Day-only admission for varicose vein surgery

Offene Varizenchirurgie – wann ambulant, wann stationär?

Hintergrund Die offene Varizenchirurgie kann sowohl in einem ambulanten als auch in einem stationären Setting durchgeführt werden. Aktuelle Leitlinien zur Therapie der Varikose nehmen zu der Frage, welche Patienten ambulant und welche stationäre zu operieren sind, nicht Stellung.

Fragestellung Erarbeitung von Kriterienkatalogen zur Frage einer ambulanten oder stationären Varizenoperation.

Material und Methode PubMed-Recherche zur Fragestellung und basierend auf den Literaturdaten Erarbeitung eines Delphi-Konsensus der Autoren.

Ergebnisse Zur Frage, ob eine Varizenchirurgie ambulant oder stationär durchgeführt werden kann, existieren lediglich 2 monozentrische retrospektive Analysen sowie eine Registerstudie. In diesen Studien werden ambulante Operationen im Wesentlichen bei Patienten mit Normalgewicht und ASA-Stadium 1 durchgeführt. Gut geeignete Lokalbefunde für eine ambulante Operation sind Primäreingriffe und ein geringeres C-Stadium der CEAP-Klassifikation. Für eine stationäre Varizenoperation sprechen ausgedehnte Befunde, bei denen mehr als eine Crosse saniert werden muss, Rezidiveingriffe in der Leiste oder der Kniekehle, vorangegangene thromboembolische Ereignisse, eine erhöhte Blutungsneigung aufgrund monströser Varizen oder einer Antikoagulation, Hautkomplikationen wie ein Ulcus cruris oder eine schwere Stauungsdermatitis bzw. Dermatosklerose sowie ein BMI über 30 bei Crossektomie.

Schlussfolgerungen Basierend auf Literaturdaten und Expertenmeinungen konnten Kriterienkataloge für eine ambulante versus stationäre offene Varizenchirurgie erarbeitet werden.

Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home

BACKGROUND

It is known that many patients encounter a variety of problems in the first weeks after they have been discharged from hospital to home. In recent years many projects have addressed discharge planning, with the aim of reducing problems after discharge. Telephone follow-up (TFU) is seen as a good means of exchanging information, providing health education and advice, managing symptoms, recognising complications early, giving reassurance and providing quality aftercare service. Some research has shown that telephone follow-up is feasible, and that patients appreciate such calls. However, at present it is not clear whether TFU is also effective in reducing postdischarge problems.

OBJECTIVES

To assess the effects of follow-up telephone calls in the first month post discharge, initiated by hospital-based health professionals, to patients discharged from hospital to home.

SEARCH STRATEGY

We searched the following databases from their start date to July 2003, without limits as to date of publication or language: the Cochrane Consumers and Communication Review Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, EMBASE (OVID), BiomedCentral, CINAHL, ERIC (OVID), INVERT (Dutch nursing literature index), LILACS, Picarta (Dutch library system), PsycINFO/PsycLIT (OVID), the Combined Social and Science Citation Index Expanded (SCI-E), SOCIOFILE. We searched for ongoing research in the following databases: National Research Register (http://www.update-software.com/nrr/); Controlled Clinical Trials (http://www.controlled-trials.com/); and Clinical Trials (http://clinicaltrials.gov/). We searched the reference lists of included studies and contacted researchers active in this area.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of TFU initiated by a hospital-based health professional, for patients discharged home from an acute hospital setting. The intervention was delivered within the first month after discharge; outcomes were measured within 3 months after discharge, and either the TFU was the only intervention, or its effect could be analysed separately.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and for methodological quality. The methodological quality of included studies was assessed using the criteria from the Cochrane Effective Practice and Organisation of Care Review Group. The data-extraction form was based on the template developed by the Cochrane Consumers and Communication Review Group. Data was extracted by one review author and checked by a second author. For as far it was considered that there was enough clinical homogeneity with regard to patient groups and measured outcomes, statistical pooling was planned using a random effects model and standardised mean differences for continuous scales and relative risks for dichotomous data, and tests for statistical heterogeneity were performed.

MAIN RESULTS

We included 33 studies involving 5110 patients. Predominantly, the studies were of low methodological quality. TFU has been applied in many patient groups. There is a large variety in the ways the TFU was performed (the health professionals who undertook the TFU, frequency, structure, duration, etc.). Many different outcomes have been measured, but only a few were measured across more than one study. Effects are not constant across studies, nor within patient groups. Due to methodological and clinical diversity, quantitative pooling could only be performed for a few outcomes. Of the eight meta-analyses in this review, five showed considerable statistical heterogeneity. Overall, there was inconclusive evidence about the effects of TFU.

AUTHORS' CONCLUSIONS

The low methodological quality of the included studies means that results must be considered with caution. No adverse effects were reported. Nevertheless, although some studies find that the intervention had favourable effects for some outcomes, overall the studies show clinically-equivalent results between TFU and control groups. In summary, we cannot conclude that TFU is an effective intervention.

