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2CHOICE OF THE VOLUME OF SURGICAL OPERATION IN ACUTE VARICOTROMBOPHLEBITIS Juraev O.U., 2Xursanov Y.E.
1National medical centre 2Samarkand State Medical University https://doi.org/10.5281/zenodo.14057378
Abstract: In basis research laid down analysis results diagnostics And treatments 102 sick With sharp thrombophlebitis of varicose veins of the lower extremities. Surgical tactics and the choice of the volume of surgery for OVTF depend on from localizations thrombotic process, according to ultrasound Doppler scanning degrees risk thromboembolic complications And duration diseases. Two-stage surgical intervention helps to reduce the risk of developing purulent-inflammatory wound complications from 13.9% to 6.3% and the frequency of damage to the subcutaneous nerve from 16.2% to 6.3%, improving the quality of life of patients.
Keywords: Varicose veins of the lower extremities, thrombophlebitis, surgical tactics.
ВЫБОР ОБЪЕМА ХИРУРГИЧЕСКОЙ ОПЕРАЦИИ ПРИ ОСТРОМ ВАРИКОТРОМБОФЛЕБИТЕ
Аннотация: В основу исследования положен анализ результатов диагностики и лечения 102 больных с острым тромбофлебитом варикозно расширенных вен нижних конечностей. Хирургическая тактика и выбор объема операции при ОВТФ зависят от локализации тромботического процесса, данных ультразвуковой допплерографии, степени риска тромбоэмболических осложнений и длительности заболевания. Двухэтапное хирургическое вмешательство способствует снижению риска развития гнойно-воспалительных раневых осложнений с 13,9% до 6,3% и частоты повреждения подкожного нерва с 16,2% до 6,3%, улучшая качество жизни пациентов.
Ключевые слова: Варикозно расширенные вены нижних конечностей, тромбофлебит, хирургическая тактика.
RELEVANCE
Acute . varicothrombophlebitis (OVTF) continues stay one from often encountered urgent pathology vascular system. Progression thrombotic process With transition V deep venous system leads To development thrombosis deep veins, frequency occurrences which, By different data, makes up from 6% to 44%. However, due to the development of a severe form of CVI, up to 40% of cases patients become deep. Massive thromboembolism pulmonary arteries due to varicothrombophlebitis , occurs in 2%-31.5% of cases, which ends in death in 98% of cases. Despite the increased interest in this problem, there is still no single opinions relatively testimony To choice method And volume treatment.
At one-stage surgical treatment celebrated high frequency such postoperative complications such as deep vein thrombosis (2.7%), necrosis skin edges wounds (4.2%), hematoma And lymphorrhea from wound (14.3%), By- damage to cutaneous nerves (21.2%), as well as wound suppuration.
By to others data results one- And two-stage surgical treatments OVTF no how, no differ, Although With economic positions character, after crossectomy (KE) deadlines conservative treatments And rehabilitation sick long lasting, are saved thrombosed veins, What lead To significant increase in the cost of treatment.
The aim of the study is to improve the results of surgical treatment of patients with thrombophlebitis varicose veins veins lower limbs.
MATERIAL AND METHODS OF RESEARCH
In basis research laid down analysis results diagnostics And treatments 102 sick With sharp thrombophlebitis of varicose veins of the lower extremities, who were in the surgery department from 2018 to 2023 vessels multidisciplinary clinic of the Samarkand State Medical University.
Among the patients there are female faces gender compiled 77 (65.6%), male - 25 (24.5%). Age sick hesitated from 18 to 71 years, on average composing 31.4±6.7 year .
According to classification SEAR at patients the following were available stages CVI (table. 1).
Table 1. Distribution of patients depending on the degree of chronicityvenous insufficiency
by classification SEAR
Degree Quantity
CVI Clinical manifestations patients
abs . %
C2 Varicose extended subcutaneous veins 31 29.8
C3 Edema 49 48.1
C4 Pigmentation and/or venous eczema; lipodermatosclerosis 17 16.6
C5 All the above skin changes + healed venous trophic ulcer 5 4.9
U majority patients (n=80) initial stages of CVI were noted. At the same time, 4.9% of patients with OVTF developed in the background healed venous trophic ulcer.
