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Prof.Dr.A.R.UNDREProf.Dr.A.R.UNDRE
Consultant Surgeon: Saifee Hospital,Consultant Surgeon: Saifee Hospital,
Jaslok Hospita...
In a 24-hour period of time----
 4,100 people diagnosed with Diabetes,
 230 amputations in people with Diabetes.
25 % of...
19.4million
1995 AD
INDIA - THE WORLD CAPITAL OF DIABETES
57.2 million
2025 AD
- WHO ESTIMATE
140 %
India
World Diabetes Capital
2025
Diabetic FootDiabetic Foot
An OverviewAn Overview
People with diabetes have a 15% lifetime
risk of developing a foot ulce...
Amputation is aAmputation is a meanmean operationoperation
in Diabetic Foot.in Diabetic Foot.
Amputation reduces remainin...
Therefore all attemptsTherefore all attempts
should be made toshould be made to
conserve the limb inconserve the limb in
D...
Path-physiology Of VascularPath-physiology Of Vascular
Disease In A DiabeticDisease In A Diabetic
Macro vascular disease
...
MACROVASCULAR DiseaseMACROVASCULAR Disease
Similar to that noted in non-diabetic
patients with athero-sclerotic disease
e...
Non-occlusive MICRONon-occlusive MICRO
VASCULAR DiseaseVASCULAR Disease
Inability of the capillaries to vasodialate
in re...
Diabetes
Tissue Necrosis
Ischemia
Sensory lossMotor loss
Neuropathy
High sugar
(prone to infection)
Gangrene
Repeated Trau...
1.Absence of protective sensation
2.Arterial insufficiency
3.Foot deformity and callus formation
resulting in focal areas ...
5.Obesity
6.Impaired vision
7.Poor glucose control leading to impaired
wound healing
8.Poor footwear that causes skin
brea...
Risk Factors For Foot UlcerationRisk Factors For Foot Ulceration
 Peripheral vascular
disease
 Biomechanical
dysfunction...
INVESTIGATIONSINVESTIGATIONS
 Routine blood inv.
 Diabetic status
 Doppler studies
 X-ray
 Pus culture and
sensitivit...
INVESTIGATIONSINVESTIGATIONS
 Angiography
(preferably DSA)
 Pulse volume recorder
(PVR)
 Transcutaneous
oxygen tension
...
Treatment ModalitiesTreatment Modalities
 CONVENTIONAL
Prevention
Medical treatment
Estimate and treat
vascular
insuff...
PREVENTIONPREVENTION
Identify and treat HIGH risk patients early
Regular blood sugar level check
Advice on ideal foot c...
Tips to keep your feet healthyTips to keep your feet healthy
A) Do’sA) Do’s
 Check your bottom of feet with mirror every ...
Tips to keep your feet healthyTips to keep your feet healthy
A) Do’s (Cont.)A) Do’s (Cont.)
 Choose the right shoes with ...
Tips to keep your feet healthyTips to keep your feet healthy
B) Don'tsB) Don'ts
 Do not walk barefoot.
 Do not wear stre...
MEDICAL TREATMENTMEDICAL TREATMENT
Early and prompt control of diabetes with
low threshold for use of INSULIN
Drugs to i...
Treatment of VascularTreatment of Vascular
InsufficiencyInsufficiency
MAJOR vessels : a) Angioplasty
 b) Vascular Neurol...
SURGICAL TreatmentSURGICAL Treatment
 Debridement
 Amputation (Minimum)
LASERLASER
 L ~ LIGHT
 A ~ AMPLIFICATION by
 S ~ STIMULATED
 E ~ EMISSION of
 R ~ RADIATION
BOHR’S TheoryBOHR’S Theory
Laser are produced by three basic
interactions between PHOTONS and
ELECTRONS
 Absorption
 Sp...
Characteristics of Laser LightCharacteristics of Laser Light
COLLIMATED
COHERENT
MONOCHROMATIC
POLARISED
Types of LASERTypes of LASER
SOLID state e.g. Ruby & Nd YAG laser
LIQUID
GAS e.g. HeNe laser
CO2 & Argon laser
CO2 Laser gas mixtureCO2 Laser gas mixture
consist of 70%, helium, 15%consist of 70%, helium, 15%
Co2 & 15% N2Co2 & 15% N2
Laser Tissue InteractionLaser Tissue Interaction
 Photochemical : Ablative decomposition
& Photodynamic therapy
 Thermal...
GAS LASER DESIGNGAS LASER DESIGN
 Consists of
1) Gas filled cavity
2) External optical pumping lights
3) Resonator with p...
Mechanism of ActionMechanism of Action
Laser Therapy is though to act through a variety of Mechanisms.
 Photons from lase...
BiophysicsBiophysics
Laser photostimulation promotes tissue
repair process by accelerating Collagen
production & promotin...
