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Cureus Jun 2024Unilateral exudative pleural effusions have been described as a rare complication of polycystic liver disease. Surgical debridement of the main cyst reduces recurrence...
Unilateral exudative pleural effusions have been described as a rare complication of polycystic liver disease. Surgical debridement of the main cyst reduces recurrence of the pleural effusion. We describe the case of an elderly Asian woman with recurrent large right-sided pleural effusion and also a large hepatic cyst under her right hemidiaphragm. She was deemed a poor surgical candidate and was treated with an indwelling pleural catheter (IPC). She was discharged from Sengkang General Hospital with improvement in symptoms. An 88-year-old Asian woman presented twice to Sengkang General Hospital with recurrent right-sided exudative pleural effusion. She had a past medical history of hypertension, type 2 diabetes, hyperlipidemia, ischemic heart disease (left ventricle ejection fraction 55%), atrial fibrillation, and chronic kidney disease stage 3 (estimated glomerular filtration rate 53). She denied any family history of polycystic kidney or liver disease. Computer tomography of her chest, abdomen, and pelvis revealed a large right pleural effusion and also a large hepatic cyst. A pleural catheter was inserted and the fluid analysis was consistent with an exudative effusion. The pleural fluid was sterile to culture for bacteria and mycobacterium. The cytology was negative for malignant cells. The pleural effusion recurred quickly despite repeated large-volume drainage from the pleural catheter. Our patient was not suitable for surgical debridement of the hepatic cyst and eventually received an IPC and was discharged. With the advent of IPC, there has been increasing interest in using IPC in the management of non-malignant pleural effusions. While surgical debridement of hepatic cysts is the preferred treatment option in recurrent pleural effusion associated with polycystic liver disease, IPCs now provide another viable and minimally invasive option for clinicians and patients.
PubMed: 38859945
DOI: 10.7759/cureus.62058 -
Plastic and Reconstructive Surgery.... Jun 2024Pilonidal cyst disease is a challenging condition requiring excision and wound management when it is chronic and symptomatic. Primary closure of the excision site can...
BACKGROUND
Pilonidal cyst disease is a challenging condition requiring excision and wound management when it is chronic and symptomatic. Primary closure of the excision site can lead to high recurrence rates, necessitating flap-based reconstruction. This article discusses the use of a partial gluteus maximus muscle flap to address recurrent pilonidal disease and reduce its recurrence.
METHODS
From 2014 to 2021, 11 patients aged 14-31 with recurrent pilonidal cysts underwent two-stage surgery involving excision and wound debridement by general surgery, followed by plastic surgery for wound closure using the partial gluteus muscle flap.
RESULTS
Eleven patients were included in the study (four women and seven men). The mean age was 23 ± 5.2, and the average body mass index was 28.59 (±6.7). The mean number of previous procedures was 2.25 (range, 2-3). Operative time was 158.7 ± 37 minutes. The average length of stay when both procedures were done in the same admission was 8 ± 6 days (range 3-21 days) and when procedures were done separately, the length of hospital stay after the wound closure using a partial gluteus muscle flap was 3 days, and the range for reliable follow-up was 1.6-7 years postoperatively. In our study cohort of 11 patients, the majority, specifically seven individuals, experienced uneventful healing. However, a subset of patients encountered complications. Three patients developed an infection recurrence: one was treated conservatively, and one required reoperation with resolution of symptoms, and one patient also experienced wound dehiscence, which was closed with a small procedure.
CONCLUSION
Partial gluteal muscle flap offers a promising approach for treating recalcitrant, difficult-to-treat pilonidal disease in young adults, enhancing wound healing and reducing the risk of recurrence.
PubMed: 38859808
DOI: 10.1097/GOX.0000000000005887 -
Plastic and Reconstructive Surgery.... Jun 2024In deep burns, the gold standard of treatment is surgical debridement and coverage, but in hands, this may lead to poor aesthetic and functional results due to the...
BACKGROUND
In deep burns, the gold standard of treatment is surgical debridement and coverage, but in hands, this may lead to poor aesthetic and functional results due to the complexity of this anatomical area. Enzymatic debridement (Nexobrid) allows for the preservation of the dermal remnant and reduces the number of skin grafts when compared with surgical excision. The study aimed to analyze the patients with intermediate second-degree or deeper burns in hands who required surgical treatment after Nexobrid and those who avoided it.
