多学科团队诊疗模式在结肠癌治疗中的重要意义

尽管外科手术是治疗结肠癌的主要手段,但依靠单一的治疗方案很难取得理想的治疗效果。近年来结肠癌的治疗已发展演变为多学科共同参与的多学科团队（multidisciplinary team,MDT）模式,这一模式保障了最佳治疗方案的实施,也促进了学科的发展和交流。临床医生需要正确理解结肠癌多学科治疗理念的更新变化,并始终贯穿于结肠癌治疗的全程,才能够改善结肠癌的治疗效果,进一步减轻病人的负担。     

多学科治疗团队在胃癌诊治中的应用

胃癌病人的管理是复杂的,需要多个专业的专家共同协作,所以多学科治疗团队(multidisciplinary team,MDT)便应运而生。从肿瘤分期的评估开始,以及随后的新辅助化疗(放化疗)、手术、术后化疗(放化疗)甚至肿瘤复发之后的姑息治疗或转化治疗,MDT团队成员便开始共同讨论,为病人制订最优的治疗方案,延长病人生存期,提高病人生存质量。本文通过简要介绍我院胃癌MDT小组的工作经验,希望可促进我国MDT制度的建立,提高我国胃癌的诊治水平。     

多学科团队诊治重症缺血性糖尿病足的策略

目的探讨糖尿病足多学科团队的建设与诊疗策略。方法收集2021年4月至2022年3月在本中心多学科诊疗的19例重症缺血性糖尿病足患者临床资料, 回顾性分析总体截肢率、踝上(大)截肢率、踝下(小)截肢率和死亡率, 学科参与率和治疗参与程度。结果 19例患者中, 男15例(78.9%), 女4例(21.1%), 年龄26～94(68.6±14.2)岁。全部为重度缺血性糖尿病足溃疡患者, 均符合卢瑟福分级5级以上、脏器功能不全合并症均累积2个及以上;合并症包括下肢动脉硬化闭塞症18例、心脏疾病18例、高血压15例、肾功能不全10例。总体截肢率为36.8%, 大截肢率21.1%, 小截肢率15.8%, 死亡率15.8%。多学科门诊共计16个学科参与, 主要参与学科为血管外科19次最高、内分泌、心内科次之, 主要治疗学科为血管外科14次最高。结论多学科协作团队模式下治疗重症缺血性糖尿病足可以更好地控制糖尿病足诱因并减少复发, 从而提高患者生活质量。     

糖尿病足患者三级甲等医院专业诊疗中心就诊前的诊治状况及影响因素分析

背景与目的:糖尿病足(DF)是糖尿病患者致残、致死的主要原因之一,而早期诊断和规范治疗不仅可提高疗效、促进溃疡愈合,也是保肢和节省医疗费用的有效途径。本研究探讨DF患者在具有专业DF多学科诊疗团队的三级甲等医院就诊前的诊治现状及相关因素,为DF的规范化诊疗提供相关依据。方法:于2017年10月-11月期间,采用随机整群抽样法,抽取湖南、浙江、上海、四川、广东、河北、黑龙江、澳门的13家具有专业DF诊疗中心的三级甲等医院共326例Wagner 1~5级DF患者行问卷调查与足部检查,以患者就诊于三级甲等医院前伤口清洗液的选择和伤口用药情况为指标评估治疗的规范性,分析可能影响其治疗规范性的因素。结果:在326例DF患者中,误诊率为25.8%,治疗不规范率为72.7%。单因素分析结果显示,患者治疗的规范性与清创人、就诊医院级别、敷料应用人、院前诊治地点、并发症个数和清创地点有关(均P<0.05);Logistic多元回归分析结果表明,医院分级和敷料应用人是DF治疗规范率的独立影响因素(均P<0.05),其中三级医院DF治疗规范率是一级医院的6.707倍,且明显优于二级医院,敷料应用人为伤口/造口治疗师的DF治疗规范率是敷料应用人为患者本人的24.117倍,且明显优于敷料应用人为医生和护士。结论:DF患者在进入具有专业DF多学科诊疗团队的三级甲等医院前存在较多的误诊和治疗不规范的现象。因此,需进一步加强对基层医院医务人员DF多学科规范化诊治的培训,尤其应重视伤口/造口治疗师的培养;完善基层医疗机构和三级医院DF患者双向转诊的标准;鼓励患者主动就医,以减少误诊和不规范诊治现象的发生。     

