Post on 15-Jun-2015
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Surgical interventions in Chronic Wounds
Sean Tierney - RCSI & AMNCH, Tallaght, DublinWMAI, Galway, October 2011
www.perfuse.net O'Brien et al Br J Surg 2003
Limerick trial - costLimerick trial - cost
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Topical preparationsTopical preparations
http://www2.cochrane.org/reviews/en/ab001103.htmlLast assessed as up-to-date: October 14. 2008
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When healedWhen healed
Recurrence
• 1/3 of patients had >4 episodes1
• Recurrence in:– 26% after 1 year – 31% at 18 months2.
1. Lothian study 2. Franks et al 1995 Age Ageing
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When healedWhen healed
• High (UK Class 3) compression hosiery is not more effective than moderate compression hosiery (relative risk of recurrence 0.82, 95% confidence interval 0.61 to 1.12).
• Some Class 2 stockings are better than others - compliance
• Both trials reported that not wearing compression hosiery was strongly associated with ulcer recurrence.
• No trials were found which evaluated compression bandages for preventing ulcer recurrence.
Last assessed as up-to-date: August 23. 2000
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Venous surgeryVenous surgery
* Gohel et al. B J Surg 2005
• open or recently healed ankle ulceration (>4 weeks)• ABI < 0·85• Either
• superficial venous reflux• mixed superficial and deep venous reflux
• Excluded• No reflux, deep reflux only, deep occlusion
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Role of SurgeryRole of Surgery
* Gohel et al. British Journal of Surgery 2005; 92: 291–297
Healing Recurrence
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Causes of UlcerationCauses of Ulceration
• Venous disease 81%*• Arterial disease 10% • Mixed (arterial venous) 7%• Diabetic neuropathy 1%• Malignancy 1%• Rheumatoid 1%
* O Brien et al. Ir J Med Sci 2000
17%
PrevalenceOverall 0.12%>70Y 1.03%
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Arterial diseaseArterial disease
• History of arterial surgery– Bypass surgery– Angioplasty– Lower limb angiogram
• Clinical History– Intermittent claudication
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Arterial diseaseArterial disease
• 827 chronic leg ulcers
• Absent pedal pulses 11%
• ABI < 0.9 21%
Lothian group, Callam et al, BMJ 1987
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Quantifying arterial perfusionQuantifying arterial perfusion
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What now ?What now ?
• ABI > 0.8 full compression• ABI > 0.6 light (20mm) compression*• ABI <0.6 vascular assessment*• Or ABI >1.3 vascular assessment
• ABI > 0.8 full compression• ABI > 0.6 light (20mm) compression*• ABI <0.6 vascular assessment*• Or ABI >1.3 vascular assessment
Moffat et al BMJ 1992
* Cautiously & in consultation/agreed local protocol/guidelines
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Arterial diseaseArterial disease
• Consider referral of patients with arterial disease or manage them cautiously according to protocols/guidelines agreed locally with vascular surgery
• Consider referral of patients with arterial disease or manage them cautiously according to protocols/guidelines agreed locally with vascular surgery
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Arterial interventionsArterial interventions
• Non-healing ulcer
• Painful
• Fit for intervention
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Role of surgeryRole of surgery
Treat arterialdisease
Superficial venous disease
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DiabetesDiabetes
• Take the opportunity to check on feet
• Check pulses and beware ABIs
• Consider toe pressures
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InfectionInfection
Routine Culture swabs
• Staphylococcus aureus 88% • Strep faecalis 74%• Enterobacter cloacae & • Peptococcus magnus 29%• Fungi 11%
Hansson C Acta Derm Venereol. 1995
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InfectionInfection
Last assessed as up-to-date: November 4. 2009
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Treating infectionTreating infection
• Pain• Purulent slough/exudate• Cellulitis• Systemic signs
• Pain• Purulent slough/exudate• Cellulitis• Systemic signs
• Oral antibiotics (gram +)• Topical potassium
permanganate• + steroid/fucidin• + flamazine
• Oral antibiotics (gram +)• Topical potassium
permanganate• + steroid/fucidin• + flamazine
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Risk of malignancyRisk of malignancy
• 10913 patients with venous leg ulcer • Swedish Inpatient Registry • 17 certain and 6 probable SCC.• median ulcer duration 25 years.• absolute risk is very small (<0.2%).
