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岭南现代临床外科 ›› 2020, Vol. 20 ›› Issue (02): 210-213.DOI: 10.3969/j.issn.1009-976X.2020.02.016

• 论著与临床研究 • 上一篇    下一篇

腔内激光微创治疗下肢静脉曲张的临床效果

  

  1. 北京大学深圳医院手显微外科,广东深圳 518036
  • 通讯作者: 彭艳斌

Effects of endovenous laser ablation technique for large saphenous varicose veins: an analysis in 248 cases

  1. Hand Microsurgery, Shenzhen Hospital, Peking University, Shenzhen, Guangdong 518036, China
  • Online:2020-04-20 Published:2020-04-20

摘要: 腔内激光微创治疗下肢静脉曲张的临床效果

腔内激光微创治疗下肢静脉曲张的临床效果

彭艳斌, 褚云峰, 陈仲, 万圣祥, 肖颖峰

[摘要] 目的 探讨腔内激光微创治疗下肢静脉曲张的临床效果。方法 选取2012年7月到2019年12月在我院完成的经静脉腔内激光消融治疗下肢大隐静脉曲张248例(激光消融组),另选取同期在我院收治采用传统大隐静脉高位结扎术+抽剥术治疗患者248例(传统手术组),对比两组患者的治疗效果。结果 激光消融组在切口长度、手术时间、术后第一天疼痛程度及持续时间及住院时间均好于常规手术组(P均<0.05);并发症主要包括切口延迟愈合、创口血肿、皮肤麻木、皮下硬结及静脉腔内热引发血栓形成,激光消融组的发生率明显低于常规手术组(P均<0.05);随访12个月,激光消融组有14例(5.6%)复发,常规手术组有8例(3.2%)复发,两组间差异没有统计学意义(P>0.05);激光消融组患者生活质量评分(SF-36)明显优于常规手术组(P<0.05)。结论 腔内激光微创治疗在改善下肢静脉曲张患者病情方面可发挥积极作用。

[关键词] 腔内激光微创治疗;高位结扎剥脱术;下肢静脉曲张;疼痛程度;并发症

大隐静脉(GSV)剥脱术是治疗静脉曲张的标准手术之一,其目的是消除静脉回流。GSV的主要并发症包括疼痛、瘀伤、感觉障碍、腿部不适、血栓性静脉炎、DVT和肺栓塞考虑到美容问题和手术的创伤和并发症,近年来的手术方法和器械均发生了变化,采用1470 nm半导体激光光纤和径向双环光纤的静脉内激光消融(EVLA)[1]、射频消融(RFA)[2]和皮下内窥镜穿支手术[3]被接受并广泛应用。尽管可能出现静脉炎、感染、感觉神经损伤和皮肤烧伤或变色等并发症[4,5],静脉腔内激光微创治疗可以改善美容效果,减少术后疼痛,加快康复[6]。本文选择了我院已完成的248例内激光消融的手术方式治疗大隐静脉(GSV)曲张,分析并与传统手术方式进行比较,具体如下。

1 资料与方法

1.1 临床资料

收集2012年7月到2019年12月在我院完成的经静脉腔内激光微创治疗的下肢大隐静脉曲张的连续临床病例,纳入标准:①患者均确诊为单纯性下肢静脉曲张,患者大隐静脉瓣功能试验结果均呈阳性,而深静脉交通试验均成阴性,超声检查患者均可见大隐静脉曲张现象,深静脉功能均无异常;②患者均无下肢静脉血栓形成;③者手术部位血管解剖结构均正常,无血管畸形、动脉瘤等;④患者无血液系统疾病及其他严重脏器疾病,意识清醒,无精神疾病、意识障碍、语言障碍等,可配合本次研究。排除标准:临床资料不全者。

共获得临床资料齐备患者248例(激光消融组),另选择同期在我院实施的传统开放的大隐静脉剥脱术248例作为对照组,两组患者基本资料见表1。本次研究经我院医学伦理委员会通过,患者均知晓本次研究,并签署知情同意书。

1.2 方法

对照组以传统手术方式治疗,即给予患者传统大隐静脉高位结扎术+抽剥术治疗,术前取患者站立位,于患处体表进行曲张静脉标记,给予患者硬膜外麻醉,然后解剖大隐静脉,并将主干切断,同时结扎分支,同时与距离股静脉5 mm处将大隐静脉切断,行近端双重结扎处理,然后行主干远端切除处理,切除长度为30~40 mm,切除后进行缝合处理,标记部位做适当大小的切口,然后对曲张静脉进行钝性分离、剥除处理,直至难以抽出,然后进行切断、结扎、缝合处理。

