Foot Gangrene in Patients with End-Stage Renal Disease: A Case Control Study

The prevalence of peripheral arterial disease (PAD) in patients with end-stage renal disease (ESRD) is high, with an annual risk of amputation estimated at 13%, and indications for limb revascularization in patients combining ESRD with stage IV PAD (foot gangrene) are still controversial. This case-controlled study compared survival, limb salvage, and quality of life in a group of patients hospitalized for foot gangrene according to their renal status (ESRD versus no renal insufficiency). All patients with ESRD hospitalized for foot gangrene (n=16) from 1996 to 2002 were compared with a control group with normal creatininemia (n=24) hospitalized for foot gangrene due to peripheral atherosclerotic arterial disease. The 2 groups were matched for age, sex ratio, and number with diabetes mellitus. After a mean follow-up of 467 ±410 days, patients with ESRD had a more severe prognosis as regards mortality (68.7% vs 12.5%, p=0.0005) and major amputation (31% versus 8%, p=0.09). The ESRD group was characterized by more frequent extensive arterial calcifications (16/16 vs 13/24, p=0.002), owing to a higher level of the calcium phosphorus product (3.54 ±1.2 vs 2.4 ±0.6, p=0.0023), and by impaired microcirculatory perfusion, as indicated by a lower oxygen pressure (TcPO2) (15.6 ±12 mm Hg vs 26 ±16, p=0.07). ESRD implies a poor prognosis in patients with stage IV peripheral arterial disease.

Comparison of Computed Tomography Angiography to Contrast Arteriography for Patients Undergoing Evaluation for Lower Extremity Revascularization

In an effort to explore alternatives to contrast arteriography, we compared computed tomography angiography to contrast arteriography for defining anatomic features of patients undergoing lower extremity revascularization. From November 2003 to March 2004, 36 inpatients with chronic lower extremity ischemia underwent contrast arteriography and computed tomography angiography before undergoing lower extremity revascularization procedures. A Siemens 16 slice multiplanar computed tomography device with bolus tracking was used for these exams. The reports of these tests and images were compared prospectively, and the differences in the aorto-iliac segment, femoral-popliteal, and infrapopliteal segments were noted. The vessels were classified as mild disease (<50%), moderate disease (50%-70%), severe (71%-99%), and occluded. The studies and treatment plans based on these data were compared. The mean age was 76 ± 12 years (SD). Indications for the procedures included gangrene (45%), ischemic ulcer (32%), rest pain (19%), and severe claudication (3%); 69% were diabetics. Accuracy of computed tomography angiography in the aorto-iliac, femoral-popliteal, and infrapopliteal segments was 100%, 81%, and 59%, respectively. Thirteen of 18 (72%) of these disagreements resulted in a different procedure than that suggested by computed tomography angiography. A review of the data obtained in this series indicated that computed tomography angiography appears to be unable to obtain adequate information in this highly selected population at our institution.

Use of the"bogota bag"for closure of open abdominal wound after exploratory laparotomy - our experience at Mayo Hospital Lahore

OBJECTIVE

To assess the efficacy of Bogota bag for closure of open abdominal wounds after laparotomy where the primary closure cannot be achieved and other closure techniques are not available.

METHODS

The descriptive study was conducted at Mayo Hospital, Lahore, Pakistan, from September 2011 to February2015, and comprised patients who underwent laparotomy and peritoneal cavities and who could not be closed primarily because of various reasons like traumatic loss and oedematous gut. They were managed with Bogota bag for abdominal closure. SPSS 18 was used for statistical analysis.

RESULTS

Of the 55 patients, 37(67.27%) were male and 18(32.73%) were female. There was traumatic loss in 34(61.8%), oedematous gut and omentum in 15(27.27%) and gangrenous abdominal wall in 6(10.9%) patients. Bogota bag was applied in all (100%) of them. In 19(34.55%) patients, delayed primary closure was possible, so the Bogota was used temporarily. In 36(65.45%) cases managed with Bogota bag, healing occurred by granulation tissue or skin grafting/flaps were applied and these patients developed hernia. Five (9.09%) patients developed small bowel fistula which was managed conservatively. No patient developed complication due to exposure or abdominal compartment. There were 7(12.8%) postoperative deaths due to the disease process and were unrelated to the closure technique.

CONCLUSIONS

Bogota bag was an effective means of closure of open abdominal wound and prevented the complications due to open abdominal wounds or closure under tension.

