Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1519_Библиотеки_им_академика_М_И_Перельмана.pdf
403© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_36
Chapter 36
Benign Anal Disease: Third Degree
Hemorrhoids – Who Really Needs Surgery?
Aneel Damle and Justin Maykel
Introduction
Surgeons posess a wide variety of therapeutic options to treat hemorrhoids. Grade I/
II hemorrhoids can usually be readily managed with dietary modification and/or
office based treatments whereas grade IV hemorrhoids commonly require surgery.
However, there are no clear-cut guidelines for the optimal treatment of grade III
hemorrhoids. Further complicating matters, the hemorrhoid grading system devel-
oped by Goligher in 1954 (grades I-IV) does not account for key factors that may
drive decision making, such as size or whether the hemorrhoids are isolated or cir-
cumferential [1].
The surgeon must decide when office-based techniques are most appropriate as
opposed to surgical intervention [2]. In broad terms, excisional hemorrhoidectomy
(EH), has an excellent success rate, but is associated with a significant amount of
postprocedural pain and related disability, not to mention cost [3]. Newer opera-
tive techniques such as the procedure for prolapse and hemorrhoids (PPH) or
Doppler- guided hemorrhoidal artery ligation (DGHAL) may be associated with
less postoperative pain but carry higher recurrence rates. Office based techniques
such as rubber band ligation (RBL), sclerotherapy or infrared coagulation offer a
relative safe and simple approach for many patients, although long-term durability
A. Damle, MD, MBA
Division of Colon and Rectal Surgery, University of Massachusetts Medical Center, 55 Lake
Avenue North, Worcester, MA 01655, USA
J. Maykel, MD (
*)
Division of Colon and Rectal Surgery, University of Massachusetts Medical Center,
67 Belmont Street, Worcester, MA 01605, USA
e-mail: maykelj@ummhc.org
www.ebook3000.com
404
remains a concern. RBL is relatively contra-indicated in patients using clopido-
grel, warfarin, or heparin due to the significant incidence of post-procedure bleed-
ing [4]. However, of the available office-based procedures, RBL is typically the
most effective option and has been used as the comparison group to surgical hem-
orrhoidectomy [5].
Complications may result from any technique and can range from minor to life-
threatening. They include bleeding, urinary retention, wound infection, inconti-
nence, anal-stricture, ectropion, and local sepsis [3]. To appropriately answer the
question of who should have surgery for grade III hemorrhoids, we must evaluate
the ability of a treatment to control symptoms, the re-treatment rate, postoperative
pain, complication rates, disability, and patient satisfaction (Table 36.1).
Search Strategy/Methods
A literature search of MEDLINE, PubMed, the Cochrane Database of Collected
Reviews, and Google Scholar was performed using English language articles from
January 2000 to present. Search terms included hemorrhoids, internal and external
hemorrhoids, hemorrhoid disease, rubber band ligation, hemorrhoidectomy, hemor-
roidopexy, and Doppler-guided hemorrhoidectomy. Selected references from arti-
cles identified in the primary literature search were used when relevant. Literature
was evaluated using the GRADE evidence quality classification system [6]. Post-
hoc data analysis was conducted using Fisher's exact test.
Results
High quality evidence comparing office techniques to surgical hemorrhoidectomy
for grade III hemorrhoids is lacking. The majority of the available evidence
focuses on EH versus RBL. A recent Cochrane Review comparing these two
groups was able to include only three of 1186 abstracts reviewed as most studies
failed to meet inclusion criteria or contained methodological problems [7]. Of
these studies, only two evaluated grade III hemorrhoids. There is a similar lack of
high quality data comparing other operative techniques such as PPH or DGHAL
to RBL. The following discussion includes the results of available studies
(Table 36.2).