Duration existence varicose diseases lower limbs varied from 3 years to 17 years.
From general numbers sick right-hand localization varicothrombophlebitis was observed at 43 (42.2%) patients, left-sided 57 (55.8%) patients. More at 2 (1.9%) patients was observed double-sided process. U 4 patients had recurrent development of OVTF, i.e. after 2-6 months after thrombophlebitis. Three of these patients had a history of By about OVTF big subcutaneous veins was done only crossectomy V different medicinal institutions, without subsequent observations.
Localization And prevalence thrombotic process determined V in accordance With classification F. Verrel et al . (1998), according to which everyone patients were distributed next way:
I type (n=40) - thrombotic process Not reached ostial valves of the great or small saphenous veins, while the distribution thrombus on deep veins were absent;
II type (n=47) - the proximal part of the thrombosis was at the level ostial valves;
III type (n=4) - spreading thrombosis on deep venoussystem through saphenofemoral And saphenopopliteal anastomosis;
IV type (n=2) - spreading thrombotic process on deep venous system through insufficient extended perforating veins.
It was found that out of 77 female patients who applied,gender 5.5 % accepted hormonal contraceptives, 12.2% were pregnant V terms from 3 to 8 months. Overweight bodies there was at 26 (25.5%) from them.
Deadlines admission patients from beginning manifestations clinical signs varicothrombophlebitis varied from 1 to 17 days, V average amounting to 4.1±0.9 days .
Most of the patients (55.1%) were admitted to hospital on the 4th or more day from the onset of the disease and only 44.9% from they were hospitalized on time to 3 days.
Spreading thrombotic process V areas hips Andshins depending on the duration of the disease are given in the following table (table. 2).
Table 2. Localization thrombotic process V depending on its terms
Localization thromboticprocess Limitation thrombotic process ( day ) Total
1 - 2 3 - 4 5 - 6 > 7
Shin 3 1/1 * 2 1/1 * 9
E Lower third 7 4 2 2 15
Average third 11 7 4 3 25
Upper third 20 17 7 3 47
Transition V deep veins 1 2 2 1 6
Note: * - small subcutaneous vein Upon examination, all patients were found to have thrombosed varicose extended veins systems big or subcutaneous veins, which manifested itself in the form of cord-like compaction and pain in the veins (Fig. 1).
Fig. 1. Thrombosed varicose extended subcutaneous veins medial surfaces right shins (5 days from beginning of the process)
Fig. 2 . Thrombosed varicose extended veins medial surfaces shins on background healed venous trophic ulcers (7 day from the beginning process)
U 11 (10.8%) sick was celebrated total thrombosis of all dilated subcutaneous veins, including the posterior and lateral venous nodes.
Localization thrombotic process on the lower leg was observed in 9 patients; in two cases, the great saphenous vein was affected, in 15 cases - the small subcutaneous veins.
Varicothrombophlebitis big subcutaneous veins And her tributaries at the level of the thigh, was the most frequent localization of signs which is marked at 93 sick.
U 6 from these patients noted transition thromboticprocess into the deep venous system, in 4 of which it was localized in femoroiliac segment, at 2 popliteal -femoral segment (table 3).
In 5 patients, OVTF developed against the background of healed venous trophic ulcer, which worsened the course of the ulcer process (Fig. 2).
When analyzing the results of ultrasound examination, the presence of thrombus V clearance subcutaneous vein.
Localization thrombotic process at the level of the lower leg was detected in 9 patients, at the level of the hip in 87 patients. At the same time, 6 patients had transition of the thrombotic process into the deep venous system through saphenofemoral (n=3) or saphenopopliteal (n=1) junction or through the system of perforating veins of the leg (n=2) (Fig. 3), causing a picture acute thrombosis deep veins With more expressed clinical symptoms.
