Peroneal Artery Adipofascial Flaps for Coverage of Distal Leg and Rearfoot

Chronic wounds of the lower extremity can pose several obstacles for the treating physician as well as the patient. Peroneal artery adipofascial flaps have been shown to be a reliable and durable option for reconstruction of these defects for many reasons, including ease of dissection, minimized donor site mobility, reliability of take to underlying surfaces, and cosmetically more pleasing outcome. This article discusses the current literature regarding the use of peroneal artery adipofascial flaps and our surgical technique for harvest, transfer, and postoperative course for this versatile flap.

Ileo-sigmoid knotting: the Parirenyatwa hospital experience

BACKGROUND

Ileo-sigmoid knotting is a rare cause of intestinal obstruction with a rapidly progressive course, for which expedient surgical intervention is required to prevent mortality. The aim of this study was to determine the characteristics, presentation, morbidity and mortality associated with ileo-sigmoid knotting at Parirenyatwa Group of Hospitals (PGH). To determine the preoperative diagnostic precision and management patterns of ileo-sigmoid knotting cases at PGH.

METHODS

A retrospective analysis was performed on patients operated on at Parirenyatwa Hospital with a diagnosis of ileo-sigmoid knotting between April 2011 and April 2018. Data inclusive of demographics, time to presentation and surgery, preoperative diagnosis, complications and in-hospital mortality was collected. The relationship between the duration of symptoms prior to surgery and incidence of both septic shock and transfusion were analysed.

RESULTS

Twenty-one cases of ileo-sigmoid knotting were identified for analysis. The median age was 37 years (range 18-65 years) with a 6:1 male to female ratio. Two of the three females included were pregnant. Twenty patients (95.2%) described an acute onset abdominal pain, with 83.3% experiencing the pain nocturnally, while asleep. The median duration of symptoms at presentation was 12.5 hours (range 2-39 hours). At admission, leucocytosis (WCC > 11x10³/dl) was noted in eleven patients (52.4%). Seventy-three per cent of patients were noted to have electrolyte derangements at presentation. Seven patients (33.3%) had recorded episodes of severe hypotension (SBP < 90) prior to surgery. The most common preoperative diagnosis, based on both clinical assessment and plain x-ray evaluation, was sigmoid volvulus (52.4%), with no preoperative diagnosis of ileo-sigmoid knotting being made. All patients had gangrenous small bowel, with 81% having a gangrenous sigmoid colon. All cases underwent small bowel resection and primary anastomosis plus Hartmann's procedure. Postoperatively, eleven patients (52.4%) developed septic shock, while 62% required blood transfusion. There was one (4.8%) early postoperative mortality.

CONCLUSION

To avoid mortality, the diagnosis of ileo-sigmoid knotting should be entertained and the imperative of emergency surgery recognised in the young male or pregnant female patient with acute nocturnal onset abdominal pain, a rapidly deteriorating small bowel obstruction clinical picture and with radiological features suggestive of both small and large bowel obstruction.

Peripheral Gangrene and Extremity Amputations - Painful Preventable Sequelae of Meningococcal Septicaemia: Case Series Reports

Extremity gangrene is a fairly common pathology, which complicates systemic vascular and endocrine diseases. Most often, it is encountered in diseases like uncontrolled Diabetes Mellitus, presenting as diabetic foot gangrene, severe peripheral arteriosclerosis with gangrene of the extremity complicating severe uncontrolled systemic hypertension and meningococcal septicaemia with peripheral gangrene. It also occurs in some cases of snake bite as well as frost bite (in regions with extreme cold weather conditions). Some of them present as monolateral extremity gangrene. However, others present as bilateral symmetrical peripheral gangrene (SPG) characterized by bilateral extremity ischaemia resulting in gangrene in which there is no major vascular occlusive disease. There is disseminated intravascular coagulation with the gangrene being considered as a cutaneous marker and some of the patients that survive ultimately require amputation of the affected limb(s) in the severe cases. The mild cases end up losing some of the digits or just exfoliation of the dead cutaneous layer. The effects are generally more severe in the lower limbs than in upper limbs. Notable among these are some of those complicating meningococcal sepsis resulting from peripheral intravascular coagulation. We present here, five patients who presented with varying degrees of peripheral gangrene during an epidemic of meningitis and the treatments that were carried out depending on the severity of their cases.

