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Electronic letters to:
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Electronic letters published:
![[Read eLetter]](/icons/misc/sectionDOWN.gif){kind=icon}
Surgical Verses Medical Management of Chronic "Venous" Leg Ulcers (Encouragement on Further Debate)
No surgical panacea
Care of Chronic leg ulcers, the problem of treating a surgical condition with medical means
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Wah Ting WONG
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wwjw{at}telus.net Wah Ting WONG
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Surgical Verses Medical Management of Chronic “Venous” Leg Ulcers; (Encouragement on further Debate and Research) I am very pleased that Dr. Harrison has taken time to address my e- letter. Her article recorded excellent improvement in the delivery of nursing care to patients with chronic leg ulcers of “venous origin”. I had already commended on the valuable services of her group. However, no matter how diligent and methodical the nursing management is executed, it can only bring out the maximum potential of the form of medical treatment prescribed. Let me reiterate that the debate is on the best mode of treatment, but not to raise doubt on the evidence based nursing services described. It surprises me that for an important condition affecting 1.8/1000 of Canadians; being treated by an array of medical and surgical disciplines (family physicians; internists; dermatologists; plastic, general and vascular surgeons etc.) such a pivotal paper has not sparked a more wide range debate from many others. If I should refrain from further communication in this forum, the impression that compression therapy is the best treatment choice according to Dr. Harrison, may adversely influence the adoption of the more efficient surgical management for these patients. Thus it will be conducive to the improvement of their care, that I should endeavour to stimulate further debate and research on the preference of surgical management. Most clinical research papers and the debates so generated, are geared to improve on the understanding or management of certain medical conditions. If one should accept the viewpoints of medical textbooks, no matter how recent, as the absolute truth, no research may need to be further conducted, and the real truth will stand the danger of not being recognized. One good example was the general acceptance of hyperacidity being the sole cause of chronic duodenal ulcer (stated in every medical and surgical textbook for many years), till B. Marshall et al postulated the importance of H.Pylori in its aetiology in the 1980’s. For the next decade the tide of medical trend gradually changed. The management was revolutionized. Only still later, the medical textbooks were altered to reflect the development. My current e-letter is just intended to supplement Dr. Harrison’s publication, in stimulating a wider debate and research, by further posting a few questions for those, who are interested in improving the management of this category of patients:- 1. What is the general understanding of the mechanism by which compression therapy works in healing chronic leg ulcers? Does it work by partially counter balancing the ill effects of the incompetent calf perforators (if we recognize them to be of aetiological importance) or by other mechanisms (if we do not recognize the important aetiological role of the perforators)? 2. Only 2% of patients with “simple” varicose veins (from incompetence of the Sapheno-femoral and Sapheno-popliteal valves) without incompetent perforators, develop chronic leg ulcers. (This category constitutes only 2 to 5% of all the chronic “venous” leg ulcers, while the other 95-98% occurs in those with incompetent calf perforator veins). If the incompetent calf perforator veins are not accepted to be responsible for the development of ulcers, what other aetiological factors are being proposed or to be substantiated? 3. I had quoted Peter Gloviczki’s original series to illustrate the relative effectiveness of the SEPS procedure. He is a strong proponent who had multiple publications on SEPS, been invited to address the topic in our Canadian Royal College meeting. For such an author to be writing in a medical textbook quoting uncertainty about the role of perforators in the development of “venous” ulcers, some questions may be raised, and certain interpretation suggested. Why does he perform SEPS at all, if the role of perforators to the development of venous ulcers really needs to be ascertained (the SEPS procedure does nothing but interrupt the incompetent perforators located on the medial side of the flexor calf compartment)? Does he want to stimulate more proponents of the procedure to speak out, before amending the medical textbook (see above re: the lag period required for the aetiological role of H.Pylori in chronic duodenal ulcer to be recorded in medical textbooks)? It is highly unlikely that a respected author will continue to perform a procedure that he does not really believe in. The question is therefore, “How to get more proponents of surgical management like me, to voice their experience and opinion, in order to positively influence the establishment of the correct approach for these patients?” 