Cervical necrotizing fasciitis caused by oral cavity infection: a case report considering therapeutic approach and its morphofunctional implications / Fascitis necrosante cervical causada por infección de la cavidad oral. Reporte de un caso considerando el abordaje terapéutico y sus implicaciones morfofuncionales

SUMMARY: Cervical necrotizing fasciitis (NF) is a rare complication of oral cavity infection with high morbi-mortality. Given its low prevalence, adequately reporting cases of NF, its therapeutic management, and associated morphofunctional modifications to the clinical and scientific community is pivotal. To that end, we herein describe a case of cervical NF in a 60-year-old patient with comorbidities and patient presented large, painful cervical swelling associated with a necrotic ulcer lesion in the anterior neck region. Intraoral examination indicated a periodontal abscess in the right mandibular area, while computed tomography indicated the lesion's extension from the right mandibular to the submandibular region. Following empirical intravenous antibiotic treatment, a broad surgical debridement was performed, and the foci of oral infection were removed. Debridement revealed communication between deep and superficial anatomical regions in the submandibular area, where we subsequently placed a Penrose drain. Biopsies showing acute inflammatory infiltrate associated with necrotic and hemorrhagic regions confirmed the diagnosis of NF. When an antibiogram revealed resistance to the empirical treatment, the antibiotic scheme was replaced with an adequate alternative. After a second debridement, we closed the defect with fascio-mucocutaneous advancement flaps with a lateral base while maintaining suction drainage. Having reacted positively, the patient was discharged 10 days after the operation. Despite an extensive morphofunctional change generated in the treated area, the patient showed no difficulties with breathing, phonation, swallowing, or mobilizing the area during control sessions. Altogether, this report contributes to the highly limited literature describing morphological aspects that can facilitate or delay the spread of infection or the morphofunctional disorders associated with the size and depth of surgical interventions for cervical NF, information that is relevant for the comprehensive, long-term prognosis of the treatment of NF.

La fascitis necrosante (FN) cervical es una rara complicación de una infección proveniente de la cavidad bucal asociada a una alta morbimortalidad. Por lo anterior, es fundamental informar a la comunidad clínica y científica los casos de FN, su manejo terapéutico y las modificaciones morfofuncionales asociadas. Se describe un caso de FN cervical en una paciente de 60 años quien presentó una gran tumefacción dolorosa asociada a una lesión ulcerosa necrótica en la región anterior del cuello. El examen intraoral mostró un absceso periodontal en el área mandibular derecha y la tomografía computarizada mostró la extensión de la lesión hacia la región submandibular. Tras el tratamiento antibiótico empírico, se realizó un desbridamiento quirúrgico extenso y se extirparon los focos de infección oral. El desbridamiento reveló comunicación entre las regiones anatómicas profundas y superficiales del área submandibular, donde se colocó un drenaje Penrose. Las biopsias mostraron un infiltrado inflamatorio agudo asociado con regiones necróticas y hemorrágicas, confirmando el diagnóstico de FN. El antibiograma reveló resistencia al tratamiento empírico, por lo que el esquema antibiótico se sustituyó. Tras un segundo desbridamiento, se cerró el defecto con colgajos de avance fascio-mucocutáneos de base lateral manteniendo drenaje aspirativo. El positivo progreso del paciente permitió su alta 10 días después. Aun cuando se generó una gran modificación morfofuncional en el área tratada, la paciente no presentó dificultades para respirar, hablar, deglutir o movilizar el área cervical intervenida durante las sesiones de control. Este informe contribuye a la limitada literatura que describe los aspectos morfológicos que pueden facilitar o retrasar la propagación de la FN y las consecuencias asociadas a los trastornos morfofuncionales provocadas por el tamaño y profundidad de las intervenciones quirúrgicas requeridas por la FN, información relevante para el pronóstico integral a largo plazo del tratamiento de la FN.

Debridement of axillary necrotizing fasciitis under anesthetic blocks of the serratus plane and supraclavicular brachial plexus: a case report

Abstract The regional techniques for axillary analgesia are well established. However, few studies have investigated surgical anesthesia. In this report, extensive debridement of axillary necrotizing fasciitis, including the posteromedial region of the right arm, performed under exclusive regional anesthesia in a patient with probable difficult airway is described. The procedure was accomplished under a Serratus Plane Block (SPB) and supraclavicular brachial plexus block, guided by ultrasound, and with venous sedation. We observed satisfactory anesthesia 15 minutes after the intervention, efficient intraoperative pain control and within the following 24 hours. Surgical axilla anesthesia is feasible with the described blocks.

Transporte sobre clavo respetando la membrana de Masquelet en defectos segmentarios severos. Serie de casos / Distraction osteogenesis technique using an intramedullary nail and an external fixator in large bone defects

Introducción: El adecuado tratamiento de los defectos óseos se presenta como un desafío para el cirujano ortopedista, en cuanto a la dificultad en la restitución de un miembro alineado, sin discrepancia ni infección. Se han descrito múltiples técnicas para reconstruir estos defectos, como el injerto óseo autólogo o de banco, la técnica de membrana inducida, la osteogénesis por distracción y los cilindros de titanio trabecular, pero ninguna ha demostrado ser significativamente superior a otra. materiales y métodos: Entre 2018 y 2021, 10 pacientes con defectos óseos de la tibia fueron tratados mediante transporte óseo guiado con osteosíntesis endomedular. Se realizó un estudio retrospectivo descriptivo analizando la magnitud de los defectos, el tiempo de transporte, las complicaciones y cirugías adicionales durante el proceso, si hubo consolidación y las deformidades residuales. Al final del proceso, se midió el puntaje de la ASAMI (óseo y funcional). Resultados: La longitud promedio de los defectos tratados fue de 9,75 cm y el índice de fijación externa promedio, de 40,62 días/cm. El 50% tenía un puntaje de la ASAMI óseo bueno; el 10%, excelente y el 40%, pobre al final del proceso reconstructivo. El 20% tenía un puntaje de la ASAMI funcional excelente; el 30%, bueno y el 50%, pobre. Conclusiones: El uso de tutores externos guiados mediante osteosíntesis es un método fiable para tratar defectos óseos, al mismo tiempo que se trata la infección de manera local y sistémica, acortando los tiempos de tutor externo y, por lo tanto, de internación y reintervención. Nivel de Evidencia: IV