Laser Tissue Interaction inLaser Tissue Interaction in
CO2 LASERCO2 LASER
 The mode of action is PHOTOTHERMAL by
two ways...
Operation ModesOperation Modes
 CUT : Laser used to incise or cut
tissue by using
#continuous wave
#super pulse wave
 AB...
Presentations of Diabetic FootPresentations of Diabetic Foot
I – Case illustrationI – Case illustration
Huge,circumferential ulcers of unknown
etiology on both lower limbs
EIGHT sit...
II – Case illustrationII – Case illustration
Cellulites both lower limbs for which
fasciotomy was done and 1.5 LITRES of
...
III – Case illustrationIII – Case illustration
 Resident of SULTANATE OF OMAN,came to us
for treatment after being advise...
Heel getting involvedHeel getting involved
Deeper Infection -Tendons affectedDeeper Infection -Tendons affected
Transmetatarsal SpreadTransmetatarsal Spread
Infarction of 1st
metatarsal
Metatarsal Ulceration – involvement of tendon sheath
Sole Ulceration-Instep regionSole Ulceration-Instep region
Near total sole affectionNear total sole affection
Charcot JointCharcot Joint
ADVANTAGESADVANTAGES
 Presence of diabetic neuropathy and non-invasive
nature of CO2 laser allows most cases to be done
u...
SummarySummary
Lasers are a treatment choice that appeals to
patients. Early research suggest that laser therapy
may have ...
Over 100 patients have been treatedOver 100 patients have been treated
successfully with CO2 Laser Therapy insuccessfully ...
Thank YouThank You
1362571102 a.r. undre
1362571102 a.r. undre
1362571102 a.r. undre
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1362571102 a.r. undre

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1362571102 a.r. undre

  1. 1. Prof.Dr.A.R.UNDREProf.Dr.A.R.UNDRE Consultant Surgeon: Saifee Hospital,Consultant Surgeon: Saifee Hospital, Jaslok Hospital & Research CentreJaslok Hospital & Research Centre Mumbai, IndiaMumbai, India ROLE OF CO2 LASER IN THE MANAGEMENT OF DIABETIC FOOT/ULCER
  2. 2. 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.
  3. 3. 19.4million 1995 AD INDIA - THE WORLD CAPITAL OF DIABETES 57.2 million 2025 AD - WHO ESTIMATE 140 %
  4. 4. India World Diabetes Capital 2025
  5. 5. Diabetic FootDiabetic Foot An OverviewAn Overview People with diabetes have a 15% lifetime risk of developing a foot ulcer They also have 15 to 40% higher risk of lower extremity amputation Varied methods of treatment are available with varying degree of success
  6. 6. Amputation is aAmputation is a meanmean operationoperation in Diabetic Foot.in Diabetic Foot. Amputation reduces remaining life span of the patient. Amputation makes the person crippled, dependent & a mental wreck.
  7. 7. Therefore all attemptsTherefore all attempts should be made toshould be made to conserve the limb inconserve the limb in Diabetic FootDiabetic Foot
  8. 8. Path-physiology Of VascularPath-physiology Of Vascular Disease In A DiabeticDisease In A Diabetic Macro vascular disease Non-occlusive micro vascular disease
  9. 9. MACROVASCULAR DiseaseMACROVASCULAR Disease Similar to that noted in non-diabetic patients with athero-sclerotic disease except… Generally occurring at an earlier age Affects men and women equally Involves more frequently the TIBIAL and PERONEAL arteries
  10. 10. Non-occlusive MICRONon-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
  11. 11. Diabetes Tissue Necrosis Ischemia Sensory lossMotor loss Neuropathy High sugar (prone to infection) Gangrene Repeated TraumaAbnormal pressure Ulceration (Pathophysiology)
  12. 12. 1.Absence of protective sensation 2.Arterial insufficiency 3.Foot deformity and callus formation resulting in focal areas of high pressure 4.Autonomic neuropathy causing decreased sweating and dry, fissured skin Causes of Ulcerations in the Diabetic Foot
  13. 13. 5.Obesity 6.Impaired vision 7.Poor glucose control leading to impaired wound healing 8.Poor footwear that causes skin breakdown or inadequately protects the skin from high pressure and shear forces Causes of Ulcerations in the Diabetic Foot
  14. 14. 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
  15. 15. INVESTIGATIONSINVESTIGATIONS  Routine blood inv.  Diabetic status  Doppler studies  X-ray  Pus culture and sensitivity  Ankle-Brachial Pressure index (ABPI)
  16. 16. INVESTIGATIONSINVESTIGATIONS  Angiography (preferably DSA)  Pulse volume recorder (PVR)  Transcutaneous oxygen tension  MRA with contrast
  17. 17. Treatment ModalitiesTreatment Modalities  CONVENTIONAL Prevention Medical treatment Estimate and treat vascular insufficiency Surgical: debridement and amputation (Minimum)  OTHER METHODS Hyperbaric oxygen Tissue Granulation Factor (Bionect) Co2 Laser (The Latest)
  18. 18. PREVENTIONPREVENTION Identify and treat HIGH risk patients early Regular blood sugar level check Advice on ideal foot care
  19. 19. Tips to keep your feet healthyTips to keep your feet healthy A) 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 doctor Cont.