4. It is known that compression therapy healed about 50% of chronic leg ulcers over a year under superb nursing care (Dr, Harrison’s series is a good example). According to Simon, Dix and McCollum referenced by Dr. Harrisson, the recurrence rate at 1 year is 20% and at 18 months, 31%. Accordingly, one can calculate that of 100 patients so treated, only 35 patients will continue to have healed ulcers by the end of 18 months. SEPS and the very complete fasciotomy, healed more than 88% of ulcers post- surgically. SEPS has 28% recurrence in 2 years, my series of very complete fasciotomy had no recurrence over 10 years median follow up. Even with the less favourable results of SEPS between the two procedures, 63 patients will remain ulcer-free by 2 years. On these grounds, how does one justify compression therapy to be the treatment of choice for the majority of cases? (Noting that in many series, patients often suffered from the ulcers for 5 to 10 years or more, being medically neglected or under less effective medical regime than that provided by Dr. Harrison’s clinic). The conclusion drawn by Simon et al on the preference of compression therapy, is negated by the above analysis. Further, their article erroneously attached great importance to superficial venous incompetence as an aetiological factor and the target of operative intervention (see (2) above for this comment). The article contained not a single word on SEPS and Fasciotomy with subfascial perforator ligation (the main stay of current surgical intervention directed against the culprit -- incompetent calf perforators). Even though their quoted surgical interventions were incorrectly directed to superficial veins, the article still mentioned a mean ulcer healing time of 31 days after surgery, compared to 63 days of compression therapy. The 3 years recurrent ulcer rate was 9% for surgically treated cases, but 38% for compression therapy. A careful scrutiny of the article therefore would have raised doubt on the authors’ conclusion. In any case, one relevant question will remain “Can one ever improve the compression therapy further, to justify its being chosen as the preferential management?” In this context, one must understand that a method of treatment used as a gold standard, against which other methods are measured, may not be the treatment of choice. A good example is:- open cholecystectomy is the gold standard against which laparoscopic cholecystectomy is measured, but loses out to the latter as the treatment of choice nowadays. 5. If procedures, such as SEPS and the Very Complete Fasciotomy are not readily available in the community, and many community general surgeons have not had the experience on their application; can we possibly stimulate the medical educators, as well as the administrators of venous ulcer clinics to organize suitable CME events and actively facilitate their availability? (This was my original conjecture as stated in the last paragraph of my E-letter of June 1, 2005). By comparison:- would the lack of facilities or manpower for coronary angioplasty or bypass graft make medical treatment of severe ischaemic heart disease the treatment of choice, rather than our strife to make the former modalities available? In summary, I had described the patho-physiology of chronic leg ulcers due to the forceful retrograde ejection of venous blood via incompetent calf perforators in my first e-letter. When such ulcers are diagnosed and other causes excluded, the treatment should be surgical (of course only if the patient is medically fit to undergo surgery and informed consent obtained). Better still, if timely surgery is performed on non-ulcer bearing patients with the retrograde ejection venous syndrome, plus clearly defined criteria and/or significant risk of ulcer development (see appendix *), the ulcers may be prevented from occurring. Compression therapy will always have the following defined roles in this syndrome: 1) conservative treatment for mild cases not meeting the surgical criteria nor bearing significant ulcer risks yet; 2) conservative treatment of those not medically fit for surgery, or having declined surgery;. 3) as an interim treatment while waiting for surgery and 4) post surgical support to augment antegrade venous return from superficial veins and minimize any gravitational oedema. When compression therapy is prescribed, the protocol of Dr, Harrison’s group would be an efficient way of delivering the management. I hope that all those interested in this common problem will take up the following challenges:- 1) to further communicate their experiences; and debate on which of the available treatment modalities may provide the most logical management and the best result, 2) To facilitate the availability of appropriate surgical treatment and utilize compression therapy according to its proper perspective; and 3) to research on newer and improved methods of management in pursuit of medical progress. Ultimately, improved care of the patients with this chronic disability may be better achieved. Wah Ting WONG FRCS (England), FRCSC Victoria, B.C. * Appendix: Indications for surgery in non-ulcer bearing patients with the retrograde ejection venous syndrome (REVS), according to clearly defined criteria and significant risk of ulcer development, include: 1. Severe eczema/lipodermosclerosis affecting the whole circumference of lower 1/3 of the leg; or more than 1/3 of the leg whether partial or full circumference. 2. Recurrent superficial phlebitis (Each time this occurs in patients with REVS, more perforator venous valves may be damaged by extension of the thrombo-phlebitic process. The REVS will invariably intensify). 3. Failed symptomatic control of REVS with compression therapy. 4. Symptoms and signs of impending ulceration of the leg (Appearance of patches of skin in the leg, with changes including mounting erythrema, pain, local heat and tenderness, possibly blistering etc.; yet the changes are not due to infection and do not respond to antibiotic treatment.) References: Per listed in my e-letter of June 1, 2005 & Dr. Harrison’s e-letter of July 28,2005. Conflict of Interest:None declared |
