Pediatric Endoscopic Pilonidal Sinus Treatment: Lessons Learned After 100 Consecutive Cases

Pediatric Endoscopic Pilonidal Sinus Treatment: Lessons Learned After 100 Consecutive Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pediatric Endoscopic Pilonidal Sinus Treatment: Lessons Learned After 100 Consecutive Cases Sonia Pérez-Bertólez, Isabel Casal-Beloy, Albert Pasten, Oriol Martín-Solé, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4737927/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Dec, 2024 Read the published version in Techniques in Coloproctology → Version 1 posted 7 You are reading this latest preprint version Abstract Aim Pediatric Endoscopic Pilonidal SInus Treatment (PEPSiT) has favorable short-term-outcomes, but there is a lack of reliable data on medium and long-term follow-up. The objective of our study was to evaluate the effectiveness and advantages of PEPSiT vs conventional surgery of pilonidal sinus in the pediatric population. Methods A quasi-experimental study was carried out in pediatric patients undergoing pilonidal sinus surgery at a single institution from 2019 to 2022. Excision and healing by secondary intention (EHSI), excision and primary closure (EPC), and PEPSiT were compared. The surgical technique chosen was surgeon-dependent. Results 149 patients were studied – 100 undergoing PEPSiT, 28 undergoing EHSI, and 21 undergoing EPC. Median full healing process was 4 weeks (IQR: 3–8) in PEPSiT, 16 weeks in EHSI (IQR: 12-26.5) and 7 weeks (IQR: 4–10) in ECP (p < 0.01). Pain on the Visual Analogue Scale (VAS) and need for analgesics were lower in the PEPSiT group (p < 0.01). Mean time to return to normal life was shorter with PEPSiT – 177 days earlier than EHSI (CI95%: 124.7-230.2; p < 0,01) and 7.2 days earlier tan EPC (CI95%: 20.2-138.6; p < 0,009). Complications with PEPSiT were 9.3 times lower tan EHSI (OR: 9.3; CI95% 3.5–24.7) and 8.5 times lower than ECP (OR = 8.5; CI95% 2.9–24.4). EHSI had 5.3 times more probability of recurrence than PEPSiT (OR = 5.3; CI95% 1.3–22.7), and ECP 15.2 times more (OR = 15.2; CI95% 3.2–71.7). Conclusions Endoscopic pilonidal sinus treatment is effective in medium-term follow-up, with fewer complications than classic techniques. It allows for an early return to normal life without restrictions. Pilonidal sinus disease Pilonidal sinus Children PEPSiT Endoscopic Treatment Minimally Invasive Surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Summary This study evaluates the effectiveness of Pediatric Endoscopic Pilonidal Sinus Treatment (PEPSiT) compared to traditional surgical methods in 149 pediatric patients. The findings indicate that PEPSiT offers superior medium-term outcomes, including shorter healing times, reduced postoperative pain, fewer complications, and faster return to normal activities. INTRODUCTION There is a wide range of treatment modalities used in the management of pilonidal sinus disease (PSD), but there is no clear consensus on the “gold standard” treatment in either adults or children [ 1 ]. The traditional operative management strategy for pilonidal disease involves excision of affected tissue paired with a variety of closure types including primary midline closure, primary off-midline closure techniques (Karydakis flap, Limberg flap, Bascom cleft lift), and healing by secondary intention [ 2 , 3 ]. However, classic excision procedures are associated with a long and painful post-operative course, long absence from school or work activities, and high rates of complications such as surgical wound infection, bleeding, partial or full dehiscence, and recurrence [ 4 ]. Recently, there has been a recent shift toward more minimally invasive operative approaches including pit-picking, sinusectomy, laser ablation of the subcutaneous tracks, curettage of the sinus cavity with an injection of phenol, fibrin glue, or thrombin-gelatin matrix, Gips procedure and endoscopic approaches [ 1 – 5 , 6 ]. In 2014, Meinero proposed the endoscopic pilonidal sinus treatment (EPSiT) performed through a dedicated fistuloscope to destroy the sinus cavity and tracts under direct endoscopic vision [ 7 ]. Shortly after that, Esposito introduced a similar technique for children called Pediatric Endoscopic Sinus Treatment (PEPSiT) [ 8 ]. According to our preliminary experience and the current literature, endoscopic techniques are associated with few complications, low pain, and allows for a quick return to normal life without restrictions [ 1 , 9 – 12 ]. However, minimally invasive procedures are still not widely adopted, perhaps due to skepticism because of the lack of long-term follow-up studies [ 13 ]. This study aimed to compare the medium-term outcomes of PEPSiT versus conventional surgery for pilonidal sinus in pediatric patients at a single center and also to describe some gained valuable insights after performing 100 consecutive cases of PEPSiT. METHODS Study design and protocol This study is an observational prospective, non-randomized cohort (quasi-experimental) study, reported according to the STROBE recommendations. Ethics and informed consent The study was approved by the Ethics Committee of our health care institution (PIC-179-20). Procedures followed were in accordance with the Helsinki Declaration and Good Clinical Practice (GCP) guidelines. Informed consent was obtained from all parents and participants over 12 years of age. Study population, clinical variables and outcomes All pediatric patients (≤ 18 years of age) undergoing pilonidal sinus surgery from 2019 to 2022 at a single institution were enrolled. Three groups of patients were compared according to the surgical technique used - Excision and healing by secondary intention (EHSI), excision and primary closure (EPC), or PEPSiT. The choice of surgical technique was surgeon dependent. During the study period, each type of procedure was performed by the same group of surgeons. Sex, age, weight, previous infections, surgical technique used, type of anesthesia, visual analog scale (VAS) pain, duration of analgesic treatment, hospital stay, time to complete healing, time to return to normal life, and complications - bleeding, infection, dehiscence, granuloma, and recurrence - were recorded for all patients. The primary outcome of this study was to evaluate the time to return to normal life according to the surgical technique used. The secondary outcomes were to evaluate the time to complete healing, risk of complications, postoperative pain on the VAS scale, analgesic treatment duration, and hospital stay for each surgical technique. Surgical Procedure Each procedure was performed under general, spinal, or local anesthesia with or without sedation, depending on patient characteristics, type of procedure and anesthesiologist decision. The patient position was the same regardless of the surgical technique used: prone position with external traction of buttocks to improve exposure of the surgical field. Further details about the surgical steps of the different techniques performed in this research, has been previously described [ 9 ]. Since our initial description, some technical details in the PEPSiT group have been modified. If the patient has abundant granulomatous tissue, we remove it with a long and thin Volkmann spoon instead of a brush (Fig. 1 ). In most patients, surgical wound care is done with local hygiene and a daily stream of povidone iodine. For larger wounds, we initially use negative pressure wound therapy (NPWT) (Fig. 2 ). Statistical analysis For statistical analysis, Fisher's exact test was used to analyze quantitative variables and Kruskal-Wallis test was used to analyze continuous variables. To reduce bias, results were adjusted for age and weight, with multiple linear regression for continuous outcome variables and multivariate logistic regression for binary outcome variables. Stata 14.2 software was used for all statistical calculations. A p-value less than 0.05 was considered a significance threshold. RESULTS A total of 149 patients were included in our study, with 100 undergoing PEPSiT, 28 undergoing EHSI, and 21 undergoing EPC (Table 1 ). The anesthesia type employed is detailed in Table 2 . Table 1 Patient’s characteristics PEPSiT EPC EHSI p-value N (female/male) 100 (52/48) 21(12/9) 28(10/18) 0.25 Mean age (years) 15,5 (9,5–22) 15,7 (11,5–18,6) 15,7 (11,9–18,1) 0.81 Mean weight (kg) 77 (42–127) 77 (42–147) 76 (41–160) 0.55 Previous infection (%) 85 90 79 0.55 Nº pits 3 (1–10) 1,6 (0–4) 2,6 (0–12) 0.01 Previous surgery (%) 14 15 11 0.94 Pit close to anus (%) 23 5 22 0.17 Granuloma (%) 32 28 19 0.51 Hirsutism (%) 5 23 23 0.02 Active infection (%) 18 0 15 0.08 Laser epilation (%) 30 10 18 0.09 Complications (%) 24 67 72 < 0.01 Recurrence (%) 5 29 18 < 0.01 Table 2 Type of anesthesia PEPSiT EPC EHSI p-value General 65 6 9 < 0.01 Spinal 26 15 15 0.21 Local 9 0 0 < 0.01 Regarding the instrument used for PEPSiT, 27 cases were performed with a compact cystoscope and 73 with the fistuloscope, with no significant difference between these groups of patients. The wider working channel of the fistuloscope allows for the utilization of larger-diameter and more robust instruments. During the study period, two monopolar electrodes of the cystoscope and one of the fistuloscope were broken during PEPSiT. In addition, one cystoscope lens had deteriorated, with blurred vision and a noticeable yellowish halo around it (Fig. 3 ). Age and weight were similar between groups, with a mean age of 15.6 (SD = 1.7) years and a mean weight of 77 (SD = 19.4) kg. Differences between groups were found regarding the number of fistulous tracts