Effect of Transluminal Injection of Foam Sclerotherapy Combined with Endovenous Thermal Ablation of Varicose Veins

Current Best Practice in the Management of Varicose Veins

This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.

Impact of the SARS-CoV-2 (COVID-19) crisis on surgical training: global survey and a proposed framework for recovery

Background

The SARS-CoV-2 pandemic had a profound impact on surgical services, potentially having a detrimental impact on training opportunities. The aim of this global survey was to assess the impact of the COVID-19 crisis on surgical training and to develop a framework for recovery.

Methods

A cross-sectional, web-based survey was conducted. This was designed by a steering committee of medical educationalists and validated by a group of trainees before dissemination.

Results

A total of 608 responses were obtained from 34 countries and 15 specialties. The results demonstrated major disruption in all aspects of training. The impact was greatest for conferences (525 of 608) and hands-on courses (517 of 608), but less for inpatient care-related training (268 of 608). European trainees were significantly more likely to experience direct training disruption than trainees in Asia (odds ratio 0.15) or Australia (OR 0.10) (χ² = 87.162, P < 0.001). Alternative training resources (webinars, 359 of 608; educational videos, 234 of 608) have emerged, although trainees expressed some dissatisfaction with them. The collective responses generated a four-pillar framework for training recovery that involved: guidance from training stakeholders with the involvement of trainees; prioritization of training, especially the roles of senior surgeons/trainers; provision of access to alternative/new teaching methods; and measures to address trainee anxiety.

Conclusion

Training has been greatly affected by the COVID-19 pandemic. The introduction of new teaching methods and a focus on training after the pandemic are imperative.