Wound Necrosis Research Articles

Mastectomy Following Preoperative Chemotherapy Strict Operative Criteria Control Operative Morbidity

The surgical morbidity associated with aggressive preoperative chemotherapy in 106 patients with advanced primary breast cancer who had chemotherapy followed by mastectomy was examined. These patients were compared with a group of 91 consecutive patients who had mastectomy without preoperative chemotherapy. Strict operative criteria were used to determine the timing of mastectomy following chemotherapy. Wound infection rates were no different in the preoperative chemotherapy group compared to the mastectomy-alone groups (7% versus 4%; p = 0.62). The incidence of wound necrosis was similar (11% versus 6%; p = 0.29). Seroma formation was decreased significantly in the preoperative chemotherapy group compared to the mastectomy-alone group (15% versus 28%; p = 0.04). Intensive preoperative chemotherapy did not delay the reinstitution of postoperative treatment (30% versus 20%; p = 0.27). However, when delay in instituting postoperative chemotherapy was more than 30 days, there was a significant decrease in overall survival rate (p = 0.04). This study provides evidence that intensive preoperative chemotherapy and mastectomy can be performed without increased morbidity. Furthermore it is important to institute systemic chemotherapy within 30 days of mastectomy to achieve maximum survival.

Complications Associated With Limb Salvage for Extremity Sarcomas and Their Management

A retrospective clinical review of 100 consecutive patients with extremity sarcomas managed by limb salvage operations was performed to evaluate local tumor control and morbidity. The mean follow-up period was 45.1 months. Overall survival was 86%. There were local recurrences in 3% of patients, and 26 complications in 22 patients. Wound necrosis was the most frequent complication. Failure of allogeneic bone graft operations occurred in 25 patients. Most of the complications were salvageable without loss of limb. Limb salvage is an acceptable surgical treatment of extremity sarcomas based on adequate local control and minimal morbidity.

Case Report Dacryocystorhinostomy in Wegenerʼs Granulomatosis

Dacryocystorhinostomy was performed on two patients with Wegener's granulomatosis that had been quiescent for many years. Excellent results were attained, with elimination of dacryocystitis, complete relief from epiphora, and maintenance of a patent outflow tract. No wound necrosis occurred postoperatively, in contrast to a previous report in the literature. Our experience suggests that nasolacrimal duct obstruction in the setting of quiescent Wegener's granulomatosis can be treated safely and effectively with dacryocystorhinostomy.

Effects of hyperbaric oxygen in cryobiologic wounds

Hyperbaric oxygen therapy (HBO) has been helpful in treating radiation burn lesions, osteomyelitis, gangrenous wounds, necrotic sites, and injuries caused by tissue hypoxia [5, 7]. For these reasons HBO could be a possible choice for a study to better define the role of hypoxia in the pathogenesis of cryobiologic wounds. Liquid oxygen, as employed in the HBO sessions described in this study, because of its ease of application can be used to show the importance of the same oxygen in the genesis and in the healing process of lesions [4, 7, 8]. For this purpose the effects of hyperbaric and normal oxygen conditions were tested on healing cryolesions experimentally induced in Winster rats. Test subjects were 20 Winster rats weighing between 200 and 220 g, housed individually in stainless steel cages and fed Purina rodent laboratory chow and tap water ad libitum. One thermocouple needle was used to measure in-depth temperature. The rats were divided into two groups of ten animals each. All were anesthetized with intraperitoneal injection of 0.5 ml ketamine. Skin epilation on two symmetrical areas of the dorsum ( 2 3 cm diameter) was done in all rats. Each area was treated with a double freeze-thaw cycle (the second immediately after the first) to 4 0 ~ using liquid nitrogen with the open spray technique (Frigitronic). The freezing time was 45 s and the thawing time was about 80 s. One group of rats was treated with HBO. The HBO session started immediately after the second thawing. HBO was accomplished by flushing a 45 pressure chamber with 100% oxygen up to 2.3 ATA. In this way HBO works on rats both locally and systemically. The treatment sessions were once a day for 45 min each, 5 days a week (pressurization and depressurization took

Wound complications following modified radical mastectomy: an analysis of perioperative factors.

