Bipolar radiofrequency-induced thermotherapy of haemorrhoids: a new minimally invasive method for haemorrhoidal disease treatment. Early results of a pilot study

Introduction: Haemorrhoidal disease is the most frequent benign anorectal disease. Conservative, minimally invasive and surgical methods are used in the treatment of haemorrhoidal disease. Radiofrequency thermoablation is a popular new technique in the treatment of varicose veins. Aim: Assessment of the use of the method in the treatment of haemorrhoidal disease using bipolar radiofrequency-induced thermotherapy (RFITT or so-called Celon method). Material and methods: We used the CelonLab PRECISION (Celon AG medical instruments, Teltow, Germany) with the bipolar RFITT applicator Celon ProBREATH for the treatment of haemorrhoidal disease stages III and IV. Results: In the Department of Surgery at the Atlas Hospital in Zlin, Czech Republic, a total of 71 patients were treated from 9/2007 to 10/2010 with this new treatment approach. The success rate was 100%, local recurrence rate was 2.8%, and medium-term satisfaction of patients who underwent the procedure was 99.5%. Complications appeared in 4.26% of cases. Conclusions: The new RFITTH technique for treatment of advanced stages of haemorrhoidal disease is a new treatment modality with good curative response, low level of complications, minimum pain and quick return of patients to their usual activities

Initial results of the bipolar RFITT coagulation in advanced stages of hemorrhoidal disorder study

Cíl práce: Ověřit v praxi novou metodiku radiofrekvenční bipolární koagulace hemoroidů. Použité metody: Metoda bipolární radiofrekvenční indukované termoterapie vnitřních a zevních hemoroidů přístrojem Olympus Celon. Za použití radiofrekvenční bipolární elektrody koagulace vnitřních a zevních hemoroidálních uzlů pod vizuální kontrolou za pomoci zpětné vazby. Aplikace RF energie průměrně z 12 vpichů nad linea dentata na ošetření vnitřních hemoroidů III. stadia. U lY. stadia hemoroidů pak podle rozsahu prolapsu i do zevních hemoroidálních uzlů. Ve 4 případech byla metodika použita v kombinaci s klasickým ošetřením podle Parkse při excizi análních fibromů či markíz. Výsledky: Od září 2007 do června 2008 byla metodika použita u 18 pacientů ve III. a lV. stadiu hemoroidální nemoci. 15 pacientů bylo podle protokolu sledováno 7. a 21. den po operaci. Prvních 5 pacientů pak po 6 měsících a v další fázi budou sledováni po 12 měsících. Průměrná doba výkonu byla 20 minut, doba hospitalizace 24 hodin. Pooperační krvácení trvalo průměrně 0-10 dní. Větší otok po operaci se vyskytl u 2 pacientů. Bolestivost byla průměrně (ve škále 0-10) 7. den 1,5; 21. den 0,46. Komplikací výkonu byl vznik anální fisury u 2 pacientů po předchozích výkonech na konečníku provázený zvýšenou bolestivostí. Průvodním jevem při ošetření IV. stadia je přechodný otok zevních hemoroidálních uzlů. Závěr: Bipolární radiofrekvečně indukovaná termoterapie hemoroidů je nová metoda semiinvazivního ošetření hemoroidů. Je bezpečná, s minimálním množstvím časných pooperačních komplikací. Pacienty je dobře snášena a dobře hodnocena. Dlouhodobé výsledky budou dále publikovány.Aim of the Study: The aim is to verify a new methodology of radiofrequency bipolar coagulation for treatment of hemorrhoids in practice. Used Methods: The method of bipolar radiofrequency- induced thermotherapy of internal and external hemorrhoids using the Olympus Celon apparatus. Radiofrequency bipolar electrode was app lied to perform coagulation of internal and external hemorrhoids under visual control and feedback. RF energy was applied, on average, at 12 sites above the dentate line to treat internal, stage III hemorrhoids. In stage IV hemorrhoids, based on the prolapse extent, it was applied to external hemorrhoids, as well. In four subjects, the method was used in combination with a standard Parks management to perform excision of perianal fibromas. Results: From September 2007 to June 2008, the method was used in 18 patients with stage III and IV hemorrhoids. 15 patients underwent a per-protocol follow up on postoperative Day 7 and Day 21. Then, the first 5 subjects were checked in a 6-month interval and will be re-assessed in 12 months. The average duration of the procedure was 20 minutes and duration of hospitalization was 24 hours. Postoperative bleeding lasted for average 0-10 days. Major postoperative edema occured in 2 subjects. The average pain intensity (on 0-10 scale) was 1.5 on Day 7; 0.46 on Day 21. The postoperative complications included anal fissures with increased pain intensity in 2 subjects with a preoperative history of anal procedures. Transient edema of external hemorrhoids occured upon management of the stage IV hemorrhoidal disorder. Conclusion: Bipolar radiofrequency-induced thermotherapy of hemorrhoids is a new, semiinvasive method of the management of hemorrhoids. It is safe, with minim al rates of early postoperative complications. It is well- tolerated and evaluated by patients. Long-term results will be published further

