Functional outcomes of transmetatarsal amputation in the diabetic foot: timing of revascularization, wound healing and ambulatory status.

Transmetatarsal amputation (TMA) is an effective surgical approach to treat forefoot infection and gangrene in diabetic patients. However, a high rate of complications and failure to heal require reamputation in a large number of cases. We analysed the outcomes of TMA to define the role of revascularization, wound healing and ambulatory status. From January 2008 to January 2013, 218 diabetic patients with foot infection and gangrene, submitted to TMA associated to revascularization were followed until healing, amputation or death. Revascularization was done in 202 (92 %) cases. In 16 (7 %) no revascularization was required. The TMA was closed in 135 (62 %) and left open in 83 (38 %) cases. The reamputation rate was 34 % and major amputation 12.6 % at 1-year follow-up. Patient following ranged 2-30 months with a mean of 15 months. The functional outcomes, living at home and ambulation outdoors, were 60 and 36 % at hospital discharge after TMA, 81 and 77 % at 1-year follow-up. TMA associated to revascularization can provide an effective limb salvage and functional results in diabetic patients with forefoot tissue loss and infection.

Extreme endovascular revascularization for limb salvage in critical limb ischemia.

AIM: Distal bypass has been considered as a primary choice for the treatment of critical limb ischemia (CLI). When bypass failed with limb threatening ischemia, the amputation rate is high in patients with increased surgical risks and lack of conduit. Percutaneous transluminal angioplasty (PTA) has been shown to be effective and safe in the setting of CLI even in patients with failed bypass graft. The aim of this study was to review our experience and results of extreme endovascular revascularization in patients with CLI following occluded lower limb bypass graft. METHODS: Retrospective review from January 2005 to June 2008 of patients with CLI following occluded bypass graft who underwent PTA was performed. All patients were studied by Duplex scanning and dual-energy computed tomographic angiography (DE-CTA) bone removal technique. Stents were used in cases of residual stenosis or dissection. Technical success was defined as a residual stenosis less than 30%. Demographics, comorbidities, functional status, details of the procedure information were recorded. Descriptive, logistic regression and life-table analyses performed. RESULTS: Thirty-six patients with occluded bypass grafts were treated. The mean age was 69 years (range 56-89), 44% were older than 80 years, 83% had diabetes mellitus, 88% of limbs treated had multiple lesions included Tasc C and D lesions. Technical success was achieved in 91%. Mean follow-up was 24 months. At follow-up, there were 19 PTA failures which were followed by subsequent procedures: redo PTA in 16 limbs, redo bypass in 2, amputation in 5. Cumulative primary patency was 60% (±0.08 SE) and 24% (±0.07 SE). Secondary patency was 96% (±0.03 SE) and 83% (±0.08 SE). Limb salvage was 84% (±0.06 SE) and 70% (±0.10 SE). Freedom from surgical revision was 78% (±0.07 SE) and 54% (±0.11 SE). Overall survival was 89% (±0.05 SE) and 58% (±0.11 SE) at 12 and 24 months, respectively. CONCLUSION: Endovascular revascularization of patients with CLI and occluded bypass graft is a safe and feasible procedure with reasonable technical and clinical success and limb salvage. PTA may be the only alternative to amputation in these patients with extensive comorbidities and limited life expectancy.

The efficacy of Iloprost for the treatment of chronic venous ulcers of the lower limbs.

BACKGROUND: The purpose of this study was to assess the effect of Iloprost in the treatment of venous ulcers. PATIENTS AND METHODS: We recruited 52 patients with uncomplicated venous ulcers of the lower limbs. They were divided into two groups: the first (29 patients) was given Iloprost in saline solution for three weeks, while the second (23 patients) received saline solution only. The size and number of ulcers were determined at the start of the treatment and then every 15 days for six months. RESULTS: Ulcer size diminished faster in the patients treated with Iloprost, with 100% healed within 120 days. In the placebo group, 82.60% had healed by the end of the 180-day observation period. This difference was statistically significant. Ulcer cicatrization was also faster in the treatment group (65.51% after 60 days, 86.20% after 90 days and 100% after 120 days), whereas in the placebo group, the ulcers had still not healed in 17.40% of patients by the study end. CONCLUSIONS: Iloprost can significantly reduce healing time for venous leg ulcers without any specific complications.

Infrainguinal endovascular procedures based upon the results of duplex scanning.

