Role Of Surgical Debridement Research Articles

Stevens Johnson Syndrome and Toxic Epidermal Necrolysis Updates on Management

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are dermatologic emergencies characterized by extensive epidermal necrolysis and sloughing. The incidence rates vary depending on location, with the UK experiencing an annual incidence of 5.76 cases per million individuals from 1995 to 2013. Females are more frequently afflicted than males, with mortality rates ranging from 4.8-9% to 14.8-48%. Nonpharmacologic treatment for SJS/TEN patients includes supportive care, fluid and electrolyte management, infection control, and wound care. The most critical component is the identification and cessation of the causative substance. Management of fluid, electrolytes, and nutrition is crucial for SJS/TEN patients, as they have lower fluid requirements than burn patients. Prophylactic antibiotics do not enhance outcomes, but infection prevention requires appropriate wound care and antiseptic handling. The role of surgical debridement has been a topic of controversy, and the decision to pursue this treatment option depends on the location of care. Anti-shear therapy, which involves aspiration of blister fluid and preservation of denuded epidermis, has been shown to be effective in reducing mortality rates. Pharmacologic treatment for SJS/TEN has been the subject of few prospective studies due to the disease's rarity. Various treatment regimens involving corticosteroids, IVIg, cyclosporine, and TNF-alpha inhibitors have been reported, but it is challenging to determine whether the disease's remission was due to a specific treatment or the natural course of the disease.

Role of Surgical Debridement in Wound Management

A wound is a disturbance of the skin's and soft tissue architecture's normal structure and function. Prior to further wound treatment, wounds with devitalized tissue, contamination, or leftover suture material benefit from debridement. Wound base preparation allows for the orderly healing and regeneration of injured tissue and may improve the performance of specialist wound care products and sophisticated biologic tissue replacements. There are now many approaches for treating individuals with Dupuytren's contracture; each case must be carefully selected to provide the most benefit, limit morbidity, and avoid recurrences.

Role of Surgical Debridement in Wound Management

Role of Surgical Debridement in Wound Management

Penetration of echinocandins into wound secretion of critically ill patients

PurposeWound infections caused by Candida are life-threatening and difficult to treat. Echinocandins are highly effective against Candida species and recommended for treatment of invasive candidiasis. As penetration of echinocandins into wounds is largely unknown, we measured the concentrations of the echinocandins anidulafungin (AFG), micafungin (MFG), and caspofungin (CAS) in wound secretion (WS) and in plasma of critically ill patients.MethodsWe included critically ill adults with an indwelling wound drainage or undergoing vacuum-assisted closure therapy, who were treated with an echinocandin for suspected or proven invasive fungal infection. Concentrations were measured by liquid chromatography with UV (AFG and MFG) or tandem mass spectrometry detection (CAS).ResultsTwenty-one patients were enrolled. From eight patients, serial WS samples and simultaneous plasma samples were obtained within a dosage interval. AFG concentrations in WS amounted to < 0.025–2.25 mg/L, MFG concentrations were 0.025–2.53 mg/L, and CAS achieved concentrations of 0.18–4.04 mg/L. Concentrations in WS were significantly lower than the simultaneous plasma concentrations and below the MIC values of some relevant pathogens.ConclusionEchinocandin penetration into WS displays a high inter-individual variability. In WS of some of the patients, concentrations may be sub-therapeutic. However, the relevance of sub-therapeutic concentrations is unknown as no correlation has been established between concentration data and clinical outcome. Nevertheless, in the absence of clinical outcome studies, our data do not support the use of echinocandins at standard doses for the treatment of fungal wound infections, but underline the pivotal role of surgical debridement.

Juvenile Mandibular Chronic Osteomyelitis: Role of Surgical Debridement and Antibiotics

To document outcomes of management of juvenile mandibular chronic osteomyelitis (JMCO) using a standardized treatment protocol including open biopsy, decortication, microbial culture, and long-term antibiotic therapy. This was a retrospective case study of pediatric patients with JMCO treated at Massachusetts General Hospital for Children from 1996 through 2014. Inclusion criteria included age younger than 18years, diagnosis of JMCO, management by the protocol, adequate clinical and radiographic data in the record, and follow-up of at least 1year after initial treatment. Inpatient and outpatient records were reviewed for demographics, clinical and radiographic findings, and histologic and laboratory evaluations. The predictor variable was the standardized treatment protocol and the primary outcome variables were disease status at end of treatment and complications of treatment. Twenty patients (mean age at onset, 10.7yr; range, 3 to 14yr) were treated, 12 (11 girls) of whom met the inclusion criteria. Management of all patients consisted of biopsy (extraoral when feasible, n= 9; intraoral, n= 3), decortication, cultures, and long-term antibiotic therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) were administered only as needed for pain control. There was complete resolution of osteomyelitis with no recurrence in 7 of 12 patients (mean follow-up, 4.3yr; range, 1 to 11yr). Five patients had partial responses, with decreased frequency and severity of disease recurrence. These were well controlled with short courses of antibiotics (4 to 12weeks) with NSAIDs only as needed for pain control (mean follow-up, 1.4yr; range, 1 to 3yr). There were no major complications related to antibiotic therapy. Minor complications included rash (n= 2), nausea and vomiting (n= 1), and vaginal candidiasis (n= 1). The results of this study indicate that 58.3% of patients were cured and had no recurrent symptoms (mean follow-up, 4.3yr). The remaining patients continue on intermittent treatment with antibiotics for recurrent episodes of swelling and pain. Favorable responses to antibiotic therapy support the hypothesis that JMCO is an infectious disease and that negative cultures might represent a failure of standard culture techniques to isolate the responsible organisms.

