Surgery for venous leg ulcers
Authors: Charles N McCollum
Journal: BMJ (2007)

Venous leg ulcers are painful, malodorous sores that impair quality of life and are difficult to treat.1 An estimated 5-8% of the world's population have venous disease, and 1% have venous ulcers at some time in their life.2 The cost to healthcare services is best known for the United Kingdom, where active ulcers affect 1.7% of the elderly population, at a cost to the NHS of around £600m (€890m; $1200m) a year.3 4 Available evidence suggests costs are high throughout Europe, the United States, and Australia. These ulcers are caused by sustained high venous pressures due to venous disease, obesity, immobility associated with arthritis, or even old age itself.

Compression using four layer bandaging is the mainstay of treatment—it completely heals ulcers in a mean of 7-8 weeks when delivered by trained leg ulcer nurses in the community.5 6 The efficacy of four layer bandaging is not influenced by the underlying venous abnormality.7 Whether novel “biologically active” dressings can improve these healing rates remains uncertain, as does the role of venous surgery. 

In this week's BMJ Gohel and colleagues report the long term results from the ESCHAR trial, which compared compression alone with compression plus superficial venous surgery in patients with open or recently healed leg ulcers and superficial venous incompetence.8 This trial was adequately powered and reported on ulcer healing, ulcer recurrence, and ulcer-free time over three or four years. Most previous trials either ignored the role of compression therapy or compared surgery with compression, which is inappropriate as both are effective treatments that should be complementary.5 6 8

ESCHAR clarifies the role of superficial venous surgery in people willing or able to have an operation.8 The trial found no significant difference between compression alone and compression plus surgery on ulcer healing at three years—but recurrence, which otherwise happens in a quarter of patients each year, was almost halved. This beneficial effect was most obvious in patients who have incompetence affecting only the superficial veins or those with “segmental” deep venous incompetence, in which reflux is found in limited segments of the deep veins without widespread valve failure. The authors' use of “isolated superficial” where the deep veins are normal, “segmental deep,” and “total deep” incompetence is unfortunate as most “segmental deep” incompetence is reflux within the common femoral or popliteal vein emptying into the incompetent long or short saphenous vein; valve failure is largely confined to the superficial veins.9

The finding of reduced ulcer recurrence after superficial vein surgery in patients with “total deep” incompetence is surprising as valve failure causes widespread deep venous reflux in such patients. However, early results from the ESCHAR study showed that ablating incompetent superficial veins improves deep venous function.10 This does not mean that all patients with combined superficial and deep incompetence would benefit from superficial surgery.9 Preoperative assessment in ESHCAR was by duplex imaging, which describes the anatomy of venous disease but not the function. Ambulatory venous pressures would be a more reliable measure of venous function, with a narrow tourniquet obstructing the superficial veins.9 Many surgeons do not use ambulatory venous pressure measurement because it requires cannulation of the foot, even though it is the only direct measure of venous pressures.

The encouraging results of surgery on ulcer recurrence rates in the ESCHAR trial will sadly have little influence on overall ulcer prevalence. Patients were recruited from specialist, hospital based leg ulcer clinics, whereas many elderly people in the community refuse to attend hospitals for either venous investigations or surgery.6 11 Even among the hospital clinic patients screened for ESCHAR, over a third refused to be randomised and a further 20% refused surgery despite consenting to the study.8 In the community, our experience is that less than half the patients would attend for investigation, and perhaps a third would consider surgery, simple pinch skin grafting being an exception as it can be done in the community by specialist nurses, under local anaesthetic, and speeds the healing of large ulcers.12

What does this mean for general practitioners looking after people with leg ulcers? Firstly, people should be referred to a specialist leg ulcer service for investigation of arterial disease before four layer bandaging, if appropriate. These services should include a local vascular surgeon to manage arterial disease and arrange venous investigations in people being considered for surgery or, in the future, microfoam sclerotherapy or endovenous laser treatment. Referral to a vascular surgeon does not need to be delayed until the ulcer has healed, and nor should a history of deep vein thrombosis be a deterrent since it is found in only 10% of people with leg ulcers, and in a third of those with deep venous incompetence.6 Superficial venous incompetence, the usual cause of varicose veins, can be detected in most patients with venous ulcers and is a potentially correctible cause of venous hypertension.8 Neither ESCHAR nor a previous study found that superficial venous surgery accelerates healing.8 13 However, there is no need to delay venous surgery where appropriate for uninfected leg ulcers.

Future research should focus on identifying patients at risk of ulceration in order to prevent rather than treat. Superficial venous surgery and compression will almost certainly both have a role in ulcer prophylaxis.