Surgery Management of Pancreatitis with Complication: A Review Article

Introduction: Acute pancreatitis is an inflammatory disease of the pancreas with clinical manifestations that vary from mild to severe manifestations to death. The incidence of pancreatitis varies in various countries in the world and depends on the cause such as alcohol, gallstones, and metabolic factors. The clinical picture and the main symptom in patients with acute pancreatitis is abdominal pain. Abdominal pain varies from mild to severe and excruciating. Abdominal pain that is felt is constant and dull, and is usually felt in the epigastrium and periumbilicus and often spreads to the back, chest, waist, and lower abdomen. Discussion: The onset of acute pancreatitis, the patient should be evaluated for hemodynamic status immediately and receive the necessary resuscitation measures. Patients with acute pancreatitis should receive aggressive intravenous rehydration (250 - 500 ml/hour with isotonic crystalloid fluid) as early as possible with close monitoring, unless contraindicated with cardiovascular and/or renal comorbidities. It is most effective within the first 12-24 hours, but after that the benefits may diminish. Debridement (necrosectomy) is the gold standard in infected acute necrotizing pancreatitis and peripancreatic necrosis. Indications for intervention either through radiological, endoscopic or surgical procedures in necrotizing pancreatitis are suspected or proven infected necrotizing pancreatitis with clinical deterioration, especially after the necrotic tissue has been encapsulated with thick walls (walled-off necrosis). Sterile necrotizing pancreatitis with persistent organ failure several weeks after the onset of acute pancreatitis, particularly after the necrotic tissue has been encapsulated with thick walls (walled-off necrosis). Conclusion: Surgical management is often used in pancreatitis associated with gallstones. Cholecystectomy within 48 hours of the complaint can increase healing time. In addition, cholecystectomy performed early may not increase the risk of complications secondary to surgery. Surgery is not performed in acute necrotizing pancreatitis until the inflammation is reduced and the fluid accumulation no longer increases in size.

Using Ultrasound Guided Needle Biopsy in Combination With GeneXpert MTB/RIF to Diagnose Epididymal Tuberculosis: a Study of 12 Cases

Objective: This study aims to investigate the diagnostic utility of percutaneous ultrasound-guided needle biopsy in combination with GeneXpert MTB/RIF for epididymal tuberculosis.Methods: Between March 2019 to March 2021, specimens obtained from 12 patients with confirmed epididymal tuberculosis by ultrasound guided needle biopsy were sent for pathology and laboratory examination at the Shandong Public Health Clinical Center. The laboratory examination included acid-fast staining, Mycobacterium tuberculosis culture by BACTEC MGIT 960, and the GeneXpert MTB/RIF test. The diagnosis and complications were comprehensively analyzed.Results: Among the 12 cases, seven cases had granulomatous inflammation and necrotic tissue, four cases had chronic inflammatory cells and necrotic tissue, and one case had chronic inflammatory cell infiltration. Furthermore, among the 12 patients, five patients were positive for Mycobacterium tuberculosis culture, two patients were positive for the acid-fast staining, and twelve patients were positive for the GeneXpert MTB/RIF assay. The sensitivity and specificity of the acid-fast staining, Mycobacterium tuberculosis culture and GeneXpert MTB/RIF in the diagnosis of epididymis tuberculosis were 16.67% and 100.00%, 41.67% and 100.00%, and 100.00% and 50.00%, respectively. The diagnostic value analysis of the three detection techniques indicated that the GeneXpert MTB/RIF technique (Kappa=0.63, AUC=0.75) is superior to the Mycobacterium tuberculosis culture (Kappa=0.17, AUC =0.71) and acid-fast staining (Kappa=0.05, AUC=0.58). Conclusion: Ultrasound guided percutaneous biopsy combined with GeneXpert MTB/RIF assay is extremely useful for diagnosing epididymitis tuberculosis and determining rifampin resistance, with superior sensitivity, specificity and AUC value.

