Surgery for HS
Watch Professor Falk Bechara discuss the use of surgery in hidradenitis suppurativa (HS), including his thoughts on when surgery should be performed and the short-term future of the treatment landscape.
HS is a specific disease, not only to its course of the disease, but also due to the fact that over time the disease shifts from inflammation to tissue destruction. And once the disease has reached that point, irreversibly damaged tissue can only be removed via surgery. That's the reason why surgery is playing such an important role in the holistic treatment approach of the disease. Well, if you think about the performance of surgery, there are two different types or indications for sure. Even in early disease, if there is a acute abscess formation, you would need a minimal surgical procedure such as incision and drainage or deroofing, for example. And there the goal is to relieve pain. But normally the indication for surgery is the irreversibly damaged tissue, which consists of scars and fistulas in HS. And once you have those lesions, you have a clear indication to excise those. Well, I think there are different barriers when it comes to surgery. I guess if you look at the patient, there's definitely a barrier for a lot of patients to undergo surgery because they had maybe insufficient or inadequate surgery before. So it takes time, and you really have to explain to the patient why surgery is necessary and clearly make sure what is the goal of your surgical procedures. On the other side, once the patient is willing to undergo the procedure, we still face the barrier that there are not a lot of highly experienced surgical centres. So unfortunately in a lot of countries, surgery is not really dealing with HS. And quite sometimes surgeons are not too interested in the disease. And I think these two points are really forming together the whole barrier of surgery nature. Well, the first barrier is really you have to be, you have to show empathy to the patient. I mean, you have to understand why probably he does not want to undergo surgery, probably too bad experience in the past. And you have to do your job and you have to explain clearly why the surgery is so important. The other barrier is even more complex in my opinion. And I think it takes a lot of work, but it's worth to go into intense cooperation with surgical disciplines to find surgeons who are somehow dedicated and interested in the disease and to start just to cooperate. And I think that's, it's long way, but it's worth going in.
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The question of recurrence and the story of recurrence is quite complicated because we have to admit that until today, there's honestly no perfect definition of the word recurrence after surgery. However, we know that recurrence, if we, for example, talk about a recurring lesion within a surgical scar or in a specific distance to the surgical scar, depends on the aggressiveness of surgery, it depends a little bit on the anatomic area and also on the quality of your surgeon. So there's a huge variety in recurrence rate really ranging from 5 to 50, 60%. So it's still a very individual story and has to be explained intensely with the patient before the surgery. Well, I guess first of all, we need a clear definition because only if you have a clear definition, you can compare study data or data in the literature. And the second point is, I strongly believe in patients where you have a high inflammatory load, surgery alone is maybe not the complete solution. So we have to talk about the holistic approach, a combined approach of medical and surgical treatment. We have to understand that after surgery, the story is not over, we are talking about the systemic disease. And so quite often patients need an additional medical treatment to control the inflammatory load. And I'm confident that this will reduce the number of recurrences significantly. Well, first of all, I think we strongly need more studies which reflect daily routine, meaning the combination of surgery and medical treatment. We have to go into studies where we can see what potentially a medication can do in regard to the surgical area and size, it may be possible to reduce the surgical size. Then the question about recurrence, what is happening to patients who have the combination? These are very interesting studies. And I also see a trend to more maybe lesion-adapted therapy, meaning, so we step away a little bit from those extensive aggressive prophylactic surgeries. I mean, if they are necessary, they have to be done. But to go more to an identification of really irreversible, destructive tissue, makes surgeries as small as possible. And I think that's the direction where the studies and the story is going.
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Well, I personally think that we get more and more adequate medications for that terrifying disease, so we clearly see we have a huge number of ongoing clinical trials. We have seen very positive results in short-term, but also more and more long-term results. And that's tremendously important to augment the armamentarium of medical options. I think maybe as an expert sometimes you tend to think that everybody should know about the disease, but in the broader medical community, the knowledge about HS is still, I would, say small. So I think it's a very important effort to raise awareness, to bring the disease to the mindset of more medical disciplines, because you can only diagnose what you know and you can only treat what you've diagnosed, so I think that's extremely important.
Professor Bechara shares his thoughts on the short-term future of the treatment landscape and stresses the importance of education in HS. View transcript .