and the grade of hirsutism. No differences were found between groups in gender, age, weight, previous infections, previous surgery, fistula close to the anus, or granuloma. However, a tendency to use more laser epilation with PEPSiT was observed (30% vs 21% EHSI and 9%ECP), and less active infection was found on the day of surgery with EPC. NPWT was used in 10 patients after PEPSiT, 8 after EHSI and 3 that suffered dehiscence after ECP. In the rest of patients, the postoperative wound management was done with local hygiene and a daily stream of povidone iodine, without adhesive dressing. Length of hospital stay was significantly lower in the PEPSiT group, as it was performed as ambulatory surgery, while others required hospitalization. Pain on the VAS scale was significantly lower in the PEPSiT group: 6.1 less than with ESI (95% CI: 5.4–6.9; p < 0.01) and 5.7 less than with ECP (95% CI: 4.9–6.6; p < 0.01), so they also had less analgesic requirement with PEPSiT. Mean time to return to normal life was shorter with PEPSiT – 177 days earlier than EHSI (CI95%: 124.7-230.2; p < 0,01) and 7.2 days earlier tan EPC (CI95%: 20.2-138.6; p < 0,01). For each additional kilogram of weight, patients took an average of 1.5 more days to resume normal activities (95% CI: 0.5 to 2.6). There were differences in the time to full healing process depending on the surgical technique used (p < 0.01): the median time to complete epithelialization with PEPSiT was 4 weeks (IQR: 3 to 8), 16 weeks (IQR: 12 to 26.5) with EHSI, and 7 weeks (IQR: 4 to 10) with ECP. The presence of infection at the time of intervention increased the time to full healing by an average of 20 weeks (95% CI: 3.6 to 36.7), regardless of the surgical technique used. Patients who underwent NWPT exhibited a longer healing time compared to those who did not receive NWPT (median healing time was 22 days with NWPT vs. 18 days without NWPT). Additionally, patients using NWPT took longer to return to their normal daily activities (a median of 30 days with NWPT vs. 1 day without NWPT). The observed difference was statistically significant (p < 0.01), which aligns with the expected outcome due to selection bias. Complications were significantly lower in the PEPSiT group. The risk of complications was 9.3 times higher with EHSI (OR: 9.3; CI95% 3.5–24.7) and 8.5 times higher with EPC (OR = 8.5; CI95% 2.9–24.4), compared with PEPSiT. In the multivariate analysis, it was found that surgery with active infection increased the risk of complications by 3 times (OR = 3; 95% CI 1.1–8.5). Recurrence was also significantly lower in the PEPSiT group. Compared to PEPSiT, EHSI had 5.3 times more probability of recurrence (OR = 5.3; 95% CI 1.3–22.7), and ECP had 15.2 times more (OR = 15.2; 95% CI 3.2–71.7). The presence of infection at the time of intervention increased the risk of recurrence by 7.5 times (OR = 7.5; 95% CI 1.8–31.9). The use of laser epilation was associated with a reduction in recurrence rates. Specifically, we observed a 13.64% recurrence rate in patients who did not receive laser treatment, whereas the recurrence rate was 2.7% in patients who underwent laser epilation (p = 0.07). Notably, among the patients who experienced recurrence despite laser treatment, they had undergone at least one session but had not completed the full treatment course. The number of fistulas was the only variable related to the need for reintervention. For each additional fistula, the risk of reintervention increased by 1.7 times (OR = 1.7; 95% CI 1.2–2.4). DISCUSSION There is still no consensus about the gold standard surgical management for pilonidal disease in either the adult or pediatric population. The choice of surgical approach generally depends on the surgeon’s experience of the procedure and perceived results in terms of healing speed and recurrence rate. Following the Soll concept that “less is more” [ 14 ], the endoscopic treatment of PSD has been introduced [ 7 , 8 ]. Preliminary experience with endoscopic treatment of pilonidal sinus has shown that it is an effective technique in pediatric and adolescent patients, it involves short postoperative periods, it causes no pain, and care is simple. It also allows for a quick return to normal life without the restrictions involved by conventional open surgery [ 9 ]. In this article, it is demonstrated that the advantages of PEPSiT over conventional surgery persist in the medium term. As we have progressively broadened the indications for PEPSiT, we have encountered increasingly complex cases. In this context, we aim to share our insights and lessons learned from our initial 100 PEPSiT procedures. Anesthesia Determining the optimal anesthetic method for PSD remains an ongoing challenge. The selection is influenced by both the anesthesiologist’s preferences and the individual patient’s condition. We employ various techniques, including general, spinal, and local anesthesia, with or without sedation. Therefore, surgeons and anesthesiologists should involve patients and parents in informed discussions, weighing the benefits and drawbacks of each approach [ 15 ]. Spinal anesthesia allows patients to remain conscious during surgery while providing effective postoperative analgesia. It remains advantageous in classic exeretic surgery. However, the PEPSiT group, experiencing minimal postoperative pain, does not routinely require spinal anesthesia. Concerns arise from perceived delays associated with administration time and its prolonged onset. Additionally, we consider the potential impact on recovery and hospital discharge due to delayed compensation. General anesthesia becomes essential for less cooperative patients or those with higher anxiety. However, its use necessitates positioning a patient—often obese—twice during the procedure. Induction and tracheal intubation occur in the supine decubitus position, followed by positioning the patient prone for surgery. Finally, after completion, the patient is rotated back to the supine position for awakening. Local anesthesia is prioritized now in PEPSiT, whenever feasible. Its advantages include faster administration, reduced operating room time, and immediate patient discharge. Importantly, local anesthesia avoids airway manipulation and mitigates the risks associated with spinal or general anesthesia. PEPSiT technical details Outcomes did not appear to be significantly affected by the use of a pediatric cystoscope over the use of the fistuloscope, as previously reported [ 10 ]. However, we advocate for the use of the fistuloscope due to its superior durability. In cases of PSD with multiple pits, rather than introducing the fistuloscope through all of them, we selectively utilize those that are sufficiently wide for initial insertion. Subsequently, we explore the remaining pits from the inside. Unlike conventional practice among other surgical groups, we intentionally avoid systematic use of the lower pit [ 16 ]. Our decision is based on infection prevention: considering its proximity to the anus, enlarging the lower orifice could potentially elevate the risk of postoperative infection. In the management of large cysts, we prioritize accessing one of the central orifices. This strategic decision enables comprehensive exploration of all aspects of the cyst cavity using the 18 cm-long fistuloscope. In situations where external orifices are too narrow to accommodate the fistuloscope, we widen one of the orifices using a mosquito forceps. To minimize procedural duration, we use the same mosquito forceps for hair and detritus removal. Additionally, we streamline the procedure by directly irrigating using the fistuloscope, eliminating the need for pre-procedure irrigation [ 16 ]. Finally, any remaining detritus and hairs are meticulously extracted under endoscopic guidance using the fistuloscope’s forceps. Regarding the type of irrigation solution, while other fluids like mannitol or normal saline can also serve this purpose, our preferred choice is glycine due to several reasons: We routinely use glycine in endourological procedures, which makes us feel comfortable with its application. We utilize the 3-liter bag of glycine, typically sufficient for the entire procedure, minimizing the need for changes. During the intervention, patients may experience some intravascular and extravascular absorption of irrigation fluid. The extent of this absorption depends on factors such as the duration of the intervention, the volume of solution used, and the hydraulic pressure applied. Glycine is an amino acid naturally synthesized by the human body and is minimally hypotonic. Consequently, hemolysis is avoided when the solution enters the bloodstream. Glycine makes the solution isoelectric, allowing for concentration of the monopolar electric current at the electrode. In contrast, when using normal saline, a substantial increase in electric power is required to achieve a comparable fulguration effect. However, this approach results in greater diffusion, thereby elevating the risk of electric injury. We utilize a brush for mechanical abrasion on fistulas and cyst walls in specific cases and to eliminate necrotic tissue. However, when abundant granulomatous tissue is present, we prefer using a long, thin Volkmann spoon for curettage instead of the brush. This allows us to remove all the granulomatous tissue more efficiently, similar to video-assisted ablation of pilonidal sinus (VAAPS) [ 17 ]. Following that, we proceed with the PEPSiT technique, introducing the fistuloscope to ensure thorough cleanliness and complete fulguration. To complete the cauterization of the fistulous