Cysts in the gluteal cleft cause pain and embarrassment – and often recur. Here’s the evidence on which treatments and techniques have the best outcomes for kids with this common condition.
I'm going to talk about Palin, idle disease and my partner, Willie Moses, who's our newest partner who just started, uh, less than a week ago. Delighted to get him talk about that in a little bit. Um Ato End of my talk. Um, is Pilon idol disease and, um, pollen idol disease, Uh, is, um, just a very insidious disease. It can be very debilitating. And I think our treatments for this historically have not been that great, But I think that there's been a lot of improvement These air patients that often need multiple clinic visits, multiple procedures on I think that the big shift has been to doing things is minimally invasive as possible initially, because that seems to work in the bulk of cases, it's pilo means hair and nights means nest. And, uh, this, uh, really the inciting event is a combination of trauma to the area, um, and penetration of here into the subcutaneous tissue with granule ation reaction. It used to be called Jeep drivers or Jeep seat disease. Because young GI's, uh, in in the mid century mid part of the last century, uh would often get this disease because of repeated trauma to the Coxes Jill area and also probably because of their age. Uh uh. Particularly hirsute patients would frequently get this and again being not so close toe extensive medical treatment. This was obvious, oftentimes very debilitating. The spectrum of the disease ranges from asymptomatic cysts to Sinuses, deep abscesses. In fact, I just drained an abscess today and then fistula, so we used to call it Climate Assist. But I think the term pilot Atal disease is actually much more appropriate. So this happens pretty commonly, and one in about 150 to 1 in a couple of 1000. There's a 4 to 1 male predominance for adults. Gender prevalence in Children maybe about the same. Or in fact, it might be more common in in females more common in whites and Caucasians, and it most commonly affects teens and young adults. Often occupations that requires sitting are often, uh, mawr affected. And, as I had mentioned history of trauma to the sacrament toxic. So you could imagine that this is really, um, you know, kids that are sitting in classes often there, um uh, they're very prone to it. So again, it's more common into hirsute patients, uh, in the hair follicles is all the pediatrician's, though. Become distended with Karen after puberty, and I often say to the parents, This is like, uh, acne. Or is it in your gluteal cleft where you're a pilot idol area your priests equal area? And that's really how I think of it is almost like acne. And then the infected follicles may rupture, or they may burrow deeper and form cysts or Sinuses or fistula. And, uh, if you have here within these sister Sinuses or officials, it will prevent healing. And often, when you, uh, look at thes Sinuses or open up a sister and abscess, you'll pull out an amazing amount of hair from these. And once you do this, your you can imagine how this wouldn't heal and the gluteal cleft is the site of the disease or a Z. The kids like to say the butt crack, and, uh, it's not surprising because that area is close to the anise. There's, Ah, high bacterial account. It's not smooth. It's sort of got a crease in it. It's a hard area to keep clean. Teenagers often sweat, and so all of that just makes for a difficult area Thio to keep clean. And once problems develop its hard thio fix it. So here's what it sometimes looks like is you see this picture over here on the left, you'll see these little holes develop. The anise would be over to the screen, right, and the upper back would be over to the screen left. And this is the gluteal cleft. You can see this patient has some hair. Not particularly Harry on these all If you When I put a probe in this, this all connects underneath the skin over here on the right side of the screen. This is very much like the one that I saw today on um, you can see that there's era theme A. There's not a a Sinus tractor and opening. Although if you look in the glue Dio Clough you might see some pinpoint openings lower down. But this is an abscess that's developing underneath the skin in this needs really, uh, incision and drainage before we do anything else. So again, if you have an acute abscess, then the treatment is incision and drainage and probably leaving some sort of drain in for some period of time a zwelling as probably antibiotics. The use of antibiotics, I think eyes not universally espoused, Uh, but I think most people would use it if there's just inflammation and no, no discreet abscess that I think antibiotics alone is reasonable. Sometimes an ultrasound can help delineate the two, because sometimes the absences air deep enough that it hasn't really come to a head. And there isn't really fluctuates there. Um, when you have chronic cysts or Sinuses or fistulas, then initially but without a discreet abscess. Then we usually start with non operative therapy, and this includes removal of hair. And this can be done either by shaving the area, other depilatory efforts, or we have one of our U. C. S F. Several of our dermatologists will do laser hair removal on them. I think that there's other people out in the community that do laser hair removal is well and then, particularly with the ones that have fistulas and Sinuses. We recommend at least once a day, but preferably twice a day showers and sits baths to keep the area clean. Um, and then, if way have still persistent disease, um, then, uh, we recommend minimally invasive therapy and if minimally invasive therapy several times and I'll go into what that is doesn't work. Then we'll talk about excision. And there have been advances in the bigger surgical excision as well. Okay, eso data. We all want data. And when we talk about excision of the whole wound, which is really what What I did when I was in training when I