Doppler-guided hemorrhoidal dearterialization with laser (HeLP): a prospective analysis of data from a multicenter trial

BACKGROUND

Doppler-guided hemorrhoidal laser procedure (HeLP) is a new minimally invasive technique to treat symptomatic hemorrhoids. The aim of this multicenter study was to prospectively assess clinical results and patients' satisfaction in patients treated with HeLP.

METHODS

Indications for HeLP included patients with symptomatic hemorrhoids resistant to medical therapy, with low-grade prolapse. Clinical efficacy was evaluated assessing resolution of symptoms and patient satisfaction. Frequency of bleeding and frequency of acute hemorrhoid-related symptoms were given a score of 0 to 4 (where 4 = more than 3 episodes/week) and 0 to 3 (where 3 = more than 5 episodes/year), respectively. Quality of life, pain at rest, and pain with evacuation were scored using a visual analogue scale (VAS) of 0 to 10. Intra- and postoperative complications were recorded. Potential predictive factors for failure were assessed.

RESULTS

Two hundred and eighty-four patients (183 males, 101 females) with a mean age of 47.5 years were included in the study. At 6-month follow-up, symptoms had completely resolved in 257/284 (90.5%) and 275/284 (96.8%) patients were satisfied with the results. An analysis of a subgroup of 144 patients followed up for a minimum of 12 months revealed a resolution of symptoms in 130/144 (90.3%) and satisfaction in 139/144 (96.5%). There was a statistically significant improvement of the bleeding score (from 2.4 ± 1.07 to 0.36 ± 0.49; p < 0.0001), acute symptoms score (from 2.03 ± 0.16 to 0.61 ± 0.59; p < 0.0001), quality of life (from 4.63 ± 1.32 to 8.96 ± 1.35; p < 0.0001), pain at rest (from 3.0 ± 2.05 to 1.1 ± 0.99; p < 0.0006), and pain with evacuation (from 4.8 ± 1.22 to 1.7 ± 1.15; p < 0.0001). No significant changes in continence and constipation were observed. Univariate analysis failed to show factors significantly associated with failure.

CONCLUSIONS

The HeLP procedure seems to be safe and effective in patients with symptomatic hemorrhoids. It is simple, minimally invasive, and relatively pain free. It can be performed in an ambulatory setting without anesthesia, and it achieves high patient satisfaction. It may, therefore, be considered a "first-line treatment" in all patients without significant hemorrhoidal prolapse in whom medical therapy has failed.

Abdominal aortic intramural hematoma related to penetrating ulcer: an inappropriate indication for endovascular repair?

PURPOSE

To present a rare case of abdominal aortic intramural hematoma with penetrating ulcer.

CASE REPORT

A 68-year-old hypertensive lady was admitted with chest pain. An echo Doppler abdominal study showed a 2.5-cm-diameter abdominal aorta with periaortic blood flow. Urgent computed tomography documented a 4-cm aneurysmal dilatation, 4 cm long, at the infrarenal level of the inferior mesenteric artery origin, which appeared on the angiogram as a very short lateral bleb. At elective open laparotomy, no true abdominal atherosclerotic aneurysm was found in the retroperitoneal space, but rather, an intramural hematoma with ulcer. An aortobi-iliac graft was inserted, and the patient was discharged with a good outcome. Histological examination of the explanted tissue confirmed adventitial calcifications, organized thrombus in the hematoma, and intimal neovascularization.

CONCLUSIONS

Considering the pathology, this case was more appropriately treated with open surgery, although endovascular repair was not excluded as an option.

Endovascular treatment of a postlaminectomy arteriovenous fistula. A case report

We report a case of iliac arteriovenous fistula (AVF) following disk surgery. A 51-year-old woman underwent hemilaminectomy for a slipped disk. Two weeks after surgery the patient experienced dyspnea and oedema of the lower limbs. Presence of a systolic murmur on the cardiac floor and on the abdomen was detected and abdomen CT scan which evidenced a AVF between the right common iliac artery and vein. The lesion, confirmed by angiography, was successfully treated with the endovascular technique. The endovascular technique appears to be a valid alternative to the traditional surgical treatment of postlaminectomy AVF.

PYCNOGENOL in chronic venous insufficiency

The aim of out study was to investigate the efficacy of Pycnogenol - a French maritime pine bark extract - in the treatment of chronic venous insufficiency (CVI). The study consisted of a double-blind phase - in which 20 patients were recruited and randomly treated with placebo or Pycnogenol (100 mg 2 3/day for 2 months) - and an open phase - in which other 20 patients were treated with Pycnogenol at the same dose schedule. In total, 40 patients were enrolled; 30 of them were treated with Pycnogenol and 10 with placebo. Pycnogenol significantly improved the legs' heaviness and subcutaneous edema; the venous pressure was also significantly reduced by the Pycnogenol treatment, thus adding further clinical evidence to its therapeutic efficacy in patients with CVI. Pycnogenol was effective, probably by either stabilizing the collagenous subendothelial basal membrane or scavenging the free radicals, or by a combination of these activities. Clinically, capillary leakage, perivascular inflammation and subcutaneous edema were all reduced. The safety of use of Pycnogenol is demonstrated by the lack of side effects or changes in blood biochemistry and hematologic parameters. Pycnogenol can be therefore recommended both for prevention and treatment of CVI and related veno-capillary disturbances.