胰腺肿瘤的多学科诊疗模式

胰腺疾病通常发病隐匿、定位困难,治疗效果不甚理想,这与胰腺本身的解剖和生物学特点有关,胰腺肿瘤特别是胰腺癌易于早期侵犯周围组织器官及远处转移,未经手术治疗的病人5年生存率始终低于5%~([1-3])。另一方面,由于胰腺疾病缺乏特异性的早期诊断手段,胰腺肿瘤的手术和综合治疗方案存在很多争议之处,使得胰腺疾病诊治过程难以     

整体观、系统观及多学科合作在糖尿病足诊治中的重要性

Oakley于1956年首先提出了“糖尿病足（DF）”的概念。1972年,Catterall将糖尿病足定义为因神经病变失去感觉或缺血、失去活力及合并感染的足。     

以血管外科为核心的多学科合作模式在糖尿病足诊治中的应用及效果

目的:研究构建以血管外科为核心的多学科合作模式在糖尿病足诊治中的应用及效果.方法:选取2018年1月—2019年1月入住我院的DF患者100例,分为多学科协作组(MT组)49例,单一学科治疗组(LT组)51例,MT组由血管外科为核心结合创面伤口科、内分泌科、骨科、伤口护理单元专科护士共同组成的多学科团队对DF患者进行诊...     

整形外科技术在糖尿病足截肢术中的应用

目的：探讨应用整形外科技术行糖尿病足（diabetic foot,DF）截肢术的优越性。方法：改进传统截肢术,在合理确定截肢平面的前提下,应用整形外科基本原则实施截肢术：①严格无菌操作,无创面遗留,适度张力缝合,合理设计皮瓣;②减少组织损伤：不使用止血带,少缝扎肌肉断端;③于残端创腔留置负压引流管以消灭死腔,防止血肿。结果：6例常规截肢组1例发生皮瓣下血肿,2例发生局部感染,经局部换药引流后愈合;1例残端出现皮瓣坏死,伤口裂开,保守治疗无效后再次手术抬高截肢平面。5例应用整形外科方法截肢者除1例伤口渗液,经再次放置负压引流管,伤口换药1周后愈合外其余4例伤口皆Ⅰ期愈合,术后顺利佩戴假肢。结论：应用整形外科技术进行截肢较常规方法在保证DF残端一期愈合,缩短患者的住院时间,减少再次手术,提高安装假肢的成功率,提高患者的生活质量等方面具有优越性。     

糖尿病足的外科治疗进展与评价

糖尿病的并发症仍是临床难题。糖尿病可导致周围神经病变、眼底病变、肾脏病变以及周围动脉（包括心、脑、外周动脉等）狭窄或闭塞性病变，糖尿病最终出现周围动脉病变（PAD）的概率是正常人的2—4倍。据统计，在美国每年约20％的糖尿病病人可能出现糖尿病足溃疡形成，因为糖尿病足而截肢的病人占非外伤性截肢的50％以上，其中须行大腿以上截肢的占30％，而那些已经有一侧下肢被截肢的病人有50％最终将失去对侧肢体。尤其是合并下肢动脉硬化闭塞症的病人，如果同时合并糖尿病周围血管病变，有50％-70％须行手术治疗；相对的，     

