Russian clinical practice guidelines for the management of c1 clinical class of chronic venous disorders (reticular veins and telangiectasias)

Recently collated scientific data on the management of C1 clinical class of chronic venous disorders; wide prevalence of the disease and high variability amongst medical practitioners in relation to managing this category of patients and absence of any regulatory documents has prompted the development of clinical guidelines for the treatment of patients with reticular varicose veins and telangiectasias of the lower extremities and various parts of the body. These guidelines have been developed by a self-regulated organization Association “The National College of Phlebology”. The purpose of the de novo guidelines is to systematize the existing evidence and offer minimal standards of care for chronic venous disorders in C1 patients.

Hemorrhoids and quality of life: “… two things incompatible”?

Hemorrhoids is one of the most common diseases in human. According to the latest data for 2017, the prevalence rates of hemorrhoids per 100 000 population in Russia are 410,3 in adults, 26.7 in children aged 15 to 17 years and 4,0 in children under 14 years old. Quality of life (QoL) is an important non-specific subjective parameter of well-being, representing an integrative characteristic of the physical, psychological, social and emotional status of the patient. Despite the high prevalence of hemorrhoids and the variety of modern methods of surgical treatment, there are very few studies addressing the QoL in this category of patients. There are significant differences between the patient and the Coloproctologist in the perception of HD, which, possibly, can lead to the hypertrophy of indications for surgical treatment. Understanding the effect of HD on social life and the concept of the well-being of a particular patient can help the doctor choose between conservative and surgical approaches in the treatment of hemorrhoids. On the other hand, due to the excessive shyness and mentality in our country, patients with HD tend to adapt to their disease, which leads to later seeking medical help and suboptimal efficacy of conservative therapy and minimally invasive surgical methods.This review presents the first Russian multicenter observational program EQUALISER (impact of different trEatment modalities on QUAlity of life of the patientS with acute and chronic hEmorRhoid disease) aimed at assessing the QoL of patients with HD, as well as the effect of the treatment method and types of surgical treatment on the social adaptation of the population.

Pleiotropic therapy for the initial stages of chronic venous insufficiency in post-thrombotic disease

Introduction. The current surgical techniques for the treatment of post-thrombotic disease are at the design phase, are performed in individual cases, not always result in an unambiguous outcome, and cannot completely solve this complex clinical problem. The use of drugs with a pleiotropic mechanism of action that act on various links in the pathogenesis of chronic venous insufficiency show promise.Objective of the study. Assess the clinical efficacy of a drug based on deproteinized hemoderivative obtained from calf blood used to treat the initial manifestations of chronic venous insufficiency affected by post-thrombotic disease.Materials and methods. Results of examination and treatment of 64 patients (30 men, 34 women) with lower extremity post-thrombotic disease and initial manifestations of chronic venous insufficiency (C1-C3). Treatment with a drug based on deproteinized hemoderivative obtained from calf blood at a dosage of 1200 mg per day (intravenous infusion, 30 ml of the drug diluted with 400 ml of Normal Saline) for 10 days. Then, per os at a dose of 1200 mg per day (2 tablets t.i.d.) for 30 days at the outpatient stage. Monotherapy was carried out without the addition of phlebotonics.Results. The therapy resulted in a significant edema syndrome decrease in the ankle area. This indicator decreased from 27.12 ± 0.41 cm to 24.95 ± 0.38 cm (p <0.05). Patients’ complaints about pins and needles decreased from 5.76 ± 0.81 to 2.31 ± 0.65 points (p < 0.05), the frequency and intensity of seizures decreased from 6.53 ± 1.40 to 3.19 ± 0, 94 points (p < 0.05). The intensity of the edema syndrome significantly decreased from 8.13 ± 1.73 to 4.31 ± 1.19 points (p < 0.05), pain syndrome – from 7.94 ± 1.86 to 3.11 ± 1.44 points (p < 0.05), heaviness in the lower extremities – from 8.54 ± 1.72 to 3.90 ± 1.46 points (p < 0.05), the overall patients’ quality of life improved (the integral indicator decreased from 63.29 ± 1.84 to 44.31 ± 1.18 points, p < 0.05).Conclusions. The use of pleiotropic drugs is justified in the early stages of chronic venous insufficiency in patients with post-thrombotic disease, as the therapy produces a complex effect on the microcirculatory bloodstream, metabolic processes in tissues and the rheological properties of blood.

