Induction of Tumor Growth After Preoperative Portal Vein Embolization: Is It a Real Problem?

Although preoperative portal vein embolization (PVE) is an effective means to increase future remnant liver (FRL) volume, little has been published on possible adverse effects. This review discusses the clinical and experimental evidence regarding the effect of PVE on tumor growth in both embolized and nonembolized liver lobes, as well as potential strategies to control tumor progression after PVE. A literature review was performed using MEDLINE with keywords related to experimental and clinical studies concerning PVE, portal vein ligation (PVL), and tumor growth. Cross-references and references from reviews were also checked. Clinical and experimental data suggest that tumor progression can occur after preoperative PVE in embolized and nonembolized liver segments. Clinical evidence indicating possible tumor progression in patients with colorectal metastases or with primary liver tumors is based on studies with small sample size. Although multiple studies demonstrated tumor progression, evidence concerning a direct increase in tumor growth rate as a result of PVE is circumstantial. Three possible mechanisms influencing tumor growth after PVE can be recognized, namely changes in cytokines or growth factors, alteration in hepatic blood supply and an enhanced cellular host response promoting local tumor growth after PVE. Post-PVE chemotherapy and sequential transcatheter arterial chemoembolization (TACE) before PVE have been proposed to reduce tumor mass after PVE. We conclude that tumor progression can occur after PVE in patients with colorectal metastases as well as in patients with primary liver tumors. However, further research is needed in order to rate this risk of tumor progression after PVE.     

Does the Surface Structure of Implants Have an Impact on the Formation of a Capsular Contracture?

Background The formation of a fibrous capsule around a silicone breast implant is part of a physiologic foreign body reaction after breast augmentation. In contrast, the formation of a capsular contracture is a local complication of unknown cause. This study aimed to discover whether the surface structure of the implant (textured vs smooth) has any impact on the formation of a capsular contracture. Methods This prospective study included 48 female patients with unilateral capsular fibrosis grades 1 to 4 in Baker’s clinical scaling system. Of these patients, 14 received implants with a textured surface (Mentor), and 34 received implants with a smooth surface (Mentor). The implants all were placed in a submuscular position by the same experienced plastic surgeon. The clinical data were assessed using standardized patient questionnaires. For histologic diagnosis, operatively excised capsular tissue was examined. Preoperatively, venous blood samples for determining serum hyaluronan concentrations were taken from the patients. The control group consisted of 20 patients without capsular fibrosis. Results The separate analysis of clinical data for the patients with textured and those with smooth-surfaced breast implants showed a slightly reduced degree of symptoms for the patients with textured silicone breast implants, as compared with those who had smooth-surfaced implants. The histologic assessment of the fibrosis showed a symmetric distribution for Wilflingseder scores 1 to 3 (29% each), whereas 13% of the capsular tissues could be assigned to Wilflingseder score 4. In contrast, the histologic assessment of the patients with smooth-surfaced implants predominantly showed a Wilflingseder score of 3 (65%). The serologic investigations via enzyme-linked immunoassay (ELISA) showed serum hyaluronan concentrations of 10 to 57 ng/ml (25.0 ± 11.7 ng/ml). Therefore, no statistically significant differences in terms of serum hyaluronan levels could be determined between the two groups of patients. In comparison with the control group, the patients with implants showed elevated serum hyaluronan levels (p < 0.05). Conclusions The histologic examination and serum hyaluronan concentration analysis showed no statistically significant difference between smooth-surfaced and textured implants (Mentor) with respect to the development of capsular contracture. On the other hand, the severity of capsular contracture showed a positive linear correlation with the degree of local inflammatory reactions, which were independent of the implant surface.     

Major Hepatectomy for Colorectal Metastases: Is Preoperative Portal Occlusion an Oncological Risk Factor?

