[The diabetic foot seen by the surgeon. Personal experience]. / Il piede diabetico visto dal chirurgo. Esperienza personale.

BACKGROUND: The aim of this study is to evaluate a major amputation risk criterion in diabetic patients with trophic lesions of the foot. The records of a series of 100 consecutive patients (65 males and 35 females) with diabetic foot ulcer treated in our surgical facilities between January 1992 and December 1997, in collaboration with diabetologists and podiatrists, have been reviewed retrospectively. METHODS: In 26 cases the ulcer involved both limbs and, therefore, the feet observed in this study have been 126. Accurate diagnosis of the underlying cause was the first step and in cases with a poor blood supply (69 limbs; 55%) unresponsive to medical therapy (44 limbs) vascular reconstruction (37 limbs), spinal cord stimulator (SCS) implantation (3 limbs) or major amputation (4 limbs) were performed. According to Wagner grading there were 42 grade 2 ulcers (33%), 38 grade 3 (30%), 43 grade 4 (34%) ad 3 grade 5 (3%). RESULTS: One patient died postoperatively after SCS implantation. All but 4 neuropathic ulcers (53 limbs) healed in a mean time (+/- SD) of 5.2 +/- 3.8 months and all but 10 vascular ulcers (59 limbs) healed in a mean time of 6.3 +/- 4.1 months. Of the latter group in 4 cases the patient died before ulcer healing while in 6 cases (8.7%) a major amputation was performed (in 2 cases after vascular reconstruction procedures). Minor amputations of the forefoot have been performed in 23 instances (33%) of vascular ulcer and in 10 cases (17%) of neuropathic ulcer. CONCLUSIONS: Since ischemia is the main risk factor for amputation, it is suggested that a particular effort should be made in improving the vascular diagnostic, both clinical and strumental, capabilities of our diabetologists and podiatrists in order to detect the vascular insufficiency in earlier stages.

Revascularization of the ischemic diabetic foot by popliteal-to-distal bypass.

BACKGROUND: Diabetic foot revascularization by popliteal-to-distal bypass is a procedure for limb salvage spread in the last decade. METHODS: The authors report their experience with a consecutive series of 15 ischemic feet (mean transcutaneous oxygen 5.3 +/- 4.1 mmHg) with gangrenous lesions due to extensive tibial arteries occlusive disease beginning at the popliteal artery trifurcation (9 cases) or involving the distal popliteal artery (6 cases). Limb salvage was achieved by popliteal-to-distal bypass with autogenous inverted saphenous vein. RESULTS: No operative death was observed. At a mean follow-up of 35 +/- 23 months (range 3-84 months) 4 bypasses were occluded and two were surgically revised after 4 and 50 months from surgery and subsequently remained patent. One patient was submitted to a major amputation. By life table analysis the cumulative primary and secondary patency and limb salvage rates for this group of diabetic patients were at 2 years 79.3%, 86.2% and 93.1% respectively (SE < 10%). CONCLUSIONS: This small experience and a review of the literature confirm the validity of the popliteal-to-distal bypass and the need for a more aggressive vascular surgical attitude to treat the ischemic diabetic foot.

Scaling regimes in the distribution of galaxies.

If we treat the galaxies in published redshift catalogues as point sets, we may determine the generalized dimensions of these sets by standard means, outlined here. For galaxy separations up to about 5 Mpc, we find the dimensions of the CfA galaxy set to be about 1.2, with only a modest indication of multifractality. For larger scales, out to about 30 Mpc, there is also good scaling with a dimension of about 1.8. For even larger scales, the data seem too sparse to be conclusive, but we fmd that the dimension is climbing as the scales increase. We report simulations that suggest a rationalization of such measurements, namely that in the intermediate range the scaling behavior is dominated by flat structures (pancakes) and that the results on the smallest scales are a reflection of the formation of density singularities.

Arteriomegaly and inflammatory abdominal aortic aneurysm. Case report.

