With the development of modern society and the change of dietary structure, more and more patients with metabolism-related diseases appear. In 2011, there were 350 million diabetic patients worldwide, and by 2025, the number of patients may reach 650 million. With nearly 100 million diabetics in 2012, China has become the world’s largest country with diabetes. With this, the number of patients with diabetes-related complications and their medical costs are increasing year by year, and the prevention and treatment of various complications are receiving more and more attention.
Diabetic foot (DF) is one of the most serious complications of diabetes mellitus due to the combination of neuropathy and various degrees of peripheral vasculopathy resulting in lower limb infection, ulcer formation, and/or deep tissue destruction. According to statistics, 4-10% of diabetic patients have foot disease, which is more common in elderly patients, and about 5-8% of diabetic patients with foot ulcers require amputation within one year. Diabetic foot disease leading to amputation accounts for 50-70% of all lower limb amputation patients, while 85% of diabetic amputations are caused by complications of foot ulcers. Therefore, how to treat diabetic foot ulcers, reduce the rate of related amputations caused by this, become the focus of attention of the majority of clinical workers, including endocrinology, vascular surgery, etc.
1, general treatment: for the lower extremity atherosclerosis occlusive disease of the various treatment measures are also applicable to the treatment of DMF. Treatment includes appropriate exercise, smoking cessation, antiplatelet therapy, neurotrophic treatment, blood pressure control, lipid control, etc.. Importantly, there is also glycemic control, and good glycemic control can significantly reduce the occurrence of diabetic vascular complications. In a UK Prospective Diabetes Study (UKPDS) in patients with type 2 diabetes, intensive glucose-lowering therapy was shown to reduce overall microvascular complications by 25%, and for every 1% reduction in HbA1c, diabetic complications decreased by 35%. The choice of oral hypoglycemic agents with different mechanisms depending on the patient’s condition should be advocated in combination, which can further reduce HbA1c. Insulin therapy may be more suitable for patients in whom insulin deficiency predominates. In DMF patients, because of infection, there are often serious hyperglycemia, and even complications such as ketoacidosis and hyperosmolar coma, insulin therapy should be preferred for good glycemic control.
2.Anti-infection treatment.
The main factor leading to amputation in patients with diabetic foot disease is the complication of uncontrollable infection, and it is important to control infection to avoid amputation and preserve the lower limb as much as possible. Diabetic foot co-infections are mostly mixed infections, including aerobic and anaerobic bacteria, and common types of infectious bacteria include Staphylococcus aureus, Streptococcus, Enterococcus, which are Gram-staining positive bacteria and Klebsiella, Pseudomonas aeruginosa and other Gram-staining negative bacteria, and the latter include Staphylococcus, Streptococcus and Bacteroidetes. It should be noted that the culture specimen should be taken from deep tissue, and cultures taken from superficial ulcers are often inaccurate. The best culture method is the culture of tissue isolated by cutting without passing through the surface of the ulcer during surgery, and if osteomyelitis is present, bone biopsy, culture and tissue examination are required.
There are culture results based on drug sensitivity to select antibiotics, and before the culture results are available, the type of antibiotic can be selected based on the depth and extent of the infection. Mild infection can choose drugs for gram-positive cocci, such as lincomycin, amoxicillin-clavulanate potassium, etc.; moderate/severe infection, in addition to the above-mentioned aerobic cocci and bacilli, there are also anaerobic bacteria mixed infection, antibacterial drugs can choose a combination of drugs, such as lincomycin + ciprofloxacin, etc., but also a broad-spectrum penicillin, carbapenems; when the infection can not be controlled, in addition to timely debridement If the infection cannot be controlled, in addition to timely debridement, stronger antibiotics should be replaced in a timely manner. After the infection is controlled, it should be promptly changed to narrow-spectrum antibiotics. The course of treatment should be long enough, about 2 weeks for mild infections and at least 6 weeks for combined osteomyelitis.