Background  This study investigates oncological risks and benefits of portal occlusion (PO) in major resection for colorectal liver metastases (CLM). Methods  Between 1995 and 2004, 107 patients were scheduled for major hepatectomy for CLM. Of these, 53 patients were selected for PO due to insufficient future liver remnant (FLR), and 54 patients had straightforward hepatectomy. Associations of clinicopathologic factors with resectability, and outcome after PO were analyzed. Results  21 of 53 patients (39.6%) after PO were unresectable. These patients had a significant smaller volume of the FLR than the 32 resected patients after PO (P = .029). In total, 17 patients (80.9%) did not undergo resection due to cancer progression. Among these, 11 patients (52.4%) exhibited either a progression of known metastases located in the occluded lobes, or new metastases in the nonoccluded portion of the liver. In another 4 individuals (19%), the decision against resection resulted from insufficient hypertrophy of the FLR. Following major hepatectomy, the 5-year survival was 43.66%. Although there was a significantly higher rate of extended hepatectomies versus formal hepatectomies (P < .001), more bilobar distributed metastases versus unilobar manifestations (P = .015), and a smaller resection margin (P = .01) in patients who had PO, no adverse effect on mortality, morbidity, recurrence and survival was observed. Conclusion  Unresectability after PO is a major problem that warrants multidisciplinary improvements, and randomization to resection with or without PO remains ethically problematic. However, following adequate patient selection, PO may provide a significant survival benefit for patients with prior unresectable CLM. L. Mueller and C. Hillert contributed equally to this work.     

Volumetric Changes after 90Y Radioembolization for Hepatocellular Carcinoma in Cirrhosis: An Option to Portal Vein Embolization in a Preoperative Setting?

Background

Contralateral hypertrophy after ⁹⁰Y radioembolization has been described in case reports, but the incidence and quantitative extent of liver volume modifications after this therapy are unknown.

Methods

This retrospective study examined patients with hepatocellular carcinoma and underlying cirrhosis treated by ⁹⁰Y radioembolization. The main inclusion criteria were unilateral treatment, no prior liver surgery, and computed tomographic scans allowing for volumetric assessments. Treated, tumor, and contralateral liver volumes were measured. Whole liver volume and the ratio of contralateral to total functional liver volume after a virtual hepatectomy were calculated.

Results

Data of 34 patients were analyzed. Response rates were 26 % according to Response Evaluation Criteria in Solid Tumors (RECIST) and 63 % according to modified RECIST. Median overall survival was 13.5 months. Median treated volume decreased from 938 mL (interquartile range [IQR] = 719) to 702 mL (IQR = 656) (p < 0.001), while median contralateral volume increased from 724 mL (IQR = 541) to 920 mL (IQR = 530) (p < 0.001). The whole liver volume remained stable, with a median volume of 1,702 mL (IQR = 568) versus 1,577 mL (IQR 670), respectively (p = 0.55). The mean maximal increase in contralateral volume was 42 % (95 % confidence interval 16–67). Overall, 13 patients (38.2 %) exhibited increases greater than 30 %, while 13 patients (38.2 %) showed no increase or showed increases less than 10 %. The median ratio of contralateral to total functional liver volume increased from 48.5 to 64.9 % (p < 0.001), with the proportion of patients with a ratio of ≥50 % increasing from 47.1 to 67.6 % (p = 0.013).

Conclusions

⁹⁰Y radioembolization induced frequent and similar increases in functional liver remnant volume compared with portal vein embolization. This technique should be tested in a prospective study phase 2 study before liver resection.     

Does the Presence of Coronary Artery Disease Impact Perioperative Outcomes Following Partial Hepatectomy?

Introduction

Coronary artery disease (CAD) is often considered a contraindication to hepatectomy despite a lack of data to support this practice. The purpose of this study is to evaluate the impact of CAD on postoperative outcomes in patients undergoing hepatectomy.

Material and Methods

A total of 1,206 consecutive patients undergoing hepatectomy from August 1995 to June 2009 were included. Propensity matching was performed to identify differences in morbidity and mortality between patients with and without CAD. Subgroup analyses were performed to stratify patients based on the severity of CAD and the interval between coronary intervention and hepatectomy.

Results

Of all patients, 138 (11.4 %) had a diagnosis of CAD and were more likely to have a malignant diagnosis and other comorbid conditions including renal insufficiency, COPD, and diabetes. Matched patients with CAD had no significant differences in complication rates, with 2.2 and 5.8 % of CAD patients experiencing a postoperative myocardial infarction or arrhythmia, respectively. Propensity matching failed to identify differences in mortality or morbidity. Subgroup analysis revealed similar rates of mortality and complications regardless of the severity of CAD or the time interval between coronary intervention and hepatectomy.

Conclusion

Despite the increased prevalence of major medical comorbidities, selected patients with CAD can safely undergo hepatectomy with acceptable rates of postoperative morbidity and mortality.     