Baldursson et al Br J Dermatol 1995
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Risk of malignancyRisk of malignancy
Indication suspicious Non-healing Inflammatory features
(n=76) 4/17 9/24 0/35
Malignancy/ Bowens
24% 37% 0%
D R Miller et al Phlebology 2004
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Exclude malignancyExclude malignancy
• Failure to progress in 8 weeks
• Failure to heal
• Unusual appearance
• Long standing (>6 months)
Biopsy
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BiopsyBiopsy
• Local anaesthetic
• 3-4mm punch
• ± multiple biopsies
• Pressure * 5mins
• No suture
• Follow up
University of Queensland
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Role of surgeryRole of surgery
Malignancy
Biopsy
Treat arterialdisease
Superficial venous disease
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Progression/dermatitisProgression/dermatitis
• Contact sensitivity common (among 106 referrals over 2 years)– Balsam of Peru 40%– Lanolin 21%, – fragrance mix 18%, – trichlocarban 13% – colophony 11%, – cetrimide cream 9% – neomycin 9%.
• Latex allergy ?
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Progression/dermatitisProgression/dermatitis
• Dermatology opinion• Patch testing • Zinc oxide paste bandage
layer• Cotton sleeve• Latex free bandages• Stop using compression!
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Dystrophic subcutaneous calcificationDystrophic subcutaneous calcification
Meidinger NEJM 2008
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Role of surgeryRole of surgery
MalignancyExcision
Calcification
Biopsy
Treat arterialdisease
Superficial venous disease
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Venous ulceration & lymphoedemaVenous ulceration & lymphoedema
• +ve Stemmer’s sign
• Typical skin changes
• Cellulitis common
Ramundo J WOCON 2005
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Lymphoedema in vascular clinicLymphoedema in vascular clinic
Gethin et al 2010 (epub)
• N= 418• Prevelance = 2.6% QOL (physical
functioning)• Clinical awareness
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Venous ulceration & lymphoedemaVenous ulceration & lymphoedema
• MLB
• MLD
• Custom hosiery
• SCD
• ? Other specific therapy
Ramundo J WOCON 2005
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Accelerating healingAccelerating healing
• 17 trials (931 participants)• Variety of grafts including
autografts and allografts• Some evidence for faster
healing with allografts
• May be role for excision and either SSG or pinch grafts in selected patients (only)
Jones JE, Nelson EA. 2009
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Role of surgeryRole of surgery
MalignancyDystrophic calcification
Biopsy
Excision & graftingTreat arterial
disease
Superficial venous disease
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Indications for referralIndications for referral
• known or suspected arterial disease;
• diabetes• biopsy indicated• extensive calcification• lymphoedema• sign of infection• varicose veins if fit for
surgery
www.perfuse.net
Indications for referralIndications for referral
• known or suspected arterial disease;
• diabetes• biopsy indicated• extensive calcification• lymphoedema• sign of infection• varicose veins if fit for
surgery
www.perfuse.net
Indications for referralIndications for referral
• known or suspected arterial disease;
• diabetes• biopsy indicated• extensive calcification• lymphoedema• sign of infection• varicose veins if fit for
surgery
www.perfuse.net
Indications for referralIndications for referral
• known or suspected arterial disease;
• diabetes• biopsy indicated• extensive calcification• lymphoedema• sign of infection• varicose veins if fit for
surgery
www.perfuse.net
Indications for referralIndications for referral
• known or suspected arterial disease;
• diabetes• biopsy indicated• extensive calcification• lymphoedema• sign of infection• varicose veins if fit for
surgery
www.perfuse.net
Indications for referralIndications for referral
• known or suspected arterial disease;
• diabetes• biopsy indicated• extensive calcification• lymphoedema• signs of infection• varicose veins if fit for
surgery
www.perfuse.net
Indications for referralIndications for referral
• known or suspected arterial disease;
• diabetes• biopsy indicated• extensive calcification• lymphoedema• signs of infection• varicose veins if fit for
surgery