The prospects for Maltese diabetics with foot problems have been improving in the past few years, with a decrease in major amputations being the most noticeable effect. John Cordina interviews consultant vascular Kevin Cassar and one of his patients, Herbert Camenzuli, on what has been taking place.

Foot and leg amputations have been a fairly common fate for people with diabetes, due to health complications which the condition leads to. People with diabetes are far more likely to require amputations than the general population. Major amputations, above or below the knee, not only severely affect patients’ quality of life, but carry significant risks, particularly in elderly patients.

But there is some good news for Maltese patients. The number of major amputations has been decreasing considerably over the past few years, thanks to a number of measures undertaken by the health authorities. These measures included the recruitment of skilled specialists, including Maltese doctors who worked abroad.

One such case was consultant vascular surgeon Kevin Cassar, who furthered his studies in Scotland after obtaining a medical degree in Malta. After completing his studies, he accepted a consultant post at Aberdeen Royal Infirmary and a lecturing post at the University of Aberdeen and stayed on.

Despite being happy there, when a consultant post in Malta was advertised in 2007, he applied and was offered the post, and has never looked back since.

Early diagnosis of problems may be crucial in preventing amputations or other complications, and efforts in this regard have included setting up a diabetic foot clinic through which podiatrists and vascular surgeons cooperate to identify problems and intervene as soon as possible.

The procurement of sophisticated equipment able to detect circulation problems even in toes has also helped greatly, Prof. Cassar observes.

Moreover, a one-stop vascular clinic has been set up through which patients are seen by a specialist and undergo investigations, and decisions about their treatment are made at the same visit. Unless a CT scan is required, the results are available immediately, and a decision can be taken there and then.

In some cases, a relatively minor intervention – an angioplasty – may be sufficient to address the circulatory problems which ultimately lead to amputations. A balloon catheter is guided into a narrowed or obstructed blood vessel through a guide wire and inflated to open it up. A stent may also be used, depending on the case at hand.

Prof. Cassar points out that the hospital has two interventional radiologists who are highly skilled in the procedure and are able to treat even the smallest of arteries – which are often the source of problems for patients with diabetes.

Despite the radiologists’ skills, angioplasties are not always an option, as the obstruction may be too great for them to work their magic. However, a surgical procedure is being increasingly used to avoid resorting to amputations: leg bypass surgery.

Similarly to heart bypass, leg bypass surgery involves creating an alternate route for blood flow through the grafting of a vein taken from another part of the patient’s body. Such surgeries have been taking place for years, but the health authorities’ efforts in the past few years have allowed their number to increase significantly.

A testament to the procedure’s effectiveness is 57-year-old Mosta resident Herbert Camenzuli, who owns a shop in his home town. Both his parents had diabetes and he was himself diagnosed as diabetic at the age of 38, subsequently becoming insulin-dependent.

A slight cut in his left big toe last August appeared to be healing well, but by late September he started feeling sharp pain in his calf which revealed that an infection had developed and was spreading.

He checked himself in at the hospital’s emergency department on 1 October and was subsequently told that he could either undergo bypass surgery or ultimately lose his leg: his choice was obvious.

The surgery was carried out by Prof. Cassar on 3 October, and was successful. Mr Camenzuli was discharged from hospital 17 days later.

As is the case with all patients undergoing the procedure, Mr Camenzuli’s surgery has been followed up by regular check-ups. Presently, around 200 people are on a graft surveillance programme, with Mr Camenzuli among them.

Prof. Cassar explains that bypasses are routinely checked to ensure that they are not narrowing, which remains a possibility particularly since a vein is being used to do the job of an artery. An angioplasty may be required if narrowing occurs.

In the meantime, Mr Camenzuli has recovered well. He required increasingly higher levels of insulin in the run-up to the surgery, but his daily dose was reduced afterwards and stayed put.

However, he does note that standing for hours on end becomes painful, which makes working at his shop an uncomfortable experience. Luckily, he can rely on his wife to keep the shop open.

Prof. Cassar explains that this is a temporary effect of the surgery. A leg becomes accustomed to a reduced blood flow, and as a result, when normal blood flow is restored, blood tends to accumulate and cause swelling. However, the leg does adapt to normal blood flow over time.

Both hope to persuade people in Mr Camenzuli’s predicament to come forward, and delay because they fear an amputation. Prof. Cassar stresses that while amputation may be necessary in some cases, it may be avoided if people seek medical assistance as soon as they detect problems.

Those who do will find a dedicated team of people who go out of their way to treat them, Prof. Cassar notes as he praises his colleagues.

Mr Camenzuli enthusiastically backs this assertion, and repeatedly praises the level of care received during the interview.

He also remarks that it was a pity that the news sometimes gave a different impression. A long wait in a stretcher was not exactly comfortable, he admits, but the level of care received afterwards more than made up for it.

Prof. Cassar insists that while deficiencies do exist at Mater Dei, they are inflated by the media, and that the hospital offers an excellent service where it matters. Drawing on his experiences in Aberdeen, he notes that while the hospital was among the best within the UK’s National Health Service, Mater Dei was head and shoulders ahead in certain areas.

He expresses his fear that continuous negative reporting risked eroding patient’s trust in medical professionals. As a result, people could either be discouraged from going to hospital altogether or go with a great sense of suspicion which does not help in their recovery.

On the other hand, Prof. Cassar points out, Mr Camenzuli’s positive mentality was exemplary.

Mr Camenzuli’s positive outlook is evident on a number of occasions. When Prof. Cassar notes that the loss of a toe is still difficult to cope with, he shrugs it off, remarking that its loss saved the rest of his foot. Before the interview starts, he also comforts a man who is calling relatives to inform them that his father will have to undergo the same procedure he went through, pointing out how well he has recovered since.

When asked to advise people with diabetes who may face situations similar to Mr Camenzuli, Prof. Cassar mentions two main issues.

The first is smoking, which he points out is one of the main factors behind complications which lead to amputations. Smokers with diabetes will “definitely, not maybe” face health problems, he remarks, and should do all they can to quit the habit. The government provided a helpline and a number of free services to help them do so, he adds.

The second issue is that diabetes is a chronic condition, and that people should ensure it is kept under control, undergo regular checkups – including of their feet and eyes – and follow the advice they received from specialists.

Of course, sometimes interventions are required even if this advice is followed, and Mr Camenzuli is a case in point. He does not smoke, having quit the habit long ago, and had also grown accustomed to carefully monitoring his condition over the years.

In such cases, one can only advise patients to overcome whatever fears they might have and seek treatment. Take Mr Camenzuli’s word for it.