In group A, there was no incidence of haematoma, ecchymosis and pigmentation but there was mild wound infection at the incision site in the groin in 4 patients (8%), which healed with local dressings. There was no incidence of paraesthesia after surgery in any patient. In group B there was ecchymosis and pigmentation at the mid-thigh region in 6 patients (12%), which appeared around the 4 ^th post operative day, decreased at 3 weeks and disappeared completely at 3 months. There was mild wound infection in two cases (4%) in the groin which was relieved after local dressings. There was no incidence of paraesthesia after surgery in any patient.

On colour Doppler study, saphenofemoral junction reflux was observed in one patient (2%) in group A at 6 months follow-up and no reflux was observed in group-B patients at 3 months and 6 months follow-up. The deep venous system was normal in both groups.

Cosmetically, there was no visible vein and telangiectasia in both group A and group B patients at 3-month and 6-month follow-up. The cosmetic result was excellent in both groups

The maximum number of patients in our study was in the age group of 16-35 years (64%). This age group requires maximum long standing activities for earning for their families. The mean age in our study was 31 years. In literature, the age distribution of varicose veins in most of the studies varied from 30-40 years⁶. But a few studies have reported a variable age of presentation. The reported mean age is 70.4 years by Pierik et al.¹⁵, 51 years by Antoch et al.⁶, 45 years by Chan et al.¹⁶ and 48.7 years by Kam et al.¹⁷

In the present study there were 78% males and 22% females. But according to the literature, females are affected twice more common as compared to males^2-4,18. The predominance of males in our study may be due to male-dominant society; more males turned up for the treatment. Females being either less health conscious or being neglected by the families in rural India reported less for treatment. The Basle Survey has also reported a male to female preponderance¹⁹.

In our study, the left side was more commonly involved (42%) than the right side (38%) and bilateral involvement was observed in 20% of cases. In the series of Killewich et al., the left side was involved in 47%, the right side in 31%, and 22% had bilateral involvement³.

Figure 2

TABLE-2 PRESENTING COMPLAINTS IN VARIOUS CLINICAL TRIALS

In the present study, 90% of patients complained of dilated and tortuous veins followed by pain during walking (78%), ankle swelling (60%) and ulceration and pigmentation in 26% of patients. In his trial of 516 patients, Jakobsen¹³ reported dilated veins in 79%, pain in 50%, oedema in 42% and ulcer in 2.5% of cases. In a group of 350 patients who underwent varicose vein surgery at the Mayo clinic, Lofgren²⁰ reported pain in leg in 71%, swelling in 60%, dilated veins in 25%, pigmentation in 16% and ulcer in 8% of cases. Munn¹⁴ gave a very brief description of preoperative features of 57 patients involved in his trial; where ulceration was found in 8% and pigmentation in 22% of cases. In a study of 114 patients, Frank²¹ found swelling in 21% and pain in 45% of patients. In his trial of 156 limbs, Kam¹⁷ et al. found dilated veins in 98%, pain in 56%, swelling in 12% and ulcer in 17% of patients. In all studies including the present study, dilated and prominent veins were the commonest presenting symptom while other symptoms were present in variable percentage in different studies depending on the stage of disease (Table 2).

The overwhelming majority of operations were performed for symptomatic disease. Patients presenting with dilated veins as a main complaint were completely relieved of varicosities on the 14 ^th postoperative day at the time of suture removal irrespective of the procedure done on them. In the study done by Kam et al., 153 of 156 limbs presented with dilated veins. Out of 153 limbs, 121 had saphenofemoral vein reflux on Doppler scans. There were five limbs (3 patients) with unresolved varicosities at 6 months postoperatively¹⁷. Thus, patients presenting with dilated veins had a 96%-chance of being free of dilated veins after stripping of the long saphenous vein and multiple ligations (116/121)¹⁷. In contrast to this, there was 100% improvement in variosities after stripping of the long saphenous vein, multiple ligations of perforators and avulsion of varicosities (25/25) in the present study. Similar results were obtained by high ligation without long saphenous vein stripping with multiple ligation of perforators and avulsion of varicosities (25/25). Thus, cosmetic results of long saphenous vein stripping were excellent in our study (100%) as compared to the study by Kam et al. where it was 96%. Kam et al. did not investigate the outcome of long saphenous vein stripping on ulcer healing and eczema, etc., whereas in our study it was observed that ulcer healing was quicker after above-knee long saphenous vein stripping in comparison to high ligation without stripping. But there was no improvement in pigmentation in the leg even at 6 months of follow-up in both groups.

In the study done by Sarin et al., with long saphenous vein stripping in addition to saphenofemoral junction ligation there was significantly greater improvement in the patients’ subjective sensation of ‘ache’. Itching was reduced in both groups and there was no significant difference between them in this respect²². In the present study also there was no significant difference in both the groups of patients in relation to pain during walking.

Figure 3

TABLE-3 COMPARISON OF COMPLICATIONS

Sarin et al. reported paraesthesia in 7% of patients in the group with high ligation without stripping while it was 4% with high ligation with stripping. But in the present study we did not find any evidence of paraesthesia in both groups. The possible reason may be that veins were properly separated from surrounding tissues before ligation in the present study to avoid any incidental ligation of nerves along with veins. Wound infection was observed in 2% cases in both groups by Sarin et al. while it was slightly higher (8%) in group A and 4% in group B in the present study, possibly because of seroma formation which got infected.

There was redness and ecchymosis at the site of stripping in 6 patients (12%) in the group with above-knee long saphenous vein stripping in the present study. However, this ecchymosis and redness disappeared at 3 months of follow-up. No such complication was observed in the group where high ligation of saphenofemoral junction alone was done. Haematoma was not observed in any group in the present study as well as in the study of Sarin et al. Kam et al. studied the complications in patients of long saphenous vein stripping only. Wound infection was observed in 5.8%, bruising in 6.4% and paraesthesia in 3.2% cases¹⁷ (Table 3).

Figure 4

TABLE-4 COMPARISON OF RESULTS WITH LITERATURE

(SGP = Strain gauge plethysmography, LSV= Long saphenous vein)

Jackobsen reported a 10.2% recurrence rate in the group where high ligation with stripping was done as compared to a 34% recurrence rate in cases where only high ligation of the saphenofemoral junction was done¹³. This study was done only on clinical basis. Munn et al. reported paraesthesia in 33% and recurrence rate in 36% of cases when LSV stripping was done while in the high-ligation group paraesthesia was observed in 14% of cases and recurrence in 60%¹⁴. This study was also done only on clinical basis. Hammarsten et al. demonstrated a recurrence rate of 12% after stripping and an 11% recurrence rate after high ligation only. This study was based on clinical basis and findings on strain gauge plethysmography²³. Sarin et al. showed paraesthesia in 7% and recurrence in 45% of cases after high ligation without LSV stripping and paraesthesia in 2% and recurrence in 18% after high ligation with long saphenous vein stripping²². This study was based on clinical basis and colour Doppler examination. In our study, residual reflux at saphenofemoral junction on color doppler examination was observed in 2% of cases after high ligation without LSV stripping. There was no saphenofemoral junction reflux after above-knee long saphenous vein stripping. Paraesthesia was not observed in any patient in both groups (Table 4). Recurrence rate was higher in high ligation of saphenofemoral junction without stripping as reported by most of the studies in the literature. So the authors recommend high ligation of the saphenofemoral junction with long saphenous vein stripping from groin to knee along with perforator ligation and multiple avulsion of variosities to decrease recurrence rate in varicose veins.