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FREE COMMUNICATION, PHNOM PENH, CAMBODGE, DECEMBER 07, 2017
ORIGINAL ARTICLE
ELEMENTARY RETROSPECTIVE STUDY OF DIABETIC FOOT, ON
180 CASES, AT PREAH KOSSAMAK HOSPITAL, PHNOM PENH,
FROM 2011 JANUARY 1 TO 2015 DECEMBER 31
NGETH Sourn, CHEA Lengkheng, PLANG Samol, NIM Mealea, SOUN Sear, KHEM Tith,
TEK Chanserey, MOM Sophal, UY Viradeth, SIN Sargata
ABSTRACT
Introduction: Diabetic foot is the one of the serious chronic complication of diabetes. In
some cases patients can not cure by use medication alone; the best way for this are
debritment, amputation and other surgical procedure. Amputation provides to patients fear
and disability.
Objective: We study on elementary treatment, and some factors related to this complication.
Material and methods: Retrospective study on 180 diabetic foot that prepare to operation at
surgical department in Preah Kossamak Hospital Phnom Penh from 1st
January 2011 to 31st
December 2015.
Results: Among 180 patients, there are 79 male and 101 female. The minimum age is 30
years old; the maximum age is 75 years old and the majority age is over 60 years old. There
are 126 (70%) farmers, 36 (20%) sellers and 18 (10%) government staff and NGO. Patients
come from 19 different provinces of the country. The total of the debritment are 58 (32.13%)
that 25 (13.8%) are male and 33 (18.33%) are female. The total of amputations are 56 (31%)
that 34 (18.8%) are male and 22 (12.2%) are female. The total of patients refuse to amputation
are 66 (36.6%) that 31 (157.2%) are male and 35 (19.4%) are female. We also found that 84
(46%) patients have high blood pressure, and 11 (6.1%) patients have end stage of renal
failure. The most antibiotic use are Penicillin G and Metronidazole. For antidiabetes Insulin is
in priority.
2
Conclusion: Diabetic foot is the terrible complication that cause disability to the patients. In
our study these complication happen both for the older diabetic patients and the young also.
Related to knowledge we found that the number of intelligence patients are less than those of
non-intelligence. Therefore these complications not only related to uncontrolled glycaemia,
duration of diabetes, but also the patients knowledge. Some of diabetic foot patients refuse to
amputation in unclear reason (no confident on doctors or religion). High blood pressure and
dyslipidemia are commonly associated with diabetic patients including diabetic foot.
Keywords: Debritment; Diabetic; Foot; Glycaemia; Insulin; Amputation; Antibiotic
I- INTRODUCTION
Diabetes mellitus is the group of metabolic disorders characterized by hyperglycemia due
either to a deficiency of insulin secretion, or an abnormal resistance of the tissues to its action.
Hyperglycaemia leads to acute ketoacidosis with a risk of coma and in the long time cause
microvascular, macrovascular damage and nerves lesions [1, 2-6]. Among its complications,
the diabetic foot has now been collected for our study. It is the set of acute and chronic
lesional conditions that initially affect the feet, poorly perforating, single or multiple, with or
without infection, varying in severity leading to simple local care or loss of substances, or
even amputations [2, 4-11]. Diabetic foot is the one of the terrible complication of diabetes.
This chronic pathology is now increasing worldwide [1, 2, 8-13]. The bulk of this increase in
diabetic foot will occur in developing countries where a 70% increase is expected, compared
with a 42% increase in the developed world. This indicates that more than 60% of the world's
diabetic population resides in the Western Pacific region [1-3, 9-13]. Our study is on
epidemiology, diagnosis, clinic, paraclinic certain elementary treatments and some related co-
risk factors. In Cambodia, the number of people with diabetic foot is now increasing,
especially for type 2 diabetes. The amputation of the feet or legs are becoming the big
problem for all diabetic patients. Its gravity is noted by the classification of Wagner said for
University of Texas [2].
II- OBJECTIVES
This study was determined elementary retrospective study of diabetic foot on 180 cases at
Preah Kossamak Hospital Phnom Penh from 1st
January 2011 to 31st
December 2015, after
our research, these results go to medical document.
3
III- MATERIAL AND METHODS
This study only collected the diabetic foot patients operated in surgical department at Preah
Kossamak Hospital in the age group of 30-75 years old from January 01 2011 to December 31
2105.
IV- RESULTS
This retrospective study collected 180 DF cases for five years (2011-2015) at the Preah
Kossamak Hospital in Phnom Penh, Cambodia, including 19 regions (provinces and cities),
79 men (39.5%) and 101 women 60.5% (sex ratio: 1.2), and an average age of 60 years
(extreme ages: 30-75 years). The profession of farmers was the majority. All patients were
prepared before surgery and under standardized anesthesia. The definitive diagnosis was
made by the report of the clinical, paraclinical and pathological examinations postoperatively.
This series was practiced as follows:
• Debridement of the diabetic foot of 58 patients (32.2%).
• The amputation of the diabetic foot by 56 (31.1%).
• Refusal of amputation of the diabetic foot of 66 patients (37 %): Operative
preparation.
Its specific morbidities and its postoperative treatments were linked to this gesture, by means
of clinical controls, imaging and biological systems in a month, three months, six months and
a year. After the surgical treatment of this lesion, the following postoperative results were
observed:
• Refusal of amputation of the diabetic foot: 66 patients (37%).
• Morbidity: 47 patients, or 26%.
• And simple surgery: 67 patients, or 38%.
The final postoperative results of this study were observed for six months to one year:
• Postoperative cure of DF: 66 patients or 37%.
• 21 patients (11.5 %): DF pain.
• 14 patients (7.7%): Recovery of the stump.
• DF persists: 12 patients or 6.6%.
• Mortality: 19 patients (10.4%).
4
• 82 patients or 45%, had not sure a definite prognosis.
