The place of subfascial endoscopic perforator vein surgery (SEPS) in advanced chronic venous insufficiency treatment

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Abstract

In spite of medical science development and initiation of new technologies in minimally invasive surgery, treatment of advanced chronic venous insufficiency at the 5 ^th and 6 ^th degree of CEAP classification is still a great clinical challenge. In case of no satisfactory results of non-surgical treatment of recurrent venous ulcers, scientists search for alternative therapeutic methods which could be more effective and lasting. Subfascial endoscopic perforator vein surgery (SEPS) as a method of reducing venous pressure in the superficial venous system could provide healing of the recurrent venous ulcer. In this study we present a review of contemporary opinions about the place and significance of subfascial endoscopic perforator vein surgery as a treatment of advanced chronic venous insufficiency.

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Most cited references 60

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Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial.

B Heather, Elizabeth D Mitchell, Paul Minor … (2004)

Chronic venous leg ulceration can be managed by compression treatment, elevation of the leg, and exercise. The addition of ablative superficial venous surgery to this strategy has not been shown to affect ulcer healing, but does reduce ulcer recurrence. We aimed to assess healing and recurrence rates after treatment with compression with or without surgery in people with leg ulceration. We did venous duplex imaging of ulcerated or recently healed legs in 500 consecutive patients from three centres. We randomly allocated those with isolated superficial venous reflux and mixed superficial and deep reflux either compression treatment alone or in combination with superficial venous surgery. Compression consisted of multilayer compression bandaging every week until healing then class 2 below-knee stockings. Primary endpoints were 24-week healing rates and 12-month recurrence rates. Analysis was by intention to treat. 40 patients were lost to follow-up and were censored. Overall 24-week healing rates were similar in the compression and surgery and compression alone groups (65% vs 65%, hazard 0.84 [95% CI 0.77 to 1.24]; p=0.85) but 12-month ulcer recurrence rates were significantly reduced in the compression and surgery group (12% vs 28%, hazard -2.76 [95% CI -1.78 to -4.27]; p<0.0001). Adverse events were minimal and about equal in each group. Surgical correction of superficial venous reflux reduces 12-month ulcer recurrence. Most patients with chronic venous ulceration will benefit from the addition of simple venous surgery.

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Investigation of chronic venous insufficiency: A consensus statement (France, March 5-9, 1997).

A N Nicolaides (2000)

This consensus document provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations. CVI is characterized by symptoms or signs produced by venous hypertension as a result of structural or functional abnormalities of veins. The most frequent causes of CVI are primary abnormalities of the venous wall and the valves and secondary changes due to previous venous thrombosis that can lead to reflux, obstruction, or both. Because the history and clinical examination will not always indicate the nature and extent of the underlying abnormality (anatomic extent, pathology, and cause), a number of diagnostic investigations have been developed that can elucidate whether there is calf muscle pump dysfunction and determine the anatomic extent and severity of obstruction or reflux. The difficulty in deciding which investigations to use and how to interpret the results has stimulated the development of this consensus document. The aim of this document was to provide an account of these tests, with an outline of their usefulness and limitations and indications of which patients should be subjected to the tests and when and of what clinical decisions can be made. This document was written primarily for the clinician who would like to learn the latest approaches to the investigation of patients with CVI and the new applications that have emerged from recent research, as well as for the novice who is embarking on venous research. Care has been taken to indicate which methods have entered the clinical arena and which are mainly used for research. The foundation for this consensus document was laid by the faculty at a meeting held under the auspices of the American Venous Forum, the Cardiovascular Disease Educational and Research Trust, the European Society of Vascular Surgery, the International Angiology Scientific Activity Congress Organization, the International Union of Angiology, and the Union Internationale de Phlebologie at the Abbaye des Vaux de Cernay, France, on March 5 to 9, 1997. Subsequent input by co-opted faculty members and revisions in 1998 and 1999 have ensured a document that provides an up-to-date account of the various methods available for the investigation of CVI.

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Conservative versus surgical treatment of venous leg ulcers: a prospective, randomized, multicenter trial.

