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Transcript of V.v.recurrencs
Assessment of causes and patterns of recurrent varicose veins after surgery in Suez Canal
University hospital
Dr.Mohammed Adel Gad Al-rabAssistant Prof. of general Surgery
Faculty of MedicineSuez Canal University
Faculty of Medicine Suez Canal University
2009
Introduction and rationale
Varicose veins are common surgical problem, the prevalence has
been variously reported from as little as 2% to over 60% in population
studies. (Perrin, et al, 2000(
The Edinburgh venous association published in 1998 study which
examined over 1500 adults and given the best current data on the
prevalence of varicose veins in UK, in this study 39.7 % of women and
32.2% of men had dilated tortuous veins. It is generally accepted that
primary varicose veins are caused by failure of the valves, secondary
varicose vein has a different pathogenesis, the most common of which is
deep venous thrombosis. ( Fischer, et al, 2001)
There are many complications following varicose veins surgery, as
damage to major venous, nervous and arterial structure but there is also
another famous complication which is the recurrence of varicose vein after
surgery. (Kostas ,et al , 2004)
Varicose vein surgery is characterized by a very high recurrence
rate of 20% to 60% after 5 years and even higher after longer periods
of follow-up observation, and this is a disappointing finding, both
for the patient and surgeon, some causes of recurrence are obvious as
insufficient insight into anatomy and hemodynamics of the superficial
venous system. (Bridget, 2006)
Recurrence has also been attributed to neovascularization ; a
phenomenon of forming new channels between the ligated stump of great
saphenous vein on the common femoral vein, or stump of short saphenous
vein on the popliteal vein and the residual main trunk of its tributaries, post
operative neovasculerization in the granulation tissue around the ligated
stump appears to be an important cause of recurrence of varicose vein,
even after correct performed surgery.) Geier, et al, 2005)
Already in the 19th century, surgeons noticed that the new vein
channels could form after ligation or extirpation of a piece of vein; this
could be responsible for recurrence after surgery.
The majority of authors in 20th century claimed that recurrence was
due to the development of incompetence in pre-existing collateral, which
had not been adequately ligated by the previous surgeon.(Creton, 2002)
Attention to technical details will decrease the regrettably high rate
of recurrence after sapheno-femoral disconnection and render safer
exploration. Early post surgical recurrence results from an incomplete
operation, late recurrence is known to occur after correct surgery but with
deterioration of the remaining superficial venous system or in case of
inappropriate surgery leaving communicating veins between superficial
&deep venous system, which have involved silently, or even recurrence
following incomplete surgery because of unrecognized anatomical
variation as double saphenous.
This distinction is merely theoretical, duplex scan shows that
incomplete removal of varicose veins remains the main cause of recurrence
. The aim of sonographic investigation is to identify the main factors,
more than the cause, before surgery assessment which could serve as a
reference being rarely available. In practice, certain technical or tactical
errors could surely be identified in the course of treatment. (Knighton, et
al, 2002)
Sonographic tests enable dynamic mapping of recurrence and allow
better choice of further treatment, surgery, sclerotherapy or various
combined technique. Ideally this mapping should be followed by skin
marking when further surgery is necessary to avoid more incomplete
treatment. (Knighton, et al, 2002)
-
Aim of the work
To identify the possible causes and patterns of recurrent varicose veins in
patients with history of varicose veins surgery.
Patients and methods
Type of Study
This study is a descriptive prospective study on patients with history
of previous varicose veins surgery, to assess the possible causes of
recurrent varicose veins after surgery.
Study locations
Out patient clinic in Suez Canal University hospital in Ismailia.
Inclusion criteria
1-All patients with recurrent varicose veins with history of previous
varicose veins surgery at the same limb.
2-All age.
3-Both genders.
Exclusion criteria
1-missed patients during follow-up.
Methods
Ninety two patients with recurrent varicose veins after surgery were
enrolled in this study, then a history, examination and investigations
were performed for them as follows :-
History:
-History of venous insufficiency (eg, date of onset of visible abnormal
vessels after previous varicose veins surgery, date of onset of any
symptoms).
-History of presence or absence of predisposing factors (eg, hereditary,
trauma to the legs, occupational as prolonged standing).
-History of superficial or deep venous thrombophelbitis ( date of onset,
site, predisposing factors, sequels).
-History of other vascular disease (eg, peripheral arterial diseases,
lymphdema and lymphangitis.