This study, among 180 patients, showed that 168 patients (92.4%) did not have stump
recovery and other postoperative complications of the lesion, and surgical treatment of twice
was 12 patients (6.6%). She presented the average expenditure during hospitalization:
• 10 days of 500 US for each our patient: 45 patients (22.5%).
• 15 days of 1,000 US for each patient: 107 patients (63.5%).
• 40 days of 2,000 US for each patient: 28 patients (14%).
• Monthly of 1,500 US for each our patient.
V- DISCUSSION
The prevalence of diabetic foot was the incidence as (Table 1):
• Our study: 18.9%.
• André Gr: 1.8 to 7.4% (United States: 15% and in France: 20%).
• Perlemuter L, and al: 15%.
Our result was between the series of Perlemuter L, and al and André Gr.
Table 1: Comparison of diabetic foot prevalence with other series
Series Percentage (%)
Our study 18.9
André Gr [2]
1.8 to 7 (United States: 15 and in France: 20 for 1,500 000
diabetis)
Perlemuter L, and al [1] 15 (for 50 000 to 150 000 diabetis)
Diabetic podiatry patients (315 cases) admitted to the Preah Kossamak Hospital were
classified into three groups (Table 2):
• Ambulatory patient (AP): 62/315 patients or < 1/5 of total (for the medical
consultation).
• Medical service patient (MSP): 72/315 patients or > 1/5 of total (for medical treatment
of diabetes).
• Surgical service patient (SSP): 180/315 patients (for surgical preparation).
5
In our patients, diabetic foot patients were prepared for short-term diabetic foot surgery (pre-
operative). Our series was almost 3/5 of total.
Table 2: Comparison of inpatients with diabetic foot
Hospitalized patients AP MSP Our serie (SSP)
Comparison
62/315 patients
(< 1/5 of total)
72/315 patients
(> 1/5 of total)
180/315 patients
(< 3/5 of total)
It is confirmed that non-traumatic foot lesions occur in diabetics (Table 3):
• Our study: 57.14%.
• André Gr: 85%.
• Perlemuter L, and al: International Consensus on the Diabetic Foot (40 to 60%).
Our study was between the series of Perlemuter L, and al and André Gr.
Table 3: Comparison of diabetic podiatric lesions with other series
Series Percentage (%)
Our study 57.14
André Gr [2] 85
Perlemuter L, and al [1] 40 to 60
In 2015 (last year of our series), in figure 7, which shows that we have increased more
patients (61 patients (40.5%) compared with the other 5 years (2011-2015), (13.6 patients or
6.5%), the patients were reduced by comparison with the other last years, the André Gr series
(5.6% per year) [2] was smaller than ours, less than 3.5 times in our series on average 20%
(Table 4). The abdications are also related to the progression of the complication of diabetes,
especially in poor countries.
6
Table 4: Comparison of annual patients with other series
Series Percentage per year (%)
Our study 20
André Gr [2] 5.6
In comparing the sexes, the following results were observed (Table 5):
• The percentage of injured foot in diabetic patients is similar in both sexes.
• The rate of the diabetic foot increases with the male sex [2].
• According to statistics in the Bang Kok hospital in 2014, the number of diabetic foot
ulcers for men is higher than the female by 60% compared with 40% [1, 2, 6].
• But our study, the number of women (60.5%) was more than the number of men
(39.5%), that is to say, the female sex was 1.2 times more important than In men,
because the woman was faster osteoporosis (menopausal factor) and overweight than
man.
Table 5: Gender comparisons with other series
Series Comparisons
Perlemuter L, and al [1] 2 sexes were similar
André Gr [2] Masculin sex > Feminin sex
Massol J [6]
Masculin sex (60%) > Feminin sex (40%): 3/5 against 2/5 in
total
Our study Feminin sex (60.5%) > Masculin sex (39.5%): Sex ratio of 1.2
The relationship of age was established (Table 6):
• The rate of diabetic foot increases with age [2].
• The age of patients in our study is 30 to 75 years, but the majority is age over 65
years: 85 patients (52.5%). This explains that atherosclerosis in diabetic patients who
take time from starting point to diabetic foot.
7
Table 6: Age comparisons with other series
Series Results
André Gr [2] It increases with age
Our study Majority: 85 patients or 52.5% (age over 65 years)
In our study, there were 70% of farmers. The quantities of this trade were therefore more
comparable to the others. This may be due to his / her cultural knowledge, education and
standard of living. This severity of the foot depended on the strong plantar pressure of his
work. For André Gr: A running subject can increase his plantar pressure by 40% compared to
that recorded during single walking. Our result was therefore more than that (Table 7).
Table 7: Trade comparisons with other series
Series Percentage (%)
Our study 70
André Gr [2] 20
In general, diabetes will develop on peripheral neuropathy or peripheral vascular disease of
the foot for an average of 20 to 25 years after starting diabetes [1, 2]. The percentage of the
foot lesion in diabetic patients is increased with the duration of diabetes (60%) for André Gr.
In the series of Perlemuter L, and al, it presents 50% of this lesion within five years. However,
our study found that the diabetic duration was decreased with the 5 year-old diabetic foot in
96 patients or 58%, which explains the lack of material and human resource resources (Table
8).
Table 8: Comparisons of diabetes duration with diabetic foot to other series
Series Percentage (%)
André Gr [2] 60 (20 to 25 years)
Perlemuter L, and al [1] 50 (in 5 years)
Our study 58 (< 5 years)
8
High blood pressure is the most common disease associated with diabetic foot patients
(diabetes) after ten to twenty years [1-3]. Sometimes it is isolated from this lesion and
sometimes it occurs after that develops for a long time because the progression of
atherosclerosis. Comparing with the other series in case, there was the following realization
(Table 9):
• Perlemuter L, and al: 15 to 45%.
• André Gr: 18 to 55%.
• Massol J: 67%.
• Our study: 42% (pre-existing HBP: 23.5% and HBP of diabetic complication with DF:
18.5 %).
This rate of our study was the resemblance to the first two series (Perlemuter L, and al, and
André Gr) and lower than the figure of Massol J.
