Utility of unilateral versus bilateral venous reflux studies for venous insufficiency.

OBJECTIVE: Duplex ultrasonography is the reference standard for diagnosing chronic venous insufficiency. Bilateral venous reflux ultrasound studies are among the most time-consuming and physically demanding tests for vascular ultrasound technologists to perform. Furthermore, if a venous procedure is required, many insurance policies require that a diagnostic venous ultrasound scan for reflux must be performed within 1 year of the procedure. If the intervention is scheduled for >1 year after the ultrasound scan, the insurance company might require a repeat venous ultrasound scan before granting insurance authorization. Hence, ordering bilateral venous duplex ultrasound scans to evaluate for reflux when an intervention might only be performed on one limb within the year could be a waste of time and resources. The aim of the present study was to determine the utility of ordering bilateral vs unilateral studies to evaluate for reflux in patients with suspected chronic venous insufficiency and to determine whether a resource-saving potential exists for vascular laboratories through optimization of the process of ordering venous duplex ultrasound studies. METHODS: A retrospective review of all patients who had undergone bilateral lower extremity ultrasound scanning to evaluate for reflux from January 1, 2016 to December 31, 2016 at the Massachusetts General Hospital vascular laboratory was performed. The demographics, indications for ultrasound scanning, comorbidities, time required to perform the ultrasound study, and interval to intervention were documented. The data were analyzed using SPSS statistical software (IBM Corp, Armonk, NY). RESULTS: During the study period, 13,854 ultrasound studies had been performed in our vascular laboratory, of which 606 (4.4%) had been bilateral ultrasound scans for venous insufficiency. The time allotted for a bilateral study was 2 hours. Of the 606 studies evaluated, 152 (25.1%) showed no evidence of reflux, 284 (46.9%) showed bilateral lower extremity reflux, and 170 (28.1%) showed only venous insufficiency in one leg. Venous ablation, phlebectomy, and/or sclerotherapy were performed for 28.7% of the patients. However only 6.2% of patients had undergone venous procedures on both legs within 1 year after the ultrasound studies. Ablation was the most common procedure performed (54.6%), followed by phlebectomy (27.%) and sclerotherapy (17.9%). Overall, 94.7% of patients had not undergone a venous procedure on both legs within 1 year after the ultrasound studies and, hence, would have required a repeat duplex ultrasound scan to ensure insurance coverage for future procedures. CONCLUSIONS: Most bilateral ultrasound scans for venous insufficiency will not result in an intervention. Thus, most patients (95%) could have undergone a unilateral scan before the initial intervention instead of bilateral duplex ultrasound scanning.

Active Observation as an Alternative to Invasive Treatments for Pediatric Head and Neck Lymphatic Malformations.

OBJECTIVES: An increasing number of treatment modalities for lymphatic malformations are being described, complicating therapeutic decisions. Understanding lymphatic malformation natural history is essential. We describe management of head and neck lymphatic malformations where decisions primarily addressed lesion-induced functional compromise (ie, breathing, swallowing) to identify factors associated with invasive treatment and active observation. We hypothesize that non-function threatening malformations can be observed. STUDY DESIGN: Retrospective case series. METHODS: Retrospective case series of consecutive head and neck lymphatic malformation patients (2000-2017) with over 2 years of follow-up. Patient characteristics were summarized and associations with invasive treatment (surgery or sclerotherapy) tested using Fisher's exact. In observed patients, factors associated with spontaneous regression were assessed with Fisher's exact test. RESULTS: Of 191 patients, 101 (53%) were male, 97 (51%) Caucasian, and 98 (51.3%) younger than 3 months. Malformations were de Serres I-III 167 (87%), or IV-V 24 (12%), and commonly located in the neck (101, 53%), or oral cavity (36, 19%). Initial treatments included observation (65, 34%) or invasive treatments such as primary surgery (80, 42%), staged surgery (25, 13%), or primary sclerotherapy (9, 5%). Of 65 initially observed malformations, 8 (12%) subsequently had invasive treatment, 36 (58%) had spontaneous regression, and 21 (32%) elected for no invasive therapy. Spontaneous regression was associated with location in the lateral neck (P = .003) and macrocystic malformations (P = .017). CONCLUSION: Head and neck lymphatic malformation treatment selection can be individualized after stratifying by stage, presence of functional compromise, and consideration of natural history. Recognizing the spectrum of severity is essential in evaluating efficacy of emerging treatments, as selected malformations may respond to observation. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1392-1397, 2021.

