Amputees have less blood


No surgeon likes to amputate. But in patients with severe circulatory disorders, this extreme intervention can sometimes be the last resort to save the patient's life.


Clinical picture



An amputation - the surgical cutting off of a leg, foot, arm or hand - can be the result of the most severe circulatory disorders. But they are always the last choice of therapeutic measures. "No surgeon likes to amputate," says Roland Raakow, chief physician for visceral and vascular surgery at Vivantes Klinikum Am Urban. Only when all other procedures to restore blood flow to the extremities have failed do doctors resort to this method to save the rest of the body.



The most common cause of tissue damage from circulatory disorders is a combination of arteriosclerosis and diabetes. While the hardening of the arteries affects the blood flow in the large blood vessels, diabetes particularly damages the capillary blood vessels, i.e. the small, fine ramifications of the blood circulation.
Since obese people are more often affected by disorders of the lipid metabolism, they also suffer more often from arteriosclerosis. Smokers are also significantly more likely to suffer from circulatory disorders, as nicotine constricts the vessels and thus inhibits blood flow.



Arms and legs with poor blood circulation often lack their natural skin complexion, are pale and often feel cool. People with severe circulatory problems hurt the affected limbs. Initially, this is only noticeable during exertion, such as longer running distances. Which is why those affected take more breaks. Colloquially, this condition is therefore also known as intermittent claudication (arteriosclerosis). As the disease progresses, patients suffer from pain at rest, even when the leg is not moved. In the final stage, when almost no more blood reaches the vessels, the tissue dies. Doctors call this necrosis. Dead tissue, however, which is then no longer protected by the immune system, offers bacteria an ideal breeding ground. Wound infections that develop in this way can spread to healthy tissue and lead to life-threatening blood poisoning - medically called sepsis.
Advanced diabetes often also damages the nerves - doctors speak of neuropathy in this case. Those affected no longer feel pain in the diseased part of the body. Therefore, severe tissue damage, which slowly arises from the circulatory disorders, often goes unnoticed for a long time. "Many patients come to the clinic relatively late," says chief physician Raakow. Doctors could often avoid amputations - if they were only treated in good time.



In 2010, around 3950 arms, hands, legs and feet were amputated in 40 hospitals in the capital.





First, the doctor has the patient's complaints, medical history and lifestyle described. In order to then check how badly the blood supply to the vessels is damaged, there are basically two methods available to the doctor: non-invasive and invasive diagnostics. All examination procedures in which the doctor does not have to open the body are non-invasive. Surgery or catheter examinations are against invasive procedures. Doctors start with the gentler and cheaper non-invasive procedures.
If the disease is still at the stage of intermittent claudication, head physician Raakow sends the patient onto the treadmill, for example. If the patient suffers from a circulatory disorder, pain will occur in the affected area after a certain period of time. The distance covered so far indicates the stage of the vascular disease - the shorter the distance, the more advanced the damage.
If the patient is threatened with amputation, such a test is no longer possible. Often the part of the body already hurts without moving it at all, or tissue has already died. Raakow then checks the so-called closure pressure by manually scanning the vessels. This value is an indicator of the blood flow to the tested body part. The greater the pressure that the blood vessel can withstand without occluding, the stronger the blood flow. In order to examine the arteries of the leg, for example, the physician works his way down from the inguinal artery to the hollow of the knee and down to the dorsal artery. He checks the locking pressure with his finger or a pressure cuff. However, this method is limited to slimmer patients, as the veins of the bulky are often no longer palpable.
The ultrasound examination is also often used by medical professionals. With the so-called duplex sonography - a special ultrasound device - the flow speed of the blood is visualized with the help of colors. In this way, a vascular narrowing can be detected based on the changed flow velocity
In addition to these non-invasive procedures, vascular surgeons can also use catheter angiography to make vascular constrictions visible. In this invasive procedure, a catheter is usually pushed over the groin over a wafer-thin wire through the blood vessels to the suspected bottleneck of a vein. There, the doctor injects a contrast medium into the blood via the catheter, which makes veins or arteries appear on X-rays - and also their constrictions.


