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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57
Tubigripbandaging
ShouldyouneedtoreplacetheouterTubigripbandageafterinjectiontreatment,
adoptthefollowingprocedure:1.Rollthebandagetogetherandpullfirmlyapart
betweenthumbs.2.Pullitoverthetoes,releasingslowly,stillkeepingit
stretchedbetweenthethumbs.3.ContinueunrollinguntilTubigrip
completelycoversinnerbandage,takingcarenottodisturbit.
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missedandthesecanthenbeinjectedatthisvisit.Ifyourequireanyfurtherinjections,youcanbeseenagainthefollowingweekandtheprocessrepeatedoncemore.
However,oncetheveinshavebeensuccessfullyinjected,youwillbeexpectedtocontinuethecompressionbandagesforanother5
6weeks,afterwhichtheycanbe
leftoff.Attheendofthisperiod,ifthetreatmenthasbeensuccessfulandwhenthebandagesarefinallyremoved,youwillbedelightedtofindthatthetreatedveins
havedisappearedcompletely.
Frequently,wherevaricoseveinsaffectbothlegs,patientsinahurrytogetthetreatmentoverwillasktohavebothlegsinjectedatthesametime.Thereisnofixedrule
aboutthis,butonthewholeitispreferabletogetonelegtreatedcompletelyandthentodealwiththeotherafterthepatienthashadaperiodoffreedom.Youwillfind
thatwalkingaboutwithbothlegsbandagedandrathersoreiscertainlymoreburdensomethanhavingonegoodleg.Therearealwaysexceptionstoanyrule,of
course,sothatifyouhadsomespecialreasonforgettingbothlegsclearedupasquicklyaspossible,animpendingmarriage,forexample,orifyoucantakeonlya
limitedtimeawayfromfullactivity,thenyoumaydecidetoputupwithmorediscomfortforthesakeofgreaterspeed.
Thereisnodoubtthathavingyourlegbandagedforupto6weeksisanuisanceforanumberofreasons,nottheleastofwhichistheproblemofhavingabathor
shower.Abandagedlegcanbekeptdryeitherinthebathorundertheshower(ashoweristheeasierofthetwo)byenclosingitinalargeplasticbagandtapingthe
toparoundthethigh.Forthispurposelargebagslikethoseusedforthedisposalofrubbishorgardenwasteareideal.Itisalsopossibletotakeashallowbath,with
thebandagedlegoutofthewater—butforthisyouhavetobequiteathletic!
IstheTreatmentPermanent?
Ofcourse,everyonewantstoknowhowsuccessfulthetreatmentwillbeinthelongterm.Isit,infact,permanent?Thisresultcannotbeguaranteedineverycase.In
someinstancestheblowoutisnotcompletelyobliteratedandwherethishappensalocalrecurrenceofthevaricoseveinmaytakeplaceovermanymonthsoreven
years.Morelikely,though,furthervaricoseveinswilldevelop,eitherinthesameorintheotherleg.However,thereisnoreasonwhytheseshouldnot,inturn,be
treatedquitesatisfactorilybyinjection.Youshouldcomparethesituationwiththatofgoingtothedentist;justbecauseonecavityhasbeenfilleddoesnotmeanthat
youwillneverdevelopaholeinanothertoothnorthatthefillingisgoingtopreservethetoothforever.
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Thegreatadvantageofinjectiontreatmentisthatthewholethingcanbedoneonanoutpatientbasiswithoutananaestheticandwithonlylittlelossoftimefromwork.
PossibleComplications
Inthemajorityofpatients,injectiontreatmentofvaricoseveinsisafairlyminorprocedure.Youmayexperiencesomepainatthesiteoftheinjectionforafewdays
butthiscanberelievedbymildpainkillerssuchasaspirinorparacetamol(acetaminophenintheUnitedStates).Plentyofwalkingalsohelpstokeeptheleg
comfortableandthisshouldbecombinedwithraisingthelegwheneveryousitorliedown.Also,avoidstandingstill.Ifyoufindthattheinnerbandagebecomestoo
tightanduncomfortable,itisworthhavingitreappliedattheclinic.Iftheouterbandagebecomesruckedup,dirtyorfrayed,youcanputanewoneonyourself(see
diagramsonpage57).ItisagoodideatoasktheclinicforsomeTubigripbandagetotakehomewithyouforthispurpose.
