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Saphenous vein stripping and quality of outcome

Saphenous vein stripping and quality of outcome CORRESPONDENCE 139 with a 2/0 silk stitch. It is not necessary to use a Foley catheter surgery: patient satisfaction. J R Coll Surg Edinb 1995; 40: 298. with balloon. Abu-Own A, Scurr JH, Coleridge Smith PD. Saphenous vein reflux without incompetence at the saphenofemoral junction. W. J. B. Hodgson Br J Surg 1994; 81: 1452-4. Department of Surgery Campanello M, Hammarsten J, Forsberg C, Bernland P, Brooklyn Hospital Center Henrikson 0, Jensen J. Standard stripping versus long 121 DeKalb Avenue saphenous vein-saving surgery for primary varicose veins. A Brooklyn prospective, randomized study with the patients as their own New York 11 201 controls. Phlebology 1996; 11: 45-9. USA Bergan JJ. Saphenous vein stripping and quality of outcome. Br J Sum 1996; 83: 1025-7. Tibbs DT. Varicose veins. In: Morris PJ, Malt RA, eds. Odord Tat-Book of Surgery. Oxford: Oxford University Press, 1994: Ruckley CV. Operations for varicose veins. In: Jamieson CW, Sir Yao JST, eds. Vascular Surgery. 5th ed. London: Chapman and We enjoyed Dr Bergan’s paper (Br J Surg 1996; 83: 1025-7) Hall Medical, 1994: 552-7. supporting stripping of the long saphenous vein (LSV) in Chun MH, Han SH, Chung JW et at. Anatomical observation varicose vein surgery. Recurrent varicose veins are a common on draining patterns of saphenous tributaries in Korean adults. problem and can be difficult to treat. In a recent study, more J Korean Med Sci 1992; I: 25-33. than 10 per cent of patients represented with recurrent veins NL Browse. Varicose veins. In: NL Browse, KG Burnand, ML within 6 months of initial operation’. Patients’ satisfaction rates Thomas. Diseases of the Veins: Pathology, Diagnosis and with varicose vein surgery are generally low and vary’,2. Treatment. London: Edward Arnold, 1988: 201-51. We support the arguments in favour of stripping the LSV. There are several mechanisms for recurrent varicose veins if the LSV is not stripped including the presence of a mid-thigh perforator and/or involvement of the LSV may be an ascending Glyceryl trinitrate prevents neutrophil activation but phenomenon rather than a descending one’. It is not unusual to not thromboxane release following ischaemia- find LSV reflux without concomitant saphenofemoral junction reperfusion injury (SFJ) incompetence. Leaving the LSV in situ after a high tie alone may leave an incompetent LSV which may result in further varicosities. This may occur after a perfectly adequate groin Sir operation’. I read with interest the paper by Mr Barry et at. (Br J Surg 1996; A recently published study from Sweden found no differences 83: 1095-1 100) suggesting modulation of neutrophil to in outcome at 4 years of follow-up whether the LSV was stripped endothelial adhesion by nitric oxide donors’. or not but a more extensive dissection at the groin was The administration of glyceryl trinitrate (GTN) in a rat model performed and ligating the mid-thigh and other perforators of aortic occlusion and distant pulmonary reperfusion injury may prevented recurrences4. These results are not comparable to the attenuate the latter by nitric oxide donation. This has also been standard operations usually performed in this country. suggested to occur in models of direct local pulmonary Careful surgery in the groin is equally important. Accurately ischaemia, preservation and reperfusion2. identifying and ligating the SFJ complex, obliterating all Much research has been performed in the field of pulmonary tfibutaries and stripping the LSV are factors that reduce the rate transplantation in which the lung must necessarily be rendered of recurrences. We wish to emphasize the importance of ischaemic, preserved and reimplanted with the expectation of tributaries opening directly into the femoral vein. The immediate perfect function after reperfusion. importance of these branches in recurrent varicose veins is well Nitric oxide under these circumstances is protective of direct recognizedh. This is especially important if the LSV has not been reperfusion injury in the lungs whether by intravenous infusion stripped. It is important to dissect the femoral vein proximal and of nitric oxide donors such as nitroglycerin’ or by inhalation of distal to the SFJ ligating all such tributaries’.”. We have found nitric oxide after established reperfusion injury4. Considerable that such tributaries exist in about 30 per cent of patients future research is being directed towards the administration of (unpublished data). such agents either in lung preservation fluids or systemically after Varicographic analysis of recurrent varicosities has lung implantation. demonstrated the role of angioneogenesis in the aetiology of Undoubtedly nitric oxide donors will prove to be a valuable recurrent varicose veins’. These can connect either to the LSV therapy against reperfusion injury, either remote, as suggested by remnant or to a missed large superficial vein of the thigh (e.g. Barry et al., or more directly following pulmonary the accessory saphenous vein). Suturing the fascia over the transplantation. cribriform opening has been advised as a measure to counter S. Clark this. Cardiothoracic Centre In conclusion, we agree that the case for stripping the LSV in Freeman Hospital varicosities involving the long saphenous system is strong and Newcastle upon fine NE7 7DN should be coupled with meticulous dissection of the SFJ and the UK femoral vein proximal and distal to the SFJ. Closure of the cribriform opening may be beneficial in avoiding recurrences due 1 Kanwar S, Kubes P. Nitric oxide is an antiadhesive molecule to angioneogenesis. for leukocytes (Review). New Horizons 1995; 3: 93-104. s. s. Shoab 2 Pinsky DJ, Naka Y, Chowdhury NO et al. The nitric oxide/ S. K. Shami cyclic GMP pathway in organ transplantation. Critical role in Vascular Unit successful lung transplantation. Proc Nut1 Acad Sci USA 1994; Havering Hospitals 91: 12 086-90. Oldchurch Hospital 3 Naka Y, Chowdhury NC, Oz MC et al. Nitroglycerin maintains Waterloo Road graft vascular homeostasis and enhances preservation in an Romford RM7 OBE orthotopic rat lung transplant model. J Thorac Cardiovasc Surg UK 1995: 109: 206-10. 4 Lindberg L, Sjoberg T, Ingemansson R et al. Inhalation on 1 Mackay DC, Summerton DJ, Walker AJ. The early morbidity nitric oxide after lung transplantation. Ann Thorac Surg 1996; of varicose vein surgery. J R Nav Med Sew 1995; 81: 42-6. 61: 956-62. 2 Davies AH, Steffen C, Cosgrove C, Wilkins DC. Varicose vein 0 1997 Blackwell Science Ltd, British Journal of Surgery 1997,84, 137-139 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png British Journal of Surgery Oxford University Press