tract, the monopolar electrode is inserted directly through the skin surface. For larger tracts or granulomas, we opt for the electric scalpel, although in most cases, the electrode alone suffices. We routinely employ a combination of spray and blend coagulation modalities setting. Patients’ conditions It is interesting to note that there was no significant difference in age, weight, gender, previous infections, previous surgery, fistula close to the anus, or granuloma between the three groups of our study. However, there was a tendency to use more laser with PEPSiT and to find less active infection on the day of surgery with EPC. Previous research has shown that hirsutism and typology of sinus (≥ 2 external pits, paramedian pits and pits more proximal to the anus) were the main predictors of postoperative PSD recurrence [ 18 ]. Our study corroborates that the number of fistulas is a crucial factor. Each additional fistula significantly increases the risk of secondary surgery by 1.7 times. Furthermore, this study found that patients with active infection face a threefold increased risk of complications following surgery and is also associated with a remarkable 7.5-fold increase in the risk of recurrence. A consensus statement has been developed for adults with PSD. We align with the consensus recommendation to adopt endoscopic treatment for cases of limited PSD (such as single or multiple midline pits), for both recurrent PSD and de novo presentations. Nevertheless, we disagree with the recommendation favoring traditional open healing in complex PSD cases [ 19 ]. From our perspective, PEPSiT remains a viable therapeutic choice for managing complex scenarios, including large chronic fistulas, extensive granulomas, lesions near the anus, and big cavities. While some authors advocate for the shift from traditional open excision to PEPSiT as the present and future approach for managing children and teenagers with PSD [ 16 ]; we recognize specific contraindications for PEPSiT, where other surgical techniques remains relevant. These contraindications include: Absence of Cavity : In specific cases of chronic PSD, where fistulas interconnect and self- marsupialize (Fig. 4 a), performing endoscopic surgery becomes unsuitable due to the absence of a true cavity. Thin Cutaneous Bridges : This represents an earlier stage in the evolution of chronic PSD, preceding the scenario described in the previous point. Fistulous tracts connected by a thin cutaneous bridge (Fig. 4 b), without a substantial cavity, pose challenges for PEPSiT. Suspicion of Tumor or Perianal Conditions : Conditions such as cryptogenic perianal fistula, septic anal fissure, gluteal abscess, hidradenitis suppurativa, Crohn’s disease, ulcerative colitis, syphilis, tuberculosis, epidural abscess, and other soft tissue infections may necessitate alternative approaches [ 19 ]. Lack of Adequate Instruments : Availability of appropriate instruments is crucial for successful PEPSiT outcomes. Furthermore, we emphasize that surgical treatment should always be customized to the individual patient. Postoperative care Effective postoperative care is essential for improving patients’ experiences and minimizing the impact of pilonidal sinus wounds on their daily activities. The efficacy of dressings and topical agents for wound healing following surgery for PSD remains uncertain based on existing studies. Most of the evidence is of low or very low certainty, often derived from single studies. However, interventions like NPWT show promise in improving wound healing outcomes [ 20 ]. NPWT involves applying negative pressure to the wound bed using a specialized device. It promotes wound contraction, reduces edema, and enhances granulation tissue formation. Patients with wider surgical wounds were offered an ultraportable NPWT device [ 21 ]. For the remaining patients or when surgical wounds in the NPWT group had reduced in size, the postoperative care recommendations included: Wound hygiene : Patients should keep the wound clean, dry, and free from debris to prevent infection. Shower heads are preferred for cleansing, once or twice per day. After a bowel movement, the surgical wound should be cleaned to avoid fecal contamination. Hair removal : Embedded hair and debris should be removed at each wound inspection due to the chronic inflammation they induce. We recommend preoperative and postoperative laser epilation as the hair removal method of choice [ 22 ]. For those who decline this option, we recommend shaving the surrounding area at least weekly. Topical agents : Daily wound care involves applying povidone iodine directly to the surgical wound at least once a day, following their shower. Dressing : Simple, non-adherent dressings may suffice for wound care. Patients are advised to use a gauze pad secured with their own underwear to prevent staining. Outcomes The success rate of PSD procedures depends on patient cooperation and adherence. Preoperative patient education plays a crucial role in achieving favorable outcomes. Specifically, emphasizing meticulous personal hygiene is essential to minimize the risk of infection. Additionally, it is important to prepare patients for the postoperative period, which may be both challenging and prolonged. Recognizing the unique needs of each patient, close monitoring remains basic to facilitate optimal wound healing and prevent complications [ 16 , 23 ]. Notably, the recurrence rate was significantly higher in patients who did not undergo laser epilation. Therefore, standardizing the technique, incorporating laser epilation, and ensuring appropriate wound care are critical factors for achieving long-term success with PDS surgery. In recent years, significant advancements have transformed the field of surgical management for PSD. Among these innovations, the PEPSiT technique stands out as a promising approach. In this article, we highlight the advantages of PEPSiT over traditional methods: Reduced Complications and Recurrence Rates: Our study revealed that PEPSiT has significantly fewer complications and lower recurrence rates when compared to other techniques such as EHSI and EPC. This finding underscores the potential of PEPSiT as a safer and more effective option for pediatric patients. Minimal Pain and Shorter Hospital Stays: PEPSiT patients experience minimal pain after the procedure. Consequently, the majority of them did not require painkillers. Additionally, the outpatient nature of PEPSiT allows for shorter hospital stays, promoting faster recovery. Early Return to Daily Activities: Perhaps the most remarkable aspect of PEPSiT is the early return to daily activities. Patients can resume routine tasks, engage in sports (including football, skating, volleyball, and gymnastics), and lead an active life almost immediately after surgery. Since the beginning of our experience with PEPSiT, we were attracted by the possibility of reducing the wound related morbidity but also fully aware of the lack of data about PEPSiT medium- and long-term recurrence rates. A higher recurrence rate was acceptable to the patients given the benefit of a minor scar and faster return to daily activities. Instead, our series showed that the medium-term recurrence rate after PEPSiT is lower to that reported in the excisional surgery studies. Our PEPSiT series is one of the largest in the literature. This extensive experience not only validates the technique but also bolsters our confidence in recommending PEPSiT as a valuable addition to the armamentarium of PSD management. The longer follow-up is a point of strength of our study. Although recurrences are more common during the first postoperative year, they may occur much later, and a short-term follow-up does not permit to draw definitive conclusions [ 24 ]. Stauffer meta-analysis of 102 randomized controlled trials and support wider use of this procedure and confirmed these procedures’ results are highly dependent on the follow-up duration [ 4 ]. The results of our study reflect both the longer follow-up period and patient selection. The main limitation of this study is that it was conducted at a single center with a medium-term follow-up. Nonetheless, further multicenter studies with larger sample sizes and long-term follow-up are required to confirm our findings. While it would be theoretically desirable to establish the superiority of PEPSiT over traditional techniques through a randomized clinical trial, the ethical considerations come into play. Considering the favorable outcomes achieved thus far, it might be deemed unethical to expose a patient who could benefit from PEPSiT to conventional surgical procedures. Therefore, our current stance prioritizes the well-being of patients by offering them the most effective and minimally invasive treatment option available. In conclusion, PEPSiT stands out as an effective and minimally invasive technique for treating PDS. Its lower complication rates, minimal post-operative discomfort, and quicker return to daily activities make it an attractive option for pediatric patients dealing with PSD. Declarations Author Contribution Conception and design: SPB; Data analysis and interpretation: SPB, OMS; Data acquisition: SPB; Critical revision of the manuscript for scientific and factual content: SPB, ICB, AP, PS, LT, XT; Drafting the manuscript: SPB, ICB, AP; Statistical analysis: OMS; Supervision: SPB. Acknowledgments: None. References Milone M, Velotti N, Manigrasso M, Vertaldi S, Di Lauro K, De Simone G, Cirillo V, Maione F, Gennarelli N, Sosa Fernandez LM, De Palma GD. Long-term results of a randomized clinical trial comparing endoscopic versus conventional treatment of pilonidal sinus. Int J Surg. 2020;74:81–85. doi: 10.1016/j.ijsu.2019.12.033 . Grabowski J, Oyetunji TA, Goldin AB, Baird R, Gosain A, Lal DR, Kawaguchi A, Downard C, Sola JE, Arthur LG, Shelton J, Diefenbach KA, Kelley-Quon LI, Williams RF, Ricca RL, Dasgupta R, St Peter SD, Sømme S, Guner YS, Jancelewicz T. The management of pilonidal disease: A systematic review. 