Spectrum of disease and outcome of primary amputation for diabetic foot sepsis in rural KwaZulu-Natal

Background: Primary amputation (stump closure) for diabetic foot sepsis is perceived to have a higher re-amputation rate due to stump sepsis. A guillotine amputation with elective stump closure is widely practised due to the lower risk of stump sepsis and re-amputation.Aims: To provide an epidemiological analysis of the spectrum of disease and outcomes of primary amputation for diabetic foot sepsis in a regional rural hospital.Methods: A prospective cohort study of 100 patients who underwent surgery for diabetic foot sepsis over a 5-year period was undertaken at Madadeni Provincial Hospital, in northern KwaZulu- Natal. Demographic data, co-morbid profile, radiographic features, anatomical level of vascular occlusion and type of surgery performed were recorded. The Wagner classification (Wag) was used to classify disease severity. Outcome measures included length of hospital stay, in-hospital mortality and re-amputation rates.Results: Of the 100 patients, females (n = 50) accounted for 50% of admissions. The median age was 61 years (range: 29 to 80 years). Most patients presented with advanced disease: Wag 5, n = 71 (71%); Wag 4, n = 20 (20%); Wag 3, n = 7 (7%); Wag 2, n = 2 (2%). The anatomic levels of vascular occlusion comprised: aortoiliac disease n = 2 (2%), femoro-popliteal n=21(21%) and tibioperoneal disease n = 77 (77%). The following surgical procedures were undertaken: above knee amputation (AKA), n = 35 (35%); below knee amputation (BKA), n = 46 (46%); transmetatarsal amputation (TMA), n = 8 (8%); toe ectomy, n = 8 (8%) and debridement, n = 3 (3%). The re-amputation rate to above knee amputation was n = 2/46 (4.3%). All AKA stumps healed completely. The overall in-hospital mortality was n = 7 (7%) and median length of hospital stay was 7.8 ± 3.83 days.Conclusion: Most patients present with advanced disease requiring a major amputation. A definitive one stage primary amputation is a safe and effective procedure for diabetic foot sepsis with distinct advantages of a short hospital stay, low re-amputation rates and mortality. A guillotine amputation should be reserved for physiologically unstable patients

Carotid Artery Stump Pressure and Associated Neurological Changes in Predominantly Symptomatic Carotid Artery Disease Patients Undergoing Awake Carotid Endarterectomy : Cardiovascular Topics

Aim : To determine the mean carotid artery stump pressure (SP) at which patients develop neurological changes while undergoing awake carotid artery endarterectomy (CEA) under cervical block anaesthesia (CBA). Methods : A prospective analysis was carried out of patients undergoing awake CEA under CBA between February 2004 and April 2007. All patients had mean SP measured; with selective shunting on those who developed neurological symptoms on carotid artery clamping regardless of stump pressure. A ball connected to a pressure sensor was put in the patient's contra-lateral hand. Results : Fifty-nine patients had awake CEA; 40 were males with a mean age of 64 years. Indications for CEA were asymptomatic high-grade stenosis in 12 (20) patients and symptomatic stenosis in 47 (80). Seven (12) patients required shunting; one for transient ischaemic attack (TIA) and six for loss of consciousness. Six of these patients had presented with symptomatic disease. Taking the threshold of mean carotid SP of 50 mmHg as an indication for shunting; 22(6 / 27) of patients with a mean SP of 50 mmHg required shunting and only 3(1 / 32) with a mean carotid SP of 50 mmHg needed a shunt. This was not statistically significant. Using a mean carotid SP of ? 40 mmHg as the threshold for shunting; 40(4 / 10) of patients required shunting and 3(1 / 31) with a mean carotid SP of 40 mmHg required shunting. This was statistically significant. Thirteen (22) patients were complicated by transient hoarseness of voice. One (2) had a haematoma that required re-exploration. None of these patients had any major postoperative neurological or cardiological complications. Conclusion : Even though the sample in this study was small; awake CEA under local anaesthesia was seen as a safe procedure. It would appear to be safe to use the mean SP of 40 mmHg as a threshold for selective shunting in CEA under general anaesthesia

The Influence of Diabetes on Short-Term Outcome Following a Prosthetic Above-The-Knee Femoro-Popliteal Bypass : Cardiovascular Topic

Objectives: To assess the influence of diabetes mellitus on early morbidity and mortality following a femoro-popliteal bypass. Methods: Clinical data on patients subjected to a prosthetic above-the-knee femoro-popliteal bypass for atherothrombotic disease over a four-year period in the Durban Metropolitan Vascular Service were culled from a prospectively maintained computerised database. The patients were divided into two groups; diabetic and non-diabetic. Results: Two hundred and seventeen patient records were analysed; 102 (47) patients were diabetic and 115 (53) non-diabetic. The mean age in the two groups was almost similar. Differences noted between the two groups were that there was a higher prevalence of males and cigarette smokers in the non-diabetic group and hypertension among the diabetics. The prevalence of ischaemic heart disease in the two groups was not statistically significant. The majority of patients in both groups presented with critical limb ischaemia. Overall; 208 (96) of the patients had their procedures performed using loco regional anaesthesia. The incidence of superficial wound infection between the two groups was not statistically significant. Deep infection; which necessitated removal of the graft; and cardiovascular complications were significantly higher in the diabetics. Four patients (3.9) in the diabetic group and only one (0.9) in the non-diabetic group died. Conclusion: Diabetes mellitus significantly increases the incidence of graft sepsis and cardiovascular morbidity in patients undergoing above-the-knee femoro-popliteal bypass

Carotid Intervention : Stent or Surgery? A Prospective Audit : Cardiovascular Topic

This study represents a prospective audit comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA); performed by a single surgical team. Between January 2005 and December 2008; 440 patients were referred; 177 had CAS and 263 CEA. Selection of procedure was individualised and contra-indications for CAS included internal carotid artery (ICA) stenosis 85-90; intraluminal thrombus; ICA tortuosity; gross surface ulceration of plaque and excessive calcification. Type III aortic arch and arch calcification also precluded CAS. Standard techniques were used for both procedures with a protection device routinely used for CAS. Most CEAs were performed under general anaesthesia; with selective intraluminal shunting. One hundred and eighty-six patients were selected for CAS; nine (48) were converted to CEA for technical reasons. The operative risk profile was similar; but significantly more in the CAS group were hypertensive. Almost half (49) in the CAS group were asymptomatic vs 26in the CEA group. All asymptomatics had 70+stenosis on Duplex Doppler. Results were reported within one month of the procedure. The stroke rate was 2.3for CAS vs 1.9for CEA (p 0.05). Stroke and death plus one M1 was 4.5after CAS vs 3.4after CEA (p 0.05). Disabling stroke occurred in 1.1of CAS patients vs 0.4of CEA patients. These results are satisfactory and compare favourably with other similar series

Fluctuating pulse deficits associated with intimal arterial injury following gunshot wounds of the extremity - a sign not to be missed

Gunshot wounds may result in intimal arterial injury without breach of the arterial wall integrity. Haemorrhage; haematoma and a pulse deficit are therefore not always found. We report on two cases of lower extremity gunshot wounds with temporal variations in the clinical and radiological assessment of the pedal pulses. In both cases surgical exploration revealed intact arterial vessel walls but significant intimal injury with overlying thrombus. We propose that the pulse deficits were due to distal thromboembolism. Subsequent clot lysis led to a return of the original pulse deficit. Variation in the distal pulses in patients with gunshot wounds of the extremities should alert one of the possibility of an intimal arterial injury; imaging of the vessels is therefore advised