負壓傷口治療不該使用於血管病變沒有被治療的糖尿病足部傷口

游朝慶

    這一篇其實從圖上可看出，PTA治療失敗的兩個個案，自始至終，不管怎麼努力，傷口仍然一動也不動。從以前的研究可知，當施予傷口一個負壓時，傷口表淺處反而血流會減少，故目前許多負壓傷口治療機廠商以及傷口學會已將缺血性傷口歸為NPWT的禁忌症（contra-indication）之一。
背景：
此研究是來分析負壓傷口治療（NPWT）在有血管病變的糖尿病傷口上的療效。
方法：

   從2010年1月至2012年9月，收集糖尿病傷口並接受NPWT治療的住院患者，將患者分為三組：第一組.未治療或無法治療的下肢血管阻塞病變，第二組.有血管病變，但已成功接受經皮血管腔內血管成形術Percutaneous Transluminal Angioplasty (PTA) ，第三組.沒有血管病變。所有的患者都已簽署同意書，在清創手術後，傷口都被以NPWT治療，以紗布或泡棉填塞後，以防水薄膜密封，經由胸管引流瓶，接到牆壁上的抽吸系統（wall suction），並以-125mmHg的連續負壓抽吸，一個禮拜換藥兩次，並記錄，連續使用3個禮拜，傷口面積縮小比率percent wound area reduction (PWAR) 用來評估傷口的癒合速度，統計方法使用使用SPSS重複測量的線性混和模型分析（linear mixed model），整個計畫由秀傳紀念醫院的IRB所認證及追蹤。
結果
   從18個患者中的22個傷口被納入研究，2個傷口在無法治療的血管病變組（PTA治療失敗），8個傷口在有血管病變，但成功接受PTA組，12個傷口沒有血管病變。第二組和第三組間在傷口癒合速度上沒有統計學上的差異，然而第一組在第二週時就和其他兩組有統計學上的差異。
討論：
   NPWT是用來治療糖尿病傷口的好方法，但若患者有血管病變時，NPWT就不適合使用，此時應該積極地先去接受PTA 或繞道手術治療，成功後再來使用NPWT。

The negative pressure wound therapy should not be used in the diabetic foot ulcer with non-treated vasculopathy

Chao-Chin Yu

Department of Surgery, Tainan Municipal Hospital

Purpose:
The aim of this study was to analyze the effect of the negative pressure wound therapy (NPWT) on the healing of the diabetic ulcer (DU) with vasculopathy.
Materials and Methods:
From 2010/1 to 2012/09, the in-patient persons with the DU were enrolled. The patients was divided to 3 groups: 1.untreated vasculopathy 2. Vasculopathy s/p percutaneous transluminal angioplasty (PTA). 3. No vasculopathy. The letter of consent was signed by the patient or patient’s family. After debridement of the infective wound, the gauze or foam based NPWT was applied to the wound, and then sealed with 3M Tegaderm Film. The system was connected to a 1-bottle water-seal chest drainage system and to standard wall suction at 125 mmHg negative pressure. The dressing was changed at 72- to 96-hour intervals (twice a week) for a period of 3 weeks. We observed and recorded the ulcer area twice a week on each time of changing dressing in the following 3 weeks. The percent change of wound size reduction was used as a predictor of wound healing. The repeated measuring data were analyzed using linear mixed mode with SPSS statistical software. This clinical study was approved and monitored by Institutional Review Board of Show Chwan Memorial Hospital.
Results:
22 diabetic ulcers from 18 patients were enrolled. We collected 2 wounds in untreated vasculopathy group (The PTA failure), 8 wounds in vasculopathy s/p PTA, and 12 wounds in the group without vasculopathy. The vasculopathy s/p PTA group shows no significance with the group without vasculopathy. However, the untreated vasculopathy group shows significant difference among other groups at week 2.
Conclusion:
NPWT is a good method for the treatment of DU. But if patient has sign of vasculopathy, it is contra-indicated to apply the NPWT. Instead, PTA or bypass surgery should be done first followed by the NPWT.

台灣外科醫學會 102年年會

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