what do you do for amputations?

[PathJet]

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how detailed of a dissection do you typically do on amputations?

i know vascular surgeosn and i dont even think they read the reports

yet some path residents i know have had to completley remove all vessels and map out the calcifications and grafts etc

is this reasonable? waste of time?

LA DOC please respond with your usual flair and honesty!!!


😱

 

[yaah]

Dissect the three main vessels, submit a section of a really calcified and stenosed one. Then cut into the deepest ulcer and take some bone out, submit that. Describe the ulcers and how deep they go and how big they are. Then describe the margin as viable.

 

[Absidia]

Dictate gross, take one section of the area of gangrene, done.

 

[Gene_]

These have already been alluded to, but two things are important:
1. Document that the surgery was indicated in the first place.
2. Let the surgeon know if the margin is viable/viable with ischemic changes/whatever.

The only thing I ever learn from the micros is the status of the margin. It makes me wonder why my staff even wants the vessels and ulcers put in. Medicolegal?

 

[rockit]

It makes me wonder why my staff even wants the vessels and ulcers put in. Medicolegal?

I did an amputation last year with a surgeon that insisted on vasculature evaluation. Could happen often enough to justify doing all of them.

 

[yaah]

If you put a section of the vessel in paraffin that at least "proves" there was significant disease. You can never go back to the actual gross specimen since it gets discarded (unless you're at mayo, apparently). I have no idea why a good gross description that states the vessels have significant calcification and stenosis would not suffice, but I have heard people say that if it is under glass, at least people who really have questions can see for themselves later.

And yes, I think there are probably enough surgeons who would like to see a vascular evaluation, just to document that they did the right thing.

 

[PathJet]

Dissect the three main vessels, submit a section of a really calcified and stenosed one. Then cut into the deepest ulcer and take some bone out, submit that. Describe the ulcers and how deep they go and how big they are. Then describe the margin as viable.

what is the definition of dissect? it sounds funny but i have had an hour discussion about this. i think it is adequate to follow the vessels along the course to determine the stenosis cutting transverse sections at decent intervals ( 1cm or so). some would say that you need to expose the muslce remove the vessels intact and then examine. i personally dont see a difference whether i leave the vessels on the leg or pull them off you still examine them. and atherosclerosis can have skip areas so why map it just find the worst area?

 

[LADoc00]

Dictate gross, take one section of the area of gangrene, done.

See above+1 section of viable looking margin. Dissecting out vessels is really pointless unless it is specifically requested, perhaps secondary to an embolic event. The main purpose which I think someone above eluded to is documentation to payors/insurance for the surgeon. Elaborate anatomic descriptions of a leg you might be doing in residency will not fly in private practice where you may have only a max 15min to gross a large specimen.

GENERAL LADOC RULE #415:
Anytime you get an unusual specimen, IMO it is worth a 30 sec phone call to the surgeon to determine what information he/she wants from it..if any.

 

[earmuff]

GENERAL LADOC RULE #415:
Anytime you get an unusual specimen, IMO it is worth a 30 sec phone call to the surgeon to determine what information he/she wants from it..if any.

As usual, excellent advice. 👍

 

[2121115]

Sorry but I had to LOL at the thought of mapping out the vasculature, grafts, and calc's on a dead leg. In my experience that has never been even close to necessary and the surgeon couldn't care less. We take a slice of viable soft tissue margin, a vascular margin, and a marrow margin (1 block) and one slice of an area of gangrene or ulcer (1 block).

 

[yaah]

I have never understood why the margin is important. If the margin is dead, the surgeon is going to know probably in a few hours. And the vascular margins don't matter that much either since it's just a stump that's left. Gross assessment of the margin is just fine - you can tell if the muscle and skin are dead. And if the bone is going to be a problem, that will probably be obvious too.

I know there are some programs out there which treat them as gross-only specimens. This is adequate. Gross tells you everything you need to know anyway. I think many programs just want that 88307 + 88311 so they make residents spend 30 minutes on them.

 

[PathJet]

if it were about charges i may be more sympathetic given how much time it can take to get detailed about one of these things. how do you get an 88307 out of it i think it is only 88305.

anyway its my theory and experience with vascular surgeons that at most the diagnostic line is read. i would really like to know the percentage of all amputation reports that have been issued where the patient/physician/administrator/ insurance whoever have read the gross description

and i certainly would pass out if they were seeking info whether it correlated with the imaging info (as has been suggested to me)

they amputate based on clinical signs and they reamputate based on clinical signs so if the "margin" is involved with any inflammation or atherosclerosis so what.... an amputation increses morbidity and mortatlity in a patient so they are actually conservative in making those decisions..

 

[DarksideAllstar]

i would really like to know the percentage of all amputation reports that have been issued where the patient/physician/administrator/ insurance whoever have read the gross description.

Sounds like an USCAP poster. ha.

 

[2121115]

I know there are some programs out there which treat them as gross-only specimens. This is adequate. Gross tells you everything you need to know anyway.

BINGO! I wish my program would do this.