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 糖尿病增加週邊動脈疾病(PAD)的風險 週邊動脈疾病是糖尿病足潰瘍患者截肢的 重要危險因子 有關糖尿病足潰瘍的處置在不同科別間， 差異很大 整合、協調的處置對於患者的助益、生活 品質及成本效益上相當重要 2 有關糖尿病足潰瘍的一些事實 糖尿病患者，終其一生發生足潰瘍的危險值估計 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 險 非外傷截肢糖尿病佔50% 截肢會降低患者的身體機能及生活品質 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% 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 1995 1982 -1991 台北 台大醫院 37.2% 曾慶孝 台灣醫誌 1994 4 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 l糖尿病足潰瘍由於是小血管疾病，因此不 會癒合 lGoldenberg (Diabetes,1959) 事實 lLoGerfo (NEJM, 1984) l糖尿病足血管疾病最常侵患小腿的中度大 小動脈 l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 Dr LoGerfo 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 8 9 F-U arteriogram: 1 year later after OP (1999) 10 11 12 手術適應症 (N=136) 靜止痛11.8%16 壞死 / 潰瘍88.2%120 13 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 15 16 80%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。 Gregorio A. Sicard: Presidential address, society for vascular surgery, 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 32 12 2 2 2 2 20 2 9 14 10 463 92 2 22 9 8 22 【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 20 Thanks for Your attention ! ! 21 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 22 Background Diabetes mellitus increase ones risk of peripheral 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 cost- effectiveness. 23 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 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% 24 DM amputation in Taiwan 57.7% Triservice General Hospital 1979-1984 Chao YC, etal. J of Formosan Med. Association 1995 37.2% National Taiwan University Hospital 1982-1991 Tseng CH, etal. J of Formosan Med. Association 1994 25 26 Myth lDiabetic ulcers do not heal because of “small vessel disease” lGoldenberg (Diabetes,1959) Fact lLoGerfo (NEJM, 1984) lDiabetic vascular disease most often involves medium size arteries of the calf lBasement membrane thickening but non- occlusive 27 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 growth factor, special wound dressing, far-infra redetc. Modified from LoGerfo F.W,etal 28 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 patients were analyzed and complete 5-year follow up, which will be presented today. 29 30 F-U arteriogram: 1 year later after OP (1999) 31 32 33 Operative Indications (N=136) Rest Pain11.8%16 Gangrene / Ulcer wound 88.2%120 34 Surgical Indication more than 90% of patients were suggested to receive B-K or A -K amputation, especially in recent series 35 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. 36 37 80%的截肢是可以預防的 Every year, about 82,000 diabetics have leg, foot or toe amputations. ”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, society for vascular surgery, Chicago 05 邵女士,79歲 38 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 39 糖尿病足中心 32 12 2 2 2 2 20 2 9 14 10 463 92 2 22 9 8 22 【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 40 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 am