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PATIENT ADVICE

Dr Denis CRETON
EC. A.Paré, Rue A Paré
54100 F-NANCY

This brochure is designed to take you through the different steps of the operation. It should give you a better understanding of what is venous disease, answer questions relating to the operation and simplify the follow-up.
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Postoperative Advice

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General Points

Venous insufficiency is a disorder widespread among the population. In France 57% of the women and 26% of the men who participated in a recent survey, were shown to suffer with problems of the venous circulation. Amongst those presenting with varicose veins, 85% are women and only 15% men.

The importance of the venous disease in society was illustrated in a survey carried out by the C.N.A.M (Caisse Nationale Assurance Maladie) in 1982: 700 varicose vein operations are performed in France every day! At the present time in our country, the better knowledge of the disease and its earlier and more efficient handling by 'doctors', has diminished the frequency of the complications which in the past represented the final stage of the disease (large red leg, varicose ulcer). The cost of the varicose disease without the complications of phlebitis has been assessed at 2 billion francs, and venous tonics at 5% of all pharmaceutical consumption.

1. The Anatomy and operation of the veins of the lower limbs

Differentiating between arteries which take blood towards the peripheries, and in which the disease is arteritis - the venous system brings the blood back towards the heart. In the lower limbs there are 2 venous circulatory systems :

Venous blood flows normally, from the foot towards the thigh and abdomen, grace of on one hand the tonicity of the venous wall amplified by the muscular activity of the leg and thigh, and on the other by the presence of valves which prevent the blood from flowing back towards the foot.

The combination between the muscles and the venous valves form what is called a 'venous- muscular motor pump', which with each contraction drives the blood in the direction of the valves - that is to say the superficial veins towards the deep veins and upwards from the bottom to the top of each vein. This is why the muscular contraction of the calf is known as the motor of the venous circulation. This 'motor' starts working after the 5th pace (it is for this reason that simply 'walking on-the-spot' is insufficient to relieve the heaviness of the leg). On the other hand, walking regularly is the best motor of the venous circulation.

The venous disease is a disease primarily 'feminine, congenital and peculiar to our industrial societies and western culture'. It is due to the inefficiency of the valvular system and the weakening of the walls in the superficial veins. In the standing position, there is a leakage of blood from high to low, and from deep in the limb towards the surface into the superficial veins which dilate and which little by little degenerate into true pockets of blood. This backward surge of blood from high to low in the superficial venous system, and its stagnation in these venous 'lakes' explains:

the heaviness of the legs, nocturnal cramps, pins and needles, restlessness and itching,

swelling of the ankles and oedematous legs,

skin problems ­ eczema, varicose ulcers, brown patches and spots,

superficial phlebitis ­ also called 'paraphlebitis' or 'periphlebitis', literally translated as a thrombosis (blood clot) of a varice.

The act of removing these varicosities and closing the leaks or perforations can only improve the venous circulation of the limb, since these varices, fed in the standing position by the leaks, trap the blood and in so doing prevent its circulation.

2. The Treatments

Medications (venous tonics)

These tone-up the venous wall and act also on the skins micro-circulation. They are often reconstitution's of extracts of natural products ( chestnut tree seeds, Ginkgo Biloba, various plant extracts, Ruscus, Rutine , white grape seeds). They act in the most part of cases on all the symptoms brought on by the varices (heaviness of the lower limbs, pins and needles, restlessness and itching).

Tights, elastic stockings and bandages

compress the limb and take away the oedema. Compression is a very useful complement in the treatment, especially if before the operation there are hard patches on the leg. The elastic support, lightly compresses the dilated veins diminishing the amount of blood in them, which if not has a tendency to go back towards the foot. This is an artificial method of preventing the harmful action of the varices on the leg tissues. It is a constrictive but extremely effective form of treatment. After the operation, elastic compression reduces the severity of the haematomas and helps in the cicatrisation.

Sclerosis

is essentially the injection of an irritant into the dilated vein which causes a venous spasm followed by the rapid thickening of the wall and its obstruction ­ the vein becomes a fibrous cord. Its main disadvantages, are the length of treatment required and the recurrences. In fact, to be effective and lasting, sclerosis of the vein must be repeated regularly.

It is the method of treatment used on the small diffuse varices, when there is neither a source varicose nor varices below. It is also used in the sclerosis of varicose veins invisible to direct examination - the injection of the sclerosing product is made under echography control (echo-guided sclerosis) Microsclerosis is an ideal technique in the treatment of non-aesthetic varicosities:- minute superficial red or bluish varicose formations, especially on the outside of the thigh.

Surgical Treatment

Its aim is to remove the abnormal communications, where there is a reflux of venous blood towards the superficial venous network.

