Meta-analysis of subfascial endoscopic perforator vein surgery (SEPS) for chronic venous insufficiency

Subfascial endoscopic perforator surgery (SEPS) for treating venous leg ulcers

BACKGROUND

Venous leg ulcers are complex, costly, and their prevalence is expected to increase as populations age. Venous congestion is a possible cause of venous leg ulcers, which subfascial endoscopic perforator surgery (SEPS) attempts to address by removing the connection between deep and superficial veins (perforator veins). The effectiveness of SEPS in the treatment of venous leg ulcers, however, is unclear.

OBJECTIVES

To assess the benefits and harms of subfascial endoscopic perforator surgery (SEPS) for the treatment of venous leg ulcers.

SEARCH METHODS

In March 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that examined the use of SEPS independently or in combination with another intervention for the treatment of venous leg ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, assessed risk of bias, and assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included four RCTs with a total of 322 participants. There were three different comparators: SEPS plus compression therapy versus compression therapy (two trials); SEPS versus the Linton procedure (a type of open surgery) (one trial); and SEPS plus saphenous surgery versus saphenous surgery (one trial). The age range of participants was 30 to 82, with an equal spread of male and female participants. All trials were conducted in hospital settings with varying durations of follow-up, from 18 months to 6 years. One trial included participants who had both healed and active ulcers, with the rest including only participants with active ulcers.There was the potential for reporting bias in all trials and performance bias and detection bias in three trials. Participants in the fourth trial received one of two surgical procedures, and this study was at low risk of performance bias and detection bias.SEPS + compression therapy versus compression therapy (2 studies; 208 participants)There may be an increase in the proportion of healed ulcers at 24 months in people treated with SEPS and compression therapy compared with compression therapy alone (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.03 to 1.33; 1 study; 196 participants); low-certainty evidence (downgraded twice, once for risk of bias and once for imprecision).It is uncertain whether SEPS reduces the risk of ulcer recurrence at 24 months (RR 0.85, 95% CI 0.26 to 2.76; 2 studies; 208 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).The included trials did not measure or report the following outcomes; time to complete healing, health-related quality of life (HRQOL), adverse events, pain, duration of hospitalisation, and district nursing care requirements.SEPS versus Linton approach (1 study; 39 participants)It is uncertain whether there is a difference in ulcer healing at 24 months between participants treated with SEPS and those treated with the Linton procedure (RR 0.95, 95% CI 0.83 to 1.09; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).It is also uncertain whether there is a difference in risk of recurrence at 60 months: (RR 0.47, 95% CI 0.10 to 2.30; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).The Linton procedure is possibly associated with more adverse events than SEPS (RR 0.04, 95% CI 0.00 to 0.60; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).The outcomes time to complete healing, HRQOL, pain, duration of hospitalisation and district nursing care requirements were either not measured, reported or data were not available for analysis.SEPS + saphenous surgery versus saphenous surgery (1 study; 75 participants)It is uncertain whether there is a difference in ulcer healing at 12 months between participants treated with SEPS and saphenous surgery versus those treated with saphenous surgery alone (RR 0.96, 95% CI 0.64 to 1.43; 1 study; 22 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias).It is also uncertain whether there is a difference in the risk of recurrence at 12 months: (RR 1.03, 95% CI 0.15 to 6.91; 1 study; 75 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias).Finally, we are uncertain whether there is an increase in adverse events in the SEPS group (RR 2.05, 95% CI 0.86 to 4.90; 1 study; 75 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias).The outcomes time to complete healing, HRQOL, serious adverse events, pain, duration of hospitalisation, and district nursing care requirements were either not measured, reported or data were not available for analysis.

AUTHORS' CONCLUSIONS

The role of SEPS for the treatment of venous leg ulcers remains uncertain. Only low or very low-certainty evidence was available for inclusion. Due to small sample sizes and risk of bias in the included studies, we were unable to determine the potential benefits and harms of SEPS for this purpose. Only four studies met our inclusion criteria, three were very small, and one was poorly reported. Further high-quality studies addressing the use of SEPS in venous leg ulcer management are likely to change the conclusions of this review.

Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan

Objectives

To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan.

Methods

This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively.

Results

Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed.

Conclusion

These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.

Management of venous ulcers according to their anatomical relationship with varicose veins

Background

Adequately excising varicose and incompetent perforating veins is necessary for reducing their recurrence rate of venous ulcer.

Method

In total, 66 venous ulcers (C6) in 1083 legs with primary varicose veins were managed through endoscopic-assisted surgery. In an endoscopic operative view, the nonvaricose, varicose, and incompetent perforating veins were clearly visualized and precisely dissected. The varicose and incompetent perforating veins were divided and completely excised.

