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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 14  |  Issue : 2  |  Page : 81-84

Superficial venous surgery as a management for chronic venous leg ulcers


1 Department of Surgery, NHTMRI, Cairo, Egypt
2 Department of Radiology, NHTMRI, Cairo, Egypt

Date of Submission27-Feb-2016
Date of Acceptance29-Apr-2016
Date of Web Publication21-Oct-2016

Correspondence Address:
Mohamed Mohamed Mogahed
Department of Surgery, NHTMRI, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-1693.192644

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  Abstract 

Background
Venous leg ulcer (VLU) is a chronic problem affecting thousands of patients annually. The aims of this study were to evaluate the effectiveness of saphenous vein surgery as a management for chronic VLUs and to determine which group of patients will gain more benefit from surgery.
Patients and methods
A prospective study was conducted over a period of 4 years on 40 patients (32 males and eight females) with chronic VLUs CEAP 6 (indicating skin changes with active ulceration) and isolated superficial venous system insufficiency. Patients were divided into two groups: group A included 20 patients who underwent compression alone and group B included 20 patients for whom surgery on the superficial saphenous system was performed followed by compression. The patients were followed up for ulcer healing rate, healing time, and incidence of recurrence for at least 12 months.
Results
The rate of ulcer healing was 65% in group A within 14–24 weeks and 100% in group B within 8–16 weeks. The recurrence rates were 30% in group A and 10% after surgical correction in group B within 12 months of follow-up.
Conclusion
Surgical correction of incompetent superficial saphenous veins improves ulcer healing rate, healing time, and reduces recurrence in patients with isolated superficial venous system incompetence.

Keywords: superficial venous system, varicose veins, venous leg ulcer


How to cite this article:
Mogahed MM, Abdellatif WM. Superficial venous surgery as a management for chronic venous leg ulcers. Al-Azhar Assiut Med J 2016;14:81-4

How to cite this URL:
Mogahed MM, Abdellatif WM. Superficial venous surgery as a management for chronic venous leg ulcers. Al-Azhar Assiut Med J [serial online] 2016 [cited 2019 Sep 23];14:81-4. Available from: http://www.azmj.eg.net/text.asp?2016/14/2/81/192644


  Introduction Top


The complicated natural history of venous ulcers requires continued development and improvement of treatments to ensure the most effective management.

Chronic venous disease can be defined as an abnormally functioning venous system caused by venous valvular incompetence with or without associated venous outflow obstruction. Venous leg ulcers (VLUs) are defined as an area of discontinuity of the epidermis and dermis on the lower leg, persisting for 4 weeks or more [1]. The occurrence of VLUs is strongly associated with venous disease (e.g. varicose veins and deep vein thrombosis), contributing to sustained venous hypertension; arterial disease is present (alone or in combination with venous disease) in ∼20% of cases [2]. The aetiology of VLUs includes inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular oedema. Other factors contributing to VLUs include immobility, obesity, trauma, vasculitis, old age, and diabetes [3].

VLUs are a common, chronic, recurring condition and a major cause of morbidity and disability.

Identification of the anatomical location of venous disease in patients with venous ulceration and chronic venous insufficiency with duplex is important to decide the treatment modality. Duplex will define the origin of venous reflux causing the varicose veins and confirm the function and patency of the deep venous system. Duplex is superior to both clinical examination and hand-held Doppler for accurate assessment of venous reflux [4]. The UK and USA now recommend duplex imaging as the standard for preoperative assessment in all patients with varicose veins [5],[6].

Previous studies have proved that more than 50% of patients have isolated superficial system reflux. In the ESCHAR study (comparison of surgery and compression with compression alone in chronic venous ulceration: randomized controlled trial), 60% of the patients had isolated superficial reflux, in the Shami study 53% of the patients had isolated superficial system reflux [7],[8], and in the study of Robertson et al. [9] in 2014 two-third of the patients had isolated superficial system reflux.

The aim of this study was to evaluate the efficacy of superficial venous system surgery as a management for chronic VLUs in patients with isolated superficial venous system incompetence.


  Patients and methods Top


The study was approved from local ethical committee. This study included 40 patients (32 males and eight females) with chronic VLUs classified according to CEAP (Clinical, Etiology, Anatomy, Pathophysiology) [10]. All the patients had CEAP 6 ulcers (indicating skin changes with active ulceration) over a 4-year period from January 2012 to January 2016, and were undergoing treatment in several hospitals. The age range was 29–61 years (median=45 years). Patients were subdivided into two groups: group A included 20 patients who underwent compression only and group B included 20 patients who underwent surgery on the saphenous system alone without perforating veins ligation followed by compression. The patients were followed up for ulcer healing rate for 24 weeks and for healing time and recurrence rate for at least 12 months.

Patients with only superficial saphenous incompetence were included. Patients with deep venous incompetence, ankle brachial index less than 8.5, previous vasculitis, collagen–vascular diseases, and dermal manifestations of systemic diseases were excluded.

For all patients, thorough history analysis, clinical examination, ankle brachial index calculation were performed. All the patients were assessed by color duplex ultrasound scanning to determine the location of the venous disease.