Carotid Body Tumor Resection: Does the Need for Vascular Reconstruction Worsen Outcome?

We evaluated outcomes after carotid body tumor resection (CBR) requiring vascular reconstruction. Patients undergoing CBR at an academic medical center between 1990 and 2005 were identified. Medical records were retrospectively reviewed for clinical data, operative details, Shamblin’s classification, tumor pathology, complications, and mortality. Comparisons were performed between those undergoing CBR alone and CBR requiring vascular reconstruction (CBR-VASC). Of the 71 CBRs performed in 62 patients, 16 required vascular reconstruction (23%). Although there was no difference in mean tumor size (CBR 29.1 ± 11.9 mm, CBR-VASC 32.5 ± 9.9 mm; p = 0.133), carotid body tumors were more commonly Shamblin’s I when CBR was performed alone (CBR 53% vs. CBR-VASC 25%, p = 0.045) and Shamblin’s II/III when vascular reconstruction was required (CBR 47% vs. CBR-VASC 75%, p = 0.045). There was also a significant difference in malignant tumor pathology when vascular reconstruction was required (CBR 4.4% vs. CBR-VASC 25%, p = 0.034). Cranial nerve dysfunction was higher in patients requiring vascular repair (CBR 27% vs. CBR-VASC 63%, p = 0.012), but there was no difference in baroreflex failure (CBR 7.27% vs. CBR-VASC 0%, p = 0.351), Horner’s syndrome (CBR 5.5% vs. CBR-VASC 6.25%, p = 0.783), or first bite syndrome (CBR 7.27% vs. CBR-VASC 12.5%, p = 0.877). There were no perioperative strokes in either group, and one death was unrelated to operation. When required, carotid artery reconstruction at the time of CBR can be performed safely. Although cranial nerve dysfunction is more common when vascular repair is required, this is more likely related to locally advanced disease and tumor pathology rather than operative techniques.Presented at Sixteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Park City, UT, January 26-29, 2006.     

Clinical Outcome of Hepatectomy for Hepatocellular Carcinomas ��2?cm

Background  

The treatment strategy for hepatocellular carcinomas (HCCs) ≤2 cm (HCC2−) is still controversial. In this study, we retrospectively analyzed clinicopathological data for HCC2− and HCCs >2 cm (HCC2+) to establish the treatment strategy for HCC2−.     

Does Estrogen Have Any Real Effect on Voiding Dysfunction in Women?

For many years, estrogen has been used to treat lower urinary tract dysfunction in postmenopausal women. The data supporting this practice vary. Large multi-institutional studies have shown little role for systemic estrogens in the treatment of urinary incontinence. Vaginal estrogen preparations show superiority to systemic estrogens for the treatment of irritative voiding symptoms in meta-analysis, but there is significant study heterogeneity and the practice remains debatable. Data from randomized controlled trials support estrogen use in the prevention of recurrent urinary tract infections. This article reviews the relevant literature addressing the role of estrogen therapy in urinary incontinence, irritative voiding symptoms, and recurrent urinary tract infections.     

Is Tumor Size the Best Predictor of Outcome for Papillary Thyroid Cancer?

Background There are many risk classification schemes that determine both treatment and outcome for patients with papillary thyroid cancer. Most of these formulas often utilize tumor size as the key predictor of outcome. Furthermore, there is no clear consensus regarding the treatment of small papillary cancers. Therefore, we reviewed our experience in order to determine which factors best predict outcome for papillary thyroid cancer. In addition, we sought to establish a tumor size threshold beyond which papillary cancers require treatment.Methods From May 1994 to October 2004, 174 patients underwent surgery for papillary thyroid cancer (PTC) at our institution. These patients were divided into five groups based on tumor size. The data from these groups were analyzed utilizing ANOVA, Chi-square and linear regression analysis.Results The mean age of the patients was 42 ± 1 years and 126 (72%) were female. Mean tumor size was 17.2 ± 1.1 mm. The overall outcome was quite good with a survival rate of 97% and a recurrence rate of 12%. On univariate analysis, there was no difference amongst the groups in regards to age or gender. However, there was a significantly higher incidence of lymph node metastasis amongst those with the largest tumors. Consequently, those patients with the largest tumors were treated more aggressively, with 75% undergoing total thyroidectomies and 85% receiving radioactive iodine therapy. However, on univariate and multivariate analysis, tumor size was not shown to correlate with higher recurrence. Rather, the only factor associated with a greater recurrence rate was the presence of lymph node metastases.Conclusion At our institution, the recurrence rates for PTC were similar for all sizes of tumors. Furthermore, presence of metastatic disease at the time of diagnosis, rather than tumor size, seems to be a better predictor of recurrence and outcome.Presented at the 59th annual meeting of the Society of Surgical Oncology, San Diego, CA, March 24, 2006.     

