The surgical correction of refractory venous trophic ulcers

Objectives. To study the effectiveness of layered dermatolipectomy and endoscopic fasciotomy in the surgical treatment of refractory venous trophic ulcers.Materials and methods. Patients (n = 105) of the C6 clinical class underwent crossectomy and short stripping. In group I (n = 35), free autodermoplasty of trophic ulcers with a perforated flap was performed. In group II (n = 36), shave therapy and autodermoplasty were performed. In group IIІ (n = 34), fasciotomy, shave therapy and autodermoplasty were performed. Long-term results of treatment were studied in the period from 1 to 12 months.Results. Complete healing of venous trophic ulcers was observed in group I at 49,4 ± 7,2, in II – at 31,4 ± 4,7, in III – at 32,1 ± 3,6 days сутки (t1-2 = 2,09; p1-2 = 0,049; t1-3 = 2,24; p1-3 = 0,024; t2-3 = 0,03; p2-3 = 0,763). Full engraftment of an autograft graft was recorded in 7 (19,4 %) patients of group I, in 27 (77,1 %) cases in group II and in 27 (79,4 %) patients of comparison group III (χ21-2 = 23,674; p1-2 = 0,001; χ21-3 = 25,173; p1-3 = χ22-3 = 0,052; p2-3 = 0,826).Conclusion. Layered dermatolipectomy with autodermoplasty and endoscopic decompression fasciotomy is an effective method for the treatment of persistent refractory venous trophic ulcers.

CURRENT STANDARDS OF SURGICAL TREATMENT FOR VENOUS TROPHIC ULCERS OF THE LOWER EXTREMITIES

Today, a wide spectrum of surgical techniques for the treatment of patients with refractory persistent venous trophic ulcers of the lower extremities based on the generally accepted standard sare proposed. The main aim of surgical therapy is the elimination of the lower extremity venous refluxso that the solution of this problem significantly reduces the incidencerate ofrecurrent ulceration in comparison with the conservative therapy alone. In addition to classical varicose vein surgery, the current options of the endovenous interventions are available: endovenous laser ablation (EVLA), radiofrequency ablation (RFA), mechanochemicalablation(MOCA), foam sclerotherapy or cyanoacrylate embolization. The most preferable method of a local surgical correction of the refractory venous trophic ulcers is layer-by-layer dermatolypectomy (shave therapy) in combination with simultaneous autodermoplastywith free split perforatedcutaneousflap. The remote results with a healing rate of over 80% cannot be achieved with any other method. Subfascial endoscopic perforator surgery(SEPS) in the presence of an epithelialized or open trophic ulcer is used for correction of pathological venous refluxin the case when endovasal and minimally invasive techniques of obliteration cannot be applied. The shin fasciotomy is used to relieve pressure in the diagnosed muscle compartment. Lower extremity fasciotomy for acute compartment syndrome is currently performed in case of special indications for the treatment of deep transfascial necrosis, recurrence of trophic ulcers after shave therapy, severe calcification of the shin tissues and correction of chronic venous compartment syndrome. Apart from the optimal choice of surgical treatment the remote healing rates of venous trophic ulcers depend on standardized in-patient treatment and care for wound in the postoperative period, followed by outpatient medical rehabilitation.

A case of successful surgical treatment of a patient with lymphedema of lower limbs

The importance of treatment of patients with lymphedema of lower limbs arises from difficulties in their medical and social rehabilitation. At the expressed stages of the disease resection surgical operations are indicated which present complicated interventions. In the work clinical observation of a 33 yearold female patient with IV stage of primary lymphedema of the right lower limb is presented. In the course of conservative treatment after a complex examination including volumetry, ultrasound, computed tomography, the patient was made dermalipofascioectomy using method of shave therapy. The operation of modified dermalipofascioectomy of the shin was performed by Karavanov II method under spinal anesthesia with use of mono and bipolar coagulation. At the stage of elimination of fibrotically changed tissue dermatome Acculan 3Ti (GA 670) was used with controlled ranges of thickness within 0.21.2 mm and width within 878 mm. Intraoperative loss of blood and lymph was 800 ml and was compensated for with crystalloid, colloid solutions and fresh frozen plasma in the volume of 600 ml. Active drainage of the region of the postoperative wound was conducted by Redon method within 1012 days. Postoperative period ran without complications, with improvement of the patient’s condition. Clinical observation showed a positive role of application of shave therapy apparatus at the main stage of resection operations.

