“Less invasive” surgery in the treatment of cutaneous chronic ulcers of the lower limb in elderly

The role of treatment of vascular lesions of the legs is very important in the elderly. Pain, inability, bandages, periodicity of medications can seriously interfere with a good quality of life because of the lower compliance of geriatric patients to accept a surgical approach. To allow a new approach to vascular lesions the Authors propose a guideline in which the topic of “less invasive” surgery is underlined based on their pathophysiological causes.

Patients affected with lesions of the legs are addressed to the Leg Ulcers Centre by general physicians and selected on the basis of age and comorbility to propose a therapeutical plan. General conditions, evaluation of lesions healing and of quality of life are correlated to final target (acceptable quality of life). The first step includes a surgical examination and cardiological, nephrological, neurological examinations. The following steps are different for pathologies (see Flow Chart).

PAD (Peripheral Arterial Disease)

The target is the limb revascularisation. It can be allowed by endovascular techniques. Vascular evaluation is obtained by a ultrasonographic study followed by an Angio-Tc study of the arterial district. In diabetic patients endovascular techniques are used to obtain therapeutical windows in which skin closure occurs.

Prostacyclin and prostanoids are very useful in those patients in which a surgical procedure is not possible. They can be administred by e.v. at low doses for 2-3 days using a reservoir. Open surgery is restricted to revascularization of profunda femoral artery.

Venous insufficiency

The target is to decrease venous hypertension in the lesion district. Surgery is useful to heal the lesion, but also to prevent recurrency and to decrease elastic compression.

For a surgical approach an haemodynamic map is necessary to propose operations (see Figure 1)

Figure 1

Topical treatment of the ulcer

Surgical debridment of the ulcer can be obtained under local anesthesia using anesthetic ointment. According to the patient’s compliance homologous skin grafts or dermal substitutes can be used with good results.

Amputations

Minor amputations allow antidolorific drugs administration to be decreased. The final result can be accelerated by reconstructive plastic surgical procedures or by implant of homologous skin grafts.

All patients have accepted surgical treatment and when necessary another option. The Authors suggest the role of the internist and of the anesthesist in the management of different comorbidiities and the use of less invasive techniques, underlining that this is a proposal to obtain a guideline for the therapy of skin lesions in the elderly.