ORGANIZATION OF MULTIDISCIPLINAR APPROACH IN TREATMENT OF PATIENTS WITH DIABETIC FOOT SYNDROME

Objective: to evaluate the effectiveness of complex treatment of patients with diabetic foot syndrome in the conditions of one health centre per one hospitalization.

Design and methods: from January to October 2017 at the research Department of vascular and interventional surgery Almazov National Medical Research Centre, adhering to a multidisciplinary approach, treated 28 patients with ischemic and neuroischemic diabetic foot syndrome. 24 of them had diabetic ulcers. The average ABI amounted to 0.44 (0.2 to 0.9). The treatment took place in three stages. The irst phase consisted in the examination and preparation of patients for vascular revascularization in the Department of endocrinology of the Centre. Examination for signiicant comorbidities, correction of glycemic proile, compensation for other late complications of diabetes and relief of systemic inlammation were performed. In the second phase the patients were in the Department of vascular and hybrid surgery where the performed reconstruction of the lower limb arteries. After revascularization, patients continued treatment at the Department of endocrinology of the Centre, which was corrected of treatment of diabetes, was performed sanation of ulcers and plastic surgery of the foot. Estimated change in the severity of pain, the dynamics of the healing of ulcers, the prospect of saving the limb.

Results and discussion: to assess the level and distribution of vascular lesions in the prehospital phase was performed by CT-A or digital angiography of lower limb arteries. In most cases, was detected distal form of atherosclerosis with a primary lesion of the popliteal-tibial segment. Endovascular treatment was performed 23 (82%) patients, 4 (14%) underwent open intervention. In one case, was applied a hybrid approach. All endovascular and hybrid operations were performed in a hybrid operating room under local anesthesia. In the early postoperative period in 79 % of patients achieved clinical improvement in the relief of symptoms of critical limb ischemia, rest pain, positive dynamics of the healing of trophic ulcers. Seven patients (25%) underwent extended necrectomy within the foot with the plastic of local tissues. In the long term (from 3 to 8 months) of observations one death due to myocardial infarction, amputations were not. 85% of patients had complete or partial healing of the ulcer.

Conclusion: complex multidisciplinary treatment of patients with diabetic foot syndrome in the conditions of one medical centre promotes an individual approach to each patient and improves the quality of medical care.

1. Lep¨antalo M, Apelqvist J, Setaccieet C, et al. Chapter V: Diabetic Foot. European Journal of Vascular and Endovascular Surgery. 2011; 42(S2): 560–574.

2. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016; 63: 39-219.

3. Standards of specialized diabetes care. 8th edition. Edited by Dedov II, Shestakova MV, Mayorov AY. M.: UP PRINT, 2017. p.112. In Russian.

4. Markakis K, Bowling F, Boulton A. The diabetic foot in 2015: an overview. Diabetes Metab Res Rev 2016; 32(Suppl. 1): 169–178.

5. Anciferov MB, Tokhmakova AYu, Galstyan GR, et al. Diabetic foot syndrome: Atlas for endocrinologists. М.: OOO “Papasha Grizli”, 2002. p. 80. In Russian.

6. Suncov YuI, Dedov II. State register of patients with diabetes mellitus basic information system to calculate the economic costs of the state on diabetes and its prognosis. Diabetes mellitus. 2005; 8(2): 2-5. In Russian.

7. Elsukova OS, Nikitina EA, Zhuravleva OL. Research of comorbid diseases among patients with diabetes mellitus type 2. Sovremennaya meditcina:aktualnie voprosi=Modern medicine: Actual questions. 2014; 31: 27-36. In Russian.

8. Hinchliffe RJ, Brownrigg JR, Apelqvist J, et al. IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes Metab Res Rev. 2016;32 (Suppl 1):37-44.

9. Zemlyanoy AB, Zhukov AO, Koltunov VA, et al. Instant and long-term results of treatment the patients with neuro-ischemic diabetic foot syndrome. ANGIOLOGIA.ru. 2010; 2. In Russian.

10. Krepkogorskiy NV, Sharafutdinov MR, Ignatyev IM, et al. Instant and long-term results of surgical treatment in patients with peripheral vascular disease as a complication of diabetes mellitus. Kazan medical journal. 2013; 94 (1): 18-22. In Russian.

11. Shumkov OA, Liubarskiĭ MS, Altukhov IA, et al. The role of vascular surgery in the multidisciplinary approach to the diabetic foot syndrome. Khirurgiia=Surgery. 2013; 11: 9-15. In Russian.

12. Zatevakhin II, Zolkin VN, Shipovskiy VN, et al. Results of treatment critical limb ischemia by patients with diabetic foot syndrome. ANGIOLOGIA.ru. 2010; 2. In Russian.

13. Ignatovich IN, Kondratenko GG, Sergeev GA, et al. Treatment of chronic critical ischemia by neuroischemic form of the diabetic foot syndrome. Khirurgiia=Surgery. 2011; 6: 51-55. In Russian.

14. Kalitko IM, Strugaylo EV, Kovalenko VI, et al. Surgical “below-the-knee” revascularization by patients with ischemic diabetic foot syndrome. ANGIOLOGIA.ru. 2010; 2. In Russian.

15. Eroshkin SN, Kutko AP, Bulavkin VP. Efficacy of lower limbs revascularization methods in patients with purulent-necrotic forms of diabetic foot syndrome. Novosti Khirurgii=Chirgical achievments. 2013; 21(3): 61-68. In Russian.

16. Faglia E, Clerici G, Losa S, et al. Limb revascularization feasibility in diabetic patients with critical limb ischemia: results from a cohort of 344 consecutive unselected diabetic patients evaluated in 2009. Diabetes Res Clin Pract. 2012; 95(3):364-371.

17. Saveljev VS, Koshkin VM, Nosenko EM, et al. Peripheral macrohemodynamics in patients with lower limb arteriosclerosis obliterans and type II diabetes mellitus. Angiology and Vascular Surgery. 2009; 9(1): 9-21. In Russian.

18. Fossaceca R, Guzzardi G, Cerini P, et al. Endovascular treatment of diabetic foot in a selected population of patients with below-the-knee disease: is the angiosome model effective? Cardiovasc Intervent Radiol. 2013;36(3):637-644.

19. Ferraresi R, Centola M, Ferlini M, et al. Longterm outcomes after angioplasty of isolated, below-the-knee arteries in diabetic patients with critical limb ischaemia. Eur J Vasc Endovasc Surg. 2009;37(3):336-342.

20. Romiti M, Albers M, Brochado-Neto FC, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg. 2008; 47(5): 975-981.

21. Katelnitskiy II, Sasina EV, Polyak MI. Balloon angioplasty of the below-the-knee arteries in group of patients with critical limb ischemia. Modern Problems of science and education. 2014; 5. In Russian.

22. Kaputin MYu, Ovcharenko DV, Soroka VV, et al. Balloon angioplasty in Diabetic Patients with Critical Limb Ischemia. Diagnostic and Interventional radiology. 2008; 2(2): 51-60. In Russian.

23. Drozdov SA, Bylov KV, Kavteladze ZA. Instant and long-term results of angioplasty and stenting of the crural arteries in patients with critical limb ischemia (clinical experience). Heart and vascular disease. 2011; 1. In Russian.