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1 Advanced Course: 순환기 Ⅰ DM foot ulcer management 1 충남대학교의과대학내과학교실, 2 울산대학교의과대학내과학교실 이재환 1, 이승환 2 Introduction 65세이상에서하지만성궤양의빈도는 3-5% 에이른다. 그중 45-60% 는정맥성궤양 (venous insufficiency) 이차지하고 10-20% 는동맥성궤양 (arterial insufficiency) 이며 15-25% 는당뇨발 (DM foot) 에의해궤양이발생한다고알려져있다. 통계에따르면전체당뇨환자의 3-4% 정도가당뇨족궤양 (DM foot ulcer) 을가지고있으며당뇨가있는경우 25% 에서당뇨족궤양을경험한다고보고된다. 당뇨족궤양이있으면신체적, 정신적장애를비롯하여사회적기능이저하되며경제적인부담도증가하게된다. 또한당뇨가있으면없는경우에비해하지절단의위험이 15배나증가하고절단을할경우 5년사망률 (5-year mortality) 이 39% 에서 80% 까지증가한다는연구도보고되었다. 그만큼당뇨환자에있어서당뇨발관리는삶의질을좌우할만큼중요한부분이며평소관리가중요하기때문에실제임상에서효과적인관리법에대해간략하게다루고자한다. Multidisciplinary Approach 당뇨발의초기양상은특별한증상이없는경우부터절단이불가피한상황까지어떠한상태로든올수가있다. 발병기전은신경병증 (neuropathy) 과허혈증 (ischemia) 이주된원인이며여기에감염 (infection) 이나외상 (trauma), 족부변형 (orthopedic deformity), 말초부종 (peripheral edema) 등이발생위험을증가시킨다. 따라서당뇨발을효과적으로관리하기위해서는이러한일련의위험성들을포괄적으로다루는것이중요하다. 당뇨발의가장일차적인치료는엄격한혈당조절과충분한영양상태를유지하는것이다. 환자를처음대할때에는 과거력을비롯하여생활환경, 직업, 치료의지등자세한정보를얻고전신적인상태와당뇨발상태를확인하여야한다. 초기당뇨발을관리할때에는내분비내과, 순환기내과, 감염내과, 성형외과, 정형외과, 혈관외과, 재활의학과및영양과등다양한협진이이루어져야하며발병기전에따라다음항목들은기본적으로반드시평가하여야한다. 1. Vascular 2. Neuropathic 3. Orthopedic 4. Infectious wound 평가가끝난후에는원인에따른검사와함께종합적인치료계획을수립하여야한다. Treatment Algorithm Neuropathy 에의한경우괴사된조직이나염증조직을적절히제거하고 (debridement) 압력부하를줄이면서 (off-loading) 적절한상처소독및드레싱 (local wound care) 만으로도창상치유에큰문제가없다. 이경우는상처가생기지않도록예방하는것이중요하다. 감각이둔하므로온찜질을피하고피부가건조하지않도록보습로션을수시로발라주며매일발상태를확인하여굳은살이생기지않도록관리하는것이중요하다. 자기발에맞는편안한신발을신도록하고특히발가락사이가눌리지않도록발볼이넓은신발을신는것이좋다. 특정한부위에압력이부하될만한뼈변형이있는지확인하고발모양에맞는맞춤신발을제작하는것이좋다. Monofilament test나 neurometer 등으로정기적인관찰이필요하며신경감압술 (nerve decompression) 시행이예방에도움이된다. 감염이의심될경우에는지체없이적절한치료가필요하

2 년대한내과학회추계학술대회 - Figure 1. Multidisciplinary algorithm for primary screening and initial treatment of diabetic foot ulcer

이재환외 1 인. DM foot ulcer management Figure 3. (A) The descending branch of the circumflex femoral artery is the main collateral of the distal perfusion of the limb.

상처바로주변에서측정을하여야의미있는결과를얻을수있다. Figure 2. Surgical algorithm for limb salvage. 다. 충분한세척술 (irrigation), 변연절제술 (debridement) 과함께보다적극적인창상관리 (advanced dressing) 가필요하다.

