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Endoscopic pilonidal sinus treatment (EPSiT)Endoskopische Pilonidalsinus Therapie (EPSiT): First single-center experience with an effective method for treating pilonidal sinusErste Erfahrungen mit einer effektiven Methode zur Behandlung des Sinus pilonidalis



Background Endoscopic pilonidal sinus treatment (EPSiT) is a minimally invasive method introduced by Meinero in 2013 that uses a fistuloscope to treat pilonidal disease. The intervention has two phases. In the diagnostic phase, the extent of the sinus cavity, the fistula ducts, and any abscess cavities are assessed. The operative phase comprises hair removal, ablation, and debridement of the sinus cavity and fistula ducts.Objective This work retrospectively analyzes and presents experiences in 67 EPSiT operations.Materials and methodsBetween October 2018 and February 2020, 67 EPSiT were performed in 64 patients (6 female) at the LKH Bludenz. The operation is performed under spinal or general anesthesia with the patient in prone position. The median pits or lateral fistula openings are excised with a 4-mm skin punch. Under endoscopic vision, hair and debris are removed using 2‑mm microforceps. The sinus is then coagulated and debrided with a 5-mm fistula brush and a Volkmann spoon. The patient is discharged on the first postoperative day. Wound irrigation 1–2 times a day with 10 ml NaCl 0.9% is performed by the patient. Outpatient follow-up at 1, 2, and 3 weeks, and 1, 2, and 4 months postoperatively.ResultsMedian operating time was 33 min (8–164). During the median follow-up of 30 weeks (0–73), wound closure was seen after a median of 4 weeks. After 1 month wounds were closed in 66% and after 2 months in 93% of patients. Due to a wound healing disorder, 4 patients had to be re-operated at least once (one radical excision in toto, two sparing superficial excisions under local anesthesia, and one and two re-EPSiT). The tiny wound(s) results in rapid wound healing, simple wound care, and a very good cosmetic result; patients have hardly any pain.ConclusionEPSiT is a simple, safe, gentle, aesthetic, and effective method for treatment of pilonidal sinus, with very high patient satisfaction.
1 23
ISSN 0174-2442
DOI 10.1007/s00053-020-00464-7
Endoscopic pilonidal sinus
Christian Angerer & Ingmar
1 23
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© Springer Medizin VerlagGmbH, ein Teil von
Springer Nature 2020
Christian Angerer1,2 · Ingmar Königsrainer1,2
1Department of General Surgery, Bludenz Sta te Hospital, Bludenz, Austria
2Department of General, Visceral and Thoracic Su rgery, Feldkirch State Hospital, Feldkirch, Austria
Endoscopic pilonidal sinus
treatment (EPSiT)
First single-center experience with an
effective method for treating pilonidal sinus
The German S3 guidelines from 2014
define pilonidal sinus as follows:
“The pilonidal sinus (‘pilus’: hair;
‘nidus’: nest) is an acute or chronic
inflammation in the subcutaneous
fat tissue, predominantly in the
sacrococcygeal region.” Since the
first description by Mayo in 1833,
various theories have existed
regarding the mechanism of
pathogenesis. Today, it is generally
assumed that pilonidal sinus is an
acquired disease that affects young
men in particular. Spontaneous
healing is de facto impossible. The
ideal surgical method has not yet
been found. Recently, minimally
invasive procedures have been
established, including endoscopic
pilonidal sinus treatment (EPSiT).
In 1995, Søndenaa et al. reported a fre-
quency of 26/100,000 [25]. However,
there has been a clear increase in recent
years, the reason for which is unclear.
In 2012 an incidence of 48/100,000 in-
habitants was given for Germany. In the
German Bundeswehr even higher values
were found, with 240/100,000 soldiers in
The lecture on the experience with the first
25 endoscopic pilonidalsinus treatment (EPSiT)
operationswasawardedtheprize forbestlecture
by the Working Group for Coloproctology (ACP)
at the 60th Austrian Surgeon Congress 2019 in
The German version of this article can be
found under
ree appearances are described: the
asymptomatic form, the acute abscess,
and the chronic form.
e asymptomatic form does not re-
quire any treatment, but spontaneous
healing is not expected. In the case of
still recommend radical excision with
secondary open wound healing as the
standard treatment; simple abscess inci-
sion with secondary definitive treatment
aerthe acutesituationis mentionedonly
as an alternative. Various elective meth-
ods for treating the chronic pilonidal si-
nus are available. In the literature, how-
ever, very high recurrence rates between
15 and 30% are found. e highest rates
are found in median excisions with pri-
mary midline closure. A large meta-anal-
ysis from Switzerland [26]reported3.5%
aer 1 year, 16.5% aer 5 years, 32% aer
10 years, and even 20% aer 20 years.
acute and chronic forms has not yet been
found. Recently, there has been a clear
trend from open toward minimally in-
vasive procedures according to the “less
is more” principle [28]. Success rates of
80–90% appear promising [11].
