Maggot debridement therapy in critical limb ischaemia: a case study.

OBJECTIVE: In critical limb ischaemia (CLI), first-line therapy is revascularisation, but alternative treatment options are needed in certain cases. Maggot debridement therapy (MDT) is historically considered to be contraindicated in ischaemic ulcers. Wound care in patients with CLI is becoming increasingly diverse with the development of novel revascularisation strategies; therefore, CLI now needs to be reconsidered as an indication for MDT. METHOD: We retrospectively reviewed five legs with CLI (five male, one female) treated with MDT between January 2013 and December 2017. Changes in skin perfusion pressure (SPP) around the ulcer before and after MDT were evaluated. One or two cycles of MDT were performed (eight in total). We also evaluated the proportion of necrotic tissue in the ulcer and the presence of exposed necrotic bone. The proportion of necrotic tissue in the ulcer was classified as NT 1+ (<25%), NT 2+ (25-50%), NT 3+ (50-75%) or NT 4+ (>75%). RESULTS: When the proportion of necrotic tissue was >50%, with no exposed necrotic bone in the wound, an increase in SPP was observed after five (62.5%) of eight cycles of MDT. And with a proportion of necrotic tissue of <25% and/or exposed necrotic bone in the wound, a decrease in SPP was observed after three (37.5%) of eight cycles. Wound healing was accelerated in the presence of increased SPP. CONCLUSION: Effective MDT with increased SPP requires an ulcerative state of necrotic tissue grade > NT 3+, with no exposed necrotic bone.

The Japanese registry for surgery of ischial pressure ulcers: STANDARDS-I.

OBJECTIVE: To clarify the surgical indications and the appropriate perioperative management of ischial pressure ulcers (PUs). METHOD: A two-year prospective, nationwide registry study was carried out across 26 medical institutions in Japan. All participating institutions managed ischial PUs according to the standardisation of total management and surgical application for the refractory decubitus (STANDARDS-I) perioperative protocol. Analysis was conducted on a range of clinically or statistically important variables for the achievement of primary or secondary endpoints: complete wound healing and hospital discharge at three months, and complete wound healing at one month after surgery, respectively. RESULTS: A total of 59 patients took part in the study. All patients underwent surgery for ischial PUs during the study period. Patients who had achieved the primary endpoint had a higer preoperative functional independence measurement (FIM score), a higher 'G' score in the DESIGN-R scale and were more likely to have healed by primary intention. Patients who had achieved the secondary endpoint were more likely to have spastic paralysis, preoperative physiotherapy and localised infection of the wound, among other variables. CONCLUSION: This survey suggests that preoperative physiotherapy increases the speed of wound healing, and good granulation of the wound bed preoperatively increases the likelihood of woundless discharge from hospital, whereas the existence of comorbidities negatively influences the likelihood of woundless discharge from hospital. The study also suggests that the existence of spastic paralysis, preoperative infection of the wound, or surgical reduction of the ischial tubercle speeds up the healing of the wound. However, the wound failed to heal significantly more often in patients with increasing white blood cell count after surgery.

Factors that Affected Functional Outcome After a Delayed Excision and Split-Thickness Skin Graft on the Dorsal Side of Burned Hands.

Early excision and skin grafting is the principle treatment for a burned hand although there are occasions when it cannot be done such as severe general condition, delayed consultation, and the lack of a definitive assessment of burn depth. This study analyzes the factors that affected function after a delayed excision and skin graft for hands with a deep dermal burn. This study retrospectively evaluated 43 burned hands that required a delayed excision and split-thickness skin graft on the dorsal side. Cases were required to only have split-thickness skin grafting from the dorsum of the hand and fingers distally to at least the proximal interphalangeal joint at least 8 days after the injury. The hands were divided into two functional categories: Functional category A, normal or nearly normal joint movements, and functional category B, abnormal joint movements. Demographic data were assessed statistically by a univariate analysis following a multiple regression analysis by a stepwise selection. A significant difference was observed between the groups in the number of days from grafting to complete wound healing of the graft site and with or without an escharotomy in the analysis. These parameters were statistically significant predictors of functional category B. The functional outcome of a burned hand after a delayed excision and split-thickness skin graft on the dorsal side became degraded depending on the number of days from grafting to complete wound healing. Cases that underwent an escharotomy also showed deterioration in function.

Promising long-term outcomes of the reused skin-graft technique for chronic gluteal hidradenitis suppurativa.