Table 36.1 Identification of patient population, intervention, comparison, and outcomes
Patient population Intervention Comparator Outcomes studied
Patients with 3rd degree
hemorrhoids
Hemorrhoidectomy Rubber Band
Ligation
Symptom control and
morbidity
A. Damle and J. Maykel
405
Control of Symptoms
Excisional hemorrhoidectomy is often referred to as the "gold standard" for the
treatment of hemorrhoids when it comes to control of symptoms [8]. A large retro-
spective case series of 693 patients who underwent EH (Ferguson closed technique)
for grade III and IV hemorrhoids reported a recurrence rate of 1 % and 3 % at 1 and
2 years [9]. When compared to other surgical techniques such as PPH, a meta-
analysis demonstrated that patients undergoing EH were significantly less likely to
complain of ongoing hemorrhoidal symptoms than those who underwent PPH (6
trials, 388 patients, OR 0.52, 95 % CI, 0.3–0.91; p = 0.02) [10]. DGHAL has also
been shown to have a high recurrence rate with 31 % of patients having symptoms
within the subsequent 5 years [11]. Conversely, a recent clinical trial comparing EH
to DGHAL with mucopexy demonstrated no difference in symptoms including pain
and bleeding at 2 years post-procedure [12].
RBL has also been shown to control symptoms for many individuals, but to a
lesser extent. A retrospective study of 701 patients showed an overall success rate
(alleviation of symptoms) of 70 % [13]. When only patients with grade III hemor-
Table 36.2 Results of studies comparing surgery to office management of grade III hemorrhoids
Study Group
No. of
patients
(Gr 3/total) Results
Quality of
evidence
Murie
et al. [14]
EH vs
RBL
56/88 RR 0.12 for prolapse for grade III (95 %
CI, 0.02–0.87, p = 0.04)
RR 0.55 for bleeding for all patients (95 %
CI, 0.2–1.3, p = 0.2)
RR 1.54 for pain > 48 h for all patients
(95 % CI, 1.2–1.9, p < 0.01)
WMD + 29 days off work for all patients
(95 % CI, 21.2–36.8, p < 0.01)
Low
Lewis
et al. [15]
EH vs
RBL
56
a
RR 0.40 for short-term symptom
recurrence (95 % CI, 0.2–0.7, p < 0.01)
RR 0.18 for long-term symptom recurrence
(95 % CI, 0.1–0.4, p < 0.01)
RR 3.75 for pain requiring systemic
analgesia (95 % CI, 2.1–6.8, p < 0.01)
Low
Gagloo
et al. [17]
EH vs
RBL
38/100 RR 0.25 for prolapsed for grade III (95 %
CI, 0.1–0.8, p = 0.02)
RR 5.0 for requiring post-operative
analgesia for all patients (95 % CI, 2.8–8.7,
p < 0.01)
Low
Peng et al.
[19]
PPH vs
RBL
55/65 RR 0.21 for bleeding symptoms 2 weeks
post-op (95 % CI, 0.1–0.4, p < 0.01)
Moderate
Gr grade, RR relative risk, WMD weighted mean difference
a
A total of 112 patients were in the study, but patients who had anal dilation or cryotherapy were
excluded from ad-hoc analysis
36 Benign Anal Disease: Third Degree Hemorrhoids – Who Really Needs Surgery?
www.ebook3000.com
406
rhoids were included, the success rate decreased to 59 %. Three studies were identi-
fied that compared outcomes of EH directly to RBL. Murie et al. evaluated 100
patients with either grade II or III hemorrhoids and randomized them to EH or RBL
[14]. Of the 56 patients with grade III hemorrhoids, 97 % of patients undergoing EH
had no symptoms of prolapse at 1 year compared to 70 % in the RBL group
(p = 0.04). When adding in the patients with grade II hemorrhoids, 86 % of EH
patients had no bleeding at 1 year compared to 74 % in the RBL group (p = 0.28).
Lewis et al. compared EH with anal dilatation, RBL and cryotherapy [15]. Of the
26 patients undergoing EH, 100 % had fewer symptoms and 65 % had no symptoms
at 1 year, as opposed to 67 % and 13 % for RBL. In the long-term (6 months–5
years) 100 % of EH patients had fewer symptoms and 86 % had no symptoms. Only
40 % of RBL patients had fewer symptoms and 23 % were symptom free. No
patients in the EH group required further treatment compared to 80 % in the RBL
group.
