ligation of children's jugulars :(

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

ligation of children's jugulars :(

Postby Cece » Fri Feb 18, 2011 12:27 pm

Am J Surg. 2006 Sep;192(3):286-90.

Surgical treatment of jugular vein phlebectasia in children.
Jianhong L, Xuewu J, Tingze H.

Department of Pediatric Surgery, Second University Hospital of Shantou University Medical College, Dongxia Bei Rd., Shantou City, Guangdong Province, People's Republic of China, 515041. Lijh2925@163.com

Comment in:

Am J Surg. 2008 Nov;196(5):799.
Am J Surg. 2008 Mar;195(3):419-20.

Abstract
BACKGROUND: Jugular vein phlebectasia (JVP) is a cervical mass that occurs relatively infrequently and usually presents in children as a soft cystic swelling in the neck during straining. It is liable to be misdiagnosed or managed inappropriately. This report elucidates the clinical presentation, diagnosis, treatment choices, and postoperative complications of JVP, and diagnostic methods and treatment choices are recommended.

METHODS: Fifty-one cases of JVP were reviewed (right vein in 38 patients, left in 7 patients, and bilateral in 6 patients). The internal jugular vein was involved the most frequently. The main complaint was a soft and compressible mass in the neck, becoming more prominent with the Valsalva maneuver. All of the children except 2 had an ultrasound or color Doppler flow imaging (CDFI) performed in combination with the Valsalva's breathing test. Surgical intervention was performed in 46 patients and the other 5 patients were followed-up conservatively for 2 to 15 years.

RESULTS: Ultrasound or CDFI showed local dilatation of unilateral or bilateral veins in all patients except 2, and confirmed the diagnosis in combination with the Valsalva's breathing test. Surgical intervention included ligation of the involved jugular vein in 32 patients, and longitudinal constriction suture venoplasty plus encapsulation with medical Dacron cloth or PTFE in 14 patients. All of the children who had surgery recovered uneventfully, except 3 patients undergoing ligation of the right internal jugular vein.

CONCLUSIONS: The Valsalva maneuver was most important for establishing the diagnosis. Ultrasound or CDFI, or in combination with the Valsalva's breathing test, was the diagnostic procedure of choice to confirm the diagnosis of JVP because of its clarity, safety, and low cost. Surgical intervention was recommended for cosmetic and psychologic purposes. Ligation or excision of the involved jugular vein was very safe, simple, and effective for most patients. However, in cases of lesions of the right and bilateral internal jugular veins, longitudinal constriction suture venoplasty plus encapsulation might be more preferable and safer, and should be recommended. Otherwise, treatment should be conservative (follow-up evaluation).

http://www.ncbi.nlm.nih.gov/pubmed/16920419

For jugular phlebectasia, for "cosmetic and psychologic" purposes, doctors are ligating children's jugulars. This was published in 2006. "Very safe, simple and effective" in the short term. But what happens to those kids when they turn 30.

It's no fault of the doctors for not knowing, but now that it's known, the jugular needs to be preserved as much as possible. I don't know what the alternative mentioned is ("longitudinal constriction suture venoplasty plus encapsulation") but if that preserves the jugular, then that is what I'd want my child to have.
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Re: ligation of children's jugulars :(

Postby drsclafani » Fri Feb 18, 2011 9:38 pm

Cece wrote:
Am J Surg. 2006 Sep;192(3):286-90.

Surgical treatment of jugular vein phlebectasia in children.
Jianhong L, Xuewu J, Tingze H.

Department of Pediatric Surgery, Second University Hospital of Shantou University Medical College, Dongxia Bei Rd., Shantou City, Guangdong Province, People's Republic of China, 515041. Lijh2925@163.com

Comment in:

Am J Surg. 2008 Nov;196(5):799.
Am J Surg. 2008 Mar;195(3):419-20.

Abstract
BACKGROUND: Jugular vein phlebectasia (JVP) is a cervical mass that occurs relatively infrequently and usually presents in children as a soft cystic swelling in the neck during straining. It is liable to be misdiagnosed or managed inappropriately. This report elucidates the clinical presentation, diagnosis, treatment choices, and postoperative complications of JVP, and diagnostic methods and treatment choices are recommended.