Table 9: Comparisons of HBP with DF to other series
Series Percentage (%)
Perlemuter L, and al [1] 15 to 45
André Gr [2] 18 to 55
Massol J [3] 67
Our study
42: HBP before diabetes (23.5) and HBP after diabetes
with DF (18.5)
A similar complication of atherosclerosis and occur simultaneously with chronic renal failure
or terminal renal insufficiency. This is the serious chronic complication of diabetes. For
patients who do not have a kidney problem when their diabetes is diagnosed,
microalbuminuria develops in 15% and proteinuria develops in 5% within five years [1-3, 6].
In patients with proteinuria, renal failure in the final stage develops about 8% in 10 years [2].
Our study showed renal insufficiency of diabetic complication of 13.5% and irreversible or
terminal renal insufficiency of 5.5%. That is, these two studies are the resemblance of those.
Dyslipidemia is the co-risk factor of atherosclerosis in diabetic patients with diabetic foot. Its
percentage increase in diabetic patients is comparable to health. Hyperlipidemia is the co-
razon factor with hyperglycemia and arterial hypertension for the progression of
atherosclerosis. Keeping lipids to normal or lower is the goal of diabetes management. It is
9
estimated that 50% of American adults with diabetic foot have lipid abnormalities requiring
counseling and medical treatment [2]. Unfortunately, in our study, hyperlipidemia was found
to be 19.5%, which is the lower rate than the above hypercaloric regimen and exercise (Table
10).
Table 10: Comparisons of hyperlipidemia with DF in other series
Series Percentage (%)
André Gr [2] 50
Our study 19.5
HbA 1c, glycaemia, total cholesterol and triglyceride tests are interesting for our patient, but
these practices are neglected. This percentage (50%) increases if patients have type 2 diabetes
by André GR. For the study of Perlemuter L, and al, it is frequent NIDD with the PD of 85%
and the IDD with the DF of 10 to 15%. Our study presented the IDD with the PD of 25% and
the NIDD with the DF for 75%. In carrying out the above studies, our study is between the
other two series (Table 11).
Table 11: Diabetes type comparisons with DF to other series
Séries Percentage (%)
André Gr [2]
• IDD with DF < 50.
• NIDD with DF > 50.
Perlemuter L, and al [1]
• IDD with DF: 10 to 15.
• NIDD with DF: 85.
Our study
• IDD with DF: 25.
• NIDD with DF: 75.
The diabetic foot is the terrible complication of diabetes among other complications. This
usually occurs when diabetic patients develop peripheral neuropathy or peripheral vascular
disease [1, 2]. The other series were collected by comparing with our study (Table 12):
• André Gr:
o DF of angiopathic origin (DFAO): 85%.
o DF of neuropathic origin (DFNO): 15%.
10
• Perlemuter L, and al:
o DF of angiopathic origin: 80%.
o DF of neuropathic origin: 20%.
• Our study:
o DF of neuropathic origin: 28%.
o DF of angiopathic origin: 72%.
Our study was contrary to the other series of the two origins of diabetic foot injury.
Table 12: Comparisons of lesional origin of diabetic foot with other series
Series Percentage (%)
André Gr [2]
• DFAO: 85.
• DFNO: 15.
Perlemuter L, and al [1]
• DFAO: 80.
• DFNO: 20.
Our study
• DFAO: 72.
• DFNO: 28.
The foot of diabetes is a chronic complication indicating that patients become atherosclerosis.
The incidence of an ulcerated wound in diabetic patients was first evaluated from
retrospective studies with 2-3 ulcers/100 patients, a prospective study of 754 diabetics found
an annual incidence of ulcerations 5.6%, and in France, the incidence of ulcerated wounds is
estimated to be 2.5% of André Gr. For the study of Perlemuter L, and al, it is 20%. Our study
performed 5.5% (Table 13).
Table 13: Comparisons of ulcerative lesion of the diabetic foot with other series
Series Percentage (%)
André Gr [2]
• Retrospective studies: 2 to 3.
• Prospective study (754 DF): 5.6.
• In France: 2.5.
Perlemuter L, and al [1] 20
11
Our study 5.5
In the study of Perlemuter L, and al, it presents the amputations of the diabetic foot by 50%.
For André Gr, in the United States, 50% of non-traumatic leg amputations are performed on
diabetic patients. It is estimated that 5-10% of diabetic patients are at risk of being amputated.
In our study, 56 patients (28%) were found to have only amputation (in women 11%). In this
situation, data can not be found in other hospitals to make a comparison in Cambodia. But it
was between the two series above (Table 14).
Table 14: Comparison of diabetic foot amputation to other series
Series Percentage (%)
Perlemuter L, and al [1] 50
André Gr [2] 5 to 10
Our study 28
The percentages of refusal of amputation (43%) are still high. The motivation for this refusal
is not clear. Perhaps because of religion or confidence in the doctor. The diabetic foot is
usually caused by Gram positive, gram negative and anaerobic bacteria [1, 2]. The common
antibiotic that is pathogen-sensitive is Quinolon, Vancomysin, the second and third generation
of Cephalosporin and the Penicillin family [2]. But sometimes, due to resistance to pathogens,
they must do an antibiogram [2]. In our study, all patients were used with single Penicillin G
(69%) and Penicillin G and Metrodinazol (31%). All studies are still probabilistic
antibiotherapies for diabetic feet (Table 15).
12
Table 15: Comparisons of diabetic foot antibiotherapy with other series
Series Antibiotherapy
Perlemuter L, and al [1] Probabilistic antibiotherapies
André Gr [2]
Probabilistic antibiotherapies:
• Quinolon.
• Vancomysin.
• Second and third generation of Cephalosporin.
• Penicillin family.
Our study
Probabilistic antibiotherapies:
• Pénicilin G unique (69%).
• Pénicilin G et Métrodinazol (31%).
Foot ulcer is one of the other chronic complications of diabetes. Usually the ulcer is cured by
antibiotics as non-diabetic patients if the vessels do not yet present complete obstruction.
