Comparative Study of Operative Tretmant of Varicose Veins According to The Klapp and Smetana Method Versus Myers Method

Venous abnormalities in lower extremities are among the most frequent disorders that affects general population with significant morbidity and mortality. Usually, the problem consists of a mild form of varicose veins and teleangiectasis. Treatment in this stage of disease is highly recommended since progression can lead to chronic venous insufficiency and chronic disability with very few effective treatment options. The most effective and popular treatment of varicose veins is operative treatment; specifically two different operative procedures: method according to Myers and method according to Klapp and Smetana. We designed this study in order to determine which method is superior based on clinical parameters and patients satisfaction. Our evidence strongly support clinical superiority, as well as patient satisfaction, of Klapp and Smetana method.


Introduction
Twenty seven percent of general population has some form of venous abnormality in lower extremities (), usually superficial varicosities and/ or telenagiectasis.Up to ,  of European adults develop venous stasis ulceration at some point ().Symptoms of venous insufficiency include leg fatigue, discomfort and heaviness.Signs include (according to gradual progression of disease) venous teleangiectasis, varicose veins, lipodermatosclerosis and venous ulceration.Risk factors associated with varicose veins may include prolonged standing, heredity, female sex, parity and history of phlebitis (,,,).With progression of the disease, and ignorance in terms of treatment, fi nal stage is chronic venous insuffi ciency and venous ulcers.Estimated incidence of venous ulcers in patients over  years is , per thousand per year ().Multivariant analysis suggests, in addition to aforementioned and age, the primary risk factors for venous ulceration are a history of deep vein thrombosis, a history of severe lower extremity trauma, male sex, and obesity ().Patients with venous ulceration have a severely impaired quality of life.Feeling of anger, depression, isolation and/ or diminished self image are present in nearly , and  have decreased mobility ().As many as  of employed patients with venous ulceration have decreased earning capacity directly attributable to the presence of venous ulcer ().As many as  million work days are lost per year in US secondary to venous ulceration, and  of patients lose job as a result of their venous ulcer ().Quite enough evidence to strive to stop the disease in early stages since it can prevent progression and chronicity.Th e most eff ective therapy in this stage is surgical therapy.Th ose not suitable for surgery, due to associated comorbidities, would benefi t from conservative treatment, that is compression therapy and pharmacological therapy.Surgical procedures are classifi ed as ablative and reconstructive.Ablative procedures are sclerotherapy and diff erent forms of varicectomias and vein stripping.Sclerotherapy is most widespread method for treatment of teleangiectasis and small varicose veins (less than  mm in diameter).Since most of the patients visiting our clinic suff er from later stages of varicose veins, they are not suitable for sclerotherapy.Th at is why most of our patients are treated by some form of vein striping and varicectomias.We apply two diff erent methods, method according to the Klapp and Smetana, and method according to the Myers (,).Both methods include stripping of greater saphenous vein through two small incisions at the ankle and in-guinal crease.Th e main diff erence is the varicectomia part.In Myers method it is accomplished through lots of small,  cm incisions directly over branch of varicosities, and varicosities are teased away from surrounding subcutaneous tissue so far proximally and distally as possible through the small incision.Th an incisions are closed by subcuticular suture or simple skin suture.On the other hand, in Klapp end Smetana procedure varicosities are approached through puncture wounds.With specially designed instruments by Klapp and Smetana, we enter the subcutaneous space and perform destruction and extraction of varicosities with concomitant release of tissue thromboplastin from destructed surrounding fat tissue.Due to the release of tissue thromboplastin, hemostasis is secured and it is not necessary to ligate the avulsed vessels.In order to deliver best quality of care to our patients, we wanted to objectively estimate superiority of one operative procedure over another.We were not able to find any study in the available literature (internet and publications) that would offer some kind of answer.Thus, we designed and performed this study.

Patients and Methods
During the period of  years, from May  to June , we performed surgery on  patients suffering from varicose veins using Myers or Klapp and Smetana method.In other to establish, as objectively as possible, conditions for the study, we divided patients in two comparable groups.Than, we matched patients from one group to patients from the other according to the stage of disease, age, gender, comorbidities and body mass index.Only  patients were eligible according to the mentioned criteria.Patients from one group ( patients) received operative treatment according to Klapp and Smetana, and patients from the other group ( patients) received operative treatment according to Myers.Other than the operative procedure performed, there were no differences between groups, meaning that the other parameters of applied medical care were the same in both groups (medications applied, topical care, etc.).We monitored the following parameters of operative outcome (postoperative complications): -Subcutaneous hemathoma formation of the operated lower extremity, -Infection of the operative wound, -Deep vein thrombosis, -Duration of hospitalization and -Patient satisfaction.

