The role of sclerosurgical phleboobliteration in the combined treatment of varicose disease

The dissertation investigates the role of sclerosurgical phleboobliteration in the combined treatment of varicose disease of the veins of the lower extremities. The work is aimed at developing a diagnostic and therapeutic algorithm that takes into account the individual manifestations of the disease, as well as a method for the combined application of sclerosurgical phleboobliteration and miniphlebectomy. The study addresses the influence of this intervention on the hemostasis system in the postoperative period, the comparative analysis of the immediate and long-term results of sclerosurgical phleboobliteration and classical phlebectomy, and the assessment of the quality of life of operated patients. The data obtained are of importance for improving the surgical management of varicose disease and for reducing the frequency of recurrences and complications.

Relevance of the Study

The problem of treating chronic venous insufficiency of the lower extremities remains far from being resolved and is of exceptional relevance. Varicose disease of the lower extremities is the most widespread vascular disease. According to data from various authors, this pathology is recorded in 15–25% of the adult population (Savel'yev V.S., 2006; Kiriyenko A.I., 2004; Dzhantet G., 1997; Labropoulos N., 2004; Fowkes F.G.R. et al., 2007; Carandina S. et al., 2008).

Women constitute the majority of patients (85%), of whom 73% are of working age (the mean age being 45.7 years). The physiology of venous outflow, gravitational forces, and connective-tissue dysplasia (genetic weakness of the venous wall and defects of the valvular apparatus) account for the prevalence of this affliction.

The relevance of the problem is determined by the high frequency of occurrence of this vascular pathology. Up to 40% of the population exhibit varicose transformation of the subcutaneous veins, which, in the figurative expression of J. Van der Stricht, represents "humanity's payment for the ability to walk upright." In Russia, 25–30 million people require rehabilitation measures for this disease. No more than 30,000 patients are covered annually by operative treatment of varicose disease of the lower extremities (Savel'yev V.S., Konstantinova G.D., 2006). The traditional organization of surgical treatment requires the patient's hospitalization and does not allow the formation of a patient flow and their rapid rehabilitation. Despite considerable progress in the diagnosis and treatment of varicose disease, the number of patients increases from year to year, their age decreases (more than 80% of cases fall within the age range of 35–50 years), and the frequency of advanced forms of this pathology rises. According to data of the World Health Organization, about 12.5% of the working-age population of Europe suffering from venous pathology are compelled to discontinue their working activity prematurely.

The annual increase in new cases of varicose disease of the lower extremities in the population of industrially developed countries reaches 2.6% among women and 1.9% among men (Callejas J.M., Manasanch J., 2004; Fowkes F.G.R. et al., 2007; Nelzen O. et al., 2007).

In Russia, disabling trophic ulcers resistant to the most modern methods of conservative therapy occur in more than 1.5 million people, while recourse to operative methods is required in 3–4% of cases (Savel'yev V.S. et al., 2001). This tendency has remained constant over the last 15–20 years (Bogachev V.Yu., Zolotukhin I.A., Kuznetsov A.N., 2008).

In industrially developed countries, the annual total expenditure on the treatment of chronic diseases of the veins of the lower extremities amounts to 1–3% of the total healthcare budget (Jawien A., 2003; Moffatt C.J. et al., 2004; Nelzen O. et al., 2007).

Contemporary conditions determine the priority of minimally invasive technologies that provide radical treatment while increasing the throughput of surgical hospitals and achieving a high aesthetic result (Savel'yev V.S., 2006).

In recent years, considerable progress has been achieved in the treatment of patients with chronic venous insufficiency. New operations and surgical manipulations have been introduced into broad clinical practice: sclerotherapy, various variants of minimally invasive phlebectomy, including sclerosurgical procedures, endoscopic dissection of perforating veins, sclerotherapy of perforating veins under ultrasonic guidance, laser coagulation; operations on the valves of the deep veins are being developed and introduced (Savel'yev V.S., 2001).

