吉林大学学报(医学版)  2018, Vol. 44 Issue (02): 383-387

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姜海军, 张弘, 杨植, 赵博, 刘彦春, 杜建青, 尹晶
JIANG Haijun, ZHANG Hong, YANG Zhi, ZHAO Bo, LIU Yanchun, DU Jianqing, YIN Jing
不同微创方式治疗下肢静脉曲张的临床疗效比较
Comparison of curative effects between different minimally invasive methods in treatment of varicose veins in lower extremities
吉林大学学报(医学版), 2018, 44(02): 383-387
Journal of Jilin University (Medicine Edition), 2018, 44(02): 383-387
10.13481/j.1671-587x.20180232

文章历史

收稿日期: 2017-08-07
不同微创方式治疗下肢静脉曲张的临床疗效比较
姜海军1 , 张弘1 , 杨植1 , 赵博2 , 刘彦春1 , 杜建青1 , 尹晶1     
1. 承德医学院附属医院血管普外科, 河北 承德 067000;
2. 承德医学院附属医院输血科, 河北 承德 067000
[摘要]: 目的: 比较不同微创手术方式治疗下肢静脉曲张的临床疗效,探讨其临床价值。方法: 选择201例下肢静脉曲张患者,采用不同的治疗方式,其中腔内激光灼闭术(EVLA)组52例、透光旋切术(TIPP)组46例、EVLA联合腔镜下交通支离断术(SEPS)(EVLA+SEPS)组49例和TIPP+SEPS组54例。比较各组患者手术时间、术中出血量、术后住院费用、住院时间以及术后并发症(残留静脉曲张、皮下硬结、浅静脉炎、隐神经损伤、瘀斑、伤口血肿、皮肤麻木和下肢肿胀)的发生率。结果: 各组患者手术时间、术中出血量及术后住院时间和住院费用比较差异均有统计学意义(P < 0.05)。与EVLA组比较,TIPP组患者残留静脉曲张、浅静脉炎、下肢肿胀和瘀斑发生率降低(P < 0.05);皮下硬结、伤口血肿、隐神经损伤和皮肤麻木发生率略高,但差异无统计学意义(P>0.05);与EVLA组和TIPP组比较,EVLA+SEPS组和TIPP+SEPS组残留静脉曲张和浅静脉炎发生率下降(P < 0.05)。与EVLA组比较,TIPP组、EVLA+SEPS组和TIPP+SEPS组术后3个月愈合率明显升高(P < 0.05);TIPP组、EVLA+SEPS组和TIPP+SEPS组术后1年复发率明显降低(P < 0.05)。结论: EVLA联合SEPS和TIPP联合SEPS治疗下肢静脉曲张的疗效优于单独EVLA和TIPP治疗方法,具有安全可靠、曲张静脉切除彻底、溃疡愈合快及复发率低等优点。
关键词: 静脉曲张    腔内激光灼闭术    透光旋切术    腔镜下交通支离断术    
Comparison of curative effects between different minimally invasive methods in treatment of varicose veins in lower extremities
JIANG Haijun1, ZHANG Hong1, YANG Zhi1, ZHAO Bo2, LIU Yanchun1, DU Jianqing1, YIN Jing1     
1. Department of General Surgery, Affiliated Hospital, Chengde Medical College, Chengde 067000, China;
2. Department of Blood Transfusion, Affiliated Hospital, Chengde Medical College, Chengde 067000, China
[Abstract]: Objective: To compare the clinical effects of different minimally invasive surgeries in the treatment of varicose veins of lower extremities, and to explore their application values. Methods: A total of 201 patients with varicose veins of lower extremities were selected and treated with different operation methods.52 cases were treated by endovenous laser therapy(EVLA group), 46 cases were treated by transilluminated powered phlebectomy(TIPP group), 49 cases were treated by EVLA combined subfascial endoscopic perforator surgery (SEPS)(EVLA+SEPS group) and 54 cases were treated by TIPP combined SEPS (TIPP+SEPS)group.The operation time, the intraoperative blood loss, the postoperative hospitalization cost, the hospitalization time, the incidence rates of postoperative complications (residual varicose veins, subcutaneous induration, superficial phlebitis, skin necrosis and saphenous nerve injury) of the patients in various groups were compared. Results: There were significant differences in the operation time, the intraoperative blood loss and the postoperative hospitalization time, the hospitalization cost of the patients between various groups(P < 0.05).Compared with EVLA group, the incidence rats of residual varicose veins, superficial phlebitis, and lower extremity swelling and ecchymosis of the patients in TIPP group were significantly decreased (P < 0.05); the incidence rates of subcutaneous induration, wound hematoma, saphenous nerve injury and skin numbness were increased, but there were no significant differences (P>0.05).Compared with EVLA group and TIPP group, the incidence rates of reidual varicose veins and superficial phlebitis in EVLA + SEPS group and TIPP + SEPS group were significantly decreased (P < 0.05).The healing rates of the patients 3 months after operation in TIPP group, EVLA + SEPS group and TIPP + SEPS group were significantly increased compared with EVLA group(P < 0.05).The recurrence rates 1 year after operation in TIPP group, EVLA + SEPS group and TIPP + SEPS group were lower than that in EVLA group (P < 0.05). Conclusion: The curative effects of EVLA combined with SEPS and TIPP combined with SEPS in treatment of varicose veins in lower extremities are superior to EVLA and TIPP, with the advantages of safe and reliable methods, complete varicose vein resection, less postoperative complications, quick ulcer healing and low recurrence rate and so on.
Key words: varicose veins     endovenous laser therapy     transilluminated powered phlebectomy     subfascial endoscopic perforator surgery    

