More About ... General Surgery

More about ... General surgery

The five common symptoms of Peri-anal haematoma anal disease is is caused by the rupture of a subcutaneous blood vessel in the peri- A Boutall,1 MB ChB, FCS (SA), Cert anal region and is sometimes incorrectly Gastroenterology, R J Baigrie,2 BSc, called an ‘external pile’. is purple pea- MB ChB, MD, FRCS (Eng) sized swelling is tender but not inamed. It is easily managed by scalpel incision 1Consultant Surgeon, Groote Schuur Hospital, aer instillation of local anaesthetic via an Cape Town, South Africa insulin syringe. Success is conrmed by the 2Professor of Surgery, Kingsbury and Groote expression of a blood clot and a grateful Schuur Hospitals, Cape Town, South Africa Fig. 1. Anal ssure with sentinel tag. patient. Scalpel incision should be reserved for acute lesions as delayed presentation Corresponding author: A Boutall (boutall@ anal. e symptoms are severe pain with results in a more diuse swelling which is icloud.com) point tenderness. Examination will reveal best managed conservatively. an obvious abscess or tender induration Pain and swelling. An internal or submucosal Anorectal cancer is is usually caused by: abscess is an unusual variant, which is Occasionally a low-lying cancer arising • anal ssure frequently missed because the peri-anal from the anus or rectum can cause severe • peri-anal abscess region appears normal. Digital examination anal pain due to sepsis or sphincter invasion • prolapsed thrombosed piles is exquisitely painful and mandates EUA. (Fig. 3). However, it is important to realise • peri-anal haematoma e management remains incision and that the absence of pain does not exclude • cancer invading the sphincters. drainage, with antibiotics occasionally used cancer. Any abnormality palpable in the as an adjunct to surgery in a few selected anal canal must be regarded as cancer until Anal fissure patients. An important point to remember proven otherwise. Internal haemorrhoids is typically presents with pain on when deciding to prescribe antibiotics is are not palpable on digital examination and defecation and blood spotting on toilet that, unlike other cutaneous abscesses, the are diagnosed with a proctoscope. paper. ese symptoms are due to an causative organisms are enteric ora and ischaemic mucosal ulcer within a high- not skin ora. Antibiotics that cover Gram- pressure sphincter. e ssure is usually negatives and anaerobes (e.g. co-amoxiclav) visible at inspection of the gently distracted are required. anus (Fig. 1). Defecation is exquisitely painful, ‘it’s like passing razor blades’, Acutely prolapsed thrombosed piles resulting in a cycle of fear of defecation, e primary symptom is severe pain, oen constipation, mucosal trauma and sphincter requiring hospital admission. Examination spasm. Digital examination is intolerable reveals a tender, oedematous, haemorrhoidal and should be avoided. Management mass protruding from the anus (Fig. 2), which requires laxatives, analgesia and internal is oen circumferential and occasionally sphincter relaxation, which can be achieved mistaken for a rectal prolapse. Treatment can with a nitrate ointment or a limited internal be conservative or surgical. A randomised sphincterotomy. Nitrate ointment applied to control trial comparing surgery to Fig. 3. Fistula with seton and abscess scar. the anus at least 3 times daily for 6 weeks conservative management demonstrated that is appropriate rst-line treatment. A mono- conservative management is appropriate for Prolapse nitrate ointment avoids the side-eect of many patients.[2] ree things may prolapse through the anus headaches associated with tri-nitrates. – polyps, the rectum and haemorrhoids, Persistent symptoms or atypical features, which are the most common. e treatment such as rolled edges or a lateral location, of prolapsing haemorrhoids is either require examination under anaesthetic rubber-band ligation as an outpatient (EUA) and biopsy. Botox has not been or surgical removal in theatre. Surgical shown to be superior to topical therapy.[1] removal provides durable results, but at the cost of signicant postoperative pain and Peri-anal abscess the possibility of surgical complications. ese develop from an obstructed anal Rubber-band ligation is ideal for grade 2 crypt gland at the dentate line. ey and 3 haemorrhoids and generally provides are named according to their location: excellent results, with very low morbidity ischiorectal (ischio-anal), peri-anal or intra- Fig. 2. Prolapsed thrombosed piles. (Table 1).[3]