A systematic review of the two aforementioned trials demonstrated greater effi-
cacy for EH over RBL for the treatment of grade III hemorrhoids (2 trials, 116
patients, RR 1.23, 95 % CI 1.0–1.5, p = 0.01). However, this difference was not seen
with grade II hemorrhoids (1 trial, 32 patients, RR 1.07, 95 % CI 0.9–1.2, p = 0.32)
[16].
A 2011 study randomized 100 patients with grade II/III hemorrhoids to EH or
RBL [17]. Of the grade III patients (38 patients), 12.5 % of the EH group experi-
enced recurrent prolapse symptoms after 6 months compared to 50 % in the RBL
group. Although no statistical analysis was included in the study, post-hoc analysis
reveals this is a statistically significant finding (p = 0.03). Consistent with the sys-
tematic review is the finding that RBL leads to better results with grade II hemor-
rhoids compared to grade III (77 % vs. 50 % without prolapse at 6 months,
respectively).
In a comparison of PPH with RBL, there was a significant decrease in the per-
centage of patients experiencing the symptoms of bleeding from hemorrhoids at
2-weeks post-procedure in the PPH group (27 % vs. 68 %, p < 0.005). This differ-
ence was not seen for prolapse, pruritis, or wound discharge [18]. By 2 months,
there was no difference in symptoms experienced in either group.
We did not identify any published results comparing DGHAL to RBL. However,
there is currently a multi-center randomized controlled trial that has been completed
comparing these two interventions for grade II and III hemorrhoids, with results
pending [19].
Post-Treatment Pain and Complications
A systematic review of trials comparing EH to RBL for grade II/III hemorrhoids
(including Murie and Lewis, et al.) demonstrated significantly more patients that
underwent EH experienced post-operative pain (3 trials, 212 patients, RR 1.94,
95 % CI 1.62–2.33, p < 0.001) [16]. There was no statistically significant difference
A. Damle and J. Maykel
407
in other postoperative complications such as urinary retention, hemorrhage, or anal
stenosis. A meta-analysis of the same three trials revealed similar results [5]. Gagloo
et al. found 100 % of patients undergoing EH required postoperative analgesia com-
pared to 20 % of patients after RBL [17]. Severe pain from RBL may result from
placement of the band below the dentate line, which precludes the banding of exter-
nal hemorrhoids [3].
While EH has been repeatedly shown to be associated with more postoperative
pain than RBL, a recent Cochrane Review has demonstrated a significant decrease
in pain when hemorrhoidectomy is performed with a LigaSure device [20]. Pain
scores on the first post-operative day showed a WMD of −2.07 (10 studies, 835
patients, CI −2.77−1.38). There was no relevant difference in other postoperative
complications. A study comparing DGHAL with mucopexy to EH demonstrated no
significant difference in post-operative pain scores up to 2 weeks [12].
In a comparison of PPH with RBL, PPH was associated with a higher maximal
pain score at discharge (5 vs 2, p < 0.001) and at 2 weeks (5 vs 0, p < 0.001). However,
by 2 months, no patient in either group complained of pain. There was no difference
in other complications such as urinary retention, bleeding, anal stenosis, or change
in continence. However, his study was not sufficiently powered for these endpoints
[18].
Lifestyle (Return to Work and Patient Satisfaction)
Murie et al. reported that 100 % of working patients undergoing EH lost time from
work with a mean of 32 days compared to 44 % of the RBL group with an average
time away from work of 3 days (SD 7 days-p < 0.01) [14]. However, the newer tech-
niques of hemorrhoid surgery have considerably improved return to work times. A
Cochrane review comparing LigaSure hemorrhoidectomy to standard EH demon-
strated a return to work 4.88 days earlier (4 studies, 451 patients, CI 2.18–7.59).
When comparing DGHAL to EH, DGHAL patients returned to work after 10 days
compared to 22 days in the EH group (p = 0.09) [12].
A systematic review demonstrated similar overall patient satisfaction in both EH
and RBL patients (RR 1.02, 2 studies, 148 patients, 95 % CI, 0.94–1.10) [16].
Gagloo, et al. reported 70 % of patients considered EH an “excellent” modality
compared to 64 % for RBL [17]. There was no difference noted between PPH and
RBL in terms of patient satisfaction at discharge, 2 weeks, 2 or 6 months [18].