-History of venous diseases ( eg,medications, injections and
compression.
-Family history of any vascular diseases of any type.
-The time of previous operation.
B) Examination:
1-General examination.
Which include, patient general condition, presence of other weak
mesenchymal syndrome as hernia or flat foot, also abdominal and
pelvic examination to exclude any problems as tumors which may lead
to varicose veins as secondary cause.
2-Local examination:
The physical examination of venous system is difficult because most of
deep venous system can't be directly inspected, palpation, ausculted or
percussed. In most areas of the body, examination of superficial venous
system must serve an indirect guide to the deep system.
Veins and their connections gradually became better defined through
inspection, palpation and percussion.
Inspection
Was performed in an organized manner, usually progressing from
distal to proximal and form front to back. The perineal region, pubic
region, and abdominal wall also must be inspected. Inspection may
revealed such findings as cutenous ulceration, telangectasia, eczema,
brown spots, dermatitis, prominent varicose veins, scar from prior
surgical operation or evidence of sclerosant injections.
Visible distension of superficial veins in other regions of leg usually
implies disease, while translucent skin may allow normal veins to be
visible as bluish sub dermal reticular pattern but dilated veins above the
ankle are usually evidence of venous pathology.
Palpation
It was important part of venous examination, the surface of the skin
was palpated lightly with finger tips because dilated tortuous veins may
be palpable even where they are not visible.
It started over the antromedial surface of the lower limb along the
course of the long saphenous vein, palpation then proceeded to the
lateral surface then the posterior surface is palpated along the course of
the short saphenous vein, the location, size, shape and the course of all
varicosities are noted, and the diameter of the largest vessels is
measured as accurately as possible.
Palpation of painful area on the leg or presence of tenderness may
reveal a firm, thickened thrombosed veins are superficial veins, but as
associated with deep venous thrombosis may occur.
c) Investigations
1-Duplex Ultra Sound was made over the superficial and deep venous
system of patients of this study.
Data collection
Sample was taken as all patients with recurrent varicose veins after
previous varicose veins surgery in outpatient clinic in Suez Canal
University hospital.
Statistical Analysis
Data entry and analysis will be accomplished using windows
operating system and the based statistics program (SPSS 10.0) adopting in
the outcome the following statistical tests:
* Continuous variables are expressed as means and standard deviation
(SD)
* Discrete variables are expressed as frequencies and percentages
* Differences will be statistically significant if probability (p value ≤
0.05) it will be calculated using epi-info statistical package 11.0
program
Presentation of the statistical outcome in form of tabulation and
graphs will be accomplished by windows based Microsoft Excel.
Ethical consideration
- Confidentiality of all data and tests results of all study population.
- Written consents were obtained from all patients before getting them
involved in this study.
- The steps of the study; the aims and the potential benefits were
discussed with each individual patient.
- Patient will be informed about any abnormal results of the
procedures and tests performed and will be instructed and treated
accordingly.
- The patient had the right for withdrawal from the study at any time
with neither jeopardizing the right of the patients to be treated nor
affecting the relationship between the patient and the care provider.
RESULTS
This study is a descriptive prospective study done over 36 months
from December 2006 to November 2009 including 92 patients, all of them
have recurrent varicose veins after surgery .
This study aimed to assess the different causes of recurrent
varicose veins after surgery, all these patients are presented to our
outpatient clinic in Suez Canal University Hospital .
60 out of 92 patients were females (65.2%) and 32 patients were
males (34.8%), table 1,graph1.
Their age ranged from 20 to 56 years old with mean age 36.5+ 9.4 and
the higher frequency of recurrence was between 50-56 years, table 2,graph2.
30 (32.6%) out of 92 patients had varicose veins operated on with
saphenofemoral disconnection (Trendelnberg operation) ,22 patients (23.9%)
with Saphenofemoral disconnection ,with stripping below knee , 28 patients
(30.4%) with Saphenofemoral disconnection with stripping above knee and
only 12 patients (13.1%) with Saphenopopliteal disconnection with stripping ,
table 3.
