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Prof.Dr.A.R.UNDREProf.Dr.A.R.UNDRE Consultant Surgeon: Saifee Hospital, Consultant Surgeon: Saifee Hospital,
Jaslok Hospital & Research CentreJaslok Hospital & Research CentreMumbai, IndiaMumbai, India
ROLE OF CO2 LASER IN THE MANAGEMENT OF
DIABETIC FOOT/ULCER
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In a 24-hour period of time---- 4,100 people diagnosed with Diabetes, 230 amputations in people with Diabetes.
25 % of admissions in any hospital are Diabetic. Still a large number of undiagnosed cases of diabetes Today 1.8% of total population is Diabetic By 2025 one out of every 5 Indian will be a high risk case
by 2025.
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19.4 million 1995 AD
INDIA - THE WORLD CAPITAL OF DIABETES
57.2 million2025 AD
- WHO ESTIMATE
140 %
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IndiaWorld Diabetes Capital
2025
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Diabetic FootDiabetic Foot An Overview An OverviewPeople with diabetes have a 15% lifetime
risk of developing a foot ulcerThey also have 15 to 40% higher risk of
lower extremity amputationVaried methods of treatment are available
with varying degree of success
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Amputation is a Amputation is a meanmean operation operation in Diabetic Foot.in Diabetic Foot.
Amputation reduces remaining life span of the patient.
Amputation makes the person crippled, dependent & a mental wreck.
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Therefore all attempts Therefore all attempts should be made to should be made to
conserve the limb in conserve the limb in Diabetic FootDiabetic Foot
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Path-physiology Of Vascular Path-physiology Of Vascular Disease In A Diabetic Disease In A Diabetic
Macro vascular disease
Non-occlusive micro vascular disease
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MACROVASCULAR DiseaseMACROVASCULAR Disease
Similar to that noted in non-diabetic patients with athero-sclerotic disease except…
Generally occurring at an earlier ageAffects men and women equallyInvolves more frequently the TIBIAL
and PERONEAL arteries
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Non-occlusive MICRO Non-occlusive MICRO VASCULAR DiseaseVASCULAR Disease
Inability of the capillaries to vasodialate in response to injury
Decreased number of WBCs reaching injury site
Over abundance of oxygen derived free radicals
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Diabetes
Tissue Necrosis
Ischemia
Sensory lossMotor loss
NeuropathyHigh sugar
(prone to infection)
Gangrene
Repeated TraumaAbnormal pressure
Ulceration
(Pathophysiology)
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1.Absence of protective sensation2.Arterial insufficiency3.Foot deformity and callus formation
resulting in focal areas of high pressure4.Autonomic neuropathy causing
decreased sweating and dry, fissured skin
Causes of Ulcerations in the Diabetic Foot
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5.Obesity6.Impaired vision7.Poor glucose control leading to impaired
wound healing8.Poor footwear that causes skin
breakdown or inadequately protects the skin from high pressure and shear forces
Causes of Ulcerations in the Diabetic Foot
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Risk Factors For Foot UlcerationRisk Factors For Foot Ulceration
Peripheral vascular disease
Biomechanical dysfunction and deformities
Trauma High plantar pressure
Limited joint mobility
Duration of diabetes
Elevated glycosylated hemoglobin levels
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INVESTIGATIONSINVESTIGATIONS
Routine blood inv. Diabetic status Doppler studies X-ray Pus culture and
sensitivity Ankle-Brachial
Pressure index (ABPI)
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INVESTIGATIONSINVESTIGATIONS
Angiography (preferably DSA)
Pulse volume recorder (PVR)
Transcutaneous oxygen tension
MRA with contrast
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Treatment ModalitiesTreatment Modalities
CONVENTIONALPreventionMedical treatmentEstimate and treat
vascular insufficiency
Surgical: debridementand amputation (Minimum)
OTHER METHODSHyperbaric oxygenTissue Granulation
Factor (Bionect)
Co2 Laser (The Latest)
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PREVENTIONPREVENTION
Identify and treat HIGH risk patients earlyRegular blood sugar level checkAdvice on ideal foot care
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Tips to keep your feet healthyTips to keep your feet healthyA) Do’sA) Do’s
Check your bottom of feet with mirror every day and consult your doctor at very first sign of redness, swelling, pain, numbness or tingling in any part.
Check inside of your shoes every day for things like gravel or a torn lining & remove dirt and dust. If shoes are torn, replace immediately.
Regular check up of your feet by doctorCont.
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Tips to keep your feet healthyTips to keep your feet healthyA) Do’s (Cont.)A) Do’s (Cont.)
Choose the right shoes with a good arch support which fit properly.
Wear white socks and check for any blood or fluid from a sore on them.
Wash your feet daily in lukewarm water. Dry them well,especially between the toes with a soft towel and blot gently; don't rub.
Keep your feet skin smooth with a cream or lotion. If your feet sweat easily, keep them dry with
nonmedicated powder
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Tips to keep your feet healthyTips to keep your feet healthyB) Don'tsB) Don'ts
Do not walk barefoot. Do not wear stretch socks, nylon socks, socks with
inside seams. Do not wear socks with a tight elastic band or garter
at the top. Do not put hot water, electric blanket or heating pads
on your feet. Do not use iodine, or astringents on your feet. Avoid things that are bad for you feet.
