Varicose vein treatment webinar transcript
Hey, good evening, everyone. Welcome to our webinar on varicose veins treatment. My name is Vicky and I’ll be your host this evening.
Our expert presenter this evening is Consultant Vascular Surgeon, Mr Eddie Chaloner. This presentation will be followed by a Q&A session, if you'd like to ask a question during or after the presentation, please do so by using the Q&A icon which is at the bottom of your screen. This can be done with or without giving you a name. Please note this session is being recorded if you do provide your name.
If you'd like to book your consultation, we'll provide contact details at the end of this session.
So I’ll now hand over to Mr Eddie Chaloner and you'll hear from me again shortly.
Mr Eddie Chaloner
Well, thank you very much Vicky and thank you everyone for joining us this evening for this webinar. Yeah so that's a slightly younger picture of me you'll see my hair hasn't grown back, I’m just slightly fatter and I’m a Consultant Vascular Surgeon working here at Benenden Hospital and also in private practice closer to London. My main interest is varicose vein surgery or more specifically minimally invasive varicose vein surgery and in this webinar we're going to cover these topics, my experience in this field and the treatments available at Benenden. A general overview of what varicose veins are and what the treatment options are for this common condition and then we're going to talk about how we assess varicose veins in clinic and what the normal sort of expectation of results is after surgery and then we'll have some time for Q&A.
So I qualified in medicine a long time ago 1989, so I’m now I think of my 30th, 34th year of practice and some of you may know it takes a long time to learn how to do surgery, it takes about 12 years in training and I was appointed my first consultant job was in London I think in 2002 and I’d just been appointed as a consultant when this chap turned up with the latest piece of equipment from New York where you could do varicose veins with a laser under local anaesthetic and prior to that we used to do it by putting people to sleep cutting them in the top of the leg and stripping the vein out, that was the standard operation for about a hundred years and I looked at this kit and I thought well that's never going to work but I’m a new consultant and I need a new thing so we'll try it and within six months I knew it was going to completely change practice in this field that which indeed it did and now EVLT which is the acronym for laser treatment and various spin-off techniques which are more or less the same thing or now the gold standard for treatments of veins and I’ll say more about that later on. We do a lot of vein surgery here at Benenden, we according to it there's an organizational PHIN that’s Private Healthcare Information Network which looks at and audits all the operations that are done in the UK and we treat more patients per year here this hospital and in my practice with Mr Sweeney than anywhere else in the UK. So that certainly doesn't make us perfect but it does mean we have a lot of experience and that generally speaking is a good thing.
So treatment here at Benenden Hospital, the majority of vein operations we do here we do under local anaesthetic which is a bit like going to the dentist so we have injections of local anaesthetic into the leg with or without a sedative for patients who are who are anxious about surgery and as I say we've been doing this for a long time and we've done thousands and thousands of cases and most patients prefer to have surgery under local anaesthetic where possible. Sometimes it isn't possible either because of the technical aspects require a general anaesthetic or because patients are very anxious about surgery, in which case we can give a general anaesthetic the operation is entirely the same it's just that the patient is asleep rather than awake.
So, what are varicose veins, what's it all about? Well, first of all they're extraordinarily common around about a third of the population will get varicose veins at some point in their lives they may not all be aware of it and they may not all require surgery but it's an extremely common condition in fact I recently noticed I have it myself on my left leg and I might touch on that a bit later on so most patients notice that they've got varicose veins because they notice swollen and then larger veins usually on the lower part of the leg between the knee and the ankle they can appear on the thigh but more commonly it's in the lower part of the leg and they look blue or purple and stick out from the skin the symptoms that patients will commonly get with varicose veins are aching heavy and uncomfortable legs with occasionally swelling of the feet in the in the evening when you've been on your on your legs all day and it seems to be worse at night that that's probably because patients aren't doing very much at night and they tend to notice it if the veins persist for a long time they can start to damage the skin usually in the lower part of the leg around the ankle and some people get a condition called venous eczema which is an irritation of the skin usually just around the ankle area and that's quite a serious matter because once that starts if it goes on for long enough the skin can be damaged sufficiently to cause and ulcer which I’ll say more about in a little while.
