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Common Operations
 LYMPHOEDEMA
WHAT IS LYMPHOEDEMA?
Lymphoedema is swelling which is due to a build up of protein-rich fluid (lymph) in the leg. Normally this fluid is drained out of the leg through a network of tiny tubes (lymphatics). Usually the swelling of lymphoedema is more noticeable at the end of the day and goes down overnight. Lymphoedema is not life threatening but can be very distressing. It can also lead to complications.
Lymphoedema may affect as many as 2% of the population of the United Kingdom.
WHAT CAUSES LYMPHOEDEMA?
The most common cause of lymphoedema is being born without enough lymphatics. If there are very few lymphatics, then the swelling may start as a teenager or even earlier. This type of lymphoedema is called Milroy's Disease. One leg is often worse than the other and sometimes only one leg is affected.
In less severe cases, the lymphatics may be able to cope initially and only start to fail as you grow older. This kind of lymphoedema is sometimes called Lymphoedema Tarda.
ARE THERE ANY OTHER CAUSES?
Lymphoedema can also be caused if the lymphatics of the arm and leg are damaged by surgery or radiotherapy for the treatment of cancer. Sometimes this is unavoidable if the cancer is to be cured. It is made worse if infection affects the superficial tissues.
There are also some rare tropical parasites (Filariasis) that invade and block the lymphatics. These parasites do not live in Great Britain.
WHAT TESTS ARE REQUIRED?
Specific tests for lymphoedema do exist but usually the diagnosis is made by exclusion of other problems. These include heart, kidney, blood protein and vein abnormalities. Veins which are blocked or have leaking valves can cause similar swelling. A venous duplex scan, which is an ultrasound investigation, may be carried out to exclude venous problems before a diagnosis of lymphoedema is made.
WHAT EFFECTS DOES LYMPHOEDEMA HAVE?
Apart from the uncomfortable and unsightly swelling, lymphoedema can cause problems. There is an increased risk of infection under the skin (cellulitis) and repeated attacks of cellulitis lead to more lymphatic damage. This vicious circle may eventually lead to severe infections, ulcers and even amputation in extreme cases.
TREATMENT
Lymphoedema cannot be cured but it can usually be controlled so that complications do not occur later. The mainstays of treatment are compression bandages or stockings, elevation of the limb, external pneumatic compression and massage techniques.
ELEVATION OF THE LIMB
Whenever the leg is elevated, fluid will tend to drain out of it. Put your legs up whenever you can and as high as you are able - the arm of a sofa is good. Elevate the end of your bed by about 8 inches so that your feet are a little higher than your head.
COMPRESSION BANDAGE OR STOCKINGS
Compression is required to squeeze the fluid out of your legs when you are standing up. Bandages may be required at first, to remove the worst of the swelling, before stockings can be used. These stockings need to be specially fitted and are much stronger than ordinary 'support tights'. If the swelling only affects the lower leg, then you should wear a below-knee stocking that is self supporting, like a pop-sock. The usual strength of stocking used is a Class II but sometimes a stronger Class III is required. If you have difficulty putting on your stockings, then you can buy a special stocking applicator.
EXTERNAL PNEUMATIC COMPRESSION (EPC)
Despite using compression stockings, many people find some swelling accumulates by the end of the day. The EPC device is a pneumatic boot that inflates and deflates to squeeze fluid out of the leg. EPC is normally used in the evening to get rid of any fluid that has built up despite compression stockings. If your doctor thinks you need EPC therapy, a trial of the device may be arranged so that you can decide whether it is worth having one.
MASSAGE TECHNIQUES
Manual lymphatic drainage (MLD) is a massage technique carried out by registered practitioners. MLD is a specialised form of therapy which is gentle and rhythmic. It was developed in Europe in the 1930's by Emil Vodder. With regular massage the fluid is encouraged to leave the leg. This increases comfort and decreases the amount of swelling which builds up on a daily basis. (www.mlduk.org.uk)
SURGERY
Many operations have been tried to cure lymphoedema but none are totally successful. Surgery to reduce the size of the lower leg (Horman's Reduction) may be suggested if your leg remains very swollen despite compression therapy. It is only helpful in extreme cases.
HOW CAN YOU HELP?
- Wear your compression stockings all day when you are up and about.
- Elevate your legs whenever they are not supported.
- Take plenty of exercise and don't put on weight.
- Keep the skin in good condition by using plenty of moisturising cream to prevent dryness.
- Ask your GP to treat any sign of infection (redness and tenderness) as soon as possible to minimise the risk of long term deterioration.
VARICOSE VEIN OPERATION
WHAT ARE VARICOSE VEINS?
