Surgical procedures in the pilonidal sinus disease: a systematic review and network meta-analysis

Siwei Bi, Kaibo Sun, Shanshan Chen, Jun Gu, Siwei Bi, Kaibo Sun, Shanshan Chen, Jun Gu

Abstract

The most appropriate surgical treatment for pilonidal sinus disease (PSD) is still in dispute. This study aims to comprehensively compare the outcomes of surgical interventions using network meta-analysis. Randomized controlled trial studies were searched systematically to identify all eligible studies in multiple databases and previous publications and Bayesian network meta-analysis was performed. Our primary outcome was the recurrence rate. Differences in the findings of the studies were explored in meta regressions and sensitivity analyses. The risk of bias of each study was assessed using the Cochrane risk of bias tool. Confidence in evidence was assessed using CINeMA (Confidence in Network Meta-Analysis). A total of 39 studies and 5,061 patients were identified and the most common surgical intervention was the Limberg flap. In network meta-analysis, modified Limberg flap and off-midline closure were associated with the lowest recurrence rate. However, the Karydakis flap was associated with shorter operation time by several minutes compared with other interventions and few significant results were found in other outcomes. Modified Limberg flap and off-midline closure provided relatively low recurrence and complications rates. Therefore, they could be two promising surgical interventions for PSD patients.

Conflict of interest statement

The authors declare no competing interests.

Figures

Figure 1
Figure 1
Flowchart for searching and identifying eligible studies.
Figure 2
Figure 2
The transitivity analysis of potential effect modifiers (A). The geography information (Mediterranean or other regions) for the included trials. (B) The frequency of each surgical intervention published in clinical trials. (C) The patient information (primary, recurrent or not specified) for each intervention. (D–F) The male proportion, median age, and average follow-up duration (month). KF Karydakis flap, PO primary open, PC primary closure, LF Limberg flap, MLF modified Limberg flap, OMC off-midline closure, MIT minimal invasive technique.
Figure 3
Figure 3
Summary of risk of bias of the included randomized controlled trials.
Figure 4
Figure 4
Network analysis results for recurrence. (A) The league plot for surgical interventions. The number in each cell represents the comparison between the name of column versus the name of row. Results with statistically significant are annotated with an asterisk. (B) The network plot showing the interventions included in the network analysis. Size of nodes represents the sample size of each intervention; edges are the frequency of comparison. (C) The leverage plots showing the goodness of random and fixed effects. The model with fewer outliers would be preferred. Dres The posterior mean of the residual deviance. pD The effective number of parameters, calculated as the sum of the leverages. DIC deviance information criterion. (D) The surface under the cumulative ranking curve (SUCRA) plot. KF Karydakis flap, PC primary closure, LF Limberg flap, MLF modified Limberg flap, OMC off-midline closure, MIT minimal invasive technique.
Figure 5
Figure 5
Meta-regression results for recurrence rate adjusted by (A) sample size, (B) year, (C) region, (1 for the Mediterranean area and 2 for the other regions) (D) median age, (E) male proportion, (F) average follow-up. All regressions were plotted as effect relative to primary closure (PC) on the linear scale.
Figure 6
Figure 6
Network analysis results for infection. (A) The league plot for surgical interventions. The number in each cell represents the comparison between the name of column versus the name of row. Results with statistically significant are annotated with an asterisk. (B) The network plot showing the interventions included in the network analysis. Size of nodes represents the sample size of each intervention; edges are the frequency of comparison. (C) The leverage plots showing the goodness of random and fixed effects. The model with fewer outliers would be preferred. Dres The posterior mean of the residual deviance. pD The effective number of parameters, calculated as the sum of the leverages. DIC deviance information criterion. (D) The surface under the cumulative ranking curve (SUCRA) plot. KF Karydakis flap, PC primary closure, LF Limberg flap, MLF modified Limberg flap, OMC off-midline closure, PO primary open.
Figure 7
Figure 7
Meta-regression results for infection rate adjusted by (A) sample size, (B) year, (C) region, (1 for the Mediterranean area and 2 for the other regions) (D) median age, (E) male proportion, (F) average follow-up. All regressions were plotted as effect relative to primary closure (PC) on the linear scale.

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