Several minimally invasive proce-
dures have been presented in recent
years. ese include pit-picking from
Bascom (1980; [3]), laser treatment (si-
nus laser-assisted closure, SiLaC; sinus
laser therapy, SiLaT) [1,22], and ra-
diofrequency ablation, as well as the
Gips method from 2008 [4,9]. e Gips
procedure is a combination of the meth-
ods of Lord and Millar (1965) and pit-
picking, using skin trephines for excision
oftheopenings. erearealsoother
minimally invasive procedures such as
installation of fibrin glue or phenol
[7], which is not approved in Germany
because of its presumed toxicity.
e goals of an ideal pilonidal sinus
treatment should be simple feasibility,
cost effectiveness, small wound(s), mi-
nor pain and impairment for the patient,
quick resumption of everyday activities
and short absenc e from work, and p artic-
ularly a low recurrence and complication
All of these newer methods seem to
have a higher recurrence rate, but the
advantage is that the procedure can be
repeated and the chance of a definitive
cure increases. e question is whether
a higher recurrence rate may be accept-
able if the other criteria are superior [2].
In 2013, Meinero presented a new
minimally invasive method for the treat-
ment of pilonidal sinus using a fistulo-
scope [16]. e prospective multicenter
study [17] with 250 patients presented
in 2015 showed a healing rate of 95%
with a median wound healing duration
of 27 days. Due to the very small wounds
and good aesthetic result, the easy wound
care and low complaints, there was also
an extremely high level of patient satis-
Due to the promising results, EPSiT
is now also mentioned in various guide-
lines, such as those from Italy and the
US [13,24].
tively analyze and present our experience
Author's personal copy
Fig. 1 9Endo-
scopic pilonidal
sinus treatment in-
struments: Meinero
fistuloscope (Karl
Storz, Tuttlingen,
Germany), 4-mm
skin punch, obtu-
rator, fistula brush
with three-ring
handle, 2-mm Red-
dick-Olsen grasp ing
forcep s, monopola r
in 67 EPSiT operations up to and includ-
ing February 2020.
Materials and methods
Endoscopic pilonidal sinus treatment
(EPSiT) is a minimally invasive method
for treatment of pilonidal sinus devel-
oped by Piercarlo Meinero in 2013. e
same instruments are used as for video-
assisted anal fistula treatment (VAAFT)
[15]. e Meinero fistuloscope (Karl
Storz, Tuttlingen, Germany) has an
8-degree angled lens, a 2.5-mm working
channel, a rotatable handgrip, and two
Luer-Lock connections for the rinsing
liquid. e operative length is 18 cm, the
outside diameter is only 4.7 × 3.3 mm.
e kit also includes a fiberoptic ca-
ble, an obturator, a 2-mm Reddick-
Olsen grasping forceps, a monopolar
electrode, a fistula brush with a 3-ring
handle (Ø 4/4.5/5 mm), and the “endo-
scopic seal” (.Fig. 1).
Surgical technique
Perioperativeantibiotic of 3 gintravenous
(iv.) ampicillin/sulbactam is adminis-
tered. e patient is operated under gen-
eral or spinal anesthesia and placed in the
prone posit ion with the legs slig htly apart,
the buttocks are separated by wide tape
strips. e intergluteal cle and adjacent
operatingarea are shavedin advance. e
screen is located le of the patient’s head,
the surgeon is also on the le side of the
patient, at least at the beginning. De-
pending on the position and direction
of the sinus openings, a switch to the
right side may be useful during surgery.
e assistant receives a suction device
for the es caping rinsing liquid (3000 ml
NaCl 0.9%).
e intervention is performed in two
phases: 1. a diagnostic phase for inspec-
tion of the sinus cavity, the fistula ducts,
and abscess cavities; 2. an operativephase
ment of the sinus cavity and fistula ducts.
Both phases are accomplished under di-
rect endoscopic vision!
At the start of the operation the pits
and fistulas are explored with a bulb-
headed probe. is allows determination
of the direction and depth of the sinus
tract. ereaer, with the probe still in
the pit, a 4-mm skin punch is pushed
over the probe and the pit is excised.
Additionalpits or secondary lateral fistula
openings are excised in the same way
during the operation (.Fig. 2).
During the diagnostic phase, the ob-
turator is inside the fistuloscope. e
extension and anatomy of the sinus and
fistula tracts are inspected, and hair is
identified. e rinsing liquid provides
a clear view and also opens the sinus.
e aim of the operative phase is to
ablate and cleanse the sinus. Existing
hair is removed with a 2-mm micro-
grasping forceps. e granulation tissue
is ablated with a monopolar electrode.
Debridement of the sinus and the fis-
brush, whereby further hair can oen be
removed. At the end of the operation,
all openings are debrided with a sharp
Volkmann spoon. If necessary, repeated
coagulation is performed for hemostasis.
e exci sion offices rema in open. Fin ally,
serted. Wound opening are closed with
Postoperative management
Patients are discharged on the first post-
operative day aer removal of the Iod-
oform strip and wound irrigation. Pa-
tients are instructed to rinse the wound
1–2 times daily with approximately 10 ml
NaCl 0.9% until complete wound clo-
sure. Oral antibiotics with amoxicillin/
clavulanic acid 2 × 1 g daily for 1 week,
analgesics (diclofenac) if necessary. Out-
patient wound checks aer 1, 2, and
3 weeks, and 1, 2 and 4 months post-
Over a period of 17 months, b etween Oc-
tober 3, 2018 and February 28, 2020, we
performed a total of 67 EPSiT operations
on 64 patients at the Landeskrankenhaus
Bludenz, which were then subjected to
retrospective analysis. Preoperatively, all
patients were informed about EPSiT and
the various alternative procedures, and
informed consent was obtained. e ret-
rospective study was conducted in ac-
cordance with the guidelines of the local
ethicscommittee. Alloperationsandout-
patient follow-up were carried out by the
author. Of the total patients, 58 (91%)
were male and 6 (9%) female. Median
age was 27 years (range 14–57 years).
e median body mass index (BMI) was
26 kg/m2(range 21–41 kg/m2). All pa-
tients were discharged home on the first
postoperative day (.Table 1).