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Surg Endosc. 2018;32(9):3754–3762. doi: 10.1007/s00464-018-6157-5 . Chen S, Dai G, Liu P, Zhao X, Zhang J, Yang C, Xu X, Wang L, Chen W, Wang M, Zhang D. Comparative analysis on the effect of the endoscopic versus conventional treatment for pilonidal sinus: A meta-analysis of controlled clinical trials. Medicine (Baltimore). 2022;101(45):e31767. doi: 10.1097/MD.0000000000031767 . Doll D. 5- and 10-year recurrence rate is the new gold standard in pilonidal sinus surgery benchmarking. Med Princ Pract. 2010;19(3):216–7. doi: 10.1159/000285292 . Soll C, Hahnloser D, Dindo D, Clavien PA, Hetzer F. A novel approach for treatment of sacrococcygeal pilonidal sinus: less is more. Int J Colorectal Dis. 2008;23(2):177–80. doi: 10.1007/s00384-007-0377-9 . Teunkens A, Valedon A. Anesthesia for ambulatory surgery. Best Pract Res Clin Anaesthesiol. 2023;37(3):267–268. doi: 10.1016/j.bpa.2023.05.001 . Esposito C, Montaruli E, Autorino G, Mendoza-Sagaon M, Escolino M. Pediatric endoscopic pilonidal sinus treatment (PEPSiT): what we learned after a 3-year experience in the pediatric population. Updates Surg. 2021;73(6):2331–2339. doi: 10.1007/s13304-021-01094-4 . Milone M, Musella M, Di Spiezio Sardo A, Bifulco G, Salvatore G, Sosa Fernandez LM, Bianco P, Zizolfi B, Nappi C, Milone F. Video-assisted ablation of pilonidal sinus: a new minimally invasive treatment–a pilot study. Surgery. 2014;155(3):562–6. doi: 10.1016/j.surg.2013.08.021 . Esposito C, Leva E, Gamba P, Sgrò A, Ferrentino U, Papparella A, Chiarenza F, Bleve C, Mendoza-Sagaon M, Montaruli E, Escolino M. Pediatric endoscopic pilonidal sinus treatment (PEPSiT): report of a multicentric national study on 294 patients. Updates Surg. 2023;75(6):1625–1631. doi: 10.1007/s13304-023-01508-5 . Milone M, Basso L, Manigrasso M, Pietroletti R, Bondurri A, La Torre M, Milito G, Pozzo M, Segre D, Perinotti R, Gallo G. Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of pilonidal disease. Tech Coloproctol. 2021;25(12):1269–1280. doi: 10.1007/s10151-021-02487-8 . Herrod PJ, Doleman B, Hardy EJ, Hardy P, Maloney T, Williams JP, Lund JN. Dressings and topical agents for the management of open wounds after surgical treatment for sacrococcygeal pilonidal sinus. Cochrane Database Syst Rev. 2022;5(5):CD013439. doi: 10.1002/14651858.CD013439.pub2 . Giordano P, Schembari E, Keshishian K, Leo CA. Negative pressure-assisted endoscopic pilonidal sinus treatment. Tech Coloproctol. 2021;25(6):739–743. doi: 10.1007/s10151-021-02431-w . Minneci PC, Gil LA, Cooper JN, Asti L, Nishimura L, Lutz CM, Deans KJ. Laser Epilation as an Adjunct to Standard Care in Reducing Pilonidal Disease Recurrence in Adolescents and Young Adults: A Randomized Clinical Trial. JAMA Surg. 2024;159(1):19–27. doi: 10.1001/jamasurg.2023.5526 . Prieto JM, Thangarajah H, Ignacio RC, Bickler SW, Kling KM, Saenz NC, Garcia SV, Lazar DA. Patience is a virtue: Multiple preoperative visits are associated with decreased recurrence in pediatric pilonidal disease. J Pediatr Surg. 2021;56(5):888–891. doi: 10.1016/j.jpedsurg.2020.09.013 . Foti N, Passannanti D, Libia A, Campanile FC. A minimally invasive approach to pilonidal disease with endoscopic pilonidal sinus treatment (EPSiT): a single-center case series with long-term results. Tech Coloproctol. 2021;25(9):1045–1054. doi: 10.1007/s10151-021-02477-w . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Dec, 2024 Read the published version in Techniques in Coloproctology → Version 1 posted Editorial decision: Revision requested 09 Sep, 2024 Reviews received at journal 09 Sep, 2024 Reviewers agreed at journal 31 Aug, 2024 Reviewers invited by journal 21 Jul, 2024 Editor assigned by journal 16 Jul, 2024 Submission checks completed at journal 16 Jul, 2024 First submitted to journal 14 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4737927","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":335968126,"identity":"ff3d6947-1ec0-4642-9637-3bd4a2323cf8","order_by":0,"name":"Sonia Pérez-Bertólez","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYFACHjApw8DAfICBsYFoLQkgki2BZC08BsRpkZ/de/Bx5Q8bHn7+M98kfu6wkWNgb3+AV4vBnXPJhmcS0ngkG85uk+w9k2bMwHPGAL8WiRwzyYaEwzwGB3u3SfC2HU5skMgh4LAZOeY/QVrsD/M8k/wL0iL/HL/DGG7kmDGCbWHjYZOG2MJAwGFAv0g2pKXxSJxhM7aWbUszZuPJwa8FFGIfG2xs5Pj7Dz+8+bYNyGA/TsBhEggmC5jNhl89qhbmDwRVj4JRMApGwYgEAAEFQxv3kQ8+AAAAAElFTkSuQmCC","orcid":"","institution":"Hospital Sant Joan de Déu, Universitat de Barcelona","correspondingAuthor":true,"prefix":"","firstName":"Sonia","middleName":"","lastName":"Pérez-Bertólez","suffix":""},{"id":335968127,"identity":"a31c536f-274a-43b8-83e0-57dcb5fcc315","order_by":1,"name":"Isabel Casal-Beloy","email":"","orcid":"","institution":"Hospital Sant Joan de Déu, Universitat de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Isabel","middleName":"","lastName":"Casal-Beloy","suffix":""},{"id":335968128,"identity":"9e784cf3-3668-4182-9e5a-9d353d186785","order_by":2,"name":"Albert Pasten","email":"","orcid":"","institution":"Hospital Sant Joan de Déu, Universitat de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Albert","middleName":"","lastName":"Pasten","suffix":""},{"id":335968129,"identity":"feca5e67-7faa-4c47-bbf8-c5952c919c7d","order_by":3,"name":"Oriol Martín-Solé","email":"","orcid":"","institution":"Hospital Sant Joan de Déu, Universitat de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Oriol","middleName":"","lastName":"Martín-Solé","suffix":""},{"id":335968130,"identity":"acb9a13e-4b6f-4f94-8236-b03487d0cdf7","order_by":4,"name":"Paula Salcedo","email":"","orcid":"","institution":"Hospital Sant Joan de Déu, Universitat de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Paula","middleName":"","lastName":"Salcedo","suffix":""},{"id":335968131,"identity":"fa7c210f-11f4-4b2d-87b2-744a75aee24a","order_by":5,"name":"Leopoldo Tapia","email":"","orcid":"","institution":"Hospital Sant Joan de Déu, Universitat de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Leopoldo","middleName":"","lastName":"Tapia","suffix":""},{"id":335968132,"identity":"0cbcff33-ee89-4fdf-8541-479e15ff8976","order_by":6,"name":"Xavier Tarrado","email":"","orcid":"","institution":"Hospital Sant Joan de Déu, Universitat de Barcelona","correspondingAuthor":false,"prefix":"","firstName":"Xavier","middleName":"","lastName":"Tarrado","suffix":""}],"badges":[],"createdAt":"2024-07-14 10:03:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4737927/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4737927/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10151-024-03049-4","type":"published","date":"2024-12-10T15:57:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62631212,"identity":"ec4a1e57-c63f-48dc-bdb5-f98dcb09954d","added_by":"auto","created_at":"2024-08-16 16:02:19","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69383,"visible":true,"origin":"","legend":"\u003cp\u003eA long, thin Volkmann spoon for curettage is introduced when dealing with abundant granulomatous tissue. This approach ensures an efficient removal of all granulomatous tissue.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4737927/v1/5152eaf7beb0d23215dfd8d8.jpeg"},{"id":62631208,"identity":"5762227b-643b-4adf-9a53-195e1e24f87b","added_by":"auto","created_at":"2024-08-16 16:02:19","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":71249,"visible":true,"origin":"","legend":"\u003cp\u003ePatients with wide surgical wounds were provided with an ultraportable Negative Pressure Wound Therapy (NPWT) device. \u003cstrong\u003ea\u003c/strong\u003e A swab is used to explore the wound cavity. \u003cstrong\u003eb\u003c/strong\u003e Porous foam is carefully introduced through the surgical wounds \u003cstrong\u003ec\u003c/strong\u003e All the wounds are covered with a film seal, and tubing is connected to a vacuum pump for NPWT treatment.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4737927/v1/e17277fe8d5df453ba28b4b7.jpeg"},{"id":62631210,"identity":"14a36156-7603-462b-805f-6fe1b3556849","added_by":"auto","created_at":"2024-08-16 16:02:19","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":119198,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003e A deteriorated cystoscope lens, exhibiting blurred vision and a noticeable yellowish halo around it. \u003cstrong\u003eb\u003c/strong\u003e A broken monopolar electrode from the cystoscope.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4737927/v1/34a352eb6e0861c94e873304.jpeg"},{"id":62631211,"identity":"10584f08-8f58-438b-bfa7-0dd57d9e4a36","added_by":"auto","created_at":"2024-08-16 16:02:19","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":187660,"visible":true,"origin":"","legend":"\u003cp\u003eExamples of contraindications for PEPSiT. \u003cstrong\u003ea\u003c/strong\u003e Chronic Pilonidal Sinus Disease (PSD), where fistulas interconnect and self- marsupialize. Examining with the fistuloscope does not provide any advantage over directly observing the PSD due to the lack of a cavity. \u003cstrong\u003eb \u003c/strong\u003eEarlier stage in the evolution of chronic PSD, prior to self- marsupialization. The thin skin bridges are delicate and tend to disintegrate after cauterization, leading us to the situation shown in Figure 4a.