Article

Lymphatic complications after varicose vein surgeries in obese patients - How to prevent them?

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Abstract

Introduction: Lymphatic complication (LC) after varicose veins (VVs) surgery is an annoying event with a variable frequency in the literature. Method: Retrospective study reviewing all surgeries carried out for VVs from January 2000 to October 2010. Postoperative LC we reported: lymphatic fistula, lymphocele including the minor ones and lymphoedema. Results: During the period studied, 5407 surgical procedures for VVs were performed in 3407 patients (74.7% women) with a mean age of 53.4 years. A postoperative LC occurred in 118 cases (2.2%): lymphocele on limb in 1.3%, inguinal LC (fistula or lymphocele) in 0.7% and a lymphoedema in 0.2%. The population with a LC was older (59.6 vs. 53.3 years, P , 0.05), had a higher frequency of C4 – C6 (22.0% vs. 6.5%, P , 0.05), a higher incidence of obesity (31.4% vs. 5.4%, P , 0.05) and was more often treated by a redo surgery or a crossectomy stripping (48.3% vs. 13.4% and 38.1% vs. 21.8%, respectively, P , 0.05). We have observed a dramatic decrease in incidence of LC after January 2004 (1.3% vs. 5.3%, P , 0.05) corresponding to a new surgical practice for the treatment of VVs: stripping, crossectomy and redo surgery at the groin were less frequent (74.6% vs. 7.7%, 74.6% vs. 0.2% and 11.3% vs. 0.1%, respectively, P , 0.05), while isolated phlebectomy was more often performed during this period (78.4% vs. 8.4%, P , 0.05). Conclusion: LC after VVs surgery is not rare but frequently limited to lymphocele on limbs. Older age, more advanced clinical stage and obesity were associated with a higher frequency of LC. A mini-invasive and selective surgery has significantly reduced the occurrence of LC.

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Minimally invasive techniques such as endovenous laser therapy, radiofrequency ablation, and ultrasound-guided foam sclerotherapy are widely used in the treatment of lower extremity varicosities. These therapies have not yet been compared with surgical ligation and stripping in large randomized clinical trials. A systematic review of Medline, Cochrane Library, and Cinahl was performed to identify studies on the effectiveness of the four therapies up to February 2007. All clinical studies (open, noncomparative, and randomized clinical trials) that used ultrasound examination as an outcome measure were included. Because observational and randomized clinical trial data were included, both the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and Quality Of Reporting Of Meta-analyses (QUORUM) guidelines were consulted. A random effects meta-analysis was performed, and subgroup analysis and meta-regression were done to explore sources of between-study variation. Of the 119 retrieved studies, 64 (53.8%) were eligible and assessed 12,320 limbs. Average follow-up was 32.2 months. After 3 years, the estimated pooled success rates (with 95% confidence intervals [CI]) for stripping, foam sclerotherapy, radiofrequency ablation, and laser therapy were about 78% (70%-84%), 77% (69%-84%), 84% (75%-90%), and 94% (87%-98%), respectively. After adjusting for follow-up, foam therapy and radiofrequency ablation were as effective as surgical stripping (adjusted odds ratio [AOR], 0.12 [95% CI, -0.61 to 0.85] and 0.43 [95% CI, -0.19 to 1.04], respectively). Endovenous laser therapy was significantly more effective compared with stripping (AOR, 1.13; 95% CI, 0.40-1.87), foam therapy (AOR, 1.02; 95% CI, 0.28-1.75), and radiofrequency ablation (AOR, 0.71; 95% CI, 0.15-1.27). In the absence of large, comparative randomized clinical trials, the minimally invasive techniques appear to be at least as effective as surgery in the treatment of lower extremity varicose veins.
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Lymphatic injuries are unavoidable during varicose vein surgery. However these injuries seldom lead to complications. This study was held to try to find an explanation to this contradiction which seems to be only noticeable. If anatomy shows that it is impossible to operate on varicose veins without injuring lymphatic vessels, the regeneration power of these latters, known for a long time, is such that complications due to these injuries are all the more exceptional that surgeries are less traumatizing than it used to be. Nowadays, each surgeon is only faced to a small number of such complications during their career. This rareness makes a methodical personal study quasi-impossible. That is why we sent a questionnaire to about thirty surgeons specialized in this field. This questionnaire, about their experience, dealt with lymphatic complications they had met during varicose veins surgery. Twenty three answers were sent in time and deal with more than 184,000 surgeries. The lymphatic complication rate is about 8.7%, 5.4% of which are lymphorrhea, 2.6% of lymphocele, 1.09% of lymphangitis and 0.5% of lymphoedema. Of course, these figures are approximate. Lymphoedema is the only long-lasting lymphatic complication of the varicose veins surgery. According to us, sclerotherapy seems to be more effective than surgery, in case of signs, even benign, of lymphatic insufficiency.
Article
Groin surgery for recurrent varicose veins can be technically difficult due to scarring from previous surgery. Access to the sapheno-femoral junction (SFJ) can be facilitated by approaching the veins indirectly (subfascially) by first exposing the common femoral artery. The aim of this paper was to document experience with both direct and indirect approaches to the SFJ for recurrent varicose veins. A retrospective analysis of all patients having groin surgery for recurrent varicose veins. Of 128 legs having surgery, the approach to the SFJ was direct in 46%, indirect in 53% and unknown in one leg. Complications occurred after 40% of all procedures but were significantly more common following indirect surgery (57% versus 20%, P < 0.001), of which the most frequent were of a lymphatic nature (26% versus 5%, P < 0.001) or wound infection (16% versus 7%, P = 0.05). Wound complications are common following groin surgery for recurrent varicose veins especially after an indirect approach to the SFJ.
Complications lymphatiques après chirurgie des varices
  • Pa Ouvry
  • H Guenneguez
  • Pa Ouvry
Ouvry PA, Guenneguez H, Ouvry PA. Complications lymphatiques après chirurgie des varices. Phlébologie 1993;46:563– 8