Does Low Birthweight Have an Impact on Living Kidney Donor Outcomes?

Introduction

Because nearly 30,000 people worldwide become living kidney donors each year, donor safety is of the utmost importance. Recent studies have shown that living kidney donation is associated with an increased relative risk for end-stage renal disease (ESRD). It is essential to determine which donors will be more likely to develop ESRD. One of the risk factors for ESRD in living kidney donors is hypertension and, because there are studies demonstrating that low birthweight is a risk factor for developing hypertension in adult life, we hypothesized that donors with low birthweight may be at higher risk of developing renal disease after donation.

Does Periacetabular Osteotomy Have Depth-related Effects on the Articular Cartilage of the Hip?

Background

Osteoarthritis may result from abnormal mechanics leading to biochemically mediated degradation of cartilage. In a dysplastic hip, the periacetabular osteotomy (PAO) is designed to normalize the mechanics and our initial analysis suggests that it may also alter the cartilage biochemical composition. Articular cartilage structure and biology vary with the depth from the articular surface including the concentration of glycosaminoglycans (GAG), which are the charge macromolecules that are rapidly turned over and are lost in early osteoarthritis. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) enables noninvasive measurement of cartilage GAG content. The dGEMRIC index represents an indirect measure of GAG concentration with lower values indicating less GAG content. GAG content can normally vary with mechanical loading; however, progressive loss of GAG is associated with osteoarthritis. By looking at the changes in amounts of GAG in response to a PAO at different depths of cartilage, we may gain further insights into the types of biologic events that are occurring in the joint after a PAO.

Questions/purposes

We (1) measured the GAG content in the superficial and deep zones for the entire joint before and after PAO; and (2) investigated if the changes in the superficial and deep zone GAG content after PAO varied with different locations within the joint.

Methods

This prospective study included 37 hips in 37 patients (mean age 26 ± 9 years) who were treated with periacetabular osteotomy for symptomatic acetabular dysplasia and had preoperative and 1-year follow up dGEMRIC scans. Twenty-eight of the 37 also had 2-year scans. Patients were eligible if they had symptomatic acetabular dysplasia with lateral center-edge angle < 20° and no or minimal osteoarthritis. The change in dGEMRIC after surgery was assessed in the superficial and deep cartilage zones at five acetabular radial planes.

Results

The mean ± SD dGEMRIC index in the superficial zone fell from 480 ± 137 msec preoperatively to 409 ± 119 msec at Year 1 (95% confidence interval [CI], −87 to −54; p < 0.001) and recovered to 451 ± 115 msec at Year 2 (95% CI, 34–65; p < 0.001), suggesting that there is a transient event that causes the biologically sensitive superficial layer to lose GAG. In the deep acetabular cartilage zone, dGEMRIC index fell from 527 ± 148 msec preoperatively to 468 ± 143 msec at Year 1 (95% CI, −66 to −30; p < 0.001) and recovered to 494 ± 125 msec at Year 2 (95% CI, 5–32; p = 0.008). When each acetabular radial plane was looked at separately, the change from before surgery to 1 year after was confined to zones around the superior part of the joint. The only significant change from 1 to 2 years was an increase in the superficial layer of the superior zone (1 year 374 ± 123 msec, 2 year 453 ± 117 msec, p < 0.006).

Conclusions

This study suggests that PAO may alter the GAG content of the articular cartilage with a greater effect on the superficial zone compared with the deeper acetabular cartilage zone, especially at the superior aspect of the joint. Some surgeons have observed that surgery itself can be a stressor that can accelerate joint degeneration. Perhaps the decrease in dGEMRIC index seen in the superficial layer may be a catabolic response to postsurgical inflammation given that some recovery was seen at 2 years. The decrease in dGEMRIC index in the deep layer seen mainly near the superior part of the joint is persistent and may represent a response of articular cartilage to normalization of increased mechanical load seen in this region after osteotomy, which may be a normal response to alteration in loading.

