A Saudi surgeon's success

Resp. Dr.Bascom,

I am Dr.Iqbal Lohia from Jeddah, finished with 12 cases of cleft lift and am thankful for solving my surgical problem. All have healed and never midline problem. patient coming only once or twice for dressings. No dressing for 6 weeks after excision. Couple of patients having some wound infection at the rectal end ,but eventually healed without problem. At the end there is no cleft and patient even did not notice the same.

I have a request to obtain new DVD if possible. My address is

Dr.Iqbal Lohia

Medical Director and Surgeon,

Khalid Idriss Hospital,

P.O.B. 75, Jeddah 21411 (saudiArabia)

N.B. It will be nice if we can download from net as you are known to use advanced technology to educate other surgeon for solving their difficult problem (suggestion)........... Excellent suggestion. http://aboilonthebutt--pilonidal.blogspot.com/       I will try my blog.  I am depending on you to comment by email.  JUB 

 wrote:

Dear Maj Williams, Bcc:pilonidal  (That means copies of our messages go to an influential 64 + surgeons.  Keep records, publish, invent, improvise, you are already changing pilonidal practice all over the world.  Pass it on!)

Michele and others, do you have a CPT answer? JUB

Begin forwarded message:

From: "Williams, John W MAJ MIL USA MEDCOM BMACH" <john.wesley.williams@us.army.mil>

Date: December 14, 2010 6:02:54 AM PST

To: "John Bascom" <jbascomr@pacinfo.com>

Subject: Cleft lift (UNCLASSIFIED)

Classification:  UNCLASSIFIED
Caveats: NONE

Dr. Bascom,

Performed my first lift last week and things are looking great!  I hope
this is the answer my patients have been waiting for.

A question:  What CPT do you use for "pit picking"?

Look forward to the video.

Thank you,

John


John Williams, M.D.
MAJ, MC
General Surgery
Ft. Benning, GA

Will a cleft lift give permanent cure?

You feel uncertain, correct?   I also feel uncertain as to the precise answer to your questions.   Being an 85 year old retired surgeon, no longer in practice, informened with part information from the mail, and in an evolving field where no one knows the final answer.    I have offered you sources of information.  I guess your job is to investigate until you are content, make phone calls, ask experienced docs questions and ask them to examine you and finally it is your job to decide.  My choice is to whether to tell you my guess--which on incomplete evidence is "a pretty good chance".  What alternatives do you suggest?   

Patient feels uneasy about cleft lift

Sounds like you feel uneasy at the prospect of an unmet surgeon chopping on your rear end, right?  Natural.  You hope that this solves the nuisance quickly and permanently, correct?  We do, too.  We both hope the cigar works to avoid surgery (see prior blog post), right?

Thanks!  I will try wearing the "cigar" for a few weeks and see how it goes.  If this doesn’t work and I still have the open wound I plan on coming to Oregon to see you. Our plan also. Since I will be coming so far to see you how would the appointment situation work?  Would you be able to look at my wound and see what needs to be done one day and then do a procedure on the next day?   If you agree with our proposal after we see the unhealed Z-plasty, probably surgery the same day.    I would like to stay in Oregon during this entire time so I don’t have to be flying back and forth.  Since my z-plasty surgery a couple years ago the top 2 inches or so of my butt crack is gone.  I am left with a short butt crack (only about 2 to 2.5 inches worth above my rectum) with the z scar right above it.  Would I still be a good candidate for a cleft lift since my wound is only about a half inch above my rectum and extends up for about an inch?   Yes, the operation is designed to solve that kind of problem. Since the wound is right in the mid line of my crack and right at my rectum it worries me that it can’t be fixed.  How many cleft lifts have you performed and what percentage of them have been successful?   Maybe 200.  As far as we know they are all healed.  Maybe 5-10 required repeat operations.  Maybe 3-5 patients three operations as we learned how to solve and teach these problems.  We are still learning. How long would I need to take off from my job (it is a sit down office job)? Also, when could I go back to jogging and playing sports? Tell your boss three weeks.  You have permission to back to both when you feel like it.  He will be surprised when you show up at 10d-2 wks   Sorry for so many questions, just trying to prepare myself for what may be to come.  Thank you for your time and have a good day!

A "CIGAR" TO GIVE THE FINAL PUSH TO HEALING

Subject: Vent cigar A patient describes an almost healed surgical wound in the cleft--no symptoms aside from minimal moisture. He wants final healing.

The buttocks, like lips, seal pus in the cleft. You might improvise around this idea and see if it helps. Minimal risk carrying this open wound for years. Surgery practically guaranteed to cure it if a Cleft Lift is used.

MD, from Seattle, wrote, "Photos, both of the products, the assembly process, and the final product, both on the table and in situ, would be an enormous help. I think I understand it, but could always improve my understanding." As soon as I learn to post photos I'll add photos to this blog.

This may interest you. The message includes three pictures that may not come through. If you don't see them, tell me. I'll try again.

The aim of this device: To let air reach non-healing wounds trapped in a cleft. I used this sort of device to heal one challenging patient with Crohn's and a non-healed wound from top of cleft to vagina where the proctectomy had fallen apart 2 years before. Plus, she had, between the coccyx and the back edge of vagina, an open cavity 7 cm deep!

A cleft lift healed almost all. However, a 2 cm skin defect refused to heal at the posterior edge of the vagina.

The defect remained open for months. Then I realized the problem! She sat with her legs together all day and lay all night with her legs together . I drew a "rim trail" on the line of contact of the thighs, down the front of the thighs from pubis to knees and up the posterior side from knees to the top of the cleft. I spread thighs to examine. The defect lay in the center of the huge airless area. She kept the cigar against the raw area day and night and it healed.

Details of construction:
Screen is soft fiberglass window screen or "fly screen". Orange is plastic kitchen scrub sponge everted by patiently pulling out the center. The steel scrub sponge is included for comparison. The thread is common cotton. A monofilament might be better.

Details of use:
Insert the "cigar" in the cleft with the side of the "cigar" against the wound. Wash the wound and cigar 1-2X/day.

Concerns expressed:
Irritation of the wound or discomfort. Falling out. Sharp ends of broken fiberglass.
Experience: The patient did not experience them. I wore the above device for a night and for several hours in a day. I found it comfortable. It did not fall out with walking despite my slack form. It did fall out with large steps or stairs. Tight briefs or other inventions should solve that.

The fiberglass is so fine and soft that I found no ends even after hours of wearing.

My interest:
I want to hear of experience of others. I will share any experiences I have or hear of. The "cigar" seems a low risk preliminary step for patients to use or doctors to recommend. It can be discontinued if uncomfortable, useless or irritating. In theory the "cigar" should help all forms of persistent pilonidal disease.

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...

Shave hair?

Q: When you say “we have not used laser”, I wonder what you do recommend. Is hair removal essential? Pilonidal.org seems to say so. A:......... Opinions change. I once thought so, and many good people still do, my attention is currently focused on the pit and the abscess, poorly drained and anaerobic because sealed at the surface as the buttocks and the cleft are squeezed closed 24/7. Hair plays a part and removal is never hurtful but I see removal as not essential. .....