Laparoscopic Ethanol Sclerotherapy for Ovarian Endometriomas: Preliminary Results.

STUDY OBJECTIVE: The purpose of this study was to evaluate the laparoscopic aspiration of endometriomas through 95% ethanol sclerotherapy. DESIGN: A single-center, retrospective study. SETTING: Endometriosis outpatient clinic of a tertiary university hospital, gynecology department of Agostino Gemelli University Foundation Polyclinic IRCCS, Rome, Italy. PATIENTS: Fifty-three women with 64 identified endometriomas measuring 4 to 10 cm with no suspected malignancy. INTERVENTIONS: Laparoscopic aspiration and 95% ethanol sclerotherapy of endometriomas were completed in the patients between September 2013 and September 2017. MEASUREMENTS AND MAIN RESULTS: Using standard laparoscopy, the ovarian endometriomas were aspirated and washed to remove all cystic material. A 95% ethanol solution was instilled in the cysts and left for 15 minutes, then removed. The patients were followed by ultrasound at 3, 6, 9, and 12 months, and then annually to identify recurrence. All patients were administered postoperative hormone therapy, suspended only in those desiring pregnancy or experiencing adverse effects. The mean age was 32 years (range 19-40 years), and the mean cyst diameter was 6 cm (range 4-10 cm). Thirteen of the 53 patients (25%) had had previous surgery for endometriomas. Forty-one patients (77%) had associated deep endometriosis, treated during the same laparoscopic procedure. No major ethanol-related complications were recorded. The mean length of follow-up was 31 months. Recurrence of endometriomas was observed in 5 patients (9%). Overall, pregnancy occurred in 16 of 28 patients (57%) desiring pregnancy. CONCLUSION: Laparoscopic aspiration and ethanol sclerotherapy as treatment for endometriomas, even in patients with bilateral endometriomas or with associated deep endometriosis, resulted in <10% recurrence and no major complications.

Sclerotherapy of Vascular Malformations in the Oral Cavity-Minimizing Postoperative Morbidity.

Vascular malformations (VMs) are a wide vascular or lymphatic group of lesions common on the head and neck. The objective of this study was to assess the efficacy and morbidity of sclerotherapy for the treatment of VMs in the oral and perioral area. Special attention was given to factors that may contribute to minimizing postoperative morbidity. Data from 25 patients (32 lesions) with oral VMs submitted to sclerotherapy with monoethanolamine oleate (EAO) were included. A structured form was used to collect data. An arbitrary score was determined to evaluate postoperative morbidity. Each of the following signs or symptoms received one point: pain, swelling, hematoma, ulceration, erythema, transient numbness, and transient itching. Pain and swelling were further divided into mild to moderate (1 point) and severe (2 points). Theoretically, the score was in the range of 0-9. Calculated scores ranged 0-4. The patients were further divided into two groups with scores of 0-1 denoting minimal morbidity (MIN) and 2-4 denoting significant morbidity (SIG). The number of lesions in each morbidity-score group were comparable (MIN 17and SIG 15). There were no statistically significant differences between the groups regarding age, number of applications, or average injection volume per mm lesion. Statistically significant differences were noted regarding gender (p = 0.05), lesion diameter (p = 0.030), total volume of first (p = 0.007) and second application (p = 0.05), and total injected volume (p = 0.03). Factors contributing to the risk for significant morbidity included being male, lesion diameter > 5 mm, volume > 0.3 mL per application, and total injected volume > 0.3 mL. A waiting time of 12 weeks prior to additional EAO application was required in 12 out of 29 lesions for clinical observation of complete regression. It was concluded that sclerotherapy with EAO as monotherapy is easy to apply, safe, and effective within a small number of sessions. Application of <0.3 mL EAO per session, and a waiting time of 12 weeks prior to the second application, would significantly minimize morbidity.

Percutaneous sclerotherapy with polidocanol under the guidance of ultrasound for venous malformations in children - A retrospective cohort study from a single tertiary medical center.

