Management of diabetic ulcers of the dorsum of the foot and distal leg ulcers.

OBJECTIVE: Diabetic foot ulceration of toes, forefoot and heel have been extensively studied; however, the dorsum of the foot and the distal leg have rarely been addressed. The objective of this study was to assess diabetic ulcers of the dorsum of the foot and of the distal leg (DUDFDLs) as primary sites, or extended lesions from other foot locations, with regard to possible causes, management and outcomes. METHOD: This was a retrospective study conducted in Jabir Abu Eliz Diabetic Centre (JADC) in Khartoum from January 2018 to August 2019. All patients with a primary DUDFDL, or one extending from a plantar or heel ulcer, were included. RESULTS: A cohort of 102 patients with DUDFDLs were studied; 74 (72.5%) were male and 28 (27.5%) were female, with a male-to-female ratio of 2.6:1, and a mean age of 57±12 years. The ulcer was a primary DUDFDL in 38 patients and a secondary ulcer in 64 patients. The outcome in 38 patients with primary DUDFDL was healing without amputation in 26 cases (68.4%), amputation of toes in 12 cases (31.6%), and no major amputation or death. Of the 64 patients presenting with secondary DUDFDL extending from the plantar surface, there was extension to the dorsum of the foot through the forefoot ulcer in 54 patients and through the ankle joint to the distal leg in 10 patients. For the plantar ulcers extending to the dorsum, five cases healed without amputation (9.3%), minor amputation was necessary in 29 cases (53.7%), major amputation in 14 cases (25.9%) and six patients died (11.1%). For the distal leg ulcers with extension through the ankle joint, five healed without amputation and five required minor amputation. CONCLUSION: Primary DUDFDLs had a favourable outcome. Dorsum extension of diabetic foot ulcer from the plantar aspect of the foot carries a high risk for major limb amputation and death.

The surgical treatment of esophageal cancer in Sudan: A 100 consecutive cases.

OBJECTIVE: Esophageal cancer is the most common gastrointestinal (GI) cancer in The Sudan. This study aimed to evaluate the outcome of the surgical management. METHODS: A 100 consecutive patients who underwent esophagectomy in Shaab Hospital in Khartoum during the period June 2003-Aug 2007 were studied. RESULTS: The mean age was 55 ± 14 years with an equal sex ratio. Fifty five per cent of patients presented with stage III&IV locally advanced and or metastatic disease. Sixty seven percent of the patients underwent a 2-stage resection, Lewis Tanner type while 27% underwent a 3-stage resection, McKeon operation and 6% had total gastrectomy with distal esophagectomy and roux-en-y reconstruction. The 30 days postoperative mortality was 10%. In 75 patients who could be traced, the overall 5 years survival was 21% (n = 16) and the 10 years survival was 8% (n = 6). CONCLUSION: There was great improvement in the early postoperative mortality from 27% in 1986 to 10% in this series. The surgical treatment offered a rapid symptoms relief which suited most patients coming from distant locations and couldn't afford to stay for long in the Capital as will be required if chemo-radiotherapy was used as sole or as a neo-adjuvant treatment.

Associated risk factors and management of chronic diabetic foot ulcers exceeding 6 months' duration.

BACKGROUND: The management of chronic diabetic foot ulcers (DFU) poses a great challenge to the treating physician and surgeon. The aim of this study was to identify the risk factors, clinical presentation, and outcomes associated with chronic DFU>6 months' duration. METHODS: This prospective study was performed in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A total of 108 patients who had DFU for >6 months were included. Recorded data included patient's demographics, DFU presentation, associated comorbidities, and outcomes. DFU description included size, depth, protective sensation, perfusion, and presence of infection. Comorbidities assessed included eye impairment, renal and heart disease. All patients received necessary local wound care with sharp debridement of any concomitant necrotic and infected tissues and off-loading with appropriate shoe gear and therapeutic devices. RESULTS: The mean age of the studied patients was 56+SD 9 years with a male to female ratio of 3:3.3. The mean duration of DFU was 18±SD 17 months (ranging from 6 to 84 months). Ulcer healing was significantly associated with off-loading, mainly the use of total contact cast (TCC) (p=0.013). Non-healing ulcerations were significantly associated with longer duration of the chronic DFU>12 months (p=0.002), smoking (p=0.000), poor glycemic control as evidenced by an elevated HbA1c (>7%), large size (mean SD 8+4 cm), increased depth (p<0.001), presence of skin callus (p<0.000), impaired limb perfusion (p=0.001), impaired protective sensation as measured by 10 g monofilament (p=0.002), neuroischemia (p=0.002), and Charcot neuroarthropathy (p=0.017). DISCUSSION: Risk factors associated with chronic DFU of>6 months' duration included the presentation of an ulcer with increased size and depth, with associated skin callus and neuroischemia, in a diabetic patient with a history of smoking and increased HbA1c >7%. Off-loading mainly with the use of TCC is an effective method of managing long-standing DFU.

