Choice of Treatment Methods for Trophic Ulcers of the Lower Extremities of Venous Etiology in Geriatric Patients

The research is dedicated to the development and evaluation of a comprehensive approach to the treatment of trophic ulcers of the lower extremities of venous etiology in elderly and geriatric patients. The relevance of the work is determined by the high prevalence of chronic venous insufficiency and associated trophic ulcers, significant socio-economic costs of treatment, and the low effectiveness of existing methods, particularly in geriatric patients with concomitant cardiovascular pathology.

The study substantiates the necessity of comprehensive application of conservative, surgical, and physiotherapeutic methods, including light therapy using the «Bioptron» device, in the pre- and postoperative periods. It has been established that the combination of minimally invasive surgical technologies with biophoton therapy allows for accelerated healing of ulcerative defects, reduced frequency of postoperative complications and recurrences, and improved quality of life of patients. A methodology for preoperative and postoperative light therapy has been developed, and its effectiveness and absolute safety in elderly and geriatric patients have been confirmed.

At present, the problem of trophic ulcers (TU) of the lower extremities, due to enormous difficulties in treatment, a sharp decline in the quality of life and working capacity of patients, and high costs of long-term therapy, is one of the most urgent tasks. The treatment of trophic ulcers is of a socio-economic nature. This pathology is encountered in 1% of the world's population, and the number of new ulcers of the lower extremities reaching annually is 0.3%. (Savelyev B.C., 2004, Pokrovsky A.B., 2003, Agrifoglio G., 2000, Azaceta G., 1999, Goodfield M., 1997, McGuckin M, 2002, Melhuish J.M., 2000).

Trophic ulcers of the lower extremities are a consequence of various diseases impairing local hemodynamics of the arterial, venous, and lymphatic systems, including the microcirculation level of damage.

To choose the optimal treatment option for a patient with a trophic ulcer of the lower extremity, a physician must, first and foremost, determine the cause of ulcer occurrence. Severe trophic changes of the lower extremities are most frequently encountered among patients suffering from chronic venous insufficiency (CVI).

According to V.S. Savelyev and his clinic (2001), chronic venous insufficiency affects up to 20% of women and 5-7% of men. In 72.85% of patients with trophic ulcers, the etiological factor is CVI.

Based on numerous demographic and epidemiological studies, it can be asserted that in Russia approximately 5 million people suffer from TA of venous etiology. (Savelyev B.C., 2001, Skobeikin O.K., 1997)

In the United States and Great Britain, the total annual economic damage resulting from reduced working capacity of patients with ulcers and the costs of their treatment amounts to more than 3 billion dollars, and approximately 2 million working days are lost. In the absence of adequate treatment of CVI, ulcerative complications are diagnosed in almost 90% of cases. Overall, the appearance of new cases of venous leg ulcers is diagnosed among women at 1.42 and among men at 0.76 per 100 persons per year. Among persons over 70 years of age, this figure reaches 1.69 per 100 persons per year. (Braithwaite B.D., 2002, Briggs M., 2002, McGuckin M, 2002, Melhuish J.M., 2000, Ruckley C.V. 2000).

Despite the obvious progress in diagnosis and treatment of CVI, the frequency of trophic ulcers has not decreased year over year over the last 20-30 years. According to researchers from the Mayo Clinic (Rochester, USA), the number of patients suffering from CVI has remained stable since 1966, and the number of patients with venous ulcers of the lower extremities has remained constant since 1981. On average, the number of CVI patients is 76.1 per 100,000 persons per year, and patients with venous leg ulcers — 18.0 per 100,000 persons per year. (Iafrati MD, 2002, Neumann H.A.M., 2000).

The cost of treating one patient with venous trophic ulcers of the lower extremities in the USA ranges from 130-550 dollars per week. Moreover, in 55-60% of patients, a recurrence is noted within one year after therapy. (Cornette J., 2002, Nicolaides A.N., 1993, Preziosi P., 2000, Ruckley C.V., 2002, Walker N, 2003, Wissing UE, 2002).

An important moment determining the treatment strategy for a trophic ulcer in the presence of CVI is its combination with chronic arterial insufficiency, which is encountered in approximately 20-30% of patients of elderly and advanced age. (I.I. Zatevakhin et al., 2005)

In connection with the worsening of the overall demographic situation of "population aging" in Russia, the increase in the number of elderly and advanced-age persons, and consequently the increase in the number of patients suffering from CVI, the number of patients with trophic ulcers grows proportionally, the treatment of which presents great difficulties. (A.I. Kirienko et al., 2005)

Taking the above into account, the necessity of developing new, more effective, and maximally safe methods of treatment of trophic ulcers of venous etiology in patients of elderly (60-74 years) and advanced age (over 74 years according to WHO classification) becomes obvious. One thing is indisputable: the treatment of trophic ulcers must be comprehensive.

However, until now, in elderly and advanced-age persons with trophic ulcers, the indications for various treatment methods have not been clarified: conservative, surgical, medicinal, physiotherapeutic).

The obviousness and necessity of solving these questions justify the search for new approaches to solving this problem.

In connection with the above, the following goals and objectives of the research have been formulated:

Research Goal.

Improvement of treatment outcomes for geriatric patients with venous trophic ulcers through the application of new effective and minimally invasive treatment methods.

Research Objectives.

1. Based on a retrospective analysis, to determine the effectiveness of standard treatment methods for elderly and advanced-age patients with trophic ulcers.

