[Ovarian carcinoid tumor responsible of permanent facial erythrosis and flushings during sexual intercourse]

INTRODUCTION

Ovarian neuroendocrine tumors are extremely rare. In the ovary, the term of neuroendocrine tumor is usually related to carcinoid tumors although it may be sometimes applied to neuroendocrine carcinomas of non-small cells or small cells cancers usually occurring in the lungs. These carcinoid tumors may develop de novo or from other tumors including teratomas.

CASE REPORT

We report a patient who presented with an ovarian carcinoid tumor developed, near or from a dermoid cyst, which was original by its mode of discovery in the dermatology department. Indeed, the patient consulted because of permanent facial erythrosis, with flushes but also facial telangiectasias. During medical examination, classic symptoms of carcinoid syndrome including heart disease were obvious. The occurrence of flushes during coitus should evoke pelvic tumor location.

CONCLUSION

A carcinoid syndrome is naturally evoked in the presence of flushes but it must also be part of the differential diagnosis in a patient with facial erythrosis or telangiectasias, especially if they are associated with diarrhea or right heart failure. The prognosis of carcinoid heart disease is considerably better in case of ovarian location than when it is a primitive carcinoid tumor of lung or from gastrointestinal tract.

A Novel Endoluminal Technique for Varicose Vein Management: The VNUS Closure

In an attempt to reduce the morbidity of high tie and strip of the long saphenous vein various extraluminal and intraluminal electrosurgical devices have been employed in the past using monopolar energy to ablate varicose veins. As result of this full-thickness skin burns and saphenous nerve injuries were observed by surgeons using these techniques. This report describes the VNUS Closure, a novel endovascular computer-feedback-controlled application of bipolar electrothermal energy which ensures transmural heating of the vein wall while minimising thermal spread to neighbouring tissues.

Botulinum A toxin as a treatment for overactive rectum with associated faecal incontinence

AIM

Rectal hypercontractility can lead to faecal incontinence (FI). Botulinum toxin (BT) has been used successfully for the treatment of bladder overactivity. This study aimed to evaluate the therapeutic value of intrarectal injections of BT in inhibiting colorectal contractions and relieving FI in patients suffering from FI as a result of overactive rectal contractions.

METHOD

A prospective open study was carried out in Rouen University Hospital. Six patients (four men and two women) with severe FI related to overactive rectal contractions underwent intrarectal submucosal injections of BT placed in three rows of 10, 1-ml injections (50 U/1 ml; Dysport(®)) starting 1 cm above the dentate line and repeated twice, at intervals of 5 cm proximally. The end-points included improvement in the FI score, in faecal incontinence quality of life (FIQL) and of manometric abnormality.

RESULTS

All patients reported improvement in the FI score [18.2±1.1 at baseline vs 9.0±1.7 at 3 months (P=0.04)] and in FIQL. Rectal contractile activity was reduced. The frequency of contractions remained unaffected (28.1±6.6/h; P=0.46 vs baseline). High-amplitude contractions of >50 cmH(2)O were significantly decreased in all patients (16.6±3.9 vs 6.6±4.1/h; P=0.03).

CONCLUSION

Patients with an 'overactive rectum' are a heterogeneous group, with varying causes of dysfunction. The dose of BT used was arbitrarily selected. Nevertheless, the study introduces a further therapeutic option in the treatment of FI caused by rectal overactivity.

Natural orifice total mesorectal excision using transanal port and laparoscopic assistance

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging concept which has been recently applied to the field of rectal excision. The authors describe a case of total mesorectal excision using a transanal port and laparoscopic assistance. We described a procedure performed in a 45-year-old for a rectal adenocarcinoma (1 cm wide, T1sm3) 3 cm above the dentate line. The procedure is described in the text and in a didactic video.

Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping

BACKGROUND

This randomized trial was undertaken to investigate the fate of incompetent perforating veins (IPVs) following saphenofemoral ligation and stripping of the great saphenous vein (GSV), with or without subfascial endoscopic perforator surgery (SEPS).

METHODS

Patients with venous reflux (greater than 0.5 s) of the GSV and additional IPVs were allocated randomly to standard surgery (saphenofemoral ligation, stripping and phlebectomies alone) or with the addition of SEPS. Patients with ulceration, recurrent veins, deep venous reflux/thrombosis or saphenopopliteal reflux were excluded. Duplex ultrasonography was carried out before operation, and at 1 week, 6 weeks, 6 months and 1 year after surgery. Quality of life questionnaires were completed and visual analogue scale scores collected at the same time points.

RESULTS

Thirty-eight patients were allocated to SEPS and 34 to the no SEPS group. Two patients in the no SEPS group were excluded (one withdrew and the other had the wrong treatment). There were no differences between the two groups with respect to pain, mobility or quality of life scores during follow-up. A significantly higher proportion of patients in the no SEPS group had IPVs on duplex imaging at 1 year (25 of 32 versus 12 of 38; P < 0.001).

CONCLUSION

IPVs do not remain closed following standard varicose vein surgery. The addition of SEPS was not associated with significant morbidity but did reduce the number of IPVs. Up to 1 year this had no effect on recurrence rates or quality of life, but late results remain to be seen.

REGISTRATION NUMBER

ISRCTN18288048 (http://www.controlled-trials.com).

Strip-track revascularization after stripping of the great saphenous vein

Background

Varicose veins that recur after standard high tie and strip are often associated with venous reflux in the thigh, as shown by duplex ultrasonography. The aim of this study was to look for evidence of revascularization in the strip track after great saphenous vein (GSV) stripping.

Methods

A consecutive series of patients with duplex-proven great saphenous varicose veins underwent saphenofemoral ligation with intraoperative confirmation of successful stripping. Duplex ultrasonography was performed 1 week and 1 year after surgery. The presence and extent of haematoma was noted, as was any venous reflux within the strip track.

Results

At 1 year, four (6 per cent) of 70 patients had complete revascularization of the strip track and 12 (17 per cent) had partial revascularization, all with duplex-proven reflux. Partial revascularization was in the distal third of the track in six legs (9 per cent of the 70 patients), in the distal half in five (7 per cent) and was almost complete in one leg (1 per cent). All patients with revascularization had a significant strip-track haematoma at 1 week after surgery.

Conclusion

Revascularization of the GSV strip track after stripping was found in 23 per cent of patients after 1 year; all of these had a postoperative haematoma in the track.

Radiofrequency ablation (VNUS closure®) does not cause neo-vascularisation at the groin at one year: Results of a case controlled study

BACKGROUND

Despite adequate training in the surgical treatment of varicose veins, recurrence continues to be a problem and a burden to the vascular services. A major cause of recurrence is reported to be neo-vascularisation at the sapheno-femoral junction (SFJ). The aim of this study was to compare the incidence of neo-vascularisation at the SFJ following radiofrequency ablation (RFA) and open high saphenous tie and stripping (HSTS).

MATERIALS AND METHODS

Fifty-one patients (55 legs) underwent standardised HSTS as part of a prospective study. These were compared with an age (range 28-83, mean 54.4) and sex (male:female 31:20) matched group of patients treated during the same time period, by the same consultant vascular surgeon, using RFA (VNUS closure). Each patient had a pre-operative duplex scan to confirm SFJ reflux, a one-week scan to confirm successful surgery and a one-year post-operative scan to assess neo-vascularisation. The same vascular technologist performed all scans. Neo-vascularisation was identified by the presence of refluxing tortuous vessels arising from the area of the SFJ.

RESULTS AND CONCLUSION

Six of 55 (11%) legs in the open surgery group showed clear evidence of tortuous refluxing veins related to the SFJ. None of the 55 in the RFA group showed any neo-vascularisation at the SFJ (Fischer exact test P = 0.028). Further randomised controlled trials are necessary to confirm these observations.

