Dr. David P. Mooney and Hajar Delshad, PA-C - Pilonidal Disease

Um OK. That I I know. I like both. Yeah that's right Even OK 00, I'm glad to hear. OK Yay. Yes, sir. Yeah. You know. You. You Uh That's really no, no, but you know I mean something that. elevator. Yeah, yeah, it's got on hand. Puts it out. Oh. I do. After midnight. Hi Yeah, yeah. That's exactly right. Sounds good. So cool. Yeah. No. You OK. Yeah so um. you. I Oh yeah, yeah, yeah, yeah. You know. OK. Oh. What Like The But you're getting better. Yes. I. Yeah, it's gonna be chilly. I guess screws. All right. Sure. All right, good morning and welcome to Surgery Grand Rounds. Um, this morning we have the pleasure of hearing from our own Doctor Mooney and Hager Delshan on the topic of, uh, pyelonidal disease, um, a problem that has vexed many of us in the clinic and elsewhere. Um, Doctor Mooney, as we all know, is, uh, an associate professor here, uh, and the director of the trauma Center at Children's Hospital of Boston. Uh, he completed his medical training in Saint Louis University prior to doing general surgery training at the University of Vermont, uh, subsequently, a, a pediatric surgery fellowship at the Children's Mercy Hospital in Kansas City. Um, he then went on to, uh, uh, New England, uh, and Dartmouth, where he served, uh, in a faculty position for several years. Uh, while in New Hampshire, he became the chair of the Committee on trauma of the New Hampshire chapter of the American College of Surgeons. Um, he's a past chair of the trauma Committee of the American Pediatric Surgical Association. Ah, as well as, uh, the founding president of the Pediatric Trauma Society. Um, among his, uh, many roles, he's, uh, served as a, um, a leader in the American College of Emergency Physicians, the Maternal Child Health Bureau's, uh, Emergency medical services for children, the New Hampshire Medical Control Board, and the Massachusetts State Trauma Committee. Um, he has conducted over 100 reviews of pediatric trauma centers around the country, um, and, uh, has been instrumental in development of pediatric trauma care systems in New Hampshire, New Mexico, and in Italy. Um, he serves as a reviewer for many journals, including the New England Journal of Medicine, ah, and GAMA Pediatrics. Um, aside from all of that, uh, he does, uh, some international work as well and has, uh, made trips to Haiti as well as Kenya, uh, where, uh, I've heard about some of the work he's done there, which has been incredible. Uh, Beyond doing all of this, he finds time to care deeply about pollinidal disease, and we'll hear about some aspects of that today. I also do happen to know that he, uh, is a training for his black belt. Uh, and we'll hear perhaps a little bit about how that's going as well. You'll be joined by Doctor, uh, by, excuse me, by Hagar Delshad, uh, who's been a PA with, uh, our surgical team, uh, for 8 years now. Uh, Hagger was born in Egypt, uh, came to, uh, this country at age 12, subsequently, uh, completed her undergraduate degree at the University of Florida before going to Chicago, uh, where she completed her PA training and subsequently, uh, residency. At Albert Einstein. After working in an ICU setting for several years, uh, she's, uh, joined the surgical service, um, where she serves a variety of roles including assisting Doctor, uh, Mooney with this role. And before we welcome Doctor Mooney to the stage, we'd just like to take a moment to acknowledge Doctor Peter. Happy birthday, sir. All right. Uh, the reason we're bringing up Doctor Peter with pyloidal disease, I'm sorry. So, uh, thank you guys for allowing us to, uh, come talk today. And, um, what we're gonna, uh, speak about, uh, I'm sorry, first, uh, just a faculty disclaimer, we really have nothing, uh, to disclose, although we'd be happy to accept whatever, uh, money anyone wants to offer up. Um. So just what we're gonna talk about today, um, most people, uh, when you're training in general surgery, you're instructed on how to resect a pyelonidal. And, um, uh, many people don't really look that much more into that, just how to remove one, how, whether to leave it open or closed, uh, staying off the midline. Those are really the key points that we learned. What we want to talk about today is a little bit more detail on what exactly is pyelonidal disease. Some of the treatments that have been, um, used for this historically, uh, what we've done out in Waltham and in some of our results from our clinic. Uh, so pyloidols were first described as, the condition overall was first described by one of the Mayo brothers in 1833, uh, as a hair-containing cyst just below the coccyx. Uh, 1880, uh, Hodge first coined, coined the term pyloidal or hair nest, uh, to describe the condition. And in the 1900s, it was believed to be embryologic in origin, and we still hear this from time to time. Pediatricians will send someone in with a, who's had a deep sacral dimple, or I've certainly seen babies with deep sacral dimple, a concerned it was going to develop into a pylo idol. World War II, I don't know if anyone's ever really ridden in an old, an old Jeep, Willie's Jeep, but they don't tend to have the best shock absorbers in the world, and the metal seat is pretty rough on the rear end. And a condition jeep seat was described in World War II. And at that time, the, the most common reason for a soldier for a new recruit to be pulled off of duty was pyelonidal disease, and believed to be first secondary to trauma from the sea. In the 1950s, Patty and Scarf, um, based on histological examination of the, the wall of the pyelonidal cyst, realized that it was, it's an acquired condition and it's not an embryologic condition, and there's really no embryologic tissue in the wall of a pyelonidal cyst, and it's not related to the deep sacral nimble. And when you look at the, the unifying theory of what in the heck is a pylo idol, it's actually uh occluded follicle. And it's part of a, um, it happens in other parts of the body too. Barbers get it, uh, in their, in between their fingers just from dealing with hair all day. Hairs can grow their way into, uh, between the fingers, as uh in this uh picture, pulled from the web. But it's part of a condition that actually occurs in various parts of the body called follicular occlusion tetrad. Uh, this is hormonal hormonally mediated. So in other words, it happens to teenagers when their hormones are raging, and they get this hyperactive gland activity, which plugs up their hair follicles. A hidradenitis, this condition called acne conglobata, which is like a really aggressive, uh, acne, which, uh, hopefully, uh, you'll never know anyone who has it. It's really difficult scalp cellulitis and then pyelonitals are the four things that show up as part of this, this, uh, follicular occlusion. And we've certainly seen a number of kids who, who have at least 2 or 3 of these, uh, these things. And uh most surgeons have seen someone with hidradenitis in the upper left. Uh, that's actually relatively common. Uh, it tends to be someone who, who isn't the skinniest