The surgery of filariasis

Wuchereria bancrofti and Brugia malayi, or W. timori behave in a similar, but not identical, way. The acute lesions they cause may mimic other diseases, so, if yours is an endemic area, keep the possibility of filariasis in mind. The first two stages are common, but filarial elephantiasis is not.

The acute stage starts within a few months of infection, as fever, lymphadenopathy, erythema, and epididymitis, usually without microfilariae in the blood. Secondary infection may occur.

The subacute stage is characterized by fever and enlarged tender lymph nodes, which persist and are accompanied by lymphangitis. The inguinal, epitrochlear, and axillary nodes are commonly involved. Lymphangitis presents as a shiny area, radiating distally from the involved lymph nodes, usually down the front or medial aspect of the thigh, or round the anterior axillary fold towards the breast. Attacks may be repeated every few months. The lesions may also be infected secondarily, so that both the affected lymph nodes and the areas of lymphangitis may suppurate to form abscesses.

A patient's spermatic cord is often infected, and also his testes and epididymes, so that he has painful recurrent attacks of funiculo-epididymo-orchitis, which may be followed by suppuration in his scrotum.

Synovitis and arthritis also occur.

The chronic stage is the result of lymphatic obstruction, commonly in the retroperitoneum. This can cause:

(1) Lymphoedema, which may progress to gross hypertrophy of his subcutaneous tissues (elephantiasis). This may involve his lower limbs and scrotum (common), or the arm, breast, or abdominal wall (less common), or the axillary or inguinal nodes (rare). No known treatment will reverse these changes. There is little you can do surgically except to excise the swellings; when you have done so, they may recur in a few years, or even a few ]]months. Charles' operation is described; its immediate results may be acceptable, but its final results may be worse than before, and are said not to stand up to the wear and tear of village life. The surgery of elephantiasis is unsatisfactory, the account we give of Charles' operation is the classical one, and we were unable to find any recent ''experts'.

(2) Hydroceles, which are common in areas of Bancroftian filariasis (23.23). Treat these as usual.

(3) Lymphatic varices (uncommon). These are soft cystic swellings in his axilla, neck, or groin.

(4) Chyluria (not uncommon, 23.30), due to rupture of dilated lymphatics into his urinary tract.

Banjara BP. ''Surgery for massive lymphoedema of the legs'. The Proceedings of the Association of Surgeons of East Africa 1982;5:79[nd]81.[-3] de Souza LJ, ''Rarer surgical aspects of filariasis'. East African Medical Journal 1964;41:413[nd]8.

FILARIASIS SPECIAL TESTS. (1) The microfilariae of W. bancrofti are usually present in blood films taken between 10 pm and 2 am. B. malayi may be semiperiodic, or nonperiodic. Take fresh blood into an anticoagulant, and look for motile microfilaria under a coverslip. (2) Puncture an enlarged node, or lymphatic varix, with a needle, and look for filariae in the small volume of fluid you aspirate.

VARIOUS FILARIAL SYNDROMES See elsewhere for hydroceles (23.23) and chyluria (23.30).

If the patient's inguinal or axillary nodes are involved (rare), treat him medically and don't operate, or a troublesome fistula discharging lymph may result.

If his spermatic cord is involved (''endemic funiculitis'), don't mistake this for a strangulated hernia (14.6), or torsion of the testis (23.24).

If he complains of a painful swelling ''like a bag of worms' above his testis, one possibility is a varicoele, and another is a lymphocele of the cord (E, Fig. 31-5). At operation you may see distended lymphatics, not distended veins.

If the swelling in his cord is like a hen's egg, it may be an hydrocele of his cord, or an encysted lymphocele (F). If gentle traction on his testis moves the swelling downwards, and makes it less mobile, it is a hydrocele. Otherwise, in an endemic area it is a lymphocele. At operation it will be connected to lymphatics in his cord. The combination of an encysted lymphocele and funiculitis may simulate a strangulated hernia closely.

If he presents as an acute abdominal emergency with inguinal pain, you may find no other pathology except inguinal adenitis, and dilated lymphatics beside his testicular vessels. Secondary infection of the lymphatics is said to lead to retroperitoneal abscesses and peritonitis.

THE LEG [s7]IN FILARIASIS If the disease is not too advanced, reduce the lymphoedema by prolonged firm bandaging; then prevent further swelling by supporting the tissues permanently. Intermittent positive pressure methods, as with podoconiosis (31.5), reduce the oedema very effectively. A patient who could no longer walk may now be able to do so.

