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腔内激光闭合术联合皮下环缝术治疗大隐静脉曲张

2018-11-09陶国强曹明华宗兵

上海医药 2018年20期
关键词:微创技术外科治疗

陶国强 曹明华 宗兵

摘 要 静脉曲张是一种常见疾病,约1/3的患者最终接受手术治疗。对于单纯性静脉曲张,传统治疗方法是高位结扎和抽剥术,若合并交通静脉或深静脉病变, 可行交通静脉结扎或深静脉瓣膜重建。20年来,随着微创技术的发展,下肢浅静脉曲张的治疗也出现了许多新方法,全文分别介绍透光静脉刨吸术、泡沫硬化剂注射法、腔内激光治疗、静脉皮下环缝术等的治疗效果。

关键词 静脉曲张;外科治疗;微创技术

中图分类号:R616.4 文献标志码:A 文章编号:1006-1533(2018)20-0003-03

The combination of intracavitary laser therapy and percutaneous continuous circumsuture in treatment of varicose veins

TAO Guoqiang1 CAO Minghua2 ZONG Bin1(1.Department of General Surgery of Punan Hospital,Pudong New Distract of Shanghai, Shanghi 200125,China; 2. Department of General Surgery of Shanghai 7th Peoples Hospital, Shanghai 200137, China)

ABSTRACT Varicose veins are common in the general population, and about 1/3 of the patients finally received surgical treatment. The methods to treat the simple varicose veins traditionally include high ligation and stripping, while the communicating vein ligation or deep venous valve reconstruction can be performed if the communicating veins or deep vein lesions are combined. In the last 20 years, with the development of minimally invasive surgery, many new methods are used in the treatment of lower extremity varicose veins. This paper introduces the efficacy of the transilluminated powered phlebectomy, foam sclerotherapy, intracavitary laser therapy and subcutaneous ring of vein.

KEY WORDS varicose veins; surgical treatment; minimally invasive technology

静脉曲张是一种常见疾病,症状表现从轻微的腿部不适到慢性静脉溃疡,约一半成年人患有轻微的静脉功能不全,15%的男性和35%的女性患有明显的静脉曲张[1]。大约1/3的患者最终接受手术治疗[2]。对于单纯性静脉曲张,传统的治疗方法是高位结扎和抽剥术,若合并交通静脉或深静脉病变, 可行交通静脉结扎或深静脉瓣膜重建。近20年来,随着微创技术的发展,下肢浅静脉曲张的治疗也出现了许多新方法, 包括透光静脉刨吸术(transilluminated powered phlebectomy)、泡沫硬化劑注射法(foam sclerotherapy)、腔内激光治疗(intracavitary laser therapy)和静脉皮下环缝术(percutaneous continuous circumsutur) 等。

1 透光静脉刨吸术

透光静脉刨吸术是通过内镜对曲张静脉进行逐步刨吸的一项技术, 与传统手术相比,可以减少手术时间、切口数量、术后疼痛和患者发病率,恢复快,有报道证实其有效和安全[3-11]。透光静脉刨吸术的并发症多见蜂窝组织炎、皮下血肿、皮肤神经损伤及局麻药的不良反应等,由于皮下游离范围较广,术野较大,术后蜂窝组织炎发生率为0~3.5%[7-11]。皮下血肿是最常见的手术不良事件,发病率差异很大(0~95%),与外科医生的手术技术直接相关。皮肤神经损伤发生率为0~36.8%[3-13],神经损伤与隐静脉剥离有关 [6]。肿胀、麻醉过量可能导致血管收缩,增加利多卡因毒性反应的可能性。如果患者出现不安,主诉周围或舌头麻木、头晕或耳鸣时,需要警惕是否出现利多卡因的毒性反应。

