title: Comparative effectiveness of surgical interventions aimed at treating underlying venous pathology in patients with chronic venous ulcer.
abstract: OBJECTIVE
  Chronic venous ulcers (CVUs) remain the leading causes for nonhealing wounds in the lower extremities. Although multilayer compression dressing remains the treatment gold standard, there are various surgical procedures aimed at healing CVUs with little or no evidence on the efficacy of these treatment methods. We conducted a systematic review of the effects of various surgical treatments for CVUs, in terms of ulcer healing rates, complete time to heal, recurrence rates, mortality, pain, and quality of life.
  
  
  METHODS
  We searched MEDLINE, EMBASE, the Cochrane Central Register for Controlled Trials, and the Cumulative Index for Nursing and Allied Health Literature databases from January 1980 through July 2012. We included studies that compared a surgical procedure with multilayer compression therapy or another surgical procedure among patients with CVUs. We also included studies without a comparison group if they were of sufficient quality. Two independent reviewers screened titles, abstracts, and articles for eligibility. Two reviewers extracted data on study design, applicability, results, and quality.
  
  
  RESULTS
  We identified 10,676 citations, of which 22 studies (23 publications) were included. Eight studies (six randomized controlled trials, two cohorts) compared a surgical procedure with compression. Fourteen studies evaluated different surgical interventions. Adding superficial vein ligation and stripping to compression did not improve wound-healing rate. However, the recurrence rate was 50% reduced when surgery corrected the underlying superficial venous pathology (moderate to high strength of evidence [SOE]). Adding subfascial endoscopic perforator surgery with superficial vein surgery to compression does not improve the healing rate of venous ulcers or reduce the recurrence rate except for medial and large ulcers (high SOE). The SOE was insufficient to support a conclusion about the effects of sclerotherapy when added to compression in healing CVUs. There was insufficient evidence on the surgical treatment of CVUs secondary to deep venous reflux and venous obstruction. We are unable to draw conclusions about the effects of surgical procedures on mortality, pain, and quality of life.
  
  
  CONCLUSIONS
  Our ability to draw conclusions on most surgical techniques is limited due to poorly designed and executed studies, with no uniformity of treatment methods, follow-up or reporting, and lack of randomization. We found some evidence to suggest superficial vein ligation and stripping may reduce the risk of wound recurrence, but these surgical techniques are infrequently performed. The newer minimally invasive techniques lack evidence. Randomized controlled trials for the endovenous procedures used today for treating CVUs are needed.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Umair
authors.initials: U
authors.lastname: Qazi
authors.affiliation: Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Gerald
authors.initials: G
authors.lastname: Lazarus
authors.affiliation: School of Nursing, University of Maryland, Baltimore, Md.
authors.forename: M Fran
authors.initials: MF
authors.lastname: Valle
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Wilson
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Elisabeth B
authors.initials: EB
authors.lastname: Haberl
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Eric B
authors.initials: EB
authors.lastname: Bass
authors.affiliation: Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Zenilman