Der Chirurg

, 79:535 | Cite as

Interdisziplinäre Wundzentren in der Behandlung des diabetischen Fußsyndroms

Die Rolle des Gefäßchirurgen
  • G. Rümenapf
  • S. Dittler
  • S. Morbach
  • K. Amendt
  • A. Radu
Leitthema
First Online:

Zusammenfassung

In Deutschland steigt die Zahl der Diabetiker jährlich an und beträgt aktuell über 6 Mio. Im Rahmen der neuropathischen und angiopathischen Spätfolgen steigt auch die Zahl der Patienten, die an einem diabetischen Fußsyndrom erkranken, kontinuierlich an. Das diabetische Fußsyndrom ist eine der häufigsten Erkrankungen, mit denen sich Patienten in interdisziplinären Wundzentren vorstellen. Aufgrund seiner multifaktoriellen Genese erfordert das diabetische Fußsyndrom eine koordinierte Therapie verschiedener Fachrichtungen.

Jährlich entwickeln mehr als 150.000 Diabetiker ein Fußulkus, das in der Regel eine verzögerte Heilungstendenz zeigt und häufig in ein chronisches Wundstadium übergeht. Trotz intensiver Bemühungen der einzelnen medizinischen Fachgebiete um Prävention, frühzeitige Diagnostik und adäquate Wundbehandlung werden jährlich über 20.000 Majoramputationen bei Diabetikern in Deutschland durchgeführt. Bei konsequenter Therapie des diabetischen Fußsyndroms in interdisziplinären Wundzentren ist mit einer Reduktion der Amputationsraten um über 50% zu rechnen.

In der vorliegenden Arbeit wird die Komplexität des Krankheitsbildes bezüglich der Pathogenese, Diagnostik und Therapie aus gefäßchirurgischer Sicht aufgezeigt. Besonderen Wert soll hierbei auf einen interdisziplinären Ansatz gelegt werden.

Schlüsselwörter

Diabetisches Fußsyndrom Neuropathische Spätfolgen Angiopathische Spätfolgen Pathogenese Therapie Wundzentren 

The vascular surgeon’s role in interdisciplinary treatment of diabetic foot syndrome

Abstract

There are more than 6 million diabetes patients in Germany. Due to long-term neuropathic and angiopathic sequelae, the number of patients with “diabetic foot syndrome” has increased dramatically in recent years. Diabetic foot ulcers have become one of the most common pathologies in interdisciplinary wound care centers. Because of its complex pathogenesis, diabetic foot syndrome needs a multidisciplinary therapeutic approach. More than 150,000 diabetics per year develop foot ulcers that often heal slowly and progress into chronic wounds. Despite all efforts at prevention, early diagnosis, and adequate therapy, more than 20,000 diabetics suffer major limb amputation in Germany every year. Applying stringent standards of care in interdisciplinary wound care centers, the amputation rate in patients with diabetic foot syndrome can be reduced to less than 50%. This article describes the complexity of diabetic foot syndrome with respect to pathogenesis, diagnostics, and therapy from a vascular surgeon’s point of view. The importance of an interdisciplinary approach is emphasized.

Keywords

Diabetic foot syndrome Neuropathic sequelae Angiopathic sequelae Pathogenesis Therapy Wound centers 
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Notes

