SL achieves global benchmark in preventing amputation | Daily News
Leg bypass surgery:

SL achieves global benchmark in preventing amputation

The European Journal of Vascular Endovascular Surgery, the top-most international scientific journal on leg bypass surgery, recently endorsed Sri Lanka’s efforts in this area of surgery in the article ‘Clinical outcomes from vein bypass surgery for amputation prevention at the University of Colombo, National Hospital of Sri Lanka’.

Diabetes is the most common cause for the blockage of blood vessels, and both problems are increasing all over the world, more so in lower- and middle-income countries, particularly in South Asia. Surprisingly, there have been no reports on the issue from where it is experienced the most, until this one. This report is the first of a large series from the lower- and middle-income world on outcomes from leg bypass operations to improve blood flow and prevent amputations. The journal reports that the results achieved are on par with those from high-income countries despite many constraints and resource-limitations in Sri Lanka.

The Daily News spoke to Professor Mandika Wijeyaratne, who is Professor of Surgery and Head of Vascular and Transplantation Surgery in the Faculty of Medicine, University of Colombo at the Unit based in the National Hospital in Colombo.

Professor Wijeyaratne explained that blockages in blood vessels that nourish the heart muscle cause heart attacks. Such a blockage cuts off the oxygen supply to the heart itself, resulting in serious consequences well known to all. Similar blockages in blood vessels in our legs is the main reason for a minor injury in the foot not to heal, but get infected, spread and destroy the entire foot ending with an amputation at the knee level. Such an illness he refers to as a ‘foot attack’ and is what often happens to people with diabetes whose circulation to the feet is poor. Treatment of such people with wounds is usually with antibiotics alone, and poor circulation is often overlooked. Antibiotics are no substitute for good circulation and oxygen, failing to contain such wounds and patients often end up with amputations.

“Bypass surgery in the leg restores blood flow and provides tissues the maximum oxygen supply to heal with minimal damage. Of course, these operations are complicated and demanding, taking four to six hours, and fails with the slightest imperfection when joining blood vessels. Such are the reasons why most countries, even some rich countries, have not published anything on this problem and the public has come to accept amputation as inevitable. Eighty percent of our patients are diabetic and come for treatment late with large infected wounds with nothing much remaining to save and requiring ‘urgent’ bypass are further challenges to us in Sri Lanka,” said Prof. Wijeyaratne

Amputation prevention and wound healing with bypass surgery was started by the University of Colombo at the National Hospital in the 1980s and has evolved through many difficult periods to reach its current status. Professor Wijeyaratne went onto explain that a successful bypass operation is only the start of a long and complicated healing process and a highly skilled and motivated team of doctors and nurses is essential for success. “More than half of our bypass operations were down to the ankle, the most demanding type of bypass surgery,” he said, cautioning us that these operations carry risks and failures, something the public fails to comprehend.

“In our study of 367 bypass operations over three years, we observed four to five percent of deaths during the first month after surgery from heart attacks. At the end of one year, 82 percent were alive, and 80 percent of them had their legs saved from being amputated. These results are within international benchmarks worked out for healthcare services in high-income countries,” Professor Wijeyaratne said.

What is even more remarkable is that such outcomes have been possible despite severe resource limits and constraints which are part and parcel of a public hospital setting in a low- to middle-income country like Sri Lanka. Professor Wijeyaratne clarified those constraints as the lack of multi-specialty teams, shoe and foot care specialists, timely x-ray studies on blood vessels, angiography and poor access to appropriate local healthcare once patients have left the hospital. Finally, what we get is a single shot at fixing the poor circulation to the wounded foot. There are no second chances to correct mistakes.

“Overcoming resource limits required acceptance, innovation and adaptation. We managed with whatever human resources available and without x-ray imaging, a practice unique to us.”

Professor Wijeyaratne reiterated that a highly motivated team of doctors and nurses and the spirit of delivery of the service as the secret of success of the University of Colombo, National Hospital service.

