糖尿病足潰瘍治療新概念

1、糖尿病足潰瘍治療新概念─足背動脈旁路手術(shù)對預(yù)防大截肢的作用,張耀中外科部 心血管中心 臺中大甲李綜合醫(yī)院 臺灣,2,背景,糖尿病增加週邊動脈疾病(PAD)的風(fēng)險週邊動脈疾病是糖尿病足潰瘍患者截肢的重要危險因子有關(guān)糖尿病足潰瘍的處置在不同科別間，差異很大 整合、協(xié)調(diào)的處置對於患者的助益、生活品質(zhì)及成本效益上相當(dāng)重要,3,有關(guān)糖尿病足潰瘍的一些事實(shí),糖尿病患者，終其一生發(fā)生足潰瘍的危險值估計約為15%(Palumbo P,

2、 et al. 1985)糖尿病患者比非糖尿病患者有15~40倍的截肢風(fēng)險非外傷截肢糖尿病佔(zhàn)50%截肢會降低患者的身體機(jī)能及生活品質(zhì)截肢部位 (Reiber GE et al.1995) 趾: 24% 半足: 5.8% 膝下截肢:38.8% 膝上截肢:21.4% 無法歸類:10%,4,臺灣糖尿病截肢近況,1979 -

3、1984 臺北 三軍總醫(yī)院 57.7% 趙有誠 臺灣醫(yī)誌 19951982 -1991 臺北 臺大醫(yī)院 37.2%曾慶孝 臺灣醫(yī)誌 1994,5,糖尿病足潰瘍,糖尿病足患者的週邊動脈阻塞類型早期發(fā)生，且有特徵性分佈(Strandness, 1946),6,迷思糖尿病足潰瘍由於是小血管疾病，因此不會癒合Goldenberg (Diabetes,1959)事實(shí)LoGerfo (NEJM, 1984)糖尿病

4、足血管疾病最常侵患小腿的中度大小動脈基底膜增厚，且非完全阻塞,7,處置的準(zhǔn)則,控制感染血管評估儘速施行血管旁路手術(shù)續(xù)發(fā)步驟: 清創(chuàng)、截趾、皮膚移植、皮瓣重建…輔助步驟: 高壓氧治療、局部生長因子、特殊敷料、照紅外線…由哈佛大學(xué) Dr LoGerfo 修訂,8,病人及方法,最近10年超過800例的遠(yuǎn)端肢體旁路手術(shù)(遠(yuǎn)端血管吻合處：足背動脈、脛後動脈、及側(cè)足底動脈) 分析最早120位患者的136例手術(shù)，完成5年追蹤，並在此次大

5、會上發(fā)表,9,10,F-U arteriogram: 1 year later after OP (1999),11,12,13,手術(shù)適應(yīng)癥 (N=136),14,手術(shù)適應(yīng)癥在最近的病例，超過90%的患者多係臺灣其他醫(yī)學(xué)中心建議要膝上或膝下截肢的。,,,,,,15,旁路手術(shù)的禁忘癥,1. 長期臥床，無法行走2. 全身狀況差，預(yù)期壽命短3. 嚴(yán)重組織破壞或感染4. 髖或膝關(guān)節(jié)固定收縮攣縮,16,17,,80%的截肢是可以預(yù)防的,美

6、國血管外科學(xué)會理事長 Dr. Sicard 說每年約有82,000糖尿病患者接受下肢、足、或趾的截肢手術(shù)，但是超過80%的截肢(趾)手術(shù)是可以避免的，且需要血管外科醫(yī)師盡力工作去避免，由於人口老化及糖尿病流行會加重對血管外科醫(yī)師的需求。Gregorio A. Sicard: Presidential address, society for vascular surgery, Chicago ‘05,邵女士,79歲,,,多科際整合包

7、括：,感染科腎臟科心臟科重癥照護(hù)(胸腔內(nèi)科)麻醉科血管外科重建整型外科骨科復(fù)健科高壓氧治療社會工作者、居家照護(hù)其他,19,,【病人來源】,下肢動脈繞道手術(shù)300例膝上截肢手術(shù) 9例膝下截肢手術(shù) 35例05-07入院人數(shù) 845人,20,結(jié)論,足背動脈旁路手術(shù)，提供足部的搏動灌注，對於嚴(yán)重缺血性的解除、組織壞死的癒合及頭防高位截肢相當(dāng)有助益糖尿病患者，週邊動

