Tsvetkov Vitaly O, Gorshunova Elena M, Kolovanova Olga V, Kozlov Jury A, Gobegishvili Vakhtang V
I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
V.V. Vinogradov Moscow Municipal Hospital, Moscow Healthcare Department, Moscow, Russia.
Ann Med Surg (Lond). 2020 Nov 24;60:587-591. doi: 10.1016/j.amsu.2020.11.045. eCollection 2020 Dec.
The results of lower limb amputation, especially in critically ill patients with severe endogenous intoxication, sepsis, multi-organ failure and severe concomitant diseases are still unsatisfactory. Guillotine amputation is a method routinely used to reduce wound complications associated with wet gangrene and severe cases of diabetic foot, however, it is unclear how well it could help to decrease mortality and improve functional outcome when dealing with critically ill patients.
of the study was to estimate the effectiveness of two-phase method of urgent low limb amputation among critically ill patients with high risk of complications. The effectiveness was evaluated in terms of perioperative mortality, frequency of early complications and ultimate level of limb loss.
Two cohort groups of patients with acute lower limb gangrene were retrospectively matched. Approximately 25.8% of patients from the comparison (control) group (N = 240) died without surgery due to severity of their condition and ineffective pre-operative treatment. The remaining patients underwent one-phase high-level amputation after 48-72 h of pre-operative intensive care. The experimental group consisted of 153 patients who underwent guillotine amputation at the lower part of tibia (34.6%), knee disarticulation (32.0%), or open thigh amputation (33.3%), depending on the level of irreversible soft tissue necrosis. The reamputation with the stump shaping was performed later when their health status improved.
The assessment of treatment outcomes showed that the two-phase amputation in critically ill patients (i) decreased the mortality from 48.7 to 37.9%, (ii) reduced the risk of wound complications from 20.9 to 11.1%, and (iii) improved functional results by saving the knee joint in 34.6 versus 4.5% in comparison/control group.
The method of two-phase amputation is recommended for critically ill patients
下肢截肢的结果，尤其是在患有严重内源性中毒、败血症、多器官功能衰竭和严重合并症的重症患者中，仍然不尽人意。断头术截肢是一种常规用于减少与湿性坏疽和严重糖尿病足病例相关的伤口并发症的方法，然而，在处理重症患者时，它在降低死亡率和改善功能结局方面的效果尚不清楚。
评估在具有高并发症风险的重症患者中采用两阶段紧急下肢截肢方法的有效性。从围手术期死亡率、早期并发症发生率和最终截肢水平方面评估有效性。
对两组急性下肢坏疽患者进行回顾性匹配。对照组（N = 240）中约25.8%的患者由于病情严重和术前治疗无效而未手术死亡。其余患者在术前重症监护48 - 72小时后接受一期高位截肢。实验组由153例患者组成，根据不可逆软组织坏死的程度，分别在胫骨下部进行断头术截肢（34.6%）、膝关节离断（32.0%）或大腿开放性截肢（33.3%）。待其健康状况改善后再进行残端整形的再次截肢。
治疗结果评估显示，重症患者的两阶段截肢（i）将死亡率从48.7%降至37.9%，（ii）将伤口并发症风险从20.9%降至11.1%，（iii）通过保留膝关节改善了功能结果，实验组为34.6%，而对照组为4.5%。
推荐对重症患者采用两阶段截肢方法
