New approaches to an old and vexing problem: improving the results of SEPS: an overview.

Lipodermatosclerosis and chronic ulceration have been longstanding and vexing problems caused by chronic venous insufficiency (CVI). While traditional approaches have been mainly medical with the use of compression, bedrest, and elevation; operative therapy for CVI has now been shown to cause earlier healing with fewer ulcer recurrences. The development of subfascial endoscopic surgery (SEPS) promises a more elegant approach applicable to outpatient or day surgery. However, in a recent trial, early results showed a 22% ulcer recurrence at 30 months, which did not compare favorably with traditional approaches. We have used extrafascial perforator interruption for SEPS recurrence and have now modified our SEPS approach particularly for low-lying ulcers. This overview suggests use of a combination of SEPS with an extrafascial perforator division when skin change relates to retro or submalleolar perforating veins. Several procedures, rather than one intervention may be required in CVI to prevent or divert transmission of venous hypertension to areas of affected skin, including saphenous stripping, staged valveplasty and treatment of iliac occlusions.

Venous ulceration: active approaches to treatment.

Traditional treatment of venous ulceration has been conservative: elevation, wound care, compression, and patient education based on prevention. Conservative treatment will heal most ulcers over time: however, the data reflect a 29% to 59% recurrence rate with optimal care and follow-up. Recurrent ulceration results in significant cost and disability. It is none accepted that limbs with all the signs of severe chronic venous insufficiency (CVI) may have a normal deep venous system. Patients in whom this is the case can be treated surgically with good long-term results. In this article, the specific underlying causes of CVI are noted and diagnostic tests are reviewed. The CEAP (clinical signs, etiology, anatomy, and physiology) classification system is discussed in terms of systematically assessing CVI. Common surgical techniques are related to the underlying pathophysiology, and the nursing care of the patient undergoing surgical intervention is also discussed. The cause of the condition should be investigated, and surgical treatment, when appropriate, should be offered as an alternative to the active symptomatic patient with CVI.

New developments in the diagnosis and treatment of impotence.

New developments in the diagnosis and treatment of impotence or erectile dysfunction are increasingly based on better understanding of the erectile process. In 1978 it was thought that the failure of arterial inflow was the main cause of male erectile dysfunction. Emphasis was placed on methods of corpus cavernosal revascularization. In recent years, interest has shifted to abnormal cavernosal smooth muscle function. An understanding of the erectile process was greatly enhanced by intracavernosal administration of vasoactive agents in 1982 and, more recently, the use of prostaglandin E1. These agents promote erection by causing smooth muscle to relax. The intracavernosal administration of vasoactive agents is now used in diagnosis and in therapy. Standard approaches to diagnosis and therapy still vary, but more rational steps are evolving. Considerable progress has been made in quantifying penile blood flow. Increasingly effective therapies are available for an estimated 10 million American men suffering from erectile dysfunction. Therapies include the use of drugs, administering vasoactive agents intracavernosally, vacuum constrictor devices, and vascular interventions in highly selected cases of arterial or venous disease. These procedures are being carefully reevaluated. Critical analysis of recent results suggests that about 7% of men are amendable to vascular interventions, with success rates approximating 70% when supplemental therapy is used.