Saphenous vein stripping and quality of outcome

Shoab, S S; Shami, S K
British Journal of Surgery , Volume 84 (1): 1 – Jan 1, 1997
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References (11)

Publisher
Oxford University Press
Copyright
Copyright © 1997 British Journal of Surgery Society Ltd.
ISSN
0007-1323
eISSN
1365-2168
DOI
10.1002/bjs.1800840152
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Abstract

CORRESPONDENCE 139 with a 2/0 silk stitch. It is not necessary to use a Foley catheter surgery: patient satisfaction. J R Coll Surg Edinb 1995; 40: 298. with balloon. Abu-Own A, Scurr JH, Coleridge Smith PD. Saphenous vein reflux without incompetence at the saphenofemoral junction. W. J. B. Hodgson Br J Surg 1994; 81: 1452-4. Department of Surgery Campanello M, Hammarsten J, Forsberg C, Bernland P, Brooklyn Hospital Center Henrikson 0, Jensen J. Standard stripping versus long 121 DeKalb Avenue saphenous vein-saving surgery for primary varicose veins. A Brooklyn prospective, randomized study with the patients as their own New York 11 201 controls. Phlebology 1996; 11: 45-9. USA Bergan JJ. Saphenous vein stripping and quality of outcome. Br J Sum 1996; 83: 1025-7. Tibbs DT. Varicose veins. In: Morris PJ, Malt RA, eds. Odord Tat-Book of Surgery. Oxford: Oxford University Press, 1994: Ruckley CV. Operations for varicose veins. In: Jamieson CW, Sir Yao JST, eds. Vascular Surgery. 5th ed. London: Chapman and We enjoyed Dr Bergan’s paper (Br J Surg 1996; 83: 1025-7) Hall Medical, 1994: 552-7. supporting stripping of the long saphenous vein (LSV) in Chun MH, Han SH, Chung JW et at. Anatomical observation varicose vein surgery. Recurrent varicose veins are a common on draining patterns of saphenous tributaries in Korean adults. problem and can be difficult to treat. In a recent study, more J Korean Med Sci 1992; I: 25-33. than 10 per cent of patients represented with recurrent veins NL Browse. Varicose veins. In: NL Browse, KG Burnand, ML within 6 months of initial operation’. Patients’ satisfaction rates Thomas. Diseases of the Veins: Pathology, Diagnosis and with varicose vein surgery are generally low and vary’,2. Treatment. London: Edward Arnold, 1988: 201-51. We support the arguments in favour of stripping the LSV. There are several mechanisms for recurrent varicose veins if the LSV is not stripped including the presence of a mid-thigh perforator and/or involvement of the LSV may be an ascending Glyceryl trinitrate prevents neutrophil activation but phenomenon rather than a descending one’. It is not unusual to not thromboxane release following ischaemia- find LSV reflux without concomitant saphenofemoral junction reperfusion injury (SFJ) incompetence. Leaving the LSV in situ after a high tie alone may leave an incompetent LSV which may result in further varicosities. This may occur after a perfectly adequate groin Sir operation’. I read with interest the paper by Mr Barry et at. (Br J Surg 1996; A recently published study from Sweden found no differences 83: 1095-1 100) suggesting modulation of neutrophil to in outcome at 4 years of follow-up whether the LSV was stripped endothelial adhesion by nitric oxide donors’. or not but a more extensive dissection at the groin was The administration of glyceryl trinitrate (GTN) in a rat model performed and ligating the mid-thigh and other perforators of aortic occlusion and distant pulmonary reperfusion injury may prevented recurrences4. These results are not comparable to the attenuate the latter by nitric oxide donation. This has also been standard operations usually