Therapy / operation:

If the vessels are so overgrown that there is a risk of damage from the congestion, the vascular surgeon first tries to get the blood in the damaged tissue to flow again with bypasses - to bypass the constriction - or with vascular supports called stents. Only tissue that cannot be saved despite these attempts at reconstruction is ultimately amputated. This is an extreme surgical procedure that has previously exhausted all alternative, body-sustaining methods. When deciding where to cut off an arm or leg, the basic rule is: "As little as possible and as much as necessary," says surgeon Raakow.
The amputation is usually carried out under general anesthesia. First, the surgeons stop the blood supply to the affected part of the body with a tightly tightened cuff. This lock prevents the patient from losing a lot of blood during the operation and gives the surgeon a clear view of the surgical field.
At the affected area, skin, muscles, nerves and blood vessels are severed and, if necessary, bones are sawn through and their edges smoothed. In the remaining part of the body, the surgeon scrapes out tissue so that he can then place the resulting flap of muscles and skin over the bone stocking and sew it.
Small amputations, such as a toe, often take no more than 25 minutes. Complicated operations such as amputation of the metatarsus, which is made up of many small bones and muscle ligaments, or operations on arthritic legs, the aim of which is to restore blood circulation as much as possible through bypasses and stents, can take up to two hours.
After the operation, the amputated limbs are sent to the pathology department. There, the tissue damage is examined again more closely and it is clarified whether the findings made before the operation were correct. A safety system to avoid unnecessary amputations. After that, the body parts are burned.


Pain Therapy:

But for many patients the suffering does not end there. You have pain in the part of your body that has long been removed: phantom pain. Doctors blame this on "short circuits", i.e. contact between the severed nerve and the surrounding muscle tissue. Because both the messages of sensory impressions passed on by the nerves to the brain and, in the opposite direction, the control stimuli for the muscles are electrical impulses. If they come into contact, this can lead to electrical stimuli that are misinterpreted as pain in the brain.
In order to avoid this excruciating burden, the surgeon has to cut the nerves of the affected arm or leg one by one and isolate the severed nerves. Either it obliterates the nerve end with electricity, a technique that doctors call coagulation. Or the surgeon ties the strand off with a thread, this method is called alloying. But despite all the efforts, more than half of the patients suffer from this symptom. "Apparently a 'short circuit' is just one of several causes of phantom pain that still have to be researched," says Raakow. But there is hope: "Often phantom pain heals over time."
Nevertheless, doctors administer painkillers immediately after an amputation for the initially severe ailments. Either a local anesthetic is injected into the affected part of the body via a pain catheter or the patient is given a tablet, a suppository or an infusion. The advantage of the first, regionally limited variant is that, in contrast to the latter, systemic pain therapy, it only affects the operated area, thereby reducing undesirable side effects such as fatigue.



How long the patient has to lie in the hospital bed after the operation depends to a large extent on the healing of the wound. In the case of smaller amputations, for example a toe, the patient can usually leave the clinic after ten to 14 days. Larger amputations of the lower leg or thigh can, however, mean hospitalization for up to four weeks.
As soon as the stump has healed after the operation, the prostheses are adjusted in the hospital. In addition, the employees of a specialist orthopedic company come to the clinic, measure the residual limb and determine the length of the prosthesis. After the hospital stay, orthopedic rehabilitation usually follows. In addition to exercise training and physiotherapy, the use of prostheses is also on the agenda.
How well a patient can cope with everyday life with a prosthesis depends on several factors: Young, physically and mentally healthy patients often find it easier to learn how to use a prosthesis, as they are usually more motivated and efficient. Often these are people who have had a serious sports or traffic accident, or patients with congenital malformations. However, this is the smaller group of prosthesis wearers. You can even - as the Paralympics, i.e. the Olympics for people with disabilities, impressively prove every four years - achieve top sporting performances.
However, the adjustment is more difficult for patients in whom atherosclerosis led to amputation. These patients are mostly older and often have to struggle with other diseases. Because of the tissue that has had poor blood supply for years, they are less able to get used to prostheses and new movements.

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