Assessment of causes and patterns of recurrent varicose veins after surgery in Suez Canal

University hospital

Dr.Mohammed Adel Gad Al-rabAssistant Prof. of general Surgery

Faculty of MedicineSuez Canal University

Faculty of Medicine Suez Canal University

2009

Introduction and rationale

Varicose veins are common surgical problem, the prevalence has

been variously reported from as little as 2% to over 60% in population

studies. (Perrin, et al, 2000(

The Edinburgh venous association published in 1998 study which

examined over 1500 adults and given the best current data on the

prevalence of varicose veins in UK, in this study 39.7 % of women and

32.2% of men had dilated tortuous veins. It is generally accepted that

primary varicose veins are caused by failure of the valves, secondary

varicose vein has a different pathogenesis, the most common of which is

deep venous thrombosis. ( Fischer, et al, 2001)

There are many complications following varicose veins surgery, as

damage to major venous, nervous and arterial structure but there is also

another famous complication which is the recurrence of varicose vein after

surgery. (Kostas ,et al , 2004)

Varicose vein surgery is characterized by a very high recurrence

rate of 20% to 60% after 5 years and even higher after longer periods

of follow-up observation, and this is a disappointing finding, both

for the patient and surgeon, some causes of recurrence are obvious as

insufficient insight into anatomy and hemodynamics of the superficial

venous system. (Bridget, 2006)

Recurrence has also been attributed to neovascularization ; a

phenomenon of forming new channels between the ligated stump of great

saphenous vein on the common femoral vein, or stump of short saphenous

vein on the popliteal vein and the residual main trunk of its tributaries, post

operative neovasculerization in the granulation tissue around the ligated

stump appears to be an important cause of recurrence of varicose vein,

even after correct performed surgery.) Geier, et al, 2005)

Already in the 19th century, surgeons noticed that the new vein

channels could form after ligation or extirpation of a piece of vein; this

could be responsible for recurrence after surgery.

The majority of authors in 20th century claimed that recurrence was

due to the development of incompetence in pre-existing collateral, which

had not been adequately ligated by the previous surgeon.(Creton, 2002)

Attention to technical details will decrease the regrettably high rate

of recurrence after sapheno-femoral disconnection and render safer

exploration. Early post surgical recurrence results from an incomplete

operation, late recurrence is known to occur after correct surgery but with

deterioration of the remaining superficial venous system or in case of

inappropriate surgery leaving communicating veins between superficial

&deep venous system, which have involved silently, or even recurrence

following incomplete surgery because of unrecognized anatomical

variation as double saphenous.

This distinction is merely theoretical, duplex scan shows that

incomplete removal of varicose veins remains the main cause of recurrence

. The aim of sonographic investigation is to identify the main factors,

more than the cause, before surgery assessment which could serve as a

reference being rarely available. In practice, certain technical or tactical

errors could surely be identified in the course of treatment. (Knighton, et

al, 2002)

Sonographic tests enable dynamic mapping of recurrence and allow

better choice of further treatment, surgery, sclerotherapy or various

combined technique. Ideally this mapping should be followed by skin

marking when further surgery is necessary to avoid more incomplete

treatment. (Knighton, et al, 2002)

-

Aim of the work

To identify the possible causes and patterns of recurrent varicose veins in

patients with history of varicose veins surgery.

Patients and methods

Type of Study

This study is a descriptive prospective study on patients with history

of previous varicose veins surgery, to assess the possible causes of

recurrent varicose veins after surgery.

Study locations

Out patient clinic in Suez Canal University hospital in Ismailia.

Inclusion criteria

1-All patients with recurrent varicose veins with history of previous

varicose veins surgery at the same limb.

2-All age.

3-Both genders.

Exclusion criteria

1-missed patients during follow-up.

Methods

Ninety two patients with recurrent varicose veins after surgery were

enrolled in this study, then a history, examination and investigations

were performed for them as follows :-

History:

-History of venous insufficiency (eg, date of onset of visible abnormal

vessels after previous varicose veins surgery, date of onset of any

symptoms).

-History of presence or absence of predisposing factors (eg, hereditary,

trauma to the legs, occupational as prolonged standing).

-History of superficial or deep venous thrombophelbitis ( date of onset,

site, predisposing factors, sequels).

-History of other vascular disease (eg, peripheral arterial diseases,

lymphdema and lymphangitis.

