Video-assisted retroperitoneal debridement for necrotizing pancreatitis: a single center experience in Colombia.

INTRODUCTION: Acute pancreatitis (AP) is a common and potentially lethal disease. Approximately 10-20% of the patients progress to necrotizing pancreatitis (NP). The step-up approach is the gold standard approach to managing an infected necrotizing pancreatitis with acceptable morbidity and mortality rates. Video-assisted retroperitoneal debridement (VARD) has been described as a safe and feasible approach with high success rates. Multiple studies in the American, European, and Asian populations evaluating the outcomes of VARD have been published; nevertheless, outcomes in the Latin American population are unknown. This study aims to describe a single-center experience of VARD for necrotizing pancreatitis in Colombia with a long-term follow-up. METHODS: A prospective cohort study was conducted between 2016 and 2024. All patients over 18 years old who underwent VARD for necrotizing pancreatitis were included. Demographic, clinical variables, and postoperative outcomes at 30-day follow-up were described. RESULTS: A total of 12 patients were included. The mean age was 55.9 years old (SD 13.73). The median follow-up was 365 days (P25 60; P75 547). Bile origin was the most frequent cause of pancreatitis in 90.1% of the patients. The mean time between diagnosis and surgical management was 78.5 days (SD 22.93). The mean size of the collection was 10.5 cm (SD 3.51). There was no evidence of intraoperative complications. The mean in-hospital length of stay was 65.18 days (SD 26.46). One patient died in a 30-day follow-up. One patient presented an incisional hernia one year after surgery, and there was no evidence of endocrine insufficiency at the follow-up. CONCLUSION: According to our data, the VARD procedure presents similar outcomes to those reported in the literature; a standardized procedure following the STEP-UP procedure minimizes the requirement of postoperative drainages. Long-term follow-up should be performed to rule out pancreatic insufficiency.

Bromelain-Based Enzymatic Debridement Versus Standard of Care in Deep Burn Injuries: A Systematic Review and Meta-Analysis.

Deep burn injuries necessitate effective debridement to promote healing and reduce complications. Traditional surgical debridement is the standard of care; however, it can lead to significant tissue loss, excessive bleeding and delayed healing. Bromelain-based enzymatic debridement offers a potential less invasive alternative that aims to selectively remove necrotic tissue while preserving viable ones. Therefore, this systematic review and meta-analysis comprehensively compares bromelain debridement versus standard care in the management of partial and full-thickness burns. Cochrane Library, Embase, and Medline were searched until May 30th, 2024 for studies comparing bromelain debridement versus standard care. R version 4.4.0 was used to pooled risk ratio and mean difference in a random-effects model. We included seven studies, comprising 484 participants, of whom 238 (49%) were treated with enzymatic debridement. Bromelain significantly reduced time to eschar removal (MD - 7.60 days 95% CI [-9.76, -5.44]; I² = 70%) in comparison with standard care. Additionally, bromelain group presented a significant reduction in the risk of surgical excision (RR 0.17; 95% CI [0.06, 0.47]; I² = 79%) and need for autografts (RR 0.40; 95% CI [0.18, 0.93]; I² = 76%) in comparison with standard group. No differences were found in behalf of time to wound closure (MD -7.64; 95% CI [-18.46]-[3.18]; I2 = 86%), nor in Modified Vancouver Scar Scale (MD -0.36; 95% CI [-0.96]-[0.23]; I2 = 0%). Bromelain-based enzymatic debridement may accelerate eschar removal and reduce the need for surgical excision and autografts, without adversely affecting wound closure time or long-term scar quality.

A Natural deep eutectic solvent as an effective material for dual debridement and antibiofilm effects in chronic wound treatment.