Due to a wound healing disorder, two
further EPSiT were performed in one pa-
tient. One other female patient under-
went a re-EPSiT. In all three cases, hair
could be removed again from the sinus
and both patients subsequently healed.
e median time from indication to
EPSiT was 5 weeks. e operations were
mainly carried out under regional anes-
thesia (72%; 45 spinal anesthesia, 3sad dle
blocks). General anesthesia was used in
19 procedures (28%). Median duration
of the operation was 33 min (8–164 min),
with a significant correlationb etween the
Author's personal copy
Abstract · Zusammenfassung
© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2020
C. Angerer · I. Königsrainer
Endoscopic pilonidal sinus treatment (EPSiT). First single-center experience with an effective method
for treating pilonidal sinus
Background. Endoscopic pilonidal sinus
treatment (EPSiT) is a minimally invasive
method introduced by Meinero in 2013
that uses a fistuloscope to treat pilonidal
disease. The intervention has two phases.
In the diagnostic phase, the extent of the
sinus cavity, the fistula ducts, and any
abscess cavities are assessed. The operative
phase comprises hair removal, ablation, and
debridement of the sinus cavity and fistula
Objective. This work retrospectively analyzes
and presents experiences in 67 EPSiT
Materials and methods. Between October
2018 and February 2020, 67 EPSiT were
performed in 64 patients (6 female) at the LKH
Bludenz. The operation is performed under
spinal or general anesthesia with the patient
in prone position. The median pits or lateral
fistula openings are excised with a 4-mm skin
punch. Under endoscopic vision, hair and
debris are removed using 2-mm microforceps.
The sinus is then coagulated and debrided
with a 5-mm fistula brush and a Volkmann
spoon. The p atient is discharged on the first
postoperative day. Wound irrigation 1–2 times
a day with 10 ml NaCl 0.9% is performed
by the patient. Outpatient follow-up at 1,
2, and 3 weeks, and 1, 2, and 4 months
Results. Median operating time was 33 min
(8–164). During the median follow-up of
30 weeks (0–73), woundclosure was seen after
a median of 4 weeks. After 1 month wounds
were closed in 66% and after2 months in 93%
of patients. Due to a wound healing disorder,
4 patients had to be re-operated at least once
(one radical excision in toto, two sparing
superficial excisions under local anesthesia,
and one and two re-EPSiT). The tiny wound(s)
results in rapid wound healing, simple wound
care, and a very good cosmetic result; patients
have hardly any pain.
Conclusion. EPSiT is a simple, safe, gentle,
aesthetic, and effective method for treatment
of pilonidal sinus, with very high patient
Dermoid sinus · Wound healing · Sacrococcy-
geal abscess · Patient satisfaction · M inimally
invasive surgery
Endoskopische Pilonidalsinus Therapie (EPSiT). Erste Erfahrungen mit einer effektiven Methode zur
Behandlung des Sinus pilonidalis
Hintergrund. Bei der endoskopischen
Pilonidalsinustherapie (EPSiT, „endoscopic
pilonidal sinus treatment“) handelt es
sich um eine von P. Meinero entwickelte
minimalinvasive Methode unter Verwendung
eines Fistuloskops zur Behandlung des Sinus
pilonidalis, welche erstmals 2013 vorgestellt
wurde. Der Eingriff läuft in 2 Phasen. In der
diagnostischen Phase werden das Ausmaß der
Sinuskavität, die Fistelgänge sowie eventuelle
Abszesshöhlen beurteilt. In der operativen
Phase erfolgen die Entfernung der Haare
sowie eine Ablation und ein Débridement der
Sinushöhle und Fistelgänge.
Ziel der Arbeit. Ziel war es die Erfahrungen
bei 67 EPSiT-Operationen retrospektiv zu
analysieren und zu präsentieren.
Material und Methodik. Zwischen Oktober
2018 und Februar 2020 führten die Autoren
am LKH Bludenz bei 64 Patienten (davon
6 weiblich) insgesamt 67 EPSiT durch. Die
Op. wird in Bauchlage in Spinalanästhesie
oder Allgemeinnarkose durchgeführt. Der
mediane Porus bzw. laterale Fistelöffnungen
werden mit einer 4-mm-Hautstanze exzidiert.
Unter videoskopischer Sicht werden mittels
2-mm-Mikrofasszange Haare und Zelldetritus
entfernt, anschließend der Sinus koaguliert
und mit einer 5-mm-Fistelbürste sowie
scharfem Löffel débridiert. Die Entlassung der
Patienten erfolgt am 1. postoperativen Tag,
Wundspülung durch den Patienten 1–2 Mal
täglich mit etwa 10 ml NaCl 0,9 %. Ambulante
Nachkontrollen 1, 2 und 3 Wochen sowie 1, 2
und 4 Monate postoperativ.
