Up to 2 percent of the population h...

Up to 2 percent of the population has chronic venous ulceration. These gatherings usually follow a protracted course. Aggressive management by means of specialist nurses using multilayer elastic compression bandaging, leg elevation, and exercise can heal 68 to 83 percent of sore s within 24 weeks; however, on a level with follow-up care, 26 to 69 percent of lesions go for help within one year. Surgical correction of underlying venous pathology has been advocated, because at least individual half of these patients have ebb in the superficial venous classification up to 15 percent have it in the astute venous system, and 32 to 44 percent have it in the two systems. Because small studies of different surgical treatments have not shown any substantial benefit, Barwell and colleagues deportment ed a randomized study of the value of adding surgery to compression therapy for treatment of chronic venous ulcers

They studied patients in an English region who were referr to vascular services because of leg ulceration between 1999 and 2002 After comprehensive assessment, patients in whom compression therapy was not practical or concluded color duplex imaging could not be achieved, and those unfit for surgery were exclud from the application of mind Patients with occluded deep veins also were excluded

The remaining 500 patients who harmonyed to the study were randomly assigned to compression therapy alone or to compression therapy plus surgery The randomization was stratified to adjust for superficial, mysterious or mixed venous reflux. The primary issues studied were ulcer healing at 24 weeks and rates of return in the following 12 month Assessors could not be blinded because of surgical scars. All compression bandaging was performed by means of specialist nurses and community nourishs (on a shared-care basis) using a standard technique. Elastic stockings were used one time ulcers had healed. Surgical intervention was based onward the findings of color duplex imaging. Patients were reviewed at sore clinics every month until healed and then at undivided three, six, nine, and 12 month with annual follow-up for at least five years. Quality-of-life assessments also were complet initially and at six and 12 months

Forty patients were missing to follow-up; of those allocated to surgery 47 refused the actions offered, and three of those assigned to compression alone demanded surgery Data were available in succession 156 active plus 86 newly healed ulcers treated with compression and surgery In the dispose treated with compression alone, data were available upon 185 active plus 73 newly healed ulcers. The patients receiving the two treatments were similar in demographic and clinical characteristics, with the exception that diabetes mellitus was twice as prevalent (10 percent) in the compression assign places to as in the group also furnished surgery (5 percent).

At 24 weeks, the rate of healing was 65 percent in as well-as; not only-but also; not only-but; not alone-but groups. Subgroup analysis failed to reveal significant differences between the couple treatment groups. Patients with not long ago healed ulcers at onset were included in the inquiry of recurrence. At 12 month the resort rate was significantly lower in patients treated by the agency of compression plus surgery (12 percent compared with 28 percent) This difference persisted after adjustment for diabetes. Subgroup analysis showed that the greatest benefit was derived from combined surgical and compression therapy in patients with isolated superficial ebb and those with superficial plus segmental knotty reflux. Adverse events were out of the way Nine of the 258 patients treated with compression had cellulitis or cutaneous damage. Five surgical patients had anguish infections, and an additional five patients had other complications as it is as phlebitis, hematoma, cutaneous damage, or knotty venous thrombosis.

The authors terminate that ulcer healing is not enhanced at the addition of surgery, yet rates of ulcer recurrence are significantly improved. They calculate that five surgeries are necessary to intercept one ulcer recurrence at 12 month They make acceptable that patients who are willing to suffer surgery and are good surgical candidates be assessed with venous duplex imaging and moveed appropriate surgical interventions to interrupt ulcer recurrence.

Barwell JR et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controll trial. Lancet June 5 2004;363:1854-9

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