Incompetent perforating veins of lower limbs are responsible for varicose ulcers and varicose veins' recurrence. Subfascial Endoscopic Perforating Surgery (SEPS) is the best option to treat perforators and has the best results compared to percutaneous ablation (laser, radiofrequency, sclerotherapy). SEPS treats more perforators than those found on the preoperative ultrasound. This means that with percutaneous ablation 2-3 perforators will be left untreated, having a negative impact on outcomes.
SEPS treats perforators by two small incisions in a skin unaffected by advanced chronic venous disease. SEPS can treat perforators even under an active ulcer. This is a very attractive concept I am using for several years, but many insist to say “no”. Why? Is it hard to perform? It is not. Does it need specific instruments? Only common laparoscopic instruments. Is it a time-consuming surgery? Only 15 to 20 minutes. Are the results not good? Results are great and better than other techniques. Is it hard to learn? It is an easy-to-learn technique if doctors already have some experience in minimally invasive surgery. Why is there so much resistance? Probably because doctors do not want to treat what they do not know how to treat, and do not want to use techniques they do not know how to perform.
In Japan, the picture is a little bit different than in Europe. Since the introduction of the two-port technique (allowing for the best visualization and easier to perform), SEPS has been accepted by the Japanese Ministry of Health, Labour and Welfare in 2009, and is a medical service covered by the Japanese health service. Most cases of SEPS in Japan are performed by the Japanese SEPS Study Group. Their results are like those published by me some years ago.
Kusagawa et al from Japan studied 1287 limbs (C2 to C6) treated by SEPS. Of those, 1078 had simultaneous saphenous surgery and 209 had previous saphenous surgery. Results were published in Phlebology during 2018. They performed a separate analysis of patients without deep veins disease (group A) and patients with deep veins disease (group B). Venous Clinical Severity Score (VCSS) significantly improved in all patients submitted to SEPS. Overall ulcer healing rate was 96,2%, and the average time from SEPS to ulcer healing was only two (2) months. These are great results, which are better than percutaneous techniques according to some publications. As expected, healing was harder in group B. It is important to highlight that the simultaneous saphenous surgery did not have any impact on the ulcer healing rate. In my opinion, this is very important data to support both the treatment of perforator veins and SEPS. Ulcer recurrence rate was 12% during a follow-up of 46 months. Group B had a higher recurrence rate. It is interesting to note that simultaneous saphenous surgery had a positive impact in lowering the recurrence rate. Additionally, deep veins disease and non-treated perforators were responsible for several cases of non-healing ulcers after SEPS. From these data, all procedures to reduce venous hypertension of lower limbs are crucial to achieve a good ulcer healing rate and lower the recurrence rate, and SEPS has a crucial role to play in that field.
One wrong idea stated by the Japanese authors is that the technique performed in Europe needs a tourniquet. I am performing the two-port technique for several years and I have never used a tourniquet or something similar. They are using screw-type trocars to reduce gas leakage. In fact, this is a common issue but easy to deal with. The authors also say that the high insufflation pressure up to 30 mmHg recommended to deal with the gas leakage can cause subcutaneous emphysema and embolism. With more than 100 procedures till now, I have never reported such complications.
The authors present important data about percutaneous ablation of perforators (PAP) and ultrasound-guided sclerotherapy. The results reported following these techniques present a short-term occlusion efficacy. However, during follow-up, there is a recanalization of perforators treated by percutaneous techniques. With SEPS perforators are ligated and cut, meaning recanalization is not possible. Cannulation of perforators is very difficult, because they are deep, tortuous, and usually near active ulcer within diseased skin. Additionally, thrombosis of a short and high-flow vein is harder to achieve than the saphenous. Another advantage of SEPS over percutaneous techniques is the ability to treat paratibial incompetent perforators under direct visualization. Finally, SEPS treats perforators subfascially while percutaneous techniques occlude perforators extrafascially with a possible negative impact on the skin.
Based on these data, if there are incompetent perforating veins SEPS is mandatory, I think. Why does Portugal keep fighting against SEPS? Why do insurances in Portugal not want to support SEPS? Why advanced varicose veins treatment is not supported? There is no reason why. SEPS is the best way to achieve the best results in varicose ulcers healing rate and the best way to reduce the recurrence rate. SEPS must be supported by all doctors treating varicose disease.
Some doctors say the future of varicose veins treatment is office-based procedures. I would say the future must belong to those techniques with the best results. Even though, the Japanese SEPS Study Group is working on a “new intravenous anesthetic with a nerve block, which enables SEPS to be performed on an office basis in the same way as endovenous ablation”.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon