Why a multidisciplinary team may represent a key factor for lowering the inferior limb loss rate in diabetic neuro-ischaemic wounds: application in a departmental institution.

UNLABELLED: INTRODUCTION/AIM OF THE STUDY: To assess the influence of a multidisciplinary approach on the limb salvage rates in the treatment of patients suffering from diabetic ischaemic inferior limb ulcers. MATERIALS & METHOD: From September 2001 until March 2008, a consecutive series of 183 limbs with diabetic ischaemic wounds in 163 patients were treated by combined multi-level angioplasties as the primary revascularization approach in an institutional diabetic programme (two departmental hospitals). The avoidance of limb loss was retrospectively analyzed before and after the year 2005, as a landmark for implementing a "multidisciplinary diabetic foot clinic" in the routine daily care. RESULTS: Initial technical success for endovascular revascularization was noted in 152 limbs (83%). The aggregate limb salvage proportions at 12, 24, 32, 60 and 66 months (+/- SEM) were: 87% (+/- 2.8), 80% (+/- 3.9), 77% (+/- 4.4) and thereafter 77% (+/- 4.4), respectively. A comparison between the limb salvage rates before and after initiating the multidisciplinary group showed a significant difference (p = 0.040, CI: 1.040-5.311, HR: 2.35, Chi square = 4.22) with better results in the latest interval, employing effective team activity. No statistical deviation was found regarding the technique itself for revascularization at the same intervals (p = 0.381). CONCLUSION: Our experience suggests that limb salvage for diabetic ischaemic wounds may be favourably influenced by a co-ordinated multidisciplinary group. Although appropriate revascularization is crucial for limb rescue, a pluralist control of the attending risk factors influencing wound healing might be of matchless importance as well.

Large non-anastomotic false aneurysm on dacron aortobifemoral prosthesis solved by endovascular exclusion.

Aortic and iliac pseudo-aneurysms are infrequent but challenging complications after open surgical graft reconstructions, mostly having para-anastomotic localisations. The true corporeal peri-prosthetic false aneurysms are, up until now, very rarely documented presentations. We report the clinical case of an 8.8 cm diameter non-anastomotic and aseptic pseudo-aneurysm developed on aorto-bifemoral Dacron prosthesis in a symptomatic and high surgical risk patient. Considering the clinical presentation and the anatomical features, a chronic tear of the posterior prosthetic wall by prominent aortic remnant calcifications was evoked as the possible aetiology. An endovascular exclusion, using a tapered aorto-uni-iliac endograft coupled to a femoro-femoral bypass revascularisation, was technically successful. Despite scarce published clinical data focusing on the optimal treatment dedicated to this category of false aneurysm, this approach is thought to be beneficial in selected cases of high-risk surgical patients.

Surgical management of acute perforation of peptic ulcers. A single centre experience.

INTRODUCTION: Acute perforation may occur in gastric and duodenal ulcers. During the past decade, the need for elective operation for peptic ulceration has decreased as medical treatment has improved. However, emergency operations for acute complications such as perforation or bleeding remain constant. Actually, the treatment of choice is simple suture-closure, with or without omentoplasty, and peritoneal lavage or even omentoplasty alone, associated with a high intravenous dose of inhibitors of the proton pump and Helicobacter pylori eradication, if needed. PATIENTS AND METHOD: The standard treatment in our team is to perform a peritoneal lavage and drainage and a simple closure of the ulcer with an omentoplasty. A first retrospective analysis was made on data collected from 1996 to 2001 and we completed a prospective study from 2001 to 2003 to compare our results with our old data and with data collected from other teams. RESULTS: The mean age and the mean ASA score were similar in the two groups. For the majority of the patients, the diagnosis was made from symptoms and the presence of free abdominal air. The delay between arrival in the emergency room and the operating room was significantly shorter in the second group, but operating time was longer in this group. Morbidity was more frequent in the first group but mortality remained quite similar. Our results indicate that in a trained team the morbidity has decreased as the delay in surgery decreased and that the rate of diagnosis on plain abdominal film has increased. Laparoscopic suture of a perforated peptic ulcer is as safe as the open procedure but allows the surgeon to search for another cause of free air and offers the possibility, if conversion is needed, to perform a shorter laparotomy.