Une enquête sur les conduites thérapeutiques chirurgicales dans le traitement de l'insuffisance veineuse superficielle primitive a été réalisée en 2001 auprès des chirurgiens, membres de la Société de Chirurgie Vasculaire de Langue Française et des chirurgiens français non-membres de cette société, mais ayant une pratique importante de la chirurgie des varices.

— recenser les différentes techniques chirurgicales utilisées dans le traitement de la maladie veineuse chronique et plus particulièrement des varices ;

— évaluer le pourcentage de recours à la pratique de l'écho Doppler pré-opératoire ;

— identifier le type d'anesthésie utilisé ;

— déterminer le traitement postopératoire prescrit et plus particulièrement la compression.

Un questionnaire semi-ouvert de 17 questions ainsi qu'une fiche complémentaire de renseignements sur le traitement compressif postopératoire prescrit aux patients ont été systématiquement envoyés par courrier aux 501 chirurgiens, membres de la SCV et à 174 chirurgiens ayant une pratique de la chirurgie des varices.

L'analyse des données a montré que la crossectomie + éveinage du tronc saphène + phlébectomie des collatérales (71,9 %) puis la crossectomie + éveinage du tronc saphène (17,3 %) sont les techniques les plus utilisées dans le traitement des varices.

La modalité d'éveinage du tronc saphène a été identifiée pour la grande et la petite veine saphène. L'invagination est utilisée par 78,1 % (217/278) des chirurgiens pour la grande veine saphène et 77,7 % (213/274) pour la petite veine saphène. Le télescopage est utilisé par 44,2 % des chirurgiens pour la grande veine saphène et 31,8 % pour la petite veine saphène.

L'exérèse du tronc est le plus souvent totale.

L'écho-Doppler est demandé ou réalisé en pré-opératoire de façon systématique par 85,4 % (234/274) des chirurgiens.

La modalité anesthésique la plus fréquemment utilisée est l'anesthésie générale.

La compression est presque systématiquement prescrite en postopératoire.

This survey was undertaken in 2001 among surgeons of the French speaking Vascular Surgery Society (SCV-Société de Chirurgie Vasculaire de Langue Française) and SCV non-members with a heavy caseload in varicose vein surgery.

To identify

This survey was conducted by mail through a “half open” questionnaire including 17 questions and a patient form (see appendices I and II). 675 surgeons were questioned (501 were SCV members and 174 non members).

Two-hundred and eighty surgeons answered (41.5%). The level of replies for French surgeons was 45.3%. A scientific committee assessed these replies. The surgeons were classified into different groups according to their membership of the SCV, own practice, and caseload (table I).

The 2 most performed procedures were respectively high ligation + saphenous trunk stripping + tributaries stab avulsion (71.9%) and high ligation + saphenous trunk stripping (17.3%). Isolated phlebectomy was 5.6%, high ligation + tributaries stab avulsion + saphenous trunk preservation 2.8%, isolated high ligation 2.2%, and ambulatory hemodynamic and conservative treatment of venous insufficiency (CHIVA) 0.3% ( fig. 1). The various procedures used (total number, average and percentage) inside the different groups are displayed in tables II, IIIand IV.

Concerning trunk stripping modality the 2 most frequently used techniques were invagination and Babcock techniques. Both were evaluated respectively for the great saphenous vein (invagination 78.1%, Babcock technique 44.2%) and the small saphenous vein (invagination 77.1%, Babcock technique 31.8%). Complete resection of the saphenous trunk was more frequently performed than partial stripping.

Pre-operative duplex scanning was systematically undertaken by 85.4% of surgeons without a statistical difference between the different groups.

General anesthesia remains the most used form of anesthesia (83.9%) followed by spinal or epidural anesthesia (70.4%), and local or loco-regional (29.2%). As multiple answers were allowed, the most frequent procedures associated with general anesthesia were spinal or epidural (36.9%). Responders prescribed postoperative compression and anticoagulation in 97.1% and 55.8% respectively.

Intra-group comparison was then undertaken in order to determine if their practice was different. Annual caseload was significantly (P = 0.001) higher in Group I (353) than in Group II (226) and Group III (152). There was no difference in terms of the various surgical procedures used between the different groups. Group 1 favored the trunk stripping modality invagination for avulsion of the great saphenous vein and small saphenous vein. Concerning anesthesia, local and loco-regional anesthesia was used more by Group I than by the other groups as was anticoagulation.

Responders perform perforator ligation and deep venous reconstructive surgery respectively in 70.3% and 22.4% without any intra group difference, however we have no information on frequency and indications for this type of surgery as these items were not included in the questionnaire.

Total number of procedures recorded in this survey is in keeping with the yearly French data concerning surgical treatment of varicose veins (ie, approximately 200,000 procedures). Since the emphasis was on surgical procedures sparing the saphenous trunks in varicose vein treatment only 10.9% of the techniques used in this survey were compatible with this purpose.

Invagination technique for stripping both the great and small saphenous trunk was preferentially used by the Group I. Although it is surprising that all groups favored total trunk stripping particularly for the small saphenous vein.

It is not surprising that a large majority, despite very little controversy on this point, performed preoperative duplex scanning.

Although postoperative compression can be only quoted as a grade C recommendation according to evidence-based medicine, it was prescribed in almost all cases.

Surgery for varicose veins is one of the most frequently performed surgical procedures in France, mainly by surgeons exercising in private practice. There is no significant difference between the various groups (SCV Member or not, type of practice and annual case load) concerning the various procedures used, although through careful analysis certain different tendencies may be identified. In addition postoperative compression is systematically prescribed.