char = [;code = 91
char = F;code = 70
char = o;code = 111
char = r;code = 114
char = e;code = 101
char = f;code = 102
char = o;code = 111
char = o;code = 111
char = t;code = 116
char = ;code = 32
char = g;code = 103
char = a;code = 97
char = n;code = 110
char = g;code = 103
char = r;code = 114
char = e;code = 101
char = n;code = 110
char = e;code = 101
char = ;code = 32
char = a;code = 97
char = n;code = 110
char = d;code = 100
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = f;code = 102
char = r;code = 114
char = a;code = 97
char = -;code = 45
char = c;code = 99
char = r;code = 114
char = u;code = 117
char = r;code = 114
char = a;code = 97
char = l;code = 108
char = ;code = 32
char = b;code = 98
char = y;code = 121
char = p;code = 112
char = a;code = 97
char = s;code = 115
char = s;code = 115
char = :;code = 58
char = ;code = 32
char = s;code = 115
char = i;code = 105
char = m;code = 109
char = u;code = 117
char = l;code = 108
char = t;code = 116
char = a;code = 97
char = n;code = 110
char = e;code = 101
char = o;code = 111
char = u;code = 117
char = s;code = 115
char = ;code = 32
char = a;code = 97
char = m;code = 109
char = p;code = 112
char = u;code = 117
char = t;code = 116
char = a;code = 97
char = t;code = 116
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = ];code = 93
char = .;code = 46
result sql = [Forefoot gangrene and infra-crural bypass: simultaneous amputation].
[Forefoot gangrene and infra-crural bypass: simultaneous amputation].
char = P;code = 80
char = a;code = 97
char = t;code = 116
char = i;code = 105
char = e;code = 101
char = n;code = 110
char = t;code = 116
char = s;code = 115
char = ;code = 32
char = p;code = 112
char = r;code = 114
char = e;code = 101
char = s;code = 115
char = e;code = 101
char = n;code = 110
char = t;code = 116
char = e;code = 101
char = d;code = 100
char = ;code = 32
char = f;code = 102
char = o;code = 111
char = r;code = 114
char = ;code = 32
char = a;code = 97
char = m;code = 109
char = p;code = 112
char = u;code = 117
char = t;code = 116
char = a;code = 97
char = t;code = 116
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = ;code = 32
char = m;code = 109
char = o;code = 111
char = s;code = 115
char = t;code = 116
char = l;code = 108
char = y;code = 121
char = ;code = 32
char = h;code = 104
char = a;code = 97
char = v;code = 118
char = e;code = 101
char = ;code = 32
char = c;code = 99
char = h;code = 104
char = r;code = 114
char = o;code = 111
char = n;code = 110
char = i;code = 105
char = c;code = 99
char = ;code = 32
char = l;code = 108
char = i;code = 105
char = m;code = 109
char = b;code = 98
char = ;code = 32
char = i;code = 105
char = s;code = 115
char = c;code = 99
char = h;code = 104
char = a;code = 97
char = e;code = 101
char = m;code = 109
char = i;code = 105
char = a;code = 97
char = ;code = 32
char = c;code = 99
char = a;code = 97
char = u;code = 117
char = s;code = 115
char = e;code = 101
char = d;code = 100
char = ;code = 32
char = b;code = 98
char = y;code = 121
char = ;code = 32
char = a;code = 97
char = t;code = 116
char = h;code = 104
char = e;code = 101
char = r;code = 114
char = o;code = 111
char = s;code = 115
char = c;code = 99
char = l;code = 108
char = e;code = 101
char = r;code = 114
char = o;code = 111
char = s;code = 115
char = i;code = 105
char = s;code = 115
char = ,;code = 44
char = ;code = 32
char = w;code = 119
char = i;code = 105
char = t;code = 116
char = h;code = 104
char = ;code = 32
char = s;code = 115
char = i;code = 105
char = g;code = 103
char = n;code = 110
char = s;code = 115
char = ;code = 32
char = o;code = 111
char = f;code = 102
char = ;code = 32
char = s;code = 115
char = e;code = 101
char = v;code = 118
char = e;code = 101
char = r;code = 114
char = e;code = 101
char = ;code = 32
char = a;code = 97
char = r;code = 114
char = t;code = 116
char = e;code = 101
char = r;code = 114
char = i;code = 105
char = a;code = 97
char = l;code = 108