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MEDICAL TREATMENTMEDICAL TREATMENT
Early and prompt control of diabetes with low threshold for use of INSULIN
Drugs to improve vascularityCorrection of anemiaAntibiotics to control infection
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Treatment of Vascular Treatment of Vascular InsufficiencyInsufficiency
MAJOR vessels : a) Angioplasty b) Vascular NeurolysisMINOR vessels : Lumbar
sympathetectomy
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SURGICAL TreatmentSURGICAL Treatment
Debridement
Amputation (Minimum)
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LASERLASER
L ~ LIGHT A ~ AMPLIFICATION by S ~ STIMULATED E ~ EMISSION of R ~ RADIATION
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BOHR’S TheoryBOHR’S Theory
Laser are produced by three basic interactions between PHOTONS and ELECTRONS
Absorption Spontaneous emission Stimulated emission
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Characteristics of Laser LightCharacteristics of Laser Light
COLLIMATEDCOHERENTMONOCHROMATICPOLARISED
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Types of LASERTypes of LASER
SOLID state e.g. Ruby & Nd YAG laser
LIQUID
GAS e.g. HeNe laser
CO2 & Argon laser
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CO2 Laser gas mixture CO2 Laser gas mixture consist of 70%, helium, 15% consist of 70%, helium, 15%
Co2 & 15% N2Co2 & 15% N2
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Laser Tissue InteractionLaser Tissue Interaction
Photochemical : Ablative decomposition
& Photodynamic therapyThermal : Photocoagulation &
PhotovaporisationMechanical : Photo disruption &
Explosive vaporization
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GAS LASER DESIGNGAS LASER DESIGN
Consists of1) Gas filled cavity
2) External optical pumping lights
3) Resonator with partially and totally reflecting mirrors
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Mechanism of ActionMechanism of Action
Laser Therapy is though to act through a variety of Mechanisms.
Photons from laser probe are absorbed into the mitochondria and membranes of the cell.
Single oxygen molecules build up which influences the formation of adenosine triphosphate which in turn leads to replication of DNA.
Increased DNA leads to increased neurotransmission. A cascade of Metabolic effects results in various physiological
changes.
In summary, this results in improved tissue repair.
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BiophysicsBiophysics
Laser photostimulation promotes tissue repair process by accelerating Collagen production & promoting overall connective tissue stability.
CO2 kills bacteriaConverts moist gangrene to dry gangrene.Probably promotes neoangiogenesis (as skin
grafts take well following Co2 Laser Therapy in an otherwise ischaemic foot)
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Laser Tissue Interaction in Laser Tissue Interaction in CO2 LASER CO2 LASER
The mode of action is PHOTOTHERMAL by two ways
1) PHOTOCOAGULATION : Laser light is absorbed by target tissue,generating heat leading to denaturation of protein
2) PHOTOVAPORISATION : High pors of laser beam lead to vaporization of tissues, used for cutting tissues
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Operation ModesOperation Modes
CUT : Laser used to incise or cut
tissue by using
#continuous wave
#super pulse wave ABLATE : Superficial ablation of tissue using
#continuous wave
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Presentations of Diabetic FootPresentations of Diabetic Foot
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I – Case illustrationI – Case illustration
Huge,circumferential ulcers of unknown etiology on both lower limbs
EIGHT sittings over a period of a monthThis was followed by regular dressings and
split skin graftEnd result completely healed wounds
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II – Case illustrationII – Case illustration
Cellulites both lower limbs for which fasciotomy was done and 1.5 LITRES of pus drained,leaving him with infected wounds
He was given 16 sittings of laserWounds healed rapidly leaving ulcers 1/3rd
original size,which were graftedEnd result completely healed wounds
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III – Case illustrationIII – Case illustration
Resident of SULTANATE OF OMAN,came to us for treatment after being advised amputation of left foot for gangrene
We did multiple fasciotomies leaving raw areas These infected areas were subjected to 8 sittings of
laser,along with last two toes amputation All ulcers healed,and foot saved
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Heel getting involvedHeel getting involved
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Deeper Infection -Tendons affectedDeeper Infection -Tendons affected
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Transmetatarsal SpreadTransmetatarsal Spread
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Infarction of 1st metatarsal
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Metatarsal Ulceration – involvement of tendon sheath
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Sole Ulceration-Instep regionSole Ulceration-Instep region
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Near total sole affectionNear total sole affection
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Charcot JointCharcot Joint
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ADVANTAGESADVANTAGES
Presence of diabetic neuropathy and non-invasive nature of CO2 laser allows most cases to be done under IV sedation
Good patient compliance Early feeding so minimum fasting period Minimal need for post procedure analgesia Negligible blood loss Patient can attend procedure on OPD basis
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SummarySummary
Lasers are a treatment choice that appeals to patients. Early research suggest that laser therapy may have a role to play in the treatment of:
A) Diabetic UlcerB) Non Healing woundsC) Bed Sores.
It is ideal for diabetic ulcer as the principle of conservatism is well applied. In deep ulcers like bed sores, laser therapy helps to limit destruction of surrounding tissues.
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Over 100 patients have been treated Over 100 patients have been treated successfully with CO2 Laser Therapy in successfully with CO2 Laser Therapy in the last 5 years. The patients are the last 5 years. The patients are evaluated fully for anemia, diabetic evaluated fully for anemia, diabetic status, bone involvement & vascular status, bone involvement & vascular insufficiency. In case of large ulcers, the insufficiency. In case of large ulcers, the patient undergoes conventional slough patient undergoes conventional slough excision followed by CO2LaserTherapy.excision followed by CO2LaserTherapy.
This protocol helps to reduce the hospital This protocol helps to reduce the hospital stay considerably.stay considerably.
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