Table (1 )
Shows sex distribution in the study group:
Sex No. PercentMale 32 34.8%
Female 60 65.2%Total 92 100 %
Results are statistically significant as P value is less than 0.05
Sex distribution
34.80%
65.20%
Male
Female
Graph No. 1 shows distribution of the patients according to their sex
Table 2
Shows age distribution in the study group:
Age groups No. Percent20-29 8 8.7%30-39 24 26.1%40-49 28 30.4%50-56* 32 34.8%Total 92 100%
Mean age 36.5+ 9.4
*Results are statistically significant as P value is less than 0.05
Age distribution
8.70%
26.10%30.40%
34.80%
0.00%5.00%
10.00%15.00%20.00%25.00%30.00%35.00%40.00%
20-29 30-39 40-49 more than50
The age groups
Th
e p
erce
nt
Graph No. 2 shows distribution of the patients according to their age
Table (3)
Shows the distribution of the patients of the study group regarding the operations which performed for them before recurrence:-
The operation before recurrence No. PercentSaphenofemoral disconnection
without stripping (Trendlenberg operation)
30 32.6%
Saphenofemoral disconnection with stripping below knee
22 23.9%
Saphenofemoral disconnection with stripping above knee
28 30.4%
Saphenopopliteal disconnection with stripping
12 13.1%
Total 92 100%
There are different findings in cases of recurrent varicose veins after
surgery in our study as there are 14 patients (15.2%) have double
saphenous, 2 patient (2.1%) has double short saphenous, 24 patients (26%)
have recurrence due to neovascularizations, 34 patients (36.9%) have deep
venous thrombosis before and after surgery and 18 patients (19.8%) have
incompetent surgery through the wrong site of incision or the performance
of non specialized surgeon in the field, table 4
The post-operative recurrence duration is noted as complaints from,
4 patients (4.3%) within 2 years , 12patients (13%) from 2-5 years, 32
patients (34.8%) from 6-10 years and 44 patients (47.8%) after 10 years,
table 5.
The patients were classified regarding their jobs as 28 patients
(30.4%) housewives, 32 patients (34.8%) teachers, 20 patients (9.3%)
workers, 4 patients (4.3%) officers and 8 patients (8.7%) employees, graph
3,table 6.
There are different patterns of recurrence in our study as 4 patients
(4..3%) with inguinal pattern , 20 patients (21.7%) with thigh pattern , 8
patients (8.7%) with the pattern of popliteal fossa , 28 patients (42.3%)
with the leg and 22 patients (23%) in both leg and thigh, table 7.
Table (4)
Shows the distribution of the patients of the study group regarding the possible causes of recurrence:
Causes of recurrence No. PercentDouble long saphenous. 14 15.2%Double short saphenous. 2 2.1%
Neovasculerization.* 24 26%Inadequate assessment DVT
preoperative(incomplete recanalization)**34 36.9%
Incompetent surgery 18 19.8%Total 92 100%
*Results are statistically significant as P value is less than 0.05.**Results are statistically highly significant as P value is less than 0.01.
Table (5)
Shows the distribution of the patients of the study regarding the post -operative recurrence duration:
The duration between surgery and recurrence No Percent
Less than 2 years 4 4.3%2-5 years 12 13%6-10 years 32 34.8%
More than 10 years 44 47.8%Total 92 100%
Table (6)Shows the distribution of the patients of the study regarding their jobs:-
The job No. percentHouse wives 28 30.4%
Teachers 32* 34.8%Workers 20 21.7%Officers 4 4.3%
Employees 8 8.7%Total 92 100%
*Results are statistically significant as P value is less than 0.05.
Distribution of the patients of the study according to their jobs
0.00%5.00%
10.00%15.00%20.00%25.00%30.00%35.00%40.00%
The job
Th
e p
erce
nt
Graph No3 Shows the distribution of the patients of the study regarding their jobs.
Table(7)
Shows the distribution of the patients of the study regarding their pattern of recurrence:-
Pattern of recurrence No. PercentInguinal 4 4.3%
Thigh only 20 21.7%Popliteal fossa 8 8.7%
Legs only 38 42.3%Both thigh and legs 22 23%
Total 92 100%
The post-operative recurrence duration has been noted that only 2
patient (6.7%) of the saphenofemoral ligation without stripping
(Trendlenberg operation) is recurred within 2 years while no patients are
recurred through the same duration in both Saphenofemoral disconnection
with stripping below knee and Saphenopopliteal disconnection with
stripping, while 20patients (66.6%), were recurred through the duration
from 6-10 years, with saphenofemoral ligation without stripping
(Trendlenberg operation), 2 patient (9.1%) with Saphenofemoral
disconnection with stripping below knee was recurred through the same
duration while 20 patients (90.9%) were recurred after 10 years of
Saphenofemoral disconnection with stripping below knee, table 8.
