ANAL CONTINENCE AFTER HAEMORRHOIDECTOMY

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require prompt investigation. Are the beneficial effects on end-of-dose akinesia sustained, and will "triple therapy" -that is, levodopa with a peripheral decarboxylase inhibitor plus deprenyl-render the illness more benign, with longer symptom control and fewer late complications?

nique, the operation is probably best determined by experience and skills of the teams concerned.

the

ANAL CONTINENCE AFTER

HAEMORRHOIDECTOMY LIVING RELATED KIDNEY DONORS IN many American centres nearly half of all transplanted kidneys come from living relatives. For the recipients, such kidneys have considerable advantages over cadaveric organs -in terms of lower morbidity and mortality, and of better graft survival.1 In Europe the proportion is much lower (only 12% in the United Kingdom) and a survey2 of 148 centres showed that 22% regarded live donation as ethically unacceptable because of the risk to the donor. A further 15% had abandoned the practice after surgical or psychological complications in the donors or ’their families. If donorspecific blood transfusion of one-haplotype-matched family members fulfils its early promise,3,4 then the number ofrenalfailure patients with suitable family donors will increase substantially, and the pressure for intrafamilial transplants will increase. The risk to the donor is small, but deaths have occurred.5 In addition, although a successful outcome will often draw a family together, a failed transplant can be 6 psychologically damaging to both donor and recipient. What are the physical risks to the donor? With careful preoperative assessment it should be possible to exclude the patient with latent renal disease, but future disease or trauma cannot be predicted. The operative technique must be the safest available-safest, that is, for the donor. Urologists harvesting the left kidney have tended to use a posterior ribresection approach, while some general transplant surgeons (perhaps concerned with the risk of pleural opening) favour the anterior abdominal approach, which affords good access to the renal vessels and makes implantation easier.’ Some postoperative discomfort is inevitable, and complications such as urinary-tract infection and urinary retention may be acceptable; but worse complications are encountered in 1-8% of cases. With the posterior approach, the main hazards are opening of the pleura, chest infection, and serious wound infection;8 with the anterior approach the pleura is clearly safe but the spleen is not. Ruiz et al.’ had to remove the spleen in 23% of their donors because of inadvertent injury. Most donors have an untroubled course postoperatively and leave hospital after as little as a week. If wider use of live family donors is to be encouraged, potential donors and their families will need to be assured that transplantation has an excellent chance of success and that major surgical complications are very unlikely. As to tech1. Najarian JS, Simmons RL Complications of related kidney donation: technique, complications and results. Transplantation. Philadelphia. Lea & Febiger, 1972. 2. Brunner FP, Broyer M, Brynger H, Donckerwolcke RA, Jacobs C, Kramer P, Selwood NH, Wing AJ Proceedings of 18th meeting of European Dialysis and Transplantation Association Tunbridge Wells: Pitman, 1981 3. Salvatierra O, Amend W, Vincenti F, Potter D, Iuaki Y, Opelz G Pretreatment with donor-specific blood transfusions in related recipients with high MLC. Transplant Proc 1981; 13: 142-49. 4. Salvatierra O, Vincenti F, Amend W. Deliberate donor-specific blood transfusions prior to living related renal transplantation. A new approach. Ann Surg 1980; 192: 543-52 5.

Jacobs SC, McLaughlin AP, Halasz NH Live donor nephrectomy Urology 1975;

HAEMORRHOIDECTOMY had already declined in popularity before wide availability of simpler methods displaced it from primacy in the treatment of piles. Nonetheless it is a reputable and occasionally indispensable measure, so reservations about its use are worth airing. One is the complication of impaired continence reported as an unfortunate sequel.l-3 Its importance is hard to judge. First, standards of personal hygiene vary, making it difficult to formulate an acceptable definition of normality. Next, because the anal sphincter is part of a greater continence mechanism-other factors being the ano-rectal angle and the normal emptiness of the rectumminor dysfunction may show itself only under stress, diarrhoea. Further, the anus controls liquid, solid, and gaseous escape as well as rectal mucous seepage and any one aspect may be affected; to complicate matters, soiling can be both the consequence of haemorrhoids and the apparent result of their excision. Lastly, consideration must be given to the anal cushions (vascular pads, lining the internal sphincter, thought to assist the fine control of continence) in view of their aetiological relation to piles. Against this complex background Read et al. have tried, in a prospective study, to determine the severity of the complication and to understand its cause. They certainly spared no effort. Haemorrhoidectomy patients both preoperatively and postoperatively, and normal controls, were questioned about continence; anal manometry was then performed, sphincter function observed, and anal sensation noted; and finally the continence mechanism was stressed with a standard load of infused saline. The results are hard to interpret. The series was small (24 patients) and assorted. 10 patients had been treated before for their piles; 13, when they came to haemorrhoidectomy, had sphincter stretching as well; and 15 had anal functional impairment preoperatively. Finally, whereas their conclusion assigns to Milligan-Morgan haemorrhoidectomy a lower (10%) incidence of incontinence than previously reported, their overall figure-25% impaired to some extent, without evident inquiry concerning inadvertent passage of gas-suggests otherwise. Again, their view that the integrity of the anal cushions is unimportant in maintaining continence, which they conclude to be predominantly dependent on normal sphincter activity, is not entirely consistent with their results. After all, at least 6 of their patients did have symptomatic or objective impairment and all had postoperative sphincter pressures in the normal range. Perhaps the lesson is that with haemorrhoidectomy it is unnecessary slavishly to produce three pedicles in every case ("the operation’s over when it looks like a clover") but to remove only the one or two grossly disrupted cushions which warrant excision, dealing with lesser degrees of trouble by more conservative means.

say in

1. Bennett 2.

J Surg 1978; 65:

5:

175-77. 6. Kamstra-Hennen L, Beebe J, Stumms S. Ethical evaluation of related donation the donor after five years. Transplant Proc 1981, 13: 60-61. 7. Ruiz R, Novick AC, Braun WE, Montague DK, Stewart BH. Transperitoneal live donor nephrectomy. J Urol 1980; 123: 819. 8. DeMarco T, Amin M, Harty JI. Living donor nephrectomy: factors influencing morbidity J Urol 1982; 127: 1082-83

RC, Friedman MHW, Goligher JC. Late results of haemorrhoidectomy by ligature and excision. Br Med J 1963; ii: 216-19. El-Maguid Farag A. Pile suture a new technique for the treatment of haemorrhoids. Br

3. Read

293-95.

NW, Harford WV, Schmulen AC,

incontinence

and diarrhea.

the anus, rectum 1975: 35. 5. Read MG, Read NW, Haynes WG, Donnelly TC, Johnson AG A prospective study of the effect of haemorrhoidectomy on sphincter function and faecal continence. Br J Surg 1982; 69: 396-98. 4.

Goligher JC. Surgery of

al. A clinical study of patients with fecal 76: 747-56. and colon, 4th ed London: Baillière Tindall, et

Gastroenterology 1979;