Preoperative Preparation of Patients with Trophic Ulcers of Venous Etiology

The dissertation is devoted to the development of complex preoperative preparation of patients with trophic ulcers of venous etiology. It examines the epidemiology, the medical-social and economic significance of chronic venous insufficiency (CVI), as well as current concepts of its etiology, pathogenesis, clinical manifestations, and classification. The rheological properties of the blood and the state of plasma-coagulation hemostasis in this category of patients are studied, along with the character of microbial contamination of ulcer surfaces and approaches to the correction of edematous syndrome. Based on clinical material, schemes of preoperative lymphotropic antibiotic therapy, "targeted" correction of hemorheological and hemostasiological disorders, and methods of lymphatic drainage and lymphostimulation have been proposed and tested, aimed at preventing postoperative purulent-inflammatory and thrombotic complications in patients with severe forms of CVI.

Relevance of the problem

The treatment of trophic ulcers of venous etiology still presents many unresolved problems. The words of S.I. Spasokukotsky have not lost their significance: "Leg ulcers represent a true cross of surgeons in their enormous persistence and difficulty of cure." Subsequently, E.C. Arnoldi (1967) published the article "Ulcus cruris venosum - Crux medicorum," which means "venous leg ulcers - the cross of medicine."

Chronic venous insufficiency (CVI) at the stage of trophic disorders represents an important medical-social and economic problem. Today, in the world, CVI is one of the most widespread diseases, affecting from 5 to 20% of the population of developed countries. From 0.2% to 3.9% of the population in different countries have trophic venous ulcers (Maffei F. et al., 1986; De Castro Silva, 1991; Savel'yev V.S., Kiriyenko A.I. et al., 2000). According to Academician V.S. Savel'yev, in Russia alone, 35 million people need specialized phlebological information. Every year, the world community incurs large economic losses associated with the costs of treating these patients (Ruckley C., 1997; Salzman E., 1990). Many patients of working age with trophic ulcers of venous etiology undergo long and unsuccessful conservative treatment, since they are denied surgical treatment because of the unhealed ulcer and the high risk of purulent-inflammatory complications (Vasyutkov V.Ya., Protsenko N.V., 1993). At the same time, only surgical operations and manipulations can change the current situation.

In recent years, significant progress has been achieved in the treatment of patients with CVI and trophic disorders. New operations and surgical manipulations have been introduced into broad clinical practice: sclerotherapy, various variants of mini-invasive phlebectomy, including sclero-surgical, endoscopic dissection of perforating veins, sclerotherapy of perforating veins under ultrasound guidance, laser coagulation, and operations on the valves of deep veins are being developed and introduced (Savel'yev V.S., 2001).

In this regard, treatment outcomes improve and surgical trauma decreases.

At the same time, the number of complications remains rather high. Treatment outcomes do not always depend on the tactics and technique of the operation. Adequate preoperative preparation is of no less importance. With the emergence of new views on the pathogenesis of CVI and modern methods of laboratory diagnosis, it has become possible to adequately assess a complex of parameters characterizing the main links of pathogenesis: hemorheological properties of the blood, changes in hemostasis, the function of lymphatic drainage, the character and severity of microbial contamination of the ulcer, and the state of macro- and microcirculation.

Despite the fact that individual methods of correcting the aforementioned links of the pathogenesis of CVI have been sufficiently developed, we have not found in the available sources a comprehensive set of diagnostic and therapeutic measures that would allow adequate preparation of the patient for surgery, proceeding from modern concepts of the pathogenesis of chronic venous insufficiency. Despite the constant improvement of surgical methods for the treatment of varicose disease, significant progress in the surgery of perforating veins, and the development and introduction of new surgical operations on the deep venous system, the problem of CVI has not been fully resolved.

Studies of the pathophysiology of CVI at the stage of trophic disorders have shown that for the complete correction of the disease, measures aimed only at eliminating venous hypertension and reflux are insufficient. Measures aimed at restoring normal microcirculation, improving lymphatic outflow, and reducing microbial contamination in the ulcer are of no less importance. They can not only be assessed but also corrected in such a way as to rationally prepare the patient for surgery, reduce the risk of postoperative complications, and accelerate ulcer healing.

Aim of the study

To improve the results of treatment of patients with trophic ulcers of venous etiology by reducing postoperative complications through adequate preoperative preparation.

Tasks of the study

1. To study the character of the microflora cultured from the surface of patients' ulcers. To substantiate the need for individualization of the antibiotic therapy program.

2. To develop an algorithm of preoperative lymphotropic antibiotic therapy for the prevention of postoperative purulent-inflammatory complications. To compare the results of the proposed approach with traditional schemes of antibiotic therapy.

3. To investigate the state of the hemorheological profile in patients with trophic ulcers of venous etiology. To assess the influence of surgical trauma on hemostasis and blood rheology parameters, the risk of developing thrombotic complications and microcirculatory disorders.

4. To introduce schemes of "targeted" correction of hemorheological and hemostasiological disorders into the preoperative preparation of patients. To evaluate the effectiveness of this approach with respect to microcirculation parameters and the risk of thrombosis.

5. To introduce methods of manual and apparatus lymphatic drainage into preoperative preparation. To develop a technique of lymphatic drainage and lymphostimulation for the preoperative preparation of patients with trophic venous ulcers.

6. To carry out a comparative evaluation of the proposed approaches to the management of the preoperative period with traditional schemes of treatment with respect to the results of surgical treatment.

Scientific novelty

1. For the first time, the necessity of complex preoperative preparation of patients with trophic ulcers has been scientifically substantiated, taking into account modern concepts of the pathophysiology of the process.

