Does Enzymatic Debridement Allow Us To Perform Conservative Treatment On Clinically Deep Hand Burns? A Retrospective Review.

The hands are one of the main locations of burns. In deep second-degree and third-degree burns, the gold standard of treatment is surgical debridement and subsequent coverage, which can result in suboptimal aesthetic and functional results. The aim of our study is to assess whether treatment by initial enzymatic debridement (NexoBrid®) of deep second-degree and third-degree burns prevents the need for surgery. We carried out a retrospective study of 53 hands with deep burns treated in our centre from May 2015 to December 2016. Two experts evaluated the initial photographs of the burns and classified them as surgical or nonsurgical (interobserver kappa index = 0.83). These assessments were compared with the actual need for surgery on each hand. Sixteen of the 32 (50%) hands that the experts considered surgical spontaneously epithelialized. Four of the 17 hands (23.5%) that were not considered surgical required a split-thickness skin graft for healing. Enzymatic debridement helps to preserve viable tissue, which reduces the number and extension of surgical interventions, thus favouring better results.

Les mains sont une des principales localisations de brûlures. Dans les brûlures du 2e degré profond et du 3e degré, le traitement de référence est l'excision chirurgicale suivie d'un geste de couverture, et donne des résultats fonctionnels ou esthétiques pas toujours parfaits. Le but de notre étude est d'évaluer si le débridement enzymatique (NexoBrid®) des brûlures du 2e degré profond et du 3e degré permet d'éviter les gestes chirurgicaux. Nous avons mené une étude rétrospective sur 53 mains présentant des brûlures profondes traitées dans notre centre entre mai 2004 et décembre 2016. Deux experts ont évalué les photographies initiales et classé les brûlures en « chirurgicales ¼ ou « non chirurgicales ¼ (coefficient Kappa inter-opérateur = 0,83). Ces évaluations ont été comparées à la nécessité réelle de prise en charge chirurgicale pour chacune des mains. 16 des 32 mains (50%) que les experts avaient jugées « chirurgicales ¼ ont cicatrisé spontanément. 4 des 17 mains (23,5%) qui ont été considérée comme « non chirurgicales ¼ ont nécessité une greffe de peau mince pour obtenir la cicatrisation. Le débridement enzymatique permet de conserver les tissus viables, ce qui diminue le nombre et l'importance des gestes chirurgicaux, et donc favorise l'obtention de meilleurs résultats.

Aplicaciones del colgajo frontonasal para la cobertura de defectos nasales / Applications of the frontonasal flap for coverage of nasal defects

Presentamos una revisión retrospectiva de los pacientes a los cuales se realizó un colgajo frontonasal para la cobertura de defectos nasales intervenidos en la Unidad de Tumores Cutáneos de nuestro Servicio en el periodo comprendido entre enero de 2010y mayo de 2014.El objetivo es analizar nuestras aplicaciones y resultados además de describir un algoritmo que permita indicar los distintos diseños en función de la localización y el tamaño del defecto a reparar. Empleamos el colgajo frontonasal en 78 pacientes (49 mujeres y29 varones) con un rango de edad de 47 a 92 años (media de 73años). Creamos un total de 81 defectos, puesto que en 3 casos se resecaron simultáneamente 2 tumoraciones, todos de etiología tumoral(64 carcinomas basocelulares, 16 carcinomas espinocelulares y 1caso de léntigo maligno melanoma), localizados en el área nasal, con un tamaño mínimo de 12 x 17 mm y máximo de 30 x 35 mm (media de 22 x 25 mm). El periodo de seguimiento fue de entre 2 meses y 4años (media de 2,5 años). Respecto a las complicaciones observadas, todas ellas menores, hubo 6 casos de necrosis marginal, 8 de dehiscencia parcial de la herida y 1 de cicatrización hipertrófica, tratándose en su mayor parte de varones fumadores. Todos los colgajos sobrevivieron con resultado estético satisfactorio. El colgajo frontonasal permite la cobertura en un sólo tiempo quirúrgico de defectos nasales independientemente de su localización, de hasta 30 x 35 mm en nuestra serie. Se trata de un colgajo seguro y versátil en sus múltiples modificaciones, con unos resultados estéticos satisfactorios. Estas ventajas son de especial importancia en pacientes de edad avanzada como alternativa a técnicas más complejas. Se trata por lo tanto, a nuestro juicio, de una opción a tener en cuenta para la reconstrucción en un único tiempo quirúrgico de defectos nasales (AU)

