The Novel Use of Laser Ablation to Treat Pilonidal Cyst Disease

Case Study By Henry Govekar, MD, FACS, FASCRS, and Ami Shah, MD, FACS

After conducting the first trial in Chicago on the use of laser ablation as a treatment for pilonidal disease, Henry Govekar, MD, FACS, FASCRS, and Ami Shah, MD, FACS, evaluated a straightforward and minimally invasive solution that could reduce the awkwardness around the condition for many patients.

Their study first appeared in the March 6, 2023 online issue of Diseases of the Colon & Rectum.

Rush physicians Ami Shah, MD, and Henry Govekar, MD, pose for a photo together

Pilonidal Disease: Awkward and Embarrassing

Pilonidal disease (PD) is a chronic infection of the skin near the tailbone and gluteal cleft where hair follicles in the region become ingrown and infected. The combination of friction and sweat in the area causes ingrown hairs to become “plugged” and they eventually turn into abscesses. Although not life-threatening, they can present challenging quality-of-life issues for patients, including pain, redness, pus drainage and a foul odor. Anyone can develop this condition, but PD is most prevalent among teenagers and young adults.

Although there is no standard of care for PD, the condition has classically been treated with an en-bloc wide, local excision of the gluteal cleft with or without flap coverage. Following surgery, patients and providers might face the problems of morbidity, an increased risk of recurrence and difficult, long-term wound care. Treatments can also present equally challenging quality-of-life issues for typical adolescent and young adult patients, such as missing extended time from school or work and the embarrassment and awkwardness associated with the side effects of the condition and surgery.

“Say you have a 16-year-old who’s bothered with PD; they’re challenged just to get through life at that age,” says Henry Govekar, MD, FACS, FASCRS, a colorectal surgeon at Rush University Medical Center. “If you have a procedure that produces a big open wound, which may require up to a month off from school or work, that can really set a patient at that age back and make things pretty awkward for them with their peer group.”

No Consensus on Treatment

Recently, several minimally invasive options, such as the Gips and the sinusectomy procedures, have been used as viable approaches to treating this condition. However, these treatments involve unroofing, curettage, endoscopic ablation, longer healing times via decreased tissue apposition and a failure to reduce the risk of recurrence. Clinicians also cannot agree on the best modality to treat PD.

“In some cases, the minimally invasive treatments are either overly complicated or the tools to treat the condition are not widely available,” Dr. Govekar says. “We wanted to find an approach that is simple and easily implementable.”

First North American Study

After attending a colorectal conference at Cleveland Clinic Florida in 2016, Dr. Govekar began treating PD with Gips, which uses trephination to clean out the infected sinus cavities. However, Gips does not treat the underlying sinus tracts between cysts, which leaves patients vulnerable to recurrence.

Research studies in Europe that looked at combining Gips with laser therapy to clean the tracts garnered success rates of up to 94% and a mean complication rate of 10%. Dr. Govekar and Dr. Shah adapted the NeoV V1470 diode laser with a two millimeter probe, which Rush uses in the treatment of perianal fistulas, to ablate the sinus tunnels.

“Patients were experiencing recurrent disease because the tunnels between the cysts were not being treated,” says Ami N. Shah, MD, FACS, a pediatric surgeon at Rush University Medical Center. “The novelty of this procedure lies within the closure of the tracts between the cysts.”

Dr. Govekar added that aside from the large excision to open these tracts, other minimally invasive procedures such as Gips are incapable of accessing and cleaning the minute tracts, which are sometimes only a few millimeters wide. Laser ablation provided the solution for cleaning the infected tracts.

In 2022, Drs. Govekar and Shah conducted a safety and feasibility study to evaluate the combination of Gips with laser ablation therapy to treat PD in both adult and pediatric patients.

Results

Twenty-five patients received Gips with laser ablation as outpatients. Eighty-eight percent of the patients reported no or mild pain at the time of discharge. Most wounds healed within two weeks.

Twenty-two of the 25 patients were followed for six months. Of these,18 were healed at six months. Overall, 76% of the patients reported being very satisfied with the procedure.

Analysis

Laser ablation of PD is a viable, minimally invasive procedure for pediatric and adult patients. Given the minimal operating time (approximately 30 minutes), quick recovery time, minimal postoperative wound care and the overall satisfaction of patients, laser therapy provides a new means for treating those affected by PD.

The next step in the research, according to Dr. Govekar, is to compare laser ablation with other minimally invasive approaches.

Pilonidal Disease: At a Glance

  • Incidence: Approximately 26 per 100,000 people
  • Approximately 78,000 potential cases per year in the United States
  • Factors that influence the development of pilonidal disease include prolonged sitting, no exercise and obesity
  • Having a genetic predisposition to the condition
  • Pilonidal disease occurs predominantly in males at a ratio of 3-4 to 1
  • Pilonidal disease occurs predominantly in white patients who are in their late teens to early 20s and incidences decrease after age 25, with only rare occurrences after age 45

Meet the Authors

Henry Govekar, MD

Henry Govekar, MD

Colon and Rectal Surgery, Surgery Request an Appointment
Ami Shah, MD

Ami Shah, MD

Pediatric Surgery, Surgery Request an Appointment