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = s;code = 115
char = u;code = 117
char = f;code = 102
char = f;code = 102
char = i;code = 105
char = c;code = 99
char = i;code = 105
char = e;code = 101
char = n;code = 110
char = c;code = 99
char = y;code = 121
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = c;code = 99
char = l;code = 108
char = u;code = 117
char = d;code = 100
char = i;code = 105
char = n;code = 110
char = g;code = 103
char = ;code = 32
char = r;code = 114
char = e;code = 101
char = s;code = 115
char = t;code = 116
char = ;code = 32
char = p;code = 112
char = a;code = 97
char = i;code = 105
char = n;code = 110
char = ,;code = 44
char = ;code = 32
char = n;code = 110
char = o;code = 111
char = n;code = 110
char = -;code = 45
char = h;code = 104
char = e;code = 101
char = a;code = 97
char = l;code = 108
char = i;code = 105
char = n;code = 110
char = g;code = 103
char = ;code = 32
char = s;code = 115
char = k;code = 107
char = i;code = 105
char = n;code = 110
char = ;code = 32
char = l;code = 108
char = e;code = 101
char = s;code = 115
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = s;code = 115
char = ,;code = 44
char = ;code = 32
char = u;code = 117
char = l;code = 108
char = c;code = 99
char = e;code = 101
char = r;code = 114
char = a;code = 97
char = t;code = 116
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = ;code = 32
char = o;code = 111
char = r;code = 114
char = ;code = 32
char = g;code = 103
char = a;code = 97
char = n;code = 110
char = g;code = 103
char = r;code = 114
char = e;code = 101
char = n;code = 110
char = e;code = 101
char = .;code = 46
char = ;code = 32
char = F;code = 70
char = o;code = 111
char = o;code = 111
char = t;code = 116
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = f;code = 102
char = e;code = 101
char = c;code = 99
char = t;code = 116
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = s;code = 115
char = ,;code = 44
char = ;code = 32
char = e;code = 101
char = s;code = 115
char = p;code = 112
char = e;code = 101
char = c;code = 99
char = i;code = 105
char = a;code = 97
char = l;code = 108
char = l;code = 108
char = y;code = 121
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = ;code = 32
char = d;code = 100
char = i;code = 105
char = a;code = 97
char = b;code = 98
char = e;code = 101
char = t;code = 116
char = i;code = 105
char = c;code = 99
char = ;code = 32
char = p;code = 112
char = a;code = 97
char = t;code = 116
char = i;code = 105
char = e;code = 101
char = n;code = 110
char = t;code = 116
char = s;code = 115
char = ,;code = 44
char = ;code = 32
char = a;code = 97
char = r;code = 114
char = e;code = 101
char = ;code = 32
char = o;code = 111
char = f;code = 102
char = t;code = 116
char = e;code = 101
char = n;code = 110
char = ;code = 32
char = m;code = 109
char = u;code = 117
char = l;code = 108
char = t;code = 116
char = i;code = 105
char = m;code = 109
char = i;code = 105
char = c;code = 99
char = r;code = 114
char = o;code = 111
char = b;code = 98
char = i;code = 105
char = a;code = 97
char = l;code = 108
char = ,;code = 44
char = ;code = 32
char = d;code = 100
char = e;code = 101
char = e;code = 101
char = p;code = 112
char = l;code = 108
char = y;code = 121
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = v;code = 118
char = a;code = 97
char = s;code = 115
char = i;code = 105
char = v;code = 118
char = e;code = 101
char = ;code = 32
char = a;code = 97
char = n;code = 110
char = d;code = 100
char = ;code = 32
char = f;code = 102
char = r;code = 114
char = e;code = 101
char = q;code = 113
char = u;code = 117
char = e;code = 101
char = n;code = 110
char = t;code = 116
char = l;code = 108
char = y;code = 121
char = ;code = 32
char = r;code = 114
char = e;code = 101
char = q;code = 113
char = u;code = 117
char = i;code = 105
char = r;code = 114
char = e;code = 101
char = ;code = 32
char = a;code = 97
char = g;code = 103
