Hemorrhoid Embolization Results: 15 years Experince

Transcription

1 Krasnoyarsk State Medical University named after prof. Voyno-Yasenetsky Russia A. Zakharchenko E. Galkin Hemorrhoid Embolization Results: 5 years Experince

2 Alexander Zakharchenko, MD No relevant financial relationship reported

3 Method of treatment should be pathogenetically based, depend on the form of hemorrhoids (acute / chronic), stage of disease and clinical manifestations

4 How to treat? The three graces. Rubens. Introduce the traditional approach to the treatment of hemorrhoids: Medicamentous Therapy (MT) Acute hemorrhoids Early stage of chronic hemorrhoids Perioperative period (I-IV stage) Minimal Invasive Instrumental Treatment (MIIT) Sclerotherapy Latex ligation ST MT MIIT HAL-RAR Surgery Treatment (ST) Hemorrhoidopexy by Longo Hemorrhoidectomy

5 How to treat? Bathing girl. Renoir. Her youth and freshness represents a new concept in the treatment of hemorrhoids: Embolization of internal hemorrhoids Emborrhoid technique

6 To date great clinical interest is the method of Embolization of internal hemorrhoids (EIH) А B Emborrhoid technique А an imbalance between arterial inflow and venous outflow prior to EIH B correct the imbalance between arterial inflow and venous outflow after EIH

7 The history of the method of EIH E. Galkin the founder of the method, the first experience of clinical use in Russia (994). Galkin EV. Interventional radiology of chronic hemorrhoids [in Russian]. Vestn Rentgenol Radiol. 994;4: A. Zakharchenko evaluation of the effectiveness and safety of the method, indication, study results ( ). Zakharchenko AA, Galkin EV, Vinnik JuS, et al. Endovascular dezarterization of internal hemorrhoids of hemorrhoids disease: justification, efficiency and safety, comparative results [in Russian]. Coloproctologia. 204;: Zakharchenko AA, Galkin EV, Vinnik JuS et al. Dearterialization of internal hemorrhoids in hemorrhoidal disease: pros and cons of the treatment choice. whether correction of venous component of pathogenesis is required? [in Russian]. Coloproctologia. 205;3: V. Vidal, M. Sapoval, Y. Sielezneff et al. the experience of clinical use in Europe. Vidal V, Louis G, Bartoli JM, Sielezneff I. Embolization of the hemorrhoidal arteries (the emborrhoid technique): a new concept and challenge for interventional radiology. Diagn Inter Imaging. 204;95: Vidal V, Sapoval M, Sielezneff Y et al. Emborrhoid: a new concept for the treatment of hemorrhoids with arterial embolization: the first 4 cases. Cardiovasc Intervent Radiol. 205;38:72-78.

8 The principal novelty of the method required a study on is safety, effectiveness and clinical outcomes? Questions What is the impact of ischemia: on the mucosa of the rectum? on the function of the sphincter of the rectum? on the cavernous tissue of internal hemorrhoids? What happens clinically?

9 Research methods Morphology and morphometry of the mucosa of the rectum Sphincterometry and electrical activity of the sphincter of the rectum Morphology of the cavernous tissue of internal hemorrhoids Microcirculation in the internal hemorrhoids and internodal space Dynamics of change in the size of internal hemorrhoids (retro flexion rectoscopy) The timing of the disappearance of the symptoms of hemorrhoids (bleeding, prolapse) Clinical assessment of immediate and long-term results

10 Safety Quantitative indicators morphometry of the mucosa of the rectum in patients with hemorrhoids after EIH (after 6 months) Parameter Control group n=40 Study group n=40 Statistical validity () (2) Thickness of mucosa 0.67±0.0 мм 0.68±0.0 мм p, 2 > 0.05 Depth of the crypts 0.62±0.0 мм 0.6±0.0 мм p, 2 > 0.05 Diameter of the lumen of the crypts 0.032±0.002 мм 0.03±0.00 мм p, 2 > 0.05 Outer diameter of the crypts 0.086±0.00 мм 0.088±0.00 мм p, 2 > 0.05 Diameter of goblet cells 25.8±0.9 мкм 26.±0.8 мкм p, 2 > 0.05 Number of crypts per mm of the mucosa.2±0.5.0±0.5 p, 2 > 0.05 Number of goblet cells in quint 28.4± ±29.8 p, 2 > 0.05

