2024 Update Course - Updates in Pilonidal Disease - Nelson Rosen & George 'Whit' Holcomb

So, um, it's time for an update because it's been many years since we've done it. Um, so to do this, we have Doctor Whitt Holcomb, who I told you helped conceive this whole event idea, this whole update course. Uh, Whitt is the, uh, editor in chief of the Journal of Pediatric Surgery. Probably a couple of you have heard of that journal. Um, also, um, is the editor of the textbook that I've always used, uh, and now Sean's on that, uh, from Kansas City and now lives in, where do you live, Nashville, Nashville, uh, and he's gonna be hosting this with Doctor Nelson Rosen, uh, who is one of my partners in Cincinnati, and, uh, a, a very advanced colorectal surgeon, and they're gonna be talking about all the updates in Pyloido. Thanks guys. So, um, I'll be brief, but I find this an interesting, uh, topic because, uh, there are a number of papers we get at the Journal of Pediatric Surgery on this topic, and I must tell you that I'm of a generation that no one would have thought about doing minimally a minimally invasive. Uh, technique to, to fix a pollinid cyst or, uh, pollinid disease. So I think it's very interesting because you're going from sort of maximally invasive treatment to minimally invasive treatment. So I'm gonna let, uh, uh, Nelson take over because he knows much more about this topic, uh, than I do, and I'll chime in with a question or two, as he goes along. That's great. Thanks. Can we have the next slide? OK, so let's start with a poll. So you have a 17 year old male. This is what you're looking at, and they, they tell you, well, like I'm bleeding. You know, most people can't see what their bottom looks like, so they know what they see in the underwear, and they, they have this, uh, I'm bleeding, some drainage, and they often describe it that way and pain on sitting in this exam. So what's your next step? And I'm not asking for your ultimate step, but what's your next step? All right. Comments hold mic closer. Yeah, sorry about that. Anyone have comments on this before we show the polls? Personal preferences. So if I could ask Nelson a question, I think it might be important to explain minimally, um, minimally severe disease, you know, maximally severe disease. Does it, does it matter in which treatment, uh, option that you look at? It's, it's a great question and it. It, uh, something we're actually looking at right now, you know, how do you define severity in pyloidol, and there's not a lot of science on that like, uh, there are people that have put out staging systems and the staging systems are some of them it's like the it's my great idea like oh I, I make classifications, but not all these classifications correlate with how they do they don't always correlate with how you need to start your inner choice of intervention. So the one thing that I can tell you that's shaking out from our looking at our own data is that patients with wounds presenting with wounds as their initial presentation for pilonidal tend to not always get to the finish line. Fully healed with a minimally invasive approach. So that's one thing to think about starting point. It, it is, it is some starting point there. All right, so we have answers on the poll. It looks like, uh, people are jumping right to minimally invasive pyelloidal surgery. Uh, wide excision and packing is pretty small. Uh, some people are, a third of you are starting with shaving and meticulous hygiene alone. Uh, and then, uh, some people jumping right to the wide excision with off midline flap closure. All right, next slide, please. I just, I mean, I love this and I use this routinely. My, I think it's all about the conversation you have with the patient and the patient context. I've got a 16 year old baseball player and it's like March and they're getting ready to start their season, and they're miserable, then we're going to go to the operating room, but I also say, You know, 60 to 70% of the time, it works every time. And you set that expectation bar that this may be, you may get partial healing, uh, especially depending on the severity of the disease, but that you, uh, may have to go back to the well. And, but it's not going to be something that takes them out of season or takes them out of their activities of daily living because they're going to be able to go right back to it. Uh, by and large, right, I like your numbers, you know, that 60 to 70% works every time. I think that's those are probably some real honest numbers there as opposed to what's published out there when you look at some very rosy reports. But for this I was going with like this is green level and I think if you're not pushing hair removal and meticulous hygiene to do the best that you can, you're probably gonna end up operating on some people that might not need an operation. Uh, but again you have to talk to your patient, you know, there's some people that no matter how many times you say you should shower, you should bathe, you should get the hair out of there, uh, they come back to the office and it looks the same when you first met them before you clean them up the first time. But, uh, if you could flick the slide, there's like I think I pop up, right? So these reports go back a long ways like John Armstrong, you know, in the, uh, United States Army. At a clinic where it's a captive audience and they just