Scott Webb (Host): Pilonidal disease is common and often painful. An Emerson Health General surgeon, Dr. Chris Schlieve, is here today to tell us who's affected most by the disease and how we can help using the minimally invasive surgical techniques that Emerson Health is known for.

Host: This is the Health Works Here Podcast from Emerson Health. I'm Scott Webb. Doctor, thanks so much for your time today. We're going to talk about pilonidal disease. And as I was just mentioning to you, this is a new one for me and maybe for listeners as well. So, let's just start here. What is pilonidal disease?

Dr. Chris Schlieve: It's a condition that affects the upper part of the buttocks right near the tailbone, and it's essentially characterized by this formation of a cyst and, typically, a sinus tract or a little communication from the skin down to the area of where the cyst or this little bubble is near the tailbone. And these can cause pain, swelling, discomfort, drainage. It's more often commonly found in young adults and children. It typically affects men more frequently than women.

The exact cause of the disease is not well understood. But typically, it's believed that it results from a combination of factors. One theory is that these are caused by ingrown hairs and that these ingrown hairs in that area near the tailbone begin to recede down into the tissue near the area of the tailbone. And as they recede and they grow over time, these can often become infected, which leads to the pain and discomfort that patients have. Another theory though is that these small cysts are just there congenitally, meaning that they're present at birth, and that the cyst just slowly grows and develops over time as we grow in age as well.

So, the symptoms of the disease can vary really in severity. Initially, you know, there may not even be noticeable symptoms. Patients may just feel a little small bump near their tailbone. It's uncomfortable to sit on. But this can be gradually, you know, experienced or the patients can have worsening pain, swelling, tenderness and drainage in that area. So, it is something that can start out as a very indiscreet problem, but can become something very great later on.

Host: Yeah, I told you that just to sort of educate myself a little bit before we got on, I watched some videos and have a sort of a little bit of an understanding anyway, and it does seem fairly common and, in some folks, fairly painful. So, let's talk about the options for treatment. Is it some nonsurgical stuff first and then you move to surgery? How does that work?

Dr. Chris Schlieve: So, the treatment options can vary pretty widely, especially for patients who have relatively asymptomatic cysts, meaning that they just feel the cyst there. It's not really causing them any problems or any discomfort. In those cases, oftentimes we can just watch to see whether or not these become a problem, whether or not they grow larger in size and take a more conservative approach. A lot of the things around that conservative management is really just maintaining good hygiene, keeping the area clean and dry, trying to avoid doing activities that put pressure or friction on the affected area. And that sort of brings up, you know, the certain risk factors that go into this disease as well. And that sometimes this runs in families, being overweight can be a contribution, having a sedentary lifestyle or engaging in activities where there's prolonged sitting or friction on the area or poor hygiene. A lot of those things can contribute to having worsening disease in that area. So, those are things that we do try and focus on with patients, especially if they're very early on in that disease process and aren't really pushed towards surgery.

Another nice option is, again, with this theoretically being attributed to hair follicles in the area, oftentimes, you know, even with or without surgery, we do recommend that patients undergo laser hair removal treatment to try and address those follicles that are remaining along that area to try and prevent future cysts from occurring or recurrence after the disease has been removed surgically.

Host: Yeah. So, let's talk about the patient experience, if you will, when it comes to surgery. What's involved, what's it like and what's the recovery time?

Dr. Chris Schlieve: So, I'll go into some of the surgical options first that I think will lead me down into the road of what we do care-wise afterwards. So, there are several different approaches as far as the surgical management of the disease.

So, one thing we often see commonly in the office is we have patients who come in with acute symptoms related to pain and infection. So oftentimes in that setting, we can't truly remove the disease at that time, but we need to treat the infection. And so, what that procedure is called is an incision and drainage. And essentially, it's a relatively simple procedure that's, again, performed generally in the office using some local anesthetic medicine to numb the area of where the disease is. And then, we make a small incision usually overlying the area where the cyst is to drain the fluid and the infection out of the cyst. And so, what that does is it helps treat the infection. It also relieves the pressure-associated discomfort that patients have. The wound is generally left open in order to heal from the inside out. Typically, there'll be a short course of antibiotics that are prescribed to treat that area and infection as it heals. But again, the incision and drainage doesn't cure the pilonidal disease. It's really just aimed at treating the symptoms from the infection in order to move forward towards an ultimate cure for the procedure.

So, the most commonly performed procedure by many general surgeons is just a local excision and closure, and what that typically means is it's generally done in the operating room where the patient is fully asleep, the area of the cysts and any communication tracks to the skin are removed in sort of a wide incision that takes the cysts, all tracks and some surrounding tissue. If the disease is not extensive, it's just closed at that time with sutures and it's relatively a pretty quick recovery thereafter with minimal pain or discomfort.

However, many patients have more extensive disease that's underneath that really isn't seen necessarily on exam. And so, those procedures are not amenable to essentially a single surgery in the sense that we oftentimes can't close at the same time. And sometimes the excision is done where the wound is left open, and then over several weeks, the body naturally heals those tissues closed. However, as you can imagine, that's a lot of weeks of wound care and other things, and that's not necessarily ideal for most patients.