BACKGROUND: The reused skin-graft technique can be used to treat chronic gluteal hidradenitis suppurativa, but long-term outcomes and the reliability of the technique have not been reported. METHODS: In a retrospective review of 18 men with chronic gluteal hidradenitis suppurativa (age range, 18-68 years) treated with a reused skin graft between June 2004 and March 2012, we evaluated disease severity (Hurley classification system), skin-graft thickness, the need for an additional normal skin graft, histological findings and recurrence rate at the surgical site. RESULTS: The mean duration of follow-up was 61.3 months (range, 17-113 months). Five cases were classified into severity group I, 12 cases into severity group II and one case into severity group III. The range of skin-graft thicknesses was 0.013-0.020 inches. An additional donor site was unnecessary in 10 cases (three cases in group I (60%) and seven cases in group II (58.3%)). Histological examination indicated that a buried epidermal cyst could cause chronic gluteal hidradenitis suppurativa recurrence, although none of the patients experienced recurrence at the surgical site during follow-up. CONCLUSION: The reused skin-graft technique is reliable for chronic gluteal hidradenitis suppurativa resection, and it shows promising long-term outcomes.

Utility of the method using the tsukisui device to control intraoperative bleeding applied to neurofibroma resection.

SUMMARY: The resection of neurofibromas in Von Recklinghausen's disease [neurofibromatosis type 1 (NF-1)] is frequently complicated due to size, location, hypervascularity, and tissue friability. A repeat resection, however, is necessary for patients with functional problems such as unexpected tumor bleeding or with changes in esthetic appearance. This report describes application of the method using the Tsukisui device to resecting NF-1 tumors while minimizing blood loss. The method using the Tsukisui device was applied for the resection of 8 NF-1 tumors (5 patients), and intraoperative blood loss, operative time, and postoperative complications were recorded. In all cases employing this method, intraoperative blood loss was <360 ml (10-360 ml), and none of the patients developed postoperative hematoma or other notable bleeding complications. The method using the Tsukisui device, which provided excellent hemostasis and was associated with few complications, shows promise for application to neurofibroma resection.

A new aspect of metastasis in cutaneous cancer: two cases of presacral squamous cell carcinoma with metastases to internal iliac nodes.

We report 2 cases of presacral squamous cell carcinoma. In these cases, it was suspicious that the tumor disseminated to the internal iliac nodes through the direct pathway called the neurovascular lymphatic space (NVLS) around the superior/inferior gluteal vessels or sciatic nerve bypassing external iliac nodes. NVLS was initially reported as accessory pathway which follows the major vessels forming a sheath like structure with an actual or potential space between the vessel wall and the enveloping membrane. NVLS has been reported to be observed as a tubular shadow within the neurovascular sheath by lymphangiographies of lymphedema patients using oil-based contrast material. These cases provide insights into the potential pathway through which a cutaneous tumor disseminates.

Merkel cell carcinoma of the face: an analysis of 16 cases in the Japanese.

BACKGROUND: There is no agreement regarding a staging system and optimal treatment of Merkel cell carcinoma. Some centres have reported results from larger series of patients, but these do not include Asian or Japanese centres. OBJECTIVE: The purpose of this study was to retrospectively review our experience with the surgical treatment of MCC of the face in the Japanese and to study its management and outcome using the staging system described by Clark et al. METHODS: We report our experiences with 16 cases between 1991 and 2004. Patients and tumour characteristics, treatment variables and outcome were analysed. RESULTS: The follow-up periods ranged from 1 to 180 months. The average was 32.6 months and the median was 17.5 months. The relapse-free survival for all patients was 51% at 2 years. The relapse-free survival was 80% for the patients with Stage I and 33% with Stage II at 2 years. CONCLUSION: This staging system was suggested to reflect prognosis although the number of patients in this series was small. Sentinel lymph node biopsy should be considered to determine the accurate nodal staging, and patients with MCC of the head and neck may be treated according to the revised staging system by Clark et al.

Treatment of ischial pressure sores by means of sclerotherapy using absolute ethanol.

The ischial region is a common site of pressure sore. The ischial pressure sore with a large subcutaneous bursa is resistant to conservative treatment and tends to require radical surgical treatment. In this article the authors describe their experience with a simple surgical treatment on 8 ischial pressure sores in 7 patients with subcutaneous bursa by means of sclerotherapy using absolute ethanol. This method involves causing the bursa to become scarred and closing it up by sterilizing, fixing, and denaturing by the pharmacologic effect of absolute ethanol instead of surgical excision of the bursa. This alternative method has a possibility of treating pressure sores as well as other fistulous diseases in various areas.