糖尿病足潰瘍治療新概念

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1背景2有關(guān)糖尿病足潰瘍的一些事實3臺灣糖尿病截肢近況1979-1984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19944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)主動脈-腸骨動脈脛動脈/腓動脈非糖尿病68%57%糖尿病27%81%5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LoGerfo(NEJM,1984)糖尿病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6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)DrLoGerfo修訂7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，並在此次大會上發(fā)表89F-Uarteriogram:1yearlaterafterOP(1999)101112手術(shù)適應(yīng)癥(N=136)靜止痛11.8%16壞死/潰瘍88.2%12013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。14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151680%的截肢是可以預(yù)防的美國血管外科學(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。GregorioA.Sicard:Presidentialaddress,societyforvascularsurgery,Chicago‘05邵女士,79歲17多科際整合包括：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18糖尿病足中心3212222220291410463922229822【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19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20ThanksforYourattention!!21NewConceptofDiabeticfootulcerManagement-RoleofDorsalisPedisBypassinthePreventionofDiabeticMajorAmputationYau-ChongChangM.D.Ph.DVascularCenterDepartmentofsurgeryLee’sMedicalCorporation(Dajia),Taiwan22BackgroundDiabetesmellitusincreaseone’sriskofperipheralarterialdisease(PAD)PADisitselfanimportantriskfactorforamputationindiabeticpatientswithchronicfootulcer.Managementofdiabeticfootulcervariesgreatlyamongsubspecialists.Integrated,coordinatedmanagementisimportantforpatientsbenefit,andalsoforqualitycareandcost-effectiveness.23FactsaboutDiabeticFootUlcerationLife-timeriskforfootulcersindiabeticsisestimatedat15%.(PalumboP,etal.1985)Diabetesresultsina15to40foldincreasedriskofamputationcomparedtothenon-diabeticpopulation1997.50%ofallnon-traumaticamputationsoccurindiabetes.Amputationsreducepatientfunctionandqualityoflife.Locationofamputation(ReiberGEetal.1995)Toes:24%Mid-foot:5.8%

BK:38.8%AK:21.4%Unclassified:10%24DMamputationinTaiwan57.7%TriserviceGeneralHospital1979-1984ChaoYC,etal.JofFormosanMed.Association199537.2%NationalTaiwanUniversityHospital1982-1991TsengCH,etal.JofFormosanMed.Association19942526MythDiabeticulcersdonothealbecauseof“smallvesseldisease”Goldenberg(Diabetes,1959)FactLoGerfo(NEJM,1984)DiabeticvasculardiseasemostofteninvolvesmediumsizearteriesofthecalfBasementmembranethickeningbutnon-occlusive27ManagementguidelinesControlinfectionVascularevaluationPromptsurgicalrevascularizationSecondaryprocedures:debridement,toeamputation,skingrafting,flapreconstructionAdjunctiveprocedures:hyperbaricoxygentherapy(HBO),topicalgrowthfactor,specialwounddressing,far-infrared…etc.ModifiedfromLoGerfoF.W,etal28Patients&MethodsMorethan800operationsofdistallimbbypass(distalanastomoticsite:dorsalispedis,post.tibiala.andlateralplantara.)weredoneinrecent10years.First136operationsin120patientswereanalyzedandcomplete5-yearfollowup,whichwillbepresentedtoday.2930F-Uarteriogram:1yearlaterafterOP(1999)313233OperativeIndications(N=136)RestPain11.8%16Gangrene/Ulcerwound88.2%12034SurgicalIndication

morethan90%ofpatientsweresuggestedtoreceiveB-KorA-Kamputation,especiallyinrecentseries35Contraindicationofsurgicalevascularization1.Bed-ridden,unabletowalk2.Poorgeneralcondition,shortlifeexpectancy3.Extensivetissuedestructionorinfection4.Fixedflexioncontractureofhiporkneejoint.363780%的截肢是可以預(yù)防的Everyyear,about82,000diabeticshaveleg,footortoeamputations.”Dr.Sicardsaid.”Morethe80percentofthoseamputationsarepreventableandeveryday,vascularsurgeonsareworkingtopreventthem.Theagingpopulationandthediabetesepidemicportendtremendousgrowthintheneedforvascularsurgeons.GregorioA.Sicard:Presidentialaddress,societyforvascularsurgery,Chicago‘05邵女士,79歲38Multidisciplinaryapproachinclude:InfectionNephrologyCardiologyCriticalcare(chestmedicine)AnesthesiologyVascularsurgeryPlasticsurgeryOrthopedicsRehabilitationHyperbaricoxygentherapySocialworker,Homecareothers39糖尿病足中心3212222220291410463922229822【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40ConclusionPedalarterybypassprovidepulsatileperfusiontofoot,whichisgoodforreliefofcriticalischemia,healingoftissuenecrosisandpreventionofmajoramputation.Themi