To assess the effect of perioperative factors on the incidence of postoperative wound complications, the authors retrospectively analyzed 101 patients who had undergone modified radical mastectomy. These factors included age, body weight, operative techniques, estimated blood loss, wound-catheter drainage, extent of axillary dissection, nodal involvement, and length of hospital stay. Complications included seroma (10.9%), wound infection (8.9%), wound necrosis (5%), hematoma (3%), lymphedema (2%), and pneumothorax (1%). The logistic regression method was used to analyze the data. When electrocautery was used to create the skin flaps, the probability of a wound complication was .462, a 44% increase over that calculated for the cold-knife technique (P = .05). A prolonged hospitalization accompanied the occurrence of a wound complication. No other factors reached statistical significance.

Wound complications of autogenous subcutaneous infrainguinal arterial bypass surgery: Predisposing factors and management

To identify factors predisposing to wound infection and necrosis complicating in situ or other subcutaneous autogenous lower extremity vein bypass procedures, we retrospectively analyzed all such cases performed in our hospital between July 1983 and July 1988. Among 163 subcutaneous autogenous bypass grafts, wound complications developed in 28 (17%). According to progressive depth of involvement as defined in the text, 10 patients had grade I complications, six had grade II, and 12 had grade III complications with threatened or actual graft exposure. Factors significantly associated with wound morbidity were female gender, chronic steroid therapy, in situ bypass grafting, use of continuous incision (all p less than or equal to 0.05, chi square); diabetes mellitus, ipsilateral limb ulcer, limb salvage indication (all p less than 0.01); and bypass grafting to the dorsalis pedis artery (p less than 0.02). A logistic regression analysis identified four factors (in situ bypass grafting, steroid therapy, ipsilateral ulcer, and dorsalis pedis bypass grafting) that predicted a cumulatively increasing risk of wound complications, and in whose absence wound complications were rare. Grade I and II complications responded to standard regimens of wound care and intravenous antibiotics without loss of any graft or limb. In spite of aggressive efforts to provide secondary soft tissue coverage, grade III complications led directly to four major amputations and one death. Measures to prevent these morbid sequelae must include preoperative control of infection in the ischemic foot and meticulous attention to operative technique.

Wound complications of autogenous subcutaneous infrainguinal arterial bypass surgery: Predisposing factors and management

To identify factors predisposing to wound infection and necrosis complicating in situ or other subcutaneous autogenous lower extremity vein bypass procedures, we retrospectively analyzed all such cases performed in our hospital between July 1983 and July 1988. Among 163 subcutaneous autogenous bypass grafts, wound complications developed in 28 (17%). According to progressive depth of involvement as defined in the text, 10 patients had grade I complications, six had grade II, and 12 had grade III complications with threatened or actual graft exposure. Factors significantly associated with wound morbidity were female gender, chronic steroid therapy, in situ bypass grafting, use of continuous incision (all p ≤ 0.05, chi square); diabetes mellitus, ipsilateral limb ulcer, limb salvage indication (all p < 0.01); and bypass grafting to the dorsalis pedis artery (p < 0.02). A logistic regression analysis identified four factors (in situ bypass grafting, steroid therapy, ipsilateral ulcer, and dorsalis pedis bypass grafting) that predicted a cumulatively increasing risk of wound complications, and in whose absence wound complications were rare. Grade I and II complications responded to standard regimens of wound care and intravenous antibiotics without loss of any graft or limb. In spite of aggressive efforts to provide secondary soft tissue coverage, grade III complications led directly to four major amputations and one death. Measures to prevent these morbid sequelae must include preoperative control of infection in the ischemic foot and meticulous attention to operative technique.

Open management of the septic abdomen: therapeutic and prognostic considerations based on APACHE II.

