Symptoms, diagnosis, modern methods of treatment of epithelial coccygeal moves (cysts, fistulas)

This abnormality is not known to a wide circle of readers, such as pneumonia or angina, however, it requires certain knowledge in time to seek medical help... As a rule, from inflammation of the epithelial coccygeal progress (hereinafter ECX) faced the doctors and surgeons Coloproctology, although to thick intestines and rectum is a disease of the does not apply. Below is a quote from one of the forums:

What is epithelial coccygeal course?

Epithelial coccygeal course (synonyms: pilonidal cyst, epithelial coccygeal cyst, pilonidal sinus) is a disease of the sacrococcygeal region unspecified etiology characterized by the formation in the skin of a traverse cord having two (sometimes more) holes inside is lined with stratified epithelium and containing hair, sweat glands and sebaceous glands. The lower (distal) is located a few inches above the anus. The total length of the ECX may be 2-3 cm.

The Frequency of epithelial cysts of the coccyx in connection with its festering – about 1-2% of all surgical diseases. The frequency of this disease 26:100 000, i.e. One of 3 900 people have this disease.

ECX Develops more frequently in men. Women and men suffer from inflammation in the ratio 1:3. Sick, as a rule, people under 35-40, later pilonidal cyst is usually not detected.

Etiology of epithelial coccygeal progress

The reasons for the formation of epithelial coccygeal progress to date not been studied. There is no conclusive scientific data on this subject. The basic theory of the emergence, currently available, are as follows:

1. Coccygeal epithelial course is the result of a wrong process of hair growth. According to this theory hair sacrococcygeal region due to the growth from the follicles into the skin can cause the formation of a canal, lined with epithelium. That is hair growth in the wrong as if pulls the skin inwards.

The Drawback of the theory is that this type of hair growth are found nowhere else on the human body (it is incorrect to take into account the ingrown hairs when injury to the skin, for example, shaving). Thus, it is unclear why in the sacrococcygeal region hair can grow in a similar way. However, this theory gave another medical name ECX, widely used in Western sources, is pilonidal sinus.

2. pilonidal Cyst is a remnant of the notochord of the embryo. Coccygeal cyst is the remnant of a vestigial tail, manifested as an atavism, a congenital disease in some people.

normally, the resorption of the tail occurs in the embryo to 3 months of muscle – opustela tail remains only the PC muscle, but some people still caudal ligament (the remains of the muscles of the podnimateli tail). It captures the area of skin above the coccyx, and in the development of the subcutaneous fat forms a space above the place of fixation of the ligaments. As a result of this recess may be formed ECX.

In any case, certainly don't have inflammation of the epithelial coccygeal course (pilonidal sinus) does not manifest itself. The whole clinic is connected with suppuration under the influence of certain factors.

The Reasons causing the development of inflammatory responses in epithelial coccygeal course are listed below:

1. Anatomically ECX is located so that its distal end is close to the anal verge, in connection with which there is an additional risk of infection of cysts of the coccyx conditionally pathogenic microflora (Escherichia coli, streptococci, staphylococci, etc.), normally live on the skin and in the intestines of humans. An important factor is the adequate hygiene of the anal area.
2. state of the immune system. By reducing their own protective forces of an organism pathogenic microflora is able to demonstrate their pathogenic properties and cause the development of infectious diseases. For example, Streptococcus pneumoniae after acute respiratory illness is able to go down the bronchial tree to the terminal bronchioles and alveoli, causing pneumonia. The pneumococcus is a normal component of the microflora of the human oropharynx. Factors of decline the human immunity is largely known: sedentary, sedentary lifestyle or, on the contrary, long-term overload, no sleep mode-the rest, poor diet with excess carbohydrate and fat-containing food, Smoking, long-term chronic or short-term acute stress, hypothermia.
3. co-morbidities. In some somatic pathology of infectious and inflammatory diseases develop more often and run longer and harder. Such pathologies include diabetes mellitus, regardless of its type, systemic diseaseconnective tissue, autoimmune diseases, congenital immunodeficiencies.

Classification of this pathology

Below is the classification developed by experts of the Russian Coloproctology Association and is Board in 2013, It is used for formulation of diagnosis.

with the flow of an epithelial coccygeal course is divided into:

1. Uncomplicated (patient no clinic and complaints).
2. Acute inflammation infiltrative stage and abscess formation.
3. Chronic inflammation infiltrative stage, recurrent abscess and purulent fistula.
4. inflammation Remission – a period of the disease that have no symptoms after the acute condition or with minor symptoms.

