Recurrent varices at the groin and popliteal fossa after surgical treatment

Patients who undergo surgery involving the groin and the popliteal fossa often develop recurrent varices which require careful management. Several surveys using various classification systems have estimated the prevalence of recurrent varices after groin and popliteal surgery. Patients may seek medical care for various reasons: unsightly recurrent varicose veins, vein-related symptoms, appearance of cutaneous or subcutaneous changes, concerns about the health risk related to their veins or limitation of activity. Recurrent varices may also be found at routine follow-up examinations. An analysis of recurrence at this location reveals three main mechanisms: incomplete resection of the saphenofemoral or saphenopopliteal junctions in patients with an initially incompetent terminal valve. The persisting reflux feeds the tributaries connected at the saphenous stump; the second mechanism is related to neovascularisation that reconnects the deep venous system with the superficial network; the neo-veins are valveless. This phenomenon appears to be more frequent when the resection of the saphenous vein ending has been complete; the third mechanism is due to a tactical error; the refluxive pelvic veins that had not been diagnosed feed the varices. Duplex scanning identifies the different possible mechanisms and provides anatomical and hemodynamic data. Interventional treatment methods after varices recurrence are redosurgery, sclerotherapy and pelvic vein embolization when they are at issue. All these methods are described in details. Results provided by these treatments are analysed. Unfortunately no randomized control study enables grade A or B recommendations. Personally we suggest that ultrasound guided foam sclerotherapy should be the first-line treatment except when duplex scanning reveals an intact incompetent saphenous stump at the saphenofemoral junction or/and saphenopopliteal junction with a massive reflux filling the varicose network.     

Surgery of the external saphenous vein

The role played by the short saphenous vein in varicose disorders is more significant than is commonly believed: about 30% in our experience of surgery. Its termination is much more variable than that of the long saphenous vein. Its precise location must be ascertained by means of detailed clinical examination. In certain cases (relapses, for instance), phlebography and echography give indispensable details which mean that radical surgery of the short saphena can be carried out.     

Recurrent varices after internal saphenectomy. Physiopathological hypothesis and clinical approach

BACKGROUND: This paper analyses the causes and describes the best care of recurrent varicose veins after internal saphenectomy. METHODS: A series of 19 patients who had previously undergone internal saphenectomy were selected for surgery due to recurrent varices in the lower limbs. Clinical examination and colour duplex sonography were used as the preoperative diagnostic tools in all patients. No patients underwent phlebography. In 17 cases the main source of reflux was an incontinent saphenous stump at the level of the saphenofemoral junction with varicose cross-groin collaterals. In 2 cases recurrence was caused by incontinence of the upper thigh perforating vein. In 1 of these patients the recurrence also involved the district of the small saphenous vein. Groin neovascularisation was detected in 1 patient. RESULTS: All patients underwent groin re-dissections using transversal incisions: in 9 cases, access to the saphenofemoral junction was obtained under or at the same level as the inguinal fold, and in 10 cases using a suprainguinal route. The vertical inguinal incision was never employed. Incompetent perforating veins (thigh or leg) were ligated or sectioned in 11 patients. Ligations and exeresis of communicating veins were executed in all patients. Müller's phlebectomies were performed intra- or postoperatively on collateral varices in practically all cases. Postoperative ambulatory sclerotherapy was necessary in 6 cases. CONCLUSIONS: A correct surgical approach is only assured by diagnostic accuracy coupled with a precise hemodynamic evaluation. Correct management of the postoperative follow-up of varicose vein surgery is also important.     

