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Iacopi E, Sbarbaro C, Pieruzzi L, Lorenzi I, Baroni L, Goretti C, Malacarne P, Piaggesi A. Necrotizing Fasciitis and Diabetic Foot: Results of a Prompt Identification, Surgery and Antibiotic Therapy (P.I.S.A.) Protocol. INT J LOW EXTR WOUND 2023; 22:733-741. [PMID: 34488474 DOI: 10.1177/15347346211041452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening infection, involving the skin, soft tissue and fascia. We evaluated outcomes of its surgical management in diabetic foot (DF) patients in a tertiary referral centre. We retrospectively searched for NF in the database of our DF Section from 2016 to 2018. All cases were treated according to a multiprofessional integrated protocol, with Prompt Identification, Surgical debridement and systemic Antibiotic therapy (P.I.S.A. Protocol). We analysed short-term evolution (surgical procedures and major amputations), and long-term outcomes (survival and healing rates). Sixty-eight patients were referred to our DF clinic for suspicion of NF. The diagnosis was confirmed in 54 (79.4%; male/female 40/14; type 1/2 diabetes 6/48; age 62.8 ± 8.1 years; duration of diabetes 13.6 ± 10.1 years). According to the microbiological results, cases were classified as Type 1 (33-61.2%), 2 (7-12.9%) and 3 (14-25.9%). No significant differences were observed. All patients underwent a decompressive fasciotomy. Six patients (11.1%) required also a forefoot amputation and 12 (22.2%) a toe or ray amputation. No major amputation was performed in the short-term period. During the follow-up (26 ± 12 months) 46 patients (85%) healed in 94 ± 11 days. Of the remaining 8: 5 (9.2%) died for other reasons before healing, 2 (3.7%) recurred and one (1.9%) required a major amputation. Our experience reveals a relatively high prevalence of NF in DF; despite this, we observed how, when promptly and aggressively treated, NF has a good prognosis and it is not associated with an excess of limb loss and deaths.
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Affiliation(s)
| | - Catia Sbarbaro
- First service of Anaesthesia and Critical Care Medicine -Pisa University Hospital, Pisa, Italy
| | | | - Irene Lorenzi
- First service of Anaesthesia and Critical Care Medicine -Pisa University Hospital, Pisa, Italy
| | - Luisa Baroni
- First service of Anaesthesia and Critical Care Medicine -Pisa University Hospital, Pisa, Italy
| | | | - Paolo Malacarne
- First service of Anaesthesia and Critical Care Medicine -Pisa University Hospital, Pisa, Italy
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Gas Where It Shouldn't Be! Imaging Spectrum of Emphysematous Infections in the Abdomen and Pelvis. AJR Am J Roentgenol 2021; 216:812-823. [DOI: 10.2214/ajr.20.23545] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Pieruzzi L, Napoli V, Goretti C, Adami D, Iacopi E, Cicorelli A, Piaggesi A. Ultrasound in the Modern Management of the Diabetic Foot Syndrome: A Multipurpose Versatile Toolkit. INT J LOW EXTR WOUND 2020; 19:315-333. [PMID: 32820699 DOI: 10.1177/1534734620948351] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Ultrasound (US) is a noninvasive and versatile technology that in recent years found acceptance in almost all the medical specialties, with diagnostic and interventional applications. In the diabetic foot syndrome (DFS), US found specific indications mainly in the screening, quantification, and follow-up of the vascular component of the pathology, but also in the study of the deformities and structural modifications induced by neuropathy and in the diagnosis and surgical management of infections, especially those that induce anatomical changes, like abscesses and fasciitis. This review will summarize all these application of US, giving special attention to the vascular aspects, and on the predominant role that US gained in recent times to guide the indication to revascularization, on the new standardized approach to the study of the arterial tree of the limb and the foot, the so-called duplex ultrasound arterial mapping, which significantly increased the utilization of US to plan the revascularizations in this complex pathology. Outside the vascular fields, the diagnosis of neuropathy and infection and the intraoperative use of US in the surgical management of abscesses and fasciitis will be discussed, leaving the last part to the new and interesting applications of US in the management of DFU, a field that is still in evolution, offering new possibilities to the health care professionals involved in the management of these chronic wounds. The variety of applications both in diagnostic and operative fields makes US a rather versatile technology-a toolkit-that should have a special place among those at reach of the specialists of DFS care.
