M.S. Gohel

Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial

Objective To determine whether recurrence of leg ulcers may be prevented by surgical correction of superficial venous reflux in addition to compression. Design Randomised controlled trial. Setting Specialist nurse led leg ulcer clinics in three UK vascular centres. Participants 500 patients (500 legs) with open or recently healed leg ulcers and superficial venous reflux. Interventions Compression alone or compression plus saphenous surgery. Main outcome measures Primary outcomes were ulcer healing and ulcer recurrence. The secondary outcome was ulcer free time. Results Ulcer healing rates at three years were 89% for the compression group and 93% for the compression plus surgery group (P=0.73, log rank test). Rates of ulcer recurrence at four years were 56% for the compression group and 31% for the compression plus surgery group (P<0.01). For patients with isolated superficial reflux, recurrence rates at four years were 51% for the compression group and 27% for the compress plus surgery group (P<0.01). For patients who had superficial with segmental deep reflux, recurrence rates at three years were 52% for the compression group and 24% for the compression plus surgery group (P=0.04). For patients with superficial and total deep reflux, recurrence rates at three years were 46% for the compression group and 32% for the compression plus surgery group (P=0.33). Patients in the compression plus surgery group experienced a greater proportion of ulcer free time after three years compared with patients in the compression group (78% v 71%; P=0.007, Mann-Whitney U test). Conclusion Surgical correction of superficial venous reflux in addition to compression bandaging does not improve ulcer healing but reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time. Trial registration Current Controlled Trials ISRCTN07549334.

Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)—haemodynamic and anatomical changes

The aim of this study was to evaluate the anatomical and haemodynamic effects of superficial venous surgery and compression on legs with chronic venous ulceration.

The relationship between cytokine concentrations and wound healing in chronic venous ulceration

OBJECTIVE The importance of wound cytokine function in chronic venous leg ulcers remains poorly understood. This study evaluated the relationship between local and systemic concentrations of wound cytokines and wound healing in patients with chronic venous ulceration. METHODS This prospective observational study was set in a community- and hospital-based leg ulcer clinic. Consecutive patients with chronic leg ulceration and ankle-brachial pressure index >0.85 were prospectively investigated. All patients were treated with multilayer compression bandaging. Wound fluid and venous blood samples were collected at recruitment and 5 weeks later. In the wound fluid and venous blood, cytokines and factors reflecting the processes of inflammation (interleukin 1beta, tumor necrosis factor-alpha), proteolysis (matrix metalloproteinases-2 and -9), angiogenesis (basic fibroblast growth factor [bFGF], vascular endothelial growth factor), and fibrosis (transforming growth factor-beta(1) [TGFbeta(1)]) were measured. Ulcer healing was assessed using digital planimetry at both assessments. RESULTS The study comprised 80 patients (43 men, 37 women). Median (range) ulcer size reduced from 4.4 (0.1-142.4) cm(2) to 2.2 (0-135.5) cm(2) after 5 weeks (P < .001; Wilcoxon signed rank), although 17 of 80 ulcers increased in size. The volume of wound fluid collected strongly correlated with ulcer size (Spearman rank = 0.801, P < .01). Initial wound fluid concentrations of bFGF correlated with ulcer size (Pearson coefficient = 0.641, P < .01), and changes in wound fluid TGFbeta(1) concentrations inversely correlated with changes in ulcer size (Spearman rank = -0.645, P = .032). There were no significant correlations between changes in other factors and ulcer healing. Wound fluid and serum cytokine concentrations correlated poorly. CONCLUSION Wound fluid collection volume correlates with ulcer size. Ulcer healing correlated with increased concentrations of TGFbeta(1), possibly reflecting increased fibrogenesis in the proliferating wound. Aside from this, there was a large variation in wound and serum cytokine levels that largely limits their usefulness as markers of healing.

The Ulcerated Leg Severity Assessment score for prediction of venous leg ulcer healing

The aim of the study was to create a reliable scoring system for the prediction of venous ulcer healing in patients treated with compression.

Significance of limb trauma as an initiating factor in chronic leg ulceration

Abstract Objectives To assess differences in clinical outcomes between patients with traumatic and spontaneous leg ulcers. Methods Consecutive leg ulcer follow-up patients seen between April 2004 and October 2005 in a specialist leg ulcer clinic were asked about the mechanism of the original ulceration. Twenty-four-week healing and 12-month recurrence rates were calculated using Kaplan-Meier analysis and outcomes were compared between groups with traumatic and spontaneous ulcers. Results Of the 300 patients assessed, 38 were excluded (incomplete data). In the remaining 262 patients, cause of ulceration was traumatic in 116/262 (44%) and spontaneous in 146/262 (56%). Age, ankle brachial pressure index <0.85 and venous reflux were equally distributed between groups with traumatic and spontaneous ulcers (P = 0.470, 0.793, 0.965 respectively, Chi-square test). Twenty-four-week healing rates were 81% for traumatic and 67% for spontaneous ulcers (P = 0.015, Log-Rank test). Twelve-month recurrence rates were 32% for traumatic and 33% for spontaneous ulcers (P = 0.970, Log-rank test). Patients with traumatic ulcers suffered a total of 53 ulcer recurrences (median 0, range 0–4) compared with 89 in patients with spontaneous ulcers (median 0, range 0–8) (P < 0.001, Mann-Whitney U test). Conclusion Approximately half of all leg ulcer patients recall a traumatic event. When managed in leg ulcer clinic, traumatic ulcers heal faster and recur less frequently than spontaneous ulcers.

RESULTS COMPARING COMPRESSION ALONE VERSUS COMPRESSION AND SURGERY IN TREATING VENOUS ULCERATION

Publisher Summary This chapter discusses the results comparing compression alone versus compression and surgery in treating venous ulceration. Chronic venous ulceration is widely accepted as a common, debilitating, and expensive health problem. Although most patients have superficial venous incompetence potentially amenable to surgical correction, evidence to support operative intervention has been scarce. Other researches strongly suggest that superficial venous surgery reduces venous ulcer recurrence and should be considered for all patients with chronic venous ulceration. Patients deemed suitable for surgical treatment should undergo color duplex venous mapping in order to identify superficial venous incompetence potentially suitable for surgical correction. Although the advantage appears greatest for legs with isolated superficial reflux, surgery may also reduce ulcer recurrence for some patients with deep venous incompetence, and hemodynamic assessment may be a useful selection tool. Despite any proven clinical benefit, it must be acknowledged that elderly patients with leg ulcers may be unfit for surgical intervention or unwilling to accept it. Local anesthetic surgery was performed in a quarter of patients, but long-term effectiveness is unlikely to match general anesthetic procedures. Residual venous reflux after venous surgery was common, although this was not associated with reduced hemodynamic function or clinical outcomes.