New approach to non-healing

I share with all "pilonidal" some recent correspondence Bcc:pilonidal

Those of us that get fixations are hard to talk sense to.

I predict, in absence of good photos, and holding true to theory, that exists a micro-abscess with micro-lips at the lower end of the tunnel. There anaerobic pus is pushed into the tunnel (I wonder why the solid step of Dakin's does not cure?) I predict the cigar alone will cure him. We'll see! JUB

Surgeon wrote

Good analogy! The cigar would be great, IF he had a ‘seal’ there, which he USED to have, prior to the procedure; now the skin is out in the air, and has healed splendidly! It’s that stuff underneath which, in this nice fellow, won’t heal without additional work!
Thanks for your response.


JUB wrote

I apologize for bursting in without acknowledging the prior work and query. Obviously either we do not understand what surgical steps we are taking or we do not teach well.

May I try my latest analogy? It concerns lips and the buttocks. It may explain my latest conviction (or my fixation) to wit: "All raw pilonidal wounds are the three walls (bottom & sides) of a sealed-in, poorly drained anaerobic abscess." Note the TOP is absent from all such abscesses THAT WE SURGEONS SEE! The examiner has destroyed the TOP (and has FOR THE MOMENT destroyed the closed abscess) by standing the patient and by spreading the cleft, thus destroying the air tight seal of the "lips of the buttocks"! (Hovever, the seal and abscess is only temporarily destroyed, because the seal and abscess is re-created when the inspector releases the pull and the buttock LIPS fall together)

Several issues follow. If there is no cleft there is no disease. That explains the success we have had with a ventilating "cigar" which brings lethal oxygen to the anaerobic contents of the anaerobic abscess.

We have tried to emphasize the importance of the "rim trails", the vertical lines we (I) NOW URGE ALL SURGEONS TO DRAW, ON THE STANDING PATIENT, LINES WHERE THE BUTTOCKS MEET. ALL RAW WOUNDS lie between the "lips", between properly drawn "rim trails", whether of primary disease of failure of healing. Success will follow results where there is no cleft, it is impossible to draw rim trails because there is no cleft.

Perhaps we have not enough stressed how to eliminate the cleft just behind the anus. Build a fat pad to eliminate the cleft behind the anus. Bring the suture line to the SIDE of the anus to move the suture line out of the vulnerable midline.


Both lips and buttocks are soft tissue barriers able to create an air and liquid tight seal. Aa active seal created by the lips, and a passive seal is created by the buttocks, especially when sitting on the buttocks! I placed an infant feeding tube on an unhealed wound, had the patient sit, slowly injected saline to mimic accumulating pus. Before first leak appeared the saline in the manometer had risen to above the patient's head!!!!! I calculated the leaking or sealing pressure as 140 mm Hg!!!! (Have your fellows repeat this demonstration for the interns. It may explain why one can leave the walls in place as one drains the abscess and stops contamination as one does a cleft lift.)

In the standing patient it falls to 30 mm Hg, not to zero. Therefore, in all pilonidal patients, they seem to me, they carry a poorly drained anaerobic sealed abscess in their cleft 24/7! Except when examined!

John

Surgeon wrote:


John:
I had written you about this patient, who has contacted your office several times. Here is the text of my question to you:

Interesting! BTW, John, I have a problem patient I want to ask you about. 17yo boy, (lives in X, referred from your office) on whom I did a cleft lift ~3 months ago (assisted by X, another disciple of the Church of Bascom, (Beware of those with those with fixations and limited teaching talent...JUB) who has come to Mecca to watch you guys do the real stuff), which fell apart about a week after the surgery. Parents quite distressed, sent you pictures, and you counseled conservative management, which we have done. After initial indications that he was healing nicely, he’s left with 2 openings, top and bottom of the flap, in the midline, complete healing of the skin and obliteration of the gluteal cleft in the appropriate area, but a tunnel underneath, connecting the two openings. I suspect he just needs another cleft lift, opening, cleaning out, and resuturing, but without needing any excision. He’s been irrigating the tunnel with ¼ strength Dakins’ BID for a month or so, without improvement. Any other suggestions? If he needs a redo, I suspect he’ll come down to you and Tom, which is certainly fine with me. He’s just starting college , so whatever is done would likely be at Christmas time.