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Literatur

  1. 1.
    Adam DJ, Beard JD, Cleveland T et al. (2005) Bypass versus angioplasty in severe ischemia of the leg (BASIL): multicentre, randomised control trial. Lancet 366: 1925–1934CrossRefPubMedGoogle Scholar
  2. 2.
    Albers M, Romiti M, Brochado-Neto FC et al. (2006) Meta-analysis of popliteal-to-distal vein bypass grafts for critical ischemia. J Vasc Surg 43: 498–503CrossRefPubMedGoogle Scholar
  3. 3.
    Al-Omran M, Tu JV, Johnston KW et al. (2003) Use of interventional procedures for peripheral arterial occlusive disease in Ontario between 1991 and 1998: a population-based Study. J Vasc Surg 38: 289–295CrossRefPubMedGoogle Scholar
  4. 4.
    Armstrong DG, Lavery LA, Harkless LB (1998) Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 21: 855–859CrossRefPubMedGoogle Scholar
  5. 5.
    Bastounis E, Felekouras E, Pikoulis E et al. (1997) The role of profunda femoris revascularization in aortofemoral surgery. An analysis of factors affecting graft patency. Int Angiol 16: 107–113PubMedGoogle Scholar
  6. 6.
    Bauer H, Germann G, Gries FA et al. (2008) Nationale Versorgungsleitlinie Typ II-Diabetes – Präventions- und Behandlungsstrategien für Fußkomplikationen. www.diabetes.versorgungsleitlinie.deGoogle Scholar
  7. 7.
    Boulton AJ (1991) Clinical presentation and management of diabetic neuropathy and foot ulceration. Diabet Med 8: S52–S57PubMedGoogle Scholar
  8. 8.
    Dorros G, Jaff MR, Dorros AM et al. (2001) Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: five-year follow-up. Circulation 104: 2057–2062CrossRefPubMedGoogle Scholar
  9. 9.
    Eckardt A, Lobmann R (2005) Der diabetische Fuß. Interdisziplinäre Diagnostik und Therapie. Springer, HeidelbergGoogle Scholar
  10. 10.
    Faglia E, Favales F, Quarantiello A (1998) Angiographic evaluation of peripheral arterial occlusive disease and its role as a prognostic determinant for major amputation in diabetic subjects with foot ulcer. Diabetes Care 4: 625–630CrossRefGoogle Scholar
  11. 11.
    Greenhalgh R (2005) Consensus. Towards Vascular and Endovascular Consensus 2005. Available from http: //www.cxvascular.com/CXsymp/CX symp.cfmGoogle Scholar
  12. 12.
    Haider SN, Kavanagh EG, Forlee M et al. (2006) Two-year outcome with preferential use of infrainguinal angioplasty for critical limb ischemia. J Vasc Surg 43: 504–512CrossRefPubMedGoogle Scholar
  13. 13.
    Heller G, Günster C, Swart E (2005) Über die Häufigkeit von Amputationen unterer Extremitäten in Deutschland. Dtsch Med Wochenschr 130: 1689–1690CrossRefPubMedGoogle Scholar
  14. 14.
    Hill DA, Jamieson CW (1977) The results of arterial reconstruction utilizing the profunda femoris artery in the treatment of rest pain and pre-gangrene. Br J Surg 64: 359–336CrossRefPubMedGoogle Scholar
  15. 15.
    Hofmann WJ, Walter J, Ugurluoglu A et al. (2004) Preoperative high-frequency duplex scanning of potential pedal target vessels. J Vasc Surg 39: 169–175CrossRefPubMedGoogle Scholar
  16. 16.
    Holstein P, Ellitsgaard N, Olsen BB, Ellitsgaard V (2000) Decreasing incidence of major amputations in people with diabetes. Diabetologia 43: 844–847CrossRefPubMedGoogle Scholar
  17. 17.
    Hunink MG, Wong JB, Donaldson MC et al. (1994) Patency results of percutaneous and surgical revascularization for femoropopliteal arterial disease. Med Decis Making 14: 71–81CrossRefPubMedGoogle Scholar
  18. 18.
    International Diabetes Federation (IDF) (2007) The Diabetes Atlas. 3rd edn. Available from: www.eatlas.idf.org/Google Scholar
  19. 19.
    International Working Group on the Diabetic Foot (2007) International Consensus on the Diabetic Foot & Practical Guidelines on the Diabetic Foot. www.idf.org/bookshopGoogle Scholar
  20. 20.
    Kastenbauer T, Irsigler K (2003) Diabetic foot syndrome. Wien Med Wochenschr 153: 474–477CrossRefPubMedGoogle Scholar
  21. 21.
    Kechagias A, Ylönen K, Biancari F (2008) Long-term outcome after isolated endarterectomy of the femoral bifurcation. World J Surg 32: 51–54CrossRefPubMedGoogle Scholar
  22. 22.
    Löndahl M, Katzman P, Fredholm O et al. (2008) Is chronic diabetic foot ulcer an indicator of cardiac disease? J Wound Care 17: 12–16PubMedGoogle Scholar
  23. 23.
    Management of peripheral arterial disease (PAD) (2000) TransAtlantic Inter-Society Consensus (TASC). Int Angiol 19: 1–304Google Scholar
  24. 24.
    McCabe CJ, Stevenson RC, Dolan AM (1998) Evaluation of a diabetic foot screening and protection programme. Diabet Med 15: 80–84CrossRefPubMedGoogle Scholar
  25. 25.
    Morbach S, Müller E, Reike H et al. (2008) Evidenzbasierte Leitlinien. Diagnostik, Therapie, Verlaufskontrolle und Prävention des diabetischen Fußsyndroms. Diabetes und Stoffwechsel (in press)Google Scholar
  26. 26.
    Muradin G, Bosch J, Stijnen T, Hunink M (2001) Balloon dilation and stent implantation for treatment of femoro-popliteal arterial disease: meta-analysis. Radiology 221: 137–145CrossRefPubMedGoogle Scholar