person on the planet, and sometimes we can be moralistic, uh, moralistic about, you know, the person's hygiene and their, their size. But it's actually, there are a lot of big people that never get this, and it, it tends to be, uh, there's probably a genetic factor at play too. This unfortunate gentleman in the upper right with his acne, um, and the scalp cellulitis turns into these chronic, um, almost a, a very odd topographic-looking, uh, scalp that secondary to these, uh, these little abscesses below the surface. And then the classic pyelonidal. Well, this is a, there's a actually a great website, Pillonale.org, and this uh slide's been pulled from them. At the bottom left, um, you can see a follicle, it's a normal hair follicle. And in the middle of the slide, it's an occluded follicle. And then as you move to the right, the follicle that's been occluded starts to become stretched out by just debris and things that collect in the follicle. So once the follicle gets occluded, um, material can't get out, and the follicle starts to stretch, and it becomes so almost like a ruptured appendage. It becomes so big, it, it can't extrude itself externally, and it ruptures internally. And when that happens, you get this tract, this lined by epithelium that starts to extend up underneath the surface of the skin. In otherwise, a pyloidal sinus. And that sinus, then, now, debris starts to get into the sinus, and eventually it turns into a pyelonidal cyst. So it's basically, it's a plugged up hair follicle that ruptures internally. Uh, the pit is the midline epithelial line entry site. And it's really the source for the trouble. Uh, we all focus on the pocket of pus, cause that's what gets your attention, the big painful thing in the child's, uh, the, we call these kids, but the teenager's cheek. But the real trouble is actually in the midline, not off on the side. The sinus is a tract, and the, the cyst is actually a pyloidal cyst really isn't a true cyst. It's not a true epithelial line cyst. It's a, it's a lined by chronic granulation tissue, uh, very similar to when you get a splinter under your skin and your body reacts to the foreign body. Uh, it's a very similar reaction. And half of pyelon idols have no hair in them. It's lint from clothing, debris, other things. We've actually found a lot of really gross things in pyloidols. And just for a schematic, so there's a sinus tract leading from the skin, um, heading down to a pocket full of stuff, and then a big foreign body reaction around the pocket. Well, how common is this? About 7 out of every 10,000 kids. Um, boys, uh, we do see a fair number of females with it, but 3 to 3 to 4 males for every female. Uh, the average age of onset, um, I bet it's a little bit younger than this. But when we read the literature, they say it's about 21 years old for a male and 19 for a female. Uh, we've seen a number of 13-year-olds and 14-year-olds with this. Um, but it might just be our referral base and uh it tends to be Caucasians. Risk factors, um, having more body hair and having that really, that sturdy eastern Mediterranean body hair, uh, tends to be a high risk, uh, for it. Increased moisture, a sedentary lifestyle. Um, so, we see, uh, a fair number of teenage boys whose main activity in life is to sit in their mother's basement and play video games. But I think there are actually a lot of teenage boys these days whose main activity is to sit in their mother's basement and play video games. Uh, family history is very common to have, uh, 1 or 2 or 3 people in the family have a history of pyelonidal, uh, being overweight and again, poor hygiene. Uh, things would lead to folliculitis, otherwise. Um, about 90% of the pyelonados, for reasons that I certainly don't understand, the sinus tract heads superiorly, and it tracks it superiorly, and then it usually takes, uh, goes left or goes right and forms a pocket in your left or right cheek, even though sometimes it's midline. But about 10% of them drain caudally down toward the anus. And in those, it's been, uh, we've seen several children who, uh, we've actually sent a couple to CGI to rule out IBD, uh, that it wasn't a perianal, a perianal abscess and a fistula. Um, and there are a couple of very rare conditions, osteomyelitis of the coccyx or TB and syphilis, which aren't obviously very common in teenagers. But those would be the things that you, this would be confused with. Um, if it's toward the anus, that's sort of understandable. We have seen some kids where it was a pretty much a classic pyelonidol, but for some reason, they came in through the GI clinic route and uh got to work up for other things first. Well, treatment options for this. So the first is hygiene and hair removal. Um, and then secondly is antibiotics. So, any, anyone who has any suspicion of a pyelloidol, anyone who doesn't have a suspicion of a pyloid, just general hygiene in their, in that part of their body like any other body part. And then for HS or people who have symptoms, uh, hair removal. Antibiotics can be pretty handy for decreasing the cellulitis and inflammation around an inflamed pocket. So they're not, certainly not a cure for the condition. Uh, and then the various resection techniques, uh, you can resect it and leave the wound open, resect it and close it, or do any variety of skin flaps. Uh, there are some, uh, herbal remedies for pyello idols you can find on the web. Things like putting a turmeric. I have no idea what turmeric is, but you can put it on your butt crack, uh, if you would like to try and resolve your pyello idol. And it's, it's one of the top 10 home remedies for this condition. Um, but I was trained, um, to excise them. And this is just, uh, uh, our, our one patient that had an operation. Uh, this is their excision, um, of their cyst. And it's very standard. Try to stay off the midline, excise, excise the pocket, excise the, the pits, uh, come all, all the way around it and try and close it so your incision is off to the side. It's fairly, fairly standard procedure. Uh, and, um, you, if you leave it open, you can put on a vac sponge and the patient can go home with a VC, um, if you've, uh, done all the case management to set it up cause it's notoriously difficult to get insurance to approve that. Um, and, um, and again, that can, uh, um, have pretty good results. There's a variety of different flaps that are done. This is a Lindbergh flap. There's a Carioca flap, there's a hitch. There are different procedures that are done to try and keep from recreating that midline crease, to try and decrease recurrence rates. But one of the things I've never quite understood about this, it's basically a plugged up hair follicle, like a really overgrown pimple. And this is a gentleman pulled off the web with some unfortunate growth on his face, who had this fascinating skin flap done on his face. And I'm not quite sure. They did this little Z-plasty in front of his ear. I assume to improve the cosmetics. I think they might have wanted to consider not doing a running locking what looks like either a silk or a big nylon