Krishnanand

Abstract

Introduction: In recent years, it has become evident that peripheral vascular disease is an important predictor of substantial coronary and cerebral vascular risk. The majority of patients present with an advanced stage of ischemia; hence, most of them require surgical intervention in the form of lumbar Sympathectomy, Omentopexy, or major or minor amputations. Patients presenting with terminal limb ischemia due to thromboangitis obliterans often have no hope for limb salvage; for such cases, omental transplantation offers a procedure which can result in improved limb circulation and limb salvage. Objective: To study the efficacy of Omental transplantation in peripheral vascular disease. Material and Methods: This is a prospective study done on a group of 25 patients. The patients were seen in surgical outdoor in emergency and routine hours and were diagnosed on the basis of history, clinical examination and investigations like Colour doppler and femoral arteriography in few cases. Omentopexy was done and patients were assessed on 7th post operative day, after 1 month and 3 months after the procedure. Results: On an average the patients smoked between 10- 25 beedis per day. Amongst these cases 10 cases had non-healing ulcers and 15 had dry gangrene of toes or forefoot, with rest pain. In 15 cases, popliteal artery pulsation was absent. After operative procedure intermittent claudication was relieved in 20 patients (80%). Rest pain was relieved in all the patients at the end of 3 months (100%). Healing of ulcer occurred in 9 out of 10 patients (90%). The healing of amputated toe site occurred in 10 out of 15 patients during 3 months follow-up (66.67%). Conclusion: Buerger’s disease is limb threatening condition occurring in productive age group and its management is challenging. If carried out with right technique and knowledge about vascular omental arcade, the results of omentopexy are good and this technique can help us avoid amputations.

Keywords: Buerger’s disease, Omental transplant, Omental transposition, Peripheral Vascular disease, Thromoboangitis Obliterans.

Introduction

Buerger’s disease (Thromboangitis Obliterans) is a condition characterised by segmental occlusion of small and medium sized arteries of the lower and sometimes of upper extremities in young male smokers, often associated with migratory thrombophlebitis. [1, 2] In recent years, it has become evident that Peripheral Vascular Disease is an important predictor of substantial coronary and cerebral vascular risk. [3-6] With the exception of cessation of smoking, none of these measures is curative. Drug therapy is of little benefit. [2, 7-10] Surgical treatment options have consisted of sympathectomy, direct arterial surgery, adrenalectomy, and amputation as a last resort. Also, patients who have ischemic signs and symptoms have been offered sympathectomy, despite the fact that relapses are frequent due to normalisation of vasomotor tone within two weeks to six months after operation. [11-13] Daniel et al [14] hoped omental transfer for revascularization of extremities will post pone amputation. Casten and Alday first studied omental transplantation. Goldsmith et al [15, 16] discovered lipid fraction from the omentum exerts angiogenic properties. Omentopexy acts by increasing the collateral circulation as it contains Angiogenic factor. Arterial reconstruction is usually impossible due to distal nature of the disease and carries a high failure rate. These considerations have always prompted surgeons to look for an alternative solution in the form of omental transfer. Omentopexy is a surgical procedure whereby the greater omentum is sutured or placed to a nearby organ to improve vascularity.

Material and Methods

Study design: This is a prospective study comprising of patients of peripheral vascular diseases of lower limbs.
Study Place: Department of Surgery, Chirayu Medical College and Hospital, Bhopal.
Study period: May 2011 to June 2013.
Sample size: A total of 25 patients presenting with sign and symptoms of Peripheral vascular disease.
Exclusion criteria: Obese, diabetic and patients presenting with wet gangrene.
Procedure: The patients were seen in surgical outdoor in emergency and routine hours and were diagnosed on the basis of history, clinical examination and investigations like Coloured doppler and femoral arteriography in few cases.

All patients underwent a Doppler scan of the lower limb prior to Surgery. The Doppler study was done mainly to demonstrate the block and the flow in the distal vessels. Surgery was done under general anaesthesia, supine position, midline vertical incision, omentum mobilized along with its vascular arcade (Figure 1), subcutaneous tunnelling done (Figure 2) and placed at the distal ulcer site (Figure 3). In the post operative period, patient were kept nil orally for 48 hours and switched on to oral feeds once the bowel sounds returned. Patients were advised to keep the limb in extension for 3-4 days. For assessment of effect of omentopexy the criteria used were both subjective and objective. Subjective assessment was done by observing improvement in symptoms and objective assessment was assessed with:
1)   Improvement in the local skin temperature.
2)   Relief in pain.
3)   Healing of ulcers and amputation site.
4)   Measurement of oxygen saturation by pulse oximetry.

The patients were assessed after 7 days, 1 month and 3 months after undergoing the procedure.

Figure 1: Vascular Omental Arcade

Figure 2: Subcutanous Tunneling

Figure 3: Omentum placed at distal ulcer site

Figure 4: Healed wound after one month

Results

The youngest patient in the study was 25yrs old and the oldest was 60yrs. All of the studied patients were male. All of the patients were from low socio-economic status. Most of them were labourers. None of these patients were on any medications except oral analgesics before admission. All the patients in the study were non-diabetic and normotensive at the time of admission

Table 1: Clinical Presentations of cases according to symptoms

Oxygen saturation was increased in toes during follow up.