Clinical case of a patient with subungual melanoma

Subungual melanoma is a rare malignant tumor, little known to practitioners. Its location makes diagnosis difficult and requires differentiation with conditions such as onychomycosis, panaritium, hematoma, etc. Unsymptomatic onset brings more problems, the error level during visual examination even among experienced oncologists reaches 25–40%, and the average life expectancy of patients with fully manifested melanoma is limited to 3–4 years.So we present a clinical case to emphasize the need for oncological alertness during an outpatient examination of the subungual lesions. A 32-year-old woman came to the reception complaining of a non-healing bleeding, relatively painless wound of the left little toe. The condition was associated with trauma, for about a month she treated the wound herself, “cauterizing” it with antiseptics.After outpatient treatment of a granulating wound, the material was sent for histological diagnosis, which showed the presence of pigmentless melanoma in the stage of active growth. The woman was urgently hospitalized in the oncology department, where 5th finger exarticulation and inguinal-iliac lymphadenectomy were performed successfully. After this, the condition remained stable, but 14 months later there was a formation in the area of the postoperative scar. A study of a new surgical material confirmed the recurrence of malignant melanoma with Clark invasion level 2.In our opinion, outpatient surgeons should not delay histological examination for all ulcerative and granulomatous lesions of the feet, which will improve the differential diagnosis.

Botulinum toxin type A injections for treatment of chronic anal fissures

An anal fissure is one of the most common diseases of the anal canal with the incident rate of 20–23 cases per 1000 citizens. Most of acute anal fissures are healed spontaneously but a few of them can become chronic process. Chronic anal fissures are characterized by any two of the criteria: pain after defecation lasts longer than 3 months, sentinel pile is present, fibers of internal sphincter at the base of the anoderm.The spasm of the internal sphincter is a guiding pathogenetic mechanism in the development of chronic anal fissures. It leads to circulatory disorder in the anoderm and non-healing wounds. Therefore, the treatment of anal fissures primarily must be focus on eliminating of internal sphincter spasms and then excising of fissures.Recently, botulinum toxin type A injection in treatment of chronic anal fissures has become popular as a noninvasive method of eliminating internal sphincter spasms.Botulinum toxin as a medical agent has been studied since the late 1960s. Botulinum toxin type A has been used to treat of various pathologies including coloproctology diseases for more than 40 years.The botulinum toxin injections make the internal sphincter relax, and as a result create optimal conditions for healing chronic anal fissures.Using of botulinum toxin type A does not cause dangerous complication. Fecal incontinence after using botulinum toxin is transitory.The review describes the use of botulinum toxin type A injections to treat chronic anal fissures.

Successful treatment of extensive recurrent keloid scar

The treatment of scars and impact by them their deformations, as well as the formation of pathological scars, remain one of the most difficult and insufficiently explored problems of plastic and reconstructive surgery. The most severe type of pathological scars is keloid a tumor-like growth of immature connective tissue due to uncontrolled proliferative fibroblast activity. The simple removal of keloids even within healthy tissue was often accompanied by their recurrence. Here presented clinical observation of the patient with benign fibroma of 1 finger of the right foot, who had after excision of formation, keloid scar has developed. Repeated operations with keloid excision and the use of free skin plastic have proved ineffective. Only long-term therapy with diprospan injections for 1.5 years allowed to achieve cure of the patient.

Selection of a topical preparation in the basic treatment of chronic hemorrhoids

Introduction. The vast majority of recommendations for conservative treatment of patients with chronic hemorrhoids contain recommendations for the use of systemic drugs with venotonic and angioprotective properties and the use of topical drugs to treat and prevent exacerbation of the disease. The action of the main components of the topical drugs used is aimed at controlling local inflammation, implemented through various mechanisms. The choice of a drug is mainly subjective.Aim of the study. Comparative clinical evaluation of the effectiveness of topical drugs for the treatment of chronic hemorrhoids.Materials and methods. There are two treatment schemes that are distinguished by the type of the drug that is used. The main group includes patients in treatment of whom a combined preparation based on lidocaine and fluocortolone in the form of rectal suppositories manufactured by Bayer (221 (50.6%) patients) was used. In the control group – a combined preparation on the basis of tribenoside and lidocaine in the form of rectal suppositories by Recordati company (216 (49,4%) people). The rate of suppositories administration and duration of their use was 21 days. Clinical efficacy was estimated by the rate of regression of the main clinical manifestations of the disease: bleeding, pain syndrome, discomfort.Results and discussion. By the 14th day of treatment with Bayer preparation, bleeding as the main sign of disease exacerbation persisted in 15.2% (5) of the main patients against 26.7% (8) of the control group patients. Positive effect was obtained in the majority of patients with the initial prevalence of pain syndrome. On the 14th day the pain remained in 17.0% (8) patients of the main group against 27.9% (12) of the control group. Sense of discomfort was preserved in 10% (4) of the main group patients against 15.8% (6) of the control group patients. Regression of combined clinical manifestations of the disease in the comparison groups showed the fastest elimination of inflammation in the main group in 79.4% of patients against 73.0% in the control group on the 14th day of treatment.Conclusions. Thus, the use of Bayer preparation allowed ensuring the regression of the main clinical manifestations of the disease in a shorter time. This drug can be recommended for use in complex treatment of chronic hemorrhoids in everyday clinical practice.

