|Year : 2021 | Volume
| Issue : 3 | Page : 97-102
Postoperative outcomes of microphlebectomy and Trendelenburg operation with stripping for saphenofemoral junction incompetence
Bhuvana Lakshmi1, Siddartha Gowthaman1, E Elamaran2, S Vinoth1, M Ramanathan1
1 Department of General Surgery, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
2 Department of Cardiothoracic and Vascular Surgery, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
|Date of Submission||12-Jun-2020|
|Date of Decision||28-Sep-2020|
|Date of Acceptance||20-Jan-2021|
|Date of Web Publication||12-Jun-2021|
Department of General Surgery, Mahatma Gandhi Medical College and Research Institute, Puducherry - 607 402
Source of Support: None, Conflict of Interest: None
Background: With more than 10 million cases occurring annually in India, varicose veins can sometimes result in severe discomfort and pain besides disfiguration of skin. The objective of the study was to assess the most viable treatment options for varicose veins between the traditional Trendelenburg procedure and microphlebectomy.
Methods: This was an interventional study conducted at a tertiary center in South India. Patients above 18 years of age, presenting with varicose veins due to saphenofemoral junction (SFJ) incompetence and scheduled for surgical management, were included in a sample size of 46. Subjects were randomized into two groups – Group 1 underwent micro phlebectomy and Group 2 underwent Trendelenburg operation with stripping of great saphenous vein (GSV). Postoperative pain was assessed on day of surgery, day after, and postoperative day 7. A venous Doppler ultrasound was conducted 6 weeks after the surgical procedure, to look for reflux at SFJ.
Results: Group 1 subjects reported lesser immediate postoperative pain and incurred significantly less cost as determined by an independent sample t-test. Chi-square test found no significant difference in the rate of occurrence of local complications (P > 0.05), and no recurrence was noted among both groups.
Conclusion: Microphlebectomy is a more feasible treatment option than Trendelenburg operation with GSV stripping on account of lower costs. It is also a patient friendly alternative due to immediate reduction in pain.
Keywords: Femoral vein, saphenous vein, varicose veins
|How to cite this article:|
Lakshmi B, Gowthaman S, Elamaran E, Vinoth S, Ramanathan M. Postoperative outcomes of microphlebectomy and Trendelenburg operation with stripping for saphenofemoral junction incompetence. Formos J Surg 2021;54:97-102
|How to cite this URL:|
Lakshmi B, Gowthaman S, Elamaran E, Vinoth S, Ramanathan M. Postoperative outcomes of microphlebectomy and Trendelenburg operation with stripping for saphenofemoral junction incompetence. Formos J Surg [serial online] 2021 [cited 2021 Sep 24];54:97-102. Available from: https://www.e-fjs.org/text.asp?2021/54/3/97/318217
| Introduction|| |
Varicose veins are enlarged and conspicuously raised bluish veins in the subcutaneous tissue that usually arise due to a venous reflux. A superficial venous reflux refers to a buildup of blood in the superficial veins of the legs as a result of weakened vein walls and malfunctioning valves. It affects 20% of adults globally and are mostly seen on calves or on the inner legs of older populations. In India, varicose veins are estimated to occur in 15%–20% of adults, disproportionately affecting low socioeconomic groups and occupations that require standing for extended periods of time., Although primarily recognized as a cosmetic problem, the consequent pain, open ulceration, and swelling can make management more expensive and result in significant losses to work hours and wages.
Surgical management is considered the standard treatment for patients with cosmetic concerns or advanced symptoms.,, Trendelenburg operation has been traditionally used for treating great saphenous vein (GSV) incompetence at the saphenofemoral junction (SFJ). It involves juxtafemoral flush ligation of the GSV after identifying and ligating its individual tributaries and in most cases is accompanied by stripping of the GSV.,,, Trendelenburg operation is an open surgery that is usually done under spinal anesthesia and requires inpatient hospital stay. More recently, less invasive techniques have been developed and are becoming popular such as microphlebectomy, foam sclerotherapy, and radiofrequency ablation.
Microphlebectomy involves excising the GSV by avulsion through serial stab incisions over the thigh and leg. Microphlebectomy has become the surgical procedure of choice as it can be done in a cost-effective outpatient department (OPD) setting under local anesthesia and does not include direct obliteration of the SFJ., It has been shown to be less painful, less likely to lead to bruising and scarring, and avoids the risk of complications related to spinal anesthesia.,,
Paucity of literature on comparison between Trendelenburg operation and microphlebectomy as treatment options for varicose veins and growing disease burden among the South Indian population has inspired this study.