stitch on his face to improve the cosmetics, but Uh, doing a big flap, but we would never ever do that on someone's arm or someone's face or some other body part for just a plug a hair follicle with a bunch of foreign material in it. But this condition is, um, I think in part because it came down through the military side, uh, went to the surgical side. And so we're basically treating this plugged follicle with a big resection and flaps. Well, um, my experience with operating on pylon idols wasn't very good. Um, I had a very high recurrence rate and I figured that I just probably wasn't a very good surgeon. And, um, which is OK. I try not to do the dishes, a very good job doing the laundry or dishes at home, so I don't have to do those either. And, um, and so I, um, we decided to look at how, how we did here at Children's, uh, with this. Uh, our old billing system for the newbies was SEDS and, um, so we pulled data from 2006 to 2010. Just every patient who was seen in the clinic or seen in the operating room here for a pyloidol. Um, and there were a lot of patients. Um, so I just picked, uh, some random patients, at least 4 or 5 patients per surgeon, um, looked up this stuff in Power chart, any operations, visits, recurrences, etc. And this is just one of the many, many pages of SEDS, uh, printouts. Uh, thank you, Steve, uh, for access to that. And this is just a, a screenshot of the data. Just so that, I'm happy to share that with whoever you want cause I was a little, I was quite surprised by what I found. So I, I looked at 50 ponadal patients seen by 11 different surgeons here. Uh, 20 of them were resected, uh, 17 were closed, 3 were left open. Um, 18 of the 20, uh, recurred. Um, 4 resolved, um, 5 was unclear, and 41 had active disease when last seen in one of our clinics. 40 of the 50 were lost to follow-up. 7 were told to return as needed despite having active disease, and 3 of them were deemed healed on their last encounter with us. And this is one thing that, that I certainly have seen in my patients that I've operated on. It's a midline incision, a granulating. Um, there may or may not be a pocket deep to that. Uh, there's still a fair bit of hair. And uh when I've told people to, you know, clean it out and, you know, take care of yourself, um, you know, it's very unbelievably difficult for these teenage boys to get in there and that really painful looking wound and to clean it. Good morning. Thank you all for allowing me to speak today about uh pyelonidal disease. And I'm just gonna do us all a favor and navigate off of the screen, so we can not have to look at that any longer. So in 2013, Doctor Moni and I were in Waltham doing outpatient clinic and operating. We started, uh, we were all We're seeing these pelloidal patients, and they were very troublesome because they, no matter what we seem to do, they never really uh seem to resolve. So we decided to start this clinic in about 2014 and uh just take a step back and learn a little bit more about the condition, um, and what causes it and get back to the basics about treating it, which would be treating the hair and the hygiene. Um, we did this by doing a few new things, um, which was for, uh, in March of 2014, we started. Um, the clinic, we had probably 1 patient a month, the first couple of months, and then by the end of the year, we had built up about 30 patients. Um, we treated everybody conservatively, so everybody was just instructed to shave if they wear her suit and everybody, um, had to soak in water every day for 20 to 30 minutes a day. We didn't operate on anyone, and we just did INDs as necessary if somebody had a recurrence, an acute abscess. Uh, we improved the patient education material and we enrolled everyone in a database so we could keep track of them. So this is our um database intake form, which was, as you can see, you can't really read anything, but um what we asked on this was their comorbid conditions, what other treatments they'd had here and elsewhere. We had about 70% of the patients had already been treated either here or at another facility, um, and this was not their first time seeking care. Uh, we asked about what other treatments they had, how, uh, how many recurrences they were having, and how it affected their life in a variety of different ways. Um, this is the improved and uh updated patient education sheet that you can find on the website that we um refreshed in 2014. And after about the first year and a half or so, we analyzed our first set of intake data. We had probably 70 patients at this point, and we had 60% males, and this was presented at the 2016 APSNA meeting. And we find the typical range of treatments that one would encounter, so 60% of people had gotten antibiotics, incision and drainage, about half, 20% had already had a resection, and as far as home care, only, so about let's say half of them were instructed to do some type of cleaning, soaking or shaving, soaking or showering, and only 20% were educated on removing the hair or instructed to remove the hair in their bottom. And when we asked about how did pyelonidal disease impact the quality of their life, we asked about these five different domains just to see how it affected these teenage patients, and they were asked to grade it from 0 to 10, and we put them in mild, moderate, severe categories. And this is the percentage of patients who had moderate or severe impact on their life. As you can see, in pain, it was really quite high. And it disrupted their routine more than half of the time, and it was embarrassing, interrupted their ability to play sports. So, at this point, we really felt like this is actually a much bigger deal to these kids than we had previously thought, and um we really needed to maybe change some of the management, some strategies that we've been using historically for this. So one other thing that we found was that by classifying pyelonidal disease by severity, we may be able to stratify the patient's treatment type and not treat everybody the same way. Not everybody necessarily has the same form of pyelonidal disease, and this was one of the findings that we had that since they all were not. in with the same symptoms, perhaps it would be better to put them in different disease categories. So here's an example of a patient with mild disease. This patient probably had an abscess that already drained, and this is what they're left with. They have these asymptomatic pits. There's no cellulitis. There's no drainage. It's a very mild form of the disease. And for moderate disease we have patients that typically have 1 to 3 pits and have a secondary exit wound that's less than 1 centimeter, and as you can see this is usually a tunnel track between the pits in the midline and that secondary exit wound typically filled with hair and other debris and Other things, um, and this drains intermittently. So the, the hallmark of the moderate disease category is somebody that's not draining every single day. They're draining once every couple of days. This builds up pressure, um, in the system, and the secondary wound