char = g;code = 103
char = r;code = 114
char = e;code = 101
char = s;code = 115
char = s;code = 115
char = i;code = 105
char = v;code = 118
char = e;code = 101
char = ;code = 32
char = m;code = 109
char = e;code = 101
char = a;code = 97
char = s;code = 115
char = u;code = 117
char = r;code = 114
char = e;code = 101
char = s;code = 115
char = ,;code = 44
char = ;code = 32
char = l;code = 108
char = i;code = 105
char = k;code = 107
char = e;code = 101
char = ;code = 32
char = d;code = 100
char = e;code = 101
char = b;code = 98
char = r;code = 114
char = i;code = 105
char = d;code = 100
char = e;code = 101
char = m;code = 109
char = e;code = 101
char = n;code = 110
char = t;code = 116
char = ;code = 32
char = a;code = 97
char = n;code = 110
char = d;code = 100
char = ;code = 32
char = d;code = 100
char = r;code = 114
char = a;code = 97
char = i;code = 105
char = n;code = 110
char = a;code = 97
char = g;code = 103
char = e;code = 101
char = ;code = 32
char = o;code = 111
char = r;code = 114
char = ;code = 32
char = p;code = 112
char = a;code = 97
char = r;code = 114
char = t;code = 116
char = i;code = 105
char = a;code = 97
char = l;code = 108
char = ;code = 32
char = o;code = 111
char = p;code = 112
char = e;code = 101
char = n;code = 110
char = ;code = 32
char = f;code = 102
char = o;code = 111
char = r;code = 114
char = e;code = 101
char = f;code = 102
char = o;code = 111
char = o;code = 111
char = t;code = 116
char = ;code = 32
char = a;code = 97
char = m;code = 109
char = p;code = 112
char = u;code = 117
char = t;code = 116
char = a;code = 97
char = t;code = 116
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = ;code = 32
char = a;code = 97
char = d;code = 100
char = d;code = 100
char = i;code = 105
char = t;code = 116
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = ;code = 32
char = t;code = 116
char = o;code = 111
char = ;code = 32
char = b;code = 98
char = r;code = 114
char = o;code = 111
char = a;code = 97
char = d;code = 100
char = -;code = 45
char = s;code = 115
char = p;code = 112
char = e;code = 101
char = c;code = 99
char = t;code = 116
char = r;code = 114
char = u;code = 117
char = m;code = 109
char = ;code = 32
char = a;code = 97
char = n;code = 110
char = t;code = 116
char = i;code = 105
char = b;code = 98
char = i;code = 105
char = o;code = 111
char = t;code = 116
char = i;code = 105
char = c;code = 99
char = s;code = 115
char = ,;code = 44
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = ;code = 32
char = p;code = 112
char = a;code = 97
char = t;code = 116
char = i;code = 105
char = e;code = 101
char = n;code = 110
char = t;code = 116
char = s;code = 115
char = ;code = 32
char = w;code = 119
char = i;code = 105
char = t;code = 116
char = h;code = 104
char = ;code = 32
char = c;code = 99
char = r;code = 114
char = i;code = 105
char = t;code = 116
char = i;code = 105
char = c;code = 99
char = a;code = 97
char = l;code = 108
char = ;code = 32
char = l;code = 108
char = i;code = 105
char = m;code = 109
char = b;code = 98
char = ;code = 32
char = i;code = 105
char = s;code = 115
char = c;code = 99
char = h;code = 104
char = a;code = 97
char = e;code = 101
char = m;code = 109
char = i;code = 105
char = a;code = 97
char = ;code = 32
char = a;code = 97
char = n;code = 110
char = d;code = 100
char = ;code = 32
char = l;code = 108
char = i;code = 105
char = m;code = 109
char = i;code = 105
char = t;code = 116
char = e;code = 101
char = d;code = 100
char = ;code = 32
char = n;code = 110
char = e;code = 101
char = c;code = 99
char = r;code = 114
char = o;code = 111
char = s;code = 115
char = i;code = 105
char = s;code = 115
char = ;code = 32
char = a;code = 97
char = n;code = 110
char = d;code = 100
char = ;code = 32
char = f;code = 102
char = o;code = 111
char = r;code = 114
char = e;code = 101
char = f;code = 102
char = o;code = 111
char = o;code = 111
char = t;code = 116
char = ;code = 32
char = g;code = 103
char = a;code = 97
