This video presents two clinical case discussions: (1) Obstructive jaundice in a 50-year-old male with progressive jaundice, weight loss, and pruritus, where the clinical approach involves systematic history-taking, physical examination, ultrasound showing CBD dilation with tapering structure, CT scan for staging, and consideration of portal vein involvement to determine operability; (2) Varicose veins in a 52-year-old male with prolonged standing, where the management includes duplex ultrasound to assess venous reflux, treatment options ranging from compression therapy to radiofrequency ablation and sclerotherapy, with emphasis on understanding pathophysiology, risk factors, and appropriate diagnostic and therapeutic interventions.
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PG CLINICS OBSTRUCTIVE JAUNDICE VARICOSE VEINSAjouté :
Uh professor K sir good evening sir. Uh sir um I request you to run the second case of varicose veins because my network is not that very good today sir.
So candidate is joined and I have trial him. He's able to connect without much of a challenge. There is if I get lost in the connectivity please run the program sir.
>> Done sir. Okay sir.
>> Thank you sir. Thank you. I think we are 8:00. Uh good evening friends. Uh we warmly welcome the invited faculty for the day. We have uh professor Wenger ready sir uh Dr. Johnson, Professor Johnson, Professor Barat and we have uh our own faculty professor Karit Palmer and then um we have two eminent bright students uh one Dr. Indranel kindly contributed by Dr. Samir Reay from KM at SGS Medical College Mumbai and Dr. Cameron is kindly contributed by professor Babu Anthony and professor Anandi ma'am at government Stanley Medical College. So professor kasir good evening sir uh we start the first case the first case will be the obstructive jaundice then the varicose spine for next week we have the portal hypertention today for some reason the boy is still held up in the so uh we will have the portal hypertention case next week so good luck to you uh kindly take over faculty uh Dr. Indranil please introduce yourself, your unit chief, head of the department and then start your presentation. Good luck to you.
>> Thank you sir. Good evening everyone. I am Dr. Indrail from SGS Medical College uh KM hospital. Uh my unit chief is Dr. Samir Ree Sir and my PJ guide is uh Dr. Yogesh Takulkar sir. I'll be presenting today on the topic obstructive jaundice.
I'll be sharing my slide.
Is it visible? Hello.
>> Yeah, we can we can see.
>> Okay, sir. Uh, so this is a case I'm I'll be presenting on obstructive jaundice. Uh, Yeah, please go ahead.
>> Yes, sir. My patient, a 50-year-old gentleman who presented with complaint of yellowish discoloration of skin scara and had trueitis since the past 15 days.
Uh so this 50-year-old gentleman who was a resident of Bihar was apparently all right 15 days back when he noticed yellowish discoloration of skin clear and there was itching all over his body which was insidious in onset and was progressively increasing in a continuous manner. He also had a history of significant weight loss which was 8 kgs in a month the past month.
There was no history of any waxing or veining jaundice or intermittent jaundice. There was no history of clay colored stools. There was no history of past blood transfusions, any malaise or low-grade fever. There was no history of easy fatigability.
Uh the patient did not complain of any sharp pain in the right hypochondric region or any pain radiating to the back. Uh he did not undergo any procedure previously. uh there was no history of ERCP or laparoscopic policyctomy.
He did not complain of hematis malina or silvery stool and did not have a history of early satiety.
Uh he did not have any easy bruisability or pitia over his body. There were no complaints of high fever with chills. Uh there was no disturbance in his sleep, bowel or bladder habits. He did not have any co-orbidities and denied any addictions.
Uh so to summarize it uh my patient is a 50-year-old gentleman who was apparently well 15 days back when he noticed yellowish discoloration of skinclar and proritis associated with high colored urine which was continuously progressive in nature which was not associated with any clay colored stools or fever.
on general examination which was done.
>> Uh can I just hold on there? Go to your summary.
>> Yes sir.
>> Okay. It's only 15 days. No.
>> Yes sir.
>> Yeah. 15 days and then um you're telling there is a proite is but there is no associated clay color tools.
>> Yes.
>> Okay. So what do you think from the history it is? I mean do you think any history is missing in the what is given to you? I think it has been given to you. No. Uh yes. Uh patient did not complain of any pain or like >> any history is missing? Nothing.
>> Uh he did not complain of any pain like localized pain in the region sir.
>> Yeah. So so to summarize it's a painless progressive jaundice. That's what you meant.
>> Yes.
>> Okay. So what do you what do you mean by intermittent jaundice? You said there is no history of intermittent jaundice.
What do you mean? Intermittent jaundice is that in which the berubin levels rises but it falls below the baseline level of 2.5 above which it is clinically evident. So there are intermittent episodes of jaundice preer period in intermittent jaundice.
>> So where do you get that? uh in uh collidocythesis in which the stones are intermittently passed and when the stones are passed there is a jaundice free period after which again if there is a collidocythesis there might be a development of obstructive jaundice yet again >> okay anywhere else you can get >> what is the difference obstructive jaundice and surgical jaundice Obstructive jaundice is there's any obstruction to the bile outflow uh there's in the ber tract and non-surgical jaundice is there might be a hemolytic or a hippatoscellular jaundice which might be the cause of the >> sir asked very I think he asked what is obstructive and surgical difference between obstructive and surgical. Oh, sorry. I heard medical um >> both are same or different.
>> Can you get obstructive jaundice in a patient with a viral hepatitis?
>> Um viral hepatitis patient uh semi No. So that might be a medical.
>> What do you mean by choleistatic jais?
>> There's a stasis to the bile outflow.
That is the the viral inflammation that is uh causing stasis of the bile. So that is the reason the berubin levels increase and the direct bubin rises.
>> So is that a surgical jaundice?
Sir is behind this is a surgical jaundice.
>> No sir.
>> So in at the end of your presentation what do you think it is? It is a surgical jaundice or a medical jaundice or obstructive jaundice. What do you what do you what is your conclusion about this presentation this summary?
>> This is an obstructive jaundice sir.
>> Why did you say obstructive jaundice?
U >> what did there to say after effective jaundice >> there the progressive uh like the jaundice is continuously progressive and uh there was also a history of uh loss of weight so there might be some >> what is that particular feature in your summary which says it is abstract jaundice Which are the points which are favoring which are favoring obstructive jies which are against obstructive jies in the history. We did not have we did not have any history of malice or any past history of blood transfusions or uh any history of uh >> yeah that that's that's all negative history but what you have in the history in the summary what you are seeing what what made you decide it's an objective >> uh the mainly the progressive yellowish discoloration sir uh the high color urine and the blue >> that we can get even in viral hepatitis it can progress or acute hepatic failure anywhere you can get.
one particular feature in your presentation which suggests that it is abstract to jaundice pluritis anything >> yes sir pluritis was present with >> so you know you can get in other cases but it's more typical for obstructive jaw disease so >> so even in viral hepatitis Please if there is severe choleistasis you can get proritis. So that's why the s was asking you whether it's obstructive jaundice or surgical jaundice. Understood.
>> Okay.
>> And clay color stools do you get clay color stools or no clay color to stools?
>> In obstructive jaundice clay colored tools are present but in this particular patient uh we did not complain of clay colored stools.
>> Maybe there was partial obstruction.
>> So and it's a short history. No.
>> Yes sir. So okay. So what do you think it is now? Can it be can it be still intrahypatic stasis?
uh choleistasis he did not present with any fever sir because uh in viral hepatitis fever is >> yeah you didn't mention that that's why I said any anything missing any promal symptoms you never said that okay it was not okay no is no such history here okay >> what is aoloric jaundice what is aoloric jaundice It means in the urine it is not yellow colored.
So scara is yellow but urine is not yellow.
So that can happen in In hemolytic jaundice you know.
>> Yes sir.
>> Hemolytic jaundice you can get the calling jaundice.
Why the urine is yellow in jaundice patient and surgical jaundice or obstructive jaundice?
>> Instructive jaundice.
>> Obstructive jaundice there is an increase in the conjugated berubin which is water soluble and which passes in the urine as a result. uh of the other there is a high caloration of the urine.
>> Okay.
>> Right.
>> Okay. Uh what what do you think your probable diagnosis if it's an objective jaundice? What do you think the cause for that? Do you think it's benign or do you think it's malignant?
based on the based on the history that the patient gave sir he uh had a history of weight loss which was significant along with the progressive prog along with the progressive nature of the jaundice so this might be malignant sir >> so when you say progressive nature of the jaund days did the patient notice that initially it was light colored and now it's a high colored >> yes sir >> why did you ask the history of blood transfusion in this patient >> uh because sir if it is a hemolytic jaundice the patient uh will have uh repeated episodes of blood transfusion in the past in view of anemia and if it is a case of viral hepatitis that's causing jaundice then the blood transmission might be a reason for the viral hepatitis so that is the reason I ask for the blood transmission >> how many days after the blood transfusion the patient get the emoticis >> it's generally a month later sir.
>> H >> uh 3 to 6 months later.
>> 3 to 6 months later of the blood transfusion >> that is that is because of what? 6 to 6 months later when what will be the cause? Usually >> um usually uh after blood transfusion if it is viral hepatitis it might be due to hepatitis B or >> yeah but then initially you can get >> okay within 24 to 48 hours you know once thereis is there >> okay hemotis is because he is there so there's a mismatched blood transfusion is there so within 24 to 48 hours initial PD you'll get because of that and usually after 4 to 6 weeks the incubation period for the hepatitis is about 4 to 6 weeks we will get at that time.
>> Okay.
>> Yeah.
What malignancy do you think in this case? Probably >> uh in this case it might be a per this is most distal colangio carcinoma in this case or a perampler carcinoma might be the reason for this jaundice.
>> Okay.
>> Why you thinking of the permploy carcinoma here based on the history it's a progressive jaundice?
uh mostly it is not going towards peramp because in paramper there's also a history of hematimuses and molina and intermittent episodes of silvery stools are present in perampary carcinoma >> which is more common permpic carcin is more common or caropen is more common is more common >> but this is too short no to have such this thing aspiration H so you may not get that Mina and then waxing and veing in 15 days.
Okay.