This study reports our experience, the therapeutic outcomes and complications of percutaneous sclerotherapy (PS) with polidocanol to treat venous malformations (VMs) in children.A retrospective analysis was conducted of pediatric patients with VMs who underwent PS using polidocanol under continuous ultrasound (US) guidance between January 2015 and January 2018 at our department. Medical records were reviewed to record demographic information, lesion characteristics, treatment sessions, therapeutic outcomes and complications. χ analysis was employed to evaluate the effects of these characteristics on outcomes.Hundred treatment sessions were performed for lesions in 47 patients. The mean age of the patients was 4.1 ±â€Š3.6 years (mean ±â€ŠSD). The female to male ratio was almost 2:1 (female 32, male 15). The location of the VMs included the head and neck in 16 cases (34.0%), upper extremity in 11 cases (23.4%), lower extremity in 10 cases (21.3%), and trunk and perineum in 10 cases (21.3%). The majority of the lesions were focal in 36 cases (76.6%), while 11 (23.4%) were diffuse. Seventeen patients (36.2%) underwent single PS session, 14 patients (29.8%) underwent 2 sessions, 10 patients (21.3%) underwent 3 sessions and 6 patients (12.7%) underwent ≧4 sessions. The mean PS session per patient was 2.1 ±â€Š1.1. The mean follow-up duration was 11.4 ±â€Š7.6 months. After the last PS session, 8 patients (17.0%) had excellent outcomes, 27 (57.4%) had good outcomes, 10 (21.3%) had fair outcomes, and 2 (4.3%) had poor outcomes. Focal lesions were more likely to have good or excellent outcomes than diffuse lesions (χ = 4.522, P = .033). No other lesion characteristic significantly affected the outcomes (good or excellent outcomes), including lesion location (χ = 2.011, P = .570) or lesion size (χ = 1.045, P = .307). After the PS procedure, temporary local swelling occurred in 81 sessions (81.0%), local pain occurred in 15 sessions (15.0%), fever occurred in 27 (27.0%) sessions, and transient local numbness occurred in four sessions (4.0%).PS with polidocanol under the guidance of US appears to be safe and effective for the treatment of VMs in children, especially for focal lesions.

Surgical management of pediatric rectal prolapse: A survey of the American Pediatric Surgical Association (APSA).

INTRODUCTION: Many management options exist for the treatment of refractory rectal prolapse (RP) in children. Our goal was to characterize current practice patterns among active members of APSA. METHODS: A 23-item questionnaire assessed the management of full-thickness RP for healthy children who have failed medical management. The survey was approved by our IRB and by the APSA Outcomes committee. RESULTS: 236 surgeons participated. The respondents were geographically dispersed (44 states, 5 provinces). 32% of respondents had twenty or more years of clinical experience. 71% evaluated 1-5 RP patients in the last 2 years, while 5% evaluated >10. 71% performed 0-1 procedure (operation or local therapy [LT]) for RP over 2 years. 59% would treat a 2-year-old patient differently than a 6-year-old with the same presentation, and were more likely to offer up-front surgery to a 6-year-old (26% vs 15%, p = 0.04), less likely to continue medical management indefinitely (2% vs 7%, p=0.01), and more likely to perform resection with rectopexy (30% vs. 15%, p=0.01). 71% perform LT as an initial intervention: injection sclerotherapy (59%), anal encirclement (8%), and sclerotherapy + anal encirclement (5%). 70% consider LT a failure after 1-3 attempts. If LT fails, surgical management consists of transabdominal rectopexy (46%), perineal proctectomy or proctosigmoidectomy (22%), transabdominal sigmoidectomy + rectopexy (22%), and posterior sagittal rectopexy (9%). CONCLUSIONS: There is wide variability in the surgical management of pediatric rectal prolapse. This suggests a need for development of processes to identify best practices and optimize outcomes for this condition.

Cost Analysis of a Multidisciplinary Vascular Anomaly Clinic.

OBJECTIVE: Multidisciplinary vascular anomaly clinics (VACs) offer important value to pediatric patients with complex vascular anomalies whose care overlaps specialties. These clinics are labor intensive and costly to operate since providers see fewer patients compared to their individual specialty clinic. Our North American tertiary care institution's VAC specialists include a pediatric otolaryngologist, pediatric surgeon, pediatric plastic surgeon, pediatric dermatologist, and interventional radiologist. To assess financial feasibility, we conducted a cost analysis of our VACs comprised of 2 half-day multidisciplinary physician attended clinics (5 specialists at our main campus and 2 specialists at a satellite clinic) and a half-day nurse practitioner clinic. METHOD: Assessment of net revenue based on net collections for clinic, professional, operative, hospital setting, and facility charges generated during 12 consecutive monthly VACs beginning July 1, 2015. Expense calculations included provider and staff salaries, benefits, supply costs, and clinic leasing costs. RESULTS: There were 469 clinic visits, of which 202 were new patient evaluations. Sixty-eight patients underwent 93 procedures under general anesthesia, including procedures performed by our interventional radiologist, most commonly sclerotherapy or embolization (n = 37), surgical interventions including endoscopy (n = 36), or laser procedures (n = 20). Three patients were admitted. Fifty-seven patients received a new diagnosis different from that for which they were referred. Gross revenue was $1 810 525, and net revenue was 42.5%, or $783 152. Expenses totaled $453 415 for a net positive revenue of $329 737. CONCLUSION: When including direct downstream revenue, particularly from operative procedures, our VAC program operates on a net positive margin, making the program financially feasible.

