Wound-healing trajectories as outcome measures of venous stasis ulcer treatment

Outcome measures of venous ulcer healing are not uniformly accepted. Stringent criteria of 100% closure fail to provide information of healing over the entire span of repair. Wound-healing trajectories (plot of percentage of wound closure versus time of wound treatment) were constructed for 232 patients treated in eight clinical trials at two independent wound care/research centres. Trajectories were constructed for ulcers that totally healed (100% closure) and those that did not (<100% closure) over a 20-week period. Kaplan-Meier survival plots determined the percentage of patients achieving total healing versus time of treatment. The wound-healing trajectories were almost identical for patients achieving complete ulcer healing, as were the trajectories for patients with less than 100% closure. The trajectories for the ulcers healing completely were significantly different from those with <100% closure. Only 60% of all patients achieved 100% closure by 20 weeks. Using linear regression, it was predicted that it would take 31 weeks for all patients to achieve total healing. Total healing is an inadequate outcome measure for healing of venous stasis ulcers. Clinical trials using this measure would require excessive time periods. As wound-healing trajectories for patients treated at two centres mimic one another, shifting the wound-healing trajectory from one of impaired healing to one of a more ideal healing course may be considered a better outcome measure for determining healing of venous stasis ulcers.     

Trends in the incidence of venous stasis syndrome and venous ulcer: a 25-year population-based study

BACKGROUND: The incidence rates of venous stasis syndrome and venous ulcer are uncertain, and trends in incidence are unknown. METHODS: We performed a retrospective review of the complete (inpatient and outpatient) medical records of a community population (Olmsted County, Minnesota) to estimate the incidence of venous stasis syndrome and venous ulcer during the 25-year period, 1966 to 1990, and to describe trends in incidence. RESULTS: A total of 1131 patients received a first lifetime diagnosis of venous stasis syndrome. A total of 263 patients received a first lifetime diagnosis of venous ulcer. The overall incidence of venous stasis syndrome and venous ulcer were 76.1 and 18.0 per 100,000 person-years, respectively. The incidence of both was higher in women than in men (83.7 vs 67.4 per 100,000 person-years for venous stasis syndrome; 20.4 vs 14.6 per 100,000 for venous ulcer) and increased with age for both sexes. There was no clear trend in the incidence of venous stasis syndrome over the 25-year period. Compared with 1966 to 1970, the incidence of venous ulcer decreased in 1971 to 1980, but was unchanged after 1981. Among 945 patients with venous stasis only, 60 subsequently had a venous ulcer. The average (+/- SD) time from venous stasis diagnosis to development of a venous ulcer was 5.0 (+/- 5.0) years. CONCLUSION: Venous stasis syndrome and venous ulcer are common, especially in the elderly population. The incidence of venous stasis syndrome has not changed since 1966, and venous ulcer incidence is unchanged since 1981. More accurate identification of patients at risk for venous stasis syndrome and venous ulcer and more effective prevention are needed.     

Choledochal cysts: Management and long-term follow-up

BackgroundCholedochal cysts are congenital anomalies that can occur at any level of the biliary tree. They carry long-term risk of biliary complications and cancer development. Complete excision of all involved bile ducts is recommended.MethodsPatients treated between 1995 and 2019 were reviewed retrospectively.ResultsSixty patients; 46 female and 14 male with a median age of 41 years (range 13–83) were included in the study. Mild abdominal pain was the most common presenting symptom (60%). Majority of the patients had Todani type I cysts (67%). Concomitant biliary malignancy was diagnosed in five patients (9%). Eight patients were followed-up conservatively (13%). Twenty-five patients were treated by excision of the extrahepatic bile ducts and Roux-en-Y hepaticojejunostomy, liver resection was added in seven, pancreatoduodenectomy was done in three and liver transplantation in one. There was no perioperative mortality. Postoperative complications developed in 17 patients (34%), two requiring surgical treatment. Four of the five patients with malignancies died at a median 42 months (range 6–95) following surgery. Median 62 months (range 8–280) follow-up was available in 45 surgically treated patients, 19 followed-up for more than 10 years. None of the patients developed malignancy during follow-up. Four patients (17%) were readmitted for anastomotic strictures requiring treatment.ConclusionThe majority of choledochal cysts are Todani type-I and early cyst excision is the mainstay of management, which may decrease the risk of malignant transformation.     

Management of vascular prosthetic infections: results of long-term follow-up

An infected vascular prosthesis is a risk to life and limb, with many of the infections insidious in nature. A retrospective analysis with a minimum 49-month follow-up identified 18 patients (mean age, 61.3 years) with culture-positive infections and exposed prosthetic grafts in the infrainguinal region. All patients were managed with muscle flaps. Mean follow-up was 59 months, with a long-term salvage of infected prosthetic grafts in 16 of 18 patients; there was no loss of life or limb. Early, aggressive reconstruction of infected prosthetic grafts using a muscle flap technique saves graft, leg, and patient.     

