Volumen
7 Número 2 Marzo - Abril 1995
Artículos Originales
| Raúl Serrano Loyola MD Gustavo Fink Josephi, MD, AFACA Correspondencia: Américas 183 Núm. 8, Colonia Moderna 08200 México, D.F. Tel. 696-35-33 |
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Introducción : Hasta la fecha se considera que el tratamiento de la patología venosa es esencialmente quirúrgico. Varady demostró la efectividad de la cirugía venosa empleando anestesia local y micro incisiones, reduciendo costos por hospitalización.
Material y métodos : Se realizó análisis retrospectivo de expedientes de pacientes intervenidos por insuficiencia venosa de 1989-93 en el servicio de cirugía cardiovascular del Hospital General de México. Los pacientes fueron clasificados de acuerdo al tipo de procedimiento anestésico: anestesia local (AL) o bloqueo epidural (BE). Se consideró cirugía ambulatoria todo aquel procedimiento que no requería más de 12 horas de hospitalización.
Resultados: Fueron incluidos 1, 531 pacientes, observándose predominancia femenina (87% mujeres vs 13% hombres).
Los pacientes fueron premedicados con diazepam (1-2 mg/kg.) o midazolam (0. 15 mg/kg.).
922 pacientes recibieron AL (60%) y 609 BE (40%). 60% de los pacientes fueron operados por presencia de colaterales (95% con AL y 5% con BE); 23.5% por safenectomía parcial (76% AL y 24% BE) y 16.5% por safenectomía total (13% AL y 87% BE).
Sesenta y ocho por ciento de los operados con AL fueron ambulatorios, 27% permanecieron 24 horas hospitalizados y 5%, 48 horas, estos últimos operados con BE (P<0.001). La morbilidad total para el grupo de AL fue de 0%, siendo el de BE de 1. 14% (p<0.00l).
Discusión: Tomando en consideración nuestros resultados, creemos que el empleo de AL en combinación con la técnica descrita por Varady es segura, económica y efectiva para el manejo de corrección quirúrgica de insuficiencia vascular de extremidades inferiores.
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Introduction: Treatment of lower limb vascular pathology is mostly surgical and Varady demonstrated the effectiveness of venous surgery using local anesthesia and micro incisions, reducing hospitalization cost.
Material and methods: Retrospective analysis of clinical records from patients operated for vascular insufficiency in a five year period (1989-93) was performed. Patients were classified according type of anesthetic procedure: local anesthesia (LA) or epidural blockade (EB). Ambulatory surgery was defined when the patient spent 12 hours or less at the ward. Results: A total of 1,531 patients were included and significant predominance of women (87% female vs. 13% mate) was observed.
All patients received premedication with diazepam (1-2 mg/kg) or midazolam (0.15 mg/kg IM).
Results: A total of 922 patients were operated using LA (60%) and 609 (40%) were operated using EB.
Sixty per cent were operated for the presence of collaterals; of them, 95% were operated using LA and 5% EBA. Twenty three per cent underwent partial aphenectomy (76% LA and 24% EB) and 16.5% for total saphenectomy (13% LA and 87% EB).
Sixty eight percent of the patients spent less that 12 hours, all of them of LA group. Twenty seven per cent spent 24 hours and 5% spent 48 hours, in these cases EB was used (p<0.001).
The overall morbidity for the LA group was 0%, and 1. 14% in the EB group.
Discussion: Considering our results, we believe using local anesthesia and the so called Varady technique is a safe, economic and effective method for surgical repair of lower limb vascular insufficiency.
Key Words : Local Anesthetics, Vascular Surgery, Ambulatory Surgery, Neural Blockade, Venous Insufficiency.
Palabras Clave : Anestésicos Locales, Cirugía Vascular, Cirugía Ambulatoria, Bloqueo Neural, Insuficiencia Venosa.
Humanity most pay for it's evolution and
upright posture with venous pathology
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Lower limb venous insufficiency is an ancient problem, contemplated even in the legendary egiptian papyrus.
In our population, venous pathology is greatly extended and its correction could cause severe repercussion in terms of hospitalization costs and duration.. Another concern is the morbidity associated with anesthesic procedures required for the surgical correction, which until now has been considered the same of that associated with epidural blockade (EB), since it is the anesthetic procedure most commonly used for lower limb surgery.
For the past five years, our surgical service has been performing lower limb vascular surgery using local anesthesia (LA) and preserving, as far as possible, the internal saphenous vein.
The latter technique was described by Varady in 1979,reporting great success rates in his population, reducing hospitalization costs and duration.
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A retrospective 5 year analysis was done using the clinical records of the Cardiovascular Surgery Department of the Mexico City General Hospital .
