ceap 5 6 hastalar icinperforator ablasyon
TRANSCRIPT
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Dr.İBRAHİM ERDİNÇKALP VE DAMAR CERRAHİSİ KLİNİĞİ
İZMİR BOZYAKA
EĞİTİM ve ARAŞTIRMA HASTANESİ
CEAP 5/6 HASTALAR İÇİN CEAP 5/6 HASTALAR İÇİN PERFORATÖR ABLASYON PERFORATÖR ABLASYON
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Ulcus cururis cerrahisinde esas cerrahi amaç
Yüzeyel ve derin venöz basıncı azaltmak ve perforan venöz icten dışa olan kaçısı(yetmezlıği) gidermektir.
Kısacası patolojik venöz yapıyı fizyolojik ve anatomik düzene sokmaktır.
Böylece venöz basınc azalması ile ödem azalacak ve doku hasarı azalacak ve ulcus gerileyecek
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Wound Healing: An overviewPlastic and Reconstructive SurgeryJune Supplement 2006
Tarihçe
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Günlük bakım Dermatolog desteği Hasta eğitimi Ek hastalıkların kontrolü Vs…..
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Mini-insizyon ile Ligasyon ve SEPS
AVANTAJLAR1- Yatış süresi bir gün
2-Tümessent veya spinal anestezi ile minimal invazif yöntemler
3-Yara veya enfeksiyon komplikasyonları az/yok
4-Kısa cerrahi girişimler(20-25 dakika)
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SEPS ÖNCESİ SEPS SONRASI DÖNEM DÖNEM
Picasso
Meninas
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Hauer 1985
Tarihçe
O’Donnell 1992 (CO2 insuflasyonu)
Conrad 1994Gloviczki 1996 (İki port tekniği)
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ANATOMİ
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CEAP Clinical Classification CEAP Clinical Classification
ClassClass Clinical IndicationClinical Indication
00 No visible or palpable signs of venous diseaseNo visible or palpable signs of venous disease
11 Telangiectases or reticular veinsTelangiectases or reticular veins
22 Varicose veins Varicose veins
33 EdemaEdema
44 Skin changes ascribed to venous disease (eg, pigmentation, venousSkin changes ascribed to venous disease (eg, pigmentation, venous eczema, lipodermatosclerosis)eczema, lipodermatosclerosis)
55 Skin changes as defined here with healed ulcerationSkin changes as defined here with healed ulceration
66 Skin changes as defined here with active ulcerationSkin changes as defined here with active ulceration
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Mayıs 2003 ile Kasım 2011 Toplam 438 SEPS
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SEPS Endikasyonları
*CEAP Sınıflandırmasına göre:
C5 (İyileşmiş venöz ülserli)
C6 (aktif venöz ülserli) hastalar
Primer perforan ven yetmezliği• !
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SEPS Kontrendikasyonları*Rekanalize olmamış akut veya kronik derin ven trombozu* Aterosklerozis obliterans*Tromboanjitis obliterans*Diabetes mellitus*Morbid obesite*Aktif enfeksiyon varlığı*Bacakta anatomik deformasyon*Büyük doku kaybı
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OPERASYONA UYGUN OLMAYAN VENÖZ ÜLSER
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AÇIK TEKNİK BAŞARISIZ GREFTLEMEAÇIK TEKNİK BAŞARISIZ GREFTLEME
OPERASYONA UYGUN OLMAYAN VENÖZ ÜLSER
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SEPS’in üstünlükleri
Yara bölgesinden uzakta küçük insizyon ile yapılabilmesi
Mükemmel görsel kontrol Ayaktan hasta prosedürü Kanamasız bir saha Nüks ve enfeksiyon oranı açık tekniğe (Lİnton
op.) oranla düşük 1 Gloviczki P, Yao JST (editor) Subfascial endoscopic perforating vein surgery. In: Handbook of Venous Disorders Guidelines of
the American Venous Forum, 2nd Edition, Kent, Arnold Publishers, 2001; pp 391-4002.Lee DWH, Lam YH, Chan ACW, Chung SCS: Subfascial endoscopic perforator surgery for venous ulcers. Hong Kong Med J 2003; 9:
279-823.Gloviczki P, Bergan JJ, Rhodes JM, Harmsen WS, Ilstrup DM: Midterm results of endoscopic perforator vein interruption for chronic
venous insufficiency, lessons learned from the North American Subfascial Endoscopic Perforator Surgery Registry, The North American Study Group. J Vasc Surg: 29; 489-502
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Balloon dissector system (Spacemaker-240®,Tyco-Healthcare®, USA) 5 mm clip applier (EndoClip®, Auto-Suture®, USA)
Araçlar
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SEPS
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TEKNİKTEKNİK
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SEPSSEPS
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SEPSSEPS
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SEPSSEPS
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ÖNCE SONRA
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ÖNCE SONRA
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ÖNCE SONRA
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ÖNCE SONRA
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ÖNCE SONRA
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ÖNCE SONRA
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ÖNCE SONRA
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40 yıllık venöz ülser ÖNCE SONRA
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ÖNCE SONRA
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Treatment of severe chronic venous insufficiency using the subfascial endoscopic perforator vein procedureH. C. Baron1, M. G. Wayne1 , C. Santiago1, I. Lown1, M. Castellano1, M. Cioroiu1 and R. Grossi1(1) Department of Surgery, Division of Vascular Surgery, Mount Sinai School of Medicine / Cabrini Program, 222 East 19th Street, Suite 2 J, New York, NY 10003, USA
Surgical EndoscopyAnd Other Interventional Techniques Official Journal of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and European Association for Endoscopic Surgery (EAES) Springer-Verlag 2004 10.1007/s00464-004-8124-6
SEPS bütün kronik venöz yetmezlik tedavileri içinde
etkinliğini kanıtlamıştır.
