Predictors of operative management in diabetic foot ulcers.

BACKGROUND & AIMS: Surgery plays a key role in the management of complicated diabetic foot disease (DFD). Currently, indications for medical versus surgical management are poorly defined. Prompt identification of patients who require surgery may reduce morbidities and length of hospital stay. This study aims to analyse factors in DFD that necessitate early surgical interventions. METHODS: All patients admitted under a multi-disciplinary diabetic foot team in a tertiary institution over 2 years were included in a retrospective case-control study comparing patients who received medical management and patients who received surgical management. Logistic regression was performed to identify factors associated with surgical management of diabetic foot complications. RESULTS: Three hundred and forty patients were included. 49% of patients required surgical management. Toe ulceration, elevated C-reactive protein (CRP), and the presence of osteomyelitis were associated with surgical management. Multivariate analysis calculated an odds ratio (OR) of 1.01 for CRP (p < 0.001), OR 2.19 (p < 0.019) favouring surgical management for forefoot ulcers, and OR 2.2 (p < 0.019) if osteomyelitis was present. CONCLUSIONS: Patients with elevated CRP levels, a forefoot diabetic ulcer and established osteomyelitis were more likely to undergo surgical management. Prompt recognition of these patients has the potential benefit of earlier decision making in definitive surgical interventions.

Proximal Arterial Inflow Revascularization Improves Pedal Arch Quality and Its Impact on Ischemic Diabetic Foot Ulcer Healing.

BACKGROUND: Arterial perfusion is a key factor in diabetic foot ulcer (DFU) healing. Although it is associated with pedal arch patency, not all patients are amenable to pedal artery angioplasty. This study aims to determine the impact of angiographic improvement of the pedal arch quality after proximal arterial inflow revascularization (PAIR) and its association with wound healing. METHODS: One hundred and fifty diabetic patients with tissue loss in 163 limbs who had digital subtraction angiography were studied. Cox regression analysis was used to determine independent predictors of wound healing. Wound healing rates in association with pedal arch patency were calculated by Kaplan-Meier analysis. RESULTS: End-stage renal disease, minor amputation, and complete pedal arch patency were significant independent predictors of wound healing following PAIR with hazard ratios for failure: 3.02 (P = 0.008), 0.54 (P = 0.023), and 0.40 (P = 0.039), respectively. The prevalence of complete pedal arches increased by 24.1% with successful intervention (P < 0.001). The overall rates of wound healing at 6, 12, and 24 months were 36%, 64%, and 72%, respectively. The wound healing rate at 1 year in patients with a complete pedal arch was 73% compared to 45% in those with an absent pedal arch (P = 0.017). CONCLUSIONS: PAIR increases complete pedal arch patency, a significant predictor of wound healing in DFU.

Small bite versus large bite stitching technique for midline laparotomy wound closure: A systematic review and meta-analysis.

Mass closure with a continuous suture using large bite stitching technique has been widely accepted for midline laparotomy wound closures. However, emerging evidence suggests the use of small bite technique to reduce rates of incisional ventral hernia, surgical site infection (SSI) and burst abdomen. This meta-analysis aims to compare small versus large bite stitching techniques to assess complication rates in midline laparotomy wound closures. A comprehensive multi-database search (OVID EBM Reviews, OVID Medline, EMBASE, Scopus) was conducted from database inception to 11th October 2021 according to PRISMA guidelines. We included studies comparing post-operative complication rates of small bite versus large bite stitching techniques for midline laparotomy wound closure. Extracted data was pooled for meta-analysis evaluating rates of incisional ventral hernia, SSI and burst abdomen. We included five randomized controlled trials (RCT) in the meta-analysis and three prospective cohort studies for qualitative analysis. A total of 1977 participants composed of 961 small bite and 1016 large bite technique patients were included from the five RCTs. There was a significant reduction in the rates of incisional ventral hernia and SSI with the small bite stitch technique with odds ratios (OR) of 0.39 (95% CI [0.21-0.71]) and 0.68 (95% CI [0.51-0.91]) respectively, and a trend in favour of reduced incidence of burst abdomen with OR of 0.60 (95% CI [0.15-2.48]). Small bite stitch technique in midline laparotomy wound closure may be superior over conventional mass closure using the large bite stitch technique, with statistically significant lower rates of incisional ventral hernia and SSI.

Receiver operating characteristic curve analysis of arteriovenous dialysis access flow using ultrasound.

