```Annexure – I
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the candidateand address
(in block letters) /
DR.ANOOP VIPIN NAIR.S
No:7 GENS HOSTEL
MVJ MEDICAL COLLEGE AND RESEARCH HOSPITAL
HOSKOTE
2. / Name of the institution / MVJ MEDICAL COLLEGE AND RESEARCH HOSPITAL
3. / Course of study and subject / M.S. (General Surgery)
4. / Date of admission to course / 03 May 2010
5. / Title of the Topic:
CLINICAL STUDY AND MANAGEMENT OF LOWER LIMB
VARICOSE VEINS IN RURAL AREAS
6. / Brief resume of the intended work:
6.1. Need for the study:
Varicose veins imply dilated, tortuous and elongated veins in the lower extremity. It is part of the penalty human beings are paying for adapting the erect posture.
Varicose veins are the most common vascular disorder of the lower extremity. These venous disorders are associated with high morbidity and invariably with cosmetic problems, while a condition like deep vein thrombosis may cause even more serious implications.
The need for study includes:
- To know the varicosities of lower limbs in relation to age, sex and occupation of the patient in rural belt.
- To study the various etiological factors which influences the development of varicose veins.
- To analyse the clinical manifestations of varicose veins.
- To analyse further the various investigations required to plan the management.
- To study the various modalities of treatment.
6.2. Review of literature
Varicose veins are a common medical condition present in at least 10% of the general population
.(2)
Risk factors for varicose veins include obesity, female sex, inactivity and family history. Varicose veins can be classified as primary or secondary. Primary varicose veins result from intrinsic abnormalities of the venous valves, whereas secondary varicose veins are associated with deep and/or superficial venous insufficiency.(2)
The symptoms of varicose veins include aching in veins after prolonged standing, ankle swelling, itching, bleeding, superficial thrombophlebitis, eczema, lipodermatosclerosis and ulceration.(1)
A prime requisite of successful varicose vein treatment is a detailed history, clinical examination and relevant investigations such as venous Doppler and Duplex ultrasound.(1)
There are various treatment options available for treatment of varicose veins. The choice of treatment depends on the size of the vairces, their extent, the symptoms they produce and patient preferences.
(1) These include,
1. Conservative management- this includes reassurance and compressive elastocrape stockings. These are helpful in early stages of varicose veins but does not prevent the development of more varices or result in disappearances of veins.(3)
2. Injection sclerotherapy - these can be successful in varices less than 3mm in diameter, telangiectatic vessels and recurrent varicosities. It aims at obliterating the superficial varices by the injection of sclerosant followed by compression which is maintained for a minimum of 3 weeks. The various sclerosants used are sodium tetradecyl sulphate, polidocanal and hypertonic saline.(2)
3.
4.
Modified sclerotherapy:
Ultrasound guided foam sclerotherapy – in which sclerosant is made into a foam and injected into the vein under ultrasound monitoring which can image the foam as it spreads up the vein.(1)
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- Surgical treatment - It is widely used and is effective in removing varicose veins of main saphenous trunks as well as their tributaries down to a size of about 3 mm. The main principles of surgical treatment are to ligate the source of venous reflux and to remove the incompetent saphenous trunks and associated varices.(1)
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- The various surgeries includes,
- Trendelenburg operation, which includes flush ligation of saphenofemoral junction.(4)
- Trendelenburg operation with stripping of varices.(4)
- Cocket and Dodd operation, which includes subfacial ligation of perforators.(5)
- Hook phlebectomy, in which varices are removed through very small incisions in the leg using a hook.(1)
- Saphenopopliteal junction ligation with subfacial ligation of perforator veins.(4)
The newer advanced techniques used in treatment of varicose veins are,
- Radiofrequency ablation therapy in which radiofrequency waves are used to destroy endothelium of main saphenous trunk.(1)
- Endovenous laser ablation therapy, which uses laser energy for ablation of saphenous trunk endothelium and is marginally less expensive than radiofrequency ablation.(1)
- Subfacial endoscopic perforator surgery (SEPS). It uses a tiny camera at the end of a thin tube
to ligate the perforators of varicose veins subfacially.(6)
6.3. Objectives of the study
1. To study the distribution, pathology and clinical features of varicose veins of lower limbs in rural areas.
2. To study the various modes of investigations and management of varicose veins in lower limbs effectively and to prevent complications.