In this connection, treatment results are improving and operative trauma is decreasing. At the same time, the number of complications and recurrences remains considerable. Different approaches and methods of treating varicose disease, competing with one another, exist. Despite the successes achieved, the frequency of postoperative recurrences of varicose disease of the lower extremities unfortunately reaches 80%, and of trophic ulcers 34.1%, which remains a pressing problem of surgical phlebology at the present time (Shulutko A.M., 2003; Kiriyenko A.I., 2006; Stoyko Yu.M., Gudymovich V.G., 2007; Gavrilenko A.V. et al., 2008; Fischt R. et al., 2001; Allegro C., 2006; Coleridge Smith P., 2006; Perrin M., 2007).

In international phlebological practice, sclerosurgical phleboobliteration is one of the widespread methods for treating varicose disease (Campbell W.B., 2001; Tibbs D.J., 2002). This is due to the simplicity and effectiveness of the method. The interest of vascular surgeons in these techniques is constantly growing (Savel'yev V.S., Kiriyenko A.I., 2006; Shatalov A.V., 2000; Shimko V.V. et al., 2000; Kushnarenko A.V. et al., 2001; Khoreyev N.G. et al., 2001; Chukin S.A. et al., 2001; Savel'yev V.S., 2001; Kungurtsev V.V. et al., 2003; Hauer G., 1985; Fisher R., 1992; Kulbaski M.J. et al., 1997; Lafrati M.D. et al., 1997). At the same time, no expensive equipment is required, which makes it possible to master the technology in any surgical hospital. This fact is relevant for Russia. The introduction of sclerosing techniques into broad practice is quite rational from both medical and economic standpoints.

However, we have not found in the literature any data on the study of long-term results in this direction. Existing publications do not allow a full judgment to be made about the degree of effectiveness of this type of operative treatment.

The facts set forth above have determined the conduct of the present study.

AIM OF THE STUDY

To assess the effectiveness of sclerosurgical phleboobliteration in the combined treatment of patients with varicose disease of the veins of the lower extremities at various degrees of chronic venous insufficiency.

OBJECTIVES OF THE STUDY

1. To develop an algorithm for the diagnosis and choice of treatment method for patients with varicose disease, taking into account the individual manifestations of the disease.

2. To develop a method for the combined application of sclerosurgical phleboobliteration and miniphlebectomy.

3. To study the effect of sclerosurgical phleboobliteration on the blood coagulation system in the postoperative period.

4. To analyse the immediate and long-term results of treatment of patients with varicose disease of the veins of the lower extremities by means of sclerosurgical phleboobliteration and to compare them with the results of classical methods of intervention on the superficial veins.

5. To study the quality of life of patients with varicose disease of the superficial veins of the lower extremities after sclerosurgical phleboobliteration combined with miniphlebectomy.

SCIENTIFIC NOVELTY

1. For the first time, a diagnostic algorithm has been developed for the application of sclerosurgical phleboobliteration combined with miniphlebectomy in patients with varicose disease, and the effectiveness of this type of operation has been studied according to the results of duplex angioscanning.

2. As a result of the studies carried out, it has been established that sclerosing treatment of patients with intracutaneous and segmental varicosis in varicose disease of the veins of the lower extremities contributes to the correction of disorders of venous outflow from the lower extremities, ensuring the necessary radical effect, eliminates the cosmetic defect, and improves the quality of life of patients.

3. For the first time, the effect of sclerosurgical phlebectomy on the hemostasis system in patients with varicose disease has been studied.

4. For the first time, the quality of life of patients who underwent sclerosurgical phleboobliteration with miniphlebectomy has been studied.

5. A comprehensive analysis of the immediate and long-term results of interventions on the superficial veins has been carried out; a comparative assessment of sclerosurgical phleboobliteration and classical phlebectomy has been given, and the causes of disease recurrences have been identified.

