Short-stay varicose vein surgery.

From 1967 patients attending for varicose vein surgery at the Meilahti Hospital, Helsinki University Central Hospital, have been operated on on the day of admission, spend the following night in the bed ward and are discharged the morning after the operation. The operation is performed under general anaesthesia with as radical approach as possible stripping the long saphenous vein and, if required, the short saphenous vein, excising the superficial side branches and ligating incompetent perforators. In the study a follow-up examination was carried out on 2334 patients. Wound infections occurred in 1.8%. Two patients had transient arrhythmia, and one a late haemorrhage. More serious complications were absent. During the follow-up period 5.2% of patients were operated on for recurrent varicose veins. 84.6% were subjectively satisfied. The number of hospital days per patient averaged 1.2. It was possible to follow the above planned course of action in 93.4%. The organization and surgical technique can be recommended in order to achieve savings in hospital days and to produce permanent and good surgical results.     

Complications of varicose vein surgery.

A retrospective review was carried out of patients who had undergone surgery for varicose veins over an 8 year period between 1985 and 1993. We wished to determine the incidence of various complications so that the risks of surgery could be openly discussed with patients. A total of 973 limbs were operated upon in 599 patients (413 F, 186 M; mean age 49 years). All patients were under the care of a single consultant vascular surgeon who was present at 92% of operations and all patients were reviewed postoperatively. There was no perioperative mortality. Wound complications (haematoma, cellulitis or abscess) occurred in 2.8% of limbs and minor neurological disturbance (numbness or tingling) in 6.6%. Leakage of lymph from the groin occurred in five patients, all of whom had undergone exploration for groin recurrence. Major complications included three cases of deep venous thrombosis (0.5%), one pulmonary embolus, and one foot-drop. There was one major vascular injury, the common femoral vein being damaged in a patient having a third operation on the groin for persistent recurrence. Vein patch repair was performed and patency was maintained. The overall incidence of major complications was 0.8%. Minor complications occurred in 17% of patients. It is unlikely that major complications can be eliminated. In this retrospective review there will be some under-reporting, but we are confident that this is restricted to minor complications.     

Digestive surgery and varicose vein surgery

The thromboembolic risk related to surgery may be considered as low for varicose vein surgery and non major digestive surgery. It could be defined as moderate in case of large dissection, long duration of procedures and emergency cases. The risk may be considered as high for major abdominal surgery involving cancer surgery or not and bariatric surgery. The absence of prophylaxis can be proposed for low risk surgery (grade B). However, elastic compression stocking are effective for all cases of digestive surgery and suggested to be used (grade A). There are no data concerning the moderate risk situation. Therefore, experts recommend the use of elastic compression stockings or low doses of LMWH (grade D). High-risk surgery requires the use of high doses of LMWH recommended for reasons of efficacy, tolerance, and easiness to use (grade A). Associated elastic stockings is efficious (grade B). The duration of prophylaxis lasts generally 7-10 days. Extension to 1 month is recommended for major abdominal cancer surgery (grade A).     

Technique of varicose vein surgery

A technique for varicose vein surgery is described which allows maximum removal of varicose veins and the trunks draining into them. Hemostasis by means of tantalum clips allows for distal ligation of branches beyond their bifurcations in sites of difficult access. This results in minimal blood loss and enables subdivision of collateral veins to prevent recurrence of varicosities.     

Rare complication of anterior spinal surgery: Horner syndrome

Horner syndrome due to injury to the cervical sympathetic trunk (CST) is a very rare complication of anterior cervical decompression and fusion (ACDF). We have not mentioned the possibility of Horner syndrome as a postoperative complication in patients before surgery. We present a patient with Horner syndrome after ACDF and discuss the anatomical background of the CST and the causes and preventative measures against postoperative Homer syndrome. A 48-year-old man presented with disturbance of fine movement and reduction of grasping power in the right hand. MRI revealed osteophytes and a prolapsed disc compressing the spinal cord at C5-6 and C6-7. Two-level ACDF with inclusion of titan cages was performed via a right-sided exposure. Anisocoria (right > left) and right blepharoptosis were observed immediately after surgery. Postoperatively, disturbance of fine movement was resolved. Japanese Orthopaedic Association (JOA) score improved from 12 to 16. Horner syndrome disappeared at 6 months after surgery. The CST runs 10-15 mm lateral to the medial edge of the longus colli muscle (LCM) and exists in the loose fascia and approaches most medially at C6. During the decompressive procedure under microscopic viewing, the right blade of a retractor was found to come out of the medial edge of the LCM on the level of C6. It is postulated that the blade injured the right CST. Knowledge of the anatomical relation between the CST and the LCM is very important to avoid Horner syndrome in ACDF. The tip of a retractor blade must be placed between the medial edge of the LCM and the vertebral body.     

Compartment syndrome of the thigh: an unusual complication after spinal surgery

Compartment syndrome of the thigh is an uncommon pathology, and its acute presentation after spinal surgery is rare. Because a large muscle mass is involved and systemic manifestations of crush syndrome and altered mental status are present, such abnormalities may lead to a delay in appropriate diagnosis and subsequent treatment. A 56-year-old man who was suspected of having a posterior compartment syndrome in the thigh after spinal decompression in the knee-chest position was evaluated clinically and with the use of a catheter for intracompartmental pressure measurement as a tool to help establish the diagnosis and monitor the evolution. Because of sciatic involvement and a demonstrated increase in the pressure in the posterior compartment with myoglobinuria and acute renal failure, prompt longitudinal fasciotomy was performed with excellent neurologic recovery and improvement of both clinical parameters and mental status.     

