Minimal Treatment of Pilonidal Disease - APSA Practice Gaps 2019

All right, so we'll switch gears to Pilonidal. Uh, we have a 17-year-old uh, young lady who presents with uh, history of pilonidal disease. On history, we find out that she's had two previous abscess drainages, both INDs in the emergency department, uh, within the past six months. And her exam shows this uh, picture as you can see. Question we have is what is the most appropriate management for this patient? Laser hair removal, minimal pit excision, unroofing and marsupialization, wide open excision or excision with flap closure? So what do you guys do? We, wow, that's interesting. So as this comes in. So, currently, uh, we are about to switch to we are just switching to the minimal pit excision. Um, at our institutions, what we've been doing is the unroofing and marsupialization. Uh, so, uh, that's what we currently have done, but um, there's lots of good evidence that the minimal pit excision may be the way to go. So, this was presented and this is another one that we're glad we're presenting again. Um, out of all of the topics that we've probably ever done with the update course, this one was the most rapidly adopted one. I think because people were looking for something different. Right. Um, uh, Aaron Lipscar presented uh, something similar about the um, pits procedure and we I have switched that day, I switched completely to the pits. What about others here? Is there I see everyone nodding their head. really in history, that must be one of the fastest overnight changes because everyone was so eager for something better to do. Uh, the the pits and you're going to go into to that I'm assuming. Just yeah, just a little bit, but um, and in this case we would choose minimal pit excision. Um, and this comes in the face that I we were one of the authors advocating unroofing and marsupialization. So we've we've also adopted a new uh technique. So based on that on that video from the previous years. So, um, I think the bottom line for this is really less invasive techniques are better. That's the bottom. The minute the least you do, the better you're off. And whether that is a a a pit picking technique, whether it's the pits procedure where you excise the the um, the sinus tracts and then clean on underneath or what we used to do is unroofing marsupialization, which is a little bit more. We just unroof the sinus cavities and cleaned it out. Um, whatever those are, whatever the minimal technique is, that's probably the most that's that's the best to do. First of all, that's the easiest to do. You can often do them in the clinic or as an outpatient basis. Uh, and then they've led to clearly improved outcomes with respect to healing times, recovery times, and most importantly, they've really decreased the the need for additional uh operations and recurrence rates. So, um, the unroofing and marsupialization, we unroof the cavity and what we found with that is you have just a significant amount of granulation tissue. Uh, you also have a lot of hair underneath and that just really needs to be cleaned out. But the Gips procedure or the minimal um, um pit excision does the same thing and does it with less invasively. That's why we're switching. Uh, what what it is, it's the trephines or really punch biopsies to really excise the track. Uh, and then you really core out everything underneath and clean it out. And I think that's it's exactly what we were accomplishing with unroofing and marsupialization, but in a less invasive technique. So, we would really. I want you to know you guys one of my partners does a lot of this Nelson Rosen. Rosen. Does all of our most of our along with two of our other partners um and they he does sinus endoscopy. when he so after he does the you know, pit excision with a punch, he actually uses a cystoscope to like look in and be able to identify other things sort of getting at your point about the hair and the that you can get out with. He actually uses the 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. Uh, I think that would be I think that just may add a little extra time and cost, but clearly as long as you clear everything out, that's probably the most important thing. I don't have experience with that, but I think that sounds like a a very um viable option. I know does that the surgeons in your group do that as an outpatient or in the clinic? So, the sinus endoscopy, I think he only does when he when he on those kids that he takes to the OR for for their s and not every, you know, a lot of them don't need to go to the OR. So for the ones that don't, I think he's just doing exactly what you're saying the with the punch biopsy. But and then sorry. And then um using the like using gauze or something on a hemostat to to really try to clean out that and get most of the stuff through the gips through the punch site. Right. Yeah, so um want to spend another minute or so on this to make sure everyone out there totally gets it. I'm going to repeat what you said. So, either in the office or in the OR, I always do them in the OR because I'm a whimp. Uh I you prep it out, you take these treffines. You have to we had to order them. I mean, we had to get them. So they're punch biopsies. And you get a pack are green and they have a little pack and you just cord out, pull it out, take a mosquito or whatever and get it some people put a scope in. I found that it's just all red when I look and it's hard to see much, but um and then uh Lipscar taught us about using hydrogen peroxide. I don't know if it really does anything, but it makes us feel good when it bubbles. And then um and then that's it. Uh is that right? Is that exactly how you do it? That that's pretty much yeah, 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 recurrence, but most of the time it's the hair coming out and then you can either repeat that procedure or you can do the pit pecking pit picking technique where you just actually pluck the hairs out. Um, and that often works as well. Oh. Okay. So minimal things. I think just for me as well, I, you know, as we are switching over, we've done our first few in the operating room. Just and under sedation and locally have not required general anesthetic outpatient procedure. After like one or two, we're switching into the clinic. So it it it does depend on how how um the extent of the disease, but but I I would recommend if you haven't done it, just do the first one or two in the operating room, get the technique down, so you're not fiddling around in clinic and and so forth. And and it is a very easily uh very easy to learn and easy to adapt. Steve, can you comment on the role if any of the use of sclerosing agents like for example, phenol or or or things like that in this situation. Uh, I don't know do you have experience using that because we have not used any of those. We we occasionally we'll use hydrogen peroxide to help clean it out, but we have not used any sclerosing