下肢静脉曲张是临床常见的下肢静脉性疾病,诊断主要依靠临床表现,常见肢体易疲劳、酸胀、疼痛和肿胀等。下肢静脉曲张好发于小腿下段,近年来发病率逐渐增高,手术为其主要治疗方法,目的是减轻症状和防止病变进展,但术后常出现并发症,包括切口感染、血肿和复发等[1-2]。随着医疗水平的进步,近年来治疗静脉曲张进入以微创、美容为目标的微创时代,临床依据患者病情而选取不同的微创术[3-4]。传统手术效果确切,但术后复发率高,并发症相对较多,而微创手术具有多种优点,如术后恢复快、痛苦小、切口小且少[5-6],因此受到医患双方的广泛关注。近年来,血管腔内激光灼闭术(EVLA)、透光旋切术(TIPP)及腔镜下交通支离断术(SEPS)是临床治疗静脉曲张的主要微创手术方式,具有微创、安全和治疗彻底等特点[7]。对于血管外科医生,掌握多种微创手术治疗不同病情患者已成为获得良好预后的关键。在实际临床中,患者的意愿成为选择治疗方法的关键因素。所有的手术方法在短、中期均有较好的临床效果,但远期效果仍需要更多的数据支持。本研究回顾性分析采用不同微创手术方式治疗的184例下肢静脉曲张患者的临床资料,旨在探讨EVLA、TIPP、EVLA联合SEPS和TIPP联合SEPS治疗下肢静脉曲张的临床价值,提供不同联合手术治疗在术中及术后的优缺点,一方面尽量减少手术治疗的并发症,另一方面为医生和患者提供更多的数据支持,为不同患者提供最合适的治疗方案。

1 资料与方法 1.1 病例和分组

采用回顾性分析方法,选择2012年1月—2015年1月于本院进行治疗的下肢静脉曲张患者201例,全部病例采用整群抽样方法,均行下肢彩色多普勒超声检查,了解大隐静脉及深静脉情况,测定深静脉瓣膜返流程度,由专家根据患者病情、结合患者意见共同商定,选取不同治疗方式,其中采用EVLA52例(EVLA组)、TIPP46例(TIPP组)、EVLA联合SEPS49例(EVLA+SEPS组)、TIPP联合SEPS54例(TIPP+SEPS组),联合组为具有溃疡、色素沉着的患者。纳入标准:①术前应用彩超排除深静脉血栓及布加综合征等引起的静脉曲张疾病;②溃疡均为5级以上;③患者性别、年龄和病程等临床资料比较差异无统计学意义(P>0.05),具有可比性;④经本院伦理委员会批准。排除标准:①先天性因素引起的下肢静脉曲张(动静脉瘘和综合征等);②下肢深静脉血栓形成后遗综合征;③有下肢深静脉血栓形成者。

1.2 治疗方案 1.2.1 治疗方法

EVLA组患者在硬膜外麻醉下行EVLA。操作方法:在患者腹股勾横纹下约1cm处切口,于患者内踝前方2cm处置入激光纤维,18号套管针于足内踝处穿刺大隐静脉,导入5F导管扩张器,将激光光纤插入5F直头导管,送至隐股静脉处,回退导管,向前推送光纤,使光纤露出导管3cm,边退光纤边激光烧灼,直至内踝。将激光仪打开,激光发射功率12W、1s脉冲、间隔1s参数,同时将导管和光纤慢慢后撤,使静脉壁闭合,术后用弹力绷带加压包扎。

TIPP组患者应用Trivex旋切系统,在硬膜外麻醉下行TIPP。操作方法:曲张静脉附近切开,于皮下浅筋膜层置入冷光源,距光源20 cm处切开置入旋切刀头,接主机,接好水泵和负压吸引器,打开水泵,调整转速为900~1000r·min-1,同时打开旋切系统,切除静脉并吸出,排尽皮直积液,术后用弹力绷带加压包扎。