2 泡沫硬化剂注射法

泡沫硬化剂治疗静脉曲张是将硬化剂注入曲张静脉,通过诱发静脉内无菌性炎症和血栓形成,最终使管腔粘连、闭塞,具有操作简单、患者痛苦小、无需住院、费用较低等优点[14-15]。常见的治疗方法有浅静脉手术联合泡沫硬化剂注射、其他微创手术联合泡沫硬化剂注射或单纯泡沫硬化剂注射,常见的注射方法有直接穿刺注射、B 超引导下注射以及DSA 引导下注射。泡沫硬化剂治疗可能并发浅表性血栓性静脉炎、深静脉血栓形成、静脉曲张残留及复发、皮肤溃烂和过敏反应等。因此,临床选择泡沫硬化剂注射治疗下肢静脉曲张应严格掌握适应证,尽可能降低术后并发症的发生。

3 腔内激光治疗

腔内激光治疗是利用激光产生高能热损伤静脉血管壁,使静脉壁收缩闭合,同时热能可以引起血液高凝状态使静脉内全程血栓形成,最终使静脉纤维化而闭合。该法治疗大隐静脉主干静脉曲张的结果与常规手术相似,早期成功率为88%~100%[16-18]。有研究比较了腔内激光治疗与传统手术在初次治疗6周内的复发率,显示在术后6周,腔内激光治疗组复发率低于传统手术组(P <0.000 01)。有研究表明,与腔内激光治疗相比,手术组术后1年的复发率更高(P = 0.02)。有研究报道腔内激光治疗组和手术组术后1年的复发率差异无统计学意义。有研究显示,腔内激光治疗组疼痛发生率及住院时间少于手术组,而在术后6周,两组疼痛及神经感觉异常等神经系统并发症的百分比差异无统计学意义。另有研究报道,手术组患者伤口感染比例高于腔内激光治疗组[19-22]。这些研究结果显示,与传统手术相比, 腔内激光治疗具有更小的手术切口、更短的住院时间和恢复时间,术后1年复发率明显更低,提示腔内激光治疗可以取得比传统手术更好的临床治疗效果。适应腔内激光治疗的曲张静脉要求有一定的直径,无严重的扭曲或闭塞,该法可以单独使用, 也可以与其他手术方式联合使用。

4 靜脉皮下环缝术

静脉皮下环缝术是一种新型疗法,其原理是通过连续皮下环状缝合,完全闭合曲张静脉,使曲张静脉壁闭合、纤维化,而达到治疗目的。应用皮下环缝术优点包括小腿皮肤无切口、美容效果好、手术时间短、创伤小、出血少、恢复快,适用于大隐静脉与交通支静脉瓣膜功能不全及合并小腿溃疡的各种单纯性大隐静脉曲张。

笔者对腔内激光联合皮下环缝术在治疗静脉功能不全中的作用进行了评估,将120例患者按治疗方法不同分为联合治疗组和对照组各60例, 两组病情、CEAP(clinical-etiology-anatomic-pathophysiology) 临床分级均为C3 级以上,对照组行腔内激光治疗, 观察组行腔内激光联合皮下环缝术治疗, 结果显示腔内激光与皮下环缝术联合组表现出更高的手术满意度,疼痛程度及血肿面积显著降低,缩短了术后住院时间,术后舒适度、生存质量及美容效果均得到了显著改善,提示腔内激光联合皮下环缝术可以取得更好的临床治疗效果。

5 总结

与透光静脉刨吸术及泡沫硬化剂注射法相比, 腔内激光技术对于大隐静脉主干的闭塞效果更好,复发率更低,但对于下肢静脉曲张的小分支静脉、曲张凸起的静脉团或扭曲严重的曲张静脉的治疗效果却不佳。静脉皮下环缝术手术时间短、创伤小、出血少、恢复快、美容效果好,适用于大隐静脉与交通支静脉瓣膜功能不全及合并小腿溃疡的各种单纯性大隐静脉曲张。近年来,采用微创技术治疗下肢静脉曲张已经逐渐成为主流,这些微创方法具有安全、美观、痛苦小、恢复快、手术和住院时间短等优点。但这些方法仍各有局限性,不能完全取代传统手术。在临床实践中,应根据患者的不同病情,严格掌握不同微创术式的适应证,选择最适宜的治疗方法,必要时可以互相搭配, 以期获得最佳的治疗效果和最少的并发症。

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