Does body mass index have an effect on clinical and pain after endovenous therapy? A retrospective study

Abstract

Objectives:

The study aims to investigate the change in postoperative clinic, pain, and general quality of life of patients who were operated on due to chronic venous disease (CVD), according to their body mass index (BMI).

Materials and methods:

150 patients (30–45 years) who were treated with cyanoacrylate embolization for CVD between January 2017 and February 2020 were analyzed retrospectively. The clinical (C) category of clinical, etiology, anatomy, and pathophysiology (CEAP) classification venous clinical severity score (VCSS) and visual analog scale (VAS) questionnaires were applied to the patients before and after the operation periodically. The patients were surveyed preoperatively and postoperatively at 1st, 6th, 12th, and 24th months.

Results:

The patients were divided into three groups according to their BMI. In the comparison between normal and overweight participants, venous reflux, CEAP C categories, and VAS scores were not statistically significantly different in preoperative and postoperative periods. In the comparison between normal and obese participants, CEAP C categories, VCSS, and VAS scores were statistically significantly different in postoperative periods. There was no statistically significant difference in terms of venous reflux preoperatively and postoperatively in all three groups.

Conclusions:

The study showed that the increase in BMI had negative effects on the CEAP C categories, pain, and quality of life independently of the venous reflux of CVD.

Keywords

chronic venous disease obesity quality of life pain C categories

Introduction

Chronic venous disease (CVD) is defined as a condition that includes subjective symptoms such as pain, itching, cramps, edema, restlessness in the legs, and skin changes. Chronic venous disease can cause a significant decrease in quality of life.^1,2 The most important predisposing factors for CVD are genetic predisposition, obesity, extended periods of standing or sitting sitting for a long time or working by standing, history of thrombophlebitis, trauma, and pregnancy.³ Although obesity is an important risk factor for the development of venous insufficiency, the prevalence is increasing in Turkey as in the world every day. Chronic venous disease is more common in women than in men.^4,6 Obesity is an important risk factor for the development of CVD. In obese patients, increased intra-abdominal and venous pressure may compromise venous return and lymphatic return. As a result, lymphovenous hypertension may occur. Increased intra-abdominal pressure in obese patients may endanger venous return and lymphatic return by creating a reverse pressure to venous return, which may be the cause of lymphovenous hypertension. Increasing venous pressure and increased capillary permeability cause changes in the skin and subcutaneous tissue. Fluid, macromolecules, and hemosiderin accumulate in the extravascular space. Edema, venous eczema and dermatitis, pigmentation, and ultimately venous ulcers may occur. The risk increases even more especially in obese individuals with a lack of mobility. Even minor trauma cause wounds as a result of the progressive damage of the dermal and subcutaneous tissues.^7,8 The aim of this study is to examine whether the increased body mass index (BMI) has postoperative effects on the venous system. For this purpose, patients were categorized according to BMI, and their effects on medium- and long-term results were compared by recording clinic, pain, and venous reflux values before and after the procedure.

Patients and methods

One-hundred fifty patients between 30 and 45 years of age who were treated with CAE (cyanoacrylate) due to severe saphenous vein failure between January 2017 and February 2020 in Bitlis State Hospital Cardiovascular Surgery Clinic were retrospectively analyzed. Patients with saphenous vein failure were graded according to CEAP category C. Reflux > 0.5 s in the great saphenous vein (GSV) was defined as saphenous vein failure. According to the CEAP C category, the patient group from C3 to 6 and reflux in the GSV with ≥4 s is defined as severe saphenous vein failure. Ethics committee approval for this study was approved by the Ethics Committee of Bitlis Eren University with the decision dated 08.05.2019 and 2019/05-8. After the demographic data of the patients were recorded, body mass indexes were calculated by measuring height and body weight (Table 1). The index formulated by WHO has been used to determine obesity.⁹ The index, called the BMI, is calculated by dividing the weights of people in kilograms by the square of their height in meters (BMI = kg/m²). According to this index, 30.00 or above BMI value is defined as obese, between 25.00 and 29.99 is described as overweight, between 18.5 and 24.99 is identified as normal weight, and <18.5 is defined as underweight. In the study, patients were divided into three groups according to their BMI (Table 1). Clinical, etiology, anatomy, and pathophysiology C categories, venous clinical severity score (VCSS) classification, and visual analog scale (VAS) questionnaires were applied to the patients at certain periods before and after the procedure (Table 2). The patients were surveyed preoperatively according to the C of the CEAP classification (Table 2). The CEAP classification was made in 1994 with a questionnaire accepted by the American Venous Forum. The questionnaire provides all the clinical findings that may occur in venous insufficiency patients but also includes numerical scoring after control. There are also etiological, anatomical, and pathophysiological controls and scoring.^10,11

Table 1.

Comparison of demographic and clinical features between the three groups.

		Group (n = 150)
		Normal weight (n = 50)		Overweight (n = 50)		Obese (n = 50)		p
Age	Mean ± SD (n)	38.00 ± 3.37		38.34 ± 4.10		38.20 ± 4.11		0.907
Duration of operation (minute)	Mean ± SD (n)	13.08 ± 2.75		14.52 ± 2.81		15.56 ± 3.41		<0.001
Preoperative USG (second)	Mean ± SD (n)	7.63 ± 1.55		7.45 ± 1.85		8.90 ± 13.7		<0.001
Sex (n/%)	Woman	25	50.0	25	50.0	25	50.0	0.999
Sex (n/%)	Man	25	50.0	25	50.0	25	50.0
DM (n/%)	No	50	100.0	47	94.0	45	90.0	0.081
DM (n/%)	Yes	0	0.0	3	6.0	5	10.0
HT (n/%)	No	48	96.0	46	92.0	41	82.0	0.056
HT (n/%)	Yes	2	4.0	4	8.0	9	18.0
CAD (n/%)	No	50	100.0	49	98.0	48	96.0	0.773
CAD (n/%)	Yes	0	0.0	1	2.0	2	4.0
Smoking (n/%)	No	21	42.0	28	56.0	27	54.0	0.318
Smoking (n/%)	Yes	29	58.0	22	44.0	23	46.0
Family history (n/%)	No	22	44.0	23	46.0	25	50.0	0.829
Family history (n/%)	Yes	28	56.0	27	54.0	25	50.0
Side OF CVD (n/%)	Right	30	60.0	28	56.0	24	48.0	0.471
Side OF CVD (n/%)	Left	20	40.0	22	44.0	26	52.0
Preoperative burning sensation in leg (n/%)	No	33	66.0	31	62.0	25	50.0	0.238
Preoperative burning sensation in leg (n/%)	Yes	17	34.0	19	38.0	25	50.0
Preoperative leg fatigue (n/%)	No	36	72.0	37	74.0	27	54.0	0.065
Preoperative leg fatigue (n/%)	Yes	14	28.0	13	26.0	23	46.0
Preoperative Pruritus (n/%)	No	35	70.0	37	74.0	32	64.0	0.551
Preoperative Pruritus (n/%)	Yes	15	30.0	13	26.0	18	36.0

a = 1 >2.3, b = 3 >2.1, and c = Fisher’s exact chi-square test.

CVD: chronic venous disease.

Table 2.

Comparison of venous reflux, CEAP C categories, VCSS, and VAS score means between the three groups in preop and postop periods.

		Group
		Normal weight		Overweight		Obese		I–II	I–III	II–III
		Mean	SD	Mean	SD	Mean	SD
Venous reflux
	Preop*	3.94	0.24	3.80	0.49	3.84	0.42	0.104	0.178	0.755
	Postop 6th month*	0.00	0.00	0.00	0.00	0.02	0.14	0.999	0.317	0.317
	Postop 12th month*	0.00	0.00	0.02	0.14	0.06	0.24	0.317	0.080	0.310
	Postop 24th month*	0.00	0.00	0.04	0.20	0.14	0.45	0.155	0.070	0.230
CEAP C categories
	Preop*	3.88	0.44	3.84	0.47	3.90	0.54	0.646	0.891	0.594
	Postop 1st month	0.68	0.74	0.96	0.60	1.28	0.61	0.085	<0.001	0.045
	Postop 6th month*	0.52	0.58	0.56	0.61	1.04	0.64	0.779	<0.001	<0.001
	Postop 12th month*	0.40	0.57	0.34	0.52	0.74	0.75	0.634	0.014	0.003
	Postop 24th month*	0.38	0.53	0.32	0.47	0.74	0.80	0.627	0.017	0.004
VCSS
	Preop	7.58	0.91	7.66	0.87	8.24	1.00	0.903	0.001	0.006
	Postop 1st month	1.84	0.47	2.40	0.95	2.22	0.68	<0.001	0.026	0.431
	Postop 6th month	1.32	0.55	1.48	0.91	1.70	0.65	0.507	0.024	0.279
	Postop 12th month*	0.54	0.61	1.02	0.68	1.34	0.69	0.001	<0.001	0.045
	Postop 24th month*	0.44	0.58	0.86	0.57	1.24	0.62	<0.001	<0.001	0.002
Preop pain scores (VAS)
	Preop	7.66	0.66	7.94	0.74	7.72	0.78	0.137	0.911	0.290
	Postop 1st month	1.36	0.88	1.36	0.69	1.82	0.66	0.999	0.007	0.007
	Postop 6th month	0.84	0.71	1.02	0.55	1.52	0.65	0.340	<0.001	<0.001
	Postop 12th month	0.66	0.59	0.80	0.73	1.24	0.89	0.619	0.011	0.008
	Postop 24th month	0.54	0.61	0.74	0.69	0.98	0.84	0.353	0.008	0.225