In chronic wound treatment, the debridement of devitalized tissue and the eradication of the biofilm must balance aggressiveness with care to protect regenerating tissues. In this study, urea, a potent chaotropic molecule, was modulated through the formation of a Natural Deep Eutectic Solvent (NADES) with betaine to develop a new debriding material (BU) suitable for application into injured dermal tissues. To evaluate BU's debriding capacity, along with its antibiofilm effect and biocompatibility, pre-clinical to clinical methods were employed. In vitro determinations using artificial and clinical slough samples indicate that BU has a high debriding capacity. Additionally, BU's de-structuring effects lead to a strong antibiofilm capability, demonstrated by a reduced bacterial load compared to the antiseptic PHMB-Betaine or medical honey, evaluated in artificial slough and ex vivo human skin. Furthermore, BU's efficacy was evaluated in a murine model of diabetic wound, demonstrating significant effects on debriding and antibiofilm capacity, similar to those observed in PHMB-Betaine and medical honey-treated animals. Finally, BU was clinically evaluated in leg ulcers, showing superiority in reduction of bacterial load and wound area compared to honey, with no adverse effects. Thus, BU represents a simple and non-biocidal option that could contributes to chronic wound care.

Oxidized Bacterial Cellulose Membranes Immobilized with Papain for Dressing Applications: Physicochemical and In Vitro Biological Properties.

This research consolidates our group's advances in developing a therapeutic dressing with innovative enzymatic debridement, focusing on the physicochemical and in vitro biological properties of papain immobilized in wet oxidized bacterial cellulose (OxBC-Papain) dressing. OxBC membranes were produced with Komagataeibacter hansenii oxidized with NaIO4, and papain was immobilized on them. They were characterized in terms of enzyme stability (over 100 days), absorption capacity, water vapor transmission (WVT), hemocompatibility, cytotoxicity, and cell adhesion. The OxBC-Papain membrane showed 68.5% proteolytic activity after 100 days, demonstrating the benefit of using the OxBC wet membrane for papain stability. It had a WVT rate of 678 g/m2·24 h and cell viability of 99% and 86% for L929 and HaCat cells, respectively. The membranes exhibited non-hemolytic behavior and maintained 26% clotting capacity after 1 h. The wet OxBC-Papain membrane shows significant potential as a natural biomolecule-based therapeutic dressing for wound care, offering efficient debridement, moisture maintenance, exudate absorption, gas exchange, and hemostasis without cytotoxic effects or cell adhesion to the dressing. Further research, especially using in vivo models, is needed to assess its efficacy in inducing epithelialization. This study advances stomatherapy knowledge, providing a cost-effective solution for enzymatic debridement in healthcare.

Relationship between Carotid Intima-Media Thickness, Periodontal Disease, and Systemic Inflammation Biomarkers in an Adult Population.

A positive relationship has been reported between advanced periodontitis and carotid intima-media thickness (cIMT) measurement. The aim of this study was to investigate this relationship with parameters for periodontitis, such as PISA and systemic inflammation biomarkers. An observational descriptive cross-sectional study was conducted. A blood sample was collected from 75 subjects to analyze glucose, total cholesterol, HDL, LDL, and cytokine values. Increased cIMT was found in 32% of the patients with fewer teeth. Patients with periodontitis had a larger periodontal inflamed surface area (PISA) (p = 0.000) and had a 1.42-times-higher risk of having increased cIMT values compared to periodontally healthy individuals, though without a statistically significant association. Higher values in the left cIMT, IL-8, and TNF-α were found in men than in women with significant differences. In the multivariate analysis involving cytokines, age continues to be linked to increased cIMT values. INF-γ showed a trend towards a protective effect; as the IMT-M decreases, there is an increase in the expression of INF-γ, and a higher proportion of subjects with elevated INF-γ concentrations demonstrated normal IMT-C. This study did not find a statistically significant association between cIMT and periodontal disease, but the risk of having increased cIMT is 1.42-times higher for individuals with periodontitis.

Mechanical debridement combined with amoxicillin and metronidazole compared with mechanical debridement alone for the treatment of chronic periodontitis: An overview of systematic reviews.

