Doppler-guided hemorrhoidal dearterialization with laser (HeLP): indications and clinical outcome in the long-term. Results of a multicenter trial.

BACKGROUND: Doppler-guided hemorrhoidal laser procedure consists of sutureless closure of terminal branches of the superior hemorrhoidal artery by laser energy. Clinical results of patients treated with this procedure were analyzed at the completion of 2-year follow-up. Primary endpoint was resolution of symptoms and secondary endpoints were recurrence rate, type of recurrences, re-operation rate, and potential predictive factors for failure. METHODS: Bleeding was assessed on a score from 0 to 4 (none = 0; < 1/month = 1; 1/week = 2; > 1/week = 3; 3-4/week = 4), frequency of hemorrhoid-related symptoms with a score of 0-3 (2/year = 1; 3-5/year = 2; < 5/year = 3). Constipation and fecal incontinence were assessed by means of validated scores. Quality of life and pain at defecation were assessed using a visual analog scale of 0-10 (0 = worst possible-10 = best possible quality of life and 0 = no pain-10 = worst pain imaginable, respectively). Recurrence rate and need for re-operation were reported. Potential predictive factors of failure were analyzed by means of univariate analysis. RESULTS: Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5 years) were included in the trial; 8 patients were lost at follow-up. Analysis of 276 patients who completed the 2-year follow-up showed an overall resolution of symptoms in 89.9% (248/276) of patients. Statistically significant improvement of quality of life, pain reduction, bleeding and frequency of acute symptoms were reported. Of 28 patients with persistent or recurrent symptoms, 12 had pain (4.35%), 10 had bleeding (3.6%) and 6 had increasing prolapse at defecation (2.2%). Eleven out of twenty-eight patients required additional surgery. Constipation and III-IV grade hemorrhoids were associated with statistically significant higher failure rates (p = 0.046 and 0.012, respectively). Better results were reported in patients reporting preoperative high-grade pain at evacuation. CONCLUSIONS: The Doppler-guided hemorrhoidal laser procedure showed efficacy at long-term follow-up. It can be considered as 'first-line' treatment in patients with low-grade hemorrhoids suffering from bleeding, pain and recurrent acute symptoms in whom conservative treatment 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.