糖尿病足的外科治疗策略

SURGICAL STRATEGY IN TREATMENT OF DIABETIC FOOT

目的探讨如何采取有效的外科措施及时处理糖尿病足(diabetic foot,DF),保留肢体,减少伤残。方法2004年7月-2007年7月,内外科协作治疗36例DF患者。其中男22例,女14例;年龄43～82岁,平均57岁。糖尿病史3个月～27年,平均12年;DF病程1个月～2年,平均7个月。Wagner分级:1级3例,2级12例,3级10例,4级7例,5级4例。踝及跟部溃疡9例,足内侧溃疡14例,足外侧溃疡8例,窦道形成5例;溃疡范围4cm×2cm～18cm×9cm。所有创面分泌物均培养出细菌,以金黄色葡萄球菌为主。围手术期对患者应用胰岛素控制血糖,全身应用敏感抗生素治疗抗感染,改善患者营养状况。1级DF扩创后植皮尽早修复创面;2级DF清除沿深筋膜与肌间隙蔓延的深部脓肿;3级DF对窦道扩创、清除死骨与破坏关节,采用邻近筋膜瓣填塞消灭死腔,对溃疡形成者扩创后采用邻近岛状皮瓣移位修复创面;4级DF切除坏疽足趾后残端创面行皮瓣移位修复;5级DF通过介入与血管外科治疗,再通闭塞、狭窄的血管,改善肢端血供,再进行低位截肢。采用单纯植皮治疗15例,筋膜瓣移位修复5例,皮瓣移位修复12例,经介入与血管外科治疗后二期行低位截肢治疗4例。结果2例术后因足部、肺部、泌尿道感染控制不良,并发多器官功能衰竭死亡。余患者保肢成功,成功率达94.4%。植皮治疗术后皮片存活率达86.1%;2例皮瓣术后部分坏死,经换药、创面肉芽生长良好后植皮修复创面;1例2～5跖趾关节解脱患者术后残端创面不愈合,再次Syme截肢治疗。29例获随访,随访时间6～15个月,平均8个月。3例原位溃疡复发,5例其他部位新发溃疡,余患者病足均能满足站立、行走功能要求。结论外科治疗是DF综合治疗的重要措施,针对各级DF的特点进行积极有针对性的治疗能够有效促进溃疡愈合,减少截肢率。

Objective To investigate the surgical strategy of diabetic foot （DF） and analyze the therapeutic efficacy. Methods From July 2004 to July 2007, 36 patients （22 males and 14 females） with DF were treated, with an average age of 57 years（43-82 years）. The disease course of diabetes was 3 months to 27 years（12 years on average） and the disease course of DF was 1 month to 2 years （7 months on average）. According to Wagner classification of DF, there were 3 cases of grade 1, 12 cases of grade 2, 10 cases of grade 3, 7 cases of grade 4 and 4 cases of grade 5. The locations of ulcer were ankle and heel in 9 cases, medial part of foot in 14 cases, in lateral part of foot in 8 cases and sinus formation in 5 cases. The ulcer sizes ranged from 4 cm × 2 cm-18 cm × 9 cm. Initial management of these patients included control of blood sugar level, proper hydration, administration of antibiotics, treatment of coexisting diseases, and repeated debridements of wounds when necessary. Ulcers were treated with debridement and split skin transplantation in 3 cases of grade 1, with debridement and drainage of abcesses and split skin transplantation in 12 of grade 2, with debridement and transplantation of flap in 17 of grade 3 and grade 4, and with transplantation of fascial flap in 5 cases of sinus; ulcers were treated firstly with artery bypass of lower extremity, and then treated with local amputation of foot to avoid high-level amputation and to save more function of foot in 4 Of grade 5. Results In 36 cases, wound in 31 cases （86.1%） cured primaryly, wound did not heal in 1 patient （2.1%） and received re-amputation, there were 2 deaths because of infection with multiple organ failure postoperatively. Twenty-nine cases were followed up 8 months （range, 6 -15 months）. Eight patients developed new ulcers, with 3 lesions in situ and 5 lesions in new site. Conclusion Surgical regimen could play an important role in treatment of diabetic foot. According to different grades of DF, there were different strategies in dealing with the accompanied inflammation and ulcer. An active and comprehensive surgical treatment of DF could save the foot, avoid the high-level amputation and result in more functional extremity.