下肢慢性静脉溃疡的综合治疗

目的探讨下肢慢性静脉溃疡的综合治疗方法。方法回顾性分析2012年7月~2013年1月我科收治的10例下肢慢性静脉溃疡患者（10条患肢）的临床资料,均采用大隐静脉高位结扎加抽剥并联合应用透光曲张静脉刨吸术、泡沫硬化剂注射、腔镜深筋膜下交通静脉结扎术等方法处理小腿病灶。分别在术前及术后3个月对临床症状的改善情况采集数据,按临床严重程度评分（VCSS）方法进行评估。结果患者均成功实施联合手术治疗方案,在术后的VCSS评分项目中得到改善[（12.3±2.06）v s （9.6±1.71）]。随访（6.70±1.45）个月,疼痛较前均有缓解,未发现患肢有曲张浅静脉残余或复发,8例溃疡基本愈合,仅有2例还有残余溃疡,但都控制在2 cm内,已愈合的溃疡未见复发。结论下肢慢性静脉溃疡经正确选择联合治疗方案进行处理后的效果是理想且安全的,而且其短期效果稳定。     

Pinch grafts in the treatment of chronic venous leg ulcers

Summary 130 patients with 170 chronic recurrent venous ulcers of the leg treated with pinch grafts following elimination of underlying venous disease are presented. Pinch grafts, when used by the method described, form a soft, pliable and highly resistant skin cover which withstands the stresses of daily life.     

Compression treatment of venous and venous/arterial leg ulcers

The French National Authority for Health has recalled recommendations for the use of compression in the treatment of venous or venous/arterial leg ulcers. Different types of bandages and compression stockings must be used. The pressure to be achieved is between 30 and 40 mm Hg at the ankle (and below 30 mm Hg in case of mixed ulcers). In daily practice, beyond these recommendations, the choice of type of compression must also take into account the size of the ulcer, the appearance of the wound, the existence of leg dysmorphia, the volume of the oedema and also the general condition of the patient.     

Low-power HeNe laser treatment of venous leg ulcers.

Clinical observations have suggested that low-energy lasers, mainly helium-neon (HeNe) lasers, might stimulate wound healing. A controlled study of the effects of low-power HeNe laser was performed in conjunction with a standard treatment for healing chronic venous leg ulcers on 46 patients divided randomly into two groups. All patients received standard treatment (paste-impregnated bandage and a self-adhesive elastic bandage) plus either HeNe laser (wave-length, 632.8 nm; beam power, 6 mW; continuous emission, energy density, 4 J/cm2) or placebo HeNe laser twice weekly for 12 weeks. The areas of healing were examined and compared percentage-wise after 2, 4, 6, 8, and 12 weeks. There were no significant differences in the proportion of healed ulcers or ulcer area in the HeNe group compared with the placebo group.     

Intermittent pump versus compression bandages in the treatment of venous leg ulcers

BACKGROUND: The purpose of the present paper was to compare healing rate and leg swelling with an intermittent compression pump versus compression bandages in the treatment of venous leg ulcers, and to also compare patient compliance and satisfaction with the two techniques. METHODS: A randomized cross-over study of patients attending an outpatient wound clinic (n = 16) was undertaken. A regular monthly follow-up with measurement of ulcer size and leg volume was carried out, as well as completion of a questionnaire. RESULTS: Assessment was possible in 11 of the 16 patients. There was no significant difference between treatment types with regards to ulcer healing rates or control of leg oedema. The survey revealed that patients found the pump easier and more comfortable to use, with a trend towards increased compliance. CONCLUSIONS: Although the present study was too small for generalizable conclusions, compression pumps and bandages are comparable in efficacy for the healing of venous leg ulcers. The compression pump is reported as being easier and more comfortable to use than bandages.     

Surgery of venous leg ulcers.

Numerical data are presented to prove the endemic nature and importance of the varicose and postthrombotic syndrome. The fact that even in the most fortunate cases conservative therapy can bring about only temporary improvement, has directed attention to surgical methods. The surgical methods of treatment of varicos (VS) and postthrombotic (PS) syndrome are reviewed. The surgical procedure considered adequate is described. It consists of the following steps. After phlebography, in the case of satisfactorily functioning deep veins, the superficial venous system is extirpated according to Trendelenburg, Madelung and Babcock, the insufficient perforants are exposed and ligated, the ulcer is excised deeply and broadly into the intact tissue. The effect is covered at a later date with a semi-thick skin graft. The importance of supplemental conservative methods (preparation and postoperative treatment) is stressed. This complex therapy was applied in 112 severe cases of venous failure; in 96% the result was excellent, in 3% adequate and in 1% poor. The guiding principles for the successful solution of chronic venous failure are a correct diagnosis and a correctly performed operation. Only proper care can guarantee good results.     

