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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4087_Библиотеки_им_академика_М_И_Перельмана

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Page108
HowtoGuardAgainstAdhesive—TapeAllergy
IfyoudosufferfromsuchanallergythentellyourdoctorornurseandtheywillprotectyourskinfromdirectcontactwiththeElastoplastbyplacingapadofordinary,
drysterilegauzeovertheulcerandthenwraptheleginasimplegauzebandagebeforebandagingyourlegfirmlyandsmoothlywithElastoplastfromthetoestojust
belowtheknee.Themethodisshownintheseriesofillustrationsonpage107.
OneproblemwiththegauzebandageisthatithasatendencytowrinkleastheElastoplastiswrappedoverit.Forthisreasoninmanyclinicssometypeofproprietary
adherentbandage(suchaslchthopaste,ColtapasteorViscopasteinBritain)oranabsorbentbandagesuchasSoffban(Smith&NephewLtd)isusednexttotheskin.
CertainlythismakesthesmoothapplicationoftheElastoplastaneasiertaskforthedoctororthenurse.
Thetreatmentofvenousulcerationhasbeenrevolutionizedbytheuseoffour
layerbandaging.Theulcerisusuallycoveredwithanonadherentdressingovertheulcer.
Thefirstlayeriscomposedofsoftwool,thesecondacrêpebandage,thethirdastrong(blue
line)compressionbandage,andlastlyanadhesivebandagetokeepitall
inplace.Thiscanbeperformedincommunityulcerclinicsorganizedbydistrictnurses,anditisahighlyeffectivetreatment.Thereisinterestinreducingthistothree
layersbyleavingoutthecrêpebandageandvarioustrialsareunderwaytocomparetheefficacyoftheseregimes.
ExerciseandLosingWeight
Withthelegfirmlybandaged,itisuptoyoutousethemusclepump.Thismeansactivewalkingexercisesagoodbrisk3miles(5kilometres)adayasaminimum.
Alltoooften,varicoseulcersuffererstendtobeoverweight.Thismakescompressionofthelegveinsdifficultandbeingfatmakesactiveexercisemoreofaproblem
thanitshouldbe.Areducingdiet(seeChapter6)forsuchpatientsisareallyimportantfirststeptowardseffectivetreatment.
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So,tosumuptherequirementsintreatingavaricoseulcer,wehavethesefourpointstoobserve:
1.Elevationofthelegatnight.
2.Skilledelasticbandaging.
3.Activeexercises.
4.Weightwatching.
Ointments,CreamsandLotions
Somereaderswillbeverysurprisedtofindnomentionofsomespecialointment,lotion,salve,cream,impregnatedgauze,antibioticorsteroidthatwerecommendas
absolutelyessentialtocleanupandhealtheulcer.Thereasonforthisisverysimplenoneofthemworks!Indeed,ourfirstdutywhenwehavetodealwithalarge,
obstinate,unhealed,angrylookingulcer,surroundedbyanintenseitchyinflammationoftheskin,istopersuadethereluctantpatienttothrowawayallthepots,tubes,
bottlesandpacketsthathavebeenusedtodateandtoadopttheinexpensive,simpleroutineoutlinedabove.
Itisveryoftenthesensitivityoftheskintothesevariousmedicamentsthatisactuallyprolongingtheproblemandpreventingthefirm,continuous,activesupportof
elasticbandaging:theessentialbasisofeffectivetreatment.
Althoughtheulcermaybenasty,smellyandinfected,thebaseoftheulcerisinfactaveryeffectivebarriertobacteriainvadingthesurroundingtissues,soantiseptics
andantibioticsarejustnotneeded.Doctorsveryrarelyhavetoprescribeantibioticsforinfectionspreadingfromanulcer,butifthisdoesoccurweuseashortcourse
eitherofinjectionsorpillsbymouth,andneveranythingapplieddirectlytotheulceroritssurroundingarea.Occasionallytheulcerwillrequiresurgery.Allthedead
tissueiscutawaytohealthyviablebleedingtissueandthiscanbecoveredbyusingskingrafts.Thiscanleadtorapidhealing,butmorethenneedstobedonetokeep
theulcerhealed.