*Mann–Whitney U test; others: Tukey test.

CEAP: clinical, etiology, anatomy, and pathophysiology; VCSS: venous clinical severity score; VAS: visual analog scale.

The patients were controlled preoperatively and postoperatively at 1st, 6th, 12th, and 24th months, and both their quality of life and clinic were evaluated. In all controls, data were recorded with the VCSS clinical scoring system questionnaire (score 0 does not represent a significant venous disease and score 30 presents the most severe score).¹² VAS was used to determine the severity of the patients’ complaints. The patients were asked to mark the degree of their complaints on a 10 cm scale. According to the scale, the value of “0” showed that there were no complaints, while the value of “10” showed that their complaints were very severe.¹³ Visual analog scale scoring questionnaire was applied to all our patients in the preoperative period and the postoperative 1st, 6th, 12th, and 24th months. Venous clinical severity score classification and visual pain scale (VAS) questionnaires were also applied at certain periods before and after the operation and recorded in the groups classified according to BMI (Table 2). With the results obtained, it was examined whether the BMI had effects on patients who were treated due to venous insufficiency. doppler ultrasound scan (DUS), grade 4 reflux flow was observed in saphenofemoral junction (SFJ) in all patients during the preoperative period. The deep venous system was evaluated as normal in all patients. The criteria for inclusion in the study were reflux in the GSV with >0.5 s in evaluation with DUS, patients group from C3 to six according to the CEAP C categories, being symptomatic, reflux in the deep venous system with <0.5 s in evaluation with DUS, and insufficiency only in the GSV, and its branches, that the 2 cm distal to the SFJ. The criteria for exclusion from the study were deep venous thrombosis (DVT), arteriovenous malformation, severe immobility, reflux in the deep venous system with >0.5 s in evaluation with DUS, and history of thrombophlebitis. Ecchymosis, pain, induration, paresthesia, superficial thrombophlebitis, and temporary color change on the skin were considered as minor complications, while motor nerve damage, large artery and vein injury, skin burn, arteriovenous fistula formation, DVT, and pulmonary thromboembolism situations requiring follow-up were considered as major complications.

Follow-up examinations

The patients were evaluated clinically in the postoperative first month, sixth month, first year, and second year. Patients were divided into groups according to their BMI, and DUS was performed in the sixth month, first year, and second year to examine venous reflux in the treated segment of GSV. Venous clinical severity score and CEAP C categories scores of the patients were also recorded at each visit (Table 2). Pain was measured using the VAS. During discharge, all patients were asked to use the VAS and fill out the given cards. Cards were taken from the patients in the first month control. Chronic venous disease symptoms and minor and major complaints were recorded as complications.

Statistical analysis

Categorical variables among normal weight, overweight, and obese participants were compared with Pearson’s chi-square analysis. Besides, the comparison of the variables that were proportionally less than 5% was analyzed with Fisher’s exact chi-square analysis. To compare venous reflux, CEAP C categories, VCSS, and VAS scores between the three groups in the preoperative and postoperative periods, ANOVA analysis and Tukey test were used in the data with normal distribution, and Mann–Whitney U test was used in the data without normal distribution. Relationships between BMI, duration of the operation, DUS, venous reflux, CEAP C categories, VCSS, and VAS in all participants were examined with Pearson correlation analysis. For normal distribution, kurtosis and skewness coefficients were tested in the range of ±1.5. The significance level was determined as p < 0.05 for all analyses. IBM SPSS 22.0 program was used to analyze the data.

