Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 46-49

A higher body mass index means worse satisfaction outcome in obese patients undergoing varicose vein surgery


Department of Vascular Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK

Date of Submission17-Sep-2020
Date of Acceptance08-Oct-2020
Date of Web Publication30-Aug-2021

Correspondence Address:
Sivaram Premnath
Department of Vascular Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_131_20

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  Abstract 


Introduction: Obesity (body mass index [BMI] >30) and lower limb venous disease (LLVD) is a common problem, yet there is a sparsity of evidence in its management. The aim was to carry out a satisfaction survey on such patients following their venous surgery from a single center. Methods: Three hundred and thirty procedures carried out from January 2017 to April 2018. Eighty-seven patients with BMI > 30 were selected and case notes reviewed retrospectively. Data on demography, risk factors, Clinical, Etiology, Anatomy, Pathology (CEAP) status, operative data, and complications were collected. Fifty-three patients had a telephone follow-up to assess satisfaction in terms of symptoms and appearance. Logistic regression analysis was carried out to identify factors contributing to a worse outcome. Results: The mean age was 53.1 (50.6% were male). The mean BMI was 36.11 (30–56). CEAP grade of more than 3 was present in 69.8% (44/87). Most patients were treated by radiofrequency ablation (81.6% [71/87]). Significant complications occurred in 3.4% (3/87) after surgery. The median follow-up was 22 months (14–30). Symptoms improvement was reported in 74% (39/53), while 5.6% (3/53) reported worse symptoms. In terms of appearance, 71.6% (38/53) reported improvement, while 7.5% (4/53) reported worse appearance. Logistic regression analysis identified BMI to be a significant risk factor (odds ratio 1.257 (95% confidence interval 1.004–1.575). Conclusions: The higher the BMI, the lesser the patient satisfaction after varicose vein surgery. Obese patients with LLVD can be treated successfully with a high satisfaction rate for BMI class 1 and 2.

Keywords: Obesity, varicose vein surgery, varicose veins, venous disease, patient satisfaction


How to cite this article:
Premnath S, Nour E, Abdelhaliem A, Rowlands TE, Kuhan G. A higher body mass index means worse satisfaction outcome in obese patients undergoing varicose vein surgery. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:46-9

How to cite this URL:
Premnath S, Nour E, Abdelhaliem A, Rowlands TE, Kuhan G. A higher body mass index means worse satisfaction outcome in obese patients undergoing varicose vein surgery. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Nov 30];8, Suppl S1:46-9. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/46/324929




  Introduction Top


Obesity affects a quarter of the adult population and the incidence is rising.[1]. It is predicted by 2030 that over 50% of the population in the western world will be obese, costing more than $500 billion in medical expenditure.[2] In the UK, 24 million people are affected, it accounts for 18 million days of sickness absence and costs the economy ≤ £2 billion each year.[3] Lower limb venous disease (LLVD) affects up to half of the adult population.[4] Therefore, many people are affected by and present to the health services for the treatment.

Obesity is a well-known risk factor for LLVD.[5] Obese patients with LLVD tend to have a higher Clinical, Etiology, Anatomy, Pathology (CEAP) clinical grade.[6] Obesity is also associated with delayed ulcer healing and increased recurrence rates.[7] Obese patients are considered high risk for surgical intervention in terms of morbidity, mortality, and venous thromboembolism.[8] Endovenous interventions (ultrasound-guided foam sclerotherapy and endothermal and nonthermal ablation) are considered less invasive, less painful, and have early recovery.[9] Many centers have adopted endovenous therapy as the first-line treatment for such patients. Some studies have shown higher technical failure rates in obese patients.[10] The efficacy of surgery in terms of patient satisfaction has not been adequately assessed in obese patients with LLVD across various obesity classes. The primary aim was to carry out a patient satisfaction survey in obese patients following their venous surgery from a single center.