表1 两组患者的手术前基本情况

注:CEAP:临床病因解剖病理生理分型(Clinical Etiological Anatomic Pathophysiologic classification)

统计值P值例数男/女年龄/岁0.195 0.365 0.741 0.329病程/年部位/例单侧双侧平均最大GSV直径/mm CEAP分型/例(%)[7]C2 C3 C4激光消融组248 50/198 53.9±12.7(32~72)16.2±8.9(5~35月)常规手术组248 54/194 52.7±10.9(35~73)15.4±7.8(6~41月)0.429 0.499 0.217 0.485 162 126 5.8±2.2 147 101 5.7±1.90.174 0.962 0.62 0.064 213(85.9)15(6.0)15(6.0)209(84.3)18(7.3)17(6.8)

观察组行腔内静脉微创治疗,术前取患者站立位,于患处体表进行曲张静脉标记,给予患者硬膜外麻醉,并常规进行消毒铺巾,然后以16号套管穿刺针于患者内踝前上方穿刺大隐静脉,穿刺后,采用Seldinger技术进行处理,沿套管针向大隐静脉放置超滑导丝,并经导丝导入Cordis 5F导管,然后再导入600 μm的光导纤维,导入位置为腹股沟韧带10~15 mm出;导入后,于B超下进行观察,明确纤维位置,确保其位置正常后对光导纤维、导管等进行固定,然后设置激光治疗仪(Velure S9)相关参数,功率设定为12 W,进行连续释放,仪器启动后,按照2 mm/s的速度将光导纤维撤回,达到小腿部位后,调整激光仪功率为8 W,主干治疗完毕后,按照同样的操作方式对曲张部位较为明显的附属枝干进行治疗。术后给予患者弹力绷带加压包扎处理,包扎时间通常为2周,并于术后6 h指导患者下床活动。术后24 h可解开弹力绷带,对患者下肢变化情况进行观察,同时给予患者循序减压弹力袜,连续穿戴4周;对于伴有溃疡者需予以患者预防性抗生素治疗3~5 d,对于伴有严重疼痛者可给予其止痛药物镇痛治疗。

1.3 观察指标

观察和记录的指标包括:①比较两组患者手术相关指征情况,如手术时间、住院时间、切口长度等;比较两组患者术后疼痛情况,以视觉模拟评分量表(VAS)评估疼痛程度;比较两组患者术后并发症。②进行6个月随访,记录复发情况,完成生活质量评定量表(SF-36),量表共包含8个维度,各维度评分均为0~100分,总分为各维度之和的平均值,分值与患者生活质量呈正比,即分值越高表示生活质量越好[8]

1.4 统计学分析

数据资料以SPSS 20.0处理,计量资料(平均年龄、平均病程、手术相关指标、疼痛持续时间、生活质量评分)以均数±标准差表示,行t检验,计数资料(性别、疗效、并发症发生率及复发率)以百分比(%)表示,行χ2检验,P<0.05为有统计学意义。

2 结果

2.1 两组临床效果与并发症

术前主要症状包括下肢隐痛、肿胀、瘙痒、色素沉着、血栓性静脉炎和皮肤溃疡。表1总结了CEAP的患者特征和疾病严重程度评分。激光消融组的切口长度、手术时间、术后第一天疼痛程度及持续时间及住院时间均好于常规手术组(P均<0.05)(表1)。并发症主要包括:切口延迟愈合、创口血肿、皮肤麻木、皮下硬结及静脉腔内热引发血栓形成,激光消融组的发生率明显低于常规手术组(P均<0.05)(表2)。术后1个月,如瘀伤、术前血栓性静脉炎、术后深静脉血栓形成(DVT)、等均消失。