Introduction: The proper treatment of bone defects represents a challenge for the orthopedic surgeon given the difficulty in restoring limb alignment without discrepancy nor infections. Multiple techniques have been described for the reconstruction of these defects. These include bone grafting, whether autologous or from a bank, the induced membrane technique, distraction osteogenesis, and, recently, the use of trabecular titanium cylinders, but none has been shown to be significantly superior to another. materials and methods: Between 2018 and 2021, ten patients with tibial bone defects were treated by guided bone transport with intramedullary osteosynthesis. We carried out a descriptive retrospective study of this series, analyzing the magnitude of the defects, the transport time, the complications and additional surgeries that took place during the process, whether there was con-solidation, and the residual deformities. The bone and functional ASAMI scores were measured at the end of the process. Results: The average length of the treated defects was 9.75 cm and the average external fixation index was 40.62 d/cm. At the end of the reconstructive process, 50% of the patients presented a good bone ASAMI score, 10% presented an excellent score, and 40% had a poor score. Regarding the functional ASAMI score, 20% were excellent, 30% were good, and 50% were poor. Conclusion: The use of fixators guided by intramedullary nails constitutes a reliable method to treat bone defects that allows treating the infection locally and systemically, shortens the times of external fixation and hospitalization, and reduces the need for reinterventions. Level of Evidence: IV

Aspectos clínicos e epidemiológicos e aceitabilidade da terapia larval em pacientes com feridas crônicas / Clinical and epidemiological aspects and acceptability of larval therapy in patients with chronic wounds / Aspectos clínicos y epidemiológicos y aceptabilidad de la terapia larval en pacientes con heridas crónicas

Objetivo: avaliar o perfil epidemiológico e clínico de pacientes com feridas e a aceitabilidade à Terapia Larval (TL). Método: acompanhados 15 pacientes com feridas crônicas e registrados em fichas clínicas. Resultados: pacientes não conheciam a TL. Idades variaram (45 a 73), pretos (46,66%), brancos (26,66%) e pardos (20,00%), predominantemente mulheres (73,33%). Tinham ensino fundamental (53,33%), médio (20,00%) e superior (26,6%) completos. 60% residiam no RJ; Lesões, (idade média de 6 anos e área média de 9,4 cm²) no terço distal das pernas (53,00%) e nos pés (47,00%), com origem vascular (40,88%), úlceras por pressão (31,69%), diabéticas (16,66%) e infecciosa (10,77%). Pacientes apresentavam três (20,00%), duas (20,00%) ou uma lesão (60,00%), com necrose (80,00%), infecção (37,60%), granulação (50,30%), epitelização (15,00%), dor (54,0%) e dificuldade de locomoção (47,00%). Insuficiência venosa como antecedente patológico mais observado. A aceitabilidade para TL foi 93,33%. Conclusão: TL é alternativa para melhor qualidade de vida

Objectives: to evaluate the epidemiological and clinical profile of patients with wounds and acceptability to Larval Therapy (LT). Method: followed 15 patients with chronic wounds and recorded in clinical records. Results: patients didn't know LT. Ages varied (45 to 73 y.o.), were black (46.66%), white (26.66%) and yellow (20.00%), predominantly women (73.33%). They had Elementary (53.33%), High (20.00%) and Higher education (26.60%). 60% lived in Rio de Janeiro; Wounds (mean age of 6 years; mean area of 9.4 cm²) in the distal third of the legs (53.00%) and feet (47.00%), with vascular origin (40.88%), pressure (31.69%), diabetic (16.66%) and infectious ulcers (10.77%). Patients had three (20.00%), two (20.00%) or one wound (60.00%), with necrosis (80.00%), infection (37.60%), granulation (50.30%), epithelialization (15.00%), pain (54.00%) and locomotion difficulty (47.00%). Venous insufficiency as the most observed pathological antecedent. Acceptability for LT was 93.33%. Conclusion: LT is an alternative to better quality of life

Objetivos: evaluar el perfil epidemiológico y clínico de pacientes con heridas y aceptabilidad a Terapia Larvaria (TL). Método: seguimiento de 15 pacientes con heridas crónicas y registrados en historias clínicas. Resultados: pacientes no conocían TL. Edades variaron (45 a 73%), negros (46,66%), blancos (26,66%) y morenos (20,00%), predominantemente mujeres (73,33%). Habían completado la educación primaria (53,33%), media (20,00%) y superior (26,6%). 60% vivían en RJ; Lesiones (edad media de 6 años y superficie media de 9,4 cm²) en el tercio distal de las piernas (53,00%) y pies (47,00%), con origen vascular (40,88%), úlceras por presión (31,69%), diabéticas (16,66%) e infecciosas (10,77%). Pacientes presentaban tres (20,00%), dos (20,00%) o una lesión (60,00%), con necrosis (80,00%), infección (37,60%), granulación (50,30%), epitelización (15,00%), dolor (54,0%) y dificultad locomotiva (47,00%). Insuficiencia venosa como antecedente patológico más observado. Aceptabilidad para TL fue del 93,33%. Conclusión: TL es una alternativa a una mejor calidad de vida

Macroporous latex biomembrane from Hancornia speciosa modulates the inflammatory process and has a debridement effect on wound healing in rats

Purpose: The angiogenic, osteogenic and anti-inflammatory activity of latex of Hancornia speciosa has been evidenced and indicates pharmacological potential with great applicability in the health area, especially in the wound healing process. The present work aimed to compare the effects of the H. speciosa macroporous latex biomembrane with saline on wound healing. Methods: Forty-three Wistar rats were submitted to excisional wound induction procedure and divided into groups according to treatment: saline (G1), and macroporous biomembrane (G2). The animals were euthanized at three, seven, 14, and 21 days after injury induction (DAI), and three animals were used for the debridement test. Morphometric, macroscopic, and microscopic analyses of general pathological processes were performed. Results: The macroporous biomembrane minimized necrosis and inflammation during the inflammatory and proliferative phases of the healing process, confirmed by the lower intensity of the crust and the debridement effect. In addition, the wounds treated with the macroporous biomembrane presented greater contraction rates in all the experimental periods analyzed. Conclusions: The macroporous biomembrane presents angiogenic, anti-inflammatory and debridement effects, contributing to the healing process, and can be considered a potentially promising new biomaterial to be used as a dressing.

