Saving limbs, saving lives

The National Hospital’s vascular surgical unit faces the daunting task of making decisions between amputating limbs or salvaging them through surgery when patients are injured or stricken with Chronic Occlusive Arterial Disease (COAD)

A patient is brought to hospital in the middle of the night, with severe pain in the leg, weakness and numbness. There is no pulse in his leg. Blood vessels are occluded; there is no more blood supply to the leg. For a moment both the doctor and the patient share the same question; and their eyes the same expression of anxiety and hope. "Can this limb be salvaged,” is the question.

This is quite a common scenario at the University Vascular Surgical Unit of the National Hospital. The unit headed by Prof. Mandika Wijeyaratne, deals with diseased blood vessels and treats many patients with compromised blood supply to the limbs. When the blood supply is compromised to a limb due to any cause, the limb is at a risk of dying, posing the terrifying threat of amputation.

N. Somasiri (name changed), 64, is one such patient, we met at Ward 28, the University Vascular Surgical Unit of the National Hospital. Having had the same illness two years ago, his left leg was amputated below the knee. He recalls the trauma he faced. "First I felt so upset that I thought life was not worth living, but later on I got used to this artificial leg, and now it's just a part of me," he says. After two years he is again in the ward, because the blood vessels in his other leg have also narrowed. He has undergone major surgery to restore the blood supply to this leg and is still being treated.

Prevention of amputation is the policy in a vascular surgical unit but the practice is never easy. It includes proper management of ulcers in the legs, and most of the time major surgery to establish the blood supply to the distal ends of the limbs.

Most of these surgeries cannot be delayed, and at times are done in the middle of the night, lasting between four to eight hours.

Depending on the extent of the disease, there are a number of patients who have no option but to undergo an amputation.

Amputation is a common cause of morbidity in Sri Lanka, with it being a common surgery performed at any surgical unit. Although there are no national figures available, MediScene learns that the University Vascular Surgical Unit gets about three to four patients per month who need amputation of legs. The causes vary from trauma due to road traffic accidents and warfare injuries in the young and chronic arterial occlusive disease in the old.

Just as in the heart, blood vessels carrying blood to the legs can have cholesterol deposits, causing disruption to the blood flow. Initially it would manifest as calf and thigh pain while walking, and then progress to pain even at rest. When the blood supply is no more, it results in a dead limb. This is called Chronic Occlusive Arterial Disease (COAD) and smoking is the main culprit.

With the changing pattern of prevalence of diabetes in Sri Lanka, diabetes is emerging as the most leading cause of limb loss in the older age group.

Diabetes causes damage to the nerves and impairment of sensation in the feet. Once a wound develops, it can also worsen due to poor wound healing properties in diabetics. Diabetes also accelerates formation of cholesterol plaques in vessels which leads to reduced blood supply to the wound, so that wound is further deprived of oxygen, nutrition and other factors needed for healing. The end result is a non-healing wound and in the long run may need amputation.

Other instances where limb loss is likely are when blood clots block the vessels or inflammation in the vessels which is quite uncommon.

Almost all the surgeries performed at the unit are aimed at restoring the blood supply and saving the limb, so that the patient can lead a normal life. The surgery is a bypass where a new vessel is introduced to the leg to bypass the site of occlusion and to maintain the blood flow to the extremities.

However, the scope of the heavy work done here is not only to prevent amputation. Treating the patient as a whole is the next important aspect. Usually these patients are diabetics, with the same type of disease affecting blood vessels of the heart, and even the vessels in the brain. Thus there is no point in saving the patient's leg by means of a 10 hour surgery, and letting him succumb to a heart attack. Therefore, a full assessment is made about the function of his heart and the state of the blood vessels in the brain. Even after the bypass surgery, tight control of blood sugar and cholesterol levels and abstinence from smoking is essential to have a good outcome.

However, preventing amputations is not solely the responsibility of a vascular surgeon. The patient has to play a major role. Abstinence from smoking is crucial. Proper foot care and tight blood sugar control, if you are a diabetic, is the next step. "I got to know that I was a diabetic only when I got admitted with this leg problem, two years ago. By that time my leg could not be saved," explains Mr. Somasiri, stressing the importance of identifying diabetes before complications set in. Then, your family physician can advise you regarding foot care, and blood sugar control. Diet and exercise all affects your blood cholesterol levels and keeping a tab on it is good for both your heart and legs.

Following amputation, there are many aspects to address. The wound is taken care of in the ward, to make it heal as soon as possible through wound dressings and medication. In the meantime it is essential to strengthen the remaining muscles so that once the wound is healed, the patient is able to use an artificial limb. Physiotherapy and limb exercise are given to maintain muscle strength. This includes training in balancing, walking and other types of exercises which are taught during the hospital stay itself.

However, depending on the site of the amputation, the outcome differs. It can vary from the removal of a toe, which does not affect life much, a fore foot amputation where the heel is conserved, a below knee amputation or an above knee amputation.

Following an amputation, a patient invariably needs equipment such as a prosthesis or artificial leg. There are organizations that supply them free of charge but these also have their limitations. Buying an artificial leg is always an option, but the cost could be in the range of Rs. 50,000 or more depending on the quality and the manufacturer. It usually takes about six months before a patient can walk using an artificial leg. Until the patient is fit to move around on a prosthetic leg, he may need a wheelchair. Some patients who are not fit even for that, need air or water mattresses to prevent bed sores.

The elderly especially, find it difficult to start anew after amputation. Patients need more energy to walk on crutches and prosthetic legs and elderly people with other diseases find it difficult to train themselves to do this. Thus an amputation in an elderly debilitated person may mean suffering for the rest of his life. This highlights the importance of prevention of amputations.

Age or the site of amputation is not the only problem. The quality of the amputation too matters. People in developed countries can afford artificial legs with artificial joints, which would be the ideal for a patient after amputation above the knee. However, we do not have such sophisticated limbs here in Sri Lanka. In addition toilets with squatting pans, split level houses and bad roads all make life difficult for an amputee.

Mr. Somasiri is only one among the hundreds of patients being followed up at Ward 28, National Hospital. Just close your eyes and imagine how you would feel waking up without your leg just above the knee. A significant number of people do wake up to that reality, after having run and walked like you and me.

(Information provided by Prof. Mandika Wijeratne, Professor of Surgery, Faculty of Medicine, Colombo and Dr. Nalaka Gunawanse, Senior Registrar, University Vascular Surgical Unit, NHSL.)