Diabetic foot infections with osteomyelitis: efficacy of combined surgical and medical treatment.

Diabetic foot infections are a high risk for lower extremity amputation in patients with dense peripheral neuropathy and/or peripheral vascular disease. When they present with concomitant osteomyelitis, it poses a great challenge to the surgical and medical teams with continuing debates regarding the treatment strategy. A cohort prospective study conducted between October 2005 and October 2010 included 330 diabetic patients with osteomyelitis mainly involving the forefoot (study group) and 1,808 patients without foot osteomyelitis (control group). Diagnosis of osteomyelitis was based on probing to bone test with bone cultures for microbiological studies and/or repeated plain radiographic findings. Surgical treatment included debridement, sequestrectomy, resections of metatarsal and digital bones, or toe amputation. Antibiotics were started as empirical and modified according to the final culture and sensitivities for all patients. Patients were followed for at least 1 year after wound healing. The mean age of the study group was 56.7 years (SD = 11.4) compared to the control group of 56.3 years (SD = 12.1), while the male to female ratio was 3:1. At initial presentation, 82.1% (n=271) of the study group had an ulcer penetrating the bone or joint level. The most common pathogens were Staphylococcus aureus (33.3%), Pseudomonas aeruginosa (32.2%), and Escherichia coli (22.2%) with an almost similar pattern in the control group. In the study group, wound healing occurred in less than 6 months in 73% of patients compared to 89.9% in the control group. In the study group, 52 patients (15.8%) had a major lower extremity amputation versus 61 in the control group (3.4%) (P=0.001). During the postoperative follow-up visits, 12.1% of patients in each group developed wound recurrence. In conclusion, combined surgical and medical treatment for diabetic foot osteomyelitis can achieve acceptable limb salvage rate and also reduce the duration of time to healing along with the duration of antibiotic treatment and wound recurrence rate.

Role of jejunostomy feeding catheter as a model for nutritional support.

INTRODUCTION: The advancement in oesophageal cancer care during the last two decades has resulted in a decrease in the use of feeding jejunostomy catheter to maintain adequate nutrition. We aim to examine the validity of feeding jejunostomy catheter in maintaining adequate nutrition for patients with oesophageal cancer. PATIENTS AND METHODS: A prospective longitudinal study was conducted on oesophageal cancer patients presenting to Khartoum Teaching Hospital with complete dysphagia between June 2005 and September 2007. Nutritional assessment was performed pre- and post-insertion of the feeding jejunostomy catheter and data were tested for any significant difference. RESULTS: Among 99 patients enrolled in the study, 48 had the feeding catheter inserted during oesophagectomy, 41 prior to neoadjuvant therapy and 10 as a palliative measure. Catheter dislodgement occurred in 3% of patients while blockage occurred in 10% and migration in only 1%. The mean ± SD of patients' weight pre-insertion was 48.08 ± 10.29, while the mean ± SD weight on day 10 post-insertion was 48.41 ± 10.27 and on day 30 was 48.14 ± 10.29. Patients on jejunostomy catheter feeding were considered optimised to receive neoadjuvant therapy based on clinical assessment, mobility and sense of well being. The post-resection mortality rate was 11.5% vs 10% compared to patients on oral feeding. CONCLUSION: Jejunostomy feeding catheter provided nutritional access to oesophageal cancer patients with complete dysphagia using a locally prepared formula. Patients managed to maintain their weight up to 30 days post-insertion of the feeding catheter. Feeding jejunostomy catheter in combination with a locally prepared feeding formula provided a reliable nutritional option for oesophageal cancer patients in developing countries.