-History of venous diseases ( eg,medications, injections and

compression.

-Family history of any vascular diseases of any type.

-The time of previous operation.

B) Examination:

1-General examination.

Which include, patient general condition, presence of other weak

mesenchymal syndrome as hernia or flat foot, also abdominal and

pelvic examination to exclude any problems as tumors which may lead

to varicose veins as secondary cause.

2-Local examination:

The physical examination of venous system is difficult because most of

deep venous system can't be directly inspected, palpation, ausculted or

percussed. In most areas of the body, examination of superficial venous

system must serve an indirect guide to the deep system.

Veins and their connections gradually became better defined through

inspection, palpation and percussion.

Inspection

Was performed in an organized manner, usually progressing from

distal to proximal and form front to back. The perineal region, pubic

region, and abdominal wall also must be inspected. Inspection may

revealed such findings as cutenous ulceration, telangectasia, eczema,

brown spots, dermatitis, prominent varicose veins, scar from prior

surgical operation or evidence of sclerosant injections.

Visible distension of superficial veins in other regions of leg usually

implies disease, while translucent skin may allow normal veins to be

visible as bluish sub dermal reticular pattern but dilated veins above the

ankle are usually evidence of venous pathology.

Palpation

It was important part of venous examination, the surface of the skin

was palpated lightly with finger tips because dilated tortuous veins may

be palpable even where they are not visible.

It started over the antromedial surface of the lower limb along the

course of the long saphenous vein, palpation then proceeded to the

lateral surface then the posterior surface is palpated along the course of

the short saphenous vein, the location, size, shape and the course of all

varicosities are noted, and the diameter of the largest vessels is

measured as accurately as possible.

Palpation of painful area on the leg or presence of tenderness may

reveal a firm, thickened thrombosed veins are superficial veins, but as

associated with deep venous thrombosis may occur.

c) Investigations

1-Duplex Ultra Sound was made over the superficial and deep venous

system of patients of this study.

Data collection

Sample was taken as all patients with recurrent varicose veins after

previous varicose veins surgery in outpatient clinic in Suez Canal

University hospital.

Statistical Analysis

Data entry and analysis will be accomplished using windows

operating system and the based statistics program (SPSS 10.0) adopting in

the outcome the following statistical tests:

* Continuous variables are expressed as means and standard deviation

(SD)

* Discrete variables are expressed as frequencies and percentages

* Differences will be statistically significant if probability (p value ≤

0.05) it will be calculated using epi-info statistical package 11.0

program

Presentation of the statistical outcome in form of tabulation and

graphs will be accomplished by windows based Microsoft Excel.

Ethical consideration

- Confidentiality of all data and tests results of all study population.

- Written consents were obtained from all patients before getting them

involved in this study.

- The steps of the study; the aims and the potential benefits were

discussed with each individual patient.

- Patient will be informed about any abnormal results of the

procedures and tests performed and will be instructed and treated

accordingly.

- The patient had the right for withdrawal from the study at any time

with neither jeopardizing the right of the patients to be treated nor

affecting the relationship between the patient and the care provider.

RESULTS

This study is a descriptive prospective study done over 36 months

from December 2006 to November 2009 including 92 patients, all of them

have recurrent varicose veins after surgery .

This study aimed to assess the different causes of recurrent

varicose veins after surgery, all these patients are presented to our

outpatient clinic in Suez Canal University Hospital .

60 out of 92 patients were females (65.2%) and 32 patients were

males (34.8%), table 1,graph1.

Their age ranged from 20 to 56 years old with mean age 36.5+ 9.4 and

the higher frequency of recurrence was between 50-56 years, table 2,graph2.

30 (32.6%) out of 92 patients had varicose veins operated on with

saphenofemoral disconnection (Trendelnberg operation) ,22 patients (23.9%)

with Saphenofemoral disconnection ,with stripping below knee , 28 patients

(30.4%) with Saphenofemoral disconnection with stripping above knee and

only 12 patients (13.1%) with Saphenopopliteal disconnection with stripping ,

table 3.