We analyzed the results of open treatment in 30 patients with abdominal sepsis (11 patients after trauma [group 1], five patients with pancreatic abscess [group 2], and 14 patients with acute GI pathology [group 3]) uncontrolled by conventional methods as evidenced by continuing fever with leukocytosis and worsening organ functions. APACHE scores at the time of initial laparotomy and at the time of open management, respectively, were: group 1, 19.8 and 16.6; group 2, 8.4 and 12.4; and group 3, 14.2 and 15.0. Twenty-seven patients had multiple system failure. Sixteen (53%) of the 30 patients survived, 73% in group 1, 60% in group 2, and 36% in group 3. Survival correlated well with age less than 50 yr and the absence of multiple organ failure. The technique was easily performed and many of the pitfalls previously reported were not observed. In patients requiring fascial prosthesis, the absorbable polyglycol acid (Dexon) mesh was found to be superior to the nonabsorbable polypropylene. We conclude that the open technique is feasible, effective, and worthy of consideration in patients with extensive wound necrosis and uncontrolled abdominal sepsis.

Gracilis myocutaneous vaginal reconstruction concurrent with total pelvic exenteration

The gracilis myocutaneous vaginal reconstruction is commonly performed in patients undergoing a total pelvic exenteration. This retrospective review compares the operative and perioperative morbidity in 107 patients who underwent reconstruction with that in 44 patients who did not have reconstruction. With incorporation of the reconstructive procedure, there were no increases in operating time, blood loss, or length of hospitalization. Before 1980, 65% of patients experienced prolapse of the neovagina; in 25% it was severe. The frequency of prolapse has since been decreased to 16% (6% severe) because of several modifications to the initial technique. Modifications have included using smaller flaps, anchoring the neovagina to the levator and retropubic fascia, and, when necessary for mobilization, ligating the neurovascular pedicle. With these modifications, 66% of patients also remained free of wound breakdown or necrosis. The frequency of severe necrosis has decreased from 24% to 13%. The anatomic result of the vaginal reconstructions appears to have been enhanced by these changes in technique. (Am J Obstet Gynecol 1989;160:1095-101.)

Septic necrosis of the midline wound in postoperative peritonitis

Septic necrosis of the midline wound in postoperative peritonitis

Treatment of major wound necrosis following total knee arthroplasty

Following total knee arthoplasty, seven patients developed significant wound necrosis and dehiscence, requiring wound coverage with soft tissue flaps. Three patients had rheumatoid arthritis, three had degenerative arthritis, and one had osteosarcoma of the distal femur. Five different prostheses were used and the wound problems were discovered on average 21 days after arthroplasty. The average wound size was 6.0 cm 2. Five were infected, four with Staphylococcus epidermidis and one with Staphylococcus aureus. All patients were treated with antibiotics and local debridement for an average of 10 days prior to the flap procedure. Medial gastrocnemius muscle flaps were used in two patients, unipedicle flaps transposed from the lateral thigh in three, and bipedicle flaps shifted from the medial thigh in two. Flaps were done an average of 56 days after arthroplasty, and knee rehabilitation was delayed an average of 76 days after arthroplasty. Patients were followed an average of 48 months after the flap procedure. Six patients had mild or no knee pain and one who remained infected had moderate constant pain. Three of the patients had greater than 90° of knee motion and one had 75° of motion. The remaining three had only 35° of motion, due in part to significant preoperative contractures, infection, local radiation, and chemotherapy. late infection developed in two patients at 20 and 45 months following the flap procedure. There was one excellent, three good, two fair, and one poor result using the Hospital for Special Surgery knee rating system at final follow-up examination.