Diverticulitis perforada causante de fascitis necrotizante de miembro inferior / Perforated diverticulitis causing necrotizing fasciitis of the lower limb / Diverticulite perfurada causando fasceíte necrosante do membro inferior

Mujer de 59 años, con antecedentes de diverticulosis de colon, que acude por dolor en la región inguinal y en el miembro inferior izquierdo de dos meses de evolución. En una primera instancia, la paciente se presentó con clínica de sepsis y se objetivó un eritema en el miembro inferior izquierdo, asociado a celulitis y crepitación subcutánea. La TC mostraba una colección hidroaérea en psoas y retroperitoneal que asciende hasta la cavidad abdominal hallándose una diverticulitis perforada. El tratamiento quirúrgico se basó en el drenaje de la colección retroperitoneal y sigmoidectomía, seguido de una fasciotomía, desbridamiento y lavado del muslo. La perforación de un divertículo puede formar un absceso intraperitoneal desarrollando una peritonitis o un absceso retroperitoneal, derivando en una translocación bacteriana hacia la extremidad inferior, debido a la comunicación existente en el anillo crural, generando una fascitis necrotizante del miembro.

Micetoma por Nocardia asteroides / Nocardia Asteroids Mycetoma

Introducción: En 1860 Henry Van Carter introdujo la definición del micetoma y desde 1884 se reportan los primeros casos en África (Sudán, Senegal). Estas infecciones afectan la piel, el tejido celular subcutáneo y, en ocasiones, los músculos, los huesos, y pueden diseminarse por la cavidad torácica, la abdominal, y por otras regiones del cuerpo. Objetivo: Presentar un caso de micetoma por Nocardia asteroides con evolución desfavorable y tratamiento. Presentación del caso: Paciente masculino de 47 años de edad que sufrió hace 18 años un trauma en la rodilla izquierda con herida avulsiva y evolución desfavorable por infección. Diez años después presentó en el mismo sitio múltiples lesiones fistulosas con drenaje activo, secreción serohemática escasa y no fétida. En varias ocasiones fue llevado al salón de operaciones para realizarle debridamientos quirúrgicos y toillete y recibió múltiples tratamientos antibióticos y antifúngicos. Se concluyó el caso como un micetoma y se aisló una Nocardia asteroides. El paciente estuvo en desacuerdo con la amputación de la extremidad como tratamiento quirúrgico definitivo. Llegó a nuestro centro en octubre del 2020 con mal estado general y extensión severa del proceso infeccioso en toda la extremidad. Se planificó una hemipelvectomía como tratamiento definitivo, pero desafortunadamente el paciente falleció antes, debido a complicaciones generales. Conclusiones: Ante la aparición del micetoma es importante definir el alcance de la infección para determinar el tipo de tratamiento a utilizar, ya que bien empleado y de forma oportuna, puede salvar la vida al paciente sin dejar graves secuelas(AU)

Introduction: In 1860, Henry Van Carter introduced the definition of mycetoma and since 1884 the first cases have been reported in Africa (Sudan, Senegal). These infections affect the skin, the subcutaneous cellular tissue and, sometimes, the muscles, the bones, and it can spread throughout the thoracic cavity, the abdominal cavity, and other regions of the body. Objective: To report a case of mycetoma due to nocardia asteroides with unfavorable evolution and treatment. Case report: We report the case of a 47-year-old male patient who suffered a left knee trauma 18 years ago with an avulsive wound and unfavorable evolution due to infection. Ten years later, he presented, in the same site, multiple fistulous lesions with active drainage, scant serohematic, non-fetid secretion. On several occasions he was taken to the operating room for surgical debridement and toilette and he received multiple antibiotic and antifungal treatments. The case was concluded as a mycetoma. Nocardia asteroides was isolated. The patient disagreed with limb amputation as definitive surgical treatment. He came to our treatment center in October 2020 with poor general condition and severe extension of the infectious process throughout the limb. A hemipelvectomy was planned as definitive treatment, but unfortunately the patient deceased before due to general complications. Conclusions: Before the appearance of mycetoma, it is important to define the extent of the infection to determine the type of treatment to use, since it can save the patient's life if properly used and in a timely manner without leaving serious sequelae(AU)

Surgical Management of Infected Pancreatic Necrosis. Case Series in a Quaternary Care Hospital in Bogotá, Colombia, 2014-2021 / Manejo quirúrgico de la necrosis pancreática infectada. Serie de casos en un hospital de cuarto nivel en Bogotá, Colombia, 2014-2021

Abstract Introduction: Pancreatitis is a frequent pathology in our environment, mostly related to benign biliary pathology. It can progress to severe forms in 10-15 % of cases, where the pancreatic tissue becomes necrotic and forms large collections with risk of infection. We do not have epidemiological data about the incidence or management of this complication in Colombia. Aim: This study aims to study the prevalence of infected pancreatic necrosis and describe the cases identified in a quaternary care hospital between 2014 and 2021. Materials and methods: A cross-sectional observational study. We analyzed records of patients diagnosed with stage 2 pancreatitis. Those cases with infected pancreatic necrosis that underwent debridement plus laparoscopic and open surgical drainage at Hospital Universitario Mayor Méderi in Bogotá, Colombia, between January 2014 and January 2021 were studied. A convenience sampling was carried out without calculating the sample size. We collected the patients' demographic and clinical variables, performing a descriptive statistical analysis in Excel. Qualitative variables were described through absolute and relative frequencies, while quantitative ones were expressed through measures of central tendency and dispersion based on their distribution. Results: We analyzed 1020 episodes of pancreatitis, finding pancreatic necrosis in 30 patients, i.e., a period prevalence of 2.9 %. Of the patients, 83 % (n = 25) underwent open drainage, with 48 % (n = 12) mortality. About laparoscopic management, the reduction in postoperative organ failure was 40 % (n = 2), with a 30 % shorter hospital stay than the open drainage approach. Those patients with a level of procalcitonin (PCT) lower than 1.8 ng/mL had less mortality. Conclusions: The laparoscopic approach shows promising results regarding final morbidity and mortality.