Results

The mean age of the normal weight participants evaluated in the study was 38.00 ± 3.37, the mean age of overweight participants was 38.34 ± 4.10, and the mean age of the obese participants was 38.20 ± 4.11, and the mean age between the three groups was not statistically different (p = 0.907). The duration of operation of normal, overweight, and obese participants were 13.08 ± 2.75, 14.52 ± 2.81, and 15.56 ± 3.41, respectively, and the mean operation times were found to be statistically different between the three groups (p < 0.001). According to the Tukey test, the duration of operation of obese participants was found to be statistically significantly higher (p < 0.05) than normal weight and overweight individuals. Preoperative DUS times of normal, overweight, and obese participants were 7.63 ± 1.55, 7.45 ± 1.85, and 8.90 ± 1.37, respectively, and DUS means were statistically significantly different between the three groups (p < 0.001). In accordance with the Tukey test, it was determined that the preoperative DUS means of obese participants were statistically significantly (p < 0.05) higher than normal weight and overweight individuals. Gender, diabetes mellitus (DM), hypertension (HT), coronary artery disease (CAD), smoking, family history, venous insufficiency on which side, preoperative burning, leg fatigue, and pruritus rates were not statistically different among the three groups (Table 1).

In the comparison between normal and overweight participants, venous reflux, CEAP C categories, and VAS scores were not statistically significantly different in preoperative and postoperative periods (p > 0.05); in addition, postop 1st month, postop 12th month, and postop 24th month VCSS scores were found to be statistically significantly different between these two groups (p < 0.001). In the comparison between normal and obese patients postop 1st month CEAP C categories scores, postop 6th month CEAP C categories scores, postop 12th month CEAP C categories scores, and postop 24th month CEAP C categories scores were found to be statistically significantly different (p < 0.05). The means of preoperative VCSS scores and each postop (from 1st to 24th month) VCSS scores were found to be statistically different between obese and normal weight participants. Besides, it was found that preoperative VAS scores were not statistically different between these two groups and each postoperative period (from 1st to 24th months) VAS scores were statistically significantly different (p < 0.05). In the comparison between overweight and obese participants, preoperative and each postoperative venous reflux scores means were not statistically significantly different (p > 0.05), whereas each postoperative (from 1st to 24th months) CEAP C categories scores, preoperative VCSS scores, postoperative 12th month VCSS scores, and postoperative 24th month VCSS scores were statistically significantly different (p < 0.05). VAS scores in the preoperative period were not statistically different between obese and overweight participants; additionally, scores of postoperative 1st month VAS, 6th month VAS, and 12th month VAS were found to be statistically significantly different (Table 2). At the 24th month follow-up, GSV recanalization was detected in seven patients due to mild to moderate reflux. However, these patients had no intervention and were followed up with medical treatment.

According to Pearson correlation analysis, there was found statistically significantly positive correlation between BMI values and duration of operation preoperative DUS results and VCSS scores among all participants (Table 3).

Table 3.

Relationship between BMI, op duration, USG, venous reflux, CEAP C categories, VCSS, and VAS values.

Correlation		BMI	Duration of operation	USG preoperative	Venous reflux preoperative	CEAP preoperative	VCSS preoperative
BMI	r	—
BMI	p	—
Duration of operation	r	0.297
Duration of operation	p	0.000
USG preoperative	r	0.282	0.101
USG preoperative	p	0.000	0.219
Venous reflux preoperative	r	−0.135	−0.079	0.117
Venous reflux preoperative	p	0.100	0.338	0.155
CEAP C categories preoperative	r	0.040	0.134	0.231	−0.023
CEAP C categories preoperative	p	0.626	0.102	0.005	0.781
VCSS preoperative	r	0.300	0.227	0.275	−0.011	0.528
VCSS preoperative	p	0.000	0.005	0.001	0.893	0.000
VAS preoperative	r	0.042	0.027	−0.005	−0.017	−0.044	−0.008
VAS preoperative	p	0.607	0.748	0.949	0.834	0.595	0.918

BMI: body mass index; CEAP: clinical, etiology, anatomy, and pathophysiology; VCSS: venous clinical severity score; VAS: visual analog scale.