Result

The varicose veins were traced to the base or periphery of the 55 ulcers. Moreover, 89.4% of the ulcers healed within 14 weeks. Kaplan–Meier analysis revealed a five-year recurrence rate of 0.0%, and the satisfaction mean score was 4.6.

Conclusion

Endoscopic-assisted surgery can be used to radically excise varicose veins complicated with venous ulcers; the surgery yields low recurrence and high satisfaction rates.

Is there a continuing role for traditional surgery?

Despite recent NICE guidance there remains a definite role for surgery in the management of varicose veins. A lot of the available evidence that has driven the transformation of care towards endovenous treatments is of good quality yet published by enthusiasts. No endovenous studies have reported long term results as far out from intervention as the open studies, yet in the meta-analysis from Murad et al, the authors suggested from their results that when surgery was compared with all endoluminal ablation therapies, surgery was associated with a non-significant reduction in the risk of varicose vein recurrence (RR0.63; 95%CI 0.37--1.07). Much of the longer-term data on recurrence following open surgery for primary varicose veins dates back well over 15 years ago. This is prior to the inclusion of routine duplex assessment and sub-specialty designation. The recent Cochrane review (13 randomised controlled studies, 3081 patients). The overall conclusion was that UGFS, EVLT and RFA were at least as effective as surgery in the treatment of the LSV. This meta-analysis did not include the CLASS (Comparison of LAser, Surgery and foam Sclerotherapy as a treatment for varicose veins) trial in which measures of clinical success were similar among the groups. Only 48% of the patients screened were eligible for the CLASS study and of these, only 24% of the eligible patients agreed to take part in the study. Similarly in the study by Carradice out of a total of 772 patients assessed for suitability, 442 did not meet the inclusion criteria. There is no doubt that endovenous surgery will increasingly become first line treatment for patients with symptomatic superficial venous reflux specifically in patients with SSV reflux. However, given the device related limitations with endothermal techniques specifically with regard to adverse anatomical features allied to the poorer results of UGFS within the treatment of LSV reflux, there is without doubt still a role for more traditional open surgical techniques that can be delivered with good short and long term outcomes and still being delivered in a cost effective manner.

A review of a new Dutch guideline for management of recurrent varicose veins

In 2013, the new Dutch guideline for "Venous Pathology" was published. The guideline was a revision and update from the guideline "Diagnostics and Treatment of Varicose Veins" from 2009 and the guideline "Venous Ulcer" from 2005. A guideline for "Deep Venous Pathology" and one for "Compression Therapy" was added to the overall guideline "Venous Pathology." The chapter about treatment of recurrent varicose veins after initial intervention was recently updated in 2015 and is reviewed here. The Dutch term "recidief varices" or the French "récidive de varices" should be used analogous to the English term "recurrent varicose veins." The DCOP Guideline Development Group Neovarices concluded that "recidief" in Dutch actually suggests recurrence after apparent successful treatment and ignores the natural progression of venous disease in its own right. So the group opted to use the term "neovarices." In the Dutch guideline, neovarices is meant to be an all embracing term for recurrent varicose veins caused by technical or tactical failure, evolvement from residual refluxing veins or natural progression of varicose vein disease at different locations of the treated leg after intervention. This report reviews the most important issues in the treatment of varicose vein recurrence, and discusses conclusions and recommendations of the Dutch Neovarices Guideline Committee.

Debate: whether venous perforator surgery reduces recurrences

Superficial venous surgery and perforator vein surgery, specifically, have a long and varied history in the evolution of vascular surgery, especially because venous disease continues to be extremely common. As with other areas of our specialty, perforator vein procedures have progressed from being purely open operations to becoming less invasive procedures. Despite this, there remains much discussion (as well as overt disagreement) about whether perforator vein surgery is actually appropriate and beneficial in the first place. Surgeons have no level I evidence from randomized controlled studies to determine whether perforator vein surgery does or does not reduce the chances of recurrence of superficial venous varicosities, so we must rely on the evidence as it currently is. Perhaps not surprisingly, our two experts have assembled divergent opinions on the role of perforator venous surgery in contemporary practice.