performed in this country. suggested to occur in models of direct local pulmonary Careful surgery in the groin is equally important. Accurately ischaemia, preservation and reperfusion2. identifying and ligating the SFJ complex, obliterating all Much research has been performed in the field of pulmonary tfibutaries and stripping the LSV are factors that reduce the rate transplantation in which the lung must necessarily be rendered of recurrences. We wish to emphasize the importance of ischaemic, preserved and reimplanted with the expectation of tributaries opening directly into the femoral vein. The immediate perfect function after reperfusion. importance of these branches in recurrent varicose veins is well Nitric oxide under these circumstances is protective of direct recognizedh. This is especially important if the LSV has not been reperfusion injury in the lungs whether by intravenous infusion stripped. It is important to dissect the femoral vein proximal and of nitric oxide donors such as nitroglycerin’ or by inhalation of distal to the SFJ ligating all such tributaries’.”. We have found nitric oxide after established reperfusion injury4. Considerable that such tributaries exist in about 30 per cent of patients future research is being directed towards the administration of (unpublished data). such agents either in lung preservation fluids or systemically after Varicographic analysis of recurrent varicosities has lung implantation. demonstrated the role of angioneogenesis in the aetiology of Undoubtedly nitric oxide donors will prove to be a valuable recurrent varicose veins’. These can connect either to the LSV therapy against reperfusion injury, either remote, as suggested by remnant or to a missed large superficial vein of the thigh (e.g. Barry et al., or more directly following pulmonary the accessory saphenous vein). Suturing the fascia over the transplantation. cribriform opening has been advised as a measure to counter S. Clark this. Cardiothoracic Centre In conclusion, we agree that the case for stripping the LSV in Freeman Hospital varicosities involving the long saphenous system is strong and Newcastle upon fine NE7 7DN should be coupled with meticulous dissection of the SFJ and the UK femoral vein proximal and distal to the SFJ. Closure of the cribriform opening may be beneficial in avoiding recurrences due 1 Kanwar S, Kubes P. Nitric oxide is an antiadhesive molecule to angioneogenesis. for leukocytes (Review). New Horizons 1995; 3: 93-104. s. s. Shoab 2 Pinsky DJ, Naka Y, Chowdhury NO et al. The nitric oxide/ S. K. Shami cyclic GMP pathway in organ transplantation. Critical role in Vascular Unit successful lung transplantation. Proc Nut1 Acad Sci USA 1994; Havering Hospitals 91: 12 086-90. Oldchurch Hospital 3 Naka Y, Chowdhury NC, Oz MC et al. Nitroglycerin maintains Waterloo Road graft vascular homeostasis and enhances preservation in an Romford RM7 OBE orthotopic rat lung transplant model. J Thorac Cardiovasc Surg UK 1995: 109: 206-10. 4 Lindberg L, Sjoberg T, Ingemansson R et al. Inhalation on 1 Mackay DC, Summerton DJ, Walker AJ. The early morbidity nitric oxide after lung transplantation. Ann Thorac Surg 1996; of varicose vein surgery. J R Nav Med Sew 1995; 81: 42-6. 61: 956-62. 2 Davies AH, Steffen C, Cosgrove C, Wilkins DC. Varicose vein 0 1997 Blackwell Science Ltd, British Journal of Surgery 1997,84, 137-139

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British Journal of Surgery – Oxford University Press

Published: Jan 1, 1997

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