Classification of the ICD (only used by medical staff for coding diseases).

The Class – Diseases of the skin and subcutaneous tissue (XII).

Block Infection of skin and subcutaneous tissue (L00-L08).

Code ICD – L05.0 Pilonidal cyst with abscess;

L05.9 Pilonidal cyst without abscess.

Clinical picture ECX

Initially pilonidal cyst does not manifest itself and has no clinical symptoms, except discovery on closer inspection of the hole just above the anus or several openings in the midline or slightly to the side (see figure 3). From this hole can be seen the tufts of hair. Hole sizes can range from 2 to 7 mm. It is necessary to distinguish the primary openings are those that were originally outside of inflammation (for example, the most distal located), and secondary holes are those that emerged as a result of chronic inflammation (fistula openings). The diameter of the secondary holes is always greater.

When obstruction of the input-output ECX products secretions of epithelial cells and sebaceous and sweat glands develops in the stage of infiltration. Externally, this stage looks like a tight painful cord length of 5 cm, the Skin over it at this point is not changed.

When the infection develops purulent inflammation, the abscess is formed. External signs at this stage – soreness of the area when walking, sitting, with pressure in the sacrococcygeal region, limited smooth red skin and swelling.

The output of the pus outside of the coccygeal cysts and the formation of fistulous occurs when the chronicity of the inflammatory process.

A Fistula of the coccyx is a kind of channel, which is formed from a cavity containing purulent material on the surface of the skin. From the inside it may be lined either by granulation tissue or epithelium. Self-healing of the fistulous tract is extremely rare.

Modern methods of diagnosis

Under koloproktologii recommendations diagnosis of coccygeal cysts should include the following methods of inspection: survey and inspection of the patient, digital rectal examination, conducting sigmoidoscopy, fistulography, ultrasound of the sacrum and coccyx.

Below let us consider the above methods and the need for diagnosis and decision on treatment strategy.

Digital rectal examination is performed for all patients without exception. The aim is to exclude a pathological process in the segments of the coccyx, the rectum and its surrounding tissue. The physician evaluates muscle tone of the pelvic floor, the degree of mobility of the coccyx, the lack of formations in the rectum, the presence or absence of pain in the study.

If ECX without involvement of surrounding organs pain, blood, pus rectal examination should not be. May increase tone of the pelvic floor muscles (reflex).

A Sigmoidoscopy is a method of further research based on the use of an endoscope (proctoscope) to visualize and assess the condition of the mucosa of the rectal wall. Sigmoidoscopy is used for the differential diagnosis of coccygeal cysts and diseases of the rectum.

If ECX according sigmoidoscopy the mucosa of the rectum and distal sigmoid pink, elastic, integrity its not broken, its vascularization is not changed. Motor function and smooth muscle tone of the rectum and distal part of Sigma is preserved. There is no cicatricial stenosis or fistulous openings or ulcerative and erosive defects.

A Study the patient is on an empty stomach, after preliminary training in the form of an enema (now, as a rule, replace "Fortrans" during the day before the study) and a low-carb diet for 3 days before the study (flatulence and fermentation processes can interfere with the visualization).

Contraindications for the use of this method:

1. Acute inflammatory processes in the rectum with severe pain.
2. Trauma to the anus.
3. Expressed cicatricial narrowing of the anus.

Fistulography is a method of further studies in medicine, designed to study the direction and localization of fistulous tract in which the opening of the fistula is injected with a contrast agent and a series of x-ray or CT images of this region.

The Aim pursued by the use of this method in medicine, is to avoid leaving any pockets, Zatecka with pus during the operation for excision of fistulous tract along its entire length, otherwise there may be a relapse of the disease.

One of the variants of this method, used in recent years is staining fistulous dyes, e.g. Methylene blue to better visualize it during surgery. This avoids the additional radiation exposure per person.

Carrying out fistulography may also be recommended for the purpose of conducting a differential diagnosis between sacrococcygeal fistula ECX and other fistulous passages, for example, abscess, proctitis and osteomyelitis of the sacrum and coccyx. The pictures in these pathologies will be revealed leakage of contrast into the cavity of the rectum, in cellular spaces, in the cavity of the segments of the coccyx and sacral vertebra.

