Pediatric Endoscopic Pilonidal Sinus Treatment,a Revolutionary Technique to Adopt in Children with Pilonidal Sinus Fistulas: Our Preliminary Experience

Introduction

Pilonidal sinus disease (PSD) is a chronic and inflammatory disease that is located at the sacrococcygeal region. Herbert Mayo is credited with the first description of this disease in 1833. ¹ In 1880, Hodges named the disease and he produced the word “pilonidal” by conjoining the word “pilus,” which means hair in Latin, and “nidus,” which means nest. ² PSD affects an estimated 26 per 100,000 persons, occurring primarily in young adults with a 3:1 male predilection. Known risk factors include family history, local trauma, sedentary occupation, and obesity. ³

For a long time, the cause of PSD has been a matter of debate. Until the second half of the 20th century, PSD was thought to be secondary to a congenital remnant of an epithelial-lined tract of postcoccygeal epidermal cell rests or vestigial scent cells. A variety of explanations have supported the congenital theory. Some authors have suggested that the persistence of a caudal remnant of the neural canal forms small cysts, which cause PSD. Another hypothesis provides that PSD is the result of a formation of dermal inclusions by the cystic changes of sequestered epithelial rests.

PSD is now, however, widely accepted as an acquired disorder. PSD is more common in men and in hirsute people. It usually occurs after puberty, and a linkage between the disease and various occupations has been demonstrated. In addition, there is a high recurrence rate of PSD after a traditional surgical excision. ⁴

Although many techniques for surgical treatment of pilonidal sinus have been described until now, there is no consensus about the gold standard treatment option, and various clinical results are still being reported about these methods. ⁵ The traditional open excision is extremely invasive, with a long and painful postoperative course, and patients, in general, doubt whether to submit themselves to this procedure.

We report our preliminary experience in pediatric endoscopic pilonidal sinus treatment (PEPSiT).

Patients and Methods

We retrospectively analyzed the data of 15 consecutive pediatric patients with an average age of 16 years (range 13–18 years), 6 girls and 9 boys, with pilonidal sinus fistulas operated using PEPSiT in our center over an 18-month period. Four cases were redo-procedures, for recurrence of pilonidal disease after an open excision repair. All the patients presented with noninfected pilonidal sinus fistulas. In case of an active infection or abscess, we usually perform an antibiotic therapy to solve the infection and after 1–3 weeks, we proceed with the surgical intervention.

From the technical point of view, we always adopted a fistuloscope, a monopolar electrode, and an endoscopic grasping forceps (Fig. 1). The fistuloscope has an 8° angled eyepiece and is equipped with an optical channel and a working and irrigation channel. Its diameter is 3.2 × 4.8 mm, and its operative length is 18 cm. A removable handle allows easier maneuvering and better ergonomy for the surgeon (Fig. 1).

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FIG. 1.

The kit includes the following: the fistuloscope with its removable handle allowing easier maneuvering and better ergonomy (a, b); the monopolar electrode (c); and the endoscopic grasping forceps (d).

All patients and their parents signed a specifically formulated informed consent before the procedure.

Patients received a specific type of subarachnoid spinal anesthesia and antibiotic prophylaxis. Under standard monitoring (noninvasive blood pressure, electrocardiogram (ECG), pulse oximetry, and pulse rate), spinal saddle block was performed with 27 Gauge Whitacre needle at intervertebral space L4–L5 or L5/S1 with a low dose of local anesthetic.

Every child had venous access at nondominant arm; there was no fluid preload. Thirty minutes before spinal anesthesia, 1 mL of skin gel of 2.5% lidocaine was applied to the lumbar puncture area.

Premedication was performed with oral (0.5 mg/kg) or intravenous midazolam (0.025–0.05 mg/kg) to obtain light sedation, and with intravenous atropine (0.01 mg/kg).

Block was carried out in a sitting position, except 1 patient who requested lateral decubitus position and moderate sedation. In this series, we achieved a good block performance with low dose of 0.5% hyperbaric bupivacaine (0.1–0.2 mg/kg) with a fast onset of sensory blockage and confined motor block. After puncture, the sitting position with knees to the chest was maintained for 10 minutes before the return to the prone position required by surgery.