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Clostridium perfringens - A bacterial pathogen gaining recognition in necrotizing pancreatitis. Anaerobe 2017; 47:111-114. [DOI: 10.1016/j.anaerobe.2017.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/11/2017] [Accepted: 05/13/2017] [Indexed: 12/25/2022]
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Takazawa T, Ohta J, Horiuchi T, Hinohara H, Kunimoto F, Saito S. A case of acute onset postoperative gas gangrene caused by Clostridium perfringens. BMC Res Notes 2016; 9:385. [PMID: 27488346 PMCID: PMC4973043 DOI: 10.1186/s13104-016-2194-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 07/30/2016] [Indexed: 02/06/2023] Open
Abstract
Background Gas gangrene is a necrotic infection of soft tissue associated with high mortality rates. We report a case of postoperative gas gangrene with very acute onset and rapid progression of symptoms. To our knowledge, this case is the most acute onset of postoperative gas gangrene ever reported. Case presentation A 65-year-old Japanese female patient developed a shock state 16 h after radical cystectomy with ileal conduit reconstruction. Two days after the operation, she was transferred to the intensive care unit because of deterioration in her respiratory and circulatory condition. Soon after moving her to the ICU, a subcutaneous hemorrhage-like skin rash appeared and extended rapidly over her left side. Blood tests performed on admission to the ICU indicated severe metabolic acidosis, liver and renal dysfunction, and signs of disseminated intravascular coagulation. Suspecting necrotizing fasciitis or gas gangrene, we performed emergency fasciotomy. Subsequently, multidisciplinary treatment, including empirical therapy using multiple antibiotics, mechanical ventilation, hyperbaric oxygen therapy, polymyxin B-immobilized fiber column direct hemoperfusion, and continuous hemodiafiltration, was commenced. Culture of the debris from a wound abscess removed by emergency fasciotomy detected the presence of Clostridium perfringens. We hypothesized that the source of infection in this case may have been the ileum used for bladder reconstruction. Although the initial treatment prevented further clinical deterioration, she developed secondary infection from the 3rd week onward, due to infection with multiple pathogenic bacteria. Despite prompt diagnosis and intensive therapy, the patient died 38 days after the operation. Conclusion Although the patient did not have any specific risk factors for postsurgical infection, she developed a shock state only 16 h after surgery due to gas gangrene. Our experience highlights the fact that physicians should be aware that any patient could possibly develop gas gangrene postoperatively.
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Affiliation(s)
- Tomonori Takazawa
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan. .,Department of Intensive Care, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
| | - Jou Ohta
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Tatsuo Horiuchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Hiroshi Hinohara
- Department of Intensive Care, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Fumio Kunimoto
- Department of Intensive Care, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.,Department of Intensive Care, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
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Gobert F, Tancredi I, Malick P, Thobois S, Monneuse O. Massive subcutaneous emphysema and septic shock revealed by a stroke-mimic episode. Rev Neurol (Paris) 2015; 172:162-5. [PMID: 26494572 DOI: 10.1016/j.neurol.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 07/26/2015] [Accepted: 09/02/2015] [Indexed: 10/22/2022]
Affiliation(s)
- F Gobert
- Service de neurologie C, hôpital neurologique Pierre-Wertheimer, hospices civils de Lyon, 59, boulevard Pinel, 69003 Lyon, France; Service de radiologie, hôpital Érasme, route de Lennik 808, 1070 Bruxelles, Belgium.
