R e s u l t s of S t r i p p i n g O p e r a t i o n f o r V a r i c o s e V e i n s T a t s u z o TANABE
A B S T R A C T : Approximately 150 stripping operations for primary varicose veins of the lower extremities were performed. Long-term evaluation (postoperative follow-up of more than five years) was made on 102 extremities and 83 per cent of these showed good or excellent results. Six patients were reoperated due to recurrence of varices. Accurate diagnosis and complete operation are most important in stripping operations. K E Y W O R D S : varicose veins, stripping operation, greater saphenous vein, smaller saphenous vein, perforating vein, communicating vein, recurrent varicose vein. INTRODUCTION
T h e r e are two treatments for varicose veins of the lower extremities, injection treatment and operative treatment. While some authors advocate injection treatment for primary management, the stripping operation is widely accepted as the most effective lasting treatmentl, 2 since the recurrence rate is only five to eight per cent. In the present report results from the standpoint of long-term follow-up are presented. CASES
AND
METHODS
This study is concerned only with cases of primary varices. Ssecondary varicose veins due to incompetence of the deep veins are not considered. One hundred thirteen patients with primary varicose veins of the lower extremities were seen since 1962. Seventy patients were female and 42 male, resulting in a female: male ratio of 1.7: 1. Sixty patients (53 p e r c e n t ) were less than 30, and 30 (27 per cent) were 51 years of age or older. In 75 of 113 patients (66 per cent), the symptoms had persisted for at least five years. The right leg was involved in 39 (35 per cent), the left in 23 (20 per cent), and both legs in 51 (45 per cent) of the cases. O f a total of 164 legs in 113 patients, 94 legs (57 per cent) had varices in the greater, 25 (15 per cent) in the smaller, and 36 (22 per cent) in the greater and smaller saphenous system simultaneously. A simple modification of Leu's classification of varicose veins 4 is used in the present study (Table 1). In 153 legs (93 per cent), tortuous involvement of the full-length saphenous system was noted. Localized dilatation of the superficial vein in the lower leg or calf, not accompanied by incompetence of the saphenous system was found in 11 legs (seven per cent) and the combination dilatation of the superficial vein and incompetent perforating veins was noted in six legs (four per cent). Recurrence of varices was found in three legs (two per cent) and stasis ulcers were noted in 11 legs (seven per cent). O u r preferential treatment is performance of the stripping operation. One handred
The SecondDepartment of Surgery, Hokkaido University School of Medicine, Sapporo, Japan. JAPANESEJOURNALOF SUROERY,VOL. 9, No. 1, pp. 71-75, 1979
Jpn. J. Surg. March 1979
Tanabe
72 T a b l e 1.
Classification of eases (Leu, 1964)
Hyphen-web varicosities Reticular-type varicosis Segmental varicose vein Varicosis of short saphenous vein Varicosis of long saphenous vein Varicosis of short and long saphenous vein (Varicosis with incompetence of perforating vein T a b l e 2.
Details of operative procedures
Stripping
No. of patients
lO2
No. of operations
(13~)
Unilateral Long saphenous vein Short saphenous vein Long and short saphenous vein Bilateral Long saphenous vein Short saphenous vein Long and short saphenous vein (Subfacial ligation Resection Subcutaneous ligation Operation not performed T a b l e 3.
2 4 5 25 92 36 6)
66 39 15 12 36 (72) 22 5 9 6) 3 3 5
Results of stripping operation Follow up over 5 yrs. Percent of No. of extremities extremities
Excellent : Good: Fair: Poor: Unknown:
No varicositis Scattered residual tributaries, less than 3 mm in diameter Varicosities larger than 3 mm in diameter Surgical treatment had made the leg worse Not followed up
48 37 5 0 12
47 36 5 0 12
forty four surgical p r o c e d u r e s were p e r f o r m e d on 108 patients a n d five patients were n o t surgically treated. T h e stripping o p e r a t i o n was p e r f o r m e d on 138 lower extremities ( T a b l e 2). T h e g r e a t e r saphenous system w i t h its tributaries was s t r i p p e d in 83 legs, the s m a l l e r saphenous system was r e m o v e d in 25 legs. T h e g r e a t e r a n d smaller saphenous veins were simultaneously s t r i p p e d in 30 legs. C o n v e n t i o n a l stripping a c c o m p a n i e d b y subfacial ligation o f the p e r f o r a t i n g vein 5 was p e r f o r m e d in six legs a n d resection or m u l t i p l e subcutaneous ligation of the localized d i l a t e d superficial vein was p e r f o r m e d in six legs. W e e x p e r i e n c e d no serious complications. T h e degree of p o s t - o p e r a t i v e s y m p t o m a t i c relief was e v a l u a t e d a t the time of follow-up e x a m i n a t i o n . W e used the classification b y L a r s o n et al. a to e v a l u a t e l o n g - t e r m results on 102 legs with a post-operative follow-up p e r i o d of m o r e t h a n five years.