The patients were placed in prone position with buttocks separated by two big plasters. Surgeon's position was on the right and the screen was at feet of the patient. We also adopted a second screen, placed at the head of the patient if we moved cranially, in relation to the fistula opening. To have a better ergonomy for the shoulders, the surgeon stood on a stool. According to the technique described by Meinero et al., ⁶ in the diagnostic phase, we identified the anatomy of pilonidal sinus and any secondary tracts and/or abscess cavities. We introduced the fistuloscope through a fistula hole and a clear view was possible, thanks to a continuous infusion of saline solution. In the operative phase, the endoscopic forceps was inserted through the operative channel of the fistuloscope to remove all the hairs under vision. Once this step was completed, the monopolar electrode was connected to an electrosurgical knife power unit for cautery ablation of the sinus granulation tissue, commencing in the main tract and where appropriate, traversing secondary tracts and abscess cavities (Fig. 2). Particular attention was paid to hemostasis during the procedure. External opening(s) were not closed. At the end of the procedure, a dressing was applied on incision(s). In the postoperative period, the patients kept a normal decubitus.

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FIG. 2.

The fistuloscope is introduced through the fistula hole (a); the hairs are removed with endoscopic forceps (b); and then the cauterization of the sinus tract is performed with the monopolar electrode (c).

Parents were instructed on how to treat the wound daily by washing it with sterile saline solution and applying topically an antiseptic solution of eosin 2% and a silver sulfadiazine spray for about 3 weeks after surgery. The external openings were left open and covered with a dressing. No drain was placed after surgery. Patients were prescribed an antibiotic therapy with amoxicillin and clavulanate for 5 days after surgery. To prevent postoperative recurrence, we advised a postoperative hair removal with shaving until the wound healing was complete and then a radical hair removal was performed with laser.

Before the introduction of PEPSiT in our institution, we performed the classic open excision technique with a wide excision of all sinus tract until the bone followed by the secondary healing of the wound. With the aim to clarify to the readers of the journal the difference between the classic open technique and PEPSiT, we analyzed the postoperative outcome of the last 15 patients who underwent the classic open excision technique in our institution and compared it with the PEPSiT group.

Statistical analysis was carried out by using the Statistical Package for Social Sciences (SPSS, Inc., Chicago, IL), version 13.0. The categorical variables were compared using χ² Pearson and Fisher tests. The ordinal variables were compared using the Student's t-test. Significance was defined as P < .05.

The study received the appropriate Institute Review Board (IRB) approval.

Results

The average length of surgery was 28.5 minutes (range 26–41 minutes). We did not report intraoperative or postoperative complications. The anesthesia of sacrococcygeal area, with preserved legs mobility, was obtained in all cases. No patient showed oxygen desaturation, bradycardia, or hypotension.

All patients were asked to evaluate postoperative pain using the Visual Analogue Scale (VAS) pain scale and the average pain score during the first 48 postoperative hours was 3.2 (range 2–5).

The average analgesic requirement was 22 hours (range 16–28). The average hospital stay length was 28 hours (range 22–48 hours). Since the postoperative management of the sinus is fundamental for the successful outcome of the surgical procedure, we prefer to perform the first dressings after surgery in the hospital, so as to well instruct the parents who will perform the dressings daily at their home. However, the majority of patients had an overnight hospitalization.

Follow-up was carried out by clinical examinations at 1 and 2 weeks and then at 1, 3, 6, 12, and 18 months after surgery.

At 1 month postoperatively, the external opening(s) were closed in all patients (Figs. 3 and 4).

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FIG. 3.

Healing process at different stages of follow-up: 1 week (a), 2 weeks (b), 3 weeks (c), and 4 weeks (d) after surgery.

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FIG. 4.

Healing process, evaluated 1 week after surgery (a), was complete after 4 weeks (b) in all patients of our series.

No case of recurrence was recorded at a mean follow-up of 6 months (range 1–18).

The average time to return to full daily activities was 2.5 days (range 1–4) and all patients were highly satisfied with the postoperative outcome and cosmetic results.

The comparison analysis of the postoperative outcome between PEPSiT group and classic open excision group confirmed that PEPSiT was associated with a significantly shorter, painless, and better outcome compared to the classic open technique. We have reported all outcome parameters of both techniques in Table 1.

Discussion

There is an ongoing debate regarding the optimal surgical management for pilonidal disease in the pediatric population. ⁷ The treatment is virtually the same as for adults and many of these patients are often operated by general surgeons. Various primary or secondary flap methods, accompanied by one of local curettage, phenol application, electrocauterization, and total sinus excision methods, have been described for the treatment of pilonidal sinus. ⁸ The defect observed after total sinus excision could be closed by marsupialization, primary closure, or flap methods. The defined flap methods in the literature include Rhomboid, Karydakis, V-Y-Z plasty, and Limberg flaps. ⁹ The main problem after a traditional open repair of PSD is the very bad and long postoperative period and in a lot of cases, the healing process is very long and painful.