The treatment of oesophageal varices: a debate and a discussion

At the Biennial Meeting of the International Association for the Study of the Liver, in Cape Town, South Africa, 20–24 February 1996, the treatment of oesophageal varices was selected as a subject for the discussion of controversies in portal hypertension. This review gives a summary of that discussion. Dr Didier LeBrec gave a broad overview of the medical management of oesophageal varices by presenting a list of 52 pharmacological agents that reduce portal venous pressure and presented the advantages and disadvantages of each. He emphasized that recent randomized clinical trials (RCT) have demonstrated that propranolol delays and decreases the occurrence of haemorrhage from varices in patients who have not previously suffered such complications. He also reported that isosorbide-mononitrate is equally effective and further enhances the effect of propranolol. He also reported that the effects of propranolol plus endoscopic sclerotherapy (EST) were more effective than EST alone in preventing haemorrhage, but not in improving survival. Finally he noted that propranolol in high dosage did not prevent the development of large varices in cirrhotic patients with small or undetectable varices. Dr John Terblanche compared the efficacy of EST and endoscopic ligation of varices (ELV) and reported that all four RCTs found ELV to be superior. He discussed portacaval anastomosis (PCA) and concluded that only emergency PCA as reported by Orloff, is thought to be truly beneficial, and suggested that EST, plus ELV may be the treatment of choice. Dr Harold O. Conn, who served as the moderator of this session summarized the presentations and pointed out that liver transplantation is the most effective form of therapy of all, albeit extremely complex and expensive. He discussed transjugular intrahepatic portosystemic shunts (TIPS), the newest form of therapy, and emphasized its virtues (immediate reduction of portal venous pressure) and its limitations (frequent portosystemic encephalopathy and frequent spontaneous stenoses). He presented a brief discussion of the prevention of the development of the varices themselves, currently termed ‘pre-primary prophylaxis’, a hope for the future. He ended with ‘Predictions’ which if proven correct will give a preview of portal hypertension in the 21st century.     

Venous ligation in ambulatory patients

The author here suggests a simple treatment not of the varicose illness but of the main functional symptomatology especially affecting old people, who, too often, are negligent or neglected. By means of a simple ligation, under local anaesthetic, of a long saphenous vein below the saphenofemoral junction, it is possible to achieve the rapid treatment of trophic disorders such as ulceration or major varicose ectasia. The one thing that counts here is the idea of a short term result, and the average three-and-a-half weeks healing time for the ulcers studied attests to this. The indications involve about 2% of the population and apply especially to old people who either refuse to be operated on or wouldn't benefit by surgery. However, this method is still an exceptional therapeutic solution.     

Middle hepatic vein reconstruction of graft for a patient with intrahepatic portosystemic shunt

Middle hepatic vein reconstructions for modified right liver grafts in living donor liver transplantation provide satisfactory results. We report a patient who had undergone transjugular intrahepatic portosystemic shunt before living donor liver transplantation, in which the middle hepatic vein was reconstructed using a preserved great saphenous vein. A 41-year-old Japanese man with a 5-year history of alcoholic liver cirrhosis and esophageal varices was admitted to our hospital for living donor liver transplantation. He had undergone endoscopic variceal ligations and transjugular intrahepatic portosystemic shunt for esophageal variceal bleeding, and ascites. He had living donor liver transplantation, which was performed using his sister's right lobe without the middle hepatic vein. The recipient's estimated standard liver volume calculated by abdominal computer-assisted tomography was 1166 mL. The exact weight of the donor's right lobe was 507 g, which was equivalent to 44% of the recipient's standard liver volume. At bench surgery, the middle hepatic vein was reconstructed using a preserved great saphenous vein, which was cut in 2 strips to make a thicker tube graft by suturing, and subsequently, the newly made tube graft end was anastomosed to V5 and V8 branches of the graft. The metallic stent for transjugular intrahepatic portosystemic shunt buried in the recipient's right hepatic vein was removed with the right hepatic vein. The other end of the saphenous tube graft was anastomosed to the right anterior aspect of the vena cava. Stumps of the middle and left hepatic veins were oversewn. Postoperative blood flow in the graft and the reconstructed hepatic veins has been satisfactory with normal liver functions.     

