The EPIC procedure (Endoscopic-assisted Pilonidal Irrigation and Cleaning): a simple and effective treatment for pilonidal disease

Outcomes of Pediatric Endoscopic Pilonidal Sinus Treatment: A Systematic Review

Treatment of pilonidal sinus disease with conventional excision techniques is associated with recurrence up to 20 to 30% (primary closure) or with prolonged healing that might last months (closure by secondary intention). Endoscopic pilonidal sinus treatment (EPSiT) is gaining increasing popularity. This systematic review aims to summarize and evaluate the reported outcomes of pediatric EPSiT (PEPSiT) to date. Systematic search was performed for all studies on PEPSiT in patients younger than 18 years, pertaining to demographics, technique, and outcomes. Fisher's test was used to assess the associations between success/recurrence rates and different approaches (fistuloscope vs. cystoscope, different wound care protocols). A total of 320 patients (9 studies, 2018-2022) with a weighted mean age of 15.7 years and follow-up duration of 13.5 months were included. PEPSiT was successful in 290 patients (90.9%) with weighted mean time to healing of 4.1 weeks. Recurrence was reported in 29 patients (9.1%) with weighted mean time to recurrence of 4.6 months. Outcomes were not significantly altered by the use of fistuloscope versus pediatric cystoscope (p = 1.0), or with perioperative laser epilation (p = 0.06), or postoperative regular shaving, depilatory creams, light pulse, or laser (p = 0.31). The weighted mean operative time was 38 minutes and hospital stay was 16 hours. Summary of available evidence confirms that PEPSiT is safe and effective. Added to its noninvasiveness, PEPSiT's pooled outcomes appear superior to those of numerous conventional techniques. Comparison with conventional techniques, particularly off-midline flap and semi-closure procedures, is, however, lacking. The superiority of PEPSiT needs to be confirmed in future comparative studies, including cost-benefit analysis.

Pilonidal sinus: an overview of historical and current management modalities

Pilonidal disease is a common condition that commonly affects the younger adult population and is often seen in both the general practice and the hospital setting. Multiple treatment methods have gained and lost popularity over the last several decades, but more recent intervention principles show promising results. This article details the different methods of managing acute and chronic pilonidal disease ranging from treatments in the primary care setting to those in hospital theatres, with special attention to newer modalities of minimally invasive interventions. As a chronic illness that often affects those of working age, pilonidal disease can confer significant morbidity especially, but not limited to, a substantial amount of time off work. Treatment of chronic disease in particular, has evolved from midline techniques to off-midline techniques, with more recent developments offering promising solutions to reduce acute flare ups and hasten recovery time.

Minimally Invasive Pilonidal Sinus Treatment: EPSIT Versus PEBAI Method

PURPOSE

We aimed to compare endoscopic pilonidal sinus treatment (EPSIT) and pit/sinus punch needle excision, brushing, ablation and irrigation (PEBAI) method that was performed with principles similar to EPSIT but without fistuloscope and vision in the treatment of pilonidal sinus disease (PSD).

METHODS

Patients who underwent EPSIT and PEBAI methods for PSD in a single center between January 2020 and October 2021 were retrospectively analyzed. The primary endpoint was healing, the secondary endpoints were operative time, pain, wound closure, quality of life, cosmetic results, and cost.

RESULTS

One hundred 4 patients who underwent EPSIT and 184 patients who underwent PEBAI were included in the study. Age ( P =0.871), sex ( P =0.669), BMI ( P =0.176), number of pits ( P =0.99) were similar in both groups. The operative time for PEBAI [20 min (18 to 32)] was shorter than EPSIT [32 min (24 to 44)] ( P <0.0000, u value=3096, z-score=-9.459). Postoperative first ( P =0.147) and 14th day( P =0.382) pain scores, postoperative analgesic requirements ( P =0.609), time to return to daily activities ( P =0.747), time to return to work ( P =0.345), and wound complications ( P =0.816) were similar, whereas the wound closure time was earlier after EPSIT [32 d (24 to 41)] than after PEBAI [37 d (26 to 58)] ( P <0.00001, u value=5344, z-score=6.22141). The median follow-up was 24 (12 to 34) months. Complete wound healing ( P =0.382), recurrence rate ( P =0.533), quality of life at first month and (Wound evaluation scale score at first year ( P =0.252) were similar in both groups. However, the cost of PEBAI [54.8 € (50.13 to 64.96)] was significantly lower than cost of EPSIT [147.36 € (132.53 to 169.60)] ( P <0.00001, u value=0, z-score=7.210).

CONCLUSIONS

PEBAI method is a cheaper alternative to EPSIT with similar surgical principles and clinical outcomes.