Ergebnisse. Die mediane Op.-Dauer betrug
33 min (8–164). Während des Follow-up von
median 30 Wochen (0–73) zeigte sich ein
Wundverschluss nach 4 Wochen median.
Nach einem Monat waren die Wunden
bei 66 %, nach 2 Monaten bei 93 % der
Patienten verschlossen. Aufgrund einer
Wundheilungsstörung mussten 4 Patienten
ein oder zweimal erneut operiert werden
(eine radikale Exzision in toto, zweimal wurde
eine sparsame oberflächliche Nachexzision
in Lokalanästhesie (LA) durchgeführt, sowie
eine bzw. zwei Re-EPSiT). Aufgrund der
winzigen Wunde(n) ergibt sich eine rasche
Wundheilung, eine einfache Wundpflege
sowie ein sehr gutes kosmetisches Ergebnis,
und die Patienten haben kaum Schmerzen.
Schlussfolgerung. Die EPSiT ist eine einfache,
sichere, schonende, ästheti sche und effektive
Methode zur Behandlung des Sinus pilonidalis
mit einer sehr hohen Patientenzufriedenheit.
Dermoidsinus · Wundheilung · Sakraldermoid ·
Patientenzufriedenheit · Minimalinvasive
number of hairs removed and the dura-
tion of the procedure.
EPSiT was pe rformed for both c hronic
pilonidal sinus and ae r acute abscess. In
the latter case, a sparing abscess incision
was made beforehand, followed by rins-
ing 1–2 times a day with approximately
10 ml NaCl 0.9%. Oral antibiotics were
not given until surgery. Aer the acute
situation had subsided, EPSiT could be
carried out a few weeks later.
Preoperative abscess incision was
performed in 20 patients (30%). In most
cases this was carried out under local
or cryoanesthesia only. Due to a spon-
taneous perforation, 13 patients (19%)
presented themselves to the hospital
(.Table 2).
Excludingthe preoperative abscess in-
cisions, a third of the patients had been
operated at least once because of an acute
Author's personal copy
Fig. 2 8Endoscopic pi lonidal sinus treatment operation. aProneposition. The nates are spread apart by wideplasters, bex-
cision of the pit with a 4-mm skin punch,cinsertion of the Meinero fistuloscope, dhair nest in the sinus, ehair removal with
2-mm micro-grasping forceps, fsalvaged hair
Fig. 3 8Course of wound healing, apreoperative, b1 week postoperatively, c2 weeks postoperatively, d3weekspostopera-
tively,e1 month postoperatively, f2 months postoperativel y
abscessing or chronic pilonidal sinus. Of
ous operation, 6 patients had undergone
two previous surgeries, and 6 patients
had had three or more pre-operations.
In 15 cases abscess de-roofing or incision
was performed, in 17 a radical excision
in toto with secondary open wound heal-
ing, in 4 cases aLimberg flap, andone pit-
picking operation was performed. Pre-
e largest diameterof the sinus cavity
was median 40 mm (20–120 mm). About
half of the cases had median pits in the
intergluteal cle, the other half presented
a combination of median pits with sec-
ondary lateral fistula openings. In 48%
of the cases, only a single pit could be
identified in the intergluteal cle, two
pits were present in 31% (.Table 3).
Author's personal copy
Tab le 1 Patient characteristics
Number Percent/range
EPSiT 67
Patient 64
Male 58 91%
Fema le 69%
Age (years) 27 (median) 14–57
BMI (kg/m2)26 (median) 21–41
General anesthesia 19 28%
Spinal anesthesia, saddle block 48 72%
Duration of surgery (min) 33 (median) 8–164
EPSiT endoscopic pilonidal sinus treatment,BMIbody mass index
Tab le 2 Preoperative events
Number Percent/range
Spontaneous perforation 13 19%
Incision under LA 20 30%
Previous operations (excluding incisions in LA)
No pre-operation 44 66%
1pre-operation 11 16%
2pre-operations 69%
≥3 pre-operations 69%
Type of pre-operation
Incision 13
Abscess cleavage 2 –
Radical excision in toto 17
Limberg flap 4 –
Schrudde-Olivari flap 1 –
Pit-picking 1 –
EPSiT 3 –
EPSiT endoscopic pilonidal sinus treatment,LAlocal anesthesia
As already mentioned, a great advan-
tage of the EPSiT method is the direct
view into the sinus cavity to clearly iden-
tify hair lying inside, which can be re-
moved with microforceps. A median
moved. In 3 patients we found about
300–500 hairs in the sinus. ere was
no correlation between the size of the
sinus and the number of hairs. However,
this significantly increases the operating
Postoperative course
e follow-up was a median of 30 weeks
(maximum 73 weeks), whereby the
2-month postoperative control had not
yet occurred in 8 patients by the end of
February 2020. Pain was assessed 1 and
2 weeks postoperatively. e intensity
was given as a median of 3 aer 1 week
and as 1 aer 2 weeks. e values refer
to phases of everyday physical activities;
fewer complaints were naturally given
at rest. B ecause of the few and very
small wound openings, oral analgesics
(diclofenac) were taken only over 4 days
on average. By default, a certificate of
incapacity to work was issued for 1 week
postoperatively until the first outpatient
checkup. is was also widely used by
the patients (.Table 4).