Cost
None of the identified studies comparing EH to RBL evaluated cost. However, in the
current healthcare climate, cost of therapy must be a consideration. Factors that may
impact cost include operative time, equipment, and need for further treatment. In
36 Benign Anal Disease: Third Degree Hemorrhoids – Who Really Needs Surgery?
www.ebook3000.com
408
addition, the time of convalescence financially impacts patients, and the economy as
a whole.
There is considerable variation of operative time based on surgical technique.
Multiple studies have demonstrated EH to have longer operative times than other
techniques such as PPH [21]. However, when accounting for equipment costs, EH
was demonstrated to be less expensive than PPH ($252 vs. $504) [22]. The addition
of disposable LigaSure diathermy forceps adds an additional $225 per operation to
EH [23].
RBL does not require operating room time and the cost of equipment is minimal.
However, a long-term study of over 700 patients demonstrated that 30 % of patients
require re-treatment with a median 2 bandings per patient and a range of 1–17 bands
placed [13]. Also, as previous studies have demonstrated increased pain with mul-
tiple bandings in a single session, patients often need to be brought back for several
sessions [13, 24, 25]. However, as stated above, RBL does allow a considerably
earlier return to work, reducing lost wages.
Recommendations
There are insufficient randomized controlled trials to make a strong recommenda-
tion based on high-quality evidence. However, there are trends in the literature suf-
ficient for recommendations.
Due to the relatively low complication rate, decreased pain, faster return to work
and reasonable efficacy, office techniques such as rubber band ligation may be an
appropriate first option for many patients. While not as efficacious as surgical hem-
orrhoidectomy, many patients may succeed without a trip to the operating room.
This technique does burn any bridges and therapy may always be escalated to surgi-
cal management.
Recommendation 1
Most patients with uncomplicated grade III internal hemorrhoids may be
effectively treated with office procedures as first line treatment after appropri-
ate medical therapy. Strong recommendation based on moderate quality
evidence.
Recommendation 2
Patients with large multi-column grade III hemorrhoids or a mixed internal/
external component should undergo surgical hemorrhoidectomy. Strong rec-
ommendation based on moderate quality evidence.
A. Damle and J. Maykel
409
Large hemorrhoids may not be treated as effectively with office-based proce-
dures. This may be due to the small size of the ligation barrel limiting the size of the
hemorrhoid banded [26]. In these cases, surgical hemorrhoidectomy is the better
choice to remove all affected tissue. In addition, as multi-column disease may
require multiple banding episodes, these patients may be good candidates for sur-
gery. Finally, as rubber band ligation should not be applied below the dentate line,
patients who seek treatment for mixed component hemorrhoids should preferably
undergo surgery.
While office based procedures such as rubber band ligation may have the advan-
tages of decreased invasiveness, many patients require repeat therapy. In addition,
while the risk of late bleeding after RBL is similar in patients who take no anti-
thrombotic therapy and those who hold antithrombotic therapy, not all patients are
able to do so [27]. Patient preference may play a large role in how many times this
is done. In patients who continue to be symptomatic from their hemorrhoids or no
longer wish to have repeat procedures, surgical therapy is appropriate.
Expert Opinion
When we see patients with symptomatic grade III hemorrhoids, they are typically
complaining of tissue prolapse, bleeding, and mucous drainage. Occasionally they
will complain of pain from hemorrhoidal engorgement with straining. By the time
the rectal mucosal prolapse requires manual reduction, we do not think that non
operative treatment alone, such as fiber supplementation, will likely provide suc-
cessful and durable relief of symptoms.
Patients with discrete, localized internal grade III hemorrhoids will be offered
in-office rubber band ligation, using a suction banding device. The rubber band is
positioned directly above the dentate line and the suction is held long enough to fill
the chamber fully with excess hemorrhoid tissue/rectal mucosa. Although caution
has been expressed re banding more than one column at a single session due to an
increased risk of complications and/or pain, we routinely band the two most promi-
nent columns at the initial session. This approach expedites the successful treatment
of the hemorrhoids while minimizing return office visits and additional procedures.