Symmetrical peripheral gangrene reconstruction after lower limb amputation

Symmetrical peripheral gangrene (SPG) is a complication of septicemia, characterized by progressive skin lesions, which can result in wide necrosis of all the extremities. Severe necrosis is often responsible of disfiguring consequences. It is important to limit the amputation and to provide a stable and functional soft tissue coverage of the stumps. Limited amputation and free flap reconstruction may help to prevent tissue loss and to provide an effective prosthetization and a prompt rehabilitation. We present a clinical case of a 60-year-old male admitted in our department for lower limbs necrosis due to SPG after a pneumococcal infection. The patient underwent bilateral forefeet amputation and microsurgical reconstruction with antero-lateral thigh flap was performed on the left stump. Vascular complications determined a progressive necrosis of the flap and the failure of the reconstruction. A careful analysis of the local and systemic inflammatory vascular and coagulative issues following the SPG has been performed to explain the failure of the microsurgery. Although the opinion of several authors is divided about the use of free tissue transfer, we believe that microsurgical reconstruction remains the first choice of treatment due to the reduced morbidity and early rehabilitation it provides. KEY WORDS: Amputation, Free flaps, Free tissue transfer, Limb salvage, Microsurgery salvage, Prosthesis, Sepsis, Septicaemia, Symmetrical peripheral gangrene.

A case of peripartum cardiomyopathy presenting as bilateral acute limb ischaemia and gangrene

Peripartum cardiomyopathy (PPCM) is a condition of unknown etiology that presents as heart failure due to left ventricular systolic dysfunction in the last of month of pregnancy and up to six months after giving birth. PPCM predisposes towards thrombo-embolism and an acute limb ischaemia can be a manifestation of this disease. We present a case of a 23-year-old lady presenting an acute lower limb ischaemia four months post-partum. Doppler ultrasound showed bilateral femoral emboli and cardiac ECHO showed a 24% ejection fraction. Amputation was performed on both limbs, below her right knee and above her left knee. The patient was started on heart failure medication and her symptoms improved with diuretic therapy, confirming the diagnoses of PPCM. It is important to recognise acute limb ischaemia as a rare manifestation of PPCM, as a timely diagnosis and effective treatment of the disease can improve the prognosis. We believe this is the first case to be reported in medical literature from Pakistan of a patient presenting PPCM with bilateral acute limb ischaemia and gangrene.

Postoperative nutritional support of the patient with gut gangrene-a case report

BACKGROUND

Bowel necrosis is a commonly observed condition in elderly patients with longstanding diabetes. In such condition, intestinal resection is usually performed for the removal of the gangrenous part. Post-surgical dietary management after bowel resection poses several challenges for the health care team.

CASE PRESENTATION

The case presented in this study is that of an elderly diabetic male who developed acute renal failure as a result of neglect in post-surgical feeding after intestinal resection. After the intervention by a trained dietitian, a transitional diet was planned and successfully executed, resulting in reversal of acute renal failure, dehydration, and post-surgical stress. Several complications including hepatic dysfunction and mouth ulcers were resolved through well-planned transitional diet. The patient was finally discharged in a stable health condition and was regularly followed up for any nutritional or medical issues.

CONCLUSION

Neglects in nutritional care of patients can have severe implications including development of medical complications, resulting in increased length of hospital stay, augmenting the disease stress of the patient and family, and finally the preventable drainage of several human and monetary resources. Therefore, recognition of nutritional intervention as an important part of in-hospital health care may have social as well as economic impacts.

