Actually, surgical revascularizations are more expensive than
amputations if you factor in the fact that most diabetic amputations
occur **after** infection is consuming the leg after starting as a
non-healing diabetic ulcer. Such **complicated** surgical
revascularizations are fraught with higher failure rates typically
leading to an amputation anyway plus the additional hidden costs of
prolonged SICU post-op care especially if the surgical wounds become
infected with one of those hospital-acquired vancomycin resistant bugs.
Prayerfully in Christ's amazing love,
Andrew
http://tinyurl.com/jjl29
When they say 85% of amputations may be preventable, don't they mean
preventable by daily foot inspection and early wound care *before* the
wound becomes gangrenous and necrotic?
Imo, the Diabetes Foundation is not advising patients that doctors are
too quick to amputate (rather than perform revascularization surgery)
so much as admonishing patients to take proper care of themselves and
get treated early.
It is my understanding, and someone please correct me if I'm wrong,
that patients often don't present at the hospital (or doctor's office)
until they have gangrene and portions of the foot have turned black,
indicating tissue is already dead. I don't believe you can successfully
revascularize *dead* tissue.
By the time a doctor sees these patients, amputation may be the only
recourse to control sepsis and remove necrotized tissue.
However, I am not a doctor and am often wrong. :)
Anytime there's gangrene, ischemic ulceration, or controllable infection,
the patient should be evaluated for revascularization, and revascularized if
feasible. The problem comes in when the infection is overwhelming, or when
it can't be controlled with antibiotics -- the same poor blood supply that
prevents delivery of oxygen to the tissues also prevents delivery of
antibiotics to the infection.
HMc
Thanks for the explanation, Howard. I didn't realize gangrenous tissue
could be salvaged. What about where it appears necrotized and has
turned black... is black tissue necessarily dead, or can
revascularization sometimes save it if circulation is restored in time?
Also, you mentioned ischemic ulceration-- I had traumatic
thrombophlebitis once (which developed into sepsis and gangrene), which
apparently announced itself via what appeared to be a large blister on
my leg near the site of the trauma. Is that ischemic ulceration? If so,
could you educate me a bit on that, if you have the time and
inclination?
Thanks again,
Marcia
No. They are proposing that 85% of non-traumatic amputations could
have been revascularizations instead.
> Imo, the Diabetes Foundation is not advising patients that doctors are
> too quick to amputate (rather than perform revascularization surgery)
> so much as admonishing patients to take proper care of themselves and
> get treated early.
The OP's use of the cite is contrary to your opinion.
> It is my understanding, and someone please correct me if I'm wrong,
> that patients often don't present at the hospital (or doctor's office)
> until they have gangrene and portions of the foot have turned black,
> indicating tissue is already dead. I don't believe you can successfully
> revascularize *dead* tissue.
Correct.
> By the time a doctor sees these patients, amputation may be the only
> recourse to control sepsis and remove necrotized tissue.
Correct.
Do you agree with this assessment?
>
> > Imo, the Diabetes Foundation is not advising patients that doctors are
> > too quick to amputate (rather than perform revascularization surgery)
> > so much as admonishing patients to take proper care of themselves and
> > get treated early.
>
> The OP's use of the cite is contrary to your opinion.
The link he provided was dead when I clicked it. I was relying on my
memory of conventional advice to diabetics. But, as I've said, I'm
often wrong. :)
This has not been my clinical experience. However, I work at centers
where there are lots of vascular surgeons around so that if anything,
the figure is more like 0% of non-traumatic amputations could have been
revascularizations instead.
> > > Imo, the Diabetes Foundation is not advising patients that doctors are
> > > too quick to amputate (rather than perform revascularization surgery)
> > > so much as admonishing patients to take proper care of themselves and
> > > get treated early.
> >
> > The OP's use of the cite is contrary to your opinion.
>
> The link he provided was dead when I clicked it. I was relying on my
> memory of conventional advice to diabetics. But, as I've said, I'm
> often wrong. :)
Actually, mortal opinions are neither right nor wrong. They just
differ :-)
The only opinion that is absolutely right is GOD's :-))
> When they say 85% of amputations may be preventable, don't they mean
> preventable by daily foot inspection and early wound care *before* the
> wound becomes gangrenous and necrotic?
>
That's not what I got from the article. I understood it to say that 85%
of the time when doctors opt for amputation, there are other options that
may save the foot.
Chak
--
You can no more win a war than you can win an earthquake.
--Jeannette Rankin
Thanks, Chak. I didn't read the article because I wasn't able to link
to it for some reason, so my response is mostly irrelevent, I'm afraid.
:)
That's not what I got from your cite either. There are some places
(Canada for instance) where a shortage of vascular surgeons might make
the figure of salvageable limbs has high as 85%.
> Thanks, Chak. I didn't read the article because I wasn't able to link
> to it for some reason, so my response is mostly irrelevent, I'm afraid.
>:)
>
I probably should have gone the extra step and included a tinyURL.
Sorry.
Now that I've actually had an opportunity to read the article, that's
not what I got from it, either. In the future I'll try to remember to
read first and form an opinion second. ;)
It's OK. Your opinion added to the discussion so there was neither
harm nor foul.
You don't do bad Marcia :-) .
> You don't do bad Marcia :-) .
Aw. You both made me feel better. My hero. :)
> Thanks for the explanation, Howard. I didn't realize gangrenous tissue
> could be salvaged. What about where it appears necrotized and has
> turned black... is black tissue necessarily dead, or can
> revascularization sometimes save it if circulation is restored in time?