Resumen Introducción: la pancreatitis es una patología frecuente en nuestro medio, mayormente relacionada con la patología biliar benigna. Esta puede progresar a formas severas en 10 %-15 % de los casos, en donde el tejido pancreático se necrosa y forma grandes colecciones, con riesgo de infección. En Colombia no conocemos los datos epidemiológicos acerca de la incidencia de este tipo de complicaciones, ni del manejo de las mismas. Objetivo: este estudio tiene como objetivo estudiar la prevalencia de la necrosis pancreática infectada y describir los casos identificados en un hospital de alto nivel de complejidad entre 2014 y 2021. Métodos: estudio observacional de corte transversal. Se analizaron los registros de pacientes diagnosticados con pancreatitis en segunda etapa. Se estudiaron aquellos casos que presentaron necrosis pancreática infectada y se sometieron a desbridamiento más drenaje quirúrgico por vía laparoscópica y abierta en el Hospital Universitario Mayor Méderi de Bogotá, Colombia, entre enero de 2014 y enero de 2021. Se realizó un muestreo por conveniencia, sin cálculo de tamaño de muestra. Se recolectaron variables demográficas y clínicas de los pacientes. Se realizó un análisis estadístico descriptivo de las variables obtenidas en Excel. Las variables cualitativas se describieron a través de frecuencias absolutas y relativas; mientras que las cuantitativas se expresaron mediante medidas de tendencia central y de dispersión en función de su distribución. Resultados: se analizaron 1020 episodios de pancreatitis y se evidenció necrosis pancreática en 30 pacientes, es decir, una prevalencia de período de 2,9 %. De los pacientes, 83 % (n = 25) se llevó a drenajes por vía abierta, con un 48 % (n = 12) de mortalidad. En relación con el manejo por vía laparoscópica, la reducción en la falla orgánica posoperatoria fue de 40 % (n = 2), con un 30 % menos de duración en la estancia hospitalaria, comparado con la vía abierta. Aquellos pacientes que presentaron un nivel de procalcitonina (PCT) menor de 1,8 ng/mL tuvieron menos mortalidad. Conclusiones: el abordaje laparoscópico muestra resultados prometedores en cuanto a la morbilidad y mortalidad final observada.

Impacto da COVID-19 no perfil cirúrgico dos pacientes de cirurgia vascular em serviço de referência em Curitiba / Impact of COVID-19 on the surgical profile of vascular surgery patients at a tertiary hospital in Curitiba, Brazil

Resumo Contexto Na pandemia de covid-19, os serviços de saúde diminuíram os atendimentos e procedimentos eletivos. Pacientes de cirurgia vascular são grupo de risco para adquirir formas graves da infecção, ao mesmo tempo que são suscetíveis a apresentar complicações de suas doenças de base caso não tenham acompanhamento rotineiro. Dessa forma, faz-se necessário entender os impactos e as consequências diretas e indiretas da pandemia com relação aos pacientes vasculares. Objetivos Avaliar o impacto de 1 ano de pandemia em um serviço de Cirurgia Vascular, assim como a mudança do perfil de cirurgias no mesmo período. Métodos Foi feita a análise de prontuários de pacientes submetidos a cirurgias eletivas e de urgência entre 2019 e 2021. Em conjunto, foi realizada uma revisão de literatura com as palavras-chave "cirurgia vascular", "covid-19" e "amputações". Os dados foram analisados com o programa computacional Stata/SE v.14.1 (StataCorpLP, EUA). Resultados Foram identificadas 1.043 cirurgias no período de estudo, sendo 51,6% pré-pandemia e 48,4% durante a pandemia. Observou-se redução no número de cirurgias eletivas e aumento no número de amputações de membros inferiores e desbridamentos cirúrgicos. Foi possível observar também aumento de pacientes com doença arterial obstrutiva periférica com classificação de Rutherford avançada, assim como de casos de pé diabético. Conclusões A diminuição dos atendimentos eletivos e o receio dos pacientes em procurar os serviços de saúde durante o período da pandemia são os prováveis motivos que justificam o aumento da gravidade dos quadros dos pacientes, com maior necessidade de amputação de membros inferiores, desbridamento cirúrgico e mudanças no perfil de cirurgia do serviço.

Abstract Background During the COVID-19 pandemic, healthcare services reduced the number of elective procedures performed. Vascular surgery patients are a group at risk of contracting severe forms of the infection, but are also susceptible to complications of their underlying diseases if they do not receive routine care. It is therefore necessary to understand the direct and indirect impacts and consequences of the pandemic on vascular patients. Objectives To assess the impact of 1 year of the pandemic on a vascular surgery service and changes to the profile of surgeries during the same period. Methods An analysis was conducted of the medical records of patients who underwent elective and emergency surgery from 2019 to 2021. A review of the literature was also conducted, using the search terms "vascular surgery", "COVID-19", and "amputations". Data were analyzed with Stata/SE v.14.1 (StataCorpLP, United States). Results A total of 1,043 surgeries were identified during the study period, 51.6% conducted pre-pandemic and 48.4% performed during the pandemic. There was a reduction in the number of elective surgeries and an increase in the number of lower limb amputations and surgical debridements. Increases were also observed in the proportion of patients with peripheral arterial occlusive disease with advanced Rutherford classifications and in the number of cases of diabetic foot. Conclusions The reduction in elective care and patients' reluctance to seek health services during the pandemic are the probable causes of increased severity of patient status, with greater need for lower limb amputation and surgical debridement and changes to the profile of the surgery performed at the service.

