The Gips Procedure for Pilonidal Disease: A Retrospective Review of Adolescent Patients

The mean (SD) duration of the operative procedure was 14 (3) minutes (range, 10–20 minutes). One patient (5%) developed bleeding that ceased spontaneously. The mean (SD) complete wound healing time was 3 (0.6) weeks (range, 2–4 weeks).

Postoperative clinical examination and telephone interviews were performed for follow-up. The mean follow-up period was 5 months (range, 1–13 months); 17 of 19 patients (89%) made a complete recovery. Two patients (11%) reported recurrence in the third and fourth months following the procedure and were treated with a repeat Gips procedure 6 months after the first treatment. Improvement was noted after a second Gips procedure in 1 of 2 patients who had recurrence, leaving the success rate of the procedure in our practice at 95% (18/19).

Comment

Treatment Options for PD
Various treatment methods for PD have been postulated,^5-7 including incision and drainage, hair removal and hygiene alone, excision and primary wound closure, excision and secondary wound closure, and various flap techniques. More recently, there has been a dramatic shift to management of patients with PD in an outpatient setting. The Gips procedure, an innovative minimally surgical technique for PD, was introduced in 2008 based on a large consecutive series of more than 1300 patients.⁸ Studies have shown promising results and minimal recovery time for the Gips procedure in adult and pediatric patients.^8-10

Nevertheless, conventional excision down to the sacral fascia, with or without midline or asymmetrical closure, is still the procedure performed most often for PD worldwide.^5,10 This surgery often requires general anesthesia and a long period of postoperative care; furthermore, children who undergo conventional excision at this age generally experience lengthy periods of missing school. In addition, conventional excision is associated with a notable recurrence rate and a potentially unacceptable cosmetic result.^10,11 Therefore, we prefer the Gips procedure of minimally invasive sinusectomy to treat PD in adolescents.

A larger study from an Israeli military pilonidal sinus clinic, in which 1358 adult PD patients were treated with the Gips procedure under local anesthesia, showed a recurrence rate of 13% at 5 years and 16% at 10 years.⁸Di Castro et al¹⁰ reported use of the same technique on 2347 patients and demonstrated a recurrence rate of 5.8% at a median follow-up of 16 months. Speter et al⁹ compared minimal incision using trephines and wide excision on a matched cohort of 42 adolescent patients (mean age, 16 years). Findings indicated better functional outcomes, shorter duration of analgesia required (≤48 hours), and fewer sick days in the minimal incision group but failed to demonstrate a statistically significant difference in overall recurrence. An overall favorable outcome was reported in 61.9% (26/42) of patients in the minimal incision group and 45% (19/42) in the wide excision group. Reoperation was performed in 28% (12/42) of patients in the minimal incision group and 9% (4/42) of the wide excision group.⁹ Delshad et al⁵ found that pit-picking procedures resolved pilonidal symptoms in 92% (47/51) of patients, without recurrence at 5 months on average.

Advantages of the Gips Procedure
Advantages of the Gips procedure are numerous. It is easily applicable, inexpensive, well tolerated, and requires minimal postoperative care. Placing the patient in the lateral position for the procedure—rather than the prone position that is required for more extensive surgical procedures—is highly feasible, permitting the easy application of a laryngeal mask for anesthesia. The Gips procedure can be performed on patients with severe PD after a period of improved hygiene and hair control and allows for less morbidity than older surgical techniques. Overall, results are satisfactory.

Health services and the hospital admissions process are less costly in university hospitals in Turkey. This procedure costs an average of 400 Turkish liras (<US $50). For that reason, patients in our review were discharged the next day; however, patients could be discharged within a few hours. In the future, it is possible for appropriate cases to be managed in an outpatient setting with sedation and local anesthesia only. Because their postoperative courses are eventless, these patients can be managed without hospitalization.

Recovery is quick and allows for early return to school and other physical activities. Because the procedure was most often performed on the last school day of the week, we did not see any restriction of physical or social activities in our patients.

Lastly, this procedure can be applied to PD patients who have previously undergone extensive surgery or phenol injection, as was the case in our patients.

Conclusion

The Gips procedure is an easy-to-use technique in children and adolescents with PD. It has a high success rate and places fewer restrictions on school and social activities than traditional surgical therapies.