The study aims to compare the short-term outcomes of traditional Trendelenburg operation with GSV stripping and microphlebectomy; to assess if the latter can be considered as a viable alternative to the former.
| Materials and Methods|| |
This interventional study was conducted at a Medical College and Research Institute Hospital, in Pondicherry between April 2018 and September 2019 using a randomized control trial. Patients above 18 years of age presenting with varicose veins at the general surgery and cardiothoracic and vascular surgery department were enrolled as participants in this study. Written informed consent was obtained from the patients and approval of the Institutional Human Ethics Committee was taken prior to the study (IRB approval no. 03/2018/109). Following which, a clinical examination was done as well as ultrasonography (USG) venous Doppler study of affected lower limb to understand the etiology and rule out the involvement of deeper veins. Patients of clinical grade C2 to C6 of saphenofemoral incompetence as per the Clinical, Etiological, Anatomical, and Pathophysiological classification were included in the study. However, patients with acute complications such as phlebitis and infected ulcers and with veins at depth of more than 5 cm were excluded from the study. A sample size of 46 patients was obtained on applying nonprobability convenience sampling technique wherein all the OPD cases registered at our institute and meeting the selection criteria during the set study period were considered. Study subjects were randomly allocated into one of two groups using computer generated list for permuted block randomization.
With 23 patients in each group, Group 1 underwent microphlebectomy and Group 2 underwent Trendelenburg operation with stripping of GSV. For subjects in both groups, who had coexisting incompetence of perforator veins needing operative management, appropriate procedure (sclerotherapy, subfascial ligation, etc.,) was done as per the operating surgeon's decision.
For Group 1, after administration of anesthesia, the patient was placed in supine position on the operating table. Betadine solution was applied to the affected limb, and surgical drapes were placed. GSV was located using USG, and tumescent anesthesia was infiltrated across the thigh. Following which, serial stab incisions were made over the thigh using a size-11 Bard-Parker blade along GSV up to the subcutaneous tissue level. Venous hook was introduced into each stab incision serially, and the vein was avulsed and removed segment by segment. Adequate hemostasis was achieved by providing manual compression throughout the avulsed length of GSV. Sterile dressing was done, and crepe bandages were applied from below to upward throughout the length of operated limb.
For Group 2, sterilization and draping were done as above. Transverse incision made over surface marking of saphenous femoral junction located 4 cm medial and inferior to ipsilateral pubic tubercle. Incision was deepened, and GSV was identified in the subcutaneous plane. Tributaries of GSV were isolated, ligated, and divided. GSV was ligated and divided as close as possible to SFJ, proximal to all tributaries. Metal wire stripper was introduced through the cut end of GSV and threaded through till knee level. Tip of stripper was located by palpation at knee level, and incision was made over it. GSV was opened at knee level. The stripper tip was brought out externally with olive attached to it. The stripper was pulled upward through the thigh wound, with the olive in situ, to strip out the GSV. After adequate hemostasis, thigh, and knee-level incisions were sutured. Sterile dressing was done and crepe bandages applied from below to upward throughout the length of operated limb [Figure 1].
|Figure 1: (a) Representative Image during microphlebectomy procedure – a length of vein is avulsed through a stab incision. (b) Pre- and post-operative images of a patient who had undergone microphlebectomy – there is no need for skin sutures, and there is minimal scarring. (c and d) Postoperative images of a patient who had undergone Trendelenburg operation with great saphenous vein stripping and ligation of incompetent perforators|
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Subjects of both study groups were followed up during their postoperative hospital stay and with OPD reviews after discharge. Postoperatively, pain was assessed on postoperative day (POD) 0, i.e., the day of surgery, on POD 1, and on POD 7. Pain was quantified on each dayby asking the subjects to self-rate the pain experienced on the current day on a scale of 0–10. Zero signifies “no pain at all” and 10 signifies “the worst pain imaginable.” Subjects were observed for occurrence of any local complications such as bleeding, hematoma, surgical site infection, paraesthesia, lymphorrhoea, and etc., daily during their hospital stay and during each OPD review. Total length of postoperative hospital stay – from POD 1 till day of discharge– was recorded for each subject. Overall cost to the patient was obtained for both procedures. Six weeks after the surgical procedure, each subject underwent a repeat USG venous Duplex study (Doppler + B-mode scan) to look for any recurrence of reflux at the SFJ.
Patient data were collected with the help of a data collection pro forma sheet and entered in Excel (MS Excel 2011). Statistical analysis was carried out using SPSS version 19.0 (IBM SPSS, US) software with regression modules installed. Parameters such as age of subject, length of hospital stay, total cost, postoperative pain on POD 0, 1, and 7, and pain reduction from POD 0 to POD 7 within each group were evaluated using mean and standard deviation. Their significance was determined using a paired t-test. Within each group, multivariate tests were done to assess significance of change in pain score between POD 0 and POD 1 and between POD 1 and POD 7. Gender distribution, clinical grade of study subjects, postoperative complications, and postoperative Doppler findings were expressed as a percentage of distribution overall and within each group. The significance of these characteristic variables was assessed with Chi-square tests.
| Results|| |
Participants of this study were aged between 18 years and 77 years of age. Group 1 subjects had a mean age of 35.09 (standard deviation [SD] = 11.92), whereas Group 2 subjects had a mean age of 41.48 (SD = 15.53) as depicted in [Figure 2]. Male preponderance was noticed in both groups with Group 1 consisting of 21 (91.3%) males and 2 (8.7%) females and Group 2 consisting of 17 (73.9%) males and 6 (26.1%) females [Figure 3]. Age and gender distribution were not significantly different between the two groups (P > 0.05). However, the difference in distribution of clinical class was found to be significant (P < 0.05). In Group 1, the majority of patients (43.5%) belonged to C2, followed by C4 (26.1%), whereas in Group 2, most patients (52.2%) belonged to C2, followed by C3 and C6, while none belonged to C4 [Figure 4].