Regarding the Duplex findings in our study, there are 24 patients
(26.1%) with incompetent perforators in the thighs, 14 patients (15.2%)
with incompetent perforators in the legs, 30 patients (32.6%) with
incompetent perforators in both thigh and leg, and 24 patients (26.1%)
without incompetent perforators, graph 4,table 9.
Table 8
Shows the relationship between the operations performed for the patients of the study before recurrence and the post-operative recurrence duration:-
Saphenofemoral disconnection
without stripping (Trendlenberg
operation)
Saphenofemoral disconnection with stripping
below knee
Saphenofemoral disconnection with stripping
above knee
Saphenopopliteal disconnection with
stripping
No percent No percent No percent No percent
Less than 2 years
2 6.7% 0 0% 2 7.1% 0 0%
2-5 years
6 20% 0 0% 4 14.2% 2 16.6%
6-10 years
20 66.6% 2 9.1% 4 14.2% 6 50%
More than 10 years
2 6.7%% 20 90.9% 18 64.5% 4 33.4%
Total 30 100% 22 100% 28 100% 12 100%
* Results are statistically significant as P value is less than 0.05.
Table 9
Shows the distribution of the patients of the study regarding the Duplex findings before operations concerning the presence of incompetent perforators:-
Finding of incompetent perforators No. Percentincompetent perforators of the thigh only 24 26.1%incompetent perforators of the leg only 14 15.2%
incompetent perforators in both thigh and leg at the same time
30 32.6%
No incompetent perforators 24 26.1%Total 92 100%
Distribution of the patients of the study according to the duplex assessment before operations about the
presence of incompetent perforators
26.10%
15.20%32.60%
26.10%
incompetent perforators of the thigh only
incompetent perforators of the leg only
incompetent perforators in both thigh and leg at the same time
No incompetent perforators
Graph No 4 Shows the distribution of the patients regarding the Duplex findings before operations concerning the presence of incompetent perforators.
Non specialized surgeons operations came with 58 patients (63.5%)
recurred whereas those of specialized ones brought about a recurrence of
34 patients (36.5%), table 10.
Table (10)
Shows the distribution of the patients of the study regarding the specialty of the surgeon performing the operation:-
Specialty of the surgeons No. percentNon specialized surgeons 58 63.5%
Vascular surgeons 34 36.5%Total 92 100%
*Results are statistically highly significant as P value is less than 0.01.
Discussion
Recurrent varicose veins remain a common, complex and costly
problem in surgical practice despite improvements in preoperative
investigations and surgery for varicose veins. We can define recurrent
varices as ‘‘the presence of varicose veins in a lower limb previously
operated on for varices.
There are few epidemiological data specifically relating to recurrent
varicose veins and the retrospective studies which have been published are
not easy to compare because of differences in the definition of recurrence,
differences in the initial treatment, the classification of recurrences and the
method and duration of follow-up.
Ninety two patients were enrolled in our study, 60
patients(65.2%)were females and 32 patients were males (34.8%), and the
highest frequency of recurrence was between the age of 50-56 years and
the least recurrence was between the age of 20-29 years.
In a study by Perrin et al, 2000, that included 120 patients, 73
patients(60.8%) were females and 47 patients (39.1%) were males, and the
highest frequency of recurrence was from the age of 20-29 years and the
least recurrence from 40-49 years.( Perrin et al, 2000)
In a study by Creton, 2002, that included 116 patients, 65 patients
(56%) were males and 51 patients (44%) were females , and the highest
frequency of recurrence was from 50-59 years.(Creton, 2002)
In a study by Van Rij, 2004, that included 93 patients, there was 61
patients(65.6%) were females and 32 patients (34.4%) were males, and the
highest frequency of recurrence was in the age between 40-49 and the least
age of recurrence was 20-29 years.( Van Rij, 2004)
Causes of recurrence are multiple, as there are many anatomical
variations from persons to another as there is double short saphenous and
double long saphenous which need good assessment by clinical and
radiological procedures as Duplex ultrasound. Moreover, there is another
cause of recurrence known as neovasculerization which is a common
cause.