Postoperatively, patients were asked
to rinse the wound openings with ap-
proximately 10 ml NaCl 0.9% 1–2 times
a day until this was no longer possi-
ble, in order to prevent early superfi-
cial wound closure. e median time to
complete wound healing was 4 weeks.
In the outpatient controls at 1, 2, and
4 months postoperatively, wounds were
completely closed in 44 (66%), 62 (93%),
and 64 (96%) patients (.Fig. 3). As al-
ready mentioned, 8 patients (11%) had
not yet been followed up for 2 months
by the end of February 2020.
Due to persistent wound healing dis-
order or relapse, 4 patients (6%) had to
be operated at least once again during
the observation period. Aer complete
wound closure, an acute abscess occ urred
in one patient. A ne w EPSiT was not pos-
sible due to the pronounced findings, for
which a radical excision in toto was nec-
essary 6 months aer EPSiT. In two pa-
tients a sparing superficial excision with
primary wound closure was performed
under local anesthesia due to incomplete
healing. In both cases, the wound healed
easily. A re-EPSiT was performed in two
other patients; in one of them (a male
patient), this was done twice. All re-op-
erations then healed completely. A re-
EPSiT is planned in two other patients.
Except for the above mentioned
wound healing disorders, there were
no surgical complications in the pa-
tient collective. However, 1 patient still
complains of back pain due to spinal
e patients were very satisfied with
the postoperative result. In the event of
a new relapse, each of the patients would
prefer to undergo re-EPSiT and would
also recommend this surgical method.
Although pilonidal disease is very com-
mon, the gold standard for treatment
of a pilonidal sinus has not been found
to date. Spontaneous healing is not
expected. Even the actual German
S3 guidelines from 2014 do not give an
answer to this question [21]. e ideal
method should be simple, effective, and
comfortable for the patient. e “right”
surgical procedure is still hotly debated
Author's personal copy
Tab le 3 Intraoperative sinus characteristics
Number Percent/range
Maximum sinus diameter (mm) 40 (median) 20–120
Sinus openings
Pit only 31 46%
Fistula only 23%
Pit + fist ula 34 51%
Median pit 1(median) 0–16
No pit 23%
1pit 32 48%
2pits 21 31%
≥3 pits 12 18%
Secondary lateral stula 1(median) 0–3
No fistula ope ning 31 46%
1 fistula opening 31 46%
2 fistula openings 46%
≥3 fistula openi ngs 12%
Distance of the fistula opening to the intergluteal cleft (mm) 10 (median) 0–50
Removed hair 5(median) 0–500
No hair 15 22%
1–5 hairs 20 30%
6–20 hairs 11 17%
21–99 hairs 15 22%
≥100 hairs 69%
Excision openings 2(median) 1–5
1 excision 17 25%
2 excisions 33 50%
≥3 excisions 17 25%
Tab le 4 Postoperative results
Number Percent/range
Follow-up 30 weeks (median) 0–73 weeks
1 week postoperatively VAS 3 (me di an )
2 weeks postoperatively VAS 1 (me di an )
Need of analgesics 4days(median)
Wound closure 4 weeks (median)
After 1 month 44 (cumulative) 66%
After 2 months 62 (cumulative) 93%
After 4 months 64 (cumulative) 96%
Patients with follow-up <2 months 811%
Reoperation needed 6 (in 4 patients) 6%
Of which re-EPSiT 3 (in 2 patients) 3%
in the current literature and there are no
clear recommendations for one method
or the other. e various processes can
be roughly classified into three classes:
1. median excision with primary midline
closure or le open to heal by secondary
intention; 2. off-midline procedures or
plastic asymmetric procedures, with the
Karydakis operation and the Limberg
flap as the main representatives; and
3. minimally invasive procedures such
as pit-picking by Bascom [3], sinusec-
tomy, or the Gips method [9]among
At least in Germany, radical excision
in toto with open wound treatment is still
considered as standardtreatment, partic-
ularly for the acute abscessing pilonidal
sinus. Recurrence rates vary in the lit-
erature, with values from 0 to 57% [11].
e biggest problem is probably the pro-
tracted open wound healing, which can
take several weeks to months, depend-
ing on the extent. is severely limits
the patient’s everyday life. Excision with
a simultaneous primary midline suture is
generally no longer recommended, due
to the high rate of wound complications
and recurrence.
e Limberg flap is the most com-
monly used asymmetric procedure in
German-speaking countries, followed
by the Karydakis operation. Recurrence
rates of up to 8% seem to be lower than
those of the median methods, but there
is a higher rate of wound complications,
infections, and wound dehiscence.
