Clinical Report: Delphi Consensus on EPSiT for Pilonidal Sinus Disease

Overview

This international Delphi consensus study, endorsed by the ALSGBI, aimed to standardize the use of endoscopic pilonidal sinus treatment (EPSiT) for pilonidal sinus disease (PD). Despite EPSiT's advantages over traditional surgery, its uptake remains limited, particularly in the UK. The study engaged expert surgeons to develop recommendations to improve EPSiT adoption and optimize patient outcomes.

Background

Pilonidal sinus disease is a chronic condition traditionally managed with open excision or flap techniques, which often result in complications such as poor wound healing, infection, and recurrence. Minimally invasive techniques like EPSiT and VAAPS, introduced in 2013 and 2014 respectively, offer reduced complications, less pain, and faster recovery. However, concerns about recurrence rates and lack of standardized protocols have limited widespread adoption. This Delphi study was initiated to address these gaps by gathering expert consensus on best practices for EPSiT.

Data Highlights

The study involved 29 invited expert surgeons practicing EPSiT, with at least 20 targeted for participation to ensure representation. Experts were defined as surgeons performing over 50 EPSiT cases. The Delphi process spanned from June 2023 to March 2024, incorporating literature review and patient input. Questionnaires covered preoperative, intraoperative, postoperative, modified techniques, and training domains using Likert scales and binary responses.

Key Findings

• EPSiT and VAAPS are considered interchangeable minimally invasive techniques for PD, performed under direct vision with small incisions and endoscopic equipment.
• Compared to conventional surgery, EPSiT reduces wound complications, postoperative pain, hospital stay, and accelerates return to daily activities, though recurrence rates are similar.
• Uptake of EPSiT remains low in the UK (~7% of cases), hindered by evolving evidence, lack of guidelines, surgeon training gaps, and procedural modifications causing ambiguity.
• The Delphi consensus aims to standardize EPSiT technique and postoperative management to improve adoption and outcomes.
• Patient involvement confirmed the relevance and positive reception of the study's aims and methodology.
• Expert consensus development included systematic literature review and structured questionnaires addressing all phases of care and training needs.

Clinical Implications

Clinicians should consider EPSiT as a minimally invasive alternative for managing pilonidal sinus disease, especially in limited disease cases, given its favorable complication profile and recovery benefits. Standardized protocols and surgeon training are essential to increase uptake and ensure consistent outcomes. Incorporating patient perspectives and evidence-based consensus can guide clinical decision-making and improve quality of care.

Conclusion

This Delphi consensus provides a foundational framework to standardize EPSiT use in pilonidal sinus disease, addressing current barriers to adoption. With endorsement from ALSGBI and expert input, it supports wider implementation of this minimally invasive technique to enhance patient outcomes.

References

1. Association of Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI) -- Utilization of EPSiT for Pilonidal Sinus Disease: An International Delphi Consensus Study