Urgent situations in phlebology--variceal bleeding and it's treatment.

The aim of this study was to compare the therapeutic results of patients whose bleeding points were sutured and patients treated with compression sclerotherapy. In the years 1983-2000, 56 patients with profuse bleeding from varicose veins were treated. In a subgroup of patients with compression sclerotherapy--Fegan's way (32 patients), bleeding wound was healed completely within 7 days on average (5-13). All ulcers have healed within 2 months. The presented approach used is a surgical procedure (stitch, removal of large varicosities). Fegan's technique of compression sclerotherapy, with a detergent sclerosing solution (S.T.D.), enables to complete sclerotherapy of all pathological reflux points during 1-2 visits not only with good results, but also as a one-day surgery, keeping the patient work (Ref. 7).

Long term results of compression sclerotherapy.

AIMS: To compare the short and long term results of different techniques of compression sclerotherapy. PATIENTS AND METHODS: In the past 10 years the authors treated 1622 pts due to chronic venous insufficiency. There were 3 groups of patients: 1) Pts treated by Sigg's technique using Aethoxysclerol, 2) Pts treated by Fegan's technique with Fibrovein, and 3) Pts treated by Fegan's procedure, but using a combination of both sclerosants. In all cases, the techniques of empty vein, bubble air, uninterrupted 6-week compression and forced mobilisation were used. RESULTS: In the group of pats. treated by Sigg's procedure, the average cure rate was 67.47% after 6 months, 60.3% after 5 years of follow-up. In Fegan's group this rate was 83.6% after 6 months and 78.54% after 5 year assessment. Statistically, significant differences were found only by the disappearance of varices and reduction of pain in favour of Fegan's technique. In the group of pts treated by Fegan's (Aethoxysclerol + Fibrovein) this rate after 5 years was 86%. The only statistically significant difference was found by the disappearance of varices in favour of Fegan's technique using a combination of 2 detergent sclerosants. CONCLUSIONS: Sclerotherapy is effective when properly executed in any length of vein no matter how dilated it has become. The recurrences are attributed more to inadequate technique than to the shortcoming of the procedure. Sclerotherapy is miniinvasive, with few complications, and can be repeated on out-patient basis. (Tab. 1, Ref. 22.).

Pancreatic duct occlusion with acrylic glue after pancreas resection.

UNLABELLED: Postoperative complications following major pancreatic surgery are mainly due to the difficulties of performing a safe and proper anastomosis between the stomach or small bowel and the rest of the pancreas. We cannot influence the main predisposing factor of pancreatic fistula--soft pancreatic parenchyma, but we can decrease or completely block postoperative pancreatic secretion. In the last 5 years we performed 61 major pancreatic resections. There were 49 men, mean age 63 years (range 31-78) and 12 women, mean age 57 years (range 45-75). The occlusion of the main pancreatic duct was performed in 33 patients with cyanoacrylate manomer indermil (Sherwood, Davies Geck) after pancreatic resection with different types of anastomosis of their pancreatic stump. Fistula developed where glue was used only in 1 case out of 33 patients (1/33-3%) compared with 28 patients where glue was not used--fistula developed in 9 cases (9/28-32%). The difference is highly significant (p < 0.05). Only 1 out of 10 patients with pancreatic fistulation was operated later on; in 9 cases fistula closed spontaneously. Fistulo-jejunoanastomosis was performed in this patient with chronic torpid fistulation. No postoperative pancreatitis developed after blind closure of pancreatic stump. IN CONCLUSION: any decrease of pancreatic secretion from the rest of the pancreas after duodenopancreatectomy can significantly reduce the development of postoperative pancreatic fistula which can have a catastrophic influence on surgery outcome. Using glue in the pancreatic main duct is not only safe but can be an effective simple procedure in any type of pancreatic stump treatment.

Oncological radicality in colonic cancer operation.

Lymphadectomy should extend to the level of the origin of the primary feeding vessel, suspected positive lymph nodes outside the standart resection should be removed when feasible. A minimum 5 cm bowel margins proximally and distally should be used and peroperative histology must confermend tumor free anastomosis. En-block resection should be performed for tumors adherent to local structures. Inadvertent bowel perforation increases the risk of recurrence and should be avoided. Ovaries grossly involved with tumor should be removed. In all women having operations for cancer of the colon bilateral oophorectomy should be performed. In premenopausal women the ovary is a frequent site for metastatic disease (the Krukenberg tumor) which occures as often as 25 percent of the time. The incidence of of ovarian metastasis is much lower in postmenopausal women but the consequences of oophorectomy are also less severe in that age group. (Ref. 9.).