Analysis of the Therapeutic Effect of Artificial Leather Embedding Combined with Fascial Sleeve Flap Transplantation on Chronic Wounds of Lower Limbs with Bone and Plate Exposure

Background: After severe trauma of lower limbs, bone、tendon or plate graft exposure is common.The traditional repair method is to use a variety of skin flap transplantation to cover the exposed part, but the wound often can not heal after operation, or the wound is cracked, ulcer, sinus, bone and steel plate are exposed again after wound healing.The reason for this result is that when the flap is covered, the space around the bone plate is not well closed, forming a dead cavity, blood and exudate accumulation, hematoma formation or infection, and finally the wound ruptures again. In addition, due to the swelling and contracture of the flap after operation, the suture tension between the flap and the receiving area becomes larger, the skin becomes thinner and broken, and then the wound is formed. In order to solve the above problems, we carried out the study of artificial true skin embedding combined with fascial sleeve flap transplantation in the treatment of chronic bone plate exposed wounds of lower limbs.Methods: In this paper, 11 cases of chronic wounds with bone exposure and skin necrosis after steel plate implantation were selected. First stage is the wound bed preparation including primary wound expansion,removal of necrotic tissue and incision of sinus wall, removal of deep necrotic bone and fibrotic scarred skin on the outer wall of steel plate to normal tissue on the outer edge of the wound, removal of precipitated peptone and purulent fur in the hole, periphery and bone space of the steel plate, and removal of tendon tissue with basal necrosis and disintegration of the wound. After vacuum sealing drainage (VSD) 1~2 weeks, the peritraumatic basal granulation tissue grew well and there was no necrotic tissue in the wound. In the second stage, the exposed bone was covered with artificial dermis, the steel plate hole or the periphery and the basal space were filled, and the exposed steel plate was completely embedded, and then the fascia sleeve flap was transplanted to cover the wound. The sural neurovascular flap was performed in 9 cases and the lateral superior malleolar artery perforator flap in 2 case. Results: The flap survived well in all 11 cases. During the follow-up of 6 months to the removal of the plate, there was no case of rupture, exposure and sinus formation.Conclusions: Artificial dermal covering combined with fascial sleeve flap transplantation can effectively avoid wound dehiscence or sinus formation caused by foreign body retention, infection and flap contracture,It has good effect in repairing chronic wounds with bone plate exposure after severe trauma of lower limbs.

Ecthyma Gangrenosum in a Pediatric Patient and Review of the Literature

Erythema Gangrenosum (EG), is an infective lesion of skin, and mucous membranes typically occurring in patients with chronic disease or immunocompromised patients. İt is a very rarely seen vasculitis with a potentially progressive and fatal course. An 8-year-old pediatric patient was referred to an external medical center with complaints of fever, abdominal pain, and skin rashes starting 2 days previously, and upon deterioration of his general health state, he was admitted into a surgical intensive care unit with manifestations of septic shock. In the treatment, all necrotic tissues including skin, and subcutaneous tissue were excised down to a healthy tissue after excision of all necrotic tissue. Vacuum Assisted Closure (VAC) was applied on this area for drainage. Herein, we aimed to indicate that definitive treatment of a neuropathic child with EG is surgery excision, and also emphasize critical importance of re-excision of newly developed necrotic tissue at an early stage, and close monetarization of the patient

Maggot debridement therapy to treat hard-to-heal diabetic foot ulcers: a single-centre study

Objective: Maggot debridement therapy (MDT) has seen a resurgence in recent years in the treatment of hard-to-heal wounds, as a result of rising antibiotic resistance. The sterilised larvae of Lucilia cuprina have been used in MDT in Malaysia since 2003, with encouraging results for the treatment of hard-to-heal diabetic wounds. We report a case series of 30 patients selected from our clinic by convenient sampling with diabetic lower limb ulcers treated with MDT. The average age of patients receiving MDT was >50 years. Of the 30 patients in the study, nine were female and 21 were male. All patients had underlying diabetes, two patients had leg ulcers and 28 patients had diabetic foot ulcers. Sterilised Lucilia cuprina larvae were applied via a standard method of 10 maggots per square centimetre and dressed with sterile gauze. The study endpoint was defined as ≤5% coverage with slough or necrotic tissue following three successive applications of MDT. In this study, maximum debridement of wounds was achieved in 96.6% (29 patients) of our patients, with ≤5% coverage with slough or necrotic tissue, in addition to a reduction in wound-related pain, as assessed by a visual analogue scale. No adverse events were reported. The findings of this study support the use of MDT as a safe, efficacious, and cost-effective method of managing diabetic wounds.