The trunk of the great saphenous vein is involved in the majority of cases: the great saphenous vein starting at the ankle climbs the length of the inner face of the leg, the knee and continues up the thigh finishing in the groin, where it joins the femoral vein.

The trunk of the small saphenous vein is involved in 15% of the cases. The small saphenous vein starts at the outside of the ankle and finishes in the hollow of the knee.

The saphenous branches are also often affected with varicosities.

Isolated varices. Independent of the saphenous network, these veins can also be affected.

Together all these superficial veins, when in good health, only drain a minor percentage of the blood (10%), and therefore can be removed without a problem when diseased (varices, stagnant veins, parasitic veins), as they don't ensure a blood circulation.

The deep veins normally assure the circulation (90%), on condition that they're not obstructed by for example a fibrosis following a phlebitis. This is a very rare eventuality, on which the diagnosis is studied by echo-doppler and occasionally by a radiography of the veins (phlebography).

3. The Different Elements of the Operation.

The Crossectomy

This is the key part of the operation, where the main route of communication between the superficial and deep vein network, in the groin or hollow of the knee, is disconnected. It enables the stoppage of the main leak with an incision of just a few centimetres.

The removal of the great and sometimes small saphenous vein

is made by the action known as 'stripping'. In the past this was performed by telescoping the vein, today it should be made by invagination.

The Stripping

With the aid of two small incisions made at the superior and inferior extremities of the saphenous vein, a semi-rigid cable or fine flexible metallic rod is introduced into the vein. The vein is then attached to this and extracted by 'invagination' (turned inside out, like the finger of a glove). The advantage of this method is that it is radical, atraumatic and prevents any recurrence.

Cryosurgery

is a technique practised no more. It involved the introduction of a flexible catheter, which then froze the vein along its entire length. Its major drawback was the recurrence of the varices, with the repermeation of the saphenous vein.

Superficial or Ambulatory Phlebectomies

are indispensable and performed systematically. They involve the removal, with small hooks, of all the varicose veins visible under the skin, by multiple incisions of 1 or 2mm made by a small lancet or simple needle. The number of incisions per operation averages at twenty. These micro-incisions heal aesthetically, and the disappearance of these varices is definitive.

Endoscopy under the fascia muscle

is a technique which allows the cutting of the abnormal communications between the deep veins of the leg and the superficial varices. It is carried out under a general anaesthetic, by passing a tube, through a small incision, into the leg (as in coelioscopy). There is only one incision of 2cm on the upper part of the leg. This technique is used in the varicose illness complicated by hard patches, brown spots or healed varicose ulcers.

Chiva's conservative method

is used rarely. It consists of removing the leaking points situated at the top of the limb's varices, conserving the working communications towards the deep system situated lower in the limb, so as to ensure the drainage of the varices. The advantage is 'ecological' (possible conservation of certain superficial varicose veins). The drawbacks are the recurrence and the non-aesthetic incomplete result, which necessitates complementary treatments.

Surgery of recurrent varices

The recurrence of the varices is sometimes induced by new varicose communications between the deep and superficial veins in the groin or hollow of the knee. It is therefore necessary to make a new incision in the proximity of the previous crossectomy, or to do another stripping on the saphenous collateral which has become varicose.

Surgical Strategy

These different surgical aspects will be chosen and combined into a single operation adapted to your particular type of varicose illness. This is the reason why before the operation, with the help of an echo-doppler machine, it is essential to have your varicose system mapped (cartography). The echo-doppler allows us to see the varices and the abnormal direction of the venous circulation. The more precise the cartography, the more accurate the choice of operation can be.

The operation should remove only the varices. This is to say, the affected branches of the principal trunk, and those affected sections of the principal trunk (saphenous). The complete saphenous trunk will only be removed if it is affected along its entire length (17% of cases). This is very important, for if blindly removing a healthy venous section is an unnecessary gesture, it is also a harmful one from the aesthetic point of view ( this can trigger the appearance of neighbouring varices).

This examination allows the realisation of an operation personally adapted, avoiding the removal of healthy working veins. This method is known as 'conservative surgery', because it conserves the working sections of the superficial venous system, and sometimes restores a better functioning in the healthy sections ­ which because of the varices, were dilated.

4. The Anaesthetic

In only exceptional cases is the operation carried out under a general anaesthetic. This then requires a two day hospitalisation.

The operation is usually carried out under a local anaesthetic, which lasts about an hour. Its a question of a normal operation ­ with the anaesthetic being administered selectively to the different nerves of the lower limb. It is neither a peridural nor a spinal anaesthetic.

Operated on in the morning, you can return home in the afternoon once your leg has 'woken-up'.

During the operation you will be covered by sterile sheets, the affected leg resting on top.