Some patients with foot ulcer have total or incomplete obstruction. This type of patient must
make a debris or an amputation [2, 7, 8]. For insulin-dependent patients who are in
perioperative operation, insulin is used and the antitetanus vaccination update is used [1]. On
the contrary, for our study, all patients used insulin before, during and after surgery in 79 %
and oral antidiabetics (29%). The drug that also uses in our study is analgesic (37% of
peripheral and 63% of low opioid), tetanus serum from all patients, saline and multivitamin
(Tables 16-18). The care is always with the products of antiseptic current in all the studies.
Table 16: Diabetic foot antidiabetic comparisons to the other series
Series Antidiabétics
Perlemuter L, and al [1] • Insulinothérapy
Our study
• Insulin: 79%.
• Oral antidiabétics: 29%.
13
Table 17: Comparison of anti-tetanus of the diabetic foot to the other series
Series Antitétanics
Perlemuter L, and al [1] Antitetanus vaccination
Our study Tetanus serum
Table 18: Diabetic foot anesthetic comparisons to the other series
Series Analgésics
Perlemuter L, and al [1] Non precision
Our study
Analgesic minor of 37%.
Analgesic low opioid of 63%.
For the study of André Gr, it presents the length of hospitalization can vary from 14 to 45
days of 20% for diabetic foot injury. In the study of Perlemuter L, and al, she notes the
hospital stay on average of 14 to 45 days for the 80% diabetic foot. At the hospitalized
duration, our study was 15 to 30 days of 77.5%, and the short time and lower rate of the study
discussed above (Table 19).
Table 19: Comparisons of hospitalized length of diabetic foot with other series
Series Percentage (%)
Perlemuter L, and al [1] 50 (14 to 45 days)
André Gr [2] 5 to 10 (14 to 45 days)
Our study 77.5 (15 to 40 days)
The amputation recurrence rate is 6 to 30% of the amputees in one to three years after the first
amputation [2]. Our study for six months to a year, we had 6 to 13%. It was lower than the
above result (Table 20).
14
Table 20: Comparisons of recidivism of the amputee diabetic foot with the other series
Series Percentage (%)
André Gr [2] 6 to 30 (1-3 years)
Our study 6 to 13 (6 m-1 year)
The survival rate of diabetic foot amputee patients is approximately 50% 5 years, which
varies according to the studies [2]. Our study for six months to one year showed mortality of
9.5% (19/91 appointments/180 cases), lower than the previous study, and unspecified
(Table 21).
Table 21: Comparisons of mortality of the amputee diabetic foot with the other series
Series Percentage (19/91 of appointment /180 cas)
André Gr [2] 50
Our study 9.5 (non précision)
The average monthly cost was 2,260 € for inpatients [2]. In our study, it totaled the average
monthly expenditure of 1,500 US for each hospitalized patient, the cost is 1.5 times less of its
study (Table 22).
Table 22: Economic cost comparisons of diabetic foot to other series
Series Hospitalization cost/month
André Gr [2] 2,260 €
Our study 1,500 US
VI- CONCLUSION
Foot Diabetes is the serious complication that can occur early if diabetic patients can not
appropriately receive proper management. In our study, it was found that diabetic foot
patients, particularly gangrene, can occur not only in elderly patients but also in young people.
Progression to chronic complications is also related to patient knowledge, education,
occupation, culture and religion. This study, 37% of patients refuse to amputation. This is not
15
clarified, perhaps because of religion or the confidence of the doctor. Finally, the foot is the
site of frequent macerations, explaining the risk of bacterial and mycotic infections, especially
since the particular structure of the foot, with its three compartments, allows an easy and rapid
propagation of the infectious process. He could have the invalid become as a burden to
society, her family and himself, and affect her own future.
Consideration of academic ethics: That is to say, all rights reserved.
VII- REFERENCES
1. Perlemuter L, Collin of L’hortet G, Sélam JL. Diabetes Abbreviations and Metabolic
Diseases. Diabetic Foot. 3rd
ed. Paris: Masson; 2000: p.237-42.
2. André Gr. Treatise on Diabetology. Diabetic Foot. Paris: Flammarion Medicine-Sciences;
2005: p. 733-57.
3. Perlemuter L, Perlemuter G. Diabetes Mellitus. In: Perlemuter L, Perlemuter G, editors.
Therapeutic Guide. 8th
ed. Paris, France: Elsevier Masson SAS; 2015. p. 354-400.
4. Dorosz. Type I and Type II Diabetes and Other Carbohydrate Metabolism Abnormalities.
In: Dorosz editor. Practical Guide to Medicines. 36th
edi. Paris, France: Maloine; 2017. p.
740-67.
5. Leguerrier A, Langanay T, Rosat P, Meunier B. New Anatomy Records P.C.E.M.:
Inferior Leg. 2nd
ed. Paris: Editions Scientifiques and Juridiques; 1988: p.201-6.
6. Massol J. Decision in Endocrinology, Diabetology and Nutrition. Diabetes. Edition Vigot.
Paris: January 1997. p. 233-328.
7. . Courtney M, Townsend CM Jr. Surgical Aspects of Diabetes Mellitus. In: Pappas TN,
editors. The biological basis of modern surgical practice. 16th
ed. Philadelphia: W.B
Saunders; 2001. p. 176-85.
8. Proye C, Dubost C. Surgical endocrinology. Transplantation of Endocrine Tissue. Paris:
MEDSI-McGraw-Hill; 1991. p. 313-22.
9. Thomas KH. Scarring (diabetes). In: Surgery (diagnosis and treatment). French edition,
PICCIN; 1990: 111-24.
16
10. Trésallet CH, Peix JP. Treaty of Endocrine Surgery. Pancreatic transplantation. Editions
Jonhn Libbey Eurotex, Paris; 2016, Volume 2: p.257-62.
11. Fred FF. Pratical Guide to The care medical patient; Elsevier MOSOBY.7th
Edit; 2007:
p.138-60.