Microfoam Ultrasound-Guided Sclerotherapy Treatment for Varicose Veins in a Subgroup with Diameters at the Junction of 10 mm or Greater Compared with a Subgroup of Less Than 10 mm

OBJECTIVE

The objective was to analyze the effectiveness of foam ultrasound-guided sclerotherapy treatment in saphenous veins and tributary veins with a diameter at the saphenofemoral or saphenopopliteal junction of > or =10 mm and compare these results with a subgroup of veins with diameters of < 10 mm.

METHODS

A subgroup of 17 saphenous veins with a diameter at the saphenofemoral or saphenopopliteal junction of > or =10 mm were compared with a subgroup of 98 saphenous veins with a diameter of < 10 mm at the saphenofemoral or saphenopopliteal junction for clinical efficacy and patient satisfaction at a mean 2-year follow-up.

RESULTS

A mean number of 2.15 treatments utilizing an average of 8.37 mL of foam sclerosing solution (3% sodium tetradecyl sulfate) were required to close all incompetent varicose veins in the < 10-mm group versus a mean of 2.8 treatments and 13.9 mL foam (3% sodium tetradecyl sulfate) for the > or =10-mm group. A total of 27.5% of saphenous veins of < 10 mm and 37.5% of saphenous veins > or = 10 mm required a second treatment at 3 months. One-hundred percent of patients believed that their legs were successfully treated at 2-year follow-up in both groups with 94% of the < 10-mm group noting improvements in quality of life and 100% in the > or =10-mm group.

CONCLUSIONS

Ultrasound-guided foam sclerotherapy is effective in treating all sizes of varicose veins with high patient satisfaction and improvement in quality of life. Duplex ultrasound findings demonstrated a small increase in failure to close the saphenofemoral or saphenopopliteal junction with increasing size of junction diameter, but this does not significantly alter the results with respect to clearance of visible varicosities and patient satisfaction with results.

Surgery versus sclerotherapy for the treatment of varicose veins

BACKGROUND

Varicose veins are a relatively common condition and account for around 54,000 in-patient hospital episodes per year. The two most common interventions for varicose veins are surgery and sclerotherapy. However, there is little comparative data regarding their effectiveness.

OBJECTIVES

To identify whether the use of surgery or sclerotherapy should be recommended for the management of primary varicose veins.

SEARCH STRATEGY

Thirteen electronic bibliographic databases were searched covering biomedical, science, social science, health economic and grey literature (including current research). In addition, the reference lists of relevant articles were checked and various health services research-related resources were consulted via the internet. These included health economics and HTA organisations, guideline producing agencies, generic research and trials registers, and specialist sites.

SELECTION CRITERIA

All studies that were described as randomised controlled trials comparing surgery with sclerotherapy for the treatment of primary varicose veins were identified.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted and summarised data from the eligible studies using a data extraction sheet for consistency. All studies were cross-checked independently by the reviewers.

MAIN RESULTS

A total of 2306 references were found from our searches, 61 of which were identified as potential trials comparing surgery and sclerotherapy. However, only nine randomised trials, described in a total of 14 separate papers, fulfilled the inclusion criteria. Fifty trials were excluded and one trial is ongoing and is due for completion in 2004. The trials used a variety of outcome measures and classification systems which made direct comparison between trials difficult. However, the trend was for sclerotherapy to be evaluated as significantly better than surgery at one year; after one year (sclerotherapy resulted in worse outcomes) the benefits with sclerotherapy were less, and by three to five years surgery had better outcomes. The data on cost-effectiveness was not adequately reported.

REVIEWERS' CONCLUSIONS

There was insufficient evidence to preferentially recommend the use of sclerotherapy or surgery. There needs to be more research that specifically examines both costs and outcomes for surgery and sclerotherapy.

Early Experience with Radiofrequency Ablation of the Greater Saphenous Vein

Radiofrequency ablation of the greater saphenous vein (GSV) has been proposed as an alternative to conventional ligation and stripping in the treatment of varicose veins. We have reviewed our initial experience with this new technology in 28 procedures on 24 patients. Preoperative duplex scans confirmed venous valvular incompetence of the GSV in all patients. Intraoperative ultrasound was used to measure the depth of the GSV, to precisely place the radiofrequency catheter adjacent to the saphenofemoral junction, and to confirm the results of the ablative procedure. Occlusion of the GSV was seen on 96% of completion scans and in all patients within 1 week of the procedure. Duplex scans were available for 21 limbs at 3 months and for 3 at 1 year. Persistent occlusion was documented in all cases. No patient had paresthesias or thermal skin injury. Two patients had transient superficial thrombophlebitis around the knee in a treated segment of the GSV. One patient was found to have extension of an asymptomatic, nonocclusive thrombus into the common femoral vein on a routine scan 3 days after surgery. Postoperative patient questionnaires showed that 96% of respondents were very satisfied with the procedure. Radiofrequency ablation of the GSV appears to be a safe alternative to conventional stripping and ligation. Subjective assessment by the surgeons suggests an earlier return to work and active lifestyle compared to traditional extirpative techniques. Longer follow-up is required to establish the durability of the procedure.