Long-term results of vein sparing varicose vein surgery

The aim of this study was to assess the long-term functional outcome of vein sparing varicose vein surgery using handheld Doppler ultrasound (HHD). The series consisted of 171 consecutive day-case surgery patients operated on for uncomplicated lower limb varicose veins. Venous segments considered competent were spared based on clinical examination and HHD, which was performed preoperatively only when deemed necessary by the surgeon. After a mean follow-up of 8 years all patients were examined, a systematic HHD evaluation was performed, and the findings were classified according to the CEAP (Clinical, Etiological, Anatomical, Pathophysiological) classification, and disability scoring was performed. During the follow-up period 17% of the legs were reoperated or scheduled for reoperation. At follow-up 79% of all patients were asymptomatic without reoperation. In 24%, recurrent varicosities were present and venous reflux was demonstrated by HHD. Recurrence was two times more common when the saphenofemoral junction had originally been left intact. Of all recurrent cases, reflux was demonstrated in the long saphenous vein (LSV) above the knee in 62%, in the LSV below the knee in 7%, in the short saphenous vein (SSV) in 16%, in the posterior arch vein in 38%, and in a thigh perforator in 8%. Of the legs reoperated during the follow-up period 41% presented with venous reflux at the follow-up visit. We conclude that HHD efficiently reveals sites of reflux that have been missed during previous surgery and that a thorough preoperative HHD examination and marking of reflux routes is required.     

Results of standard varicose vein surgery

The principles of modern varicose vein surgery are based on the interruption of the cranial and distal points of venous insufficiency. Especially due to the rise of alternate surgery procedures, we have scrutinized our results of varicose vein surgery. In a retrospective analysis, the results of those patients (pat.) who underwent venous surgery in our institution in 1995 were analysed. In 1995 we performed 1 575 varicose vein operations (n = 1 019 pat., 16.8 % male, 83.2 % female). 63.5 % were on an outpatient basis. During a follow-up period of 4 to 66 months (av. 38 months) the patients were re-examined, 481 (47.2 %) by Duplex sonography, 94 (9.2 %) by clinical examination alone, from 103 (10.1 %) information was obtained through a written inquiry. 341 pat. (33.5 %) had just perioperative follow-ups. We didn't find any signs of varicosis in 301 pat. (33.3 %). Minor side branches could be detected in 515 pat. (56.8 %). In 90 pat. (9.9 %) a clearly visible varicosis could be seen. Based on the results of the Duplex examinations, 86 % of the pat. showed no recurrence after ligation of the sapheno-femoral junction and stripping of the LSV, the results after stripping of the short saphenous vein were similar. Analysis of the inquiry forms concluded that 62.3 % of the pat. were satisfied with surgery and the results. The results of the standard varicose vein surgery are satisfactory regarding recurrence rate and patient satisfaction. Our results are comparable to those published in prospective randomised studies. Alternate procedures, for example the CHIVA method, have still to proof their efficiency, especially in view of long-term results.     

Anomalies encountered during varicose vein surgery

During 5,050 stripping operations for varicose veins, three noticeable deviations from the normal anatomy were encountered. In two patients (0.04%) the long saphenous vein entered the femoral vein completely separate from its branches, which joined to form a common trunk before emptying into the femoral vein. In one patient (0.02%), the femoral vein and artery were transposed in the region of the fossa ovalis. In one patient (0.02%), a long saphenous artery was encountered. It arose from the femoral artery just proximal to the origin of the deep femoral artery and accompanied the long saphenous vein along the medial aspect of the upper thigh. In some patients, a large venous cluster overlying the fossa ovalis was encountered, usually the result of a congenital venous anomaly. Surgical problems can be minimized if the possibility of these congenital anomalies is always considered.     

Compartment syndrome as a complication of the Hauser procedure.

A compartment syndrome developed in eleven patients who had undergone the Hauser procedure. The residual disabilities ranged from mild weakness and contracture of the muscles in the anterior compartment of the leg to complete muscle necrosis necessitating above-the knee amputation in two patients. Dissections of ten cadaver limbs demonstrated that the anterior tibial recurrent vessels have numberous leash-like branches that terminate along the lateral border of the tibial tubercle. When these vessels are sectioned they retract laterally and distally under the fascia and within the muscles of the anterior compartment. It is postulated that continued postoperative bleeding from these vessels after the Hauser procedure may lead to an ischemic compartment syndrome in the leg.     

Incidence of deep vein thrombosis after varicose vein surgery

BACKGROUND: Varicose vein surgery is generally considered to have little risk of postoperative deep vein thrombosis (DVT). This prospective study examined the incidence of DVT in patients undergoing varicose vein surgery. METHODS: Lower leg veins were assessed before operation by duplex ultrasonography in 377 patients, and reassessed 2-4 weeks after surgery, and again at 6 and 12 months. Patients were instructed to contact a physician if symptoms consistent with DVT occurred before the scheduled follow-up appointment. Preoperative prophylaxis (a single dose of subcutaneous heparin) was left to the discretion of the vascular surgeon. RESULTS: DVT was detected in 20 (5.3 per cent) of the 377 patients. Of these, only eight were symptomatic and no patient developed symptoms consistent with pulmonary embolus. Eighteen of the 20 DVTs were confined to the calf veins. Subcutaneous heparin did not alter the outcome. No propagation of thrombus was observed and half of the DVTs had resolved without deep venous reflux at 1 year. CONCLUSION: The incidence of DVT following varicose vein surgery was higher than previously thought, but these DVTs had minimal short- or long-term clinical significance.