2. To evaluate the role of bacteriological and cytological research methods in determining the effectiveness of treatment of venous trophic ulcers in geriatric patients.

3. To develop indications for light therapy using the "Bioptron" device in complex treatment, as well as in the pre- and postoperative periods.

4. In light of immediate and long-term results, to evaluate the effectiveness of the combination of conservative, surgical treatment methods, and light therapy.

Scientific Novelty of the Research.

Indications for conservative and surgical treatment of geriatric patients with trophic ulcers have been clarified. Optimal combinations of conservative, surgical methods, and light therapy for the treatment of trophic ulcers have been determined.

The effectiveness and absolute safety of the application of polarized polychromatic light emitted by the "Bioptron" device for the treatment of trophic ulcers in elderly and advanced-age persons have been determined.

For the first time, in choosing a treatment strategy, the main emphasis has been placed on the necessity of comprehensive application of maximally safe and effective methods, minimally invasive surgical technologies, in elderly and advanced-age patients with trophic ulcers.

A methodology for preoperative and postoperative light therapy using the "Bioptron" device in geriatric patients with trophic ulcers has been developed.

Practical Significance of the Work.

The developed comprehensive approach to the treatment of trophic ulcers of venous etiology in geriatric patients, including angioprotective therapy, light therapy, local treatment, as well as surgical treatment, leads to a substantial improvement in treatment outcomes, quality of life of patients, general and psychoemotional state of patients, acceleration of ulcer cleansing, reduction of microbial contamination, stimulation of reparative processes, and acceleration of the closure of ulcerative defects when it is impossible to perform radical surgical intervention due to the presence of concomitant cardiopulmonary pathology in virtually all patients.

The proposed methodology is simple to execute and can be used both in departments of purulent surgery of hospitals and in outpatient practice.

Basic Propositions for Defense.

1. The main method of treatment of trophic ulcers of venous origin is the elimination of pathological reflux — the cause of the disease — using minimally invasive accesses and technologies.

2. The application of biophoton therapy in the pre- and postoperative periods in patients with trophic ulcers against the background of venous pathologies leads to accelerated healing of the ulcerative defect, a sharp reduction in postoperative complications, a decrease in the development of recurrences, and is an absolutely safe method.

3. Dynamic cytological and bacteriological control is an objective criterion for the effectiveness of the conducted treatment of trophic ulcers.

Work Validation.

The dissertation validation was conducted at a clinical conference of the Department of Surgery with a course in clinical angiology at MGMSU on January 17, 2005. The main provisions of the dissertation were reported at 5 conferences and discussed at the 10th All-Russian Congress of Cardiovascular Surgeons (Moscow, 2004).

Publications.

Six scientific works have been published on the dissertation topic, which reflect the main provisions of the dissertation:

1. "Possibilities of Performing Minimally Invasive Sympathectomies in Elderly and Advanced-Age Patients". Dibirov M.D., Kirtadze D.G., Cherkezov D.I., Beloedova E.V., Lazareva E.V., Pannikova A.B., Lakreeva M.G. / "Cardiovascular Diseases" Bulletin of the NCSCH named after A.N. Bakuleva RAMN — Vol. 5, No. 11 November 2004, p. 140.

2. "Surgical Treatment of Patients with Infected Diabetic Foot". Dibirov M.D., Kirtadze D.G., Cherkezov D.Yu., Sarkisyanu Yu.G., Dibirov A.A., Lazareva E.V., Lakreeva M.G. / "Cardiovascular Diseases" Bulletin of the NCSCH named after A.N. Bakuleva RAMN — Vol. 5, No. 11 November 2004, p. 140.

3. "Complex Treatment of Large Trophic Ulcers of the Shin in Advanced-Age Patients". Dibirov M.D., Shimanko A.I., Lakreeva M.G., Poltorak M.L., Mutaev Sh.M., Tsuranov S.V., Solomatina S.A., Shvidko V.S. / "Cardiovascular Diseases" Bulletin of the NCSCH named after A.N. Bakuleva RAMN — Vol. 5, No. 11 November 2004, p. 141.

4. "Minimally Invasive Methods of Surgical Treatment of Shin Ulcers in Advanced-Age Patients". Dibirova M.D., Lakreeva M.G., Poltorak M.L. / Materials of the Conference of Russian Surgeons, dedicated to the 100th anniversary of Professor V.S. Semenov. Tver, 2004, pp. 257-258.

5. "Treatment of Trophic Ulcers in Geriatric Patients". M.D. Dibirov, M.G. Lakreeva. "Actual Questions of Clinical Medicine" vol. 2. "Materials of the Conference dedicated to the 50th anniversary of the 50th City Clinical Hospital of Moscow", Moscow, 2005, pp. 6-8.

6. "Dynamics of the Wound Process under the Influence of an Ointment Based on Biologically Active Substances and Polarized Light "Bioptron"". M.D. Dibirov, M.G. Lakreeva. "Actual Questions of Clinical Medicine" vol. 2. "Materials of the Conference dedicated to the 50th anniversary of the 50th City Clinical Hospital of Moscow", Moscow, 2005, pp. 71-73.

Volume and Structure of the Dissertation.

The dissertation consists of an introduction, 4 chapters, conclusion, conclusions, practical recommendations, and a reference list comprising 66 domestic and 92 foreign works. The dissertation text is presented on 126 pages of typed manuscript, illustrated with 11 tables and 67 figures.