METHODS
A descriptive retrospective study of all patients who underwent Nexobrid following hand burns between May 2015 and April 2020 treated in Vall d'Hebrón University Hospital was conducted. After the enzymatic debridement, the burn unit team determined if the burn required conservative treatment or surgery, based on the characteristics of the wound bed.
RESULTS
A total of 202 hands were collected. Most hands included in this study had deep second-degree burns (122; 60.4%). Almost half of the hands underwent surgery (99; 49%), and most had deep second-degree burns (61; 61.62%). During follow-up, 24 hands required surgery for sequelae (11.88%) and 62 did not undergo follow-up (30.69%). In the group that needed sequelae surgery, 21 needed surgery after Nexobrid and three of them were healed with conservative treatment after Nexobrid ( < 0.001).
CONCLUSIONS
Nexobrid decreases the number of surgical procedures in deep burns of the hand because more conservative attitudes are adopted. Also, it seems to reduce the need of surgery due to burn sequelae.
PubMed: 38859806
DOI: 10.1097/GOX.0000000000005886 -
European Review For Medical and... May 2024Recently, the infiltration of a subpopulation of cells represented by mononucleated cells extracted from peripheral blood [Peripheral Blood-Mononuclear Cells (PB-MNCs)]...
BACKGROUND
Recently, the infiltration of a subpopulation of cells represented by mononucleated cells extracted from peripheral blood [Peripheral Blood-Mononuclear Cells (PB-MNCs)] is becoming a useful technique for medical and surgical regenerative procedures. Due to the angiogenetic and regenerative properties of PB-MNCs, the infiltration of these cells is, in our opinion, a new option indicated in the treatment of pathologies characterized by tissue dystrophy, loss of vascularization, and non-healing wounds.
CASE PRESENTATION
A 25-year-old active smoker patient was diagnosed with Rhabdomyosarcoma of the anterior tibial muscle of his left leg and treated with neoadjuvant chemo- and radiotherapy (RT). After the tumor excision, the patient developed wound dehiscence with bone exposure and a perilesional radiation-induced chronic dermatitis characterized by skin dyschromia and hair thinning along the treated area. The patient underwent surgical debridement and reconstruction with autologous skin grafts and dermal substitutes, with poor outcomes due to graft failure. The patient was subsequently treated with surgical debridement and coverage with a reverse sural fascia-cutaneous flap. After 13 days, wound dehiscence was observed, and reconstruction of the dehiscent areas was performed with a split-thickness autologous skin graft with no success. After wound debridement, a new split-thickness skin graft was performed, and a concentrate of autologous PB-MNCs was injected in the flap and perilesional skin. After 14 days, graft take was reached, and improvements in perilesional tissue tropism were noted. At 2 months follow-up, the patient appeared completely healed.
CONCLUSIONS
In our opinion, the use of PB-MNCs to treat conditions characterized by tissue dystrophy, which require neoangiogenesis and cell regeneration, can be a useful and unconsidered technique that could be utilized to improve tissue tropism. Furthermore, prospective trials are necessary to validate our observations.
Topics: Humans; Male; Adult; Leukocytes, Mononuclear; Plastic Surgery Procedures; Lower Extremity; Rhabdomyosarcoma; Wound Healing
PubMed: 38856134
DOI: 10.26355/eurrev_202405_36295 -
Plastic and Reconstructive Surgery.... Jun 2024The treatment of a sternal wound infection is challenging because it requires radical debridement and reconstruction with a well-vascularized flap. The defects after...
The treatment of a sternal wound infection is challenging because it requires radical debridement and reconstruction with a well-vascularized flap. The defects after debridement are three-dimensionally complex, especially if synthetic grafts are involved. Although the pectoralis major muscle (PMM) flap is useful for reconstruction, it is difficult to fill up the complex dead space surrounding the vascular prosthesis when using a conventional PMM flap. Herein, we describe a new technique of splitting and shaping the PMM flap to fit the complex defect. Intraoperative indocyanine green fluorescence angiography was used to assess dynamic blood flow of the PMM supplied by internal mammary artery perforators. This technique allows the PMM flap to be split and shaped to securely fit the dead space, which may improve the healing rate.
PubMed: 38855140
DOI: 10.1097/GOX.0000000000005876 -
Plastic and Reconstructive Surgery.... Jun 2024Scalp reconstruction provides a unique challenge to the reconstructive surgeon, especially in terms of matching skin color and contour. We present a case of a...