But as I was saying, the vast majority of veins can be fixed with a very effective technique what we call minimally invasive so we don't have to make any big incisions in people and very few or almost no patients nowadays need to stay in hospital overnight here at Benenden we do well over 90 of our cases under local anaesthetic and on average in this hospital we do somewhere between 800 and a thousand a year because we know I do you know about the same elsewhere as well so we've got a lot of practice.
Now in medicine we grade varicose veins on a scale of one to six and this is basically a severity score and I’ll just go through that because it helps to explain what veins need treatment for medical reasons and what might have treatment for cosmetic reasons so grade one you can see in this picture here are cosmetic thread veins sometimes called spider veins or reticular veins and these are very common indeed particularly in women get them much more than men because they're affected by the female hormones effect on the skin these are of cosmetic significance only they don't make and people on well or give you any symptoms of aching throbbing swelling and so on and you don't get skin damage with this type of vein and they can either be safely left alone or if patients don't like the look of them because they're cosmetically unappealing they can be treated with that technique called injection sclerotherapy where we insert a very tiny needle into a very tiny vein and inject a chemical in which irritates the vein and makes it seal and eventually disappear it does take quite a long time for these veins to go away even when they've been injected you can expect to bruise them for a good six to eight weeks or sometimes longer than that but that's a very easy thing to do we do it in clinic and the number of sessions that people require for this sort of thing depends on how many veins they have and on what they want their legs to look like at the end of the treatment.
So these are grade two veins again these are very minimally important to the medical side of things they sometimes cause a little bit of aching but not terrible symptoms and these can also be treated with sclerotherapy or occasionally they can just be physically removed to get rid of them that's very easy and straightforward thing to do foreign three veins are the commonest type of what I would call proper varicose veins around about 50 percent of patients with varicose veins will have grade three varicose veins and this is a typical picture here you can see the prominent twisty bulgy veins on the surface of the skin what you can't see on this picture is the important bit which is the bit inside the leg where the leaky pipe is that is actually filling their veins in the picture and the relevance of that is that if one was just to take this patient to theatre and physically remove the veins that you can see in the photograph it won't help at all because without fixing the underlying problem the veins on the surface will just come back straight away and the only way of getting on top of this is to fix the leak inside the leg patients can alternatively if they choose not to have surgery can control these sorts of veins by using a compression stocking but I’ve never met anybody that found that a congenial thing to do on a long-term basis so really compression stockings are only advisable of patients who can't have surgery for various other medical reasons or in whom we think surgery would be quite risky again for other medical reasons.
Grade four veins are veins that are starting to damage the skin and you can see here in this photograph there's a sort of slight discontinuity of roughness of the skin surface you get this thing called venous eczema which is a very itchy patch of skin sometimes there's a darkening of the skin which called hemocidrine deposition and occasionally patients can have a condition called superficial phlebitis where the veins become lumpy and hard and that's not the deep vein thrombosis that's a totally different thing but thrombosis is annoying and it and it will continue to recur if the veins aren't attended to and that's a grade four vein.
Grades five and six are the most serious and this is the sort of end of the road really and ideally would never happen so on the left hand side you can see grade five you've got very dark skin staining around the ankle with an area of rough skin on the right hand side there's a horrible picture of a venous ulcer you don't need much imagination to work out that you really don't want to be like the picture on the right hand side of the screen we can heal venous ulcers but it takes a lot of intensive treatment with compression bandaging and various other adjuncts to get them to heal usually takes about three to four months to get them to heal they're extremely painful very debilitating and most of them are entirely preventable by prior surgery to veins before they get to this stage.
So moving on to the bit inside the leg the bit you can't see with the naked eye there there's a what we call a trunk vein it's usually a vein called the saphenous vein and there are two main trunk veins saphenous vein in the leg one running down the inside of the thigh which is called the long saphenous vein or the greater saphenous vein and there's another one running down the back of the calf from the knee crease down to the ankle down the back of the calf called the short saphenous vein or the lesser saphenous vein now you can't see these veins with the naked eye you need an ultrasound scan which we do in clinic when we see patients and if we can detect what we call reflux or backwards flow or in common language leaky vein in either of those two territories we can then seal it using the laser and the picture on the left hand side shows the laser having been inserted into the blue vein just above the knee and passed all the way up to the top and in this particular picture we've turned the laser on and slowly withdrawn it down the thigh sealing the vein as you go and in this particular picture the tip of the laser is now in the mid-thigh section circle around it and you can see a white dot and that's the laser working and we slowly draw it down the leg to the entry point and seal the veins shut as we go.