Morphological features of vasa vasorum in pathologically changed human great saphenous vein and its tributaries

BACKGROUND: The question whether the primary increase of vasa vasorum (VV) of venous wall (i) plays an initial role in varicogenesis or (ii) is an expression of impairment of the nutritional conditions in superficial veins of lower extremities is not unambiguously solved yet. The aim of the study was to describe the arrangement of the VV within the wall of the human great saphenous vein (GSV) qualitatively, and of its tributaries at different stages of varicosis and in other pathological states like thrombophlebitis or phlebosclerosis. MATERIAL AND METHODS: 22 patients deserving an aorto-coronary bypass surgery or GSV surgery were subdivided into three groups according to the staging of their varices and other pathology. The harvested GSV were prepared for light and scanning electron microscopy. One cadaverous specimen of GSV was injected with India ink. RESULTS: In specimens from reticular and primary large varices local intimal hyperplasia was regularly found, partially accompanied with a mild increase of VV. Tortuosities and irregular dilations of adventitial veins were also found. In patients with recurrent primary varices or thrombophlebitis severe intimal and medial hyperplasia, thrombosis and a striking increase of VV were found. The intima remained avascular in all cases. CONCLUSIONS: Remarkable increase of VV accompanies the most severe forms of varices as well as all cases of the extreme grades of phlebosclerosis, medial hyperplasia and thrombosis. We hypothesize that this increase in VV is rather a secondary vascular reaction to the impaired metabolic conditions within the venous wall than a primary varicogenic factor.     

An epidemiologic study of the pathogenesis of varices. The Bochum study I-III]

A longitudinal study was carried out at 11 secondary schools (Gymnasium) of the city of Bochum to investigate the early and preclinical stages of developing varicose veins. The same pupils were examined when being in the 5th, 9th, and 13th classes (Bochum Study I, II and III). A significant correlation between familial predisposition and the occurrence of varicose veins could not be found until the Bochum Study III. The girls dominated with respect to reticular varices and telangiectasias, the boys with respect to trunk varices, branch varices and incompetent perforators. Photoplethysmography showed shorter refilling times for children and adolescents than for adults, but was not suitable to distinguish between pathological and normal findings. Large varices appeared later than small varices and were preceded by refluxes of the long and short saphenous veins. We thus have for the first time a preclinical sign, which clearly identifies individuals at risk.     

Massive Lower Gastrointestinal Bleeding From Idiopathic Ileocolonic Varix: Report of a Case

Idiopathic varices of the entire colon are very rare. We report on a 64-year-old patient with massive lower gastrointestinal hemorrhage from an extensive ileocolonic varix. Diagnosis was established by colonoscopy. The patient underwent an emergency ileocolectomy with satisfactory results. This rare case shows the importance of colonoscopy in the evaluation of patients with lower gastrointestinal hemorrhage and reminds us that sometimes the diagnosis is not what we expect. Recognition of this abnormality is important because varices may be the cause of massive lower gastrointestinal hemorrhage.     

Various aspects of phlebology in Sweden]

The incidence of symptomatic varicose veins seems to be about the same in most industrialized countries. After decades of radical surgical treatment of most cases with this condition a much more restrictive attitude seems to be present. Patients with limited varicose veins are often told that since there is no medical danger suffering from simple varicose veins, surgery is not necessary. A simple compression stocking is frequently advised. For those patients suffering from symptoms or a finding that their varicose veins are cosmetically disturbing, surgery is performed, however, restricted to be as minor as possible. The long saphenous vein is saved in those parts being competent. The surgical procedures are performed on an outpatient basis in almost all cases which means that the cost has been very much decreased. The incidence of venous leg ulcers has also decreased in Sweden. We seem to have an incidence of 0.3 p. cent ulcers of which 54 p. cent are of venous etiology. The cost for treatment of these patients is here as everywhere else very high as is also the cost for sick-leave. A conservative attitude using compressing stockings and screening to find out in which cases reconstructive venous surgery might be a possibility seems advisable especially in recurrent ulcer cases.     

Varicography in the management of recurrent varicose veins

Forty lower extremities in 29 patients with recurrent varicose veins have been investigated by varicography. In 29 lower extremities the recurrent varicosities were on the long saphenous venous system and in 11 lower extremities on the short saphenous system. The recurrences consisted of varicose segments or tributaries of the long or short saphenous veins, varicose tributaries at the sites of previous ligations of varicose veins, and varicosities associated with incompetent perforating veins in the midthigh and calf. It is suggested that varicography is a useful method for demonstrating the sites of recurrent varicose veins and for enabling definitive surgery to be performed.     

