Surgical treatment of varicose veins of the lower limbs in liver transplant recipients: a case report

Abstracts

O transplante hepático vem progressivamente apresentando melhores resultados e maior preocupação com a qualidade de vida dos pacientes. As varizes dos membros inferiores são comuns na população e causam sintomas em boa parte dos casos, comprometendo a qualidade de vida. Em pacientes com boa condição clínica e funcionamento normal do enxerto, o tratamento cirúrgico das varizes de membros inferiores pode ser a opção com resultado mais eficaz e duradouro. Os autores relatam dois casos de pacientes que haviam sido submetidos a transplante hepático e apresentavam varizes sintomáticas de membros inferiores, e foram submetidos a cirurgia de varizes após liberação pela equipe de transplante hepático. As operações ocorreram sem intercorrências, com bom resultado no seguimento. A cirurgia de varizes dos membros inferiores pode ser realizada com segurança em pacientes receptores de transplante hepático, sendo uma opção eficaz e duradoura no tratamento da insuficiência venosa crônica nesses pacientes.

Varizes; membros inferiores; transplante hepático; insuficiência venosa

CASE REPORT

Surgical treatment of varicose veins of the lower limbs in liver transplant recipients: case report

Jorge R. Ribas Timi^I; Carlos Eduardo Del Valle^II

^I

^IIMSc. in Surgical Clinic, UFPR, Curitiba, PR, Brazil. Surgeon, Vascular Surgery Service Prof. Dr. Elias Abrão Curitiba, PR, Brazil

Correspondence

ABSTRACT

Liver transplantation is having progressively better outcomes, and quality of life is being more often addressed. Varicose veins of the lower limbs are common in the general population and cause symptoms in a significant number of cases, impairing quality of life. For patients in good clinical condition, with adequate graft function, surgical treatment for varicose veins of the lower limbs can be a safe option, with more effective and longer lasting outcomes. The authors report two cases of liver transplant recipients who had symptomatic varicose veins of the lower limbs and were submitted to varicose vein surgery following authorization from the liver transplantation team. Operations were uneventful, with good follow-up results. Surgery for varicose veins of the lower limbs can be safely performed in liver transplant recipients, and it is an effective and long lasting treatment for chronic venous insufficiency in these patients.

Keywords: Varicose veins, lower limbs, liver transplantation, venous insufficiency.

Introduction

Liver transplantation has had constant progress over the past decades and has become the treatment of choice for a large number of patients with liver failure of varied causes. Survival rates of transplanted patients has improved, reaching 67-72% in 4-5 years in some series^1-3 thanks to improvement in surgical technique, selection of patients and postoperative care. A cohort study showed mean survival rate of 22 years after the procedure.⁴ In addition to survival rates, another important factor that has received more attention is the quality of life of patients that were submitted to liver transplantation.^5-7

Varicose veins of the lower limbs are common in the general population, with clinical symptoms in a significant number of cases.^8-12 As symptoms become more significant, there is a proportional worsening in the patient's quality of life.

Some drug treatments for symptoms of chronic venous insufficiency are inadequate for liver transplant recipients. This is a result of liver toxicity of certain oral phlebotropics, especially coumarin, which can cause increase in liver enzymes.¹³ Coumarin is found in the market in its purified form, combined with troxerutin, and as an active component in herbal extracts, such as Melilotus officinalis.

A significant part of patients that received liver transplantation have clinical condition to be submitted to surgical treatment of varicose veins of the lower limbs. This is a treatment modality that has a more definite nature, with even more significant improvement in quality of life.

Case reports

Case 1

A 52-year-old female patient was submitted to liver transplantation (graft from cadaver) due to liver cirrhosis secondary to infection by hepatitis B virus (HBV). She already had varicose veins of the lower limbs before being submitted to transplantation. Fifty months after the transplantation, which had progressed uneventfully, the patient had symptoms of pain, weight, tiredness and edema, with impairment in her quality of life. There was no clinical contraindication against being submitted to surgical repair of varicose veins, and there was no reflux in the deep venous system. Partial right saphenous vein stripping was then performed and collaterals were removed, under peridural anesthesia, uneventfully and using paracetamol for postoperative analgesia. There was no change in graft function. The patient has been followed for 18 months and has no symptoms of venous or liver failure.

Case 2

A 52-year-old male patient, 48 months after liver transplantation, due to cirrhosis secondary to hepatitis C virus received a graft from a cadaver. He had large-diameter varicose veins of the lower limbs before transplantation. The deep venous system was not affected. Symptoms of venous insufficiency were responsible for impairment of quality of life. Surgical treatment was chosen due to the reasons mentioned above. The procedure was authorized by the liver transplant team, as the patient had not had events and the graft had proper functioning. The patient required total great saphenous vein stripping to the left and bilateral excision of varicose collateral veins. The procedure was performed under peridural anesthesia, and paracetamol was used for postoperative analgesia. The patient had satisfactory postoperative course both from the perspective of liver graft and lower limb symptoms. He is now in the 60-month follow-up after varicose vein surgery.

Discussion

The authors performed a wide review of the Brazilian and international literature and found no reports of liver transplant recipients that had been submitted to surgical treatment of varicose veins of the lower limbs. Patients were indicated for varicose vein surgery because they had significant symptoms and because the intervention had low morbidity rate. In addition, they had consent from the transplant team. The procedure can be performed under peridural regional block, which has good safety levels, little bleeding and little postoperative pain. Patients whose graft have good function should not have their surgery contraindicated. Postoperative analgesia was performed using paracetamol due to its lower risk of liver lesion in relation to non-hormonal anti-inflammatory and opioids.¹⁴Paracetamol toxicity is dose-dependent, therefore it is safe in low doses,^15,16 while non-hormonal anti-inflammatory may have idiosyncratic reactions.¹⁷ Both procedures were uneventful. There was no change in operative technique in relation to non-transplanted patients. Partial segments of the saphenous vein were removed according to clinical assessment using Doppler ultrasound as usual. Hospital discharge occurred 12 hours after the end of the procedure, as in most patients. Surgery is planned according to color Doppler ultrasound findings, and segmental or total saphenous vein stripping is performed according to reflux topography. Thus, the great saphenous vein can be preserved in case it is competent, because its proximal segment, adjacent to the saphenofemoral junction, can be used as peritoneal venous shunt if the patient has refractory ascites in the future.^18-20

Conclusion

When consented by the transplant tram, varicose vein surgery improves quality of life of transplant patients, and the successful transplant is not a barrier against such procedure.

References

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Publication Dates

• Publication in this collection
  13 Mar 2009
• Date of issue
  Mar 2009

History

• Accepted
  26 Dec 2008
• Received
  20 Mar 2008