Tips for GP trainees working in colorectal surgery

Laura Smith; Neil Cripps; Matthew Burkes

doi:10.3399/bjgp14X677699

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First do no harm: Managing pilonidal sinus disease
Emer Forde

Published on: 20 May 2023

Published on: (20 May 2023)
Page navigation anchor for First do no harm: Managing pilonidal sinus disease
First do no harm: Managing pilonidal sinus disease
Emer Forde, GP, The Adam Practice, Dorset
‘Tips for GP trainees working in colorectal surgery’ offers one sentence on pilonidal sinus disease (PSD). It is “unusual in the over 40s”.¹ GPs need so much more knowledge about this relative common, and often poorly managed, disease. There is almost an acceptance that PSD is ‘difficult to treat’, recurrence rates inevitably high, and patients should not be surprised if their wounds to take months to heal. Recurrence rates are high, but this is often iatrogenic harm following surgery. Mahmood explains that “early recurrence is due to failure to identify one or more sinuses at operation, whereas late recurrence is usually due to secondary infection, residual hair or debris not removed at operation, inadequate wound care or insufficient attention to depilation”.²

Training for surgeons seems to be woefully inadequate. Less than half carrying out pilonidal operations considered themselves sufficiently trained, and more than 70% felt that PSD was an underprioritized, low status area of medicine.³

Training for GPs is inadequate too and if you have never talked to your patients about pit picking⁴ or cleft lift surgery, you are not alone. What practical advice do you give patients about wound management, cleansing and hair removal?

It is true that PSD tends to affect young people, with a deleterious impact on their physical, social, working, and emotional lives....
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‘Tips for GP trainees working in colorectal surgery’ offers one sentence on pilonidal sinus disease (PSD). It is “unusual in the over 40s”.¹ GPs need so much more knowledge about this relative common, and often poorly managed, disease. There is almost an acceptance that PSD is ‘difficult to treat’, recurrence rates inevitably high, and patients should not be surprised if their wounds to take months to heal. Recurrence rates are high, but this is often iatrogenic harm following surgery. Mahmood explains that “early recurrence is due to failure to identify one or more sinuses at operation, whereas late recurrence is usually due to secondary infection, residual hair or debris not removed at operation, inadequate wound care or insufficient attention to depilation”.²

Training for surgeons seems to be woefully inadequate. Less than half carrying out pilonidal operations considered themselves sufficiently trained, and more than 70% felt that PSD was an underprioritized, low status area of medicine.³

Training for GPs is inadequate too and if you have never talked to your patients about pit picking⁴ or cleft lift surgery, you are not alone. What practical advice do you give patients about wound management, cleansing and hair removal?

It is true that PSD tends to affect young people, with a deleterious impact on their physical, social, working, and emotional lives. ‘Patient regret’ can be high in relation to pilonidal surgery⁵ with patients reporting a poor understanding of their disease and little meaningful choice in terms of treatment options.

Surgeons need more training, and we need specialist centres of expertise. As GPs, we must be advocates for our patients. We should refer to surgeons known to have an interest in PSD. We can empower our patients to ask the right questions. We can upskill our practice nurses, and have clear protocols, so they manage these wounds well. Post operative wound care is a prognostic factor in recovery and recurrence.⁶ We can, and we must, do our bit to ensure that patients with pilonidal disease come to no more harm.

References

1. Tips for GP trainees working in colorectal surgery. Smith L, Cripps N & and Burkes M. Br J Gen Pract 2014; 64 (620): 157-158.
2. Mahmood F, Hussain A, Akingboye A. Pilonidal sinus disease: Review of current practice and prospects for endoscopic treatment. Ann Med Surg (Lond) 2020; 57:212-217. doi: 10.1016/j.amsu.2020.07.050.
3. Odlo M, Horn J, Xanthoulis A. Surgery for pilonidal sinus disease in Norway: training, attitudes and preferences-a survey among Norwegian surgeons. BMC Surg 2022; 28;22(1):442. doi: 10.1186/s12893-022-01889-1.
4. NICE. Clinical knowledge summary. Pilonidal sinus disease. 2019. https://cks.nice.org.uk/topics/pilonidal-sinus-disease.
5. Strong E, Callaghan T, Beal E. Patient decision-making and regret in pilonidal sinus surgery: a mixed-methods study. Colorectal Dis 2021; 23(6):1487-1498.
6. Harris CL, Laforet K, Sibbald RG, Bishop R. Twelve common mistakes in pilonidal sinus care. Adv Skin Wound Care 2012; 25(7):324-32; quiz 333-4.
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Competing Interests: None declared.