METHODS: Fifty-one cases of JVP were reviewed (right vein in 38 patients, left in 7 patients, and bilateral in 6 patients). The internal jugular vein was involved the most frequently. The main complaint was a soft and compressible mass in the neck, becoming more prominent with the Valsalva maneuver. All of the children except 2 had an ultrasound or color Doppler flow imaging (CDFI) performed in combination with the Valsalva's breathing test. Surgical intervention was performed in 46 patients and the other 5 patients were followed-up conservatively for 2 to 15 years.

RESULTS: Ultrasound or CDFI showed local dilatation of unilateral or bilateral veins in all patients except 2, and confirmed the diagnosis in combination with the Valsalva's breathing test. Surgical intervention included ligation of the involved jugular vein in 32 patients, and longitudinal constriction suture venoplasty plus encapsulation with medical Dacron cloth or PTFE in 14 patients. All of the children who had surgery recovered uneventfully, except 3 patients undergoing ligation of the right internal jugular vein.

CONCLUSIONS: The Valsalva maneuver was most important for establishing the diagnosis. Ultrasound or CDFI, or in combination with the Valsalva's breathing test, was the diagnostic procedure of choice to confirm the diagnosis of JVP because of its clarity, safety, and low cost. Surgical intervention was recommended for cosmetic and psychologic purposes. Ligation or excision of the involved jugular vein was very safe, simple, and effective for most patients. However, in cases of lesions of the right and bilateral internal jugular veins, longitudinal constriction suture venoplasty plus encapsulation might be more preferable and safer, and should be recommended. Otherwise, treatment should be conservative (follow-up evaluation).

http://www.ncbi.nlm.nih.gov/pubmed/16920419

For jugular phlebectasia, for "cosmetic and psychologic" purposes, doctors are ligating children's jugulars. This was published in 2006. "Very safe, simple and effective" in the short term. But what happens to those kids when they turn 30.

It's no fault of the doctors for not knowing, but now that it's known, the jugular needs to be preserved as much as possible. I don't know what the alternative mentioned is ("longitudinal constriction suture venoplasty plus encapsulation") but if that preserves the jugular, then that is what I'd want my child to have.


dr zamboni told me the story of his public service after completion of medical training. He was in sardinia and treated several patients with jugular phlebectasia. All developed MS i think
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Re: ligation of children's jugulars :(

Postby CuriousRobot » Sat Feb 19, 2011 9:00 am

drsclafani wrote:
Cece wrote:
Am J Surg. 2006 Sep;192(3):286-90.

Surgical treatment of jugular vein phlebectasia in children.
Jianhong L, Xuewu J, Tingze H.

Department of Pediatric Surgery, Second University Hospital of Shantou University Medical College, Dongxia Bei Rd., Shantou City, Guangdong Province, People's Republic of China, 515041. Lijh2925@163.com

Comment in:

Am J Surg. 2008 Nov;196(5):799.
Am J Surg. 2008 Mar;195(3):419-20.

Abstract
BACKGROUND: Jugular vein phlebectasia (JVP) is a cervical mass that occurs relatively infrequently and usually presents in children as a soft cystic swelling in the neck during straining. It is liable to be misdiagnosed or managed inappropriately. This report elucidates the clinical presentation, diagnosis, treatment choices, and postoperative complications of JVP, and diagnostic methods and treatment choices are recommended.

METHODS: Fifty-one cases of JVP were reviewed (right vein in 38 patients, left in 7 patients, and bilateral in 6 patients). The internal jugular vein was involved the most frequently. The main complaint was a soft and compressible mass in the neck, becoming more prominent with the Valsalva maneuver. All of the children except 2 had an ultrasound or color Doppler flow imaging (CDFI) performed in combination with the Valsalva's breathing test. Surgical intervention was performed in 46 patients and the other 5 patients were followed-up conservatively for 2 to 15 years.

RESULTS: Ultrasound or CDFI showed local dilatation of unilateral or bilateral veins in all patients except 2, and confirmed the diagnosis in combination with the Valsalva's breathing test. Surgical intervention included ligation of the involved jugular vein in 32 patients, and longitudinal constriction suture venoplasty plus encapsulation with medical Dacron cloth or PTFE in 14 patients. All of the children who had surgery recovered uneventfully, except 3 patients undergoing ligation of the right internal jugular vein.

