Management of hemorrhoidal disease in patients with chronic spinal cord injury.

Hemorrhoidal disease is a common pathology in patients with chronic spinal cord injury (SCI). We describe our experience with the primary approach to this problem at the Proctology Division of the Sheba Medical Center. We treated 29 patients (26 men) with paraplegia due to SCI between 1995 and 1999. The mean age was 49 years (range, 22-74 years). All patients had hemorrhoids in stages ranging between II and IV. Main complaints were rectal bleeding (83%), difficulties in evacuation (38%) and discomfort or pain (28%). Eleven patients (38%) were treated conservatively (e. g. diet, hygiene and laxatives), while 18 patients (62%) underwent either banding or sclerotherapy of hemorrhoids or both. No major complication were observed. In 28 of 29 patients (96%), there was a significant reduction or cessation of bleeding and/or relief of symptoms; one patient (3%) required hemorrhoidectomy. Of the 28 successful treatments, 16 (57%) had partial reduction of bleeding or relief of symptoms, while in 12 (43%) response was complete. Of those who were treated conservatively, 9 (82%) had partial and 2 (18%) had complete relief of symptoms. Of those who had banding/sclerotherapy, 7 (41%) had partial and 10 (59%) had complete relief. We also examined the effect of perianal sensation on the treatment outcome. Of 16 patients with complete anesthesia, 11 (69%) had partial and 5 (31%) had complete relief, whereas of the 12 patients with preserved sensation, 5 (42%) had partial and 7 (58%) had complete relief. In conclusion, the approach of banding or sclerotherapy of hemorrhoids in SCI patients is safe and effective. When sensation of the perianal region is preserved, the outcome seems to be better. The cause of SCI has no impact on the treatment results. There was no difference in the outcome of treatment between patients with stage II and stage III hemorrhoids; patients with stage IV hemorrhoids seem to do worse than those with stages II and III.

Effects of hyaluronic acid on fibroblast behavior in peritoneal injury.

The process of intraperitoneal adhesion formation is affected by macrophages and fibroblasts which are major components of postsurgical peritoneal repair. Hyaluronic acid (HA) has been shown to affect cellular behavior. We studied the effects of HA on experimental adhesions in vivo and its in vitro effect on cultured postsurgical macrophages and fibroblasts. Experimental adhesions were facilitated by laparotomy and localized peritoneal controlled trauma in two groups of rats (A, B). Postoperatively, group A received intraperitoneal (ip) treatment by HA (1 mg/kg) for 7 days, and group B, ip saline. The rats were then reoperated upon, and adhesions scored. In vitro studies were performed on postsurgical macrophages and fibroblasts. Fibroblasts were obtained using a single-cell suspension technique by debridement of adhesions. The fibroblasts were cultured for 7 days, and their metabolic activity was assessed by the uptake of [3H]thymidine. Postoperative macrophages were obtained from the peritoneal fluid of the rats operated on, and their effect upon fibroblast [3H]thymidine uptake was studied in mixed cultures. The adhesion score of the HA-treated rats was smaller than the score of the saline-treated group. This observation suggests that ip treatment by HA may decrease adhesion formation in this rat model. [3H]Thymidine uptake by cultured postsurgical fibroblasts was significantly lower in the HA-treated group compared to that of controls. In vitro addition of HA to cultured "saline fibroblast" resulted in a significant decrease in [3H]thymidine uptake, suggesting a direct effect of HA on postsurgical fibroblast metabolism. However, [3H]thymidine uptake by fibroblasts in mixed cultures with macrophages obtained from HA-treated rats was significantly increased. These observations suggest that HA may affect the process of peritoneal healing by direct effect on fibroblast metabolic activity, and indirectly via modification of the macrophage-fibroblast interrelationship.

Vascular complications of total abdominal perfusion and aortic stop-flow infusion.

During a 2 year period (1992-1993), 149 patients with advanced abdominal cancer underwent total abdominal ischemic perfusion (TAP) and stop-flow infusion (SFI) 159 times in an attempt to achieve palliation. These procedures and aortic stop-flow infusion require insertion of balloon catheters into the abdominal aorta and inferior vena cava by a transfemoral approach. Flow is arrested for 15 minutes, during which time chemotherapeutic agents are infused into the aorta, distal to the balloon occlusion. Femoral access is by a surgical incision. The passage of the catheters is guided by fluoroscopy. Some tumor response was observed in 35% of the patients. Ten patients had major vascular complications; two iliac artery aneurysms were lacerated and required emergency repair. There were two femoral artery false aneurysms that required surgical correction, one early and one late. Aortic dissection was detected in four patients, but these did not require surgical intervention. Two patients had thrombosis distal to the occluded vessel, both required surgical intervention. To reduce the incidence of these vascular complications we recommend: (1) a clinical and vascular laboratory evaluation before the procedure, and (2) angiography of normal flow in patients with underlying vascular disease.

Total abdominal perfusion (TAP) in the treatment of abdominal metastatic melanoma.

Total abdominal perfusion (TAP) is a recently described technique in which the abdominal organs are isolated from the systemic circulation and perfused by means of an external pump. Administering chemotherapy into the circuit provides higher locoregional drug exposure with lower systemic toxicity. Two patients with melanoma metastatic to the abdomen were treated using this technique. The first patient suffered from intractable upper gastrointestinal bleeding due to unresectable melanoma metastasis of the duodenum. He underwent TAP with melphalan and cisplatinum. His bleeding stopped and the tumor regressed. The patient's response lasted for 6 months. The second patient had an unresectable liver metastasis. She underwent TAP with melphalan and DTIC, resulting in a complete response with disappearance of the liver mass, which lasted until her death in 13 months. Our conclusion is that TAP should be considered as a technique for regional chemotherapy, which may be used in the treatment of unresectable metastatic melanoma of the abdomen.

Use of magnetic resonance imaging in pregnancy to diagnose intussusception induced by colonic cancer.

Intussusception of the colon initiated by a malignant tumor is an extremely rare occurrence during pregnancy. The nonspecific presenting symptoms may be attributed to the pregnancy itself, making diagnosis difficult. We report a case in which the use of magnetic resonance imaging led to prompt diagnosis.

Raynaud's phenomenon as a presenting sign of metastatic melanoma.

The authors report a case of metastatic melanoma in a 22-year-old woman who initially presented with episodic attacks of digital ischemia. Review of the literature amassed another 22 cases of digital ischemia as an early or presenting feature of malignant disease. This is, however, the first description of Raynaud's phenomenon preceding by months the detection of a malignant melanoma. The possibility of occult malignant disease should be considered in evaluation of patients who present with digital ischemic changes without known predisposing conditions.

Isolation perfusion with cisplatin for malignant melanoma of the limbs.

The role of hyperthermic isolation perfusion in the treatment of advanced melanoma of the limbs is clearly important. However, attention has in the past been focussed mainly on surgical aspects of the procedure. Whereas, equivalent interest in chemotherapy considerations has been lacking. A group of 15 patients have been treated by hyperthermic isolated perfusion for advanced melanoma of the limbs. The chemotherapeutic agent used was cisplatin. The follow-up period was 6 to 60 months. None of these patients had any sign or symptoms of toxicity from the drug. Twelve of these 15 patients are free of disease currently. There was one case of mortality due to unrelated cause and two cases of mortality due to disseminated disease which developed 6 months and 30 months, respectively, posttreatment. Since not uncommon toxic side effects from other drugs used for this procedure is significant, these results suggest that cisplatin may be used as an alternative chemotherapeutic agent in isolation perfusion for advanced melanoma of the extremities.