Factors contributing to fatal snake bite in the rural tropics: analysis of 46 cases in Thailand

Records of 46 cases of fatal bites by identified snakes from 15 provincial hospitals throughout Thailand contained sufficient information for detailed analysis. Bungarus Candidus and Calloselasma rhodostoma were each responsible for 13 deaths, Naja kaouthia for 12, Vipera russelli for 7 and B. fasciatus for one. Major causes of death among elapid victims were respiratory failure (26) and complications of prolonged mechanical ventilation (10), and among viper victims shock (12), intracranial haemorrhage (9), complications of local wound necrosis (7) including tetanus (2), and renal failure (2). Factors contributing to fatal outcome included inadequate dose of antiyenom (15 cases), misidentification of the snake leading to use of the wrong antivenom (12), problems associated with mechanical ventilation (10), and delayed arrival in hospital after traditional (herbal) treatment (10). Similar problems have been identified in other tropical countries. Education of medical staff and the patient population at highest risk could reduce snake bite mortality.

Septic necrosis of the midline wound in postoperative peritonitis. Successful management by debridement, myocutaneous advancement, and primary skin closure.

Wound management following laparotomy for postoperative peritonitis and varying degrees of parietal necrosis remains a challenging and controversial problem. Because maintained peritoneal integrity and primary wound closure offer the best opportunity for survival, an original technique involving bilateral incisions to relax skin and rectus fascia is proposed. This technique permits medial myocutaneous advancement and primary tension-free skin closure of midline laparotomy incisions. Sixty-nine patients with severe postoperative peritonitis were treated according from 1980 through 1985. Nine of these patients died of advanced multiple organ failure soon after referral, and eight more died after prolonged treatment. Fourteen patients had one or more reoperations for complications. Only nine wound failures resulted, including five eviscerations and four wound infections followed by progressive dehiscence. The bilateral relaxing incisions healed secondarily without complication. Survivors developed midline wound hernia; ten of the 52 surviving patients have had these repaired. This method of primary closure is safe when performed in conjunction with rigorous surgical care of intraperitoneal infection and may enhance survival. We recommend the technique to surgeons who treat severe postoperative peritonitis and septic necrosis of midline laparotomy wounds.

MANAGEMENT OF NECROTIC NECK WOUNDS WITH A “SANDWICH” PECTORALIS MYOCUTANEOUS FLAP

A modified pectoralis major myocutaneous flap was used to stabilize necrotic neck wounds rapidly in irradiated patients. The flap was a "sandwich" flap that included an overlying "parasternal" pectoral skin paddle for pharyngeal reconstruction, the pectoralis muscle for carotid protection, and a meshed skin graft applied to the undersurface of the muscle to replace cervical skin. This flap has been used to reconstruct seven patients with severe wound necrosis from pharyngeal fistula and infection. All patients had carotid exposure in the infected wound. Reconstruction in all patients accomplished restoration of pharyngeal continuity, carotid protection, and cervical skin replacement. Some patients required more than one procedure for closure. There were no carotid "blowouts" in any of the patients. This technique enables the head and neck surgeon to stabilize these contaminated wounds rapidly and to reconstruct complex defects of the pharynx and cervical skin.

Revision Total Knee Arthroplasty for Aseptic Failure

Twenty-four patients with 28 failed total knee arthroplasties replaced with porous-coated anatomic (PCA) primary or revision components were studied over a two- to four-year period. Overall, there were 68% good and excellent results and three failures. When evaluated according to mode of failure, 83% of the patients who had a definable mechanical problem achieved good or excellent results. Patients who had revision operations for incapacitating pain or in whom no clearly definable problem could be ascertained before operation were not significantly improved. Complications that led to poor results were deep sepsis, wound necrosis, and extensor mechanism abnormalities.

Wound Necrosis Following Dacryocystorhinostomy in Patients With Wegener's Granulomatosis

Two patients with Wegener's granulomatosis underwent dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction and epiphora. Wound necrosis occurred in each individual with the formation of a nasal-cutaneous fistula. A pedicle flap was the treatment of choice in one case, while direct closure of the necrotic incision site and high-dose steroid therapy was used in the other. Both did well with complete wound healing. The tearing persisted in one and resolved in the other. Dacryocystorhinostomy should be avoided whenever possible in patients with Wegener's granulomatosis, and steroid dosage should be increased if surgery is necessary in the presence of active inflammation.