多学科团队协同延续护理在糖尿病视网膜病变患者中的应用

目的观察多学科糖尿病照护团队协同延续护理模式在糖尿病视网膜病变患者中的应用效果。方法将160例2型糖尿病视网膜病变患者按照入院时间分为对照组与观察组各80例。对照组按常规糖尿病视网膜病变管理模式,观察组采用多学科糖尿病照护团队协同延续护理模式。干预前及干预后6个月、1年测量患者血糖,并评估患者糖尿病视网膜病变防治知识知晓率,患者生活质量、遵医行为和糖尿病自我管理行为,出院后再入院行眼科手术或调节血糖的例数。结果干预后观察组患者空腹血糖、餐后2 h血糖、糖化血红蛋白控制水平,知识掌握情况、低视力者生活质量,遵医行为和糖尿病自我管理行为显著优于对照组(P0.05,P0.01)。结论多学科糖尿病照护团队协同延续护理模式可改善2型糖尿病患者血糖水平,提高低视力者生活质量、遵医行为和糖尿病自我管理行为,延缓糖尿病视网膜病变进展。     

新型冠状病毒肺炎疫情期间糖尿病足病多学科诊疗策略

新型冠状病毒肺炎(COVID-19)疫情正处于暴发和相持相交替的关键阶段。糖尿病足病(以下简称糖尿病足)是常见的严重糖尿病慢性并发症,诊治难度大且常需要多学科协作,在COVID-19疫情背景下,糖尿病足诊治面临着新的严峻形势。糖尿病足患者比一般人群更容易患COVID-19,而对于合并糖尿病足的COVID-19患者在糖尿病足处理和COVID-19处理上都更为困难。此外,COVID-19疫情期间糖尿病足诊疗的医疗资源相对减少,而多数糖尿病足患者需要长期门诊随访,部分患者需要限期手术或急诊手术。医护人员需要依据新形势对糖尿病足患者采取新的诊疗流程和措施。本文结合武汉等地多家医院的一线COVID-19和糖尿病足患者诊治经验,参考相关诊疗方案和专家共识,对COVID-19疫情下糖尿病足的多学科诊疗策略进行归纳总结。     

The current burden of diabetic foot disease

Neuropathy and ischaemia are two great pathologies of the diabetic foot which lead to the characteristic features of foot ulceration (neuropathic and ischaemic) and Charcot neuroarthropathy. These can be complicated by infection and eventually may result in amputation (minor or major) and increased mortality. All of these features contribute to considerable clinical and economic burden.Peripheral nerves in the lower limbs are susceptible to different types of damage in patients with diabetes leading to distinctive syndromes. These include symmetrical sensory neuropathy associated with autonomic neuropathy, which advances gradually, and acutely painful neuropathies and mononeuropathies which have a rather acute presentation but usually recover. Ischaemia in the form of peripheral arterial disease is an important contributor to the burden of the diabetic foot. The incidence of atherosclerotic disease is raised in patients with diabetes and its natural history is accelerated. Diabetes causes severe and diffuse disease below-the knee. The lifetime risk of developing a diabetic foot ulcer is between 19% and 34%. Recurrence is common after initial healing; approximately 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years, and 65% within 5 years. Charcot neuroarthropathy is characterised by bone and joint destruction on the background of a neuropathy. Its prevalence in diabetes varies from 0.1% to 8%.Infection develops in 50%–60% of ulcers and is the principal pathology that damages diabetic feet. Approximately 20% of moderate or severe diabetic foot infections result in lower extremity amputations. The incidence of osteomyelitis is about 20% of diabetic foot ulcers.Every 20 s a lower limb is amputated due to complications of diabetes. Of all the lower extremity amputations in persons with diabetes, 85% are preceded by a foot ulcer. The mortality at 5 years for an individual with a diabetic foot ulcer is 2.5 times as high as the risk for an individual with diabetes who does not have a foot ulcer. The economic burden exacted on health care systems is considerable and includes direct and indirect costs, with loss of personal earnings and burden to carers. The diabetic foot is a significant contributor to the global burden of disability and reduces the quality of life. It remains a considerable public health problem.     