Foam Sclerotherapy: An Emerging, Minimally Invasive And Safe Modality Of Treatment For Varicose Veins.

BACKGROUND: Ultrasound guided foam sclerotherapy is an outdoor, office based and minimally invasive procedure for the treatment of varicose veins. This study was carried out to highlight the potential of foam sclerotherapy as a first line treatment for varicose vein. METHODS: This prospective observational study was conducted at CMH Rawalpindi, form 1 Aug 2017 to 30 Aug 2018The demographic and outcome data of the patients, who underwent ultrasound guided foam sclerotherapy, were collected and analysed. RESULTS: A total of 662 patients and 752 legs were treated with foam sclerotherapy. Four hundred and ten (61.93%) were males and 252 (38.06%) were females. Their ages ranged from 17 to 68 years with the mean age of 43.21 years. Six hundred and sixty-eight (88.82%) legs were having Great Saphenous Vein while 84 (11.17%) legs were having short saphenous vein disease. Maximum legs 256 (34.04%) had C3 disease. single session of Foam sclerotherapy was enough in 511 (67.95%) legs, while 197 (26.19%) legs were treated with two and 44 (5.85%) legs were treated with three sessions of foam sclerotherapy. Percentages of main trunk occlusion were 98.01% at 1 month while 97.39% at 3 months follow up. Only 2 (0.30%) patients had Deep Venous Thrombosis while 3 (0.45%) patients had thrombophlebitis which required surgery. CONCLUSION: Ultrasound Guided Foam sclerotherapy is an OPD based, innovative, minimally invasive and safe method of treatment for varicose veins. In the context of prevalence of varicose vein disease in our community, it relieves the Burdon of operation theatre list and creates the theatre space for vascular surgeon for arterial Surgery.

Long-term health-related quality of life in children with lymphatic malformations treated with sclerotherapy generally matched age-appropriate standardised population norms.

AIM: We assessed the long-term health-related quality of life (HRQoL) of children who received sclerotherapy for lymphatic malformations. This treatment involved injecting drugs into the blood vessels to make them shrink. METHODS: Our cross-sectional study retrospectively reviewed patients who received OK-432 sclerotherapy injections at Karolinska University Hospital, Stockholm, Sweden, from 1998 to 2013. We studied 49 patients (63% female) aged 8-18 at least five years after their first injection. HRQoL was assessed with the KIDSCREEN-52 questionnaire and a study-specific questionnaire addressed disease consequences and patient satisfaction. We determined associations between HRQoL and disease and treatment and the patient's sex. RESULTS: Overall HRQoL paralleled age-appropriate norms in the general population, but some subgroups had lower levels. Regression-based estimates showed that larger numbers of injections were negatively associated with HRQoL in the dimensions autonomy, parent relations and home life, financial resources and school environment (p = 0.01-0.03). Malformations in the head and neck area were negative predictors across dimensions and were strongest for psychological well-being (p = 0.009), parent relations and home life (p = 0.017) and school environment (p = 0.006). CONCLUSION: Despite generally positive outcomes, multiple injections and malformations in the head and neck were associated with impaired HRQoL.

A national survey on management of varicose veins in China.