Periodontal mechanical debridement is the most common therapy for the treatment of periodontitis. However, depending on the severity of the disease, mechanical debridement has been recommended in combination with systemic antibiotics. In this study, we performed an overview of systematic reviews using the Friendly Summaries of Body of Evidence using Epistemonikos (FRISBEE) methodology on the effectiveness and safety of mechanical debridement combined with amoxicillin and metronidazole compared to mechanical debridement alone for the treatment of chronic periodontitis. We conducted a systematic search of the Epistemonikos database, extracted data from 10 systematic reviews and re-analyzed data from 23 primary studies to generate a summary of findings (SoF) table. We used RevMan 5.3 and GRADEpro for data analysis and data presentation. The following outcomes were analyzed: probing depth (mean difference (MD): 0.07 mm); clinical attachment level (MD: 0.04 mm); bleeding on probing (MD: 5.06%); and suppuration (MD: 0.31%). There was no evidence of a clinically relevant benefit of periodontal mechanical debridement therapy combined with amoxicillin and metronidazole compared to periodontal mechanical debridement therapy alone for the treatment of chronic periodontitis in the studied periodontal outcomes.

Early diagnosis and aggressive surgical resection matters to cure rhinocerebral mucormycosis: Six case reports.

Rhino-cerebral mucormycosis (RM) is a rare and opportunistic fungal infection observed in immune-compromised patients and metabolic imbalances such as Diabetes Mellitus. RM rapidly infiltrates blood vessels, leading to vascular thrombosis, subsequent tissue necrosis, and high mortality rates (23.6-60%). Due to its fast advancement, RM is a life-threatening condition requiring accurate clinical decisions by the medical and surgical teams. Based on the report of six cases, we emphasize the need for an early diagnosis and starting antifungal pharmacological therapy at the slightest suspicion of RM. Moreover, the restitution of metabolic balance and aggressive surgical debridement are vital steps to control RM, reducing the possibility of fatal outcomes.

Necrotizing fasciitis of the thigh secondary to perforated rectal cancer: the sciatic foramen as a route for infective spread.

Necrotizing fasciitis (NF) is a potentially life-threatening surgical emergency. It is a rapidly progressive infection of soft tissues, and mortality is related to the degree of sepsis and the general condition of the patient. It is a rare condition that requires a rapid diagnosis and surgical treatment is aggressive debridement. There are a small number of reported cases of perforation of a rectal malignancy leading to NF of the thigh. We present a case with rectal cancer in which the sciatic foramen had provided a channel for the spread of pelvic infection into the thigh.

La fascitis necrotizante es una emergencia quirúrgica potencialmente mortal. Es una infección de tejidos blandos rápidamente progresiva y la mortalidad está relacionada con el grado de sepsis y el estado general del paciente. Es una condición poco común que requiere un diagnóstico rápido, y el tratamiento quirúrgico consiste en un desbridamiento agresivo. Existe un pequeño número de casos notificados de perforación de neoplasia maligna de recto que conduce a fascitis necrotizante del muslo. Presentamos un caso de cáncer de recto en el cual el foramen ciático fue el canal para la propagación de la infección pélvica al muslo.

The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment.

Aim: This prospective study assessed the clinical and radiological outcomes of open tibia fractures treated with a dynamic external fixator. Materials and methods: Twenty-five patients underwent surgical debridement and stabilisation with a dynamic external fixator between November 2016 and April 2022. Regular follow-up evaluated bone healing progression. Results: Favourable outcomes were demonstrated in 20 patients. However, there were three cases of non-union, two of which subsequently deformed, and two cases of pin site-related infection. There were no fracture site infections. Conclusion: This study demonstrates the use of dynamic external fixation in the treatment of open tibia fractures. The low incidence of complications suggests its effectiveness and potential. How to cite this article: Bezerra BS, Araujo TA, Cardonia GG, et al. The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment. Strategies Trauma Limb Reconstr 2024;19(1):36-39.

Intraoperative Wound Lavage System for Deep Neck Infection: A Retrospective Cohort Study.

