Kuldeep Singh, MD, calls them a labor of love. They are tough—the patients having endured repeated hospitalizations, infections, embarrassment: The sorts of severely affected lymphedema cases he ends up treating find individuals in the end stage of the disease and almost out of options.
The director of limb salvage surgery and peripheral vascular interventions at Staten Island University Hospital/Northwell Health in New York is gaining a reputation for taking on seemingly impossible cases—and getting positive results. Visual representations of his work have become a semi-recurrent feature and conversation point in the world of #VascTwitter among fellow vascular surgeons.
To tackle these cases, Singh carries out radical debulking of skin and soft tissue—essentially a modified Charles’ procedure using his specially created protocol. But until about 10 years ago, it was a surgery he had never performed before. Now, Singh says, he confidently takes on such extreme cases.
“I encountered this patient who came to see me as a second or third opinion; she had gone to multiple centers down in Baltimore. Then she came up here [to NYC],” he tells Vascular Specialist.
“Her one leg was massively swollen; it was to about three-to-four times her other leg, getting bigger over time, with multiple weeping ulcers. It affected her life, she ended up getting divorced, lost her job, and was clinically depressed, all because of the affected leg. Every center she went to essentially said, ‘Well, this is a disease that we really don’t take care of, it has poor outcomes,’ she couldn’t find anybody to help her. She had gone to multiple vascular and plastic surgeons. When she came to me, she was crying in my office and said that I could just take the entire leg off.”
That’s when he informed her of a procedure he could potentially undertake in partnership with a burn surgeon at his institution—albeit, he explained, one that he had never before attempted.
“I told her about total debulking of skin and fatty tissue circumferentially, all the way down to the fascia, multiple skin grafts and a long stay in the hospital—I told her that there may be a chance that she could lose her leg because I’m not sure whether this will work or not,” Singh relates.
“She agreed to it, and said that she had no other hope. So, with that understanding, we went ahead and did the procedure, and she had a wonderful result. For 20 years, she wished to fit in normal clothing, and now she was finally able to do so.
“Coincidentally enough, she happened to have a friend who had the exact same issue, and she came to me, we carried out the procedure, and had another wonderful outcome. The first patient told multiple doctors, the doctors that she visited, the second patient did the same thing, and those doctors told other doctors, and slowly we started to build a referral.”
Thus far, Singh and colleagues have carried out about 25 severe cases. He reports “excellent” long-term results, with no recurrences and no limb loss. The first case—the original patient—involves nine years of follow-up, with the shortest about six months.
“We have one patient who was bed bound for about six months and is now ambulating,” he says. “Another great story we have is about a musician who has worked with many big acts, who lost a lot of potential to become a big-name background musician because he had chronic drainage and terrible smell from his lymphedematous leg. He was so embarrassed to go to rehearsals that he ended up quitting. He’s about three years out from the procedure with a great result, and now back doing what he loves.”
Singh and colleagues are currently in the process of putting together submissions on their case series for peer-reviewed publication. Along the way, they have learned a number of key lessons that he says are essential for best outcomes when conducting the procedure.
Along the way, they have learned a number of key lessons learned that he says should be borne in mind when conducting the modified Charles’ procedure.
“There are huge venous tributaries that you cut through, which can cause a lot of bleeding. That’s something that we’ve learned over time.”
“The length-of-stay for these patients can be pretty long—at a minimum three weeks,” he explains. “Multiple dressing changes (very painful) are needed because they require circumferential skin grafts to the leg, which can be very difficult to manage. A knowledgeable, dedicated team is a must or you’re sure to end up with complications.
“A wound VAC seems to make a big, big difference, especially immediately post-op. We tend not to do any skin grafts until we see perfect granulation because you’re limited to how much skin you can graft, especially if you have to do bilateral legs. At some point, you’re going to runout of places to take skin. We tend to wait five-to-seven days to ensure there is granulation tissue and no infection that can destroy the grafts.”
Singh’s team operate under their own Singh-Cooper protocol.
“We have the patient admitted the night before; we wash the legs because there can be wounds in skin folds that you can’t see; the patient is placed on weight-based heparin because we keep them at bed rest; a DVT [deep vein thrombosis] on the leg could prove to be catastrophic,” he says.
“Additionally, some of the intraoperative issues we have encountered include cutting through the tissue: This is end-stage lymphedema, so the fat may eventually becomes calcified and sometimes indistinguishable from the fascia and muscle. In extreme cases we’ve had to use wire cutters, rongeurs and those type instruments—just to cut through the skin and through the subcutaneous fat. A significant amount of smoke is also produced so you want to use some sort of a Bovie that has a suction attached to it to eliminate the smoke.”
The lessons learned extend to scalpel choice as well, Singh adds. “A LigaSure scalpel has proven to be instrumental with its ability to limit some of the blood loss,” he explains. “There are huge venous tributaries which can cause a significant amount of bleeding. That’s something that we’ve learned over time.
“Aside from the condition itself, it’s sad to know that most patients don’t know where to get help, and doctors don’t know where to refer, since there are only a handful of centers in the U.S. willing to tackle such a problem.”