The treatment of venous leg ulcers by compression sclerotherapy.

PURPOSE: To assess the results of complex sclerotization therapy of pure venous ulcers on all levels of venous system. PATIENTS: Over the last 10 years the authors treated 698 patients with venous ulcerations and compared the therapeutic results in 3 groups of patients treated by Fegan's technique of compression sclerotherapy combined with an antireflux operation of the deep venous system in ulcers not responding to superficial and perforator therapy. RESULTS: 84% of patients with venous ulcers had pathological reflux in the deep venous system and all of them (100%) had insufficiency of the perforators. Using Fegan's technique of compression sclerotherapy the authors managed to heal 95.4% of ulcers with an average time of complete ulcer epithelialization of 39 +/- 12 days. The recurrence rate within 5 years was 18% (126 patients). The average time of disability during the course of sclerotisation was 7 days and no hospitalisation was needed. The healing process depends on the presence of reflux in the popliteal vein in statistically significant fashion. In patients, where a new valve was constructed or direct valvuloplasty was done, all ulcers (except 3) responded to the compression sclerotherapy and healed within 3 months. CONCLUSION: The authors consider compression sclerotherapy (Fegan's technique) to be the easiest and most effective way of treating patients with venous ulcers. Direct valve repair techniques are appropriate only in non-thrombotic deep vein reflux which is very rare (0.6% - 4 patients). In patients with torpid ulcers, where compression sclerotherapy failed (4.6% - 28 patients) in situ construction of a new venous valve helped to heal these ulcers. (Tab. 1, Ref. 18.).

Could deep vein thrombosis be safely treated at home?

BACKGROUND: The aim of this prospective study was to analyse the group of patients with DVT (deep vein thrombosis) treated at home with LMWH (low-molecular weight heparin), compression, intensive mobilization. METHODS: 106 consecutive patients with the diagnosis of DVT were treated at home with enoxaparin (Clexane Rhône-Poulenc) administered subcutaneously (1 mg/kg) b.i.d. for a minimum of 7 days. All patients wore elastic second degree compression stockings during the whole treatment and for further 12 months, and were encouraged to walk 1-2 kms daily. In this group of 106 patients the upper limit of thrombosis was iliofemoral vein--45 pts (42.4%), femoral or popliteal vein--33 pts (31%), crural veins--28 pts (26%). The diagnosis was done by compression ultrasonography, by contrast phlebography, platelet scintigraphy (Tromboscint test). RESULTS: Perfusion gammagraphy of the lungs was done in 54 patients where thrombosis was localised in the popliteal and iliofemoral veins. In 28 patients there were signs of non-fatal pulmonary embolism (52%), but only 7 pts (25%) suffered from mild non-specific clinical signs; 21 pts (75%) with the diagnosis of pulmonary embolism were symptom-free. 8-12 weeks after this treatment, control sonography and phlebography were done in 75 pts (71%), in 53% (40 pts), we found partial, and in 32% (24 pts) total recanalisation. In the rest of 11 pts (15%) there were no signs of recanalisation. Compared with the group of patients treated by the classical method (UH, immobilisation) in the period from January 1995 to February 1997, out of 48 pts where the recanalisation was retrospectively analysed, 17 pts (36%) did not show any signs of recanalisation. The difference is significant (p < 0.01). In this group of 54 pts, 4 died of PE (post mortem verified) compared with no death in the group treated with LMWH and mobilisation. The difference is not significant (p < 0.9). Eighty six patients (81%) out of 106 were satisfied and pleased with home treatment and mobilization. From this group of patients treated with LMWH and forced mobilisation 46 were investigated after one year by duplex scan. None of these patient had recurrence, but 7 pts (15%) had pathological reflux (more than 0.5 s) in the deep venous system, majority of them--5 pts on the popliteal vein. CONCLUSION: Home treatment of DVT is possible and effective, safe and cost-effective. On the average, 40 percent of expenses per patient were saved when compared with hospital stay in spite of more expensive LMWH. The patients who received LMWH spent a mean of 1.2 days in the hospital, as compared with 12.7 days for the standard-heparin group. A long-term (12 months at minimum) of compressive stocking (45 mmHg) with activation of the muscle-venous pump by forced mobilisation can prevent recurrence and decrease the percentage of the post-thrombotic syndromes. (Ref. 15.)