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Table 1. Clinical ndings and treatment Classi cation Clinical ndings Treatment

Grade 1 Bleeding but no prolapse Stool soeners, reassurance Grade 2 Prolapse but reduces spontaneously Rubber-band ligation Grade 3 Prolapse requiring manual reduction Rubber-band ligation or haemorrhoidectomy Grade 4 Permanent prolapse Haemorrhoidectomy

Rectal prolapse is most commonly seen in anal complaint, and those with an underlying elderly women and occasionally in young sinister cause. Unfortunately both cancer and women, but is rare in men. e management haemorrhoids are common and can co-exist. is surgical, which can be via a perineal approach or an abdominal rectopexy, which All patients with anorectal bleeding require is well suited to the laparoscopic approach. a careful history, digital examination, proctoscopy and sigmoidoscopy. If the patient Discharge cannot tolerate this, then ssure or cancer is is a symptom of anal stula, mucosal/ is likely. A suspicion of cancer mandates haemorrhoidal prolapse or incontinence, an EUA. When a fissure is confidently which is beyond the scope of this article. Fig. 4. Anal squamous carcinoma. diagnosed, an examination can be avoided at Hidradenitis and pilonidal sinus are not the rst consultation. A failure of ssure to usually in the immediate peri-anal region opening is usually easy to identify and respond to topical therapy also mandates an but should also be considered. gentle pressure around the lesion will oen EUA. Remember ‘piles are impalpable’. produce a bead of pus. ese lesions can be Anal stulae present a major proctological associated with a cycle of abscess formation, Indications for colonoscopy in patients with challenge. e primary symptom is a spontaneous drainage and persistent rectal bleeding: purulent discharge from an external peri- discharge. Diagnosis of a cryptoglandular • no local cause identied anal opening. It is painless unless associated stula requires exclusion of Crohn’s disease, • a patient 50 years or older with an underlying abscess. Fistulae tuberculosis, or cancer. e majority of • any alert symptoms: result from a peri-anal abscess forming a stulae are supercial and can be laid open • change in bowel habit granulation-lined tract between the anal with the division of an inconsequential • loss of weight canal and the peri-anal skin. e external amount of sphincter. In complex stulae • iron deciency anaemia this approach can result in incontinence • family history of colorectal cancer. and other strategies are required. ese e yield of sinister pathology in patients include long-term seton drainage and/or under 50 is low. However, sinister ndings stulae repair such as mucosal advancement are possible in this group and a high index ap (Fig. 4). A steady stream of new repair of suspicion must be maintained. techniques is testimony to the demands of this challenging condition. Itch Pruritus ani refers to itching of the anus. Bleeding is troublesome symptom can be caused Bleeding per rectum (PR) is a common by many conditions but is most commonly complaint, which can range from a few self-inicted. Over-zealous cleaning can spots on the tissue to frank blood in the cause micro-abrasions of the delicate peri- toilet. Haemorrhoids classically present with anal skin and removal of protective oils bright red painless bleeding. Fissures and secreted by the anal glands, resulting in a bleeding due to excessive wiping (which cycle of inammation, irritation and itch. causes micro-abrasions) will result in blood History and examination will reveal any on the paper. Bleeding from the rectum underlying pathology. Particular attention or more proximally will present as altered should be paid to a history of dermatological blood mixed with the stool and mandates conditions and the use of potential allergens. colonoscopy. e common causes are cancer, Examination should focus on excluding colitis, a diverticular bleed or angiodysplasia. anatomical abnormalities like mucosal e major problem with PR bleeding is trying prolapse, skin tags, etc. to distinguish between those patients who can be safely diagnosed as having bleeding ‘ e anus thrives on neglect’ is a useful adage from haemorrhoids or another minor peri- when treating pruritus. Patients should be