Femoral Artery to Prosthetic Graft Anastomotic Dehiscence Owing to Infection: Successful Treatment with Arterial Reconstruction and Limb Salvage

A 66-year-old man had foot gangrene and a fixed contracture of the knee following two failed femoropopliteal bypasses, one with vein and one with polytetrafluoroethylene (PTFE). An external iliac to anterior tibial artery bypass and skeletal traction via the os calcis resulted in limb salvage and successful normal ambulation. After 3 months, he ruptured the infected femoral anastomosis of the failed PTFE femoropopliteal bypass with external bleeding. The use of arteriography and a balloon catheter to obtain proximal control allowed arterial repair, removal of the graft, and preservation of flow within a patent common and deep femoral artery. This flow preservation maintained the viability and function of the limb when the anterior tibial bypass closed 4 years later, and the limb continues to be fully functional 3 years later. Aggressive secondary attempts at limb salvage are worthwhile even in unfavorable circumstances.

Does Conversion of Intended Remote Iliac Artery Endarterectomy Alter the Early and Long-Term Outcome?

The purpose of this study was to compare the perioperative and long-term results of initial successful remote iliac artery endarterectomies (RIAEs) with converted procedures.

From April 1994 to September 2003, 63 remote endarterectomies of the external and/or common iliac artery were planned in 62 patients (41 males, 42 procedures). The median age was 65 years (range 39–83 years), and the indication for operation was severe claudication in 37 (59%), rest pain in 16 (25%), and gangrene in 10 (16%) procedures.

Initial technical success was achieved in 56 (89%) procedures (group 1); seven conversions (group 2) were necessary. In group 1, the 5-year primary patency rate improved from 64 ± 15% to a primary assisted patency of 88 ± 9.3% after percutaneous transluminal angioplasty in 11 patients, with 7 requiring stent placement. The 5-year secondary patency rate was 94 ± 7.4%. The primary and secondary patency rates in group 2 were 86 ± 19% and 100%, respectively.

RIAE can be offered to patients with long occlusions of the iliac arteries as a first treatment option. The inherent risk of a possible conversion of an intended RIAE to a more invasive surgical procedure has no significant adverse clinical effect on the early and 5-year clinical outcomes.

Simultaneous Ipsilateral Infrainguinal Angioplasty and Bypass Procedures

We studied the efficacy of surgeon-performed combined ipsilateral endovascular and open arterial concomitant reconstruction at the infrainguinal level. It was a retrospective analytic study. The study included 15 patients (9 men, 6 women) who underwent 15 combined procedures between January 2000 and January 2004. They were divided into two groups. The first group consisted of nine patients with an inflow angioplasty. The second group included six patients with an outflow angioplasty. Indications for arterial reconstruction were claudication (one patient), ischemic rest pain (three patients), and gangrene (eleven patients). Immediate technical success of the combined procedures was 100%. In the first group, one patient died owing to a myocardial infarction, ischemic lesions healed in eight patients, one patient required revision of the graft and three reconstructions occluded, with one amputation of the affected limb. In the second group, one patient died owing to stoke, one patient needed a graft revision and one underwent a limb amputation. The cumulative limb salvage at 42 months was 85%. Our results suggest that simultaneous ipsilateral infrainguinal angioplasty and bypass procedures could be performed with good results. Inflow and outfow angioplasty allow using a shorter single graft segment. Outflow angioplasty ameliorates the bypass flow and accelerates the healing of ischemic lesions. The restenosis rate of the inflow angioplasty at the femoral level remains low.

[Pedal bypass using venous allograft]

INTRODUCTION

Pedal or distal crural bypass surgery for limb salvage is a method with very good long-term results. For patients in whom a suitable autologous venous graft is not available, the use of a venous allograft is an alternative procedure.

CASE REPORT

A 68 years old man with ischaemic disease of lower extremities and gangrene of the left foot was admitted to our Centre in August 2014. He underwent percutaneous transluminal angioplasty of crural arteries of his left lower extremity. This, however, failed to improve peripheral circulation. The patient was then indicated for pedal or distal crural vascular reconstruction. Since no suitable autologous vein was available, distal bypass surgery using a donor graft remained the only option for limb salvage. Amputation of the toes on the left foot due to gangrene was necessary. Subsequently, femoro-pedal bypass to the left common plantar artery was performed using a great saphenous vein allograft. The post-operative course was without complications, the pedal bypass was patent and toe amputation was with good healing. The patient remained in follow-up care.