U on general examination which was done for the patient in a well-lit room after taking informed consent. Uh the patient was conscious. He was oriented to time, place and person. He was obese with a BMI of 31.25.
He was abrill saturation was 98% on room air.
Respiratory rate was 16 and the blood glucose was 112.
Uh general condition of the patient was fair. Ectrus was present. There was no evidence of any valor clubbing cyanopis lymphnopathy or edimema. uh he had scratch marks present over a bilateral lower limb. There was no foul smelling breath and no additional discoloration or lesions which were present over the skin. Other systemic examination was normal.
Uh on abdominal examination after getting proper consent from the patient and adequate exposure under well condition inspection was done in supine position. Uh the umbilicus was central and inverted. Abdomen was normal in shape. There was no localized fullness, scar, sinus or dilated veins. There was generalized yellowish discoloration of the skin present and all the quadrants were moving equally with respiration.
On palpation uh which was done with the patient in supine position with hips and knees flexed. On superficial palpation, uh the abdomen was soft and non- tender and there was no localized rise of temperature. On deep palpation, there was no palpable lump, no hippatosphere or megaly or no cuff impulses were present over the hernial orififices.
On percussion, the liver span was normal and there was no shifting dness and on oscultation, the normal bowel sounds were present. U I also did a perctile examination for the patient. There was no molina and it was roomy with yellowish tooth staining and normal tone.
So provisionally uh this is a case of obstructive jaundice probably due to malignant ideology after Yes sir.
>> Why do you say malignant ideology? Short history 15 days no loss of weight no loss of appetite patient is obese well preserved. So he was obese but he had lost significant weight. Uh he had a weight of 72 kilos 8 kilos you said no 8 kilos 8 kilos in one man.
>> Okay.
>> U after which I would like to do some investigations for the patient.
>> No we'll stop there. I mean I think need to be >> examination. What do you think your diagnosis now? You should have some provisional diagnosis now. uh provisionally s uh the uh provisional diagnosis of the patient it might be a distal colangio carcinoma it might be a perampillary carcinoma.
>> So if it is a distangio carcinoma what do you what what findings would you expect in this patient one while examining him? uh in uh there might be a lump in abdomen but it would be painless but in this patient the lump would not >> what what what do you refer to when you say that lump what what is your idea behind that lump >> uh it is the the lump might be due to the palpable gallbladder sir >> so if you say distangio now and if you don't find a palpable gallbladder what does it suggest >> it is not completely lumin occluding sir or or else or else it is an obstice. You are saying collangio but gal is not pulpable. So where do you want to put the lesion?
>> It can also be higher up like within black skin tumor or >> that's what what do you want as a first thing what you want? See, it's not seen, not felt is a different thing. With this clinical findings, you should put your lesion first. Now, where do you put above the cystic duct opening or below the cystic duct opening? What?
>> Uh, if it is not valuable, it would be above the cystic duct.
>> So, but you have been telling all all the while it's a distangio. What made you say it's distangio?
with your clinical findings. DR colangio is a distant possibility not the first possibility.
>> Yes or no?
>> Yes. So the distant possibility.
>> So what other reasons can be there uh in in your in your from your clinical examination? What other other possibilities can be thought about?
>> It can be a hilarangopathoma.
Sir, >> okay. Or >> it could be a collidocal cyst.
>> Colido cyst.
>> Yes sir.
>> But 8 kilos weight loss.
>> Why? Why would you say a colocal cyst?
What made you say that?
>> Because of the obstructive jaundice mainly s finding.
>> So what's the primary feature of a gold system? Is it obstructive jaundice or something else?
Does present like this progressive painless?
>> No sir.
>> John this h you said something else. No, you're intermittent on all that something >> presence in sometimes in colonitis and if there's obstruction at the >> yeah is something which is against something which is against okay and unless developed a malignancy in that system and okay what is the gallbladder.
>> U it could be carcinoma of the gallbladder. But uh if the since uh if the carcinoma extends like into the bile duct and obstructs the bile duct then it could cause obstructive jaundice otherwise it could present as a lump.
>> What are the causes of jaundice in carog?
uh there might be some metastasis into the liver or in case of carcinoma gallbladder which might be a cause u there >> how how severe it should be for a metastatic disease to cause obstructive jaundice where I mean see if you there's a metastasis of the liver do we think that patient present with obstructive jaundice >> no no sir >> so where where should be the metastasis True.
>> It should be to the bile doctor in case of um gallbladder carcinoma for it to be obstructive jaundice.
>> Okay. So that's a direct direct infiltration. Would you say we are trying to tell is it that metastasis?
No, it's a direct infiltration.
>> Direct infiltration.
>> So what do you mean by metastasis in this case? Where does where does the tumor metastasize to other than liver?
>> Uh to the lymph nodes to the aot periportal lymph nodes to the per pancreatic lymph node and to the aottocable lymph nodes.
>> So that can cause obstructive jaundice then >> if the spread to the nodes is causing compression upon the bile duct then it can lead to the obstructive jaundice. So in your differential diagnosis after your uh colangocarinoma can you can you think about any lymphodal masses obstructing that bile duct there?
>> Yes sir. If it's a case of gastric carcinoma which is causing periportal metastasis which can cause obstruction and can lead to obstructive jaundice.
>> So now you're saying that this patient has gastric malignancy with lymph nodes.
Is it >> not this patient?
talking about this particular patient.
We are talking talking about this particular patient.
>> What are the other differential diagnosis is the question. So we started there.
>> Okay. So can you think about any lymphodal mass in that area obstructing the bile duct is the question I'm asking.
>> Um there might be a lymphoma but it did not have any u like systemic features there.
There was no lympadnopathy present in other areas of the body.
What kind of limpom are thinking here?
>> What are the causes few known causes for periphortal lymph nopathy? Do you can you remember any >> uh there can be tuberculos and uh apart from that uh it might be distant spread of a tumor.
Uh >> so the question the problem here is you have a patient with obstructive jaundice.
>> You don't have any palpable mass no liver is not enlarged. No palpable gallbladder. Okay. So now you need to fix the location of the tumor right so that's why we are doing this exercise but you started saying that it is distangio which we didn't agree to because if it is distangio we would expect a gallbladder to be enlarged and palpable right >> yes sir >> so now we need to fix the lesion where there is no palpable gallbladder yet patient has obstructive jaundice that's what we are trying to understand yes sir >> yes or no >> yes sir It can be a flat skin tumor sir.
>> Yeah, that you already told. Yeah. Apart from that, any other any other things which you can which can come to your mind is the question.
>> Any disease of the gallbladder?
>> Any disease of the gallbladder?
Um syndrome sir where gallbladder is not pulpable but the gallbladder is not possible then there might be uh polidoctheasis and chronic policy but uh that would be a benign was >> so why are you so why are you so fixed on being it being malignant that's the question I'm asking >> why are you so fixed on it being malignant except for except for his weight loss which is 8 kilos >> according to you apart from that is there anything in the history which says it is malignant or you know not not malignant >> the Yes sir.
>> Whenever you are not clear about your diagnosis, you can always put a differential diagnosis and then you have to say the which is the most likely diagnosis depending upon the findings and the clinical examination. Sir is asking the same thing only that the gallbladder is not pulpable. Then why you want to keep on asking except weight loss?
The things are not clear then you have to put a differential diagnosis.
What is Cor's law?
>> Uh if in a case of obstructive jaundice the gallbladder is partable, it is uh rarely due to a benign cause.
>> Fine. So what are the fallacies of the law?
>> Uh there might be if the gallbladder is palpable in a benign cause it might be due to a double impacted stone one in the CBD and one at the cystic duct. It might be due to me syndrome.
Yes. Yes sir. And another >> patient is having malignancy but gallbladder is not pulpable. Then what are the different causes?
>> That might be due to a flat skin tumor.
Something >> one is flat skin t.
>> Second.
>> Yes sir.
>> Recurrent attack of choleiccyritis. The gallbladder is shrunken.
>> Yes sir.
>> Two three patient might have undergone choleicyctomy. In your case it is not done. I in generally we are discussing about the fallacies of the corver's law where it suggests that there is a obstructive jaundice but gallbladder is not pulpable and the last one is intraipetic gallbladder that where you cannot palpate the gallbladder right >> yes sir >> now back to our case what do you think the since he did not have any previous history of lap policy restrict I mean uh possibility of a benign I mean possibility of a post-operative stricture is ruled out sir and uh we did not have a papable gallbladder so it's going more towards uh causes above the level if there is a malignant cause it is going more towards the above the level of the cystic duct like flat skin tumor and uh it might also be an intriatic gallbladder Yeah, >> let us keep the two diagnosis here and one is the proximal carcinoma and second is the car neck of the car.
>> Okay, let us go ahead with these two diagnosis.
>> What were the investigations done?
>> Yes.
>> So what what you want to do?
>> Investigations, we did blood investigations for the patient. uh the hemoglobin was 12.5 and the counts were normal.
>> So that is the first investigation you want to do the blood investigation in a patient of the obstructive round.
>> No sir I would like to proceed with the sonography ultrasound of abdomen and pelvis.
>> Okay. So what was the report of the ultrasound?
>> Yes sir. The ultrasound showed the gallbladder distended with clutch and the CBD was 18.1 mm at the porta with moderate central IHPR. There was no evidence of any calculi in the gallbladder or the CBD.
>> And what about the pancreatic duct?
>> The pancreatic duct was not dilated sir.
This case in the US findings >> specifically see for that pancreatic duct.
>> Uh yes sir the I mean they did not mention about the but they did mention that the pancreatic duct was not dilated. Uh and that was >> CBD measures 18.1 at border. What about the lower CBD?
>> Uh the lower CBD >> they dilated or not?
>> No sir. Lower CBD was there was tapering structure. A tapering structure was mentioned in the US in the distal CBD part.
>> So with this ultrasound finding what is your diagnosis?
>> Uh based on this there might be some obstruction in the distal part of the CBD s which is the cause of the obstructive jaundice.
So that's the reason you have been biased initially. Huh? So >> kept on saying distangio why so are you happy with the diagnosis I mean the findings which you found on the ultrasound. Are you happy with the are you want to know more further anything more on from the radiologist.
