Q: My father suffered from gangrene and underwent surgery. He is 64 years old and diabetic. How to avoid the recurrence of gangrene and what are the causes for it?

A:Even though the information provided is woefully insufficient, I shall try to give the guidelines that are needed for the management of this condition. The Diabetic PVD (Peripheral Vascular Disease) is a fairly common condition in India, so the incidence is much commoner than non-diabetic Atherosclerotic PVD. With the increase in the incidence of diabetes in India, the PVD from this condition will be a significant aetiological factor in the morbidity and mortality due to diabetes in the population. The diabetics have an accelerated progression of arterial disease as opposed to general population. The gangrene is the result of either vascular occlusion or infection induced thrombosis leading to vascular occlusion. Usually it is both conditions working in tandem to destroy the tissues causing gangrene. What you have not written is if the operation was just amputation or revascularisation i.e. bypass. The best way to limit the problems from diabetic PVD is to follow the following guidelines: - If there is any suspicion of diabetes the same should be investigated and diagnosed as early as possible. - Once diagnosed there should be regular monitoring of the glycaemic control and treatment for diabetes and not forgetting that diabetes cannot be cured and can only be kept under control. - If the oral medication is not able to control the blood sugar one should not hesitate to use insulin. - The feet should be cared for all the time and checked for and loss of vascularity and sensation. - If there is any loss of vascularity then the same should be assessed and preventive medication started. - There may not be need to do intervention in all cases but a Doppler assessment in all cases is imperative. - Diabetics invariably have a degree of neuropathy so they are prone to develop minor injuries and at times the bony deformities leading to the callosities and skin abrasion or cracks. These are the portals for infection. - Meticulous care should be taken for the feet, like keeping clean and dry and to always wear proper footwear. - In case there is any infection then it should be treated expeditiously and effectively, including using antibiotics. - In the event if there is onset of gangrene then a proper vascular assessment with Doppler and if need be angiography, using non-invasive techniques first. It is possible to make a good assessment using Doppler and MR Angiograpy. This prevents radiographic dye induced renal damage. Once assessment is made then a decision about revascularisation, both surgical and endovascular can be made and executed. Finally, last but not the least, is a word of caution that once the gangrene of the toe is seen one should not rush to amputate the toe without thorough assessment of the vascular and diabetic assessment. This black toe should be treated as a warning sign for the danger to the limb and preventive action may be needed before the toe is amputated.