The normal weight patients in the first postoperative month, 4 (8%) of the patients had leg fatigue, 4 (8%) of them had pruritus, and 2 (4%) of them had a burning sensation in the leg. In the sixth month postoperative period, it was evaluated that 1 (2%) of the patients had leg fatigue, 1 (2%) of them had pruritus, and none had burning sensation. No minor complications were observed in patients with normal weight in the postoperative 12th month follow-up. No major complications were observed in patients with normal weight patients (Table 4).

Table 4.

Changes of the venous insufficiency symptom rates of the normal weight participants for 12 months.

Complication	Symptom	Postop 1st month n (%)	Postop 6th month n (%)	Postop 12th month n (%)
Minör	Fatigue in leg	4 (8)	1 (2)	0 (0.0)
Minör	Pruritus in leg	4 (8)	1 (2)	0 (0.0)
Minör	Burning sensation in leg	2 (4)	0 (0.0)	0 (0.0)
Minör	Redness in leg	1 (2)	0 (0.0)	0 (0.0)
Minör	Thrombophlebitis	—	—	—
Major	Deep venous thrombosis	—	—	—
Major	Pulmonary embolism	—	—	—

The overweight patients in the first postoperative month, 5 (10%) of the patients had leg fatigue, 4 (8%) of them had pruritus, 3 (4%) of them had burning sensation, and 2 (4%) of them had redness. In the sixth month postoperative period, it was evaluated that 2 (4%) of the patients had leg fatigue, 1 (2%) of them had pruritus, and 1 (2%) of them had burning sensation. No minor complications were observed in patients with overweight in the postoperative 12th month follow-up. No major complications were observed in patients with overweight patients (Table 5).

Table 5.

Changes of the venous insufficiency symptom rates of the overweight participants for 12 months.

Complication	Symptom	Postop 1st month n (%)	Postop 6th month n (%)	Postop 12th month n (%)
Minör	Fatigue in leg	5 (10)	2 (4)	0 (0.0)
Minör	Pruritus in leg	4 (8)	1 (2)	0 (0.0)
Minör	Burning in sensation leg	3 (6)	1 (2)	0 (0.0)
Minör	Redness in leg	2 (4)	0 (0.0)	0 (0.0)
Minör	Thrombophlebitis	—	—	—
Major	Deep venous thrombosis	—	—	—
Major	Pulmonary embolism	—	—	—

The obese patients in the first postoperative month, 8 (16%) of the patients had leg fatigue, 7 (14%) of them had pruritus, 7 (14%) of them had burning sensation, and 4 (8%) of them had redness. In the sixth month postoperative period, it was evaluated that 3 (6%) of the patients had leg fatigue, 3 (6%) of them had pruritus, 2 (4%) of them had burning sensation, and 1 (2%) of them had redness. In the 12th month, 1 (2%) of the patients had leg fatigue and 1 (2%) of them had pruritus. No major complications were observed in patients with obese patients (Table 6).

Table 6.

Changes of the venous insufficiency symptom rates of the obese participants for 12 months.

Complication	Symptom	Postop 1st month n (%)	Postop 6th month n (%)	Postop 12th month n (%)
Minör	Fatigue in leg	8 (16)	3 (6)	1 (2)
Minör	Pruritus in leg	7 (14)	3 (6)	1 (2)
Minör	Burning sensation in leg	7 (14)	2 (4)	0 (0.0)
Minör	Redness in leg	4 (8)	1 (2)	0 (0.0)
Minör	Thrombophlebitis	—	—	—
Major	Deep venous thrombosis	—	—	—
Major	Pulmonary embolism	—	—	—

Discussion

Results from this study confirm that the increase in BMI had an impact on the CEAP C category, pain, and quality of life independently of the venous reflux of CVD. In the comparison between normal weight and obese patients, it was found that the CEAP C category, VCSS score averages, and VAS score averages were statistically different in postoperative (1st to 24th month) controls. In this study, postoperative 12th month follow-up, no minor or major complications were observed in normal weight and overweight patients. Minor complications were seen in 2 (4%) patients at 12 months in the obese group. These patients were followed up with medical treatment and their complaints were resolved. There were no major complications in obese patients.