agents. It's certainly been described especially phenol. Uh, some people have filled the the air pockets or the sinuses with the phenol and and that's helped in sclerosing some of that granulation tissue and reducing it. Probably is the same the the same concept of really trying to get rid of that granulation tissue. We found the easiest is just to scrape it out. Uh, and and the most minimal way is with the with the minimal pit excision or the procedure. So we have a couple comments, but that paper there was another paper on phenol again published in this issue of JPS. So that's happening uh a lot internationally are people using little crystallized No, because I have this. crystallized phenol. Uh, so um it's an interesting thing. I scares me a little bit. I don't know what kind of skin injury you may get, but has anyone here used it? Okay. Um, Dr. Rose? I'd be interested in the panels. What specifically do you use to scrape out the cavity and how aggressive do you get at trying to remove the granulation tissue? Yeah. We use we use currets 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 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. I just want to make the comment that uh you started off sort of with what's the right procedure and we've now had a dozen variations in our discussion about what's the right procedure. Somewhere along the line, somebody needs to like show a video of the perfect operation because every every one of us have said, well, I add this or I do that. So uh we're we're a great topic, Todd. Yeah. Get a comment? Um, I think I'm going to disagree well, I think that for the most part we're all the big thing is that it's minimal surgery. That's the agreed upon thing. It's not the big wax. We used to do these huge. It's the minimal less is more. Right. Yes, his variations will probably get to the bottom of that and beat it to death like appendicitis, but right now at least it's minimal procedure. Yes. Um so a question from the audience, they notice 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. That's a that's a great question. Um I don't have any tips for that. That's why we did the unroofing 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 four to six 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 followup. Uh, if they start to close too early, you often will see some granulation and you 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. Okay. Any other tips from. Anyone else who has? No, um I've always wondered that exact same thing about should we put a vessel loop in uh to keep the hole open. I haven't had a problem. We've tried that to to to that point of keeping loops or or a drain in place for that and that just caused a lot more pain and seemed to develop more granulation tissue along the track. So we've stopped doing that. I think if you clean out the cavity well enough and you have enough drainage points, it'll heal fine. Mira, did you have a question for Kasar? So, Alex, do you want to comment on the the pilonidal study that you're starting to work on with the Midwest pediatric surgical consortium? Uh, so we are actually about to start our recruitment for a multi-center study, the cohort study of Pilonidal disease with the Midwest pediatric surgical consortium. And we will be doing pretty much any largely invasive procedure compared to minimally invasive procedures sort of trying to standardize the Gips and medical management that's also with standardized recommendations. Uh, we're doing everything surgeon choice and the reason for this is so many pediatric surgeons are unwilling to randomize their patients right now because they are very, very supportive of one technique over another. I was very surprised to hear that half of the hospitals and half of the surgeons in the consortium had never done a Gips or never seen a Gips. Wow. So part of this project is actually going to be education and implementation of minimally invasive techniques. Uh, and another one there's going to be an overlap with uh a study that's the nation widest is conducting for the laser hair removal. And their their data is looking really good. So. What outcomes are you going to be looking at Alex? Like what are you going to be following these patients? Uh, so our primary outcome is going to be uh recurrence or I guess non recurrence uh at one year and we just got funded for that by so this this May. Congratulations. Uh, but the other outcomes that we're going to be doing are time to healing, uh quality of life, uh we're doing cost. Uh we're doing use of antibiotics, uh narcotics, days of pain, uh days where kids are not able to perform activities, return to school, return to sports. Uh, so we we're going to try to do a good analysis on on just patient center outcomes. I'm glad you I think I'm glad you mentioned the nationwide thing. I think Laser it's going to be Gips plus laser. I think is what we're going to find is going to bring. But that will help answer Max's issue of the standardization problem. Um I think everyone can agree that at least theoretically laser should help this procedure a lot. The problem is that it's not covered by insurance and patients can really just not afford it. Yeah. Uh, but hopefully uh when the data from this NIH or funded study comes back, uh we'll actually have some push to get insurance companies to cover it uh so that our patients can do better. Okay. Um really quickly onto the um the skin healing faster than the pit. Um want someone from the audience um said Rock salt works as good as silver nitrate to keep the skin open. Another variation. What are you talking about? We all do it the same. Somebody just also asked what is the role of antibiotics in uh minimally invasive pilonidal sinus surgery. Um antibiotic stewardship. Yeah. 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 Gips in the audience. So the initial uh Gips technique paper uh does Gips even in the presence of acute abscess, even if that's the presentation. He didn't do INDs. He did the Gips. But you have to You mean he didn't stage it. He didn't stage it. Right. So the question is would you even in the face of an abscess instead of just making a nick, would you just take them at that time from the ER to the OR and do a Gips procedure as your IND? So, go ahead. So, so I've done that and it depends upon how obviously if they have a lot of cellitis, if they're sick, it 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. Yep. Right? So do your gips and then put a vessel loop in for the 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 you have a higher failure rate if you do it in the face of infection. That's the question. What would hope 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 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 op room then I think you can adopt what Liz just said. Awesome. Awesome. All right, any comments. We're going to move on then. Uh, thank you Dr. Lee. All right, we're going to move to.