Resolution of Primary Aortic Thrombosis after Dabigatran therapy-A New Hope for the Rare and Old Disease

The primary aortic thrombosis (PAT) is an uncommon noncardiac cause of distal peripheral embolization to lower extremities. Also, this condition develops in the absence of extensive atherosclerosis of aorta or abnormal dilatation like aneurysm of the aorta. In most of the cases, there was either no or minimal atherosclerosis of the aorta. The disease can involve any part of the aorta, but in most of the cases, the thoracic aorta below the origin of the left subclavian artery followed by the infrarenal portion of the abdominal aorta was the most common site of involvement. In our case, there was extensive thrombosis starting from the lower part of the thoracic aorta extending across both the renal arteries up to the aortic bifurcation without any underlying aortic pathology or hypercoagulable disease. There are no guidelines for the management of the PAT, but our experience is based on few case series, case reports, and meta-analysis where there are variable success rate using conservative medical management, endovascular procedure, or surgical thrombectomy. Vitamin K antagonist was the drug of choice in all the cases as a part of conservative medical management or used to prevent recurrence after the endovascular or surgical procedure. We present a case of PAT where the use of dabigatran leads to complete resolution and prevented the recurrence of the disease during two-year follow-up, which is the first and unique case report of the literature.

Operative versus non-operative treatment in diabetic dry toe gangrene

BACKGROUND AND AIM

Diabetic foot is a major comorbidity of diabetes, with 15-25% of diabetic patients developing diabetic foot ulcer during their lifetime. Other major diabetic foot complications include cellulitis, abscess, wet gangrene, dry gangrene, and necrotizing fasciitis. Dry gangrene involves tissue necrosis due to chronic ischemia whereby the tissue becomes numb, dry, wrinkled, and dead. Although diabetic foot complications have been extensively studied in literature, there is limited data on the management of dry gangrene.

METHODS

We report a case series of 12 patients with diabetes-related dry gangrene in the toes, initially planned to be managed conservatively with autoamputation.

RESULTS

One patient had an autoamputation, while eight patients underwent surgical amputations (six major amputations, two minor amputations) for better clinical outcomes. Two patients died, while no change was observed in one patient even after 12 months of follow-up.

CONCLUSION

Managing diabetic dry toe gangrene by waiting for autoamputation may lead to worse clinical outcomes and should be practiced cautiously on a case-by-case basis. Early surgical intervention should be opted to improve patients' quality of life.

Digital gangrene induced by inadvertent intra-arterial cocktail injection of anesthetic agents such as pentazocine, promethazine, and atropine: A serious adverse drug experience

Gangrenous changes in skin due to accidental intra-arterial injection of promethazine and pentazocine have been reported. Accidental intra-arterial injection is most commonly encountered in the antecubital fossa. However, recent reports in the radial and ulnar arteries have also been encountered. We hereby report a serious, preventable adverse drug experience in the form of digital gangrene induced by inadvertent intra-arterial cocktail injection of anesthetic agents such as pentazocine, promethazine, and atropine, which seems to be in the radial artery as the lateral three digits and dorsum of the hand are affected.

[Secondary amputation of the limb after primary surgery of open fractures of the lower limb]

This study reports the complications occurred during the management of open fractures of the lower limbs, resulting in secondary amputations, observed in clinicians' practice in recent years as well as different risk factors and possible deficiencies in management at the origin of these complications. We conducted a retrospective study over a period of 06 years (January 2006 - January 2012). It included patients with open fracture of the lower limb initially treated in our institution and whose complications resulted in amputation. All patient undergoing emergency amputation after examination at the Emergency Department were excluded. All patient treated in another hospital before being referred to us were excluded by the study, even if secondary amputation had been performed in our institution. We collected data by analyzing the records of patients (clinical and complementary examinations, surgical reports). We evaluated our management of open fractures of the lower limb according to the guidelines and recommendations found in the literature. These complications were observed in 9 out of 306 open fractures of the lower limb treated in the same period (January 2006 - January 2012), reflecting a rate of 2.9%. The average age was 42.6(26-57) years, all patients were male. We recorded 1 case of fracture of the femur, 7 cases of fracture of 2 leg bones and 1 case of foot crushing. These were open fractures including 1 case of type 1 fracture, 3 cases of type II fracture and 5 cases of type III fracture, according to Gustilo and Anderson classification. We performed 5 amputations of the thigh and 4 amputation of the upper third of the leg. Various complications motivated these amputations, including bone infections or soft-tissue gangrenes of ischemic or infectious origin. The patients had no morbidities such as diabete and were not chronic smokers. No patient died. Open fractures deserve special attention of the surgeon on immediade complications both from a diagnostic and therapeutic point of view in order to reduce the amputation rates after primary surgery giving patients the impression that they had an incorrect procedure performed on them. Particular attention should be paid to the degree of initial contamination and to the presence of a virulent germ at the site of trauma which may motivate particular attitudes during primary management.

