Round Table Pilonidal Disease. Pilonidal Disease: Anatomy. Disclosure Information. 26th Annual Scientific Conference May 1-4, 2017 Hollywood, FL

Transcription

1 Round Table Pilonidal Disease Pilonidal Disease: Anatomy Kelly Finkbeiner, RN, MSN, CPNP-PC/AC Ann & Robert H. Lurie Children s Hospital of Chicago Chicago, IL Disclosure Information I have nothing to disclose 1

2 Pilonidal Disease - Objectives 1. Describe the history of Pilonidal Disease 2. Review Anatomical structures 3. Discuss tips for taking a thorough history and physical Pilonidal Disease - History First described by Mayo Hodge - coined the term "pilonidal" from its Latin origins called Jeep disease b/c so many WWII soldiers were treated for this - nearly 80,000 US soldiers Fueled research and treatment techniques (return to battle fast) Etiology- initially thought to be from embryologic origin, after WWII prevailing idea was from hair penetrating skin and causing granulomatous effects in the cavity - Patey and Scarf Pilonidal Disease Epidemiology/Definition Incidence - 26 per 100,000 population Male to female ratio - 3-4:1. Patient characteristics predominantly white, late teens to early 20s - decreasing after age 25 and rarely occurs after age 45 PILONIDAL referring to presence of hair in a dermoid cyst or in deeper layers of the skin Dermoid cyst saclike growth present at birth can contain hair, teeth etc. Skin structures trapped inside same make-up as outer skin (hair, sweat glands, sebaceous glands etc) 2

3 How does it happen? 3 parts to pilonidal formation: (1)the invader, hair (2)the force, causing hair penetration (3)the vulnerability of the skin 3

4 Forms of Pilonidal Disease Pilonidal: Pits tiny openings that may or may not cause problems Sinus Cyst symptomatic vs asymptomatic Infected Cyst Recurrent Cyst Pits Pilonidal Sinus 4

5 Pilonidal Cyst Pilonidal Cyst Pilonidal Disease References Ahmed, N., & S.H. Ein. A pediatric surgeon s 35 year experience with pilonidal disease in a Canadian children s hospital. Canadian Journal of Surgery (2011) 54;1, Aysan, E., Ilhan, M., Bektas, H. et al. Prevalence of sacrococcygeal pilonidal sinus as a silent disease. Surgery Today (2013) 43: Fitzpatrick, E.B., P.M. Chesley, M.O Oguntoye, J.A. Maykel, E.K. Johnson & S.R. Steele. Pilonidal disease in a military population: how far have we really come? The American Journal of Surgery (2014) 207; 6,

6 Pilonidal Disease: Preoperative Management Jessica Pech, MSN, APN, CPNP Ann & Robert H. Lurie Children s Hospital of Chicago Chicago, Illinois Disclosure Information I have nothing to disclose. 6

7 Pilonidal Disease Preoperative Objectives Identify common risk factors associated with Pilonidal disease Describe significant findings of Preoperative History and Physical Exam Define common differential diagnoses associated with Pilonidal disease Define acute, chronic and complex stages of Pilonidal disease Discuss preoperative care of Pilonidal disease Discuss non-operative management of Pilonidal disease Pilonidal Disease - Preoperative Risk Factors Common in Adolescents (puberty-40 years of age) Male to female ratio 3:1 Family history of Pilonidal disease Obesity/sedentary lifestyle Poor personal hygiene/sweating Thick, coarse hair Buttocks friction/sitting jobs Pilonidal Disease - Preoperative Chief Complaint History of Presenting Illness (HPI) Duration and severity of symptoms including presence of painful mass to sacral area, fevers, redness or swelling, purulent/blood tinged drainage, sacral pits History of pilonidal disease or recurrent abscesses Previous MRSA infections Prior non-operative treatment including hair removal, skin exfoliation, sitz baths, prior use of antibiotics, wound care Past surgical history including incision and drainage, excision of pilonidal abscess/cyst, wound care, silver nitrate to granulation tissue 7