OBJECTIVE: This study aimed to investigate the current clinical practice and management strategies for varicose veins among Chinese physicians in general and in specific case vignettes. METHODS: A questionnaire survey was conducted among 726 Chinese physicians who were attending the vascular surgery academic conferences during August 2016 to May 2017 in China. Physicians were eligible if they were familiar with several currently used treatment techniques for varicose veins. RESULTS: A total of 681 physicians from 527 hospitals in 29 provinces across China completed the questionnaire. Of them, 80.0% were vascular surgeons, 13.1% were general surgeons, and 6.9% were interventional radiologists. More than half (67.0%) of them had >5 years of experience in management of varicose veins. A third of the participants performed routine venography for patients with suspected varicose veins. Moreover, 87.5% believed that the patient's medical insurance would influence their choice of treatment modalities. Only 38.5% of the participants' departments could perform day surgery for varicose veins. The most common average hospitalization time was 4 to 7 days, with an average cost of 4000 to 8000 yuan per leg. In the basic case (Clinical, Etiology, Anatomy, and Pathophysiology classification C2,SEpAsPr2,3), 63.8% preferred traditional surgery for great saphenous vein reflux, followed by endovenous laser ablation (24.3%), radiofrequency ablation (5.6%), and ultrasound-guided foam sclerotherapy (3.1%). Physicians in coastal China were more likely to choose endovenous thermal ablation than those from western China (P < .05). In modified case vignettes complicated with hyperpigmentation and lipodermatosclerosis or ulceration, more participants chose traditional surgery for great saphenous vein (73.2% vs 63.8% [P < .001]; 75.9% vs 63.8% [P < .001]) compared with the basic case. Moreover, 31.9% preferred continuation of compression therapy for patients with varicose veins and deep venous reflux, and 65.4% preferred correction of iliac vein compression before treatment of varicose veins. Distributions of management strategies were significantly different between the basic and modified case vignettes (all P < .01). CONCLUSIONS: Both traditional surgery and minimally invasive techniques are used for patients with varicose veins in China, but traditional surgery is the mainstay of treatment for varying degrees of varicose veins. Related clinical factors, duplex ultrasound scan findings, medical insurance, and economy may have influenced the physicians' choice of treatment modality for varicose veins.

First venous thromboembolism and hormonal contraceptives in young French women.

Information on the clinical and biological characteristics of combined hormonal contraceptives (CHC) users experiencing a venous thromboembolism (VTE) event is scarce. Better knowledge of factors determining the VTE risk in CHC users could help identify women at high risk.Data were obtained from a large cohort of consecutive women with the first documented VTE event. Cross-sectional analysis of clinical and biological characteristics of the women was performed.Of the 3009 women with the first VTE included, 31% were nonusers and 69% CHC users at time of VTE. CHC users were significantly younger (29.0 ±â€Š7.2) than nonusers (31.6 ±â€Š7.1) (P < .001). No difference in VTE familial history was observed between the 2 groups. Compared with nonusers, the CHC users experienced more frequently pulmonary embolism: odds ratio (OR) = 1.28 (1.06-1.55; 95% confidence interval [CI]), factor V Leiden mutations were more frequent in this group (OR = 1.41 [1.11-1.80; 95% CI]). Venous sclerotherapy and travel were associated with VTE in CHC users, whereas surgery and bed rest were significantly associated with VTE in nonusers. Finally, 2/3 of CHC users with VTE had additional VTE risk factors.CHC users experiencing the first VTE differ from nonusers with respect to clinical and genetic background. Better understanding of the characteristics of VTE and associated risk factors could allow more appropriate management of these women and contribute to more accurate benefit-risk assessment before prescribing a CHC.

Factors influencing the choice of treatment modality for individual patients with varicose veins.

INTRODUCTION There is evidence of effectiveness for a range of different treatment modalities for varicose veins but limited information about factors that influence treatment choice for individual patients. METHODS A postal survey was sent to 438 UK members of the Vascular Society of Great Britain and Ireland. RESULTS Overall, 251 responses were received (response rate 57%). A total of 222 respondents treated varicose veins using conventional surgery (84%), endothermal ablation (82%) and foam sclerotherapy (68%). The clinical pattern of veins appeared to have the greatest influence on treatment choice. This was followed by guidance from the National Institute for Health and Care Excellence, patient expectations, facilities, cost and whether treatment was carried out in the public or private sector. Respondents were asked to indicate whether each of 13 clinical 'scenarios' (eg very extensive varicose veins in both legs) would influence them towards or against using specified treatment modalities. 'Consensus' was defined as ≥80% of responses either towards or against any treatment modality; and disagreement as 41-59% both towards and against any modality (i.e. ∼50:50 split). There was consensus towards using endothermal ablation for truncal reflux, towards UGFS for localised varicose veins and towards conventional surgery for large, extensive, bilateral veins. There was consensus against UGFS for large truncal veins, and against surgery for obese patients and those with a history of venous thromboembolism. There were important disagreements about the influence of large or extensive veins, about whether patients were obese or slim and about a prior history of venous thromboembolism. CONCLUSIONS Conventional surgery is still widely available in the UK. Disagreements about treatment choice in different clinical scenarios suggest substantial variation in the treatments patients are offered. Attention to identifying subgroups in trials would help to guide treatment choice for individual patients.