表2 两组患者术后相关临床手术指标

切口长度/cm手术时间/min平均GSV消融长度平均脉腔内能量强度/J·cm-1术后第一天疼痛/例/%术后第1天VAS疼痛评分/分术后第1天疼痛持续时间/h术后住院时间/天术后第7天瘀斑/瘀伤/例(%)并发症/例(%)切口延迟愈合创口血肿皮肤麻木皮下硬结复发静脉腔内热引发血栓形成/例(%)激光消融组1.2±0.3 50.2±12.1 33.2±5.1 60.4±8.8 22(8.9)1.9±0.7 2.8±1.3 2.1±0.9 3(1.2)常规手术组3.5±1.2 63.2±14.5统计值3.118 P值0.021<0.001--79(31.9)4.1±2.3 10.1±4.1 6.3±2.9 22(8.9)40.309 8.641 17.125 7.554 15.206<0.001<0.001<0.001<0.001<0.001 0 8(3.2)49(19.8)12(4.8)14 12(4.8)6(24.2)20(8.1)80(32.3)30(12.1)8(3.2)-4.218 4.580 9.429 8.428 1.712 0.030 0.031 0.002 0.006 0.275

激光消融组患者有14例(5.6%)、常规手术组有8例(3.2%)复发,两组间差异没有统计学意义。

2.2 两组患者生活质量比较

平均随访36个月,对两组患者生活质量评分进行对比,观察组患者SF-36评分为(85.4±5.3)分,对照组患者为(72.1±3.2)分,观察组明显高于对照组(t=14.883,P=0.000)。

3 讨 论

目前手术是临床上治疗下肢静脉曲张最常用的方法,传统的大隐静脉高位结扎+抽剥手术方式具有手术时间长、切口大、术后恢复慢、术后并发症、美观性差等不足之处,且易复发,患者术后5年的复发率可高达18%~40%,因此,临床上需探究更加安全、有效的治疗方式。EVLA是一种类似于剥离术的微创手术,EVLA能缩短术后恢复时间,减少与伤口相关的并发症、皮肤病的发病率,如瘀斑和瘀伤[9]。作为隐静脉曲张的主要手术方法,GSV最大静脉直径在10~15 mm的患者大多采用消融治疗,但EVLA联合消融和部分剥离,可对最大GSV直径>15 mm和慢性充血性静脉症状的患者实施[6]。本研究采用的腔内激光微创手术结果符合当今文献报道。

大隐静脉曲张的热消融已发展成为治疗静脉曲张的标准方法。激光消融的主要原理即通过静脉腔内光纤输送激光,以促使光纤周围的血红蛋白对能量进行吸收,促使蒸汽气泡产生,从而促使内膜发生广泛热损伤及收缩现象,进而造成静脉闭塞,然后逐渐促使闭塞的静脉纤维化、逐渐被吸收,进而达到治疗效果[10]。且本次研究中所用的激光治疗仪是Velure S9红外激光治疗仪,该系统采用的是一种新型的光纤过热保护系统,能够有效地对激光光纤顶端温度进行控制,对预防因功率升高而造成的腔内温度升高、周围组织、神经及皮肤被烫伤的现象发生有重要帮助,其安全性更高。且本次研究结果还显示,观察组患者手术时间及住院时间均较对照组明显缩短,且手术切口长度明显小于对照组(P<0.05),疼痛持续时间、疼痛程度评分均明显优于对照组(P<0.05),且观察组患者术后并发症发生率及复发率均明显低于对照组(P<0.05);提示腔内静脉激光微创治疗在促进下肢静脉曲张患者及早恢复、提高治疗的安全性、减少术后复发现象发生等方法同样可发挥积极的作用。

静脉内消融手术的远期效果与高位结扎+剥脱术相当[11],唯一不同的是在超声检测的大隐静脉复发的发生方面:新血管生成发生在高位结扎和剥离术后,大隐静脉腔内消融后复发主要通过残留的副隐静脉(AASV)发生。同时,与剥离手术相比,在门诊进行的静脉内消融手术的费用有所降低[11]。尽管EVLA广泛报道能够于减轻疼痛和减少术后复发,但仍然可能会出现静脉炎、感染、感觉神经损伤和皮肤烧伤或变色等并发症[5,6]。另外虽然EVLA是微创的,能够改善美容效果,减少术后疼痛,加快康复,但0.4%~2.7%发生静脉腔内热引发深血栓形成(DVT),大多数由于静脉腔内热引发深血栓形成病例在2~4周内缓解[12]。Kane等[13]认为这种静脉腔内热引发深血栓形成(EHIT)的实际发生率更高,在最初的报告中,共治疗血管528条,其中男性192条,女性336条,CEAP等级分别为1(0)、2(291例)、3(65例)、4(104例)、5(26例)和6(40例)。最终EHIT发生率为5.1%,治疗包括观察(13例)、抗凝(9例)、抗血小板治疗(2例)和非甾体抗炎药(1例),治疗时间通常为1周,有7例患者的治疗时间为1~7周。所有患者均未发生肺栓塞,所有病人的EHIT完全消失。因此EVLA术后EHIT发生主要由低风险的3、4、5级深静脉血栓形成,通常1周后消失。本组病例中EHIT共发生12例(4.8%),均在短期好转,未发生肺栓塞等严重并发症。