  20. 20. Tips to keep your feet healthyTips to keep your feet healthy A) 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
  21. 21. Tips to keep your feet healthyTips to keep your feet healthy B) 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.
  22. 22. MEDICAL TREATMENTMEDICAL TREATMENT Early and prompt control of diabetes with low threshold for use of INSULIN Drugs to improve vascularity Correction of anemia Antibiotics to control infection
  23. 23. Treatment of VascularTreatment of Vascular InsufficiencyInsufficiency MAJOR vessels : a) Angioplasty  b) Vascular Neurolysis MINOR vessels : Lumbar sympathetectomy
  24. 24. SURGICAL TreatmentSURGICAL Treatment  Debridement  Amputation (Minimum)
  25. 25. LASERLASER  L ~ LIGHT  A ~ AMPLIFICATION by  S ~ STIMULATED  E ~ EMISSION of  R ~ RADIATION
  26. 26. BOHR’S TheoryBOHR’S Theory Laser are produced by three basic interactions between PHOTONS and ELECTRONS  Absorption  Spontaneous emission  Stimulated emission
  27. 27. Characteristics of Laser LightCharacteristics of Laser Light COLLIMATED COHERENT MONOCHROMATIC POLARISED
  28. 28. Types of LASERTypes of LASER SOLID state e.g. Ruby & Nd YAG laser LIQUID GAS e.g. HeNe laser CO2 & Argon laser
  29. 29. CO2 Laser gas mixtureCO2 Laser gas mixture consist of 70%, helium, 15%consist of 70%, helium, 15% Co2 & 15% N2Co2 & 15% N2
  30. 30. Laser Tissue InteractionLaser Tissue Interaction  Photochemical : Ablative decomposition & Photodynamic therapy  Thermal : Photocoagulation & Photovaporisation  Mechanical : Photo disruption & Explosive vaporization
  31. 31. GAS LASER DESIGNGAS LASER DESIGN  Consists of 1) Gas filled cavity 2) External optical pumping lights 3) Resonator with partially and totally reflecting mirrors
  32. 32. 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.
  33. 33. BiophysicsBiophysics Laser photostimulation promotes tissue repair process by accelerating Collagen production & promoting overall connective tissue stability. CO2 kills bacteria Converts moist gangrene to dry gangrene. Probably promotes neoangiogenesis (as skin grafts take well following Co2 Laser Therapy in an otherwise ischaemic foot)
  34. 34. Laser Tissue Interaction inLaser Tissue Interaction in CO2 LASERCO2 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
  35. 35. 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
  36. 36. Presentations of Diabetic FootPresentations of Diabetic Foot
  37. 37. I – Case illustrationI – Case illustration Huge,circumferential ulcers of unknown etiology on both lower limbs EIGHT sittings over a period of a month This was followed by regular dressings and split skin graft End result completely healed wounds
  38. 38. 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 laser Wounds healed rapidly leaving ulcers 1/3rd original size,which were grafted End result completely healed wounds
  39. 39. 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
  40. 40. Heel getting involvedHeel getting involved
  41. 41. Deeper Infection -Tendons affectedDeeper Infection -Tendons affected
  42. 42. Transmetatarsal SpreadTransmetatarsal Spread
  43. 43. Infarction of 1st metatarsal
  44. 44. Metatarsal Ulceration – involvement of tendon sheath
  45. 45. Sole Ulceration-Instep regionSole Ulceration-Instep region
  46. 46. Near total sole affectionNear total sole affection
  47. 47. Charcot JointCharcot Joint
  48. 48. 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
  49. 49. 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 Ulcer B) Non Healing wounds C) 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.
  50. 50. Over 100 patients have been treatedOver 100 patients have been treated successfully with CO2 Laser Therapy insuccessfully with CO2 Laser Therapy in the last 5 years. The patients arethe last 5 years. The patients are evaluated fully for anemia, diabeticevaluated fully for anemia, diabetic status, bone involvement & vascularstatus, bone involvement & vascular insufficiency. In case of large ulcers, theinsufficiency. In case of large ulcers, the patient undergoes conventional sloughpatient undergoes conventional slough excision followed by CO2LaserTherapy.excision followed by CO2LaserTherapy. This protocol helps to reduce the hospitalThis protocol helps to reduce the hospital stay considerably.stay considerably.
  51. 51. Thank YouThank You

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