Endovascular reflux-elimination of perforating veins by RFITT and foam sclerotherapy

Introduction: During the last years, many endovascular techniques have been developed in order to eliminate not only the reflux in stem veins but in perforating veins and their tributaries, too. Aim: The aim of this study was to use endo - vascular RFITT and the foam sclerotherapy for the occlusion of perforating veins as the prime source of reflux and their tributaries. Material and Methods: The Celon method was used for the thermal treatment. Polydocalon with the concentration 1% and 2% with DSS technique was used for the foam sclerotherapy. The RFITT was accomplished in 127 perforating veins in total. This group was divided into three subgroups. The first one consists of patients where only RFITT was carried out (n= 41), in the second, there were patients with RFITT realized with sclerotherapy during one session (n= 48), in the third, RFITT was completed with sclerotherapy in one month after the RFITT intervention (n= 38). The control group included perforating veins treated only with sclerotherapy (n= 81). The power setting 6W was used on the generator during the RFITT with Celon- ProSurge micro and 18W for usage of Celon ProCurve probe. Results: The effectiveness of the procedure in the group 1 was 8.8%, in the group two 93.7%, in the group three 92.1% and in the control group 76.5% in one year follow up. There was no significant difference between the effectiveness in groups 1, 2 and 3. The marginal difference was among all three groups with RFITT and the control group. Significant differences were in the parameter of the extinction of visible varicose veins with the reflux from perforators. The extinction was faster in group 3 than in group 2 and in the control group and the slowest was in group 1. The significant difference was observed between groups 2 and 3 compared with group 1 and the margin difference was between groups 2 and 3 compared with the control group. No significant difference was observed between groups 1 and the control group. Conclusions: All procedures are effective. The most important is the combination of RFITT and the sclerotherapy one month after thermal intervention. This is associated with a low risk of recanalization and the fastest extinction of visible varicose veins

Lymphadenectomy in Papilary Thyroid Cancer

Studie hodnotí vlastní soubor pacientů s papilárním karcinomem a postižení lymfatických uzlin. Celkem bylo odstraněno 351 uzlin a 113 bylo postiženo metastázou karcinomu.Study described metastases in lymph mode by thyroid papilocarcinoma. There were examined 351 nodes and 113 were positive

Sentinel node biopsy and neoadjuvant chemotherapy in the treatment of breast cancer

Purpose: Sentinel lymph node biopsy (SLNB) has become a safe and accurate alternative to axillary lymph node dissection (ALND) in the surgical management of early breast cancer. The aim of this study was to determine the false negative rate of SLNB in patients with advanced breast cancer after neoadjuvant chemotherapy. Methods: Forty-eight patients with 49 advanced breast cancers (one patient had bilateral disease) underwent neoadjuvant chemotherapy. All of them had SLNB, followed by standard level I/II ALND. SLNs were identified in 47 out of 49 tumors (detection rate 95.9%). Results: Axillary nodal metastases were detected in 28 patients; SLNs were positive only in 14 patients. Four sentinel internal mammary nodes were removed in 4 patients, while one of them was positive with micrometastasis but axillary nodes were negative. False-negative results occurred in 2 (7.14%) patients. The results of our study confirm that SLNB in patients with advanced breast cancer is not significantly altered by the preoperative chemotherapy. Biopsy results were very similar to those without any neoadjuvant chemotherapy. Conclusion: ALND, known for its serious complications, can be replaced in some cases by SLNB. © 2012 Zerbinis Medical Publications

Distribution of metastatic affection in colorectal carcinoma using lymphatic mapping and radiation-navigated biopsy of the sentinel lymph node