EVLA+SEPS组患者在硬膜外麻醉下行EVLA和SEPS。操作方法:麻醉后,于患者胫骨粗隆下6 cm、胫骨内侧4 cm处切开深筋膜,置入Trocar及腔镜,游离交通静脉,电凝钩烧灼、止血后离断,将深筋膜下交通支静脉一一离断,缝合切口,完成交通支离断术;在患者腹股勾横纹下约1 cm处切口,于患者内踝前方2 cm处置入激光纤维,18号套管针于足内踝处穿刺大隐静脉,导入5F导管扩张器,将激光光纤插入5F直头导管,送至隐股静脉处,回退导管,向前推送光纤,使光纤露出导管3 cm,边退光纤边激光烧灼,直至内踝。同时将导管和光纤慢慢后撤,使得静脉壁闭合,术后用弹力绷带加压包扎。

TIPP+SEPS组患者在硬膜麻醉下行TIPP和SEPS。操作方法:麻醉后,于患者胫骨粗隆下6 cm、胫骨内侧4 cm处切开深筋膜,置入Trocar及腔镜,游离交通静脉,电凝钩烧灼、止血后离断,将深筋膜下交通支静脉一一离断,缝合切口,完成交通支离断术;曲张静脉附近切开,于皮下浅筋膜层置入冷光源,距光源20 cm处切开置入旋切刀头,接主机,接好水泵和负压吸引器,打开水泵,调整转速为900~1000r·min-1,同时打开旋切系统,切除静脉并吸出,排尽皮直积液,术后用弹力绷带加压包扎。

1.2.2 观察指标

观察静脉曲张患者手术时间、术中出血量、术后住院费用、术后住院时间以及术后并发症(残留静脉曲张、皮下硬结、浅静脉炎、隐神经损伤、瘀斑、伤口血肿、皮肤麻木和下肢肿胀等)。指标判定:①瘀斑;术后72h,出现面积大于1 cm2的青紫或淤血斑;②皮肤烧伤:术后72 h,手术区域皮肤出现浅Ⅱ度以上的烧伤;③曲张复发或残留:术后1年复查B超原病变处发现长径大于2 cm血管未闭合;④术后麻木:术后72h,手术相关区域存在任何程度的麻木;⑤1年后复发率:采用门诊就诊及电话联系等方式进行随访,术后1年彩超观察术后静脉腔内血流再通情况,复发率=复发患者数/调查患者总数×100%。

1.3 统计学分析

采用SPSS16.0统计软件进行统计学分析。各组患者手术时间、出血量及术后住院费用和住院时间均以x±s表示,组间样本比较采用单因素方差分析,计数资料组间比较采用χ2检验,所有检验均为双侧检验。以α=0.05为检验水准。

2 结果 2.1 各组患者手术时间、出血量及术后住院费用和时间

EVLA+SEPS组和TIPP+SEPS组患者手术时间均高于EVLA组和TIPP组(P < 0.05),但EVLA+SEPS组和TIPP+SEPS组患者住院时间缩短(P < 0.05);TIPP组和TIPP+SEPS组患者术中出血量略高于EVLA组和EVLA+SEPS组(P < 0.05);EVLA+SEPS组和TIPP+SEPS组患者住院费用明显高于EVLA组和TIPP组(P < 0.05);各组患者手术时间、术中出血量及术后住院时间、住院费用比较差异有统计学意义(P < 0.05)。见表 1

表 1 各组患者手术时间、出血量及术后住院费用和时间 Table 1 Operation time, bleeding loss and postoperative hospitalization costs and time of patients in various groups
(x±s)
Group n Operation time(t/min) Bleeding loss(l/mL) Postoperative hospitalization cost(yuan) Postoperative hospitalization time(t/d)
EVLA 52 57.4±8.3 82.3±10.2 16 829±2 010 11.1±1.7
TIPP 46 50.1±7.9 150.6±15.0*# 19 441±2 179 10.4±2.1
EVLA+SEPS 49 70.3±6.6*△ 90.8±9.9 24 038±1 984*△ 6.7±1.5*△
TIPP+SEPS 54 75.6±4.8*△ 100.2±11.5*# 27 390±2 031*△ 5.0±1.4*△
* P < 0.05 compared with EVLA group; P < 0.05 compared with TIPP group; # P < 0.05 compared with EVLA+SEPS group.
2.2 各组患者术后早期并发症发生率

与EVLA组比较,TIPP组患者残留静脉曲张、浅静脉炎及下肢肿胀和瘀斑发生率降低(P < 0.05);皮下硬结、伤口血肿、隐神经损伤和皮肤麻木发生率略高,但差异无统计学意义(P>0.05)。与EVLA组和TIPP组比较,EVLA+SEPS组和TIPP+SEPS组患者残留静脉曲张和浅静脉炎发生率降低(P < 0.05);而其他并发症发生率比较差异无统计学意义(P>0.05)。见表 2

