Perioperative quality assessment of varicose vein surgery : Commission for quality assessment of the German Society for Vascular Surgery.

PURPOSE: An estimated 350,000 varicose vein (VV) surgical procedures are performed in Germany each year, with annual treatment costs amounting to about 800 million Euro. To evaluate the outcome quality of this treatment, we examined the intraoperative and postoperative complication rates on record in the VV surgery quality assessment (QA) registry of the German Society for Vascular Surgery (GSVS). METHODS: Data on 89,647 patients (27,463 men, 62,184 women; average age 52.8 years, range 15-96 years) collected in the GSVS varicose surgery QA registry between 2001 and 2009 were analyzed. In these patients, 95,214 surgical procedures were performed on 105,296 limbs. Complication rates were correlated with the type of VV surgical procedure, with whether surgery was performed on an inpatient or outpatient basis, and with the CEAP classification (C stage) and American Society of Anaesthesiologists' (ASA) stage at the time of surgery. Statistical analyses were performed using a chi-square test, a Cochrane-Armitage test, and an odds ratio calculation. RESULTS: Intraoperative and postoperative complication was low (0.18 and 0.43 %, respectively), being the lowest for radiofrequency ablation (0.25 %) but not differing significantly from those for endovenous laser therapy and high ligation and stripping. General complications occurred in 0.67 % of outpatients and in 0.25 % of inpatients, a highly significant statistical difference (p < 0.0001, chi-square test). With regard to C stage, the higher the stage, the higher the local complication rate. A clear correlation was also found between preoperative ASA stage and postoperative complication rates: for ASA stages I and II, the complication rates were 0.2 and 0.5 %, respectively, increasing for ASA stage III to 1.2 % and for ASA IV to 2.2 %. The differences between the ASA classes were highly statistically significant (p < 0.0001, Cochrane-Armitage test) CONCLUSIONS: Outcome quality as reflected in the intraoperative and postoperative complication rates was very good for all patients undergoing inpatient or outpatient VV surgery. Data from the GSVS QA registry shows that VV surgery is performed with very good perioperative results in specialized centers in Germany.

[Treatment of primary varicosis]. / Therapie der primären Varikosis.

While the treatment of varicose veins has remained unchanged over the past 100 years based on the three principles of compression, sclerotherapy, and classic varicose vein surgery, alternative approaches and advancements in treatment have developed in the last 10 years such as foam sclerotherapy, endovenous laser therapy, and radiofrequency obliteration. In contrast to classic varicose vein surgery, prospective, randomized, comparative studies are available with respect to the modern treatment procedures. They clearly show that endovenous thermal techniques are not inferior to the classic operation regarding the perioperative complication rate. There appears to be a tendency toward considerably fewer perioperative complaints with endovenous laser therapy and in particular with radiofrequency obliteration. Foam sclerotherapy represents a minimally invasive alternative that is markedly cost-effective. Even though the occlusion rate of the root veins after foam sclerotherapy is not as good as after endovenous therapy, the method is initially very effective. Especially in cases of recurrent varicose veins from the saphenofemoral or popliteal junction, foam sclerotherapy should be considered as the ideal method. All procedures significantly improve the patients' quality of life and the symptom complaints related to varicose veins. They are not in competition, but rather partially complement each other so that a combination of several approaches is quite judicious.

[Primary varicosis]. / Primäre Varikose.

The classic varicose vein operation still represents the "gold standard" in the operative therapy of varicose veins. The results of this procedure in view of perioperative complications are very good, with the incidence of perioperative deep venous thrombosis varying between 0.05% and 0.1%. Recurrence rates between 6% and 60% are published. However, the true recurrence rate is unknown since an exact definition of recurrent varicosis is still lacking. In recurrent varices it is essential to distinguish between disease progression, including neorevascularisation, and technical errors. Endovascular procedures for elimination of the superficial venous system - radiofrequency obliteration and endovenous laser therapy - meanwhile have established themselves as alternative, minimally invasive procedures. The perioperative complication rate of endovenous procedures is very low and comparable to that of the classic operation. Good results, with occlusion rates of the treated vein around 87% to 93% up to 2 years postoperatively, have been published for both endovenous laser therapy and radiofrequency obliteration. For the latter, 5-year results were published, with occlusion of the treated vein in 87%. Results in the literature for radiofrequency are better documented than for endovenous laser treatment because there are now five prospective randomised trials for the former and most publications for endovenous laser treatment are single-center experiences. The advantage of endovenous procedures, especially radiofrequency obliteration, over the classic operation is the lower rate of perioperative pain and better quality of life. The spectrum of operative treatment methods of the superficial venous system has increased tremendously due to new technical developments. For the surgeon this implies the necessity of informing patients conscientiously about the pros and cons and available results of each procedure, and carefully weighing which methods are at the time best for the patient.