Table (1 )

Shows sex distribution in the study group:

Sex No. PercentMale 32 34.8%

Female 60 65.2%Total 92 100 %

Results are statistically significant as P value is less than 0.05

Sex distribution

34.80%

65.20%

Male

Female

Graph No. 1 shows distribution of the patients according to their sex

Table 2

Shows age distribution in the study group:

Age groups No. Percent20-29 8 8.7%30-39 24 26.1%40-49 28 30.4%50-56* 32 34.8%Total 92 100%

Mean age 36.5+ 9.4

*Results are statistically significant as P value is less than 0.05

Age distribution

8.70%

26.10%30.40%

34.80%

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%

20-29 30-39 40-49 more than50

The age groups

Th

e p

erce

nt

Graph No. 2 shows distribution of the patients according to their age

Table (3)

Shows the distribution of the patients of the study group regarding the operations which performed for them before recurrence:-

The operation before recurrence No. PercentSaphenofemoral disconnection

without stripping (Trendlenberg operation)

30 32.6%

Saphenofemoral disconnection with stripping below knee

22 23.9%

Saphenofemoral disconnection with stripping above knee

28 30.4%

Saphenopopliteal disconnection with stripping

12 13.1%

Total 92 100%

There are different findings in cases of recurrent varicose veins after

surgery in our study as there are 14 patients (15.2%) have double

saphenous, 2 patient (2.1%) has double short saphenous, 24 patients (26%)

have recurrence due to neovascularizations, 34 patients (36.9%) have deep

venous thrombosis before and after surgery and 18 patients (19.8%) have

incompetent surgery through the wrong site of incision or the performance

of non specialized surgeon in the field, table 4

The post-operative recurrence duration is noted as complaints from,

4 patients (4.3%) within 2 years , 12patients (13%) from 2-5 years, 32

patients (34.8%) from 6-10 years and 44 patients (47.8%) after 10 years,

table 5.

The patients were classified regarding their jobs as 28 patients

(30.4%) housewives, 32 patients (34.8%) teachers, 20 patients (9.3%)

workers, 4 patients (4.3%) officers and 8 patients (8.7%) employees, graph

3,table 6.

There are different patterns of recurrence in our study as 4 patients

(4..3%) with inguinal pattern , 20 patients (21.7%) with thigh pattern , 8

patients (8.7%) with the pattern of popliteal fossa , 28 patients (42.3%)

with the leg and 22 patients (23%) in both leg and thigh, table 7.

Table (4)

Shows the distribution of the patients of the study group regarding the possible causes of recurrence:

Causes of recurrence No. PercentDouble long saphenous. 14 15.2%Double short saphenous. 2 2.1%

Neovasculerization.* 24 26%Inadequate assessment DVT

preoperative(incomplete recanalization)**34 36.9%

Incompetent surgery 18 19.8%Total 92 100%

*Results are statistically significant as P value is less than 0.05.**Results are statistically highly significant as P value is less than 0.01.

Table (5)

Shows the distribution of the patients of the study regarding the post -operative recurrence duration:

The duration between surgery and recurrence No Percent

Less than 2 years 4 4.3%2-5 years 12 13%6-10 years 32 34.8%

More than 10 years 44 47.8%Total 92 100%

Table (6)Shows the distribution of the patients of the study regarding their jobs:-

The job No. percentHouse wives 28 30.4%

Teachers 32* 34.8%Workers 20 21.7%Officers 4 4.3%

Employees 8 8.7%Total 92 100%

*Results are statistically significant as P value is less than 0.05.

Distribution of the patients of the study according to their jobs

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%

The job

Th

e p

erce

nt

Graph No3 Shows the distribution of the patients of the study regarding their jobs.

Table(7)

Shows the distribution of the patients of the study regarding their pattern of recurrence:-

Pattern of recurrence No. PercentInguinal 4 4.3%

Thigh only 20 21.7%Popliteal fossa 8 8.7%

Legs only 38 42.3%Both thigh and legs 22 23%

Total 92 100%

The post-operative recurrence duration has been noted that only 2

patient (6.7%) of the saphenofemoral ligation without stripping

(Trendlenberg operation) is recurred within 2 years while no patients are

recurred through the same duration in both Saphenofemoral disconnection

with stripping below knee and Saphenopopliteal disconnection with

stripping, while 20patients (66.6%), were recurred through the duration

from 6-10 years, with saphenofemoral ligation without stripping

(Trendlenberg operation), 2 patient (9.1%) with Saphenofemoral

disconnection with stripping below knee was recurred through the same

duration while 20 patients (90.9%) were recurred after 10 years of

Saphenofemoral disconnection with stripping below knee, table 8.