Introduction Multiple solutions are currently used to cleanse a deep neck infection (DNI), and a variety of devices are available to deliver wound irrigation solutions. An essential difference between these devices is the pressure that the irrigation solution exerts over the wound tissue. Objective To compare low-pressure and high-pressure irrigation delivery systems for wound cleansing in DNI. Methods we designed a retrospective cohort study and reviewed the medical records of patients operated on due to DNI from June 2016 to December 2017 at our institution. One cohort included patients treated with an intraoperative irrigation method that exerts low pressure over the irrigated tissue, and the other cohort, to a system capable of generating higher pressure. The Pearson Chi-squared test was used to analyze the data. Results A total of 42 patients whose ages ranged from 16 months to 72 years were included. The low-pressure irrigation system was used in 18 patients, and the high-pressure system was used in 24 patients. No statistical differences were observed regarding the irrigation methods, the complexity of the DNI, and the overall outcomes. Conclusions The present is the first study in which low- and high-pressure systems for wound lavage were evaluated in the treatment of DNI. When comparing these methods, we did not find one to be superior to the other; however, the additional cost associated with the high-pressure devices may not justify their in head and neck procedures.

Management of acute compartment syndrome: case report / Manejo del síndrome compartimental agudo: informe de caso / Manejo da síndrome compartimental aguda: relato de caso

Introduction: Acute compartment syndrome (ACS) is defined as any increase in interstitial pressure within the bony-fascial compartment and consists of an adverse event in the intraoperative period, resulting from surgical positioning. Objective: To report a case of fasciotomy in the lower limbs after ACS. Method: Case report registered in a large public teaching hospital, with a highly complex care profile. Results: Patient underwent videolapa-roscopic surgery to remove endometriosis, having remained in the gynecological position for 9 hours, developing ACS in the immediate postoperative period (IPO). The patient underwent decompressive fasciotomy to treat ACS in the second postoperative period, and nine other surgical approaches to continue treatment. She remained hospitalized for 45 days. Conclusion: The training of nursing professionals, knowledge about surgical patient safety and teamwork throughout the anesthetic-surgical procedure are essential for reducing adverse events and quickly identifying and treating complications. (AU)

Introducción: El síndrome compartimental agudo (SCA) se define como cualquier aumento de la presión intersticial dentro del compartimiento óseo-fascial y consiste en un evento adverso en el período intraoperatorio, resultante de la posición quirúrgica. Objetivo: Reportar un caso de fasciotomía en los miembros inferiores después de un SCA. Método: Informe de caso registrado en un gran hospital público de enseñanza, con un perfil de atención de alta complejidad. Resultados: La paciente se sometió a una cirugía videolaparoscópica para extirpar la endometriosis, permaneciendo en posición ginecológica durante 9 horas, desarrollando SCA en el período postoperatorio inmediato (POI). La paciente se sometió a una fasciotomía descompresiva para tratar el SCA en el segundo período postoperatorio, y a otros nueve abordajes quirúrgicos para continuar el tratamiento. Permaneció hospitalizada durante 45 días. Conclusión: La formación de profesionales de enfermería, el conocimiento sobre la seguridad del paciente quirúrgico y el trabajo en equipo durante todo el procedimiento anestésico-quirúrgico son esenciales para reducir los eventos adversos y para identificar y tratar rápidamente las complicaciones. (AU)

Introdução: A síndrome compartimental aguda (SCA) é definida como qualquer elevação na pressão intersticial dentro do compartimento ósseo-fascial, e consiste em um evento adverso no período intraoperatório, decorrente do posicionamento cirúrgico. Objetivo: Relatar um caso de fasciotomia em membros inferio-res após SCA. Método: Relato de caso registrado em um hospital escola público de grande porte, com perfil assistencial de alta complexidade. Resultados: Paciente submetida à cirurgia videolaparoscópica para remoção de endometriose, tendo permanecido 9 horas em posição ginecológica, desenvolvendo SCA, no pós-operató-rio imediato (POI). A paciente foi submetida à fasciotomia descompressiva, para o tratamento da SCA no segundo pós-operatório (PO), e outras nove reabordagens cirúrgicas, para a continuidade do tratamento. Ela permaneceu hospitalizada por 45 dias. Conclusão: O treinamento dos profissionais de Enfermagem, o conhe-cimento acerca da segurança do paciente cirúrgico e o trabalho em equipe durante todo o procedimento anestésico-cirúrgico são essenciais para a diminuição dos eventos adversos e a rápida identificação e tratamento de complicações. (AU)

Should supragingival scaling be performed separately prior to subgingival scaling and root planning in nonsurgical periodontal therapy? A systematic review of randomized trials.