Professor Wijeyaratne highlighted the impact of diabetes as the main cause for leg amputation and other ways by which it can start a wound. One could even say that few diseases are as deadly as diabetes. Once it goes beyond a certain point, the complications it causes are both extremely distressing to the mind and devastating to the body. The end result may even be an amputation of the foot. However, there is saying that ‘prevention is better than cure’. We spoke to Professor Wijeyaratne, in great detailabout how diabetes causes the tragic outcomes we are all familiar with.

“The problem is once you have got diabetes most people do not control their blood sugar levels. These people forget the fact that they have a disease or illness because they feel normal. So, negligence here is the mistake that is made. If you go on neglecting diabetes for a long period, you end up with complications. One complication is that you lose sensation in your legs. You become numb. Numb feet will not protect you from injuries and this is because you will not feel pain. We are all naturally protected because of pain. In the old days the ‘demon’ was leprosy that made you lose toes and fingers. Now diabetes has become the new ‘demon’. Diabetics have lost the pain sensation and the most frightening thing is that most of them are unaware of it. Even though some may be aware, most of them don’t believe they cannot protect themselves. So, this is the general neglect.

“Because they have poor sensation they walk around without protection. A good pair of shoes is important to protect yourself from all types of objects. We must keep in mind that those who are not diabetic are naturally protected by pain. So, diabetes causes nerve damage called ‘neuropathy’ which causes easy wounding. Walking barefoot on hot surfaces can give you burns. Diabetics are unaware that they have had an injury. They also develop deformities in their feet. These deformities alter the weight distribution on the sole of the foot. Then you develop pressure points and the skin thickens and you get callosities. Under the callosities you get bleeding, infections and wounds,” explained Prof. Wijeyaratne.

“Diabetes has other complications. One being that you do not sweat. And then the skin dries up and then it cracks allowing infections and bacteria to enter the body causing infections. So, all this combined with a lack of sensation puts you in big trouble. That is what destroys toes, causes easy wounds and prevents them from healing. And if the infection progresses, part of the leg or the entire leg will have to come off. There is another factor that contributes to the progression of infection and that is poor circulation. It is circulation that provides oxygen to the tissues. Oxygen is extremely important to fight infection and heal. If there is poor circulation the infection will spread very fast and wounds will not heal. This is one of the main reasons why a simple injury, a simple tiny wound will end up in the person losing his leg near the knee level.

“Now how do we prevent this? First of all, before there is anything obviously wrong with the feet, doctors can check the feet. The check can tell us if there is poor sensation, if there is poor circulation, if there are deformities and callosities and if there has been a previous wound. You will be classed at high risk or standard risk. You will get a warning certificate that you risk is high and you have to take care of your feet more than other people. You have to always be in footwear, ideally with straps around the ankle because sometimes the shoe comes off and they are not aware of it. Then the feet need to be checked for scratches, wounds and infections by someone else because the patient may not be aware of it. So there needs to be detection and early prevention,” said Dr. Wijeyaratne.

“The second way to prevent amputation is to heal the wound. Either the wound heals or it destroys the foot. So we need to heal the wound. You cannot heal a wound without knowing what is preventing them from healing. There are four important reasons why wounds do not heal. The main problem is infection. We all know that infection can be cured with antibiotics. But if your blood sugar is high, your defences and immunity and fight against bacteria is impaired and infection wins. Another very important contributor to us being unable to manage infection is poor circulation. If the circulation is poor, infection wins again. Then wounds will not heal. As long as the wound is not healing it is liable to infection. We need to heal the wound and take away the risk.”

Professor Wijeyaratne explained what a person with diabetes can do to prevent amputation. He emphasized on reasonable blood sugar control and foot risk assessment. A foot should be classed as high risk if there had been previous wounds, impaired sensation in the feet, patchy thickening of the skin on the soles known as callosities and finally, circulation to the feet based on feeling foot pulses and ankle blood pressures. Those with high-risk feet must be careful not to allow punctures, scratches, burns from walking on bare feet and checking for injuries daily to get early attention. Protective footwear is a must at all times. In the case of injury, healing is most dependent on a good circulation, and whenever foot pulses are absent, a vascular surgeon must consider a bypass operation. Currently, there are many vascular surgeons in Sri Lanka, and all are competent to perform bypass surgery and are working in all parts of the country at present.