11 Safety Control group х00 A B C Study group х00 A B C Quality characteristics morphology of the mucosa of the rectum after EIH: A the thickness of mucosa less than mm, a large number of crypts, the epithelium throughout saved, crypts are arranged correctly, form a cylindrical; B a large number of goblet cells, the basal location of the nuclei of the epithelium of the crypts; C moderate infiltration of the mucosa by mononuclear cells Morpho-functional state of the mucosa after EIH has no significant differences from the state of the mucosa in the control group Revealed no inflammatory, dystrophic or atrophic changes

12 Safety The sphincterometry in patients with hemorrhoids before and after EIH The period of observation Indices of contractility of the internal sphincter (grams) n=40 Indices of contractility of the external sphincter (grams) n=40 Man s Woman s Man s Woman s Norm 420.0± ± ± ±3. 4 Before EIH 48.0± ± ± ±2. 5 After EIH ( month) 423.0± ± ± ±7.2 6 Statistical validity p, 2 < 0.05; p 2, 3 < 0.05; p, 3 > 0.05 p 4, 5 > 0.05; p 5, 6 > 0.05; p 4, 6 > 0.05 I-III when stage dysfunction of the internal sphincter compensatory increases in tone in response to hypertrophy IH The degree of dysfunction depends on the degree of hypertrophy of node stage of the disease EIH leads to normalization of the tonic tension of internal sphincter

13 Safety The electrical activity of the external sphincter in patients with hemorrhoids before and after EIH The period of observation Background electrical activity (mkv) n=40 Random electrical activity (mkv) n=40 Man s Woman s Man s Woman s Norm 43.0± ± ± ±0.9 Before EIH 45.0± ± ± ±.07 2 After EIH ( month) 44.0± ± ± ±.4 3 Statistical validity p и 2, 3 > 0.05; p 2, 3 > 0.05 EIH not adversely affected by background and random electrical activity of external sphincter, does not violate the contractility Neuro-reflex regulation of the sphincter device is not broken

14 Safety The morphology of internal hemorrhoids after hemorrhoidectomy х00 х cavernous veins dilated, filled with blood cells 2 cochlear arteries dilated, filled with blood cells 3 the node stroma has moderate amount of smooth muscle fiber bundles with moderate degenerative changes

15 Safety The morphology of internal hemorrhoids.5 months after embolization х00 х00 3 А B 2 2 A cavernous veins () are desolated and have no blood cells B cochlear arteries () are collapsed and have no blood cells. The node stroma has moderate amount of smooth muscle fiber bundles (2) with moderate degenerative changes The process of thrombus organization (sclerosis) (3) is extended to the venous wall with their following confluence

16 Safety The Doppler results on internal hemorrhoids Group Patients without clinic hemorrhoids (n=40) Indicator Doppler (ml / min / 00 g) On internal hemorrhoids On the mucosa of the rectum (the internodal space) 76.3± ±.2 3 Patients with hemorrhoids disease (n=40) 09.5± ±4. 4 Statistical validity p, 2 < 0.0; p 3, 4 > 0.05 The intensity of the blood supply to internal hemorrhoids when hemorrhoids disease 2 time more, than in internodal space The rate of blood flow internal hemorrhoids when hemorrhoids disease.5 time more, than in patients without clinical hemorrhoids The rate of blood flow in the internodal space has no reliable differences in the comparison groups

17 Safety The Doppler results in patients with hemorrhoids before and after EIH (n=40) The timing of the measurement Indicator Doppler (ml / min / 00 g) On internal hemorrhoids On the mucosa of the rectum (the internodal space) At day before EIH 09.5± ±4. 4 day after EIH 60.2± ±4.3 5 month after EIH 59.6± ±4. 6 Statistical validity p, 2 < 0.0; p 2, 3 > 0.05; p 4, 5, 6 > 0.05 After EIH interstitial velocity of blood flow in cavernous tissue is reduced in 2 times Indicators of blood supply to the mucosa of the rectum in the internodal space indicate the absence of ischemia