Ultrasound changes at the saphenofemoral junction and in the long saphenous vein during the first year after VNUS closure

BACKGROUND

The VNUS Closure is an endoluminal, percutaneous catheter-based device using a radiofrequency current to cause permanent closure of the long saphenous vein (LSV) as an alternative to high tie and stripping. This study describes our postoperative ultrasound scan surveillance results of VNUS Closure cases over a one year period.

METHODS

Between March and August 2000, 79 patients had 127 legs treated. Postoperative ultrasound scans were performed in order to evaluate persistence of a patent superficial inferior epigastric vein at the saphenofemoral junction (SFJ), stump length of the remaining SFJ and changes in morphology and diameter of the ablated LSV. Ten legs were chosen randomly for this evaluation at each follow-up appointment.

RESULTS

Fifty-seven per cent of the patients' legs had a patent SFJ-stump with a remaining patent superficial epigastric vein but none of the patients showed neovascularisation at the SFJ or recanalisation of the LSV. The stump length at the SFJ appeared to be getting smaller as our experience grew greater.

CONCLUSIONS

This new technique of radiofrequency ablation provides a minimal access alternative to the classical high tie and stripping. Our results to date show that this procedure leaves a small patent stump at the SFJ with no evidence of neovascularisation and a completely atrophied closed LSV.

A novel approach to the treatment of recurrent varicose veins

BACKGROUND

A variety of approaches has been described for the treatment of recurrence at the saphenofemoral junction (SFJ) after primary varicose vein surgery most, of them based on dissection through virgin tissue. This observational study describes our clinical experience with the VNUS Closure, a percutaneous catheter-based procedure in which the long saphenous vein (LSV) is ablated from within by resistive heating.

METHODS

Twelve patients who had undergone previous high tie and stripping procedures had 18 legs treated with the VNUS Closure between March 1999 and April 2000. In one patient VNUS Closure was performed also in an anterior thigh branch. Postoperative ultrasound scans were performed at regular intervals in order to assess successful closure of the LSV.

RESULTS

None of the patients showed recanalisation of the LSV during the duplex ultrasound scan surveillance and the only complication related to the VNUS Closure noted were sensory disturbances at the inner thigh in 6 legs.

CONCLUSION

This new endovascular technique is the authors' preferred method of treating recurrent varicose veins where an incompetent LSV persists either due to neovascularisation at the saphenofemoral junction or to a persisting midthigh perforator.

Clipping perforators without dividing them could reduce postoperative pain and swelling following subfascial endoscopic perforator surgery

Images

Incompetent Perforating Veins are Associated with Recurrent Varicose Veins

AIMS

we suspected incompetent perforating veins of having a role in the development of recurrent varicose veins in some patients. The aim was to look for an association between perforators and recurrent varicose veins.

METHODS

a consecutive group of patients presenting with varicose veins were examined using colour duplex ultrasonography by an experienced vascular technologist. Pathological perforating veins were defined as those exhibiting bi-directional flow and a diameter of 4 mm or greater at the fascia.

RESULTS

between September 1998 and July 1999, 204 patients were examined. Primary varicose veins were found in 198 legs (135 patients) and recurrent varicose veins in 91 legs (69 patients). In patients with primary varicose veins, 88 (44%) had incompetent perforators compared to 57 (63%) of those with recurrent varicose veins (Chi-squared, p <0.005). Also, for recurrent varicose veins, the percentage of patients with any given number of incompetent perforators was higher than for primary varicose veins. Overall, there was a higher number of incompetent perforators in those with recurrent veins compared to primary veins and this difference was significant at 95% confidence interval.

CONCLUSION

patients with recurrent varicose veins have both a higher prevalence and a greater number of incompetent perforating veins than patients with primary varicose veins.