Impact of site of venous reflux in healing of recalcitrant leg ulcers: An observational study

Meenaakshi, N (2014) Impact of site of venous reflux in healing of recalcitrant leg ulcers: An observational study. Masters thesis, Stanley Medical College, Chennai.


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BACKGROUND: Venous ulcers (ulcus cruris) are wounds in legs due to malfunctioning of venous valves. Among leg ulcers they are the major contributors nearly 79- 83%. Approximately 24-30% of patients are of the age of 42-45 and 60-70% are between age of 60-64.They are otherwise healthy individuals losing their productive period of living because of these ulcers. The pathophysiology of venous insufficiency may be due to valvular reflux, destroyed valves, or perforator paucity. Leucocytes cause inflammation, and later the platelets adhere form a pericapillary cuff of fibrin, leading to tissue hypoxia, cell death and ulceration. More common cause 75% of venous ulcer being superficial, perforator or deep venous reflux rather than obstruction which is a less frequent cause 1-3%. Trauma are in 23% of cases, and congenital anomaly in 1-2%. Color Duplex scan is the investigation of choice, which gives information about patency and reflux. The treatment options for venous problems are conservatively by limb elevation and a compression bandage. Medically managed with drugs like pentoxifylline, aspirin and micronized flavinoids. Once the patient does not respond to conservative management, surgical intervention becomes mandatory, both for the underlying cause and a cover for ulcer should be instituted. The various surgical option available for superficial venous system reflux are ligation and stripping of superficial varicose veins, endoscopic subfascial perforator ligation, foam sclerotherapy, endovenous laser or radiofrequency ablation. The medical cost incurred towards treating these is much their financial burden of lost work is huge for the patient and the government as these venous ulcers are either neglected or managed inappropriately. METHODS: Between December 2012 to November 2013, the patients who had presented to the general surgery and vascular surgery outpatient department of inclusion criteria were admitted evaluated using duplex, ulcer was documented on visitrak treated and periodically observed. RESULTS: In this study we observed majority of patients 69.6% belonged to age group of 40-59. Men 92 % were affected more. Right lower 48% limb slightly predominates left 40%. The patients have recalcitrant ulcer ranging from 12- 38 weeks duration peeks between 20-22 weeks. On duplex the SFJ reflux 56.5% dominated followed by the SFJ along with perforators 28.9%. Most common anatomic presentation was incompetence in the SFJ (grade II reflux 69. 7% dominates over grade III 30.3%). Among perforator’s leg perforators are most common site. CEAP 4 heals earlier then its counterparts approximately by 12 weeks followed by CEAP 5 which takes 22 weeks and then CEAP 6 which takes 28-30 weeks’ time. Finally The SFJ are the first to heal majority heal by 16 weeks. Perforators as pathology took longer duration to heal 28 weeks. When all three the SFJ, SPJ and Perforator are present it takes the maximum time of around 30 weeks to heal. CONCLUSION: This study clearly suggest that as far as pigmentation and ulceration are concerned the underlying pathophysiology and reflux in the SAPHENOFEMORAL JUNCTION and PERFORATOR are more harmful and if left untreated take longer time to heal. They are statistically significant with the p value being 0.029 and .007 for saphenofemoral junction and perforator reflux respectively. As ever, the reality is more complicated as there is much still to be discovered as in this study the sample size was small and more number of cases will be needed for precious conclusions. In the meantime a working knowledge of the underlying process can help these ulcer patients heal faster.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Venous ulcer ; Reflux disease ; chronic venous insufficieny.
Subjects: MEDICAL > General Surgery
Depositing User: Devi S
Date Deposited: 05 Jul 2018 03:43
Last Modified: 05 Jul 2018 17:09

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