AIM: The aim is to define distribution of the lymphonode metastatic affection in colorectal carcinoma and to evaluate a new methodology of lymphatic mapping and the sentinel lymphonode detection during colorectal carcinoma procedures in practice. USED METHODS: A method of peroperative lymphatic mapping using a Patentblue method in vivo. Rectoscopic peritumoral application of a radiocoloid in a two-day or a single-day protocol, scintigraphy, peroperative quants of radioactivity detection using a gamma probe. Radical or paliative tumor resection. Detection of the sentinel and non-sentinel nodes on a preparation ex vivo, divided according to levels. The metastatic affection distribution is assessed in three levels, marked U1 - U3, a S1 - S3. Histopathological examination of the nodes on series sections and, event, immunohistochemistry. RESULTS: The methods were used in 66 patients. A total of 970 nodes have been examined, with an average of 14.6 nodes/ patient. The metastases quantity decreases with distance from the tumor. The peritumoral levels (U1a S1) record the highest rates of metastases. In our patient group, 92% of the metastases were recorded in the S1 level, 4% in the S2 level and 4 % in the S3 level. CONCLUSIONS: The highest rate of metastases was recorded in the levels, closest to the tumor, therefore, in case of negative findings of sentinel nodes in the S1 level, the nodes from this level may be closely examined (using the method of series sections and immunhistochemistry) and the staging be established more precisely

Locoregional Recurrence after Conservative Surgery by Early Breast Carcinoma

Konzervativní výkony u karcinomu prsu jsou alternativou mastektomie, avšak počet lokálních recidiv je větší. Cílem prospektivní studie bylo zjistit počet lokálních recidiv v prsu po konzervativních výkonech a určit rizikové faktory, které se na vzniku podílí, se zvláštním zaměřením na rozsah resekce. Do studie bylo zařazeno 330 pacientek. Lokální recidivy byly diagnostikovány 5x (1,51%). Dvě recidivy byly prvními známkami generalizace procesu. Tři byly velikosti 8 mm až 20 mm a nebyla prokázána generalizace. Doporučujeme dodržet vzdálenost 5 mm resekční linie od nádoru.Conservative surgery is considered as standard and alternative mastectomy in early stage breast cancer but number of local recurrence is higher. Aim of the study was to detect number of local recurrence after conservative surgery and to identify risk faktors of local recurrence especially importance of resection margins. Conservative surgery was performed in 330 patients. In breast local recurrence appeared in 5 (1,51%) patients and one had regional recurrence without in breast recurrence. We recommend keeping this resection distance

Local recurrences after conservative surgery in breast carcinoma

Východisko: Lokální recidivy v prsu po konzervativní chirurgické terapii musíme hodnotit jako selhání primární léčby. Ve studii jsme sledovali počet lokálních recidiv po konzervativních chirurgických výkonech i ve vztahu k relapsům a úmrtí na karcinom. Metoda a výsledky: V období od 1.12. 1998 do 30.06.2004 bylo na chirurgickém oddělení nemocnice Atlas ve Zlíně léčeno 143 pacientů s karcinomem prsu, které podstoupily konzervativní výkon. U všech následovala radioterapie prsu a boost. Minimální makroskopická vzdálenost byla l,0 cm. Reexcise následovala, když minimální mikroskopická vzdálenost byla pod 5mm. Minimální dávka na lůžko tumoru a na celý prs byla 50Gy během 5-6 týdnů, denně 2Gy. Vždy byla nasazena brachyterapie. Kombinace chemoterapie s hormonální terapií následovala u 56x, jen chemoterapie 31x, jen hormonální terapie 31x, bez adjuvantní terapie 25x. Výsledky: Medián sledování byl 32 měsíců. Velikost nádoru dle TNM klasifikace: TIS 10, pT1a 1x, pTb 28x, pTc 55x, pT2 44x, pT3 5x. Stadium: 0 1x, I 58x, IIA 56x, IIB 24x, IIIA 4x. Lokální recidiva v prsu se objevila 5x, (3, 49%). Vzdálené metastázy byly registrovány 6x, (4,1%) a z nich 3x(2,09%) došlo k úmrtí základní onemocnění. Lokální recidiva byla pouze jedenkrát následována vznikem vzdálených metastáz a úmrtím na karcinom a to v intervalu 12 měsíců. Velikost primárního tumoru, který recidivoval, se pohybovala od l0mm do 45mm a recidivy objevily se v intervalu od 12 do 42 měsíců. Lokální recidivy byly řešeny mastektomií 4x, jedenkrát reresekcí. Závěr: Počet lokálních recidiv v souboru je v souladu s mezinárodním doporučením a je výsledkem moderní multimodální léčby.Backgrounds: Local recurrences in breast after conservative surgery are failure of primary therapy. The aim of the study was monitoring of local recurrences after conservative surgery and also relationships of local recurrences with disease free interval and survival. Materials and Methods: Between 1.12. 1998 and 30.06.2004, 143 patients with breast carcinoma were treated at Department of Surgery Atlas Hospital Zlin by conservative surgery. All patients received radiotherapy and boost in breast. Macroscopic free margins were l0 mm and reexcision were done in all patients with free margins less than 5mm. Dose of the radiotherapy whole breast and cavity were 50Gy, interval 5-6 weeks, daily 2Gy. Brachytherapy received all patients, combination of chemotherapy and hormonal therapy were 56x, only chemotherapy 31x, only hormonal therapy 31x and without adjuvant therapy 25x. Results: Median follow-up was 32 month. Tumor size according to TNM classification: TIS 10, pT1a 1x, pTb 28x, pTc 55x, pT2 44x, pT3 5x. Stage: 0 1x, I 58x, IIA 56x, IIB 24x, IIIA 4x. Local recurrences in breast were 5x, (3, 49%), distant metastases 6x, (4, 1%) and 3x (2, 09%) appeared distant metastases and death at breast carcinoma without local recurrence. Only in one patient local recurrence were followed by distant metastases and death. Interval from local recurrence and death was 12 month. Size of the original tumor with local recurrences was from 10mm to 45 mm. Interval from the time of initial treatment to local recurrences was from12 to 42 month. Surgical treatment of local recurrences included mastectomy 4x and conservative surgery 1x. Conclusion: Number of local recurrences is in correspondence with international guideline and results of modern multimodal therapy