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Margaret B. Harrison, Queen's University, 78 Barrie St., Kingston, Ontario, Canada K7L 3N6 Associate Professor, Queen's University
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harrisnm{at}post.queensu.ca Margaret B. Harrison
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Dr. Wah Ting WONG (June 1/05) presents an interesting perspective on our article, “Leg-ulcer care in the community, before and after implementation of an evidence-based service” which appeared in CMAJ, May 2005 issue. Our research focused on the conservative management of leg ulcers in the community. Dr. Wong’s communication seems to imply that all venous leg ulcer patients should be managed surgically. In our view, it is an oversimplification to suggest that all venous ulcers be managed surgically and that conservative management is somehow neglectful. Surgical textbooks continue to reiterate that compression therapy is the mainstay for venous ulcers. To quote Peter Gloviczki, also referenced by Dr. Wong, from the most recent edition of Rutherford's Textbook of Vascular Surgery 2005, "Nonoperative management in patients who are compliant with therapy remains highly effective in controlling symptoms and promoting healing of venous ulcers . . . compression therapy continues to be the standard against which all other therapies for venous ulcer and chronic venous insufficiency should be compared." With regard to SEPS and other perforator surgery, he elaborates "Level 1 evidence is still required not only to confirm the effectiveness of surgical treatment over medical management but also to ascertain the role of perforators to the development of venous ulcers" (1). Numerous surgical procedures have been tried over the years with various degrees of success and in some cases outright failure - there is no surgical panacea. In some cases, surgical intervention of venous ulcers to promote healing and prevent recurrence may offer a useful option. After careful evaluation/investigation of the etiology of an individual patient's ulcer, procedures can be carefully targeted to their specific pathophysiology. However, many of the procedures Dr. Wong mentions are not readily available to the average patient in the community(e.g. SEPS) and many community general surgeons have not had experience with specialized surgeries such as the "Very Complete Fasciotomy". Given the extent of this problem, and the compounding factor of an aging population, the best conservative management available remains the most viable option. Current best evidence indicates compression technology, particularly high compression, is the treatment of choice for the majority of cases (2). Margaret B Harrison RN, PhD Queen’s University, Tim Brandys, MD, FRCSC, University of Ottawa, Ian D. Graham PhD University of Ottawa, Karen Lorimer RN MScN The Victorian Order of Nurses Elaine Friedberg RN MHA Queen’s University, Tadeusz Pierscianowski, MBBS, FRCPC, FAAD University of Ottawa 1. Rutherford RB VASCUALR SURGERY sixth Edition Philadelphia, PA,Elsevier/Saunders 2005 PGs.2119-2120. 2. Simon, Dix, McCollum BMJ 2004;328:1358-1362; (Cochrane review). Conflict of Interest:None declared |
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Wah Ting Wong nil
Send letter to journal:
wwjw{at}telus.net Wah Ting Wong
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Dear Editor: The article ”Leg ulcer care in the community, before and after implementation of an evidence based service” by M.B. Harrison et al. CMAJ Mar. 24, 2005. Vol. 172 no.11 1447-1452., is a well documented study, achieving cost/labour reduction and a better result of management. It brings to light the significant Canadian perspective of this problem; namely: 1.8/1,000 of case load; ½ of the patients have been suffering from the ulcers for 5-10 years; 1/3 over 10 years; only ½ the ulcers treated may heal. The study period is too short to comment on the rate of recurrence yet. For treating only 192 patients, the resources used included $1million for nursing services within a year, and $¼ million for wound care supplies. This certainly reflects on the similar magnitude of financial burden, for operating the chronic venous ulcer clinics in the UK (1). The basic problem, however, rests in treating a surgical condition with medical means; thus the high expenses, unrewarding results and the unnecessarily prolonged suffering of patients. I usually consider the majorities of these patients have been treated with conservative neglect and others with operative inadequacy. Using compression dressing alone for these