scabs over. Once the pressure builds up, it drains for a couple of days and then it stops, and then the cycle repeats. And here are some examples of severe disease. Now this is a patient who had multiple pits. The pits are so irritated that they're now quite widened. They typically have a larger open wound, and this is a patient who's usually draining every single day. So every day they go to school or they go to college and they have drainage on their clothes. And here's some examples of DeHist wounds. We put them in a separate category just because their treatment was more focused on the wound care um component. And on the left, you see a patient with a fairly um robust granulation response and it's a DeHist wound from a previous operation done somewhere else. And the patient on the right has actually a stalled wound that um is actually not healing. Um. So when we looked at pyelonidal severity and classified the patients by severity score, we found some interesting patterns. So, one pattern we found that males were much more likely to to be in the high severity group. So 83% of high severity patients were males. The other interesting finding was, although this disease is commonly associated with obesity, um, not necessarily. All patients are obese. You see patients in the mild uh severity score have a median BMI of 25, and then it goes up to 28 for moderate and moves up to 30 for high severity. So the more obese you are, the more likely you are to have high severity disease, as well as um the different hair types. So having coarser suit hair more likely uh predispose you to uh severe disease. So what did we learn at this point from our first intake data? We learned that classifying patients by severity may help. Improving the hygiene and the hair removal is helpful. When patients complied and did the show, the shaving and the soaking, their symptoms got a lot better. They stopped draining all the time. They were having less pain, and the wounds actually would start to heal. But it really wasn't realistic for patients to be able to do that for the remainder of their adolescence. And let's face it, teenage boys really were not going to allow their mom to be shaving their bottom every week or two. So we needed something more permanent that would be able to provide long-lasting hair removal at least and maintain the hygiene in the area. So we looked around the literature and found a couple of published studies on laser hair removal and pyloidal disease, and a lot of them were published in the adult literature, and most of them were actually published in the Middle East. So, I won't comment on the hirsutism in the Middle East because I'm from there. So, this, this study was published in the Journal of Pediatric Surgery in 2009, and this looked at a population of teenagers with a mean age of 17. And they looked at 28 patients. They treated 25 of the 28 had surgical procedure followed by laser with a YA laser, and 3 of the patients were asymptomatic and did not get a resection. Then received 5 laser treatments like the other patients. And of the 28 patients, only 1 patient had a recurrence. So these results were fairly promising. So we decided, along this with the other studies that we saw, to go ahead and offer laser hair removal as a treatment option for our patients. So laser is the light amplification by stimulated emission of radiation, and it uses the melanin in the hair as the chromophore that's gonna absorb the laser energy and produce a clinical effect, which hopefully is, is destruction of the hair. So this is a pretty busy slide. So, uh this is just the absorption uh ability of various chromophhores available in the skin. So there's, there's oxyhemoglobin, there's water, and you see the brown line coursing across is the melanin. And the melanin absorbs uh the, the different wavelengths that you see ruby, Alexandrite, diode, and yag, all of those wavelengths are easily absorbed. By, um, by the melanin in hair. So it will, uh, when the, uh, when the laser energy is absorbed by melanin, it causes selective photothermolysis, which causes thermal damage of the target area, which would be the hair follicles. Um, and that is what we're looking to do with laser hair removal and with repeated treatments, this hair removal becomes permanent or near near permanent. So everyone has varying degrees of melanin in their skin. Everybody has a combination of the melanin and E melanin, and more redheaded individuals have a lot of the melanin, almost no U melanin. U melanin is the dark pigment, and the melanin is kind of an orangey yellow pigment, and you can see in the cortex of a blonde individual on the left, they have a lot more phom melanin to E melanin. And then as you get into darker hair types, you have uh a much higher level of U melanin. So U melanin is the only melanin that actually picks up um the laser energy. So we need some U melan in this, in the hair to be able to deliver laser hair removal. And we do this by determining the person's skin type using a Fitzpatrick scale, type 1 to 6, and with increasing degrees of view melanin in the skin. So type 1 is somebody like Snow White with really, really fair skin and dark hair, and the difference between the dark skin, dark hair and light skin allows them to be the best receiver of laser hair treatments. And as you progress through the different skin types, there's more melanin available in the skin. Which also competes for absorption of laser, um, as the patients uh receive it. So here you can see an untreated hair follicle. This is a normal hair follicle, hair follicle with melanin inside and you can see the lower picture is a laser treated follicle. The follicle has now been miniaturized after treatment. So hair receiving laser hair removal must be treated in the antigen, which, uh, which is the, the phase of growth where the hair is actively reproducing. Um, and when that happens, the reproducing, uh, follicles are destroyed by the thermal energy produced by the laser. And then we repeat the treatments every 2 months so that we're catching hair always in a growth cycle. It usually takes about 4 to 8 treatments for the, for the hair, um, for the laser appellation to become permanent. One of the best things about doing laser hair removal is for the 1st 4 to 6 weeks, patients have no hair growth whatsoever right after the treatment. Um, so a lot of times for 4 to 6 weeks of no hair growth, patients actually, um, completely heal their pelonidals oftentimes, by the time we see them next time. So this is our 2nd analysis that we did on our um patients and this was presented at the most recent AAP meeting. Um, and this was more looking at our laser outcomes. So in this study, we analyzed 77 patients that had complete follow-up. 35 of them had been treated with laser and 42 without, uh, with no laser. No patients had any operations. And in univariate analysis, we found that there were certain um characteristics that predicted success. So female gender were more likely to resolve their disease. Treat patients treated for a longer period of time