So, there are several more advanced options that can be taken and that leads us into what are called flap procedures, which is essentially the area of the disease is removed, taken away. But in order to close the area of the defect, we take native tissue, so native fat and skin within the area, and we transpose those to an overlying area and are able to close. That is more of a complicated surgery. There can be a hospital stay that's associated with that in order to do the surgery. But what's great about all of these options that have been offered to patients, this has now led us into the area of more minimally invasive approaches, which is what we tend to take here at Emerson. And I'll kind of go into that more specifically because this new surgery has really sort of changed the treatment paradigm for many patients and has led to a better quality of life after surgery.

So just like the advent of minimally invasive surgery or laparoscopic surgery where we do tiny incisions and we're able to do big surgeries inside through little tiny incisions, we can now do that with pilonidal disease. And so, rather than making a big excision, removing a bunch of healthy tissue and tissue that's diseased, we can now take small instruments and core out just the areas of disease. So, go down the tracks, identify the cyst on the inside using tiny instruments and removing the bad tissue, and leaving a lot of the remaining healthy tissue. This is known as a Gips procedure, or also they call it pit-picking surgery. And again, what's great is that in this case, rather than weeks to months of wound care, patients are going back to their normal activities within a few days, pain control with Tylenol, minimal dressing changes for a week or two, and most people are going back to all their normal activities within a couple days after surgery. So, this has really dramatically changed the way we approach this disease and it's, you know, not being offered at all centers. And I think that's something that we pride ourself here in Emerson in doing is trying to offer, you know, the latest techniques to patients in the community.

Host: Yeah, it's really amazing. What would you want parents to know if their child has this disease? What would you most want them to know?

Dr. Chris Schlieve: So, I think especially with this disease, there are many different ways to approach it and there's different severities of the disease. But I think in children, really this minimally invasive approach that's now being offered and this is something that I learned to do when I was at the Children's Hospital in Colorado. Really, you know, this has led to a better option and recovery for both the child as well as care for the parents to give afterwards.

You know, there are many patients and, for very understandable reasons, where the traditional approaches, that was a pretty dramatic way to be treating the disease. And when you have a young child with this type of disease, to be doing, you know, daily dressing changes that can be quite painful and waiting for weeks and months for things to heal, you know, there are many patients, both children and adults who would forgo even having this disease treated in a surgical manner just because this procedure wasn't necessarily offered the minimally invasive approach.

And so, I think for parents to know, you know, we're in a very fortunate part of the country where there are many great medical centers throughout the state and the region. But in anything that you're being offered treatment-wise to really ask your provider, you know, what are the options? Are there options that can be provided elsewhere that may not be provided here? You should always be fully educated on, you know, certain situations may not be offered at the place that you're providing care for, and to know that you're getting the most advanced care, and I think that's exceptionally important, especially in kids.

Host: Yeah. As a parent myself, absolutely. I want to give you an opportunity just to tell us a little bit about yourself. You know, as a pediatric and adult general surgeon, what are some of the other common surgeries that you do?

Dr. Chris Schlieve: So, I am a general surgeon. It's one of the reasons I was attracted to both pediatric general surgery and adult general surgery, was to be able to operate and treat a variety of conditions. And, you know, the community setting has been very important to me in that it allows me the time to be able to connect with my patients' families and really be able to sit down and have important conversations with them and involve them in their care, which sometimes can get lost in much larger settings. To connect with families and children, it's wonderful, right? It's an exceptional opportunity to work together as a team in taking care of the patient. And kids are fun, right? Every different stage of their life, there are different hobbies, talents, you know, engagements that they have, and it keeps you young, right? I still feel that I'm a kid at heart and it's very easy for me to connect with children and it provides a very different perspective than, you know, in the adult setting. While, again, I love my adult patients and what I'm able to offer, the kids really bring a different scope to the table.

So, I do, again, generally all over the body, so lumps and bumps, hernias, gallbladders, colon surgery. I'm also part of the breast cancer health program here, so I do the oncologic, breast resections. So again, a very, very wide approach to my practice here at Emerson. But in children, it's traditionally hernias. I do a lot of pilonidal disease. I have many, many pediatrician groups referring to the area specifically because of offering that Gips minimally invasive procedure, gallbladders, you know, et cetera, the whole gamut. So really, it's a great place to be able to provide all of these services in the community setting. We have really great places in this area, but there are things we can always offer in the community setting that for a lot of parents, I think, is helpful in being able to stay home.

Host: Yeah. Absolutely. Well, it's been nice to get to know you today, learn more about what you do, how you do it, why you do it, and so on. And especially learn more about pilonidal disease, which as it turns out, you know much to my amazement, it's much more common than I realized it was. There's different sort of varieties and it affects people in different ways and there's different surgical options. And then, of course, you there at Emerson Health, doing the minimally invasive laparoscopic surgery. So, good stuff today. Thank you so much. And you stay well.

Dr. Chris Schlieve: You too. Appreciate the talk.

Host: And call 978-287-3547 or visit emersonhealth.org/surgery for more information or to make an appointment. And thanks for listening to Emerson's Health Works Here podcast. I'm Scott Webb. And make sure to catch the next episode by subscribing to the Health Works Here Podcast on Apple, Google, Spotify or wherever podcasts can be heard.