[Diagnosis and treatment of varicose veins. Part 1: definition, epidemiology, etiology, classification, clinical aspects, diagnostic and indications]. / Diagnose und Therapie der primären Varikose. Teil 1: Definition, Epidemiologie, Ätiologie, Klassifikation, Klinik, Diagnostik und Indikationsstellung.

This is the first of two articles on the diagnosis and treatment of varicose veins. Primary varicosis is a congenital degenerative disease of the peripheral venous system of the lower extremities. The realisation factors are age, female sex and pregnancy. Degeneration of the peripheral veins leads to dilatation of the lumen and insufficient closure of the valves resulting in a backflow of blood from deep to the superficial venous system. This leads to ambulatory hypertension in the superficial venous system and recirculation of noteworthy amounts of venous drainage blood in the affected leg. Without treatment this results in the long term in variable degrees of decompensation of the recirculation pathways and an increasing (volume-induced) secondary insufficiency of the deep venous system. The result corresponds to the clinical symptoms of chronic venous insufficiency (CVI). When treatment is started early enough the pathological course can be reduced or avoided. The various therapeutic measures will be described in the second article of this series.

[Diagnosis and treatment of varicose veins: part 2: therapeutic procedures and results]. / Diagnose und Therapie der primären Varikose: Teil 2: Therapieverfahren und Ergebnisse.

This is the second of two articles on the diagnosis and treatment of varicose veins. Primary varicosis is a congenital degenerative disease of the peripheral venous system of the lower extremities. Treatment is carried out according to an individualized concept which takes the incurability and progression of the disease into consideration. Conservative treatment with compression bandages is an option for all forms of varicosis and the accompanying complications. Veins can be specifically ablated by sclerotherapy of varices. In addition to high ligation and stripping mini-phlebectomy and subfascial endoscopic perforator surgery (SEPS) can also be performed. The indications in cases of SEPS should be extremely limited because of possible severe complications. Radiofrequency ablation (RFO) and endovenous laser therapy (ELT) are also available as endovenous therapy options. Information in the literature on recurrence rates of the various procedures is extremely variable and the reasons for recurrent varicosis are the subject of controversy. The data relating to the results of RFO and ELT are relatively good and both procedures show a significant improvement in quality of life and the venous clinical severity score (VCSS).

[Current status of standard and endovascular varicosity surgery]. / Gegenwärtiger Stand der operativen und endovaskulären Varizenchirurgie.

The classical varicose vein operation represents the "gold standard" in the operative approach to this condition. The results of the standard procedure are very good especially with regard to complications. The recurrence rate is estimated between 6% and 60%, but the true rate is unknown, since there is no generally accepted definition of recurrent varicosities. Endovascular procedures for the elimination of the superficial venous system - radiofrequency obliteration and laser therapy - have established themselves as alternative, minimal invasive procedures. Good results up to 2 years post operatively have been documented; for radiofrequency obliteration, very good results 5 years after surgery are available. Less well-known procedures are available, such as the CHIVA method, which represents a totally different pathophysiological concept. Data on the efficacy of this method are limited, making an evaluation difficult. The spectrum of operative treatment methods of the superficial venous system and its side branches has increased tremendously because of new technical developments. The surgeon must inform the patient about the pros and cons of each procedure and the anticipated results, as well as making an accurate decision as to which methods are best suited for the patient.

[Ambulatory operation of varicose veins]. / Ambulante Operation bei Stammvarikose.

Over the past years out-patient operations of varicose veins have become increasingly accepted. In the year 1998 the number of patients treated for long saphenous vein varicosis on an outpatient-basis has risen to 66,922. For the individual risk assessment of the patient the ASA-classification is proven. ASA-class I and II patients may be considered for out-patient treatment. 98.2% of our patients that were operated upon 1995 on an outpatient-basis were classified as ASA I or II. Beside the risk assessment the extension of the disease should determine the indication for outpatient or inpatient treatment. During the year 1995 the majority of operations were performed for long or short saphenous vein varicosis (51.3% in the outpatient group, 61.9% in the inpatient group). But the percentage of isolated treatment of sidebranches and perforating veins was much higher in the outpatient group with 30% in comparison to the inpatient group with 3.4%. Under these conditions outpatient varicose vein surgery can be carried out with good result and a low complication-rate. In our outpatient group a deep vein thrombosis occurred in 0.03%, in other outpatient centers the incidence of deep vein thrombosis was reported with 0.08%. Wound infection was seen in 0.49%, a bleeding complication in 0.16% of the patients.

[Relaparotomy after appendicectomy in childhood (author's transl)]. / Die Problematik der re-laparotomien nach Appendektiomien im Kindesalter.

In 591 appendectomies a repeat laparotomy was necessary in 19 children (3.2%). 12 of these children had had perforated appendicitis. After a so-called "chronic appendicitis" we have never seen an indication for a second operation. The most important indications requiring relaparotomy were the post-operative ileus and the septic complications. We found intra-abdominal infections mainly after perforated appendicitis, the re-laparotomy was never carried out before the eighth post-operative day.