Impotence due to corporeal veno-occlusive dysfunction: long-term follow-up of venous surgery.

Corporeal veno-occlusive dysfunction is an important cause of organic impotence and is characterized by increased flow rates to create and to maintain erection during artificial erection produced by intracavernous saline infusion. Sixty-seven patients with this erectile insufficiency underwent penile ligature-resection of deep dorsal vein between 1982 and 1986, and were evaluated by nocturnal plethysmography, pharmacocavernometry as well as a questionnaire about their sexual life for long-term follow-up. The surgical procedure was controlled in the operating room by reduction of the erectile flow rates. Thirty-one patients were potent postoperatively and were able to have satisfactory intercourse. Results after resection were slightly better than after simple ligation of the deep dorsal vein. Four patients had penile glans insensibility resulting from the surgical dissection. There were 7 relapses several months after the procedure due to leakage through other deeper veins. Eight failures were due to additional psychogenic disorders or to neurologic disease not accurately diagnosed before the treatment because they all developed normal papaverine-induced erection after venous surgery while before it they only developed a slight tumescence. Reduction of the erectile flow rates within normal values was impossible during surgery in 3 patients. Eleven failures were due to concomitant arterial disease. Resection of the deep dorsal vein can restore penile erection in patients with cavernovenous leakage in about 50% of well-selected patients.     

Additional follow-up with microvascular transfer in the treatment of chronic venous stasis ulcers.

Nine patients presented with non-healing venous ulcers of the lower limb. All had failed both non-surgical and surgical therapies. Following wide wound excision, perforator ligation, and microsurgical reconstruction, all wounds were healed. In two instances, separation at the flap/wound perimeter interface occurred and required additional dressing care to obtain wound closure. This was probably the result of incomplete excision of surrounding liposclerotic soft tissue. At 26 postoperative months, all wounds remained healed. Microsurgical transfer for properly selected patients can achieve healing of recalcitrant venous wounds, both over the intermediate and long term.     

Management and long-term follow-up of hepatic cysts.

PURPOSE: To provide an algorithm for the management of hepatic cysts through an analysis of our series over 16 years. METHOD: We reviewed the surgical management and outcome of patients with hepatic cysts between 1984 and 2000 at a single institution. Data were collected by chart review, telephone interview, and follow-up hepatic ultrasonography. RESULTS: Forty-four patients (36 females, 8 males) underwent a total of 46 operations for hepatic cysts (mean size 12.0 +/- 5.2 cm) with a mean follow-up of 5.1 +/- 4.0 years. We treated 28 simple cysts, 4 polycystic liver disease (PCLD), 7 cystadenomas, 2 hydatid cysts, 1 cystadenocarcinoma, 1 endometrioma, and 1 hepatic foregut cyst. Operations included simple drainage, wide unroofing (open and laparoscopic), and hepatic resection. Four patients experienced a symptomatic recurrence after definitive treatment; 3 of these patients had PCLD. Four of the 7 patients with cystadenomas had undergone previous operations that required subsequent definitive resection without a recurrence. CONCLUSIONS: The preoperative distinction between simple cysts and cystadenomas/cystadenocarcinomas can be difficult, yet the management is different. Unroofing is a safe and effective operation for patients with simple cysts. Patients with PCLD frequently have recurrences. Cystadenomas should be completely resected owing to the likelihood of recurrence after partial excision and the risk of eventual cystadenocarcinoma. We present a treatment algorithm for the preoperative evaluation and management of hepatic cysts based on the largest number of patients with the longest follow-up reported to date.     

Altered proliferative responses of dermal fibroblasts to TGF-beta1 may contribute to chronic venous stasis ulcer