In addition, following the pilonidal sinus surgery, patients may encounter problems such as esthetical problems, infection, hematoma, dehiscence, and recurrence. Despite various surgical techniques being described, reported recurrence rates are as high as 30%, with prolonged recovery times, increased use of resources, repeat surgeries, and patient frustration. ¹⁰

Analyzing literature reports, there are interesting data. A retrospective review about an over 35-year pediatric surgeon's experience at a Canadian children's hospital ¹¹ concluded that the excision and packing open produced a longer morbidity, but the same results in terms of recurrences, when compared with both marsupialization or excision and primary closure without drainage.

In 1983, Bascom described a new technique involving short incisions and removal of the infected area based on a minimally invasive philosophy.^12,13

Minimally invasive surgical techniques are becoming widespread in recent years due to the increased experience and development of new instruments. New minimally invasive techniques derive from the concept of operating endoscopically and removing all the infected area by way of small circular incisions. One of these options is endoscopic pilonidal sinus treatment (E.P.Si.T.) that was inspired by video-assisted anal fistula treatment (VAAFT) described by Meinero and Mori in 2011. ¹⁴ VAAFT includes two phases: a diagnostic and an operative phase. Key steps are visualization of the fistula tract, correct localization of the internal fistula opening under direct vision, and endoscopic treatment of the fistula. This is followed by an operative phase with fulguration of the fistula tract using glycine solution mixed with mannitol and curetting the tract with curette and fistula brush. Internal opening is closed with a Vicryl suture. VAAFT was associated with a recurrence rate of 30%. ¹⁴

Similar to the VAAFT procedure, E.P.Si.T. was first described by Meinero et al. in 2014 and it has two phases: a diagnostic phase and an operative phase. In the diagnostic phase, the aim is to identify the anatomy of the pilonidal sinus, and secondary tracts and/or abscess cavities. The spontaneously draining opening, which is normally situated on the midline cleft, must be removed by making a 0.5-cm-circular incision around the opening. The number and site of incision vary, depending on the presence of secondary fistula tracts or abscesses, as well as on the overall size of the area involved, so that in some more complex cases, two incisions may be required. The operative phase consists of cautery ablation of the sinus granulation tissue, commencing in the main tract and where appropriate, traversing secondary tracts and abscess cavities. Necrotic material is removed with an endobrush passed through the fistuloscope or with a Volkmann spoon if more superficially located. Where two incisions have been used because the infected area is extensive, a special brush, designed with bristles in the middle part of a flexible metallic thread, is passed through the incision site. ⁶

We have applied this procedure in the pediatric population, calling it Pediatric EPSiT or PEPSiT, with some modifications, and we obtained excellent results. In contrast to the technique described by Meinero, we adopt a continuous jet of saline solution instead of glycine-mannitol to ensure, during the procedure, a clear visual field, but optimizing the economic impact of the procedure. In addition, in our technique, the surgeon stood on a stool to obtain a better ergonomy during the procedure. Finally, we prefer to not use the endobrush to avoid bleeding.

The PEPSiT procedure demonstrated to have many advantages compared with traditional open techniques. First of all, the direct vision allows the surgeon to see perfectly not only the pilonidal sinus but also any possible fistula tracts or abscess cavities. The destruction can be modulated and there is the certainty of complete removal of the infected area. Moreover, the hemostasis is done thoroughly under direct vision. This direct vision also allows the complete removal of hairs and their follicles, often located not only in the pilonidal sinus but also in the surrounding tissue.

The esthetic result is excellent and so is the patient's quality of life and satisfaction. There is no need for painful dressings and healing occurs within 3–4 weeks, as reported in our series.

Our results confirmed that PEPSiT was associated with a significantly shorter, painless, and better outcome compared to the classic open excision technique (Table 1).

In addition, the spinal saddle anesthesia with the savings of general anesthesia and its related risks, the low dose of local anesthetic, and the concomitant light sedation provided all components in balance, performing anesthesia with minimum cardiorespiratory disturbances, early ambulation, and high level of satisfaction of patient, of surgical team, and of patient's caregivers. In addition, the anesthesiologic technique used allowed a good postoperative pain control without the need of pharmacological overtreatment.^15,16

On the basis of our preliminary experience, we believe that PEPSiT is a promising technique for surgical treatment of pilonidal sinus in children. Until a few months ago, many patients refused surgery for important postoperative pain, prolonged hospital stay, and long time for healing. In the last months, we have seen an increase of patients who choose to undergo this procedure. In fact, it is technically easy and quick to perform, with a short and painless hospital stay, and allows the operated patients an early return to full daily activities without restrictions as for the classic treatment technique.

However, we believe that a larger series and a longer follow-up are needed to confirm these preliminary results and set up the best length of follow-up for this procedure.