Duplex scanning can provide the necessary anatomical and
functional information about the nature of recurrence and has become the
investigation of choice in patients with recurrent varicose veins, also
inadequate preoperative assessment in presence of deep venous thrombosis
is one of the most common cause of recurrence, in addition to this,
incompetent surgery of the wrong site of incision containing excess fat lead
to incomplete ligation of all tributaries of the superficial system.
In our study 14 patients (15.2%) have double long saphenous and 2
patient(2.1%) had double short saphenous and 24 patients (26%) the cause
of recurrence was neovasculerization, 34 patients (36.9%) the cause was
deep venous thrombosis preoperative and 18 patients (19.8%) the cause
was incompetent surgery.
In a study by Stonebridge,1995,that included 113 patients, 11
patients (9.7%) have double long saphenous, 3 patients (2.7%) have short
saphenous, 37 patients(32.7%) have neovasculerization, 19 patients
(16.8%) have deep venous thrombosis, while 43 patients (38.1%) are due
to incompetent surgery.( Stonebridge,1995)
In a study by Fischer, 2002, that included 63 patients, 5 patients
(7.9%) have double long saphenous, 1 patients (1.6%) have short
saphenous, 29 patients(46%) have neovasculerization, 19 patients (17.5%)
have deep venous thrombosis, 9 patients (14.3%) have incompetent
surgery.( Fischer, 2002)
In a study by Winterborn,2004, that included 119 patients , 13
patients (10.9%) have double long saphenous,6 patients (5%) have short
saphenous ,47 patients(39.4%) have neovasculerization, 29 patients
(24.4%) have deep venous thrombosis, 24 patients (20.3%) have
incompetent surgery( Winterborn,2004).
Prolonged standing is one of the main factors which can cause
varicose veins and it is also one of the main factors of recurrence due to
increase venous pressure especially in diseased venous valves.
In our study, 28 patients (30.4%) were house wives, 32 patients
(34.8%) were teachers, 20 patients (21.7%) were workers, 4 patients
(4.3%) were officers and 8 patients (8.7%) were employees.
In a study by Kostas, 2004, that included 71 patients, 17 patients
(23%) are policeman, 19 patients (26.8%) are teachers, 26 patients (36.6%)
are workers and 9 patients are officers.( Kostas, 2004)
In a study by Fischer, 2002, that included 63 patients, 13 patients
(20.6%) are officers, 17 patients (27%) are employees , 8 (12.7%) patients
are policemen 10 patients (15.9%) are teachers, and 15 patients (23.8%) are
housewives.( Fischer, 2002)
In our study there are different mode of recurrence which take
different patterns, as 4 patients (4.3%) has recurrence in inguinal pattern,
20 patients(21.7%) has recurrence in the form of thigh pattern , 8 patients
(8.7%) are in the popliteal fossa , 38 patients (42.3%) are in the legs and
22 patients (23.9%) are in the thigh and legs.
In a study by Van Rij, 2004, that included 93 patients, as 5 patients
(5.4%) has recurrence in inguinal pattern, 22 patients(23.7%) has
recurrence in the form of thigh pattern , 12 patients (12.9%) are in the
popliteal fossa , 39 patients (41.9%) are in the legs and 15 patients (16.1%)
are in the thigh and legs. .( Van Rij, 2004)
The relation between the type of operation and the duration between
the surgery and recurrence is very important as we can reach to the method
which can avoid or decrease the higher incidence of recurrence.
In our study 92 patients were enrolled in, 30 patients (32.6%) from
the whole study saphenofemoral disconnection without stripping was
performed for them and 2 patients (6.7%) recurred within 2 years while
from 22 patients (23.9%) saphenofemoral disconnection and below knee
stripping was performed for them without recorded recurrence through the
same duration (within 2 years).
Twenty patients (66.6%) who had history of saphenofemoral
disconnection without stripping recurred through the duration from 6-10
years while only 2 patients (9.1%) who had history of saphenofemoral
disconnection and below knee stripping at the same duration and 12
patients (50%) who had history of saphenopopliteal disconnection with
stripping of the short saphenous.
Twenty patients (90.9%) who had history of saphenofemoral
disconnection and below knee stripping recurred after 10 years duration
while 2 patients (6.7%) recurred at the same duration of the group of
saphenofemoral disconnection without stripping, and 4 patients (33.4%)
recurred from the group of saphenopopliteal disconnection with stripping
of the short saphenous.