OBJECTIVE: To systematically evaluate randomized controlled trials (RCTs), with at least 6 months of follow-up, on whether professional mechanical plaque removal (PMPR) including supragingival scaling should be performed prior and separately from subgingival scaling and root planning (SRP) in nonsurgical periodontal therapy (NSPT), in terms of clinical and patient-reported outcomes (PROs) (CRD42020219759). METHODS: The MEDLINE, EMBASE, CENTRAL, LILACS and Web of Science electronic databases, as well as grey literature sources, were searched by two independent reviewers up to May 2023. The Cochrane Collaboration's Risk of Bias tool (RoB 2.0) was used for quality appraisal and GRADE for assessing the certainty of evidence. Random-effects pairwise meta-analyses compared the changes in probing pocket depth (PPD), clinical attachment loss (CAL), and bleeding on probing (BoP) of a stepwise NSPT approach (PMPR prior and separately from SRP) and conventional one-step NSPT through mean differences (MDs) and associated confidence intervals (95% CI). RESULTS: Two RCTs were included, including data of 77 participants with severe periodontitis. One RCT presents high risk of bias and the other has some concerns. No significant differences were found between the stepwise approach and performing both steps simultaneously for any clinical outcomes, with overall very low certainty on evidence. No adverse effects were detected and there was no data on PROs. CONCLUSIONS: There is very-low certainty evidence of no significant difference on PPD and BoP reductions and CAL gain between supragingival scaling performed prior and separately from SRP and conventional one-step NSPT.

Photodynamic therapy adjuvant to non-surgical periodontal therapy: Systematic review of randomized clinical trials.

OBJECTIVES: To systematically evaluate randomised controlled trials (RCTs) on whether adjuvant application of antimicrobial photodynamic therapy (aPDT) through the technique of irradiation in the external region of the periodontal pocket with optic-fibre tip offers benefits to scaling and root planning (SRP). METHODS: Five databases were searched by two independent reviewers according to pre-specified eligibility criteria up to April 2023. No restrictions regarding date of publication, language and minimum follow-up period were imposed. The Cochrane Collaboration's Risk of Bias tool (RoB 2.0) was used for quality appraisal and Grading of Recommendations, Assessment, Development and Evaluation for assessing the certainty of evidence. RESULTS: A total of 1388 publications were identified and reviewed for eligibility. Four of them fulfilled the inclusion criteria. The sample consisted of a total of 83 patients with periodontitis. In these, 330 periodontal sites were evaluated. The clinical findings of the majority of the included studies demonstrated that patients who received the association of aPDT + RAR with the protocol evaluated here, obtained clinical results similar to patients who received only the SRP alone. In none of the evaluated RCTs, clinical advantages were observed that would categorise this aPDT protocol as superior to conventional treatment. CONCLUSION: Applying aPDT after SRP with external irradiation of the periodontal pocket does not seem to result in any clinical benefit compared to the use of SRP alone in patients with periodontitis.

Papain Covalent Immobilization in Bacterial Cellulose Films as a Wound Dressing.

Ideally, the dressings used in the clinic have characteristics that help the wound closure process. Among several factors that affect the success of this healing process, there is debridement. It manages the wound bed components and the re-epithelialization process. Still, the property of debridement is not generally associated with dressings. Here, we show a chemically modified bacterial cellulose film conjugated to a proteolytic enzyme, papain, as a dressing with debridement properties. Bacterial cellulose films were reacted with a spacer derived from succinic acid and finally had this enzyme covalently immobilized in its structure by an amide bond. FT-IR and UV-vis showed bands typically of bioconjugated polymer. Enzymatic immobilization was very effective under the conditions applied with high yield (33% w/w), and these remained activated after the coupling reaction. The bacterial cellulose film with the enzyme papain attached to it was also very compatible with fibroblast cells, suggesting that it could be a promising wound dressing material for future research.