Minimally invasive procedures have
gained more and more importance in re-
cent years. e great advantage of these
destruction. e interventions can also
be carried out on an outpatient or short
inpatient basis. e relatively small sur-
gical wounds result in less pain, faster
wound healing, and a shorter absence
from work. In 2008, Gips et al. [9]re-
porteda wound healing rate of 89.7% aer
4 weeks. e recurrence rate was 6.5%
aer 1 year and 13.2% aer 5 years. Pit-
picking by Bascom, first presented in the
early 1980s, shows similar values, with
10% aer 1 and 16% aer 3.5 years. In
the event of treatment failure or relapse,
the above procedures can be repeated.
EPSiT is also a minimally invasive
method which was presented for the first
time by Meinero et al. in 2013 [16]. e
big difference to other minimally invasive
methods is the use of a fistuloscope, with
the major advantage of a direct view into
the sinus. is also benefited one of our
patients who had undergone pit-picking
4 months previously, during which some
hairs had already been removed. Due to
a wound healing disorder, we then per-
formed EPSiT, in which 24 additional
hairs could be removed under direct vi-
Author's personal copy
efirstprospective multicenter study
followed in 2015, with 250 patients [17].
e cure rate was 95%, with a median
wound healing duration of 27 days. is
also correlates with our data (96% and
4 weeks). A study by Pini Prato et al. [23]
shows comparable values in 43 children.
at a follow-up of 4 months.
Almost simultaneously and indepen-
dentlyof Meinero, Milone et al. presented
video-assisted ablation of pilonidal sinus
(VAAPS) [20]. A hysteroscope is used
instead of the fistuloscope. In 2016, the
first data were presented in a randomized
study. In comparison to the Bascom cle
li operation, patients had fewer infec-
tions and significantly less pain. Return
to work was faster and postoperative pa-
tient satisfaction was significantly higher
[18,19]. A recent review of 9 studies with
a total of 497 patients by Emile et al. [5]
reports a me dian absence from work of up
to 3 days, significantly shorter compared
to the Limberg flap with 9.5 days or other
off-midline procedures with 15.3 days.
When using a laser alone, i.e., SiLaC
[1]orSiLaT[22], success rates are about
90% aer a single intervention. It is pos-
sible that a combination of EPSiT and the
use of a diode laser might provide addi-
tional benefits, because laser ablation of
the granulation tissue is more targeted
than with use of a monopolar electrode.
Gupta et al. [10] refer to a success rate of
95.3% for a small number of 21 patients.
ere is controversy in the literature
regarding whether postoperative hair re-
moval in the area of the intergluteal cle
makes sense. ere are studies that show
an increased relapse rate when shaving,
while others report a lower rate. Other
epilation techniques, such as laser treat-
ment, seem to be advantageous. A rec-
ommendation for shaving was given in-
dividually to our patients [6].
An indication for EPSiT in case of
acute abscessing pilonidal sinus was sup-
ported by a British group and termed
endoscopic pilonidal abscess treatment
(EPAT) [12]. Of a total of 19 patients,
71% did not need any further interven-
tion during an observation period of
10 months. e wound was closed aer
a median of 4 weeks.
Due to the very small wounds and
good aesthetic result, the simple wound
care, andthe small number of complaints,
similar to Milone et al., we found ex-
tremely high patient satisfaction and rec-
ommendation rate in our patients [19].
Giarratone et al. [8]reportedaVASscore
of 1–3 in 95% of all patients. is also
corresponds to our results, where pain
was given as VAS 3 in the first postoper-
ative week and only VAS 1 aer 2 weeks.
A high level of patient satisfaction, good
healing rates of approximately 95%, and
low recurrence rates are also described
in the review of 8 studies by Tien et al.
Furthermore, our patients who re-
quired another surgery because of a pro-
tracted recovery or relapse preferred re-
EPSiT over the other methods. EPSiT
can be repeated as oen as necessary,
and therefore the proportion of defini-
tive healing increases [8,14].
4e fistuloscope enables a direct view
into the sinus, which enables exact
assessment of the sinus and possible
fistula ducts, targeted removal of
the hairs, and coagulation and
debridement of the tissue altered
by inflammation.
4e tiny wound(s) results in rapid
wound healing, simple wound care,
and a very good cosmetic result.
4Patients have little or no pain and can
therefore return to work immediately.
4Patient satisfaction is very high, with
an equally high recommendation
4In case of protracted wound healing
or recurrence, EPSiT can be repeated.
4EPSiT is a simple, safe, gentle,
aesthetic, and effective method for
treatment of pilonidal sinus, with
very high patient satisfaction.
Corresponding address
OA Dr. Christian Angerer
Department of General
Surgery, Bludenz State
Spitalgasse 13, 6700 Bludenz,
Compliance with ethical
Conflict of interest. C. Angererand I. Königsrainer
declare that they haveno competing interests.
All proceduresperformed in studies involving hu-
dance with the ethical standards ofthe institutional
and/or national research committee and with the
1975 Helsinki declaration and its late r amendments or
comparable ethical standards. A statement regarding
the retrospective analysis ofthe data is available: no
involvementor vote by the Ethics Committee of the
State of Vorarlbergwas required to conduct the study.
Informed consentwas obtained from all individual
participants included in the study.