Volume 9 Number I
Stripping Operation Table 4.
Case Age & sex
73
Cases of recurrent varicose veins
Cause
Duration
Symptoms
1 2 3
M.N. 42. M K.F 38. F T.M 44. F
Low-level ligature Inadequate stripping Partial resection
5 yr. 6 yr. 10 yr.
Persistent varices Persistent varices Recurrence
4 5 6
T.K 39. F N.T 45. F Y.M. 60. M
Inadequate diagnosis Progression Inadequate diagnosis
3 yr. 13 yr. 2 yr.
Residual varices (short saphenous vein) Recurrent varices (long saphenous vein) Residual varices (perforating vein)
RESULTS
Eighty three per cent of the operated extremities showed excellent or good, and five per cent fair results. No poor results were obtainedS, 9 (Table 3). Six patients, three of which had received inadequate operations at other hospitals, underwent re-operation due to residual or recurrent varices. Primary causes of recurrence were thought to be low level ligation in the upper part of the thigh, inadequate stripping or partial resection of the varices. The other three patients had undergone the initial stripping operation at our institute, but recurrence appeared due to inadequate diagnosis or primary operation. Residual varices became apparent in the lower part of the legs after single-stripping of the long saphenous vein. Recurrent varices around the knee seemed to occur due to progression of residual small lesions of a tributary (Table 4). DISCUSSION In order to prevent recurrence of varices and to obtain excellent results, accurate diagnosis of the points of reverse flow from the deep veins, complete stripping of the saphenous system and communicating veins, or ligation of the incompetent perforating veins are of utmost importance. The stripping operation is comprised of I) high flush ligation of the saphenous vein and its tributaries at the saphenofemoral or saphenopopliteal junction, 2) complete stripping of the saphenous vein from groin or popliteal fossa to ankle and 3) multiple stripping, dissections by tunneling and excision of the varices. Care is required in the application of these techniques.6, 7 Two common technical faults in the thigh are shown in Fig. 1, a) failure to ligate the saphenous vein close enough to the saphenofemoral junction and to ligate all its tributaries and b) failure to find the communicating or accessory veins. Two common technical faults in the calf are shown in Fig. 2, a) failure to ligate the communicating vein and b) failure to find the incompetent perforating vein. A correct preoperative diagnosis can be obtained by careful inspection and palpation of the varices and by evaluation of ascending function M phlebograms.7, s As varicose veins have a slow course of progression, a minimum follow-up period of five years is required before any assessment of the results of varices surgery can be made. In a 10-year operative follow-up study reported by the Mayo Clinic, 3 85 per cent of the patients were reported to have maintained good to excellent results. In our five-year follow-up study, we obtained similar gratifying results in that 83 per cent of the operated extremities were found to show good to excellent results.
74
Tanabe
a
Fig. 1.