Oncetheulcerbeginstoheal,wecandealwiththeunderlyingvaricoseveinsthatsooftenalsoneedtobetreated.AsweexplainedinChapter5,thesecanbe
injectediftheyareconfinedtothecalf,butwhenitisacaseoflargevaricoseveinsinthethighandatthegroinsurgerywillbenecessarytoclearthem.Allsuch
patientsshouldbeinves
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tigatedwithduplexscanstoseeifthereisanysuperficialveinrefluxthatcanbedealtwithsurgically.ThereismuchinterestinanewtechniquecallSEPS,orsubfascial
endoscopicperforatorsurgery.Asmallincisionismadebelowthekneeontheinsideoftheleg.Ascopethroughwhichinstrumentscanbepassedisintroducedbelow
thefasciallayers(thelayersiftissuejustundertheskin)andthetissuesareseparated.Theperforatingveinscanbeeasilyidentifiedastheyrunfromthedeepveins
belowthemusclethroughthefasciatothesuperficialveins.Thesecanbeclippedanddividedwithscissors.Somesurgeonsuseatourniquet.However,althoughitis
anappealingtechniquewhichisrelativelysimpletoperform,theuseofsuchsurgeryiscontroversial.Thistechniqueneedstobeassessedinthecontextofaclinical
trialtoascertainitsplaceinthetreatmentofvenousulcers.
LongTermPrecautions
Gettingtheulcerhealedanddealingwiththeunderlyingveinsareonlyphasesoneandtwo;phasethreeisvitallyimportant.Ifyouhavesufferedfromanulcer,it
means,aswehavepointedout,thatseveredamageispresentintheveinsystemoftheleg.Constantsurveillancewillbeessentialinthefuture.Thismeansalife
timeof
elasticstockingsupportwhenupandaboutnotreallyagreatburden,sincemodernelasticstockingsarecomfortableandlookgood(seepage48);alifetimeof
sleepingwithyourlegorlegsraisedinbedatnight;and,justasimportant,keepinguptheexcellenthabitofactivewalking,aswellasacarefulwatchonanytendency
toputonweight.
Rememberthatittakesonlyaminorinjurytobringaboutulceration,sothatitisimportanttocareforyourlegsasamothercaresforherbaby.Therewardiswell
worthwhile:thepreventionofafurthertroublesomespelloftreatmentforanewulcer.
LegAilmentsSometimesConfusedwithVaricoseVeins
SpiderVeins(Telangiectases)
Itisquitecommonforwomentohavetiny,swollenveinsintheirupperlegsandlowerthighs;theyareseenlessofteninmen.Theyseemtooccurearlyinpregnancy,
whichsuggeststhattheymayhavesome
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thingtodowiththeeffectsofthesexhormonescirculatinginthebloodstream.Theselittlemarksaresimplytinyvisibleveinsintheskin;theyhavenothingtodowith
varicoseveinsalthoughmanypeoplewiththesespiderveinsalsohavevaricoseveins.Theyaregivenallkindsofothernames,includingcapillaryveins,burstveins,
spidernaeviandtelangiectases.
Womenareoftenveryselfconsciousabouttheseskinblemishesbutwehavealwayspersonallyadvisedagainstanytreatmentforthem.Somesurgeonsdouse
injectiontreatment(similartothatusedintreatingordinaryvaricoseveins),othersuseheattreatment(diathermy)ortheydestroytheveinsbyelectricneedles
(electrolysis).Althoughthesemethodsmaybesuccessful,theymayalsofail,inwhichcasetheycouldleaveabrownishdiscolourationoftheskinthatmaybeworse
thanthe
Spiderveinsarenotrelatedtovaricoseveins.
Theyareharmlessandrequirenotreatment.
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originalblemish.Theseveinsdonotspreadorgetworseandtheyarenotrelatedtovaricoseveins.Astheyarealsocompletelyharmless,wefeelthatthepatientis
bestadvisedjusttoignorethemortodisguisethemwithskinmakeup.Therearesomeextremelyeffectivemoderncamouflagecosmeticsonthemarket.
OtherCausesofPainintheLeg
Itistruethatprominentvaricoseveinscancauseachinganddiscomfortinyourlegswhenyouhavebeenstandingforalongtime,buttheachingcanhaveothercauses
suchassciatica,arthritis,obstructioninalegarteryormusclecramps.Uptohalfofallpatientswhohavesurgeryforpainfullegsassociatedwithvaricoseveinswill
continuetohavepainfollowingsurgery.
Sciatica
Sciataisoftenduetoadisplacementofoneofthediscsbetweenthevertebraeinthelowerspine.Whenthishappenspainspreadsdownthebackoftheleg.Itis
usuallymuchmoreseverethantheacheofvaricoseveinsanddoesnotdisappearassoonasyouraiseyourlegintheair—anactionthatimmediatelyrelievesthe
congestingdiscomfortthatcomeswithvaricoseveinsandwhichoftenmakesthepainofsciaticamuchworse!Doctorsdothis`straightlegtest'tofindoutwhetherthe
achingintheirpatient'slegisduetovaricositiesortosciatica.