8 Pilonidal Disease - Preoperative Preoperative History and Physical (H&P) Past medical history: Review of systems, birth history, medication/food allergies, current medications/vitamins, immunization status Past surgical history: Prior anesthesia/sedation (reactions), OSA/asthma, seizures, bleeding/clotting disorders, cardiac history, diabetes (may impair wound healing), other specialists involved (preoperative clearances), recent use of steroids Social history: School attendance, involvement in activities or sports, support for home wound care and follow up visits Family history: Preoperative risk factors such as obesity, clotting/bleeding disorders, HTN, sudden cardiac death, complications with anesthesia, cancers Pilonidal Disease - Preoperative Physical Exam Sacral tenderness, erythema or cellulitis Fluctuant abscess or mass Location and quality of drainage Sacral dimple Sacral sinus/pit formation above natal cleft Perianal abscess or fistula Anal fissures Pilonidal Disease Preoperative Pilonidal Disease 8

9 Pilonidal Disease - Preoperative Differential Diagnoses Perianal abscess or fistula Crohn s disease Skin infections Sacrococcygeal teratoma Dermoid cyst Hidradenitis suppurativa Sacral dimple Squamous cell carcinoma Pilonidal Disease - Preoperative Diagnosis: Pilonidal Disease Categorization Acute: Acute formation of abscess or pilonidal cyst infection requiring incision and drainage, antibiotics for cellulitis, sitz baths, warm compresses, good hygiene, future hair removal Chronic: Asymptomatic pits or sinus formation that occurs after pilonidal cyst/abscess drainage and may cause recurrent infections. The sinus pits may heal, close on own or require surgical excision. May require local wound care such as silver nitrate application to granulation tissue or dressing changes Complex or recurrent: Surgical excision of previous wound and scar with removal of inflamed tissue. Occurs with reinfection of first abscess drainage, chronic friction or a sinus present that was not previously seen Pilonidal Disease - Preoperative Operative Management PMD history and physical within 30 days of OR date Preoperative clearances Review surgical risks and benefits Incision and drainage of abscess/pilonidal cyst Pilonidal cyst excision with primary versus delayed closure, wound vac device, etc. Postoperative wound care/dressing changes, activity or return to school restrictions, follow up considerations 9

10 Non-operative Management Hair removal with chemical depilatories every 2 weeks, shaving, electrolysis, laser hair treatments Good personal hygiene, sitz baths, warm compresses Oral antibiotics for recurrent abscess or cellulitis Phenol injections or fibrin glue to fill sinus cavity and eliminate granulation tissue Abscess reoccurrence rate is ~25-50% Pilonidal Disease Preoperative Seek medical attention with erythema or pain, redness or swelling, purulent drainage to sacral area, sinus/pit formation, fevers Pilonidal Disease - Preoperative Family counseling How do you support? No imaging needed unless concern for sacral dimple or spina bifida No labs unless concern for bleeding/clotting disorders, anemia or other chronic medical conditions Explanation of diagnosis and treatment options including non-operative versus operative management, review surgical risks and benefits Wound care teaching Abscesses require drainage & antibiotics for cellulitis but chronic pilonidal disease or sinus drainage is not usually infectious! Pilonidal Disease Preoperative Preoperative teaching Methods and Documentation Discussion Patient education handouts APSNA website Preoperative booklet Pain management Wound care and dressing changes Parent return demonstration Follow up care After visit summary 10