Jpn. .[. Surg. March 1979
b
Common faults of operations in the thigh a. Non-terminal flush ligation b. low level ligation
il a
Fig. 2.
b
Common faults of operations in the calf. a. overlooked incompetent perforator b. undiagnosed communicating vein
Volume 9 Number 1
Stripping Operation
75
CONCLUSION A f i v e - y e a r p o s t - o p e r a t i v e s t u d y was m a d e o n t h e results o f s t r i p p i n g o p e r a t i o n s o n 102 l o w e r e x t r e m i t i e s a n d 83 p e r c e n t o f these s h o w e d e x c e l l e n t or g o o d results. T h e r e fore, we c o n c l u d e t h a t t h e s t r i p p i n g o p e r a t i o n is t h e m o s t effective m e t h o d in t h e t r e a t m e n t o f v a r i c e s o f t h e l o w e r extremities. A c c u r a t e p r e - o p e r a t i v e diagnosis a n d c o m p l e t e p e r f o r m a n c e o f t h e s u r g i c a l p r o c e d u r e a r e o f g r e a t e s t i m p o r t a n c e in the s t r i p p i n g o p e r a t i o n for v a r i c o s e veins. (Received for publication on February 13, 1978) References 1. Dodd, H. and Cockett, F. : The Pathology and Surgery of the Veins of the Lower Limb, pp. 59-160, Churchill Livingstons, London, 1976. 2. Hafner, C.D., Krause, R.J. and Meese, E.H.: The Venous System of the Lower Extremities, in Vascular Surgery, Vol. II, Peripheral Venous Diseases, pp. 1-10, Harper & Row, New York, 1975. 3. Larson, R.H., Lofgren, E.P., Myers, T.T. and Lofgren, K.A. : Long term results after vein surgery, Mayo Clin. Proc. 49: 114-117, 1974. 4. Leu, H.J.: The modern conception of therapy of varicose veins, Angiology 15: 371-377, 1964.
5. Linton, R.R.: Atlas of Vascular Surgery, p 86, Saunders Co., Philadelphia, 1973. 6. Lofgren, E.P.: Present-day indications for surgical treatment of varicose veins, Mayo Clin. Proc. 41: 515-523, 1966. 7. Lofgren, E.P. and Lofgren, K.A.: Recurrence of varicose veins after stripping operation, Arch. Surg. 102: 111-114, 1971. 8. Sugie, E.: Varicose Veins, Gendai-gekkagakuTaikei 15. pp. 387-401, Nakayama-shotten, Tokyo, 1968 (in Japanese). 9. Tanabe, T. : Varicose veins, Medicina 13 : 328-329, 1976 (in Japanese).
A B S T R A C T : Approximately 150 stripping operations for primary varicose veins of the lower extremities were performed. Long-term evaluation (postoperative follow-up of more than five years) was made on 102 extremities and 83 per cent of these showed good or excellent results. Six patients were reoperated due to recurrence of varices. Accurate diagnosis and complete operation are most important in stripping operations. K E Y W O R D S : varicose veins, stripping operation, greater saphenous vein, smaller saphenous vein, perforating vein, communicating vein, recurrent varicose vein. INTRODUCTION
T h e r e are two treatments for varicose veins of the lower extremities, injection treatment and operative treatment. While some authors advocate injection treatment for primary management, the stripping operation is widely accepted as the most effective lasting treatmentl, 2 since the recurrence rate is only five to eight per cent. In the present report results from the standpoint of long-term follow-up are presented. CASES
AND
METHODS
This study is concerned only with cases of primary varices. Ssecondary varicose veins due to incompetence of the deep veins are not considered. One hundred thirteen patients with primary varicose veins of the lower extremities were seen since 1962. Seventy patients were female and 42 male, resulting in a female: male ratio of 1.7: 1. Sixty patients (53 p e r c e n t ) were less than 30, and 30 (27 per cent) were 51 years of age or older. In 75 of 113 patients (66 per cent), the symptoms had persisted for at least five years. The right leg was involved in 39 (35 per cent), the left in 23 (20 per cent), and both legs in 51 (45 per cent) of the cases. O f a total of 164 legs in 113 patients, 94 legs (57 per cent) had varices in the greater, 25 (15 per cent) in the smaller, and 36 (22 per cent) in the greater and smaller saphenous system simultaneously. A simple modification of Leu's classification of varicose veins 4 is used in the present study (Table 1). In 153 legs (93 per cent), tortuous involvement of the full-length saphenous system was noted. Localized dilatation of the superficial vein in the lower leg or calf, not accompanied by incompetence of the saphenous system was found in 11 legs (seven per cent) and the combination dilatation of the superficial vein and incompetent perforating veins was noted in six legs (four per cent). Recurrence of varices was found in three legs (two per cent) and stasis ulcers were noted in 11 legs (seven per cent). O u r preferential treatment is performance of the stripping operation. One handred
The SecondDepartment of Surgery, Hokkaido University School of Medicine, Sapporo, Japan. JAPANESEJOURNALOF SUROERY,VOL. 9, No. 1, pp. 71-75, 1979