Layered shaving of venous leg ulcers

A method for the quick preparation of refractory venous ulcer beds for autografting is described. Irrespective of their clinical or bacteriological state, ulcer granulations and other products of frustrated healing are shaved in layers down to an even and surgically clean base using an ordinary skin grafting knife. Our experience with 32 consecutive patients (58 ulcers) is reported. The mean duration of hospital stay, the patient being completely healed on discharge, was 18.3 days. This represents a decrease of more than 3 weeks when compared to a previously used standard method. No investigation into the question of recurrence was carried out as available evidence, which is critically reviewed, indicates no significant relation between the method of grafting and the incidence of recurrence.     

Analysis of therapy-resistant venous leg ulcers

Chronic leg ulcers represent a major health-care problem with considerable socioeconomic impact. Patients with seemingly therapy-resistant leg ulcers are common to all clinics. The purpose of the present study was to (1) examine a group of patients with nonhealing venous leg ulcers treated with a double-layer bandage and (2) evaluate whether the addition of an interactive hydrocolloid wound dressing could initiate healing in these patients. Twenty-two patients with ulcers caused by venous insufficiency were included. The patients had a mean ulcer duration of 27.6 years. Duration of the present ulcer was at least 1 year (mean >/= 4.1 years). Twenty of the 22 patients showed massive lipodermatosclerosis. Before inclusion, all patients had used double-layer bandage consisting of a zinc-impregnated bandage or stocking and a self-adhesive compression bandage for 1 year or longer without improvement. The new regimen was a triple-layer treatment with the hydrocolloid water applied over the ulcer and the traditional double-layer bandage unchanged. Three patients were dropped from the study. Nineteen patients were followed until healing or for 10 months. Nine of the 19 patients who completed the study healed. Ulcer area was reduced by 70% or greater in 7 patients and by 30% to 40% in two patients. One ulcer did not respond to the treatment and worsened slightly. The results of this study were encouraging and indicate that the triple-layer treatment with the hydrocolloid dressing applied to the ulcer should be evaluated in a randomized, controlled study in patients with less pessimistic prognoses.     

Compression and venous surgery for venous leg ulcers

This article reviews published data on the effects of surgery and compression in the treatment of venous ulcers and the best options for compression therapy. Randomized controlled studies reveal that surgery and compression have similar effectiveness in healing ulcers but surgery is more effective in preventing recurrence. Most leg ulcers have a venous pathophysiology and occur because of venous ambulatory hypertension caused by venous reflux and impairment of the venous pumping function. Proposed surgical interventions range from crossectomy and stripping to perforator vein interruption and endovascular procedures (laser, radiofrequency). More conservative procedures (foam sclerotherapy, conservative hemodynamic treatment) have also been proposed.     

Oxidative stress in chronic venous leg ulcers

Venous leg ulcers are common and cause considerable morbidity in the population. As healing may be slow or may never be achieved, ulcers create persistent and substantial demands on clinical resources. Great efforts have been made to accelerate tissue repair in chronic venous leg ulcers with limited success. This may at least be partly due to the limited knowledge on the microenvironment of chronic wounds. In fact, the tremendous impact of the microenvironmental conditions on the outcome of wound healing has increasingly become apparent. Oxidative stress as a consequence of an imbalance in the prooxidant-antioxidant homeostasis in chronic wounds is thought to drive a deleterious sequence of events finally resulting in the nonhealing state. The majority of reactive oxygen species are most likely released by neutrophils and macrophages and to an unknown extent from resident fibroblasts and endothelial cells. As the inflammatory phase does not resolve in chronic wounds, the load of reactive oxygen species persists over a long period of time with subsequent continuous damage and perpetuation of the inflammation. In this article, we will critically discuss recent findings that support the role of oxidative stress in the pathophysiology of nonhealing chronic venous leg ulcers.