Comparative Study of Diluted Hydrogen Peroxide and Sulfur Hexafluoride in the Contrast-Enhanced Ultrasound Assessment of Anal Fistulas.

BACKGROUND: Endoanal ultrasound for the diagnosis of anal fistulas requires the injection of hydrogen peroxide, but it is often uncomfortable for the patient and possesses potential complications. Novel ultrasound contrast is currently available. OBJECTIVE: We aimed to assess the efficacy and safety of sulfur hexafluoride as an ultrasound contrast agent for the diagnosis of perianal fistula by comparing it with those of 50% diluted hydrogen peroxide. DESIGN: Double-blind superiority study with 4 consecutive visits to perform an ultrasound without contrast, a hydrogen peroxide-enhanced ultrasound, a sulfur hexafluoride-enhanced ultrasound and a rectal exploration in the operating room (the gold standard). The ultrasound images were independently reviewed by three expert surgeon sonographers. CLINICAL SETTING: This study was conducted at a single university hospital. PATIENTS: Data from 176 patients were evaluated. PRIMARY OUTCOME MEASURES: Demographic and exploratory data and the ultrasound findings related to the location of the internal fistula orifice, description of the primary and secondary tracts, and presence of cavities and sphincter defects were analyzed. The complications occurring before and after the contrast agent administration and the presence of pain measured using a score were considered. RESULTS: Eighty-eight patients were included (men: 71.5%; mean age: 48.3 years).62.5% had a complex type and 83.7% had a transsphincteric type. Sulfur hexafluoride-enhanced ultrasounds demonstrated a higher interobserver agreement in determining the secondary tracts (κ= 0.604) and anal fistula height (κ=0.604) compared with other methods. Both hydrogen peroxide-enhanced ultrasound (90.91%) and sulfur hexafluoride-enhanced ultrasound (89.77%) detected the internal orifice more frequently than ultrasounds without contrast (62.5%) (p < 0.001),with no differences between contrast agents (p = 0.810). Sulfur hexafluoride-enhanced ultrasound were less painful than peroxide-enhanced ultrasound (p < 0.001). LIMITATIONS: Most of the patients had transsphincteric anal fistulas. CONCLUSIONS: Sulfur hexafluoride proved comparable to hydrogen peroxide in evaluating fistulous tracts and identifying the internal orifice and additionally reduced significantly pain and discomfort. Furthermore, demonstrated a higher interobserver agreement in determining the secondary tracts and anal fistula height compared with other methods. See Video Abstract.

Resultados a un año tras desarterialización hemorroidal guiada por doppler / One year follow-up after doppler-guided haemorrhoidal artery ligation

Introducción: La desarterialización hemorroidal guiada por doppler (THD) es una técnica no exerética para el tratamiento de las hemorroides, consistente en la ligadura de las ramas distales de la arteria rectal superior. El propósito de este trabajo es evaluar la seguridad y eficacia de esta técnica tras un seguimiento de un año. Material y método Se intervienen 30 pacientes mediante THD por hemorroides sintomáticas grado II o III. La media de edad fue de 49,9 años (30-70 años). En todos se utilizó el dispositivo THD®. Los procedimientos se realizaron bajo anestesia intradural en régimen de corta estancia. Evaluamos tiempo operatorio, dolor, sangrado, estancia postoperatoria, complicaciones y síntomas tras 3-6 y 12 meses. Resultados El tiempo operatorio medio fue de 23 minutos (15-50). El valor de dolor según la escala visual analógica (EVA) fue durante el primer día de 5,5 (el 90% requirió analgesia). Tras el segundo día, sólo 2 pacientes necesitaron analgesia. Un paciente describió dolor persistente hasta los 3 meses, 2 sangrado leve. Una reintervención por trombosis hemorroidal al 10° día. No otras complicaciones. No reingresos. Estancia media: 1,4 días (0-2), y el restablecimiento de actividad diaria normal se realizó a los 7-8 días. 26 pacientes (87%) describen tenesmo, autolimitado en 3 meses. Tras un año, 2 pacientes han sido reintervenidos, 3 han recurrido (2 prolapsos leves y 1 sangrado ocasional). La tasa de resolución total fue del 80%.ConclusionesLa desarterialización hemorroidal guiada por doppler parece ser efectiva tras un año, con un porcentaje de complicaciones bajo (AU)