7. / Materials and Methods:
7.1. Source of data:
The materials for the present study is proposed to be collected from 50 patients of lower limb varicose veins admitted as O.P.D and Casualty cases in the department of General Surgery at MVJMC&RH, Hoskote.
7.2. Method of collection of data:
- Detailed history taking.
- Thorough physical examination.
- Relevant investigations
- Assessment of patients following treatment at regular intervals in comparison to his/her pre-treatment with regards to symptoms.
Inclusion criteria:
- Symptomatic varicose veins with symptoms of aching, heaviness, ankle swelling and cramps.
- Complications of venous stasis such as pigmentation, dermatitis, ulceration and superficial thrombophlebitis.
- Large varicosities subject to trauma.
- Cosmetic concern.
Exclusion criteria
Patients with secondary varicose veins due to venous obstruction were not included in the study.
7.3. Does the study requires any investigation or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
Yes, routine investigations will be conducted on patients for assessment of their fitness for anesthesia and surgery. The following investigations are necessary:
· Haemoglobin percentage
· Total and differential WBC count
· ESR
· Bleeding and clotting time
· Urine routine
· Blood sugar
· Blood urea
· Serum creatinine
· Chest x-ray
· ECG
Special investigations
· Doppler venous study.
· Duplex scanning for accurate diagnosis and planning of treatment.
· Plain x-ray of affected part in case of venous ulcers particularly in presence of sings of infection for evidence of periostitis and calcification.
No investigations will be conducted on other human beings or animals.
Treatment:
Depending on the merits of the disease appropriate treatment options are selected
1 Conservative treatment
2 Sclerosant treatment
3 Surgical treatment like,
a) Trendelenburg operation, which includes flush ligation of saphenofemoral junction.
b) Trendelenburg operation with stripping of varices.
c) Cocket and Dodd operation, which includes subfacial ligation of perforators.
d) Hook phlebectomy, in which varices are removed through very small incisions in the leg using a hook.
e) Saphenopopliteal junction ligation with subfacial ligation of perforator veins.
7.4. Has ethical clearance been obtained from your institution in case of 7.3?
Yes
8. / List of references:
- Norman S.Williams, Christopher J.K.Bulstrode, P.Ronan O’connell, Baily and Love’s short practice of surgery, 25th edition, 2008,Venous disorders, chapter 54, 925-943
- Y.Lam, Mary E.Giswold, and Gregory C.Momenta, Schwartz Principles of surgery, 9th edition, 2010, “Venous and Lymphatic disease” , chapter 24
4. Farquharson: Farqharson’s Text Book of Operative Surgery, Charchill Livingstones, Vascular Surgical Techniques, 9th edition, 2005, 81-86.
- S.R.B.Manual of surgery, Sriram Bhat.M. Venous disorders, 2nd edition, 149-163.
- B.Kianifard, J.Holdstock, C.Allen, C.Smith and M.S.Whitley, Randomised clinical trial of effect of adding subfacial endoscopic perforator surgery to standard great saphenous vein stripping. “British Journel of Surgery” Volume 94, Number, September 2007, 1075-1080.
9. / Signature of Candidate
10. / Remarks of the Guide:
More number of patients suffering from varicose veins and its complications are attended with surgical care in our rural setup hospital. There is a need for study about varicose veins in rural patients.
11. / Name & Designation of:
(in block letters)
11.1 Guide: / Dr.N.SRINIVASAN M.S, F.R.C.S (Glasgow)
PROFESSOR, DEPARTMENT OF GENERAL SURGERY
MVJMC&RH
11.2 Signature
11.3 Co-Guide (if any)
11.4 Signature
11.5 Head of Department / Dr NISITH KUMAR RAY.
PROFESSOR AND HOD,
DEPARTMENT OF GENERAL SURGERY,
MVJMC&RH.
11.6 Signature
12. / 12.1 Remarks of the Chairman And Principal:
12.2 Signature