Sometimes,inspiteofthegreatestcare,alittleoftheinjectionmaterialwillhaveescapedfromtheveinintothesurroundingtissues.Thismayproduceadark
coloured
areaontheskin,whichmaypersist.Thepatchisquiteharmlessandisnocauseforconcern.Ifyouareworriedabouttheappearanceofyourlegs,byallmeansusea
skincolouredcosmeticcreamtocamouflagethearea.Occasionallytheskinintheareawheretheinjectionsolutionhasescapedbreaksdownintoalittleulcer.This
shouldslowlyhealandsimplyneedstobecoveredbyasterile,drydressing.
Thrombosis(orclotting)ofthedeepveinsofthelegisararecomplicationofthisformoftreatment.Withtheolderinjectiontechniquesthereislittledoubtthatsomeof
thesolutionoccasionallypassedintothedeepveinsanddamagedthem.Thisisunlikelynowwiththesmallamountsofthemoderninjectionsolutionused.Onthose
rareoccasionswhenathrombosisoccurs,itismorelikelytobeduetothepatientnotexercisingthelegaftertheinjectiontreatmentsothatclottingtakesplaceinthe
sluggishcolumnofbloodwithinthelegmuscles.Youcanavoidthisbyfollowingtheactivewalkingprogrammethatwealwaysadviseafterinjectiontherapy.
LaserTreatment
Morerecently,lasertherapyhasbecomeavailableforthetreatmentofsmallvaricoseveinsandthreadveins.Someverygoodresultshave
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beenreported.Thelaserpulseisofaveryshortdurationanddestroystheveinswhicharebrokenintoverysmallparticles.Thesearethenremovedbythebody's
immunesystem.Theremaybesomereactiontothelaserforthefirst24hours,withrednessatthesite,butthisresolvesquitequickly.Thistreatmentisgivenonan
out
patientbasisanddoesnotrequireanyanaesthesia.Thecomplicationsofthistherapyincludepigmentationatthesiteandlossofpigmentatthesite.Thereisusually
lossofhairgrowthintheareaifthelasertreatmentisrepeated.Veryoccasionally,theremaybesomecrustingoftheskintogetherwithblisteringbutagain,theseside
effctsdonotlastlong.
SurgicalTreatment
Thisisreservedforpatientswhosevaricoseveinsaretooextensiveforinjectionstobeeffective.Thedecidingfactorforthisiswhenlargevaricositiesextendupthe
thigh,oftentothegroin.Theseveinsaredifficulttocompresswithbandages(particularlyifthelegisratherfat)andgenerallytheydonotrespondatallwelltoinjection
treatment.Theremay,evenso,besurgeonswhowillofferinjectionsunderthesecircumstances,butmostwouldrecommendanoperation.
Anotherreasonforsurgicaltreatmentisthatsomepatientsjustdonotlikeinjectionsandinthissituationanoperationtotieoffthelinkingveinslowerdowntheleg
mightbejustifiable.Also,inthosecaseswhenpatientsdonotseemtorespondtoinjectiontreatment,anoperationmaybetheonlyanswer.
TheOperation
Usuallyageneralanaestheticisrequired,whichwillputyouintoadeepsleepuntiltheoperationisover.Theoperationcan,ifnecessary,becarriedoutunderalocal
anaesthetic,inwhichcaseonlytheareaaroundtheveintobeoperatedonisnumbedandyoustayawakeduringtheprocedure.
Therearetwotypesofoperationthatcanbeusedtodealwithvaricoseveins.Theonemostpeopleknowaboutiscalledthestrippingoperation.Herethesurgeon
passesawireoralengthofplasticalongthelengthofthevaricosesurfaceveinandusesthistopulloutawholesegmentofvein.Theotheroperationinvolvesthe
separationandtyingoffofthevaricosevein.