Arthritis
Arthritisofthekneeiscommoninplump,middleagedandelderlywomen.Thekneecracklesandispainfulwhenitismoved.
ArterialDisease
Arterialdiseaseisacommonfactoflifeaswegetolderandisusuallytheresultofarteriosclerosisthickeningofthearterywalls.Itisparticularlymarkedwherethere
isastrongassociationwithalifetimeofcigarettesmoking.Oneofthetypicalsymptomsofthisdiseaseisapaininyourcalfafteryou'vebeenwalkingacertain
distance,perhaps98195yards(90180metres);youwillfindyouhavetostandstillforseveralminutesbeforethepaingoesaway.Youwillthenbeabletowalka
similardistancebeforethepainstartsupagain.Whenyourdoctor
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examinesyou,hewillfindthatthefootyoucomplainofiscoolerthantherestofyourbody(arterialbloodcirculatingthroughtheskingivesoutwarmth),andhewill
alsofindthatthepulsesinthelegbelowtheconstrictedarterycannotbedetected.Thiswillindicatetohimthatyouhavearterialdisease.
MuscleCramps
Thesespasms,whenthemusclescontractverytightly,causeseverepainandoftenoccuratnight.Theagonizingpainlastsforonlyafewseconds,althoughitseems
muchlongertothevictim.Asfarasweknow,noonehasanyexplanationforthisconditionoranyrationalsuggestionforitstreatment.
Manypeoplewiththeseandotherpainfulconditionsoftheirlegsmayalsohavesomesmallvaricoseveins.Incontrast,manypeoplewithquitelargevaricoseveins
mayhavenosymptomsatallapartfromtheunsightlyappearanceoftheirlegs.
Whatyoushouldnotdoisalwaystoattributepaininyourlegstothevaricoseveins.Youarethenlikelytobeverydistressed,andquiterightlyso,ifthepainremains
afterthevaricoseveinshavebeentreatedinthemistakennotionthattheyweretheprimecauseofyourtroubles.
UlcersoftheLeg
Weknowthataveryhighproportionofulcersofthelegareduetovaricoseveins.However,itisveryimportantnottooverlookthemoreunusualcausesofaleg
ulcer.
Aftervaricoseveinsthemostcommoncauseofulcerationoftheleg,andthisamountstoperhaps5%ofallthepatientswesee,isinsufficientbloodsupplyfromthe
arteries.Thereasonforthisisusuallyarteriosclerosis(thickeningofthearteries)anditisalmostalwaysfoundinheavysmokers.Thesepatientsmayalsobesuffering
fromvaricoseveins,ofcourse,andunlessthedoctorlookscarefullyforevidenceofarterialdisease(acoldfootwithpoorcirculationandalackofpulsesintheleg)he
maywellthinkthattheulcerationisdueentirelytotheobviousvaricoseveins.
Injuryisanothercauseofanunhealedulcerontheleg.Again,thisiscommonlyseeninelderlypatients.Thecombinationofanastyinjurytothelegandthelackofany
evidenceofveindiseasemakesthistypeofulcerquiteobviousinmostcases.
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Chapter10—
QuestionsandAnswers
Thereisnothingnewherethatwehavenotdiscussedalready,butweanswerthecommonquestionsthatpatientssooftenworryaboutintheclinic.
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Ifyouorsomeoneinyourfamilyhasvaricoseveins,wehopethisbookwillhavegivenyouabetterunderstandingofwhatvaricoseveinsareandwhatyoucando
aboutthem.Wealsohopeitwillhaveremovedsomeofyourdoubtsandfearsaboutthem.
InthislastChapterwewanttogathertogethersomeofthequestionsthatdoctorsandnursesarefrequentlyaskedaboutvaricoseveinsandwhich,thoughtheyhave
beendealtwithmorefullyinthecourseofthebook,thoseofyouwhowouldlikeaquickanswermayfinduseful.
WhatareVaricoseVeins?
Theyaretwisted,swollen,bluishveinslyingjustbelowtheskinoftheleg.Theycanbeseenclearlywhenyoustand,butifyouliedownandputyourlegupintheair,
theveinsemptyandusuallydisappear.Theirunsightlinessisoneofthemostfrequentreasonswhypeoplewantthemtreated,butapartfromtheirappearancetheyalso
causeachingpaininthelegsandifneglectedtheymaydevelopunpleasantcomplications,whichincludeeczema,discolouration,ulcerationoftheskin,thrombosisand
haemorrhage.
WhydoPeoplegetVaricoseVeins?