CONCLUSIONS: The Valsalva maneuver was most important for establishing the diagnosis. Ultrasound or CDFI, or in combination with the Valsalva's breathing test, was the diagnostic procedure of choice to confirm the diagnosis of JVP because of its clarity, safety, and low cost. Surgical intervention was recommended for cosmetic and psychologic purposes. Ligation or excision of the involved jugular vein was very safe, simple, and effective for most patients. However, in cases of lesions of the right and bilateral internal jugular veins, longitudinal constriction suture venoplasty plus encapsulation might be more preferable and safer, and should be recommended. Otherwise, treatment should be conservative (follow-up evaluation).

http://www.ncbi.nlm.nih.gov/pubmed/16920419

For jugular phlebectasia, for "cosmetic and psychologic" purposes, doctors are ligating children's jugulars. This was published in 2006. "Very safe, simple and effective" in the short term. But what happens to those kids when they turn 30.

It's no fault of the doctors for not knowing, but now that it's known, the jugular needs to be preserved as much as possible. I don't know what the alternative mentioned is ("longitudinal constriction suture venoplasty plus encapsulation") but if that preserves the jugular, then that is what I'd want my child to have.


dr zamboni told me the story of his public service after completion of medical training. He was in sardinia and treated several patients with jugular phlebectasia. All developed MS i think


Crap, that's awful.
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Re: ligation of children's jugulars :(

Postby Cece » Sat Feb 19, 2011 10:02 am

drsclafani wrote:dr zamboni told me the story of his public service after completion of medical training. He was in sardinia and treated several patients with jugular phlebectasia. All developed MS i think

We've heard about Zamboni seeing Sardinian children with jugular malformations developing MS, but this must be the rest of the story, that it was Sardinian children treated for phlebectasia developing MS.

CuriousRobot, it's really, really awful. And we see our share of awful here. Speaking as someone with MS, for it to happen to a kid who wouldn't otherwise have gotten it, it's an awful, disabling, confusing, emotionally and physically painful disease.

The jugular phlebectasia, being a big swelling mass, is probably itself an outflow obstruction, even before it is treated by ligation.
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Re: ligation of children's jugulars :(

Postby Cece » Fri Dec 30, 2011 5:22 pm

Almost as bad as children with ligated jugulars? War heroes with ligated jugulars.

http://www.ncbi.nlm.nih.gov/pubmed/16828429

RESULTS: Suspected vascular injury from penetrating neck trauma occurred in 63 patients. Injuries were to zone II in 33%, zone III in 33%, and zone I in 11%. The remaining injuries involved multiple zones, including the lower face or posterior neck. Explosive devices wounded 50 patients (79%), 13 (21%) had high-velocity gunshot wounds, and 19 (30%) had associated intracranial or cervical spine injury. Of the 39 patients (62%) who underwent emergent neck exploration in Iraq or Afghanistan, 21 had 24 injuries requiring ligation (18), vein interposition or primary repair (4), polytetrafluoroethylene (PTFE) graft interposition (1), or patch angioplasty (1). Injuries occurred to the carotid, vertebral, or innominate arteries, or the jugular vein. After evacuation to the United States, all patients underwent radiologic evaluation of the head and neck vasculature. Computed tomography angiography was performed in 45 patients (71%), including six zone II injuries without prior exploration. Forty (63%) underwent diagnostic arteriography that detected pseudoaneurysms (5) or occlusions (8) of the carotid and vertebral arteries. No occult venous injuries were noted. Delayed evaluation resulted in the detection of 12 additional occult injuries and one graft thrombosis in 11 patients. Management included observation (5), vein or PTFE graft repair (3), coil embolization (2), or ligation (1).

If people do face a tougher recovery or possible neurological sequellae after having a jugular ligated, they don't even know that the ligation may be the trouble. It is not suspected of causing harm, because of the other drainage routes.
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Re: ligation of children's jugulars :(

Postby frodo » Wed Jan 04, 2012 8:16 am

drsclafani wrote:
dr zamboni told me the story of his public service after completion of medical training. He was in sardinia and treated several patients with jugular phlebectasia. All developed MS i think


It is interesting to see that no long-term studies were performed for this surgery and no doctor Fredman appeared in the media complaining. Maybe just because he felt no threat to his bussines by this. I would love to hear an explanation from him about his silence back then.
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Re: ligation of children's jugulars :(

Postby Cece » Wed Jan 04, 2012 9:18 am

The standard for treatment of phlebectasia seems to be conservative, with no treatment needed. I don't think we'll see any long-term studies of jugular ligation in phlebectasia.
I would think Dr. Freedman would think the ligation of jugulars for phlebectasia to be irrelevant, because of the odd notion that the presence or absence of working jugulars does not affect the organ that the jugulars drain.
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