11 Pilonidal Disease - Preoperative References Bascom J, Bascom T. Failed pilonidal surgery: new paradigm and new operation leading to cures. Arch Surgery 2002;137(10): ; discussion 51. Humphries AE, Duncan JE. Evaluation and management of pilonidal disease. The Surgical Clinics of North America 2009;90(1): Lee SL, Tejirian T, Abbas MA. Current management of adolescent pilonidal disease. Journal of Pediatric Surgery 2008;43(6): Smith, Caroline Mary et al. Early experience of the use of fibrin sealant in the management of children with pilonidal sinus disease. Journal of Pediatric Surgery 2015:50(2): Velasco AL, Dunlap WW. Pilonidal disease and hidradenitis. The Surgical Clinics of North America 2009;89(3): Pilonidal Disease: Intraoperative Care Carrie Wilson, MSN, RN, CPNP-PC, CPNP-AC, WCC Washington University/St. Louis Children s Hospital St. Louis, MO 11

12 Disclosure Information No Disclosures Objectives Review risk factors of surgical intervention of pilonidal cyst/sinus disease Discuss different surgical techniques used in excision of pilonidal cyst/sinus disease Discuss risks and recurrence of different surgical techniques used in pilonidal cyst/sinus disease excision Pilonidal Sinus/Cyst Disease Etiology under debate Penetration of hair in the intergluteal cleft Foreign body reaction Inflammation Abscess formation 12

13 Pilonidal Abscess Pilonidal Sinus Probing of Sinus Tract Probe the sinus tract Unroof Dressing care to avoid premature healing of skin Multiple daily Sitz baths Recovery: 6 to 13 weeks 60% resolve without further need for intervention 13

14 When to Excise Recurrent exacerbations/infections Multiple I&Ds, drain placements Complex and persistent wound care Pain Missed school days or productivity over time Surgical Techniques Excision & Curettage of all sinus tracts Excision & Curettage of all sinus tracts and/or Marsupialization Bascom s operation Flaps Karydakis flap Limberg rhomboid flap VY-plasty Z-plasty Excision & Curettage of All Sinus Tracts Sinus located (methylene blue) Excision of all sinus tracts Washout Incision left out to heal by secondary intention 14

15 Intra-op Closure Techniques Primary closure (sutures or staples) Daily cleansing and packing of cavity Negative Pressure Wound Therapy (NPWT) closure* * Time for closure (2-6 weeks-many months) depends on many factors-body habitus, wound size, wound environment, compliance, and complicatins. Negative Pressure Wound Therapy 15

16 NPWT Dressing Change S/P Excision Additional therapies to assist healing Antiobiotics (optional) Hair removal (shaving, depilatory, clipping, or laser hair removal) Marsupialization Decrease wound size Faster healing time Prevent early wound closure Primary closure techniques After removal of sinuses, close incision: Midline Oblique Lateral to midline Flap over wound 16

17 Surgical Techniques-Marsupializaton Bascom s Operation Pilonidal follicles excised individually Small incision lateral to natal cleft/excised follicles Gauze run through excised follicles and incision Left open or closed Karydakis Flap Asymmetric technique that distorts the appearance of the gluteal cleft and are often avoided in the pediatric population. 17

18 Limberg rhomboid flap Lower recurrence rate (incision away from midline) Less tension, less pain (faster return to work & shorter hosp.) Complications Wound infection Seroma Wound separation Flap necrosis VY-plasty Fasciocutaneous flap Complex disease Unilateral or bilateral Used in wide excision and recurrent PSD Close larger defects Recurrence 0=11.1% (2) Z-plasty Shorter healing time 18

19 Recurrence Rates Sinus tract unroofing 2% to 10% Marsupialization 4% to 8% Excision and closure 1% to 21% Case Study Pilonidal mass vs Pilonidal Case Study (cont d) Myxopapillary Ependymoma Rarely occurs in pelvic cavity In pediatrics, usually presents intracranial In adults, in spinal Most anaplastic Treatment: Full resection, clear margins Case: 12 year old male with 1-2 week hx of mass Imaging (CT chest, abd., pelvis, Bone scan, MRI brain, & then continued imaging q3months with hemoc with pelvic MRI) 19