Scalp reconstruction provides a unique challenge to the reconstructive surgeon, especially in terms of matching skin color and contour. We present a case of a 67-year-old man with a chronic scalp wound requiring soft tissue coverage after major debridement and coverage of a skull defect. We chose to use a super thin deep inferior epigastric perforator (DIEP) flap to provide good skin coverage along with good contour to the scalp. The use of a super thin DIEP flap, dissected above the superficial fascial plane, is a newer technique in the realm of free tissue transfers that has shown improved outcomes in wound contour. Although the DIEP flap has been popularized for breast reconstruction, the authors believe that it has the ability to provide good soft tissue and skin coverage to other areas of the body, including in head and neck reconstruction.
PubMed: 38855132
DOI: 10.1097/GOX.0000000000005891 -
Journal of Clinical Orthopaedics and... May 2024Prosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA); and the gold standard surgical approach involves a two-staged,...
INTRODUCTION
Prosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA); and the gold standard surgical approach involves a two-staged, revision TKA (TSR). Owing to the newer, emerging evidence on this subject, there has been gradual shift towards a single-stage revision approach (SSR), with the purported benefits of mitigated patient morbidity, decreased complications and reduced costs. However, there is still substantial lacuna in the evidence regarding the safety and outcome of the two approaches in chronic PJI. This study aimed to comprehensively review of the literature on SSR; and evaluate its role within Revision TKA post PJI.
METHODS
The narrative review involved a comprehensive search of the databases (Embase, Medline and Pubmed), conducted on 20th of January 2024 using specific key words. All the manuscripts discussing the use of SSR for the management of PJI after TKA were considered for the review. Among the screened manuscripts, opinion articles, letters to the editor and non-English manuscripts were excluded.
RESULTS
The literature search yielded a total 232 studies. Following a detailed scrutiny of these manuscripts, 26 articles were finally selected. The overall success rate following SSR is reported to range from 73 % to 100 % (and is comparable to TSR). SSR is performed in PJI patients with bacteriologically-proven infection, adequate soft tissue cover, immuno-competent host and excellent tolerance to antibiotics. The main difference between SSR and TSR is that the interval between the 2 stages is only a few minutes instead of 6 weeks. Appropriate topical, intraoperative antibiotic therapy, followed by adequate postoperative systemic antibiotic cover are necessary to ascertain good outcome. Some of the major benefits of SSR over TSR include reduced morbidity, decreased complications (such as arthrofibrosis or anesthesia-associated adverse events), meliorated extremity function, earlier return to activities, mitigated mechanical (prosthesis-associated) complications and enhanced patient satisfaction.
CONCLUSION
SSR is a reliable approach for the management of chronic PJI. Based on our comprehensive review of the literature, it may be concluded that the right selection of patients, extensive debridement, sophisticated reconstruction strategy, identification of the pathogenic organism, initiation of appropriate antibiotic therapy and ensuring adequate follow-up are the key determinants of successful outcome. To achieve this will undoubtedly require an MDT approach to be taken on a case-by-case basis.
PubMed: 38854773
DOI: 10.1016/j.jcot.2024.102431 -
Medicine Jun 2024Patients with traumatic ischemic mangled extremities first undergo arterial reconstruction using autogenous vein grafts, followed by flap transplantation as a staged... (Observational Study)
Observational Study
Patients with traumatic ischemic mangled extremities first undergo arterial reconstruction using autogenous vein grafts, followed by flap transplantation as a staged treatment for soft tissue reconstruction. This study aimed to report the outcomes of such a staged treatment. Thirteen patients underwent arterial reconstruction between February 2015 and April 2017 due to damage to the major blood vessels by the traumatic mangled extremities. Of them, 6 patients (5 males and 1 female with a mean age of 51 years, age range: 36-60 years) who underwent soft tissue reconstruction due to necrosis were retrospectively analyzed. The average Mangled Extremity Severity Score was 7.2 (range, 6-8). Injuries were found in the lower leg (4 cases), foot (1 case), and wrist and hand (1 case). Arterial reconstruction was performed using autologous venous grafts. The reconstructed arteries included the posterior tibial artery (3 cases), anterior tibial artery (1 case), dorsalis pedis artery (1 case), and radial artery (1 case). The blood circulation status of the reconstructed blood vessels was assessed using computed tomography angiography at an average of 5 weeks (range, 4-6 weeks) after arterial reconstruction. For some necrotic soft tissues, debridement and flap transplantation were performed an average of 7 weeks (range, 6-8 weeks) after arterial reconstruction. Soft tissue reconstruction was performed with an anterolateral thigh free flap in 4 cases, a local flap in 1 case, and a muscle flap in 1 case. In 5 out of 6 cases, blood circulation was maintained in the reconstructed blood vessels, resulting in the salvaging of the extremities. All the patients who underwent flap surgery survived. Notably, there were no special complications during a follow-up visit conducted at an average of 19 months post-reconstruction. To treat an ischemic mangled extremity, the limbs should first be salvaged with arterial reconstruction, followed by subsequent appropriate flap surgery when soft tissue necrosis occurs at the mangled site as a staged treatment.