BACKGROUNDS: Despite numerous studies investigating the use of ultrasound (US) in assessing arteriovenous fistulas (AVF), there are no universally agreed threshold flow velocities in diagnosing significantly abnormal flow that are useful in predicting thrombotic flow-related dysfunction. This study evaluates a predictive model using receiver operating characteristic curve (ROC) analyses to establish threshold velocities. METHODS: Five hundred and eleven US scans were analysed. ROC curves were used to determine the optimal threshold time average mean velocity (TAMV), peak systolic velocity (PSV) and end diastolic velocity (EDV) of the brachial artery supplying the AVF in determining the need for intervention or thrombosis within 3 months of the scans. Estimated flow volume (FV) ROC was used as an evaluative comparison. RESULTS: There were 356 negative and 155 positive scan results in relation to the need for intervention or thrombosis. Empirical flow velocity parameters of TAMV, EDV and PSV were analysed using ROC curves, yielding an area under the curve (AUC) of 0.95, 0.92 and 0.86, respectively. FV ROC analysis yields a comparative AUC of 0.90. A TAMV cut-off at 48.6 cm/s yielded the highest AUC. Subgroup analysis yielded an optimal TAMV cut-off of 45 cm/s for forearm and 49 cm/s for arm AVF. The EDV was also highly predictive of outcomes. PSV has the lowest accuracy. CONCLUSION: The TAMV of inflow brachial artery to AVF is highly predictive of outcomes of thrombotic flow-related dysfunction. Our study confirms TAMV cut-offs of 45 cm/s for forearm and 49 cm/s for arm AVF. These results require prospective validation.

Inferiority of arteriovenous grafts, in comparison to autogenous fistulas, is underestimated by standard survival measures alone.

BACKGROUND: It has been argued that a prosthetic arteriovenous graft (AVG) is a reasonable alternative to an arteriovenous fistula (AVF) for dialysis. We aimed to compare the patency rates and requirements for the intervention of newly formed AVF and AVG. METHODS: A retrospective analysis was undertaken of AVF and AVG formed between 1 January 2013 and 31 December 2015 at two tertiary referral centres and followed up until 31 December 2017. Outcome measures included successful use for dialysis, patency rates and the number of interventions required to maintain dialysis access per patient-year (PPY). RESULTS: Four hundred and seventy AVF and 92 AVG were constructed. Of 470 AVF, 324 (68.9%) were used compared to 80 of 92 (87%) AVG. One year assisted primary patency of AVF was 75% (confidence interval 71-79%) compared to 47% (confidence interval 36-57%) for AVG. Secondary patency rates for AVF at 1, 2 and 3 years were 77%, 71% and 69%, respectively. At the same time points, secondary patency rates for AVG were 77%, 60% and 46%, respectively (log rank P = 0.034). AVG required 2.4 times the number of interventions PPY than AVF. Surgical thrombectomy of AVG was at a rate of 0.49 PPY compared with 0.042 PPY for AVF. CONCLUSION: AVG have a substantially higher rate of thrombosis than AVF, evident from early in the life of the graft. AVF demonstrate superior patency rates to AVG throughout the life of the access, with far fewer interventions PPY than grafts.

Timely surgical intervention for ureteric complications ensures adequate graft function in renal transplantation: a 10-year review.

BACKGROUND: Ureteric complications can cause significant morbidity in renal and simultaneous pancreas-kidney (SPK) transplantation. This 10-year review identified transplant patients with ureteric complications necessitating surgical intervention in an Australian tertiary centre. METHODS: The hospital records were scrutinized in detail to identify all patients who underwent renal or SPK transplantation from 1 June 2009 to 31 May 2019 with subsequent surgical management of ureteric complications. A case series of patients with ureteric complications was generated and findings were analysed. RESULTS: A total of 893 renal and SPK transplants were performed over the 10-year period. Ten of these (1.12%; seven renal and three SPK) had ureteric complications. All were managed surgically. Five of the 10 had ureteric leaks (0.56%); three had ureteric strictures (0.34%), one had ureteric obstruction from extraluminal compression (0.11%) and one had both leak and stricture (0.11%). All 10 patients underwent ureteric reimplantation. Two patients required more than one operation for their ureteric complication. No graft loss or surgical mortality occurred. All 10 patients currently have functioning kidney transplants and none require maintenance dialysis. CONCLUSION: We report a low rate (1.12%) of ureteric complications in our renal and SPK transplants. Our standard practice of definitive correction by ureteric reimplantation is proving successful. The authors confirm that appropriate surgery is a viable and durable option in renal transplant patients with excellent graft outcomes.

