[Guideline 'Diagnosis and treatment of varicose veins']. / Richtlijn 'Diagnostiek en behandeling van varices'.

The Dutch guideline on the diagnosis and treatment of varicose veins recommends that the 'C' from the North American Venous Forum classification CEAP ('C' = clinical, 'E' = aetiological, 'A' = anatomical, and 'P' = pathophysiological classification ) be recorded in the clinical case notes and that traditional tests as described by Trendelenburg and Perthes be omitted as they are of no use in patients with C2 and C3 varicose veins. In primary C1, C2 and C3 varicose veins that have not previously been treated, a handheld Doppler may be used to exclude reflux. If reflux is found or if in doubt, duplex investigation is necessary. Before any invasive treatment of C2 or C3 varicose veins is scheduled, duplex investigation of the superficial and deep systems is mandatory. In C2 and C3 varicose veins functional investigations such as plethysmography and intravenous pressure measurement are superfluous. With respect to treatment of an insufficient greater saphenous vein, stripping from knee to groin with side branch interruption in the groin is the gold standard in the treatment of C2 and C3 varicose veins. Endovenous techniques such as radio frequency ablation or laser are comparable with the classical stripping method in the treatment of C2 and C3 varicose veins. Insufficient perforating C2 or C3 veins in these patients need no specific treatment. Prior to surgery the entrance level of the lesser saphenous vein into the popliteal vein should be marked with the patient lying in supine position and with the aid of duplex. For patients with side-branches hook needle extraction through mini- incisions is the treatment of choice.

Endovenous or open venous surgery: choices to make.

Numerous techniques are available to treat varicose veins. In this overview a balance is sought between the advantages and the disadvantages of all techniques. Endovenous techniques have been introduced by comparing them with classical stripping, resulting in favourable results for the former procedures. In daily practice the quality of life to be gained by using endovenous procedures can be achieved with state of the art open surgery as well, and loss due to recurrences e.g. after neovascularization is compensated by superior single session results. At the end, optimum treatment will be tailored to each individual patient, be it endovenous, open or a combination of both. Health care providers will have to be able to offer a range of open and endovenous treatment modalities.

Relation between hospital volume and outcome of elective surgery for abdominal aortic aneurysm: a systematic review.

OBJECTIVES: Our aim was to analyse the relation between hospital volume and peri-operative mortality in abdominal aortic aneurysm surgery. DESIGN: Systematic review. METHOD: The Medline, Embase and Cochrane databases were searched to identify all population based studies reporting on the volume outcome relationship published between 1966 and 2006. Two independent observers performed methodological quality assessment and data extraction. Outcome was 30-day or in-hospital mortality in relation to hospital volume. RESULTS: Twenty-four articles were included. Overall peri-operative mortality ranged from 2.3 to 9.9%. The cut-off values for a high- or low-volume hospital appeared to range from 8 to 50 operations annually. The peri-operative mortality in low volume hospitals (LVH) ranged from 3.0 to 13.8% (median 6.2%) and from 1.8 to 7.4% in high volume hospitals (HVH) (median 4.3%). In 14 studies a significantly lower mortality was found in HVH as opposed to LVH; in 10 articles no such difference between HVH and LVH could be proved. CONCLUSION: We found some evidence for a relation between the volume of AAA surgery and peri-operative mortality. There seems to be a nonsignificant trend in favour of high volume hospitals. However we could not derive an unequivocal volume threshold for safely performing AAA surgery.