We present a retrospective review of patients in whom the frontonasal flap technique was performed to repair oncologic nasal defects. All patients were treated in the Skin Cancer Unit of our Department between January 2010 and May 2014.The aim of this study is to analyze our applications and results ,in addition to describe an algorithm that allows us to indicate the different flap designs, according to the location and size of the defect. A total of 78 patients (49 females and 29 males) with an age range from 47 and 92 years (average of 73 years), underwent nasal reconstruction with a frontonasal flap after surgical resection of an basal skin cancer (64 basal cell carcinomas, 16 squamous cell carcinomas and 1 melanoma) in a total of 81 defects (3 cases had 2 simultaneous carcinomas). The smallest defect measured 12 x 17 mm and the largest 30 x 35 mm (average of 22 x 25 mm). Follow-uptime ranged from 2 months to 4 years (average of 2,5 years). Complications, which were minor in all patients, included marginal necrosis(6 cases), partial wound dehiscence (8 cases) and hypertrophic scar formation (1 case), mostly in male smokers. No flap loss was observed and the aesthetic result was satisfactory. In conclusion, the frontonasal flap offers the possibility of a single-stage reconstruction of the nasal area, including defects up to 30 x 35 mm of the nasal tip in our series. Is a reliable and versatile flap, which may present advantages over more complex techniques, especially in older patients (AU)

Use of an autologous bioengineered composite skin in extensive burns: Clinical and functional outcomes. A multicentric study.

OBJECTIVE: We report clinical and functional outcomes obtained after application of an autologous bioengineered composite skin (ABCS) produced in a single Spanish tissue-engineering unit. MATERIALS/METHODS: Twenty-five burned patients treated with ABCS from 1999 to 2007 in five burn centres were included in the study. Mean age was 29 years (SD 11), with mean total body surface area (TBSA) burned being 74% (SD 17) and mean full-thickness injury of 61% (SD 19) of TBSA. RESULTS: The mean area initially engrafted with ABCS was 24% (SD 13) of TBSA, with a final take of 49% (SD 30, range 0-100%). ABCS achieved permanent coverage of a mean of 11% (SD 8) of TBSA. In subset analyses, lack of pre- and post-application wound bed infection and lack of serious acute systemic complications at the time of engraftment were significantly associated with better ABCS take. CONCLUSIONS: Final take obtained with ABCS could be improved with the use of non-cytotoxic topical antibiotics following engraftment. The use of plasma to prepare ABCS reduces production costs: cost-effectiveness ratio is not a limitation for its use. In terms of patient satisfaction, cosmetic/functional outcomes (general appearance, texture, flexibility, sensitivity and colour) of ABCS and split-thickness autografts are not different statistically.

Chemical burns: pathophysiology and treatment.

Chemical burns continue to pose a variety of dilemmas to the clinician managing such cases. Assessment of burn depth is often difficult and the decision whether to excise the wound early is not always clear-cut. In this updated review, common agents are classified and the basic principles of management and specific recommendations are examined. The complications arising from exposure to these chemicals and the supportive measures needed during treatment are also described.

Burned breast reconstructive surgery with Integra dermal regeneration template.

Reconstruction of the burned breast poses several clinical challenges, since scarring can adversely affect the development, contour and positioning of the breast as well as the cosmetic appearance of the skin surface. Conventional management entails contracture release and thick split-thickness skin grafting. We investigated an alternative approach employing dermal regeneration template (Integra) for breast reconstruction in 12 consecutive patients who had suffered anterior chest wall burns in childhood. Integra is a bilayer material consisting of a collagen and chondroitin-6-sulfate dermal regeneration template and a temporary silicone epidermal layer. Portions of the scar contracture preventing the breast from assuming the desired shape and position were excised. Unmeshed Integra sheets were applied to the wound bed immediately following excision. Sufficient vascularization of the forming neodermis occurred within 28 days on average to enable removal of the silicone layer and placement of unmeshed 0.005in. epidermal autografts. Upon histological examination one month postoperatively, naturally-formed collagen fibres were observed in the dermal regeneration template. By one year, host collagen had typically completely replaced the Integra matrix, and elastic fibres were evident throughout the neodermis. Durable improvements in breast contour and shape were attained in all patients, and clinically-relevant recontracture of the graft site did not occur within the follow-up period. A statistically significant improvement of 6.0 (95% CI, 5.0-6.5) in Vancouver Scar Scale score was demonstrated at one year. A very high level of satisfaction in the outcome of reconstruction was expressed by 92% of the patients. Grafting with Integra provides an effective and well-tolerated alter-native to thick split-thickness grafting for breast reconstruction. Chief advantages are the availability of a biocompatible material in unlimited quantity that can be tailored to the particular wound site and the avoidance of a deep donor site wound with attendant potential for infection, scarring and permanent pigment changes.