shaved their patients every week and they really found a dramatic improvement and uh not a lot of need for surgery but if you look, uh, you know, just a large percentage of patients will be healed with non-surgical measures alone so I really do think that it's a good starting point and I can't tell you how many people have come to me from. Hospital and hospital and hospital and they're full of hair, hair tufts sticking out of holes and nobody clipped them in the office nobody removed the hair nobody mentioned that hair had anything to do with the with the problem of pyloidal we use the term nest of hairs, but if you're not getting the hair out of there for the patients that have hair as a part of the issue. Then you're not doing all you could do. Can you comment on techniques for hair removal and hygiene, shaving versus, uh. Uh, na type agents or laser hair removal or maybe you're gonna get to that. I don't know, right? Well, like I have the, the adjunct to my slide here that talks about, uh, like I think on the last slide I had a picture of the clipper. So on this slide I have a picture of Nair and so many people will struggle with that, you know, like a lot of our patients are teenagers or people going to college and they don't sometimes they don't have anybody to help with them. Uh, if there's a parent, an active caregiver involved, then the clipping we think is probably the easiest, simplest thing to do, uh, and have somebody once a week do it. Uh, if you struggle, you can come into our office, uh, and, but for the college student who lives alone and doesn't have like a friend to say, hey, I feel comfortable with you clipping my bottom, right, like that, that's not gonna happen, uh, then there, and so we, we do also recommend. I will, I will routinely, uh, when my patients in the operating room, I'll have parents bring in late, uh, wax strips, and we'll all sit there during the prep verification, the timeout and be warming up those wax strips, and we will give them a really good head start in getting that entire natal cleft area in the, the buttocks on both sides free of hair to give them like this is the expectation when they come out of the operating room. They should have this sort of degree of hair removal, whether it's clippers they're on, but It's, it's a great time to get a wax is when you're under general anesthesia. That's amazing. I, I, I hadn't thought of using wax strips in the office. Uh, one of the things I did have on there, uh, some other adjuncts like, like showering, the hand shower. I think very important. People actually putting water in there. You can't, I can't tell you how many people said. Well, they told me I couldn't bathe and I'm so confused because wounds love water and if you don't wash then you're probably not gonna heal anything so we talk about all these adjuncts including washlets for people who struggle to clean their bottom after having a bowel movement so all of that goes into the education piece. All right, but let's like, I know we're pushing for time, so moving on, uh, the poll. They're doing their best with hygiene, they're doing their best with hair removal. And now, what is your next step? Ongoing symptoms, what's your next step? I got wide excision and pack, wide excision midline closure, wide excision off midline flap closure, and then minimally invasive, and I'm particularly vague on what that phrase means because it means different things to different people while we're waiting for the um pole to come up. So even that first picture you showed, you would still start with the uh hair removal. I would, I absolutely it looked pretty. Yeah, pretty severe, it's pretty severe, but if you clip them, you get the hair out of there. Some of those patients, again, depending on the extent that symptoms are disabling from their lives, uh, some of those patients will actually do OK without a surgical intervention. All right, let's see the results we got the over half are jumping to a minimally invasive, OK, uh, wide excision and packing. There are still people doing that, I suspect worldwide. Uh, that that is probably the most common operation that happens, you know, there's still a bulk of pyloidal work is not done by people who are doing advanced pyloidle work. That's what, when you use the, you know, medical treatment, you know, hair removal, and it, do you add in those cases the, the nasty ones, antibiotics for a while or nothing? I don't put people on antibiotics unless they're coming in with an active infection. You know, when they have painful cellulitis, uh, uh, you know, and, and that's a subset because some people don't drain very effectively, you know, and those are the people that have the most minimal external manifestation. They, they have like horrible pain and a big bulging abscess and almost nothing visible there that the people that, that have all these holes, they drain. They don't come in with pain. They don't come in with those types of infections, you know. All right, why don't we go on, uh, yeah, all right, so next slide. Here's my answer slide. Yeah, so, uh, oh, that's not exactly my answer so that's an acceptable answer. I really do think that if you look at it, wide excision and packing wounds is, uh, probably not the way to go. It's got a very high failure rate. It's extremely challenging. For patients and families, uh, and we just really think that it's not a, a, a