char = n;code = 110
char = g;code = 103
char = r;code = 114
char = e;code = 101
char = n;code = 110
char = e;code = 101
char = ,;code = 44
char = ;code = 32
char = d;code = 100
char = i;code = 105
char = s;code = 115
char = t;code = 116
char = a;code = 97
char = l;code = 108
char = ;code = 32
char = b;code = 98
char = y;code = 121
char = p;code = 112
char = a;code = 97
char = s;code = 115
char = s;code = 115
char = ;code = 32
char = s;code = 115
char = u;code = 117
char = r;code = 114
char = g;code = 103
char = e;code = 101
char = r;code = 114
char = y;code = 121
char = ;code = 32
char = i;code = 105
char = s;code = 115
char = ;code = 32
char = t;code = 116
char = h;code = 104
char = e;code = 101
char = ;code = 32
char = t;code = 116
char = r;code = 114
char = e;code = 101
char = a;code = 97
char = t;code = 116
char = m;code = 109
char = e;code = 101
char = n;code = 110
char = t;code = 116
char = ;code = 32
char = o;code = 111
char = f;code = 102
char = ;code = 32
char = c;code = 99
char = h;code = 104
char = o;code = 111
char = i;code = 105
char = c;code = 99
char = e;code = 101
char = .;code = 46
char = ;code = 32
char = T;code = 84
char = h;code = 104
char = e;code = 101
char = ;code = 32
char = m;code = 109
char = a;code = 97
char = i;code = 105
char = n;code = 110
char = ;code = 32
char = q;code = 113
char = u;code = 117
char = e;code = 101
char = s;code = 115
char = t;code = 116
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = ;code = 32
char = i;code = 105
char = s;code = 115
char = ;code = 32
char = w;code = 119
char = h;code = 104
char = e;code = 101
char = t;code = 116
char = h;code = 104
char = e;code = 101
char = r;code = 114
char = ;code = 32
char = a;code = 97
char = m;code = 109
char = p;code = 112
char = u;code = 117
char = t;code = 116
char = a;code = 97
char = t;code = 116
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = ;code = 32
char = s;code = 115
char = h;code = 104
char = o;code = 111
char = u;code = 117
char = l;code = 108
char = d;code = 100
char = ;code = 32
char = b;code = 98
char = e;code = 101
char = ;code = 32
char = p;code = 112
char = e;code = 101
char = r;code = 114
char = f;code = 102
char = o;code = 111
char = r;code = 114
char = m;code = 109
char = e;code = 101
char = d;code = 100
char = ;code = 32
char = s;code = 115
char = i;code = 105
char = m;code = 109
char = u;code = 117
char = l;code = 108
char = t;code = 116
char = a;code = 97
char = n;code = 110
char = e;code = 101
char = o;code = 111
char = u;code = 117
char = s;code = 115
char = l;code = 108
char = y;code = 121
char = ;code = 32
char = o;code = 111
char = r;code = 114
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = ;code = 32
char = a;code = 97
char = ;code = 32
char = s;code = 115
char = e;code = 101
char = c;code = 99
char = o;code = 111
char = n;code = 110
char = d;code = 100
char = a;code = 97
char = r;code = 114
char = y;code = 121
char = ;code = 32
char = s;code = 115
char = t;code = 116
char = a;code = 97
char = g;code = 103
char = e;code = 101
char = .;code = 46
char = ;code = 32
char = O;code = 79
char = u;code = 117
char = r;code = 114
char = ;code = 32
char = o;code = 111
char = w;code = 119
char = n;code = 110
char = ;code = 32
char = e;code = 101
char = x;code = 120
char = p;code = 112
char = e;code = 101
char = r;code = 114
char = i;code = 105
char = e;code = 101
char = n;code = 110
char = c;code = 99
char = e;code = 101
char = ;code = 32
char = d;code = 100
char = e;code = 101
char = a;code = 97
char = l;code = 108
char = s;code = 115
char = ;code = 32
char = w;code = 119
char = i;code = 105
char = t;code = 116
char = h;code = 104
char = ;code = 32
char = 3;code = 51
char = 4;code = 52
char = 2;code = 50
char = ;code = 32
char = f;code = 102
char = e;code = 101
char = m;code = 109
char = o;code = 111
char = r;code = 114
char = o;code = 111
char = c;code = 99
char = r;code = 114
char = u;code = 117