Veins are the blood vessels that carry blood back to the heart. Varicose veins are abnormally swollen (dilated) veins that are visible just below the surface of the skin. Smaller veins in the skin itself are sometimes called "thread veins" or "spider veins".
Although these may be unsightly, they are not harmful and are not the same as varicose veins.
WHAT CAUSES VARICOSE VEINS?
Varicose veins are due to a fault in the one-way valve system inside the veins. Valves normally only allow blood to flow up the leg towards the heart. If the valves leak, then blood can flow back the wrong way on standing. This reverse flow causes increased pressure on the veins which swell and become varicose.
Varicose veins often run in the family and as you get older, they are more likely to occur. They may also be caused by pregnancy or weight gain that increases pressure on the leg veins. Occasionally varicose veins may appear because the deep veins of the leg have been blocked or damaged by blood clots in the past.
COMING INTO HOSPITAL
You will usually be asked to come in on the morning of your operation. Please do not bring medications with you, but do bring a list of all medications that you are currently taking.
You will be received in the ward by a nurse who will note your personal details.
The position of the veins will be marked. Many people are concerned about anaesthetics, so please ask the anaesthetist if you have any specific worries so that he may reassure you. Special scans may be needed before the operation and this will be explained to you.
THE OPERATION
This is usually performed under a general anaesthetic. The commonest operation involves a cut being made in the groin over the top of the main varicose vein. This is then tied off where it meets the deeper veins. Blood can still flow up the leg along the deeper unaffected veins. The cut in the groin is closed with a stitch, usually hidden under the skin. The other veins marked before the operation are then pulled out through tiny cuts. Some other veins may be affected, especially one behind the knee.
A dressing will be placed on the cut in the groin and your leg will be bandaged up to the top of the thigh.
GOING HOME
The procedure is usually carried out as a day case. Following discharge from hospital, you should resume normal activities as soon as possible. For the first week, when you sit down, you may find it comfortable to sit with your feet elevated, so that your heels are higher than your hips. Some discomfort is normal. Occasionally, severe local twinges of pain may occur and may persist for some months. In the first week after the operation, you may need to take a mild painkiller, such as paracetamol to relieve discomfort. In addition to the bruising you will also develop lumps on your legs. A lump will develop in the groin as a result of your own body dissolving away the sutures. This will subside over a few weeks. Further lumps will probably develop in association with bruises further down the leg.
Care will be needed when washing, in order to keep the dressings dry. Most people are able to drive within 2 days, and most return to work or normal leisure activities within two weeks.
POSTOPERATIVE PLAN
Day 1.
Operation. At the end of the operation your leg will be bandaged tightly in an attempt to reduce the amount of bruising which you experience. Bruising is inevitable after this operation.
Day 2.
The bandages and stocking will be removed and stocking put on.
Day 4.
You can remove the stocking and have a bath. In the bath you can remove all of the dressings.
Day 4-9.
Wear the stocking when you are up and about during the day. You can remove the stocking at night when you go to bed and when you have a bath.
You do not have to walk excessively during the period following your operation. If you behave completely normally that will be quite sufficient.
COMPLICATIONS
There are risks with any operation or anaesthetic.
Sometimes a little blood will ooze from the wound during the first 12-24 hours. This usually stops on its own. If necessary, press on the wounds for ten minutes. If bleeding continues after doing this twice, phone your GP or the ward.
Hard, tender lumps appear near the operation scars in the line of the removed veins. These can appear even some weeks after the operation and need not be a cause for concern. However, if they are accompanied by excessive swelling, redness and much pain, they may represent a wound infection.
Numbness can develop around a wound or the ankle. This is unavoidable and is due to bruising nerves during the operation. It usually settles after some weeks or months. Occasionally the numbness is permanent. The scars on your legs will continue to fade for many months.
Not every visible vein will disappear as a result of your operation and there is a chance that in the future, further varicose veins may develop, as you are clearly disposed to them. Thread veins sometimes develop or progress following the operation.
The taking of regular exercise, the avoidance of becoming overweight, and the wearing of light support tights or stockings will all help prevent your being troubled by varicose veins in the future.
VENOUS THROMBOSIS AND AIR TRAVEL
The information contained in this patient information sheet is not a substitute for medical advice or treatment. Remember - The risk of deep vein thrombosis
on long journeys is very small. The best precaution is to stretch and move your legs regularly.
People have become concerned about the risks of deep vein thrombosis (DVT) during long air flights, following reports in the press about occasional deaths due to fatal pulmonary embolism. The aims of this advice are: -
- to provide reassurance that the risk for most people is tiny
- to explain about DVT and pulmonary embolism
- to identify people who may be at increased risk
- to advise on possible precautions to reduce the risk
The advice is similar for all long journeys - whether by air, coach, car, or train.