Implementação da teoria do conforto no cuidado ao paciente com ferida neoplásica a partir do desbridamento com papaína: um estudo misto / Implementation of the comfort theory in the care of patients with a neoplastic wound after papain debridement: a mixed study

As feridas neoplásicas são formadas a partir de uma proliferação descontrolada das células tumorais e sua infiltração nas estruturas da pele, sendo a meta principal do cuidado o conforto do paciente a partir do manejo dos sintomas físicos e psicossociais. Este estudo inovador teve como objetivo analisar a implementação da Teoria do Conforto a partir da intervenção clínica de desbridamento no cuidado de enfermagem ao paciente com ferida neoplásica. Trata-se de uma pesquisa de método misto onde as abordagens quantitativa e qualitativa foram contempladas nas diferentes fases da pesquisa passando pela coleta, análise de dados e interpretação dos resultados. No primeiro momento foi desenvolvido um estudo piloto de um ensaio clínico randomizado e no segundo momento foram analisados os dados coletados durante o cuidado e registrados em um diário de campo. Após a aprovação pelo Comitê de Ética em Pesquisa sob o número de parecer 4.292.777, iniciou-se a coleta de dados em novembro de 2020 até novembro de 2021. Os participantes foram distribuídos de forma aleatória em dois grupos, Intervenção (Papaína 6%) e Controle (Gel de Carboximetilcelulose a 2%) por um tempo de seguimento de 12 semanas. Foi realizada uma análise descritiva dos dados baseada em distribuições de frequências e gráficos sendo a mediana a medida síntese principal utilizada. Os resultados apontam que nenhuma participante apresentou evolução positiva de melhora na quantidade de exsudato. No que se refere a variável dor, em termos medianos, houve melhora da dor ao longo das 12 avaliações. Quanto ao odor, pode-se afirmar que no global, houve evolução positiva de melhora do grau de odor das feridas das participantes. Os dados referentes à análise do desconforto mostram um aumento tanto da mediana, de 9,0 na primeira avaliação para 10,0 na segunda avaliação, quanto na média, que passou de 8,0 na primeira avaliação para 8,5 na segunda avaliação. Conclui-se que quanto ao desconforto, houve melhora do escore em apenas 20% das participantes. Com relação aos eventos adversos, o mais incidente e recorrente foi a hiperemia perilesional, que ocorreu para 60,0% das participantes em 64,3% das avaliações. O prurido tem um índice de recorrência igual a 54,2% e a maceração de 20,8%, estando presentes para 40,0% das participantes. O sangramento apresentou um índice de recorrência de 16,7%, estando presente em 20,0% das participantes, sendo induzido pelas remoções das gazes. A identificação das variáveis intervenientes, a partir dos dados coletados durante o cuidado, subsidiou a construção da Estrutura Taxonômica da Teoria de Conforto para pacientes com feridas neoplásicas. Esse produto técnico pode contribuir para a prática profissional, na orientação do enfermeiro para a elaboração do plano de cuidados baseado nas necessidades relatadas pelo paciente. A partir da construção da Estrutura Taxonômica foi possível elaborar um diagrama da Teoria do Conforto de Kolcaba aplicada ao paciente com ferida neoplásica. Na primeira etapa do estudo, apesar dos resultados da análise descritiva terem apontado indícios de benefícios no quesito dor e odor para as participantes no geral, os dados obtidos não mostraram significância suficiente para refutar ou aceitar as hipóteses formuladas. Cabe ressaltar que o número reduzido de participantes, imposto pela pandemia COVID-19, período em que ocorreu a coleta de dados, foi um fator de limitação para o desenvolvimento do estudo. Já na segunda etapa, a partir da análise das diferentes formas de conforto em seus diversos contextos, há indícios favoráveis de que a intervenção clínica de desbridamento é efetiva para o alivio, relaxamento ou transcendência do paciente com ferida neoplásica, à luz da Teoria do Conforto. Este estudo mostra-se relevante ao contribuir com evidencias científicas que podem apoiar um cuidado de enfermagem de qualidade ao paciente com ferida neoplásica tendo em vista a expectativa de aumento no número destas lesões concomitante a um aumento na estimativa do número de casos de câncer. Ao contribuir na formação de profissionais qualificados, integra-se às ações de controle do câncer que propõe um cuidado integral a este paciente, impactando ainda nos custos da assistência de enfermagem. A complexidade desta situação associado ao sofrimento imposto a esta parcela da população demanda uma urgência na implementação de intervenções efetivas e seguras e neste sentido este estudo mostra-se relevante em seu aspecto inovador ao buscar associar uma tecnologia técnica de enfermagem ao conforto do paciente com ferida neoplásica.

Neoplastic wounds develop from an uncontrolled proliferation of tumor cells with infiltration into the skin structures. The main goal of wound care is patient comfort by managing physical and psychosocial symptoms. The objective of this innovative study was to analyze the implementation of the Comfort Theory, drawing on clinical intervention of debridement in nursing care to neoplastic wound patient. This was a mixed method research with quantitative and qualitative approaches contemplated in the various phases of collection, data analysis and interpretation of outcomes. In the first stage, a pilot study of a randomized clinical trial was developed; in the second stage, there was the analysis of data collected during care, which were registered in a field diary. The research was approved by the Research Ethics Committee, under the Opinion Nº 4.292.777. Data collection was conducted from November 2020 to November 2021. The participants were randomly distributed in two groups, Intervention (papain 6%) and Control (Carboxymethyl Cellulose gel 2%), for care continuity of 12 weeks. The descriptive analysis of data was performed based on distribution of frequencies and graphics, with the median used as main synthesis measure. The outcomes point that no participant presented a positive improvement evolution of exudate amount. Regarding the variable pain, in median terms, there was pain improvement during the 12 assessments. Regarding odor, it can be stated that globally there was a positive improvement evolution of the degree of odor of the participants' wounds. Data referring to the analysis of discomfort show an increase of the median, of 9.0 in the first assessment to 10.0 in the second assessment, and of the average, of 8.0 in the first assessment to 8.5 in the second assessment. The conclusion was that in terms of discomfort, there was score improvement in only 20% of participants. In relation to adverse events, the most incident and recurrent was perilesional hyperemia, which occurred for 60.0% of participants in 64.3% of assessments. Itching had a recurrence rate of 54.2% and necrosis of 20.8%, being present in 40.0% of participants. Bleeding presented a recurrence rate of 16.7%, being present in 20.0% of participants, induced by gauze removal. The identification of intervening variables drawing on data collected during care subsidized the construction of the Taxonomic Structure of the Comfort Theory for patients with neoplastic wounds. This technical product can contribute to the professional practice, in guiding the nurse on the elaboration of a plan of care based on the needs reported by the patient. From the construction of the Taxonomic Structure, it was possible to develop a diagram of the Kolcaba's Comfort Theory applied to the patient with neoplastic wound. In the first stage of the study, although the results of the descriptive analysis had pointed indication of benefits in the aspects of pain and odor for participants in general, the data obtained did not show sufficient significance to refute or accept the formulated hypotheses. A limiting factor for the development of the study was the reduced amount of participants due to the Covid-19 pandemic, period when data collection took place. In the second stage, drawing on the analysis of different forms of discomfort in several contexts, there are favorable indications that clinical debridement intervention is effective for relief, ease or transcendence of the patient with neoplastic wound, in the light of the Comfort Theory. This study is relevant by contributing with scientific evidence that can give support to quality nursing care to patients with neoplastic wound, considering the probability of the increase in the number of lesions, concomitant with an estimated increase in the number of cancer cases. By contributing to the training of qualified professionals, this study is integrated to the actions of cancer control that propose patient integral care, with an impact on nursing care costs. The complexity of this situation, associated to the suffering imposed to this segment of the population, requires urgency in the implementation of effective and safe interventions. In this sense, this study is relevant in its innovative aspect by seeking to associate nursing technical technology to the comfort of the patient with neoplastic wound.