|Figure 4: Bar chart showing distribution of clinical class within each study group|
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Throughout the first postoperative week, pain reported by subjects of Group 2 was consistently higher than that reported by subjects of Group 1 [Table 1]. [Table 1] shows that, in both groups, there was highly significant reduction in pain score from POD 0 to POD 1, POD 1 to POD 7, and POD 0 to POD 7 (P < 0.001). However, a slightly greater reduction in mean postoperative pain score was noticed among Group 2 patients in comparison with Group 1 patients (P < 0.05).
|Table 1: Mean reduction in postoperative pain score within each study group|
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From [Table 2] it is inferred that the difference in length of hospital stay between the two groups was not found to be significant (P > 0.05). The difference in cost incurred, however, between the two study groups was found to be significant (P < 0.05). In terms of postoperative complications, the difference between the two study groups was not found to be significant (P > 0.1). In Group 1, one patient developed hematoma, one developed surgical site infection, and one developed paraesthesia. In Group 2, two patients developed hematoma andtwo developed surgical site infection. However, majority of patients in both groups did not develop any local complications. None of the subjects from both groups had recurrence of reflux on Duplex study of the operated limb done 6 weeks postoperatively.
|Table 2: Mean distribution of monetary cost and length of postoperative hospital stay across Group 1 and Group 2|
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| Discussion|| |
Although the Trendelenburg procedure has been in use for over a century, some complications such as deep venous thrombosis, pulmonary embolus, foot-drop, hematoma, and a high recurrence rate have been seen in patients., In recent times, microphlebectomy has replaced the Trendelenburg operation as the primary mode of management of SFJ incompetence due to greater pre- and postoperative convenience. Our study aimed to assess the short-term outcomes of both of these procedures among the local population suffering from varicose veins.
Gender and age distribution were not significantly different between study groups. It is interesting to note, however, that while varicose veins had been found to be more prevalent in women in the general population, the patients seeking treatment at our center and therefore enrolled in the study were mostly men., A similar finding was reported by Evans et al. showing male preponderance among subjects with varicose veins. This indicates that, among the local populace, men are more engaged in occupations associated with the occurrence of varicose veins and are perhaps more likely to seek surgical treatment than women.
Postoperation, Group 2 subjects having undergone the Trendelenburg operation reported more pain than Group 1 subjects who underwent microphlebectomy. By the end of 1 week, both groups showed a significant reduction in pain and commensurate pain levels were recorded. Analysis of postoperative outcomes revealed that the monetary cost incurred by Group 2 patients was significantly higher than Group 1. The average length of hospital stay for Group 1 was not found to be significantly longer than that for Group 2. Rate of occurrence of local complications was not significantly different between the two study groups. None of the subjects showed the evidence of recurrence of reflux at SFJ at the end of 6 weeks. Occurrence of hematoma at operated site and surgical site infection were reported in both study groups. In addition, one subject of Group 1 developed paraesthesia over the operated limb. There were not much literature available directly comparing microphlebectomy and Trendelenburg operation, and no similar studies conducted in southern India were found. The population specificity of the study made it unique.
Hence, it can be inferred that microphlebectomy causes lesser immediate postoperative pain; however, this advantage is more or less neutralized within the 1st week. The difference in cost between the two groups appears to be mainly due to the need for suture materials in Group 2 and the use of local anesthesia in microphlebectomy instead of expensive spinal anesthesia used in Trendelenburg procedure. None of the subjects belonging to either study groups were found to have persistence of varicosity or reflux on Doppler scan 6 weeks following the surgery. These findings are congruent with studies conducted by Pittaluga et al. and by Zolotukhin et al., which reported elimination of reflux following avulsion of GSV even without ligation.,
This study has its share of limitations. The sample size studied was limited and details on demographic factors, presence of comorbidities, and clinical class of disease were not considered nor correlated. Mode of anesthesia was left up to the discretion of operating surgeons and anesthesiologist and was not controlled between the two groups. Procedures in Group 2 were performed by or under the supervision of a vascular surgeon and procedures in Group 1 were performed by surgeons with varying levels of experience. Standardization of these protocols may be suggested for future studies to eliminate the subjective bias. The procedure for the management of coexisting perforator incompetence was not standardized between the two groups. The duration of follow-up was relatively short for assessing recurrence of reflux. Future research can delve into the epidemiology of venous disorders among South Indian population by analyzing demographic data and in-depth study of recurrence patterns.
| Conclusion|| |
This pioneer study was successful in reporting that microphlebectomy causes lesser immediate postoperative pain, lesser cost to the patients. In addition, there are no significant differences in the local complications nor short-term recurrence of reflux when compared to Trendelenburg operation with GSV stripping. Microphlebectomy can therefore be considered as a more convenient alternative to Trendelenburg Operation with GSV stripping for the treatment of varicose veins with SFJ incompetence.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]