Basic wound care principles were followed, such as proper wound environment, control of clinical signs of infection, and debridement. Removal of all necrotic tissue, densely adherent slough, and exudates was carried out for all patients.

Elastic, multilayered compression bandages were used. Compression bandage systems were wrapped around the leg from the foot to the upper calf, which provided a pressure of 20–40 mmHg. Care was taken to avoid excessive compression of skin against any bony prominences. The patients were instructed to walk to achieve the full compressive effect of the bandage. Compression was the mode of treatment in group A and used postoperative care in group B.

Spinal or general anesthesia was administered in the 20 patients who underwent surgery.

Saphenofemoral junction disconnection and long saphenous vein stripping to the knee were performed in 19 patients, and saphenofemoral junction disconnection was performed only in one patient because of his general condition. For all 20 patients, no perforator ligation was performed.


  Results Top


This study was conducted on 40 patients, 32 males (80%) and eight females (20%), with chronic VLUs and superficial venous system insufficiency over a 4-year period. Patients were divided into two groups: group A included 20 patients who underwent compression only, and group B included 20 patients who underwent surgery on the saphenous system alone followed by compression. The patients were followed up for time of ulcer healing, rate of healing, and the rate of recurrence for at least 12 months.

Rate of ulcer healing was 65% in group A (13 patients) within 14–24 weeks and 100% in group B (20 patients) within 8–16 weeks. The recurrence rates at 12 months were 30% (six patients) in group A and 10% (two patients) after surgery in group B, as shown in [Figure 1].
Figure 1: Healed and recurrent ulcers in group A and group B.

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Time of healing was markedly reduced in group B (8–16 weeks) when compared with group A (14–20 weeks) as shown in [Figure 2].
Figure 2: Average time for ulcer healing in group A and group B in weeks.

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  Discussion Top


Chronic VLUs represent a major burden to healthcare services affecting at least 1% of the population [11].

Because of the substantial morbidity and the financial and psychosocial costs involved, it is important to identify the most effective means of treatment for venous ulceration. The progressive development and modification of treatments are essential to overcome the natural history of prolonged ulceration and recurrence that make venous ulceration extremely difficult to cure.

Full clinical history analysis and physical examination are critical to the identification of underlying co-morbidities and provide important information regarding the aetiology of VLUs.

In over half of the patients with venous ulceration, the disease was confined to the superficial venous system. In their study, Shami et al. [8] found that isolated deep venous reflux was present in only 15%, a combination of deep and superficial venous reflux was found in 32%, and in 53% of their patients there was only superficial venous reflux. In the ESCHAR study, 60% of the patients had isolated superficial reflux, and in the Robertson study in 2014 two-third of the patients had isolated superficial system reflux [9].

In our study, we selected patients with isolated superficial venous reflux to exclude the effect of deep venous incompetence on the outcome.

Over the years, clinicians have been faced with numerous treatment options for VLUs. The aim of this study was to evaluate the efficacy of superficial saphenous venous system surgery as a management for chronic VLUs with isolated superficial venous reflux.

Chronic venous disease is commonly stratified using the CEAP (Clinical, Etiology, Anatomy, Pathophysiology) classification, which grades venous disease on the basis of the presence of dilated veins, edema, skin changes, or ulceration. Chronic venous insufficiency is defined as CEAP 3 to 6 and represents advanced venous disease [10].

Being the cornerstone of management for patients with chronic venous insufficiency (venous valvular reflux), the use of elastic multilayered compression bandages was the mode of treatment in group A and used for postoperative care in group B in this study.

The results of this study showed that the rate of ulcer healing was higher and faster in group B (100%) within 8–16 weeks compared with group A (65%) within 14–24 weeks.

Results of the ESCHAR study and the Van Gent studies revealed no statistically significant difference in healing rates in patients managed with compression plus surgery and those managed with compression alone [7],[12]. In contrast, Taradaj et al. [13] reported a statistically significant difference favoring surgery plus compression.

The accepted statistics indicated that VLUs require an average of 24 weeks to heal [14],[15].

Gohel and colleagues in 2007 concluded that surgical correction of superficial venous reflux does not increase healing rates in patients with VLUs receiving compression therapy. In 500 patients with open or recently healed VLUs and superficial venous reflux, healing rates at 3 years were 89% for the compression group and 93% for the compression plus surgery group (P=0.73) [16].This conclusion could be explained by the longer duration for compression (3 years) used in the Gohel study.

However, in our study, the healing rate improved to 100% by surgery and the time of healing was reduced (8–16 weeks); the higher surgical success may be due to patient selection with isolated superficial saphenous incompetence. This is in agreement with the study of Nachbur [17], who reported a 100% healing rate for limbs without deep venous thrombosis (DVI) or post-thrombotic syndrome, and with Nash [18] who achieved 100% healing in patients with superficial venous incompetence alone.