Juvenile Mandibular Chronic Osteomyelitis: Role of Surgical Debridement and Antibiotics

Juvenile mandibular chronic osteomyelitis (JMCO) is characterized by multiple episodes of pain, swelling, tenderness and limited jaw motion, predominantly occurring in girls. Radiographic and computed tomographic (CT) imaging is consistent with osteomyelitis: subperiosteal bone formation and mixed radio-dense/radiolucent trabecular pattern. Inflammatory markers (erythrocyte sedimentation rate and C-reactive protein) are often elevated. Because standard bacterial cultures are frequently negative, there is controversy as to whether this is an infectious disease or a non-infectious inflammatory disorder. We hypothesize that JMCO is an infectious disease and that standard culture techniques simply fail to identify the responsible organisms1for a variety of reasons. The purpose of this study was to document the response and long-term outcomes of JMCO using a standardized protocol of extraoral biopsy, culture, decortication and long-term antibiotic therapy.

The role of surgical debridement in different clinical manifestations of invasive aspergillosis.

Invasive aspergillosis (IA) has a wide spectrum of clinical presentations and is associated with high mortality rates. Early initiation of systemic antimould therapy remains the most important measure to reduce mortality. Surgical debridement is an important additional therapeutic option mainly in cases of extrapulmonary IA. The main intention for surgical intervention in IA is to obtain material for diagnosis and antifungal susceptibility testing. There are, however, also therapeutic implications for surgical interventions in rare manifestation of IA such as endocarditis or mycotic aneurysm. Here, we will review the role of surgical interventions in the treatment of different clinical manifestations of IA.

Systemic Antibiotic Therapy for Chronic Osteomyelitis in Adults

The standard recommendation for treating chronic osteomyelitis is 6 weeks of parenteral antibiotic therapy. However, oral antibiotics are available that achieve adequate levels in bone, and there are now more published studies of oral than parenteral antibiotic therapy for patients with chronic osteomyelitis. Oral and parenteral therapies achieve similar cure rates; however, oral therapy avoids risks associated with intravenous catheters and is generally less expensive, making it a reasonable choice for osteomyelitis caused by susceptible organisms. Addition of adjunctive rifampin to other antibiotics may improve cure rates. The optimal duration of therapy for chronic osteomyelitis remains uncertain. There is no evidence that antibiotic therapy for >4-6 weeks improves outcomes compared with shorter regimens. In view of concerns about encouraging antibiotic resistance to unnecessarily prolonged treatment, defining the optimal route and duration of antibiotic therapy and the role of surgical debridement in treating chronic osteomyelitis are important, unmet needs.

Taenia crassiceps upper limb fasciitis in a patient with untreated acquired immunodeficiency syndrome and chronic hepatitis C infection – the role of surgical debridement

We report a rare case of human Taenia crassiceps infection in a 47-year-old female patient with untreated acquired immunodeficiency syndrome and chronic hepatitis C infection. Little experience exists regarding the appropriate treatment of this infection. Usually, a combination of anthelmintic drugs is applied. Whether surgical measures are indicated have not been clarified. In our patient, initial surgery showed an abscess and fluid collection with numerous transparent cysts localised in the subcutaneous tissue of the cubital fossa. Parasitological and pathological examinations identified these structures as larvae of the cestode T.crassiceps. After treatment with anthelmintic medications, the patient was discharged in good condition. However, the patient presented with the clinical symptoms of an acute fasciitis of the right upper extremity 7 days later. The deteriorating general condition entailing a pre-septical state demanded emergency debridement and fasciectomy of the right arm. After the surgery, the patient recovered fully. Surgical treatment appears to be an important measure to reduce the tissue parasite load in patients with severe immunodeficiency. It also has to be questioned whether the bioavailability and the penetration of the drugs commonly administered is sufficiently high to treat such a fulminant infection alone.

The role of surgical debridement in healing of diabetic foot ulcers

An estimated 15% of patients with diabetes mellitus will develop a foot ulcer during their lifetime. Debridement is included in multiple guidelines and algorithms for the care of patients with diabetic neuropathic foot ulcers, and it has long been considered an essential step in the protocol for treating diabetic foot ulcers. In addition to altering the environment of the chronic wound, debridement is a technique aimed at removing nonviable and necrotic tissue, thought to be detrimental to healing. This is accomplished by removing abnormal wound bed and wound edge tissue, such as hyperkeratotic epidermis (callus) and necrotic dermal tissue, foreign debris, and bacteria elements known to have an inhibitory effect on wound healing. While the rationale for surgical debridement seems logical, the evidence for its role in enhancing healing is deficient. In this paper, we systematically review five published clinical trials, which met the criteria and investigated surgical debridement of diabetic foot ulcers to enhance healing. Most existing studies are not randomized clinical trials optimized to test the relationship between debridement of diabetic foot ulcers and wound healing. Therefore, a focused, well-designed study is needed to elucidate the effect of surgical debridement on the healing status of chronic wounds.

Thoracoscopic Debridement and Stabilization of Pyogenic Vertebral Osteomyelitis

The role of surgical debridement and internal fixation in treatment of vertebral osteomyelitis has been evolving. The standard surgical approach to thoracolumbar vertebral osteomyelitis requiring extensive thoracotomy or retroperitoneal exposure carries significant associated morbidity and postoperative pain. Minimally invasive thoracoscopic spine surgery is designed to improve postoperative morbidity associated with the traditional open surgery. We report a case of a 70-year-old man who developed T11-T12 pyogenic vertebral osteomyelitis 3 months after undergoing posterior laminectomy and microsurgical excision of a herniated thoracic disc. The patient underwent minimally invasive thoracoscopic radical debridement and anterior spinal reconstruction and fusion. Patients with vertebral osteomyelitis may benefit from the decreased postoperative morbidity that is associated with minimally invasive thoracoscopic spinal surgery.