3. Treatment of ulcerated wounds.
The principles of ulcer management are to minimize tissue damage, ensure proper blood supply, remove infection and provide nutrients to ensure ulcer healing. The trauma must be cleared to remove necrotic tissue, bacteria, fibrin, foreign bodies, etc. Early debridement should be advocated, and large and thorough debridement is beneficial for ulcer healing and infection control. If ischemic factors are present, only removal of necrotic tissues and dilation and drainage can be performed, and further expansion of debridement can be postponed until the necessary vascular examination is completed or even after completion of blood flow reconstruction. Dilute soap and water, saline and harmless wound cleansers should be used to clean the wound, not too strong alkaline soaps, surgical surface disinfectants including iodine and alcohol, which may damage the cellular basis of the ulcer. Ultrasonic debridement is available clinically, with probes for both superficial and deep areas, killing bacteria by ultrasound, reducing the application of antibiotics and facilitating the removal of necrotic tissue. After debridement, appropriate dressings should be selected to prevent wound contamination, control wound water, reduce edema, and promote granulation formation. Different dressings should be selected for different periods. In the early debridement period, hydrogel should be used as the main dressing, and in the granulation growth period, foam and low viscous dressings are used; in the epithelial period, hydrocolloid and low viscous dressings are used.
4, hematologic reconstruction: from the pathological changes of diabetes, most patients with diabetic foot disease have ischemic vasculopathy performance, no matter how should be reconstructed hematologically. Only after the reconstruction of blood flow, the foot infection of DMF can be easily controlled and the ulcer can be healed. In addition, there is evidence that the improvement of microcirculation after revascularization can lead to a certain degree of improvement of diabetic neuropathy. Reconstruction of blood supply to the lower extremity can avoid amputation or reduce the plane of amputation.
4.1 Methods of blood supply reconstruction
(1) Lower limb artery bypass graft: including main-iliac artery, femoral-N artery bypass graft, and distal lower limb artery bypass graft. The method of early blood supply reconstruction is mainly action artery bypass grafting, and lower extremity revascularization in diabetic foot patients should ensure that blood flow can reach the lower leg, ankle and even foot after surgery. The appropriate inflow and outflow tract vessels, as well as the autologous venous bridge vessels connecting these two arteries, are selected depending on the lesion. It should be noted that most patients with diabetic foot have infrapopliteal vasculopathy and relatively small distal outflow tract vessels, so it is difficult to ensure anastomotic patency and distal perfusion, and the chances of postoperative restenosis and reocclusion are high, so the long-term outcome is not very satisfactory.
(2) Endoluminal treatment: The methods of endoluminal treatment include balloon dilation, stent implantation, intravascular ultrasound ablation, and intravascular plaque spinning. Different methods are chosen depending on the lesion site. For the treatment of diabetic foot, the main iliac artery and femoral N artery, as inflow vessels, should be ensured to be patent. Generally speaking, balloon dilation and stent implantation are the main methods for femoral N artery lesions, while intravascular plaque spinning and ultrasonic ablation can also be used. Vascular lesions below the knee are mainly based on balloon dilatation. Diabetic foot vasculopathy is characterized by the most common lesions of the tibiofibular artery in the lower leg (including the anterior tibial, posterior tibial and peroneal arteries). Due to the thin diameter of the vessels, conventional surgical bypass treatment is often ineffective, and the application of small balloon intracavitary treatment designed for tibiofibular artery lesions can achieve more satisfactory results. With the advancement of technology, the application of drug balloons or stents has also been chosen for infrapopliteal lesions, which can be of great help in maintaining the long-term patency rate.
(3) Autologous stem cell transplantation (bone marrow blood, peripheral blood, umbilical cord blood and embryonic stem cells). This procedure is an option for patients with small vessel occlusion in the distal outflow tract who also have poor results with endoluminal therapy. Stem cell transplantation can promote vascular proliferation in local tissues, increase tissue blood flow, and provide help for ulcer healing.