So that's Endovenous Laser Treatment or endothermal ablation which is the same thing really and it seals the leaky vein using a heat based technique so that's EVLT that's what we use we've been using that I mean I’ve used all the techniques over the 20 years of plus I’ve been doing this but the laser was the first minimally invasive technique to be developed it was the first one I used I was the second surgeon in the UK to use it, the first surgeon was a chap called Mark Whiteley, I used it in 2002 and I’m still using it I still think it's the best option. There are some other options the most the other common option is a thing called radio frequency ablation which you'll sometimes see in the literature on google searches sometimes called venus closure and that's also a heat based technique in layman's terms it's virtually identical to lasering there are some technical differences about it which is why I still prefer the laser but it seals the vein by generating heat the difference is that it generates heat using electricity rather than amplified light which is what a laser is and then there are a number of chemical techniques sclerotherapy have already mentioned you can use it in a number of different ways and some of my colleagues do use it on the bigger trunk veins I tend not to because it has a couple of drawbacks one is that it makes patients quite sore for about six weeks after treatment whereas with the laser most people will get better within a fortnight and it also tends to have prolonged bruising it does have its place in certain circumstances where the laser isn't technically feasible but it's really for the smaller veins rather than for big ones clary vein is a is a hybrid technique using sclerotherapy and a mechanical device to rough the vein up and I was the first surgeon in the UK to use ClariVein in 2010 and in certain cases it can work quite well but I and it's relatively well tolerated it's very it doesn't hurt much for most people but I stopped using it because I thought it had a higher rate of recurrence than the laser and that's why I still favour the laser.
I was quite intrigued to see just this last week in one of our scientific publications about vein surgery one of my colleagues at a chap Hull has just done a big randomized controlled trial which shows exactly the same thing that I found 13 years ago which is why I stopped using ClariVein but it's nice to have one's prejudices confirmed and then finally some there is still some people that use glue tissue glue to treat varicose veins it's an it's a it's a cyanoacrylate glue it's not that different from super glue really and that that is also kind of used by some people from things but I’ve never been keen on it because it's very expensive and there have been a number of cases where that operation has gone spectacularly wrong and led to severe complications of the skin breakdown and stuff like that it hasn't happened commonly but it's happened sufficiently frequently for me to know about and to avoid it really. So those are the broadly speaking those are the available techniques.
Now before we get anywhere near an operating theatre one needs to have a look at the patient in some detail and take a history of what has gone on before and to most importantly scan the leg now Mr Sweeney my colleague and I here we do all our own scans and I think that's very important a lot of surgeons still don't use their own ultrasound they send patients off for scanning somewhere else and whilst there are a small number of patients who for technical reasons we need to send off for scans on a bigger machine in the x-ray department we can scan 90 plus of people perfectly adequately in clinic with our mobile ultrasounds and I think that really is the key to being a decent venous surgeon you have to be able to scan to a good standard yourself I don't think surgeons who haven't bothered to learn how to use ultrasound will ever really achieve technical proficiency in these techniques so once we've examined the patient and scanned the patient we're then able to be able to comb down on the on what the treatment options are what technically is feasible and what the pros and cons of each approach would be including no operation and I think it's important to stress that that no operation is sometimes the best option for all sorts of reasons sometimes because of technical difficulties sometimes because of risk because there's always risk in any procedure no matter how good an operation is it always carries a risk tariff and so all of that stuff needs to be taken into consideration but once we've made a plan and the patients either decided what they want to do some a lot of patients come to clinic already having decided that they want to have surgery some people haven't really considered it in any depth and they like to go away and think about it and then let us know later on but we can usually book patients in within a few weeks and the vast majority of our surgery as I say is local anaesthetic and it's you know what we call walk-in walkout most procedures on the local take around about 20 to 30 minutes we put a bandage on and then the patient's able to go home can't drive a car for a few days but for most people by the end of the first week they're back to normal household activities and by the end of the second week they're back to life sports.