12. Hemant G, Michael N. The Washinton Manual of Medical Therapeutic; Indian: 34th
Edit;
2014: p.608-19.
13. Thomas MH. Endocrinology. In: Mayo Clinic Internal Mediccine Board Revieew. USA:
5th
ed; 2002-2003: p. 223-88.

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  • 1. 1 FREE COMMUNICATION, PHNOM PENH, CAMBODGE, DECEMBER 07, 2017 ORIGINAL ARTICLE ELEMENTARY RETROSPECTIVE STUDY OF DIABETIC FOOT, ON 180 CASES, AT PREAH KOSSAMAK HOSPITAL, PHNOM PENH, FROM 2011 JANUARY 1 TO 2015 DECEMBER 31 NGETH Sourn, CHEA Lengkheng, PLANG Samol, NIM Mealea, SOUN Sear, KHEM Tith, TEK Chanserey, MOM Sophal, UY Viradeth, SIN Sargata ABSTRACT Introduction: Diabetic foot is the one of the serious chronic complication of diabetes. In some cases patients can not cure by use medication alone; the best way for this are debritment, amputation and other surgical procedure. Amputation provides to patients fear and disability. Objective: We study on elementary treatment, and some factors related to this complication. Material and methods: Retrospective study on 180 diabetic foot that prepare to operation at surgical department in Preah Kossamak Hospital Phnom Penh from 1st January 2011 to 31st December 2015. Results: Among 180 patients, there are 79 male and 101 female. The minimum age is 30 years old; the maximum age is 75 years old and the majority age is over 60 years old. There are 126 (70%) farmers, 36 (20%) sellers and 18 (10%) government staff and NGO. Patients come from 19 different provinces of the country. The total of the debritment are 58 (32.13%) that 25 (13.8%) are male and 33 (18.33%) are female. The total of amputations are 56 (31%) that 34 (18.8%) are male and 22 (12.2%) are female. The total of patients refuse to amputation are 66 (36.6%) that 31 (157.2%) are male and 35 (19.4%) are female. We also found that 84 (46%) patients have high blood pressure, and 11 (6.1%) patients have end stage of renal failure. The most antibiotic use are Penicillin G and Metronidazole. For antidiabetes Insulin is in priority.
  • 2. 2 Conclusion: Diabetic foot is the terrible complication that cause disability to the patients. In our study these complication happen both for the older diabetic patients and the young also. Related to knowledge we found that the number of intelligence patients are less than those of non-intelligence. Therefore these complications not only related to uncontrolled glycaemia, duration of diabetes, but also the patients knowledge. Some of diabetic foot patients refuse to amputation in unclear reason (no confident on doctors or religion). High blood pressure and dyslipidemia are commonly associated with diabetic patients including diabetic foot. Keywords: Debritment; Diabetic; Foot; Glycaemia; Insulin; Amputation; Antibiotic I- INTRODUCTION Diabetes mellitus is the group of metabolic disorders characterized by hyperglycemia due either to a deficiency of insulin secretion, or an abnormal resistance of the tissues to its action. Hyperglycaemia leads to acute ketoacidosis with a risk of coma and in the long time cause microvascular, macrovascular damage and nerves lesions [1, 2-6]. Among its complications, the diabetic foot has now been collected for our study. It is the set of acute and chronic lesional conditions that initially affect the feet, poorly perforating, single or multiple, with or without infection, varying in severity leading to simple local care or loss of substances, or even amputations [2, 4-11]. Diabetic foot is the one of the terrible complication of diabetes. This chronic pathology is now increasing worldwide [1, 2, 8-13]. The bulk of this increase in diabetic foot will occur in developing countries where a 70% increase is expected, compared with a 42% increase in the developed world. This indicates that more than 60% of the world's diabetic population resides in the Western Pacific region [1-3, 9-13]. Our study is on epidemiology, diagnosis, clinic, paraclinic certain elementary treatments and some related co- risk factors. In Cambodia, the number of people with diabetic foot is now increasing, especially for type 2 diabetes. The amputation of the feet or legs are becoming the big problem for all diabetic patients. Its gravity is noted by the classification of Wagner said for University of Texas [2]. II- OBJECTIVES This study was determined elementary retrospective study of diabetic foot on 180 cases at Preah Kossamak Hospital Phnom Penh from 1st January 2011 to 31st December 2015, after our research, these results go to medical document.
  • 3. 3 III- MATERIAL AND METHODS This study only collected the diabetic foot patients operated in surgical department at Preah Kossamak Hospital in the age group of 30-75 years old from January 01 2011 to December 31 2105. IV- RESULTS This retrospective study collected 180 DF cases for five years (2011-2015) at the Preah Kossamak Hospital in Phnom Penh, Cambodia, including 19 regions (provinces and cities), 79 men (39.5%) and 101 women 60.5% (sex ratio: 1.2), and an average age of 60 years (extreme ages: 30-75 years). The profession of farmers was the majority. All patients were prepared before surgery and under standardized anesthesia. The definitive diagnosis was made by the report of the clinical, paraclinical and pathological examinations postoperatively. This series was practiced as follows: • Debridement of the diabetic foot of 58 patients (32.2%). • The amputation of the diabetic foot by 56 (31.1%). • Refusal of amputation of the diabetic foot of 66 patients (37 %): Operative preparation. Its specific morbidities and its postoperative treatments were linked to this gesture, by means of clinical controls, imaging and biological systems in a month, three months, six months and a year. After the surgical treatment of this lesion, the following postoperative results were observed: • Refusal of amputation of the diabetic foot: 66 patients (37%). • Morbidity: 47 patients, or 26%. • And simple surgery: 67 patients, or 38%. The final postoperative results of this study were observed for six months to one year: • Postoperative cure of DF: 66 patients or 37%. • 21 patients (11.5 %): DF pain. • 14 patients (7.7%): Recovery of the stump. • DF persists: 12 patients or 6.6%. • Mortality: 19 patients (10.4%).