were also more likely to resolve their disease and patients who presented with mild disease. When we adjusted for all of those positive predictors, we found that patients receiving laser hair removal were more likely to be symptom-free. And we also looked at 36 patients who had had 4 or more treatments. So this is now nearing the, the point where I can say they've completed their treatment. Um, and 31 of the 36 patients, so 86% of them were disease and symptom-free for uh interval of about 9 months of follow-up, and none of them had any operations. So what can you expect after multiple courses of laser? This is about 6 treatments, and you can see the patient on the right, for example, is a fairly hirsute individual that's been treated 6 times with an Alexandrite laser, and you can see the hair reduction between the treated and untreated components. And on the left is a patient as well who's been who's had 6 treatments, and you can see that one. Uh, consistent problem that we were still having despite all the laser treatment was that the pits weren't really shrinking, weren't going away. We thought that by treating them with the laser and observing for some time, that this would, um, somehow get better. And you can see here this patient didn't resolve this one pit here in the middle. We also had a problem with a lot of the, especially females that were not really her suit, um, who would, would come and see us every once in a while and still have those pits and be having intermittent uh recurrences in between, but there was no hair to get rid of, so now how could we help them? And these are the kind of um strange things that we found in The pits, we found, especially girls with really long hair, sometimes had really long head hair entrapped in these tiny little pits, which is a bizarre thing. We've also found dog hair. We found lint from their clothes. There's other things other than the body hair that can plug these follicles up. So Dr. Mooney's going to talk to you more about how we treated this problem. Thank you. Well, I, I, I think it's not OK to leave a hole in someone's skin that dog hair can get into that just doesn't feel right. And, um, so, um, we were trying to figure out a way to, or find a way to take care of these holes in the skin, figuring that just like your fingers aren't gonna stick together, the hole is never gonna seal up because it's lined by epithelium. And I didn't want to make that, that incision that I've had so much trouble with over the years. Um, I've had patients take over a year to hear the heel of the pentitol, with the granulation tissue to just Uh wouldn't go away. And we've had several kids come in uh with chronic wounds after pylonel surgery, where they've been getting silver nitrate treatments. Uh, some have been silver nitrating their wound repeatedly, which, uh, most of them, uh, remember, uh, deeply. Um, and, uh, so we, we're looking around through the literature again at what was available and found, um, and, um, on this one website, uh, a reference to an article from John Bascombe, who is like the father of bilateral surgery, which is probably the last thing you ever want to be as a surgeon, but From 1980 describing a procedure that could be done just with local anesthesia. And uh sedation is needed. Um, we've done 3 of them now, uh, maybe 4 in the operating room for especially, uh, 3 anxious kids and 1 autistic kid. Um, it's an outpatient. We do it right in the treatment room in Waltham. Um, but anyway, an outpatient procedure, he says people drive home. Uh, the adults he does it too, they drive home from there, sometimes several hours home. And, um, and, uh, then we, he does a little thing for the abscess pocket. So we started to look into this pit picking thing, which is a terrible name. But, um, just to go to this one, there are these little skin biopsy punches. We have them here and we have them all out in Waltham. It's just a little razor tip, and you just spin it. Like if I wanted to get, say, one of these multiple freckles taken off of my, probably age spots, taken off of my hand, uh, I could just spin this little thing and it would take out a little core of tissue. Um, there are different sizes. We typically use one that's 2 millimeters. So we make a 2 millimeter opening in the patient's skin. Well, first, we Oftentimes these kids get laser too, but we numb them with some LMX cream, then shave them, numb them with LMX. If they're getting a laser, we do the laser. Then what we do is basically inject local anesthetic on either side of the, of the holes and next to the abscess pocket, doing these little skin punches and make a 2 millimeter opening around each pit. And um sort of like this, just removing the epithelial lining down to the sinus and do that for each of them. And then if there's a pocket, we open up the pocket and sort of scrunch out all the stuff that we can and leave the pocket open and make a little notch in the skin with the idea that if you make a notch in your linear incision, it, it takes longer for that to heal with the intention that we want that pocket to stay open and heal from the inside out. And uh here's that picture of the one of the kids with a very minor disease. Uh, it's hard to see, but this is actually, here's a little hair going in a pit. And here's two pits there. Um, it can be very hard to see pits when you're looking at someone's butt. And if you just, if you pull down toward the floor, they just pull the cheeks down toward their anus, the pits will show up. And as an indent, and sometimes when we're doing, going to do one of these, when I put the betadine on, the betadine will, will go into the hole, which makes it really handy to see the pit. Um, and this is that child a month later. So you can see there are 3 scars here where we basically made up a 2 millimeter holes. We inject it all around your 2 millimeter incisions, and then we put a single, uh, stitch in. We, we put a single, we were doing a vertical mattress, 40 nylon or 30 nylon stitch depending on the size of the child. And then we give their parents, um, a suture removal kit. Then in 10 days, they can take the stitch out at home. You have a friend or a family member or someone take the string out. I think we've taken out a few patients, squeamish patients, sutures in 10 days. Um, but the, um, and, uh, we tell them, do whatever you want. Run, play, skip, jump, whatever activities you want. They walk out the door of the treatment room, um, and, uh, they can, uh, we want them to keep soaking their bottom, whatever they were doing to take care of it before. Um, this is a slide you saw earlier of someone with more moderate disease. They've got a couple of good pits in the middle and then they've got that gross looking pocket off into their left butt cheek in a fairly hirsute person. So this is somebody we would laser them. And then we would uh do their pit picking. And this is a picture of the, the pitpicking itself. It's a little hard to see, but, so, each one of these stitches is a vertical mattress through, um, we, we tried leaving them open, but