| | - I Tancredi
- Service d'accueil des urgences, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
| | - P Malick
- Université Claude-Bernard Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France
| | - S Thobois
- Service de neurologie C, hôpital neurologique Pierre-Wertheimer, hospices civils de Lyon, 59, boulevard Pinel, 69003 Lyon, France; Service de radiologie, hôpital Érasme, route de Lennik 808, 1070 Bruxelles, Belgium; CNRS, UMR 5229, centre de neuroscience cognitive, 67, boulevard Pinel, 69675 Bron, France
| | - O Monneuse
- Service de radiologie, hôpital Érasme, route de Lennik 808, 1070 Bruxelles, Belgium; Service de chirurgie d'urgence et de traumatologie, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
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Iacopi E, Coppelli A, Goretti C, Piaggesi A. Necrotizing Fasciitis and The Diabetic Foot. INT J LOW EXTR WOUND 2015; 14:316-27. [PMID: 26415868 DOI: 10.1177/1534734615606534] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Necrotizing fasciitis (NF) represents a rapidly progressive, life-threatening infection involving skin, soft tissue, and deep fascia. An early diagnosis is crucial to treat NF effectively. The disease is generally due to an external trauma that occurs in predisposed patients: the most important risk factor is represented by diabetes mellitus. NF is classified into 3 different subtypes according to bacterial strains responsible: type 1 associated to polymicrobial infection, type 2 NF, generally associated to Streptococcus species, often associated to Staphylococcus aureus and, eventually, Type 3, due to Gram-negative strains, such as Clostridium difficile or Vibrio. NF is usually characterized by the presence of the classic triad of symptoms: local pain, swelling, and erythema. In daily clinical practice immune-compromised or neuropathic diabetic patients present with atypical symptomatology. This explains the high percentage of misdiagnosed cases in the emergency department and, consequently, the worse outcome presented by these patients. Prompt aggressive surgical debridement and antibiotic systemic therapy are the cornerstone of its treatment. These must be associated with an accurate systemic management, consisting in nutritional support, glycemic compensation, and hemodynamic stabilization. Innovative methods, such as negative pressure therapy, once the acute conditions have resolved, can help fasten the surgical wound closure. Prompt management can improve prognosis of patients affected from NF reducing limb loss and saving lives.
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Carloni R, Pechevy L, Isola N, Vidal L, Goga D, Watier E, Bertheuil N. [Fournier's gangrene: Cervical and facial extension. A very rare case]. ANN CHIR PLAST ESTH 2015; 61:84-9. [PMID: 25766003 DOI: 10.1016/j.anplas.2015.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 02/09/2015] [Indexed: 10/23/2022]
Abstract
Fournier's gangrene is a fearsome disease with a bad prognosis and a mortality rate ranging between 10 and 80% according to the literature. It is extensive in 13 to 54% of cases. Up to date, cervico-facial extension has never been reported. We describe the case of a 51-year-old overweighed woman with a history of type 2 diabetes and a narrow lumbar canal who was referred to our institution for significant fatigue and increasingly painful legs. A diagnosis of Fournier's gangrene was made after correlating the physical findings with the results of a full body scan. Diffuse subcutaneous emphysema involving the face, neck, mediastinum, abdominal wall, right buttock, perineum and the right thigh was identified. Treatment included multiple surgical debridements, admission to intensive care unit, and an efficient antibiotic therapy that enabled preservation of the patient's life. To our knowledge, this is the first case of cervical and mediastinal extension of Fournier's gangrene to be reported. No clear guidelines exit on the management of this complication (cervico-facial and mediastinal drainage). We share our experience of this unusual case.
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Affiliation(s)
- R Carloni
- Service de chirurgie plastique et reconstructrice, centre des brulés, hôpital Trousseau, CHRU de Tours, avenue de la République, 37170 Chambray-les-Tours, France.
| | - L Pechevy
- Service de chirurgie plastique et reconstructrice, centre des brulés, hôpital Trousseau, CHRU de Tours, avenue de la République, 37170 Chambray-les-Tours, France
| | - N Isola
- Service de chirurgie plastique et reconstructrice, centre des brulés, hôpital Trousseau, CHRU de Tours, avenue de la République, 37170 Chambray-les-Tours, France
| | - L Vidal
- Institut de recherches médicales A.-Lanari, université de Buenos-Aires, C1427ARO Buenos-Aires, Argentine
| | - D Goga
- Service de chirurgie plastique et reconstructrice, centre des brulés, hôpital Trousseau, CHRU de Tours, avenue de la République, 37170 Chambray-les-Tours, France
| | - E Watier
- Service de chirurgie plastique et reconstructrice, hôpital Sud, CHU de Rennes, boulevard de Bulgarie, 35200 Rennes, France
| | - N Bertheuil
- Service de chirurgie plastique et reconstructrice, hôpital Sud, CHU de Rennes, boulevard de Bulgarie, 35200 Rennes, France; Inserm U917, université de Rennes 1, 35033 Rennes, France; Laboratoire SITI, établissement français du sang Bretagne, CHU de Rennes, 35033 Rennes, France; STROMAlab, UMR5273 CNRS/UPS/EFS - Inserm U1031, hôpital Rangueil, 31059 Toulouse, France