[Balloon angioplasty of the radial artery in critical hand ischaemia]

Presented herein are the results of treatment of five 63-to-72-year-old patients (four men and one woman) with critical upper limb ischaemia, which is one of rarely encountered pathologies. All patients suffered from type 2 diabetes mellitus. Two of them had end-stage renal disease (ESRD) and for 2 years were on haemodialysis. Four patients had gangrene of 1 finger and one patient had gangrene of 2 fingers. The main diagnostic methods included duplex scanning with measuring the gradient of pressure between the humeral and radial arteries, and MSCT angiography. The patients with ESRD received conservative therapy with the use of prostaglandin E1 and after limitation of necrosis sustained amputation of the fingers. Three patients were successfully managed by recanalization and balloon angioplasty of the radial artery's occluded segment. The patients underwent follow-up examinations at 1, 6, 12, 18 and 24 months. During this period two patients with ESRD died. They had no relapses of critical ischaemia of the hand but developed gangrene of toes and were both subjected to successful balloon angioplasty of the crural arteries. One patient at 18 postoperative months was found to have reocclusion of the radial artery with hand pain at rest. He was subjected to successful repeat balloon angioplasty of the radial artery. CONCLUSION: Timely restoration of blood flow in this situation reduces the frequency of amputation. Percutaneous balloon angioplasty may become a method of choice in treatment of patients with critical hand ischaemia caused by occlusive lesions of arteries of the forearm.

Ecthyma gangrenosum in a 3-month-old, previously healthy infant: A Case Report

RATIONALE

Ecthyma gangrenosum (EG) is an aggressive cutaneous disease caused by local or systemic infection with Pseudomonas aeruginosa. EG is characterized by cutaneous manifestations ranging from nodule and papule, to necrotic ulceration with surrounding erythema, especially with black eschar or central crust. EG presents with characteristic skin lesions which is important to establish diagnosis of sepsis caused by P aeruginosa, a serious condition that can be treated efficiently if diagnosed early.

PATIENT CONCERNS

A 3-month-old female infant was presented with characteristic skin lesions of EG and developed sepsis 3 days later.

DIAGNOSES

Ecthyma gangrenosum and sepsis caused by Pseudomonas aeruginosa.

INTERVENTIONS

Meropenem was used in combination with ceftazidime at first and excision of necrotic skin lesions was performed later.

OUTCOMES

Cure.

LESSONS

Early recognition of EG plays an important role in providing appropriate empiric antibiotic treatment at early stage of sepsis, and improves the prognosis. Surgical excision may be helpful if no improvement was achieved via antibiotic treatment.

An unexpected gangrenous duplication of ileum

Alimentary tract duplication is a rare congenital anomaly which may involve any part of the alimentary tract extending from stomach to rectum. Clinical presentation may mimic an inflamed appendix as described in this case. A 9-year-old boy with a clinical diagnosis of perforated appendix was noted to have a normal appendix intra-operatively. On further search for an underlying pathology, a gangrenous ileal duplication was discovered. En-bloc resection with primary bowel anastomosis was done. Histopathology report revealed a gangrenous small bowel duplication. We discuss the preoperative diagnostic dilemma and management options in approaching this rare entity.