started my surgical training 30 years ago, Uh, every time we would see one of these patients, we would all just get, you know, very sort of, uh, sanguine about it because we knew that there was a high recurrence rate. And for many years, the debate was we excise the area of the Pilon Idol disease in these patients that had multiple recurrences, and then would we, um, leave the wound open or where we close the wound. And really, that was a debate that the surgeons, uh, had for many, many years when that was really our only options. And, um, overall, there was less recurrence when we left the wounds open. But we're talking about, you know, quite a large defect, you know, oftentimes, like maybe 12 by six centimeters in kids that are trying to go to school. Eso although there were less recurrences and you know we're still talking even with open wounds sometimes 30 40 50% Recurrence of pollen Otto disease It healed faster after we close the defect on when you looked at lots of different Siri's wound, recurrence rates were varied widely from like 10% to 80%. Eso the Cochrane Library There was analysis from the Cochrane Library that did a meta analysis and there was found to be no benefit tow an open wound. Really. The major advance came from looking at doing midline versus non midline closure. So for many, many years, what we do is we'd making a lips around the gluteal cleft include all the diseased area we get down to the precinct wolf ASHA and then we would close the wound in midline. What some surgeons identified was that if we close the wound not in the midline, but created a little flap and closed it off of midline, that that seemed to decrease recurrences. And in fact, uh, there have been multiple Siri's to show that the incidents of recurrences is far decreased when you do non midline closures. And in fact, they have better quality of life is well, so when we talk about recurrence, um, it in fact, is hard to compare different techniques. Um uh, but a zai have stated that non midline closures of there's a variety of different ones seem to have lower recurrence. Ah, little bit of wound separation is common because especially when we create these flaps, its under a little bit of tension. So there's a little bit of wound separation. But that is not the same as having ah, complete wounded Hisense on, then having a recurrence of the disease. Andi, really? You know what you call recurrence is sort of dependent on the point of view. Is a little bit of wound separation recurrence Or is it, you know, sort of ah, full blown cyst again? It also depends on the length of follow up eso In one large analysis of meta analysis of almost 90,000 patients in 2018. If you follow them up for for a year, there's only a 2% recurrence. But if you follow them up for, uh, 240 months, which is obviously a very, very long time as many as 60% may have recurrence eso you know, um, really a lot of the recurrences, depending on your point of view. So getting back thio non operative therapy, which is what we would use first again if there is an abscess, then drain the abscess to get rid of the initial acute problem, and it often hurts. It's often very painful, especially when they tried to sit. Remove all the hair in the glue Tiel area as well as on the buttocks. Um, consider antibiotics. Although I said I had mentioned that, um, it's it's not completely, uh, espouse that Antibiotics air helpful for acute infections and then shave the area or consider laser hair removal. Avoid trauma to the sacrament Cox six. Because that could be an exciting event on then frequent showers and sits bath. And again, the recurrence rate here is still pretty high. It's you know, I would say about 30 40 50% eso uh, despite, uh, initial non operative therapy, many of these patients will go on to recur. What? What I think has really been the game changer has been minimally invasive surgery, and, uh, some people refer to it as the Gibbs procedure picnicking. But really, what one does is we excise the Sinus tracts because you have these epithelial i Sinus tracts that go into the, um, common sort of cis deeper down. Then oftentimes, when we do this and we get into this, um, really, this cave underneath the skin, I'm just shocked that won't pull up clumps of hair. And you can imagine how this would just never heal. Then we debris the deeper tissue because a lot of this tissue is chronically infected. D vitalized. It's just nasty donkey tissue. And so we just scoop this tissue out. We irrigate. Sometimes we use peroxide. But I think really the most important thing is exciting, exciting. These epithelial eyes, Sinus tracts because over time, they become so epithelials there like a piercing, and they'll never completely close up. So we were excited that epithelial eyes tissue, get rid of the hair, get rid of the vitalized tissue. And amazingly, uh, in most cases, even after non operative therapy has failed, this usually works. Some people have advocating using a scope to go in there and look around and pick away. It's, um, revitalized tissue. Really, That hasn't really proven to be that helpful. Ah, fiber and glue. To try to help everything stick together hasn't really been helpful. I do feel like these patients need to be closely monitored, and we see these patients pretty often on continue the other aspects of non operative therapy, which is keeping the hair out, shaving their laser depilatory twice a day. Six baths and or showers. Aziz. Well, sometimes after either i nd and drainage or pit picking. Sometimes we leave drains in for a period of time to allow these areas to stay open toe. Let everything adequately drain out. Using this. The best cases show reports rates of about 10%. Some still have recurrence rates of about 50%. Um, we found probably about 2030% recurrence rate, but this is a, you know, 30 minute operation, and the patients have Basically they could just go back to school with no disability, really at all. When you get to the non midline closures, there's a