Contraindications for the use of this method:

1. Allergic reactions and individual intolerance in the history of x-ray contrast agents.
2. Bleeding from the fistula.
3. Unstable hemodynamics, severe condition of the patient.

ultrasound sacrococcygeal region

Ultrasound using 10 MHz transducer allows the physician to assess the size and localization of inflammation, the visualization of the fistulous tract, the degree of involvement in the pathological process of the surrounding tissues. This method requires high qualification of the doctor-uzist, as visualization of the soft tissues is quite complex, the detection and precise localization of the fistulous can be difficult.

Contraindications to the use of this method no.

tomography and magnetic resonance imaging

This modern research methods, is reasonably capable of establishing the presence, location, size ECX, estimate the number of branches, pockets, and also to exclude other diseases of the Sacro-coccygeal region, accompanied by inflammation of the area and the formation of fistulous.

The Only contraindication to the MRI can be called the inability to lie still for 20 minutes. However, even these difficulties can be circumvented by using anesthesia. Magnetic resonance imaging does not bear radial load.

Absolute contraindications for CT no, from a relative can be called a patient has metal implants, acute psychiatric disorders, pregnancy, and child age, ARF.

The Diagnostic features of cysts of the coccyx are presented in the table below.

research Method	Signs ECX
Inspection	the Presence of one or more holes in close proximity from the anus, with detachable or not, the presence of signs of inflammation (redness, swelling, local rise of temperature)
Digital examination of the rectum	muscles of the pelvic floor
Sigmoidoscopy	the Absence of signs of lesions of the rectum and distal sigmoid
Fistulography	the Study of localization, the number and complexity of the fistulous pockets, no communication with other organs (except skin)
ultrasound sacrococcygeal region	study of the involvement in the pathological process of the surrounding tissues
MRI and CT scan	the Study of localization, the number and complexity of the fistulous pockets, no communication with other organs (except skin)

An Important aspect in the practice of the physician, the differential diagnosis of the disease, i.e. The ability to distinguish ECX (cyst of the coccyx) from other diseases of this region.

Coccygeal cyst should be distinguished from:

• dermoid cyst of the coccyx;
• indolent chronic paraproctitis localized abscess in the subcutaneous or submucous cellular space;
• of the fistulous rectum;
• tumors of the sacrococcygeal region;
• osteomyelitis of the coccyx and of the sacrum.

treatment disease

To Treat coccygeal cyst is invited, usually by surgery, sometimes use some methods of conservative treatment to prepare the patient for surgery.

Cure conservatively ECX with suppuration cannot. You can only reduce the intensity of the inflammatory response. In this connection, the Association of Russian coloproctologists does not recommend prolonged delay of surgical intervention.

The Types of operations used in thispathology:

• ECX Excision with suturing of the wound tightly. The operation is performed under local or General intravenous anaesthesia. In this case, you uninstall the ECX together with the skin and surrounding tissues as a single block, then the edges are sutured tightly. It is believed that this method of management of patient with uncomplicated ECX less risk of cicatricial deformations.
• ECX Excision, the wound edges are filed down. This operation is a modification of the first, only the edges of the wound are not sutured together, and shall be attached to the bottom of the wound. Why is it necessary? The open method of reference is used in patients with severe purulent process when a full closure can cause the progression of inflammation. However, the remaining wound edges, as studied, resulting in the formation of rough scars and requires a long postoperative period. Due to these shortcomings of the open method was proposed to sew the edges to the bottom of the wound. In this case, there remains the possibility of drainage of purulent wounds (pus outflow) and decreases the wound surface. Therefore, the recovery time is also reduced.
• two-stage treatment ECX, open surgery. Two-stage treatment of epithelial coccygeal progress is made when expressed deep abscess sacrococcygeal region. First the puncture and aspiration syringe, breast pump pus, and then cut the abscess cavity and its drainage. After decrease acute inflammatory reactions are ECX and excision of surrounding tissue, then the wound is open. That is all the disadvantages of the open method for this type are also characterized.
• In complicated ECX with extensive purulent inflammation of the sacrococcygeal region and the formation of purulent streaks in the gluteal areas of experts recommended to the patient with wide excision of the ECX and the plastic skin by the method of "displaced flaps". To explain this surgery easier, you need to submit the amount of tissue required for removal (see figure 4)

• Sinusotomy – this method can be applied in uncomplicated ECX or in remission chronic course, but in the absence of complex branching ECX. The principle of this method is the introduction of the probe into ECX and electrocautery probe. Pre-cyst stained with methylene blue.