WHAT ARE DEEP VEIN THROMBOSIS (DVT) AND PULMONARY EMBOLISM?
There are two systems of veins in the legs - the important deep veins (which carry most of the blood up the legs towards the heart) and the less important superficial veins just under the skin (which can form varicose veins). Deep vein thrombosis (DVT) means thrombosis (clotting) of blood in the deep veins of the legs. It can cause swelling and pain in the leg, but often occurs without giving any symptoms. A DVT may well settle completely, as the thrombosis is dissolved by natural processes. If a DVT extends up the deep veins, two things can sometimes happen:
- The thrombosis can become dislodged from the vein, and carried through the main veins and heart to lodge in the lungs. This is called a pulmonary embolism. Small pulmonary emboli may cause chest pain, and sometimes coughing up of blood. Multiple or larger pulmonary emboli may cause breathlessness. A large pulmonary embolus which blocks the main blood vessels to the lungs will be fatal.
- The thrombosis can cause chronic blockage in the deep veins or damage to their valves, leading to long term swelling and sometimes skin problems at the ankle.
WHY DOES DEEP VEIN THROMBOSIS OCCUR?
All the veins in the leg have valves which should direct blood flow upwards, towards the heart. The deep veins lie between the muscles, and muscular activity (moving the legs, walking or any leg exercise) helps to pump the blood up these veins. When the legs are inactive, and particularly when sitting or standing, blood tends to stagnate in the deep veins. Stagnation of blood can eventually lead to thrombosis. Sitting with the legs bent (as in an aircraft or coach seat) may also restrict flow of blood up the veins in the calf. The longer the period of stagnation, the more likely is thrombosis.
If the blood is unusually "thick" or "sticky" then the risk of thrombosis is greater: this can be caused by dehydration and some medical conditions.
WHO IS AT SPECIAL RISK OF DEEP VEIN THROMBOSIS?
We have no direct evidence about people at special risk of DVT as a result of long journeys, but based on evidence about surgical operations the following increase the risk of thrombosis:
- Having had a DVT or pulmonary embolism before
- Having had a recent major operation
- Pregnancy
- The contraceptive pill or hormone replacement therapy (HRT)
- Malignant disease
- Obesity (being overweight)
- Severe heart disease
- Some blood disorders
- Varicose veins
The risks of DVT are probably highest for people with more than one of these risk factors.
HOW LARGE IS THE RISK?
For people without any of the risk factors listed above the risk of DVT (even on a long haul flight) is very small - one in hundreds at the most. For people with risk factors who take no precautions against thrombosis, the risk of DVT detectable on special scans is as high as one in twenty on long haul flights (but many of these thromboses are minor and cause no problems).
WHAT CAN BE DONE TO REDUCE THE RISK?
There is now evidence that wearing below knee graduated compression stockings reduces the chance of DVT for people with special risk factors. Because so few people without risk factors even develop DVT or pulmonary embolism as a result of long journeys, there is no definite evidence about other measures which reduce the risk. However, based on what is well known about the causes of DVT and the successful methods of prevention used in hospital, the following are sensible precautions, particularly on long haul flights and other journeys lasting several hours:
- Move your legs.
- Don't sit with your legs bent for hours on end. Stretch your legs out from time to time, and move your feet up and down at the ankles. Stand up to stretch the legs now and then. Stretching and moving the legs stops blood stagnating in the deep veins of the calf, and is the simplest and most effective thing you can do.
- Go for a walk up and down the aisle.
- Don't get dehydrated.
- Drink plenty of fluid - water is ideal.
- Avoid excessive alcohol, which tends to cause dehydration.
- Wear compression stockings.
- Graduated compression stockings reduce the risk of DVT. They also help to prevent the ankle swelling which many people experience on long journeys.
- BELOW KNEE stockings are the most comfortable kind, and seem just as effective as full length stockings.
- Medical graduated compression stockings are supplied in three classes: Class 1 or Class 2 stockings are suitable for most people (Class 3 are excessively strong for this purpose).
- Compression stockings can be prescribed by a doctor if there is a medical need. They can be bought at chemists, surgical appliance specialists, and now at some other shops, for example in airports.
- These stockings come in a range of sizes, and your legs will need to be measured to get the right fitting.
- People who have trouble with the arteries of their legs should seek medical advice before using compression stockings.
- Aspirin.
Taking an Aspirin tablet (either a 75 mg "junior Aspirin" or a normal 300 mg Aspirin tablets) a few hours before a long journey may provide a small amount of extra protection against DVT.
- Anticoagulants.
Special anticoagulants drugs (e.g. Heparin injections, or Warfarin by mouth) may be advisable for a few people who have medical conditions with a particularly high risk for DVT. This kind of treatment will always be on an explicit advice of a doctor.
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