We warn all patients they should expect 48 h of rectal “pressure” but do not prescribe
pain medications beyond Tylenol. We caution them regarding the risks of bleeding,
pain, and infection, although serious complications are rare. We see patients back in
Recommendation 3
Patients who are unable to tolerate or have failed office-based techniques
should undergo surgical hemorrhoidectomy. Strong recommendation based
on moderate quality evidence.
36 Benign Anal Disease: Third Degree Hemorrhoids – Who Really Needs Surgery?
www.ebook3000.com
410
1 month for repeat banding if necessary, recognizing that the majority of patients
will not return when the initial RBL has successfully resolved their symptoms. When
patients are anticoagulated on medications beyond aspirin, we hold the anticoagula-
tion prior to RBL due to the risk of hematoma and bleeding.
When patients present with symptomatic, circumferential internal grade III hem-
orrhoids or when they do not tolerate in office anoscopy and/or RBL, we typically
offer them PPH hemorrhoidectomy. When the purse string stitch is properly placed
one cm above the hemorrhoids themselves, we have found this to be a very success-
ful and durable option for symtomatic grade III hemorrhoids. This provides a
single- procedure solution for extensive disease, as opposed to serial RBL sessions.
Patient pain experience varies based on location of the staple line as well as vari-
ability of anal canal innervation. An alternative remains Doppler-guided hemor-
rhoid artery ligation; the addition of a mucopexy significantly improves outcomes
and long term success.
References
1. Goligher JC, Leacock AG, Brossy JJ. The surgical anatomy of the anal canal. Br J Surg.
1955;43(177):51–61.
2. Acheson AG, Scholefield JH. Management of haemorrhoids. BMJ. 2008;336:380–3.
3. Sneider EB, Maykel JA. Diagnosis and management of symptomatic hemorrhoids. Surg Clin
North Am. 2010;90:17–32.
4. Rivadeneira DE, Steele SR, Ternent C, et al. Practice parameters for the management of hem-
orrhoids (revised 2010). Dis Colon Rectum. 2011;54:1059–64.
5. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. Dis Colon
Rectum. 1995;38(7):687:94.
6. Brozek JL, Akl EA, Alonso-Coello P, et al. Grading quality of evidence and strength of recom-
mendations in clinical practice guidelines. Allergy. 2009;64:669–77.
7. Shanmugam V, Hakeem A, Campbell KL, et al. Rubber band ligation versus excisional haem-
orrhoidectomy for haemorhoids (Review). Cochrane Database Syst Rev. 2005;(3):CD005034.
8. Yeo D, Tan KY. Hemorrhoidectomy-making sense of the surgical options. World
J Gastroenterol. 2014;20(45):16976–83.
9. Milone M, Maietta P, Leongito M, et al. Ferguson hemorrhoidectomy: is it still the gold stan-
dard treatment? Updates Surg. 2012;64:191–4.
10. Nisar PJ, Acheson AG, Neal RK, et al. Stapled hemorrhoidopexy compared with conventional
hemorrhoidectomy: systematic review of randomized, controlled trials. Dis Colon Rectum.
2007;50(9):1297–305.
11. Avital S, Inbar R, Karin E, et al. Five-year follow-up of Doppler-guided hemorrhoidal artery
ligation. Tech Coloproctol. 2012;16:61–5.
12. De Nardi P, Capretti G, Corsaro A, et al. A prospective, randomized trial comparing the short-
and long-term results of Doppler-guided transanal hemorrhoid dearterialization with muco-
pexy versus excision hemorrhoidectomy for grade III hemorrhoids. Dis Colon Rectum.
2014;57:348–53.
13. Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band ligation for symptomatic
primary and recurrent internal hemorrhoids. Dis Colon Rectum. 2004;47:1364–70.
14. Murie JA, Mackenzie I, Sim AJ. Comparison of rubber band ligation and haemorrhoidectomy
for second and third degree haemorrhoids: a prospective clinical trial. Br J Surg.
1980;67:786–8.
A. Damle and J. Maykel
411
15. Lewis AAM, Rogers HS, Leighton M. Trial of maximal anal dilatation, cryotherapy and elastic
band ligation as alternatives to haemorrhoidectomy in the treatment of large prolapsing haem-
orrhoids. Br J Surg. 1983;70:54–6.