Topics: Humans; Male; Female; Middle Aged; Adult; Retrospective Studies; Surgical Flaps; Plastic Surgery Procedures; Ischemia; Soft Tissue Injuries; Arteries; Debridement; Treatment Outcome
PubMed: 38847727
DOI: 10.1097/MD.0000000000038385 -
Frontiers in Dental Medicine 2024Peri-implantitis is a complex infectious disease that manifests as progressive loss of alveolar bone around the dental implants and hyper-inflammation associated with...
Peri-implantitis is a complex infectious disease that manifests as progressive loss of alveolar bone around the dental implants and hyper-inflammation associated with microbial dysbiosis. Using antibiotics in treating peri-implantitis is controversial because of antibiotic resistance threats, the non-selective suppression of pathogens and commensals within the microbial community, and potentially serious systemic sequelae. Therefore, conventional treatment for peri-implantitis comprises mechanical debridement by nonsurgical or surgical approaches with adjunct local microbicidal agents. Consequently, current treatment options may not prevent relapses, as the pathogens either remain unaffected or quickly re-emerge after treatment. Successful mitigation of disease progression in peri-implantitis requires a specific mode of treatment capable of targeting keystone pathogens and restoring bacterial community balance toward commensal species. Antimicrobial peptides (AMPs) hold promise as alternative therapeutics through their bacterial specificity and targeted inhibitory activity. However, peptide sequence space exhibits complex relationships such as sparse vector encoding of sequences, including combinatorial and discrete functions describing peptide antimicrobial activity. In this paper, we generated a transparent Machine Learning (ML) model that identifies sequence-function relationships based on rough set theory using simple summaries of the hydropathic features of AMPs. Comparing the hydropathic features of peptides according to their differential activity for different classes of bacteria empowered predictability of antimicrobial targeting. Enriching the sequence diversity by a genetic algorithm, we generated numerous candidate AMPs designed for selectively targeting pathogens and predicted their activity using classifying rough sets. Empirical growth inhibition data is iteratively fed back into our ML training to generate new peptides, resulting in increasingly more rigorous rules for which peptides match targeted inhibition levels for specific bacterial strains. The subsequent top scoring candidates were empirically tested for their inhibition against keystone and accessory peri-implantitis pathogens as well as an oral commensal bacterium. A novel peptide, VL-13, was confirmed to be selectively active against a keystone pathogen. Considering the continually increasing number of oral implants placed each year and the complexity of the disease progression, prevalence of peri-implant diseases continues to rise. Our approach offers transparent ML-enabled paths towards developing antimicrobial peptide-based therapies targeting the changes in the microbial communities that can beneficially impact disease progression.
PubMed: 38846578
DOI: 10.3389/fdmed.2024.1372534 -
Eplasty 2024Pyoderma gangrenosum (PG) is a rare disease characterized by ulcerative cutaneous lesions that can occur postoperatively and is often associated with autoimmune...
Pyoderma gangrenosum (PG) is a rare disease characterized by ulcerative cutaneous lesions that can occur postoperatively and is often associated with autoimmune disorders. PG is diagnosed by excluding other conditions that can cause ulcerations, such as infections, which may also result in immunosuppressive treatment delays and suboptimal wound care. Operative debridement of wounds has traditionally been avoided in the acute setting secondary to pathergy. This article presents a case of extensive breast PG that was successfully treated with surgical debridement, porcine-derived extracellular matrix, and negative pressure wound therapy while on systemic immunosuppressive therapy.
PubMed: 38846508
DOI: No ID Found