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A retrospective comparison on surgical management of varicose veins with and without venous stripping

Varicose veins, one of the oldest known diseases of mankind were treated by various modalities starting from simple phlebotomy to minimally invasive approaches. Aim and Objectives: In this study the outcome of two surgical treatment modalities of varicose surgery with and without venous stripping was compared based upon a follow up period of two months. Materials and Methods: Among the 92 patients operated for varicose veins between September 2018 to November 2019 in all surgical units of Trichy SRM Medical College Hospital, S50 patients of age group 16 – 70 yrs were taken up for the study after matching. Results: In this study males contribute the maximum bulk of about 82%. As for as the age is considered, patients aged between 40 – 70 yrs was more, which was about 58%.The hematoma formation after venous stripping was 28% whereas it was only 4% in the other group. There was no significant difference in healing of leg wounds in both the studies The first postoperative comfortable ambulation with minimal pain was possible in more patients who did not undergo venous stripping (92%) than who underwent stripping (68%).Long postoperative stay of more than 6 days was found in 8% of those who underwent stripping and 4% of the other group. The long stay was mostly due to pain and delayed wound healing. Pain relief was seen in 96% of those who had venous stripping and 88 % of those who did not undergo venous stripping at the end of second month. Conclusion: This study on observation concludes there was no significant difference in healing of leg wounds, hospital stay and pain relief in both the studies, but the Trendelenburg procedure with incompetent perforators ligation without venous stripping appears to be better than Trendelenburg procedure with incompetent perforators ligation with venous stripping.


Introduction
In this comparative study the outcome of surgical management of varicose veins with and without venous stripping is compared and analyzed. There is no universally accepted definition for varicose veins [1] . The word varicose vein was first proposed by Hippocrates [2] in 460 B.C [3] . In Latin varix refers to enlarged vein, artery or lymphatics. In routine usage the word varix is used to mention vein and varicosity refers to a vein that is enlarged in diameter and tortuous. Varicose veins are superficial veins of the lower limb that has lost its valvular function and as a result of resulting venous hypertension becomes dilated, thickened and tortuous [4,5] .

Objectives of the study
The main objective of this comparative study is to compare the outcome of two surgical treatment modalities of varicose veins. One group of patients undergoes Trendelenburg procedure with Subfascial ligation of incompetent perforators whereas the other group undergoes Trendelenburg procedure with Subfascial ligation6 of incompetent perforators with stripping of long saphenous vein from groin to knee. The two modalities are compared in terms of 1. Hematoma formation in the thigh. 2. Healing of wounds in the leg at the site of incompetent perforators. 3 For all the patients, detailed history, clinical examination, basic blood investigations, chest x-ray, ECG, venous Doppler11,12 of the affected limb were taken. The selected cases were matched for sex, age so as to avoid bias. After explaining the procedure and getting informed consent from the patients, they were subjected to one of the two types of surgical treatment modality.

Group I
In one group 25 patients underwent Trendelenburg procedure by making a transverse incision of length 3cm just below the groin crease extending from femoral artery pulsation site towards medially. The incompetent perforators in the thigh and leg are ligated and divided subfascially by making small transverse incision across the path of the vein at the site of incompetent perforators marked preoperatively. Then the long saphenous vein is stripped from groin to just below the knee by passing stripper into the vein.

Group II
In the other group 25 patients underwent Trendelenburg procedure is done by making a transverse incision of length 3cm just below the groin crease extending from the site femoral artery pulsation medially. The incompetent perforators in the leg are ligated and divided subfascially by making small transverse incision across the path of the vein at the site of incompetent perforators marked preoperatively. In both groups the wounds closed with good hemostasis, limb elevated and elastocrepe bandage applied. All the patients were followed in the postoperative period and for a period of next two months. The details of all the patients and their investigations, procedure undergone, follow up were recorded in separate proforma for individual patients.

Observations of the study
The following observations were recorded by follow up of the patients for a period of two months. The factors that are taken for comparison are

Hematoma formation in the thigh
All the patients were examined daily in the postoperative period to look for hematoma formation in the thigh.

Healing of wounds in the leg at the site of incompetent perforators
The time taken for the wound in the leg made for approaching the incompetent perforators was noted down. If the wound takes more than 6 days to heal it was considered as delayed and were recorded.

Comfortable ambulation without much pain on first postoperative day
On the first postoperative day, all the patients were encouraged to walk for some time with elastic stockings. The patients who were able to walk comfortably on first postoperative day with minimal pain were recorded.

Postoperative hospital stay
Usually the patients were discharged on third postoperative day. Those who were in the ward for more than 6 days because of pain, delayed wound healing were noted.

Pain relief of the patient after two months
The pain in the affected limb of the patient was enquired and recorded as per visual analog scale preoperatively. All the patients were enquired after two months of the procedure about their pain relief and recorded as per visual analog scale. An improvement of more than five score was considered as good pain relief.
The following table shows the magnitude of all the observed variables in both the procedure and the same is depicted in the bar chart below.

Discussion
The two studies were compared statistically to find out whether there is significant difference between the outcomes of two surgical procedures. The null hypothesis was assumed: That is to begin with it was assumed that there is no significant difference between the two procedures. By using chisquare test all individual variables were checked for significance.
Since we use 2x2 table, the degree of freedom is 1.If the chisquare value is >3.84, the P value is < 0.05 the difference is significant.  Chi square = 5.34 which is more than 3.84. The P value is less than 0.05.Hence it is significant. So the null hypothesis is not true and there is significant difference between the two procedures with respect to hematoma formation.

Healing of wounds in the leg at the site of incompetent perforators
Observed frequency (O)

Comfortable ambulation without much pain on first postoperative day
Observed frequency (O)  Chi square value is 4.5 which is more than 3.84 and the P value is less than 0.05. Hence the null hypothesis is false. So there is significant difference between the two procedures.   Chi square value is 0.356 which is less than 3.84 and the P value is >0.05. So the null hypothesis is true and there is no significant difference between the two procedures.   The chi square value is 1.0434 which is less than 3.84 and the P value is >0.05. So the null hypothesis is proved and hence there is no significant difference between the two procedures.

Pain relief after two months: Observed frequency (O)
So, among the observed variables, only the hematoma formation and the comfortable ambulation on first postoperative day were significantly different between the two procedures.  3. The left leg was more commonly involved than the right side. The left limb was involved in 66% and the right limb was involved in 33% of patients. The frequency of involvement of the left and the right limbs is shown in the pie chart.

Discussion
~ 618 ~    The pain relief during the follow up period in two studies is shown in the following bar graph.

Conclusion
In this comparative study which was done in 50 patients, the observations of short term variables show that the venous stripping has increased incidence of hematoma formation and the ambulation of patients on first post operative day was very painful. With reference to wound healing, hospital stay and pain relief there is no significant difference between the two ~ 619 ~ procedures. So, as for as the variables observed, the Trendelenburg procedure with incompetent perforators ligation10 without venous stripping appears to be better than Trendelenburg procedure with incompetent perforators ligation with venous stripping.