the hair was getting in the holes before they would seal. So we tried a simple stitch where they were pulling out and now you see these little vertical mattress stitches. And 3 here, and then the pocket is open with this little notch and sort of scrunge out the pocket. And, um, we just take a snap and try to pull out as much as we can and just again, leave that open. Um, and that's immediately following the completion of the procedure. And this person was a little squeamish, and so we took their stitches out, and it seemed like a great opportunity to take a photo of what it looks like in 10 days. So you can see 10 days later, they've got these sort of dark areas where their skin is healing up, and it's sort of a dark area where their pocket is, is sealed over. Um, and that's their, that's what it looks like pretty soon after the procedure. And, and again, um, Um, well, we then, actually, did I say that? OK, but then we decided to write this up. Um, and it, it's been submitted to APSA and if APSA ever, um, lets people know what's been accepted or not, we could tell you whether it's gonna get on. Um, and we wrote up our 1st 38 patients that we've done pit pickings to. Um, 27 to 38 were male. They're pretty much our standard clinic population. Uh, 18, 7.5, 17.5 years of age. Um, mild, moderate, and severe. You can see, you know, there are, this is our general distribution of our clinic patients. Uh, and, uh, 25 of them had gotten laser, 13 of them had not needed laser. And when we asked them when they came back and we quizzed them on, you know, what pain meds they need, etc. Many of them said nothing. Um, some said a dose or two doses of Tylenol or Motrin. Uh, one sort of a more anxious person had taken pain meds for 3 days, like Tylenol and or, um, uh, ibuprofen. Uh, they had all returned to full activity level. Um, 34 patients, uh, we're actually, well, 30, we published 34 patients, but we've tracked down 2 more of them. Um, 32 of the 34 were symptom-free, so either 84% of the whole patient group or 94% of the people we could find. Uh, the two we subsequently tracked down are both also symptom-free. Um, two of them have ongoing, uh, site drainage. Uh, one, this one, Armenian gentleman is, uh, unbelievably, uh, hirsute and, uh, keeps getting hair in the exit site when his pits have healed, but the exit site keeps getting hair from his body hair into the hole. Uh, and, uh, we, uh, he, he stopped replying to us. We can't, we can't find him to see how he's doing. Uh, and one autistic girl, uh, that didn't come back for follow-up. Uh, but from her clinic notes from her other children's visits, um, is reportedly still having some sort of issue, so it's unclear what exactly that is. But 32 of the 34 on follow-up have fully healed the pyloidal so far with no recurrence. Um, and just as, um, mention a little bit about, uh, what we're currently, uh, doing. Um We stopped keeping track clearly of the numbers, but we're well over 200 patients. Um, in fact, last week, uh, Hugger saw 5 new patients, uh, in Boston. Uh, we've had at least 50 people who we've graduated. We've told them that you're done. Um, we'll see you later, you know, come back for trouble, uh, and they haven't come back. And, um, we started off with just hygiene and soaking and then added on the laser, and now I've added on the pit picking. Um, and, um, we're dragging, we're stretching out our follow-up time. Uh, we're contacting people later on to see, uh, what they, um, you know, how they're doing. Uh, and we'd like to have 2 or 3 or 4-year follow-up to truly make sure that it hasn't come back. Um, we have 5 sessions per month in Waltham, and we're limiting ourselves to, um, 10 patients per session. Uh, but somehow on the 21st, we have 17 patients in one afternoon in Waltham, so that'll be a busy day. Um, and we're having one session per month only for new patients here in Boston, uh, along with campus. Um, and that's, uh, been fairly popular. Uh, we've done over 300 laser procedures and, um, uh, we're able to overcome some hurdles to allow, um, we were trained by a, uh, cosmetologist in how to do laser hair removals. And, uh, it was quite a struggle for the hospital to allow us to be credentialed in laser hair removal. And um they've allowed a physician's assistant to do it and now they've finally allowed a nursing uh RN to do laser. Um, we continue to do, um, intake and progress of surveys, and, um, we're a part of, uh, we've been using Trivox, which is this, um, web, it's a text service. The, the latest feature, um, they're teasing us that they're gonna have a text, they'll send our patients a text on their phone that will tell them to fill out their survey, so, for how is your pelloidal disease going. Uh, we've been the guinea pigs for them, and it's always a little tough when you're the guinea pig cause stuff, you know, it always, the promise sounds great and the, the function is OK. Um, and we've so far done one operation on a gentleman who had, uh, several operations, uh, elsewhere, had a big non-healing wound, um, and, um, had a resection and a flap for his, uh, non-healing wound. And, um, um, our current care plan, um, basically what we do when we see a new patient, uh, if need be, we'll IND their abscess. Um, happy to have someone other than us I&D abscesses cause that's not, not the favorite thing on the planet. Um, but we'll IND them as needed. And then we start, we start them to shave and soak. Um, a lot of the patients, it's either every 7 to 14 days, someone needs to shave the rear end and, uh, soak their wound. We can't do laser while everything is actively inflamed because it really hurts. It kicks up more inflammation. Once it settles down to the point where, uh, the inflammation has settled down, uh, then they can start laser hair removal. Uh, we've typically seen pretty rapid improvement once someone starts laser, and it may be partially related to compliance, may be partially related to the fact that now there's no hair or the hair burden has decreased from that, that pause that Hager mentioned about the 4 to 6 weeks before the hair comes back. Um, once their disease has settled down to the point where there's no active inflammation, then they get a pit picking. Um, and then again, that young man's rare excision. And I'd have to say, um, it seems like about 1/3 of my time in clinic involves being a life coach with these young men who, um, don't seem to understand that it's a problem to have blood and pus and disgusting things in your butt crack, and uh that they actually do need to mature a little bit and take care of this if they ever intend to get a date. And, um, and that we, uh, it has been interesting watching a lot of these troubled teenagers, uh, suddenly realize, oh, I do have to grow up a little bit here and, uh, take care of this thing. Um, and once that happens, then it's amazing how quickly, uh, things come around. Um, so, uh, conclusion, um, well, pyelonidal disease is just It's just folliculitis. It, it's, it's a foreign body reaction based upon plugged up pair of follicles in the gluteal crease. And