Update Course Rewind: Surgical Management of Pilonidal Disease 2024

Globalcast MD. Along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm Emgodi 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 talk about the updates in surgical management of pilonidal disease with Dr. Nelson Rosen, a pediatric surgeon from Cincinnati Children's, and Dr. Beth Holcomb, 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. They have 17 year old male, they have bleeding, some drainage, and they often describe it that way, and pain on sitting in this exam. They're doing their best with hygiene and hair removal, ongoing symptoms. What's your next step? Some of those patients, depending on the extent that symptoms are disabling from their lives. Some of those patients will actually do okay without a surgical intervention. According to our poll, over half of our audience is going for the minimally invasive surgery option. I suspect worldwide, uh wide excision and packing is probably the most common operation that happens. There's still a bulk of pilonidal work is not done by people who are doing advanced pilonidal work. Do you add in those cases antibiotics for a while or nothing? I don't put people on antibiotics unless they're coming in with an active infection. Some people don't drain very effectively. Those are the people that have the most minimal external manifestation. These patients often experience severe pain and develop large, bulging abscesses. Yet, there is almost nothing visibly wrong. In contrast, some patients present with multiple draining abscesses, but typically don't report pain or require antibiotics for infections. There seems to be that the wide excision with off midline closure, which is really goes back to the 60s when Caris first described that, and then John Bascom with the Limberg flap has been used since like the 40s, you know. These are old operations, but they do work. But the minimally invasive, the best answer here and the ideal starting point. And then, ironically, you talk about like the older genera would never have thought of doing that, except like for those are my international colleagues who come from Commonwealth Nations that the Lord and Millard described this in 1965. It's almost the same operation that Dr. Gibbs described with this article in 2008. It's been out there for a while, just people haven't adopted it. Dr. Gibbs's study, they had a 15% recurrence rate over 10 years. 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. Some institutions are using laser dial tract ablation, while others are applying phenol to sclerose the tracts or using fibrin glue. Each of these methods has its proponents, but none have been proven superior. 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 Myboso? For somebody first abscess, we drain them, we take a look and we see what we're dealing with. We tend to be very quick to offer minimally invasive approaches because it really is a 20 minute intervention under sedation in our place with no activity restriction and no narcotic requirement. You showed a picture with 8 to 10 pits. When you do a Gibbs, how many of those pits are you actually excising? All of them. That's a elliptical wound at that point, right? If there's eight of them right in a row, you can't individually leave a bridge between those. 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. And sometimes if they're close enough together, you can get two with one punch and have less overall wounds. And that's the art of doing the Gibbs procedure. Maximizing the preservation of skin bridges and avoiding the creation of a large wound. So want you just briefly explain to the worldwide audience what the Gibbs procedure is. It 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 there, necrotic fat, and then leaving them open to heal. We can't talk about Gibbs without mentioning the Ebzi procedure. Ebzi, this was described in 2013, doing it all through a small incision and putting a big scope down there. That scope is not available in the United States. Dr. Rosen mentioned that he refers to his version of this procedure as a hybrid Gibbs. Once I cleaned everything out, I put an eight French cystoscope 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 five years uh and we're quite happy with it. And so, honestly, if we're not starting out with minimally invasive as our first surgical intervention for most people, we really should be. I'm going to be adamant and provocative to say, if you're not doing this, you're doing it wrong. No, I think you're I think you're right right on Todd. Here are some newer studies. The first one is a Swedish study by Roland Anderson in 2017. 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. And then the second one is by Nationwide Children's, which is a very large prospective study on laser hair removal after surgery. And they found that it significantly reduced recurrent disease. And this is the first randomized prospective study on this subject. I think that we should be getting all our patients to laser once they're healed. The question is, how long do you tell patients they need to be attentive to the Na, the waxing, or the laser throughout their adolescence or into young adulthood? Into adulthood, definitely. The longer they can sustain it, the better. Laser is not permanent, but it certainly knocks it down to a lower level. Our graduated treatment approach. For patients that one or two minimally invasive approaches did not work and they have significant ongoing symptoms, we move to an off midline closure and our choice is a Bascom cleft lift. In summary, minimally invasive approaches like the Gibbs procedure are preferred for treating pilonidal disease, offering quicker recovery and fewer complications. For more severe and recurrent cases, off midline closure techniques such as Bascom cleft lift may be necessary. Ongoing hair removal and hygiene practices, including laser treatments, help reduce recurrence and are essential for long-term management. Thank you for watching this video. Globalcast MD. Along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.