See you mentioned only few points here.
Galbra distended with sludge porta CBD dilated the porta and mil. What else you want to know from this?
>> Um, I wanted to know about the pancreas whether the hetro whether there is hetrogenity in the pancreatic parimea or there is any inflammatory changes in the paranka of the pancreas.
>> Do you expect that in this patient?
Now what do you what do you expect in this patient and are you happy with the entire report or you want to know anything like sir asked what about the distal CBD it's not mentioned here.
So why why that was that that part is excluded in this?
>> I should have included it if the CBD had a tableing structure which was mentioned.
>> No if the findings are written you should have explained it. No why why are you concealing it from us?
>> Yes sir.
>> H >> see you have not written but what are the findings of distb? You have not written here but what are the findings?
uh it uh showed a tapering structure tapering distal CBD the dilotation was present 18.1 which is maximum at the kota but the distal CBD part the size of the the luminal size was uh 8.3 mm distally and if they had mentioned tapering structure >> so gallbladder is distended gallbladder is distended with sludge and CBD is there is a tapering stricture can it be inflammatory stricture post the passage of stone.
>> Yes sir.
>> So what do you expect in a case of benign structure and malignant structure? How do you how will you differentiate these two from the ultrasound findings or radological findings?
Radiologically some malignant stricture would be there would be irregularity if benign structure would be smooth and there will be smooth dist tapering in a case of benign structure and in case of malignant that might not be the case the there might be irregular control.
>> So what's it called? How do how do they describe it radologically? How does a sonologist describe that particular lesion in the distal CBD if it is malignant >> for benign smooth tapering? What about malignancy?
Malignancy has irregular like the stricture which was smooth in case of benign that is not the case in the case of malignant stricture.
>> What is the opposite of that? What is the opposite of that?
Abrupt cutff.
>> Abrupt cut off. Yes sir.
>> Shouldering signs.
Okay.
Since here we are discussing ultra sonography on ultra sonography most of the times it is difficult to comment upon the type of stricture at the distal end of CBD.
>> Yes.
>> Right. So what next investigation would you like to go for after this sonography report?
>> I could have gone for an endoscopic ultrasound sir.
>> Blood investigations.
In the blood investigations were done sir in the blood investigations the total bel rubin was elevated it was 18 and the direct rubin was uh 13 and the coot and hcp were mildly elevated the alp was 770 and the INR was uh I mean it was not deranged based on our reference values sir >> so what is your inference from that bill rupin 18 sgv elevated sgb elevated al what does it suggest?
>> The if the SCOT and FCPT had been uh very like elevated in in the level of thousands then it might have moved more towards hepatitis C. No. What is this?
You you comment.
>> What is the inference of this? You tell me.
>> This you tell >> uh based on this it's an obstructive jaundice due to some CVD pathology based on due to some obstruction at the common bioduct level.
That is the reason the direct pillar is elevated.
>> So SG130 do you think that a significant elevation or non-significant elevation?
>> It is mild elevation. So why why do you say why do you say it's mild when you when you think that it's significant >> in case of hepatitis viral hepatitis C versus the S >> what value what value of SG would would prompt you to say that it is a significant elevation now whatever value you're seeing here is it significant or non-significant >> how do you know that it's normal or abnormal >> more than three uh it is if it is more than three times time the normal level then it is >> so you should also mention the lab normal values here okay otherwise it is of course 130 looks really high but then you should also mention the normal lab values so that for people to understand how much it is elevated understood >> yes >> okay so which particular uh investigation which particular report in investigation would suggest you that it is obstructive jais one particular >> directive >> that suggest that is obstructive joint is >> and the ALP level.
>> Yeah.
So what else you would want to do now?
You have these reports with you.
So what is your next line of approach?
>> Uh based on this uh I would like to stage the patient sir. If uh >> stage you already went to stage. Do you have a diagnos in your hand? Come on.
It looks like you are completely taken with the you know you know the reports.
So you're this is the problem. No see in examination you'll find it really tough for yourself if you if you speak like this. You're jumping to the final reports already. We haven't have a we haven't had a any discussion on that. We don't know the diagnosis that you are talking about staging. What staging are you talking about? What is the diagnosis you have in your hand right now?
>> US is only showing the tapering of the CBD validated CBD. That's it. Sir is asking that what next? How will you diagnose? Then comes the staging. Is it benign, malignant? At what level the obstruction, type of obstruction? How you can make out?
>> With the ultrasound report you showed us, would you want to stage the disease?
>> No sir, not >> then then tell us what what else can be done to identify the problem. No, we haven't diagnosed the problem yet.
>> We know that the buildin levels are high. It looks like an obstructive picture. You have a ultrasound report showing that no IHBRD is there and bilect is dilated. But what is the lesion? Where is the lesion?
>> We can go for a >> we can go for a CT scan of the abdomen sir. C A plus B.
>> CT >> C A plus B sir for this patient.
>> What is A plus B?
>> Abdominal pelvis sir.
>> Yeah please be specific. No we will not understand what it is. Vehicle speeds.
Okay.
>> So why why why kind of CT want a plain CT?
>> No sir. Contrast enhance.
>> Is there any specific way to mention that?
>> Do you want to have just a contrast enhance or more specifically something?
>> Uh triple phase sir.
>> Uh why why triple phase? Because uh tumors are better visible in the portal fac.
>> Which which tumor?
>> If there is any hypatic like uh intraatic collangopathino it is or uh that might be better visible in the portal phase. So that is the reason we go for a triple phase PT.
>> That's such a vague answer. See why do you do a triple phase only to identify intraidangio?
Is it >> what all you expect in if you later on if you want to treat this patient? What all you want to see in the CT?
>> Uh I need to uh look for the lesion first like what is the site of the lesion?
>> Okay. And uh and uh based on the extension into where it is extending if it is uh if it is a mass whether it's extending >> let us be specific no let us talk about this particular patient okay >> okay so whether it's extending into the hpatic artery whether there is abutment of the hpatic artery or the portal vein if it is involving the portal vein so we can get that based on the CT finding what is operability and what is receptivity of the tumor?
>> Uh if the hypatic artery is uh there is more than 180° involvement of the hpatic artery then the patient is termed as uh nonoperable >> only one one feature of that is it only one one feature will say it is operable or >> so you should categorize huh tell tell one two three four points.
Yes.
>> Okay. The these particular points will say that patient is inoperable. So you have to categorize them. Okay. Tell them one by one. Yes.
>> Operability whether it is operable or not.
>> If it is involving the confluence and uh both the bucks if it's a bismouth call it stage four tumor then it is termed inoperable sir.
And uh apart from that if it is involving both the loes of the liver then it is uh termed inoperable sir.
Apart from that uh >> we are talking about this particular patient only. No we why are we going there?
You you know the findings of the ultrasound. You ask for a CT scan.
>> Now you why did you ask for a CT scan to know the lesion and see if it is operable or not? Yes or no?
>> Yes sir.
>> So talk about this particular patient.
Why are we going to confluence >> in this particular patient? the the the CT showed dilated CBD and with abrupt cut off in the distal most part and there were loss of fat PL with the medial wall of the D2 and there were multiple enlarged lymph nodes and the largest of which was 14 mm at the port and uh the SMV and there was involvement of the uh portal vein but it was less than 180 ° abotment of the portal vein.
>> Can you show me the picture? Can you show us the picture? That particular picture where the portal vein is involved Just stop at that point where you feel that portal is involved.
Okay. In this particular picture, can you show us the structures what you see?
Yes, it is.
Can you trace the portal vein? That's what my this thing is. If you can trace the portal when you'll identify that Show us the confluence of the portal vein. First confluence of the portal vein.
Those are much lower because no confluence is higher up.
Stop there. Stop there.
>> Yes.
>> Uh where is the portal vein in this picture? Show point us point towards the portal vein. No, don't don't change anything now. Point towards portal vein.
With your pointer, shows a portal vein.
Which is the portal vein.
Just place it on one point and just say this is portal vein.
This one.
So that is not the portal vein. Sorry.
So see you should also learn reading this. H uh you should not depend on the radiologists. Okay. Now otherwise how will you know whether it's operable or you are the one who is going to operate right?
>> Now just depend on what they say and uh that's a difficult problem for you. H so now so you you what about the report?
Did did they say that the portal is involved?
>> They said that it was less than 180° uh I mean the portal pin was not completely involved. It was less than 180° abotment of the portal vein and the hpatic artery was not involved mentioned in the report.
>> So fat plane between the tumor and the portal vein is not is lost. That's what they said >> between the fat planes between D2 and fat planes with the portal vein >> like less than 180°. Yes sir.
>> Okay.
>> So what do you want to do now?
uh after this I would like to go for the staging of the patient sir since I've localized the tum I would like to go for the tumor marker sir >> I'd like to send CA99 if it is elevated or not >> okay what do you expect in this case >> you said the USC endoscopic ultrasound has been done in this patient >> yes sir >> what is the report of that >> in the US they could not canulate beyond the like uh the distal part of the CBD because they could not reach >> sorry sorry what did you say you you did they try to canulate canulate which which part >> which part >> the dist part of the they mentioned that they could not canulate the dist part >> why do you want to canulate this patient >> why the reason huh sorry huh >> they did not provide the proper report sir for this >> no you you you tell me now why why do you want to do when you did a EU US.
>> Yes sir.
>> You do you want to canulate this patient?
What is the purpose of doing EU? To understand the lesion, right?
>> Yes sir.
>> Okay. Now why why why someone is trying to canulate the patient then?
Would you approve it or not?
>> No, not for us sir. Hm. Would you would you want to do a drainage of this patient ERCP and drainage of this patient before?
>> Um since the total organ levels are in the range of 18 s I would like >> why what what advantage would you get or what what is the issue with that?
it uh however it may lead to like uh more like pre-operative there might be a chance of increased infection and sepsis >> so you want to drain this before because it's also if patient doesn't have any fever it doesn't have any colangitis are why why do you want to drain why do you want to do an ERC in this patient where is the lesion it's the distal CBD that's what you said right >> yes sir more close to the diodnum. Yeah. H >> yes sir.
