多学科团队协作模式下游离股前外侧穿支皮瓣修复糖尿病足溃疡的临床效果

Clinical effects of free anterolateral thigh perforator flaps in repairing diabetic foot ulcers under a multi-disciplinary team cooperation model

目的探讨多学科团队(MDT)协作模式下游离股前外侧穿支皮瓣修复糖尿病足溃疡(DFU)的临床效果。方法该研究为回顾性观察性研究。2018年6月—2022年12月,河南省人民医院(郑州大学人民医院)手足显微与创面修复外科收治49例符合入选标准的DFU患者,其中男28例、女21例,年龄47~68岁,2型糖尿病病程6个月~21年。在MDT协作模式下,内分泌科医师全面评估患者、稳定患者全身情况、控制并发症,血管外科医师评估和改善患者下肢血供,感染性疾病科医师提供抗感染治疗方案,麻醉手术部医师评估患者围手术期风险、保障患者围手术期安全,心内科、神经内科、营养科、康复科等科室医师根据患者情况主动适时参与治疗。手足显微与创面修复外科医师行创基准备,采用游离股前外侧穿支皮瓣修复创面。Ⅰ期行1次或多次清创后,创面面积为5.0 cm×4.5 cm~17.0 cm×10.0 cm。行1次或2次负压封闭引流治疗后,Ⅱ期采用游离股前外侧穿支皮瓣(面积为6 cm×5 cm~18 cm×11 cm)修复创面,将皮瓣的旋股外侧动脉降支及其伴行静脉分别与受区动、静脉吻合,皮瓣供区创面直接拉拢缝合。术后观察患者是否平稳度过围手术期、皮瓣成活情况、皮瓣供受区创面愈合情况;术后随访时,观察皮瓣质地、外形,有无新发溃疡及患者的行走能力。结果患者均平稳度过围手术期。46例患者皮瓣顺利成活;2例患者皮瓣完全坏死,其中1例患者行小腿带蒂皮瓣修复后溃疡愈合,另1例患者行小腿截肢;1例患者皮瓣部分坏死,经换药、移植皮片后愈合。患者皮瓣供受区创面均愈合良好。术后随访6~24个月,皮瓣质地良好、外形较佳,无新发溃疡,患者日常行走无明显障碍。结论MDT协作模式能充分地保障DFU患者围手术期安全。采用游离股前外侧穿支皮瓣修复DFU创面,皮瓣成活率较高,可降低截肢率,临床效果较佳。

Objective To explore the clinical effects of free anterolateral thigh perforator flaps in repairing diabetic foot ulcers(DFUs)under a multi-disciplinary team(MDT)cooperation model.Methods The study was a retrospective observational study.From June 2018 to December 2022,49 DFU patients who met the inclusion criteria were admitted to the Department of Hand and Foot Microscopy and Wound Repair Surgery of Henan Provincial People's Hospital(People's Hospital of Zhengzhou University),including 28 males and 21 females,aged from 47 to 68 years,with type 2 diabetes history period ranging from 6 months to 21 years.Under a MDT cooperation model,the physicians from department of endocrinology comprehensively assessed the patients,stabilized the patients'general condition,and controlled their complications,the surgeons from department of vascular surgery assessed and improved the patients'lower limb blood supply,the physicians from department of infectious diseases provided anti-infection treatment plans,the physicians from department of anesthesiology and perioperative medicine assessed the patients'perioperative risk and ensured their perioperative safety,and according to the patients'condition,the physicians from departments such as cardiology,neurology,nutrition,and rehabilitation actively and timely participated in the treatment.The surgeons from department of hand and foot microscopy and wound repair surgery prepared the wound base and used free anterolateral thigh perforator flaps to repair the wounds.After once or multiple debridement in the first stage,the wound area ranged from 5.0 cm×4.5 cm to 17.0 cm×10.0 cm.After once or twice vacuum sealing drainage treatment,the free anterolateral thigh perforator flaps were used to repair the wounds with incision area of 6 cm×5 cm to 18 cm×11 cm in the second stage.The descending branches of lateral circumflex femoral artery and the accompanying veins of flaps were anastomosed to the arteries and veins in the recipient sites,respectively.The wounds in the flap donor sites were sutured directly.After surgery,whether the patient's perioperative period was stable,the survival of flaps,the healing of wounds in the flap donor and recipient sites were observed.During the follow-up,the texture and appearance of flaps,whether there was a new ulcer,and the patient's walking ability were observed.Results All the patients had stable perioperative period.Among them,the flaps in 46 patients survived successfully;the flaps in 2 patients developed complete necrosis,including 1 case whose ulcer was healed after repair of pedicled flap from the lower leg,and 1 case who underwent amputation of the lower leg;the flap in 1 patient developed partial necrosis,which was healed after dressing change and skin grafting.The wounds in the flap donor and recipient sites healed well.During the postoperative follow-up of 6-24 months,the flaps had good texture and appearance with no new ulcers,and the patients had no obvious impairment in daily walk.Conclusions The MDT cooperation model can sufficiently ensure the perioperative safety of DFU patients.The free anterolateral thigh perforator flaps can repair the DFU wounds achieving good clinical effects with high flap survival rate and decreased amputation rate.