Broad-Ranging Nutritional Deficiencies Predict Amputation in Diabetic Foot Ulcers.

Diabetic foot ulcers present across the spectrum of nonhealing wounds, be it acute or many months duration. There is developing literature highlighting that despite this group having high caloric intake, they often lack the micronutrients essential for wound healing. This study reports a retrospective cohort of patients' micro- and macro-nutritional state and its relationship to amputation. A retrospective cohort was observed over a 2-month period at one of Australia's largest tertiary referral centers for diabetic foot infection and vascular surgery. Patient information, duration of ulcer, various biochemical markers of nutrition and infection, and whether the patient required amputation were collected from scanned medical records. A cohort of 48 patients with a broad-spectrum of biochemical markers was established. Average hemoglobin A1c (HbA1c) was 8.6%. A total of 58.7% had vitamin C deficiency, including 30.4% with severe deficiency, average 22.6 L} 5.8 µmol/L; 61.5% had hypoalbuminemia, average albumin 28.7 L} 2.5 g/L. Average vitamin B12 was 294.6 L} 69.6 pmol/L; 57.9% had low vitamin D, average 46.3 L} 8.3 nmol/L. Basic screening scores for caloric intake failed to suggest this biochemical depletion. There was a 52.1% amputation rate; biochemical depletion was associated with risk of amputation with vitamin C (P < .01), albumin (P = .03), and hemoglobin (P = .01), markedly lower in patients managed with amputation than those managed conservatively. There was no relation between duration of ulceration and nutrient depletion. Patients with diabetic foot ulceration rely on multidisciplinary care to optimize their wound healing. An important but often overlooked aspect of this is nutritional state, with micronutrients being very important for the healing of complex wounds. General nutritional screening often fails to identify patients at risk of micronutrient deficiency. There is a high prevalence of vitamin deficiency in patients with diabetic foot ulcers. This presents an excellent avenue for future research to assess if aggressive nutrient replacement can improve outcomes in this cohort of patients.

Stenting of the Brachiocephalic Vein Following Occlusion After Coronary Artery Bypass Surgery.

We describe a case of left arm swelling over nine months post coronary artery bypass grafting (CABG), due to occlusion of the left brachiocephalic vein. The patient's perioperative course, diagnosis, and management of this complication are presented. doi: 10.1111/jocs.12765 (J Card Surg 2016;31:432-434).

Initial Australasian experience with portal-enteric drainage in simultaneous pancreas-kidney transplantation.

BACKGROUND: Pancreas-kidney transplantation is currently the most effective method to re-establish euglycaemia in insulin-dependent diabetics with associated renal failure. The standard technique employed has been bladder drainage of exocrine secretions coupled with systemic venous drainage ('systemic-bladder' (SB) drainage). The more physiological technique, enteric exocrine with portal venous drainage ('portal-enteric' (PE) drainage), has been utilized sparingly in the past as a result of fears of technical complications. This paper compares the Monash Medical Centre experience with both techniques. METHODS: A total of 68 simultaneous pancreas-kidney transplantations were performed at Monash Medical Centre from 1991 until 2004. The first 37 received SB drainage. Since March 2001, 27 have received PE drainage. This retrospective study compared the SB group (n= 37) with the PE group (n= 27), with a 2-year follow-up, examining a number of surgical outcomes. RESULTS: Two-year patient (94.3 versus 96.0%), kidney (89.2 versus 85.2%), pancreas (77.9 versus 71.4%) and event-free (73.0 versus 67.7%) survivals were all similar between the SB and PE groups, respectively. Although surgery took longer in PE subjects (4 h : 47 min ± 0:48 versus 5 h : 16 min ± 1:00; P= 0.045), less intraoperative transfusions were required (1.3 ± 1.43 versus 0.52 ± 0.90; P= 0.024). Length of hospital stay and time to insulin independence were similar. Pancreas graft thrombosis rates were similar (10.8% SB versus 7.4% PE, P= 0.497). CONCLUSIONS: PE drainage is a safe and viable method for pancreas transplantation, which can be performed with excellent outcomes. An increased rate of complications with PE drainage has not been demonstrated in this series.

Polycystic ovarian syndrome in adolescence.