271 Treatment of thrombophlebitic necrotic lesions in a patient with syncardia—a case report

Aims The 58 years old male patient with an important dilated cardiomyopathy, carrier of ICD, numerous malignant arrhythmias (VT) and without the possibility of a timely heart transplant, underwent emergency surgery by implanting a total artificial heart syncardia. Necrotic tissue was already present on the forearm and in the antecubital region before the surgery; it was caused by extravasation and thrombophlebitis due to continuous intravenous therapies and the lesions were deep down to tendons and bones after a surgical toilet. Years of unstable haemodynamics caused by dilated cardiomyopathy and low cardiac output led to poor peripheral vascularization giving priority to noble structures. Restoration of the tissue using advanced dressings without the use of skin grafts avoiding bacterial infections in a fragile patient. Methods and results A Pubmed search for advanced dressings was performed and a Webinar on the Wound Hygiene technique was attended. In the first instance, a polyurethane foam dressing was used and the wound on the forearm showed major improvements, subsequently with the synergistic help of the ‘Wound Hygiene’ technique and dressings based on connectivine, the tissue healed. The wound located in the antecubital region had continuous biofilm formation and a VacTherapy was planned for this. After 7 days, the conditions worsened and for this reason it was decided to use the Aqua Cell Ag +. This dressing with the silver helps in the formation of granulation tissue and it also prevents infections ‘trapping’ bacteria inside it. Conclusions The use of dressings with the Wound Hygiene technique led to the formation of new tissue without the need to perform a skin graft in a patient with a total artificial heart and without bacterial infections.

Asymptomatic COVID-19 as a Risk Factor of Diabetic Ketoacidosis and Mucormycosis: A Case Report and Review of the Literature

Mucormycosis is a lethal and life-threatening fungal infection. Several cases describing the association of COVID-19 and mucormycosis have been reported. In this article, we report a 58-year-old female with a history of diabetes mellitus type 2 who presented by diabetic ketoacidosis, rhino-orbital mucormycosis, and COVID-19. The patient was treated with liposomal amphotericin B and debridement of necrotic tissue of the rhino-orbital area and paranasal sinuses. Unfortunately, she passed away a few days after orbital surgery. We also conducted a review of the literature and reported 3 other similar cases that suffered from mucormycosis in association with COVID-19 and diabetic ketoacidosis and discussed the importance of this association.

Application of Artificial Dermal Graft Combined with Fascia Sleeve Flap in the Treatment of Chronic Bone and Steel Plate Exposed Wounds of Lower Extremities

Background:Bone tendon or graft exposure such as steel plate is common after severe trauma of lower extremity.The traditional repair method is to use a variety of skin flaps to cover the exposure, but the wound can not heal after operation, or the wound dehiscence, ulcer, sinus, etc. occur again after short healing, and the bone plate is exposed again.The reason for this result is that the space around the bone plate is not well closed when the flap is covered，dead space is formed, blood and exudate accumulate, hematoma forms or infection occurs, and finally the wound breaks.Also due to swelling and contracture after flap operation,the tension of the suture between the flap and the receiving area is too large and becomes thin and cracked, forming an exposed state.In order to solve the above problems, we have carried out the research on "Application of artificial gradient combined with fascia sleep flap in the treatment of chronic bone and steel plate exposed woods of lower extremes".Methods:In this paper, 11 cases of chronic wounds with bone exposure and skin necrosis after steel plate implantation were selected. First stage is the wound bed preparation including primary wound expansion,removal of necrotic tissue and incision of sinus wall, removal of deep necrotic bone and fibrotic scarred skin on the outer wall of steel plate to normal tissue on the outer edge of the wound, removal of precipitated peptone and purulent fur in the hole, periphery and bone space of the steel plate, and removal of tendon tissue with basal necrosis and disintegration of the wound. After vacuum sealing drainage (VSD) 1~2 weeks, the peritraumatic basal granulation tissue grew well and there was no necrotic tissue in the wound. In the second stage, the exposed bone was covered with artificial dermis, the steel plate hole or the periphery and the basal space were filled, and the exposed steel plate was completely embedded, and then the fascia sleeve flap was transplanted to cover the wound. The sural neurovascular flap was performed in 6 cases and the lateral superior malleolar artery perforator flap in 1 case. Results:The flap survived well in all 11 cases. During the follow-up of 6 months to the removal of the plate, there was no case of rupture, exposure and sinus formation.Conclusions:Artificial dermal covering combined with fascial sleeve flap transplantation can effectively avoid wound dehiscence or sinus formation caused by foreign body retention, infection and flap contracture,It has good effect in repairing chronic wounds with bone plate exposure after severe trauma of lower limbs,.