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4737927/v1/fc661c450003dbf8439a3a45.jpeg"},{"id":71552498,"identity":"dc320656-fd7d-4662-97d6-26ac58bc8d78","added_by":"auto","created_at":"2024-12-16 16:06:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":979243,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4737927/v1/4ee355b7-1ac6-4e30-9778-04c0079cbbda.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePediatric Endoscopic Pilonidal Sinus Treatment: Lessons Learned After 100 Consecutive Cases\u003c/p\u003e","fulltext":[{"header":"Summary","content":"\u003cp\u003eThis study evaluates the effectiveness of Pediatric Endoscopic Pilonidal Sinus Treatment (PEPSiT) compared to traditional surgical methods in 149 pediatric patients. The findings indicate that PEPSiT offers superior medium-term outcomes, including shorter healing times, reduced postoperative pain, fewer complications, and faster return to normal activities.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eThere is a wide range of treatment modalities used in the management of pilonidal sinus disease (PSD), but there is no clear consensus on the \u0026ldquo;gold standard\u0026rdquo; treatment in either adults or children [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe traditional operative management strategy for pilonidal disease involves excision of affected tissue paired with a variety of closure types including primary midline closure, primary off-midline closure techniques (Karydakis flap, Limberg flap, Bascom cleft lift), and healing by secondary intention [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, classic excision procedures are associated with a long and painful post-operative course, long absence from school or work activities, and high rates of complications such as surgical wound infection, bleeding, partial or full dehiscence, and recurrence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecently, there has been a recent shift toward more minimally invasive operative approaches including pit-picking, sinusectomy, laser ablation of the subcutaneous tracks, curettage of the sinus cavity with an injection of phenol, fibrin glue, or thrombin-gelatin matrix, Gips procedure and endoscopic approaches [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In 2014, Meinero proposed the endoscopic pilonidal sinus treatment (EPSiT) performed through a dedicated fistuloscope to destroy the sinus cavity and tracts under direct endoscopic vision [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Shortly after that, Esposito introduced a similar technique for children called Pediatric Endoscopic Sinus Treatment (PEPSiT) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to our preliminary experience and the current literature, endoscopic techniques are associated with few complications, low pain, and allows for a quick return to normal life without restrictions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, minimally invasive procedures are still not widely adopted, perhaps due to skepticism because of the lack of long-term follow-up studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aimed to compare the medium-term outcomes of PEPSiT versus conventional surgery for pilonidal sinus in pediatric patients at a single center and also to describe some gained valuable insights after performing 100 consecutive cases of PEPSiT.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and protocol\u003c/h2\u003e \u003cp\u003eThis study is an observational prospective, non-randomized cohort (quasi-experimental) study, reported according to the STROBE recommendations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEthics and informed consent\u003c/h2\u003e \u003cp\u003e The study was approved by the Ethics Committee of our health care institution (PIC-179-20). Procedures followed were in accordance with the Helsinki Declaration and Good Clinical Practice (GCP) guidelines. Informed consent was obtained from all parents and participants over 12 years of age.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy population, clinical variables and outcomes\u003c/h2\u003e \u003cp\u003eAll pediatric patients (\u0026le;\u0026thinsp;18 years of age) undergoing pilonidal sinus surgery from 2019 to 2022 at a single institution were enrolled.\u003c/p\u003e \u003cp\u003eThree groups of patients were compared according to the surgical technique used - Excision and healing by secondary intention (EHSI), excision and primary closure (EPC), or PEPSiT. The choice of surgical technique was surgeon dependent. During the study period, each type of procedure was performed by the same group of surgeons.\u003c/p\u003e \u003cp\u003eSex, age, weight, previous infections, surgical technique used, type of anesthesia, visual analog scale (VAS) pain, duration of analgesic treatment, hospital stay, time to complete healing, time to return to normal life, and complications - bleeding, infection, dehiscence, granuloma, and recurrence - were recorded for all patients.\u003c/p\u003e \u003cp\u003eThe primary outcome of this study was to evaluate the time to return to normal life according to the surgical technique used. The secondary outcomes were to evaluate the time to complete healing, risk of complications, postoperative pain on the VAS scale, analgesic treatment duration, and hospital stay for each surgical technique.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Procedure\u003c/h2\u003e \u003cp\u003eEach procedure was performed under general, spinal, or local anesthesia with or without sedation, depending on patient characteristics, type of procedure and anesthesiologist decision. The patient position was the same regardless of the surgical technique used: prone position with external traction of buttocks to improve exposure of the surgical field.\u003c/p\u003e \u003cp\u003eFurther details about the surgical steps of the different techniques performed in this research, has been previously described [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Since our initial description, some technical details in the PEPSiT group have been modified. If the patient has abundant granulomatous tissue, we remove it with a long and thin Volkmann spoon instead of a brush (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In most patients, surgical wound care is done with local hygiene and a daily stream of povidone iodine. For larger wounds, we initially use negative pressure wound therapy (NPWT) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eFor statistical analysis, Fisher's exact test was used to analyze quantitative variables and Kruskal-Wallis test was used to analyze continuous variables. To reduce bias, results were adjusted for age and weight, with multiple linear regression for continuous outcome variables and multivariate logistic regression for binary outcome variables. Stata 14.2 software was used for all statistical calculations. A p-value less than 0.05 was considered a significance threshold.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 149 patients were included in our study, with 100 undergoing PEPSiT, 28 undergoing EHSI, and 21 undergoing EPC (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The anesthesia type employed is detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient\u0026rsquo;s characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e PEPSiT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEPC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEHSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN (female/male)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (52/48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(12/9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28(10/18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean age (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15,5 (9,5\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15,7 (11,5\u0026ndash;18,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15,7 (11,9\u0026ndash;18,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean weight (kg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (42\u0026ndash;127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (42\u0026ndash;147)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76 (41\u0026ndash;160)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious infection (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN\u0026ordm; pits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3 (1\u0026ndash;10)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,6 (0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,6 (0\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious surgery (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePit close to anus (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGranuloma (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHirsutism (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eActive infection (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaser epilation (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplications (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e24\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecurrence (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eType of anesthesia\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePEPSiT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEPC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEHSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGeneral\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e65\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpinal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding the instrument used for PEPSiT, 27 cases were performed with a compact cystoscope and 73 with the fistuloscope, with no significant difference between these groups of patients. The wider working channel of the fistuloscope allows for the utilization of larger-diameter and more robust instruments. During the study period, two monopolar electrodes of the cystoscope and one of the fistuloscope were broken during PEPSiT. In addition, one cystoscope lens had deteriorated, with blurred vision and a noticeable yellowish halo around it (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAge and weight were similar between groups, with a mean age of 15.6 (SD\u0026thinsp;=\u0026thinsp;1.7) years and a mean weight of 77 (SD\u0026thinsp;=\u0026thinsp;19.4) kg. Differences between groups were found regarding the number of fistulous tracts and the grade of hirsutism. No differences were found between groups in gender, age, weight, previous infections, previous surgery, fistula close to the anus, or granuloma. However, a tendency to use more laser epilation with PEPSiT was observed (30% vs 21% EHSI and 9%ECP), and less active infection was found on the day of surgery with EPC.