char = r;code = 114
char = a;code = 97
char = l;code = 108
char = ;code = 32
char = a;code = 97
char = n;code = 110
char = d;code = 100
char = ;code = 32
char = f;code = 102
char = e;code = 101
char = m;code = 109
char = o;code = 111
char = r;code = 114
char = o;code = 111
char = p;code = 112
char = e;code = 101
char = d;code = 100
char = a;code = 97
char = l;code = 108
char = ;code = 32
char = b;code = 98
char = y;code = 121
char = p;code = 112
char = a;code = 97
char = s;code = 115
char = s;code = 115
char = ;code = 32
char = g;code = 103
char = r;code = 114
char = a;code = 97
char = f;code = 102
char = t;code = 116
char = s;code = 115
char = ;code = 32
char = f;code = 102
char = o;code = 111
char = r;code = 114
char = ;code = 32
char = t;code = 116
char = h;code = 104
char = e;code = 101
char = ;code = 32
char = t;code = 116
char = r;code = 114
char = e;code = 101
char = a;code = 97
char = t;code = 116
char = m;code = 109
char = e;code = 101
char = n;code = 110
char = t;code = 116
char = ;code = 32
char = o;code = 111
char = f;code = 102
char = ;code = 32
char = c;code = 99
char = r;code = 114
char = i;code = 105
char = t;code = 116
char = i;code = 105
char = c;code = 99
char = a;code = 97
char = l;code = 108
char = ;code = 32
char = l;code = 108
char = i;code = 105
char = m;code = 109
char = b;code = 98
char = ;code = 32
char = i;code = 105
char = s;code = 115
char = c;code = 99
char = h;code = 104
char = a;code = 97
char = e;code = 101
char = m;code = 109
char = i;code = 105
char = a;code = 97
char = .;code = 46
char = ;code = 32
char = T;code = 84
char = h;code = 104
char = e;code = 101
char = ;code = 32
char = r;code = 114
char = e;code = 101
char = s;code = 115
char = u;code = 117
char = l;code = 108
char = t;code = 116
char = s;code = 115
char = ;code = 32
char = s;code = 115
char = h;code = 104
char = o;code = 111
char = w;code = 119
char = e;code = 101
char = d;code = 100
char = ;code = 32
char = n;code = 110
char = o;code = 111
char = ;code = 32
char = s;code = 115
char = i;code = 105
char = g;code = 103
char = n;code = 110
char = i;code = 105
char = f;code = 102
char = i;code = 105
char = c;code = 99
char = a;code = 97
char = n;code = 110
char = t;code = 116
char = ;code = 32
char = d;code = 100
char = i;code = 105
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char = o;code = 111
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char = s;code = 115
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char = ;code = 32
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char = u;code = 117
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char = ,;code = 44
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char = h;code = 104
char = e;code = 101
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char = a;code = 97
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char = g;code = 103
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char = e;code = 101
char = n;code = 110
char = o;code = 111
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char = s;code = 115
char = ;code = 32
char = p;code = 112
char = a;code = 97
char = r;code = 114
char = t;code = 116
char = ;code = 32
char = i;code = 105
char = s;code = 115
char = ;code = 32
char = a;code = 97
char = m;code = 109
char = p;code = 112
char = u;code = 117
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char = a;code = 97
char = t;code = 116
char = e;code = 101
char = d;code = 100
char = .;code = 46
char = ;code = 32
char = I;code = 73
char = n;code = 110
char = ;code = 32
char = c;code = 99
char = a;code = 97
char = s;code = 115
char = e;code = 101
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char = f;code = 102
char = ;code = 32
char = d;code = 100
char = e;code = 101
char = e;code = 101
char = p;code = 112
char = ,;code = 44
char = ;code = 32
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char = e;code = 101
char = t;code = 116