W. Hop, Albert J Mackaay, W. Van Den Wollenberg … (2006)

The prevalence of venous leg ulcers is as high as 1% to 1.5%, and the total costs of this disease are 1% of the total annual health care budget in Western European countries. Treatment modalities are conservative or surgical. Subfascial endoscopic perforating vein surgery (SEPS) combined with superficial vein ligation is performed in many centers to address vein incompetence in patients with chronic venous leg ulcers. Several reports describe good healing and low recurrence rates, although a randomized trial to compare surgical treatment including SEPS and treatment of the superficial venous system to conservative modalities has never been performed. Therefore, a prospective, randomized, multicenter trial was conducted to study whether ambulatory compression therapy with venous surgery is a better treatment than just ambulatory compression therapy in venous leg ulcer patients. Patients with an active (open) venous leg ulcer (CEAP C6) qualified for the study. The study consisted of two treatment groups. All patients were treated by standardized ambulatory compression therapy, and half of the patients received SEPS. Concomitant superficial venous incompetence was also treated in the second group. For allocation to both treatment groups, each patient was assigned by a computer program at the randomization center. The primary goal of the study was to compare the ulcer-free period during follow-up in both study groups. Secondary end points were ulcer healing and recurrence rates. From April 1997 until January 2001, 200 ulcerated legs (170 patients) were included in the study in 12 centers in The Netherlands. A total of 97 ulcers were allocated to the surgical group and 103 to the conservative group. Patient characteristics were similar in the two treatment groups at baseline, with the exception of a higher proportion in the conservative group of diabetes mellitus. Healing rates were 83% in the surgical group and 73% in the conservative group (not significant; median time to healing, 27 months). Recurrence rates were the same in both treatment groups (22% surgical vs 23% conservative). During follow-up of a mean of 29 months (median, 27 months) in the surgical group and 26 months (median, 24 months) in the conservative group, we found that in the surgical group, the ulcer-free rate was 72%, whereas in the conservative group this rate was 53% (P = .11; Mann-Whitney test). Patients with recurrent ulceration or medially located ulcers in the surgical group had a longer ulcer-free period than those treated in the conservative group (P = .02 for both). A first-time ulcer and one of the centers also had a positive effect on the ulcer-free period during follow-up (P < .001 and P = .02), independent of the treatment group. Deep vein incompetence did not affect the ulcer-free period. In conclusion, we suggest that patients with medial and/or recurrent ulceration should receive surgery combined with ambulatory compression therapy. A dedicated center should provide care for those patients.

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Author and article information

Journal

Journal ID (nlm-ta): Wideochir Inne Tech Malo Inwazyjne

Journal ID (iso-abbrev): Wideochir Inne Tech Malo Inwazyjne

Journal ID (publisher-id): WIITM

Title: Videosurgery and Other Miniinvasive Techniques

Publisher: Termedia Publishing House

ISSN (Print): 1895-4588

ISSN (Electronic): 2299-0054

Publication date (Electronic): 20 December 2011

Publication date (Print): December 2011

Volume: 6

Issue: 4

Pages: 181-189

Affiliations

[1 ]Department of General and Minimally Invasive Surgery, University Hospital and Clinics, Olsztyn, Poland

[2 ]Department of Anatomy, University of Warmia and Mazury, Olsztyn, Poland

[3 ]Department of Internal Diseases, Gastroenterology and Hepatology, University Hospital, Olsztyn, Poland

Author notes

Address for correspondence Wiesław Pesta MD, PhD, Department of General and Minimally Invasive Surgery, University Hospital and Clinics, 30 Warszawska, 10-082 Olsztyn, Poland. phone: +48 89 728 323 310. e-mail: wieslaw.pesta@ 123456vp.pl

Article

Publisher ID: 17848

DOI: 10.5114/wiitm.2011.26252

PMC ID: 3516943

PubMed ID: 23255980

SO-VID: 2c3bbaf8-52b9-422f-9c40-a6c06c8e2fe8

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 04 March 2011

Date revision received : 12 May 2011

Date accepted : 02 September 2011

The place of subfascial endoscopic perforator vein surgery (SEPS) in advanced chronic venous insufficiency treatment

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Most cited references 60

Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial.

Investigation of chronic venous insufficiency: A consensus statement (France, March 5-9, 1997).

Conservative versus surgical treatment of venous leg ulcers: a prospective, randomized, multicenter trial.

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