Theoperationisquitestraightforward.AsdescribedinChapter2,thesurfaceveinatthegroin—thesaphenousvein—entersthedeep
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Thesurgeonwillfirstlocatethejunctionbetweenthedeepandsurface
veins,andthenseparateandtieoffthetwosystems.
femoralvein,whichliesimmediatelyontheinnersideofthemainarteryoftheleg,thefemoralartery.Thesurgeonmakesashortincisionovertheregionofthe
junctionbetweenthelongsaphenous(surface)veinandthefemoral(deep)vein.Hedividesthelittlebranchesofthesaphenousveinatthegroinandtiesthemoffwith
fineligaturesofabsorbablematerial,thenhedividesandtiesoffthemaintrunkofthesaphenousveinflushwithitspointofjunctionwiththefemoralveinitself(see
diagramsoppositeandabove).Thiseffectivelysealsoffthismainblowoutorincompetentjunctionbetweenthesurfaceanddeepveinsystems,thusstoppingthehigh
pressureflowofbloodintothevaricosesurfaceveinbelowthejunction,andreducingtheswellingofthevein.Hewilltheninsertthestripper(usuallyalength
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Byseparatingthedeepveinsandthevaricosesurfaceveins,thelatter
becomedrainedofbloodandtheirswellingisreduced.
ofplasticormetal)alongthelengthoftheveinuntilitpassesbelowthelevelofthekneejoint.Anothersmallincisionisplacedatthissiteandthelowerendofthe
stripperisbroughtoutthroughtheskin.Thetopendoftheveinisthentiedtothestripper,andasmallheadmaybeattachedtoittoensurethattheveindoesnot
comeoffthestripper.Thestripperisthenpulledthroughcompletelyremovingthedilatedveinbetweenthetwoincisions.Somesurgeonsprefertoremovetheveinby
usingsmallincisionsalongitslengthinsteadofusingthestripper.However,therecurrenceratemaybehigherifnoattemptismadetoremovethisvein.Thewoundin
thegroinisrepairedusingabsorbablestitches(sutures)tothedeepertissuesandeitherabsorbablesuturesorpaperstrips(steristrips)totheskin.Varicoseveinsinthe
legareremovedbysmallincisionsplaceddirectlyoverthem.Themajorityofsurgeonsdonotusethestrippertoremoveveinsinthecalfduetopossibledamageto
theadjacentnerves,whichliemuchclosertothesaphenousveinthaninthethigh.
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Thismaycausenumbareasinthelegandveryrarelyitmaycauseaburningpainknownascausalgia.
ThePatient'sRole
Whatdoesthevaricoseveinoperationinvolveasfarasthepatientisconcerned?
Themajorityofuncomplicatedvaricoseveinsurgerycanbeperformedinthedaysurgeryunitunderageneralanaesthetic,inwhichcaseyouwouldbeallowedhome
thesameday.Thosepatientswithcomplexvenousproblems,particularlythosewhohaverecurrentvaricoseveins,andthosepatientswhoarenotsuitableforday
surgery,eitherbecauseofobesityorbecauseofconcurrentmedicalproblemssuchasdiabetesorasthma,shouldbeadmittedtohospitalforinpatienttreatment.This
mayrequireadmissionthedaybeforesurgeryoronthedayofsurgeryiftheoperationisplannedfortheafternoon.Patientswhorequirebothlegstobeoperatedon
atthesametimeshouldprobablybeadmittedsothatbothlegscansafelybedealtwithatthesameoperatingsessioninordertosaveasecondadmissiontohospital.
Youwillusuallybedischargedthenextday.
Afterreturninghome,youcanwalkaboutrightawayandindeedyoucanoftenreturntolightworkimmediately.Thediscomfortrequiresnomorethanafewpain
relievingpills(suchasaspirinorparacetamol).Thedressingsareonusuallyfor10days.Usuallywaterproofdressingsareusedsothatyoucanwashafter48hours.
Donothaveanyprolongedcontactwithwater,otherwisethedressingsmaycomeoffprematurely.After10daysalldressingsareremoved.Itisbesttosoaktheseoff
whileinthebath.Anynonabsorbablesuturesareremoved,andifanywoundsremainunhealed,furtherdressingscanbeapplied(usuallybandaids)untiltheyhave
healed.Thevastmajorityofpatientshavingvaricoseveinsurgerydonotneedtoattendtheoutpatientclinic.