糖尿病足截肢技术进展

目的总结各种糖尿病足截肢技术的研究进展。方法查阅近年关于糖尿病足截肢技术的文献,进行综合分析。结果根据截肢平面的不同,糖尿病足的截肢技术可分为小范围截肢术和大范围截肢术两种,并衍生出多种截肢方法,截肢方式与方法的选择需要综合各种因素考虑。结论 对于糖尿病足截肢,应在保证截肢效果的前提下,尽可能降低截肢平面。患者的身体状况、糖尿病足累及的部位、组织的血流灌注情况、局部组织对感染的易感性、创口的愈合能力等是影响选择糖尿病足截肢方式和方法的重要因素。截肢后仍要重视糖尿病的综合治疗,防止截肢平面的进一步上升。     

Literature review on the management of diabetic foot ulcer

Diabetic foot ulcer (DFU) is the most costly and devastating complication of diabetes mellitus, which affect 15% of diabetic patients during their lifetime. Based on National Institute for Health and Clinical Excellence strategies, early effective management of DFU can reduce the severity of complications such as preventable amputations and possible mortality, and also can improve overall quality of life. The management of DFU should be optimized by using a multidisciplinary team, due to a holistic approach to wound management is required. Based on studies, blood sugar control, wound debridement, advanced dressings and offloading modalities should always be a part of DFU management. Furthermore, surgery to heal chronic ulcer and prevent recurrence should be considered as an essential component of management in some cases. Also, hyperbaric oxygen therapy, electrical stimulation, negative pressure wound therapy, bio-engineered skin and growth factors could be used as adjunct therapies for rapid healing of DFU. So, it’s suggested that with appropriate patient education encourages them to regular foot care in order to prevent DFU and its complications.     

Keeping an eye on the diabetic foot: The connection between diabetic eye disease and wound healing in the lower extremity

Diabetic eye disease is strongly associated with the development of diabetic foot ulcers (DFUs). DFUs are a common and significant complication of diabetes mellitus (DM) that arise from a combination of micro- and macrovascular compromise. Hyperglycemia and associated metabolic dysfunction in DM lead to impaired wound healing, immune dysregulation, peripheral vascular disease, and diabetic neuropathy that predisposes the lower extremities to repetitive injury and progressive tissue damage that may ultimately necessitate amputation. Diabetic retinopathy (DR) is caused by cumulative damage to the retinal mic-rovasculature from hyperglycemia and other diabetes-associated factors. The severity of DR is closely associated with the development of DFUs and the need for lower extremity revascularization procedures and/or amputation. Like the lower extremity, the eye may also suffer end-organ damage from macrovascular compromise in the form of cranial neuropathies that impair its motility, cause optic neuropathy, or result in partial or complete blindness. Additionally, poor perfusion of the eye can cause ischemic retinopathy leading to the development of proliferative diabetic retinopathy or neovascular glaucoma, both serious, vision-threatening conditions. Finally, diabetic corneal ulcers and DFUs share many aspects of impaired wound healing resulting from neurovascular, sensory, and immunologic compromise. Notably, alterations in serum biomarkers, such as hemoglobin A1c, ceruloplasmin, creatinine, low-density lipoprotein, and high-density lipoprotein, are associated with both DR and DFUs. Monitoring these parameters can aid in prognosticating long-term outcomes and shed light on shared pathogenic mechanisms that lead to end-organ damage. The frequent co-occurrence of diabetic eye and foot problems mandate that patients affected by either condition undergo reciprocal comprehensive eye and foot evaluations in addition to optimizing diabetes management.     

