Who Am I?
In the medical profession, we are the butt of all jokes. But many times we are needed. The purpose of this Blog is to educate the public on who to turn to in a time of need. When someone has a colorectal issue usually it is an embarrassing topic; therefore, it is important to visit a surgeon with the proper skills and training who can help.
This is especially important in Israel where it is not so clear which doctors are actually trained or skilled in the advertised profession. It is just as important to know that there is a surgeon who speaks your language and knows your culture.
I am one of the few USA fellowship trained, Board Certified General and Colon & Rectal Surgeons in Israel. I earned my medical degree at New York Medical College and completed my General Surgery residency at North Shore-Long Island Jewish Medical Center, including a final year as Chief Resident in Surgery. I acquired additional specialty training during a fellowship in Colon and Rectal Surgery at the Georgia Colon and Rectal Surgical Clinic. I have a strong interest in offering care for all aspects of the prevention and treatment of colon and rectal conditions.
I made Aliyah with my family to Israel in July 2013 from Atlanta, Georgia, USA. I worked for 2 years as a full time CRS surgeon at Georgia Colon and Rectal Surgical Associates. Afterwards, I established the colorectal surgery division at Atlanta Medical Center; I was there for 4 years. At that time I acquired the designations of Clinical Assistant Professor of Surgery at the Medical College of Georgia and Clinical Associate Professor of Surgery at the Ross University School of Medicine. I also participated in a CBS Television infomercial for Colorectal Cancer Awareness Month.
Currently I am on the full time teaching faculty of the General Surgery Department at Kaplan Medical Center in Rehovot, which is affiliated with Hadassah Medical School. I am also an associate of Assia Medical group located in Tel Aviv and operate at Assuta and Herzlia Hospitals.
Through my blogs I intend to educate the public on many common issues in my field. This blog will start with a common condition of young people, especially soldiers in the IDF — Pilonidal Disease. In Hebrew called ” pee-lo-nidal see-nus” or “se`ar hafucha” (ingrown hair).
Pilonidal Disease is a common infective process occurring in the lower back in the “butt crack” or natal cleft. It mainly affects young adults and teenagers. In the military, this is a major concern. For example, during World War II over 77,000 US Army soldiers were hospitalized for treatment of pilonidal disease, NOT due to battle trauma! The condition was termed “jeep seat” or “Jeep riders’ disease”, because a large portion of people who were being hospitalized for it rode in Jeeps, and prolonged rides in the bumpy vehicles were believed to have caused the condition due to irritation and pressure on the coccyx.
This condition was named “pilonidal disease” by a USA surgeon, Dr. Richard Hodges in 1880. The term means “nest of hair,” because the sinus cavity usually contains hair. The word “cyst” is a misnomer, since there is no epithelialized wall, the proper term is pilonidal disease or sinus.
This condition is more common in boys than girls. It is also found in those with increased body hair, family history , obesity, history of trauma and sedentary occupation (prolonged sitting).
Pilonidal Disease, is an acquired and not congenital condition, as once thought. The theory of how this problem begins is with an obstruction of hair follicles. Then the hair follicle becomes enlarged, ruptures and turns into an abscess or sinus. The disease is perpetuated by hair entering the skin pits. The midline pits that ensue communicate with a chronic abscess cavity which commonly contains hair. These pits need to be excised in order to have a cure.
Conservative therapy includes shaving the natal cleft, good hygiene and a lateral incision to drain the abscess (NOT antibiotics alone). There is a minimal invasive surgery technique to just remove the midline pits with a 90% cure rate. Thus, it makes sense to start with this procedure if possible.
Once there is a large chronic sinus cavity with either pus or hair a more invasive approach is usually needed. A commonly practiced old technique is a wide excision of the entire abscess cavity and pits (unroofing with secondary healing), leaving a large slow to heal elliptical wound. This has a 13% recurrence rate. The wound should never be sutured closed in the midline, since this has a high recurrence and infection rate. Unroofing with secondary healing, also has the disadvantage of a large slow healing wound with daily wound care for months.
There are several flap based operations described especially for recurrent disease. It makes no sense to repeat an unroofing procedure a second time if it did not work the first time. This is commonly done by surgeons. To quote Albert Einstein: “Insanity is doing the same thing over and over again and expecting different results.” Based upon the surgical literature and my experience, the best option, especially for recurrent disease, is to perform the technique of the Bascom Cleft Lift with a 96% healing rate.
There are only a few surgeons in Israel who perform this technique. The purpose of the Bascom procedure is to obliterate the cleft, excise the midline pits, cover the wound with a gluteal flap and keep the suture line off the midline. This was first described in 2002 in the Archives of Surgery Journal. Evidence based medicine is in favor of using an off midline flap to cure this disease.
A Cochrane evidence based medicine review in 2011 concluded:
- There is NO benefit to leave the wound open
- There IS a clear benefit to use an off-midline closure
- Off-midline closure should be the standard management
However, most surgeons still perform excision leaving a large open wound. In the colorectal surgery journal called the DCR (Diseases in Colon in Rectum) in 2012 , an editorial on this topic concluded, “There is no place for simple excision of Pilonidal Disease and a midline closure because of the poor outcomes.” The stated reason why most surgeons still using outdated techniques is because they did not have any formal training in flap based reconstructions. Therefore the editorial in the DCR concluded, “…hand over management of Pilonidal Disease to… colleagues… who have… training …of flap-based surgery.”
This can be a very debilitation and embarrassing condition. I have seen many young patients in the USA and recently in Israel who are looking for the most up to date treatment of this condition.