Page 46 - Journal of WALS

WJOLS

Subfascial Endoscopic Perforator Surgery in Perforator Vein Insufficiency

following dimensions: Death at 6 months [OR 3.00 (95% CI 0.11- compared. Those patients with prior deep vein thrombosis
78.27)], rate of hospital readmission [OR 0.21 (95% CI 0.03 - (< 6 months) or prior to SEPS procedure were excluded from
1.31)], healing rate of ulcer at four months [OR 0.44 (95% CI their study. Results of the study was that there were 27 men
0.09-2.12)], and the rate of deep vein thrombosis (DVT) [OR and 53 women with a median age of 59.8 years (range: 34.3-80.0
0.35 (95% CI 0.01-8.85)]. Conclusion drawn from the study was years). The distribution of clinical classes (CEAP) were: Class
that when SEPS used as a part of a treatment regimen for severe 2, 13.1% (12 limbs); Class 3, 22.8% (21 limbs); Class 4, 19.6% (18
CVI benefits most patients in the short term regarding ulcer limbs); class 5, 21.7% (20 limbs); and Class 6, 22.8% (21 limbs).
healing and also prevention of ulcer recurrence. And SEPS, if The etiology of patients with venous insufficiency was primary
safely performed, has less early postoperative complications valvular incompetence in 83 limbs (90.2%) and secondary
compared with the Linton procedure. However, still further disease in nine limbs (9.8%). Concomitant superficial vein
prospective randomized trials are required to define the long- surgery was performed in 89 limbs (95.7%). For 20 patients (95%),
term benefits of SEPS. leg ulcers healed spontaneously within 12 weeks after operation,
In a randomized study by Kianifard B, Holdstock J and whereas one patient required an additional split-thickness skin
15
Allen C et al, the effect of adding subfascial endoscopic graft. Eighteen patients had previous surgery of the great and/
perforator surgery to standard great saphenous vein stripping or short saphenous vein before SEPS. During a mean follow-up
was studied. The authors studied the fate of incompetent of 3.7 years, recurrence of 22 IPVs was observed in 20 (21.7%)
perforating veins (IPVs) in patients undergoing standard of 92 limbs, and recurrent leg ulcers were observed in two (9.5%)
varicose vein surgery vs those treated with standard varicose of 21 limbs. They also performed univariate and multivariate
vein surgery and SEPS. Patients were included in this study, if analyses to predict factors which influencing the recurrence of
they were undergoing surgery for varicose veins and also had IPVs [recurrent superficial varicosis, secondary disease, active
venous reflux (0.5 seconds) in the great saphenous vein (GSV). or healed leg ulcer (C5/6), compression treatment, and previous
All patients in the study also had IPVs. Patients were randomly operation]. The multivariate analysis showed that patients with
allocated to standard surgery (saphenofemoral ligation, previous surgery (p = 0.014) were identified as the only
stripping and phlebectomies alone) or standard surgery with significant factor for the recurrence of IPVs. Conclusion of the
the addition of SEPS. Patients were excluded from the study, if study was SEPS is a safe and highly effective treatment for
they had recurrent varicose veins, deep venous reflux, deep IPVs. In the study, within a median follow-up period of 3.7
venous thrombosis, ulceration or saphenopopliteal reflux. Using years, only two of 21 venous ulcers recurred, both in patients
duplex ultrasound, incompetent perforating veins were with secondary disease. Nevertheless, they observed recurrence
determined preoperatively, and at 1 week, 6 weeks, 6 months of IPVs in 21.7% of the operated limbs. The multivariate analysis
and 1 year after surgery. Visual analogue scores for pain and showed that patients who had undergone previous surgery
quality of life questionnaires were obtained at the same time were found to have a significantly higher rate of recurrence.
periods.
There were 34 patients in the no SEPS group and 38 patients CONCLUSION
in the SEPS group. During the follow-up period, the groups did SEPS is a feasible, safe and effective treatment of the incompetent
not differ with respect to quality of life scores, pain, or mobility, perforator veins in patients with advanced chronic venous
but at 1 year, there was a higher proportion in the no SEPS vs insufficiency.
SEPS group that had IPVs (25 of 32 vs 12 of 38; p = 0.001). The In our review, it has been found that SEPS is a promising
conclusion drawn was that subfascial endoscopic perforator technique for treatment of patients with perforator
surgery (SEPS) when used as an adjunct to standard varicose incompetence. It may be optimally utilized in cases with failure
vein surgery reduces the number of incompetent perforating of conservative therapy or those with advanced chronic venous
veins at 1 year but has no effect on quality of life or recurrence insufficiency. The favorable ulcer healing rate and improvement
of varicose vein at 1 year. in clinical symptoms suggest that SEPS plays a considerable
16
Florian Roka et al in their study, they investigated the role in correcting the underlying pathology in chronic venous
mid-term (mean, 3.7 years) clinical results and the results of insufficiency caused by incompetent perforating veins.
duplex Doppler sonographic examinations of subfascial
endoscopic perforating vein surgery (SEPS) in all patients with REFERENCES
mild to severe chronic venous insufficiency (clinical class 2 to 6) 1. Linton RR. The communicating veins of the lower leg and the
and also assessed the factors associated with the recurrence of operative technique for their ligation. Ann Surg 1938;107:582-
insufficient perforating veins (IPVs). Around 80 patients with 93.
mild to severe chronic venous insufficiency undergoing SEPS 2. Linton RR. The post-thrombotic ulceration of the lower extremity:
Its etiology and surgical treatment. Ann Surg 1953;138:415-32.
were evaluated, duplex findings as well as clinical severity and 3. Cockett FB. The pathology and treatment of venous ulcers of
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World Journal of Laparoscopic Surgery, May-August 2011;4(2):117-122 121