Sclerotherapy in the management of ovarian endometrioma: systematic review and meta-analysis.

OBJECTIVE: To evaluate the efficacy of sclerotherapy for ovarian endometrioma on the risk of recurrence, clinical symptoms, and reproductive function. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Patients who underwent sclerotherapy of ovarian endometrioma. INTERVENTION(S): An electronic-based search with the use of Pubmed, Embase, Ovid Medline, Google Scholar, Clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials. MAIN OUTCOME MEASURE(S): Recurrence rate, symptoms relief, fertility outcome, and adverse events. RESULT(S): Eighteen studies were included in our review. The overall recurrence rates of endometrioma after sclerotherapy ranged from 0 to 62.5%. The risk of recurrence was significantly higher in women who were treated by means of ethanol washing than by means of ethanol retention. The number of oocytes retrieved was higher after endometrioma sclerotherapy compared with laparoscopic cystectomy, but clinical pregnancy rates were similar. There was no difference in the number of oocytes retrieved and the clinical pregnancy rates between the sclerotherapy-treated group with and the untreated group. CONCLUSION(S): Sclerotherapy for ovarian endometrioma may be considered in symptomatic women who plan to conceive.

Efficacy and Safety of Aspiration Sclerotherapy of Simple Hepatic Cysts: A Systematic Review.

OBJECTIVE: Aspiration sclerotherapy is a percutaneous procedure indicated for treatment of symptomatic simple hepatic cysts. The efficacy and safety of this procedure have been sources of debate and disagreement for years. The purpose of this study was to assess the long-term efficacy and safety of aspiration sclerotherapy in a systematic review of the literature. MATERIALS AND METHODS: A systematic search was conducted of the electronic databases PubMed MEDLINE, Embase, Web of Science, and the Cochrane Library (until August 2015). Studies of proportional volume or diameter reduction after aspiration sclerotherapy of simple hepatic cysts were included for full-text evaluation. Case reports and case series were excluded. Risk of bias was assessed by use of the Newcastle-Ottawa scale. RESULTS: From 9357 citations, 100 were selected for full-text assessment. We included 16 studies, which included 526 patients with a total of 588 treated cysts. Overall, risk of bias was high, with 12 of 16 studies having a score of poor. Proportional cyst volume reduction ranged between 76% and 100% after a median follow-up period of 1-54 months. Change in symptoms was evaluated in 10 studies: 72-100% of patients reported symptom reduction, and 56-100% reported disappearance. Postprocedural pain occurred most frequently, at a rate of 5-90% among studies. Ethanol intoxication occurred in up to 93% of cases and was reported more frequently in studies with either high ethanol volumes (133.7-138.3 mL) or long sclerotherapy duration (120-180 minutes). CONCLUSION: We found excellent results with respect to long-term efficacy and safety after aspiration sclerotherapy of hepatic cysts. Nevertheless, because of the high risk of bias in the included studies, definite conclusions regarding efficacy cannot be drawn.

[Head and neck superficial venous malformations]. / Malformations veineuses superficielles cervico-faciales. Mise au point.

Management of vascular malformations and vascular tumors has recently been maximized by the establishment of an accurate clinical and histological classification and by the development of multidisciplinary expert consultations. Head and neck localizations of venous malformations are common, thus maxillo-facial surgeons should be aware of the characteristics of this pathology and the principles of its management. Diagnosis is mainly clinical and must be certified by Doppler-ultrasonography and contrast enhanced magnetic resonance imaging with T2 fat-saturation sequence. Therapeutic decision depends on the volume of the lesion, and on functional, cosmetic and psychological complaints. Sclerotherapy is now the preferred treatment of head and neck venous malformations. It is performed in specialized interventional radiology units by intralesional injections of sclerosing solution under fluoroscopic guidance. Surgery is useful in some cases, either on its own or following sclerotherapy. In case of bulky lesion, it is necessary to search for and prevent a severe coagulopathy before planning any intervention.

Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial.