Jpn. J. Surg. March 1979
Tanabe
72 T a b l e 1.
Classification of eases (Leu, 1964)
Hyphen-web varicosities Reticular-type varicosis Segmental varicose vein Varicosis of short saphenous vein Varicosis of long saphenous vein Varicosis of short and long saphenous vein (Varicosis with incompetence of perforating vein T a b l e 2.
Details of operative procedures
Stripping
No. of patients
lO2
No. of operations
(13~)
Unilateral Long saphenous vein Short saphenous vein Long and short saphenous vein Bilateral Long saphenous vein Short saphenous vein Long and short saphenous vein (Subfacial ligation Resection Subcutaneous ligation Operation not performed T a b l e 3.
2 4 5 25 92 36 6)
66 39 15 12 36 (72) 22 5 9 6) 3 3 5
Results of stripping operation Follow up over 5 yrs. Percent of No. of extremities extremities
Excellent : Good: Fair: Poor: Unknown:
No varicositis Scattered residual tributaries, less than 3 mm in diameter Varicosities larger than 3 mm in diameter Surgical treatment had made the leg worse Not followed up
48 37 5 0 12
47 36 5 0 12
forty four surgical p r o c e d u r e s were p e r f o r m e d on 108 patients a n d five patients were n o t surgically treated. T h e stripping o p e r a t i o n was p e r f o r m e d on 138 lower extremities ( T a b l e 2). T h e g r e a t e r saphenous system w i t h its tributaries was s t r i p p e d in 83 legs, the s m a l l e r saphenous system was r e m o v e d in 25 legs. T h e g r e a t e r a n d smaller saphenous veins were simultaneously s t r i p p e d in 30 legs. C o n v e n t i o n a l stripping a c c o m p a n i e d b y subfacial ligation o f the p e r f o r a t i n g vein 5 was p e r f o r m e d in six legs a n d resection or m u l t i p l e subcutaneous ligation of the localized d i l a t e d superficial vein was p e r f o r m e d in six legs. W e e x p e r i e n c e d no serious complications. T h e degree of p o s t - o p e r a t i v e s y m p t o m a t i c relief was e v a l u a t e d a t the time of follow-up e x a m i n a t i o n . W e used the classification b y L a r s o n et al. a to e v a l u a t e l o n g - t e r m results on 102 legs with a post-operative follow-up p e r i o d of m o r e t h a n five years.
Volume 9 Number I
Stripping Operation Table 4.
Case Age & sex
73
Cases of recurrent varicose veins
Cause
Duration
Symptoms
1 2 3
M.N. 42. M K.F 38. F T.M 44. F
Low-level ligature Inadequate stripping Partial resection
5 yr. 6 yr. 10 yr.
Persistent varices Persistent varices Recurrence
4 5 6
T.K 39. F N.T 45. F Y.M. 60. M
Inadequate diagnosis Progression Inadequate diagnosis
3 yr. 13 yr. 2 yr.