something about the suction of when cheeks rub together as you walk that forces things to the crease. Whatever is there gets put up into the pylo idol. Um, we all have focused on the, the abscess, but the abscess is really sort of a bystander. The problem is the pits. And doing source control with the pits. It has seemed to be the thing that's taking care of it without needing to remove someone's gluteal crease. Um, and a large majority of our patients so far, and again, we're, I suspect we're the largest clinic in the country for kids with pyelonitis. In fact, I think we may be one of the only clinics in the country because ofitis. Um, but they have not needed an excision, and we're up to, uh, and again, it takes about 1 year of treatment. By the time you see us, we tell them it's 1 year. If you have 5 to 8 laser treatments, 6 to 8 weeks apart, you're looking at hanging out with us for a year. And, um, it's, uh, Treating the pits and the hair seems to be the thing that's, that's doing it uh for these kids. And the big thing that we've, I, I think been able to achieve, um, when we see these kids who come in, who've had a recurrence after an operation, um, their lives are disrupted. They can't play sports. They don't want to leave the house, they don't wanna go on a date, you know, there's, it's like, they're just disrupted by this thing. And, um, The, we've, we've been able to convert during these kids, you know, delicate teenage years, this disrupting thing into more of an annoyance that they have to come into Waltham and, you know, they have to soak in a shower and all that kind of stuff, you know, they're like annoyed by it, but it's not, they can go on and do all these silly adolescent things that they want to do. Um, and, uh, Sure, but there, um, we didn't have enough room on this slide for all the acknowledgments that we need to make. Uh, first, I actually acknowledge Doctor Shamburger for, um, helping us along the way. I had this happen. And, um, Cause it wouldn't, it wouldn't have happened without his, uh, encouragement and support. Um, Susan Zotto is our, uh, partner in crime, uh, nurse out in Waltham, who is, uh, with us at every clinic and somehow unbelievably cheery every day. Uh, Michelle Dawson, who, uh, runs our Red Cap and our, uh, struggles through our survey data, Patrice Melvin is a statistician, uh, that has done our papers with us. Uh, Sandy, who has far too many letters after her name that, uh, trained hugger in uh wound care. Rodney did our web stuff for us. Todd, uh, assigned us an intern, uh, a financial intern to do a business plan of our clinic, which helped, uh, help tune our operations. And then, uh, the Waltham staff, um, We use a laser and basically burn people's body hair, uh, which can sometimes be a little smelly in the multidisciplinary clinic. And the, the clinic staff in Courtney, especially their administrator has been very, uh, helpful with things like getting us the smoke suckers, so the smoke doesn't go out in the hallway. You know, quieting down the revolt among the nurses for what we're doing and allowing us clinic space. We, we've rapidly expanded and we have these busy clinics with all these, you know, our clients are crazy and people come in this mob of people coming and going right smack in the middle of multidisciplinary clinic. And they've been unbelievably nice to us about uh getting us a space and time there. And uh thank you very much and I left a little bit of time for questions. I'd, I'd first like to start by saying that I think it's remarkable what you and Hubbard have done. You've taken a not very glamorous topic, and I think that's the best thing we can say about pyonatal disease and really offered an entirely different paradigm of, of treatment. And uh I think you've, you've, in your presentations this morning, you've nicely documented how much more efficacious your approach is than the, than the uh Prior surgical and hope that the wound heals up and And uh your patients get by with it. Your statistics of the recurrence is certainly much higher than I ever thought I got, but I'm sure I'm one of the 11 surgeons whose patients you were following. Um, I think the one, missing piece which you don't, didn't talk about this morning, I'd be interested if you have any data yet or you're still in the collection is, is that the cost implications when you've avoided having the patients having the surgery, the, the anesthesia and everything, and the cost with that. Do you have any idea of what the, what the, what the physical, uh, results of your new new paradigm have, have been? Well, I'm sure it's astronomically less expensive than an operating room visit. And, um, and some of the patients who come to the OR will be admitted afterward in an inpatient stay for a day or two, you know, for the initial dressing changes, DNA at home, etc. Um, our typical patient gets 5 to 8 visits with us. Um, and, um, we haven't done the numbers up, uh, because we wanted to, um, get some, uh, historical data to compare. Um, and we'll probably use just sort of crude historical data like an operation costs X and estimate some average operation expense and inpatient stay expense. Uh, I'm, I'm sure it's way less than, than the, um, than an operate anytime you can stay out of the operating room, you're gonna save a lot of money. And, um, I suspect that's true here. Interestingly, the insurance companies don't pay for the laser, laser treatments. Um, and, um, we are able to build a level 4 visit based on the length of time that we spend with these kids. Um, and that's sort of making it up for the foundation for not being able to, uh, currently charge for the laser, but we're hoping to accrue the data, um, that will support the use of laser for this. Well, I think as the two of you continue to put out your academic publications, that will hopefully be the final nail in the coffin, so to speak, to get the insurers to cover for the uh for the laser therapy as well because they're, they've got to be doing much better, um, and, and your efforts are certainly one example we've, we're always using of how we're changing the efficiency of care of our patients. So I'm sure there are questions um that people have other than your referral number. I'll start with Doctor Liliha. And David, one of the, uh, uh, my mentors described one time that, uh, that it's not the things that I, that I don't know that bother me so much. It's the things that I know that are absolutely false, that, uh, that are really troublesome. And I think for, for me, the idea that this was a congenital condition, and it just, it, it showed up in, as a, it showed up in teenage years as opposed to an acquired, uh, that's really eye-opening. Uh, what I wanted to ask you specifically about was the, the pit picking and when you did it. Uh, that is, you described, and a lot of patients will still have the pits and maybe have relatively mild disease. Is it with one recurrence? Is it with an abscess? Is it with a couple of abscesses? When do you, when do you go after those, those specific pits? Well, well, the, the, the, the