This is a sort of photograph of how normally things progress bear in mind and I’m saying this you know just to warn you nobody ever shows a bad photograph in a in a lecture or on a website so this is a patient I’ve treated this a long time ago in fact this patient was actually a medical photographer at Lewisham hospital so it was quite convenient she was able to go to colleagues to take the photographs for us and on the left-hand side you see the veins in the calf before surgery on the right hand side you see the veins two weeks after the operation they've already shrunk I didn't take any out I just sealed the vein and thigh with the laser and within two weeks the veins had already gone down substantially and decompressed markedly and by six weeks they'd vanished without any further treatment now it's not always as good as that sometimes we do we take the veins out or we subsequently inject them but that's a you know as a rough guide that's how things progress after EVLT.
This is a patient of mine from a few years ago, they kindly did a video to sort of explain all the stuff that I’ve just been talking about, just lasts about four minutes I think.
My name is Jo Crossey. Varicose veins was making my legs more uncomfortable as the years went on feeling very heavy and tired especially in the hot weather my feet would swell and just generally feeling achy most of the time and I did start working part-time and part of that reason was probably unconsciously thinking actually I can't keep on my feet all day long every day. We thought it was worth the drive to go and especially when it was a beautifully new hospital and it was it was a very pleasant experience and I wouldn't hesitate to go back again if I needed to in the future my GP referred me on the 22nd of January and I had my consultation with Benenden on the 31st of January so I was quite impressed by that.
The operation was very straightforward you are given a booklet to explain what the procedure is and Mr challenger who I saw also talked me through it but obviously when you're in consultation it's a lot of information to take in so I came home and read the leaflet I also looked online for him and he did a very good explanation online everything that was in the booklet is exactly what happened on the day you would talk through it and the staff were very helpful supportive and talked you through every process. I felt as if I am walking into a lovely environment like that that everything was going to be okay that it would be state-of-the-art and technology and processes so I felt very confident that I was in good habits my recovery was again like it said on the tin you know I had to wear my bandages for five days and then take those off I couldn't drive for five days obviously because they say for insurance purposes if I had to stop quickly and I or if I was in an accident insurance might not be so happy if I was wearing bandages and then I was back to work in a week it was a bit achy and a bit sore but they give you advice about putting your feet up whenever you can putting in local anaesthetics sorry rubbing in local anaesthetic gels wearing a support bandage if I needed to and I did that a few times because the weather was quite warm I post-surgery so I made use of those devices and advice and that certainly helped [music] my life now has changed in that I I’m not feeling the heaviness in my legs and I have been wearing shorts out and about which I hadn't done before so it certainly boosted my confidence in terms of that and yes getting back to running after two grandchildren.
If anybody was thinking about having their varicose veins done I would recommend the Benenden Hospital their technology and the processes they do is it's a it's just a laser treatment is the way forward and in terms of not making you lie in a bed getting you up and getting your mobile and certainly Benenden Hospital is highly recommended as far as I’m concerned.
Okay so I think that completes the fall bit of the talk I’m now going to hand back to Vicky who will moderate the questions we'll take a few questions if anyone's got any of course.
Thank you, Mr Chaloner, for that very interesting presentation, and so we now take some questions so please don't be shy. So, the first attendee asks, will varicose veins always lead to grade five and six if they're left?
Mr Eddie Chaloner
No, they won't fortunately vast majority of patients who have symptomatic veins are grade three and as a the statistics show that out of people with grade three veins about only about a third of them will go on to develop serious skin change and of those only about half will go on to develop something which could become an ulcer so it's a relatively small percentage and the other important point as I said before is this process usually takes a very long time it takes decades to happen and that indeed is the reason why the vast majority of people who end up with a venous ulcer are elderly nevertheless if you do get an ulcer that's really bad and it for all the patients who have venous ulcers it effectively ends their independence in in certain circumstances because they can't go out they have to have bandages on the thing smells and weeps and it's just horrible and that really is the rationale for fixing it at an earlier stage and certainly if you have signs of skin damage then an operation is certainly something to consider it's not the only option but it's certainly worth considering to prevent progression once you start to get bad skin change you're pretty likely to get an ulcer if you don't have it fixed.
Okay thank you, that's provided some information reassurance to the question asker. So, the next one is from Noel asks is there an increased risk of blood clotting or other serious risks due to having varicose veins for example grade three and upwards?