>> So US you want to do what what is the purpose of EU in this patient? You already had a diagnosis. Why do you want to do US in this case?
Um to US can be done to stage the patient based on the findings of the US.
The depth of invasion can be >> depth of invasion can be found out based on the US findings whether it is involving how how much wall of the bile duct is involved like if it and we can t-stage the patient based on those findings.
>> So your management is going to change with that is it?
No sir.
>> Then >> yes, >> what is the purpose of doing US >> in the CTE? You had a doubt about portal vein involvement.
>> Yes sir.
>> So you want to know whether it's really infiltrating the portal vein or not.
That could be one reason to do an EU.
Or else second reason >> first US was done or CT was done.
>> CT was done.
>> Okay.
Probably you can take a biopsy from that needle biopsy.
>> Yes sir.
>> Yes or no? Because dou di diagnosis doubtful. If you have still doubts about the diagnosis.
Yes or no?
>> Yes sir.
>> So I wouldn't encourage anyone to do a ERCP in this patient because he's not in a colangitis.
He's not in a colangitis.
So unless unless the patient is in fever has fever elevated counts colangitis you know draining drainage of this particular system is not necessary.
Okay.
So, so how what what what is your what is your conclusion about diagnosis? Tell us the type no tumor. Tell us what uh what is your management from this point.
>> Uh based on this it is a distal fangio carcinoma and uh I would like to go for a pancreatic or datadnectomy for this patient because it is in the distal part of the bile.
>> Okay.
So what about the portal when involvement how are you going to deal with that?
uh if it is uh since in this case it was uh less than 180° and reectable so we will resect a part of the tumor surrounding the portal vein and however if it is involving a great part of the port inoperatively then we would uh proceed with grafting PTF graft for the same >> would you not consider any pre-operative new therapy for this patient New juven.
>> What are the criteria for a borderline reectable tumor? Can you name them?
>> Yes. Borderline dissectable tumor uh is a case in which the portal vein is involved less than portal vein is more than 180° involved and the hpatic artery involvement is abotment is less than 180° in those cases you can go for a new chemotherapy before proceeding with the oph So are you happy with the imaging and uh do you want to do a PET scan in this patient >> to find out the distant areas if there is any metaphases we can go for a pet scan.
>> So in this particular case would you want to do it?
>> Yes sir.
Why the CT looks fine? No CT there's no no lesion in the liver.
>> What is what when would you ask for a PET scan?
>> When we are suspecting that the patient might have different metastaples in that case.
>> So your CA 999 comes into play here.
Right. Okay. If you you ask for a tumor marker CA9.
So did you do the test here?
>> Yes sir, we did the test and the CA91 was uh on the higher end of the baseline level. The reference it was >> given how much >> in this case it was the C99 was uh 15 >> 399 was the value is it?
>> C9 was 399.
No, no, no. 15, sir. 15.
>> 15.
>> Yes, sir.
>> Just 15.
>> Yes, sir.
>> What is the normal value?
>> What's the normal value?
It looks like it's less than the normal value.
What is the normal range of C99?
>> 15 is less than normal. No, isn't it?
So then how do you consider that obstet to join patient otherwise also you expect a high CA 999?
Okay.
>> Has your patient undergone USFAB?
>> U no sir they could not they could not canulate and reach the mass. So they could not get a biopsy for the patient.
>> Okay. So histoath I mean the biopsy findings I mean hisystopathological report was not with you.
>> No sir.
>> Okay. So do you can any patient develop chenitis in absence of stone or malignancy in millary?
Do you know any other uh pathology where person can patient can present to you with obstructive joint is still not having any luminal pathology?
Have you have you heard of uh I mean primary primary sclerosing colitis?
>> Yes sir.
>> Why this patient is not having primary scarosin collitis? No multiple in the multiple there were no areas of multiple structures identified in the biod for the patient >> on on which radiological examination you did not find out the multiple uh strictures the in the ULC report so there was the distal only that was mentioned apart from that >> the CT finding did not show any additional strictures in the proximal part sir >> but ultra sonography ultra sonography suggestive of disture with dilated interipetic belie >> yes sir >> so there can be a possibility of sclerosing colitis and I believe MRCP may help.
>> Yes, MRCP was done. I mean Mrp there was uh >> MRCP also showed uh growth in the distal pariampary region and the similar findings as in the CT.
>> Okay.
>> What are the other signs of malignancy on MRCP?
What is double duck sign?
>> Was there double duct sign in the MRCP of this patient?
>> Um no sir, not in this patient. The main pancreatic duct was not dilated.
>> Okay. So what was the size of main pancreatic duct >> in this patient? It was 3 mm.
>> Okay.
So can can this mass be non-malignant?
Can it be inflammatory mass?
Hello Yes sir. Intamatory mass is less likely because the patient also had a history of uh significant weight loss that is moving more towards a malignant pathology >> weight loss per say only I mean how can you can't it be pancreatic pancreatitis in head region >> but there was but there was no complaint of any uh epigastric pain or similar to pancreatitis there was no complaint of pain radiating to the back as is a typical finding in see a head of panca.
>> So that's why I mean you need a definitive diagnosis before you proceed for definitive treatment that can be a possibility. Do you think any other kind of chenitis can present like this apart from sclerosing colitis patient of your I mean your patient is a 50 year old male can there be other possibility than sclerosin colitis no malignancy no stone obese patient >> there can be a benign structure >> main structure but what can what can be the ideology >> so there is a autoimmune chenitis >> though it is uh and it is becoming quite uh I mean detected very commonly now onwards >> so uh you must keep a I mean differential diagnosis like this.
>> Yes.
>> So the more important question is if there is a permpularary mass or mass in the distal CBD the hystopathological or biopsy diagnosis is indicated before you go for any definitive management like pancreatic or diodenectomy.
>> Yes. Yeah. That is what I want to convey.
That is why I'm scared.
The traditional teaching said that it's a radological diagnosis. You can carry on with the pancreatic.
But in the recent era when you have all the investigations all the modalities like endoscopic ultrasound you can go for you must confirm the pathologically then proceed for procedure.
>> Okay. So uh so what is your plan now?
You have this want to you want to do a US and then do biopsy or you want to go and resect it? I would like to go for a US car biopsy sir and based on the report if it is uh proven malignant then I would like to proceed with the definitive uh resection.
So what are the ways you deal with the portal vein here? So you already had infiltration.
You said one one method is to put a graft. What are various options you have to deal with that lesion involving the portal vein?
>> Already ask you why why don't you go for new aduent chemo?
If it is uh borderline resistable then we can go for new massage.
So what is the challenge for you to do new chemo in this particular case?
What is the challenge for you to give new advent chemo or else we'll just start it tomorrow?
>> No sir. We need to also look for the nutritional status of the patient.
>> He's well preserved. You saw you told us you know we know that he's well preserved. What else?
And there might be some complications due to the gases. There might be uh some bleeding episodes or >> so tomorrow morning you would want to start him on your joint therapy.
>> What is what will prevent you or what are you okay to go? Go ahead. Would you like to optimize the patient for the NCT?
>> Yes sir.
>> What optimization? What are you thinking about?
>> U firstly the nutritional status which in >> nutrition is good. We know nutrition is good. I'm not worried about nutrition.
Next >> John.
>> He's an ic patient. He's a jaundice patient. Would you want to start him on chemo chemotherapy immediately?
>> Yes.
>> Is it okay?
>> No sir, we would like to reduce it possible. But in this case the mass which would not allow the >> yeah so the mass would not be allowed did not allow you to docp but there are other modalities to decrease no if you want to start if you want to start him on chemo radiation I mean new argument >> we can go for a percutinous transipatic >> uh so first of all first of all if you want to give a new argument his buildin should be less than two right three in fact two or H >> yes.
>> So unless you decrease the buildup levels to that level, you're not supposed to start him on new chemotherapy. H so that's a challenge for you. So how do you want to do it is a different story.
Okay.
Okay. anything.
So you you didn't answer that one question for me. Uh what are other possibilities to reconstruct that portal vein or how do you what are the ways you can can you can remove the tumor from the that is the crux of the problem. No, so you have something involved there you want to go ahead and do the procedure.
So how do you going to deal with it is the question.
We can go for uh primary repair if the defect is small in the SMB after removing the >> how much? How? What do you mean by small? What length?
>> Not sure less than 2 cm. I'm not sure.
>> Sorry.
>> Um less than 1 cm is the defective. uh then we can go for a primary repair.
>> H okay.
>> Uh if it is more uh and more than 1 cm then we can go for a graft placement.
>> What grafts?
>> Uh interposition grafts we can go for a jugular venus graft or a poral venus graph.
>> Vein patch vein patch is a possibility.
vein patch I'm not sure but >> okay so what are the challenges you expect in case of when you when you proceed uh to do a ripples apart from the portal vein in this particular patient And other challenges.
What about the pancreatic duct?
>> The pancreatic duct in this particular patient was not dilated.
>> This 3 mm you said? Mhm.
>> Yes sir.
So what are the challenges for you to do that?
So small duct what are you anticipating like we can go for a like pancreatical gastrotomy because the dog was small in this What are the ways to deal a small duct?
Pancreative vaginostomy, pancreatic gastrotomy.
What else? You can you can think about >> distal pancreattomy but uh >> distal pancreattomy.
>> No but not in >> why why distal pancreattomy? What are you talking?
What do you mean medic to me?
>> Not in this case sir.
>> Now which case you will do that?
>> No.
>> In any case you are not going to do sthing very specific question that you are doing a pancreatic ordintomy and pancreatic duct is 3 mm. So what are the different options surgically if you are doing pancreatic oenostomy?
What are the different methods you know and particularly for the smaller ducts was this patient operated?
>> Yes sir. What was done >> um in this case pancreatic dnic tummy along with pancreatic gastrotomy and hpaticotomy and >> okay so you have to do pancreatic oenostomy what are the different options >> so was portal involved when you operated Yes sir. Uh portal no sir on operation the portal vein was the tumor mass was very close to the portal vein but it was not like aboting the portal ve so we could resect the m by leaving the portal vein intact.
>> Okay.