Residual varices (short saphenous vein) Recurrent varices (long saphenous vein) Residual varices (perforating vein)
RESULTS
Eighty three per cent of the operated extremities showed excellent or good, and five per cent fair results. No poor results were obtainedS, 9 (Table 3). Six patients, three of which had received inadequate operations at other hospitals, underwent re-operation due to residual or recurrent varices. Primary causes of recurrence were thought to be low level ligation in the upper part of the thigh, inadequate stripping or partial resection of the varices. The other three patients had undergone the initial stripping operation at our institute, but recurrence appeared due to inadequate diagnosis or primary operation. Residual varices became apparent in the lower part of the legs after single-stripping of the long saphenous vein. Recurrent varices around the knee seemed to occur due to progression of residual small lesions of a tributary (Table 4). DISCUSSION In order to prevent recurrence of varices and to obtain excellent results, accurate diagnosis of the points of reverse flow from the deep veins, complete stripping of the saphenous system and communicating veins, or ligation of the incompetent perforating veins are of utmost importance. The stripping operation is comprised of I) high flush ligation of the saphenous vein and its tributaries at the saphenofemoral or saphenopopliteal junction, 2) complete stripping of the saphenous vein from groin or popliteal fossa to ankle and 3) multiple stripping, dissections by tunneling and excision of the varices. Care is required in the application of these techniques.6, 7 Two common technical faults in the thigh are shown in Fig. 1, a) failure to ligate the saphenous vein close enough to the saphenofemoral junction and to ligate all its tributaries and b) failure to find the communicating or accessory veins. Two common technical faults in the calf are shown in Fig. 2, a) failure to ligate the communicating vein and b) failure to find the incompetent perforating vein. A correct preoperative diagnosis can be obtained by careful inspection and palpation of the varices and by evaluation of ascending function M phlebograms.7, s As varicose veins have a slow course of progression, a minimum follow-up period of five years is required before any assessment of the results of varices surgery can be made. In a 10-year operative follow-up study reported by the Mayo Clinic, 3 85 per cent of the patients were reported to have maintained good to excellent results. In our five-year follow-up study, we obtained similar gratifying results in that 83 per cent of the operated extremities were found to show good to excellent results.
74
Tanabe
a
Fig. 1.
Jpn. .[. Surg. March 1979
b
Common faults of operations in the thigh a. Non-terminal flush ligation b. low level ligation
il a
Fig. 2.
b
Common faults of operations in the calf. a. overlooked incompetent perforator b. undiagnosed communicating vein
Volume 9 Number 1
Stripping Operation
75
CONCLUSION A f i v e - y e a r p o s t - o p e r a t i v e s t u d y was m a d e o n t h e results o f s t r i p p i n g o p e r a t i o n s o n 102 l o w e r e x t r e m i t i e s a n d 83 p e r c e n t o f these s h o w e d e x c e l l e n t or g o o d results. T h e r e fore, we c o n c l u d e t h a t t h e s t r i p p i n g o p e r a t i o n is t h e m o s t effective m e t h o d in t h e t r e a t m e n t o f v a r i c e s o f t h e l o w e r extremities. A c c u r a t e p r e - o p e r a t i v e diagnosis a n d c o m p l e t e p e r f o r m a n c e o f t h e s u r g i c a l p r o c e d u r e a r e o f g r e a t e s t i m p o r t a n c e in the s t r i p p i n g o p e r a t i o n for v a r i c o s e veins. (Received for publication on February 13, 1978) References 1. Dodd, H. and Cockett, F. : The Pathology and Surgery of the Veins of the Lower Limb, pp. 59-160, Churchill Livingstons, London, 1976. 2. Hafner, C.D., Krause, R.J. and Meese, E.H.: The Venous System of the Lower Extremities, in Vascular Surgery, Vol. II, Peripheral Venous Diseases, pp. 1-10, Harper & Row, New York, 1975. 3. Larson, R.H., Lofgren, E.P., Myers, T.T. and Lofgren, K.A. : Long term results after vein surgery, Mayo Clin. Proc. 49: 114-117, 1974. 4. Leu, H.J.: The modern conception of therapy of varicose veins, Angiology 15: 371-377, 1964.
5. Linton, R.R.: Atlas of Vascular Surgery, p 86, Saunders Co., Philadelphia, 1973. 6. Lofgren, E.P.: Present-day indications for surgical treatment of varicose veins, Mayo Clin. Proc. 41: 515-523, 1966. 7. Lofgren, E.P. and Lofgren, K.A.: Recurrence of varicose veins after stripping operation, Arch. Surg. 102: 111-114, 1971. 8. Sugie, E.: Varicose Veins, Gendai-gekkagakuTaikei 15. pp. 387-401, Nakayama-shotten, Tokyo, 1968 (in Japanese). 9. Tanabe, T. : Varicose veins, Medicina 13 : 328-329, 1976 (in Japanese).