20 References 1. Abcarian, H, & Orangio, GR. (2014). Chapter 24: Complex pilonidal disease and acute and chronic perineal wounds: point-counterpoint. In SR Steele, et al (eds.), Complexities in Colorectal Surgery, (pp ), New York: Springer Science + Business Media. 2. Cameron, JL & Cameron, AM. (2016). Pilonidal surgery. In Current Surgical Therapy 12 th ed. Philadephia: Elsevier. 3. Stack, T, et al (2017). Chapter 7:Pilonidal sinus. In Fazio, VW, et al (eds.), Current Therapy in Colon and Rectal Surgery, 3 rd ed., p.36-40, Philadephia: Elsevier. 4. Foster, ME & Mackey, WL. (2013). Chapter 12: Common cysts. In NT Browne, et al (eds.), Nursing care of the pediatric surgical patient (3 rd ed., pp ). Burlington: Jones & Bartlett Learning, LLC 5. O z B, et al., A comparison of surgical outcome of fasciocutaneous VeY advancement flap and Limberg transposition flap for recurrent sacrococcygeal pilonidal sinus disease, Asian Journal of Surgery (2015), j.asjsur Yildiz, T, et al. (2014). Modified limberg flap technique in the treatment of pilonidal sinus disease in teenagers. Journal of Pediatric Surgery, 49, Pilonidal Disease: Postoperative Care Kris Rogers, ARNP, CWON Johns Hopkins All Children s Hospital St. Petersburg, FL 20

21 Disclosure Information I have nothing to disclose. Objectives Discuss care after drainage of acute abscess or removal of pits Review recommendations after extensive intraoperative surgical excision of pilonidal disease and/or reconstruction Describe aspects of maintenance care common to all procedures Care recommended after all procedures Good, consistent hygiene must be stressed Routine hair removal Both are imperative to promote healing and prevent recurrence Dressing to allow aeration of area Only 15% of patients with Pilonidal Disease need large excision, remaining can be managed successfully with above measures 21

22 Pit Removal in Office Minor procedure performed with local anesthetic May require 1 2 sutures Possible need for packing of fistulas or opening created off midline for drainage Dressing over area Silver nitrate to hypergranulation tissue or open fistula tracts at follow-up visit Hygiene and hair removal Bascom pit-picking pictures, (2017, March 8), retrieved from Gips et al, (2008) Minimal surgery for pilonidal disease using trephines: Description of a new technique and long-term outcomes in 1358 patients, Diseases of the colon and rectum, 51,

23 Incision and Drainage of Acute Abscess If cellulitis present treat with antibiotics, including coverage of anaerobes Do not pack Sitz baths Silver nitrate if hypergranulation forms Dressing to allow aeration Hygiene and hair removal May need pit removal to prevent recurrence after edema resolves Open Procedure Excision of pits and sinus tracts with wound left open to heal by secondary intention Lower recurrence but longer healing time NPWT Wet to dry Irrigations Hygiene and hair removal May return to activity immediately in most cases open wound excision picture, (2017, March 8) retrieved from 23

24 Cleft Lift Procedure Excision with closure Incision will be off midline considered standard treatment for surgical excision with closure Discharge from hospital on day of surgery or POD #1 Cephalexin and metronidazole pre-op, then some recommend PO for 4 days post-op, not well supported that antibiotics decrease post-op infection Drain placement will be individualized to patient - vessel loop, penrose, bulb drain Early mobility, slow walking, may sit, some recommend minimally Cleft Lift Procedure - continued Remove sutures in 1 2 weeks, some surgeons remove ½ at one week then other half Closure varies: tape in X to decrease shearing, mattress sutures, glue, absorbable sutures Incision care varies by specifics but all recommend cleaning routinely Hygiene and hair removal continues long-term to prevent recurrence and infection References Bascom, J. & Bascom, T. (2007), Utility of the cleft lift procedure in refractory pilonidal disease. The American Journal of Surgery,!93, Gips et al, (2008) Minimal surgery for pilonidal disease using trephines: Description of a new technique and long-term outcomes in 1358 patients, Diseases of the colon and rectum, 51, Kitchen, P, (2010), Pilonidal sinus management in the primary care setting, Australian Family Physician, 39(6), Segre, D., Pozzo, M., Perinotti, R. & Roche, B. (2015) The treatment of pilonidal disease: guildelines of the Italian Society of Colorectal Surgery (SICCR), Technical Coloprotcology, 19: Yamashita, Y., Nagae, H. & Hashimoto, I. (2016), Ambulatory surgery for pilonidal sinus: Tract excision and open treatment followed by at-home irrigation, The Journal of Medical Investigation, 63,