Debridement ability of the WaveOne Gold and TruNatomy systems in the apical third of root canals: ex vivo assessment

Abstract Cleaning and shaping the root canal system are essential steps for performing successful endodontic therapy, and are challenging procedures in the apical region. This study aimed to conduct an ex vivo assessment of the debridement ability of the WaveOne Gold (Medium 35/.06) and TruNatomy (Medium 36/.03) systems in the apical third of round root canals of mandibular premolars. Forty-eight teeth, extracted for orthodontic or periodontal reasons, were divided into three groups (n=16), as follows: Group C, control (without instrumentation or irrigation); Group WOG, instrumentation with WaveOne Gold; Group TN, instrumentation with TruNatomy. A total of 40 mL of 2.5% sodium hypochlorite and 5 mL of 17% ethylenediamine tetraacetic acid were used per root canal in all the groups. Ten 0.5-μm serial cross-sections per specimen were obtained every 0.2 mm from a 2-mm segment of the apical region, extending from 1 to 3 mm short of the root apex. The sections were stained with hematoxylin-eosin and analyzed under a digital microscope (100x). The percentages of unprepared walls and remaining debris were quantified using ImageJ software. Generalized linear models were used to analyze the results (α=5%). Groups WOG and TN had significantly lower percentages of unprepared walls and remaining debris than Group C (p<0.05). There was no significant difference between groups WOG and TN for either of the variables studied (p>0.05). Instrumentation with the WaveOne Gold Medium and TruNatomy Medium instruments was associated with equivalent percentages of unprepared walls and remaining debris in the apical third of round canals of mandibular premolars.

Resumo A limpeza e modelagem do sistema de canais radiculares são etapas fundamentais para o sucesso da terapia endodôntica e são procedimentos desafiadores na região apical. O objetivo deste trabalho foi realizar uma avaliação ex vivo da capacidade de debridamento dos sistemas WaveOne Gold (Medium 35/.06) e TruNatomy (Medium 36/.03) no terço apical de canais radiculares circulares de pré-molares inferiores. Quarenta e oito dentes que haviam sido extraídos por razões ortodônticas ou periodontais foram divididos em três grupos (n=16),da seguinte forma: Grupo C, Controle (sem instrumentação nem irrigação); Grupo WOG, instrumentação com WaveOne Gold; Grupo TN, instrumentação com TruNatomy. Um total de 40 mL de hipoclorito de sódio a 2,5% e 5 mL de ácido etilenodiamino tetraacético a 17% foi utilizado por canal radicular em todos os grupos. Dez secções transversais em série de 0,5 μm por espécime foram obtidas a cada 0,2 mm de um segmento de 2 mm da região apical, estendendo-se desde 1 até 3 mm aquém do ápice radicular. As seções foram coradas com hematoxilina-eosina e analisadas sob um microscópio digital (100x). As porcentagens de paredes não tocadas e detritos remanescentes foram quantificadas utilizando-se o software ImageJ. Modelos lineares generalizados foram utilizados para analisar os resultados (α=5%). Os grupos WOG e TN apresentaram porcentagens significativamente menores de paredes intocadas e detritos remanescentes do que o grupo C (p<0,05). Não houve diferença significativa entre os grupos WOG e TN quanto a nenhuma das variáveis estudadas (p>0,05). A instrumentação com os instrumentos WaveOne Gold Medium e TruNatomy Medium foi associada a porcentagens equivalentes de paredes intocadas e detritos remanescentes no terço apical de canais circulares de pré-molares inferiores.

