For April's 'Ask the Specialist' Q&A forum, Associate Professor Chong Tze Tec, Head & Senior Cosultant, from the Vascular Surgery Department at Singapore General Hospital (SGH), a member of the SingHealth group, answers your questions on two common vascular conditions:

Diabetic foot ulcers

Singapore declared a war against diabetes. We have an increasing incidence of diabetes due to a combination of genetics, diet and our lifestyle. Diabetics have a 25% chance of having a foot ulcer over their lifetime. With appropriate wound care, infection control and revascularization most ulcers can heal. However if neglected, these could lead to amputation.

As a vascular surgeon, Assoc Prof Chong Tze Tec is most concerned with limb preservation and early ulcer treatment to maximise the chances of wound healing. Now with endovascular options, minimally invasive treatments are common to improve the blood flow to the foot and thus ulcer healing rates.

Varicose vein disease

Symptomatic venous reflux is a common health condition affecting males and females alike. The incidence increases as we age and is more prevalent in people with long standing occupations such as sales staff, teachers, nurses, food sellers etc. Often patients complain of swelling, dull aches, heaviness in legs, pigmentation and varicose veins.

These should be investigated and simple solutions not requiring hospitalisation could be offered including venous ablation. SGH offers the complete range of therapy for venous diseases.

This 'Ask the Specialist' forum has closed. Thank you for your interest and participation.

1. Question by C******
Hi, I am male, 72 years of age. I am diabetic and I notice that over the last few years, I have brown color patches on my skin around both the ankles. It seems to spread slowly up higher to my calves. What is the cause? Thank you.

Answered by Associate Professor Chong:
Hi C******, diabetes can cause hyperpigmentation in the areas you mentioned. If you do not have symptoms of heaviness in the legs on long standing, large varicose veins or swelling around the ankles, no further workup is necessary. If you are concerned, a visit to your doctor can be arranged. Please be vigilant with your foot for ulcers given your diabetes history and seek medical attention if that happens.


2. Question by j*****
Question with regard to varicose veins. Daughter has chosen a career in hospitality which requires long hours on her feet. What preventive measures can she take now in her 20s to minimize or prevent varicose veins in her older years?

Answered by Associate Professor Chong:
Hi j*****, varicose formation is multifactorial and includes risk factors which are modifiable eg wearing compression to somewhat modifiable eg taking breaks to put your legs up for rest from standing to non modifiable eg genetic predisposition to varicose veins and reflux disease. For now proper footwear, good standing posture, class 1 compression stockings and rest from standing position when possible would be recommendations for your daughter.


3. Question by E**********
Greetings Doctor, I am 33 year old female leading an active lifestyle but I have discovered an early onset of varicose vein at the back of my knees. Is surgery the only option to consider at this point given that even using Hirudoid doesn't seem to work? Thank you.

Answered by Associate Professor Chong:
Greetings E**********, Hirudoid cream does not prevent formation of varicose veins in general. What you can do is to minimize long standing periods, putting up your legs for rest when possible and consider wearing class 1 compressiong stockings. Other than the visibility of varicose veins, we consider more strongly symptoms associated with them eg heaviness in the legs on long standing, aches, swelling around the ankles and hyperpigmentation in the inside area of the ankle region.


4. Question by T****
I am a 55 yr old pre-diabetic male. I have occasionally experienced blisters under my feet with mild pain & itch at times. It sometimes just subsides but does burst & heal eventually at times also. Will such blistering wounds be a concern for people like myself with a pre-diabetic condition?

Answered by Associate Professor Chong:
Hi T****, as you are pre diabetic, pay attention to the glucose levels and manage your diet appropriately. Blisters can reflect ill fitting footwear. Footwear choices are important and keep a daily check on your foot for ulcers. In general patients with ulcers with any signs of infection eg warmth, redness, fever, purulent discharge should seek medical attention. If there is any concern, please consult your doctor.


5. Question by B*******
Both my legs starts to have visible varicose veins over the years. I would like to know more about the solutions to varicose veins problems.

Answered by Associate Professor Chong:
Hi B*******, as we age, varicose veins are more common as we stand for a longer period of time. What we can do is to minimize long standing, even taking a few steps to activate the calf muscle pumps help decrease the pressure in the veins. Another option would be to wear compression stockings of class 1 grade.


6. Question by R******
Hi Dr,
I went through a surgery to remove varicose veins (legs) 3 years ago.
Now, when I stand for prolonged period e.g. 20 minutes, I still feel heaviness in my legs. Why is this so?
My heartbeat can go up to 100 per minutes upon standing prolonged period e.g. 20 minutes. Otherwise, my heartbeat is 80 at rest 
Please share your expert advice. Thanks.

Answered by Associate Professor Chong:
Hi R******, it is difficult to ascertain this via email but this could represent residual venous reflux. A possible workup could include duplex ultrasound scanning of your veins. Heart rate changes are not usual with prolonged standing and unlikely related to varicose vein pathology, it is worth consulting your family physician further on this.