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Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg 2014; 1:36. [PMID: 25593960 PMCID: PMC4286984 DOI: 10.3389/fsurg.2014.00036] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 08/24/2014] [Indexed: 01/18/2023] Open
Abstract
Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that develops in the scrotum and perineum, the abdominal wall, or the extremities. The infection progresses rapidly, and septic shock may ensue; hence, the mortality rate is high (median mortality 32.2%). Prognosis becomes poorer in the presence of co-morbidities, such as diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and liver cirrhosis. NF is classified into four types, depending on microbiological findings. Most cases are polymicrobial, classed as type I. The clinical status of the patient varies from erythema, swelling, and tenderness in the early stage to skin ischemia with blisters and bullae in the advanced stage of infection. In its fulminant form, the patient is critically ill with signs and symptoms of severe septic shock and multiple organ dysfunction. The clinical condition is the most important clue for diagnosis. However, in equivocal cases, the diagnosis and severity of the infection can be secured with laboratory-based scoring systems, such as the laboratory risk indicator for necrotizing fasciitis score or Fournier's gangrene severity index score, especially in regard to Fournier's gangrene. Computed tomography or ultrasonography can be helpful, but definitive diagnosis is attained by exploratory surgery at the infected sites. Management of the infection begins with broad-spectrum antibiotics, but early and aggressive drainage and meticulous debridement constitute the mainstay of treatment. Postoperative management of the surgical wound is also important for the patient's survival, along with proper nutrition. The vacuum-assisted closure system has proved to be helpful in wound management, with its combined benefits of continuous cleansing of the wound and the formation of granulation tissue.
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Affiliation(s)
- Evangelos P. Misiakos
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - George Bagias
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Paul Patapis
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Dimitrios Sotiropoulos
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Prodromos Kanavidis
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
| | - Anastasios Machairas
- 3rd Department of Surgery, Attikon University Hospital, University of Athens School of Medicine, Athens, Greece
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Garg D, Garg N, Gupta M. Gas gangrene in the abdominal wall: a physician's nightmare. Clin Res Hepatol Gastroenterol 2013; 37:549-50. [PMID: 23684577 DOI: 10.1016/j.clinre.2013.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/19/2013] [Accepted: 02/28/2013] [Indexed: 02/04/2023]
Affiliation(s)
- Deepak Garg
- Santosh University Medical College and Hospital, 1, Ambedkar Road, 201001 Ghaziabad, India.
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Park SH, Choi JR, Song JY, Kang KK, Yoo WS, Han SW, Kim CK. Necrotizing fasciitis of the thigh secondary to radiation colitis in a rectal cancer patient. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2013; 28:325-9. [PMID: 23346513 PMCID: PMC3548149 DOI: 10.3393/jksc.2012.28.6.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 08/04/2012] [Indexed: 10/28/2022]
Abstract
Necrotizing fasciitis usually occurs after dermal injury or through hematogenous spread. To date, few cases have been reported as necrotizing fasciitis of the thigh secondary to rectal perforation in rectal cancer patients. A 66-year-old male complained of pelvic and thigh pain and subsequently developed necrotizing fasciitis in his right thigh. Four years earlier, he had undergone a low anterior resection and radiotherapy due to of rectal cancer. An ulcerative lesion had been observed around the anastomosis site during the colonoscopy that had been performed two months earlier. Pelvic computed tomography and sigmoidoscopy showed rectal perforation and presacral abscess extending to buttock and the right posterior thigh fascia. Thus, the necrotizing fasciitis was believed to have occurred because of ulcer perforation, one of the complications of chronic radiation colitis, at the anastomosis site. When a rectal-cancer patient complains of pelvic and thigh pain, the possibility of a rectal perforation should be considered.
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Affiliation(s)
- So Hyun Park
- Department of Infectious Diseases, Veterans Hospital Seoul Medical Center, Seoul, Korea
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Khalil H, Tsilividis B, Schwarz L, Scotté M. Necrotizing fasciitis of the thigh should raise suspicion of a rectal cancer. J Visc Surg 2010; 147:e187-9. [PMID: 20708997 DOI: 10.1016/j.jviscsurg.2010.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Perforation of rectal cancer usually occurs intraperitoneally. Extraperitoneal perforation is rare and usually presents as perineal sepsis, leading to diagnosis and urgent surgical management plus antibiotic therapy. We report the case of a patient presenting with a perforated rectal carcinoma which presented as necrotizing fasciitis of the right thigh.
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Affiliation(s)
- H Khalil
- Service de chirurgie digestive, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76000 Rouen cedex, France
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