Management of ischemic diabetic foot.

Diabetic foot pathology represent the more disabling complication of diabetes. More the 1 million of diabetes patients undergo a lower limb amputation per year; 85% of these amputation are preceded by un ulcer that can be avoided by a prevention program. Critical limb ischemia (CLI), the only independent cause of major amputation in diabetic population, can be correctly treated when an early diagnosis is made. Both endoluminal and surgical revascularization procedures can be applied in diabetes with high rate of success when performed by skilled operator. Infection of diabetic foot, in particular in patients suffering from peripheral artery disease (PVD), may rapidly evolves in severe local or systemic infection putting the patient at high risk of major amputation or death. Together with an early diagnosis of infection and ischemia it is mandatory to apply a correct medical and surgical treatment protocol with the aim to control infection and to improve blood perfusion to the foot. In case of infection surgical procedure should be applied first while revascularization procedure will follow soonest. Antibiotic therapy should be chosen considering different local biological pattern and different type of infection. Reconstructive surgery, the last step in treatment of any diabetic foot lesion, must obtain a functional residual foot or a stump that will allow the patient to go back walking soonest with residual good walking capacity.

Multicentre observational study of the natural history of left-sided acute diverticulitis.

BACKGROUND: The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. METHODS: The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. RESULTS: Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment. CONCLUSION: Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Long-term outcomes after angioplasty of isolated, below-the-knee arteries in diabetic patients with critical limb ischaemia.

BACKGROUND: It has been shown that concomitant percutaneous transluminal angioplasty (PTA) of above-the-knee (ATK) and below-the-knee (BTK) arteries is highly beneficial for limb salvage in patients with critical limb ischaemia (CLI), but few published studies have specifically investigated outcomes in diabetic patients with CLI associated with isolated small BTK-vessel disease. This study aimed to evaluate the long-term results of successful PTA for limb salvage in such patients. MATERIALS AND METHODS: From among the 634 patients with CLI in our database, we retrospectively selected a consecutive series of 101 diabetics (16%) with 107 critically ischaemic limbs (33 Rutherford 5 and 74 Rutherford 6) and no critical ATK lesion, who underwent PTA on isolated BTK lesions. RESULTS: The limb salvage rate was 93% after a mean follow-up of 1048+/-525 days (2.9+/-1.4 years). Transcutaneous oxygen tension significantly increased after 1 month (18.1+/-11.2 vs. 39.6+/-15.1; p<0.05). After 1 year, target-vessel re-stenosis had occurred in 42% of the non-amputated limbs, nine patients (9%) had died because of medical conditions unrelated to PTA and three patients had undergone repeat PTA for recurrent CLI. CONCLUSIONS: In our selected patient population with ischaemic diabetic foot and isolated BTK lesions, a successful endovascular procedure led to a high percentage of limb salvage at long-term follow-up.