LIFE IS STRANGE.IT KEEPS THROWING CHALLENGES AND ITS UPTO YOU TO COPE WITH THEM.THEY TEST YOUR SENSIBILITIES TO THE CORE AND KEEP YOU ON YOUR TOES.BUT THEN THATS LIFE. UNPREDICTABLE....
WE RECENTLY HAD A SIMILAR CASE WITH US.THIS GENTLEMAN IN HIS FIFTIES CAME TO US IN EMERGENCY WARD WITH CRITICAL LIMB ISCHEMIA OF BOTH THE LEGS.HE HAD UNBEARABLE PAIN IN HIS LEFT LEG.ON EXAMINATION WE REALISED HE HAD IRREVERSIBLE ISCHEMIA OF THE LEFT LEG AND THE RIGHT LEG SEEMED SALVAGABLE THOUGH SIGNS AND SYMPTOMS WERE SUGGESTIVE OF ADVANCED ISCHEMIA.INTERESTINGLY THIS PATIENT UNDERWENT LEFT AXILLO-UNIFEMORAL BYPASS(TO ME THIS WAS NOT THE BEST TREATMENT OPTION AT THE OUTSET) TWO MONTHS BACK AT SOME OTHER CENTRE.THE GRAFT GOT OCCLUDED AND ALL ATTEMPTS TO RECANALIZE IT INCLUDING THROMBOLYSIS FAILED.THIS PATIENT HAD JUXTARENAL AORTIC OCCLUSION AS THE UNDERLYING PATHOLOGY WITH PORCELAIN(HEAVILY CALCIFIED)ABDOMINAL AORTA.PROBABLY THIS WOULD HAVE BEEN THE REASON FOR ATTEMPTING AX-FEM BYPASS IN HIM EARLIER.
WE DID A DECENDING THORACO-BIFEMORAL BYPASS IN THIS PATIENT BY CREATING A RETROPERITONEAL TUNNEL AS SUGGESTED BY KEAGY ET AL IN HIS PATHBREAKING ARTICLE PUBLISHED IN VARIOUS INTERNATIONAL VASCULAR SURGERY JOURNALS.WE REVASCULARISED THE LEFT LOWER LIMB STUMP FOR THE PURPOSE OF TISSUE HEALING.
THE REAL STORY BEGINS HERE.THE SURGERY WENT OFF WELL BUT POST OPERATIVELY THE PATIENT DEVELOPED WOUND DEHISCENCE IN THE LEFT GROIN,LEFT ABOVE KNEE AMPUTATION STUMP AND IN THE CHEST WITH GRAFT EXPOSURE .SUBSEQUENT INVESTIGATIONS REVEALED SEVERE HYPOALBUMINEMIA AS THE UNDERLYING CAUSE OF RAMPANT WOUND DEHISCENCE.
HYPOALBUMINEMIA AS WE ALL KNOW IS ASSOCIATED WITH POOR WOUND HEALING,DECREASED COLLAGEN SYNTHESIS,IMPAIRED IMMUNE RESPONSES LIKE MACROPHAGE ACTIVATION ETC AND DELAYED RECOVERY OF BOWEL FUNCTION POSTOPERATIVELY.
I MUST THANK THE PLASTIC SURGERY DEPARTMENT OF OUR HOSPITAL WHO FINALLY TREATED THIS COMPLICATION WITH AN EXTERNAL OBLIQUE FLAP.RECENTLY THIS PATIENT CAME FOR FOLLOWUP AND THE WOUND LOOKS HEALTHY.THE CHEST WOUND WAS DEBRIDED AND WOULD BE READY FOR RESUTURING IN A FEW DAYS FROW NOW.
I AM TRAINED IN ONE OF THE BUSIEST VASCULAR SURGERY CENTRES IN THE COUNTRY BUT HAVE NEVER SEEN AN AWFUL COMPLICATION LIKE THIS WHEREIN ALL SUTURE LINES GIVE IN.I REALIZE WHY PEOPLE PREFER GOING TO EXPERIENCED SURGEONS FOR THEIR AILMENTS (THEY HAD SEEN IT ALL I GUESS....).
I WOULD BE FAILING IN MY DUTY IF I DONT THANK MY PATIENT FOR HAVING PERSEVERENCE AND FAITH IN OUR CAPABILITIES.