good solution in 2024, uh, the, um, wide excision and midline closure, there are people that are still doing that and we see a lot of those patients come to us, uh, struggling with recurrent disease and ongoing disease. Uh, there seems to be that the wide excision with off midline closure, which is really goes back to the 60s when Cary Dakis first described that and then John Bascombe, but the Lindbergh flap has been used since like the 40s, you know, these are old operations, but they do work. Uh, but the minimally invasive now that most of us know about that, we really do think that that's the best answer here in the starting point and then I. Ironically, you talk about like the older generation would never have thought of doing that except like for those are my international colleagues who come from Commonwealth nations that the Lord and Millar described this in 1965. It's really the same almost the same operation that Moshe Gibbs described with this big article in 2008 so it's been out there for a while just people haven't adopted it. Uh, but it seems to do very, very well. You look at Doctor Gibbs's study, they had a 15% recurrence rate over 10 years. What I found in our practice is that we have not been able to match those numbers. Our numbers are a lot closer to the 70, 75% range where one minimally invasive operation gets you to full healing and a lasting recurrence-free healing. Let's see the next slide there. Yeah, so now other adjuncts to minimally invasive clean out and, and again the wording I think matters here because like people think of like well in my operation I use a 1470 nanometer laser probe to ablate the tracks. That is an operation but those operations usually all start with clipping, washing, getting all the hair out of there so they're very, very similar to all the. Steps of a minimally invasive, uh, you know, what some people would call a GIPS procedure, uh, in the first place, but there are people doing laser diode tract ablation. There are people putting phenol in there to sclerose the tracts, fiber and glue, and all of these have proponents, but none of them have been proven superior. So, all right, why don't we, we got about 5 minutes left left. Uh, why don't we go ahead? I have a question, um. I'm out here. So it seems to me that we are lumping all ploidal disease together when maybe there are different phases of presentation. So what you presented was like kind of a chronic wound, multiple pits. What about a patient that just presents with an abscess and maybe one pit and not a lot of hair? Are you going to offer them a mpe also? So, uh, for somebody first abscess we drain them, we take a look and we see what we're dealing with, and then we put it to the patient actually we tend to be very quick to offer minimally invasive approaches because it really is a 20 minute intervention under sedation in our place, uh, with no activity restriction and no narcotic requirements so we, we're pretty aggressive about offering that again we are surgeons, uh, so that's that's how we start. You showed a picture with like 8 to 10 pits. When you do a gifts, how many of those pits are you actually excising? All of them. So that's a, that's a. Elliptical wound at that point, right? Because you can't, if there's 8 of them right in a row, you can't individually leave a bridge between those. Well, like that, that one, that's a tough one, but most of the time you can get acceptable skin bridges and not create somebody to a large open midline wound. Yeah, and sometimes if they're close enough together, you can get two with one punch and have less overall wounds. Yeah, that's the art of doing the GIPS procedure, I think, is trying to maximize those skin bridges and not give somebody a big wound. So why don't you just briefly explain to the Worldwide audience, what the GIPS procedure is, right? It's basically using, uh, circular punches to punch out the holes and then going through the opening, scraping out the internal cavity, getting all the inflammation and all the hair out of their necrotic fat, and then leaving them open to heal. Uh, but I think we should, if we fly through, then we can, we can, uh, hit any other questions, but Esit, this was described in 2013, doing it all through a small incision and putting a big scope down there. Uh, that scope is not available in the United States. Next slide. So I started doing what what I call a hybrid GIPS. An 8 French cystoscope is available in most institutions. So once I cleaned everything out, I put a scope just into the openings from a diagnostic, uh, point of view to make sure we got out all the hair, and we've been doing that for the past 5 years, uh, and we're quite happy with it. Next slide. Yeah, so this is again like GIPs again Aaron presenting 10 years ago and, and really Gipps is not new and so honestly green level if we're not doing starting out with minimally invasive as our first surgical intervention for most people we really should be emphasize that this is, this is a uh green. This is green, green, green as green gets. Like I, I'm gonna be adamant and provocative to say if you're not doing this, you're doing it wrong. I'm gonna be that provocative. OK. Is there anyone that challenges that because this is just wrong if you're not doing this. No, I think you're, I think you're right, right on, Todd. What was the mic was the mic off that whole time. But