Wound management Association Ireland 2011

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Indications for surgical referral in patients with venous ulcers

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  • Elevated ABIs often indicate vascular calcification and this will ferquently co-exist with neuropathy. These patients are at risk for neuropathic foot ulcers and should be screened. Toe pressure are a better measure of perfusion in this patient group. In general, in our wound care guidelines, we recommend referral of known diabetics with leg ulcers for a vascular surgery opinion. However, where the ABIs are normla and the pulss are easily palpable we would ususally proceed with compression therapy. We do not rely on ABIs in those without palpable pusles and check toes pressures which requires equipment not usually found in community clinics in Ireland.
  • Bacterial contamination is common – no correlation between these results and the outcomes and there is no need to treat. In fact, there is no need to send swabs at all as this incurrs unecessary cost and increases the risk that patients will be inappropriately treated with antibiotics on eh absis of swab results.
  • The vast majority of venous ulcers are benign. There is a risk of malignant transformation in long standing venous ulcers – the so called Marjolins ulcer. This is no common and typically would occur in a very long standing ulcer. It is much more common for a primary (or even metastatic skin cancer to be misdiagnosed or mistreated as a venous ulcer. It is not possible to exclude malignancy based on appearance of the ulcer and any ulcer that faisl to progress with compression therapy or fails to heal within a reasonable time period should have a punch biopsy performed under local anaesthesia. Where there are facilities and expertise, this could be done in a nurse lead clinic or other community setting but, at least in our healthcare system, this will usually require referral to a hospital setting. This data from professor Harding’s wound care group shows that the incidence of unsuspected malignancy is quite high. In this small study, the ulcers were divided into three groups based on the indication for biopsy. As you can see, the ulcers which did not look suspicious for malignancy were more likely to harbour either a cancer or in situ carcinoma. The lesson of this study, and the bitter lessons of experience in any leg ulcer clinic is to biopsy liberally. We would propose that any ulcer which does not progress in 8 weeks or heal in 12 weeks should be biopsied.
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  • Wound management Association Ireland 2011

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

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