  • 4. 4 • 82 patients or 45%, had not sure a definite prognosis. This study, among 180 patients, showed that 168 patients (92.4%) did not have stump recovery and other postoperative complications of the lesion, and surgical treatment of twice was 12 patients (6.6%). She presented the average expenditure during hospitalization: • 10 days of 500 US for each our patient: 45 patients (22.5%). • 15 days of 1,000 US for each patient: 107 patients (63.5%). • 40 days of 2,000 US for each patient: 28 patients (14%). • Monthly of 1,500 US for each our patient. V- DISCUSSION The prevalence of diabetic foot was the incidence as (Table 1): • Our study: 18.9%. • André Gr: 1.8 to 7.4% (United States: 15% and in France: 20%). • Perlemuter L, and al: 15%. Our result was between the series of Perlemuter L, and al and André Gr. Table 1: Comparison of diabetic foot prevalence with other series Series Percentage (%) Our study 18.9 André Gr [2] 1.8 to 7 (United States: 15 and in France: 20 for 1,500 000 diabetis) Perlemuter L, and al [1] 15 (for 50 000 to 150 000 diabetis) Diabetic podiatry patients (315 cases) admitted to the Preah Kossamak Hospital were classified into three groups (Table 2): • Ambulatory patient (AP): 62/315 patients or < 1/5 of total (for the medical consultation). • Medical service patient (MSP): 72/315 patients or > 1/5 of total (for medical treatment of diabetes). • Surgical service patient (SSP): 180/315 patients (for surgical preparation).
  • 5. 5 In our patients, diabetic foot patients were prepared for short-term diabetic foot surgery (pre- operative). Our series was almost 3/5 of total. Table 2: Comparison of inpatients with diabetic foot Hospitalized patients AP MSP Our serie (SSP) Comparison 62/315 patients (< 1/5 of total) 72/315 patients (> 1/5 of total) 180/315 patients (< 3/5 of total) It is confirmed that non-traumatic foot lesions occur in diabetics (Table 3): • Our study: 57.14%. • André Gr: 85%. • Perlemuter L, and al: International Consensus on the Diabetic Foot (40 to 60%). Our study was between the series of Perlemuter L, and al and André Gr. Table 3: Comparison of diabetic podiatric lesions with other series Series Percentage (%) Our study 57.14 André Gr [2] 85 Perlemuter L, and al [1] 40 to 60 In 2015 (last year of our series), in figure 7, which shows that we have increased more patients (61 patients (40.5%) compared with the other 5 years (2011-2015), (13.6 patients or 6.5%), the patients were reduced by comparison with the other last years, the André Gr series (5.6% per year) [2] was smaller than ours, less than 3.5 times in our series on average 20% (Table 4). The abdications are also related to the progression of the complication of diabetes, especially in poor countries.
  • 6. 6 Table 4: Comparison of annual patients with other series Series Percentage per year (%) Our study 20 André Gr [2] 5.6 In comparing the sexes, the following results were observed (Table 5): • The percentage of injured foot in diabetic patients is similar in both sexes. • The rate of the diabetic foot increases with the male sex [2]. • According to statistics in the Bang Kok hospital in 2014, the number of diabetic foot ulcers for men is higher than the female by 60% compared with 40% [1, 2, 6]. • But our study, the number of women (60.5%) was more than the number of men (39.5%), that is to say, the female sex was 1.2 times more important than In men, because the woman was faster osteoporosis (menopausal factor) and overweight than man. Table 5: Gender comparisons with other series Series Comparisons Perlemuter L, and al [1] 2 sexes were similar André Gr [2] Masculin sex > Feminin sex Massol J [6] Masculin sex (60%) > Feminin sex (40%): 3/5 against 2/5 in total Our study Feminin sex (60.5%) > Masculin sex (39.5%): Sex ratio of 1.2 The relationship of age was established (Table 6): • The rate of diabetic foot increases with age [2]. • The age of patients in our study is 30 to 75 years, but the majority is age over 65 years: 85 patients (52.5%). This explains that atherosclerosis in diabetic patients who take time from starting point to diabetic foot.
  • 7. 7 Table 6: Age comparisons with other series Series Results André Gr [2] It increases with age Our study Majority: 85 patients or 52.5% (age over 65 years) In our study, there were 70% of farmers. The quantities of this trade were therefore more comparable to the others. This may be due to his / her cultural knowledge, education and standard of living. This severity of the foot depended on the strong plantar pressure of his work. For André Gr: A running subject can increase his plantar pressure by 40% compared to that recorded during single walking. Our result was therefore more than that (Table 7). Table 7: Trade comparisons with other series Series Percentage (%) Our study 70 André Gr [2] 20 In general, diabetes will develop on peripheral neuropathy or peripheral vascular disease of the foot for an average of 20 to 25 years after starting diabetes [1, 2]. The percentage of the foot lesion in diabetic patients is increased with the duration of diabetes (60%) for André Gr. In the series of Perlemuter L, and al, it presents 50% of this lesion within five years. However, our study found that the diabetic duration was decreased with the 5 year-old diabetic foot in 96 patients or 58%, which explains the lack of material and human resource resources (Table 8). Table 8: Comparisons of diabetes duration with diabetic foot to other series Series Percentage (%) André Gr [2] 60 (20 to 25 years) Perlemuter L, and al [1] 50 (in 5 years) Our study 58 (< 5 years)