Clinical Relevance

This study looks at the biochemical changes in the articular cartilage before and after a PAO for dysplastic hips using MRI in a similar manner to using histological methods to study alterations in articular cartilage with mechanical loading. Although PAO alters alignment and orientation of the acetabulum, its effects on cartilage biology are not clear. dGEMRIC provides a noninvasive method of assessing these effects.     

Does Extralaryngeal Branching Have An Impact on the Rate of Postoperative Transient or Permanent Recurrent Laryngeal Nerve Palsy?

Background  This prospective study assessed the prevalence of the extralaryngeal branching of the recurrent laryngeal nerve (RLN) and its impact on the incidence of postoperative transient or permanent RLN palsy. Methods  Total or hemithyroidectomy was performed in 115 patients, with a total of 195 RLNs displayed. The RLN extralaryngeal branches were routinely identified and preserved. The postoperative course of each patient was evaluated. Outcomes of patients with and without branching RLN were compared. Results  In all, 36 of 195 (18.5%) nerves showed extralaryngeal branching: 27 cases (25.5%) on the right and 9 on the left side (10.1%; p = 0.0088).Trifurcation of the RLN was identified in two dissections (1%). Bilateral bifurcations were observed in 3 of 80 (3.7%) patients. We reported four (2.1%) unilateral permanent RLN palsies, eight cases of unilateral transient nerve palsy (4.1%), and one bilateral transient RLN injury (0.6%). The comparative analysis of postoperative outcomes between branched and nonbranched RLNs revealed that the anatomical variation was more frequently associated both with unilateral permanent RLN palsy (relative risk, 13.25; 95% confidence interval, 1.42–123.73; p = 0.0204) and unilateral transient RLN palsy (relative risk, 7.36; 95% confidence interval, 1.84–29.4; p = 0.0061). The only case of bilateral transient RLN injury was associated with a nonrecurrent inferior laryngeal nerve. Conclusions  Branched RLNs represent a risk factor both for transient and permanent nerve palsy after surgery. Awareness of this anatomical variation and its routine investigation are essential during thyroid surgery to limit its relevant impact on postoperative RLN injury rate.     

Does Pretransplantation Etiology Have Any Effect on Exercise Results in Heart Transplant Patients?

Objective

The objective of this study was to analyze the effect of pre-transplantation etiology and post-transplantation exercise on pulmonary function tests, functional capacities, psychological symptoms and quality of life among heart transplant patients.

Methods

An eight-week exercise program was applied to 35 heart transplant patients with histories of ischemic heart failure (HF; n = 20) or dilated HF (n = 15). All patients were evaluated before and after exercise in terms of breathing function tests, functional capacity (FVC; maximal oxygen consumption, pVO2), psychological symptoms (Beck Depression Scale (BDS), Spielberger's State-Trait Anxiety Inventory (STAI)) and quality of life (Short Form 36, SF-36).

Results

At the end of the exercise compared to the pre-exercise period significant improvements were observed in all FVC%, FeV1%, FeV1/FVC%, pVO2, SF 36 scores reflecting physical function, physical role, pain, general health, vitality, social function, and emotional role (P < 0.05) among heart transplant patients who were operated due to ischemic or dilated heart failure. In contrast, no significant improvement was observed in the BDS and STAI scales (P > 0.05). There was no significant etiology-related difference between the groups in terms of the evaluated parameters (P > 0.05).

Conclusion

We demonstrated improvements in function tests, functional capacity and quality of life for both ischemic and dilated heart transplant patients following a supervised exercise program. We concluded that the positive effect achieved by exercise was not related to pre-transplantation etiology. Whatever the preoperative etiology, a regular exercise program is recommended for heart transplant patients in the rehabilitation unit.     

Impact of Preoperative Risk Factors on Morbidity after Esophagectomy: Is There Room for Improvement?

Background

Despite progress in multidisciplinary treatment of esophageal cancer, oncologic esophagectomy is still the cornerstone of therapeutic strategies. Several scoring systems are used to predict postoperative morbidity, but in most cases they identify nonmodifiable parameters. The aim of this study was to identify potentially modifiable risk factors associated with complications after oncologic esophagectomy.