[Apropos of preventive ophthalmologic interventions in the child population of compulsory school age. Authors' experience]

The results are reported of work carried out during the last five years by the Center of Social Ophthalmology, director Prof. G. Scuderi, which is part of the II Division of the Ophthalmologic Clinic of Rome University "La Sapienza" with the object of trying out together with territorial units a model of preventive intervention acting as a filter for specialized university facilities. In other words, already existing facilities and medical personnel were to be used and trained for specific methods and techniques. From 1985 through 1990, 787 children selected by ophthalmologic screening by school doctors among the compulsory school population of the RM 3 and 5 districts were seen and submitted to periodic checks. This cohort included children aged 5 to 14 without significant differences in sex distribution and with prevalence of the 8 to 10 year olds. Each subject was submitted to complete eye examination including refractometry and orthoptics, color vision, biomicroscopic and ophthalmoscopic examination. The principal findings show that about 36% of subjects examined have a natural vision of 11/10 while the high percentage of ametropia observed was mainly represented by astigmatism and hypermetropy, albeit of minor intensity. Strabismus was found in 2.79% and implied marked visual deficit that was often refractory to any type of treatment. In addition, the prevalence was determined of other abnormalities concerning eye motility, color vision and pathologies involving anterior segment and eyeground. In their conclusion, the authors stress the rarity of organic ocular pathology in children (mostly represented by inflammatory changes of the adnexes and conjunctiva) whereas amblyopia was one of the main causes of visual deficit in children. They stress the importance of early therapeutic intervention in order to allow complete visual rehabilitation. The results of the clinical model for prevention were excellent so that it can even be proposed for large scale prevention of amblyopia.

Diet and metabolism: large-bowel cancer

Epidemiological data demonstrate that colon cancer incidence is associated mainly with high dietary fat consumption. Studies in metabolic epidemiology indicate that high fat intake influences both the amount and type of bile acids and neutral sterols and intestinal microflora acting on these compounds which may contain tumorigenic activity for the colon. This is compatible with the results of studies comparing populations with high or low risk for the colon cancer and patients with colon cancer.

Metabolic epidemiology of colon cancer: enzymic activity of fecal flora

Because of the potential significance of secondary bile acids and cholesterol metabolites formed by the intestinal microflora in the pathogenesis of colon cancer, fecal microbial 7alpha-dehydroxylase and cholesterol dehydrogenase activities were assayed in colorectal cancer patients, patients with adenomatous polyps, asymptomatic controls, and normal controls. The mean 7alpha-dehydroxylase activity per 100 mg of dry feces per 2 hr incubation for colorectal cancer patients was significantly greater than either asymptomatic controls or normal controls. Patients with polyps had greater activity than controls, but did not differ significantly from the cancer patients or asymptomatic controls. The mean cholesterol dehydrogenase activity for colorectal cancer patients was significantly greater than controls. Patients with polyps also had greater activity than controls. No differences in the level of fecal beta-glucuronidase activity were found among the four risk groups. These data support the concept that patients with colorectal cancer are more able to convert primary bile acids and cholesterol to microbial products in colon contents than are controls. Such differences in the activity of intestinal microflora may serve as biochemical indicators that will reflect the enzymic activity of the fecal flora as well as the key intraluminal compounds in identifying populations at different risk for developing colorectal cancer.

Fecal bile acids and neutral sterols in patients with familial polyposis

Fecal neutral steroids and bile acids were measured in patients with familial polyposis, family controls who are immediate relatives of patients, and controls other than relatives. All subjects were consuming a mixed Western diet at the time of collection of stool specimens. Although the total fecal neutral sterol concentrations were not different between the groups, the patients with familial polyposis excreted a high amount of cholesterol and low levels of coprostanol and coprostanone compared with other groups. Patients with familial polyposis excreted levels of total bile acids in their feces comparable to those excreted by controls; lithocholic acid excretion was decreased in patients with familial polyposis. These findings suggest that analysis of stools for cholesterol and its metabolites be useful in screening the siblings of polyposis families for latent disease.

Further leads on metabolic epidemiology of large bowel cancer

Studies in metabolic epidemiology have shown that the dietary intake of high fat affects the composition of the intestinal bacteria and their metabolic activity as well as the levels of certain neutral sterols and bile acids that may act as tumor promoters for the colon. A strong association has also been established between microbially modified bile acids and cholesterol metabolites and the risk of colon cancer among different populations. The patients with colon cancer had high concentrations of fecal bile acids and cholesterol metabolites compared with the controls. It remains to be shown whether this established association is causative in nature.