Effects of taurine on polymorphonuclear phagocytosis activity in burned patients.

This study determines the effects of taurine (Tau) on phagocytosis of polymorphonuclear neutrophils (PMN) isolated from normal subjects (n = 41) and severely burned patients (n = 20). Phagocytosis was measured by nitroblue of tetrazolium (NBT) reduction in samples with and without latex bead stimulation. Taurine was added at doses of 0.2, 0.4, 0.8 and 1.6 mM to stimulated samples. In control cells there were statistically significant increases in phagocytosis after addition of Tau 0.8 mM and 1.6 mM to as compared to samples without Tau addition (295 +/- 23% and 330 +/- 35% vs. 248 +/- 18%; mean +/- S.E.; p < 0.05). A statistically significant increase in phagocytosis was observed in cells from the burned population after addition of Tau 1.6 mM (288 +/- 38% vs. 198 +/- 13%; mean +/- S.E.; p < 0.05). No changes in phagocytosis were found in cells from a subgroup of burn patients (n = 13) followed over 7, 15 and 21 days. These results indicate that taurine supplementation in vitro at doses of 0.8 to 1.6 mM improves the phagocytic capacity of neutrophils in healthy subjects and in patients with severe burn injury, mainly when neutrophil function is unaltered.

Self-inflicted burns.

Of 3371 patients admitted to the Vall D'Hebron Burns Center, Barcelona, between the years 1983 and 1991 inclusive, 67 patients had attempted self-inflicted burns (1.98 per cent). Over 75 per cent of these patients had previous psychiatric illness and 20 per cent had previously attempted suicide. The mean age was 38 years and the overall mortality rate was 30 per cent. Over 71 per cent were male patients.

[Primary gastrointestinal lymphoma]. / Linfoma primario gastrointestinal.

20 patients were evaluated and found to have a radiologic-endoscopic diagnosis of primary gastrointestinal lymphoma, in the Digestive Tract Department of the "Padre Machado" Oncological Hospital in a 19 years period (1970-1989). In 17 patients diagnosis of non-Hodgkin's Lymphoma was made and the 3 other patients were diagnosed with the Hodgkin's Lymphoma. It was located more frequently in the stomach: 14 (70%). Through double contrast radiology, endoscopy and deep biopsy, the diagnosis was made in 12 (67%) patients. The most frequent hystological type was diffuse histiocytic lymphoma. Surgery was the most used treatment. The value of double contrast radiology, and deep biopsy stand out as adequate methods to obtained a positive diagnostic, avoiding unnecessary surgical procedures.

[Multi-technical management of biliary fistula]. / Manejo multitécnico de las fístulas biliares.

Biliary fistula is an occasional complication of cholecystectomy and are usually associated to retained biliary stones, surgical trauma of the biliary ducts and local infection. They were mainly treated by surgical methods up to the acquisition of the new endoscopic and percutaneous techniques used together with parenteral and enteral nutrition and new antibiotics. A total of seven patients with diagnosis of biliary fistula were seen between 1984 and 1990 at the "Unidad de Gastroenterología y Cirugía Digestiva" of the Clínica Sanatrix en Caracas. Average age was 50 with ranged between 31 and 76, 4 were male and 3 female. The fistulas were in 1 due to necrotizing pancreatitis, in 3 to lost of the ligation of the cystic duct, 2 were due to accidental injury of the common duct and the last case was a partial dehiscence of a choledoco-jejunostomy after the resection of a common duct cyst. Four of the cases were choledoco-cutaneous fistula, one hepatocutaneous, two hepatoduodenal. All the seven patients had subhepatic collections, one had a retroperitoneal collection, two had subdiaphragmatic collections and one had multiple hepatic abscesses. The abdominal collections were treated by percutaneous drainage using mainly the Ring-McLean and Van Sonnenberg tubes. The fistula was occluded with biliary prosthesis in four cases, using either endoscopic, percutaneous or mixed technique to place the stent. Patency of the stents ranged between 2 weeks and 24 months. Control time was from 2 to 40 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ambulatory laparoscopy]. / Laparoscopia ambulatoria.