In a study by Donaldson,2005, that included 202 patients, 35 patients
(50.7%) of the group of saphenofemoral disconnection without stripping
recurred before 2 years from surgery, and only 4 patients (5.4 %) of the
group of saphenofemoral disconnection and above knee stripping recurred
before 2 years. 49 patients (55.1%) of the group of saphenofemoral
disconnection and above knee stripping recurred in the duration between 6-
10 years while 63 patients (70.8%) of the group of saphenofemoral
disconnection and below knee stripping recurred after 10
years( Donaldson,2005).
The presence of incompetent perforators is also one of the risk
factors of recurrence especially if not ligated during the 1st surgery as it
may be responsible for dilatation and incompetence of the superficial
venous system.
In our study there are 24 patients (26.1%) had incompetent
perforators in the thigh, 14 patients (15.2%) had incompetent perforators in
the legs, 30 patients (32.6%) had incompetent perforators in both leg and
thigh, and 24 patents (26.1%) hadn't incompetent perforators.
In a study by Kostas, 2004, that included 71 patients, 27 patients
(38%) had incompetent perforators in the thigh, 31 patients (43.7%) had
incompetent perforators in the leg while 13 patients (18.3%) hadn't
incompetent perforators.( Kostas, 2004)
In a study by Winterborn, 2004, that included 119 patients, 24
patients (20.2%) had incompetent perforators in the thigh, 31 patients had
incompetent perforators in both thigh and leg, while 39 patients (32.8%)
had incompetent perforators in the legs, and 25 patients (21%) had no
incompetent perforators.( Winterborn, 2004)
The specialty of the surgeon is very important in recurrence as there
are many errors occurred during the surgical procedure as the site of
incision must be at the crease to avoid excess fat, which can lead to miss
branches of the saphenofemoral or saphenopopliteal junction and lead to
incompetent surgery..
Also the preoperative Duplex ultrasound assessment is important
which may lead to true diagnosis or false one as assessment of incompetent
valves at the saphenofemoral and saphenopopliteal junctions and the
perforators and also the patency of the deep venous system and absence of
thrombosis.
In our study 58 patients (63.5%) were operated by general surgeons,
while 34 patients (36.5%) were operated with vascular surgeons.
In a study by Kostas, 2004, that included 71 patients, 47 patients
(66.2%) were operated by general surgeons, while 24 patients (33.8%)
were operated with vascular surgeons. .( Kostas, 2004)
In a study by Perrin et all, 2000, that included 120 patients, 71
patients (59.2%) operated by non specialized surgeons, while 49 patients
(40.2%) operated with vascular surgeons. (Perrin et al, 2000)
In a study by Creton, 2002, that included 116 patients, 82 patients
(70.7%) operated by non specialized surgeons, while 34 patients (29.3%)
operated with vascular surgeons.( Creton, 2002)
Summary and Conclusion
-This study is concerned with assessment of the causes of recurrent
varicose veins after surgery in Suez Canal University hospital.
-The study was carried out in Suez Canal university hospital in Ismailia,
the study group included patients with recurrent varicose veins after surgery
presented to surgery outpatient clinic in the duration from December 2006 to
November 2009.
-The study population consists of 92 patients with recurrent varicose
veins after surgery at any age in both genders.
-Assessment was done through taking history, examination (general and
local), and Duplex ultrasound.
-There are different causes of recurrent varicose veins after surgery as
inadequate assessment through clinical and radiological methods as Duplex
ultrasound through anatomical variation as double long or short saphenous,
presence of incompetent perforators in thigh or legs or both , presence of
deep venous thrombosis neovasculerization and incompetent surgery as
wrong site of incision which was lower than appropriate site at the inguinal
crease in saphenofemoral incompetence which lead to open and dissect in a
fatty region lead to inappropriate ligation of all branches of the superficial
venous system through the saphenofemoral or saphenopopliteal region.
The specialty of the surgeon who perform the operation is very important
as recurrence occurs with less frequency with vascular surgeon as he know
the anatomical variation and the proper preoperative assessment and
postoperative than others; 63.5% of recurrent patients were performed by
non specialized surgeons and 36.5% of the patients were performed by
vascular surgeons.
-In our study the causes of recurrence are distributed as follow, 15.2%
was caused by double saphenous, 2.1% was caused by double short
saphenous, 26% was neovasculerization, 36.9% was presence of deep
venous thrombosis and 19.8% was incompetent surgery.