\u003c/p\u003e \u003cp\u003eNPWT was used in 10 patients after PEPSiT, 8 after EHSI and 3 that suffered dehiscence after ECP. In the rest of patients, the postoperative wound management was done with local hygiene and a daily stream of povidone iodine, without adhesive dressing.\u003c/p\u003e \u003cp\u003eLength of hospital stay was significantly lower in the PEPSiT group, as it was performed as ambulatory surgery, while others required hospitalization.\u003c/p\u003e \u003cp\u003ePain on the VAS scale was significantly lower in the PEPSiT group: 6.1 less than with ESI (95% CI: 5.4\u0026ndash;6.9; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and 5.7 less than with ECP (95% CI: 4.9\u0026ndash;6.6; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), so they also had less analgesic requirement with PEPSiT.\u003c/p\u003e \u003cp\u003eMean time to return to normal life was shorter with PEPSiT \u0026ndash; 177 days earlier than EHSI (CI95%: 124.7-230.2; p\u0026thinsp;\u0026lt;\u0026thinsp;0,01) and 7.2 days earlier tan EPC (CI95%: 20.2-138.6; p\u0026thinsp;\u0026lt;\u0026thinsp;0,01). For each additional kilogram of weight, patients took an average of 1.5 more days to resume normal activities (95% CI: 0.5 to 2.6).\u003c/p\u003e \u003cp\u003eThere were differences in the time to full healing process depending on the surgical technique used (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01): the median time to complete epithelialization with PEPSiT was 4 weeks (IQR: 3 to 8), 16 weeks (IQR: 12 to 26.5) with EHSI, and 7 weeks (IQR: 4 to 10) with ECP. The presence of infection at the time of intervention increased the time to full healing by an average of 20 weeks (95% CI: 3.6 to 36.7), regardless of the surgical technique used.\u003c/p\u003e \u003cp\u003ePatients who underwent NWPT exhibited a longer healing time compared to those who did not receive NWPT (median healing time was 22 days with NWPT vs. 18 days without NWPT). Additionally, patients using NWPT took longer to return to their normal daily activities (a median of 30 days with NWPT vs. 1 day without NWPT). The observed difference was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), which aligns with the expected outcome due to selection bias.\u003c/p\u003e \u003cp\u003eComplications were significantly lower in the PEPSiT group. The risk of complications was 9.3 times higher with EHSI (OR: 9.3; CI95% 3.5\u0026ndash;24.7) and 8.5 times higher with EPC (OR\u0026thinsp;=\u0026thinsp;8.5; CI95% 2.9\u0026ndash;24.4), compared with PEPSiT. In the multivariate analysis, it was found that surgery with active infection increased the risk of complications by 3 times (OR\u0026thinsp;=\u0026thinsp;3; 95% CI 1.1\u0026ndash;8.5).\u003c/p\u003e \u003cp\u003eRecurrence was also significantly lower in the PEPSiT group. Compared to PEPSiT, EHSI had 5.3 times more probability of recurrence (OR\u0026thinsp;=\u0026thinsp;5.3; 95% CI 1.3\u0026ndash;22.7), and ECP had 15.2 times more (OR\u0026thinsp;=\u0026thinsp;15.2; 95% CI 3.2\u0026ndash;71.7). The presence of infection at the time of intervention increased the risk of recurrence by 7.5 times (OR\u0026thinsp;=\u0026thinsp;7.5; 95% CI 1.8\u0026ndash;31.9).\u003c/p\u003e \u003cp\u003eThe use of laser epilation was associated with a reduction in recurrence rates. Specifically, we observed a 13.64% recurrence rate in patients who did not receive laser treatment, whereas the recurrence rate was 2.7% in patients who underwent laser epilation (p\u0026thinsp;=\u0026thinsp;0.07). Notably, among the patients who experienced recurrence despite laser treatment, they had undergone at least one session but had not completed the full treatment course.\u003c/p\u003e \u003cp\u003eThe number of fistulas was the only variable related to the need for reintervention. For each additional fistula, the risk of reintervention increased by 1.7 times (OR\u0026thinsp;=\u0026thinsp;1.7; 95% CI 1.2\u0026ndash;2.4).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThere is still no consensus about the gold standard surgical management for pilonidal disease in either the adult or pediatric population. The choice of surgical approach generally depends on the surgeon\u0026rsquo;s experience of the procedure and perceived results in terms of healing speed and recurrence rate. Following the Soll concept that \u0026ldquo;less is more\u0026rdquo; [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], the endoscopic treatment of PSD has been introduced [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePreliminary experience with endoscopic treatment of pilonidal sinus has shown that it is an effective technique in pediatric and adolescent patients, it involves short postoperative periods, it causes no pain, and care is simple. It also allows for a quick return to normal life without the restrictions involved by conventional open surgery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this article, it is demonstrated that the advantages of PEPSiT over conventional surgery persist in the medium term.\u003c/p\u003e \u003cp\u003eAs we have progressively broadened the indications for PEPSiT, we have encountered increasingly complex cases. In this context, we aim to share our insights and lessons learned from our initial 100 PEPSiT procedures.\u003c/p\u003e\n\u003ch3\u003eAnesthesia\u003c/h3\u003e\n\u003cp\u003eDetermining the optimal anesthetic method for PSD remains an ongoing challenge. The selection is influenced by both the anesthesiologist\u0026rsquo;s preferences and the individual patient\u0026rsquo;s condition. We employ various techniques, including general, spinal, and local anesthesia, with or without sedation. Therefore, surgeons and anesthesiologists should involve patients and parents in informed discussions, weighing the benefits and drawbacks of each approach [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eSpinal anesthesia\u003c/em\u003e allows patients to remain conscious during surgery while providing effective postoperative analgesia. It remains advantageous in classic exeretic surgery. However, the PEPSiT group, experiencing minimal postoperative pain, does not routinely require spinal anesthesia. Concerns arise from perceived delays associated with administration time and its prolonged onset. Additionally, we consider the potential impact on recovery and hospital discharge due to delayed compensation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eGeneral anesthesia\u003c/em\u003e becomes essential for less cooperative patients or those with higher anxiety. However, its use necessitates positioning a patient\u0026mdash;often obese\u0026mdash;twice during the procedure. Induction and tracheal intubation occur in the supine decubitus position, followed by positioning the patient prone for surgery. Finally, after completion, the patient is rotated back to the supine position for awakening.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eLocal anesthesia\u003c/em\u003e is prioritized now in PEPSiT, whenever feasible. Its advantages include faster administration, reduced operating room time, and immediate patient discharge. Importantly, local anesthesia avoids airway manipulation and mitigates the risks associated with spinal or general anesthesia.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePEPSiT technical details\u003c/h2\u003e \u003cp\u003eOutcomes did not appear to be significantly affected by the use of a pediatric cystoscope over the use of the fistuloscope, as previously reported [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, we advocate for the use of the fistuloscope due to its superior durability.\u003c/p\u003e \u003cp\u003eIn cases of PSD with multiple pits, rather than introducing the fistuloscope through all of them, we selectively utilize those that are sufficiently wide for initial insertion. Subsequently, we explore the remaining pits from the inside. Unlike conventional practice among other surgical groups, we intentionally avoid systematic use of the lower pit [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our decision is based on infection prevention: considering its proximity to the anus, enlarging the lower orifice could potentially elevate the risk of postoperative infection.