Regarding the Duplex findings in our study, there are 24 patients

(26.1%) with incompetent perforators in the thighs, 14 patients (15.2%)

with incompetent perforators in the legs, 30 patients (32.6%) with

incompetent perforators in both thigh and leg, and 24 patients (26.1%)

without incompetent perforators, graph 4,table 9.

Table 8

Shows the relationship between the operations performed for the patients of the study before recurrence and the post-operative recurrence duration:-

Saphenofemoral disconnection

without stripping (Trendlenberg

operation)

Saphenofemoral disconnection with stripping

below knee

Saphenofemoral disconnection with stripping

above knee

Saphenopopliteal disconnection with

stripping

No percent No percent No percent No percent

Less than 2 years

2 6.7% 0 0% 2 7.1% 0 0%

2-5 years

6 20% 0 0% 4 14.2% 2 16.6%

6-10 years

20 66.6% 2 9.1% 4 14.2% 6 50%

More than 10 years

2 6.7%% 20 90.9% 18 64.5% 4 33.4%

Total 30 100% 22 100% 28 100% 12 100%

* Results are statistically significant as P value is less than 0.05.

Table 9

Shows the distribution of the patients of the study regarding the Duplex findings before operations concerning the presence of incompetent perforators:-

Finding of incompetent perforators No. Percentincompetent perforators of the thigh only 24 26.1%incompetent perforators of the leg only 14 15.2%

incompetent perforators in both thigh and leg at the same time

30 32.6%

No incompetent perforators 24 26.1%Total 92 100%

Distribution of the patients of the study according to the duplex assessment before operations about the

presence of incompetent perforators

26.10%

15.20%32.60%

26.10%

incompetent perforators of the thigh only

incompetent perforators of the leg only

incompetent perforators in both thigh and leg at the same time

No incompetent perforators

Graph No 4 Shows the distribution of the patients regarding the Duplex findings before operations concerning the presence of incompetent perforators.

Non specialized surgeons operations came with 58 patients (63.5%)

recurred whereas those of specialized ones brought about a recurrence of

34 patients (36.5%), table 10.

Table (10)

Shows the distribution of the patients of the study regarding the specialty of the surgeon performing the operation:-

Specialty of the surgeons No. percentNon specialized surgeons 58 63.5%

Vascular surgeons 34 36.5%Total 92 100%

*Results are statistically highly significant as P value is less than 0.01.

Discussion

Recurrent varicose veins remain a common, complex and costly

problem in surgical practice despite improvements in preoperative

investigations and surgery for varicose veins. We can define recurrent

varices as ‘‘the presence of varicose veins in a lower limb previously

operated on for varices.

There are few epidemiological data specifically relating to recurrent

varicose veins and the retrospective studies which have been published are

not easy to compare because of differences in the definition of recurrence,

differences in the initial treatment, the classification of recurrences and the

method and duration of follow-up.

Ninety two patients were enrolled in our study, 60

patients(65.2%)were females and 32 patients were males (34.8%), and the

highest frequency of recurrence was between the age of 50-56 years and

the least recurrence was between the age of 20-29 years.

In a study by Perrin et al, 2000, that included 120 patients, 73

patients(60.8%) were females and 47 patients (39.1%) were males, and the

highest frequency of recurrence was from the age of 20-29 years and the

least recurrence from 40-49 years.( Perrin et al, 2000)

In a study by Creton, 2002, that included 116 patients, 65 patients

(56%) were males and 51 patients (44%) were females , and the highest

frequency of recurrence was from 50-59 years.(Creton, 2002)

In a study by Van Rij, 2004, that included 93 patients, there was 61

patients(65.6%) were females and 32 patients (34.4%) were males, and the

highest frequency of recurrence was in the age between 40-49 and the least

age of recurrence was 20-29 years.( Van Rij, 2004)

Causes of recurrence are multiple, as there are many anatomical

variations from persons to another as there is double short saphenous and

double long saphenous which need good assessment by clinical and

radiological procedures as Duplex ultrasound. Moreover, there is another

cause of recurrence known as neovasculerization which is a common

cause.

Duplex scanning can provide the necessary anatomical and

functional information about the nature of recurrence and has become the

investigation of choice in patients with recurrent varicose veins, also

inadequate preoperative assessment in presence of deep venous thrombosis

is one of the most common cause of recurrence, in addition to this,

incompetent surgery of the wrong site of incision containing excess fat lead

to incomplete ligation of all tributaries of the superficial system.

