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EDITORIALS: John Bascom Surgical treatment of pilonidal disease BMJ 2008; 336: 842-843 [Full text]

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Here we go again!

peter j mahaffey   (21 April 2008)

Pilonidals: On cartels and mistreatment risks

John U Bascom MD PhD   (15 May 2008)

Here we go again! 21 April 2008
peter j mahaffey, consultant plastic & reconstructive surgeon bedford hospital mk42 9dj Send response to journal: Re: Here we go again!	It appears that Bascom, an enthusiast for the distinctly unproven hair follicle theory, has been 'suckered' into believing that the midline wound in pilonidal sinus surgery is the cause of the problem. McCallum et al's analysis of a rag-bag of papers includes, disgracefully, some which they admit reached their conclusions on the basis of telephone follow-up. That's no way to conduct proper research. Effectively McCallum took a whole lot of apples, oranges and pears and attempted to decide which was the 'best' fruit. Fruitless! For example, they inform us that "recurrences after primary cloure were higher". Of course they were. Its a much more demanding procedure in which ideally the full extent of the infected pilonidal sinus track needs to be stained and excised meticulously, but rarely is. In many ways, pilonidal sinus surgery represents the pinnacle of application of good surgical principle. It demands attention to the precise definition of the extent of the disease, good tissue care, haematoma avoidance, sterility, meticulous closure, and military precision in post-operative nursing. It also requires a regime for the prevention of recurrence with full patient advice and monitoring rather than the speedy discharge or follow up by phone which it seems satisfied the authors. Now it appears that those of us who practice those principles will be ostracised unless we are on the Pilonidal Support Foundation's list of 58 surgeons who are "familiar with off-midline repairs". And no doubt patients will be encouraged to ask for our credentials. On the basis of the flimsy evidence which McCallum and Bascom adduce, that sounds worryingly like the creation of a cosy cartel. Competing interests: As a plastic surgeon I'm privileged to receive many referrals after failed pilonidal sinus surgery.
Pilonidals: On cartels and mistreatment risks 15 May 2008
John U Bascom MD PhD, Attending surgeon-semi retired Sacred Heart Medical Center 97401 Send response to journal: Re: Pilonidals: On cartels and mistreatment risks	Mr. Mahaffy properly fears a cartel. We offer to add his name to the physician list. Requirements for listing have included an interest in pilonidal disease and an acquaintance with options in treatments, which he now meets. We intended the list to serve patients who fear of the risk of unhealed wounds and want to discuss options and their results with knowledgeable professionals. Mr. Mahaffy fears I was persuaded to endorse off-midline repair by McCallum’s study. I was persuaded twenty-five years earlier when I faced my own failures and read what Karydakis had to offer. My experience through 48 years led to my endorsement of McCallum‘s recommendation. Experience has included treatment of some 700+ pilonidals. Most recently we reported on 70 patients who had 210 prior operations and had been open a sum of 365 years. They are all healed, to the best of our knowledge, all but 5% after a single operation. Phone contacts produced many of our follow- up numbers but we trusted this battered group to know the difference between success and failure. As to his observation that “…… the sinus tract needs to be stained and excised meticulously…” Mr. Mahaffy has likely examined the slides prepared by the pathology department from his specimens. He and they likely agree the sinuses are simple abscess cavities. Chronic re-injections of hair, keratin and debris may keep these cavities open. We and others find cavities heal if repeated insult is controlled after drainage. Mr. Mahaffy likely shares our observations that suture lines in the midline can be trusted to heal is exposed on a flat or convex surface. Only when the suture line dives into a cleft do some failures occur. Thus the villain seems not midline closure itself, though it makes failure more likely. The villian seems not the fragments of sinus that Mr. Mahaffy is at pains to remove. We join others who trust healing if the inciting source is controlled. We offer evidence. We now slice open all cavities, scrub away granulation tissue with gauze, slice contracted scar to release tension. We then close the wound leaving in place the fragments of the scrubbed wall connected to their blood supply through attached fat. We have gradually extended to this practice because wounds continue to heal. We think four villains give postoperative failures: 1) pits initially overlooked, 2) scar in midline skin, that overhangs, 3) hairs that largely play an auxiliary role, 4) the climate generated in a tight gluteal cleft. As to the “distinctly unproven” origin from hair follicles, microphotos of the bottom of a follicle close to the moment of rupture suggested follicles as source. Other slides show stages in enlargement of follicle from normal to pits. I have found follicle origin easier to defend than the belief in congenital origin. In the midline openings may appear after the old midline skin has been removed. When holes appear in new skin, or when an excised wound fails to heal, one questions congenital weakness. McCallum’s group has my respect for making the effort to bring order to a bag of mixed fruit. I further congratulate them for looking beyond their original end point, for recognizing the value of an incidental finding, and for making a bold recommendation for off-midline closure that may improve practice and results. Competing interests: I'm semi-retired. A surgeon son treats referred pilonidal problems.