Surgeons, please partner with me in changing the way we treat pilonidal disease.
During my training as a general and colon and rectal surgeon, I was complicit in many poorly planned and executed operations for pilonidal disease. Patients would come to the operating room with a symptomatic but small appearing problem, and they would leave with a huge hole in their backside. In the resident clinic I would see these patients for the 2 months or so before I moved onto a new rotation. It’s my recollection that few of these patients seemed greatly improved even after 2 months of wound care. I trained at a well know academic center in Boston and the attending surgeons were in most ways excellent, but not in the treatment of pilonidal disease. I think that excellence in care was well off their radar for this condition.
But this is not an isolated problem with surgical choice. I have learned it is a problem that is present with most academic and non-academic surgeons. Its present in our cities and rural areas. It is a problem with training and changing the ways as surgeons we treat various conditions after we learn a singular way to treat them during residency. I chose to learn a new way after my fellowship in colon and rectal surgery. It’s not easy to learn new techniques once one has finished formal training, especially if there are no intensive courses or training seminars sponsored by national surgical societies.
Asymmetric flap procedures (such as the Karydakis and Cleft Lift procedures) in the surgical treatment of pilonidal disease have been known to be superior to standard midline excisions for over 40 years. Drs. Karydakis and Bascom taught us this in the 1970s and 1980s. A Cochrane study reinforced this in 2010 as did a well-done meta-analysis in 2018. In the latter, the Cleft and Karydakis procedures had the lowest recurrence rates of 0.6% at 24 months.
So why are so many surgeons not familiar with the literature that points us to a new standard of care for pilonidal disease? I can only speak from my experience. I learned the Cleft Lift Procedure right out of training from Dr. John Bascom himself and have been using it for over 21 years and improving upon it. It is a great procedure for any form of pilonidal disease that requires surgery as the recovery is about a week or two and it is usually curative, even in very complex disease. But there is a long learning curve (especially for complex disease) and as it is a flap procedure, it is in a precarious no-man’s land: not in the purview of general, colon and rectal, or plastic surgeons (read on). Surgeons who I have worked with have chosen not to adopt the Cleft Lift Procedure in their treatment of pilonidal disease. Why? It’s not so easy, maybe.
Plastic surgeons typically are the go-to surgeons for flap procedures. But I would argue that many plastic surgeons are not experienced operating around the anal sphincter and the tissues beneath. General and Colon and Rectal Surgeons (who are typically the ones who operate on pilonidal disease) are not often comfortable with flap procedures. So, flap procedures such as the Karydakis and Cleft Lift procedures have been poorly adopted and their non-descriptive name hasn’t helped. The Cleft Lift Procedure, for instance, is a rotation (around the anus) and advancement (across the midline natal cleft) flap and I suggest it be renamed the Pilonidal RAF.
The scope of this problem with failed pilonidal surgery is huge and greatly underappreciated. It is estimated (from data extrapolated from the EU) that there are over 100,000 operations performed each year in the US for pilonidal disease. Most of these are “traditional” operations which historically have a recurrence rate of over 30%. This means that over 30,000 patients having pilonidal surgery each year in the US will require another operation. Unless they find someone performing the right surgery well, they may have another recurrence.
This is an urgent problem to solve. With over 30,000 failed operations for pilonidal disease occurring each year in the US, why isn’t there a public outcry? It’s a hidden disease like Crohns and Ulcerative colitis, best not spoken about at fundraisers. We need to fix this problem. My goal is to improve the surgical standard of care for pilonidal disease and train surgeon to do the right thing. This a fixable problem! Please reach out if you have ideas on how we can solve this problem and train our current and future surgeons.