pit picking is such a minor procedure. I mean, it's, you know, 2 or 3 or, we've done actually one kid had 12 pits. So we did them sequentially. We did like 4 and 4 and 4. But it's, um, it's a 2 millimeter cut with a single stitch in it. So, it's, uh, in the world of procedures that we do, um, you know, it's less than getting stitches in some ER. So, anyone who has pits, we've been getting rid of their pits. And, um. Again, just, we've seen a number of, even, we've seen like tall, thin, fairly hairless women whose head hair has been getting down into their pits. And uh we've been getting rid of theirs. We, we've seen them coming back with uh ongoing symptoms, even though they're, you know, they can't, they're not a laser candidate, you know, it's their body hair getting in. And so, um, We, uh, once they're settled down, if there's an active infection in the pocket, you can't really do a pitpicking cause the wounds won't heal. Um, once that infection is settled down though, then we do them for, offer it to pretty much everyone. Uh, I would, uh, second my Senior colleagues, um, thanks. I actually used to like to do this operation and I deceived myself to think that I was actually making their lives a lot better. As you say, you really can change somebody's life and make this problem go away. But I'm, I'm afraid that in your statistics, some of those patients were probably mine that came back and I didn't know about, um. I, I, I, I would second that if you can really document, uh, fiscal improvement for insurance companies in, in some quasi-scientific, uh, uh, or, um. Statistical way we might be able to get the insurance companies to pay for these. So I can understand that you're not getting paid for the laser. Are you getting paid for the pit picking, which is actually a skin biopsy? It's a simple excision of a pyelonidol. OK. Uh, and, um, my, my next practical question is, um, Unless you plan to work forever, when you retire, can Hugger do this by herself, or we have to find somebody else who wants to do this. I can also not do this forever. Excuse me. My lips are sealed. Well, so the um We're not doing anything that needs a surgeon. I mean, and to me, we're not doing anything that needs a doctor. Um, you know, it's, we're shaving. I shave a lot of butts. I mean, but uh We're, we're shaving butts, we put cream on them, we do a laser treatment. When you get to the point where it's settled down, it's a 2 millimeter thing with a single stitch and scraping out a hole. I mean, uh, well, I think Doctor Muni demonstrated that it's actually more a dermatologic condition than a surgical condition and hopefully will navigate the needle away from us a little bit and Not so much for us here. We're more well resourced, but hopefully nationally when we, when we go to national meetings, people ask us, so what can we do? Our surgeons are not going to get trained in laser and all this. So our recommendation sometimes is to partner with the dermatologists at their institutions to maybe partner up and the, and they do laser and the surgeons do pit pickings if they're going to follow this model, and we've got to figure something out over here. So maybe it'll be a, uh, what, what do we call it advanced practice clinician. Um, type of clinic where a surgeon is not necessary. And just one before Chris, the, um, one thing I forgot to mention, a couple of these kids in their pictures, you could see little pimples on their butt. It's not uncommon for these kids. They've got acne on their back. And sometimes we've had a few patients who've just had these really very sad wounds like around their body from this, this terrible folliculitis that we send a derm and they get very. Aggressive treatment for the folliculitis, which then settles down the pyelonidol. So it's part of a package and it's, it's unusual to have somebody with this is it. I mean, they've got other stuff like Hibiclens showers, uh, chlorine baths. I mean, there's a whole package of things to settle down their whole body, terrible adolescent skin. Mhm. So, we share clinic often on Thursdays, and I just want to echo what the whole clinic says at Waltham is that you guys are beyond efficient, you're beyond nice. Your patients come and go quickly. They never stay late because of you. And, you know, you came in with a whole new concept of like patience and procedures almost simultaneously, and it really has worked well. And so kudos to you, Dave, for really kind of spearheading this. But I really want to applaud Hugger. Um, I was at Waltham for 5 years pre-hugger, and then I was with her post coming. And I will say that she's done a tremendous job. If you guys don't work with her, you're really missing out. She took all of my post op orders and put them into a PowerPoint document that I could just print out. She's very efficient. You've done a great job. You're a true asset to the department, um, and I just want to applaud you publicly because you really helped me. Thank you. Thank you. Thank you. What, what's obvious, I'm just the, the name on the slide. Any additional questions for Doctor Mooney or? Doctor Delcha, as she was already called this afternoon, this morning. I got a promotion. So I've been guilty of putting silver nitrate on, on sinuses. So when you have the effervescent granulation tissue, does that go away, or do you need to scrape that out or do something to remove that? It goes away with soaking. We never use silver nitrate. Um, so when they soak some of the inflammatory reaction and the foreign body reaction, which is just the hair scraping, as well as meticulous shaving of the hair, it, it goes away by itself. The, the hair is like sandpaper. It's unbelievable. It gets in there and it just rubs the daylights out of the granulation doesn't let it heal. The order of events is if they have a jacuzzi, that's great, like a hot tub jacuzzi. That's the best. The chlorinated water that's moving is #1. Number 2 would be a, uh, Like an indoor jacuzzi bathtub kind of thing that some, you know, a lot of people have and never use. Um, swimming pool, and ocean or after that. Those are really great because you're moving around in the water and it's, we try to do things like, um, sits baths are terrible. Uh, no one ever does it. They do it a couple of times and you're sitting in some little plastic tub. We try to do things where it's socially acceptable cause all these kids are high school, college kids. And we tell the college kids, just become a swimmer. Tell everybody you're trying to work off your beer gut and you're trying to swim so they won't think something weird is going on that you're in the pool. Um, and then so it goes sort of jacuzzi, hot tub jacuzzi, uh, pool, ocean, bathtub, shower, is sort of the order of one and then sitz bath, shower has been a sitz bath. Mhm. Great. Any other questions? If not, I'd like to thank you for your innovative treatment and dedication to it. Thank you. Good job. Thank you. It is done. Boom. All that next lecture. I'm trying to figure all her names. I didn't want to miss anything. She's got a lot. Yeah.