Intraoperative Wound Lavage System for Deep Neck Infection: A Retrospective Cohort Study

Abstract Introduction Multiple solutions are currently used to cleanse a deep neck infection (DNI), and a variety of devices are available to deliver wound irrigation solutions. An essential difference between these devices is the pressure that the irrigation solution exerts over the wound tissue. Objective To compare low-pressure and high-pressure irrigation delivery systems for wound cleansing in DNI. Methods we designed a retrospective cohort study and reviewed the medical records of patients operated on due to DNI from June 2016 to December 2017 at our institution. One cohort included patients treated with an intraoperative irrigation method that exerts low pressure over the irrigated tissue, and the other cohort, to a system capable of generating higher pressure. The Pearson Chi-squared test was used to analyze the data. Results A total of 42 patients whose ages ranged from 16 months to 72 years were included. The low-pressure irrigation system was used in 18 patients, and the high-pressure system was used in 24 patients. No statistical differences were observed regarding the irrigation methods, the complexity of the DNI, and the overall outcomes. Conclusions The present is the first study in which low- and high-pressure systems for wound lavage were evaluated in the treatment of DNI. When comparing these methods, we did not find one to be superior to the other; however, the additional cost associated with the high-pressure devices may not justify their in head and neck procedures.

Impacto económico de desbridamientos quirúrgicos y amputaciones de miembros inferiores en pacientes diabéticos / Economic impact of surgical debridements and lower limb amputations in diabetic patients

Introducción: La diabetes mellitus tipo 2 (DM2) constituye un problema de salud pública. Objetivos: Determinar la frecuencia de los desbridamientos quirúrgicos y amputaciones de miembros inferiores en pacientes diabéticos tipo 2 y su impacto económico. Materiales y métodos: Se realizó un estudio Observacional descriptivo de corte transversal. Se estimaron los costos médicos directos tanto de desbridamientos quirúrgicos como de amputaciones de miembros inferiores en pacientes diabéticos en el Hospital de Clínicas San Lorenzo, durante el año 2019. Resultados: El total de desbridamientos quirúrgicos y amputaciones de miembros inferiores en el año 2019 representan el 1,9% (314/16.484) de los procedimientos quirúrgicos realizados en el Hospital de Clínicas. El monto total de gastos es de 1.804.185.116 (262.541 USD), de los cuales 172.514.000 (38.857 USD) constituyen gastos de bolsillo y 1.631.671.116 (237.437 USD) constituyen gastos erogados al Estado Paraguayo a través del Hospital de Clínicas de San Lorenzo. Conclusión: Las complicaciones de la diabetes imponen considerables costos tanto en el gasto de bolsillo, al sector de la salud como a la economía en general en el Paraguay, por lo que es necesario re evaluar el manejo de esta problemática teniendo en cuenta el gran impacto que tienen dichos procedimientos producen en la vida de los pacientes a nivel físico, emocional, familiar y social, así como la carga económica que conlleva el tratamiento para el Sistema de Salud.

Introduction: Type 2 diabetes mellitus (T2DM) constitutes a public health problem. Objectives: Determine the frequency of surgical debridement and lower limb amputations in type 2 diabetic patients and their economic impact. Materials and methods: A descriptive cross-sectional observational study was carried out. The direct medical costs of both surgical debridement and lower limb amputations in diabetic patients at the Hospital de Clínicas, San Lorenzo were estimated during 2019. Results: The total of surgical debridement and lower limb amputations in 2019 represents the 1.9% (314/16,484) of surgical procedures performed at the Hospital de Clínicas. The total amount of expenses is 1,804,185,116 (262,541 USD), of which 172,514,000 (38,857 USD) constitute out-of-pocket expenses and 1,631,671,116 (237,437 USD) constitute expenses disbursed to the Paraguayan State through the Hospital de Clínicas de San Lorenzo. Conclusion: The complications of diabetes impose considerable costs both in out-of-pocket spending, on the health sector and on the economy in general in Paraguay, so it is necessary to re-evaluate the management of this problem taking into account the great impact that these procedures have on the lives of patients on a physical, emotional, family and social level, as well as the economic burden that the treatment entails for the Health System.

