Paediatric Endoscopic Pilonidal Sinus Treatment (PEPSiT) in children – information for parents and carers

What is a pilonidal sinus?

A pilonidal sinus is a small pit, or tunnel, at the top of your bottom, between your buttocks, in which hairs can get trapped leading to infection. The infection can turn into a collection of pus called an abscess, which can cause a painful swelling and lead to regular discharge of blood or pus onto underwear.

What causes pilonidal sinus?

The cause of pilonidal sinuses is not known, but it results from hairs growing between the buttocks or loose hairs gathering in the ‘natal cleft’ (the groove which separates the buttocks) being pushed inwards into the skin and forming a tunnel where increasing numbers of hairs get trapped. This causes an infection.

The hairs may be pushed into the skin due to risk factors such as tight clothing, cycling and prolonged periods of sitting. The condition is seen most commonly in teenagers with a family history of pilonidal sinus disease, those with a lot of hair (hirsutism), or obesity. Though more common in males, it is often seen in females with polycystic ovary syndrome.

Treating a pilonidal sinus

A pilonidal abscess can burst by itself, or it can be treated with antibiotics or incision (making a cut) and drainage. However, in many cases, surgery is the only way to effectively treat the cause of the abscess and remove all of the sinuses to prevent recurrence.

Pilonidal sinus disease can be more extensive than on first inspection as it can extend deep into the tissues so without surgery there is a high chance of recurrent abscesses.

Surgical approaches have evolved over the years. Traditional approaches have included incision and drainage of abscess followed by excisional open surgery and closure of the wound with stitches or deep packing of the cavity (filling the cavity with dressings that need regular changes) to allow healing with time. This involves a large wound to the lower natal cleft that can take a long time to heal; restricting full physical activities for up to 2-3 months.

Paediatric endoscopic pilonidal sinus treatment (PEPSiT) is a newer, minimally invasive technique that we have performed in children at Addenbrooke’s hospital since 2022 (see Reference 1) Research has shown success rates of 90% with healing rates on average of four weeks. The aim is to reduce the recovery time that traditional, more invasive approaches require.

Before admission to hospital

Prevent progression of infection

After your clinic consultation with a surgeon you will be advised that attention to hair removal is essential to avoid progression of infection in the short term whilst awaiting surgery. As a matter of priority, hair removal with shaving of the buttocks and also use of a tweezer to pull out the hairs within the pits should be commenced. If your child has signs of skin infection you should start to use Octenisan wash (an antimicrobial wash lotion) in baths/showers should commence.

Preoperative assessment

You will be asked to complete a ‘health screening questionnaire’ when your child is added to the waiting list; this may be completed immediately after your appointment (if your child was seen in one of our clinics at Addenbrookes) or, over the telephone.

Purchasing suitable painkillers

It is important that you purchase some children’s pain killers such as Paracetamol (such as Calpol) and Ibuprofen before admission to hospital so that you have these available at home after discharge.

If your child becomes unwell

If your child has a cold, cough or illness such as chicken pox the operation will need to be postponed to avoid complications. Please telephone us (the telephone number is provided at the end of this leaflet) to discuss, prior to coming to hospital.

Starvation times

Your child will not be able to eat and drink before the operation. Specific advice about this will be given on the booking letter once a date for surgery is confirmed.

What happens when my child is admitted to hospital?

You will be asked to bring your child to one of our children’s wards, usually early in the morning on the day of surgery. When you arrive you will be seen by the nursing staff plus a doctor and an anaesthetist.

A parent will be able to accompany your child when they go to the anaesthetic room to go to sleep for the operation and also be present in the recovery area when your child wakes.

What happens during the operation?

The area will be shaved and cleaned.

The surgeon will use a thin keyhole instrument called a ‘fistuloscope’ to look inside the pilonidal sinus cavity.

The surgeon will then use small instruments through the fistuloscope to remove all hairs and infected tissue and ‘cauterise’ (burn with a surgical instrument to clear infection) the cavity to help to heal the pilonidal sinus cavity from within.