Alternatively, put him to bed and bandage his leg with crepe bandages from his foot upwards, using sponge rubber to protect his tissues from too tight bandaging. Remove the bandages every day, and replace them a little tighter. When you have reduced the swelling, fit a spiral elastic stocking (Dickson Wright).

If the disease is advanced, mobilize the oedema fluid by initial elastic compression, and then consider the operation below. Its benefit is said to be temporary only, although episodes of lymphangitis and cellulitis may be reduced. Afterwards his leg needs lifelong elastic compression, or the swelling will recur.

CAUTION ! Diuretics, steroids, and antibiotics are useless!

Fig. 31-6 CHARLES' OPERATION for elephantiasis. A, suspend the patient's leg and apply a tourniquet. B, incise the thickened tissue and reflect it. C, his leg ready for grafting. D, grafts sewn in place. E, both his legs originally looked like this. F, his left leg after surgery. G, using a scalpel to cut a graft from the excised tissue. H, doing the same with a Humby knife. You will probably find it easier to cut grafts while his skin is still on his leg.

CHARLES' OPERATION [s7](modified) INDICATIONS. Massive solid lymphoedema (elephantiasis) of the lower leg, from any cause, which has not responded to other treatments. The method which follows is for the patient shown in Fig. 31-6. If the swelling has a different distribution, modify the operation accordingly.

PREPARATION. Admit him several days beforehand, and scrub the part twice daily to get his ''mossy foot' (if he has one) really clean. Find a colleague to prepare the skin grafts while you are stripping his leg.

If both his legs are involved, operate on one leg at a time, but prepare both, in case you need to obtain grafts from the other one. Have three units of blood ready. Pass a Steinmann pin through his calcaneus, fix it to a stirrup and attach this to the ceiling light.

METHOD. Apply a tourniquet to his upper thigh. Mark the proximal limit of the excision by two lines going distally, medially, and laterally from his tibial tubercle, to form a triangle on both sides. Make the distal limit the base of his toes, but exclude the sole of his foot and his tendo Achilles.

Use a Humby knife to take long, wide partial-thickness skin grafts from the skin over the area to be excised. Keep these grafts in saline, until you apply them. Don't take grafts from ]]fissured, or warty or eczematous skin.

Make a medial longitudinal incision from the distal incision to the base of his great toe, and deepen it to his deep fascia. Make a lateral incision to the base of his 5th toe. Raise flaps by a combination of sharp and blunt dissection on either side of the incision in the same plane. Excise the whole area of skin and subcutaneous tissue, down to the deep fascia between the incisions. Tie his long and short saphenous veins at the level of the proximal incision. Tie any other vessels as you meet them. Incise his deep fascia longitudinally in 2 or 3 places to establish communication between his muscle lymphatics, and the skin grafts.

CAUTION ! (1) Leave his knee, or it may stiffen. (2) To obtain good haemostasis and prevent recurrence, excise his subcutaneous tissue completely.

Control bleeding by tying abdominal packs over his deep fascia. Release the tourniquet, and compress his leg between your hands for about 7 minutes. Gradually remove the packs, working from the distal area proximally, cauterizing or tying vessels as you meet them.

Graft the raw area with split skin (57.2) taken from the elephantoid skin you have removed, where this is not too warty. You can: (1) cut very thin full-thickness skin grafts with a scalpel, keeping as close to the surface as you can. Or, (2) you can cut the excised tissue into very long slabs, and then cut grafts from these slabs with a skin-graft knife.

Lay skin grafts over the raw surface, and stitch them in place with 2/0 or 3/0 chromic catgut. There is no need to cover the whole surface: epithelium will soon grow across any small bare areas. If necessary, use mesh or patch grafts (57-6). Cover the whole area with ''Vaseline' gauze, plain gauze, and a thick layer of cotton wool secured with crepe bandages.

Keep his leg suspended from the Steinmann pin. Change the dressings on the seventh postoperative day. Where the grafts have taken, cover them only with ''Vaseline' gauze and a sterile towel. Remove the Steinmann pin at 3 weeks and allow him up. Advise him to use an elastic stocking, or bandage, for at least a year.

AMPUTATION. Don't amputate if you can avoid it (Chapter 56).

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