variety of techniques which, again all show that they're superior of midline closure because when you do the midline closure, you still have that incision down in the gluteal, cleft and It's deep, hard to keep clean. It's under tension, Uh, but when you move it over to the side, it's more on the buttock, and that incision is flat. Uh, in the recurrence rate. Really? When we used to talk to patients about midline closures, we're talking consistently about 50% recurrence rates, and now I quote them less than 10% and I think really less than 5%. The most common operation that's done is the gluteal cleft lip, Um, or the Bascomb procedure. And what we do is Aziz, you can see in this image we excise the skin overlying the area will get rid of all the gunky tissue, but then we create flaps, including in fear, Lee, all the way down to the anise, and then we move the skin from one side over to the other. And then we have this flat incision over on the buttock, and in fact, it flattens out the gluteal cleft as well. And since I've adopted doing this procedure about six years ago, you know, I used to be very sort of, um uh, sanguine about recurrence rates and now really, uh, even when the minimally invasive procedure doesn't work. Uh, you know, I quote them less than 10% recurrence rate, which is great. Now, having said that, this is a big operation. It's hard for kids to sit for several weeks to a month. Uh and they have to be very careful because if the skin and underlying tissue comes apart thin, that could be problematic. One of the things that sometimes for the most difficult cases that we use for multiple recurrence rates despite all of these advances is using a wound back. Eso we have this big open wound. We used to just leave this open, but putting a wound back over this actually facilitates the closure of this incision on will close much quicker than if you just left it open with what to dry dress. So that's something that we use rarely but can be effect. So here's the treatment algorithm. In a couple of years ago, our national organization, Absa, had this, um, consensus meeting. It was amazing that everybody kind of agreed so non operative management which includes hygiene, hair removal in avoiding trauma. If that doesn't work, then go to this minimally invasive pit picking procedure that I talked about while continuing non operative therapy. If that doesn't work, then go to non midline closure, continuing to do all these things. And if that doesn't work with recurrences despite non midline closure, then you can consider a wound vac therapy. And so the red line is, uh, treatment failure. Now, if you I would advocate for doing the minimally invasive procedure at least two or three times, sometimes four or five times because again, this is so minimally invasive and so quick and, uh, that I think it's the difference between doing this procedure as faras missing school and pain and debilitation is much less than from doing the bigger excision procedure. So finally, I just wanted to end with our team. Then I'll take questions. Some of the of our team, I'm sure many of you know, and our friends with and have referred many patients. But our most senior surgeons, who are just iconic surgeons and have contributed so much to our community. Um, Dr Bets over here and Doctor do have been, uh, just icons with, uh, Benny of Children's Hospital Oakland, and are, in fact, both one uh, the, uh um the Bronze Bambina Beano award, including Dr Do, Just one that this past year Dr Kim, who you just met who's really a world leader in the treatment of chest wall deformities. Dr. Kris Newton, who is our trauma director and peri operative medical director in the, uh, many of Children's Hospital Oakland. Dr. Jensen, who were recruited a year and a half ago from Children's Hospital Los Angeles, and both Dr Newton and Dr Jensen or both also boarded in, Um uh, trauma, critical care Dr Willie Moses. Who? I'm just delighted Dr Moses. I've known since he was a medical student in the resident on and, uh, just finished his training down at C h l. A eyes coming back to do the full range of, uh, pediatric surgical care with our partners in the East Bay, but will focus primarily on pediatric surgical oncology. So he was mentored, thereby Dr Kim in Dr Stein, who are leaders in surgical oncology and Children and Dr Bet's Excuse me, Dr Moses gonna br lead surgical oncologist. Um, and then over in the West Bay, Uh, here you see a picture of me. Dr Tippy Mackenzie, who also is does basic science research and has about $20 million in in N i h serum funding for her work in stem cells and other fetal, minimally invasive therapies. Uh, Dr Lan Vu, who's been my partner for almost 10 years and does a lot of colorectal work in Children and as well is our surgical quality. Lead uh, for the Benioff Children's Hospital, San Francisco, Dr Nagel, who focuses on, uh, biliary tract diseases in Children and also has, ah, basic science lab. And then, along with Dr Moses, we were very fortunate to recruit. Dr Drew Osgood is back to UCSF. Darragh was one of our residents as well. Has spent about the last 10 years at Yale on Came Back to Join Us. He also does work in surgical oncology, but really is one of the world's leaders in health disparity in Children and global surgical care. Darragh speaks about seven different languages. English, Turkish, uh, mandarin, Swahili, Spanish on Portuguese, most of them fluently has. For the past 10 years or so. I spent 3 to 6 months in Uganda, where he collaborates with surgeons there on both learning from them and trying Thio teach some of their residents in some of our taking CSA's well, and so it's been a great collaboration and back and forth learning eso. That's our team. We also have a terrific team of advanced practice providers in both the East and the West Bay. That you may interact with is, well, a czar, clinic administrative staff. And we just have a terrific team. Our team is growing on. Um, we're always happy to take any referrals.