  • 8. 8 High blood pressure is the most common disease associated with diabetic foot patients (diabetes) after ten to twenty years [1-3]. Sometimes it is isolated from this lesion and sometimes it occurs after that develops for a long time because the progression of atherosclerosis. Comparing with the other series in case, there was the following realization (Table 9): • Perlemuter L, and al: 15 to 45%. • André Gr: 18 to 55%. • Massol J: 67%. • Our study: 42% (pre-existing HBP: 23.5% and HBP of diabetic complication with DF: 18.5 %). This rate of our study was the resemblance to the first two series (Perlemuter L, and al, and André Gr) and lower than the figure of Massol J. Table 9: Comparisons of HBP with DF to other series Series Percentage (%) Perlemuter L, and al [1] 15 to 45 André Gr [2] 18 to 55 Massol J [3] 67 Our study 42: HBP before diabetes (23.5) and HBP after diabetes with DF (18.5) A similar complication of atherosclerosis and occur simultaneously with chronic renal failure or terminal renal insufficiency. This is the serious chronic complication of diabetes. For patients who do not have a kidney problem when their diabetes is diagnosed, microalbuminuria develops in 15% and proteinuria develops in 5% within five years [1-3, 6]. In patients with proteinuria, renal failure in the final stage develops about 8% in 10 years [2]. Our study showed renal insufficiency of diabetic complication of 13.5% and irreversible or terminal renal insufficiency of 5.5%. That is, these two studies are the resemblance of those. Dyslipidemia is the co-risk factor of atherosclerosis in diabetic patients with diabetic foot. Its percentage increase in diabetic patients is comparable to health. Hyperlipidemia is the co- razon factor with hyperglycemia and arterial hypertension for the progression of atherosclerosis. Keeping lipids to normal or lower is the goal of diabetes management. It is
  • 9. 9 estimated that 50% of American adults with diabetic foot have lipid abnormalities requiring counseling and medical treatment [2]. Unfortunately, in our study, hyperlipidemia was found to be 19.5%, which is the lower rate than the above hypercaloric regimen and exercise (Table 10). Table 10: Comparisons of hyperlipidemia with DF in other series Series Percentage (%) André Gr [2] 50 Our study 19.5 HbA 1c, glycaemia, total cholesterol and triglyceride tests are interesting for our patient, but these practices are neglected. This percentage (50%) increases if patients have type 2 diabetes by André GR. For the study of Perlemuter L, and al, it is frequent NIDD with the PD of 85% and the IDD with the DF of 10 to 15%. Our study presented the IDD with the PD of 25% and the NIDD with the DF for 75%. In carrying out the above studies, our study is between the other two series (Table 11). Table 11: Diabetes type comparisons with DF to other series Séries Percentage (%) André Gr [2] • IDD with DF < 50. • NIDD with DF > 50. Perlemuter L, and al [1] • IDD with DF: 10 to 15. • NIDD with DF: 85. Our study • IDD with DF: 25. • NIDD with DF: 75. The diabetic foot is the terrible complication of diabetes among other complications. This usually occurs when diabetic patients develop peripheral neuropathy or peripheral vascular disease [1, 2]. The other series were collected by comparing with our study (Table 12): • André Gr: o DF of angiopathic origin (DFAO): 85%. o DF of neuropathic origin (DFNO): 15%.
  • 10. 10 • Perlemuter L, and al: o DF of angiopathic origin: 80%. o DF of neuropathic origin: 20%. • Our study: o DF of neuropathic origin: 28%. o DF of angiopathic origin: 72%. Our study was contrary to the other series of the two origins of diabetic foot injury. Table 12: Comparisons of lesional origin of diabetic foot with other series Series Percentage (%) André Gr [2] • DFAO: 85. • DFNO: 15. Perlemuter L, and al [1] • DFAO: 80. • DFNO: 20. Our study • DFAO: 72. • DFNO: 28. The foot of diabetes is a chronic complication indicating that patients become atherosclerosis. The incidence of an ulcerated wound in diabetic patients was first evaluated from retrospective studies with 2-3 ulcers/100 patients, a prospective study of 754 diabetics found an annual incidence of ulcerations 5.6%, and in France, the incidence of ulcerated wounds is estimated to be 2.5% of André Gr. For the study of Perlemuter L, and al, it is 20%. Our study performed 5.5% (Table 13). Table 13: Comparisons of ulcerative lesion of the diabetic foot with other series Series Percentage (%) André Gr [2] • Retrospective studies: 2 to 3. • Prospective study (754 DF): 5.6. • In France: 2.5. Perlemuter L, and al [1] 20
  • 11. 11 Our study 5.5 In the study of Perlemuter L, and al, it presents the amputations of the diabetic foot by 50%. For André Gr, in the United States, 50% of non-traumatic leg amputations are performed on diabetic patients. It is estimated that 5-10% of diabetic patients are at risk of being amputated. In our study, 56 patients (28%) were found to have only amputation (in women 11%). In this situation, data can not be found in other hospitals to make a comparison in Cambodia. But it was between the two series above (Table 14). Table 14: Comparison of diabetic foot amputation to other series Series Percentage (%) Perlemuter L, and al [1] 50 André Gr [2] 5 to 10 Our study 28 The percentages of refusal of amputation (43%) are still high. The motivation for this refusal is not clear. Perhaps because of religion or confidence in the doctor. The diabetic foot is usually caused by Gram positive, gram negative and anaerobic bacteria [1, 2]. The common antibiotic that is pathogen-sensitive is Quinolon, Vancomysin, the second and third generation of Cephalosporin and the Penicillin family [2]. But sometimes, due to resistance to pathogens, they must do an antibiogram [2]. In our study, all patients were used with single Penicillin G (69%) and Penicillin G and Metrodinazol (31%). All studies are still probabilistic antibiotherapies for diabetic feet (Table 15).
  • 12. 12 Table 15: Comparisons of diabetic foot antibiotherapy with other series Series Antibiotherapy Perlemuter L, and al [1] Probabilistic antibiotherapies André Gr [2] Probabilistic antibiotherapies: • Quinolon. • Vancomysin. • Second and third generation of Cephalosporin. • Penicillin family. Our study Probabilistic antibiotherapies: • Pénicilin G unique (69%). • Pénicilin G et Métrodinazol (31%). Foot ulcer is one of the other chronic complications of diabetes. Usually the ulcer is cured by antibiotics as non-diabetic patients if the vessels do not yet present complete obstruction. Some patients with foot ulcer have total or incomplete obstruction. This type of patient must make a debris or an amputation [2, 7, 8]. For insulin-dependent patients who are in perioperative operation, insulin is used and the antitetanus vaccination update is used [1]. On the contrary, for our study, all patients used insulin before, during and after surgery in 79 % and oral antidiabetics (29%). The drug that also uses in our study is analgesic (37% of peripheral and 63% of low opioid), tetanus serum from all patients, saline and multivitamin (Tables 16-18). The care is always with the products of antiseptic current in all the studies. Table 16: Diabetic foot antidiabetic comparisons to the other series Series Antidiabétics Perlemuter L, and al [1] • Insulinothérapy Our study • Insulin: 79%. • Oral antidiabétics: 29%.