Mr Eddie Chaloner
Yeah, so we've gone complicated grade three veins there's no increased risk of DVT in certain grade four veins so when patients are getting recurrent bouts of phlebitis there is a slightly increased risk of DVT not huge but slightly increased and in very bad phlebitis where you get it up the trunk vein which doesn't happen that often but when it does then that does increase the risk of DVT as well so the vast majority of people don't have increased risk but there are some categories of vein that do there's also paradoxically of course I mean there's a risk of DVT after vein surgery it doesn't happen often it's around about one people still argue about them the risk of it a lot of people quote one in 200 I don't think it's that high in our practice it's around about one in 500. Um we give everybody anticoagulants in our practice which might be why we've got a slightly lower incidence than the than the quoted figures in the literature but yes you can get a DVT after surgery if you're really unlucky.
Okay, thank you. Next one is from Roz. Roz has two questions so we just take one at a time, so they say you mentioned muscle cramps as possible symptoms of varicose veins but didn't elaborate can you elaborate on why they happen and what you can do about them?
Mr Eddie Chaloner
Yeah, so that happened because the vein is stretched and the pressure in the vein is too high when you measure that when you scan somebody you measure I might measure the diameter of the saphenous vein and a normal long saphenous vein should have a diameter for about three to three and a half millimetres but the varicose vein might be anywhere from four five six even bigger one of the patients I saw just this afternoon had a 10 millimetre of arax vein which is really quite swollen and it's the pressure because of the swelling that is uncomfortable anything in the body which is pressurized or distended is uncomfortable it doesn't matter whether it's the varicose vein or you know a pregnant uterus or a gallbladder or it doesn't matter what anything that's swollen is uncomfortable and that's why you get the discomfort as far as treating it other than mechanisms other than surgery the best way of dealing with it without surgery is to wear a baloney compression stocking because that squeezes the vein flat and will reduce the swelling and attendant discomfort but the downside is of course you have to wear the stocking and the stocking has to be firm because if it's not firm it won't work and so that's the that's the downside of stockings but they do work and they work effectively if people wear them.
Okay, thank you, and the second part of Roz’s question, is your handheld scanner a doppler or is that only the big one in major hospital vascular departments?
Mr Eddie Chaloner
Doppler? That depends what you mean by you might have a different understanding of the word doppler than I do so from a technical point of view a doppler is it's just an imaging technique and my small scanner has a doppler facility I don't really need that much actually I can use the colour flow to pick up directional blood flow on it in just the same way as we do on the scanner in the big scanner in the x-ray department the advantage of the scans in the in the x-ray department is that the big machines have greater depth and you can look at the deep veins of the leg in a more comprehensive way than you can with a portable scanner you can still image the deep veins with a portable scanner but it's just it's not as accurate but the vast majority of patients you don't really need to do an extensive deep vein scan so the patients that need a scan in the in the x-ray departments are usually only patients where there's a past history of deep vein thrombosis there's a clinical suspicion that there's a problem with the deep veins or the leg is so big that it's really difficult to image properly with the with the small machine so the vast majority of the stuff that we do is perfectly amenable to scanning with a small machine.
Okay, that's great to hear, I hope that's answered them your questions. Next one is from Rachel. Rachel asks if you have pelvic varicose veins is there any point in cheating veins in the leg?
Mr Eddie Chaloner
Yeah that's a very good question and that and the answer is it kind of depends on how bad they are around about a third of women who've had pregnancies will have some form of pelvic vein reflux most of them won't even be aware of it but sometimes the pelvic vein reflux will manifest itself by varicose veins in the leg and if those veins are large then there's little point really in treating them just in the leg because they always come back or very often come back extremely quickly and so for the patients with large pelvic varicosities draining into the leg mike for a method of tracing them is to send them for a pelvic vein embolization which is a long word but and it sounds a bit scary but it's not really but it is very technically demanding and that's a technique where a radiologist will insert a catheter a very fine tube into the leaking vein in the middle of the pelvis and seal it from within there aren't many radiologists who are good at this fortunately I have to know one of the best ones in the country a guy called Narayan Karunanithy who's a consultant radiologists at St Thomas's we've been working together for a very long time we have you know he we have the same secretary and so all of my patients with pelvic vein reflux will be referred to Narayan and he will do the pelvic vein embolization but once that's been done patient will then come back to see me and I’ll fix the veins in the leg and that's the most effective way of getting a durable result.
That's great, thank you. Next question is from Alison. Alison is 45 and she has four children, and she says she has veins in her right leg only due to pregnancy, she's a busy mum and runs every day for her mental health. How long before she can run again and then initially after treatment will she have to rest, or can she be the busy mum that she is? If that makes sense, and also what's the chance of that they come back?