>> Which arteries uh you liated?
uh the gastroal artery and >> and the superior inferior pancreatic dial artery.
So you lated superior and inferior pancreatic or dural uh I mean separately at the upper and the lower part of the Okay.
>> Okay.
>> Since we were discussing about the portal vein, I would like to ask Dr. Vau, what is your experience of uh this portal vein involvement?
>> Portal vein involvement. Uh actually uh we don't do portal vein resection. If uh the mass is involving portal vein more than uh 2 cm then uh we we refer that patient uh to more uh experience center but up to 2 cm we can mobilize the portal vein and superior mentric vein and end to end anastmosis can be carried out with I mean that is possible but if it is more than 2 cm cmter we don't touch and as a principle if uh tumor is more than 4 cm uh then also we don't touch the tumor uh after downstaging after neoadent t uh therapy if the size is uh not coming down below 4 cm and it is close to I mean unseen process involvement then we don't touch the tumor then again also we refer it to the more experience Thank you.
>> I had an experience of uh doing uh three surgeries uh with portal vein resections.
Uh in one case we could only shave it off by doing a sleeve like you know partial exition of the portal vein.
>> Okay.
>> In one case like Dr. Viber said you could when the when the gap between the uh two ends of portal vein is less about 1 to 2 cm we can mobilize it and then also do end to end anastmosis which I could do in one patient >> and one patient we we removed the uh vein from the neck and then uh did a primary you know uh graft >> patch or >> graft graft the the difficult so we had to use the graft.
>> Okay.
>> We never use I never use other than you know patches other than the graft uh natural way. So >> Okay. Great.
>> Yes. Great. Yeah.
>> Ka sir kil sir is there. Kag sir ka sir.
>> Yes sir.
>> Yes sir. Um normally we allow the candidate to ask any doubts to be clarified in general. Do you have any doubts to be clarified?
>> Um yes.
>> So let me let me conclude first before Indil speaks. Indil I think you were little biased to start with you know you already had your diagnos in your mind.
So you kept on saying dist whereas all your findings were on the contrary they were not supporting your you know diagnosis. First thing. Okay. Number two you should be very categorical in asking your investigations. The investigations are again done in three folds. First one to di one to confirm the diagnosis.
Second to prepare the page the disease and then third to prepare the patient for the surgery or any therapy. So you should you should always answer your diagnose your investigations in that order. So it will be more clear for the listeners also and uh they'll understand how clarity what is the clarity you have regarding the approach to that particular problem. Okay. And uh third thing is um you should be very clear in your understanding about CT scan findings.
You should also have a habit of looking into your CT scans. No, not just depend on the reports. Okay. reports can be very very deceiving.
So if you can really see follow the CT scan you can decide on whether this patient is really operable or not. No and also when you mention don't conceal anything from the >> examiners. You should always show all your findings here. Uh please whatever findings you have you should cons you should not you should not conceal from the examiners. when when they ask for a report you should show the complete report not the ones which you want to highlight. Okay.
>> Yeah.
>> Yeah. These are my observations. I think other examiners can tell their observations.
>> N you did very well. But the s the most important part was that only you should not get biased what patient is having.
Whenever examiner is asking you should always keep your options open. Right. It was not a clearcut case. You should always whenever you are in doubt you always put a differential diagnosis and put the first diagnosis which is most likely and then you can ask the examiner that I would like to confirm by the investigations right otherwise you did well >> yeah it was nice I think uh even in your history part the negative history was so specific I mean you were talking only on in one direction so I think I agree with uh all seniors that you should not get biased right from the meaning you should present a case and have differential diagnosis.
>> But otherwise it was a good presentation. Yeah. Nice.
>> Thank you.
>> So you may ask your question.
>> I had any doubts. Yeah. Please ask.
>> Yes sir. Regarding the pancreatic duct that you were seeing what are the challenges and I wanted to ask about that. So whenever there is the small duct and uh the duct and the gland is so uh soft you know like you know in in this particular case the leak rates are very high leak rates are very high and handling the gland will be a difficult uh task because your sutures will be cutting through and that will be a problem first thing and also when the duct is so thin so small stricture rates also can be higher.
So if you want to do uh uh I mean I at our center we still practice duct to mucosal anostmosis only. So we use loops and then do sixo uh sutures you know to do the anastmosis. So that's how I I do. So there are other centers where they do dunking.
>> Yes. Dunking is inserting the pancreas into the junum or into the stomach and doing a mass leure like you know anastmosis. So that is also a possibility. So the leak rates are higher, the stricture rates are higher and the anastmotic disruption rates are higher when the ducts are small and the gland is so soft. So this is one of the most difficult scenarios for any pancreatic surgeon to operate upon.
Okay. So that is the reason why I was insisting on for you to understand these things.
>> Thank you sir. And when duct is small one one thing I would like to add to sir's explanation that what we do is we take pancreatic parenma to sirrosa suture with the junum and then we take six evering sutures of pancreatic duct.
So that may help in approximating the duct to mucosa very precisely.
>> Yeah. I mean every interrupted and then we may place a small infant feeding tube or so as a stand also we do and we fix the inner uh I mean with proline we fix that uh stent so it helps in sustaining the but yeah when the uh pancrea gland is soft and duct is small it is a difficult situation very difficult situation >> one one other technical when the gland I agree with yeah >> yeah one other technique we do when the gland is so soft is >> just give a shot of octoride >> just before doing the anesmosis that will make the gland little stiffer >> help us in holding the sutures >> one technique which we follow luckily we didn't have very many troubles doing it so far but centers which do uh these procedures in high volumes they very commonly only encounter such situations. So that is one of the you know heal we say know heal of a pancreat pancreative surgery.
>> Yeah.
>> So that is why MRCP is very important to know the duct size. Right.
>> Yes.
And one thing I would like to add is before you plan pancreatic orctomy you have to make sure the any variations of epipitic arterial anatomy. If there is any anomalous vessel coming from SMA right accessory or replace that you have to keep in mind before you proceed. This is just a additional point.
So it's always better to get a triasic CT uh instead of just a contrast enhanced CT because like uh Dr. survivor head all the anatomical variations involvement of the tumor in relation to the artery and veins and also periportal lympadnopathies all these things if you can understand better you can plan your surgery better and then definitely that will help in improving your outcomes >> yes >> thank you sir >> thank you very much uh and other faculty With your permission we move on to the next case. Uh I think today we have all gastroenterologist.
Next case was supposed to be portention and for some reason the candidate could not be here. So portention case is shifted for the next day. So we have a case of swings to be discussed.
I'm sure if you have interest you are welcome to stay back but I will not pressurize you. Thank you for joining today.
>> Thank you sir. Thank you.
>> Thank you. Thank you sir. Yeah, >> thank you sir. Thank you very much for taking time off to help us out. Thank you very much. Please introduce yourself and uh start your presentation.
>> Sure sir.
>> Sir, please take over sir. Thank you.
>> Yes sir.
>> Started with thank you D. Go to the first slate.
>> Yes sir. Just give me a minute sir.
prepared a very good evening to one and all sir.
So I'm Dr. Kamaran third year postgraduate from government Stanley Medical College. So my guides are uh HD professor Dr. Yanandi madam and chief professor Dr. Tab and sir. So today I'm going to present a case of vm. Uh shall I start sir?
Yes please.
>> So my patient is a 52-year-old gentleman Mr. Anandan a Kuk by occupation hailing from Turbalur presented to the OPD with chief complaints of dilated veins over the right lower limb for the past 3 years.
He also has pain in the right lower limb for the past 3 months. History of presenting illness. The patient was apparently normal about 3 years back after which he presented with compliance of dilated veins in the right lower limb for the past 3 years which was in series in onset. Initially started in the right leg above the ankle. Now it has progressed up to the mid thigh region.
It is aggravated by walking and on prolonged standing. It is relieved by rest and liation.
History of pain over the right leg for the past 3 months which is driing type of pain intermittent and it is aggravated by prolonged standing and walking rel by lying down and on resting. Uh he also has history of itching over the medial aspect of right lower leg for the past 3 months. History of hyperpigmentation around the ankle joint for the past 3 months. History of prolonged standing 8 to 10 hours per day for the past 25 years. No history of flex swelling. No of bleeding. No of ulcer fever. No history of difficulty in walking. No history of prolonged immobilization. No history of trauma. No history of abdominal distension. Chronic constipation. No history of breathlessness.
So past history uh the patient does not have a history of similar complaints in the past. He's not a known case of type two diabetes mal systemic hypertension, COPD, CAD or seizures. No history of previous hospitalization or prolonged immobilization. No history of previous major surgeries. Personal history. The patient consumes a mixer diet. He's not a smoker. No of alcohol consumption. The patient has normal bowel and bladder habits. No significant family history.
So summarizing with the history, my patient is a 52 year old gentleman cooked by occupation with history of prolonged standing. Came with complaints of dilated veins along the medial aspect of right leg and thigh for the past 3 years associated with the pain for the past 3 months which is aggravated on prolonged standing and walking.
and relieved by rest and limb vision.
The patient also has history of itching and hyperpigmentation.
He has no history of ulcer. Uh no significant past history. This is likely a case of symptomatic varicose veins involving the right lower limb.
>> You can please go to first slide.
>> Yes sir.
>> What are the risk factors in your patient?
Sir um uh the my patient uh has history of prolonged standing sir. He stands for almost 8 to 10 hours per day for the past 25 years.
>> Okay.
>> So that is a very major risk factor for developing varicus swings in my patient sir.
>> Okay. What are the other risk factors apart from prolonged standing sir?
>> What are the varicose veins? Sir uh uh in case of secondary varicosines if the patient uh had any previous history of a deep venous thrombosis or prolong immobilization it can be secondary to DVT sir >> tell what are the causes secondary varicose ve >> sir causes of secondary vicosines it can be either um um due to increased intraabdominal pressure like u abdom Domino pelvic tumors. In case of females, uh the female might have a giant fibroid or ovarian cyst which compresses the venus outflow which indirectly results in varicose veins. Um they may they might also have iliac thrombosis which again can lead to vicos. Um some congenital causes um like clipronomy syndrome the patient might have varicospins.
