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Khamdamov Bahtiyor Zarifovich, PhD., in Medicine, Associate Professor of the Department of Faculty and Hospital Surgery, Bukhara State Medical Institute Islomov Anzur Anvarovich, Resident Magister's Department of Faculty and Hospital Surgery, Bukhara State Medical Institute Jabborova Nigora Jafarovna, student of Medical Faculty of the Bukhara State Medical Institute Khamdamov Ilkhom Bahtiyorovich, Resident Magister's Department of Faculty and Hospital Surgery, Bukhara State Medical Institute Khamdamov Alisher Bahtiyorovich, student of Medical Faculty of the Bukhara State Medical Institute, Bukhara, Uzbekistan E-mail: ss-1961@mail.ru
METHOD OF PREVENTION OF POSTOPERATIVE COMPLICATIONS OF SURGICAL TREATMENT OF DIABETIC FOOT SYNDROME
Abstract: The results of lower limb amputations at the level of the lower leg in 130 patients with diabetic foot syndrome (DFS) were analyzed. All patients, depending on the method of treatment, were divided into 2 groups: the first consisted of 63 patients who underwent complex conservative therapy after amputation; the second consisted of 67 patients who underwent complex conservative therapy + laser photodynamic therapy (LPDT) after amputation at the level of the upper third of the tibia. The use of LPDT is a promising development that increases success in the prevention of postoperative wound infections from the amputation stump of the tibia.
Keywords: diabetes mellitus, diabetic foot syndrome, amputation, leg, stump, laser photodynamic therapy, postoperative period, tibia.
In recent years have been observed a steady increase in the incidence of diabetes mellitus (DM), which already occupied the 3rd place after cardiovascular and oncological diseases. The number of patients approaches the 3.0% and in the older age group to 7-9% in relation to the entire population of Earth. According to some authors the prevalence of DFS among patients with diabetes reaches to 25%, and 15-40% of them will sooner or later develop ulcerative necrotic complications, which requires surgical treatment and often leads to amputations. Early complications after amputation of lower limbs, according to foreign authors, ranges from 20 to 50% [1-4].
The risk of postoperative complications often lead to the selection of unjustifiablehigh but a "more reliable"level of amputation and this causes damage the patient's rehabilitation.The
result of amputation is usually estimated only from the point of view of healing of the stump and mortality.Postoperative mortality is high and the survivals of patients areconsidered success ofsurgeons.So, after amputations at the hip 10-40%, and at the tibia 5-20% of the operated patientsdies.During the 3 year after high amputation at the hip dies from 40 to 57% patients, and after 5 years die 50-75% of patients. In coming five years in patients who witnessed amputation at the hip level, arise destructive complications of the sole collateral limb and this also in 50-67% cases ends with amputation [3; 5].
The basis of modern principles of choice of the level of amputation is the preservation most part of the lower limb in condition healing of the stump and its suitability for prosthetics. As is known, in recent years, in advanced stages of DFS
METHOD OF PREVENTION OF POSTOPERATIVE COMPLICATIONS OF SURGICAL TREATMENT OF DIABETIC FOOT SYNDROME
alternative high amputations at the hip began applying the amputation at tibia with preservation of the knee joint with its main function, which enables fast recovery of the patients because of convenience this of prosthetic limbs. However, the high rate of development of wound infection in the postoperative period, limits wide use of low-level amputations of the leg. There are many publications devoted to the treatment of purulent wounds. At the same time, neither experimental data nor by numerous clinical and special researches were not able to find the method that brought to the decide the problem of treatment of wound infection [7].
Photodynamic therapy (PDT) is one of the most promising methods of treatment of patients with wound infection.It should be emphasized that the effectiveness of PDT does not depend on the spectrum of sensitivity of microorganisms to antibiotics, it is destructive even for antibiotic-resistant strains of microorganisms[6]. In pathogens do not arise resistance toward PDT, photodynamic damage locally impacts on pathogens, and the bactericidal effect is limited because of the area of laser radiated sensitized tissues, thus avoiding adverse effects associated with the use of traditional methods of treatment of surgical infection [4; 6; 7].