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discouraged from repeated wiping and over- better quality of life for these patients than Patients are presented at a panel meeting, cleansing. Washing using a hand shower, dialysis. But transplantation in South Africa which consist of physicians, surgeons, sponge or cotton cloth should be encouraged. is far more than just kidney transplantation. transplant co-ordinators and other nursing Soap, topical preparations, toilet paper and Liver transplantation has become more sta as well as social workers and psychologists. tight-tting garments are discouraged.[4] common over the last 10 years, with In the state sector, where dialysis is limited, Donald Gordon Hospital expanding their patients will only be accepted for dialysis if Conclusion programme and now also oering living- they are also good transplant candidates. In • Piles are impalpable. related liver transplantation. In the Western the private sector there are patients on chronic • Digital examination is contraindicated Cape the liver transplant programme is dialysis programmes who are not eligible for in acute anal pain. based at Groote Schuur Hospital and Red transplantation. • Unexplained rectal bleeding requires Cross Children’s Hospital. A smaller kidney- colonoscopy. pancreas programme is running at Donald For kidney transplantation we have now • Peri-anal abscess requires surgery. Gordon Hospital – especially useful to type accepted a points system in most regions. • Cancer and haemorrhoids can co-exist. 1 diabetic patients with renal failure. Heart Patients are allocated points according to • Cancer can occur in the young. transplantation takes place in Johannesburg the following criteria: • ‘ e anus thrives on neglect.’ and Cape Town and lung transplantation • time on the waiting list forms a small, but important, part of the • age References country’s solid organ transplantation • previous transplants 1. Nelson RL, omas K, Morgan J, Jones A. Non programmes. • sensitisation surgical therapy for anal ssure. Cochrane Colorectal • other medical issues, e.g. a lack of vascular Group. Published online 15 Feb 2012. [http://dx.doi. How do we decide who gets on to the access on dialysis. org/10.1002/14651858.CD003431.pub3] deceased donor waiting list for organ 2. Allan A, Samad AJ, Mellon A, Marshal T. Prospective transplantation? When a donor becomes available all suitable randomised study of urgent haemorrhoidectomy In most regions there is now a shared recipients of that blood group will be cross- compared with non-operative treatment in the waiting list between state and private matched against the donor and the organ management of prolapsed thrombosed internal sector units for all solid organs. When a will be allocated according to the position haemorrhoids. Colorectal Disease 2006;8(1):41-45. patient approaches end-stage renal failure on the waiting list aer cross-matching. 3. Shanmugam V. Rubber band ligation versus and glomerular ltration rates are less than excisional haemorrhoidectomy for haemorrhoids. 10 ml/kg/h, the patient is eligible for a kidney For liver and heart transplantation the Cochrane Library Oct 2008 [http://dx.doi. transplant. However, the potential candidate waiting list is much shorter, and physicians org/10.1002/14651858.CD005034.pub2] must be t for such a procedure from a are able to allocate according to the patient’s 4. Schubert MC, Sridhar S, Schade RR, Wexner general and cardiac point of view as well. current clinical condition and urgency. SD. What every gastroenterologist needs to Only patients who can tolerate surgery and know about common anorectal disorders. World postoperative immunosuppression should Shortage of organs and ways to Journal of Gastroenterology 2009;15(26):3201- be listed. Waiting time for a kidney will expand organ utilisation 3209. [http://dx.doi.org/10.3748/wjg.15.3201] vary according to the patient’s blood group. Declining numbers of deceased donors is As O blood group is the most prevalent a big problem in transplantation in South among potential recipients, their waiting Africa. Despite an increasing waiting list Organ donation and time is the longest. O blood group livers and for solid organs, the number of transplants transplantation in South Africa hearts are oen used for patients with other annually remains stable in South Africa. In – an update compatible blood groups, but because of many centres living donation has become lengthy kidney transplant waiting lists only the mainstay of kidney transplantation. E Muller, MB ChB, MMed, MRCS O-positive recipients are cross-matched Although this is an acceptable alternative, (Edin), FCS (SA) against O-positive deceased donors. putting a living donor at risk is not an ideal

Department of Surgery, Groote Schuur Hospital, 15 Cape Town, South Africa 10

Corresponding author: E Muller (elmi.muller@uct. 5 ac.za) 0 South Africa has one of the highest incidences of renal failure in Africa. It is Jan Feb Sept Oct Dec April May June July Aug Nov estimated that we now have over 5 000 March patients with end-stage renal failure, and more than 2 500 of these patients are Total deaths Actual referrals awaiting transplantation. Transplantation is more cost-eective and provides a much Fig. 1. Total deaths versus actual referrals, Groote Schuur Hospital (2007).

