Update Course Rewind: Pilonidal Disease 2019

Hey there, listeners. It's Rod from Cincinnati Children's. Have you downloaded the new version of the Stay Current pediatric surgery app? If you're listening to this podcast on anything other than the app, it's totally fine. Just know that we're designing these specifically for the app. There's content in the app that goes along with the podcast, videos, images, articles that we're gonna give you that you can look at while the people in the podcast are referring to them. So download it today. It's in the Apple App Store, it's in the Google Play Store. But until then, enjoy the episode. Pyelonidal disease can be a real pain in the butt. Not just for the patients, but for the providers too. I mean, think about it, when that patient comes back with a recurrence, you just feel so bad as the surgeon, like, did I choose the right method to excise the cyst? Cause there's so many ways to do it, right? And a mentor once told me, there's a million ways to do something, that means that there's probably not a single one of them that's really good. Until a few years ago at our update course. When a pediatric surgeon talked to us about a minimally invasive technique for pyonidal cyst excision, it's called a GIPS procedure. Hey Rod. Hey, what's up, Todd? The first time this was actually presented was in 2017 by Doctor Aaron Lipscar, and he talked to us about this very novel procedure called a GIPS procedure, and none of us had heard of it. How did everyone like it? Within a year after his presentation, most of the people I spoke to. Switched from their preferred technique to the GIPS procedure. Why do you think that is? Mostly because it was easy, it was minimally invasive, and it had equal if not better outcomes than the big wax we were all doing, which we were all very frustrated with. And that's what we're gonna talk about today. You see, in 2019, a couple of years after Doctor Lipscar's original update course session, we had another panel talk about their experiences with the GIPS procedure. We're gonna give that session to you. We're calling it the Update Course rewind on pyloidal cyst. Enjoy. We have a 17-year-old young lady who presents with a history of pelonidal disease. That's Doctor Steven Lee. He's a pediatric surgeon out at UCLA. On history, we find out that she's had two previous abscess drainages, both I&Ds in the emergency department. Uh, within the past 6 months. So you go down to do an exam and you see the image below the media player. Just scroll down, open it up. That's what her pyelonidal disease looks like. Question we have is, what is the most appropriate management for this patient? So think to yourself, what would you or your colleagues do for this specific extent of pelonidal disease? At our institutions, what we've been doing is the unroofing and marsupialization. This was recorded in 2019. Back then, Doctor Lee explains how while they were doing the marsupialization at that time, they were in the midst of transitioning to a minimal pit excision instead. Because it seems that there's lots of good evidence that the minimal pit excision may be the way to go. Out of all of the topics that we've probably ever done with the update course. That's Todd Ponsky from Cincinnati Children's. This one was the most rapidly adopted one, I think because people were looking for something different, right? Todd actually switched to doing the GIPPS procedure the day that he learned about it. And when he looked around the room, Everyone else's hands shot up. They all switched once they heard about it too. We were one of the authors advocating on roofing and marsupialization, so we've, we've also adopted a new uh technique. So why is everyone switching over to this technique? I think the bottom line for this is really less invasive techniques are better. And I mean, this is a lot less invasive. So much so that sometimes Doctor Lee does these in his office. You can often do them in the clinic or as an outpatient basis. Wait, Rod, hold up, hold up. Yeah, what's up, Todd? In the office? Yep, that's what Doctor Lee said. Wow, I'm curious if anyone else out there does these in their office. I've only done these in the operating room. Good point. So, if you're listening to this in the Stay Current app, leave a comment. Let us know how you do your GIBS procedure. Are you always in the OR? Are you in the office? Are there some factors that maybe sway you one way or the other? Now, here's Doctor Lee talking about the efficacy of GIB's procedure compared to the usual big open Excisions that we're used to. Clearly improved outcomes with respect to healing times, recovery times, and most importantly, they've really decreased the, the need for additional operations and recurrence rates. All right, I'm on the edge of my seat here. So how do you do this GIPS procedure? Prep it out, you take these trophines. What is a trophine? They're punch biopsies, and you just pour it out. Pull it out, and then you can use something like a mosquito to make sure that you clear that tract. Uh, Lipscar taught us about using hydrogen peroxide. I, I don't know if it really does anything, but it makes us feel good when it bubbles. As much as I love Todd's description of that. Scroll down under the media player and I'll put a link there so you can watch an actual video of how this is done. But here's a question from the panel. One of my partners does a lot of this. That's Doctor Mira Kotigal. She's a pediatric surgeon at Cincinnati Children's Hospital. And they, he does sinus endoscopy. When he, so after he does the, you know, pit excision with the punch, he actually uses a cystoscope to look in and be able to identify other things, sort of getting at your point about the hair and the granulation tissue that you can get out with marsupialization. He actually uses sinus and asked me to try to make sure that he's completely cleaned out the cavity to allow it to best heal and not have that sort of hair still stuck behind. OK, so the most prudent way to make sure they don't have a recurrence would be to go ahead and just stick a scope in there, look around, make sure you've cleared the entirety of the tract, because if you leave any disease behind, then they're gonna have a recurrence. But keep in mind that this could take a lot of extra time. You might not be able to do that in the office, you need extra equipment to do that. And if you're like Todd, then all you see is blood, so, do it if you can, if you can't, that's OK. Let's keep in mind the key principles of how to successfully do this pit excision. If you excise all the pits, they tend to lead to a cavity. And I think that's the key is with the multiple pit excisions, even though they're small, you can access that cavity and really clean that out. I think that's the key. If you leave stuff in there, uh, you