Circulatory effect of saphenous reflux in primary varicose veins

The authors studied venous pressure in the posterior tibial vein and the internal saphenous vein in primary varicose veins and after saphenous ligation with stripping. It is saphenous reflux which is the cause of all the disorders and which it is necessary to suppress by a perfect saphenous arch ligation. He has done this successfully in 358 cases.     

Endoscopic sclerotherapy for esophageal varices

Sclerotherapy for esophageal varices is now well established as a method of treatment for varices which have bled initially and then have been controlled by medical means. The long term outcome of such treatment is now under study. The value of sclerotherapy for acutely bleeding varices or as a prophylactic measure in patients with varices that have not bled is more controversial and its role awaits the outcome of additional controlled trials.     

Vulvar varices

Vulval or vulvoperineal varicose veins generally appear in the course of child-bearing under the influence of hormonal impregnation on susceptible terrain. The vulval venous network is drained by the external pudendal veins, collateral with the internal saphenous veins, and by the internal pudendal veins affluent from the internal iliacs. Hormonal influence appears to play a major role in associating estrogen, progesterone, gonadotropin and corticosteroids, which have a lytic action on elastic tissues during motherhood. In the course of pregnancy, functional symptomatology is generally visible from the fifth month. The varices located at the vulva are generally unilateral, and gradually become congestive, appearing as purple protrusions of a soft consistency. After delivery, they are attenuated without usually totally disappearing. Outside pregnancy, clinical manifestations are less frequent and vulvoperineal varices are only revealed by close clinical examination. They are often the causal factor for reflux which, regardless of whether it is associated with incontinence of the saphenous trunks, provokes varicose dilatation of the lower limbs. Differential diagnosis is performed with the post-phlebitic syndrome. Doppler echography allows any participation of the deep venous trunks to be ruled out. Phlebography is reserved for severe angiomatous dilatations of the vulval region. In the non-pregnant patient, treatment consists of sclerotherapy, surgery being reserved for cases refractory to this method. In our direct experience with 386 cases, only 85 females presented isolated vulvoperitoneal varices. Of the 83 patients, treated by sclerotherapy, 63% of the cases have shown no recurrence within the subsequent three years.     

Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices

A 48-year-old Indian male with alcoholic liver cirrhosis was admitted after being found unresponsive. He was hypotensive and had hematochezia. Esophagogastroduodenoscopy (EGD) showed small esophageal varices and a clean-based duodenal ulcer. He continued to have hematochezia and anemia despite blood transfusions. Colonoscopy was normal. Repeat EGD did not reveal any source of recent bleed. Twelve days after admission, his hematochezia ceased. He refused further investigation and was discharged two days later. He presented one week after discharge with hematochezia. EGD showed non-bleeding Grade 1 esophageal varices and a clean-based duodenal ulcer. Colonoscopy was normal. Abdominal computed tomography (CT) showed liver cirrhosis with mild ascites, paraumbilical varices, and splenomegaly. He had multiple episodes of hematochezia, requiring repeated blood transfusions. Capsule endoscopy ident i f ied the bleeding s i te in the jejunum. Concurrently, CT angiography showed paraumbilical varices inseparable from a loop of small bowel, which had herniated through an umbilical hernia. The lumen of this loop of small bowel opacified in the delayed phase, which suggested variceal bleeding into the small bowel. Portal vein thrombosis was present. As he had severe coagulopathy and extensive paraumbilical varices, surgery was of high risk. He was not suitable for transjugular intrahepatic porto-systemic shunt as he had portal vein thrombosis. Percutaneous paraumbilical embolization via caput medusa was performed on day 9 of hospitalization. Following the embolization, the hematochezia stopped. However, he defaulted subsequent follow-up.     