Effect of sinus resection combined with vacuum-assisted closure on sacrococcygeal pilonidal sinus

This study was aimed at investigating the effect of sinus removal combined with vacuum-assisted closure in the treatment of sacrococcygeal pilonidal sinus. From January 2019 to May 2022, 62 patients with sacrococcygeal pilonidal sinus were treated and their information was collected at our hospital. These patients were randomly divided into two groups: an observation group (n = 32) and a control group (n = 30). The control group underwent a simple sinus resection and suture, while the observation group received a sinus resection combined with closed negative pressure drainage of the wound. A retrospective analysis of the data obtained was conducted. Perioperative indicators, clinical efficacy, postoperative pain, complications, aesthetic effects, and satisfaction scores at six months after the operation were compared between the two groups, and the recurrence rate at six months after the operation was recorded. Through this study, we found that the observation group had significantly shorter surgery time, hospital stay, and return time compared with the control group (P < 0.05). Additionally, the observation group had a higher overall recurrence rate (ORR) of 100.00%, which was significantly better than the control group's ORR of 86.67% (P < 0.05). The visual analog scale (VAS) score at 6, 12, and 24 h after the operation was significantly lower in the observation group compared with the control group (P < 0.05). Although the differences were not significant (P > 0.05), the observation group had decreased white blood cell, neutrophil, and C-reactive protein levels after the operation. Moreover, the total occurrence rate of postoperative complications in the observation group was significantly lower (6.25%) than that of the control group (26.67%; P < 0.05). The observation group also had significantly lower scores on the postoperative scar scale and higher satisfaction scores than the control group (P < 0.05). However, there was no significant difference in the postoperative recurrence rate between the two groups (P > 0.05). Our study demonstrated that sinus resection combined with vacuum-assisted closure was more effective in treating sacrococcygeal pilonidal sinus compared with simple sinus resection and suture. This approach significantly reduced surgery time, hospital stay, and return time. It also effectively relieved postoperative pain, reduced the occurrence of postoperative complications, resulted in smaller postoperative scars, and yielded better aesthetic outcomes and higher patient satisfaction.

Five-year recurrence after endoscopic approach to pilonidal sinus disease: A multicentre experience

PURPOSE

The aim of this study was to evaluate the 5-year recurrence rate of pilonidal sinus disease (PSD) after endoscopic sinusectomy and identify risk factors for recurrence.

METHODS

All consecutive patients from September 2011 through December 2017 who underwent endoscopic sinusectomy at seven referral centres for pilonidal sinus treatment were retrospectively analysed from a prospectively maintained database.

RESULTS

Out of 290 patients (185 males versus 105 female, with a mean age of 25.5±6.9), 73 presented recurrence at 5-year follow-up with a recurrence rate of 25.2%. The number of pilonidal sinus with pits off the midline (p = 0.001) and the mean (SD) distance from the most lateral orifice to the midline (p = 0.001) were higher in the group of patients with recurrence at 5-year follow-up. Multivariate analysis demonstrated that the position of the pits off the midline (p = 0.001) and the distance of the most lateral orifice from the midline (p = 0.001) were independent risk factors for recurrence at 5-year follow-up. Receiver operating characteristic (ROC) curve analysis showed that the distance of lateral orifice from midline predicted an 82.2% possibility of recurrence at 5-year follow-up and Youden's test identified the best cut-off as 2 cm for this variable. Out of 195 cases with the most lateral orifice less than 2 cm from the midline, 13 presented recurrence at 5-year follow-up with a recurrence rate of 6.7%. Out of 95 cases with the most lateral orifice more than 2 cm from midline, 60 showed recurrence at 5-year follow-up with a recurrence rate of 63.2%.

CONCLUSIONS

This data may help guide which disease characteristics predict the optimal use of an endoscopic pilonidal sinus technique.

Management of Pilonidal Disease: A Review

Importance

The management of pilonidal disease continues to be a challenge due to high rates of recurrence and treatment-associated morbidity.

Observations

There is a heterogeneous repertoire of treatment modalities used in the management of pilonidal disease and wide practice variation among clinicians. Available treatment options vary considerably in their level of invasiveness, associated morbidity and disability, risks of complications, and effectiveness at preventing disease recurrence. Conservative nonoperative management strategies, including persistent improved hygiene, depilation, and lifestyle modification, focus on disease prevention and minimization of disease activity. Epilation techniques using both laser and intense pulse light therapy are also used as primary and adjunct treatment modalities. Other nonoperative treatment modalities include phenol and fibrin injection to promote closure of pilonidal sinuses. The traditional operative management strategy for pilonidal disease involves excision of affected tissue paired with a variety of closure types including primary midline closure, primary off-midline closure techniques (ie, Karydakis flap, Limberg flap, Bascom cleft lift), and healing by secondary intention. There has been a recent shift toward more minimally invasive operative approaches including sinusectomy (ie, trephination or Gips procedure) and endoscopic approaches. Overall, the current evidence supporting the different treatment options is limited by study quality with inconsistent characterization of disease severity and use of variable definitions and reporting of treatment-associated outcomes across studies.

Conclusions and Relevance

Pilonidal disease is associated with significant physical and psychosocial morbidity. Optimal treatments will minimize disease and treatment-associated morbidity. There is a need for standardization of definitions used to characterize pilonidal disease and its outcomes to develop evidence-based treatment algorithms.