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way of increasing organ availability. With of 300 deceased donors per year. A small and referral of brain-death donors in the the extent of renal disease present in our unpublished study comparing head injury Western Cape is huge. population, transplants will only increase if deaths with donor referrals was done by the deceased donation continues to grow. It is author at Groote Schuur Hospital in 2007. Because of a shortage of organ donors in the ethical responsibility of every medical Results showed that a signicant number South Africa constant eorts are made to doctor to refer potential deceased-organ of potential donors were not referred to improve public education around organ donors to transplant co-ordinators. transplant co-ordinators for discussion with donation and brain death. However, the family (Fig. 1). education among medical professionals is At Groote Schuur Hospital, the number of still lacking.[1,2] e introduction of a lecture referrals made for deceased donation has Table 1 reects a further breakdown of on organ donation and transplantation in declined over the last 10 years. is is a referrals of potential organ donors from the both the h and sixth year of study from result of more aggressive treatment of head dierent units to the transplant co-ordinators. 2009 at the University of Cape Town should injury and other neurosurgical patients with At Groote Schuur Hospital these referral help address this problem. a good prognosis and an earlier withdrawal rates vary tremendously, with the trauma of treatment in similar patients with a poor surgeons referring most of the potential Consent rates for organ donation are prognosis. Most suitable deceased donors donors. e option of having a hospital inuenced by religion, socio-economic status have a history of trauma to the head or policy of required referral is currently being and race. Consent rates in the private sector, medical conditions aecting the brain, such explored. is option would improve referral where the higher socio-economic groups are as subarachnoid haemorhage or isolated numbers, as it will force doctors to refer every situated, are much better than in the state brain conditions. potential donor to transplant co-ordinators. sector. In a recent comparison consent rates At Tygerberg Hospital fewer than 5 brain- in the private sector were between 80% and South Africa currently has the potential to death donors are certied and referred per 100% (Table 2). In the state sector consent almost double or triple our current number year. e potential to expand organ donation rates are as low as 30% (Table 3).

Table 1. Donor referrals at Groote Schuur Hospital 1991 1996 2001 2006 2011 Total Trauma unit 26 42 40 32 50 190 Emergency unit 7 1 3 1 7 19 Neurosurgical ICU 20 10 1 3 0 34 Other ICU 5 3 7 5 3 23 Other 3 3 Total 61 56 51 41 60

Table 2. Private sector consent rates Black Coloured White Private sector Number of Consent given Number of Consent given Number of Consent given Cape Town families asked N (%) families asked N (%) families asked N (%) 2001 0 - - 3 1 (33.3) 8 7 (87.5) 2006 1 1 (100) 4 3 (75) 12 12 (100) 2011 2 0 (0) 3 3 (100) 9 8 (88.8)

Table 3. State sector consent rates Black Coloured White Number of Consent given Number of Consent given Number of Consent given GSH families asked N (%) families asked N (%) families asked N (%) 1991 7 2 (28.5) 31 18 (58.0) 7 5 (71.4) 1996 13 7 (53.8) 21 17 (80.9) 10 8 (80.0) 2001 17 6 (35.2) 19 10 (52.6) 6 5 (83.3) 2006 7 0 (0) 19 6 (31.5) 2 2 (100) 2011 28 9 (32.1) 12 4 (33.3) 0 - -