Endoscopic Clipping with a New Rotatable Clip-Device and a Long Clip

Abstract: We developed a rotatable, highly durable clipping device (rotatable clip-device) and a long clip which can be used to effectively grasp a large bite of tissue. However, application of the long clip required a special reinforced clipping device. The new rotatable clip-device can be appropriately used in combination with the long clip because of its improved strength and rotatability. The rotatable clip-device was used for endoscopic treatment of 133 patients, including 43 requiring hemostasis of gastrointestinal bleeding, 43 with prophylactic clipping following polypectomy, 39 with mucosal closure following endoscopic mucosal resection (EMR), and 10 undergoing prophylactic ligation of esophageal varices. The long clips were used mainly for mucosal closure after EMR. The rotatable clip-device was found to be especially useful for hemostasis of soft bleeding lesions. Prophylactic clipping following polypectomy prevented complications in 40 out of 41 patients. Mucosal closure by means of clipping following EMR prevented complications in all 39 patients, and the rotatability of the rotatable clip-device and the large bite capacity of the long clip greatly facilitated closing mucosal defects, especially large defects. In the 10 patients who underwent prophylactic clipping of esophageal varices, the rotatable clip-device allowed the varices to be grasped securely and ligated effectively. During endoscopic treatment, three of the four clip-devices functioned normally despite frequent auto-claving and clipping procedures.     

The role of phlebography in pre and peri-surgical varicose veins

The author has given up per-operative phlebography of varicose veins, since many years. It causes complications and is subject to errors of interpretation. Pre-operatively, the conventional ascending phlebography is not justified. On the contrary, a selective dynamic phlebography is indicated before any procedure for venous insufficiency of the calf in order to specify the morphology and function and the external saphenous veins and veins to the gastrocnemius and the soleus. Selective phlebography is sometimes useful in case of recurrence of the varices.     

Effect of a portal venous stent for gastrointestinal hemorrhage from jejunal varices caused by portal hypertension after pancreatoduodenectomy

We report herein the case of a 64-year-old man successfully treated by portal venous stent placement for repeated gastrointestinal bleeding associated with jejunal varices. He was admitted to our hospital with melena 8 years after having a pancreatoduodenectomy for carcinoma of the papilla of Vater. From portogram findings showing severe portal vein (PV) stenosis and dilated collaterals through the jejunal vein of the Roux-en-Y loop, jejunal varices resulting from PV stenosis were suspected as the cause of the melena. A metallic stent was placed in the PV following percutaneous transhepatic PV angioplasty. Although the cure of hemorrhagic jejunal varices caused by PV stenosis is difficult in patients who have undergone major abdominal surgery, patency of the stent in this patient has been maintained for 32 months without gastrointestinal hemorrhage. Metallic stent placement is recommended as a useful treatment for PV stenosis that is less invasive than open surgery.     

Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices

A 48-year-old Indian male with alcoholic liver cirrhosis was admitted after being found unresponsive. He was hypotensive and had hematochezia. Esophagogastroduodenoscopy （EGD） showed small esophageal varices and a clean-based duodenal ulcer. He continued to have hematochezia and anemia despite blood transfusions. Colonoscopy was normal. Repeat EGD did not reveal any source of recent bleed. Twelve days after admission, his hematochezia ceased. He refused further investigation and was discharged two days later. He presented one week after discharge with hematochezia. EGD showed non-bleeding Grade 1 esophageal varices and a clean-based duodenal ulcer. Colonoscopy was normal. Abdominal computed tomography （CT） showed liver cirrhosis with mild ascites, paraumbilical varices, and splenomegaly. He had multiple episodes of hematochezia, requiring repeated blood transfusions. Capsule endoscopy identified the bleeding site in the jejunum. Concurrently, CT angiography showed paraumbilical varices inseparable from a loop of small bowel, which had herniated through an umbilical hernia. The lumen of this loop of small bowel opacified in the delayed phase, which suggested variceal bleeding into thesmall bowel. Portal vein thrombosis was present. As he had severe coagulopathy and extensive paraumbilical varices, surgery was of high risk. He was not suitable for transjugular intrahepatic porto-systemic shunt as he had portal vein thrombosis. Percutaneous paraumbilical embolization via caput medusa was performed on day 9 of hospitalization. Following the embolization, the hematochezia stopped. However, he defaulted subsequent follow-up.