Role of Subfascial Endoscopic Perforator Surgery (SEPS) in Management of Perforator Incompetence in Varicose Veins : A Prospective Randomised Study

The study was carried out to compare the efficacy of subfascial endoscopic perforator surgery (SEPS) and open subfascial ligation of perforators in varicose veins. This study was conducted on 100 patients of varicose veins from January 2006 to December 2010. Clinical scoring and color Doppler were performed in all the patients before surgery. Patients were divided into two groups: Group A and Group B alternately. Management of the perforators was done by subfascial endoscopic perforator surgery (SEPS) in Group A and by open subfascial ligation of perforators in Group B. Fifty patients were treated in each group. All the patients underwent ligation of incompetent saphenofemoral junction with stripping of long saphenous veins wherever the junction was incompetent with multiple ligation of superficial prominent veins. SEPS was done by two-port method without any tourniquet or balloon dissector. Total numbers of perforators ligated were 178 in Group A and 136 in Group B. Patients in both the groups got symptomatic relief of symptoms, but ulcer healing in 33 % patients in Group A was faster as compared to Group B. However, at 3 months of follow-up the ulcers healed in all the patients in both groups. Incidence of wound infection was higher in group B (16 %) as compared to group A (0 %). There were residual perforators in 8 % of patients on color Doppler at 3 months of follow-up in Group B while there was no residual incompetent perforator in Group A. Subfascial endoscopic perforator vein surgery is a safe and effective method for treating incompetent perforating veins. The number of perforators ligated in SEPS was more as compared to the open subfascial ligation group. Possibly some perforators may be missed on Doppler localization and missed ligation, which may be a cause of future recurrence in varicose veins. Early relief of symptoms in terms of ulcer healing was better in the SEPS group with less wound complication rate; however, all the ulcers healed in both the groups at 3 months of follow-up. Cosmetic results were equal in both the groups. Major advantage of SEPS was less incidence of wound complications and less incidence of residual incompetent perforators. Hence, SEPS should be added for the management of perforators along with conventional surgery in varicose veins.

Wound Healing Society (WHS) venous ulcer treatment guidelines: what's new in five years?

Since the establishment of the guidelines for the treatment of venous ulcers by the Wound Healing Society in 2006, there has been an abundance of new literature, both in accord and discord with the guidelines. The goal of this update is to highlight new findings since the publication of these guidelines to assist practitioner and patient in appropriate health care decisions, as well as to drive future research endeavors.

Guidelines for the management of varicose veins

Recently published evidence-based guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) include recommendations for evaluation, classification, outcome assessment and therapy of patients with varicose veins and more advanced chronic venous insufficiency (CVI). The need for such guidelines has been evident since imaging techniques and minimally invasive technologies have progressed by leaps and bounds and radiofrequency ablation, laser and sclerotherapy have largely replaced classical open surgery of saphenous stripping. This report reviews the most important guidelines recommended by the SVS/AVF Venous Guideline Committee. It is obvious, however, that some of the technology that is recommended in North America is either not available or not affordable in some parts of the world for patients with varicose veins and CVI. The readers are urged therefore to also consult the guidelines of their national societies, recent publications of the National Institute for Clinical Excellence and the Venous Forum of the Royal Society of Medicine. Venous specialists should also keep in mind that scientific evidence should always be combined with the physician's clinical experience and the patient's preference when the best treatment is selected for an individual patient.

Subfascial endoscopic perforator surgery using screw-type ports is a very useful component of a comprehensive treatment program for chronic venous insufficiency

BACKGROUND

Subfascial endoscopic perforator surgery (SEPS) with a two-port system utilizing screw-type ports, CO2 insufflation and an ultrasonic coagulation system, is a useful procedure that does not require burdensome apparatus and techniques. SEPS was accepted as a national advanced medical system by the Japanese Ministry of Health, Labor and Welfare in May 2009.

PATIENTS AND METHODS

Forty-one limbs of 35 patients with 10 active ulcers (C6) and 2 healed ulcers (C5) were treated by SEPS between February 2010 and December 2011. Thirty-three limbs had concomitant superficial vein surgery. SEPS alone was performed on 8 limbs, in 6 of which the superficial veins had already been ablated. In 2 limbs, incompetent perforating veins (IPVs) existed under the affected skin, around the scars of past surgery.

RESULTS

All stasis ulcers of the 10 C6 limbs healed between 1 week and 14 months after SEPS (mean 2.9 months), with no ulcer recurrence during the follow-up period (2 to 24 months). IPVs under the scars were easily and safely interrupted by SEPS.

CONCLUSION

SEPS is a very useful component of a comprehensive treatment program for chronic venous insufficiency, especially in patients with venous stasis ulcers and IPVs under the scars of past surgery.

Venous leg ulcerations: a treatment update

OPINION STATEMENT

Selecting the appropriate treatment for venous leg ulcerations is essential for optimal wound healing and patient quality of life. Compression therapy remains the mainstay of treatment for these wounds. Compression methods should be carefully selected and tailored for compatibility with patients' daily life. Pain management should not be neglected. When response to compression therapy is limited, adjuvant therapy such as medication, débridement, or surgical procedures should be considered on an individual basis.