Methods

All consecutive patients with complete data sets undergoing oncologic esophagectomy in our department during 2001–2011 were included in this study. As potentially modifiable risk factors we assessed nutritional status depicted by body mass index (BMI) and preoperative serum albumin levels, excessive alcohol consumption, and active smoking. Postoperative complications were graded according to a validated 5-grade system. Univariate and multivariate analyses were used to identify preoperative risk factors associated with the occurrence and severity of complications.

Results

Our series included 93 patients. Overall morbidity rate was 81 % (n = 75), with 56 % (n = 52) minor complications and 18 % (n = 17) major complications. Active smoking and excessive alcohol consumption were associated with the occurrence of severe complications, whereas BMI and low preoperative albumin levels were not. The simultaneous presence of two or more of these risk factors significantly increased the risk of postoperative complications.

Conclusions

A combination of malnutrition, active smoking and alcohol consumption were found to have a negative impact on postoperative morbidity rates. Therefore, preoperative smoking and alcohol cessation counseling and monitoring and improving the nutritional status are strongly recommended.     

Diabetes Mellitus and Gender Have a Negative Impact on the Outcome of Hip Fracture Surgery—A Pilot Study

Diabetes mellitus (DM) is associated with an elevated risk of post-operative complications. The impact it has on patients living with DM following hip fracture surgery (HFS) is not completely understood and may represent a predictor of increased mortality. This study investigates the impact of DM, gender, American Society of Anaesthesiologists (ASA) grade, and fracture location, on the outcome of HFS in Ireland. The Hospital Inpatient Enquiry (HIPE) database records all fragility hip fractures within Galway University Hospital. Retrospective data collection was performed over a 3-year period. Data collected included patient age, gender, date of HFS, anatomical fracture location, type of operation, ASA grade, DM status, and mortality. A database of 650 individuals was created including 461 females and 189 males, with an average group age of 80.2 ± 9.3 years. Results showed a significantly higher incidence of hip fractures in males with DM (19.57%) than females with DM (12.36%) (χ² test, p = 0.020). Cox regression survival analysis indicated that DM status and ASA grade were the two main independent predictors of patient survival following HFS. Nevertheless, when examining the combined impact of gender and DM status on survival after HFS, results showed that survival post HFS differed significantly with gender and presence of DM (log-rank test, p < 0.001), with males with DM performing worse than females with DM (p = 0.021) or males without DM (p = 0.001). This gender and disease-associated outcome should prompt an early multi-disciplinary team approach to the management of hip fractures in patients with DM. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:834-842, 2020     

Adjunctive Proximal Vein Ligation with Endovenous Obliteration of Great Saphenous Vein Reflux: Does It Have Clinical Value?

The risk of clot extension to the deep venous system or pulmonary embolism following endovenous great saphenous vein (GSV) obliteration is possibly related to the size of the proximal GSV. Some practitioners therefore exclude endovenous GSV obliteration for veins greater than an arbitrary size, starting as little as 15 mm. Others provide adjunctive proximal GSV ligation either routinely, or in selected patients with large veins. The clinical value of adjunctive proximal GSV ligation is unknown. A survey of either the American Venous Forum or the American College of Phlebology, selected for their pedagogic or long-time experience with endovenous GSV obliteration. Respondent characteristics included obliteration technique (laser, radiofrequency [RF], or foam sclerotherapy), academic status, surgical training, indication for and frequency of adjunctive proximal GSV ligation, and society membership. The incidence of pulmonary embolus (PE) and deep vein thrombus (DVT) was also tallied. Twenty-one thousand nine hundred sixty-five endovenous GSV obliteration cases were reported, 10,290 with a laser (46.8%), 6,275 (28.6%) with RF, and 5,400 (24.6%) with foam. Only two PEs were reported. Of the 34 patients with DVT, at least 11 had only asymptomatic ultrasound evidence of thrombus extension into the femoral vein, and at least five had only calf vein thrombosis. Comparing ligators (7) with non-ligators (15), the only characteristic significantly correlating with adjunctive proximal GSV ligation was whether the respondent had complete general or vascular surgical training; non-surgeons never ligated the saphenous vein (p < .001). There was no difference between outcomes of ligators and non-ligators. Endovenous obliteration of the GSV poses little risk of PE or DVT, no matter what size the proximal GSV. Although these adverse events may be reduced with adjunctive proximal GSV ligation, the results of this study suggest that adjunctive proximal GSV ligation is superfluous in most patients.