Update Course Rewind: Patient Education and Non-Surgical Management of Pilonidal Disease 2024

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm M. Godi from Cincinnati Children's Hospital Medical Center. In this video series, we'll be recapping the sessions and sharing the key highlights from our 12th annual update course in pediatric surgery, which was held in August 2024. This year, we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three categories: Green circle for established practice, blue square for promising newer practice, and black diamond for early adopter practice only. Today, we will review the updates in non-surgical management of pilonidal disease and the importance of patient education with Dr. Nelson Rosen, a pediatric surgeon from Cincinnati Children's, and Dr. with Holcomm, the editor-in-chief of Journal of Pediatric Surgery. This one classified as a green circle for established practice. Okay, so let's start with a poll. You have 17-year-old male, this is what you're looking at. Most people can't see what their bottom looks like. So they know what they see in the underwear and they they have this, I'm bleeding, some drainage and they often describe it that way. Pain on sitting in this exam. So what's your next step? So if I could ask Nelson a question. Yeah. I think it might be important to explain minimally severe disease, maximally severe disease, does it does it matter in which treatment option that you look at? It's a great question and it's something we're actually looking at right now. How do you define severity in pilonidal? And there's not a lot of science on that. According to Dr. Nelson, staging systems have been introduced previously, but not all of these classifications correlate with how cases are managed. These systems don't always align with the necessary course of intervention. One thing that I can tell you that from our looking at our own data is that patients 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. Let's check out our poll results. It looks like uh people are jumping right to minimally invasive pilonidal surgery. Wide excision and packing is pretty small. A third of you are starting with shaving and meticulous hygiene alone. I love this and I use this routinely in 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 they're miserable, then we're going to go to the operating room, but I also say 60 to 70% of the time, it works every time. And you set that expectation bar that you may get partial healing, especially depending on the severity of disease, but it's not going to be something that 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. And I like your numbers. That 60 to 70% works every time. Those are probably some real honest numbers there as opposed to what's published out there when you look at some very rosy reports. And here's an important point from Dr. Rosen. I think if you're not pushing hair removal and meticulous hygiene to do the best that you can, you're probably going to end up operating on some people that might not need an operation. But again, you have to talk to your patient. Here, we see some case reports go back a long way. John Armstrong in the United States Army had a clinic where patients were shaved weekly and closely monitored, leading to dramatic improvement and a reduced need for surgery. But if you look, 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 and nobody clipped them in the office. We learned from Dr. Rosen that in these cases, no one removed the hair or even mentioned it, acting as if the hair had nothing to do with the problem of pilonidal disease. Can you comment on techniques for hair removal and hygiene? Shaving versus Nare type agents or laser hair removal or maybe a lot of our patients are teenagers or people going to college and sometimes they don't have anybody to help with them. If there's a parent or an active caregiver involved, we believe that clipping is probably the easiest and simplest approach. And having someone do it once a week is recommended. 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 going to happen. Then Nare. And so we we do also recommend that. When my patients are in the operating room, I'll have parents bring in wax strips. Yeah. And we'll all sit there during the prep verification and the timeout and be warming up those wax strips and we will give them a really good head start in getting that entire natal ft area and the the buttocks on both sides free of hair to give them like this is the expectation. Whether it's clippers, they're on, but it's a great time to get a wax as when you're under general anesthesia. That's amazing. 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, showering, the hand shower, I think very important. People actually putting water in there. I can't tell you how many people said, well, they told me I couldn't bathe and I'm so confused because if you don't wash, then you're probably not going to heal anything. There are also various adjuncts, including washlets for those who struggle to clean themselves after a bowel movement. And all of this is a part of the patient education process. In conclusion, pilonidal disease severity varies, and treatment options from non-invasive hygiene measures to surgery should be tailored to the individual case. Non-surgical measures like regular shaving and even waxing can lead to significant improvement and should be considered before moving to surgery, especially in cases of mild to moderate severity. Thank you for watching this video. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.