The Pros and cons of each of these methods can be represented in the form of a table.

Methods of surgical treatment ECX	Pros	Cons
Excision with suturing of the wound surface tightly	Less than the duration of the postoperative period, faster recovery, less chance of the formation of rough scar	According to some higher risk of disease recurrence in a delayed period. More risk of septic complications. It is preferable to apply in uncomplicated ECX
Excision with suturing of the wound edges to the bottom	Less likely to develop septic complications, can be applied in complicated cases ECX, almost two times less risk of relapse	Long postoperative course required long-term medical monitoring. Higher the probability of scar formation in comparison with the previous item
two-phase treatment with the conduct of open method	Low risk of septic complications and the spread of inflammation to the surrounding tissues	Long postoperative period, long rehabilitation, high risk of cicatricial deformities and relapse
Sinusotomy	minimally Invasive intervention, good long-term results, fast health recovery after operation	can be used only in a limited number of cases: uncomplicated ECX, stage of remission and a certain anatomy of the pilonidal sinus

Russian scientists have formulated the principles of surgical treatment ECX depending on the anatomical features and the complexity of the disease (2).

Complexity:

1. fistula (primary or due to the chronicity of the process), you'll be in the buttock crease.
2. Fistulous openings are arranged no further 2 cm from the buttock folds.
3. Holes are rendered not closer than 2 cm from the fold.
4. Secondary fistula with multiple fistulous openings, with extensive infiltrates, necrosis of the skin, which are located in the area of the inner semicircle of the buttocks.
5. Secondary fistulas, extensive infiltrates, located on the outer semicircle of the buttocks and beyond.

The research Results presented in the table below.

Degree of difficulty	buttocks
	high	average	low
1	Excision with grafting replacement skin graft	Excision with suturing of the wound edges to the bottom	Radical excision with dull seam
2	tonalitatea Excision with grafting replacement skin graft	tonalitatea Excision with suturing of the wound edges to the bottom	Excision of tonalitatea with a blind stitch
3	Excision to subcutaneous fat, suturing the edges to the bottom	Excision to subcutaneous fat, suturing the edges to the bottom	Excision to subcutaneous fat, suturing the edges to the bottom
4	Wide excision with plastic surgery displaced flap	Wide excision with plastic surgery displaced flap	Wide excision with plastic surgery displaced flap
5	VLC to the Excision of pathologically changed tissues, continue to open method, the wound closing after the process of calming down perforated flap	VLC to the Excision of pathologically changed tissues, suturing the edges to the bottom	VLC to the Excision of pathologically changed tissues, suturing the edges to the bottom

It is Conservative to treat the ECX is possible in the following cases:

1. preparing the patient for surgery during the chronic ECX.
2. Infiltrative stage ECX.
3. After the intervention to shorten the postoperative period and rehabilitation.

In the acute phase surgical treatment. For conservative treatment are used:

1. Methods of physiotherapy: UFO, UHF-therapy, electrophoresis.
2. Cryotherapy – freezing of the epithelium in ECX.
3. Diathermy – destruction of epithelium ECX under high temperature.
4. Ozone therapy – the use of cameras of HBO to inhibit the growth of microflora and secretions of mediators in the area of inflammation, enhanced regeneration of damaged tissues.

Forecast

The Most unpleasant consequences after undergoing suppuration ECX – relapses. The highest frequency of their occurrence was observed during surgical maintenance with suturing of the wound tightly and open way. The lowest probability is when the excision with suturing of the edges, sinusotomy. Data on the frequency of relapses presented in the table below.

surgery	the rate of relapse
deaf Excision and wound closure	20-40
Excision and suturing the edges	7-10
two-phase treatment, open surgery	20-30
Sinusotomy	7
Excision + plastic moving skin graft	15-20

Additional sources:

1. Clinical guidelines for the diagnosis and treatment of adult patients with epithelial coccygeal passage. The Association of Russian coloproctologists.
2. Surgical treatment of epithelial coccygeal progress: clinical anatomical aspects. A. I. Zhdanov, S. V. Krivonosov, S. G. Brezhnev.
3. digestive tract No. 1 1, 2015 – Epithelial coccygeal course and sacrococcygeal abscesses. – V. L. Rivkin, JSC "Center of endosurgery and lithotripsy", Moscow.