The home treatment of deep vein thrombosis with low molecular weight heparin, forced mobilisation and compression.

BACKGROUND: The aim of this prospective study was to analyse a group of patients with DVT (deep vein thrombosis) treated at home with LMWH (low-molecular weight heparin), compression and intensive mobilisation and to evaluate its feasibility, efficacy and safety from possible risks of pulmonary embolism. METHODS: From March 1997 to September 1999, 96 consecutive patients with diagnosed DVT were enrolled in a prospective study and treated at home with enoxaparin (Clexane Rh ne-Poulenc) administered subcutaneously at doses depending on body weight (1 mg/kg) b.i.d. for a minimum of seven days. Oral anticoagulants were started two days before discontinuing LMWH and given later for three months according to the haemocoagulation parameters. All patients wore elastic second degree compression stockings during the whole period of treatment and for 12 months there after. They were encouraged to walk 1-3 km daily. The sites of thrombosis were ilio-femoral vein--38 patients (40%), femoral or popliteal vein--32 patients (33%), crural veins--26 patients (27%). According to our surgical criteria two years ago 17 patients would have been operated on and trombectomy performed. The diagnosis was made by compression ultrasonography using a colour duplex scanner (Acuscan 125), by contrast phlebography, and platelet scintigraphy (Tromboscint test). Perfusion-ventilation scintigraphy of the lungs was performed only if there were clinical signs or even a suspicion of pulmonary embolism and on all patients with iliofemoral thrombosis. Perfusion gamagraphy of lungs was carried out on 51 patients where thrombosis was localised in proximal veins. RESULTS: In 27 patients there were signs of non-fatal pulmonary embolism (53%), but only seven patients (26%) suffered mild non-specific clinical signs; 20 patients with diagnosed pulmonary embolism (74%) were symptom-free. Out of 96 patients, three admitted to hospital (3%), 67 (70%) injected LMVH themselves and felt comfortable. Eight to 12 weeks after this treatment control sonography and phlebography were carried out in 70 patients to assess the localisation and progress of the thrombosis. In 51% (36 patients) partial and 31% (22 patients) total recanalisation was found. Five out of 96 complained of minor bleeding (5%). No thrombocytopenia was noticed. The first five days on home treatment were crucial. All patients were able to walk and live at home without difficulty. None of our patients with proximal deep vein thrombosis used a vena cava filter. CONCLUSIONS: Home treatment of DVT is possible and is effective, safe and less costly on average and per patient 40% in costs was saved compared with those of a hospital stay in spite of the greater expense of LMWH. The patients who received LMWH spent a mean of 1.2 days in the hospital, as compared with 12.7 days for the standard-heparin group.

[Pathophysiologic aspects of chronic venous insufficiency]. / Patofyziologické aspekty chronickej zilovej insuficence (CHZI).

Knowledge of the pathophysiology of the venous circulation and its evaluation before treatment determines not only the best therapeutic plan, but at the same time makes it possible to avoid operations which are not necessary and a priori doomed to lead to a relapse. The basic therapeutic principles in the treatment of chronic venous insufficiency after evaluation and localization of the functional disorder by an objective examination method (duplex sonography, phlebography ...) are: a) compression, b) severing of pathological points of insufficient perforators, orifices of both saphenous veins, c) antireflux operation of the deep veins with preference of the popliteal vein. Any therapeutic procedure which does not have the aim to reduce venous hypertension is a priori doomed to failure and very soon a relapse develops. From this aspect it is not important to remove chaotically and extensively superficial varicosities (surgically or by sclerotherapy) but to severe the insufficient perforators and the insufficient orifices of saphenous veins surgically or by sclerotherapy.

[Occurrence of tumors of the small intestine]. / Výskyt nádorov tenkého creva.

The authors present in this article the occurrence of the tumors of small intestine in the group of patients operated on at the Ist Department of Surgery, Teaching Hospital of Commenius University in Bratislava in the years 1957-1997. During this period 39 primary tumors of small intestine were registered, 29 of them being malignant. Histologically, the most frequent malignant lesion was adenocarcinoma, and the most frequent benign lesion adenomatous polyp. The highest frequency of occurrence of tumors of small intestine was in the 6th and the 7th decennium. (Tab. 4, Ref. 11.)