Thesimpleansweristhatinthemajorityofcaseswejustdonotknow.Thenormalsurfaceveinsoftheleghaveanefficientsystemofvalvesthatdirectthebloodback
totheheart.Theunderlyingcauseofvaricoseveinsisundoubtedlyfailureofthesevalves,whichthenpermitbloodtoflowbackwardsintheveinsofthelegathigh
pressure.Weknowthatvaricoseveinsruninfamiliessotherewouldappeartobeaninheritedfactorwhichmaybesomecongenitaldefectinthevalves,especially
whenvaricoseveinsdevelopinadolescentsoryoungadults.Inothercases,thedamagetothevalvesmayresultfromaninjuryorfromthrombosis(clotting)inthe
deepveinsoftheleg—somethingwhichmayfollowasurgicaloperation,aprolongedillnessoroccasionallychildbirth.
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DoTightStayupStockingsCauseVaricoseVeins?
Thereisnoevidencethattightstayupstockings,constrictingclothesorprolongedstandingcausevaricoseveins.However,ifyoualreadyhavevaricoseveinsthen
thereisnodoubtthatanythingwhichraisesthepressureinyourveinssuchastightclothingorprolongedstandingwillmaketheveinsdistendandache.Foryourown
comfort,therefore,theseshouldbeavoided.
DoesSmokingCauseorAggravateVaricoseVeins?
Althoughwestronglyadvisepatientsnottosmoke,becauseoftheundoubtedlinksbetweencigarettesmokingandlungcancer,chronicbronchitisandarterialdisease,
thereisnoconnectionbetweensmokingandeithertheoriginofvaricoseveinsortheaggravationofvaricoseveinsthatarealreadythere.However,wewouldnotlike
anybodytotakethisasanexcuseforcontinuingthehabit!
ShouldItaketheContraceptivePillifIhaveVaricoseVeins?
Womenwithvaricoseveinsaredefinitelyataslightlygreaterriskofdevelopingclotting(orthrombosis)onthepillthanwomenwithnormallegs.Thisriskisespecially
soovertheageofabout35.Ifyouhaveseverevaricoseveinsyourdoctorwillprobablyadviseagainstthepillandrecommendsomeotherformofcontraception.
Oncetheveinshavebeenadequatelytreated,however,thepillcanbeprescribedquitesafely.
DoesPregnancyCauseVaricoseVeins?
Manywomenattributetheirvaricoseveinstopregnancy.Indeed,varicoseveinsoftenbecomeobviousearlyoninpregnancy.Theoestrogen
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hormonelevelisraisedinthebloodduringpregnancyandthisundoubtedlyhastheeffectofrelaxinganddistendingtheveins.Moreover,thepressureoftheenlarging
wombpressesonthepelvicveinsandraisesthepressurewithinthelegveinsthatdrainupintothem.Verylikelypregnancydoesnotactuallycausevaricoseveins,but
ifyouhaveatendencytovaricoseveinstheyareundoubtedlygoingtobecomeworseduringpregnancyandalsoduringsubsequentpregnancies.Anotherrelated
problem,whichisalmostuniquetopregnancy,isthedevelopmentofvaricoseveinsonthevulva,aroundtheentrancetothevagina.Althoughthesecanbequite
uncomfortableandunsightly,theynearlyalwaysdisappearshortlyafterthebirthofthebaby.
HowareVaricoseVeinsTreatedduringPregnancy?
Mostdoctorsareveryconservative.Youcankeepyourlegscomfortablebywearingelasticsupportstockings.Youshouldrestyourlegsintheelevatedposition
duringthedayandlearntosleepwithyourlegselevatedinbed.Avoidstanding;butwalkingexercisesareexcellent.Theveinsmayimproveremarkablyonceyour
babyisdelivered;iftheydonot,thenmoreactivetreatmenteitherbyinjectionsorsurgerymayberequired.Unfortunately,ifyouhaveveintroubleinonepregnancy
youarelikelytogetitinthenext,butbytakingearlyprecautions,supportstockings,elevationandexercise,yoursymptomscanbekeptundercontrol.
CanElasticSupportStockingsCureVaricoseVeins?
Unfortunately,noAwellfittingpairofelasticstockingsareinvaluableforthosewhoarenotfitenoughorwhoareunwillingtoundergomoreextensivetreatmentfor
theirveins.Elasticstockingsupportiswhatwecallapalliative:inotherwords,itrelievessymptoms(bycompressingthevaricoseveins)butitcertainlydoesnotcure
them.Elasticstockingsareveryhelpfulinthefollowuptreatmentaftersurgeryorinjectionsforvaricoseveinsandarealsoextremelyusefulinrelievingthesymptoms
ofvaricoseveinsduringpregnancy.
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