(4) Others: venous arterialization, large omental transplantation, etc. With the development of endoluminal therapy, these methods are nowadays less and less used in clinical practice, and such procedures can be performed in units where endoluminal therapy is not carried out.
4.2 Perioperative management of lower extremity revascularization
As with the perioperative management of most patients with lower extremity atherosclerotic occlusive disease, the perioperative management of revascularization in patients with diabetic foot includes anticoagulation, antithrombotic, vasodilator and fibrin-lowering therapy.
(1) Anticoagulation: Patients with diabetic lower limb ischemia have a lot of hypercoagulable blood, so they can be anticoagulated to prevent thrombosis, especially if they have acute ischemic symptoms, and the necessity of anticoagulation therapy is emphasized. If the distal outflow tract is poor, combined anticoagulation therapy should be given after surgery to keep the outflow tract unobstructed.
(2) Antithrombotic therapy: preoperative and postoperative application of antithrombotic therapy to stop platelet aggregation and prevent arterial thrombosis is the most basic treatment when reconstructing diabetic foot blood flow. There are a variety of antiplatelet drugs with different mechanisms to choose from, such as aspirin, Bolivar, Ambulac, cilostazol, etc. Some reports show that Ambulac has a better therapeutic effect on diabetic vasculopathy, not only inhibiting platelet aggregation and thrombosis, but also inhibiting vasoconstriction and increasing local blood perfusion. In addition, there is evidence that Ambulac is also effective in diabetic neuropathy and can significantly improve the numbness of patients.
(3) Vasodilator drugs: Vasodilator drugs include prostaglandin dil, salvia, saffronin, etc., which are beneficial to reduce peripheral vascular resistance and increase the long-term patency of transplanted vessels, PTA or/and implanted stents.
(4) Fibrin-lowering therapy: diabetic foot patients mostly have hyperfibrinogenemia, so fibrin-lowering therapy is preferable and important, and can be used as a class of drugs such as Dongling keratase and herbicase, but attention should be paid to monitoring the fibrinogen content in the blood to prevent bleeding.
5, the treatment of neuropathy: diabetic neuropathy drug treatment includes hypoglycemia, analgesia, nerve nutrition, antioxidant reduction, vitamins and vasodilatation to improve circulation, etc.. There is evidence that positive and stable glycemic control can improve the signs and symptoms of neuropathy, therefore, good glycemic control is the basis for the treatment of diabetic complications including diabetic neuropathy. For those patients with painful peripheral neuropathy, tricyclic antidepressants such as promethazine with amitriptyline are preferred. Those with poor symptom control may be switched to gabapentin or even opioids. For the pathogenesis of diabetic neuropathy, α-thiozinc acid and vitamin E are used clinically, but the efficacy is not completely certain. Methylcobalamin is a methylated active agent of vitamin B12, a coenzyme of methionine synthase. The results of some studies have shown that vitamin B12 can effectively improve symptoms such as pain and sensory abnormalities, but has no significant effect on nerve conduction velocity. Blood flow reconstruction can improve neuropathy which has long been experimentally confirmed, therefore, clinically, in addition to actively carry out lower limb vascular surgery, can also apply some such as prostaglandin dil and other vasodilator drugs.
6.Hyperbaric oxygen therapy.
In addition to other treatments with hyperbaric oxygen therapy can promote ulcer healing and reduce the risk of amputation caused by diabetic foot ulcers. The principle may be related to the fact that under hyperbaric conditions, fibroblasts and endothelial cells, keratinocytes in will undergo significant proliferation, and the antibacterial function of white blood cells is also significantly enhanced. Conventional treatment can take the form of intermittent aspiration of 100% pure oxygen for 1-2 hours in a hyperbaric chamber at a pressure of about 2-3 atmospheres, adhering to 30-40 times. However, hyperbaric oxygen therapy also has certain side effects, including pneumatic injuries to the ear and sinuses, pneumothorax, transient blurred vision, and seizures.