综上所述,腔内激光微创治疗在改善下肢静脉曲张患者病情、促进患者及早康复、减少手术创伤方面均较传统的大隐静脉剥脱术具有优势,且安全性较高。

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Effects of endovenous laser ablation technique for large saphenous varicose veins:an analysis in 248 cases

PENG Yan-bin,CHU Yun-feng,CHEN Zhong,WAN Shen-xiang,XIAO Ying-feng
Hand Microsurgery,Shenzhen Hospital,Peking University,Shenzhen,Guangdong 518036,China

[Abstract] Objective To investigate the clinical effect of intracavitary laser minimally invasive treatment of varicose veins of lower extremities.Methods From July 2012 to December 2019,248 patients(laser ablation group)with varicose great saphenous vein of lower extremities were treated by endovenous laser ablation in our hospital,and another 248 patients(traditional operation group)were treated by traditional high ligation of great saphenous vein plus extraction at the same time in our hospital.The clinical effects were compared between the two groups.Results The incision length,operation time,first day postoperative pain degree,duration and hospitalization time of laser ablation group were better than those of conventional operation group(all P values <0.05).The complications mainly included delayed healing of incision,hematoma of wound,numbness of skin,subcutaneous induration and thrombosis caused by heat in vena cava.The incidence of laser ablation group was significantly lower than that of conventional operation group(all P values< 0.05).After 12 months follow-up,14 cases(5.6%)recurred in the laser ablation group and 8 cases(3.2%)recurred in the conventional operation group.There was no significant difference between the two groups(P>0.05).The quality of life score(SF-36)in the laser ablation group was significantly better than that in the conventional operation group(P<0.05).Conclusion Intraluminal laser minimally invasive treatment can play an active role in improving the condition of patients with varicose veins of lower extremities,which is worthy of popularization and application.

[Key words] intracavitary laser minimally invasive treatment;high ligation and stripping;lower extremity varicose;pain degree;complications

doi: 10.3969/j.issn.1009-976X.2020.02.016

中图分类号:R654.4

文献标识码:A

作者单位:北京大学深圳医院手显微外科,广东深圳518036

通讯作者:彭艳斌,Email:p1y1b1@163.com

(收稿日期:2019-11-20)

关键词: 高位结扎剥脱术, 腔内激光微创治疗, 疼痛程度, 并发症, 下肢静脉曲张

Abstract: [Abstract] Objective To investigate the clinical effect of intracavitary laser minimally invasive treatment of varicose veins of lower extremities. Methods From July 2012 to December 2019, 248 patients (laser ablation group) with varicose great saphenous vein of lower extremities were treated by endovenous laser ablation in our hospital, and another 248 patients (traditional operation group) were treated by traditional high ligation of great saphenous vein plus extraction at the same time in our hospital. The clinical effects were compared between the two groups. Results The incision length, operation time, first day postoperative pain degree, duration and hospitalization time of laser ablation group were better than those of conventional operation group (all P values <0.05). The complications mainly included delayed healing of incision, hematoma of wound, numbness of skin, subcutaneous induration and thrombosis caused by heat in vena cava. The incidence of laser ablation group was significantly lower than that of conventional operation group (all P values < 0.05). After 12 months follow-up, 14 cases (5.6%) recurred in the laser ablation group and 8 cases (3.2%) recurred in the conventional operation group. There was no significant difference between the two groups (P>0.05). The quality of life score (SF-36) in the laser ablation group was significantly better than that in the conventional operation group (P<0.05). Conclusion Intraluminal laser minimally invasive treatment can play an active role in improving the condition of patients with varicose veins of lower extremities, which is worthy of popularization and application.

Key words: intracavitary laser minimally invasive treatment, pain degree, lower extremity varicose, complications, high ligation and stripping

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