Wearanelasticstocking—overthebandagesatfirst
whenwalkingaboutduringthedayforthefirst10daystokeepthesurfaceveinsemptied,butyoucanremove
thestockingbeforeretiringtobed,providedthatyoukeepthelegwellraisedonacoupleofpillowsduringthenight.Ifyouhaveuncomplicatedveins,youmaynot
needtowearcompressionstockingsforalongtermperiod.Youshouldconsultyoursurgeonregardingthenecessityofwearingthemafterthisperiod.Usually
patientswithcomplicatedveins,thosewithrecurrentveins
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andthosewithvenousulcersshouldprobablywearsomeformofcompressionstockingforlife.
ProsandConsofTreatment
Althoughtheoperationisquiteminorandthousandsareperformedeveryyearinhospitalsincompletesafety,wemuststressthatnooperation,however
uncomplicated,isentirelywithoutrisk.Theremaybequitemarkedbruisingbeneaththeskinorevenasmallcollectionofblood(haematoma)whichmayneedtobelet
outthisismorelikelytohappeninthecaseofpatientswhoareoverweight.Althoughrare,aslightinfectioninthewoundmaytakeplacebecause,afterall,thegroin
areaisnotthecleanestpartofthebody.Again,thisismorelikelytooccurinanoverweightpatientwithexcessfatatthetopoftheleg.
Itisjustpossiblethatyoumightexperienceathrombosisalongthecourseofthesurfaceveins(phlebitis)whichmayrequireafewdaysrestwithyourlegraisedand
somemildpainrelievingpills.
Damagetothesuperficialnervesmaycausesmallpatchesofnumbnessintheleg.However,theseusuallygetsmallerwithtimeasthenervesrecoveriftheyarejust
bruised,orasothernervestakeovertheirfunction.Sometimestheymaybepermanent.Veryrarelythesaphenousnervemaybedamagedduringoperationsonthe
longsaphenousvein,andthesuralnerveduringoperationsontheshortsaphenousnerve.Thesecancauseeithernumbnessoraburningpain(causalgia)inthefoot,
whichcanbesevere.Thenumbnessmaybepermanentifthenervehasinadvertentlybeenremoved,butitcanrecoverifthenervehasonlybeenbruised.Causalgia
usuallyimproveswithtime,andvariousmeasurescanhelp,suchastranscutaneousnervestimulationandsometablets,suchasamytriptylineandcarbamazepine.
Occasionallynerveblocksarerequiredtoablatethenerve.Thesenecessarilycausenumbnessintheterritorysuppliedbythenerve,butmaybepreferableforyou
whencomparedwithcausalgia.
Soyoumustweighuptheprosandconsandfeelquitesurethattheveinsaresufficientlyirksomeeitherfromtheirappearanceortheirdiscomfort,orbothto
warrantthelossoftimefromwork,theinconvenience,thediscomfortandeventheslightrisksofsurgicaltreatment.
ChoiceofTreatment
Doctorsareoftenaskedwhichtreatmentisbetter—injectionsoroperation?Theansweristhattheyarenotrivals,butthateachhasitsown
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applications.Indeed,veryoftenthetwomethodsarecombinedindealingwithextensivevaricoseveins.
Injectionshaveanadvantagebecausetheycanbecarriedoutwithoutyourhavingtocomeintohospital.Alsoyoudonotneedagneralanaesthetic.Certainlythelong
periodofbandagingafterinjectionistedious,butitisnomorethananuisance.
Surgerymeansageneralanaestheticandashortperiodasaninpatientinhospital.ItisthepreferredmethodoftreatmentintheUnitedStatesforvaricoseveins.
However,wehavealreadypointedoutthatinBritainthetwomethodsoftenhavedifferentareasofapplication:injectionsareusedforrelativelysmallvaricoseveins,
especiallythosebelowtheknee,whereassurgeryisneededforthelargevaricoseveinsextendinguptothethighandgroin.Thesurgeonmayhavetooperateoncases
suchasthisandthenuseinjectionstotidyupanyfurtherveinslowerdowntheleg.