BACKGROUND: Polycystic ovarian syndrome (PCOS), which is a common endocrinopathy seen not only in adult women but also in female adolescents nowadays, is associated with reproductive, metabolic and cardiovascular problems. OBJECTIVE: This article aims to review the current evidence on managing PCOS in adolescence. In addition, the pathophysiology, risk factors, clinical presentations and existing diagnostic criteria of PCOS will also be discussed. DISCUSSION: Certain risk factors are available to assist the clinicians to identify adolescents at risk of PCOS as the signs can be masked by the normal physiological changes during puberty. It is important to screen and diagnose adolescent PCOS in order to prevent the development of future infertility, type II diabetes mellitus, cardiovascular disease, and even endometrial cancer. Lifestyle modification is of the greatest benefit for adolescents in terms of management, with the condition that full support is available from both the clinicians and their families. The psychological impact of PCOS also constitutes a major concern in adolescent PCOS.

Initial experience of abdominal aortic aneurysm repairs in Borneo.

BACKGROUND: Abdominal aortic aneurysms (AAA) repairs are routine operations with low mortality in the developed world. There are few studies on the operative management of AAA in the Asian population.This study reports the initial results from a unit with no previous experience in this surgery by a single surgeon on completion of training. METHODS: All patients with AAA repair from a prospective database between 1996 and 1999 in the south-east Asian state of Sarawak in Borneo Island were analyzed. Three groups were identified on presentation according to clinical urgency of surgery. Elective surgery was offered to all good risk patients with AAA of >or= 5 cm. All symptomatic patients were offered surgery unless contraindicated medically. RESULTS: AAA repairs were performed in 69 patients: 32 (46%)had elective repairs of asymptomatic AAA; 20 (29%) had urgent surgery for symptomatic non-ruptured AAA; and 17 (25%)had surgery for ruptured AAA. The mortality rate for elective surgery was 6%; the two deaths occurred early in the series with the subsequent 25 repairs recorded no further mortality. The mortality rates for the urgent, symptomatic non-ruptured AAA repair and ruptured AAA repair were 20% and 35%, respectively. Cardiac and respiratory complications were the main morbidities.Sixty-three patients seen during this period had no surgery; three presented and died of ruptured AAA, 34 had AAA of or= 5 cm diameter had either no consent for surgery or serious medical contraindications. CONCLUSION: This study showed that AAA can be repaired safely by highly motivated and adequately trained surgeons in a hospital with little previous experience.

Comparative audit of abdominal aortic aneurysm repairs using POSSUM scores.

Abdominal aortic aneurysm (AAA) repairs represent a significant workload in vascular surgery in Asia. This study aimed to audit AAA surgery and evaluate the application of the Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM) in an Asian vascular unit for standard of care. Eighty-five consecutive surgical patients with AAA from a prospective vascular database from July 1996 to December 2001 in Sarawak were available for analysis. Comparisons between predicted deaths by P-POSSUM and observed deaths in both urgency of surgery categories (elective, urgent, emergency ruptures) and risk range groups (0-5%, >5-15%, >15-50%, >50-100%) were made. No significant difference was found between the predicted and observed rates of death for elective, urgent and emergency AAA repairs. The observed mortality rates were 5%, 18% and 30%, respectively. The observed rates of death were also comparable to P-POSSUM predicted rates of death in the various risk range groups. The POSSUM score used with the P-POSSUM mortality equation is easy to use and applicable as a comparative vascular auditing tool in Asia.

Epidemiology of abdominal aortic aneurysm in an Asian population.

BACKGROUND: Abdominal aortic aneurysms (AAA) are common in the Caucasian population. Apart from reported differences in the occurrence of AAA in the black and white populations, there are few studies on the incidence of AAA in the Asian population. METHODS: A prospective database of all patients with AAA seen between 1996 and 1999, in the South-East Asian state of Sarawak in Borneo Island, was analysed. The demographic data included patient's age, sex, ethnic group, date of diagnosis, comorbidities, presentations and treatment outcomes. These were compared with the state population's demographic statistics. RESULTS: Diagnoses of AAA were made in 123 patients during the study period. The male to female ratio was 3.5 : 1. The age range was 39-88 years with a median age of 70 years. Four patients were younger than 55 years. The incidence rate for the at-risk male population older than 50 years was 25.6/100,000. The incidence rate reached 78.3/100,000 for males older than 70 years. The incidence rate for females older than 50 years was 7.6/100,000 and for those older than 70 years it was 18.7/100,000. All races were affected. Smoking, hypertension or respiratory disorders were present in more than 40% of the patients. Half of the patients underwent surgical repair. CONCLUSION: This study shows that AAA in this Asian population is not uncommon and the incidence is comparable to the Western world.