18 Stage of hemorrhoids The size of internal hemorrhoids before to EIH (cm) (n=40) () Efficacy Dynamics of change in the size of internal hemorrhoids after EIH The size of internal hemorrhoids month after EIH (cm) (n=40) (2) Dynamics of change in the size of internal hemorrhoids I stage 0.9± ±0. The reduction of nodes in.8 times (by 45%) II stage.4± ±0.2 The reduction of nodes in.7 times (by 43%) III stage 2.0±0.5.2±0. The reduction of nodes in.6 times (by 40%) Statistical validity p, 2 < 0.05 month after EIH on the background of sclerosis of the size of the nodes is reduced on average by 43% The reduction of nodes in the larger at stages I or II (.8 and.7 times, respectively), than in III (.6 times)

19 Stage of hemorrhoids n Efficacy Short-term results EIH depending on the stage of hemorrhoids Cessation of bleeding No prolapse internal hemorrhoids day 2 days 7 days 4 days month 2 months I stage II stage III stage Total At I-II stages in time to 2 months, the symptoms cropped fuly (exellent result 00%) At stage III bleeding ceased in all patients, prolapsed internal hemorrhoids treated only in 6 (66.7%) In 8 (33.3%) patients with stage III remained episodic prolapse internal hemorrhoids, nodes did not require manual reposition (a satisfactory result)

20 Retro flexion rectoscopy before EIH Hyperthrophic internal hemorrhoids () at positions of 3, 7 and o clock (with dimensions of up to.5 cm) 2 Tube of colonoscope Hypertrophic IH at positions of 3, 7 and o clock (with dimensions from 0.7 to.2 cm) 2 Hypertrophic IH at positions of 5, 6 and 9 o clock 3 Tube of colonoscope

21 Retro flexion rectoscopy month after EIH 2 Reduced IH at positions of 3, 7 and o clock (with dimensions of up to 0.8 cm) 2 Tube of colonoscope

22 Short-term results of the treatment (n=24) Parameter Anesthesia Anal pain syndrome Wound bleeding Inflammation / Wound exudation Embolization of internal hemorrhoids (EIH) Local (in the right inguinal area) No No No Parameter Impaired anal sensitivity Reflex urinary retention Time to full activation of patients (hours) Embolization of internal hemorrhoids (EIH) No No 9.2±.4

23 Short-term results of the treatment (n=24) Parameter Length of hospital stay (days) Disability period (days) Embolization of internal hemorrhoids (EIH).6± ±0.7 Parameter Patients satisfied with outcome and willing to advice treatment to others Embolization of internal hemorrhoids (EIH) 236 (97.9%)

24 Long-term results of the treatment ( ) The period of observation from year to 5 years (n=24) Parameter Stenosis of the anal canal Anal incontinence Favorable outcome (no symptoms) Embolization of internal hemorrhoids (EIH) No No 230 (95.4%) Parameter Relapse of the disease Additional treatment required Embolization of internal hemorrhoids (EIH) (4.6%) Drug treatment 2/ (8.2%) HAL-RAR 5/ (45.4%) Hemorrhoidectomy 4/ (36.4%)

25 Indications for EIH Method is not a panacea has a definite place among the known methods of treatment chronic hemorrhoids Chronic hemorrhoids I-II stage and partially stage III*, with recurrent bleeding of varying intensity The recurrence of hemorrhoids after traditional minimally invasive interventions and hemorrhoidectomy Somatic contraindications to hemorrhoidectomy Temporary stop hemorrhoidal bleeding with severe anemia (stage III- IV) the preliminary stage of preparation for hemorrhoidectomy, allowing up to operation to restore the volume of circulating blood to eliminate anemia * - episodic prolapse IH: the patient s motivation fear of negative phenomena transanal intervention

26 Conclusion EIH modern pathogenetically based method of treatment of chronic hemorrhoids I-II and partially III stage: Leads to reduction of arterial inflow to the internal hemorrhoids and reduce them in size 2 times, with subsequent sclerosis = regression symptoms of bleeding and prolapse nodes Minimally invasive (atraumatic in pathological area) with the maximum possible radicalism, comfortable for patients Chortens the period of hospitalization and disability, reduces the number of relapses Quite effective and safe

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