AtpresentthereisaveryseriousproblemregardingtheavailabilityofthetreatmentjustoutlinedontheNationalHealthService.Injectiontherapyhasnotbeen
availableinmanyregionsformanyyears,andyoumayhavetoconsultyourdoctoraboutwhetheritisavailable.Morerecently,somepurchasingauthoritieshave
decidedthattheywillnotbuycertainoperationsfromproviderhospitals.Insomeregionsthisincludesvaricoseveins.Theyarguethatcompressionstockingsoffera
viablealternativetosurgery.Someauthoritieshavestatedthatvaricoseveinsurgerycanonlybeperformedwhenassociatedwithseverepainorskinproblems,such
asulceration.Youwillneedtodiscusstheseproblemswithyourgeneralpractitioner.
Recurrence
Varicoseveinscanbecompletelyclearedup,orcertainlygreatlyimproved,byinjectionorsurgicaltreatment.However,nodoctorwouldeverclaimthattheresults
arepermanent.Indeed,somethinglike20%ofpeopleundergoingsurgerywilldevelopfurthervaricositiesduringthe5yearsfollowingtreatment.Insomecasesthisis
becauseveinsthathavebeeninjectedhaveexpandedagainorasmallveinthathasnotbeentiedoffsurgicallygraduallyexpands.
Theseareprobablynotrecurrencesbutfreshvaricoseveinsthathavedevelopedbecauseofnewblowouts.Recentstudieshaveshownthatnewsmallveinscan
growacrossthegapproducedbysurgeryforsimpleligation.Thiscanbedecreasedbystrippingtheveinout.
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Thismeansthatalotofpatientsaregoingtobedisappointedwhentheyfindanothervaricoseveinappearingontheleg.However,onthepositivesideitmustbe
pointedoutthatthisisquiteaslowprocesssothatthelegisnotsuddenlygoingtodeteriorateintoamassofnewlyformedvaricoseveins.Itisusuallyaverysimple
mattertoclearupanewlydevelopedvaricositybymeansofoneortwoinjectionsorsurgeryandthis,inturn,willbefollowedbyagood,longperiodoffreedomfrom
furthertrouble.
Ifyouhaveacavityinyourtoothfilledbythedentist,youarenotatallsurprisedwhenafewyearslateracavityappearsinanothertoothorthatparticularfillingneeds
tobechanged.Sufferersfromvaricoseveinsmustdevelopthesamesortofphilosophicalapproachtothetreatmentoftheirlegs.
NewValvesforOld?
Youmayask,`Ifvaricoseveinsresultfromdamagedvalves,whycannotsurgeonsgraftnewvalvesbackintothevein,whichwouldrestorethemechanismofreturnof
bloodtotheheartandbringthesituationbacktonormal?Afterall,surgeonsareabletoreplaceheartvalves,whynotveinvalves?'
Well,firstofall,bythetimemostpatientsgettoseetheirsurgeontheirvaricoseveinsareusuallyquitepronouncedandtheyhaveprobablyprogressedtothestage
whereirreversibleexpansionandstretchingoftheveinshasoccurred.Theyarebythenunlikelytorespondtoanytreatmentotherthanbyinjectionorsurgery.The
secondproblemisthatareconstructiveoperationonaveinwouldbeverydifferentfromoneonanarteryandmuchmorelikelytobefollowedbyclottingwithinthe
vein.Thereasonisthattheflowofbloodismuchslowerandmoresluggishinveinsthaninarteries,andstagnationofbloodisaverypowerfulallyofbloodclotting.
Frankly,forthesetworeasons,surgeonshavebeenhesitantabouttryingtodevisesomewayofrepairing,replacingorgraftingveinvalves.However,somesurgeons
haveattemptedtorepairthevalves,whileothershaveeithertransposedortransplantedhealthyvalves,oftenfromthearm.However,theresultsfromthese
procedureshavebeendisappointing,particularlywhencomparedwiththeresultsfromcompressionstockings.Variousingeniousexperimentalprocedureshavebeen
devisedtocreatevalvesusingthenormalvein,butasyetthesehavenotbeensuccessfullyperformedinpeople.Meanwhile,letusgetbackto
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