PRACTICAL SIGNIFICANCE

1. The application of the therapeutic and diagnostic algorithm for the provision of surgical care to patients with varicose disease of the lower extremities makes it possible to identify the character of the pathological venous blood flow in the main veins, to choose the adequate scope of operative intervention and the most effective method of correction of the pathological retrograde blood flow, and to improve the immediate and long-term results of treatment.

2. The studies carried out have made it possible to develop concrete recommendations and to define the indications and contraindications for performing sclerosurgical phleboobliteration in patients with varicose disease of the veins of the lower extremities.

3. The use of vein sclerotherapy, taking into account the features of the disturbance of venous outflow from the lower extremities and with mandatory ultrasonographic angioscanning control, makes it possible, while preserving the necessary radical effect of treatment, to improve the cosmetic result and the quality of life of patients with varicose disease.

4. The introduction of sclerosurgical phleboobliteration combined with miniphlebectomy into everyday practice is economically expedient, allowing an increase in the volume of surgical sanation of varicose disease by reducing the time of the patient's stay in the hospital.

5. The causes of recurrence of varicose disease that we have identified will contribute to a decrease in the frequency of disease return.

6. The results obtained in the study may be used in modern medicine and in the practice of vascular surgery, in the development of programs of preventive and therapeutic orientation, and may serve as a basis for further research work in this field.

MAIN POINTS PRESENTED FOR DEFENSE

1. Sclerosurgical phleboobliteration is an effective, safe, minimally invasive method of treatment of varicose dilation of the veins of the lower extremities. Its application must be strictly limited with account taken of the character of the pathological process. Ultrasonographic angioscanning is necessary for the choice of the scope and the assessment of the radical nature of the operative procedure.

2. Sclerosurgical phleboobliteration in patients with varicose disease reduces the trauma of the operation and enhances its cosmetic effect. Preliminary dissection of incompetent perforating veins and removal of large venous tributaries make it possible to achieve a high radical effect of the operation while preserving its low-traumatic character.

3. The immediate and long-term results of sclerosurgical phleboobliteration, in terms of radical effect, correspond to those of classical phlebectomy, but surpass them with respect to the cosmetic and aesthetic effect, the terms of medico-social rehabilitation, and the quality of life of operated patients, which makes sclerosurgical phleboobliteration the method of choice for intervention on the superficial veins.

4. During the first twenty-four hours after sclerosurgical phleboobliteration, changes occur in the hemostasis system that are less pronounced than after classical phlebectomy but that require prophylaxis of possible thrombotic complications.

IMPLEMENTATION

The main points of the dissertation have been implemented in the work of the Vascular Surgery Department of the Municipal Clinical Healthcare Institution "Medical-Sanitary Unit of the Novo-Yaroslavl Oil Refinery" (MSCh NYa NPZ).

The results of the study are used for delivering lectures and conducting classes at the Department of Faculty Surgery of the Yaroslavl State Medical Academy with fourth-year students of the medical faculty, interns, clinical residents, and listeners of the Faculty of Advanced Training of Teachers of Medical Colleges of the Yaroslavl State Medical Academy.

APPROVAL OF THE DISSERTATION

Based on the materials of the dissertation research, 8 printed works have been published, of which 5 are in journals and publications defined by the list of the VAK. The main points of the work were reported at the tenth jubilee scientific-practical conference of physicians of MSCh NYa NPZ dedicated to the 50th anniversary of MSCh NYa NPZ (Yaroslavl, 2006); the fifth conference of the Association of Phlebologists of Russia (Rostov-on-Don, 2007); the 11th annual session of the Scientific Center for Cardiovascular Surgery named after A.N. Bakulev of the RAMS with the All-Russian Conference of Young Scientists (Moscow, 2007).

VOLUME AND STRUCTURE OF THE DISSERTATION

The dissertation is set out on 178 pages of typewritten text and consists of an introduction, a review of the literature, a description of the material and methods, 5 chapters, a conclusion, conclusions, and practical recommendations. The list of references includes 77 domestic and 52 foreign sources. The text is illustrated with 17 tables, 32 figures, and 3 appendices.