Herida facial por mordedura canina en un anciano / Facial wound due to canine bite in an old man

Se presenta el caso clínico de un anciano de 73 años de edad, que fue asistido en el Cuerpo de Guardia del Hospital General Docente Enrique Cabrera Cossío de La Habana por haber sido mordido en el rostro, en la región supraciliar derecha, por un perro, que le causó una herida avulsiva, con pérdida considerable de tejidos blandos, abundante sangrado y dolor. Luego de efectuar antisepsia del área y profilaxis con antibióticos, se practicó rápidamente el procedimiento quirúrgico, que consistió en desbridamiento de la herida y reconstrucción del defecto a través de plastia primaria con técnica de colgajos locales de avance y rotación, lo que permitió una evolución favorable, tanto estética como funcional, en el paciente.

The case report of a 73 years old man is presented. He was assisted in the Emergency Service of Enrique Cabrera Cossío Teaching General Hospital in Havana city, due to a dog bite in his face, in the right supraciliary region, that caused him a lacerated wound, with considerable loss of soft tissues, abundant bleeding and pain. After making antisepsis of the area and prevention with antibiotics, the surgical procedure was quickly practiced that consisted on debridement of the wound and reconstruction of the defect through primary plasty with technique of advance and rotation local flaps, that allowed a favorable clinical course in the patient, both cosmetic and functional.

Treatment and Chest Reconstruction for Mediastinitis Following Sternotomy for Cardiac Surgery at the Heart Institute of the University of São Paulo Medical School

Abstract This study presents the method used for chest reconstruction and treatment of mediastinitis following cardiac surgery at the Heart Institute of the University of São Paulo Medical School. After infection control with antibiotic therapy associated with aggressive surgical debridement and negative pressure wound therapy, chest reconstruction is performed using flaps. The advantages and disadvantages of negative pressure wound therapy are discussed, as well as options for flap-based chest reconstruction according to the characteristics of the patient and sternum. Further studies are needed to provide evidence to support the decisions when facing this great challenge.

Tendoscopía en disfunción del tendón tibial posterior Estadío I: 8 años de seguimiento / Tendoscopy in stage I Posterior Tibial dysfunction: 8 years follow up

Cuando fracasa el tratamiento conservador en el Estadio I de Disfunción del Tendón Tibial posterior (DTTP), se debe indicar sinovectomía y debridamiento del tendón. En este estudio evaluamos la evolución con 8 años mínimo de seguimiento, de los pacientes con esta patología tratados vía tenoscópica. Este es un estudio retrospectivo de pacientes operados entre el año 2008 y el año 2011. En ese período de tiempo se intervinieron 11 pacientes con esta patología. Sólo 9 de los 11 pacientes operados pudieron ser evaluados. 7 pacientes mejoraron su sintomatología según el VAS y no progresaron a estadio II. En 3 pacientes se evidenció lesión tendinosa durante la tendoscopía y ameritaron reparación a cielo abierto. La sinovectomía tendoscópica del TTP es un procedimiento quirúrgico efectivo para tratar a los pacientes con DTTP Estadio I, rebeldes a tratamiento conservador(AU)

When conservative treatment fails for Stage I Posterior Tibial tendon dysfunction (PTTD), synovectomy and tendon debridement is indicated. In this study we evaluate tendoscopic treatment results for this pathology with a minimum of 8 years follow up. This is a retrospective study of patients after tendoscopic surgery performed between 2008 and 2011. 9 of the 11 patients were available for evaluation. 7 improved their symptoms according to VAS scale, and did not progress to stage II. In 3 patients tendon tear was visualized during tendoscopy and needed open repair. PTT tendoscopy is an effective surgical treatment to treat Stage I PTTD, failing to conservative treatment(AU)

Treatment strategy for bilateral severe subepithelial fibrosis after photorefractive keratectomy enhancement / Estratégia de tratamento para fibrose subepitelial grave bilateral após aprimoramento com ceratectomia fotorrefrativa

ABSTRACT A 27-year-old healthy man with a history of bilateral photorefractive keratectomy (PRK) enhancement after femtosecond laser in situ keratomileusis (LASIK) presented with decreased uncorrected distance visual acuity (UDVA) of 20/125 in the right eye (OD) and 20/300 in the left eye (OS) six months after PRK. Examination revealed bilateral dense subepithelial opacities. Both eyes (OU) were treated with superficial keratectomy combined with phototherapeutic keratectomy (PTK) and adjunctive application of mitomycin C 0.02%. At three months follow up UDVA was 20/30 OD and 20/25 OS. Superficial keratectomy combined with PTK seems to be a safe and efficient technique for treatment of dense subepithelial scar formation following PRK enhancement after LASIK.