8、脈疾病係起因於微血管的不正確看法，應(yīng)該揚(yáng)棄整合、協(xié)調(diào)的處置，對於患者的助益、生活品質(zhì)及成本效益是相當(dāng)重要,21,Thanks for Your attention ! !,New Concept of Diabetic foot ulcer Management-Role of Dorsalis Pedis Bypass in the Prevention of Diabetic Major Amputation,Yau-C

9、hong Chang M.D. Ph.DVascular Center Department of surgery Lee’s Medical Corporation(Dajia), Taiwan,23,Background,Diabetes mellitus increase one’s risk of peripheral arterial disease(PAD)PAD is itself an important ris

10、k factor for amputation in diabetic patients with chronic foot ulcer.Management of diabetic foot ulcer varies greatly among subspecialists. Integrated , coordinated management is important for patients benefit ,and als

11、o for quality care and cost-effectiveness.,24,Facts about Diabetic Foot Ulceration,Life-time risk for foot ulcers in diabetics is estimated at 15%.(Palumbo P, et al. 1985)Diabetes results in a 15 to 40 fold increased ri

12、sk of amputation compared to the non-diabetic population 1997.50% of all non-traumatic amputations occur in diabetes.Amputations reduce patient function and quality of life.Location of amputation (Reiber GE et al.1995

13、) Toes: 24% Mid-foot: 5.8% BK:38.8% AK:21.4% Unclassified:10%,25,DM amputation in Taiwan,57.7% Triservice General Hospital 1979-1984Chao YC, etal. J of Formosan Med. Associa

14、tion 199537.2% National Taiwan University Hospital 1982-1991Tseng CH, etal. J of Formosan Med. Association 1994,26,,,27,MythDiabetic ulcers do not heal because of “small vessel disease”Goldenberg (Diabetes,1959)

15、FactLoGerfo (NEJM, 1984)Diabetic vascular disease most often involves medium size arteries of the calfBasement membrane thickening but non-occlusive,28,Management guidelines,Control infectionVascular evaluationProm

16、pt surgical revascularizationSecondary procedures: debridement, toe amputation, skin grafting, flap reconstructionAdjunctive procedures: hyperbaric oxygen therapy (HBO), topical growth factor, special wound dressing, f

17、ar-infra red…etc.Modified from LoGerfo F.W,etal,29,Patients & Methods,More than 800 operations of distal limb bypass(distal anastomotic site: dorsalis pedis, post. tibial a. and lateral plantar a.) were done in rec

18、ent 10 years.First 136 operations in 120 patients were analyzed and complete 5-year follow up, which will be presented today.,30,31,F-U arteriogram: 1 year later after OP (1999),32,33,34,Operative Indications (N=136),3

19、5,Surgical Indicationmore than 90% of patients were suggested to receive B-K or A-K amputation, especially in recent series,,,,,,36,Contraindication of surgical evascularization,1. Bed-ridden, unable to walk2. Poor gen

20、eral condition, short life expectancy3. Extensive tissue destruction or infection4. Fixed flexion contracture of hip or knee joint.,37,38,,80%的截肢是可以預(yù)防的,Every year, about 82,000 diabetics have leg, foot or toe amputatio

21、ns. ”Dr. Sicard said.”More the 80 percent of those amputations are preventable and every day, vascular surgeons are working to prevent them. The aging population and the diabetes epidemic portend tremendous growth in the

22、 need for vascular surgeons.Gregorio A. Sicard: Presidential address, society for vascular surgery, Chicago ‘05,邵女士,79歲,,,Multidisciplinary approach include:,InfectionNephrologyCardiologyCritical care ( chest medici

23、ne )AnesthesiologyVascular surgeryPlastic surgeryOrthopedicsRehabilitationHyperbaric oxygen therapySocial worker, Home careothers,40,,【病人來源】,下肢動脈繞道手術(shù)300例膝上截肢手術(shù) 9例膝下截肢手術(shù) 35例05-07入院人數(shù) 8

24、45人,41,Conclusion,Pedal artery bypass provide pulsatile perfusion to foot, which is good for relief of critical ischemia, healing of tissue necrosis and prevention of major amputation.The misconception of PAD in diabeti

25、c patients was thought to be micro-vascular in origin should be abandoned.Integrated , coordinated management is important for patients benefit, and also for quality care and cost-effectiveness.,42,Thanks for Your