25 Pilonidal Disease: Long-Term Management Hajar R. Delshad, M.S., PA-C Boston, MA Disclosure Information - No financial disclosures or conflicts of interest 25

26 Objectives - Identify best practices for long-term management of pilonidal disease - Optimize open or closed wound environment for wound healing - Understand the role of hair control and hygiene in successful pilonidal care - Consider the role of long-term, permanent hair removal to prevent pilonidal disease recurrence and improve wound healing Post-Surgical Care: Primary Closure Optimize wound healing: - No sports/gym for 6 weeks - Off-loading to prevent shear injury - Monitor for wound dehiscence, infection, or recurrence Open Wounds: The Basics - SHAVING, SHAVING, SHAVING 3-5 cm margin - SOAKING, SOAKING, SOAKING daily after removing packing - Document size, depth, skin, visits - Optimize wound environment: warm, moist, minimize trauma - Manage pain prior to dressing changes compliance 26

27 Open Wound Packing - Avoid saline gauze packing (poor absorption, no antibacterial property, frequent changes, lint, abrasive) - Two dressings: - Packing: Alginate with silver, honey, etc for 24 hours+ (next slide) - Packing must be flexible, adherent, prevent wound cooling/disruption, avoid wound contamination from stool, be in intimate contact with entire surface area) - Secondary dressing: soft, woven gauze with border or cover with tape to absorb extra drainage dressing should prevent granulation tissue from touching - Dressings should never be too dry or too soaked adjust material or frequency prn Dressings Open Wounds - For very large, cavernous wounds consider NPWT - Moisture-management is key for surrounding skin (prevent rashes) - For small, contracted wounds: d/c packing and only soak - Beware of biofilm for non-healing chronic stalled wounds 27

28 Biofilm Prevention of Recurrences - Hygiene soaking - Hair control most important shaving + watch for head hair - 2 inch margins - Pit-picking procedure described by Bascom in Small incisions using a punch biopsy - Done under local - In office - Minimal recovery - Consider Laser Hair Removal Laser Hair Epilation 28

29 Midlevel Clinic - Pilonidal Clinic started March 2014 by 1 PA + 1 Pedi Surgeon - All patients enrolled in database, intake and f/u questionnaires - Streamlined patient education, revamped materials, conservative, non-operative treatment approach, easy access to clinicians - December 2014 laser hair removal initiated - As of March 2017 seen >160 new patient referrals, 450+ patient encounters, patients received laser treatments, 2 patients underwent traditional surgery Family Education Materials References Malone, et al. The Prevalence of biofilms in chronic wounds: a systematic review and meta-analysis of published data. Journal of Wound Care :1, Lee SL, Tejirian T, Abbas MA. Current management of adolescent pilonidal disease. Journal of Pediatric Surgery 2008;43(6): Harris, et al. Twelve common mistakes in pilonidal sinus care. Advances in Skin and Wound Care :7, Dumville, et al. Negative pressure wound therapy for treating surgical wounds by secondary intention. Cochrane Database Syst Rev Jun 4;(6):CD Fike, et al. Experience with pilonidal disease in children. J Surg Res Sep;170(1):165-8 Delshad, et al. Laser Epilation Improves Resolution of Pilonidal Disease: Early Outcomes from a Specialized Pilonidal Care Clinic. Original data abstract submitted. 29