CONCLUSION

A good outcome of vascular reconstruction with an allograft depends on the availability of a suitable allograft and good patient compliance with post-operative care. In the case presented here, the pedal bypass grafting by means of an allograft helped to save the patients limb.

KEY WORDS

pedal bypass venous allograft limb salvage.

Detection of undisclosed neuropathy and assessment of its impact on quality of life: a survey in 25,000 Romanian patients with diabetes

AIMS

The objective of this cross-sectional survey was to capture undiagnosed neuropathy in Romanian patients with self-reported diabetes using Norfolk QoL-DN as a screening tool and to assess its impact on quality of life (QoL).

METHODS

25,000 Romanian-translated, validated Norfolk QoL-DN questionnaires were distributed between June and December 2012. 21,261 patients who self-reported diabetes and answered questions related to neuropathy, ulceration, gangrene and amputation were included in the analysis.

RESULTS

52% of diabetic patients (n = 6615) who answered "no" to the question "Do you have neuropathy?" had total QoL scores above the cut-off, suggesting the presence of diabetic neuropathy. 13,854 (65.2%) patients answered "yes" to the question "Do you have neuropathy?" and 3,150 (14.8%) reported at least one episode of ulceration, gangrene or amputation. Total QoL score was 3-fold higher (worse) for patients who answered "yes" to the question "Do you have neuropathy?" than for those who answered "no" (38.39 vs. 13.71; p < 0.001) and 1.4-fold worse for patients who reported ulceration, gangrene or amputation than for those who did not report any of these (50.38 vs. 34.87; p < 0.001).

CONCLUSIONS

We found a high prevalence of undisclosed diabetic neuropathy in this population and showed that neuropathy severity has an increasing impact on total QoL and its domains.

Management of finger gangrene caused by steal syndrome in vascular access for hemodialysis Personal experience and a brief review of the literature

INTRODUCTION

Severe dialysis-associated steal syndrome (DASS) is an uncommon and severe complication after arteriovenous fistula (AVF) creation that can lead to finger gangrene and amputation. As the number of patients on hemodialysis increases in western countries the number of patients at risk for DASS will continue to rise.

METHODS

We retrospectively reviewed all patients who underwent a surgical intervention for the management of DASS with finger gangrene from January 2004 to July 2013. Demographic data, pre-operative work-up, procedure details and outcomes were collected. A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles. Cross-references from these articles were also used.

RESULTS

A total of nine patients were identified. Mean age was 53 years, 67% were women. All patients presented with finger tissue loss or gangrene. Surgical procedures included AVF closure/ligation (5), distal artery ligation (DRAL) (2), distal revascularization with interval ligation (DRIL) (1), banding (1). All patients had improvement of symptoms during follow-up. No major amputation occurred.

CONCLUSIONS

Surgical interventions to correct DASS in patients with finger gangrene are mandatory while conservative management is not recommended. The decision for which type of procedure is made individually, according to clinical symptoms, technical findings, and patients' general state of health.

[A rare case of an acute abdomen patient with gangrene of the colon as a complication of systemic lupus erythematosus]

The authors present a case report of a 39-year-old woman with acute abdomen - a comorbid patient with systemic lupus erythematosus, chronic renal insufficiency as a complication of lupus nephritis, included in a haemodialysis programme. The patient had also undergone transplantation of the left kidney in the past. She was initially admitted to the Department of Traumatology for a total endoprosthesis procedure due to bionecrosis of the head of the thigh bone. Postoperatively, the patients condition was complicated by gangrene of the colon confirmed by CT scan and during the operation. The patient was operated on - subtotal colectomy, terminal ileostomy and left-sided ovariectomy was performed. The postoperative course was complicated by perforation of the jejunum which was sutured. The patient was admitted to ICU and, after recovery, to our surgical department. Because of the metabolic disturbance she was treated in the internal medicine department. After 60 days she was discharged in a good condition, walking and with full per os realimentation.Key words: lupus erythematosus gangrene of the colon acute abdomen.

Acute mesenteric ischemia after cardiac surgery. Role of the abdominal compartment syndrome treatment

BACKGROUND

The management of abdominal compartment syndrome (ACS) has been included as a standard of care in our therapeutic algorithm after diagnosis of acute mesentheric ischemia (AMI), following cardiac surgery. This report is an updated review of our results compared to previous experience.