When considering recurrence rates, in this study, the rates of ulcer recurrence at 12 months were lower in group B (10%) (compression plus surgery) than in group A (30%) (compression), and this was similar to both the ESCHAR study and the Taradaj study [13], who found lower incidence of recurrence among patients who underwent surgery in addition to compression as compared with patients who were managed with compression alone [7],[13]. In the ESCHAR study, there was a 12% recurrence rate at 1 year for patients managed with compression plus surgery, as compared with 28% in the group managed with compression alone (P<0.0001) [7]. Recurrence rates at 4 years continued to favor surgery plus compression versus compression alone (31 vs. 56%; P<0.001) [12]. Taradaj et al. [13] also reported lower recurrence rates at 2 years after intervention in patients who underwent surgery, compression, and drug therapy compared with the group that received compression stockings and drug therapy (P<0.001). In contrast, Van Gent et al. [12] did not find any statistical difference in recurrence rates among patients treated with compression alone and those treated with compression plus surgery (23 and 22%, respectively).These findings support the role of surgery in addition to compression therapy in patients with chronic VLUs.


  Conclusion Top


Accurate diagnosis by routine preoperative duplex ultrasound will enable the direction of appropriate therapy and should be considered mandatory. With proper patient selection, surgical correction of superficial venous reflux in addition to compression bandaging improves healing rate, reduces healing time, and reduces the recurrence rate of chronic VLUs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Royal College of Nursing Institute. The management of patients with venous leg ulcers: recommendations for assessment, compression therapy, cleansing, debridement, dressing, contact sensitivity, training/education and quality assurance. London: Royal College of Nursing; 1998.  Back to cited text no. 1
    
2.
O’Brien JF, Grace PA, Perry IJ, Burke PE. Prevalence and aetiology of leg ulcers in Ireland. Ir J Med Sci 2000; 169:110–112.  Back to cited text no. 2
    
3.
Simon DA, Dix FP, McCollum CN. Management of venous leg ulcers. BMJ 2004; 328:1358–1362.  Back to cited text no. 3
    
4.
Mercer KG, Scott DJ, Berridge DC. Preoperative duplex imaging is required before all operations for primary varicose veins. Br J Surg 1998; 85:1495–1497.  Back to cited text no. 4
    
5.
Glovicki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML et al. The care of patients with varicose veins and associated chronic venous disease: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53(Suppl):2S–48S.  Back to cited text no. 5
    
6.
Marsden G, Perry M, Kelley K, Davies AH, Guideline Development Group. Diagnosis and management of varicose veins in the legs: summary of NICE guidance. BMJ 2013; 347:f4279.  Back to cited text no. 6
    
7.
Barwell JR, Davies CE, Deacon J, Harvey K, Minor J, Sassano A et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet 2004; 363:1854–1859.  Back to cited text no. 7
    
8.
Shami SK, Sarin S, Cheatle TR, Scurr JH, Smith PD. Venous ulcers and the superficial venous system. J Vasc Surg 1993; 17:487–490.  Back to cited text no. 8
    
9.
Robertson LA, Evans CJ, Lee AJ, Allan PL, Ruckley CV, Fowkes FG. Incidence and risk factors for venous reflux in the general population: Edinburgh Vein Study. Eur J Vasc Endovasc Surg 2014; 48:208–214.  Back to cited text no. 9
    
10.
Takahashi PY, Chandra A, Cha SS, Crane SJ. A predictive model for venous ulceration in older adults: results of a retrospective cohort study. Ostomy Wound Manage 2010; 56:60–66.  Back to cited text no. 10
    
11.
Eklof B, Rutherford RB, Clement D, Norgren L, Baccaqlini U et al. American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement 2004; 40(6):1248–1252.  Back to cited text no. 11
    
12.
Van Gent WB, Hop WC, van Praag MC, Mackaay AJ, de Boer EM, Wittens CH. Conservative versus surgical treatment of venous leg ulcers: a prospective, randomized, multicenter trial. J Vasc Surg 2006; 44:563–571.  Back to cited text no. 12
    
13.
Taradaj J, Franek A, Cierpka L, Brzezinska-Wcislo L, Blaszczak E, Polak A et al. Early and long-term results of physical methods in the treatment of venous leg ulcers: randomized controlled trial. Phlebology 2011; 26:237–245.  Back to cited text no. 13
    
14.
Kurz N, Kahn SR, Abenhaim L et al. VEINES Task Force Report, The management of chronic venous disorders of the leg (CVDL): an evidence based report of an international task force. McGill University. Sir Mortimer B. Davis-Jewish General Hospital. Summary reports in: Angiology 1997; 48(1): 59–66; and Int Angiol. 1999; 18 (2): 83–102  Back to cited text no. 14
    
15.
Heit JA. Venous thromboembolism epidemiology: implications for prevention and management. Semin Thromb Hemost 2002; 28:(Suppl 2): 3–13.  Back to cited text no. 15
    
16.
Gohel MS, Barwell JR, Taylor M, Chant T, Foy C, Earnshaw JJ et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 2007; 335:83.  Back to cited text no. 16
    
17.
Nachbur B. Surgical treatment of venous leg ulcers. Wien Med Wscchr 1994; 144:264e268.  Back to cited text no. 17
    
18.
Nash TP. Venous ulceration: factors influencing recurrence after standard surgical procedures. Med J Aust 1991; 154:8–50.  Back to cited text no. 18
    


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