Um >> what is the normal physiological cause for the varicose veins?
>> Sir, uh pregnancy is one of the physiological causes for varicose veins.
The gravity compresses the major veins in the abdominal pelvis which results in varicose veins.
>> So your patient is of a primary varicose vein or it's a secondary varicose vein?
uh my patient is likely likely to have a primary varicose swings. He does not give any history uh regarding the ideological factors that contribute for a secondary variation.
Okay.
Can you go to the next slide?
Why is having the pain sir? Um um pain might be due to the uh dependent pooling of the blood in uh lower limb veins uh which ultimately cause stretching of the veins and the patient might have pain towards the end of the day or when he stands for a prolonged period of time or after walking. Uh pain might be also present in a patient uh with the association of DVD. In that case the patient will have bursting type of pain especially in the cough region sir.
The pain might be also contributed by the tissue hypoxia which is ultimately um sequel of chronic venous insufficiency.
>> Can any inflammation can cause that?
>> Sorry sir, >> any inflammation of the veins can cause the pain?
>> Yes sir. uh any associated superficial thromboplitis.
>> Uh the patient might also have pain along the course of the wing. Sir, >> no.
>> Next slide.
>> Yes sir.
Do you know what is Venus cloudication?
>> Sir, uh Venus claudication occurs in a patient um with the deep Venus obstruction. So uh for compensating the venus return uh the patient develops multiple collateral vein channels. So this collateral vein channels are usually able to compensate for the obstructed deep venous system at rest or mild exercise. But when the patient uh is uh exercising out of proportion the collaterals are not able to carry the Venus return. So the patient might develop pain when he's exercising too much and this pain uh is not promptly relieved by rest uh as in uh arterial claication pain. The patient might need to rest for some time and then put his limb into elevation and then after some time the patient might get some relief from the pain.
>> What is the neurogenic claudication?
>> Sir uh neurogenic claudication the patient will develop pain as soon as he takes the first step. So it is this type of pain is relieved when the patient uh exerts some type of posture in which the pressure on the nerve is relieved. Sir go to the next slide.
Why there is itching sir? Um due to uh chronic venus hypertension as in this case the patient uh saying he's having varicose veins for 3 years due to chronic venus pulling that occurs chronic venus insufficiency um and the patient might develop eczema as a complication of this varicose veins so he's having itching >> dermatitis >> sorry sir Dermatitis.
>> Yes, a dermatitis.
>> Yes.
>> Yes. Dermatitis along with itching and redness over the affected area.
>> So the patient sir, >> why there is hyperpigmentation?
>> Sir, hyperpigmentation is due to heosiderine deposition in the tissues.
uh when there occurs chronic venous pooling uh uh there occurs uh capillary damage and the RBCS breakdown and then hemoglobin is getting released and is converted into hemoceterine. So this hemoceterine deposition around the tissues can cause hyperpigmentation sir.
>> Why it is around the ankle region? What is that area called as >> sir? uh this is more common in gus area.
Gus area is the lower oneird of the leg uh especially in the medial aspect of the lower third of limb.
>> Mhm. which is prone for chronic signs and symptoms of chronic venus insufficiency because of its because of uh so many perforators are present around this joint and it is more prone for getting the signs and symptoms of chronic venus inferior >> which is the longest vein in the body >> sir grades of venus vein is the longest vein in the >> why do you get the venus s on the media side mainly.
>> Sir, >> you get the venus ass most of the time it's on the medial side of the ankle joint.
>> Yes sir.
>> What is the reason for that >> sir? Um most of the perforators of the leg are located around the gateus area especially in the medial aspect and >> yes >> and the pressure is also higher when compared to other parts of the leg. It is much higher in this region.
So the patient is more likely to develop an ulcer in the medial aspect rather than the lateral aspects. And there is almost no muscle in that area and it is just sir >> underneath the skin is the very osteal area is there.
>> Yes.
>> That is what is more common in the lower part of the on the medial sides.
>> Yes sir.
>> Okay.
Go to the next slide. Now if there is bleeding from the vicles vein is there what should be done? Immediate treatment.
>> Sir uh we should uh compress the bleeding site and elevate the limb sir.
uh most of the times it is able to settle on its own.
>> If at all if the bleeding is not settling we have to intervene sir. But most of the times it is just compression and elevation of the limbs.
>> Okay.
Next slide.
Is the family history still makes any difference?
>> Families does it run in the families?
>> No.
No sir.
>> It runs in families.
They run in families. Yes sir. Do >> you know what is the incidence of the varicose veins in the general population?
>> Sir around 30 to 40% of the population have varicose veins but most of them are asytomatic.
>> Yes.
But almost about half of the population they have got the vices.
>> Yes sir.
>> What is ambulatory venous hypertension?
>> Sir normally the Blood in the lower limbs is getting pumped higher into the uh central venous system by three mechanisms. One is due to the pumping mechanism of the thigh, cough and the food and then due to intrathoracic pressure that becomes negative during inspiration that is venus return and that is the pushment mechanism exerted by the arterial system. So when normally the venus pressure at the lower end of the leg is around 80 to 100 mm of Hg in standing position. So when the patient is walking the cough pressure rises to 200 to 300 mm of mercury. This increase in cough pressure uh pushes the blood from superficial venous system into the deep uh Venus system. And when the cough muscle is getting relaxed, the blood from the superficial uh venous system is getting pulled into the deep venous system. And uh there is a fall in the superficial venous system pressure from 100 to around 30 sir. But when the uh valves are incompetent, when the perforators are incompetent, this uh um mechanism does not happen and the pressure in the superficial venous system does not fall to 30 which is normal and then it it remains high and the blood is not getting emptied into the deep venous system. So when the patient ambulates the pressure does not fall in the superficial venous system.
This is known as ambulatory venus hypertension.
Okay. How does that correlate clinically if there is a increased ambulatory venure is there?
Sir, um it is demonstrated by modified peris test sir. Uh >> uh what pathology will occur in a patient who has got a increased ambulatorous pressure?
>> Sir, >> they are more likely to develop the venus ulceration.
>> Yes sir.
>> Okay. So the C6 disease which is there >> Yes. It is more common with a higher ambulatory special.
>> Yes sir.
>> Okay.
Go to your next slide.
Anybody wants to ask any question?
Dr. Permar.
>> No sir, we can continue.
>> Okay.
Go on the examination now.
>> Yes sir. So moving on to examination.
General examination. After getting concerned the patient was examined in a well lit room with adequate exposure below the amicus in standing and lying position. The patient is conscious oriented a fibral hydration fair well built and well nourished. No porous clubbing sinosis. No generalized lympadinopathy or pedalma. The vital signs are stable. Pulse rate 85 per minute. Blood pressure is 120 by 80 mmg.
Respiratory rate is 16 per minute. Um saturation in rumor is 99%.
So examination of the right level. On inspection, attitude of the limb remains neutral. No visible discrepancy in size when compared with the contraateral limb. No visible deformity. Dilated and torturous veins over the middle aspect of the right lower limb from ankle till mid thigh. No dilated veins along the posterior or lateral aspects of the lower limb. Hyperpigmentation of the skin noted over the middle aspect of lower one third of the ankle. No ankle or legade edema. No redness. No also no scar. No lipodomat sclerosis. No malular hair. No visible cough impulse seen at suffinous opening. The gate of the patient is normal. No loss of hair. No brittleleness of page. So this is the clinical picture of my patient.
So moving on to palpation. The inspector findings are confirmed. Uh palpable dilated veins present along the course of the great suffiness system up to mid thigh. No local warmth tenderness. No thickening of veins. No thickening of skin. Uh sorry sir I forgot to add. Uh no pitting edema in this patient.
Uh modified birthday dilated veins present. Um but there was no pain which suggests the patient does not have a deep penis thrombosis. Broady Tendalenberg's test one positive. Um SFG incompetence is present. Uh Tendrenberg's test two positive perforator incompetence is present. Mars is cough impulse impulse filled in the suffiness opening.
Multiple tunic test positive at at above knee and below the knee indicates perforators incompetence. PR test bulging of perforators noted above and below. Fe test multiple defects noted in the deep fasia along the axis of the dilated veins. Fourth question shorts test positive on oscultation no bruy or venus in heart examination of the left lower limb normal no dilated veins.
So the neuro neurom motor examination and arterial pulse examination of both the limbs. Sensation remain intact in both the lower limbs. No discrepancy in mid thigh and midcuff pul between both the lower limbs. Range of movements is full in both the lower limbs. All peripheral pul arterial pulses are palpable in both the lower limbs. Other system examination CVS to her no mus is normal. Per abdomen soft bowel sounds no tenderness. No palpable mass in the abdomen focal neurological deficit.
Summarizing a 52-year-old gentleman cooked by occupation came with complaints of dilated veins along the middle aspect of the right leg and thigh for the past 3 years associated with pain for the past 3 months which is aggravated on prolonged standing and walking and relieved by resting and limb elevation. The patient also has history of itching and hyperpigmentation. Um there is no significant past history. On examination there is dilated and spins.
along the middle aspect of right leg and thigh. There is associated hyperpigmentation around right lower one third of lip trends test one and two were positive multiple tonic test was positive above and below knee there is no answer so my diagnosis for this patient is right lower limb primary varicose veins with sophomore junction incompetence and incompetence of above and below perforus. Uh the C classification comes out to be C symptomatic 4A uh EP A superficial P uh plus perforator and P is the reflexer. Sorry for to add.
Okay. Can you go to the special test which you have done? Go to that slide.
>> Yes sir.
>> Yeah. Go on telling about what did you do in the modified birth test.
Uh sir um in modified birth tests um we identify uh for every other test we have to empty the veins by milking of the veins for this modified pist we don't do that uh we just identify the sophus opening and then we uh tie a tonic just below the sapino junction and then we ask the patient to ambulate for 1 minute sir uh if there is any presence of deep venous thrombosis Um the patient will feel bursting type of pain in his calf which is a subjective response and then u the uh we will be able to uh observe the uh engulgement of previously existing varicosity which indicates that the patient is likely having a DVD.
>> Okay. Yeah. Broadly tendber one and two.