Mr Eddie Chaloner
Okay, so the as I said before though for most patients they're selling straightforward EVLT by the end of the first week after treatment most people are back to their normal household activities so driving a car doing all that household chores stuff and most people are going back to work as long as their work isn't unduly onerous physically most patients will need to take tablets for two or three days not much more than that and by the end of the second week most people are back to the gym or to light sports by the end of the third week most people there might still have a few lumps and bumps and be a bit bruised but for all intents and purposes most people have forgotten about it by that point and that's in comparison with when we did it the old way where we used to put people to sleep and strip the veins out with a big plastic rod and most patients took about six weeks to get better from that so there is a recovery period it can be a bit sore but for most people by the end of the second week they're getting back to their normal exercise routine as far as recurrence is concerned there is a risk of recurrence and for most patients it's around about five percent at five years so one in 20. Um and again one has to compare that with what went before the high time strip operation had a recurrence rate of 30 at five years so EVLT is by no means perfect but it's certainly a lot better in every domain than what we used to do when I was a young surgeon you know the people get better faster they have less pain they've got lower rates of recurrence and they're lower risks of other complications such as wound infections and nerve damage and stuff like that.
Okay, great. Hopefully that's answered your question. Got time for a couple more so we've got a question from Ryan who asks after EVLT surgery how long I might need to wait before I can fly?
Mr Eddie Chaloner
Yeah, so lots of different views on this point it's all about the risk of deep vein thrombosis after flight when we're not you know it's very difficult to produce any hard and fast statistical evidence on this because you just can't power up the studies statistically to make them relevant but the majority of my colleagues and certainly my view is I recommend patients don't fly for four weeks after surgery the risk after four weeks after treatment is almost certainly the same as background so as if you hadn't had an operation and I think that's probably you know that's a sort of consensus advice.
Okay, great thank you. All right I hope that's answered your question. Moira asks is there an age limit for someone who is otherwise healthy? I’m 75 with a prominent vein running down the front of my left leg from the kneecap.
Mr Eddie Chaloner
No, it's the not so much you know how many miles you've got on the clock it's depends on the state of your engine really and if you're otherwise fitting well no I mean we operate on you know everybody from 19 to 90 and older on occasions I mean it depends really what why you want why you want to have an operation I mean you know whether it's symptoms or whether it's prevention of ulcers or whether it's cosmetic for most older patients it's a combination of symptoms and prevention of deterioration and ulceration in later life those are the main drive is why people come for treatment but it's one of the big advantages of EVLT and the shift to minimally invasive surgery particularly under local anaesthesia that we can do operations on older patients who might otherwise have been turned down for general anaesthetic in days gone by because the risks of doing it under local are much lower so we're able to treat older and more infirm patients with good levels of safety and good efficiency.
Okay, and we've got time for one more question. This person asks are there any issues if you're on blood thinners?
Mr Eddie Chaloner
Yes, a bit but it's not necessarily you know it's not necessarily the case that you can't have surgery because you're taking anticoagulant so lots of reasons why people take anticoagulants the commonest is a condition called atrial fibrillation which is a irregular heartbeat and people are on anticoagulants in that circumstance to reduce the risk of stroke and so for patients like that we normally stop the anticoagulant for a couple of days beforehand do the operation and restart it afterwards and that works pretty well there are some patients who are on anticoagulants for more serious issues like for example they've had multiple DVTs or they've got mechanical heart valves which you and you can't stop the anticoagulation in those patients and for those sorts of patients you've really got to think carefully about whether or not surgery is the best option or whether treatment with compression is better but you know I have treated many patients who needed to remain on their anticoagulants for various medical reasons and on balance we considered that surgery was the best option and I’ve treated patients very successfully with them with EVLT while they were still taking anticoagulants you do get more bruising fairly obviously you would and it might take a bit longer for them that those sort of patients to get better but in the right circumstances if it's necessary you can do it without stopping the anticoagulants if you have to.
Okay, thank you Mr Chaloner. So that's all the time we've got for questions, sorry if we didn't get to answer yours but if you provided your name, we'll get back in touch with you via email.
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So, on behalf of Mr Chaloner and our expert team at Benenden Hospital, I’d like to say thank you ever so much for joining us today and we hope to hear from you very soon. Thank you and goodbye.