  • 13. 13 Table 17: Comparison of anti-tetanus of the diabetic foot to the other series Series Antitétanics Perlemuter L, and al [1] Antitetanus vaccination Our study Tetanus serum Table 18: Diabetic foot anesthetic comparisons to the other series Series Analgésics Perlemuter L, and al [1] Non precision Our study Analgesic minor of 37%. Analgesic low opioid of 63%. For the study of André Gr, it presents the length of hospitalization can vary from 14 to 45 days of 20% for diabetic foot injury. In the study of Perlemuter L, and al, she notes the hospital stay on average of 14 to 45 days for the 80% diabetic foot. At the hospitalized duration, our study was 15 to 30 days of 77.5%, and the short time and lower rate of the study discussed above (Table 19). Table 19: Comparisons of hospitalized length of diabetic foot with other series Series Percentage (%) Perlemuter L, and al [1] 50 (14 to 45 days) André Gr [2] 5 to 10 (14 to 45 days) Our study 77.5 (15 to 40 days) The amputation recurrence rate is 6 to 30% of the amputees in one to three years after the first amputation [2]. Our study for six months to a year, we had 6 to 13%. It was lower than the above result (Table 20).
  • 14. 14 Table 20: Comparisons of recidivism of the amputee diabetic foot with the other series Series Percentage (%) André Gr [2] 6 to 30 (1-3 years) Our study 6 to 13 (6 m-1 year) The survival rate of diabetic foot amputee patients is approximately 50% 5 years, which varies according to the studies [2]. Our study for six months to one year showed mortality of 9.5% (19/91 appointments/180 cases), lower than the previous study, and unspecified (Table 21). Table 21: Comparisons of mortality of the amputee diabetic foot with the other series Series Percentage (19/91 of appointment /180 cas) André Gr [2] 50 Our study 9.5 (non précision) The average monthly cost was 2,260 € for inpatients [2]. In our study, it totaled the average monthly expenditure of 1,500 US for each hospitalized patient, the cost is 1.5 times less of its study (Table 22). Table 22: Economic cost comparisons of diabetic foot to other series Series Hospitalization cost/month André Gr [2] 2,260 € Our study 1,500 US VI- CONCLUSION Foot Diabetes is the serious complication that can occur early if diabetic patients can not appropriately receive proper management. In our study, it was found that diabetic foot patients, particularly gangrene, can occur not only in elderly patients but also in young people. Progression to chronic complications is also related to patient knowledge, education, occupation, culture and religion. This study, 37% of patients refuse to amputation. This is not
  • 15. 15 clarified, perhaps because of religion or the confidence of the doctor. Finally, the foot is the site of frequent macerations, explaining the risk of bacterial and mycotic infections, especially since the particular structure of the foot, with its three compartments, allows an easy and rapid propagation of the infectious process. He could have the invalid become as a burden to society, her family and himself, and affect her own future. Consideration of academic ethics: That is to say, all rights reserved. VII- REFERENCES 1. Perlemuter L, Collin of L’hortet G, Sélam JL. Diabetes Abbreviations and Metabolic Diseases. Diabetic Foot. 3rd ed. Paris: Masson; 2000: p.237-42. 2. André Gr. Treatise on Diabetology. Diabetic Foot. Paris: Flammarion Medicine-Sciences; 2005: p. 733-57. 3. Perlemuter L, Perlemuter G. Diabetes Mellitus. In: Perlemuter L, Perlemuter G, editors. Therapeutic Guide. 8th ed. Paris, France: Elsevier Masson SAS; 2015. p. 354-400. 4. Dorosz. Type I and Type II Diabetes and Other Carbohydrate Metabolism Abnormalities. In: Dorosz editor. Practical Guide to Medicines. 36th edi. Paris, France: Maloine; 2017. p. 740-67. 5. Leguerrier A, Langanay T, Rosat P, Meunier B. New Anatomy Records P.C.E.M.: Inferior Leg. 2nd ed. Paris: Editions Scientifiques and Juridiques; 1988: p.201-6. 6. Massol J. Decision in Endocrinology, Diabetology and Nutrition. Diabetes. Edition Vigot. Paris: January 1997. p. 233-328. 7. . Courtney M, Townsend CM Jr. Surgical Aspects of Diabetes Mellitus. In: Pappas TN, editors. The biological basis of modern surgical practice. 16th ed. Philadelphia: W.B Saunders; 2001. p. 176-85. 8. Proye C, Dubost C. Surgical endocrinology. Transplantation of Endocrine Tissue. Paris: MEDSI-McGraw-Hill; 1991. p. 313-22. 9. Thomas KH. Scarring (diabetes). In: Surgery (diagnosis and treatment). French edition, PICCIN; 1990: 111-24.
  • 16. 16 10. Trésallet CH, Peix JP. Treaty of Endocrine Surgery. Pancreatic transplantation. Editions Jonhn Libbey Eurotex, Paris; 2016, Volume 2: p.257-62. 11. Fred FF. Pratical Guide to The care medical patient; Elsevier MOSOBY.7th Edit; 2007: p.138-60. 12. Hemant G, Michael N. The Washinton Manual of Medical Therapeutic; Indian: 34th Edit; 2014: p.608-19. 13. Thomas MH. Endocrinology. In: Mayo Clinic Internal Mediccine Board Revieew. USA: 5th ed; 2002-2003: p. 223-88.