\u003c/p\u003e \u003cp\u003eIn the management of large cysts, we prioritize accessing one of the central orifices. This strategic decision enables comprehensive exploration of all aspects of the cyst cavity using the 18 cm-long fistuloscope.\u003c/p\u003e \u003cp\u003eIn situations where external orifices are too narrow to accommodate the fistuloscope, we widen one of the orifices using a mosquito forceps. To minimize procedural duration, we use the same mosquito forceps for hair and detritus removal. Additionally, we streamline the procedure by directly irrigating using the fistuloscope, eliminating the need for pre-procedure irrigation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Finally, any remaining detritus and hairs are meticulously extracted under endoscopic guidance using the fistuloscope\u0026rsquo;s forceps.\u003c/p\u003e \u003cp\u003eRegarding the type of irrigation solution, while other fluids like mannitol or normal saline can also serve this purpose, our preferred choice is glycine due to several reasons:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWe routinely use glycine in endourological procedures, which makes us feel comfortable with its application.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWe utilize the 3-liter bag of glycine, typically sufficient for the entire procedure, minimizing the need for changes.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDuring the intervention, patients may experience some intravascular and extravascular absorption of irrigation fluid. The extent of this absorption depends on factors such as the duration of the intervention, the volume of solution used, and the hydraulic pressure applied. Glycine is an amino acid naturally synthesized by the human body and is minimally hypotonic. Consequently, hemolysis is avoided when the solution enters the bloodstream.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGlycine makes the solution isoelectric, allowing for concentration of the monopolar electric current at the electrode. In contrast, when using normal saline, a substantial increase in electric power is required to achieve a comparable fulguration effect. However, this approach results in greater diffusion, thereby elevating the risk of electric injury.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eWe utilize a brush for mechanical abrasion on fistulas and cyst walls in specific cases and to eliminate necrotic tissue. However, when abundant granulomatous tissue is present, we prefer using a long, thin Volkmann spoon for curettage instead of the brush. This allows us to remove all the granulomatous tissue more efficiently, similar to video-assisted ablation of pilonidal sinus (VAAPS) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Following that, we proceed with the PEPSiT technique, introducing the fistuloscope to ensure thorough cleanliness and complete fulguration.\u003c/p\u003e \u003cp\u003eTo complete the cauterization of the fistulous tract, the monopolar electrode is inserted directly through the skin surface. For larger tracts or granulomas, we opt for the electric scalpel, although in most cases, the electrode alone suffices. We routinely employ a combination of spray and blend coagulation modalities setting.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; conditions\u003c/h2\u003e \u003cp\u003eIt is interesting to note that there was no significant difference in age, weight, gender, previous infections, previous surgery, fistula close to the anus, or granuloma between the three groups of our study. However, there was a tendency to use more laser with PEPSiT and to find less active infection on the day of surgery with EPC.\u003c/p\u003e \u003cp\u003ePrevious research has shown that hirsutism and typology of sinus (\u0026ge;\u0026thinsp;2 external pits, paramedian pits and pits more proximal to the anus) were the main predictors of postoperative PSD recurrence [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our study corroborates that the number of fistulas is a crucial factor. Each additional fistula significantly increases the risk of secondary surgery by 1.7 times. Furthermore, this study found that patients with active infection face a threefold increased risk of complications following surgery and is also associated with a remarkable 7.5-fold increase in the risk of recurrence.\u003c/p\u003e \u003cp\u003eA consensus statement has been developed for adults with PSD. We align with the consensus recommendation to adopt endoscopic treatment for cases of limited PSD (such as single or multiple midline pits), for both recurrent PSD and de novo presentations. Nevertheless, we disagree with the recommendation favoring traditional open healing in complex PSD cases [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. From our perspective, PEPSiT remains a viable therapeutic choice for managing complex scenarios, including large chronic fistulas, extensive granulomas, lesions near the anus, and big cavities.\u003c/p\u003e \u003cp\u003eWhile some authors advocate for the shift from traditional open excision to PEPSiT as the present and future approach for managing children and teenagers with PSD [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]; we recognize specific contraindications for PEPSiT, where other surgical techniques remains relevant. These contraindications include:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eAbsence of Cavity\u003c/em\u003e: In specific cases of chronic PSD, where fistulas interconnect and self- marsupialize (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ea), performing endoscopic surgery becomes unsuitable due to the absence of a true cavity.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eThin Cutaneous Bridges\u003c/em\u003e: This represents an earlier stage in the evolution of chronic PSD, preceding the scenario described in the previous point. Fistulous tracts connected by a thin cutaneous bridge (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eb), without a substantial cavity, pose challenges for PEPSiT.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eSuspicion of Tumor or Perianal Conditions\u003c/em\u003e: Conditions such as cryptogenic perianal fistula, septic anal fissure, gluteal abscess, hidradenitis suppurativa, Crohn\u0026rsquo;s disease, ulcerative colitis, syphilis, tuberculosis, epidural abscess, and other soft tissue infections may necessitate alternative approaches [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eLack of Adequate Instruments\u003c/em\u003e: Availability of appropriate instruments is crucial for successful PEPSiT outcomes.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFurthermore, we emphasize that surgical treatment should always be customized to the individual patient.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative care\u003c/h2\u003e \u003cp\u003eEffective postoperative care is essential for improving patients\u0026rsquo; experiences and minimizing the impact of pilonidal sinus wounds on their daily activities. The efficacy of dressings and topical agents for wound healing following surgery for PSD remains uncertain based on existing studies. Most of the evidence is of low or very low certainty, often derived from single studies. However, interventions like NPWT show promise in improving wound healing outcomes [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. NPWT involves applying negative pressure to the wound bed using a specialized device. It promotes wound contraction, reduces edema, and enhances granulation tissue formation.\u003c/p\u003e \u003cp\u003ePatients with wider surgical wounds were offered an ultraportable NPWT device [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. For the remaining patients or when surgical wounds in the NPWT group had reduced in size, the postoperative care recommendations included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eWound hygiene\u003c/em\u003e: Patients should keep the wound clean, dry, and free from debris to prevent infection. Shower heads are preferred for cleansing, once or twice per day. After a bowel movement, the surgical wound should be cleaned to avoid fecal contamination.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eHair removal\u003c/em\u003e: Embedded hair and debris should be removed at each wound inspection due to the chronic inflammation they induce. We recommend preoperative and postoperative laser epilation as the hair removal method of choice [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. For those who decline this option, we recommend shaving the surrounding area at least weekly.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eTopical agents\u003c/em\u003e: Daily wound care involves applying povidone iodine directly to the surgical wound at least once a day, following their shower.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eDressing\u003c/em\u003e: Simple, non-adherent dressings may suffice for wound care. Patients are advised to use a gauze pad secured with their own underwear to prevent staining.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe success rate of PSD procedures depends on patient cooperation and adherence. Preoperative patient education plays a crucial role in achieving favorable outcomes. Specifically, emphasizing meticulous personal hygiene is essential to minimize the risk of infection. Additionally, it is important to prepare patients for the postoperative period, which may be both challenging and prolonged. Recognizing the unique needs of each patient, close monitoring remains basic to facilitate optimal wound healing and prevent complications [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNotably, the recurrence rate was significantly higher in patients who did not undergo laser epilation. Therefore, standardizing the technique, incorporating laser epilation, and ensuring appropriate wound care are critical factors for achieving long-term success with PDS surgery.