  Material and Methods Top


This was a retrospective study and a patient satisfaction survey. Hospital electronic records and case notes of 330 patients who had varicose vein surgery from January 2017 to April 2018 were reviewed. Patients with a body mass index (BMI) >30 were then selected for detailed data collection (n = 87). Patients whose BMI data were not recorded and non-English speaking patients were excluded from the study. Data on demography, risk factors, CEAP status, operative data, and complications were collected. The primary outcome measure was patient's satisfaction after their surgery. Patients were contacted by telephone. Verbal consent was obtained prior to questioning. Data obtained from the hospital records were verified. Complications and reinterventions not gathered on the hospital system were obtained. Patient satisfaction was assessed in terms of symptoms and appearance. Two questions were asked regarding this. ”Compared to symptoms before surgery how do you rate your symptoms now?” Patients were given three options ”improved, same and worse” to choose from. A similar question was asked regarding the appearance. Two attempts were made to contact patients and those who did not respond were excluded from further analysis.

Logistic regression analysis was carried using IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.. Data from Excel spreadsheet was transported to SPSS format. Age and BMI were analyzed as continuous variables. CEAP grading was simplified into two categories -above 3 and below 3. The combined outcome was created for satisfaction. Patient describing worse satisfaction for either appearance or symptoms were classed as ”worse.” Variables were entered stepwise for the analysis. Backward elimination method was used to retain variables. Variables were entered into the model at P = 0.05 and removed at 0.10.


  Results Top


The mean age of the population was 53.1 years (range 25–83). Males were 50.6% (44/87) and the mean BMI was 36.11 (range 30–56). Current smokers were 14.9% (13/87) and 16.1% (14/87) were diabetic. Previous deep-venous thrombosis (DVT) and PE were present in 6.9% (6/87) and 1.1% (1/87), respectively. Previous surgery was carried out in 11.5% (10/87) of the patients. Of the patients who had previous surgery, eight had open high ties, four had bilateral, and treated vein was great saphenous vein (GSV) in nine. CEAP grade of more than 3 was present in 69.8% (44/63) of the patients [Table 1].
Table 1: Baseline characteristics

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Most patients were treated by radiofrequency ablation (81.6% [71/87]), while 17.2% (15/87) had a high tie and 17.2% (15/87) had foam sclerotherapy. Avulsions were carried out in 66.7% (58/87) and 13.8% (12/87) had bilateral surgery. GSV was operated on in 83.9% (73/87) and small saphenous vein was treated in 16.1% (14/87). Majority of the cases were carried out under spinal anesthesia (46%, 40/87), as a day case 95.4% (83/87). Significant complications occurred in 3.4% (3/87) after surgery. The median follow-up was 22 months (range 14–30) [Table 2].
Table 2: Current interventions for lower limb venous disease

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Symptoms improvement was reported in 74% (39/53), while 5.6% (3/53) reported worse symptoms. In terms of appearance, 71.6% (38/53) reported improvement, while 7.5% (4/53) reported worse appearance [Table 3].
Table 3: Patient satisfaction

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Logistic regression analysis identified BMI to be a significant risk factor (odds radio [OR] 1.257 (95% confidence interval [CI]: 1.004–1.575). None of the other 14 variables were significant [Table 4]. [Figure 1] shows that the patient satisfaction was worse with higher classes of obesity. Of the total of 35 patients with class 1 obesity (BMI: 30.1–35 kg/m2), only one patient reported a worse outcome after the procedure; meanwhile, 2 out of a total of 7 patients with class 3 obesity (BMI > 40 kg/m2) reported a worse outcome.
Table 4: Logistic regression analysis

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Figure 1: Patient satisfaction for obesity classes Frequency is plotted in Y-axis. Improved or same patient satisfaction is depicted in blue, while the worse outcome is in orange for various obesity classes

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  Discussion Top


The current study has shown that higher the BMI, the lesser satisfaction among obese patients. There are several possible reasons for this result. Obesity has altered hemodynamics in the venous system. Intra-abdominal pressure is elevated in obese patients.[11] The raised intra-abdominal pressure is associated with increased femoral vein pressure and diameter. This will result in decreased venous flow and increased resistance in the lower legs. Obese patients are often immobile and have poor calf muscle pump function compared to nonobese patients.[12] Higher the BMI, the more pronounced the altered hemodynamics, thus might be contributing recurrence of symptoms or treatment failure. Obese patients have poor compliance with compression therapy following surgery.[13] There is a technical difficulty with applying adequate and sustained compression in obese patients. The surgery itself can be technically difficult in obese patients' legs. Some studies have identified higher recanalization rates following endovenous ablation.[10] The altered hemodynamic can be present at the microcirculatory level in obese patients contributing to ulcer formation.[14] Thus, treating macrocirculation with surgery may not lead to complete ulcer healing.