How did you do that? In trend's test one, we make the patient uh lie down flat and then u elevate his limb and milk the veins and empty it. Identify the sophomoreal junction and then tie a tonic key just below it and then we ask the patient to stand up and then we observe for any rapid filling I'm sorry we observe for uh any gradual filling of the uh veins from below downwards which indicate this is more of a uh inference of a test two by this we can uh infer that the patient is having perforator incompetence. Uh if at all he does not develop any gradual Venus filling from below downwards, we release the tonic above and then there occurs rapid retrograde filling of the great sufferous mean from above downwards.
This indicates the patient is having a sufferal junction incompetent.
>> Okay.
Moricia cough impulse.
>> What?
>> Sir Morris cough impulse. We again make the patient lie down and then we ask the patient to cough and then observe at the sophinus opening area uh for any appearance of any swelling which indicates the patient might have a safmeral junction incompetence gain sir >> in which case the mar is positive >> um the patients who have subarics >> okay >> will have Maris cough is positive sir.
>> Yes we will get a there will be v sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw swelling in the seas regionally.
So what is the differential diagnosis of that verics >> sir? Um >> yeah femoral hernia can can be one of the differential diagnosis in which case the femoral hernia will be more medial than the sophina. Sir.
>> Mhm.
>> Also in safaris the patient will be having associated dilation of veins over the thigh and leg regions. Sir in case of a femoral hernia the patient most likely will not have varicos.
>> Any other var can be there apart from the sephinoics.
>> Sir patient can also have lymphics sir.
>> Lymph good.
Okay. Multiple tuning test.
Multiple multiple tunic test you applied >> sir. Um four tum sir. Uh one uh above the ankle um below knee above knee and one just below the sophus opening sir.
>> Mhm.
>> And then um uh we remove the tunic from below upward s. Um uh the if the dilotation of veins is seen above the tunic that region uh has a perforator incontinence sir >> red test >> sir uh perhaps test um we tie and we ask the patient to lie down empty the veins and then we tie an ashmark bandage from below downwards uh until the sophus opening and then we tie it tunic just below the sophus opening and then uh we remove the hmark bandage uh to look for any blowouts um along the blowouts in the lower limb which indicates uh the corresponding blowouts areas have perforator incompetence which is again confirmed by fig test by running our fingers along the Venus pathway. Okay. We can feel the effect in the deep fia sir.
>> Do you have thear bandage with you?
>> No sir. We simply tie a cre bandage sir in practice.
>> Yes. So you have to in fact apply the ashmar bandage not the simple that one.
Okay. Okay sir. To demonstrate that.
Yeah.
Okay.
No, please can sir.
>> Yes sir. The next slide please.
>> Yes sir.
>> Next slide.
>> Yes sir.
>> Okay.
So what is difference between Venus ulcer and varicose ulcer?
>> Sir a varicose ulcer. Mhm. uh is primarily due to a solely dilated superficial Venus system. Uh whereas a Venus ulcer can be a stasis equal wherein the patient previously had one Venus occlusion in the deep Venus system and the patient subsequently has developed this ulcer sir. Uh the stasis equal is more prominent in a Venus ulcer. The patient will have uh uh hyperpigmentation, itching uh and then redness along with the alerts.
These signs and symptoms are more pronounced in Venus than >> the next slide please.
>> Yes sir.
>> Next slide.
>> Yeah.
Okay.
So there are how many percentage of the patients can have unilateral and bilateral varicose vein which is common?
Unilateral or bilateral?
>> Unilateral varicose veins are more common.
>> Unilateral is very common. If it is a bilateral then what is the significance of that? Sir if the patient is having a bilateral varicosence we should um probably rule out any abdominal pelvic causes that is responsible for secondary varicose any midline.
>> Yes sir. So sir initially said that second causes of secondary varicose vein you must rule out whenever there is a bilateral varicose vein. Okay. So now how will you proceed further? How will you manage this case?
>> I think we can start with this right sir. Is it is it more common on left side or right side?
>> Sir, varos means more common on the left lower length.
>> The reason for that why it is more common on the left side not sir >> especially it is because of the secondary type of the vicose veins which are there. Okay. Because of the compression of the iliac veins by the iliac artery. What is that called as >> sir? Moral cockit syndrome sir.
>> Yeah mal.
So mainly because of that reason it is more common on the left side as compared to the right side.
>> Now this se classification which you have given.
>> Yes sir.
>> What is 4 a?
Uh sir four is um when the patient is having eczema sir >> does your patient has the eczema?
>> Yes sir. Uh but the patient is having hyperpigmentation. Um and then um he also has itching.
>> Okay.
>> Yes sir.
>> What is 4C?
>> Sir uh 4 C is coronasia sir. fan shaped pattern of injectia reticular vessels present over the medial malular regions.
>> So what is the significance of that 4D corona?
>> So so that is the patient is already having an advanced venus disease.
Initially in the last se classification where was the this one corona >> corona was in the C1.
>> Okay. It means it is a very initial phase but then it was found that it is not a spider veins or the reticular veins which are there but it is a advanced disease where there is very high chance of having the ulceration that is why this corona came into the four C.
>> Yes sir.
>> Okay. Yeah.
Okay. Go to the next slide.
So >> your diagnosis is here. There's no differential diagnosis.
>> There's no differential diagnosis or you want to give any differential diagnosis >> sir? No sir, I'll go with varosine s.
>> Yeah. Okay.
So how you are going to go ahead >> sir? Um sir I'll proceed with the basic investigations. First of all, >> have you looked for the ABPI in your patient?
Have you looked for ABPI in your patient >> sir? Um, no sir.
>> Do you think it should be done?
>> Sir, ABPA.
Yes sir. Should be done in patients with genus to rule out arterial insufficiencies which can often coincide.
You should always do the ABPI you know in all the vicles because the treatment may also differ >> depending on the ABPI.
>> What is the normal ABI >> sir? Um more than.9 sir >> up to >> up to 1.3 can be up to 1.3 sir.
>> If it is more than 1.3 what does that mean? Sir if it is more than 1.3 it indicates the calcification of the arterial walls arterioclerosis can be present sir the atrial sclerosis is there that is more likely to be the higher API >> yes sir >> okay so you done the duplex ultrasound in your patient what do you understand with duplex >> sir uh duplex ultrasound is a combination of um B mode ultra sonogram plus Doppler ultra sonogram sir.
>> Okay. What you want to see by the B mode and what you want to see by the >> uh B mode ultrasound is the grayscale imaging that we see sir. We see the anatomy of the veins. Whereas Doppler ultrasonog is mainly for the to identify the normal flow and reflex if any present sir mainly to understand the flow and reflex of the venus systems. So function of the venus system sir.
>> So what are the things you want to see on duplex ultrasound in the case of vico vein? Sir um we have to mainly see the patency of the deep vener system if there is any uh DVT present or not sir.
Um we look for uh any reflex um that is present uh in the SFG, SPG and perforator sir. And then if the reflex is present, we have to grade the reflexer. And uh we'll also look for any complications like thromboplimate is associated with vicus spins. Um we can also look for any uh secondary causes that attributes to this varus pain. Sir, >> so when do you say that the sepumal junction is incompetent?
Sir um um the patient is asked to stand and then u the ultrasound probe is kept over the uh safal junction area. Sir uh uh we ask the patient to do a vala maneuver or we gently compress the uh cough area of the affected limbs. Um uh this um creates uh an augmented flow in the sophomore femeral junction area which is normally heard as a whoosh sound in Doppler. Uh we can see the flow as a bluish uh flow in the monitor. uh if the uh SFG is incompetent that is reflex of the u forwardly push blood back into the suffinous vein sir. So this is indicated by color change from blue to red sir >> but when do you say it is incompetent?
So normally uh um the reflex can be present up to.5 seconds. If it is >> 5 seconds >> more than.5 seconds >> 5 seconds then you say it is incompetent.
>> Yes sir.
>> Right. And how do you say there's a perforator incompetence is there if it is more than.3 seconds is there okay >> and the defect in the deep fasia is more than 3 mm in size then you say that particular perforator is incompetent.
Yes sir.
>> Okay. So more than.3 seconds and 3 mm defect in the deep facial.
>> Yes sir.
>> Do you measure diameter? Yeah please.
Yeah carry on.
>> That was that was also I was asking what is the importance of diameter of sephanophimmeral junction and the great senus vein diameter.
Sir um it helps in determining the modality of treatment which we are going to choose sir if it is a very grossly dilated more than um to >> feal junction up to what is considered normal size >> up to 5 mm >> up to 5 to 5.5 mm it is considered normal if it is more than that >> when it is significant sir >> how it is sign if if uh diameter is 7 mm and diameter is 12 mm what change it will make what is the importance so you should always look for the sephanopmoro junction diameter >> yes sir >> first to confirm the reflux taken to for the management point of view.
>> Yes sir.
>> Right.
>> Yes sir.
>> Sir you were asking something.
>> Yeah >> m what how do you define the varicose veins?
So varicose veins are uh dilated uh elongated and torturous superficial veins which are more than 3 mm in size with a demonstrable reflexer.
>> Okay. Now tell if you want to measure the GSV diameter which is the best place to measure the GSV diameter.
Sir, usually we take mid thigh level in the mid size of that.
>> Okay.
So, what was the finding in your patient?
>> Sir. Yes sir. So, Doppler of my patient right lower limb superficial Venus system. The great suffiness vein measures to be 8 mm in diameter to be incompetent with the grade two reflex. The short suffenous vein measures 4 mm in diameter with the competent sufferial junction with no reflex. Two incompetent perforators noted one above the knee and one below the knee along the medial aspect. The deep pen system is found to be patent.
No evidence of DVT arterial system triasic flow pulsatile left lower limb normal study. Sir, >> what is the inference?
Sir uh my patient is having right lower limb varicose veins with the sapino femoral junction incompetence and perforator incompetence above and below the knee sir with the latent deepen system >> deep are normal.
>> Yes sir deep system normal no evidence of dity.
>> Okay.
So what else you want to do? Any other investigations for this patient?
>> Sir, other basic investigations that we usually do for a pre-operative assessment sir.