AIM: The aim of this study was to report the role of duplex scanning in selection of patients with lower limb ischemia for infrainguinal endovascular revascularization. METHODS: From January 2002 to December 2005, 95 patients (66 male, 29 female) underwent infrainguinal endovascular revascularization based on duplex scanning. The indications for surgery were severe claudication (11%), rest pain (15%), gangrene (40%), and non-healing ulcer (34%). RESULTS: Duplex procedure time averaged 60+/-30 min. A total of 120 arterial hemodynamic relevant lesions were treated with endovascular therapy, 47 were localized in the aorto-iliac segment, 55 in the femoro-popliteal segment and 18 were infrapopliteal. Out of a total of 120 lesions, 107 (89%) were successfully dilated; 105 lesions (88%) predicted by preoperative duplex scanning were confirmed by contrast arteriography (CA) at the time of surgery. Additional lesions were revealed by intraoperative arteriography in 15 cases (12%). The accuracy and sensitivity of duplex scanning in the selection of aorto-iliac lesions for endovascular procedures was 86%, 91% for femoro-popliteal lesions, and 78% for infrapopliteal lesions. CONCLUSION: The results of this experience show that duplex scanning may be a safe alternative to CA for patients with chronic limb ischemia. Adequate training and experience is necessary to utilize this technique for the selection of patients for infrainguinal endovascular procedures.

[Post-operative analgesia in thoracic surgery: physiopathological features, therapeutic framework and methodologies]. / Analgesia post-operatoria in chirurgia toracica: aspetti fisiopatologici, basi terapeutiche e metodi.

Pain after surgery is a major handicap for patients as it bounds and decreases ability for spontaneous movement, cough and deep breathing, aiding the onset of complications and invalidating the recovery capabilities of operated patients. In thoracic surgery, the need to compile and employ guidelines for post-surgical pain management has become a pressing requirement in recent years. Currently available protocols include several options of treatment that are frequently a subject in the most recent scientific papers and play a key role, as they constitute the framework upon which building with changes and fixes that take account of incidental circumstances, in relation to both patients and surgery, again for both the organizational and structural features of the surgical environment. Purpose of this job is a thorough analysis of post-operating analgesic treatments for thoracic surgery, introducing the most effective ones currently available as for channels and procedures of administration, as well as possible side effects or complications.

Infrainguinal revascularization based on duplex ultrasound arterial mapping.

AIM: Recent reports have advocated duplex ultrasound arterial mapping (DUAM) as the sole preoperative imaging modality for planning infrainguinal revascularization. This study reports the outcome of arterial revascularization procedures for chronic limb ischemia based on DUAM. METHODS: From January 2002 to December 2004, 253 patients (175 men, 78 women) underwent infrainguinal revascularization based on DUAM. The indications for surgery were severe claudication (11%), rest pain (15%), gangrene (40%), non-healing ulcer (34%). Preoperative evaluation consisted of DUAM alone in 208 cases (82%) or a combination of DUAM and contrast arteriography (CA) in 30 (12%) and intraoperative angiography or direct exploration in 15 (6%). DUAM allowed imaging from the distal aorta to the pedal arteries and the selection of inflow and outflow bypass anastomosis sites. CA was deemed necessary due to technical difficulties or medico-legal reasons. RESULTS: DUAM procedure time averaged 90+30 min. Proximal anastomosis was located in common femoral arteries in 202 cases, popliteal in 51. Distal anastomosis was to the tibial arteries in 144 cases and pedal arteries in 109. Primary patency was 89% and 67% at 12 and 36 months. Secondary patency was 93% and 82% at 12 and 36 months. CONCLUSIONS: This experience shows that DUAM may be a safe alternative to CA for patients with chronic limb ischemia. Adequate training and experience is necessary to utilize this technique as the sole preoperative imaging modality for planning infrainguinal revascularization.

[Thromboembolic risk and prevention of deep venous thrombosis in open and laparoscopic surgery]. / Rischio tromboembolico e profilassi della trombosi venosa profonda in chirurgia tradizionale e in chirurgia laparoscopica.

Deep Vein Thrombosis (DVT) and pulmonary embolism are the dangerous and serious complications in patients undergoing surgery. It is known that prognosis is strictly linked to timely recognition of the pathogenetic-clinical phase of the thromboembolic disease and that prevention, therefore, plays the leading role in patients at risk. The most recent series show that, in absence of prophylaxis, the frequency of DVT, diagnosed by objective tests, is still significant in abdominal surgery. Modern diagnostic tools make possible to identify relatively silent clinical thrombosis, also with laboratory tests (i.e., D-dimer plasma levels). The Authors report a study on thromboembolic episodes in patients who underwent pneumoperitoneum with CO2 during laparoscopic abdominal surgery, compared to a control group submitted to open surgery. They underline the importance of a careful preoperative evaluation of the venous system, by Doppler study, in order to identify, patients at risk of DVT and establish a suitable anti-thrombotic prophylaxis.