The research is aimed to study measures prevention of postoperative wound complications by the applying of PDT and this is considered the topical problem of medicine.
The purpose of the research: to study of the role of PDT in the prevention of postoperative wound complications associated with amputation stump of the tibia in patients with DFS.
Material and methods. Analyzed 130 patients the after amputations of the lower limb at the tibia with DFS syndrome who was hospitalized in Purulent Surgery Department of the Bukhara multidisciplinary medical center from 2010 to 2017. The age of patients ranged from 40 to 84 years
All patients depending on the method of conducting in the postoperative period, were divided into 2 groups. During the comparing patients in both groups statistically significant differences by gender, age, severity of the main and concomitant pathology were not detected.
The first control group consisted of 63 patients, who after performing the amputation of the lower extremity at the upper third of the leg, was conducted a complex conservative therapy with the inclusion of antibiotic therapy (selection of antibiotic was carried out by bacteriological studies on sensitivity of microorganisms to antibiotics sown from the exudate ofwounds in patients in the preoperative treatment period).
II - the main group consisted of 67 patients, who after amputation at the upper third of the leg, was carried out similar complex conservative therapy with the inclusion of laser LPDT in the regions ofthe amputation stump during surgery and in postoperative period.
LPDT during surgery was performed by using a photo-sensitizer 0.05% buffer solution of methylene blue, which was moistened the wound surface of the stump of the tibia for 5 minutes, then photosensitizer was washed and the wound surface was lighted by device PDT - "ALT Vostoc" model 03 for 5-7 minutes. PDT in the postoperative period was carried out as follows, subcutaneous area of the amputation stump of the tibia through the set during the operation the perforated microdrainage enter the same photosensibilisator (0.05% buffer solution of methylene blue) with an exposure of 20-30 minutes, and then the cavity is rinsed with physiological solution, for rinsing ofa photosensitiser followed by irradiation of the surface area of the amputation stump of the tibia with a wavelength of 600-640 nm with power density of 200 mW/cm2 for 10-15 minutes. In average, were conducted 3 sessions of PDT.
Results and discussionro Analysis of results of treatment of patients who by reason of DFS were performed in lower limb amputation in the upper third of the tibia showed that the first group of patients in whom the postoperative period was carried out the complex of therapeutic measures with the inclusion of targeted antibiotic therapy, the development of wound infections from the amputation stump was observed in 37.5% of patients. The generalization of wound infection in 17.5% patients caused death. The progression of wounding in amputation stump was observed in 10.0% of patients, what caused the implementation of reamputation lower limb at the hip level.
Second group, which includes 67 patients, which in addition to a comprehensive conservative measures were performed PDT the area of amputation stump of the tibia, the development of wound infection from the stump of the tibia was detected in only 7.0% of patients. In 3.5% of patients developed necrosis of the stump of the tibia, which had forced the surgery re-amputation at the hip level. Mortality outcome in connection with the generalization of wound process in patients of the second group were not observed.
The analysis of the effectiveness of different methods of postoperative management in patients of examined groups showed that it is reasonable in respect to both reduce postoperative wound complications and lethality, and the generalization of wounding process from the amputation stump of the leg in the syndrome of diabetic foot, with the inclusion complex of therapeutic measures during and postoperative period LPDT, which resulted in sharp decrease wound infections at the amputation stump from 37.5% to 7.0%.
Conclusions:
1. The application of PDT is considered a promising development that enhances the success of efforts in the prevention of postoperative wound infections from the amputation stump of the tibia.
2. The method is simple, and it pathogenetically and eco- vantages compared with traditional treatment and does not
nomically justified, highly effective, which is one of the ad- requires considerable financial and physical effort.
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