A Skin-Sparing Approach to the Treatment of Necrotizing Soft-Tissue Infections: Thinking Reconstruction at Initial Debridement

Tom, Laura K.; Wright, T.; Horn, Dara L.; Bulger, Eileen M.; Pham, Tam N.; Keys, Kari A.

doi:10.1016/j.jamcollsurg.2016.01.008

Cited by 22 publications

(23 citation statements)

References 22 publications

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“…However, since most NSTI patients are severely physiologically compromised, short and efficient debridements might be recommended, as a major difference in mortality rate was noted between the published results of patients with an operating time shorter and longer than 90 min. The risk at more postoperative complications associated with longer operative times should be considered when skin-sparing debridement for NSTIs is contemplated [37,40]. Therefore, the clinical condition of the patient should determine the course of actions and surgical strategy.…”

Section: Discussionmentioning

confidence: 99%

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

et al. 2020

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Background: Although the phrase "time is fascia" is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs. Methods: A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models.Result: A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26-0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27-0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively.Conclusion: Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.

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Section: Discussionmentioning

confidence: 99%

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

et al. 2020

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“…Described strategies for definitive wound closure have included healing by secondary intention, complex flap coverage, primary wound closure, and skin grafting. [5][6][7][8][9][10][11][12][13][14][15] Choice of wound management is left to surgeon judgment.…”

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confidence: 99%

“…Ideal incisions for exploration and debridement of necrotizing infections have been outlined in a skin sparing manner. 15 Although not included in this review, attention to surgical approach starting with the first debridement may certainly help with achieving complete primary wound closure.…”

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confidence: 99%

Definitive Wound Closure Techniques in Fournier's Gangrene

Lauerman

Kolesnik

Park

et al. 2018

The American Surgeon

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Necrotizing soft tissue infection of the perineum, or Fournier's gangrene (FG), is a morbid and mortal diagnosis. Despite the severity of FG, the optimal definitive wound closure strategy is unknown, as are long-term wound outcomes. A retrospective review was performed over a 3-year period at a single trauma center. Patients were managed according to our institutional approach focusing on primary wound closure and secondary intention healing in residual wounds. Overall 168 patients were included. Complete primary wound closure was accomplished in 39.9 per cent of patients. Patients undergoing primary wound closure were primarily male (89.6 vs 64.4%, P < 0.001), had lower mean sequential organ failure assessment (SOFA) scores (1.70 ± 2.30 vs 2.98 ± 3.36, P = 0.004), more often had perineum-limited FG (67.2 vs 42.6%, P = 0.003), and required fewer debridements (2.40 vs 2.79, P = 0.02). On logistic regression, predictors of primary closure included gender (odds ratio 4.643, 95% confidence interval 1.885–11.437, P = 0.001) and SOFA score (odds ratio 0.834, 95% confidence interval 0.727–0.957, P = 0.01). Wound healing rates increased over time, to an 82.1 per cent wound healing rate without further intervention at greater than six months of follow-up. Wounds healed with secondary intention ranged from 70 to 9520 cm3 and primary closure ranged from 126 to 6912 cm3, whereas wounds requiring skin grafts ranged from 405 to 16,170 cm3. Complete primary wound closure is often achievable in FG patients. Using this standardized approach to FG wound management, even large wounds and wounds undergoing secondary intention healing will often close with long-term wound care and do not require flap creation or early skin grafting.

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“…Techniques of skin-sparing exploration include placing incisions to preserve vascular arcades and exploration techniques such as trapdoor incisions and counter incisions. 10 At our institution, we often explore extremity NSTIs along longitudinal incisions, which is similar to the skin-sparing technique. Exploration in a standardized fashion may influence coverage choice by minimizing subsequent wound size.…”

Section: Discussionmentioning

confidence: 99%

Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections

Lauerman

Scalea

Eglseder

et al. 2018

The American Surgeon

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Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique ( P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.

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A Skin-Sparing Approach to the Treatment of Necrotizing Soft-Tissue Infections: Thinking Reconstruction at Initial Debridement

Cited by 22 publications

References 22 publications

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

Definitive Wound Closure Techniques in Fournier's Gangrene

Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections

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