糖尿病足的手术截肢治疗

目的探讨糖尿病足的手术截肢治疗方式。方法通过对34例晚期糖尿病足病人截肢治疗,包括小腿截肢24例,经足截肢10例,手术后控制血糖,改善局部循环,积极处理残端疼痛等。结果术后平均随访8个月(3~16个月),残端完全愈合者28例,占82%。结论对于糖尿病足的治疗,采用截肢手术虽然迫不得已,但可以提高病人生存率,改善生存质量。     

Amputation in diabetic foot ulcer: A treatment dilemma

Diabetic foot is a clinical manifestation of diabetes with a wide range of symptoms, including ulceration, osteomyelitis, osteoarticular destruction, and gangrene, as a consequence of advanced disease. Some diabetic foot cases present general indications for amputation, including dead limb, threat to the patient’s life, pain, loss of function, or nuisance. Various tools have been introduced to help decision-making in amputation for diabetic foot. However, it remains a conundrum because diabetic foot involves multiple pathomechanisms and factors that hinder its outcomes. Sociocultural issues often impede treatment from the patient’s side. We reviewed different perspectives in diabetic foot management, particularly related to amputation. In addition to deciding whether to amputate, physicians should address amputation level, timing, and ways to avoid patient deconditioning. Surgeons should not be autocratic in these circumstances and should be aware of beneficence and maleficence when considering whether to amputate. The main goal should be improving the patients’ quality of life rather than preserving the limb as much as possible.     

胫骨横向搬移治疗糖尿病足溃疡

目的:探讨采用Ilizarov技术行胫骨横向搬移术治疗糖尿病足溃疡的临床疗效。方法 :自2013年7月至2017年3月,采用Ilizarov胫骨横向搬移术治疗20例糖尿病足溃疡患者,男14例,女6例;年龄46～61(51.6±6.8)岁。Wagner分级:3级5例,4级15例。手术前后观察并记录截肢平面、溃疡愈合情况、创面愈合时间、VAS疼痛评分、患足皮温,CTA观察血管再通及血管网重建情况。结果:20例患者均进行了随访,时间12～58个月,平均22.4个月,所有患者足部溃疡顺利愈合,时间6～18(13.2±3.7)周,坏死及截肢平面没有上移,患足疼痛明显缓解,VAS评分由术前的5.6±0.8降低至术后1年的0.9±0.4,差异有统计学意义(t=-26.55,P0.05);患足皮温由治疗前的(27.9±1.1)℃提高至术后1年的(30.9±1.1)℃(t=-5.98,P0.05)。CTA可见术前闭塞的血管再通,微血管数量明显增加,足部血管网重建。结论:Ilizarov胫骨横向搬移术能促进足部血管的再生、微血管网的再通或重建,从而改善糖尿病足患者的血液循环,促进溃疡的愈合,适合以微血管病变为主的糖尿病足患者。对于主干大动脉严重狭窄或闭塞的患者应当慎重或配合介入等血管再通技术联合应用。     

Outcomes of allogenic acellular matrix therapy in treatment of diabetic foot wounds: an initial experience

The purpose of this study was to evaluate outcomes of persons with UT grade 2A neuropathic diabetic foot wounds treated with an acellular matrix. Data were abstracted for 17 consecutive patients with diabetes--76.5% males, aged 61.5 +/- 8.5 years with a mean glycated haemoglobin of 9.2 +/- 2.2% presenting for care at a large, multidisciplinary wound care centre. All patients received surgical debridement for their diabetic foot wounds and were placed on therapy consisting of a single application of an acellular matrix graft (GraftJacket; Wright Medical Technologies, Arlington, TN, USA) with dressing changes taking place weekly. Outcomes evaluated included time to complete wound closure and proportion of patients achieving wound closure in 20 weeks. Acellular matrix therapy was used as initial therapy and was sutured or stapled in place under a silicone-based non adherent dressing. Therapy was then followed by a moisture-retentive dressing until complete epithelialisation. In total, 82.4% of wounds measuring a mean 4.6 +/- 3.2 cm(2) healed in the 20-week evaluation period. For those that healed in this period, healing took place in a mean 8.9 +/- 2.7 weeks. We conclude that a regimen consisting of moist wound healing using an acellular matrix dressing may be a useful adjunct to appropriate diabetic foot ulcer care for deep, non-infected, non-ischaemic wounds. We await the completion of further trials in this area to confirm or refute this initial assessment.