BACKGROUND: Foam sclerotherapy (foam) and endovenous laser ablation (EVLA) have emerged as alternative treatments to surgery for patients with varicose veins, but uncertainty exists regarding their effectiveness in the medium to longer term. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins. DESIGN: A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation. SETTING: Eleven UK specialist vascular centres. PARTICIPANTS: Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212). INTERVENTIONS: Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres). PRIMARY OUTCOME MEASURES: Disease-specific [Aberdeen Varicose Vein Questionnaire (AVVQ)] and generic [European Quality of Life-5 Dimensions (EQ-5D), Short Form questionnaire-36 items (SF-36) physical and mental component scores] quality of life (QoL) at 6 months. Cost-effectiveness as cost per quality-adjusted life-year (QALY) gained. SECONDARY OUTCOME MEASURES: Quality of life at 6 weeks; residual varicose veins; Venous Clinical Severity Score (VCSS); complication rates; return to normal activity; truncal vein ablation rates; and costs. RESULTS: The results appear generalisable in that participants' baseline characteristics (apart from a lower-than-expected proportion of females) and post-treatment improvement in outcomes were comparable with those in other RCTs. The health gain achieved in the AVVQ with foam was significantly lower than with surgery at 6 months [effect size -1.74, 95% confidence interval (CI) -2.97 to -0.50; p = 0.006], but was similar to that achieved with EVLA. The health gain in SF-36 mental component score for foam was worse than that for EVLA (effect size 1.54, 95% CI 0.01 to 3.06; p = 0.048) but similar to that for surgery. There were no differences in EQ-5D or SF-36 component scores in the surgery versus foam or surgery versus EVLA comparisons at 6 months. The trial-based cost-effectiveness analysis showed that, at 6 months, foam had the highest probability of being considered cost-effective at a ceiling willingness-to-pay ratio of £20,000 per QALY. EVLA was found to cost £26,107 per QALY gained versus foam, and was less costly and generated slightly more QALYs than surgery. Markov modelling using trial costs and the limited recurrence data available suggested that, at 5 years, EVLA had the highest probability (≈ 79%) of being cost-effective at conventional thresholds, followed by foam (≈ 17%) and surgery (≈ 5%). With regard to secondary outcomes, health gains at 6 weeks (p < 0.005) were greater for EVLA than for foam (EQ-5D, p = 0.004). There were fewer procedural complications in the EVLA group (1%) than after foam (7%) and surgery (8%) (p < 0.001). Participants returned to a wide range of behaviours more quickly following foam or EVLA than following surgery (p < 0.05). There were no differences in VCSS between the three treatments. Truncal ablation rates were higher for surgery (p < 0.001) and EVLA (p < 0.001) than for foam, and were similar for surgery and EVLA. CONCLUSIONS: Considerations of both the 6-month clinical outcomes and the estimated 5-year cost-effectiveness suggest that EVLA should be considered as the treatment of choice for suitable patients. FUTURE WORK: Five-year trial results are currently being evaluated to compare the cost-effectiveness of foam, surgery and EVLA, and to determine the recurrence rates following each treatment. This trial has highlighted the need for long-term outcome data from RCTs on QoL, recurrence rates and costs for foam sclerotherapy and other endovenous techniques compared against each other and against surgery. TRIAL REGISTRATION: Current Controlled Trials ISRCTN51995477. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 27. See the NIHR Journals Library website for further project information.

Nonvariceal upper gastrointestinal bleeding in Portugal: a multicentric retrospective study in twelve Portuguese hospitals.

BACKGROUND: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is associated with important mortality. More information is needed in order to improve NVUGIB management. The aims of this study were: (a) characterizing Portuguese patients and clinical approaches used in NVUGIB, (b) comparing management used in Portugal with management globally used in European countries, (c) identify factors associated with management options, and (d) identify factors associated with adverse outcome. METHODS: ENERGiB was an observational, retrospective cohort study, on NVUGIB with endoscopic evaluation, carried across Europe. This study focuses on Portuguese patients of the ENERGiB study. Patients were managed according to routine care. Later, data were collected from files. Multivariate/univariate analyses were conducted on predictive factors of poor outcome and clinical decisions. RESULTS: Patients (n=404) were mostly men (66.8%), mean age 68, with co-morbidities (72%), frequently on NSAIDs/aspirin. Most were assisted by general medical (57.8%) or surgical team (20.6%), only 19.4% by gastroenterology/GI-bleeding team. PPI was largely used. Gastric/duodenal ulcers, erosive gastritis and esophagitis were the main bleeding causes. 10% had bleeding persistence/recurrence. Death occurred in 24 patients, 20 from a non-bleeding related cause. Poor outcomes were related with age >65, co-morbidities, fresh blood haematemesis, shock/syncope, bleeding through previous nasogastric tube, massive fluid replacement or transfusions besides erythrocytes. CONCLUSIONS: This study contributed to characterization of Portuguese patients and NVUGIB episodes in real clinical setting and identified factors associated with a poor outcome. It also identified differences, especially in the organization of GI bleeding teams, which might help us to improve the management of these patients.