Surgery of Dupuytren's disease: A review of the open palm method

Experience with 49 cases of Dupuytren's disease treated by the open palm method and followed for an average of 5 years is reported. This method permits excision of the involved fascia while minimizing early postoperative morbidity associated with the surgical management of this condition. There were no cases of wound necrosis, hematoma, or infection with this technique, and all wounds closed spontaneously within 3 to 5 weeks. Long-term follow-up, however, revealed a significant rate of recurrence (32%) and extension (48%), as well as flexion loss at one or more joints in 41% of involved hands. While helpful in the early care of these patients, the open palm method does not modify the long-term results in Dupuytren's disease, which is a pervasive condition without simple surgical solution.

Adverse Reactions to Virgin Silk Sutures in Cataract Surgery

During the past 3 years, 12 patients (14 eyes) were encountered with severe reactions to virgin silk sutures used in cataract surgery. These reactions included nodular episcleritis, peripheral corneal ulceration, and wound necrosis with dehiscence, sometimes resulting in endophthalmitis or epithelial downgrowth. Conjunctival and scleral histopathologic studies in four eyes showed acute and chronic inflammation with multinucleated giant cells. Successful treatment included removal of the virgin silk sutures, resuturing with 10-0 nylon sutures, securing the necrotic tissue with cyanoacrylate adhesive, and resection of the inflamed superior conjunctiva. All four patients who had bilateral cataract surgery experienced either simultaneous flare-ups of both eyes or accelerated reactions after surgery on the second eye, which suggests a possible role of prior sensitization.

Long term results of superselective sacral nerve resection for motor urge incontinence.

Eight female patients suffering from severe urge incontinence not manageable by conservative treatment were subjected to superselective sacral nerve resection in the period 1974-1977. The aim of the resection was a complete parasympathetic decentralization of the bladder. The resection was carried out according to the results of pre-operative sacral nerve blockade and per-operative electrical nerve stimulation. Post-operatively all cystometrograms were shifted to the right and four patients had bladder areflexia. At six months follow-up, three patients were continent, four were improved and one patient had an indwelling catheter for persistent retention. However, incontinence and detrusor instability returned in all the patients within one year. After seven to eight years follow-up one patient had died, two patients had had a urinary diversion operation and three had an indwelling urethral catheter. Only two patients were permanently improved. The surgical procedure was complicated by wound necrosis in one patient, by persistent dysesthesia in two and hypesthesia in three.

Necrotizing fasciitis: A preventable disaster : Rouse TM, Malangoni MA, Schulte WJ. Surgery 1982; 84:765–769

Twenty-eight cases of necrotizing fasciitis (NF) were treated in 27 patients. Most commonly these infections were caused by perineal disease, operative procedures, and cutaneous ulcers. Associated chronic diseases were present in 21 patients. Postoperative fasciitis occurred when prophylactic antibiotics were omitted or used inappropriately during clean-contaminated or contaminated procedures and when primary skin closure was done in the presence of intra-abdominal contamination. All but four infections were polymicrobial. The overall mortality rate was 73% (20 of 27). Death was due to persistent would sepsis in nine, systemic septic complications despite apparent local control of the infection in nine, and myocardial infarction in two patients. Five of seven survivors had NF limited to one region (leg, perineum, or abdomen). Only 2 of 15 patients survived when more than one debridement was necessary to control ongoing wound necrosis. Eleven of 12 patients who had a delay in treatment for more than 12 hours died. These results suggest that prompt recognition and treatment of NF are essential for survival. The presence of chronic debilitating diseases may contribute to the uncontrollable nature of both local and systemic infection, further emphasizing the need for early diagnosis. Postoperative fasciitis is potentially preventable by strict adherence to the principles for management of contaminated procedures.