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1 23
coloproctology
ISSN 0174-2442
coloproctology
DOI 10.1007/s00053-020-00464-7
Endoscopic pilonidal sinus
treatment(EPSiT)
Christian Angerer & Ingmar
Königsrainer
1 23
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coloproctology
Originalien
coloproctology
https://doi.org/10.1007/s00053-020-00464-7
© 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
2007.
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
Innsbruck.
The German version of this article can be
found under https://doi.org/10.1007/s00053-
020-00462-9.
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
acuteabscess,theGermanguidelines[21]
still recommend radical excision with
secondary open wound healing as the
standard treatment; simple abscess inci-
sion with secondary definitive treatment
aerthe 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%
aer 1 year, 16.5% aer 5 years, 32% aer
10 years, and even 20% aer 20 years.
eoptimalsurgicalmethodforthe
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,
rapidwoundhealing,simplewoundcare,
quick resumption of everyday activities
and short absenc e from work, and p artic-
ularly a low recurrence and complication
rate.
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-
faction.
Due to the promising results, EPSiT
is now also mentioned in various guide-
lines, such as those from Italy and the
US [13,24].
eaimofthisstudywastoretrospec-
tively analyze and present our experience
coloproctology
Author's personal copy
Originalien
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
electrode
in 67 EPSiT operations up to and includ-
ing February 2020.
Materials and methods
Instruments
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
forhairremoval,ablation,anddebride-
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. ereaer, 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-
tulaductsisperformedwiththefistula
brush, whereby further hair can oen 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,
atamponadewithaIodoformstripisin-
serted. Wound opening are closed with
asmallplaster.
Postoperative management
Patients are discharged on the first post-
operative day aer 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 aer 1, 2, and
3 weeks, and 1, 2 and 4 months post-
operatively.
Results
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
coloproctology
Author's personal copy
Abstract · Zusammenfassung
coloproctology https://doi.org/10.1007/s00053-020-00464-7
© 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
Abstract
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 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
postoperatively.
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
satisfaction.
Keywords
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
Zusammenfassung
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.
Schlüsselwörter
Dermoidsinus · Wundheilung · Sakraldermoid ·
Patientenzufriedenheit · Minimalinvasive
Chirurgie
number of hairs removed and the dura-
tion of the procedure.
EPSiT was pe rformed for both c hronic
pilonidal sinus and ae 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. Aer 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
coloproctology
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Originalien
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
thesepatients,11hadhadasingleprevi-
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-
viousEPSiTwasrecordedthreetimesin
2patients.
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).
coloproctology
Author's personal copy
Tab le 1 Patient characteristics
Number Percent/range
EPSiT 67 –
Patient 64 –
Sex
Male 58 91%
Fema le 69%
Age (years) 27 (median) 14–57
BMI (kg/m2)26 (median) 21–41
Anesthesia
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
offivehairsperpatientcouldbere-
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
time.
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 aer 1 week
and as 1 aer 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. Aer 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 aer 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
anesthesia.
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.
Discussion
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
coloproctology
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Originalien
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
Pain
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
others.
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
methodsisthatthereisonlylimitedtissue
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% aer
4 weeks. e recurrence rate was 6.5%
aer 1 year and 13.2% aer 5 years. Pit-
picking by Bascom, first presented in the
early 1980s, shows similar values, with
10% aer 1 and 16% aer 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-
sion.
coloproctology
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.
Acompletecurerateof88%wasachieved
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% aer 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 aer
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 aer 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.
[27].
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 oen as necessary,
and therefore the proportion of defini-
tive healing increases [8,14].
Conclusion
4e 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.
4e 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
rate.
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
Hospital
Spitalgasse 13, 6700 Bludenz,
Austria
christian.angerer@vlkh.net
Compliance with ethical
guidelines
Conflict of interest. C. Angererand I. Königsrainer
declare that they haveno competing interests.
All proceduresperformed in studies involving hu-
manparticipantsoronhumantissuewereinaccor-
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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