Negative pressure therapy in combination with mesh-mediated fascial traction in the treatment of infected pancreatic necrosis. A new therapeutic option.

BACKGROUND: Acute pancreatitis represents one of the most frequent digestive pathologies worldwide, which can be complicated as an infected necrotizing acute pancreatitis, that may require treatment with necrosectomy and open abdomen with the risk that this leads to the appearance of intestinal fistula and giant incisional hernias difficult to manage. CLINICAL CASE: A 35-year-old woman underwent laparoscopic cholecystectomy for acute cholecystitis, which was re-admitted due to jaundice and abdominal pain 3 days after her hospital discharge. Diagnostic laparoscopy is performed, where a 3200 cc biliperitoneum secondary to a cystic duct stump leak is located and drained. Likewise, an endoscopic retrograde cholangiopancreatography (ERCP) is performed, with extraction of an impacted bile gallstone in the distal common bile duct. It presents as a complication of the procedure an acute post-ERCP pancreatitis with infected pancreatic necrosis. Open pancreatic necrosectomy was performed with a negative pressure therapy and mesh-mediated fascial traction, achieving resolution of the infectious condition with definitive closure of the abdominal cavity without incisional hernia or postoperative intestinal fistula. CONCLUSION: Patients with complicated acute pancreatitis with infected pancreatic necrosis represent a challenge in their treatment due to the serious nature of the condition and the morbidity associated with it. A therapeutic option is presented with the combined use of negative pressure therapy (ABThera™) and mesh-mediated fascial traction. With this report we propose a potential line of research to determine its role in the treatment of these patients, as well as their possible advantages and complications.

ANTECEDENTES: La pancreatitis aguda representa una de las enfermedades digestivas más frecuentes en todo el mundo, la cual puede complicarse como una pancreatitis aguda necrotizante infectada, que puede necesitar tratamiento con necrosectomía y abdomen abierto, con el riesgo que esto conlleva de aparición de fistula intestinal y hernias incisionales gigantes de difícil tratamiento. CASO CLÍNICO: Mujer de 35 años, intervenida de colecistectomía laparoscópica por colecistitis aguda, que es reingresada por ictericia y dolor abdominal 3 días después de su egreso hospitalario. Se realiza laparoscopia diagnóstica, en la que se encuentra y drena un biliperitoneo de 3200 cc secundario a una fuga de muñón del conducto cístico. Así mismo, se practica una colangiopancreatografía retrógrada endoscópica (CPRE), con extracción de un lito biliar impactado en el colédoco distal. Presenta como complicación del procedimiento pancreatitis aguda tras la CPRE con necrosis pancreática infectada. Se realiza necrosectomía pancreática abierta con sistema de presión negativa y tracción fascial mediante malla, logrando la resolución del cuadro infeccioso con cierre definitivo de la cavidad abdominal sin presentar hernia incisional ni fistula intestinal posoperatoria. CONCLUSIÓN: Los pacientes con pancreatitis aguda complicada con necrosis pancreática infectada representan un reto en su tratamiento por la naturaleza grave del padecimiento y la morbilidad asociada. Se presenta una opción terapéutica con el uso combinado de presión negativa (ABThera™) y tracción fascial mediante malla. Con el presente reporte se propone una potencial línea de investigación para determinar su papel en el tratamiento de estos pacientes, así como sus posibles ventajas y complicaciones.

Primary Cutaneous Mucormycosis Caused by Rhizopus oryzae: A Case Report and Review of Literature.

Mucormycosis is an invasive infection caused by opportunistic fungi. Rhizopus, Lichtheimia, Mucor and Rhizomucor are the most common isolated genera. Primary cutaneous mucormycosis is usually related to traumatic injuries, but immunocompromised cases are associated with underlying conditions such as diabetes mellitus and malignancies. The treatment of choice is surgical debridement and liposomal amphotericin B. We present a 40-year-old male with fever and a painful necrotic lesion on the middle back and history of poorly controlled diabetes mellitus. Rhizopus oryzae was isolated and identified using an internal transcribed spacer regions ITS1 and ITS2. An initial good response to treatment was observed; however, 7 days later a diabetic ketoacidosis due to poor adherence to treatment caused a lethal outcome.