The study has also shown overall high satisfaction in obesity class 1 and 2. However, this might not be the case for patients with higher BMIs. Particularly BMI over 40, the satisfaction was poor. A study of 418 patients compared to obese and nonobese patients with C2 and C3 disease who were treated with radiofrequency ablation (RFA).[15] The study concluded that both the groups benefited from the operation equally. A further study of 116 patients compared obese and nonobese patients treated with foam sclerotherapy. At 5 years, obese patients had greater symptomatic improvement, more recanalization, greater recurrence, and high satisfaction.[16] The current study is the first to show increasing BMI to be a significant risk factor for patient satisfaction. One might argue patients with BMI greater than 40 should ideally have weight reduction before the intervention. This might be in the form of bariatric surgery.[17] Newer compression techniques could have a role in providing adequate and sustainable compression.[18] It is fair to conclude more high-quality evidence is needed to have a clear management plan for patients with LLVD and obesity. Until high-quality evidence is available, venous surgery should be cautiously considered in patients with a BMI > 40.

There are several methods to assess the effectiveness of surgery. Commonly used in the literature are the generic and disease-specific quality of life questionnaires. Short form 36, EuroQoL, and Aberdeen Varicose Vein Questionnaire are some used in the literature.[19] These are labor intensive and time consuming and are unsuitable for a telephone assessment. In the current study, a simplified questionnaire was used to aid telephone assessment to be effective. The current study is a retrospective study and satisfaction survey was completed in 53 of the 87 patients. The current study is the first to show that an increase in BMI to be associated with poor patient satisfaction. The study further shows surgery is effective in BMI between 30 and 40. The study shows the preference of the vascular unit to treat this patient cohort with RFA and avulsions under spinal anesthesia as a day-case procedure. There were three significant complications after surgery. One patient had a DVT, while others had chest infection and urinary tract infection within 30 days. This study shows that venous surgery can be safely carried out in obese patients as a day-case procedure.

The NICE guidelines suggest that surgery should be offered for symptomatic patients with LLVD.[9] It also suggests that endothermal ablation should be the first line of treatment. There are no high-quality data on obese patients with LLVD despite it being a common problem facing many clinicians. The lack of evidence has led to variation in practice in the UK with some vascular units not offering surgery while others treating all comers. The current study shows the association between increasing BMI and worse patient satisfaction. The study further shows the high satisfaction for surgery in obesity class 1 and 2 and surgery can be delivered safely. The current study poor patient satisfaction was obtained in class 3 obese patients suggesting a cautious recommendation for venous surgery.


  Conclusion Top


The higher the BMI, lesser the patient satisfaction after varicose vein surgery.

Acknowledgments

The authors would like to thank Denise Green, for secretarial help and retrieval of patient notes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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National Audit Office. Tackling Obesity in England. Report by the Comptroller and Auditor General HC 2000-2001. Available from: https://www.nao.org.uk/report/tackling-obesity-in-england. [Last accessed on 2019 Dec 01].  Back to cited text no. 3
    
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Fernández CF, Roizental M, Carvallo J. Combined endovenous laser therapy and microphlebectomy in the treatment of varicose veins: Efficacy and complications of a large single-center experience. J Vasc Surg 2008;48:947-52.  Back to cited text no. 10
    
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Willenberg T, Schumacher A, Amann-Vesti B, Jacomella V, Thalhammer C, Diehm N, et al. Impact of obesity on venous hemodynamics of the lower limbs. J Vasc Surg 2010;52:664-8.  Back to cited text no. 11
    
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Marston WA, Carlin RE, Passman MA, Farber MA, Keagy BA. Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency. J Vasc Surg 1999;30:491-8.  Back to cited text no. 13
    
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Melissas J, Christodoulakis M, Schoretsanitis G, Sanidas E, Ganotakis E, Michaloudis D, et al. Obesity-associated disorders before and after weight reduction by vertical banded gastroplasty in morbidly vs super obese individuals. Obes Surg 2001;11:475-81.  Back to cited text no. 17
    
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Brittenden J, Cooper D, Dimitrova M, Scotland G, Cotton SC, Elders A, et al. Five-year outcomes of a randomized trial of treatments for varicose veins. N Engl J Med 2019;381:912-22.  Back to cited text no. 19
    


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