3 이재환외 1 인. DM foot ulcer management Figure 3. (A) The descending branch of the circumflex femoral artery is the main collateral of the distal perfusion of the limb. (B) The anterior tibial and dorsalis pedis arteries are barely seen (circled), whereas the posterior tibial artery is well presented (right arrow). Figure 4. TcPo 2 를측정하는모습. 상처바로주변에서측정을하여야의미있는결과를얻을수있다. Figure 2. Surgical algorithm for limb salvage. 다. 충분한세척술 (irrigation), 변연절제술 (debridement) 과함께보다적극적인창상관리 (advanced dressing) 가필요하다. Swap 이나 tissue culture 를통해적절한항생제를선택하고감염전문의의의견을고려하여알맞은용법으로사용하며 C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) 등의수치를통해경과관찰이필요하다. 염증이퍼지지않도록관절을고정시키는것 (immobilization) 이좋으며체중부하를막기위해부목 (splint) 을대는것이좋다. 치료에잘반응하지않을경우 cell therapy, hyperbaric oxygen therapy, growth factor treatment, negative pressure wound therapy (NPWT) 등을시도해볼수있다. 특히 NPWT 의경우결손이있는부위에육아조직 (granulation tissue) 생성을촉진하고부종을줄여주며염증을완화시켜줌으로서최근각광받는치료방법중하나이다. 치료계획을세우는데있어서가장중요한부분은 ischemia에관한부분이다. 앞에서언급한적절한치료에도호전되지않거나창상이악화되는경우에는대부분혈관병변이존재하게된다. 이때에는 transcutaneous oxygen pressure (TcPo 2) 나 CT-angiogram 등으로혈관상태를파악하고필요하면혈관성형술 (percutaneous transluminal angioplasty) 이나혈관우회술 (bypass surgery) 등을준비해야한다. Vascular Intervention 1. CT-angiogram 수술적치료를계획하고있는경우 CT-angiogram은혈관상태를평가하기위해반드시필요하다. 하지의전반적인 vascular anatomy를확인하면서동맥경화성변화 (atherosclerotic change) 가있는지, 혈관협착 (stenosis) 이존재하는지등을평가하여야한다. 간혹혈관폐색 (occlusion) 이있을경우측부혈관 (collateral vessel) 이주된혈관역할을하는경우가있어조심하여야한다. 2. TcPo 2 표준기압산소 (normobaric oxygen) 에서측정값이 30 mmhg 이상일경우창상치유를기대해볼수있지만그이하일경우에는악화될가능성이높다. Vascular intervention을시행한후에도산소압력이낮을경우고압산소치료를병행해야하며호전되지않을경우적절한범위에서절단술 (amputation)

- 2015 년대한내과학회추계학술대회 - 이필요할수있다. 3. Perfusion Ankle-brachial index (ABI) 검사는당뇨환자에게있어서는유용하지않다. 일반적으로당뇨환자들은혈관에석회화빈도가높기때문에위양성 (false positive) 결과가나타날수있기때문이다.

4 년대한내과학회추계학술대회 - 이필요할수있다. 3. Perfusion Ankle-brachial index (ABI) 검사는당뇨환자에게있어서는유용하지않다. 일반적으로당뇨환자들은혈관에석회화빈도가높기때문에위양성 (false positive) 결과가나타날수있기때문이다. Arterial flow를쉽게확인할수있는방법으로는 hand-held Doppler가있다. 이는주요혈관의개통성 (patency) 을쉽게확인할수있고폐색이있을경우측부혈관의상태나후향적혈행 (retrograde flow) 의유무를확인할수있어수술적치료계획에꼭필요한검사이다. 4. Percutaneous transluminal angioplasty (PTA) 낫지않는상처의경우근본적인원인은충분한혈액공급이되지않는것이다. 따라서혈액순환에장애가있다고판단될시에는혈관조영술을시행하여상태를파악하고바로 PTA를시도해보는것이좋다. 석회화가심한혈관은실패할확률도있지만숙련된전문의의경우족부원위부의말초혈관까지혈행을개선시킬수가있어원활한창상치유를기대해볼수있고특히수술적치료를계획하고있을때에는필히선행되어야할중재시술이다. 최근에는중재의와성형외과가팀이되어 TA로혈행을개선시킨혈관에바로 microvascular flap surgery 를동시에시행하는 hybrid surgery 가시도되어좋은성적을보이고있다. Surgical Algorithm 과거에는 microvascular surgery에대해서논란이많았었다. 그이유는당뇨환자에게발생하는 vascular problem 때문이며주로절단술이많이시행되었다. 그러나작은혈관들은석회화가잘발생하지않는다는연구결과가나오면서재건수술이많이시행되고있으며성공했을경우환자의경제적인요소뿐만아니라전체적인삶의질, 그리고생존율까지높인다는보고가나오고있다. 당뇨발에서첫번째수술적원칙은충분한 debridement이다. 앞서언급한다방면의접근과병행하면서반복적으로 debridement를시행하는것은창상치유를도모할뿐만아니라결정적인수술을하기위한상태로만드는과정이기도하다. 이과정은혈당과영양상태를조절하여전신상태를 Figure 5. A 65-year-old diabetic man is shown with ischemic change, infection, and osteomyelitis. The angiogram showed poor supply of dorsalis pedis. The microvascular flap operation done after complete debridement is performed. Follow-up at 18 months shows good contour without recurrence of osteomyelitis and recurrence of ulceration. 개선시키고국소적으로는감염을억제하고혈행을개선시키며육아조직생성을촉진시키게된다. 물론중간에재건수술이힘들다고판단되면절단술이불가피할것이다. 그러나 vascular intervention의발달과더불어많은당뇨발환자에게 microvascular surgery 를시행하고있으며성공률이매우높다. Summary 당뇨발의초기치료는다방면의, 종합적인접근이필요하다. 절단할수밖에없는상태에이르기까지궤양의진행이빠르고치료에반응하지않는상태에잘접어들기때문에가장중요한것은상처가생기지않도록철저히환자를교육하는것이다. 그리고문제가발생했을시빠른원인파악과그에맞는전문과의협진이같이이루어져야하며삶의

5 이재환외 1 인. DM foot ulcer management 질을높이기위해재건을위한노력을아끼지않아야할것이다. REFERENCES 1. Mekkes JR, Loots MA, Van Der Wal AC, et al. Causes, investigation and treatment of leg ulceration. Br J Dermatol 2003; 148: Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Plast Reconstr Surg 2006;117(Suppl 7):212S-238S. 3. Reiber GE. The epidemiology of diabetic foot problems. Diabet Med 1996;13(Suppl 1):S Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293: Wraight PR, Lawrence SM, Campbell DA, et al. Creation of a multidisciplinary, evidence based, clinical guideline for the assessment, investigation and management of acute diabetes related foot complications. Diabet Med 2005;22: Holstein P, Ellitsgaard N, Olsen BB, et al. Decreasing incidence of major amputations in people with diabetes. Diabetologia 2000; 43: Apelqvist J. Wound healing in diabetes. Outcome and costs. Clin Podiatr Med Surg 1998;15: Conrad MC. Large and small artery occlusion in diabetics and nondiabetics with severe vascular disease. Circulation 1967;36: Colen LB. Limb salvage in the patient with severe peripheral vascular disease: the role of microsurgical free-tissue transfer. Plast Reconstr Surg 1987;79: Hong JP. Reconstruction of the diabetic foot using the anterolateral thigh perforator flap. Plast Reconstr Surg 2006;117: Searles JM Jr, Colen LB. Foot reconstruction in diabetes mellitus and peripheral vascular insufficiency. Clin Plast Surg 1991;18: Oishi SN, Levin LS, Pederson WC. Microsurgical management of extremity wounds in diabetics with peripheral vascular disease. Plast Reconstr Surg 1993;92: Knox KR, Datiashvili RO, Granick MS. Surgical wound bed preparation of chronic and acute wounds. Clin Plast Surg 2007;34: Attinger CE, Bulan EJ. Debridement. The key initial first step in wound healing. Foot Ankle Clin 2001;6: Badia JM, Torres JM, Tur C, et al. Saline wound irrigation reduces the postoperative infection rate in guinea pigs. J Surg Res 1996; 63: Clemens MW, Attinger CE. Angiosomes and wound care in the diabetic foot. Foot Ankle Clin 2010;15: Attinger C, Cooper P, Blume P, et al. The safest surgical incisions and amputations applying the angiosome principles and using the Doppler to assess the arterial-arterial connections of the foot and ankle. Foot Ankle Clin 2001;6: Kim JY, Lee YJ. A study of the survival factors of free flap in older diabetic patients. J Reconstr Microsurg 2007;23: Christensen KS, Klarke M. Transcutaneous oxygen measurement in peripheral occlusive disease. An indicator of wound healing in leg amputation. J Bone Joint Surg Br 1986;68: Goss DE, de Trafford J, Roberts VC, et al. Raised ankle/brachial pressure index in insulin-treated diabetic patients. Diabet Med 1989;6: Randon C, Jacobs B, De Ryck F, et al. 15-year experience with combined vascular reconstruction and free flap transfer for limb-salvage. Eur J Vasc Endovasc Surg 2009;38: Yue DK, McLennan S, Marsh M, et al. Effects of experimental diabetes, uremia, and malnutrition on wound healing. Diabetes 1987;36: Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg 2009; 123: Rainer C, Schwabegger AH, Meirer R, et al. Microsurgical management of the diabetic foot. J Reconstr Microsurg 2003;19:

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$(Microsoft PowerPoint - S16-1_\271\332\305\302\274\261 [\310\243\310\257 \270\360\265\345])$ 제 23 차대한당뇨병학회춘계학술대회 May 6-8. 2010 전북대학교의학전문대학원 내분비대사내과 박태선 Lancet 2005; 366 Nov 12 :1673-1750 Neuropathic foot Ischemic foot Plantar aspect of the foot under the metatarsal heads or on the plantar