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char = r;code = 114
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char = i;code = 105
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char = f;code = 102
char = e;code = 101
char = c;code = 99
char = t;code = 116
char = i;code = 105
char = o;code = 111
char = u;code = 117
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char = ;code = 32
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char = g;code = 103
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char = n;code = 110
char = e;code = 101
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char = ;code = 32
char = t;code = 116
char = h;code = 104
char = e;code = 101
char = ;code = 32
char = f;code = 102
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char = r;code = 114
char = e;code = 101
char = f;code = 102
char = o;code = 111
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char = t;code = 116
char = ,;code = 44
char = ;code = 32
char = a;code = 97
char = n;code = 110
char = ;code = 32
char = o;code = 111
char = p;code = 112
char = e;code = 101
char = n;code = 110
char = ;code = 32
char = t;code = 116
char = r;code = 114
char = a;code = 97
char = n;code = 110
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char = m;code = 109
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char = t;code = 116
char = a;code = 97
char = r;code = 114
char = s;code = 115
char = a;code = 97
char = l;code = 108
char = ;code = 32
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char = m;code = 109
char = p;code = 112
char = u;code = 117
char = t;code = 116
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char = t;code = 116
char = i;code = 105
char = o;code = 111
char = n;code = 110
char = ;code = 32
char = i;code = 105
char = s;code = 115
char = ;code = 32
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char = r;code = 114
char = f;code = 102
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char = e;code = 101
char = d;code = 100
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char = U;code = 85
char = s;code = 115
char = i;code = 105
char = n;code = 110
char = g;code = 103
char = ;code = 32
char = t;code = 116
char = h;code = 104
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char = s;code = 115
char = ;code = 32
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char = p;code = 112
char = r;code = 114
char = o;code = 111
char = a;code = 97
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char = h;code = 104
char = ;code = 32
char = w;code = 119
char = e;code = 101
char = ;code = 32
char = h;code = 104
char = a;code = 97
char = v;code = 118
char = e;code = 101
char = ;code = 32
char = f;code = 102
char = u;code = 117
char = r;code = 114
char = t;code = 116
char = h;code = 104
char = e;code = 101
char = r;code = 114
char = ;code = 32
char = i;code = 105
char = n;code = 110
char = c;code = 99
char = r;code = 114
char = e;code = 101
char = a;code = 97
char = s;code = 115
char = e;code = 101
char = d;code = 100
char = ;code = 32
char = l;code = 108
char = i;code = 105
char = m;code = 109
char = b;code = 98
char = -;code = 45
char = s;code = 115
char = a;code = 97
char = l;code = 108
char = v;code = 118
char = a;code = 97
char = g;code = 103
char = e;code = 101
char = ;code = 32
char = a;code = 97
char = n;code = 110
char = d;code = 100
char = ;code = 32
char = e;code = 101
char = s;code = 115
char = p;code = 112
char = e;code = 101
char = c;code = 99
char = i;code = 105
char = a;code = 97
char = l;code = 108
char = l;code = 108
char = y;code = 121
char = ;code = 32
char = t;code = 116
char = h;code = 104
char = e;code = 101
char = ;code = 32
char = n;code = 110
char = u;code = 117
char = m;code = 109
char = b;code = 98
char = e;code = 101
char = r;code = 114
char = ;code = 32
char = o;code = 111
char = f;code = 102
char = ;code = 32
char = u;code = 117
char = s;code = 115
char = u;code = 117