MATERIALS AND METHODS

A retrospective, observational, cohort study on a series of 26 patients (20 males, 6 females, mean age 75.2 years, min 64, max 83) who developed AMI, out of 7.719 patients undergoing cardiac operations (january 2005 - December 2014). The initial treatment consisted of laparotomy with abdominal decompression and temporary abdominal closure, performing visceral resections just in case of gangrenous tracts and providing for a "secondlook" during the variable period of resuscitation and vacuum assisted dressing.

RESULTS

A non-occlusive mesentheric ischemia with diffuse visceral underperfusion was confirmed in every case. Temporary abdominal closure was applied to treat ACS in every case, 13 patients required associated resection of gangrenous tracts (50%). Seventeen patients died following first operation as a consequence of multiple organ failure (65.4%). Nine patients survived (34.6%) and underwent re-establishment of intestinal continuity and definitive closure of abdominal wall within 30 DAYS.

DISCUSSION AND CONCLUSIONS

AMI occuring after cardiac surgery is associated with an increase of intra-abdominal pressure and subsequent ACS. Basing on this case series, an early ACS treatment using open abdomen techniques may be results in a better outcome of critically injured cardiac patients. These results compared favourably with literature experiences (mortality rate > 85%).

KEY WORDS

Abdominal compartment syndrome, Acute mesentheric ischemia, Cardiac surgery.

Peristomal necrotizing fasciitis - peculiar evolution of a patient with metachronous colonic tumors

We hereby present a case report of a patient with an unusual neoplasic and surgical history. M.V. is a 54-year-old patient who had been operated, two years ago, for intestinal obstruction caused by a sigmoid tumor; a segmental rectal and sigmoid resection (Hartmann's procedure) was then performed. Two other surgical procedures were attempted during the last two years, in another surgical department: a colo-rectal anastomosis and a repair of the parastomal hernia, both failed due to postoperative adhesions syndrome. The patient was hospitalized for peristomal gangrene with necrotizing fasciitis. Emergency action was taken to resolve the parietal gangrene. The postoperative local evolution of the wound was favourable and allowed a skin graft for parietal restoration. An intestinal obstruction occurred 2 months later, caused by an extended metachronous tumor of the splenic flexure. The patient underwent other surgeries including the completion of the left hemicolectomy, total gastrectomy, caudal splenopancreatectomy and left adrenalectomy. The patient has a favourable postoperative evolution after 1 year.

CONCLUSION

We noticed a very severe evolution of the peristomal gangrene and the rapid growth towards intestinal obstruction of the metachronous colonic tumor.

Type of incision for below knee amputation

BACKGROUND

Below knee amputation (BKA) may be necessary in patients with advanced critical limb ischaemia or diabetic foot sepsis in whom no other treatment option is available. There is no consensus as to which surgical technique achieves the maximum rehabilitation potential. This is the third update of the review first published in 2004.

OBJECTIVES

To assess the effects of different types of incision on the outcome of BKA in people with lower limb ischaemia or diabetic foot sepsis, or both. The main focus of the review was to assess the relative merits of skew flap amputation versus the long posterior flap technique.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched 28 March 2013) and CENTRAL (2013, Issue 2).

SELECTION CRITERIA

Randomised controlled trials comparing two or more types of skin incision for BKA were identified. People with lower limb ischaemia (acute or chronic) or diabetic foot sepsis, or both, were considered for inclusion. People undergoing below knee amputation for other conditions were excluded.

DATA COLLECTION AND ANALYSIS

One review author identified potential trials. Two review authors independently assessed trial quality and extracted the data. Additional information, if required, was sought from study authors.

MAIN RESULTS

Three studies with a combined total of 309 participants were included in the review. One study compared two-stage versus one-stage BKA; one study compared skew flaps BKA versus long posterior flap BKA; and one study compared sagittal flaps BKA versus long posterior flap BKA. Overall the quality of the evidence from these studies was moderate. BKA using skew flaps or sagittal flaps conferred no advantage over the well established long posterior flap technique (primary stump healing was 60% for both skew flaps and long posterior flap (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.71 to 1.42) and primary stump healing was 58% for sagittal flaps and 55% for long posterior flap (Peto odds ratio (OR) 1.04, 95% CI 0.45 to 2.43). For participants with wet gangrene, a two-stage procedure with a guillotine amputation at the ankle followed by a definitive long posterior flap amputation led to better primary stump healing than a one-stage procedure (Peto OR 0.08, 95% CI 0.01 to 0.89). Post-operative infection rate or wound necrosis, reamputation, and mobility with a prosthetic limb were similar in the different comparisons.