PURPOSE: Venous ulcer fibroblasts demonstrate decreased proliferative responses to growth factor stimulation, suggesting cellular senescence. However, the role of chronic venous insufficiency (CVI) disease progression and extracellular matrix (ECM) proteins in agonist-induced cellular proliferation is ill-defined. We hypothesize that CVI-induced fibroblast proliferative resistance to growth factors worsens with disease progression and is regulated by the composition of ECM. METHODS: Fibroblast explants were isolated from biopsy specimens from two patients without CVI and 16 patients with CVI of the lower calf (LC) and lower thigh (LT) and stratified according to CEAP disease severity: non-CVI (NC; n = 2), class 2-3 (n = 5), class 4 (n = 5), class 5 (n = 3), and class 6 (n = 3). Proliferation experiments were standardized with a neonatal foreskin fibroblast cell line (HS68). A 10-day course and dose response experiment with 0, 0.5, 1.0, 2.5, 5, 10, and 20 ng/mL of transforming growth factor-beta(1) (TGF-beta(1)) demonstrated maximal cell proliferation at 5 ng/mL of TGF-beta(1) on day 4. Under these conditions, CVI dermal fibroblasts were challenged with and without TGF-beta(1) and evaluated for proliferative responses on plates coated with polystyrene, collagen, and fibronectin. RESULTS: No differences in unstimulated proliferation were observed in LT and LC fibroblasts from patients with class 2-3 disease and LT fibroblasts from patients with class 4 and 5 disease, compared with NC and HS68 cells. LC fibroblasts from patients with class 4 disease (P <.05) and class 5 disease (P <.001), and LC (P <.001), and LT fibroblasts from patients with class 6 disease (P <.001) proliferated to a lesser degree than did NC and HS68 cells. The diminished proliferation observed in class 4 LC cells was reversible with TGF-beta(1) stimulation (P <.004); however, class 5 and class 6 LC and LT fibroblasts did not respond to stimulation with TGF-beta(1). Collagen increased proliferation of HS68 cells with (P <.05) and without (P <.01) TGF-beta(1), compared with cells grown on polystyrene, but did not increase proliferative responses in NC or CVI fibroblasts with and without TGF-beta(1). Similarly, fibronectin increased proliferation of HS68 cells (P <.05) compared with cells grown on polystyrene, but did not alter proliferation in CVI fibroblasts. Fibronectin did seem to inhibit TGF-beta(1)-induced proliferation observed in class 4 LC cells. CONCLUSION: These data indicate that clinical disease progression correlates with cellular dysfunction. Fibroblasts from patients with class 2-3 disease retain their unstimulated and agonist- induced proliferative capacity, compared with NC and HS68 cells. The onset of inflammatory skin changes (class 4 and class 5 disease) diminishes agonist-induced proliferation, and ulcer formation (class 6 disease) severely inhibits it. In addition, the composition of ECM does not affect TGF-beta(1)-induced proliferation of fibroblasts in CVI.     

Mosaicplasty: long-term follow-up

The successful treatment of chondral and osteochondral defects of the weightbearing surfaces is a challenge for orthopaedic surgeons. Autologous osteochondral transplantation is one method that can be used to create a hyaline or hyaline-like repair in the defect area. Ten years of clinical experience with autologous osteochondral mosaicplasty are described. Clinical scores, imaging techniques, arthroscopy, histological examination of biopsy samples, and cartilage stiffness measurements were used to evaluate the clinical outcomes and quality of the transplanted cartilage in a total of 831 patients who underwent mosaicplasty. According to our investigations, good-to-excellent results were achieved in 92% of the patients treated with femoral condylar implantations, in 87% of those treated with tibial resurfacing, in 79% of those treated with patellar and/or trochlear mosaicplasties, and in 94% of those treated with talarprocedures. Long-term donor-site disturbances, which were assessed using the Bandi score, showed that patients had 3% morbidity after mosaicplasty. Sixty-nine of 83 patients who were followed arthroscopically showed congruent gliding surfaces, histological evidence of the survival of the transplanted hyaline cartilage, and fibrocartilage filling of the donor sites. Four deep infections and 36 painful postoperative hemarthroses were experienced as complications arising from the surgical procedures. On the basis of both these promising results and also those of other similar studies, autologous osteochondral mosaicplasty would appears to be an alternative for the treatment of small and medium-sized focal chondral and osteochondral defects of the weightbearing surfaces of the knee and other weightbearing synovial joints.     

A long-term follow-up study of diabetic foot ulcer using micronized acellular dermal matrix

Treating a diabetic foot ulcer (DFU) extending to the tendon or bone can be a challenge for physicians. Recent studies have shown positive results of micronized acellular dermal matrix (ADM) treatment for treating DFU. However, studies on such ADM with a long-term follow-up are rare. Thus, the objective of this study was to retrospectively analyse patients treated with micronized ADM with a long-term follow-up to assess the effectiveness of the treatment and determine the recurrence rate. The rate of success of complete healing was 62.96% and the time of complete healing was 86.96 days in this study. The recurrence rate of DFUs was 41.17% in the overall group. However, it was only 23.52% in the micronized ADM group. The average duration of recurrence was 720.50 ± 505.12 days. The recurrence rate was 50% in weight bearing areas such as the plantar and heel. It was 12.5% in toes and non-weight bearing areas. In conclusion, micronized ADM can be used to effectively treat DFUs that have invaded ligaments or bones. A close follow-up of weight bearing area wounds will allow us to identify and treat recurrence early.     

Pathogenesis of venous ulcer

The underlying pathophysiology of venous ulceration is venous hypertension, which initiates a complex cascade of cellular humeral events that are then magnified by genetic factors. Hemodynamic abnormalities are features of primary and secondary chronic venous diseases that lead to disease progression. Through a sequence of events, some patients develop venous leg ulcers, if the process is not interrupted. The exact science of the pathophysiology of the progression of chronic venous disease to venous leg ulcers is still in its infancy, but the framework for future study has been established.