chronic leg ulcers, is as undependable as using a truss to treat an inguinal hernia. At best it is just a temporary measure. Leg ulcers of venous origin occur mainly as a complication of incompetent calf perforators (simple varicosity causes less than 5% of venous leg ulcers). Every time the calf muscles contract during walking or running, a very high retrograde ejection venous pressure shoots the venous blood from the deep veins via the incompetent perforators into the extrafascial, subcutaneous capillary network. The pressure is the sum total of:- the end arteriolar pressure, the hydrostatic pressure (being the pressure exerted by the column of blood measured from the lower leg to the level of the heart), and the calf muscular pump pressure produced by the contraction of muscles in the flexor calf compartment). The capillaries are distended with venous blood under abnormally high pressure. Chronic hypoxaemia occurs. The same offending pressure produces oedema, disruption of capillaries and extravasation of blood elements and exudation of inflammatory mediators. These mechanical, ischaemic and biochemical factors combine to cause chronic damages to the skin and subcutaneous tissues, ultimately result in ulcers that are recalcitrant to treatment. The whole symptom complex should best be called the Retrograde Ejection Venous Syndrome (2). Compression dressing using 40mm Hg of compression, works by increasing the subcutaneous interstitial pressure thus reducing oedema. By helping to empty the capillaries of congested hypoxaemic blood during calf muscle relaxation, some arteriolar blood can enter and helps to increase oxygenation. Healing of ulcers can be achieved in about 50%-79% of ulcers over 12 weeks (3) but 30% recurrent ulcers will occur with compression treatment alone within 5 years (4). The basis of surgical intervention lies in the total interruption of the calf perforator veins. By performing a properly done “Very Complete Fasciotomy (VCF)”(2), healing of all ulcers may be achieved with no recurrence on a median follow up of 10 years. Similar experiences are being collected in other centres (5, 6). Subfascial Endoscopic Perforator Surgery (SEPS), is another surgical option. It is not as universally applicable as VCF. Further, total interruption of all the calf perforators is difficult by this technique. The importance of such totality in interrupting the perforator veins, and cost effectiveness of surgical management, are increasingly being recognized (7). Due to technical difficulties, exclusion of cases with infected ulcers, severe oedema and extensive lipodermosclerosis is necessary for SEPS. According to the Mayo Clinic experience and others, among the applicable cases, the healing rate of about 88% may be attained (8, 9,10). Failed cases or exclusions can always be salvaged by VCF. In the Portuguese Surgical Society symposium on the treatment of chronic leg ulcers (Coimbra, Portugal, Nov. 15, 2004), where I delivered a lecture on the usage of VCF in the treatment of chronic leg ulcers caused by the Retrograde Ejection Venous Syndrome, there was consensus on the preference of surgical options. I hope that my letter may convince the authors, who while continuing to devote their valuable services to these chronic leg ulcer patients, will bring attention to the directors of regional health, or venous ulcers clinics, and the attending doctors, about the need to address the problem with a surgical solution. Only by abolishing the perforators, the patho- physiology may be averted, and a permanent cure may be achieved for the chronic leg ulcers. By doing so, you will truly be those patients’ advocates, and bring additional improvement to their ultimate management. Dr. Wah Ting WONG, General Surgeon (Retd.), Victoria, BC. References: 1. Laing W. Chronic venous diseases of the leg. Office of Health Economics, UK. 1992:25. 2. Wong WT. Surgical management of the Post-Phlebitic Leg Syndrome. Am. J Surg. Vol.165 May 1993. 613-17 3. Moffatt CJ, Simpson DA, Franks PJ, et al. Randomized trial comparing two four-layer bandage systems in the management of chronic leg ulceration. Phlebology 1999:14: 139-142 4. Rutherford RB Vascular Surgery, Philadelphia, WB Saunders, 1984 5. Mocho L, Gomes L, Barata AP, Cabrita D. Diagnosticl diferencial da Ulcera Cronica dos Menbros Inferiores. Nursing Junho (Portugal) 2002. No. 167 6. Cabrita D. Dept. of Surgery, Hospital dos Covoes, Coimbra, Portugal. (Personal communication 2004). 7. Iafrati MD, Harold J, O’Donnell T Jr. Subfascial Endoscopic Perforator Ligation: An Analysis of Early Clinical Outcomes and Cost. Paper presented at a meeting of the New England Society for Vascular Surgery, September 27, 1996. 8. Rhodes JM, Gloviczki P, Canton LG, et al. Factors affecting clinical outcome following endoscopic perforator vein ablation. Am J Surg. 1998, 176:162-7 9. Kalra. M., Gloviczki. P., Surgical treatment of varicose ulcers, role of subfascial endoscopic perforator vein ligation. Surgical Clinics of North America, WB Saunders, June 2003 83(3) 10. Almeida C. Treatment of chronic leg ulcers by SEPS. Video/lecture presented in the Symposium on treatment of chronic leg ulcers, Portuguese Surgical Society, Nov. 15, 2004. (Address: Hospital dos Covoes, Coimbra, Portugal.) Conflict of Interest:None declared |
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