Endoscopic sinusectomy: 'a rose by any other name'. A systematic review of different endoscopic procedures to treat pilonidal disease

AIM

Pilonidal sinus or Pilonidal Disease (PD) is a relatively common, benign but challenging condition. Although commonly encountered in practice, its ideal treatment is controversial. One of the most validated treatments is video-assisted surgery. In this context, very similar endoscopic techniques have been published under different names. The aim of this systematic review is to assess the differences among these proposed techniques and their outcomes.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during all stages of this systematic review. A systematic search of the English literature was performed on multiple databases from 1 January 2014 to 3 April 2022. The primary outcome measure was the IDEAL framework stage of innovation. The key secondary outcome measures were the adherence to the IDEAL reporting guidelines, the Blencowe framework and the core outcome set (COS) for studies evaluating the introduction and evaluation of novel surgical techniques, the qualitative assessment using appropriate tools, the procedural variations and outcomes of each technique.

RESULTS

A total of 38 articles were included reporting a very similar technique under eight different acronyms. The number of patients varied from 9 to 250. Mean follow-up ranged from 1 to 60 months. There was only one published study of IDEAL 3. The majority (58%) were IDEAL 2a studies. Reporting of domains in the IDEAL reporting guidelines and Blencowe framework was poor, with most studies not reporting the component steps of procedures or efforts to standardize them. Half of COS domains were markedly underreported. The quality of the evidence was categorized as having a risk of bias from moderate to critical level in all nine comparative non-randomized series. Postoperative complications occurred in 0%-6% of cases, including surgical site infection, poor or failed wound healing bleeding, granuloma, haematoma, and pain requiring intervention. The recurrence rate varied from 0% to 22%.

CONCLUSION

The study demonstrates that reporting on technical aspects of interventions for PD is poor, thus warranting a better-quality control of surgical techniques. It is advisable to group all endoscopic procedures under the umbrella term of 'endoscopic sinusectomy', thus embracing the two main principles of this technique, that is, video assistance and PD ablation.

Long-term results of EPSiT in children and adolescents: still the right way to go

INTRODUCTION

Endoscopic pilonidal sinus treatment (EPSiT) has been advocated promising excellent outcomes with low rates of complications and recurrences. In this study, we aimed at reporting long-term results of a unicentric series of pediatric patients who underwent EPSiT during a 5-year period.

MATERIALS AND METHODS

We retrospectively reviewed patients who underwent EPSiT between January 2017 and December 2021. Patients under 18 years of age at first surgery were included. Details regarding demographic data, surgical procedure, and recurrences were recorded. Patients were also divided into short-term (follow-up of 12 months) and long-term (follow-up longer than 36 months) to compare results and detect all possible delayed recurrences.

RESULTS

A total of 99 patients underwent 115 EPSiT procedures in a 5-year period. Median age was 16 years (8-19 years). Median length of surgery was 32 min (25 to 50 min). Eighty-three of these patients were assessed for short-term results and reported an 8% incidence of recurrences occurring after a mean of 6 months. Fifty-nine patients have been followed up for at least 36 months (long-term results) with a median follow-up of 49 months (36-61 months) and reported a 15% incidence of recurrences occurring after a mean of 19 months postoperatively. All patients who recurred required a redo EPSiT. Infections occurred in 5 (2 recurred) and bleeding in 1 (no recurrence).

CONCLUSIONS

Recent reports underlined impressive results and an extremely low recurrence rate of EPSiT. Our retrospective study addressed the long-term results and seems not to support these expectations. Even so, EPSiT remains easy, straightforward, allows rapid recovery and is, therefore, to be considered as one of the most promising surgical techniques available for pilonidal disease. EPSiT is here to stay and to remain.

Endoscopic Treatment of Pilonidal Sinus Disease: State of Art and Review of the Literature

Background: Pilonidal sinus disease (PSD) is a chronic troublesome pathology of the natal cleft of the sacrococcygeal region, with an estimated incidence of 26 cases in every 100,000 inhabitants. The aim of this review is to give a snapshot of the current literature on the endoscopic approach to PSD. Methods: A search on endoscopic treatment of pilonidal disease was performed according to PRISMA guidelines, adopting the following search terms: (pilonidal OR sacrococcygeal) and (endoscopic OR VAAPS OR EPSiT OR minimally invasive OR video-assisted OR video assisted). Results: Thirty-four articles were included in the final analysis, among which 23 were on adults and 11 were on pediatric population. The endoscopic approach is associated with painless postoperative pain, good aesthetic results, short time off work, and high patient satisfaction. Despite these advantages in short-term outcomes, results on recurrence rate in a long-term follow up are needed to definitively confirm the importance of this technique. Conclusions: The endoscopic approach is associated with significant postoperative advantages over other standard surgical approaches, and it should be included in the surgical portfolio for the treatment of PSD. According to the Italian guidelines, this technique could be considered as the gold standard for limited PSD. However, the favorable short-term-outcomes and lack of reliable data on long-term follow-up must be a stimulus to perform further high-quality studies to give definitive conclusions on this technique.