>> Okay.
In case if the deep veins are not patient, >> then what other investigations can be done?
The deep fins are not written. Venoggram can be ascending or descending.
Venoggram can be done. Sir can be done. Anything else?
Any other just for sake cardiography can >> no in the limb.
What are other things which can be done?
It is not the practical one just for the investigation sake I'm asking otherwise the duplex is the one only investigation >> sorry >> okayography can be done you can measure the ambulatory vess pressure.
>> Yes sir.
>> You can use the colloid studies.
>> Yes sir.
>> What is ivas?
>> Sir >> it is intravascular ultrasound.
>> Okay sir.
>> Yes. In the cases of the deep pins problem which is there for the patient where the recurrent problem is there then in those cases you can go for the IO strategies.
Yes sir.
>> Okay.
So based on this you will do the routine investigations and you find everything is normal. So what are your plans now?
>> Sir we can do proceed with the radio frequency ablation for this patient. Sir both the both the superficial veins are dilated and incompetent.
Sir uh we can >> is competent. Okay. SPJ is competent. No reflux.
>> GSV SFJ is incompetent. Okay.
>> Yes sir.
>> What are you going to do?
>> So radio frequency ablation for this patient can be done.
>> Okay. For both GSV and SSV are both great sephus vein and the small zapus vein.
Sir um if uh both sopus systems are affected we can still 4 mm and even on the clinical picture also you can see that in the calf area there are prominent veins are there just show the picture >> sir see here on the cuff area you can see >> yes sir yes sir >> because of a short surface system sir So you have to also tackle that also.
>> Yes sir.
>> Only tackling the GSP will not help.
>> Yes sir.
>> Yeah.
So >> sir we can proceed with.
>> Can you do the RFA or the short seance system also?
>> Yes sir.
>> It can be done.
>> Yes sir.
>> Okay. What are the other various techniques which are there >> sir? Um minimally invasive techniques.
So we have two >> is a minimal engine technique is it?
>> Yes sir.
>> Yes sir. Mineral. Yes.
>> Yes sir.
>> What are the techniques >> sir? Other techniques we have endovvenous laser ablation sir.
>> Yes.
>> And then we have ultrasound guided forms clear theapy sir.
>> Yes.
>> And then we have a mechanochemical ablation and then we have endovvenous glue application sir.
>> Good.
Now what is a tissant anesthesia?
um to anesthesia we forla and rfas um it is a mixture of uh 400 ml of ringer lactate with 30 ml of 2% lino and then 10 ml of soda bicarbonate along with adrenalineer um 2% anesthesia along the vein that we are going to ablate mainly to um compress the walls of the vein and to protect the skin of cutaneous tissue from the thermal effects which are likely to cause cutaneous bone circ and then it also helps in hydro dissection of the nose to keep it away from the vein that is going to be ablated >> and um also provides local anesthetic effect sir.
>> Yeah.
So what is thermal ablation and what are non-therrmal ablations?
Sir uh thermal ablations ablations sir uh thermal ablations we have endovvenous slicer ablation and radio frequency ablation sir nonral >> any other you know apart from these two not very common but they can be also used >> sirovvenous microwave therapy >> microwave is one yes >> and then endovvenous steam therapy >> steam therapy can be So they are the thermal ones and the non-therrmal. What are the non-thermal >> sir? Uh non-therrmal we have ultrasound guided form sclerotherapy, catheter directed sclerotherapy and then mechanochemical ablation endovvenous glue therapy sir.
>> Good.
Do you know any non-invasive technique for treatment of the vertical veins?
>> Um high frequency ultra sonogram >> I4 you know.
Yes. Now in your center are you doing the endovvenous therapy?
>> Yes sir. We are doing um radio frequency ablation sir.
>> You're doing that. Okay.
>> Yes sir. As long as we have a indogenous light ablation both of the modalities.
>> So which laser you have?
Sir um radial fiber we use sir laser you know which laser is used >> diode laser >> diode laser yes and what is the frequency of that >> sir uh470 nanometer wavelengths >> 1470 and >> yes sir 1470 is the commonest frequency which is used using 980 You can use the 19 20 also but the comment 1470.
>> Yes sir.
>> When you are putting the fiber inside that what precaution is taken?
>> So not to reach too close to the sophenofmeral junction we have to keep the distal end of the fiber a little bit 2 to 3 cm away from the safinoal junction.
>> Good. Yes. And then up to what level you are going to from which level you are going to approach >> no need to see >> sir from uh knee level we'll make a puncture just below the knee and then we'll introduce the laser fiber 2 cm distal to the can you please mute Okay. Thank you.
How you do that?
>> Up to what level you are going to from where you are going to approach >> sir? From below knee level just below the knee till 2 cm up to the sophomore junction sir.
>> Why not below the knee means more distal? Reason for that >> sir the sophus now lies in very close proximity to the sinus vein uh below the midcuff levels that >> okay because the sepus nerve which is there >> yes sir >> you do not want to give the thermal energy there >> yes sir >> what complications can occur because of the endovvenous treatment >> sir um um the patient patient might develop cutaneous burns if not sufficient or adequate to miss.
>> Mhm.
>> So patient might um develop superficial thromboplabites. Patient might also develop deepenous thrombosis.
What are the various non-surgical treatments for the varicose veins?
Ultra um phone sclerotherapy sir.
>> Okay.
>> And then endovvenous treatments.
>> You know how do you do the sclerotherapy?
>> Sir uh we use um 3% sodium tetrael sulfate. We use tesser technique to prepare the foam.
We take 1 is to3 or 1 is to4 um ratio of sclerosen to the air and then we um agitate the sclerosent with the air uh using two syringes which are connected by a three-way valve um and then we agitate it for uh um 3 to 5 minutes and then we prepare the foam and then u uh using a needle we have to locate the site of sclerotherapy sir by ultrasound variance and then we have to inject the sclerosent into the desired site.
>> Okay. After injection of foam about each time we apply only 2 ml of foam and then we apply tight compression over the area under ultrasound guidance we are monitoring we are keeping a track of where the foam goes and how far it goes.
Sir >> what is the importance of creating foam?
Sir um foam uh is able to encounter a much larger surface area uh when compared with the plane clear sensor and then it displaces all the blood that is existing in the Venus column so that all the foam gets um the whole of the vein gets in contact with the foam cell.
In present day scenario, are there any indications for the open highation?
>> Sir, um in resource board setting we can opt for opt for conventional surgery.
Trenalenburg surgery with stripping of chasing and operator stab >> and also for the very big >> very big yes >> diameter is very >> yes sir >> much more in the case of sapna varics >> in all these cases you may require the open surgery here >> yes sir >> it can be 3 cm up to 3 cm in sephanavar so in that case you might have to go for open otherwise It's all you can manage.
>> Yes sir.
>> Do you know what is the compression therapy for the varicose vein?
>> Yes sir. We have medical grade stockings for uh varicose ve class 1 2 and three.
>> Yes.
>> What is one? What is two? What is three?
Sir one is when the applied pressure is from 17 mm of mercury up to 24 class 2 stockings exert a pressure of about 25 to 35. When the pressure is uh 35 to 40 it is class 3 stockings.
>> What is class 4 where pressure is more than 40 to 50.
Okay. It is usually used for the which type of the cases >> limp.
>> Okay sir.
>> Okay. The lympadema you can use the grade four.
>> Yes sir.
>> Okay.
Any drugs which can be used for the vicose veins?
>> We can use uh pentoxify sir. We can use flavonoids.
Yes, nodes can be used. Penttoxipylin can be used.
Okay, I think you have done so good.
>> Yeah, very excellent.
>> Excellent.
>> Well read. Well read.
>> Yeah.
>> Thank you, sir.
>> Dr. Kagwell, sir.
Dr. So can I get well?
>> What are the complications of sclerotherapy?
>> Sir um sclerotherapy patient might develop allergic reaction to the injected uh sclerotherapy patient might um develop skin pigmentation or skin ulceration. Sir Patient might also develop superficial thromoflabetes.
Um or some part of the form can dislodge and cause DVT. Sir >> you know what is Venus gangrine?
>> Sorry sir.
>> Venus gangrine >> sir. Venus gangrine um is the one which occurs when both the superficial and deep venous system of the limb are totally obstructed uh leading to a totally impeded venus outflow. Uh there occurs severe congestion of the limb and there occurs severe hypoxia the patient might develop gangrines.
So that is why doing before doing any procedure for the superficial varose veins we should always go for look for the deep vein patency under Doppler right?
>> Yes sir.
>> What is biscard's regime? Sir Biscard's regime um sir 5 years sir uh we have to elevate the limb sir and then we have to make the patient exercise and then uh we have to educate the patient about the disease we have to evaluate the disease sir and then we have to apply elastic elastic compression to the rims before you do this in which case you will like to evaluate the heart of the patient.
Sorry sir I don't it >> any any condition where you will not like to give this sclerotherapy >> sir patients with a right to left shunt such as ASD uh >> patent for a >> yes sir >> if the patent for a is there then in that case there can be the paradoxical emolism there and >> so you should not do that.
>> Yes sir.
Can the sclerotherapy cause the blindness?
>> Yes sir. It Yes sir. If uh the patient develops parad par paradoxical embolism it can lead to blindness.
>> Yes it has been reported. Yes sir.
>> There can be blindness after that the scale of therapy.
Okay. Dr. Can I Dr. Can?
>> Huh?
>> We can stop.
>> Sir was telling that there might be some issue with the this thing uh his uh uh network or all something like >> Okay. Okay. Okay.
Governor, you want to ask anything from me or Dr. Parma?
I must say that you have done extremely well. Extremely.
>> Yes. Yes. Yes. Yes. We must admit that you have done extremely well. You are well read and you know the things. Very good. Excellent.
>> Thank you sir.
>> Okay.
>> So if you don't have any question sir.
>> Yeah we can call up now. Yeah.
>> Yeah. Yeah. Dr. Kane is Dr. Kane are you there?
I think let us say goodbye.
>> Yes sir. Bye-bye.
>> Bye-bye. Bye-bye.
>> Yes, sir. Thank you, sir.
>> Thank you.
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