Discussion

Buerger's disease is a limb-threatening condition occurring in the young and productive age group and its management has always been a challenging problem. [17] Buerger’s disease (Thromboangitis Obliterans) is a condition characterised by segmental occlusion of small and medium sized arteries of the lower and sometimes of upper extremities in young male smokers, often associated with migratory thrombophlebitis. In recent years, it has become evident that Peripheral Vascular Disease is an important predictor of substantial coronary and cerebral vascular risk. With the exception of cessation of smoking, none of these measures is curative. In patients with critical limb ischemia, surgery is required to salvage the limb. Traditionally, patients who have ischemic signs and symptoms have been offered sympathectomy despite the fact that relapses are frequent due to normalization of vasomotor tone within 2 weeks to 6 months after operation. Sympathectomy removes the vasoconstrictor tone improving blood flow and promoting ulcer healing and improving pain. But it does not increase flow to ischemic muscles and thus no improvements occur in claudication distance. Its long term role in chronically dilated ischemic vessels is also questionable [18 ,19] Direct revascularization surgeries are not possible due to diffuse involvement and absence of distal target vessel. [20]

In patients who are in imminent danger of requiring major amputation, omental pedicled transplantation is a viable alternative for limb salvage and also significantly improves signs and symptoms. Babu et al [21] report in this article relief in intermittent claudication in 92% patients with TAO, relief from rest pain in 86%, healing of ulcers in 100% of their patients. 14% of their patients required major amputation. Ranwaka et al [22] obtained relief in intermittent claudication in 86.6%, from rest pain in 66.6% and healing of ulcers in 80% in their patients. The results in our study are consistent with these results of some previous studies. The mechanism by which omentopexy increases vascularity of the ischemic limb is not exactly known, probably omental transposition works by promoting local collateralization, since omentum is known to possess angiogenic factor, which stimulates the formation of capillary channels making available collateral channels in the existing circulation. Subodh.et al [23] report in this article to find out the mechanism by which the omental graft increases the blood supply to the limbs. They performed Doppler ultrasound studies and celiac digital subtraction angiography to study the circulation though the omental graft. Only in 6 out of 12 patients could they visualize omental vessels till mid-thigh and only in four up to the knee joint. They concluded that omental transposition acts not by significantly supplying extra blood to the limbs but by acting locally on the limb musculature and probably causing increased collateral circulation. Although in the absence of such investigating facilities and financial constraints, we were not able to visualize omental vessels but we could certainly appreciate an excellent symptomatic relief obtained in these patients. There was immediate relief of pain, the progression of gangrene stopped, and ulcers healed; a certain major amputation was avoided in 90% of patients. Another interesting finding in the present series was that most of the patients experienced pain relief, immediately following surgery. Possible causes may be (i) Psychological relief that operation has been performed (ii) Bed rest (hospital admission) (iii) Supervision and almost complete stoppage of smoking leading to remission of the disease. In the present study, objective tests were carried out to see improvement in circulation. Skin temperature increased in 90% of patients. Pulse oximetry, an excellent method of assessing limb perfusion revealed a clear benefit in tissue oxygenation after pedicled omental transplantation.

Conclusion

Omental transplantation offers a procedure which can result in improved limb circulation and limb salvage in patients with Buergers disease.with limb ischemia. Omental transplantation induces neo-angiogenesis thereby improving circulation of surrounding tissues. Single stage lumbar sympathectomy and omental transplantation is a better procedure in end state. Thrombo angitis obliterans. Omental transplantation is a operation, which can be performed by general surgeon and immediate improvement in symptoms cannot be explained on psychological basis alone as was demonstrated by increase in skin temperature and improved tissue oxygenation by pulse oximetry. The present study has short comings in the form of (i) short duration of follow up (ii) no Doppler or angiographic evidence during follow up (iii) No histological proof of neovascularization of muscles. (iv) Abdominal approach & bowel handling (v) Small series. The present study however proved beyond doubt the role of omental transplantation in clinical improvement and as a limb salvage procedure in Buerger’s disease. Long term prospective randomised and controlled clinical trials with good follow up is needed to establish this procedure as the first line management of patients with Buerger’s disease.

Funding: Nil
Conflict of interest: Nil
Permission from IRB: Yes

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Addiction	No. of patients	Percentage (%)
Smoking	25	100
Alcohol	15	60
Smokeless tobacco	5	20

Duration of smoking (in yrs)	No. of patients	Percentage (%)
≤10 yrs	6	24
10-20 yrs	14	56
20-30 yrs	5	20

Arterial Pulsation	Absent (n)	Weak (n)	Normal (n)
Dorsalis Pedis Artery	25	0	0
Anterior Tibial Artery	25	0	0
Posterior Tibial Artery	23	0	2
Popliteal Artery	20	3	2
Femoral Artery	0	3	22

Disease Extent	No. of patients	%
Disease restricted to one limb	25	100
Disease involving B/L lower limbs	13	52
Disease involving B/L lower limbs and upper limbs	1	4

Duration of hospital stay	No. of patients	Percentage (%)
<2 days	1	3
20-30 days	17	67
30-40 days	4	16
>40 days 5	3	12

Symptoms	No. of patients	Percentage (%)
Intermittent claudication	25	100
Rest pain	15	60
Ulceration	10	40
Gangrene	15	60

Symptom	At the time of diagnosis No (%)	7th day No (%)	1st Month No (%)	3rd Month No (%)
Intermittent claudication	25 (100)	17 (66)	7 (27)	4 (17)
Rest pain	15 (60)	7 (27)	4 (17)	0 (0)
Healing of ulcer	10 (40)	9 (37)	7 (27)	1 ( 4)
Healing of amputated site	15 (60)	15 (60)	11 (43)	4 (17)

O2 saturation	At time of diagnosis	7th day	1st month	3rd month
	70	80	90	96