-Saphenofemoral ligation with below knee stripping has the least frequency
of recurrence through the 1st ten years after surgery while 9.1%, while
Trendlenberg operation (Saphenofemoral ligation without stripping) has the
highest frequency of recurrence in the 1st ten years with 88.6%.
The gender has also carries risk of recurrence as females has tendency of
recurrence more than males as 65.2% of the patients are females while 34.8
patients are males.
The jobs which need prolonged standing has the highest frequency of
recurrence among patients as 34.8% patients are teachers and 30.4% are
housewives, 21.7% are workers and 4.3% patients are officers and 8.7%
patients are employees.
There are different pattern of recurrence, the highest pattern of recurrence
was in the legs with 42.3%, and 4.3% of the patients has recurrence in the form
of popliteal fossa varicosities, 21.7 % in the thigh.
Conclusion -:
It was concluded that recurrent varicose veins after surgery is a
common problem which has different causes as anatomical variation
between person and other which is need good assessment by clinical and
radiological procedure as Duplex ultrasound, and also there is another
cause of recurrence as neovasculerization also inadequate assessment
preoperative as presence of deep venous thrombosis is one of the most
common cause of recurrence and also incompetent surgery as wrong site of
incision which may be away from the inguinal crease which contain excess
fat lead to incomplete ligation of all branches of the superficial system.
Recommendations
We recommended that good preoperative assessment through
clinical and radiological methods, as Duplex ultrasound which must be
done by an expert radiologist is the main way to avoid causes of recurrence
and also need specialist surgeons know the anatomical variations to do it
perfect.
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الملخص العربي
تعتبر مشكلة ارتجاع دوالي الساقين بعد إجراء الجراحة من
المشكالت الملحة التي تواجه كل من المريض و الجراح، لذلك
تقوم هذه الدراسة على تقييم األسباب المحتملة الرتجاع دوالي
الساقين بعد الجراحة بمستشفى جـامعة قــناة السويس.
أقيمت هذه الدراسة في مستشفى جامعة قناة السويس
باإلسماعيلية للمرضى الذين يعانون ارتجاع دوالي الساقين بعد
إجراء الجراحة و الذين يترددون على العيادات الخارجية
.2008 و فبراير 2006بالمستشفى في الفترة ما بين ديسمبر
مريضا من مختلف األعمار من92أقيمت هذة الدراسة على
الجنسين ، و كان التقييم يشتمل على أخذ التاريخ المرضي و عمل
الفحص اإلكلينيكي و عمل أشعة بالموجات فوق الصوتية على
أوردة الساق التي تعاني من االرتجاع بعد الجراحة.
تبين من الدراسة أن هناك أسباب كثيرة لالرتجاع مثل
الفحص غير الكامل قبل الجراحة و الذي يشتمل على الفحص
اإلكلينيكي و عمل األشعة بالموجات فوق الصوتية على األوردة
حيث أنه توجد اختالفات من الناحية التشريحية من شخص آلخر
مثل وجود ازدواج في الوريد الصافني األكبر أو األصغرو الذي كان
% او وجود جلطة في األوردة العميقة و اكان ذلك17.3يمثل
% ، حدوث قنوات دموية جديدة بين األوردة التي تم39.6بنسبة
% أو تتم26لربطها من قبل و بعضها البعض و كانت بنسبة
العملية بشكل خاطئ مثل مكان الجرح التي تتم من خالله
%.19.8الجراحة و ذلك بنسبة
يعتبر تخصص الجراح من العوامل الهامة لحدوث االرتجاع
حيث ان نسبة ارتجاع المرض بين المرضي الذين تم أداء الجراحة
% بينما كانت نسبة االرتجاع بين36.5بواسطة جراح أوعية دموية
المرضى اآلخرين الذين تمت اجراء الجراحة لهم بواسطة جراح
%. 63.5غير متخصص
من خالل الدراسة وجدنا أن هناك عوامل أخرى مسئولة عن
االرتجاع مثل طبيعة عمل المريض فكانت أعلى نسبة لألرتجاع بين
% ، نوع الجراحة التي تمت للمريض حيث34.8المدرسين بنسبة
ان أعلى نسبة لالرتجاع كانت بين المرضى الذين تم اجراء جراحة
ربط للوريد الصافني عند اتصاله بالوريد الفخذي دون نزع الوريد
% خالل العشر سنوات األولى بعد الجراحة.88.6الصافني بنسبة