Introduction: The Doppler-guided haemorrhoidal artery ligation (DG-HAL) is a non-exeresis technique for the treatment of haemorrhoids, consisting in the ligature of the distal branches of the upper rectal artery. The aim of this work is to evaluate the safety and efficacy of this technique after one year of follow-up. Material and method: A total of 30 patients were operated on using DG-HAL for grade II or IIIhaemorrhoids. The mean age was 49.9 years (30-70 years). The THD1 (Transanal Haemorrhoidal Dearterialisation) device was employed in all cases. The procedures were performed under intradural anaesthesia in a short-stay surgery unit. The operating time, pain, bleeding, postoperative stay, and complications and symptoms after 3-6 months and 12 months were recorded. Results: The mean operating time was 23 minutes (15-50). The pain according to a visual analogue scale (VAS) was 5.5 during the first day (90% required analgesia). Only 2 patients required analgesia after the second day. One patient described persistent pain up to3 months, and 2 slight bleeding. A further operation was performed due to a haemorrhoidal thrombosis on the 10thday. There were no other complications and no re-admissions. The mean hospital stay was 1.4 days (0-2), and normal daily activity re-established at 7-8 days. Alarge majority (87%) of patients described having tenesmus, which disappeared in 3months.After one year, two patients had had further operations, 3 had recurrences (2 slightprolapses and 1 occasional bleeding). The success rate was 80%.Conclusions: Haemorrhoidal de arterialisation using Doppler-guided arterial ligation seems to be effective after one year, with a low percentage of complications (AU)

Homocistinuria y accidente cerebrovascular en la infancia / Homocystinuria and stroke in childhood

La hemocistinuria es una enfermedad genética caracterizada por la deficiencia de diversas enzimas vinculadas al metabolismo de la metionina.La presencia de eventos trombóticos y tromboembólicos constituye la principal causa de mortalidad y morbilidad en estos pacientes.Se describen 2 hermanos de 5 y 9 años,que presentaron episodios compatibles con accidente cerebrovascular.En el primero se constató obstrucción de ambas carótidas internas y el segundo paciente tenía una oclusión del seno longitudinal superior.El diagnóstico se efectúo con el dosaje de homocisteína y metionina elevados en sangre y orina,que se normalizó con el tratamiento de B6 y ácido fólico,Al primero de los niños se le efectúo,además tratamiento quirúrgico:colocación de un stent en la arteria vertebral derecha para mejorar la vascularización cerebral.La evolución fue buena en ambos niños.Se recomienda considerar el diagnóstico de homocistinuria ante todo paciente que presente un episodio de accidente cerebrovascular u oclusión vascular

Ocular lesions and experimental choline deficiency

Previous studies have shown ocular haemorrhages in choline-deficient rats. The aim of this paper is to study further the relationship between ocular and renal lesions and biochemical alterations in rats fed a choline-deficient diet. Fifty one weanling male Wistar rats, were divided into two groups. Thirty one ofthem were fed a choline-deficient diet and the rest was fed a choline- supplemented diet ad libitum. Animalsfrom both groups were killed between the fifth and the eighth day. Urea, creatinine and homocysteine concentrations in blood were determined. Eyes were used for light microscopy study; high resolution lightmicroscopy and the study of the retina as “rétine a plat”. Kidneys were studied by light microscopy. Cholinesupplementedrats did not show ocular or renal lesion. Choline-deficient rats that showed renal lesions, tubular or cortical necrosis, did not always have ocular changes. There were no ocular changes in the only cholinedeficient rat without renal lesion. The ocular changes consisted mainly in haemorrhage in both cameras andciliary and vitreous bodies. Correlations between ocular and renal lesion (r=0.72, p<0.0001, CI 95%: 0.48-0.86); ocular lesion and creatinine (r=0.86, p<0.0001, CI 95%: 0.72-0.93) and ocular lesion and urea (r=0.70, p<0.0001, CI 95%: 0.44-0.85) were positive. Choline-deficiency induces ocular haemorrhagic lesions after the development of renal necrosis. The ocular pathology could be due to the immaturity of the ocular vasculature at this age. The hyaloid, choroid and retinal system are involved

Estudios previos han demostradohemorragia ocular en ratas deficientes en colina. El objetivo de este trabajo es profundizar en la relación entre las alteraciones oculares, renales y bioquímicas en ratas deficientes en colina. Cincuenta y una ratas Wistar macho recién destetadas fueron divididas en dos grupos: treinta y una fueron alimentadas con una dieta colino deficiente y el resto con colina suplementada ad-libitum. Los animales de ambos grupos fueron sacrificados entre el quinto y el octavo día. Se midió la concentración de urea, creatinina y homocisteína en sangre. Los ojos fueron estudiados por microscopía de luz, microscopía óptica de alta resolución y para el estudio de la retina como retina plana. Los riñones fueron estudiados por microscopía de luz. Las ratas suplementadas con colina no mostraron lesiones oculares o renales. Las colino deficientes que mostraron lesiones renales, necrosis tubular o cortical, no siempre tuvieron cambios oculares. No se encontraron cambios oculares en la única rata deficiente en colina sin lesión renal. Los cambios oculares consistieron principalmente en hemorragia enambas cámaras, cuerpo ciliar y vítreo. La correlación entre la lesión ocular y renal (r=0.72, p<0.0001, CI 95%:0.48-0.86), lesión ocular y creatinina (r=0.86, p<0.0001, CI 95%: 0.72-0.93) y lesión ocular y urea (r=0.70,p<0.0001, CI 95%: 0.44-0.85) fue positiva. La deficiencia de colina induce lesiones oculares luego del desarrollode la necrosis renal. La patología ocular podría ser debida a la inmadurez de los vasos oculares. El sistemahialoide, coroideo y retinal están involucrados