The 'local', is the type of anaesthetic which allows the surgeon, to carry out the operation in the most efficient and optimum conditions (minimal bleeding, non-traumatic gestures, ideal positioning of the operated leg), and give the patient the best guarantees of efficiency. Local anaesthetic is therefore always strongly advised.

For those patients who are anxious, specific drugs to relieve the anxiety can be administered both before and during the operation.

It is not possible to operate on both legs on the same day, as the injections of local anaesthetic would exceed the maximum dose tolerated. One must therefore wait about 24 hours before operating on the second leg, giving the body time to eliminate the products before reinjecting a second dose. The operation on the second leg can therefore be carried out the next day.

Whatever the type of anaesthetic, a consultation with one of the clinic's anaesthetists is obligatory in the week or month leading up to the operation. The anaesthetic consultation will also include a pre-operative biological check-up and possibly a cardiac examination, which may be carried out at the clinic at the same time. The law forbids that this consultation takes place the day of your arrival.

5. Your stay in the Surgical Clinic

If you wish to have a single room during your stay, you can be admitted the day or evening before the operation.

You can come in the morning of the operation, in which case you won't be hospitalised (you'll spend the day in Ambulatory Care).

Admissions are between 7.30 and 10.30, depending on the operating timetable ­ which is only finalised the day before the operation. My assistant will then telephone you with the time you must arrive the next day, this being calculated to cut to a minimum your waiting time.

You can leave the establishment the afternoon of the operation, or spend one night at the clinic ­ either leaving lunchtime the next day, or later if having the second leg operated on.

6. Following the operation

It is imperative that the first time you stand up after the operation, it is with the aid of the Registered Nurse. She'll take you through various exercises of knee flexion, on the operated leg in the standing position, in order to test that the anaesthetic has completely worn off, and that you have regained full sensation in the thigh muscle. If you get up alone, you risk falling and being unable to catch yourself.

After the operation the leg will be enclosed in one of two types of dressings, the choice of which being made depending on the type of varices and type of operation carried out.

Firstly, either a compressive elastic dressing fixed at the thigh and the foot. Elastic bandages are then wound over the top, and you will leave with this combination of fixed elastic dressing and elastic bandages. This type of dressing is indicated after an endoscopy under the fascia muscle, and in those patients who present with the cutaneous complications of varices. These patients are often those who already wear bandages before the operation.

The fixed elastic dressing will be removed at the same time as the groin dressing three or four days after the operation. There are no stitches to take out.

The elastic bandages wound tightly over the fixed elastic dressing should allow you, from the first day to stand and walk without any restrictions, posing no risk to the operation's success. Being nice and tight, they ensure no discomfort while in the standing position, they do however become unsupportable at night with the legs raised in the sleeping position. It is therefore necessary to remove them to avoid this pain, notably in the foot. For 4 weeks after the operation the leg is therefore bandaged every morning on getting up, and unbandaged at night just before sleeping.

One can get up briefly in the night without being obliged to rebandage the leg. The bandage must be wound tightly around the leg, this is to say as soon as it starts from the foot and the ankle, to be effective. During the first two days following the operation, there is often considerable discomfort.

Or secondly, two pairs of compressive elastic tights or stockings class 2, will be put on the leg, one on top of the other and left in place night and day for four days: for this reason remember to bring a pair of pants and a sanitary towel to the theatre.

If you, during the night in the lying position experience pain, (a burning or piercing sensation like that of a needle) you should remove the overlying or top pair of tights (this applies even the first night).

The marks or mini-wounds of the operation are sometimes quite impressive, but there is no risk of bleeding.

The tights are often stained with blood the day after the operation without this being a risk to your health. For this reason it is advisable to bring black tights, the aesthetic aspect being better than that with the beige or grey. It is possible to provide yourself with a pair of tights and a pair of stockings, or two pairs of tights of different colours, as long as they are the same make and size. Above all it is very important that the size is well chosen, as tights too small are unsupportable, and those too big form creases often behind the knee or in the groin causing a triple ring of compression which can harm the skin. Tights which aren't right when you try them on, will never be right the next day.

On the 4th day, take off the two pairs of tights and take a light shower to clean the leg, then put back on one pair of the tights ­ which should be worn from morning to evening while in the standing position.

You can, as soon as the day after the operation, resume one of your normal activities. The first week, if it seems more comfortable, you can continue to wear the two pairs of tights during the day.

In a survey, where 800 people were questioned, 75% of the operated patients resumed a normal domestic activity the day following the operation.

During this week, you may have a "Fraxiparin" or "Lovenox" injection (heparin of a low molecular weight), which should be given at the same time every day. This treatment is very effective in preventing the formation of emboli, or phlebitis. For this reason it is imperative to have your platelets checked, in a simple blood test, by your G.P (General Practitioner).