\u003c/p\u003e \u003cp\u003eIn recent years, significant advancements have transformed the field of surgical management for PSD. Among these innovations, the PEPSiT technique stands out as a promising approach. In this article, we highlight the advantages of PEPSiT over traditional methods:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eReduced Complications and Recurrence Rates: Our study revealed that PEPSiT has significantly fewer complications and lower recurrence rates when compared to other techniques such as EHSI and EPC. This finding underscores the potential of PEPSiT as a safer and more effective option for pediatric patients.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMinimal Pain and Shorter Hospital Stays: PEPSiT patients experience minimal pain after the procedure. Consequently, the majority of them did not require painkillers. Additionally, the outpatient nature of PEPSiT allows for shorter hospital stays, promoting faster recovery.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEarly Return to Daily Activities: Perhaps the most remarkable aspect of PEPSiT is the early return to daily activities. Patients can resume routine tasks, engage in sports (including football, skating, volleyball, and gymnastics), and lead an active life almost immediately after surgery.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSince the beginning of our experience with PEPSiT, we were attracted by the possibility of reducing the wound related morbidity but also fully aware of the lack of data about PEPSiT medium- and long-term recurrence rates. A higher recurrence rate was acceptable to the patients given the benefit of a minor scar and faster return to daily activities. Instead, our series showed that the medium-term recurrence rate after PEPSiT is lower to that reported in the excisional surgery studies.\u003c/p\u003e \u003cp\u003eOur PEPSiT series is one of the largest in the literature. This extensive experience not only validates the technique but also bolsters our confidence in recommending PEPSiT as a valuable addition to the armamentarium of PSD management. The longer follow-up is a point of strength of our study. Although recurrences are more common during the first postoperative year, they may occur much later, and a short-term follow-up does not permit to draw definitive conclusions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStauffer meta-analysis of 102 randomized controlled trials and support wider use of this procedure and confirmed these procedures\u0026rsquo; results are highly dependent on the follow-up duration [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The results of our study reflect both the longer follow-up period and patient selection.\u003c/p\u003e \u003cp\u003eThe main limitation of this study is that it was conducted at a single center with a medium-term follow-up. Nonetheless, further multicenter studies with larger sample sizes and long-term follow-up are required to confirm our findings. While it would be theoretically desirable to establish the superiority of PEPSiT over traditional techniques through a randomized clinical trial, the ethical considerations come into play. Considering the favorable outcomes achieved thus far, it might be deemed unethical to expose a patient who could benefit from PEPSiT to conventional surgical procedures. Therefore, our current stance prioritizes the well-being of patients by offering them the most effective and minimally invasive treatment option available.\u003c/p\u003e \u003cp\u003eIn conclusion, PEPSiT stands out as an effective and minimally invasive technique for treating PDS. Its lower complication rates, minimal post-operative discomfort, and quicker return to daily activities make it an attractive option for pediatric patients dealing with PSD.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConception and design: SPB; Data analysis and interpretation: SPB, OMS; Data acquisition: SPB; Critical revision of the manuscript for scientific and factual content: SPB, ICB, AP, PS, LT, XT; Drafting the manuscript: SPB, ICB, AP; Statistical analysis: OMS; Supervision: SPB.\u003c/p\u003e\u003ch2\u003eAcknowledgments:\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMilone M, Velotti N, Manigrasso M, Vertaldi S, Di Lauro K, De Simone G, Cirillo V, Maione F, Gennarelli N, Sosa Fernandez LM, De Palma GD. 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Negative pressure-assisted endoscopic pilonidal sinus treatment. Tech Coloproctol. 2021;25(6):739\u0026ndash;743. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10151-021-02431-w\u003c/span\u003e\u003cspan address=\"10.1007/s10151-021-02431-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinneci PC, Gil LA, Cooper JN, Asti L, Nishimura L, Lutz CM, Deans KJ. Laser Epilation as an Adjunct to Standard Care in Reducing Pilonidal Disease Recurrence in Adolescents and Young Adults: A Randomized Clinical Trial. 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A minimally invasive approach to pilonidal disease with endoscopic pilonidal sinus treatment (EPSiT): a single-center case series with long-term results. Tech Coloproctol. 2021;25(9):1045\u0026ndash;1054. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10151-021-02477-w\u003c/span\u003e\u003cspan address=\"10.1007/s10151-021-02477-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pilonidal sinus disease, Pilonidal sinus, Children, PEPSiT, Endoscopic Treatment, Minimally Invasive Surgery","lastPublishedDoi":"10.21203/rs.3.rs-4737927/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4737927/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003ePediatric Endoscopic Pilonidal SInus Treatment (PEPSiT) has favorable short-term-outcomes, but there is a lack of reliable data on medium and long-term follow-up. The objective of our study was to evaluate the effectiveness and advantages of PEPSiT vs conventional surgery of pilonidal sinus in the pediatric population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA quasi-experimental study was carried out in pediatric patients undergoing pilonidal sinus surgery at a single institution from 2019 to 2022. Excision and healing by secondary intention (EHSI), excision and primary closure (EPC), and PEPSiT were compared. The surgical technique chosen was surgeon-dependent.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e149 patients were studied \u0026ndash; 100 undergoing PEPSiT, 28 undergoing EHSI, and 21 undergoing EPC. Median full healing process was 4 weeks (IQR: 3\u0026ndash;8) in PEPSiT, 16 weeks in EHSI (IQR: 12-26.5) and 7 weeks (IQR: 4\u0026ndash;10) in ECP (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Pain on the Visual Analogue Scale (VAS) and need for analgesics were lower in the PEPSiT group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Mean time to return to normal life was shorter with PEPSiT \u0026ndash; 177 days earlier than EHSI (CI95%: 124.7-230.2; p\u0026thinsp;\u0026lt;\u0026thinsp;0,01) and 7.2 days earlier tan EPC (CI95%: 20.2-138.6; p\u0026thinsp;\u0026lt;\u0026thinsp;0,009). Complications with PEPSiT were 9.3 times lower tan EHSI (OR: 9.3; CI95% 3.5\u0026ndash;24.7) and 8.5 times lower than ECP (OR\u0026thinsp;=\u0026thinsp;8.5; CI95% 2.9\u0026ndash;24.4). EHSI had 5.3 times more probability of recurrence than PEPSiT (OR\u0026thinsp;=\u0026thinsp;5.3; CI95% 1.3\u0026ndash;22.7), and ECP 15.2 times more (OR\u0026thinsp;=\u0026thinsp;15.2; CI95% 3.2\u0026ndash;71.7).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eEndoscopic pilonidal sinus treatment is effective in medium-term follow-up, with fewer complications than classic techniques. It allows for an early return to normal life without restrictions.\u003c/p\u003e","manuscriptTitle":"Pediatric Endoscopic Pilonidal Sinus Treatment: Lessons Learned After 100 Consecutive Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-16 16:02:14","doi":"10.21203/rs.3.rs-4737927/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-09T19:40:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-09T10:13:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34253175026727951556489232770064281915","date":"2024-08-31T13:49:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-21T16:59:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-16T23:10:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-16T07:36:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2024-07-14T10:01:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4ac32e55-4c96-4ac3-8d78-72b2e42d9f41","owner":[],"postedDate":"August 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-16T16:03:28+00:00","versionOfRecord":{"articleIdentity":"rs-4737927","link":"https://doi.org/10.1007/s10151-024-03049-4","journal":{"identity":"techniques-in-coloproctology","isVorOnly":false,"title":"Techniques in Coloproctology"},"publishedOn":"2024-12-10 15:57:57","publishedOnDateReadable":"December 10th, 2024"},"versionCreatedAt":"2024-08-16 16:02:14","video":"","vorDoi":"10.1007/s10151-024-03049-4","vorDoiUrl":"https://doi.org/10.1007/s10151-024-03049-4","workflowStages":[]},"version":"v1","identity":"rs-4737927","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4737927","identity":"rs-4737927","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}