Role of Subfascial Endoscopic Perforator Surgery (SEPS) in Management of Perforator Incompetence in Varicose Veins : A Prospective Randomised Study

Abstract

The study was carried out to compare the efficacy of subfascial endoscopic perforator surgery (SEPS) and open subfascial ligation of perforators in varicose veins. This study was conducted on 100 patients of varicose veins from January 2006 to December 2010. Clinical scoring and color Doppler were performed in all the patients before surgery. Patients were divided into two groups: Group A and Group B alternately. Management of the perforators was done by subfascial endoscopic perforator surgery (SEPS) in Group A and by open subfascial ligation of perforators in Group B. Fifty patients were treated in each group. All the patients underwent ligation of incompetent saphenofemoral junction with stripping of long saphenous veins wherever the junction was incompetent with multiple ligation of superficial prominent veins. SEPS was done by two-port method without any tourniquet or balloon dissector. Total numbers of perforators ligated were 178 in Group A and 136 in Group B. Patients in both the groups got symptomatic relief of symptoms, but ulcer healing in 33 % patients in Group A was faster as compared to Group B. However, at 3 months of follow-up the ulcers healed in all the patients in both groups. Incidence of wound infection was higher in group B (16 %) as compared to group A (0 %). There were residual perforators in 8 % of patients on color Doppler at 3 months of follow-up in Group B while there was no residual incompetent perforator in Group A. Subfascial endoscopic perforator vein surgery is a safe and effective method for treating incompetent perforating veins. The number of perforators ligated in SEPS was more as compared to the open subfascial ligation group. Possibly some perforators may be missed on Doppler localization and missed ligation, which may be a cause of future recurrence in varicose veins. Early relief of symptoms in terms of ulcer healing was better in the SEPS group with less wound complication rate; however, all the ulcers healed in both the groups at 3 months of follow-up. Cosmetic results were equal in both the groups. Major advantage of SEPS was less incidence of wound complications and less incidence of residual incompetent perforators. Hence, SEPS should be added for the management of perforators along with conventional surgery in varicose veins.

Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan

“…Most clinical reports of SEPS were those of cases performed in the 20th century. Recent clinical reports were limited to the Netherlands, 10 Sweden, 11 India, 12 China, 13 Italy, 14 and Japan, 4,5 although endoscopic surgery has progressed remarkably in the 21st century. Favorable results of SEPS have been documented in reports from North America 2,15,16 and Europe.…”

Subfascial Endoscopic Perforator Surgery: A safe and novel minimal invasive procedure in treating varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence

“…[ 2 ] SEPS helps to visualise all the perforators which may be missed on Doppler or by other surgical methods. [ 3 ] Dividing them all minimises the risk of residual perforators and recurrence. It enables to improve visual control of perforator interruption.…”

“…SEPS causes early healing of leg ulcers, less wound complications. [ 3 ] SEPS creates a virtual space which avoids further damage to scarred tissue around ulcers reducing the risk of wound complications. [ 2 ] It eliminates the risk of permanent paraesthesia and nerve damage.…”

Leg Venous Ulcer Size Inversely Related to Number of Notable Perforating Veins: A Word of Caution

“…Evidence to ligate/obstruct perforating veins in patients with venous ulcers has been published for a variety of surgical or minimally invasive techniques. 7–34 There are, however, questions and critiques about (a) proper indications, (b) selection of perforating veins that should be excluded, and (c) contribution of perforating vein ligation in comparison to other treatments necessary for ulcer healing. 1,30–34…”

“…Superficial endoscopic perforating vein surgery, or SEPS, has been proposed as a minimally invasive procedure to ligate the veins under direct visualization, particularly in patients with ulcers. 10–15 Interest on subfascial endoscopic perforator surgery (SEPS) procedure, however, has decreased significantly. A pubmed.org search on “SEPS” showed a decrease in significant publications from around 10 per year in 1999–2003 to ≍4 per year from 2004 on.…”