Obesity is one of the primary risk factors for CVD. In a study, 482 CVD patients between C0 and C4 were evaluated, and it was determined that the patients’ BMI values increased as they progressed from C0 to C4.¹⁴

How high BMI has an impact on CVD has not been fully explained. Visceral obesity increases intra-abdominal pressure, and high pressure is transmitted to the lower extremity veins through the femoral vein, thereby causing stasis and venous valve dysfunction. This situation causes the vein walls to be constantly under the high pressure in obese individuals.¹⁵ However, high intra-abdominal pressure affects lymphatic return, and it triggers lymphovenous hypertension.¹⁶ Other factors such as low physical activity level, sedentary life, and limitation in ankle joint movements increase the prevalence of CVD in obese people.¹⁷

In the current study, it was detected that there was no statistically significant difference between the three groups separated according to patients’ BMI values in terms of CEAP C categories scoring before the procedure.

In a study, it was observed that in patients with increased BMI, VCSS and CEAP C categories grading increased in parallel, but no relationship was observed with DUS findings.¹⁸ In another study, although CEAP C categories and pain scores in patients with increased BMI and venous insufficiency were found to be relatively higher despite not statistically significant compared to other groups.¹⁹

In the current study, venous reflux, CEAP C categories, and VAS scores were not statistically different between preoperative and postoperative periods in the comparison between normal and overweight participants; it was, however, found that each postoperative (from 1st to 24th months) VCSS scores were statistically significantly different between the two groups. Postoperative (1st‐ 24th month) CEAP C categories score means, and VCSS preoperative and postoperative (1st‐24th month) score means were statistically significantly different between the normal weight and obese patients. In addition, it was found that preoperative VAS scores did not differ between the two groups, and postoperative period (1st–24th month) VAS score means were statistically different. Preoperative and postoperative venous reflux means were not statistically different, whereas postop (1st‐24th month) CEAP C categories scores and preoperative VCSS scores were statistically different between overweight and obese participants. Visual analog scale scores were not statistically significantly different in the preoperative period between obese and overweight participants; additionally, postop 1st and 12th months VAS scores were determined to be statistically significantly different between the two groups.

Obesity is associated with diabetes, reproductive disorders, osteoarthritis, gastrointestinal and respiratory diseases, sleep apnea, and some types of cancer, especially cardiovascular diseases, and it is defined as a disease that adversely affects the individuals’ life expectancy and quality of life. Additively, its frequency is increasing worldwide and causes serious mortality and morbidity.²⁰ In a study, the relationship between comorbidities and CVD was examined in 1679 CVD patients. This study, which shows that the frequency of comorbidities increases as the severity of the disease increases, has been the only study that examined a large number of comorbidities in patients with CVD.²¹

In the present study, the rates of HT, CAD, and DM between the groups were not statistically different.

The Organization for Economic Cooperation and Development reports in 2017 indicate that the prevalence of obesity and overweight in adults aged between 20 and 79 years in 34 countries was 19.4% and 34.5%, respectively, whereas this rate was found to be 22.3% and 33.1%, respectively, in Turkey according to the statistical findings of 2015.²² Protection programs for reducing obesity prevalence are very important as they are easier, cheaper, and more effective than treatment methods. In these programs, it is emphasized that “high-calorie food intake” and “sedentary life” should be taken into consideration.²³

Although this study was a single-center, it had some limitations. Probably, one of the most important limitations of this study is the nature of a retrospective analysis with a short follow-up time. The other limitation was that any patient with underweight (<18.5 kg/m²) or patients with 2nd and 3rd level—severe—obesity (>35 kg/m²) considering the BMI criteria were excluded from the study because of the limited participation.

Conclusions

After the 24-month follow-up, we conclude the increase in BMI had an impact on the CEAP C categories, pain, and quality of life independently of the venous reflux of CVD. When we look at the current studies on obesity, we see that it supports our study. It was observed that protection programs for obesity were also important when planning the treatment of venous insufficiency in patients with increased BMI with venous insufficiency. In addition to medical treatment, patients were informed about the risk of weight gain and the importance of diet programs and walking programs for CVD during discharge. In chronic venous system diseases associated with obesity, it is known that struggling with obesity is an important step in combating these diseases. However, due to the lack of sufficient and long-term results in the literature regarding the effects of increased BMI on the venous system, new studies on the subject are needed.

Footnotes

Acknowledgements

I thank you for your contribution to Bitlis provincial health directorate public health department.

Author contributions

During my stay at Bitlis State Hospital, I took care of all the patients myself. I performed surgery on patients, designed the idea and procedure, searched the literature, analyzed data, and wrote the article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval/Patient consent

Ethics committee approval for this study was approved by the Ethics Committee of Bitlis Eren University with the decision dated 08.05.2019 and 2019/05-8.

ORCID iD

Mehmet O Donbaloğlu

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