RESUMO Um homem saudável de 27 anos de idade com história de aprimoramento com ceratectomia fotorrefrativa (PRK) bilateral, após Ceratomileuse Assistida por Excimer Laser In Situ (LASIK) com laser de femtossegundos, apresentou diminuição da acuidade visual à distância não corrigida (AVNC) de 20/125 no olho direito (OD) e 20/300 no olho esquerdo (OE) seis meses após PRK. O exame revelou opacidades subepiteliais densas bilaterais. Ambos os olhos (AO) foram tratados com queratectomia superficial combinada com ceratectomia fototerapêutica (PTK) e aplicação adjuvante de mitomicina C a 0,02%. Aos três meses de acompanhamento, o AVNC foi de 20/30 OD e 20/25 OE. A ceratectomia superficial combinada com PTK parece ser uma técnica segura e eficiente para o tratamento da formação densa de cicatrizes subepiteliais após o aprimoramento com PRK pós-LASIK.

Pancreatitis aguda necrotizante infectada. Desbridamiento retroperitoneal video asistido / Infected necrotizing pancreatitis. Video-assisted retroperitoneal debridement

Resumen El tratamiento escalonado de la pancreatitis aguda necrotizante infectada consiste en el uso de antibióticos de amplio espectro, drenaje y necrosectomía mínimamente invasiva, si fuese necesaria. Esto ha reemplazado a la cirugía abierta como el estándar de tratamiento. El desbridamiento retroperitoneal video asistido (VARD), es una forma de necrosectomía quirúrgica mínimamente invasiva. Presentamos una serie de 5 casos (2 mujeres y 3 varones) con pancreatitis aguda grave y necrosis pancreática infectada tratados de forma escalonada y VARD. El rango de edad fue de 27 a 60 años. Todos los pacientes tuvieron pancreatitis de etiología biliar. El rango del APACHE II fue de 16 a 20. El rango del tiempo para el drenaje percutáneo lumbar fue de 4 a 7 semanas. Hubo una complicación del drenaje percutáneo (fistula duodenal) que se resolvió con tratamiento médico. Los cultivos de todas las necrosis fueron positivos. El tiempo para la realización del VARD tuvo un rango de 6 a 10 semanas. Un paciente requirió dos procedimientos. Hubo dos fístulas pancreáticas tipo B asociadas al VARD, que se trataron conservadoramente. No hubo mortalidad. A largo plazo, dos pacientes fueron diagnosticados de insuficiencia pancreática exocrina y endocrina. Concluimos que en los pacientes con necrosis pancreática infectada que requieran desbridamiento, el VARD es una alternativa segura, efectiva y con buenos resultados a largo plazo.

Abstract The step-up approach for infected necrotizing pancreatitis, consisting of broad-spectrum antibiotics, drainage followed, if necessary, by minimally invasive necrosectomy, has replaced open surgery as the standard of management. Video-assisted retroperitoneal debridement (VARD) is a surgical minimally invasive necrosectomy. This is a 5 cases series (2 female and 3 males) with severe acute pancreatitis and infected pancreatic necrosis who underwent step up approach and VARD. The age ranged from 27 to 60 years old. Al patients had biliary pancreatitis. APACHE II ranged from 16 to 20. The time to percutaneous lumbar drainage ranged from 4 to 7 weeks. There was one complication associated with percutaneous drainage (duodenal fistula) with nonoperative management. All necrotizing pancreatitis had positive cultures. The time to perform VARD ranged from 6 to 10 weeks. One patient required two procedures. There were two type B pancreatic fistulas associated with VARD, managed nonoperatively. There was no mortality. During long-term follow-up two patients were diagnosed with exocrine and endocrine pancreatic insufficiency. We conclude that VARD is a safe and effective procedure in patients with infected necrotizing pancreatitis requiring debridement, and with good long-term outcomes.

Tratamento de crescimento epitelial persistente pós-Lasik com debridamento mecânico, uso de álcool a 20% e cola de fibrina / Treatment of persistent epithelial ingrowth after Lasik with mechanical debridement, use of 20% alcohol and fibrin glue

RESUMO O Lasik é a técnica de cirurgia refrativa mais utilizada no mundo. Apesar de segura e efetiva, ela pode levar a algumas complicações. O crescimento epitelial pós-Lasik é uma complicação pós-operatória incomum, com prevalência maior em casos de retratamento. Geralmente, é um achado não progressivo e assintomático, que não requer tratamento, mas, em uma minoria de pacientes, os sintomas podem ser clinicamente significantes e variados. O tratamento é feito com debridamento mecânico do crescimento epitelial, mas alguns recursos adjuvantes também podem ser utilizados. O presente estudo consiste em um relato de caso de paciente com crescimento epitelial pós-Lasik que apresentou quatro recidivas após intervenções de debridamento epitelial, sutura de lamela corneana e ablação a laser. No quinto procedimento, o paciente foi finalmente tratado com combinação de debridamento epitelial, uso de álcool a 20% e cola de fibrina. Entretanto, a regressão do crescimento epitelial e a melhora da acuidade visual só ocorreram ao longo dos meses após a intervenção, o que mostra a importância de esperar um tempo para que ocorra a melhora da visão no pós-operatório, evitando-se reintervenções.

ABSTRACT Lasik is the most often performed laser refractive surgery worldwide. Despite its efficacy and safety, some complications may occur. Epithelial ingrowth is a rare postoperative complication of Lasik, with an increased prevalence in cases of retreatment. Epithelial ingrowth is usually a nonprogressive and asymptomatic finding, which requires no treatment; however, in a minority of cases, symptoms may be clinically significant and diverse. Treatment is done with mechanical debridement of the affected interface, and additional interventions may be required. This study reported a case of recalcitrant epithelial ingrowth after Lasik, whichrelapsed four times after mechanical debridement, flap lift and laser ablation. In the fifth intervention, the patient was finally treated with a combined scraping/use of 20% alcohol and fibrin glue. However, regression of epithelial ingrowth and better visual acuity were only observed some months after the intervention, which shows the importance of waiting for better vision in the postoperative period, thus avoiding new reinterventions.