I subsequently spoke to Tom, who confirmed that it will need to be redone. (If the "cigar" fails.....JUB) The skin over the top is healed, with a tunnel beneath, so I doubt that the “cigar” is going to help the underlying defect. Unless you have some magic which we haven’t tried, I will contact the boy’s mother, and tell her of the fact that it needs to be redone. I know she and her husband will accept nothing less than Tom and yourself working with them on this.






Dear X,

I reviewed the pictures of Y's huge nuisance. I suspect you feel frustrated and heartily fed up, correct? For you would like this healed promptly and permanently, right? So would we all! I would be helped in understanding the problem and its solution if you can have taken some special photos. Michele in Tom's office can send you directions. We are helped if the pictures arrive in jpeg format.

Occasionally in our practice we have had similar results. A recent device has not been described in the literature. We have had good results recently with a simple plastic mesh "cigar" made out of a curly plastic scrub ball. The purpose of the device is to ventilate the bottom of the residual cleft--admit dry air and bacteria killing oxygen. If you will send me Evan's mail address I will send the "cigar" I fashioned today. This has a reasonable chance of solving the problem--there are others means but this is the simplest and is worth a try. He is to scrub the cleft with a soapy rag twice a day and wear the cigar at the bottom of the cleft 24/7 for a few weeks..

Your are on the right track to healing for you will continue learning about the disease at pilonidal.org and are asking good questions. I predict this nuisance will solved by Dec 1.

If you have have looked at the list of surgeons at the pilonidal.org site there may be a pilonidal surgeon near Evan's school if it is not convenient for him to visit Dr. Z for follow-up:

http://www.pilonidal.org

under Find a Surgeon.

If you have considered working with one of them in his area, and after a time still feel a visit to Eugene is your best option then we would be glad to see you. You can arrange a visit with Michele.

Call or e-mail if you have further questions after you study the material at the web site www.pilonidal.org especially at http://www.pilonidal.org/medical_profs.htm.

Good luck!

John Bascom MD
65 W 30th St Apt. 3512
Eugene, OR 97405
Phone 541-343-4118


Patient's mother wrote

I had contacted you regarding my son's pilonidal disease last spring having heard about your cleft lift procedure. Under your suggestion, we sought out a Surgeon in our area (X) who performed the surgery in mid June 2010 It is now the end of Sept., and he is still not healed, and in the last couple of weeks has developed what looks like a new cyst, just above the cleft line. x has just gone off to college, and this has become an enormous stress point in his life. We were under the impression that with the cleft lift procedure, he would have healed within a couple of weeks. Dr. X tells us that this is normal and it just takes time and that it is healing well. He does not know about the new cyst yet. As X is away at school, he suggested X follow-up with a physician in the town where his college is. I have included some photos of X dated Sept 24, 2010 and am hoping that you can give me your opinion. We would not hesitate to come to you if you can help. We desperately want to get rid of this problem in X's life, so that he can focus on his new college life and education with the confidence and self esteem that this has taken from him. Feeling lost! Please help!

Sincerely,

Choice of treatment

A new font is much easier for me to read (I am 85). The Font "Arial Black" Size 18 under Format, under Show Fonts is easier to read so please use it when you type your message.

If you continue to have little trouble I advise you to continue cleaning. If you continue to have discharge you have probably considered seeing Dr. A again, also Dr. B. The knowledge on pilonidals is changing rapidly. They have 6 years and 1 year of experience and may have learned new skills. Their job is to give advice. They do not own you. Your job is to decide, to learn about pilonidals and hear many opinions and to decide which course is to bring the result you want. Pilonidal.org lists many doctors in Saudi Arabia, Israel and in countries closer than Oregon. You have my permission to call or Email 5 of them, continue to learn opinions.

After study of your photos, if we were taking care of you, we would recommend a cleft lift to permanently eliminate the cleft. The trouble starts, in my opinion, at the depth of the midline fold and likely will cause repeated infections as long as a cleft exists...