糖尿病足潰瘍治療新概念.ppt

1、糖尿病足潰瘍治療新概念足背動(dòng)脈旁路手術(shù)對(duì)預(yù)防大截肢的作用,張耀中 外科部 心血管中心 臺(tái)中大甲李綜合醫(yī)院 臺(tái)灣,2,背景,糖尿病增加週邊動(dòng)脈疾病(PAD)的風(fēng)險(xiǎn) 週邊動(dòng)脈疾病是糖尿病足潰瘍患者截肢的重要危險(xiǎn)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(duì)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(xiǎn)值估計(jì)約為15%(Palumbo P, et al. 1985) 糖尿病患者比非糖尿病患者有1540倍的截肢風(fēng)險(xiǎn) 非外傷截肢糖尿病佔(zhàn)50% 截肢會(huì)降低患者的身體機(jī)能及生活品質(zhì) 截肢部位 (Reiber GE et

2、 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(tái)灣糖尿病截肢近況,1979 -1984 臺(tái)北 三軍總醫(yī)院 57.7% 趙有誠(chéng) 臺(tái)灣醫(yī)誌 1995 1982 -1991 臺(tái)北 臺(tái)大醫(yī)院 37.2% 曾慶孝 臺(tái)灣醫(yī)誌 1994,5,糖尿病足潰瘍,糖尿病足患者的週邊動(dòng)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(huì)癒合 Goldenberg (Diabetes,1959) 事實(shí) LoGerfo (NEJM, 1984) 糖尿病足血管疾病最常侵患小腿的中度大

3、小動(dòng)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(píng)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(zhǎng)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(dòng)脈、脛後動(dòng)脈、及側(cè)足底動(dòng)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(huì)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

4、%的患者多係臺(tái)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(zhǎng)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,美國(guó)血管外科學(xué)會(huì)理事長(zhǎng) 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(huì)加重對(duì)血管外科醫(yī)師的需求。 Gregorio A. Sicard: Presidential address, society for vascular sur

5、gery, Chicago 05,邵女士,79歲,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(huì)工作者、居家照護(hù) 其他,19,【病人來源】,下肢動(dòng)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(dòng)脈旁路手術(shù)，提供足部的搏動(dòng)灌注，對(duì)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(dòng)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(duì)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 att

6、ention ! !,New Concept of Diabetic foot ulcer Management-Role of Dorsalis Pedis Bypass in the Prevention of Diabetic Major Amputation,Yau-Chong Chang M.D. Ph.D Vascular Center Department of surgery Lees Medical Corporation(Dajia), Taiwan,23,Background,Diabetes mellitus increase ones risk of peripher

7、al arterial disease(PAD) PAD is itself an important risk 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 also for quality care and cos

8、t-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 risk of amputation compared to the non-diabetic population 1997. 50% of all non-traumatic amputations occur

9、in diabetes. Amputations reduce patient function and quality of life. Location of amputation (Reiber GE et al.1995) Toes: 24% Mid-foot: 5.8% BK:38.8% AK:21.4% Unclassified:10%,25,DM amputation in Taiwan,57.7% Triservice General Hospital 1979-1984 Chao YC, etal. J of Formosan Med. Association 1995 37

10、.2% National Taiwan University Hospital 1982-1991 Tseng CH, etal. J of Formosan Med. Association 1994,26,27,Myth Diabetic ulcers do not heal because of “small vessel disease” Goldenberg (Diabetes,1959) Fact LoGerfo (NEJM, 1984) Diabetic vascular disease most often involves medium size arteries of th

11、e calf Basement membrane thickening but non-occlusive,28,Management guidelines,Control infection Vascular evaluation Prompt surgical revascularization Secondary procedures: debridement, toe amputation, skin grafting, flap reconstruction Adjunctive procedures: hyperbaric oxygen therapy (HBO), topical

12、 growth factor, special wound dressing, far-infra redetc. 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 recent 10 years. First 136 operations in 120 pat

13、ients 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),35,Surgical Indicationmore than 90% of patients were suggested to receive B-K or A-K amputation, especially in recent series,36

14、,Contraindication of surgical evascularization,1. Bed-ridden, unable to walk 2. Poor general condition, short life expectancy 3. Extensive tissue destruction or infection 4. 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 am

15、putations. ”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 need for vascular surgeons. Gregorio A. Sicard: Presidential address, so

16、ciety for vascular surgery, Chicago 05,邵女士,79歲,Multidisciplinary approach include:,Infection Nephrology Cardiology Critical care ( chest medicine ) Anesthesiology Vascular surgery Plastic surgery Orthopedics Rehabilitation Hyperbaric oxygen therapy Social worker, Home care others,40,【病人來源】,下肢動(dòng)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,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.