these are actually two of the things that I've really learned about in the past 6 months or 8 months or something and so I think these are new. Uh, Roland Anderson in 2017, Swedish study, uh, they did 113 patients where they did a minimally invasive approach and he suture closes all but one hole which he leaves open to drain, and they had excellent results. What's that? I think top one. I think he's leaving the top one. I would not leave any bottom hole open if I was closing. Yeah, always that lower down is always harder to heal and higher up in the cleft. Uh, so this is a great question. We should we be suturing our openings? And then the second thing is that nationwide they did this very large prospective study on. Laser hair removal after surgery and they found that it's significantly reduced recurrent disease and this is the first randomized prospective study on this subject. There's been like little case reports here small series retrospective review, and anybody who has ever worked with a patient on this knows that the insurance companies will do any. Thing to avoid paying it even if it means that they're gonna pick up a $5000 emergency room bill when the patient comes back with an abscess. So as we say, penny wise, pound foolish on the part of the the, the, um, the third party payers, but I think that we should be getting all our patients to, to, to laser once they're healed. So Nelson, yeah. And so I just wanna say I haven't found the scope useful like at all compared to just doing the punch with the circle stuff. The other thing I found very useful to use, I is it sorry I haven't used um the scope useful just my experience um I found very useful to use the the metal probe just to get the direction of the sinus, otherwise you just kind of chunk a hole in the middle communicating with the big cavity instead of doing a proper sinusectomy. And I've also changed my dressing. I, when I was doing flaps, I would keep a very occluded dressing, uh, uh, ask the patient to lay on their tummy for a few days, not, not to touch anything. And actually I now I encourage quite the opposite. Like if they're laying on top of the wound, they're, they're obliterating the remaining cavity and they're kind of getting that all that fluid out. I don't know if you've done anything like that. You know, we basically have them to their own devices for wound care and we just have them keep a gauze roll in the cleft and it keeps the cleft from burying the openings so that they can drain while the thing is closing up. Uh, in terms of the scope, like, I like the scope. I don't think that the scope, like if we really would look at it, would be like a, a huge evidence. Based measure and maybe makes me a little bit lazier from the perspective of like, I don't spend too much time scraping before I put in the scope and take a look and like, oh, I missed hair here and missed hair here and then we can just focus the effort. So it also helps irrigation, you know, I, I, I think it's a nice adjunct. But again, I, I agree, it's not uh essential. Another comment and then we have like 1 minute left. So yeah, yeah, so I, I have a comment related to Pete's paper, but also the fact that, you know, I've tried to be a cure, you know, somebody that cures this disease too. We all have our, our moments. And so I've had a patient come back at 6 months. And, you know, you think you've had a 6 month cure, and then there's this granuloma, he's got some drainage, he's got some blood. So what happens though is that the life cycle of these things is not, you know, it's, it's long. So, uh, what he, what you need to do is actually do the laser hair removal probably over and over again. We just started waxing or he started waxing after that in, and there again, we've got another uh cure for however, how long it takes again to regrow the hair. So the question is, how long do you tell patients they need to be. Attentive to the nail, the waxing, or the laser throughout their adolescence or into young adulthood. Yeah, but into adulthood, definitely, you know, the longer they can sustain it, the better. Laser is not permanent, but it certainly knocks it down to a lower level. Yeah, uh, I send my patients to Amazon where you can buy a laser hair removal device for about 150 bucks. So if insurance companies don't pay it, there are very affordable options, uh. It did for, for that patient, it did, yeah. Yeah. And then I think maybe we go to the last slide. Yeah, that, that just shows my graduated treatment approach, our graduated treatment approach. Like for patients that one or two minimally invasive approaches did not work and they have significant ongoing symptoms, which is important. You have to really push it back to that. If they're like, well, no, doc, I'm good, like, well, then, OK. But if they have ongoing symptoms, we move to an off midline closure and our choice is a Bascom cleft lift. Next slide there. And then uh check out the uh International Pilonidal Society if you do a fair amount of this work, it's a great group. It's free to join like the, the meeting, uh, there's like a meeting every other year so that's where you can meet with other people that do a lot of this and it's, it's fun you find out the ideas from others who are sharing your struggle. Next slide and I think that's all I got. Thank you, great, awesome. Thank you guys so much. This was, this was great, great job.