Servier – Phlebolymphology

VENOUS DISEASE SIMPLIFIED

A review by John J. Bergan

In today’s medical publishing, this book is unique. This is because it is almost entirely about venous insufficiency and venous reflux. Despite the fact that venous insufficiency is exceedingly common, no recent book deals exclusively with this subject.
This book brings under one cover the opinions of 25 physicians, most of whom have published heavily in British and international journals. Collectively, they have contributed clearly formulated chapters on primary varicose veins, management of recurrent varicose veins, quality of life, in addition to essays on symptomatology, history, and epidemiology. Altogether, very good and complete coverage of a very important subject.

A single American surgeon, Joseph Caprini of Northwestern University, enters this august company. He has contributed the only chapter on venous thrombosis in an entire volume devoted to venous insufficiency. His chapter on thromboprophylaxis is the longest in this slim volume.
The most innovative chapter in what proves to be a very well written volume is by Linda de Cossart of Chester, UK. She emphasizes: “getting it right before patients get to the operating theatre,” and provides a long and detailed checklist of how to do so. Example: “On reading the referral letter and meeting the patient, look up and greet the patient.” Equally detailed is her list of what to do in the operating room. For example, when “performing the strip, you should be thinking: How do I get the stripper out of the limb with the best cosmetic results?”
As expected in this new century, new methods of vein ablation are included, but are not as dominant as might be expected. Mark Whiteley, a very experienced British surgeon, covers these in a single chapter. Philip Coleridge-Smith, whose chapter is so complete and informative that he includes a key reference from 1956 in the German language, fortunately counters Whiteley’s brief views of foam chemical ablation of veins. His is perhaps the most forward-looking chapter in the entire book.

Venous reconstruction carries the imprint of Kevin Burnand, and a unique series of chapters have to do with nurse-led clinics, venous leg ulcer services, and quality of life in patients with varicose veins, and those with leg ulcers.

It’s all here. From stripping to subfascial endoscopic perforator vein surgery (SEPS), and even beyond to recurrent varicose veins. This is a most informative book covering the important subject of venous insufficiency in a very condensed fashion. It is thoroughly up-to-date and modern, and should be in the library of every physician who has the slightest interest in venous disorders.

A review by Michel Perrin
This book, written mainly by physicians in the United Kingdom, with just about one exception, aims to provide an update on acute and chronic venous diseases of the lower limbs through a simplified presentation, as its title suggests. It is intended for general practitioners, specialist physicians not specializing in venous disease, angiologists, phlebologists, as well as vascular surgeons. But the latter will not find a detailed description of methods of investigation or surgical procedures.

The book is divided into 17 chapters, each of which ends with a descriptive insert clearly and precisely summarizing the main points of the chapter. Readers will notice the unfortunate absence of a chapter on anatomy, physiology, and pathophysiology.

After the usual historical review, epidemiological data are analyzed by the epidemiologist in the group who produced the Edinburgh survey. He clearly differentiates the classes of the CEAP classification, and, in particular, reminds the reader that the term chronic venous insufficiency should be reserved for the C3-C6 classes of disease. In the following chapter, the signs and symptoms of chronic venous disease are reviewed, as well as the manner in which the interview and physical examination should be conducted since, depending on the findings that they provide, instrumental investigations will be decided. Classically, these findings will be classified according to the anatomical and functional information they provide. Quality of life of patients who present with varicose veins or a skin ulcer is analyzed in two separate chapters, and the results of surgical treatment are objectively reviewed, in particular, the cost-to-efficacy ratio. It is emphasized that surgery for treatment of varices improves quality of life and symptoms, in spite of a recurrence rate of about 25% at 10 years.

One of the three chapters devoted to varices is especially original: it describes advice that circumvents peri- and post-operative complications, and possible disappointment or complaints by patients treated with surgery. But the reader with a Cartesian mindset may be surprised by the fact that the indications for treatment are not the subject of recommendations.

On the other hand, the management of skin ulcers as performed in the United Kingdom, by nurses and physicians in specialized centers, deserves careful analysis and reflection. It shows an outstanding pragmatic approach.

Venous compression therapy and pharmacological treatments of chronic venous disease are not discussed. Sclerotherapy of venules, telangiectasias, and foam sclerotherapy are discussed in 2 separate, well-documented chapters. Thromboembolic disease is very well detailed with over 100 references and is supplemented by a chapter on possible travel-related risks. Reconstructive deep vein surgery is discussed briefly.

Of course, as is true for all works written by several authors (25 in this book), contradictory opinions are voiced on certain points, but the overall presentation remains very consistent and of high quality. Some chapters are traditional, while others are truly original in format and content. References appear throughout the body of the text, and Internet web sites are listed. A limited number of black and white photographs are included.

VENOUS AND LYMPHATIC DISEASES

A review by John J. Bergan
This book is deceptive. Sitting on the desk it looks like a small novel. However, a glance at the Table of Contents reveals otherwise. Few books attempt to cover all of the problems of venous disorders, as well as those affecting the lymphatic systems of the extremities. This book does this task and does it exceedingly well.

There are six sections, which treat venous disorders, and an additional section, which deals with lymphatic disorders.

On the venous side, one of the strengths is the contribution by Alberto Caggiati, who provides an interesting and novel historical background, and then turns to another subject and provides a chapter on venous and lymphatic anatomy. He is, after all, Professor of Anatomy at the University of Rome. Professor Caggiati has been a part of the movement towards standardizing nomenclature of the veins. He includes the new terms in his chapter, also providing a very clear diagram of the saphenous compartment and its companion accessory saphenous veins.

Physiology of the veins and lymphatics is explained by Philip Coleridge- Smith, and no one can do it better.

Other chapters in this first section include epidemiology of venous disorders, health economics, and quality of life, as well as classification of chronic venous disease and outcome assessment.

The following sections are testimony to the authors’ interest in providing a mixture of North American and European contributors. Junior authors are listed, but the chapters have the imprint of each of the senior contributors. There are chapters on clinical assessment, noninvasive evaluation, and invasive tests. A section follows the chapter on diagnosis of deep vein thrombosis. Because of the importance of this subject, its diagnosis, epidemiology, treatment, relationship to malignant disease, and thrombolysis occupy the next seven chapters, each representing an authoritative opinion of an internationally well-known author.

The authors have not given short shrift to the subject of varicose veins. Here, there are eight chapters, including an interesting diversion into medical-legal aspects of treatment of varicose veins. It is appropriate that most of the authors in this section are from Europe and the United Kingdom. Superficial venous surgery appears again in the section on chronic venous insufficiency, simply because the majority of patients with chronic leg ulcer have only superficial incompetence, with or without perforator incompetence. Illustrating the fact that this is a complete book is the final venous section, which covers the subjects of upper extremity venous thrombosis, mesenteric and portal vein thrombosis, as well as superior vena cava obstruction and congenital venous abnormalities. Reflecting their recent experience, the authors of the chapter on venous trauma are from Belfast, and cover their subject exceedingly well in very few pages.

Physicians and surgeons interested in venous disorders inevitably see a great number of patients with lymphedema. Only two chapters are devoted to this subject, but they are thorough, discuss clinical features, investigations, the role of conservative, medical, and surgical treatments, and the management of the very difficult problems of chylous ascites and chylothorax. This is an excellent book on many important topics and could be a farewell gift to a good vascular trainee. It also belongs in the libraries of every teaching vascular service, both in America and abroad.