B D Bilton | PubMed Health

PubMed1998

Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study.

Necrotizing fasciitis is an aggressive soft-tissue infection that in the past has carried a significant mortality rate. One of the most important determinants of outcome is recognition of the disease process. This is followed by aggressive resuscitation measures and radical debridement at the initial operation to control the infectious spread at the outset. The objective of this study is to help reveal the benefits of aggressive early surgical debridement in the treatment of necrotizing fasciitis. A retrospective review of the medical records of 68 patients between the years 1980 and 1996 with the diagnosis of necrotizing fasciitis was performed. The patients were assigned to two groups, Group A (21; 31%), who had delay in therapy or inadequate preliminary therapy and Group B (47; 69%), who underwent aggressive surgical debridement from the outset. Concomitant disease processes were noted. The medical records of 68 patients were studied. Age ranged from 13 to 67 (mean, 52) years of age. There were 38 (56%) females, 21 (64%) of the patients were African-American, 24 (73%) of the patients had concomitant disease processes, 29 (42%) of the patients had a history of tobacco use, 11 (16%) of the patients had a history of alcohol consumption, and 11 (16%) of the patients were obese. Mortality in Group A was 8 of 21 patients (38%). Mortality in Group B was 2 of 47 patients (4.2%). The difference in mortality was found to be statistically significant (P = 0.0007). Early recognition and expeditious initial wide excision and debridement along with appropriate antibiotic coverage and support of systemic effects of necrotizing fasciitis serve to decrease morbidity and mortality. We believe the above is an absolute necessity followed by frequent washing and minor debridement of the wound until granulating tissue is observed. This can then be followed by procedures to close/cover the surgical defect (i.e., split-thickness skin grafts or various coverage flaps).

Adolescent↗

PubMed1997

Nonoperative therapy for acute necrotizing pancreatitis.

Acute necrotizing pancreatitis is a highly morbid and lethal condition. We performed a retrospective study of all patients admitted to Louisiana State University Medical Center between 1980 and 1995 with a diagnosis of pancreatitis (N = 617) and specifically examined those (N = 26) who developed acute necrotizing pancreatitis. During the period 1980 to 1989, there were 7 patients who progressed to acute necrotizing pancreatitis. Six of these seven patients died (mortality, 86%). These patients were managed with multiple operations for debridement and necrosectomy. The age ranged from 31 to 86 years in this group, with a mean of 58.5. The patients' total hospital days ranged from 2 to 125 days with a mean of 63.5 days. In 1989, we adopted an initial nonoperative approach to necrotizing pancreatitis and began using CT-guided catheter drainage for this condition. During this time period, 19 patients have progressed to necrotizing pancreatitis. The range of hospital days was from 13 to 90 days, with a mean of 43.8 days. There were 2 deaths in this last group, resulting in a mortality rate of 10.5 per cent. All of these patients were treated nonoperatively in the acute phase of their illness. Two patients (15.8%) subsequently underwent laparotomy and drainage when the collections were not amenable to CT-guided drainage. Morbidity in this population approached 70 per cent; however, the mortality was only 10 per cent compared to 86 per cent in the previous group. Although nonoperative therapy has its associated morbidity, and although we understand the controversy surrounding the management of this condition, it appears at least in this population to have much less mortality than those who were treated operatively in the acute phase.

Adolescent↗