16. Shanmugam V, Thaha MA, Rabindranath KS, et al. Systematic review of randomized trials
comparing rubber band ligation with excisional haemorrhoidectomy. Br J Surg.
2005;92(12):1481–7.
17. Gagloo MA, Hijaz SW, Nasir SA, et al. Comparitive study of hemorrhoidectomy and rubber
band ligation in treatment of second and third degree hemorrhoids in Kashmir. Indian J Surg.
2013;75(5):356–60.
18. Peng BC, Jayne DG, Ho YK. Randomized trial of rubber band ligation vs. stapled hemorrhoid-
ectomy for prolapsed piles. Dis Colon Rectum. 2003;46(3):291–7; discussion 296–7.
19. Tiernan J, Hind D, Watson A. The HubBLe trial: haemorrhoidal artery ligation (HAL) versus
rubber band ligation (RBL) for haemorrhoids. BMC Gastroenterol. 2012;12:53.
20. Nienhuijs SW, de Hingh IHJT. Conventional versus LigaSure hemorrhoidectomy for patients
with symptomatic hemorrhoids (Review). Cochrane Database Syst Rev. 2009;21(1):CD006761.
21. Singer M, Abcarian H. Stapled hemorrhoidopexy: The argument for usage. Clin Colon Rectal
Surg. 2004;17(2):131–42.
22. Wilson MS, Pope V, Doran HE, et al. Objective comparison of stapled anopexy and open
hemorrhoidectomy: a randomized, controlled trial. Dis Colon Rectum. 2002;45(11):1437–44.
23. Jayne DG, Botterill I, Ambrose NS, et al. Randomized clinical trial of Ligasure
TM
versus con-
ventional diathermy for day-case haemorrhoidectomy. Br J Surg. 2002;89:428–32.
24. Kombrorozos VA, Skrekas GJ, Pissiotis CD. Rubber band ligation of symptomatic internal
hemorhoids: results of 500 cases. Dig Surg. 2000;17:71–6.
25. Lee HH, Spencer RJ, Beart RW. Multiple hemorrhoidal bandings in a single session. Dis
Colon Rectum. 1994;37:37–41.
26. Cintron J, Abcarian H. Benign anorectal: hemorrhoids. In: Wolff BG, Fleshman JW, Beck DE,
et al., editors. The ASCRS textbook of colon and rectal surgery. New York: Springer; 2007.
p. 156–77.
27. Nelson RS, Ewing BM, Ternent C, et al. Risk of late bleeding following hemorrhoidal banding
in patients on antithrombotic prophylaxis. Am J Surg. 2008;196(6):994–9.
36 Benign Anal Disease: Third Degree Hemorrhoids – Who Really Needs Surgery?
www.ebook3000.com
413© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_37
Chapter 37
Which Patients with Fecal Incontinence
Require Physiologic Workup?
Tracy Hull
Introduction
Anal physiology testing is part of the initial diagnostic workup used in patients
presenting with fecal incontinence (FI) but the value in defining the disease severity,
predicting and assessing treatment outcomes has been debated [1]. This chapter will
present the available evidence in the literature to define the role of anal physiology
testing for FI.
Search Strategy
PubMed was queried using different combinations of search terms. The search
terms were: faecal/fecal incontinence, anal incontinence, assessment, testing, evalu-
ation, fecal incontinence/diagnosis, outcome and process assessment (Health Care),
diagnostic techniques and procedures, diagnosis, physical examination, diagnostic
techniques, digestive system workup, diagnostic evaluation, predictive value of test,
physiological test, physiologic workup, manometry, anal manometry, anorectal
manometry, balloon expulsion, pudendal nerve terminal motor latency, costs and
cost analysis, cost, and quality of life. The filters used were: English; adult: 19+
years; dates: January 1994-present; and humans. References of relevant articles
were also reviewed.
T. Hull
Department of Colon and Rectal Surgery, Digestive Disease Institute, The Cleveland Clinic
Foundation, Cleveland, OH, USA
e-mail: hullt@ccf.org