Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (55 page)

A pilonidal sinus arises from infection within a hair follicle, usually in the natal cleft. It is an acquired condition caused either by an ingrowing hair, which then sets up a local foreign body reaction, or by obstruction of a hair follicle, which then ruptures into the surrounding tissues. It affects twice as many men as women and is more common in the hirsute.
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In the Second World War it was known as ‘Jeep disease’ due to its prevalence amongst the drivers in the United States army. The usual emergency presentation of pilonidal disease is with an acutely inflamed tender swelling adjacent to the natal cleft. Midline pits are usually visible. The causative organism is, as with many skin infections, staphylococcus but mixed anaerobes are not infrequently cultured.
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In the emergency setting the objective of treatment is to drain the abscess, which usually relieves the acute symptoms and prevents spreading sepsis. Excision for the whole sinus tract at the same time as abscess drainage has been attempted but this has been associated with recurrence rates of up to 60%.
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In fact, primary drainage alone has a similar recurrence rate of around 50%,
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but with a much smaller initial wound.

A comparative study from Israel assessed 58 patients with acute pilonidal abscess; 29 patients were treated with incision and drainage, the other 29 with wide excision (without closure). The results are displayed in
Table 11.2
. The risk of recurrent pilonidal suppuration was similar between the two groups, although those who underwent excision had a longer time off work.
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It is therefore recommended that excision of the fistula tract is not undertaken synchronously.
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It is the authors' usual practice only to offer formal excision after the second presentation with a pilonidal abscess and this is always performed as a separate procedure after the acute sepsis has settled. To ensure optimum wound healing it is recommended that the incision is made away from the midline and, as with other abscesses, that packing the wound with dressings is avoided.

A primary anal fissure is a benign, superficial ulcer within the anal canal. Patients present with severe pain on defecation, which is caused by chemical irritation of the ulcer and spasm of the internal sphincter. Some patients will also complain of bright red bleeding caused by irritation of the ulcer bed. Although most patients with anal fissures will be seen in the outpatient clinic, some present acutely with an exacerbation of pain or just out of desperation with their chronic symptoms. It is often an easy diagnosis to make on inspection; gently parting the buttocks will usually reveal the lower edge of the fissure, most commonly in the posterior midline (6 o'clock) position.

The key to treatment is to stop the muscle spasm, which can be achieved by topical administration of smooth muscle relaxants such as glycerine trinitrate (GTN)
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or diltiazem,
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which reduce sphincter pressure and aid fissure healing. Diltiazem has a significantly lower side-effects profile than GTN and so should be used preferentially, if available.
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These treatments typically take weeks to exert their full effect, but one study has shown that they can be useful in the acute setting – most patients presenting with fissures are too sore to tolerate digital rectal examination but administration of sublingual GTN allowed 13 of the 16 patients to be examined.
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This allows more sinister pathology to be ruled out without recourse to admission and anaesthesia in some patients.

Medical treatment has excellent short-term results, leading to the healing of 90% of acute fissures without the need for surgery.
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However, the long-term outlook is less encouraging, with one meta-analysis showing recurrence rates of up to 50%.
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Lateral internal sphincterotomy (LIS) is much better at reducing recurrence (rates of about 2%) and although some studies have raised concerns about continence disturbance, it has been shown that a well-planned procedure in selected patients has very little effect on continence.
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,
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This, however, has no place in the acute setting and should be reserved for patients with chronic problems. Botox (botulinium toxin) injections into the internal sphincter are something of a middle ground, affecting a temporary sphincterotomy to allow fissure healing. These have again been mostly used for patients with chronic problems but a recent Eygptian randomised control trial has shown good results when used for acute fissures.
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It is important not to underestimate the pain caused by anal fissures and if patients are in pain for long periods of the day or unable to sleep at night an EUA should be performed to exclude occult sepsis and botox and local anaesthetic infiltrated into the internal sphincter and under the fissure, respectively, to provide symptomatic relief.

Haemorrhoidal disease is very common, causing symptoms in approximately 5% of the population.
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Haemorrhoids can be divided into internal, which originate above the dentate line, and external, which originate below the dentate line and are thus covered in mucosa and sensitive to pain. Although haemorrhoids are associated with symptoms including perianal irritation and small amounts of bleeding, they do not usually cause pain and uncomplicated haemorrhoidal disease is rarely seen as an emergency. However, external haemorrhoids can thrombose spontaneously (this process may be associated with straining to defecate), and internal haemorrhoids may prolapse, strangulate and thrombose. This thrombosis, with associated oedema and sometimes necrosis of the overlying mucosa, combines to cause exquisite tenderness such that patients are often unable to sit, walk or defecate.

These tense, tender, purple swellings can be seen by simply parting the buttocks. Although immensely painful they tend to resolve spontaneously after 4–5 days and therefore many surgeons advocate non-surgical management, the mainstays of which are good analgesia, laxatives and topical treatments such as nifedipine.
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The main argument for this approach is that surgical treatment of haemorrhoids is likely to be painful for about the same amount of time as for natural healing, with little significant advantage in the longer term. However, a review by the American Society of Colon and Rectal Surgeons suggests that although those who present after 72 hours of symptoms are best served by non-operative treatment, those who present before this time would benefit from excision of the external component.
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However, definitive emergency surgical treatment can be difficult as swollen, congested tissues distort normal anatomy and restrict views. Although many retrospective and case-controlled studies suggest that outcomes are favourable when emergency haemorrhoidectomy is performed by experienced surgeons,
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,
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the only prospective randomised controlled study to investigate this showed that non-operative treatment was associated with shorter hospital stay and less sphincter damage.
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If surgery is to be undertaken, several studies have shown that in the acute, as in the elective setting, a stapled procedure is associated with shorter hospital stays, reduced pain and earlier return to work.
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–
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One case–control study from Singapore compared 204 patients who underwent emergency haemorrhoidectomy with 500 who underwent an elective procedure during the same time period. They demonstrated no difference in any of the assessed end-points (haemorrhage, stricture, incontinence and portal pyaemia) between the two groups (see
Table 11.3
).
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