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e Organ Donor Foundation of South Africa and the USA, DCD donor rates now equal the withdrawal of treatment will be discussed is constantly trying to improve consent rates the traditional brain-dead donor rates. with the family as part of the consent process. among the public through their educational outreach programmes. But it remains the In the case of a dismal prognosis and a e retrieving surgeon awaits the death of responsibility of transplant professionals to decision to withdraw treatment from a patient, the patient in theatre, ready and scrubbed in think of new ideas to get more donors and the treating physician is asked to consider order to shorten the warm ischaemic time. to make sure all referred donors are utilised. referring the patient to the transplant team as e operating theatre needs to be ready and a DCD donor. is is then followed up with prepared so that the body is transported Increasing organ donation and a conversation with the family and consent is to theatre immediately aer death. It is transplantation by using marginal obtained for organ donation aer cardiac or generally acceptable to allow the family 5 donors circulatory death. e family does not need minutes with the deceased before the body Many new programmes have been introduced to understand the concept of brain death – is moved to theatre. For practical purposes to improve organ donor numbers. e they are only asked for permission to use the this waiting period has a 2-hour cut-o time use of marginal donors is being explored patient as an organ donor once the patient’s at Groote Schuur Hospital. If the potential worldwide and, as a result, the threshold heart has stopped and circulation has ceased. donor does not arrest in this 2-hour period, for using patients with pre-existing medical organ retrieval aer death is abandoned. conditions as organ donors is getting lower. Aer death certication the patient is taken to theatre, where the kidneys are removed Although it is logistically a challenge, this South Africa has a huge HIV-positive and ushed with cold Euro Collins or Brett option is an excellent way of increasing organ population and for this reason an HIV- Schneider solution. A warm ischaemic time donation. At Groote Schuur Hospital we positive-to-positive transplant programme between 10 and 30 minutes is acceptable. Cold have done 15 transplants from DCD donors was started at Groote Schuur Hospital in ischaemic times should be kept to a minimum. to date. 2008 for HIV-positive patients with end- Machine preservation has improved the stage renal failure.[3,4] To date 22 patients have outcome of these kidneys elsewhere, but this received transplants, with good outcomes. is not yet available in South Africa. References 1. Sobnach S, Borkum M, Homan R, et al. Medical Donation after cardiac death – the Aer the family has given consent, a theatre students’ knowledge about organ transplantation: A South African perspective. Transplantation way forward in South Africa? is opened and prepared for organ retrieval. Proceedings 2010;42:3368-3371. [http://dx.doi. One way of increasing organ donation Inotropes, uids and ventilation are stopped org/10.1016/j.transproceed.2010.08.036] dramatically is to use patients after in the ward or unit. At Groote Schuur Hospital 2. Sobnach S, Borkum M, Millar AJW, et al. Attitudes circulatory death in a donation aer cardiac the family are reassured that this is not done and beliefs of South African medical students toward organ transplantation. Clin Transplant (Early view). death (DCD) programme. Patients who are because the patient will be an organ donor, [http://dx.doi,org/10.1111/j.1399-0012] not brain dead and possibly will not become but that this is our normal policy in the 3. Muller E, Barday Z, Mendelson M, et al. Renal brain dead can still give consent for organ case of head injury, namely that, because of transplantation between HIV-positive donors and donation aer cardiac death if they die of a resource limitations, we do not treat patients recipients justied. S Afr Med J 2012;102(6):497-498. suitable cause. In most European countries with a dismal prognosis with ventilation or 4. Muller E, Kahn D, Mendelson M. Renal transplantation between HIV-positive donor and this type of organ donation has expanded aggressive treatment. However, this should be recipients. N Engl J Med 2010;362(24):2336-2337. dramatically over the last 10 years. In Spain possible in the private sector as well, because [http://dx.doi.org/10.1056/NEJMc0900837]

Single suture Polio: e last salvo Will this be the end of an old foe? A new global assault on polio will involve the biggest roll-out of a vaccine ever attempted. Until now, the World Health Organization’s eradication drive has used a vaccine made from weakened live virus. It is cheap and eective, but the virus in it can sometimes revert to causing disease – and spread. Circulating vaccine-developed polio viruses (cVDPV) now cause more outbreaks of polio than wild viruses. e original plan was for every country to stop using live vaccine when wild polio disappeared, switching to a killed vaccine that would protect children as cVDPV died out. But if either virus returns aer that, we will need live vaccine to contain it. By then drug rms will not be making it, says Bruce Aylward, head of the WHO’s polio programme. e new plan, launched this week, is for the 140 countries at most risk of the polio resurgence to start giving the vaccine once the wild virus is largely gone. ey will also use live vaccine eective against 2 of polio’s 3 strains. Virtually all cVDPV is type 2 – which was eradicated in the wild in 1999. By using live vaccine made with types 1 and 3 countries can maintain immunity while cutting o the source of cVDPV. All 140 countries will have to switch vaccines at the same time. New Scientist, 18 May 2013

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