Tratamiento quirúrgico de pie diabético basado en clasificación Wagner / Surgical treatment of diabetic foot based on Wagner classification

Se realizó un estudio que caracterizó a los pacientes que reciben tratamiento quirúrgico en el Hospital Roosevelt por pie diabético según la Clasificación Wagner. El objetivo era determinar el tratamiento quirúrgico brindado al paciente con pie diabético, basado en la clasificación Wagner, en el Departamento de Cirugía del Hospital Roosevelt durante el período de enero a octubre 2015. Se realizó un estudio descriptivo estudiando a los pacientes con diagnóstico de pie diabético, con una muestra de 81 pacientes. Se encontró que 56% presentaron grado IV, edad de 56-65 años en 38%, de sexo masculino 65%. 134 procedimientos quirúrgicos realizados, más común lavado y desbridamiento en 38%. Principalmente diagnóstico de Diabetes mellitus tipo II, con tiempo diagnóstico mayor a 10 años en 51%. Uso de hipoglucemiantes orales 49%. De los estudiados, 41% no presentaba ninguna comorbilidad. Se concluyó que el tratamiento quirúrgico más frecuente para Pie diabético Wagner II y III fue el lavado y desbridamiento, grado IV amputación de dedos y grado V las amputaciones femorales supracondíleas. Caracterizados como pacientes en rango de edad entre los 56-65 años, de sexo masculino, que padece Diabetes mellitus tipo II, clasificado como pie diabético Wagner IV, ameritando tratamiento quirúrgico como amputación de dedos seguido de amputaciones radicales descritas como amputación supracondílea, con tiempo de diagnóstico mayor a 10 años, con tratamiento de hipoglucemiantes orales, y sin ninguna comorbilidad médica asociada. (AU)

A study was conducted that characterized patients receiving surgical treatment at Roosevelt Hospital for diabetic foot according to the Wagner Classification. The objective was to determine the surgical treatment provided to the patient with diabetic foot, based on the Wagner classification, in the Department of Surgery at Roosevelt Hospital during the period from January to October 2015. A descriptive study was carried out studying patients with a diagnosis of diabetic foot, with a sample of 81 patients. It was found that 56% had grade IV, age 56-65 years in 38%, male 65%. 134 surgical procedures performed, the most common was lavage and debridement in 38%. Mainly diagnosis of type II diabetes mellitus, with a diagnosis time greater than 10 years in 51%. Use of oral hypoglycemic agents 49%. Of those studied, 41% did not present any comorbidity. The conclusion was that the most frequent surgical treatment for Wagner II and III was lavage and debridement, grade IV finger amputation and grade V supracondylar femoral amputations. Characterized as patients in the age range between 56-65 years, male, suffering from type II diabetes mellitus, classified as Wagner IV diabetic foot, meriting surgical treatment such as amputation of fingers followed by radical amputations described as supracondylar amputation, with time of diagnosis greater than 10 years, with treatment of oral ypoglycemic agents, and without any associated medical comorbidity. (AU)

Informe de caso: Resultado clínico de TOE conservado después de un evento traumático de pie / Case report: Clinical outcome of TOE preserved after Traumatic event of foot

Introduction: Decision making in determining management of post-trauma patient is very important, especially for traumatic in the small bones, fingers and toes. The global predictor to determine the management of retaining or amputating the limb is using the Mangled Extrimity Severity Score (MESS) scoring system, values above 7 are the indication for amputation. The decision maker have to pay attention for the end result of the actions which were performed in the initial management. Material and Methods: One case is reported from Orthopaedic emergency department Hospital in Makassar, South Sulawesi, Indonesia. A 39-year old male with motor vehicle accident trauma at left foot region since 6 hours before admitted to hospital, later was diagnosed with open comminutive fracture shaft proximal phalang of left 5th toe, the Mangled Extrimity Severity Score (MESS) was 8. Patient underwent emergency debridement and retained the toe by performed Open Reduction Internal Fixation (ORIF) K-Wire. Results: This patient has a good clinical outcome by following up 2 weeks and 8 months after surgery by retain the affected side with debridement and Open Reduction Internal Fixation (ORIF) K-Wire. Patient can ambulate normally with full weight bearing, and there is no difficulty to wearing shoe or sandal. Conclusions: Determination of action by retaining the traumatized limb needs to be considered for the good of the patient, but it is necessary to provide informed consent to the patient and family that there will be a possibility of tissue death with the worst possibility of limb amputation

Firearm-Related Fractures: Epidemiology and Infection Rate / Fraturas causadas por armas de fogo: Epidemiologia e taxa de infecção

Abstract Objective To investigate the incidence of infection in patients with gunshot-related fractures, and to correlate this finding with the occurrence of surgical debridement in the emergency room. Methods A retrospective, observational, descriptive study that included all cases of fractures caused by firearms between January 2010 and December 2014; 245 fractures in 223 patients were included. Results There was surgical-site infection in 8.5% of the fractures, and the mean number of debridements required to control the infectious process was of 1.273 ± 0.608. A correlation was identified between the surgical treatment chosen and the affected body segment (p< 0.001). The surgical treatment in the emergency room had a correlation with the occurrence of infection (p< 0.001; Chi-squared test). Conclusion Patients with gunshot injuries treated non-operatively presented less severe and stable lesions; thus, the incidence of complications in this group was found to be lower. On the other hand, those patients with complex lesions underwent debridement and external fixation. Therefore, a greater number of infectious complications in patients submitted to external fixation was found, as expected.

Resumo Objetivo Investigar a incidência de infecção em pacientes com fraturas por arma de fogo, e correlacionar esse achado com a ocorrência de desbridamento cirúrgico na sala de emergência. Métodos Estudo retrospectivo, observacional e descritivo, que incluiu todos os casos de fraturas causadas por armas de fogo entre janeiro de 2010 e dezembro de 2014; foram incluídas 245 fraturas em 223 pacientes. Resultados Houve infecção do local cirúrgico em 8,5% das fraturas, e a média de desbridamentos necessários para controlar o processo infeccioso foi de 1,273 ± 0,608. Foi identificada correlação entre o tratamento cirúrgico escolhido e o segmento corporal afetado (p< 0,001). O tratamento cirúrgico na sala de emergência teve correlação com a ocorrência de infecção (p< 0,001; teste do qui-quadrado). Conclusão Pacientes com ferimentos à bala tratados de forma não operatória apresentaram lesões menos graves e estáveis; portanto, a incidência de complicações nesse grupo foi menor. Por outro lado, os pacientes com lesões complexas foram aqueles submetidos a desbridamento e fixação externa. Portanto, como esperado, foi encontrado um maior número de complicações infecciosas em pacientes submetidos à fixação externa.