In our study 14 patients (15.2%) have double long saphenous and 2

patient(2.1%) had double short saphenous and 24 patients (26%) the cause

of recurrence was neovasculerization, 34 patients (36.9%) the cause was

deep venous thrombosis preoperative and 18 patients (19.8%) the cause

was incompetent surgery.

In a study by Stonebridge,1995,that included 113 patients, 11

patients (9.7%) have double long saphenous, 3 patients (2.7%) have short

saphenous, 37 patients(32.7%) have neovasculerization, 19 patients

(16.8%) have deep venous thrombosis, while 43 patients (38.1%) are due

to incompetent surgery.( Stonebridge,1995)

In a study by Fischer, 2002, that included 63 patients, 5 patients

(7.9%) have double long saphenous, 1 patients (1.6%) have short

saphenous, 29 patients(46%) have neovasculerization, 19 patients (17.5%)

have deep venous thrombosis, 9 patients (14.3%) have incompetent

surgery.( Fischer, 2002)

In a study by Winterborn,2004, that included 119 patients , 13

patients (10.9%) have double long saphenous,6 patients (5%) have short

saphenous ,47 patients(39.4%) have neovasculerization, 29 patients

(24.4%) have deep venous thrombosis, 24 patients (20.3%) have

incompetent surgery( Winterborn,2004).

Prolonged standing is one of the main factors which can cause

varicose veins and it is also one of the main factors of recurrence due to

increase venous pressure especially in diseased venous valves.

In our study, 28 patients (30.4%) were house wives, 32 patients

(34.8%) were teachers, 20 patients (21.7%) were workers, 4 patients

(4.3%) were officers and 8 patients (8.7%) were employees.

In a study by Kostas, 2004, that included 71 patients, 17 patients

(23%) are policeman, 19 patients (26.8%) are teachers, 26 patients (36.6%)

are workers and 9 patients are officers.( Kostas, 2004)

In a study by Fischer, 2002, that included 63 patients, 13 patients

(20.6%) are officers, 17 patients (27%) are employees , 8 (12.7%) patients

are policemen 10 patients (15.9%) are teachers, and 15 patients (23.8%) are

housewives.( Fischer, 2002)

In our study there are different mode of recurrence which take

different patterns, as 4 patients (4.3%) has recurrence in inguinal pattern,

20 patients(21.7%) has recurrence in the form of thigh pattern , 8 patients

(8.7%) are in the popliteal fossa , 38 patients (42.3%) are in the legs and

22 patients (23.9%) are in the thigh and legs.

In a study by Van Rij, 2004, that included 93 patients, as 5 patients

(5.4%) has recurrence in inguinal pattern, 22 patients(23.7%) has

recurrence in the form of thigh pattern , 12 patients (12.9%) are in the

popliteal fossa , 39 patients (41.9%) are in the legs and 15 patients (16.1%)

are in the thigh and legs. .( Van Rij, 2004)

The relation between the type of operation and the duration between

the surgery and recurrence is very important as we can reach to the method

which can avoid or decrease the higher incidence of recurrence.

In our study 92 patients were enrolled in, 30 patients (32.6%) from

the whole study saphenofemoral disconnection without stripping was

performed for them and 2 patients (6.7%) recurred within 2 years while

from 22 patients (23.9%) saphenofemoral disconnection and below knee

stripping was performed for them without recorded recurrence through the

same duration (within 2 years).

Twenty patients (66.6%) who had history of saphenofemoral

disconnection without stripping recurred through the duration from 6-10

years while only 2 patients (9.1%) who had history of saphenofemoral

disconnection and below knee stripping at the same duration and 12

patients (50%) who had history of saphenopopliteal disconnection with

stripping of the short saphenous.

Twenty patients (90.9%) who had history of saphenofemoral

disconnection and below knee stripping recurred after 10 years duration

while 2 patients (6.7%) recurred at the same duration of the group of

saphenofemoral disconnection without stripping, and 4 patients (33.4%)

recurred from the group of saphenopopliteal disconnection with stripping

of the short saphenous.