Desbridamiento retroperitoneal video asistido: una nueva técnica quirúrgica para una vieja patología, la pancreatitis aguda severa presentación de caso clínico / Video-assisted retroperitoneal debridement: a new surgical technique for an old pathology, severe acute pancreatitis clinical case presentation

INTRODUCCIÓN: el desbridamiento retroperitoneal video asistido (DRVA) es una técnica mínimamente invasiva usada para el tratamiento de la necrosis pancreática infectada (NPI). MATERIAL Y MÉTODO: reporte de caso. RESULTADOS: se presenta un caso de pancreatitis aguda severa tratada con DRVA en una paciente femenina de 43 años, con un cuadro clínico de 5 días de evolución caracterizado por dolor abdominal espasmódico en hipocondrio derecho, de moderada intensidad, irradiado a epigastrio y en cinturón a ambos flancos. La paciente recibió atención privada en dos centros previos al ingreso al nuestro. Al ingreso, en el laboratorio, presenta leucocitosis y desvió izquierdo, amilasémia y lipasémia altas. Se realizaron tomografías contrastadas y punciones guiadas por TAC y DRVA cuando se evidencia necrosis amurallada. Se describe la técnica quirúrgica. Súbitamente la paciente presenta insuficiencia respiratoria y datos compatibles con tromboembolia pulmonar y fallece. CONCLUSIÓN: bajo la visión de terapia escalonada, el desbridamiento retroperitoneal video asistido va ganando adeptos en el manejo de la Pancreatitis Aguda Severa

BACKGROUND: video-assisted retroperitoneal debridement (VARD) is a minimally invasive technique used for the treatment of infected necrotizing pancreatitis. MATERIAL AND METHODS: case report. RESULTS: a case of severe necrotizing pancreatitis is presented in a 43 years old female patient, with 5 days clinical evolution with spasmodic abdominal pain in epigastrium and right hypochondrium of moderate intensity, irradiated to both flanks in belt. The patient received private care in two centers upon the admission in our hospital. In the laboratory at the admission, she showed leukocytosis and left deviation, high level in amylase and lipase. Contrasted enhanced tomography and guided punctures were realized and VARD were considered when evidence of wall of necrosis was observed in scanner. The surgical technique is described. Suddenly the patient presented acute respiratory failure with massive pulmonary thromboembolism and died. CONCLUSION: under the step-up approach vision, the video-assisted retroperitoneal debridement is gaining popularity in the management of the acute necrotizing pancreatitis

Full Endoscopic Treatment for a Fibrosis Complication after Psoas Abscess.

BACKGROUND: Psoas abscess is a challenging disease that may sometimes lead to a devastating prognosis. Early diagnosis and treatment are mandatory for better results in their treatments and to avoid complications. PURPOSE: There is no article regarding a fibrosis treatment of the psoas muscle with a psoas abscess that is treated with full endoscopic debridement (FED). STUDY DESIGN: a case report and literature review. RESULT: we successfully treated this case, who suffered from psoas fibrosis with a clinical and MRI diagnosis, with full endoscopic debridement. CONCLUSIONS: FED is a viable alternative to open debridement for this rare complication of a psoas muscle abscess.

Nasal Crust-Related Morbidity and Debridement After Endoscopic Skull Base Surgery

Abstract Introduction: Nasal crust after endoscopic skull base surgery can cause nasal congestion, obstruction, and pain, which can affect quality of life. The use of debridement aims to provide symptomatic relief and improve quality of life. Generally, most adult patients tolerate office-based debridement, except in a few select patients that require further sedation in the operating room for a debridement. The study sought to determine the rate of symptomatic crust-related morbidity and the rate of debridement in both the office and the operating room. Methods: Premorbid, operative, and postoperative data of adult patients who had endoscopic skull base surgery in our institution from 2014 to 2018 were reviewed retrospectively. The characteristics of nasal symptoms in the postoperative period were determined and the numberofdebridementsin theoffice and the operatingroomwere analyzed. Results: Two hundred and thirty-four (234) patients with 244 surgeries were included in the study. The majority, 68.9%, had a sellar lesion and a free mucosa graft (FMG) was the most common skull base reconstruction at 53.5%. One hundred and twenty (49.0%) had crust-related symptoms during the postoperative period and 11 patients (4.5%) required the operating room for debridement. The use of a pedicled flap, anxiety, and preoperative radiotherapy were significantly associated with intolerance to in-office debridement (p-value=0.05). Conclusions: The use of a pedicled flap or anxiety may predispose patients to require an OR debridement. Previous radiotherapy also influenced the tolerance to the in-office debridement.