The treatment of PSD remains controversial and paediatric surgeons are yet to agree on a ‘Gold
Standard’ approach. The technique chosen is determined by both surgeon preference and their
perception of which method has the lowest recurrence, rates of complication and fastest healing
time (20). Many treatment methods are used, including excisional techniques such as en-bloc
resection, healing by secondary intention, flap techniques and marsupialization, all of which
have been described with differing success rates (10).
However, all techniques demonstrated high recurrence rates and a high frequency of surgical
complications, which are unacceptable in the treatment of such a prevalent disease (10). Patients
treated using the above methods often have a long and painful post-operative period with much
time spent off school and work (10). The ideal treatment for PSD should have a clear,
reproducible surgical procedure with a low incidence of recurrence, morbidity, minimal pain and
quick return to activities of daily living (19).
The surgical procedure is one of the clear advantages of the endoscopic treatment of PSD.
The direct endoscopic view of the sinus cavity obtained by the fistulascope during the procedure,
allows for straight forward exploration, identification and removal of any hair and debris, as well
as identification of any sinus tracts or abscess cavities that are present, while achieving effective
haemostasias (14, 18). The use of pre-existing sinus openings as the site of entry minimizes tissue
disruption and local trauma, reducing surgical morbidity (17). This method is seen
to significantly reduces post-operative pain, with only a single patient in our study reporting the
need to use simple analgesia, and all reporting a pain scope of < 2 on the FACES paediatric
pain score index (16). Larger scale studies such as that by Milone et al report
comparable results with an average VAS score of 1–2, in comparison to studies of conventional
methods which show average pain scores of 7 in these patients (15). All patients reported that their daily activities were not impacted by post-operative pain.
Traditional surgical methods are associated with prominent levels of recurrence, varying in different
techniques from 4–31% (19). A study by Abraham et al found recurrence rates in both primary
closure (PC) and excision and healing by secondary intention (EHSI) to be 11–18% in their
group of 135 patients (19). Research undertaken by Fike et al has demonstrated high recurrence
in both EHSI (25%) and in PC (25%), showing that almost a quarter of patients treated by these
methods can expect recurrence, with PC having the highest rate of wound complications
(20). Concerningly, some European countries have advocated for abandonment of primary
midline closure due to reported recurrence rates as high as 48% and over half of patients
suffering wound dehiscence during the recovery phase (21).
Although most of the data describing recurrence rates thus far is heterogenous with large
differences in results, papers analysing EPSiT versus conventional methods show the clear
advantages of endoscopic treatment (1, 15, 17, 18). A comparison study by Milone et al found
recurrence rates in those treated with EPSiT to be 7.8% at four years compared to 25% in those
treated with sinusectomy (15).
Although out study is relatively small scale in comparison to the above, we reported no
recurrence over an average follow up of 13 months, which is comparable to those in the
literature. Large scale studies assessing the outcome of treatment using EPSiT over a longer
period show a recurrence rate of < 5% over a 36month period in those treated with EPSiT (24).
This clearly demonstrates the superiority of EPSiT over other methods with regards recurrence.
The second consideration in the treatment of paediatric pilonidal sinus disease is the rate of
complications. Traditional methods are associated with high morbidity and significant post-
operative complications. This may be due to their lengthy post-operative course, large cavities at
substantial risk of seroma or haematoma formation and frequent dressing changes (15, 20, 26, 27).
A European study of paediatric patients comparing OW and Karydakis procedure by Roldon
Golet et al found Karydakis to be the superior method with regards recurrence (4% vs 28.6%),
however, they found high rates of wound infection at 15.4%, with over a quarter of patients
having some type of wound complication (Claven-Dindo Grade I-III) (27, 28).
These rates are lower than a study by Bali et al which found complications as high as 23% in
their population (29). Fike et al demonstrated flap techniques to be the most successful operative
intervention with the lowest rates of recurrence, and complications however they still had
considerable recurrence and complication rates at 15% and 21% (20).
In our study no patients suffered wound complications with a time to complete wound healing
being approximately 28 days. The literature states complication rates in those treated with EPSiT
to be approximately 5%, with significantly reduced rates of post-operative infection, with a
comparative complete healing time on average being 28.5 days (24). A promising study by
Esposito et al reported a wound infection rate of 0% when EPSiT was used in conjunction with
laser epilation and either silver nitrate or oil-based dressings (25).
The low complication rates may be explained by the minimal tissue disruption caused during
surgery, the small surgical site, and the lack of interaction with the site post operatively by means
of daily dressings and surgical drains, all which pose an infection risk. Our patients underwent
wound review at 1 and 6 weeks post operatively, with little interaction with the surgical site. The
prompt time to complete healing also has a positive effect on reducing wound related complications
with complete healing in endoscopic treatment occurring on average in 3.1 weeks compared to
6.1 weeks in EPC and 14.9 weeks in EHSI (1).
EPSiT, due to the nature of the procedure, as well as low rates of complication and recurrence is
associated with a faster return to school and work with lower pain scores than conventional
methods (1, 2, 10, 15, 22). In our study, patients reported feeling well enough to return to school at
2 days post operatively, with all patients being discharged on the day of surgery. This is in
keeping with the literature which reports an average LOS in hospital at 20 hours with return daily
activities being reported at between 1–5 days postoperatively (30, 1). Recent studies advocate for
safety of EPSiT to be performed as a day case procedure, a significant improvement on the
average 4–6-day hospital stays associated with conventional methods (25).
In conjunction with treating the disease, addressing the risk factors of PSD formation plays a key
role in reducing recurrence. Hirsutism or excess hair at the natal cleft is a recognized risk factor
for PSD formation (3, 5, 6, 8). Laser epilation, in multiple studies has been shown to reduce
recurrence by eradication of the risk factors - excess hair in the natal cleft, being recommended
by the ASCRS for the treatment of PSD (19, 31, 32, 33). All our patients carried out post-operative
laser hair epilation post total wound closure which may contribute to the low rates of recurrence.
Quality of life is a significant factor to consider, especially in the paediatric patient. In a study by
a group of researchers at Stanford University comparing quality of life factors pre and post
minimally invasive treatment they found that 66% of patients reported severe impact on
activities of daily living by PSD, with 94% of patients reporting little to no impact of PSD post
treatment and 92% experiencing improvement in sport participation, school, and work attendance
as well as socializing (34). Traditional methods such as PC or EHSI, as discussed, lead to high
post-operative morbidity, length of stay in hospital, time off daily activities as well as laborious
and painful dressing changes. Most concerning are the high recurrence rates. This results in many days of school or work, avoidance of social scenarios, inability to participate in sport causing significant social isolation, emotional and psychological burden on these patients and their families at a crucial age of development (10, 34).
In our study, all patients reported a significant improvement in quality-of-life post treatment,
with all patients reporting that they would recommend this treatment to a person in a similar
scenario. This speaks volumes of the effectiveness of the use of PEPSiT.