Effectiveness of compression therapy in chronic venous insufficiency

The article provides an overview of modern literature on the problem of etiology, pathogenesis and principles of complex therapy of chronic venous insufficiency. Data on possible surgical correction methods of this pathology are given. Also, modern tactics assign a significant role to pharmacotherapy, and an overview of the phleboprotectants used is given. Efficiency of compression therapy application is evaluated. A critical review of literature of modern compression agents was carried out, advantages and disadvantages of elastic binting, compression knitting and application of variable compression are described. In comparison with elastic bandages, compression knitting has a number of advantages, such as: patients independently and correctly use compression laundry, the created therapeutic pressure does not depend on the correct application of compression, is more convenient and aesthetic when wearing, is air-permeable and can be used at any time of the year. Evaluation of efficiency of application of compression knitwear in therapy of chronic venous insufficiency is given. The effect of the compression article is due to a decrease in capillary permeability, a decrease in blood viscosity, which leads to a decrease in edema, lymphoprotective action and an increase in vascular wall tone. Modern means of compression have proved to be effective due to the polyvalent mechanism of action on all factors of disease pathogenesis, high bioavailability and minimal side effects. Early application of compression knitwear allows to buy or reduce clinical manifestations of venous insufficiency and its complications, as well as to influence indicators of patients quality of life. Detailed study of literary data will help to correctly select the method and type of compression therapy in case of chronic venous insufficiency.

Experimental clinical study on the using of adhesive in the obliteration of varicose veins in humans

Introduction. In order to perform endovasal vein lining, the American Rodney D.Raabe developed a system for varicose veins obliteration, consisting of a glue gun and two catheters, called “VenaSeal”. As an occlusant for varicose veins in this system, “Medtronic” company today proposes to use an adhesive compound synthesized on the basis of butyl ether of α-cyanacrylic acid.Materials and methods. Endovasal catheter obliteration of tributaries and main trunks of the great saphenous vein on the tibia was performed in 15 patients with varicose disease (C2 to CEAR) in order to substantiate the possibility of using the adhesive compound Sulfacrylate. Severity of pain, presence or absence of phlebitis and thrombophlebitis, hyper pigmentation, neurological disorders, allergic reaction were clinically evaluated.Results and discussion. All patients after the introduction of the glue Sulfakrilat had a clinic of moderate phlebitis, without the formation of blood clots in the lumen of the vein. No local or general allergic reaction was observed. From day 7 occluded venous segments were palpated in the form of moderate density bands, without infiltration to surrounding tissues. In the absence of blood flow ultrasound examination showed gradual biodegradation of the adhesive strip inside the vein with the development of complete obliteration of the lumen starting from the 4th month. Starting with the 7th day gradually stopped aseptic inflammation in the wall of the vein was observed on histological examination. Monocytic infiltration of the venous wall with the formation of multinucleated cells of foreign bodies was present until the time of complete biodegradation of the glue. The process of diffuse growth of connective tissue with the presence of fibroblasts from the subendothelium and in the middle shell was most actively observed in histological material from 90 to 120 days after occlusion. Within 180 days, the lumen of the veins occluded by “Sulfacrylate” was completely obliterated by mature connective tissue, in the absence of glue particles, which indicated its complete biodegradation.Conclusion. The experimental studies conducted with the assessment of clinical symptoms, ultrasound examination and histological study of morphogenesis in the lumen of blood vessels in different periods up to 6 months allow us to conclude the potential use of the adhesive compound “Sulfacrylate” (produced in Russia) for endovasal obliteration of varicose veins in humans.

Excisional biopsy of a dysplastic nevus in a district polyclinic is a path to early detection of skin melanoma

Introduction. Russia has a high mortality rate of cutaneous melanoma – 2.5 per 100,000 population whereas the incidence rate is 7.7 per 100,000 population, i.e. one in every three patients dies. In the foreign countries (the USA, Australia), melanoma mortality rate is 10-15%. Such high rates are explained by the fact that patients with early-stage disease do not seek medical advice, as in early stages a tumour does not cause inconvenience to a patient and looks like an ordinary mole.The purpose of the study was to confirm the advisability of removing a progressive dysplastic nevus (grade 3 lentiginous melanocytic dysplasia) with a view to prevent and make early diagnosis of cutaneous melanoma.Materials and methods. The authors removed 180 pigmented lesions that were clinically diagnosed as a progressive dysplastic nevus in the Surgery Department of Central Polyclinic of Literary Fund from 2009 to March 2020. The patients were referred to the Surgery Department by physicians, dermatologists and other specialists of the polyclinic. Following an oncologist consultation, excisional biopsy of a nevus was performed under local anesthesia.Results. Histological examination revealed 29 (16%) dysplastic nevi with grade 3 LMD and 18 (10%) early-stage melanomas.Conclusions. If excisional biopsy of a dysplastic nevus becomes routine in Ambulatory Surgery practice, it will increase the early diagnosis of melanoma and significantly reduce mortality rates of this disease. For excisional biopsy, the authors recommend to excise at a distance of 0.5 to 1.0 cm from the lesion boundaries, since it is not possible to clinically distinguish a progressive dysplastic nevus from early melanoma.