ome debates S Is there a place for phlebectomy? Denis Creton
CONTROVERSIES & UPDATES IN VARICOSE DISEASE
Clinique A. Paré, Nancy, France Phlebectomy has greatly improved since its initial description as cited by Robert Muller in 1966: under local anesthesia, removal of varicose veins by sagittal incision as small as some millimeters, performed with N° 1 scalpel blades, hooks and clips and closure of the incisions by simply bringing together the edges in an elasto-cotonned compressive bandage. Nowadays, in a standing position, the mapping precisely defines the areas where varicose veins are protruding. Anesthesia is ideally a tumescent local anesthesia (TLA) using isotonic sodium bicarbonate 1.4% as excipient (lidocaine dilution at about 0.003%) which allows an immediate and very deep anaesthesia without any sedation. The use of needles 18 gauge to perform incisions results in almost invisible scars after 30 days. The use of mini Pin-stripper allows stripping of incontinent tributaries and incontinent accessory saphenous veins. Phlebectomy also allows extracting saphenous trunk after invagination rupture or extracting a trunk for introducing an endovascular catheter. Every varicose vein can be removed by phlebectomy (foot varicose veins, big varicose veins and telangiectasias draining veins) except deep tortuous varicose veins, neovascular and recanalisation varicose veins or varicose veins embedded in trophic disorders or fibrosis tissue after numerous reoperation for recurrence. Phlebectomy has been said to be time-consuming, boring and painful for patients. In fact, in a bicentric and prospective study of 215 varicose veins surgery carried out without any sedation (including 32% strippings, 20% inguinal or popliteal incisions), there were 24 (3-63) phlebectomy incisions per surgery. Average surgery duration was 31 min (8 min - 1H15). Peroperative pain level (evaluated on a 1 to 10 analog visual scale) was significantly higher (3.4 versus 2.2) for more than 30 incisions 1. In another prospective bicentric study of 707 operations with the same operative acts, there were 20 (1-78) phlebectomy incisions. Average surgery duration was 24 min. Peroperative pain (1.5 on the day following surgery) and activity (normal or subnormal in 93% of the cases) was not related to the number of phlebectomies. Not to mention surgery cost 2, for patients it is interesting to perform all the surgical acts at one go: trunk treatment (stripping or endovascular technique) and phlebectomies. This one step treatment is carried out in a 30-minute operation, 45 minutes in operating room, and a few hours in surgical centre and in 80% of the cases without any sedation. Phlebectomy is performed in every varicose vein surgery and alone in 43.5% of the cases. It requires a lot of patience, a very good practice and determination, whereby it is a quick and effective operation. To the question “Is there still a place for phebectomy” the answer is “Phlebectomy not only has still a place but has always all the place!” REFERENCES 1. Creton D, Réa B, Pittaluga P, Chastanet S, Allaert FA. Evaluation of pain in varicose vein surgery under tumescent local anethesia using sodium bicarbonate as excipient without any intravenous sedation. Phlebology. 2012;27:368-73. 2. Carradice D, Mekako AL, Hatfield J, Chetter IC. Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins. Br J Surg 2009;96:369-75
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