  27. 27.
    Norgren L, Hiatt WR, Dormandy JA et al. (2007) Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg [Suppl 1] 33: S1–S75Google Scholar
  28. 28.
    Perkins BA, Olaleye D, Zinman B, Bril V (2001) Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabetes Care 24: 250–256CrossRefPubMedGoogle Scholar
  29. 29.
    Peters EJ, Lavery LA (2001) International Working Group on the Diabetic Foot. Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care 24: 1442–1447CrossRefPubMedGoogle Scholar
  30. 30.
    Pfeifer KJ, Krotz M, Kessler SB (1999) Diagnostic imaging of diabetic foot syndrome with spezial reference to radiologic interventional therapy option. Internist 40: 1042–1050CrossRefPubMedGoogle Scholar
  31. 31.
    Rathmann W, Haastert B, Icks A et al. (2003) High prevalence of undiagnosed diabetes mellitus in Southern Germany: target populations for efficient screening. The KORA survey 2000. Diabetologia 46: 182–189PubMedGoogle Scholar
  32. 32.
    Reike H (1999) Wound healing and local wound treatment in diabetic foot syndrome. Internist 40: 1009–1017CrossRefPubMedGoogle Scholar
  33. 33.
    Reiners K (2003) Diabetic neuropathies. Basic principles, clinical manifestations and drug therapy. Zentralbl Chir 128: 726–733CrossRefGoogle Scholar
  34. 34.
    Expert Committee on the Diagnosis and Classification of Diabetes (2003) Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care [Suppl 1] 26: S5–S20Google Scholar
  35. 35.
    Rümenapf G (2003) Borderline amputations in diabetics – open questions and critical evaluation. Zentralbl Chir 128: 726–733CrossRefPubMedGoogle Scholar
  36. 36.
    Rümenapf G, Kammerer I, Hayna S et al. (2007) Kombinations- und Hybrideingriffe in der Gefäßperipherie. Vasomed [Suppl 4] 19: 3–4Google Scholar
  37. 37.
    Rümenapf G, Lang W (2003) Diabetic neuropathic osteoarthropathy (Charcot foot). Zentralbl Chir 128: 734–739CrossRefPubMedGoogle Scholar
  38. 38.
    Rümenapf G, Neufang A, Schmiedt W et al. (2004) Gefäßchirurgie bei Diabetikern mit Fußproblemen. Dtsch Arztebl 101: A3348–A3354Google Scholar
  39. 39.
    Schillinger M, Sabeti S, Loewe C et al. (2006) Balloon angioplasty versus implantation of nitinol stents in the superficial femoral artery. N Engl J Med 354: 1879–1888CrossRefPubMedGoogle Scholar
  40. 40.
    Stiegler H (2004) Diabetic foot syndrome. Herz 29: 104–115CrossRefPubMedGoogle Scholar
  41. 41.
    Stiegler H, Standl E, Frank S, Mendler G (1998) Failure of reducing lower extremity amputations in diabetic patients: results of two subsequent population based surveys 1990 and 1995 in Germany. VASA 27: 10–14PubMedGoogle Scholar
  42. 42.
    The Vascular Surgical Society of Great Britain and Ireland (1995) Critical limb ischemia: Management and outcome. Report of a national survey. Eur J Vasc Endovasc Surg 10: 108–113CrossRefGoogle Scholar
  43. 43.
    Thomsen HS (2006) Nephrogenic systemic fibrosis: a serious late reaction to gadodiamide. Eur Radiol 16: 2619–2621CrossRefPubMedGoogle Scholar
  44. 44.
    Van der Veen C, Neijens FS, Kanters SDJM et al. (2002) Angiographic distribution of lower extremity atherosclerosis in patients with and without diabetes. Diabet Med 19: 366–370CrossRefGoogle Scholar
  45. 45.
    Veith FJ, Gupta SK, Wengerter KR et al. (1990) Changing arteriosclerotic disease patterns and management strategies in lower-limb-threatening ischemia. Ann Surg 212: 402–412CrossRefPubMedGoogle Scholar
  46. 46.
    Wagner FW Jr (1981) The dysvascular foot: a system for diagnosis and treatment. Foot Ankle 2: 64–122PubMedGoogle Scholar
  47. 47.
    Williams DR (1985) Hospital admissions of diabetic patients: information from hospital activity analysis. Diabet Med 2: 27–32PubMedCrossRefGoogle Scholar
  48. 48.
    Wölfle KD, Bruijnen H, Reeps C et al. (2000) Tibioperoneal arterial lesions and critical foot ischaemia: successful management by the use of short vein grafts and percutaneous transluminal angioplasty. VASA 29: 207–214CrossRefPubMedGoogle Scholar
  49. 49.
    Wu S, Armstrong DG (2005) Risk assessment of the diabetic foot and wound. Int Wound J 2: 17–24CrossRefPubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag 2008

Authors and Affiliations

  • G. Rümenapf
    • 1
  • S. Dittler
    • 2
  • S. Morbach
    • 3
  • K. Amendt
    • 4
  • A. Radu
    • 2
  1. 1.Gefäßzentrum Oberrhein,Klinik für GefäßchirurgieDiakonissen-Stiftungs-KrankenhausSpeyerDeutschland
  2. 2.Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, SchwerbrandverletztenzentrumBG-Unfallklinik Ludwigshafen, Plastische- und Handchirurgie der Universität HeidelbergLudwigshafenDeutschland
  3. 3.Abteilung Diabetologie und Angiologie, Fachbereich Innere MedizinMarienkrankenhaus gGmbH SoestSoestDeutschland
  4. 4.Gefäßzentrum Oberrhein, AngiologieDiakonie-KrankenhausMannheimDeutschland

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