char = a;code = 97
char = b;code = 98
char = l;code = 108
char = e;code = 101
char = ;code = 32
char = l;code = 108
char = i;code = 105
char = m;code = 109
char = b;code = 98
char = s;code = 115
char = .;code = 46
char = <;code = 60
char = b;code = 98
char = r;code = 114
char = /;code = 47
char = >;code = 62
result sql = Patients presented for amputation mostly have chronic limb ischaemia caused by atherosclerosis, with signs of severe arterial insufficiency including rest pain, non-healing skin lesions, ulceration or gangrene. Foot infections, especially in diabetic patients, are often multimicrobial, deeply invasive and frequently require aggressive measures, like debridement and drainage or partial open forefoot amputation in addition to broad-spectrum antibiotics, in patients with critical limb ischaemia and limited necrosis and forefoot gangrene, distal bypass surgery is the treatment of choice. The main question is whether amputation should be performed simultaneously or in a secondary stage. Our own experience deals with 342 femorocrural and femoropedal bypass grafts for the treatment of critical limb ischaemia. The results showed no significant difference in graft patency between crural and pedal grafts. Clinical factors like diabetes mellitus, poor distal run-off and site of the distal anastomosis had no adverse effect on the functioning and patency of the graft. In this series we found that in diabetic patients significantly more amputations were required because of persistent foot infection. Since in these patients amputation was performed in a secondary stage, we changed our policy to simultaneous amputation. After completion of the bypass, closure and coverage of all the wounds, the gangrenous part is amputated. In case of deep, wet or infectious gangrene of the forefoot, an open transmetatarsal amputation is performed. Using this approach we have further increased limb-salvage and especially the number of usuable limbs.

Publication: J Mal Vasc 1996 ;21 Suppl A:171-3.
Publication Date: 1996
Study Author(s): Jacobs, M J;
Institution: Department of Vascular Surgery, Academic Medical Center, Amsterdam, Pays-Bas.
Shortcut link to this study:
Patients presented for amputation mostly have chronic limb ischaemia caused by atherosclerosis, with signs of severe arterial insufficiency including rest pain, non-healing skin lesions, ulceration or gangrene. Foot infections, especially in diabetic patients, are often multimicrobial, deeply invasive and frequently require aggressive measures, like debridement and drainage or partial open forefoot amputation in addition to broad-spectrum antibiotics, in patients with critical limb ischaemia and limited necrosis and forefoot gangrene, distal bypass surgery is the treatment of choice. The main question is whether amputation should be performed simultaneously or in a secondary stage. Our own experience deals with 342 femorocrural and femoropedal bypass grafts for the treatment of critical limb ischaemia. The results showed no significant difference in graft patency between crural and pedal grafts. Clinical factors like diabetes mellitus, poor distal run-off and site of the distal anastomosis had no adverse effect on the functioning and patency of the graft. In this series we found that in diabetic patients significantly more amputations were required because of persistent foot infection. Since in these patients amputation was performed in a secondary stage, we changed our policy to simultaneous amputation. After completion of the bypass, closure and coverage of all the wounds, the gangrenous part is amputated. In case of deep, wet or infectious gangrene of the forefoot, an open transmetatarsal amputation is performed. Using this approach we have further increased limb-salvage and especially the number of usuable limbs.
PMID: 8713389

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