糖尿病足溃疡治疗新概念

糖尿病足潰瘍治療新概念─足背動脈旁路手術對預防大截肢的作用張耀中外科部心血管中心台中大甲李綜合醫院台灣1背景2有關糖尿病足潰瘍的一些事實3台灣糖尿病截肢近況1979-1984台北三軍總醫院57.7%趙有誠台灣醫誌19951982-1991台北台大醫院37.2%曾慶孝台灣醫誌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處置的準則控制感染血管評估儘速施行血管旁路手術續發步驟:清創、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DrLoGerfo修訂7病人及方法最近10年超過800例的遠端肢體旁路手術(遠端血管吻合處：足背動脈、脛後動脈、及側足底動脈)分析最早120位患者的136例手術，完成5年追蹤，並在此次大會上發表89F-Uarteriogram:1yearlaterafterOP(1999)101112手術適應症(N=136)靜止痛11.8%16壞死/潰瘍88.2%12013手術適應症

在最近的病例，超過90%的患者多係台灣其他醫學中心建議要膝上或膝下截肢的。14旁路手術的禁忘症1.長期臥床，無法行走2.全身狀況差，預期壽命短3.嚴重組織破壞或感染4.髖或膝關節固定收縮攣縮151680%的截肢是可以預防的美國血管外科學會理事長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，但是超過80%的截肢(趾)手術是可以避免的，且需要血管外科醫師盡力工作去避免，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症照護(胸腔內科)麻醉科血管外科重建整型外科骨科復健科高壓氧治療社會工作者、居家照護其他18糖尿病足中心3212222220291410463922229822【病人來源】下肢動脈繞道手術300例膝上截肢手術9例膝下截肢手術35例05-07入院人數845人19結論足背動脈旁路手術，提供足部的搏動灌注，對於嚴重缺血性的解除、組織壞死的癒合及頭防高位截肢相當有助益糖尿病患者，週邊動脈疾病係起因於微血管的不正確看法，應該揚棄整合、協調的處置，對於患者的助益、生活品質及成本效益是相當重要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300例膝上截肢手術9例膝下截肢手術35例05-07入院人數845人40ConclusionPedalarterybypassprovidepulsatileperfusiontofoot,whichisgoodforreliefofcriticalischemia,healingoftissuenecrosisandpreventionofmajoramputation.Themi