A case of successful surgical treatment of a patient with lymphedema of lower limbs

The importance of treatment of patients with lymphedema of lower limbs arises from difficulties in their medical and social rehabilitation. At the expressed stages of the disease resection surgical operations are indicated which present complicated interventions. In the work clinical observation of a 33 yearold female patient with IV stage of primary lymphedema of the right lower limb is presented. In the course of conservative treatment after a complex examination including volumetry, ultrasound, computed tomography, the patient was made dermalipofascioectomy using method of shave therapy. The operation of modified dermalipofascioectomy of the shin was performed by Karavanov II method under spinal anesthesia with use of mono and bipolar coagulation. At the stage of elimination of fibrotically changed tissue dermatome Acculan 3Ti (GA 670) was used with controlled ranges of thickness within 0.21.2 mm and width within 878 mm. Intraoperative loss of blood and lymph was 800 ml and was compensated for with crystalloid, colloid solutions and fresh frozen plasma in the volume of 600 ml. Active drainage of the region of the postoperative wound was conducted by Redon method within 1012 days. Postoperative period ran without complications, with improvement of the patient’s condition. Clinical observation showed a positive role of application of shave therapy apparatus at the main stage of resection operations.

Surgery of ulcus cruris venosum

SummaryAdvanced chronic venous stasis syndrome is characterized by irreversible and self-perpetuating morphological alterations in the lower leg. A chronic inflammatory process results in sclerosis, which progresses from the skin to the subcutaneous tissue and ultimately the fascia, sometimes including muscle and ankle joint and leading to chronic compartment syndrome. To cure these severe alterations with non healing ulcers decompression of the compartments like paratibial fasciotomy with SEPS and crural fasciectomy or removal of sclerosis like shave therapy are successful surgical procedures. Indication should be adapted to the extension of ulcer. Indications of the operations and the techniques are described, complications and results are discussed. Due to ulcer extension especially shave therapy (removal of the sclerotic tissue epifascial) and crural fasciectomy (removal of sclerosis including fascia) are very successful with up to 80% healing rate, even in severe cases and even after long term (up to 8 years). Since shave therapy is easy, short and simple with short healing time, few complications and good aesthetical result it is the first choice of treatment for non healing leg ulcers. Fasci ectomy is reserved for special indications such as deep transfascial necrosis or failure of shave therapy.

Veränderungen von Faszie und Muskulatur vor und 12 Monate nach erfolgreicher Shave-Therapie des therapieresistenten Ulcus cruris venosum

Background: In chronic venous insufficiency (CVI) III typical changes of skin, subcutaneous tissue, fascia and muscle can be found. It was believed, that the thickening of the fascia is irreversible and it has been postulated that the degeneration of muscles is causative for the persistence of recalcitrant leg ulcers. Patients and methods: By computed tomography (CT) and magnetic resonance imaging (MRI) 8 patients with therapy resistant venous ulcers were examined. Changes of fascia and muscles were determined preoperatively and 12 months after successful shave therapy. Results: By CT a thinning of the preoperatively thickened fascia could be demonstrated in all patients one year after surgery. Before shave therapy MRI showed that the fascia was not only thickend and blurred, but also had fluid accumulations perifascial. 12 months after therapy the fascia was thinner and sharply demarcated. The fluid was either absent or distinctively reduced. Refering to the thickness of fascia an average decrease of 0.084 cm (0.03–0.17 cm) was observed. Before surgery the muscles showed a fatty degeneration as a sign of atrophy; with CT and MRI no changes could be demonstrated after one year in all patients. Conlusion: The results after one year demonstrate for the first time, that the changes of the fascia in CVI III are reversible and that there is no direct correlation between the degeneration of muscles and the persistence of venous leg ulcers.