Varicose veins in obese patients are a problem hidden in plain sight. Standard management cannot be easily applied and thus, individualised treatment is crucial for better management of this problem.
Obesity is a rising epidemic. With the 2013 National Health Surveillance Survey reporting that 8.6% of all Singaporean adults are obese, it is safe to say that we are dealing with a social problem of epic proportions. While it is common knowledge that heart disease, diabetes and joint issues are consequences of obesity, a lesser well-known fact is that varicose veins and chronic venous insufficiency are strongly correlated to raised intra-abdominal pressure caused by obesity.
Varicose veins are a condition where veins become dilated and tortuous. It is a common medical condition affecting 25% of the adult population, in particular women in their 20s to 40s.
They occur most commonly in the superficial veins of the legs. Veins have a series of one-way valves that keeps blood flowing in one direction. When these valves become incompetent, the blood flows backwards, resulting in varicose veins.
SYMPTOMS
A person with a normal body size who has varicose veins will commonly complain of:
- Ugly bulging veins,
- Swelling, heaviness, aching, and cramps in the affected leg, especially after long periods of standing
In obese patients, the varicose veins and swelling are not so visible, due to excessive fat. The heaviness and cramps in obese patients are often attributed to weight and joint problems. Hence, obese patients tend to present late.
COMPLICATIONS
Left untreated, it can result in complications such as:
- Lower limb eczema (itch)
- Hyperpigmentation (discolouration)
- Ulceration
- Bleeding
- Phlebitis (inflammation of the affected vein)
DIAGNOSIS
Varicose veins can be easily accessed and diagnosed through the use of a duplex ultrasound scan. These veins in a standard size leg are usually 1 or 2 cm under the skin. In very large legs, the scanning is much more difficult to do as the veins are much deeper, being covered by layers of fat, hence making the scan less accurate.
If the varicose veins are small and not too uncomfortable, elastic compression stockings may be prescribed. These stockings compress the veins, improving blood flow from the leg to the heart and thereby preventing the pooling of blood and the above described symptoms. These stockings should be worn during daily activities.
However, in the obese patients, sizing will be an issue, with some patients deemed to be too large to fit a suitable stocking. Compression stockings are notoriously prone to slipping down the legs in this group of patients.
TREATMENT
The surgical treatment described below becomes necessary when the stockings fail to improve symptoms and they become bothersome.
Ligation and Stripping
The traditional method of open surgery is ligation and stripping of veins. This may not be a palatable option as an incision at the groin crease needs to be made and the risk of infection of incision in an obese patient is high.
In addition to the surgical risk, this procedure requires general anaesthesia. In obese patients, the general anaesthesia risks are much higher compared to a patient with normal body size.
Minimally Invasive Techniques
Minimally invasive techniques such as Endovenous laser therapy and Radiofrequency ablation are also more difficult in obese patients. The veins are further away from the surface, making the access more difficult. The patient will either require a greater amount of local anaesthesia or even general anaesthesia.
CONCLUSION
Varicose veins in obese patients are a problem hidden in plain sight. A high index of suspicion is needed as the symptoms are often attributed to other obesity-related problems. Standard management cannot be easily applied and thus, individualised treatment is crucial for better management of this problem.
GPs can call for appointments through the GP Appointment Hotline at 6321 4402.
By: Dr Ch’ng Jack Kian, Consultant,
Department of Vascular Surgery, Singapore General Hospital
Dr Ch’ng Jack Kian is a Consultant with the Department of Vascular Surgery at the Singapore General Hospital (SGH). He sub-specialises in vascular and endovascular surgery.
His clinical interests are in aortic aneurysm surgery, carotid surgery, lower limb salvage revascularization surgery, as well as the treatment of varicose veins.
Dr Ch’ng graduated with MB Bch BAO from the Royal College of Surgeons in Ireland in 2006. In 2014, he obtained his Master of Medicine (Surgery), completed his General Surgery training, and was subsequently admitted as a Fellow of the Royal College of Surgeons of Edinburgh.
As part of his HMDP, Dr Ch’ng served as a senior clinical fellow at Waikato Hospital, New Zealand. During this time, he trained under the expert tutelage of Dr Thourdor Vasudevan, chairman of The Royal Australasian College of Surgeons for Vascular Surgery who is a renowned pioneer in advanced aortic stent grafts, fenestrated devices, peripheral devices and endovascular surgery.
Dr Ch’ng was also awarded the Singapore National Medical Research Council scholarship for clinical research training and he attained his MCI (Master in Clinical Investigation) from National University Singapore in 2012.