>
No, gangrene *is* necrosis, and necrosis is dead. The problem with gangrene
is that it implies more dead tissue which acts as an excellent substrate for
infection. Gangrenous tissue can't be salvaged, and generally must be
debrided (cut away). The reason for revascularization is to halt the process
of necrosis, not reverse it. The body will recover to an extensive degree
from such local insults.
> Also, you mentioned ischemic ulceration-- I had traumatic
> thrombophlebitis once (which developed into sepsis and gangrene), which
> apparently announced itself via what appeared to be a large blister on
> my leg near the site of the trauma. Is that ischemic ulceration? If so,
> could you educate me a bit on that, if you have the time and
> inclination?
Yes, likely ischemic ulceration. But the source of the ischemia isn't clear.
It sounds conceivable that you developed a clot in the vein (thrombosis)
which in turn set up inflammation (phlebitis), with the resultant local
swelling compressing local arterial supply (ischemia), causing dead tissue
(gangrene) which became infected (sepsis).
HMc
As long as you don't injure yourself in the process.
Reminds me of the following observation:
You don't pay a surgeon to cut you with a scalpel. Anyone could do
that.
You pay him/her because s/he knows where to cut.
Okay, thanks for clearing up my confusion. Yes, you're right that I
developed a blood clot, and the series of events you described fits
with my memory of the experience. I should probably have said I
developed septicemia (meaning the infection became systemic?) and was
very sick for awhile.
Thanks again. I really appreciate that you took time to respond. :)
Marcia
Yes, septicemia occurs when an infection gets into the blood stream.
Normally the body is very adept at walling off infections and keeping them
local. If severe enough, the infection can get into the bloodstream, which
can indeed be dangerous.
HMc
This would be one reason why you did not lose the limb.
> The surgery was a bear for the gal handling my vitals. The heart
> tried to stop. That was the reason for a dye injection test. All four
> coronary arteries were over 90% clogged.
Such blockages increase the risk of a cardiac event from induced
myocardial ischemia either during or immediately after surgery.
> The heart surgery has lasted for over six years but the side
> issues did not go so well.
I suspect your kidneys have been one of the side issues since you
mention being a brittle diabetic.
> Dr Chung, an old country doc said it would been better for us
> to go home and forget this type of surgery.
It does not sound like that was a viable option. Raging infection in a
limb with osteomyelitis plus the additional stress of surgical
debridement and post-op recovery from same would have increased risk of
prolonged periods of induced myocardial ischemia in someone with
severely occlusive multivessel coronary disease.
> At our age and condition
> we had developed natural bypasses.
If the natural bypasses were sufficient, your heart would not have
tried to stop during the surgical debridement.
> I will say there is a quality
> life and "a life." I am very unsure if I would have the surgery if
> I had it to do.over.
It is possible that you would not be here now if the coronary
revascularization were not done.
> I ask you to take the time to think this over and
> give me an honest answer. i have no fear of bad
> news. I do have a fear of reentering a famous Houston
> heart hospital. I would prefer to drop out trying to cut
> down a tree.
Understandably.
One non-surgical way to boost up the size and number of natural
bypasses so that they might become more sufficient is by receiving
enhanced external counterpulsation (EECP). This is a non-invasive
treatment clinically proven to be effective in managing angina
pectoris. A recent study published in the Journal of Internal Medicine
demonstrated this:
This reference can also be used to pull up all the other studies that
have demonstrated clinical efficacy for EECP.
> Your comments would be appreciated..
You are welcome, Guy.
All thanks and praises redirected to LORD GOD Almighty, Who is the
source of all knowledge and wisdom.
> Added Mona's first husband died during bypass
> surgery early and she was left with two very
> young boys. I still see her sad sometimes.
> People have said the young mavericks killed him.
> This surgery was very new then and to loss of patients was very
> common..
It would be my choice to refrain from judging others. Often find it
difficult to love those whom I have judged. Really don't want to
disappoint my LORD and Savior.
> This is your area and I hope you might offer us some
> opinions.
Yes, this is how my LORD has shaped me. May the information in this
post help you.
> She worked and sent both boys through college.
> Both are doing well and her two grandchildren
> both finished college, the last this year.
Many praises to LORD GOD Almighty.
> Some say the surgery should not have ever happened.
> Any comments.
Hindsight is 20-20.
> A friend's surgeon kept him alive from age 38
> until he was 69. He negated a suggest surgery.
> in the friends mid years.
Different person. Different plan.
> This brash old specialist used to say if a
> patient died leaving his office, they were
> to turn the client around so it would seems like
> t hey were coming in. I like him and he
> was respected by all.
Sounds like he had a sense of humor.
> I sure could use a lot of sensible unbiased
> info .
Again, hope the above helps you.
My apologies in advance for the fallout you will receive for
participating in this discussion with me.
Reminds me of something I witnessed some years ago:
There was once this beautiful golden eagle, graceful in flight,
majestic in carriage, quite a sight to behold. It perched high and on
the lower branches there were a group of black grackles making heckling
sounds but the eagle ignored them.
I have observed this heckling in the avian kingdom for other eagles and
hawks. The more majestic and powerful the raptor, the larger the
number of hecklers.
The beautiful golden eagle reminded me of LORD Jesus Christ.
Maranatha !
Still praying for you, dear Guy.
Some patients simply can't be revascularized - not physically possible. And
in some patients infection is so advanced that it's too late for antibiotics
and too late for hyperbaric oxygen - amputation is the only way to save the
patient's life from overwhelming sepsis and multiple organ failure.
HMc
Would add that I have never met a surgical colleague that relished the
opportunity to perform an amputation.
Instead, it always feels as though a favor were being asked.
Prayerfully in Christ's amazing love,
Andrew
http://tinyurl.com/oq5k3
I would certainly hope not, or we are all in deep shit, including all the
surgeons also :-) .
Indeed :-)