Actualización en malformaciones venosas / Current management of venous malformations

Las malformaciones venosas representan 2/3 de todas las malformaciones vasculares y con frecuencia son mucho más complejas de lo que realmente parecen. Los pacientes con grandes malformaciones venosas requieren un estudio analítico y radiológico profundo, así como tratamiento específico para controlar una posible coagulación intravascular localizada. Si las lesiones son extensas, especialmente en el miembro inferior, se debe estudiar la presencia de una osteoporosis subyacente con la idea de prevenir fracturas patológicas. Igualmente debe controlarse la artropatía, y valorar la realización de una sinovectomía profiláctica precoz cuando la extensión radiológica lo aconseje, con la idea de evitar daños articulares irreversibles con el paso de los años. Actualmente la escleroterapia con microespuma se preconiza como el tratamiento de elección para las malformaciones vasculares de bajo flujo. En un futuro no muy lejano la utilización de fármacos antiangiogénicos selectivos, además de las heparinas de bajo peso molecular, servirán para controlar y tratar las malformaciones venosas (AU)

Las malformaciones venosas representan 2/3 de todas las malformaciones vasculares y con frecuencia son mucho más complejas de lo que realmente parecen. Los pacientes con grandes malformaciones venosas requieren un estudio analítico y radiológico profundo, así como tratamiento específico para controlar una posible coagulación intravascular localizada. Si las lesiones son extensas, especialmente en el miembro inferior, se debe estudiar la presencia de una osteoporosis subyacente con la idea de prevenir fracturas patológicas. Igualmente debe controlarse la artropatía, y valorar la realización de una sinovectomía profiláctica precoz cuando la extensión radiológica lo aconseje, con la idea de evitar daños articulares irreversibles con el paso de los años. Actualmente la escleroterapia con microespuma se preconiza como el tratamiento de elección para las malformaciones vasculares de bajo flujo. En un futuro no muy lejano la utilización de fármacos antiangiogénicos selectivos, además de las heparinas de bajo peso molecular, servirán para controlar y tratar las malformaciones venosas (AU)

Secondary care treatment of patients with varicose veins in National Health Service England: at least how it appeared on a National Health Service website.

OBJECTIVES: This study aimed to assess the trends and regional variations in secondary care treatment of patients with varicose veins in National Health Service (NHS) England based on data published by the Hospital Episode Statistics which was freely and readily available to the public and health-care policy-makers. METHODS: Hospital Episode Statistics data for patients being treated for varicose veins, and UK Statistics Authority population estimates in all 28 Strategic Health Authorities (SHAs) in England from 2002 to 2006 were retrieved and analysed. RESULTS: Between 2002 and 2006 there was a 20% overall reduction (46,190-37,135) in the total number of varicose vein procedures performed in NHS England per year. The number of varicose vein procedures performed per 100,000 population per year varied significantly across the SHAs (P < 0.0001). Similarly, significant regional variations were also noted in the frequency of primary procedures of greater and small saphenous vein (P < 0.0001). During this time, injection sclerotherapy was only performed in 15 (53.6%) SHAs. The annual proportion of varicose vein procedures performed as daycases had increased from 56% to 64% during the period. CONCLUSION: From 2002 to 2006 there was an overall reduction in the total number of varicose vein procedures performed in NHS England with major regional variations.

Trends in varicose vein therapy in England: radical changes in the last decade.

INTRODUCTION: We aimed to analyse national trends in varicose vein treatment in the UK National Health Service (NHS). SUBJECTS AND METHODS: The National Hospital Episode Statistics website (www.Hesonline.nhs.uk) was interrogated for patients treated (1998-2008) in the NHS for varicose veins. RESULTS: There has been a 34% decline in patients presenting for an intervention for varicose veins. For surgical procedures alone, the waiting times have fallen by 59%. In 2007-2008, 30,663 (72%) fewer bed days were used in comparison to 1998; accompanied by a 49% decline in the number of patients undergoing surgery. After a 47% decrease between 1998 and 2001, the number of patients requesting sclerotherapy treatment has increased by a substantial 311% over the subsequent 7 years. Transluminal procedures were used almost twice as often in 2007-2008 as in 2006-2007. CONCLUSIONS: There has been a steady decline in the number of patients treated for varicose veins. Fewer patients are undergoing surgery but are being managed more efficiently, with an increase in day cases and a reduction in total bed days. The demand for minimally invasive procedures has increased substantially. These trends will be of great importance for the future planning of vascular surgical services.