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Full-text available
The management of chronic pilonidal disease remains controversial, but recently, new minimal invasive approaches have been proposed. Whereas in the conventional surgical treatment an elliptical wedge of skin and subcutaneous tissue is created to remove the sinus and its lateral tracks, the basis for our new treatment is to create a minimal elliptical wedge of the subcutaneous tissue, including all the inflamed tissue and debris while leaving the overlying skin intact. The mechanism of an endoscopic approach relies on use of the endoscope without cutaneous tissue damage. Advantages include shorter operative time and time to discharge, which impact resource management in both primary and secondary care: patients undergoing endoscopic technique have a high satisfaction rate, probably due to the low level of postoperative pain and early return to work and daily activities. However, it is mandatory that further studies would analyze surgical approaches to pilonidal sinus disease (PSD) with a consistent and adequate follow-up of at least 5 years. Both sinusectomy and endoscopic approach to PSD were found to be safe and effective compared with conventional techniques. Publishedresults of studies of newer approaches have demonstrated a low short-term complication rate, comparable to conventional surgery results.
Full-text available
Pilonidal disease can be treated by less invasive methods such as simple mechanical cleansing of the sinus and cavity of hairs and granulation tissue eventually supplemented by filling the space with an antiseptic or sclerosing agent like phenol (forbidden in Germany due to its toxicity) or space-holding fibrin glue. Minimal excision or debridement of the sinus and/or cavity through a midline or a separate paramedial excision can also be performed, leaving the wounds open or closed. These methods are simple and cost-efficient, and associated with low pain, rapid healing, and a rapid return to normal activity. A disadvantage is the higher recurrence rate; however, these methods can be used repeatedly for recurrences. Whereas the evidence for treatment with phenol or fibrine glue is weak, there are numerous reports supporting the safety and efficiency of the minimally invasive surgical methods. Because of the associated low risk for complications and morbidity, these procedures are suitable for first-line treatment in the majority of pilonidal disease patients.
Full-text available
Background Pilonidal disease (PD) is a common disease of the natal cleft, which can lead to complications including infection and abscess formation. Various operative management options are available, but the ideal technique is still debatable. Recurrent PD after surgical treatment is frequent event for the 25–30% of cases. The present study evaluated endoscopic pilonidal sinus treatment (EPSiT) in recurrent and multi-recurrent PD. Methods Of the consecutive prospective patients with recurrent PD, 122 were enrolled in a prospective international multicenter study conducted at a secondary and tertiary colorectal surgery centers. Primary endpoint was to evaluate short- and long-term outcomes: healing rate/time, morbidity rate, re-recurrence rate, and patient’s quality of life (QoL). Results Complete wound healing rate was occurred in 95% of the patient, with a mean complete wound healing time of 29 ± 12 days. The incomplete healing rate (5%) was significantly related to the number of external openings (p = 0.008), and recurrence was reported in six cases (5.1%). Normal daily activity was established on the first postoperative day, and the mean duration before patients returned to work was 3 days. QoL significantly increased between the preoperative stage and 30 days after the EPSiT procedure (45.3 vs. 7.9; p < 0.0001). Conclusions The EPSiT procedure seems to be a safe and effective technique in treating even complex recurrent PD. It enables excellent short- and long-term outcomes than various other techniques that are more invasive.
Full-text available
Background Pilonidal disease is a troublesome acquired condition for whom various surgical treatments have been proposed with relatively high recurrence and complication rates. Since EPSiT technique has been described in 2013, it became an alternative treatment in adult practice. Our study reports the results of a multicentre series of pediatric patients who underwent EPSiT procedure over a 21-month period. Methods Between July 2015 and March 2017, all consecutive patients undergoing EPSiT in four different pediatric surgical units have been enrolled. Details regarding demographic data, detailed surgical procedure, outcome and complications have been recorded. ResultsA total of 43 patients underwent EPSiT procedure. Mean age was 15 years. There was a slight female preponderance. Mean weight and height at surgery were 67 kg and 168 cm, respectively. In 14% of cases a previous ineffective procedure was performed. Mean length of procedure was 34 min and median hospital stay was 24 h (12–72 h). Median length of follow-up was 4 months (range 3–18 months). Complications leading to reoperation were reported in 9% of cases with an overall resolution rate of 88%. DiscussionEPSiT proved to be feasible and safe even in the pediatric population. The effectiveness and safety of the procedure suggest that this technique can represent a valid alternative for the treatment of pilonidal disease in children.
Full-text available
Background: Sacrococcygeal pilonidal disease (SPD) is a common surgical condition for which a multitude of surgical treatments have been described. The present review aimed to evaluate the efficacy and safety of a novel endoscopic procedure for the treatment of SPD. Methods: An organized literature search was conducted. Electronic databases including PubMed/Medline, Scopus, Embase, and Cochrane library were searched for articles that assessed the endoscopic treatment for SPD. The main outcome parameters were failure of the technique including persistence and recurrence of SPD, postoperative complications and pain, time to complete healing, and time to return to work. Results: Nine studies with a total of 497 patients were included. Mean age of patients was 24.8 years. Mean operation time was 34.7 min. The procedure was performed as day-case surgery in all studies. The mean Visual analogue score of pain within the first week was 1.35. Failure of the technique was recorded in 40 (8.04%) patients, 20 (4.02%) had persistent SPD and 20 (4.02%) developed recurrence. The weighted mean failure rate of the technique was 6.3% (95% CI 3.6-9.1). Mean weighted complication rate was 1.1% (95% CI 0.3-2.4). Mean time to complete healing was 32.9 days and mean time to return to work was 2.9 days. Conclusion: The endoscopic treatment of pilonidal sinus is a promising and safe method of treatment of SPD. The main advantages of the endoscopic treatment as compared to conventional surgery are the minimal postoperative pain, quick healing, and short time to return to work and daily activities.