[Ambulatory treatment of deep venous thrombosis using low-molecular heparin, compression and mobilization]. / Ambulantná liecba hlbokej zilovej trombózy nízkomolekulárnym heparínom, kompresiou a mobilizáciou.

From data in the literature as well as the authors' own experience ensues that diagnosed and objectively confirmed deep venous thrombosis can be successfully treated in out-patients departments by low-molecular heparin and compression with full mobilization without any major risk of pulmonary embolism and without the need of hospital admission (65 out-patients). Despite the high price of low-molecular heparin, treatment is economical as it does not require monitoring of haemocoagulation for hospital admission. Partsch et al. 1997 proved unequivoca lambda y that the rate of new attacks of pulmonary embolism during treatment is significantly lower than during classical treatment with non-fractionated heparin and immobilization.

[Compressive sclerotherapy monitored by ultrasound]. / Kompresívna skleroterapia monitorovaná ultrazvukom.

Echosclerotherapy and sonographic control of aimed sclerotherapy resp. is a major advance in the treatment of chronic venous insufficiency. It facilitates not only aimed administration of highly active substances but ensures above all prevention of serious complications. Functional examination of the venous system helps to locate relatively accurately the sites of pathological reflux which are in the first place responsible for the development of the whole symptomatology and it prevents the administration of excessive amounts of sclerotizing substances into intact portions of the venous system. Similarly as Baccaglini et al. (1995) the authors achieved by compressive sclerotherapy with monitoring by ultrasound occlusion of up to 90% important reflux sites such as the saphenofemoral and saphenopopliteal orifice which are to a great extent responsible for serious clinical symptoms.

[Anti-reflux surgery of the popliteal vein]. / Antirefluxná operácia na popliteálnej véne.

Any effective therapy of chronic vein insufficiency resides in the replacement or at least reduction of the pathological reflux causing venous hypertension. The aim of our study is to indicate the significance of the reconstruction of the damaged valves in the profound venous system, namely in the most critical popliteal area. On the basis of the experimental works of Wilson et al. (1991) we have introduced his technique of anti-reflux operation by the technique of invagination after the prolongation of the popliteal vein by three-fold average of its diameter by means of the axillary vein with a valve. This operation was performed in 6 patients on 7 veins. The operation lasted 3 hours in average without marked operative and post-operative complications. On the seventh day after operation, the full sufficiency is investigated by means of descendent phlebography in 5 newly formed valves and in two valves a particular insufficiency is developed. 4 patients yield a full recovery of ulcers, one patient slipped out from evidence, however sclerotisation of insufficient perforators leads quickly to recovery of dermal defects. Reconstruction of prothrombotically damaged valves is practically impossible and thus, valvuloplastic operation constructed from vascular wall in the target segment is not only possible but effective at the same time. (Fig. 3, Ref. 13.)

[Acute low triiodothyronine syndrome in the perioperative period]. / Akútny syndróm nízkeho trijódtyronínu v perioperacnom období.

Serum concentrations of thyroxine (T4), triiodothyronine (T3) and reverse triiodothyronine (rT3) were determined by radioimmunoassay in 11 patients (8 females and 3 males aged 42-65 years) before cholecystectomy and at various time intervals following operation up to 10 days. The surgical procedure was uncomplicated in all the cases studied. The level of rT3 was significantly increased (P less than 0.01) already on the first postoperative day and was then decreasing to its initial value. The levels of T4 and T3 were markedly reduced particularly on postoperative days 2 to 5 (the drop was significant on calculating individual values as percentages of the preoperative level of the given patient). This acutely developing syndrome of low triiodothyronine disappeared spontaneously within 7 to 10 days at a noncomplicated postoperative course.

Iodothyronines in human bile.

Bile was collected from 7 patients after cholecystectomy with routine T-tube drainage of bile duct postoperatively. In all patients reported, the total volume of bile collected was more than 500 ml which was considered to be close to the volume of bile excreted by the liver during the 24 h collection period. The excretion of total thyroxine (T4), triiodothyronines (T3 and rT3) and diiodothyronines (3,3'-T2, 3,5-T2 and 3'.5'-T2) was estimated with the aid of specific radioimmunoassay described previously. It was found that the total amount of T4 corresponded to its content in about 100 ml plasma, while corresponding figures for triiodothyronines were about 1000-1500 ml and these for diiodothyronines about 10-15 liters. It was concluded that in man the biliary excretion of iodothyronines appears to be of much less importance for their total body balance than in rats.