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.
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.
Introduction. The simplicity of the sclerotherapy procedure, its high efficiency and low cost along with the possibility of performing the procedure on an outpatient basis stimulate the widespread use of the method.Objective of the study. Examine the current state of actual clinical practice regarding the treatment of patients with varicose veins using the sclerotherapy procedure.Materials and methods. An anonymous survey of 162 doctors, members of the professional community of specialists engaged in the treatment of venous diseases was performed. It comprised 15 questions concerning the features of the sclerotherapy procedure and following up of the patients.Results and discussion. The lack of clear-cut standardization for sclerotherapy in the regulatory documents contributes to the significant heterogeneity in the approaches of specialists to the performance of the procedure. The views on the use of sclerotherapy to remove perineal varicose veins (routinely performed only by 25.3% of physicians) and the upper extremity veins (less than 4%) turned out to be controversial. There were significant differences in the therapeutic approaches to the administration of anticoagulants by the patients (refusal in the procedure – 26.3% of respondents, discontinuation of drugs during sclerotherapy – 7.5%). Approximately a third of the respondents regularly exceed recommended 10 ml-volume of foam per session, there is no consensus on the choice of the needle diameter, drug concentration even in the similar clinical situations. About half of them have experience in using glucose as the sclerosant, every third – in using a transcutaneous laser, 5.6% – in using the mechanochemical obliteration techniques that are not currently certified in the Russian Federation. The use of compression therapy after sclerotherapy is not standardized; the regulatory documents provide contradictory durations of its use, which is due to the weakness of clinical research data on this issue. Up to 99% of physicians observe pigmentation, 83.2% – development of secondary telangiectasias and 60.2% – superficial necrosis in their practice. These circumstances arouse legal suspicion in relation to this type of treatment and the legal vulnerability of physicians. At the same time, physicians need to be more informed about the current requirements for some issues.Conclusion. The current legislation regulating the practical aspects of the sclerotherapy considers it largely through the lens of medicine, ignoring a significant cosmetic component. It is necessary to work out the provisions describing the specifics of cosmetic manipulations performed by the phlebologists, and the need for more detailed familiarization with the regular updates of the guidelines.
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.
Introduction. The adjustable non-extensible compression bandage is a new product recently registered and approved for clinical use in the Russian Federation. The main indications for its use are severe chronic venous insufficiency and lymphedema, which cannot be corrected with traditional bandages and flat knit medical compressions. On the affected limb, an adjustable, non-extensible compression bandage allows high working pressure to be created at low, approaching zero, resting pressure. And depending on the tension of the velcro fastener, the working pressure can be adjusted between 20 and 50 mmHg or more. At the same time, the patient can maintain the actual pressure independently, regardless of the reduction in the volume of the limb. Low resting pressure makes it possible to use this type of bandage all day without the discomfort that is typical for traditional bandages and therapeutic compression knitwear felt by patients during sleep.Clinical case. Patient diagnosed with chronic lymphovenous insufficiency in both lower limbs. CEAP class C5 on the left, CEAP class C5 on the right. After undergoing acute iliofemoral thrombosis on the left, complicated by thromboembolism of small branches of the pulmonary artery, he was treated in a specialized vascular unit, where anticoagulant, antiplatelet and phlebotropic therapy was carried out. After the second episode of deep vein thrombosis, pain in the lower extremities, swelling of the tibia, skin itching and the appearance of small trophic ulcers started to worry, which temporarily closed against the background of increased compression therapy, prescription of phlebotropic drugs and local treatment. Subsequently, large trophic ulcers were formed on the inner surface of both shins above the ankle joint. An adjustable, non-extensible compression bandage was used on the right shin to correct chronic venous insufficiency and heal a trophic ulcer. The use of an adjustable, non-extensible compression bandage within 2 to 4 weeks resulted in the disappearance of chronic swelling, reduction of the pain syndrome, and then 5 months later – led to a reduction in trophic ulcer and the disappearance of infection signs.Conclusions. This clinical case of the successful closure of a large infected trophic ulcer that occurred after deep vein thrombosis against the background of coxarthrosis and which remained unhealed for 7 years clearly illustrates the broad possibilities of an adjustable, nonextensible compression bandage.
