]</div> <h3>ICD-10/SKS-koder</h3> <div>[ICD10]</div> <h2>Patientinformation</h2> <h3>Hvad bør du informere patienten om</h3> <ul> <li>Hygiejniske tiltag med håndbruser</li> <li>Behandling er operation ved symptomatisk pilonidal cyste</li> <li>Mulighed for hårfjernelse med laser </li> </ul> <h3>Link til patientinformation</h3> <ul> <li><a href="~/link.aspx?_id=8C9A2C5E910943B08E5D442E69A0A11D&_z=z">Pilonidalcyster</a></li> </ul> <h2>Link til vejledninger</h2> <ul> <li>The American Society of Colon and Rectal Surgeouns, ASCRS: <a rel="noopener noreferrer" href="https://fascrs.org/ascrs/media/files/downloads/Clinical%20Practice%20Guidelines/the-american-society-of-colon-practical-guideline-sinus-pilonidalis.pdf" target="_blank">Practice parameters for the management of pilonidal disease</a></li> <li>Forløbsbeskrivelser og pakkeforløb [ICPC] </li> </ul> <h2>Illustrationer</h2> <h3>Billeder</h3> <p><img src="8F66B76C9C124810B6387A51E241ABCC-240-189" style="height: 189px; width: 240px;" alt="Tegning der viser pilonidal sinus" title="Tegning der viser pilonidal sinus" height="189" width="240"></p>]]></HtmlField> <HtmlField Name="Resume"><![CDATA[<h2>Resumé</h2> <h3>Diagnose</h3> <ul> <li>Klinik (klassisk placering af cyste/absces ved crena ani)</li> </ul> <h3>Behandling</h3> <ul> <li>Asymptomatisk pilonidalcyste kræver ingen behandling</li> <li>Symptomatisk pilonidalcyste kræver kirurgisk behandling</li> </ul> <h3>Henvisning</h3> <ul> <li>Symptomatisk pilonidal cyste</li> </ul>]]></HtmlField> <LinkListField Name="Spot2"> <LinkField linktype="internal">{99A85AFD-2F7A-4B5D-A1C9-C2701D5E7D30}</LinkField> </LinkListField> <TextField Name="DoctorsHandbookID">8856</TextField> <TextField 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