Results
The results of our study are listed in Tables -.
Men, between  and  years of age; stage II of disease; without associated comorbidities; BMI between  and . and .Th at caused prolonged hospitalization (averagely for two days) in this patient population.
Women are more susceptible to infection and hemathoma formation than men -Tables  and .We assume this to be the result of higher percentage of subcutaneous fat in women since fat tissue is inert and has low resistance to infection.Also, fat tissue creates weak mechanical barrier that prevents hemathoma formation.

Conclusion
Before articulating the conclusion itself we wish to emphasis that we weighed all the available evidence according to the data above and their medical consequences.Th is means we graded all complications in a way they threaten patient's life and abilities, like deep vein thrombosis weighed more in comparison than infection, and infection more than hemathoma formation.Also, total associated costs are indisputably higher in Myers method.We can conclude that Klapp and Smetana method of treatment of varicose veins is superior to Myers method and no attempts should be made to perform Myers procedure in future unless medically indicated -very large varicosities with need for individual communicating veins ligation (of course, and in case of limited instrumentation preventing performance of Klapp and Smetana procedure).
EMIR SOLAKOVIĆ ET AL.: COMPARATIVE STUDY OF OPERATIVE TRETMANT OF VARICOSE VEINS ACCORDING TO THE KLAPP AND SMETANA METHOD VERSUS MYERS METHOD Each monitored parameter was expressed as the number of patients with complication occurrence and percentage of total number of patients in the group.Duration of hospitalization was expressed in number of days in postoperative period.On the other hand, patient satisfaction is expressed as the number of satisfied patients and percentage of total (this time higher number means positive value in chart).
There were  patients in Klapp and Smetana group, and  patients in Myers group.Female, between  and  years of age; stage II of disease; without associated comorbidities; BMI between  and .There were  patients in Klapp and Smetana group, and  patients in Myers group.Men, between  and  years of age; stage III of disease; diabetics; BMI between  and .Th ere were  patients in Klapp and Smetana group, and  patients in Myers group.EMIR SOLAKOVIĆ ET AL.: COMPARATIVE STUDY OF OPERATIVE TRETMANT OF VARICOSE VEINS ACCORDING TO THE KLAPP AND SMETANA METHOD VERSUS MYERS METHOD is associated with Myers procedure -  versus   -Table .These are mostly totally harmless incision infections that affect skin and surrounding subcutaneous tissue, averagely spreading not more than  cm from the age of the wound and with discrete secretion.This result of the study is understandable since Klap and Smetana procedure is not associated with signifi cant disruption of skin integrity (access to the subcutaneous tissue through puncture wounds).Deep vein thrombosis is also more frequent in Myers procedure.As shown from the study, we did not report DVT in Klapp and Smetana group.Actually, we had no DVT in patients operated according to Klapp and Smetana at all, since we perform this procedure in our Clinic.Th ere is no sound evidence for having DVT in Myers group but the results are in accordance with world statistics (,,).Most of patients complained of swelling and feeling of discomfort in the calf on second or third postoperative day.We examined them using Doppler US and found incipient thrombosis of deep calf veins.That prolonged hospitalization of affected patients for additional  days with application of medications according to international guidelines.Subcutaneous hemathoma formation is more common in Klapp and Smetana procedure than Myers procedure -  versus   -Table .These hemathomas are mostly blood suff usion of subcutaneous tissue (not collections of blood in subcutis!) and none of them required surgical drainage.Th is result is also understandable from the nature of procedure itself.While in Myers procedure we tend to ligate bigger proximal and distal tributaries of the extracted varicosities, in Klapp and Smetana procedure we rely on tissue thromboplastin to initiate hemostasis in disrupted varicosities and their tributaries.
Female, between  and  years of age; stage II/III of disease; diabetics; BMI between  and .There were  patients in Klapp and Smetana group, and  patients in Myers group.talization.Most of them never supposed that operation of varicose veins could be done without operative scars, or that they could leave hospital the day after surgery.Also, most of satisfied patients expected that postoperative pain would be harder.Higher frequency of postoperative wound infections  BOSNIAN JOURNAL OF BASIC MEDICAL SCIENCES 2008; 8 (3): 294-294