In a study by Donaldson,2005, that included 202 patients, 35 patients

(50.7%) of the group of saphenofemoral disconnection without stripping

recurred before 2 years from surgery, and only 4 patients (5.4 %) of the

group of saphenofemoral disconnection and above knee stripping recurred

before 2 years. 49 patients (55.1%) of the group of saphenofemoral

disconnection and above knee stripping recurred in the duration between 6-

10 years while 63 patients (70.8%) of the group of saphenofemoral

disconnection and below knee stripping recurred after 10

years( Donaldson,2005).

The presence of incompetent perforators is also one of the risk

factors of recurrence especially if not ligated during the 1st surgery as it

may be responsible for dilatation and incompetence of the superficial

venous system.

In our study there are 24 patients (26.1%) had incompetent

perforators in the thigh, 14 patients (15.2%) had incompetent perforators in

the legs, 30 patients (32.6%) had incompetent perforators in both leg and

thigh, and 24 patents (26.1%) hadn't incompetent perforators.

In a study by Kostas, 2004, that included 71 patients, 27 patients

(38%) had incompetent perforators in the thigh, 31 patients (43.7%) had

incompetent perforators in the leg while 13 patients (18.3%) hadn't

incompetent perforators.( Kostas, 2004)

In a study by Winterborn, 2004, that included 119 patients, 24

patients (20.2%) had incompetent perforators in the thigh, 31 patients had

incompetent perforators in both thigh and leg, while 39 patients (32.8%)

had incompetent perforators in the legs, and 25 patients (21%) had no

incompetent perforators.( Winterborn, 2004)

The specialty of the surgeon is very important in recurrence as there

are many errors occurred during the surgical procedure as the site of

incision must be at the crease to avoid excess fat, which can lead to miss

branches of the saphenofemoral or saphenopopliteal junction and lead to

incompetent surgery..

Also the preoperative Duplex ultrasound assessment is important

which may lead to true diagnosis or false one as assessment of incompetent

valves at the saphenofemoral and saphenopopliteal junctions and the

perforators and also the patency of the deep venous system and absence of

thrombosis.

In our study 58 patients (63.5%) were operated by general surgeons,

while 34 patients (36.5%) were operated with vascular surgeons.

In a study by Kostas, 2004, that included 71 patients, 47 patients

(66.2%) were operated by general surgeons, while 24 patients (33.8%)

were operated with vascular surgeons. .( Kostas, 2004)

In a study by Perrin et all, 2000, that included 120 patients, 71

patients (59.2%) operated by non specialized surgeons, while 49 patients

(40.2%) operated with vascular surgeons. (Perrin et al, 2000)

In a study by Creton, 2002, that included 116 patients, 82 patients

(70.7%) operated by non specialized surgeons, while 34 patients (29.3%)

operated with vascular surgeons.( Creton, 2002)

Summary and Conclusion

-This study is concerned with assessment of the causes of recurrent

varicose veins after surgery in Suez Canal University hospital.

-The study was carried out in Suez Canal university hospital in Ismailia,

the study group included patients with recurrent varicose veins after surgery

presented to surgery outpatient clinic in the duration from December 2006 to

November 2009.

-The study population consists of 92 patients with recurrent varicose

veins after surgery at any age in both genders.

-Assessment was done through taking history, examination (general and

local), and Duplex ultrasound.

-There are different causes of recurrent varicose veins after surgery as

inadequate assessment through clinical and radiological methods as Duplex

ultrasound through anatomical variation as double long or short saphenous,

presence of incompetent perforators in thigh or legs or both , presence of

deep venous thrombosis neovasculerization and incompetent surgery as

wrong site of incision which was lower than appropriate site at the inguinal

crease in saphenofemoral incompetence which lead to open and dissect in a

fatty region lead to inappropriate ligation of all branches of the superficial

venous system through the saphenofemoral or saphenopopliteal region.

The specialty of the surgeon who perform the operation is very important

as recurrence occurs with less frequency with vascular surgeon as he know

the anatomical variation and the proper preoperative assessment and

postoperative than others; 63.5% of recurrent patients were performed by

non specialized surgeons and 36.5% of the patients were performed by

vascular surgeons.

-In our study the causes of recurrence are distributed as follow, 15.2%

was caused by double saphenous, 2.1% was caused by double short

saphenous, 26% was neovasculerization, 36.9% was presence of deep

venous thrombosis and 19.8% was incompetent surgery.