Full-text available
We systematically searched available databases. We reviewed 6,143 studies published from 1833 to 2017. Reports in English, French, German, Italian, and Spanish were considered, as were publications in other languages if definitive treatment and recurrence at specific follow-up times were described in an English abstract. We assessed data in the manner of a meta-analysis of RCTs; further we assessed non-RCTs in the manner of a merged data analysis. In the RCT analysis including 11,730 patients, Limberg & Dufourmentel operations were associated with low recurrence of 0.6% (95%CI 0.3–0.9%) 12 months and 1.8% (95%CI 1.1–2.4%) respectively 24 months postoperatively. Analysing 89,583 patients from RCTs and non-RCTs, the Karydakis & Bascom approaches were associated with recurrence of only 0.2% (95%CI 0.1–0.3%) 12 months and 0.6% (95%CI 0.5–0.8%) 24 months postoperatively. Primary midline closure exhibited long-term recurrence up to 67.9% (95%CI 53.3–82.4%) 240 months post-surgery. For most procedures, only a few RCTs without long term follow up data exist, but substitute data from numerous non-RCTs are available. Recurrence in PSD is highly dependent on surgical procedure and by follow-up time; both must be considered when drawing conclusions regarding the efficacy of a procedure.
Background: Pilonidal disease is an acute or chronic infection in the subcutaneous fatty tissue, mainly in the natal cleft. Its incidence in Germany in 2012 was 48 cases per 100 000 persons per year. Methods: This review is based on pertinent publications retrieved by a selective literature search. Results: The numerous minimally invasive techniques that are available for the treatment of pilonidal disease have the advantages of being relatively atraumatic and of enabling the patient to continue working almost without interruption. They are suitable for small lesions that have not been previously surgically treated. These techniques are associated with a higher recurrence rate than excisional methods (level of evidence [LoE]: Ib). It is not yet clear whether minimally invasive techniques employing laser or endoscopic technology can reduce the recurrence rate. In systematic meta-analyses, the duration of wound healing was shorter after off-midline techniques (the Karydakis procedure, the Limberg procedure, and others) than after excision with open wound treatment; the off-midline techniques should, therefore, be preferred for patients who have undergone previous surgery and for those with large lesions (LoE: Ia). Excision with midline suturing should not be performed (LoE: Ia). Postoperative permanent shaving cannot be recommended either (LoE: IV). Conclusion: Further randomized trials are needed to clarify the role of newer techniques in the treatment of pilonidal disease.
Background Various surgical techniques are available for the management of pilonidal sinus, but there is still controversy concerning the optimal surgical approach. The aim of our study was to evaluate the safety, efficacy and clinical outcome of the laser procedure for the treatment of pilonidal sinus. Patients – Methods Patients suffering from pilonidal sinus were operated with Sinus Laser Therapy (SiLaT) in our Institute. SiLaT was applied under local anaesthesia after a small skin incision of 0.5‐1cm and careful cleaning of the sinus tracts with a curette. A radial fiber connected to a diode laser set at the wavelength of 1470 nm was then introduced into the tracts. The laser energy was delivered in continuous mode. Results Two‐hundred and thirty‐seven (237) patients suffering from pilonidal sinus were operated using the theSiLaT laser procedure in our referral Institute and prospectively evaluated (183 males, median age 24 years, range 14‐58). A high healing rate was observed after the first session (90.3%, 214 of 237) with a median healing time of 47 days (range 30‐70 days). A second treatment was offered for patients failing in the first session and was successful in 78.3% (18/23). The procedure duration ranged between 20 and 30 minutes and had limited morbidity (wound infection in 7.2%, 17 of 237). Conclusions The Sinus Laser Therapy (SiLaT) proved to be a safe and effective procedure to treat patients suffering from pilonidal sinuses. Clinical results showed low morbidity and recurrence rates comparable to the published literature for other modern techniques. This article is protected by copyright. All rights reserved.
Background Pilonidal sinus is a common disease of the natal cleft, which can lead to complications including infection and abscess formation. Various operative management options are available, but the ideal technique is still debatable. More recently minimally invasive approaches have been described. Our aim was to review the current literature on endoscopic pilonidal sinus treatment (EPSiT) and its outcomes. MethodsA systematic literature review was conducted and reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of EMBASE, MEDLINE and Cochrane Library was conducted in November 2017. Full-text studies on the use of endoscopy for the treatment of pilonidal sinus were included in the review. ResultsInitial search results returned 52 articles. Eight studies (eight case series and one randomised control trial) were included in the final qualitative synthesis. These studies demonstrated that EPSiT has good complete healing rates and low recurrence rates. There was also a high level of patient satisfaction and little time taken off work. Two studies reported modifications to the original technique. The main limitation was the lack of comparative studies. Conclusions Initial studies on EPSiT have shown promising results. However, there is a need for a standardised technique and more comparative studies to validate this novel procedure.