Fig. 3. UZDAS. Distribution thrombus Fig. 4. UZDAS. Visualized total through saphenofemoralfistulas (arrow) thrombosis varicose extended veins medial indicated thrombus tip) surface shins
Us was carried out comparative grade proximal border venous thrombotic process, installed clinical methods And By data UZDAS (table 4).
IN most cases length thrombotic process, revealed on basis UZDAS, was some more By comparison such determined on basis clinical data. Thus, if the average length of the thrombotic process on the veins of the lower leg, identified on the basis of clinical data amounted to 31.2±4.5 cm, then the same figure, revealed with the help of ultrasound, was 38.4±5.1 cm. Necessary note, What such reliable indicators were also identified when determining the boundaries of the thrombotic process on thigh. The average length of the thrombotic process on the thigh is determined clinically compiled 32.6±5.3 cm, A at help UZDAS 52.3±7.1 cm (p<0.05).
It should be noted that 6 (5.9%) patients showed ultrasound imagingtotal thrombosis of all dilated subcutaneous veins, including the posterior and lateral venous nodes (Fig. 4).
Table 4. Comparative grade results UZDAS With clinical data
Localization thrombotic process Clinically UZDAS R
Shin 9 9 >0.05
Hip Lower third 15 12 <0.05
Average third 25 22 <0.05
Upper third 47 51 <0.05
Transition to the deep veins 6 6 >0.05
Note: p - reliability differences
RESULTS AND DISCUSSION
Conservative therapy was carried out 17 patients, at which there was a distal form of OVTF, which does not have an ascending flow,was absent failure perforating veins shins, And transition thrombotic process into deep venous system.
Two-stage surgical treatment OVTF held 48 patients, which on first stage was carried out preventive crossectomy With subsequent conservative therapy. After abate inflammatory processes Vsubsequently (2 stage) this sick was done radical phlebectomy .
At the first stage, patients were given bandages and intersection big or small subcutaneous veins With estuarine ligation alltributaries ( crossectomy ), purpose which showed up prevention transition blood clots V deep venous system And prevention TELA.
Isolated CE without thrombectomy was performed in 42 patients (Fig. 5) in whom thrombus spread to the femur was not observed. vein. CE with thrombectomy from the saphenofemoral junction was performed 6patients (rice. 6).
Fig.5 . Insulated crossectomy of the great Fig . 6. Open thrombectomy from the saphenous vein with thrombectomy from the mouth of the small saphenous and common femoral vein popliteal veins
After first stages treatments All patients given groups underwent radical surgical treatment within 1 to6 months.
Volume surgical interventions, completed sick, given V the table below.
Table 5. Volume second stages surgical interventions with varicothrombophlebitis
Name operations Quantity patients %
Combined phlebectomy 41 85.4
Combined phlebectomy + dissection perforating veins shins By Cocktail 5 10.4
Combined phlebectomy + dissectionperforating veins of the leg 2 4.2
according to Linton + resection back tibial veins
Total 48 100
One-stage radical phlebectomy for OVTP was performed in 37 patients (Table 6). The rationale for performing one-stage radical surgical correction of OVTF and VB was a limited thrombotic process in the subcutaneous veins in younger patients and regression of the inflammatory process along the veins. Such a picture was usually observed at later stages of the disease - 5-7 days after the onset of the disease. The duration of the disease in this group of patients (n = 92) ranged from 5 to 16 days from the onset of the thrombotic process.
Table 6. Characteristics of simultaneously performed operational procedures
interventions
Name operations }uantitypatients %
Crossectomy + combined phlebectomy 30 81.1
Crossectomy + combined phlebectomy + 5 13.5
dissection perforating veins shins By Cocktail
Crossectomy + combined phlebectomy +dissection perforating
veins shins By Linton 2 5.4
+ resection back tibial veins
Total 37 100
In most cases sick was completed crossectomy And one-time combined phlebectomy .
In 7 cases of perforating vein insufficiency, their dissection using the Cockett (n=5) and Linton (n=2) methods . If available, vertical reflux through the posterior tibial vein in two observations also carried out their resection.