Significance of the resection margin and risk factors for close or positive resection margin in patients undergoing breast-conserving surgery

Purpose: While positive resection margin (RM) in women undergoing breast-conserving surgery (BCS) represents a clear indication for re-resection, there is no unequivocal recommendation regarding the extent of the clear RM. The aim of this study was to define the optimal extent of the RM and the risk factors for close or positive RM. Methods: Patients scheduled for BCS had diagnosis confirmed before BCS (lumpectomy and quadrantectomy) by core biopsy. Sentinel lymph node biopsy followed BCS, and in case of positive findings axillary lymph node dissection followed. According to RM patients were categorized into 4 groups: 1) Patients with positive RM; 2) Clear RM 5 mm. In the first 3 groups where re-resection was indicated, the presence of tumor cells in the re-resection specimen was determined. All patients were followed for local recurrence. Results: 330patients undergoing BCS were studied. Median follow up was 39.6 months (range 12-70). Lumpectomy was performed in 111 cases and quadrantectomy in 219. In 19 cases the final procedure was mastectomy due to the impossibility to achieve negative RM. In 78 cases re-resection followed the primary procedure due to close or positive RM. Clear RM was < 2 mm in 12 cases (15%), 2-5 mm in 56 (72%) and positive margin in 10 (13%). Positive re-resection specimen was detected in 31 cases (39.7%) (in 10 cases with positive RM after primary procedure, in 3 with negative margin < 2 mm and in 18 with 2-5 mm margin). The re-resection rate according to the location of the primary tumor was 77% (n=60) in the upper outer quadrant, 8% (n=6) in the lower outer quadrant, 6% (n=5) in the upper inner quadrant, 4% (n=3) in the lower inner quadrant, and 5% (n=4) in centrally located tumors. Multicentric/multifocal tumor was diagnosed in 16 cases from which re-resection was indicated in 12 cases (75%). The number of re-resection according to tumor size was as follows: Tis 8 cases (30.7%), T1a none, T1b 14 (20.2%), T1c 34 (22.5%), T2 22 (28%). Re-resection was performed in 8 cases (31%) of ductal carcinoma in situ (DCIS), in 53 (22%) of ductal carcinoma, in 10 (37%) of lobular carcinoma, and in 7 (15%) of other histology. Five cases with local relapse were detected during follow up. Conclusion: The generally recommended clear RM of 1-5 mm is not sufficient because of the high number of positive specimens in the case of clear RM of 2-5 mm. The risk factors for close or positive RM are multicentric tumors and upper outer location of the primary tumor. Longer follow up will be needed to analyze local relapse rate according to RM status