2. The necessity of combating infection in the ulcer, proceeding from information on the sensitivity of the flora to antibiotics in each individual patient, has been proved, and the expediency of using lymphotropic methods of antibiotic administration in the preoperative period has been substantiated.

3. An analysis has been carried out of the dependence of thrombotic complications and microcirculatory disorders in the early postoperative period on the state of hemorheology and hemostasis, and the features of the formation of hemorheological and hemostasiological disorders have been revealed.

4. Preoperative "targeted" schemes of correction of disorders of hemostasis and hemorheology have been developed for the prevention of thrombotic and microcirculatory disorders in the early postoperative period.

5. The significance of adequate lymph flow for the course of the postoperative period and the necessity of preoperative lymph-drainage measures in patients with severe forms of CVI have been proved.

6. For the first time, an algorithm of preoperative preparation has been proposed with the possibility of correcting all links of pathogenesis.

Practical significance

1. Rational preoperative preparation allows reducing the risk of postoperative complications, accelerating the timing of ulcer healing, improving the quality of life of operated patients, and also abandoning a number of traditional therapeutic measures in the postoperative period.

2. The practical use of methods of bacterial control allows a rational approach to the choice of an antibacterial drug.

3. The method of lymphotropic administration of an antibiotic allows reducing the frequency of administration of the drug and its dose, and makes it possible to avoid the patient's stay in a hospital and to perform the manipulation under conditions of a day hospital.

4. Investigation of the systems of microcirculation and hemorheology makes it possible to correct them adequately, thereby improving tissue trophism.

5. The practical use of "targeted" schemes of correction of disorders of hemostasis and hemorheology makes it possible to correct them in the preoperative period, which leads to a reduction of thrombotic and microcirculatory complications in the intraoperative and early postoperative periods.

6. The practical use of methods of lymphatic drainage allows improving lymph flow, reducing the phenomena of lymphostasis in the preoperative and early postoperative periods, achieving its stable remission, thereby improving ulcer healing.

7. The proposed algorithm can be widely used in the practice of departments of vascular surgery, phlebological centers, departments of wounds and wound infection, and outpatient and one-day hospital-replacing surgery.

Main propositions submitted for defense

1. Patients with trophic ulcers of venous etiology require complex preoperative preparation, taking into account modern concepts of the pathophysiology of the process.

2. The applied preoperative "targeted" schemes of correction of disorders of hemostasis and hemorheology make it possible to carry out prevention of thrombotic and microcirculatory disorders in the early postoperative period, which reduces the risk of postoperative complications.

3. Rational preoperative preparation allows reducing the risk of postoperative complications, accelerating the timing of ulcer healing, improving the quality of life of operated patients, and also abandoning a number of traditional therapeutic measures in the postoperative period.

4. Patients with severe forms of CVI require preoperative lymph-drainage measures for adequate lymph flow in the postoperative period in order to prevent secondary lymphostasis.

Implementation

The main propositions of the dissertation have been implemented in the work of the Department of Vascular Surgery of the Municipal Clinical Institution "Medical Sanitary Unit of the Novoyaroslavl Oil Refinery." Schemes for the examination of patients in the departments of general surgery and vascular surgery of the MSCh NYaNPZ have been developed for the prevention of purulent-septic complications in persons with trophic ulcers of venous etiology.

The results of the investigations are used in the educational process at the Department of Faculty Surgery of the Yaroslavl State Medical Academy with 4th-year students of the medical faculty, interns, clinical residents, and students of the faculty of advanced training.

Approbation of the dissertation

The main propositions of the dissertation were reported at: the Second Regional Conference of the All-Russian Association of Lymphologists (Yaroslavl, May 24, 2004), the International Surgical Congress "New Technologies in Surgery" (Rostov-on-Don, October 5-7, 2005), the Plenum of the Board of the All-Russian Society of Angiologists and Vascular Surgeons "Current Problems of Angiology and Vascular Surgery" (Rostov-on-Don, November 28-29, 2006). On the topic of the dissertation, 12 works have been published, of which 6 are in local and 6 in central press.

Scope and structure of the dissertation

The dissertation is presented on 143 pages of typewritten text and consists of a table of contents, an introduction, a review of the literature, a clinical characterization of patients and methods of investigation, three chapters of original investigations, a conclusion, conclusions, practical recommendations, and a list of references that includes 107 domestic and 122 foreign sources. The material presented is illustrated by 30 tables, 5 figures, and 1 diagram.

The work was carried out at the State Educational Institution of Higher Professional Education "Yaroslavl State Medical Academy of the Federal Agency for Health Care and Social Development" (Rector - Academician of RAMS, Professor Yu.V. Novikov) at the Department of Faculty Surgery (Head of the Department - Doctor of Medical Sciences, Professor A.A. Chumakov). The clinical material consisted of data from the examination and treatment of patients with trophic ulcers of venous etiology who were treated at the Department of Vascular Surgery of the Municipal Clinical Health Institution MSCh NYaNPZ in the city of Yaroslavl (Chief Physician - Doctor of Medical Sciences, Professor A.N. Khorev). The investigation of the hemostasis system was carried out on the basis of the Laboratory of Clinical Immunology of MKUZ MSCh NYaNPZ (Head of the Laboratory - Doctor of Medical Sciences, Professor A.A. Baranov); the investigation of hemorheological indices was carried out in a laboratory at the Yaroslavl State Pedagogical University under the guidance of Professor A.V. Muravyov. The assessment of microflora from the surface of ulcers was carried out at the Department of Microbiology of the Yaroslavl State Medical Academy.