First Report of Cladosporium tenuissimum Causing Leaf Spots on Carnation in China

Carnation (Dianthus caryophyllus L., Caryophyllaceae) is a popular and important market flower in China (Kayamori et al., 2012). Leaf spots of Cladosporium tenuissimum Cooke were first observed in early October 2016 on carnation grown on the academy of agricultural sciences as well as in parks in Xi’an city (108°54'18.6696"E, 34°15'12.9"N), with nearly 80% of leaves on individual plants infected. Carnation in five nearby parks were surveyed with 60 to 100% disease incidence. Initially, the symptoms appeared as small dark elliptical necrotic lesions surrounded by a dark brown halo. Some leaf spots in severe cases covered the entire leaf surface. Necrotic tissue was treated with lactophenol and used for microscopic examination. Sporulation was seen on the necrotic tissue. To identify the pathogen, eighteen leaf pieces (3-5 mm) with both infected and healthy portions were taken at the edge of lesions and surface-disinfected by placing them in 75% ethanol for 5 s, then transferred to a 0.1% aqueous mercuric chloride solution for 30 s and rinsed with sterilized water three times. Six sections were placed on each potato dextrose agar (PDA) at 25°C in the dark. Ten pure fungal cultures were obtained from single spores. Colonies on PDA were greyish to dark brown and showed a velvety texture. Subcylindrical to subclavate conidiophores were solitary or in loose groups, on leaves and stems erumpent through the cuticle or emerging through stomata, and measured 49-513 × 3-7 µm (n=50). Ramoconidia were subcylindrical, 15-31 × 4-5 µm, aseptate, basal hilum 2-3.5 µm diam. Morphological characteristics of the pathogen were similar to Cladosporium tenuissimum Cooke (Bensch 2010). For molecular identification, pure cultures of ten single-spore isolates were extracted from mycelium using the Plant Genomic DNA Kit (TIANGEN, China). Three different genomic DNA regions-ribosomal DNA internal transcribed spacer (ITS) region, partial translation elongation factor-1 alpha (EF), and actin (ACT) were amplified using the primers ITS1/ITS4 (White et al. 1990), ACT-512F/ACT-783R (Carbone and Kohn 1999), and EF1-728F/EF1-986R (Carbone and Kohn 1999), respectively. Phylogenetic analysis of multiple genes was conducted with the neighbor-joining method using MEGA 7 (Bakhshi et al. 2018). The sequences of our isolate (CTK) and seven published sequences of C. tenuissimum were clustered into one clade with a 100% bootstrap supporting level. The sequences of CTK have been deposited in GenBank with accessions MZ351731 for ITS, MZ351730 for ACT, MZ351732 for TEF1. Isolate pathogenicity was tested on surface disinfested leaves of two-month-old carnation plants by spraying a 2 × 106 conidial per ml at 25°C incubation temperature. Another set of plants was sprayed with sterile water as non-inoculated controls. Three replicates of every isolate were conducted, and each replicate included 5 carnation plants. After twelve days, only the inoculated leaves showed leaf blight resembling those observed on naturally infected carnation leaves. The pathogen was consistently reisolated from the infected leaves with the aim of completing Koch’s postulates. To our knowledge, this is the first report of C. tenuissimum causing carnation leaf spots in China and worldwide. Thus, the identification of C. tenuissimum for this disease is important for the advancement of effective prevention and control approaches as future prospects.