-Saphenofemoral ligation with below knee stripping has the least frequency

of recurrence through the 1st ten years after surgery while 9.1%, while

Trendlenberg operation (Saphenofemoral ligation without stripping) has the

highest frequency of recurrence in the 1st ten years with 88.6%.

The gender has also carries risk of recurrence as females has tendency of

recurrence more than males as 65.2% of the patients are females while 34.8

patients are males.

The jobs which need prolonged standing has the highest frequency of

recurrence among patients as 34.8% patients are teachers and 30.4% are

housewives, 21.7% are workers and 4.3% patients are officers and 8.7%

patients are employees.

There are different pattern of recurrence, the highest pattern of recurrence

was in the legs with 42.3%, and 4.3% of the patients has recurrence in the form

of popliteal fossa varicosities, 21.7 % in the thigh.

Conclusion -:

It was concluded that recurrent varicose veins after surgery is a

common problem which has different causes as anatomical variation

between person and other which is need good assessment by clinical and

radiological procedure as Duplex ultrasound, and also there is another

cause of recurrence as neovasculerization also inadequate assessment

preoperative as presence of deep venous thrombosis is one of the most

common cause of recurrence and also incompetent surgery as wrong site of

incision which may be away from the inguinal crease which contain excess

fat lead to incomplete ligation of all branches of the superficial system.

Recommendations

We recommended that good preoperative assessment through

clinical and radiological methods, as Duplex ultrasound which must be

done by an expert radiologist is the main way to avoid causes of recurrence

and also need specialist surgeons know the anatomical variations to do it

perfect.

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الملخص العربي

تعتبر مشكلة ارتجاع دوالي الساقين بعد إجراء الجراحة من

المشكالت الملحة التي تواجه كل من المريض و الجراح، لذلك

تقوم هذه الدراسة على تقييم األسباب المحتملة الرتجاع دوالي

الساقين بعد الجراحة بمستشفى جـامعة قــناة السويس.

أقيمت هذه الدراسة في مستشفى جامعة قناة السويس

باإلسماعيلية للمرضى الذين يعانون ارتجاع دوالي الساقين بعد

إجراء الجراحة و الذين يترددون على العيادات الخارجية

.2008 و فبراير 2006بالمستشفى في الفترة ما بين ديسمبر

مريضا من مختلف األعمار من92أقيمت هذة الدراسة على

الجنسين ، و كان التقييم يشتمل على أخذ التاريخ المرضي و عمل

الفحص اإلكلينيكي و عمل أشعة بالموجات فوق الصوتية على

أوردة الساق التي تعاني من االرتجاع بعد الجراحة.

تبين من الدراسة أن هناك أسباب كثيرة لالرتجاع مثل

الفحص غير الكامل قبل الجراحة و الذي يشتمل على الفحص

اإلكلينيكي و عمل األشعة بالموجات فوق الصوتية على األوردة

حيث أنه توجد اختالفات من الناحية التشريحية من شخص آلخر

مثل وجود ازدواج في الوريد الصافني األكبر أو األصغرو الذي كان

% او وجود جلطة في األوردة العميقة و اكان ذلك17.3يمثل

% ، حدوث قنوات دموية جديدة بين األوردة التي تم39.6بنسبة

% أو تتم26لربطها من قبل و بعضها البعض و كانت بنسبة

العملية بشكل خاطئ مثل مكان الجرح التي تتم من خالله

%.19.8الجراحة و ذلك بنسبة

يعتبر تخصص الجراح من العوامل الهامة لحدوث االرتجاع

حيث ان نسبة ارتجاع المرض بين المرضي الذين تم أداء الجراحة

% بينما كانت نسبة االرتجاع بين36.5بواسطة جراح أوعية دموية

المرضى اآلخرين الذين تمت اجراء الجراحة لهم بواسطة جراح

%. 63.5غير متخصص

من خالل الدراسة وجدنا أن هناك عوامل أخرى مسئولة عن

االرتجاع مثل طبيعة عمل المريض فكانت أعلى نسبة لألرتجاع بين

% ، نوع الجراحة التي تمت للمريض حيث34.8المدرسين بنسبة

ان أعلى نسبة لالرتجاع كانت بين المرضى الذين تم اجراء جراحة

ربط للوريد الصافني عند اتصاله بالوريد الفخذي دون نزع الوريد

% خالل العشر سنوات األولى بعد الجراحة.88.6الصافني بنسبة