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Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: Lessons learned from the North American Subfascial
Endoscopic Perforator Surgery registry Peter Gloviczki, MD et al.
ortalama iyileşme süresi 54 gün
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IZMIR EGITIM VE ARASTIRMA HOSPITAL, IZMIR, TURKIYE
0
5
10
15
20
25
30
Patients
1 2 3. 4 5 6 7 8 9 10 11 12
Weeks
Cumulative Wound Healing Time
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Subfascial Perforator Vein Ablation: Comparison of Open Versus Endoscopic TechniquesDean T. Sato, MD, RVT1; Charles D. Goff, MD, RVT1; Roger T. Gregory, MD, RVT1 ; Barry F. Walter, MD1; Robert G. Gayle, MD, RVT1; F. Noel Parent, III, MD, RVT1; Richard J. DeMasi, MD, RVT1; George H. Meier, MD, RVT1; and Jock R. Wheeler, MD1
•SEPS grubunda belirgin derecede daha az komplikasyon gözlenmiştir.
•SEPS; kısa dönem sonuçlarına göre kronik venöz yetmezlik ve perforan ven yetmezliğinin tedavisinde etkili bir tedavidir.
Journal of Endovascular Surgery: Vol. 6, No. 2, pp. 147–154. 1999
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Surgical anatomy for subfascial endoscopic perforating vein surgery of laterally located perforating veins Piet A. R. de Rijcke MD , , a, Tejo Schenk MDb, Wijnand B. van Gent MDa, Gert-Jan Kleinrensink PhDb and Cees H. A. Wittens MD, PhDa
Lateral venöz ülserlerde SEPS yararlı değildir.
Journal of Vascular Surgery Volume 38, Issue 6 , December 2003, Pages 1349-1352
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RF ABLASYON
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REDO SUBFASYAL ENDOSKOPİK PERFORAN VEN CERRAHİSİ (SEPS): GEREKTİĞİNDE YAPILMALI MI? Fleboloji Kongresi 2012/ Dr.Mustafa Karaçelik
Residü veya yeni gelişmiş 3,5mm çapın üstündeki Coccket perforan venlerinin gösterilmesi ve venöz ülserin nüksetmesi reoperasyon endikasyonu
Subfasyal diseksiyonlar 10mm lik rigid kamera ile yara bakımı konvansiyonel pansuman yöntemleri Mayıs 2003 ile Kasım 2011 Toplam 438 SEPS 32 (%7,30) venöz ülser nüksü 14 redo-SEPS yapıldı. 9'u (%64,28) tamamen iyileşti. 18 inop olgu yara bakım ürünleriyle 5 yara (%35,72) kapanmadı. Xelma TEDAVİSİ Subfasyal alanda yapışıklık yoktu. Diseksiyon kolaylıkla yapılabildi. Subfasyal alanda eskiden kliplenmiş perforanlar gözlendi. Yeni perforan ven klipleme sayısı olgu başına 1 ya da 2 idi. Teknik zorluk yaşanmadı. Kompolikasyon veya ölüm gözlenmedi.
SONUÇ: Venöz ülseri olup, daha önceden SEPS yapılan, ancak venöz ülseri nüks eden olgularda Redo-SEPS gerektiğinde güvenli bir şekilde yapılabilir.