will have a little bit of a recurrence, but most of the time it's the hair coming out and you can either repeat that procedure or you can do the pit pecking, pit picking technique where you just actually pluck the hairs out. So, even if they have a recurrence, you can still try some minimally invasive tactics to Taking care of their disease. Now, here's another question from Dr. Saleem Islam from University of Florida. Steve, can you comment on the role, if any, of the use of sclerosing agents, like, for example, phenol? We occasionally will use hydrogen peroxide to help clean it out, but we have not used any sclerosing agents. But sclerosing agents have been described. So if you scroll down under the media player, I'll put a link to a JPS article that talks about using phenol, and there are a lot of other options out there if you search. But what Doctor Lee is trying to drive home is that. Regardless of whether or not you use hydrogen peroxide, phenol, or anything else, the key is you really gotta scrape some of that tissue to make sure that you're not leaving any of the disease behind. And how does he do that? We use, we use Cottes to scrape it out, and we're very aggressive. We'll also use the gauze to, to rub it and, and so forth. Initially, Uh, it's a mosquito or any kind of clamp to really pull out all that hair in there. But once all the hair is removed, then you really need to scrape out all the granulation tissue that's left behind. Um, so question from the audience. That's Ray Hankey. She's a general surgery resident out of Penn State University. They noticed that the skin closes faster than the cavity in pit excisions and asked, Do you have any maneuvers to keep the skin open so that it granulates from within? Good question. I don't have any tips for that. That's why we did the roofing and marsupialization, uh, because we wanted to heal from the inside out and we left the skin incision bigger. The downside to that was the time for healing was roughly 4 to 6 weeks for complete healing. Uh, I think the key aspect, um. Uh, for this is one is during the time this heals, is make sure that you continue to keep the area free of hair. We, we shave once a week, we have them come back, um, with one week follow-up. Uh, if they start to close too early, you often will see some granulation and in the clinic, you can, you can kind of reopen that up and silver nitrate that around the side to keep the, the incisions open. That's what we've done. So, I think that there's a lot of opportunity for growth here and we're gonna learn more as more publications come out. I mean, that's where you gotta go next, like, you gotta go to the research. Uh, so we are actually about to start our recruitment for a multi-center study, the cohort study of pelonidal disease. That's Alex Cassar. She's a general surgery resident out at UT San Antonio. She's talking about a study with the Midwest Pediatric Surgery Consortium, where they're looking at largely invasive procedure compared to minimally invasive procedures, sort of trying to standardize the Gibbs and medical management that's also with standardized recommendations. Sounds like an awesome study. Can't wait for it to come out. Here's another question from the audience. Somebody just also asked, that's Alex Gibbons. He's a general surgery resident at the Cleveland Clinic. What is the role of antibiotics in, uh, minimally invasive pollinidal sur sinus surgery, um, antibiotic stewardship. Personally, um, unless there's an abscess, uh, but for the, for this, I don't use them because you're leaving the, the wounds open and they should drain. So there's no need for even perioperative antibiotics for this. I have a question for people doing Gibbs in the audience. So the initial uh Gibbs technique paper, uh, does GIBS, even in the presence of acute abscess, even if that's the presentation? Ah, great question. So if the patient presents with an acute ponidal abscess. Can you just forego an I&D and go straight to a GIPS procedure? So I've done that. That's Doctor Elizabeth Byerly. She's a pediatric surgeon at Children's of Alabama. Done that, and it depends upon how. Obviously, if they have a lot of cellulitis, if they're sick, then you're going to probably do more of a formal abscess drainage. But what I've done is then use the vessel loop technique, right? So do your gips and then put a vessel loop in for the abscess cavity to really allow it to Drain better. I think, I think it makes complete sense. That's how Tony Sandler does it in DC. Um, I think it makes, I don't know why not. Uh, the question is, would it have a higher failure rate if you do it in the face of infection? That's the question. What would, hopefully you'll figure that out. But, um, yeah, I, I think it depends if you have to go to the operating room or not. If you're doing a local drainage in the emergency department with that much inflammation and infection, often you can't really get enough, uh, of a Clean out during that time. So I would just, in, in that setting, I would just drain the abscess. I would also advocate draining the abscess off midline. So when the cavity does, that tract does form, it'll be off midline. Um, but those would be the things that I would do. If I go to the operating room, then I think you can adopt what just Liz just said. Awesome. So, let's summarize. When it comes to pyelonidal disease, a minimally invasive approach is probably your best way to go. Now, like I said previously, I'm gonna link a video to a GIPS procedure so you can watch it on your own time, but the basics are this. You can do this in your office or in the OR, prep the area out, make sure the patient's nice and numb, use a trephine, or basically a punch biopsy, to excise as many pits as you can. Those pits should lead to a tract, that sinus tract. Use hemostats or whatever you need to, to clean that tract out. Then if you want to use sclerosing agents, hydrogen peroxide, you're welcome to do so. That could vary based on your own practice. If you aren't sure, and you wanna make certain that you've cleaned out this tract completely, you can put a cystoscope in, you can look around. That is optional. Overall, you don't really need antibiotics perioperatively for this because we do want it to heal by secondary intention, so we're gonna let it drain. If a patient presents with a florid pelonidal abscess, Use your own discretion, but know that a minimally invasive approach is certainly one of the options that you can utilize here. So, Hopefully this helps. Hopefully you learned something. If not, I assure you there's plenty more content for you to learn something on our stay current pediatric surgery app. So download it today, it's in the Apple App Store, it's in the Google Play Store. And until then, I'm Rod from Cincinnati Children's. Remember, knowledge should be free.