Factors influencing postoperative pain after subfascial endoscopic perforator surgery (SEPS)

Abstract

SEPS became a widely used mini-invasive technique for interruption of pathological venous reflux through perforator veins (PVs) of the calf, localised under trophic injuries of soft tissues in patients with severe chronic venous insufficiency (CVI). The aim of the study was to identify the potential factors that can influence postoperative pain after SEPS. Methods. Type and duration of required postoperative analgesia (PA) in relation to clinical, surgical and anesthesiological peculiarities were studied in 68 patients underwent unilateral SEPS procedure. Results. Overall duration of PA was higher in the presence of extensive subfascial fibrosis, insufflation of CO2 in subfascial working space under pressure >15 mm Hg and using of diathermocoagulation for PVs disconnection than in limited subfascial fibrosis, insufflation pressure ≤15 mm Hg and PVs interruption by clipping – 6±1,68 vs 3,52±0,27 days; 3,96±0,54 vs 3,46±0,31 and 3,86±0,41 vs 3,2±0,42 days, respectively. Necessity in opioids was longer in the presence of expanded lipodermatosclerosis, large dissection of subfascial space and SEPS duration >30 min compared to the cases of focal dermatosclerosis, moderate subfascial dissection and the average SEPS duration ≤30 min – 0,79±0,07 vs 0,68±0,11 days; 0,81±0,11 vs 0,72±0,07 and 0,89±0,08 vs 0,58±0,09 days, respectively. Both, the total duration of PA and the need for opioids prescription were greater in the cases of PVs transection without prior vasal luminal occlusion and intraoperative subfascial bleeding with subsequent development of hematoma comparing to the cases of PVs interruption by other methods (coagulation or clipping) and absence of subfascial haemorrhagia during SEPS – 4,5±0,84 and 0,8±0,2 vs 3,54±0,41 and 0,65±0,09 days; and 3,92±0,81 and 0,83±0,11 vs 3,61±0,3 and 0,7±0,07 days, respectively. Opioids requirement was lower after spinal than consecutively intravenous or endotracheal anesthesias – 0,57±0,15 vs 0,83±0,11 and 0,85±0,06 days, respectively. Duration of PA after spinal anesthesia was significantly lower than after general – 2,83±0,44 vs 4,61±0,54 days (p<0,01). PA was not influenced by aditional surgical techniques (open PVs ligation and phlebectomy). Conclusions. Absence of lipodermatosclerosis, subfascial fibrosis and intraoperative bleeding; careful subfascial dissection; gas insufflation pressure ≤15 mm Hg; duration of SEPS ≤30 min; PVs interruption by clipping as well as using of spinal anesthesia are associated with reduced PA duration and/or opioids requirement after SEPS. Subsequent larger studies of factors influencing postoperative pain after SEPS might contribute to faster recovery of patients with severe CVI.