We present our experience with laparoscopy in 600 outpatients with several diseases in seven years (1982-1988). We performed 707 studies in 594 patients (99%), in six cases (1%) the examination was not feasible because of intra-abdominal adhesions. In 235 patients (39.16%) previous abdominal surgery was not considered a contraindication for the examination. We performed 295 hepatic biopsies, 69 adhesions cuts, 9 laparoscopic placement of Tenckhoff catheter and other procedures. The incidence of complications was 5.23%, related to laparoscopy 3.67% and to procedures 1.55%. Major complications occurred in four patients (0.56%), surgical intervention was required in one patient (0.14%). We neither had infectious complications, nor mortality. We conclude that laparoscopy can be an ambulatory procedure, because it has a low incidence of complications in skilled hands and is well tolerated.

[Ultrasound, computed tomography and laparoscopy. Efficacy in the detection of primary and metastatic hepatic tumors. Comparative study]. / Ultrasonido, tomografía computarizada y laparoscopia. Eficacia en la detección de tumores hepáticos primarios y metastásicos. Estudio comparativo.

OBJECT: To compare ultrasound, computed tomography and peritoneoscopy in the diagnosis of primary and metastatic hepatic tumors. DESIGN: Prospective trial of a cohort patients during a year. PLACE: Digestive Disease Department in a National referral Cancer Center. PATIENTS: Forty five patients with intraabdominal tumors for pretreatment evaluation. Intervention; Ultrasonography, computed tomography and peritoneoscopy performed in a period of ten days. MEASUREMENTS: sensibility, specificity and efficiency comparison of results by Chi square test, with Yates correction (X2 Yates), measure of pre test and post test probabilities using Bayes theorem. RESULTS: In hepatic humors, peritoneoscopy was the most sensitive, specificity was similar for the three procedures (p greater than 0.1), in the detection of hepatic metastases peritoneoscopy was the most sensitive 91.6% vs 50% (p less than 0.05) similar specificity and high positive predictive value for the three procedures, comparable with the post test probabilities. CONCLUSIONS: In the detection of focal hepatic lesions, peritoneoscopy was the best method; in case of doubt, failure of non invasive procedures or the need of biopsy samples must be considered the procedure of choice.

[Cancer of the ampullar region]. / Cáncer de la región ampular.

The clinical-pathological spectrum of ampullary cancer in 18 patients studied at the Department of Gastroenterology (Hospital Oncológico Padre Machado) during the last decade (1980-88) is presented. Involvement of the extrahepatic bile ducts was due to cancer of the ampullary region. In all cases diagnosis was confirmed by pathology. The value of ERCP is presented and the need to set apart this tumors from carcinoma of the head of the pancreas is emphasized. None of the nine cases treated with radical resection (Whipple) had operative mortality, and although follow-up for all cases is not long enough, two patients are alive and free of disease, five years after surgery. The value of prosthesis and biliary drainage for palliation is commented upon. Emphasis is placed on the need of using the term ampullary cancer in its proper connotation. Criteria for differentiating periampullary tumors (specially cancer of the head of the pancreas) are presented.

[Colonoscopy as primary procedure in the diagnosis of colonic neoplasms]. / Colonoscopia como exploración primaria en el diagnóstico de las neoplasias del colon.

Experience with colonoscopy as an initial procedure in the study of the colon is presented. 3.450 colonoscopies in patients with GI symptoms were performed by trained endoscopists using the intermediate length scopes (130cm) without fluoroscopy. In 90% of the cases the whole colon was studied in a mean time of 20 minutes. 382 neoplasms (11.07%) were diagnosed. Polips represented 90% of the lesions and 34.3% of them were adenomas. 30% of the adenomas and 34.4% of the malignant tumors were localized in the right colon. We emphasise that 82.7% of the polips found in the right colon were adenomas. As a side effect we had a sigmoid perforation, it represents 0.03%. Colonoscopies performed by a trained endoscopist is a highly diagnostic method with low degree of complications, making it the procedure of choice in the study of the colon in specialized centers.

[Colitis caused by radiation: 20 years' experience]. / Colitis por radiación: 20 años de experiencia.

The 20 year experience with diagnosis and management of radiation colitis at the Gastroenterology Department of the Hospital Oncológico "Padre Machado" is presented. Of 404 cases, 98% were treated for carcinoma of the cervix. The most frequent symptoms were rectal bleeding (71%) and changes in the intestinal habitus (27.2%). Symptoms were present from one month to one year prior to radiation. Flexible sigmoidoscopy in 77.5% of patients showed Grade I and II actinic disease, and X Ray studies sowed Grade II and III in 80%. Thirty eight patients required surgical treatment.