Gallstone ileus presenting as obstructive gangrenous appendicitis

We present the very unusual case of a 38-year-old woman with acute appendicitis and intestinal obstruction. During surgery, a 2.5 cm gallstone impacted at the base of the cecal appendix was found as the cause of a gangrenous appendicitis and obstruction; a choledochal-duodenal fistula was found during the same surgery with no gallstones remaining in the gallbladder or elsewhere. The case was managed by appendectomy with retrieval of the gallstones and no other procedure was performed for the gallbladder or the fistula, since no other gallstone was found on examination. Previously, she was found to have a round, radio-opaque image on the right iliac fossa on imaging, initially identified as an appendicolith, but after pathological examination it turned out to contain cholesterol and calcium bilirubinate. Gallstone ileus as the cause of an obstructive gangrenous appendicitis is a very unusual disease presentation that should be kept in mind when finding an unusual appendicolith presentation in or out the appendix.

Hemodialysis patient with finger ulcerations

The patient reported pain and paresthesias of his left ring finger, and his left hand was cooler than his right. An angiogram helped us recognize the cause of his symptoms.

['Life-saving' interventions in subacute thrombosis of crural and plantar arteries]

The authors report a clinical case concerning successful endovascular treatment for subacute thrombosis of crural and plantar arteries in a patient with the only leg, substantiating therapeutic decision making with due regard for the duration of thrombosis and localization of the lesion of the arterial bed. Taking into consideration the statistical data on survival in case of performing major amputation in this cohort of patients, an 'aggressive' endovascular approach including three vascularizations made it possible not only to preserve the leg but also to save the patient's life.

[COMPLEX TREATMENT OF PURULENT-NECROTIC COMPLICATIONS IN THE PATIENTS, SUFFERING DIABETIC FOOT SYNDROME, USING NEGATIVE TRESSURE AND CAPICOR PREPARATION]

The comparative analysis data were presented, concerning the results of complex treatment of 28 patients, suffering ischemic-gangrenous form of the diabetic foot syndrome, developing on background of chronic ischemia of the lower extremities stage IV. In 14 patients (main group) a routine complex of the treatment measures was added by application of an active pressure (negative pressure wound therapy - NPWT) and a capicor preparation; 14 patients (the comparison group) were treated in accordance to routine scheme. In accordance to the comparative analysis data, in patients of the main group the wound surface sarea have kept reducing in twice more rapid, than in a comparison group, the wounds healing was achieved in 94% patients, duration of the patients’ stationary stay have reduced by (5.2 ± 1.4) days.

[АNALYSIS OF LETHALITY IN COMPLICATED DIABETIC FOOT SYNDROME AND SEPSIS]

There were examined in dynamics 724 patients, in whom complicated diabetic foot syndrome (DFS) was diagnosed, and in 71 (9.8%) of them the disease was complicated by sepsis. The state severity in a DFS patients have depended upon duration of purulent-necrotic process on the foot, in septic patients such dependence was not revealed. All the DFS patients without sepsis were operated on. In total 36 died (lethality 5.5%), in presence of sepsis - 42 (lethality 59.1%). The cause of sepsis in the patients, suffering complicated DFS, was predominantly a wet gangrene of the lower extremities. Among those, who were not operated on, 13 (30.9%) septic patients died, of them 5 – who refused operative intervention performance - died in first hours after admittance to hospital due to irreversible injury of organs and systems.

[Salvation of the diabetic foot through a comprehensive individualized treatment of the patient with type 2 diabetes: case study]

This is a case of men with type 2 diabetes mellitus and diabetic foot. The patient was in danger of limb amputation. After improvement of diabetes, hypertension and dyslipidemia therapies a comprehensive treatment of diabetic foot including angioplasty, antibiotics and local maggot therapy was used for diabetic foot management. Therapy result was very satisfying for the patient. Despite of amputation of the 2nd digit due to advanced gangrene, the whole foot function was saved.Key words: diabetes foot - maggot therapies - type 2 diabetes mellitus.