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

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.

19.4 million 1995 AD

INDIA - THE WORLD CAPITAL OF DIABETES

57.2 million2025 AD

- WHO ESTIMATE

140 %

IndiaWorld Diabetes Capital

2025

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

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.

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

Path-physiology Of Vascular Path-physiology Of Vascular Disease In A Diabetic Disease In A Diabetic

Macro vascular disease

Non-occlusive micro vascular disease

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

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

Diabetes

Tissue Necrosis

Ischemia

Sensory lossMotor loss

NeuropathyHigh sugar

(prone to infection)

Gangrene

Repeated TraumaAbnormal pressure

Ulceration

(Pathophysiology)

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

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

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

INVESTIGATIONSINVESTIGATIONS

Routine blood inv. Diabetic status Doppler studies X-ray Pus culture and

sensitivity Ankle-Brachial

Pressure index (ABPI)

INVESTIGATIONSINVESTIGATIONS

Angiography (preferably DSA)

Pulse volume recorder (PVR)

Transcutaneous oxygen tension

MRA with contrast

Treatment ModalitiesTreatment Modalities

CONVENTIONALPreventionMedical treatmentEstimate and treat

vascular insufficiency

Surgical: debridementand amputation (Minimum)

OTHER METHODSHyperbaric oxygenTissue Granulation

Factor (Bionect)

Co2 Laser (The Latest)

PREVENTIONPREVENTION

Identify and treat HIGH risk patients earlyRegular blood sugar level checkAdvice on ideal foot care

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.

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

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.

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

Treatment of Vascular Treatment of Vascular InsufficiencyInsufficiency

MAJOR vessels : a) Angioplasty b) Vascular NeurolysisMINOR vessels : Lumbar

sympathetectomy

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 Spontaneous emission Stimulated emission

Characteristics of Laser LightCharacteristics of Laser Light

COLLIMATEDCOHERENTMONOCHROMATICPOLARISED

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 mixture CO2 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 therapyThermal : Photocoagulation &

PhotovaporisationMechanical : Photo disruption &

Explosive vaporization

GAS LASER DESIGNGAS LASER DESIGN

Consists of1) Gas filled cavity

2) External optical pumping lights

3) Resonator with partially and totally reflecting mirrors

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.

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)

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

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

Presentations of Diabetic FootPresentations of Diabetic Foot

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

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

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

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 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

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.

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.

Thank YouThank You