The wounds made during this procedure are small and should heal relatively quickly, allowing for a much quicker return to school and normal activities than a more invasive surgery.

What happens after the operation?

When your child returns from theatre they will have a dressing over the wound.

A member of the nurse specialist team will visit you on the ward and will discuss how you will need to care for your child at home, and how to apply the dressings.

How long will my child need to stay in hospital after the operation?

Your child is usually able to be discharged home on the same day, a few hours after surgery.

You will be able to stay with your child until they are asleep in the anaesthetic room, and will then be called to recovery area as soon as they are awake again. If your child does need an overnight stay, there will be a bed provided beside theirs that you can sleep in.

What are the complications or risks?

The risks of surgery include:

• Infection in the area where your child had surgery which can be treated with antibiotics
• Bleeding or a blood clot (called a haematoma). This does not usually cause serious problems, but may occasionally require another operation to drain the blood
• Excess scar tissue called granulation tissue that can prolong wound healing and may require cauterisation
• There is a 10% risk the pilonidal sinus and symptoms can return after surgery. We advise long term hair removal to minimise this risk. In this case, further surgery would likely be required.

What are the alternatives?

Treatment with antibiotics can be tried, but ultimately if the infection keeps reoccurring, then surgery is the only option. An alternative to PEPSiT is open excisional surgery that has been shown to have a more prolonged recovery but similar risks of recurrence.

Discharge advice – how do I look after my child at home after surgery?

Analgesia (pain relief)

Your child will have had some numbing gel applied inside the sinus tract during the operation. After surgery over-the-counter medicines such as ibuprofen and paracetamol should be sufficient.

Wound care

Your child will initially have a dressing in place over the wound. The nurse specialist team will explain to you how to change this on a daily basis. The purpose of the dressing is to keep the wound dry and help prevent infection – once there is no longer any discharge, dressings can stop.

Bathing:

• 1st 5 days: Your child will not be able to have a bath, but will have a pink treatment spray called Chlorhexidine that will need to be applied to the wound daily
• After day 5: Your child will have a special body wash called Octenisan which they will need to use every day along with the pink spray.

Hair removal:

Meticulous hair removal is required following surgery. The nurse specialist team will explain how to do this safely. This will initially be carried out by shaving, hair removal cream and plucking with tweezers.

Once full healing has been achieved, then long-term laser hair removal may be something that you wish to explore privately.

Follow up

Your child will have an initial follow up appointment with the clinical nurse specialist team on approximately day 5 after surgery.

They will then need to attend clinic 6 at Addenbrookesto see the nurse specialist team weekly until the wound has fully healed. This is usually 2-4 weeks, but can take much longer in some cases if the cavity was found to be very large at surgery.

Your child will be seen by their surgeon approximately 4 weeks after their wound has fully healed, and then at regular intervals over the next year.

Chaperoning

During your child’s hospital visits your child will need to be examined to help diagnose and to plan care. Examination may take place before, during and after treatment, is performed by trained members of staff and will always be explained to you beforehand. A chaperone is a separate member of staff who is present during the examination. The role of the chaperone is to provide practical assistance with the examination and to provide support to the child, family member/carer and to the person examining your child.

Who shall I contact if I have any queries, concerns or questions?

For further information/queries please contact:

Your nurse specialist (Monday to Friday 08:00 to 18:00)…01223 586973………………...

The ward your child was on …………………………….

Reference

1 Mentessidou A, Mirilas P, Maravilla V, Malakounides G. Outcomes of Pediatric Endoscopic Pilonidal Sinus Treatment: A Systematic Review. Eur J Pediatr Surg. 2023 Jul 26. doi: 10.1055/s-0043-1771224. Epub ahead of print. PMID: 37494954.

Useful contact numbers:

Paediatric surgery clinical nurse specialist team

Office: 01223 586973

(Mon to Fri 08:00 to 18:00 except bank holidays) For emergency queries call 01223 245151 and ask for the Clinical Nurse Specialists in Paediatric Surgery (08:00to 18:00 Monday to Friday excluding public holidays)

Addenbrooke’s contact centre

01223 245151

Your children’s community nurse ................................