Last updated: December 2009
Keywords: pilonidal sinus; vacuum assisted closure; V.A.C.® Therapy; paediatric surgery; inpatient-to-outpatient transfer..
A teenage patient with a recurrent pilonidal sinus was successfully treated with V.A.C.® Therapy.
After 14 days of treatment, the wound was closed and healed uneventfully.
The use of V.A.C.® Therapy would prove useful in patients in an outpatient setting, which is not currently permissible in Germany.
This short paper reports on the successful treatment of a teenage patient with a pilonidal sinus. It describes the use of vacuum assisted closure therapy in this patient. The advantages of changing German healthcare policy to allow this therapy to be used in outpatient and home-based care settings is also discussed.
The fast and effective management of wounds has posed a considerable challenge to all clinicians, especially surgeons, for many years . Clinicians must combine the use of proven treatment modalities with new and progressive wound management strategies      . The vacuum assisted closure technique (V.A.C.Â® Therapy, KCI Medical, Wiesbaden) is one such treatment. Such modern techniques can be useful even in a relatively small discipline such as paediatric surgery, where chronic wounds occur less frequently than in older patients and are generally less troublesome    .
In the following case report we describe the experience of using V.A.C.Â® Therapy for the treatment of a classic pilonidal sinus in a teenager.
A pilonidal sinus occurs when hairs in the natal cleft penetrate the skin  . These subcutaneous displaced hairs cause irritation and inflammation. The area subsequently becomes infected, which may lead to abscess formation with a proximal and presacral extension. On examination, the area feels as though multiple â€˜grape pipsâ€™ are present under the skin. A lack of stringent personal hygiene and microtrauma can increase the likelihood of abscess formation and fistulae .
The traditional treatment of a pilonidal sinus involves wound healing by secondary intention, since primary wound closure is considered to be prone to postoperative complications and leads to frequent recurrence of the problem. Therefore, broad excision and daily cleansing of these wounds is advised. Granulation tissue may take several weeks to appear and time to healing may be lengthy   .
In the majority of cases, this procedure is performed as an inpatient treatment with multiple major daily dressing changes for the hospital staff and a considerable number of days off school or work for the individual patient. In addition, personal hygiene may be difficult for a patient to maintain and participation in sports and social activities may be a problem during healing. Since these concerns are of key importance for teenagers, it can be argued that the use of V.A.C.Â® Therapy in an outpatient setting may be advantageous for such patients.
A 15-year-old boy presented with an ongoing fistulating pilonidal sinus in his ano-genital region, which had been present for approximately 18 months. The area was producing a continuous, offensive exudate that had caused him to withdraw from all sports and was affecting his school and social life. The area had previously been treated by performing a daily wash-out of the wound during showering and the application of a diluted iodine solution (Betadine) and dry gauze dressings.
After staining with methylen blue, the fistula network was excised under general anaesthesia (see Figure 1 and Figure 2). After meticulous cleansing of the wound, a V.A.C.Â® foam dressing (V.A.C. GranufoamÂ®) was applied to the wound and the FreedomÂ® V.A.C. unit was used to apply continuous pressure at 125mmHg (see Figure 3). The V.A.C.Â® dressing was changed by the surgeon without anaesthesia every two days. On the third dressing change the patient reported having experienced a sudden leakage of increased exudate, and slough and debris were detected on the wound surface (see Figure 4).
The slough and debris were removed and a new V.A.C.Â® foam dressing applied. During the next dressing change, four days later, more slough was removed (see Figure 5 and Figure 6). After another two days of V.A.C.Â® Therapy the wound was clean and there was enough granulation tissue (see Figure 7) to perform secondary wound closure (see Figure 8). In total, V.A.C.Â® Therapy was used for 12 days. After removal of the drains the wound healed uneventfully (see Figure 9).
The patient was treated as an inpatient for the initial operation and at the point when the exudate, slough and debris were removed because these two procedures were performed under general anaesthesia. All other dressing changes were carried out without anaesthesia on a day-surgery basis, thus avoiding a long hospital stay, the costs this would involve and the impact on the patientâ€™s quality of life.
A literature review found that V.A.C.Â® Therapy is often a useful alternative to traditional treatment in these type of wounds because it supports granulation tissue formation, and provides continuous wound drainage    . Use of the V.A.C.Â® Therapy system markedly reduced the number of dressing changes needed. Former leakage problems, especially around the anus or an artificial anus have been solved by new gluing techniques, allowing patients to take showers again and resume a social life  . Better fixation around this sensitive and critical area improves patient comfort and care by reducing the risk of unwanted leakage of stool or discharge from the wound and the resulting malodour. The patient in this case study did not require such new gluing techniques.
The use of the V.A.C.Â® Therapy system offers many benefits and potential cost savings. The amount of time spent as an inpatient can be substantially reduced as shown in this case. In addition, potentially more patients could be managed on an outpatient basis .
In Austria and Switzerland, VAC therapy is used in this way with positive feedback from all parties involved      . The necessary requirements for a successful transfer in these countries include:
A correct diagnosis
A doctorâ€™s prescription for the V.A.C.Â® system
Complete wound documentation (including digital images)
A nursing care planning sheet   .
The patients have been in favour of the rapid return home the therapy enabled   , while the carers found the interdisciplinary team approach led to more effective and efficient care     .
Despite these obvious advantages, at present it is not routinely possible for inpatient-to-outpatient transfer of V.A.C.Â® Therapy for a paediatric surgical patient within the German health insurance system. This is because the Health Insurance Association states that it is unable to refund the cost of V.A.C.Â® Therapy until the federal decision authority has evaluated the therapy. The medical services department of the Health Insurance Association has also stated that the VAC technique has not yet been sufficiently evaluated. The use of single-case decisions, based on the evaluation of individual treatment needs, seems inappropriate . This approach is usually taken with new therapies, but using the V.A.C.Â® as an outpatient therapy is not a new treatment; it is simply the continuation of a successful and already well-established inpatient therapy  .
The German social law statute book states â€˜that any health insurance has to provide adequate, useful and economic care only and that care providers are not allowed to provide any unnecessary or uneconomic care to their patientsâ€™ . A major piece of research by Augustin et al  has shown that V.A.C.Â® Therapy does indeed provide adequate, useful and economic care.
Augustin et al performed a utility analysis of V.A.C.Â® Therapy from the patientsâ€™ point of view on behalf of the Institute for Quality and Economic Research in Healthcare. The authors undertook a prospective, open and uncontrolled multicentre study, using the short version of the validated Freiburg Life Quality Assessment patient questionnaire. The study involved 98 adults with acute and chronic wounds who had received V.A.C.Â® Therapy, and who were asked to fill in questionnaires at the start and end of treatment. Of the 176 completed questionnaires, all stated that V.A.C.Â® Therapy achieved the desired therapeutic goal and that the patients felt comfortable with the therapy. All experienced a significant increase in their quality of life .
It is hoped that the continuing successful use of V.A.C.Â® Therapy in the treatment of pilonidal sinus wounds on an inpatient basis will lead to the routine inpatient-to-outpatient transfer of this therapy in Germany before too long.
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