7. Question by t******
Hi,
Is it normal to feel slight numbness on the top part of the foot that has a lot of varicose veins? This usually occurs at the end of the day. Thanks.

Answered by Associate Professor Chong:
Hi t******, varicose veins can cause a wide variety of symptoms especially when there is venous reflux in the superficial venous system. These could include a feeling of heaviness, swelling, pigmentation and aches. If the symptoms are worse at the end of the day, it lends itself to the venous reflux diagnosis. You may want to consider a check up.


8. Question by S****
Hi Doctor,
Is pain on calf of left leg due to diabetes? The discomfort / tightness/ muscle like pain comes during walking / standing for too long. however after taking rest w leg resting, the pain / discomfort goes off.. i.e. it comes n go type of pain / discomfort.. is it related to sciatic nerve pain? Thank you!

Answered by Associate Professor Chong:
Hi S****, it is difficult to diagnose your left calf pain this way. Like you correctly pointed out, it could be related to sciatica or peripheral vascular disease amongst other causes. Clues that help the diagnosis include if there is presence of back pain, the character of the pain, positions that reproduce the pain, if the pulses in the foot are present. Simple tests like lumbar spine x rays and arterial pulse examination can help distinguish between the various causes. If this bothers you, please seek a medical opinion.


9. Question by R******
Hi Dr,
I find my pain often at the back of my left foot, usually in the morning, it goes away after sometime.
Not sure is this called Plantar Fasciitis pain. Can you advise? Thanks.

Answered by Associate Professor Chong:
Plantar fasciitis is due to inflammation of the plantar fascia at the sole of the foot more around the heel area. It can be treated conservatively with foot rollers, appropriate foot wear and oral anti inflammatory medications if needed. A consult with a podiatrist may help your condition to follow up.


10. Question by p***************
Hi Doc,
WRT Varicose veins, my mum has underwent surgery to remove the veins however it doesn't seem to help and it came back. Is a second surgery really needed and what might cause the veins to return? She is rather active and goes for brisk walk/light job at least 4 times a week. 
Thanks.

Answered by Associate Professor Chong:
Hi p***************, venous ablation or stripping surgery is usually successful so its important to understand more about the specifics of the surgery and problem. A repeat duplex interrogation may be required to better delineate the problem. With a consultation, these problems can be well assessed and an opinion rendered directly. Exercise is always encouraged and your mother should keep up the good work there.


11. Posted by J**
My questions are regarding the topic of veins, specifically regarding surgery to cure/prevent leg ulcers. My mother is not diabetic. She has a palm-sized closed wound leg ulcer due to vein issues.

1.Must the swelling totally go down before surgery can be considered?
2.What are the side effects and recovery time of vein ablation surgery for elderly in their late 70s, both common and rare cases?
3.What if after vein ablation surgery the leg swelling and ulcer issue isn't resolved, what else can be done? An extension of Q3, what if more than one vein requires the surgery to completely resolve the issue, will that affect her physical ability?

Answered by Associate Professor Chong:
Hi J**, surgery for venous ulcers can be done even if there is some swelling. The indication for surgery is the ulcer and the aim is to reduce ulcer healing time and risk of ulcer recurrence. Vein ablation surgery like all forms of surgery have risks and side effects. These are small in general as it is usually minimally invasive and depend on the type of ablation chosen. These are best discussed with the medical practitioner. Compression therapy remains a viable option for venous disorders including venous ulcer disease and it can be used as an adjunct or primary therapy in these conditions.


About Assoc Prof Chong Tze Tec

Associate Professor Chong Tze Tec graduated from the University of Sydney with MBBS (First class honours). He did his general surgery training at Johns Hopkins Hospital, Baltimore and Tufts New England Medical Center, Boston. Upon being awarded the John Homan’s fellowship, he pursued his subspecialty training in vascular and endovascular surgery at Brigham and Women’s Hospital, Harvard Medical School.

He is double boarded by the American Board of Surgery in general surgery and vascular surgery. He was then recruited to Brown Alpert School of Medicine to develop their vascular and endovascular surgery program at The Miriam and Rhode Island Hospitals.

After four successful years of practice, he has relocated to Singapore with his family to be at SGH. He is currently Head, Department of Vascular Surgery. As a key opinion leader in the region, he frequently proctors cases in Complex Aortic, Peripheral Vascular and Venous territories.

As the founding Head, SingHealth Duke-NUS Disease Center (Vascular), he is keen to improve the level of treatment in vascular diseases in all SingHealth institutions and focus on data driven improvements in clinical care. He also strongly believes in medical education of the next generation of doctors, he is currently the Vice Chair Undergraduate Education in Surgery ACP and Assistant Dean at Duke-NUS Graduate Medical School.

Because #healthiswealth #healthforgood

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