In this case report inflammatory abdominal aortic aneurysm (IAAA) was superimposed on an arteriomegaly condition complicated by bilateral aneurysm of the common iliac arteries. Obstruction of the right ureter, mild hydronephrosis of the left system and a slight impairment of renal function were also present. Preoperative cellular and humoral immunological parameters were within normal limits while the erythrocyte sedimentation rate (ESR) was elevated (74 mm). Histological analysis showed numerous scattered lymphoid cells or organized in follicles with germinal centers within the adventitial thickening of the IAAA wall. Immunohistochemical analysis on frozen sections demonstrated that dispersed and perivascular lymphoid cells were mainly composed of similar amounts of CD3+/CD4+ and CD3+/CD8+ T lymphocytes. Histological analysis of the common iliac artery aneurysm showed a mild intimal thickening will small aggregates of macrophages. After aneurysm repair all peripheral blood analysis normalized within one month after surgery. The IAAA observed in our patient with arteriomegaly as underlying arterial disease cannot be interpreted as an inflammatory variation of an atherosclerotic aneurysm. The histological pattern of the inflammatory reaction and its resolution after surgery give, in our opinion, more credit to the etiopathogenetic hypothesis of a reaction elicited by an antigen within the arterial wall of the infrarenal aorta which might be enhanced by the lymphatic stasis subsequent to aneurysm compression.

[Acute abdominal pain in emergency surgery. Clinical epidemiologic study of 450 patients]. / Il dolore addominale acuto in chirurgia d'urgenza. Studio clinico-epidemiologico su 450 pazienti.

A retrospective study on 450 patients admitted in emergency with acute abdominal pain in a general surgical unit of the Ist Institute of Surgery of the University of Rome "La Sapienza" was carried out during a 7 years period. The aim of the study was to identify the most frequent causes of acute abdominal pain correlated with age, sex, onset of pain and other conditions in order to improve diagnosis and reduce mobility for mortality. Appendicitis was the most frequent diagnosis (75 pts = 16.4%). Non-specific abdominal pain (NSAP), found in 71 pts (15.5%), cholelithiasis in 57 pts (12.5%), abdominal malignancy in 47 pts (10.3%) were other frequent conditions. The largest number of admissions occurred in the age groups 60-70 years (16.6%) and 20-30 years (14.2%). Surgical operations were performed in 206 patients (45.7%). The overall mortality was 4.2% (19/450 pts) and the rate increased significantly in patients aged > 60 years. Postoperative mortality was 5.8% (12/206 pts) while mortality rate in non-operated patients was 2.8%. The causes of perioperative death included perforated peptic ulcer, abdominal malignancies (15.4%) and urgent colonic resections (9.4%). The duration of inpatients stay increased significantly with the age of the patients, including those with nsap. The results of the study indicate a need to review the methods of diagnosis of appendicitis and to obtain a better clinical performance in patients with nsap.

[Distal popliteal bypass in the diabetic patient. Clinical case]. / Il bypass popliteo distale nel paziente diabetico. Caso clinico.

Foot revascularization by popliteal-to-distal bypass is a well documented procedure for limb salvage in diabetic patients. The authors report their experience with a diabetic patient admitted with an ischemic left foot [transcutaneous oxygen (PtcO2): 3 mmHg] due to extensive tibial artery occlusive disease beginning at the popliteal artery trifurcation. Limb salvage was achieved by anatomical popliteal-anterior tibial bypass with inverted saphenous vein. Nine months later the patient was readmitted with an ischemic right foot (PtcO2: 16 mmHg) and a similar pattern of peripheral arterial occlusive disease. Limb salvage was achieved by extranatomical popliteal-dorsalis pedis bypass with a reversed saphenous vein. At six months from the latest surgery both feet are healed, PtcO2 is 60 mmHg and 37 mmHg for the left and right foot respectively and the patient has resumed a normal walking distance. This experience, and a review of the literature, confirm the validity of the popliteal-to-distal bypass and the need for more aggressive vascular surgical attitude to treat the ischemic diabetic foot.

