Die Gefäßmedizin braucht mehr Evidenz: Aktuelle Ergebnisse und Metaanalysen zur Behandlung des diabetischen Fußes

 

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Zusammenfassung

Hintergrund: In dieser Übersicht soll zu aktuellen Ergebnissen klinischer Studien und Metaanalysen der Literatur bei Behandlung des diabetischen Fußes Stellung genommen werden. Methodik: Für die Literaturübersicht wurde die Datenbank MEDLINE (PubMed) unter den Schlüsselwörtern „diabetic foot“ durchsucht. Abgefragt wurden die Veröffentlichungen der letzten 3 Jahre (2012–2014). Ergebnisse: Für Patienten mit diabetischem Fuß kommen sowohl endovaskuläre (ER) als auch offene (OR) Revaskularisationen infrage, evidenzbasierte Empfehlungen, welchem Verfahren der Vorzug zu geben ist, sind nicht möglich. Die Registererhebungen zeigen aber, dass mittlerweile ER mengenmäßig deutlich bevorzugt wird. Zu prüfen ist das Angiosom-Konzept in diesen Situationen. Für die lokale Behandlung des Ulkus stehen eine Vielzahl von Wundauflagen zur Verfügung, die Evidenz ihrer Empfehlungen ist gering. Bei Versorgung eines Ulkus können folglich die Kosten und das Exsudatmanagement den Therapieentscheid wesentlich beeinflussen. Mit Bezug auf die Heilungsrate bieten teure Verbände keine Vorteile im Vergleich zu preiswerteren Basisabdeckungen. Zur Entlastung plantarer diabetischer Ulzera sind nicht entfernbare Vorrichtungen gleich welchen Typs abnehmbaren Vorrichtungen überlegen, wahrscheinlich weil die Patientencompliance mit der Druckentlastung so erleichtert wird. Zu den sinnvollen druckentlastenden Maßnahmen zählen auch die Achillessehnenverlängerung, ein plantarer Faszien-Release und die perkutane Flexortenotomie. Der Wert einer standardisierten Behandlung durch Spezialisten konnte in großen Registern anhand sinkender Amputationsraten bewiesen werden. Schlussfolgerung: Diese Übersicht deckt ein deutliches Missverhältnis zwischen der Vielzahl der Therapieempfehlungen und ihrer Evidenz auf. Für die Zukunft ist es deshalb vordringlich, in Registererhebungen Behandlung und Ergebnisse bei diesen Patienten flächendeckend zu erfassen.

Abstract

Background: This overview comments on clinical trials and meta-analyses from the literature on the treatment of diabetic feet. Methods: For the literature review, the MEDLINE database (PUBMED) was searched under the key words “diabetic foot”. Publications of the last three years (2012 to 2014) were extracted. Results: For patients with diabetic feet, both endovascular (ER) and open (OR) revascularisation techniques are possible. There are not sufficient data to demonstrate whether open bypass surgery or endovascular interventions are more effective in these patients. However, registries show that ER has now in terms of quantity become the preferred method. Angiosome-targeted revascularisation has to be considered in these situations. For the local treatment of a diabetic foot ulcer a variety of dressings are available, the evidence for their recommendation is low. Dressing cost and the wound management properties, e.g. exudate management therefore can influence the choice of dressing. There is no evidence that more expensive dressings as compared to basic dressings offer advantages in terms of healing. In plantar diabetic foot ulcers, non-removable off-loading devices regardless of type are more likely to result in ulcer healing than removable off-loading devices, presumably, because patient compliance with off-loading is facilitated. Meaningful pressure-relieving interventions for treating diabetic foot ulcers also include Achilles tendon lengthening, a plantar fascia release and percutaneous flexor tenotomy. The value of a standardised treatment protocol carried out by a specialist team could be proven in large registries based on decreasing amputation rates. Conclusion: This survey reveals a significant disparity between the large number of treatment recommendations and their evidence. For the future, therefore it is imperative to implement nationwide register surveys with respect to treatment and outcome of these patients.

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