Systematic review of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery.
BACKGROUND
In the United States more than 6 million persons have chronic venous insufficiency and more than 500,000 have venous ulcers. Patients in whom conservative therapies fail may improve after surgical treatment of superficial and perforating venous disease, but the degree of this benefit is uncertain.


OBJECTIVE
We performed a systematic review of health outcomes in patients with severe chronic venous insufficiency treated with surgical management that incorporated subfascial endoscopic perforator surgery (SEPS), to quantify the overall rates of surgical outcomes.


METHODS
Published studies in English reporting venous ulcer healing and recurrence outcomes after SEPS were obtained from a MEDLINE search. Data regarding patient characteristics and surgical outcomes were abstracted from each study, and the outcomes were combined by using a random effects model.


RESULTS
Our search identified 20 studies, 1 randomized trial and 19 case series, involving 1140 treated limbs. CEAP classification was secondary cause (E(S)) in 36%, deep venous involvement (A(D))in 56%, and obstructive (P(O)) in 12%. Overall, after surgical treatment including SEPS, with or without concomitant superficial venous ablation, ulcers in 88% of limbs healed. Ulcers recurred in 13%, at mean time of 21 months. Risk factors for nonhealing and recurrence included postoperative incompetent perforator veins, pathophysiologic obstruction, secondary cause, and ulcer diameter greater than 2 cm. Complications and their overall rates after surgical treatment including SEPS were wound infection (6%), hematoma (9%), neuralgia (7%), and deep venous thrombosis (1%).


CONCLUSIONS
Our results suggest that surgical management of venous ulcer including SEPS, with or without saphenous ablation, leads to an 88% chance of ulcer healing and a 13% chance of ulcer recurrence over the short term. Randomized controlled trials are needed to discern the contributions of compression therapy, superficial venous surgery, and SEPS in the treatment of venous ulcer disease.
Division of Clinical Decision Making, Department of Medicine, Tufts-New England Medical Center, Boston, MA 02111, USA. miafrati@tufts-nemc.org
John A
JA
Tenbrook
Mark D
MD
Iafrati
Thomas F
TF
O'donnell
Michael P
MP
Wolf
Stuart N
SN
Hoffman
Stephen G
SG
Pauker
Joseph
J
Lau
John B
JB
Wong
D002908:Chronic Disease; D004724:Endoscopy / Q000379:methods*; D006801:Humans; D017063:Outcome Assessment, Health Care; D012008:Recurrence; D012307:Risk Factors; D014647:Varicose Ulcer / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000379:methods*; D014689:Venous Insufficiency / Q000150:complications / Q000601:surgery*; D014945:Wound Healing / Q000502:physiology