[Efficacy of the popliteal to distal bypass in salvage of the ischemic diabetic foot]. / Efficacia del by-pass popliteo distale per il salvataggio del piede diabetico ischemico.

Foot revascularization by popliteal-to-distal by-pass is a well documented procedure for limb salvage in diabetic patients. The authors report their experience with a consecutive series of 5 ischemic feet [transcutaneous oxygen (PtO2): 6 +/- 5.6 mmHg] due to extensive tibial artery occlusive disease beginning at the popliteal artery trifurcation. Limb salvage was achieved by popliteal-to-anterior tibial bypass (1 case) and popliteal-to-dorsalis pedis artery by-pass with autogenous inverted saphenous vein. No operative death was observed. At follow-up (range 3-34 months) one patient died at 3 months after surgery because of an intestinal bleeding. All 4 remaining by-passes are well functioning [PtcO2 46 +/- 11.2 mmHg) and all patients have resumed their normal walking distance. This preliminary experience, and a review of the literature, confirm the validity of the popliteal-to-distal by-pass and the need for more aggressive vascular surgical attitude to treat the ischemic diabetic foot.

[Obturator foramen bypass for revascularization of the leg with infection of the femoral area. A clinical case]. / Il bypass transotturatorio per la rivascolarizzazione dell'arto con infezione dell'area femorale. Caso clinico.

Infection of the femoral artery together with limb acute ischemia represent for the vascular surgeon a challenging condition to manage. To solve this complicated vascular problem in the groin, the obturator foramen bypass has been described as an alternative procedure for ischemic limb salvage. The authors report their experience with a diabetic patient admitted in critical conditions with an ischemic leg and sepsis of the femoral area due to an infected extra-anatomical crossover femoro-femoral bypass complicated by hemorrhagia and which was partially removed in another Hospital. Limb revascularization was achieved by an obturator foramen PTFE expanded iliopopliteal bypass. The residual infected prosthesic stump was, thereafter, removed from the groin wound. The post-operative period was uneventful and the patient was discharged in the XIII post operative day. At follow-up, latest control at 10 months (July 1993) documented a patent graft and an ankle pressure index > 1. This experience, and a review of the literature, confirm the validity of the obturator foramen bypass as a route of choice for infected femoral artery and ischemic limb salvage.

[Role of ultrasonography in emergency surgery]. / Ruolo dell'ecografia in chirurgia d'urgenza.

A prospective study was carried out to compare the value of ultrasound examination with conventional management in patients presenting with emergency surgical problems. During an 4 years period the authors followed 301 patients referred to the Ist Institute of Surgery of the University of Rome "La Sapienza". After immediate clinical evaluation one or more US examinations were performed in each patient following a standard protocol of study. Abdominal emergencies were the most frequent conditions, found in 75% of the cases and the acute abdomen due to trauma in 17.6% of the cases. The overall sensibility, specificity and accuracy of clinical examinations and US examinations were respectively of 88%, 33%, 70% and 95%, 94%, 95%. In 38 patients (12.7%), a diagnosis was made up by sonographic examination which had not been clinically expected (group A). The principal condition in this group was gynaecological pathology, found in 17 patients. In 161 patients (53.3%) sonography confirmed the first diagnosis clinically suspected (group B) and in 23 cases the second or third differential diagnosis (group D). Sonography made no contribution to the diagnosis in 77 cases (25,5%) and only in 2 cases was considered misleading. The result of this study demonstrate the usefulness of emergency ultrasonography in gynecological, gall bladder, pancreatic and vascular diseases. Moreover sonography must be considered the principal diagnostic tool in patients with trauma. In order to recognize gynecological diseases which can simulate appendicitis US examination must be considered necessary in young female patients. When appendicitis is suspected US is useful in children and in older patients too.