表 2 术后各组患者常见并发症发生情况 Table 2 Common complications of patients in various groups after operation
[n(η/%)]
Group n Residual varicose veins Subcutaneous induration Superficial phlebitis Hidden nerve injury Ecchymosis Wound hematoma Skin numbness Lower extremity swelling
EVLA 52 8(15.4) 7(13.4) 4(7.7) 7(13.4) 14(26.9) 7(13.4) 8(15.4) 11(21.2)
TIPP 46 3(6.5)* 8(17.4)* 2(4.3)* 8(17.4) 11(23.9)* 8(17.4) 9(19.6) 8(17.4)
EVLA+SEPS 49 2(4.1)*△ 5(10.2) 1(2.0)*△ 4(8.2) 6(12.2) 6(12.2) 5(10.2) 8(16.3)
TIPP+SEPS 54 1(1.9)*△ 7(13.0) 0(0.0)*△ 7(13.0) 7(13.0) 7(13.0) 7(13.0) 8(14.8)
* P < 0.05 compared with EVLA group; P < 0.05 comapred with TIPP group.
2.3 各组患者术后3个月溃疡愈合率

与EVLA组[63.46%(33/52)]比较,TIPP组[71.70%(33/46)]、EVLA+SEPS组[83.67%(41/46)]和TIPP+SEPS组[90.74%(49/54)]患者术后3个月溃疡愈合率明显升高(P < 0.05)。

2.4 各组患者术后1年复发率

与EVLA组[59.61%(5/52)]比较,TIPP组[6.50%(3/46)]、EVLA+SEPS组[4.08%(2/49)]和TIPP+SEPS组[5.56%(3/54)]患者术后1年复发率降低(P < 0.05)。

3 讨论

随着医疗技术的不断发展进步,目前国际上临床应用微创疗法治疗静脉曲张已成为主旋律,微创疗法主要包括血管内激光凝固法、皮下内镜交通支结扎、射频闭合法、TIPP、微创剥脱器法和泡沫硬化剂法等,临床上各种微创手术方式有其各自的特点[8-9]。本研究采用的治疗静脉曲张的微创手术方法包括EVLA、TIPP、SEPS及联合手术方法,旨在探讨不同微创手术治疗下肢静脉曲张的临床价值,分析不同手术治疗方法的术中及术后优缺点,一方面尽量减少手术治疗的并发症,另一方面为医生和患者提供更多的数据支持,为不同患者提供最合适的治疗方案。

EVLA是利用激光热效应引起血管变性凝固闭合,从而达到治疗静脉曲张的目的。EVLA优点是简便、术后疼痛轻、不留瘢痕、恢复快和并发症少等,患者更易于接受,但存在隐神经损伤、容易灼伤皮肤、浅静脉炎和手术局部肿胀等问题[10-12]。本研究结果显示:单一EVLA手术时间短、术中出血少、花费少,但术后住院时间最长,平均达(11.1±1.7)d,而且术后并发症如残留静脉曲张、皮下硬结和浅静脉炎发生率较高。

TIPP由照明系统和旋切系统组成,从一端先剥除静脉主干,于皮下置入照明系统,再从另一端置入旋切系统,直视下对曲张静脉进行切除。研究[13-16]显示:其微创切口少而小,适应证广、疗效好,术后恢复快,但血肿发生率较高。本研究结果显示:单一TIPP手术时间短,花费少,但术后隐神经损伤、浅静脉炎和皮下硬结及残留静脉曲张等并发症发生率略高;与EVLA组比较,TIPP组患者残留静脉曲张、浅静脉炎及下肢肿胀和瘀斑发生率降低,而皮下硬结、伤口血肿、隐神经损伤和皮肤麻木发生率略高。与EVLA组和TIPP组比较,EVLA+SEPS组和TIPP+SEPS组并发症发生率均明显降低。SEPS是利用下肢深筋膜和肌肉之间的腔隙,剥离后冲入气体建立操作空间,直视下离断下肢静脉的交通支,是临床应用较多的微创方式,被大多数医师所认同和采用[17-19]。本研究结果显示:虽然2个联合组手术时间相对略长,费用较高,但住院时间减少,同时术后并发症发生率减少,而且TIPP联合SEPS效果最好。本研究结果显示:与EVLA组比较,TIPP组、EVLA+SEPS组和TIPP+SEPS组患者术后3个月愈合率明显升高,同时1年复发率降低。

综上所述,微创联合治疗下肢静脉曲张优于单独一种微创治疗方法,具有安全可靠、曲张静脉切除彻底、溃疡愈合快及复发率低等优点。

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