All patients consulted for lower limb venous insufficiency were considered form 1989 to 1993, classifying them in one of two groups:
Group I: Local anesthesia. In this group, 2% lidocaine was administered locally in a paravascular manner, using a 20 F needle along the trajectory of the vein to be removed. Atop dose limit was established at 300 mg to avoid toxicity.
Group II. Epidural blockade. 2% plain lidocaine was used in a dose range from 70-100 mg.
In all cases the patient was conscious and pain reference was the indication for either supplementary dose, anxiolysis or intravenous analgesics.
Type and extent of surgical procedure, morbidity attributable to anesthesic or surgical procedures and hospitalization length were considered, and a two year follow up period was done, in order to search for venous disease recidivation.
Statistical Analysis
All results are expressed as mean or percentages. Demographic data were analyzed using Chi square and differences concerning hospital length and associated morbidity between groups were determined using Fisher exact test. Any "p" value < that 0.05 was considered significant. |
Atotalof 1531 patients were included in the five year period analysis. As expected, a female predominance was observed, constituting 87% of the studied population (13% male) (p=0.001).
Mean age for the group was 48 years; 45 years for females and 52 years for males (p>0.05).
No history of local anesthetics allergy was detected in all the cases and the only associated disease observed was obesity (75% of the overall population). Diabetes was observed in 15 cases (1.3%) and cardiac failure in 7 cases (0.45%).
A total of 922 patients were operated using LA (60.2%) and 609 (39.8%) using epidural blockade.
Concerning type of surgery, 60% (919 procedures) was done for collateral resection and of them, 95% (873 procedures) were operate using LA an 5% (46 procedures) using EB. Twenty three per cent (352 procedures) underwent partial saphenectomy, 75% of them (267procedures) using LA and 24% (85 procedures) using EB. Finally, 17% of the patients (260 procedures) were operated for total saphenectomy, 13% (34 procedures) of them using local anesthesia and 87% (226 procedures) using EB. (Figure 1).
Type of anesthetic procedure used according surgical procedure. Abbreviations: LA - Local Anesthesic, EB - Epidural Blockade .
Sixty eight per cent of the patients were classified as ambulatory (spent less than 12 hours at the ward), all of them of the LA group. 27% spent 24 hours and 5% spent 48 hours. In the latter cases EB was used. (P<0.001).
The overall morbidity for the LA group was 0% and 1. 14% in the EB group. The main morbidity causes were: blockade failure (5 patients), pain that required adjuvant analgesia (10 patients) and postpunctural headache (2 patients).
Until 1993, follow up was successful in 95% of the cases (1 454 patients) at the cardiovascular department consultation clinic. Of the overall population, only a 5% (72 patients) showed venous disease recidivation, 45.3% of the cases belong to the LA group and 54.7% belong to EB group (no statistical difference). |
Ambulatory surgery has gained popularity in certain surgical areas such as plastic surgery, laparoscopic surgery, etc. Usually, vascular surgery has not been treated as ambulatory, due to the fact that it has a high bleeding potential.
Since Varady's description, a more "aggressive" approach has been reached and consequently, more patients have been operated.
Due to our characteristics, maybe one of the hospitals in Mexico able to concentrate a great amount of patients is Mexico City General Hospital and due to the population characteristics, lower limb vascular insufficiency is very common.
In spite of the above mentioned, this trial might be one of the largest trials directed to analyze the characteristics of Varadi's technique associated with different type of anesthetic interventions.
From our point of view, ambulatory surgical treatment combines the benefit of both surgery and sclerosis, avoiding many disadvantages.
As showed in this report, Varady's technique is relatively simple, and long incisions are substituted with minute needle pricks. Also, there is no post operative disability and little or no scar tissue is formed.
Maybe one of the most important findings is the fact that minimal trauma to adjacent structures and perivenous tissue with minimal peripheral nerve lesion is achieved, finding that is coincident with other author's reports.
Another important point to mention is the fact of the very low rate of anxiety, situation probably associated with the adequate preoperative visit and premedication.
Avery controversial fact is the number of patients operated for total saphenectomy using local anesthesia, and even our population is not big enough (specially compared. with the population operated for partial saphenectomy). The low complication rate in the overall group supports the fact that it may be possible to manage total saphenectomy using local anesthesia. Nevertheless, actually we do not recommend the general use of the forementioned technique, until a greater amount of experience is achieved.
In conclusion, considering our results, we believe using local anesthesia combined with the so called Varady's technique is a safe, economic and effective method for surgical repair of lower limb vascular insufficiency, specially when collaterals resection and partial saphenectomy are concerned, obtaining the same stability and lack of adverse reactions as with EB. If the use of local anesthesia for total saphenectomy could be securely done, remains controversial, and we still are not able to recommend it, until more experience is obtained. |
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