IN postoperative period to all patients were appointed antiplatelet agents , antiinflammatory And antihistamines drugs, antibiotics wide spectrum actions (Ciprofloxacin By 500 mg; Ceftriaxone By 1 gr ) And painkillers. Elastic compression lower limbs With compliance active regime considered main components management postoperative period.
In the early postoperative period, various specific and non-specific complications arose at sick, characteristic which is given V Table 7.
Table 7Characteristic postoperative specific and non-specific complications
Characteristic One-stage Two-stage r
complications phlebectomy phlebectomy
Thrombosis deep veins 2 ( 5.4 %) 1 ( 2.1 %) >0.05
Bleeding 2 ( 5.4 %) 1 ( 2.1 %) >0.05
Damage subcutaneous 6 ( 16.2 %) 3 ( 6.3 %) <0.05
nerves
Suppuration And infiltrate 5 ( 13.5 %) 3 ( 6.3 %) <0.05
wounds
Note: p is statistical significance of differences in indicators between in groups
Despite the complex conservative therapy conducted V postoperative period, Deep vein thrombosis developed in 3 patients ( one after a two-stagephlebectomy , And at 2 after at one moment operated sick), TELA developed at one from them. Volume conservative therapy at deep vein thrombosis corresponded to the protocol for the behavior of patients with sharp thrombosis deep veins lower limbs.
IN 3 cases developed bleeding from postoperative wounds, which were liquidated conservative methods, or revision wounds with ligation vessels.
At execution one-stage surgical corrections, because of presence Not verseinflammatory process there were more high frequency (16.2%) damage to the n. saphenus compared to patients operated on in two stage (6.3%).
Remote The results were assessed after patients were discharged at term from 6 months to 5 years.
Table 8. Indicators qualities life patients according to CIVIQ questionnaire 2
Indicators qualities life One-stage (n= 37 ) Two-stage (n= 48 ) r
Violations insignificant or Not there are (0-25%) 12 ( 32.4 %) 29 ( 60.4 %) <0.001
Moderate violations (2650%) 19 (51.3 % ) 16 ( 33.3 %) <0.001
Serious violations (51-75%) 4 ( 10.8 2 ( 4.2 %) >0.05
Heavy violations (75-100%) 2 ( 5.4 %) 1 (2, 1 %) >0.05
Note: r - statistical significance differences indicatorsbetween in groups
U majority patients (60.4% with two-stage and 32.4% with one-stage treatment) had minor impairments in the quality of life of patients. However , 51.3% patients which done one-stage radical phlebectomy was associated with moderate impairment of quality of life, whereas This indicator was significantly lower in patients operated on twice stages. Also noted statistically significant serious decrease quality of life at patients operated radically.
Despite the severity of the pathology, only 9 patients in both groups serious and severe cases were noted violations quality life, without statistically significant differences (p>0.05).
Thus, in patients operated in two stages, the indicators quality of life is better than that of patients who underwent single-stage surgery . Monitoring definitions qualities life is important independent characteristic the patient's well-being and the effectiveness of the procedure treatment. The data obtained during the study testify to volume, What carrying out two-stage treatments How clinically, So And socially has more high efficiency, than how one-stage correction. IN connections With this choice two-stage tactics at treatment OVTFis justified And May be recommended How method choice.
CONCLUSIONS
1 Acute thrombophlebitis of varicose veins of the lower extremities most often (48.1%) occurs in grade C 3 chronic venous insufficiency according to the CEAP classification, and in 46.1% thrombosis was found at the level of the ostial valves.
2 Surgical tactics and the choice of the volume of surgery for OVTF depend from localizations thrombotic process, according to ultrasound Doppler scanning degrees risk
thromboembolic complications And duration diseases.
3 At localizations thrombotic process closer To safeno - femoral and saphenopopliteal anastomoses for the purpose of prevention DVT And TELA optimal counts crossectomy With conducting conservative therapy. U patients young age with quieted down inflammatory process effective is one-time combined phlebectomy .
4 Two-stage surgical intervention helps to reduce the risk of developing purulent-inflammatory wound complications from 13.9% to 6.3% and the frequency of damage to the subcutaneous nerve from 16.2% to 6.3%, improving the quality of life of patients.
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