The Bigger They Are, The Worse the Ulcers!

Dear Readers:

Obesity is so common that we rarely think much about it. However, it has progressed to the point that obesity is considered an epidemic in the United States, with about 40% of people being obese, per the 2015–2016 numbers.¹ I am pleased to know that Alabama is no longer the “fattest” state; it seems West Virginia recently inherited that title.¹ This problem is acutely noted in our wound center when we are confronted with a patient who is obese and has a venous leg ulcer. Those in wound care deal with the challenges of appropriately treating this patient population and realizes that treating a venous ulcer in a “very large” patient may require unique approaches.

There is no question that a significant etiology of venous ulcers is chronic venous insufficiency. It follows that venous insufficiency worsens with an increasing body mass index (BMI).² One thing that is striking in the patient who is obese and has venous insufficiency is that 66% of these patients have no anatomic evidence of venous disease.³ These patients have “functional” venous insufficiency with no evidence of valvular incompetence or venous obstruction—a problem called obesity-associated dependency syndrome.⁴ Venous dilatation and venous insufficiency occur because the patient’s extremities are chronically dependent. Another problem is the loss of the calf-muscle pump due to restricted mobility of the ankle resulting from patient immobility. This is known as arthrogenic stasis syndrome.⁵ Other issues contributing to venous insufficiency include increased intraabdominal pressure due to the large abdominal pannus applying pressure on the intraabdominal veins.⁶ At a BMI greater than 25, femoral venous pressure is elevated because of the pannus increasing pressure on and partially obstructing the groin vessels, especially while sitting.⁷ This increased venous pressure both in the abdomen and groin compromises lymphatic return, causing more problems.³ With these multiple causes of increased venous pressure in the extremities, it would seem that more than ordinary treatments may be required to help treat these patients.

Compression therapy is still the standard of care, but unique approaches will be necessary in these patients. It has been found, and I think majority would agree, that compression hose are not practical.³ Short-stretch compression bandages have been recommended because of their higher pressure with muscle contraction and their ability to stay on an abnormally shaped leg.⁸ Compression with the adjustable Velcro garments and intermittent (sequential) compression devices have proved useful.³ Remember that venous ablation will not be useful unless anatomical valvular reflux can be documented, but this will be found in only about 30% of patients who are obese and have venous disease and venous ulcers.³ One of the most important treatments is to get the patient moving to involve the calf-muscle pump to improve venous return. Advanced methods to stimulate the calf-muscle pump include nerve and muscle electrical stimulation, which causes calf muscle contraction.^9,10 These techniques have shown some early promise and may be helpful if the patient is unable to ambulate. Obviously, an important treatment component would be to have the patient lose weight. This would not only help their venous disease and venous ulcers but other diseases that accompany obesity. Gastric bypass or other weight loss operations have been said to be among “the most effective management tools” for the patient with obesity and venous disease.¹¹

Patients who are obese and have venous disease and venous ulcers will continue to present a major treatment challenge for the wound care provider. Hopefully, we will be able to enlist the patient’s help in doing what it may take to successfully treat these problems. As the epidemic of obesity continues, we have our work cut out for us.

Correspondence: 
Terry Treadwell, MD, FACS
Senior Clinical Editor, Wounds
woundseditor@hmpglobal.com

1. World Population Review. Accessed January 15, 2021. www.worldpopulationreview.com.

2. van Rij AM, De Alwis CS, Jiang P, et al. Obesity and impaired venous function. Eur J Vasc Endovasc Surg. 2008;35(6):739–744. doi:10.1016/j.ejvs.2008.01.006

3. Padberg Jr F, Cerveira JJ, Lal BK, Pappas PJ, Varma S, Hobson II RW. Does severe venous insufficiency have a different etiology in the morbidly obese? Is it venous? J Vasc Surg. 2003;37(1):79–85. doi:10.1067/mva.2003.61

4. Doerler M, Altmeyeer P, Stücker M. Venous leg ulcer caused by obesity-associated dependency syndrome. Phlebologie. 2013;42(4):205–208. doi:10.12687/phleb2150-4-2013

5. Kugler AC, Strunk M, Rudofsky G. Effects of impaired joint mobility on venous pump function of the healthy lower limb, a phlebodynamometric analysis. Phlebologie. 1999;28(1):16–22.

6. Arvidsson B, Eklof B, Balfour J. Iliofemoral venous pressure correlates with intraabdominal pressure in morbidly obese patients. Vasc Endovascular Surg. 2005;39(6):505–509. doi:10.1177/153857440503900607

7. Willenberg T, Clemens R, et al. The influence of abdominal pressure on lower extremity venous pressure and hemodynamics: a human in-vivo model simulating the effect of abdominal obesity. Eur J Vasc Endovasc Surg. 2011;41(6):849–855.

8. International Lymphoedema Framework. Compression Therapy: A Position Document of Compression Bandaging. Best Practices for the Management of Lymphedema. 2^nd ed. International Lymphoedema Framework; 2012.

9. Harris C, Loney A, Brooke J, et al. Refractory venous leg ulcers: observational evaluation of innovative new technology. Int Wound J. 2017;14(6):1100–1107. doi:10.1111/iwj.12766

10. Shashar D, Rosenblum J, Miller M, Heldinberg E, Tamir J. An evaluation of a novel compression device on popliteal venous blood flow. Angiology. 2016;4(3):178. doi:10.4172/2329-9495.1000178

11. Sugerman HJ, Sugerman EL, Wolfe L, Kellum Jr JM, Schweitzer MA, DeMaria DJ. The risks and benefits of gastric bypass in morbidly obese patients with severe venous stasis disease. Ann Surg. 2001;234(1):41–46. doi:10.1097/00000658-200107000-00007