For the aesthetic quality of the scars, it is important not to take a bath for the first two weeks following the operation. Showering is however authorised as soon as the elastic dressings or two pairs of tights are removed.

It is possible to have on these mini-wounds, small spiky scabs which resemble hair or a piece of stitch sticking out of the wound: they are not stitches. Like all healing scabs, you should not pick them off, merely cut them level to the skin with a pair of scissors.

You can without apprehension, leave the clinic at the end of the afternoon the day of your operation, bearing in mind that the law states that one must be accompanied on leaving the clinic and for 24 hours after, and have a telephone in the house.

Living far away is not a drawback. Out of 2000 operated patients, 95% of them lived up to 100km away from Nancy. It is forbidden to drive, to carry out dangerous activities or to sign important documents for 24 hours after the anaesthetic. Driving a car is medically authorised the day after the operation, in so far as you are in perfect control of your vehicle. Sport is allowed in the first weeks, as long as it causes no pain.

If your wish, the return to work is medically possible a few days after the operation ­ provided that you are able to adapt your profession to the physical condition of your leg. The main restriction being your ability to carry out your profession rather than for your state of health. In a recent personal survey, 53% of the patients had returned to work after less than 8 days sick leave, and 77% with less than 15 days. The possibility to return rapidly to work, is possible thanks to an operation which should be both comfortable and almost pain free afterwards.

7. Following Surgery

The treatment of the varicose illness doesn't end at your discharge from the clinic: in the years which follow, a regular check-up of the condition of your veins is vital in order to avoid the reappearance of the varices. Indeed, if the varices removed surgically cannot reappear, on the other hand, other veins can become varicose with the passing of the years ­ necessitating small local interventions (without hospitalisation). This is the reason why it is necessary, even several years after the operation, to keep an eye on your venous state. To leave in place affected veins without caring for them, exposes the healthy veins to the risk of contamination. This medical supervision uses sclerosis to remove regularly the varices which appear.

The wearing of elastic compression is the best prevention for the future. The ideal is to take advantage of the operation, to integrate into your daily life the wearing of support tights, stockings or simply knee-high's, buying them every autumn for the winter months. Several hours per week or per day is already a prevention for the future.

Various precautions allow you to protect your venous circulation

8. Remember:

If you need to wear elastic bandages before the operation ­ for extensive skin lesions (hard or stained areas, ulcers and eczema), they should be tightened as strongly as possible and worn without exception when in the standing position. The improvement will only appear after the first 15 days ­ which are in general hard to bear. Think, if this is your case, to come to the consultation with your bandages in place ­ in order that I can see how you normally put them on.

It is impossible to develop a paraphlebitis after the operation, the varices having been removed (the unnormally hard lines under the skin are haematomas which follow the operating paths, and which after several weeks spontaneously disappear.

To be operated on during your menstrual cycle poses no medical risk, affecting only your post-operative comfort.

The fact of having been operated on once, doesn't increase the risk of the reappearance of varices several years later, on the contrary.

The inflammatory and healing processes last several months.

At the end of a year the state of your leg will be definitive.

Exposing your leg and above all your scars to the sun is contra-indicated as long as the scars are red and visible (1 year). A 'total' sun-block cream is nevertheless a very efficient protection, resting in the knowledge that it should be applied regularly on the scars.

All the brown marks and varicosity's which existed before the operation, can in no way disappear.

The varicose condition is a chronic illness, and in as such all cutaneous lesions acquired are irreversible.

It is common for several weeks after, to have small hard balls on the skin inside the thigh and below the scar in the groin.

A slight oedema of the foot notably behind the internal malleolus, in the first week following the operation, disappears with the correct application of the bandages beginning at the base of the toes.

It is possible after the operation to have a small numb area at the side of your foot, ankle or behind the calf ­ this will disappear after a few months.

In order to avoid having your leg and pubic area shaved before the operation, you can have an epilation by your beautician the day before.

Think to bring wide comfortable shoes to wear on leaving the clinic.

Remember to bring the 2 pairs of tights, stockings or elastic bandages prescribed during your consultation, as well as any medicines that you usually take, along with any examinations. One operated leg requires either 2 boxes of tights, or 1 box of two thigh-length stockings. Two legs operated require either 2 boxes of tights or 2 boxes of two thigh-length stockings.

The day of your admission don't put cream on your legs, as this hampers the location and marking of the varices.

The advice presented in this brochure is for the complete operation. When it's a matter of a partial or small operation, the recommendations are less extensive.

All patients suffering with varicose veins, can without exception be operated on under a local anaesthetic, and can in 90% of cases, if desired, leave the clinic in the hours which follow.


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