AUTHORS' CONCLUSIONS

There is no evidence to show a benefit of one type of incision over another. However, in the presence of wet gangrene a two-stage procedure leads to better primary stump healing compared to a one-stage procedure. The choice of amputation technique can, therefore, be a matter of surgeon preference taking into account factors such as previous experience of a particular technique, the extent of non-viable tissue, and the location of pre-existing surgical scars.

Mortality and reoperations following lower limb amputations

BACKGROUND

Above-the-knee amputations (AKA) and below-the-knee amputations (BKA) are commonly indicated in patients with ischemia, extensive tissue loss, or infection. AKA were previously reported to have better wound-healing rates but poorer rehabilitation rates than BKA.

OBJECTIVES

To compare the outcomes of AKA and BKA and to identify risk factors for poor outcome following leg amputation.

METHODS

This retrospective cohort study comprised 188 consecutive patients (mean age 72 years, range 25-103, 71 males) who underwent 198 amputations (91 AKA, 107 BK 10 bilateral procedures) between February 2007 and May 2010. Included were male and female adults who underwent amputations for ischemic, infected or gangrenotic foot. Excluded were patients whose surgery was performed for other indications (trauma, tumors). Mortality and reoperations (wound debridement or need for conversion to a higher levelof amputation) were evaluated as outcomes. Patient- and surgery-related risk factors were studied in relation to these primary outcomes.

RESULTS

The risk factors for mortality were dementia [hazard ratio (HR) 2.769], non-ambulatory status preoperatively (HR 2.281), heart failure (HR 2.013) and renal failure (HR 1.87). Resistant bacterial infection (HR 3.083) emerged as a risk factor for reoperation. Neither AKA nor BKA was found to be an independent predictor of mortality or reoperation.

CONCLUSIONS

Both AKA and BKA are associated with very high mortality rates. Mortality is most probably related to serious comorbidities (renal and heart disease) and to reduced functional status and dementia. Resistant bacterial infections are associated with high rates of reoperation. The risk factors identified can aid surgeons and patients to better anticipate and possibly prevent severe complications.

[The thoracoscopy in complex treatment of non-specific pleural empyema and purulent-destructive diseases of lungs]

The results of treatment of 697 patients with different kinds of non-specific pleural empyema and gangrenous lesions of lungs are presented in the article. Need for complex and differentiated treatment of pleural empyema with obligatory use of thoracoscopy is revealed. High efficiency of early thoracoscopic sanitation improving outcomes and length of hospital stay is proved. Thoracoscopic necrosectomy is alternative and effective surgery in treatment of gangrenous lesions of lungs.

Missed diagnosis of a delayed diaphragmatic hernia as intestinal obstruction: a case report

Penetrating diaphragmatic injury rarely occurs in isolation. Diagnosis of traumatic diaphragmatic hernia resulting from penetrating diaphragmatic injury may be delayed or missed with attendant high morbidity and mortality. We reported a 28-year-old man who presented with features of subacute intestinal obstruction which became severe over the last four days. He had a stab injury to his left lower chest wall that was sutured 31/2 years prior to the development of symptoms. Emergency laparotomy with incidental findings of missed diaphragmatic hernia with gangrenous jejunal segment was found. The hernia was reduced, gangrenous segment resected with end to end anastomosis, and repair of diaphragmatic rent done. He had an uneventful recovery and follow up. There is the need to maintain high index of suspicion of Traumatic Diaphragmatic Hernia (TDH) in a patient with recent or previous thoraco-abdominal injury that will reduce the rate of missed or delayed diagnosis.

Littré meets de Garengeot: Meckel's diverticulum and appendix in a femoral hernia

Littre's and de Garengeot hernias are rare operative findings, the former describing the presence of a Meckel's diverticulum in a hernia sac and the latter describing the presence of the vermiform appendix in a femoral hernia. The finding of both of these anatomical structures in the same hernia is exquisitely rare and infrequently described. In the following report such a case is described and the current knowledge surrounding these unusual hernias is discussed.

[Incarcerated De Garengeots hernia complicated by gangrenous appendicitis]

Femoral hernias account for only about 0.7% of all operated hernias and are rather infrequent among male patients. By contrast, acute appendicitis is one of the most frequent diagnoses in surgery requiring urgent operation. The authors present one of the rare cases in which both these diagnoses occur together - De Garengeots hernia. Incarcerated femoral hernia with acute appendicitis is diagnosed preoperatively only sporadically. Imaging methods can help in the diagnosis, but often the final diagnosis, and especially the final solution, is brought about only by surgical intervention.