Annali italiani di chirurgia
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Review Case Reports
[Fournier's gangrene: case report and review of recent literature].
The authors report their experience in diagnosis and treatment of one case of Fournier's gangrene; recent international literature review. ⋯ Fournier's gangrene is an uncommon and aggressive synergistic fasciitis of the perineum and genital organs, which may bring the patient to death; it is a true surgical emergency. The disease can no longer be considered to be idiopathic; in most cases a urologic, colorectal or cutaneous source can be identified. Despite antibiotics and aggressive debridement, the mortality rate remains high, particularly in the elderly, in patients with renal failure, and in patients with extensive disease. The presentation is highly variable, necessitating a high index of suspicion. High risk patients include diabetics, alcoholics and debilitated and immunosuppressed individuals. As the AIDS population increases, the incidence of Fournier's gangrene may increase as well. In questionable cases, imaging modalities should be performed to allow early diagnosis and to reduce misses diagnosis. Broad spectrum antibiotics (while waiting for the results of culture and antibiogram effectuated on tissue specimens obtained during necrosectomy) and aggressive debridement remain the hallmarks of treatment. Hyperbaric oxygen therapy and improved local wound care may decrease the extent of tissue destruction. The surgical operation has to be performed in emergency to avoid a rapid spread of tissue necrosis and a possible development towards septic shock. Reconstructive techniques afford better cosmetic results. With early recognition, prompt treatment, improved wound care and reconstructive efforts, the mortality rates and cosmetic results should continue to improve.
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Surgical Site Infection (SSI) continues to be a major source of morbidity following operative procedures. The aging of the population means that not only will the number of operations likely increase, but the National Nosocomial Infections Surveillance (NNIS) Risk Index, which standardizes the risk of SSI for an aging population, will be greater. The NNIS report for 1986-1996 described an SSI rate of 2.6% for all operations at the reporting hospitals. ⋯ The SSI are the biological summation of several factors: the inoculum of bacteria introduced into the wound during the procedure, the unique virulence of contaminants, the microenvironment of each wound, and the integrity of the patients host defense mechanisms. Risk factors were studied in single and multivariate analyses. Although an SSI rate of zero may not be achievable, continued progress in understanding the biology of infection at the surgical site and consistent applications of proven methods of prevention will allow us to further reduce the frequency, cost, and morbidity associated with SSI.
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Case Reports
Large extrapleural hematoma in an anticoagulated patient after a thoracic blunt trauma.
We report the 7th case of a traumatic extrapleural hematoma that developed in an anticoagulated patient with a thoracic blunt trauma and rib fractures, and required an emergency surgical treatment. Extrapleural hematoma is a rare and life-threatening condition characterized by a collection of blood between the pleura parietalis and the endothoracic fascia. Related symptoms and chest x-ray findings are not characteristic and may present several hours after the injury, leading to delayed diagnosis and treatment. Etiological, surgical and prognostic implications of this finding are briefly discussed.
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Case Reports Comparative Study
[Recurrent parastomal hernia and middle incisional hernia: surgical treatment through midline incision with wide prosthetic mesh].
Parastomal hernia is a frequent complication of stoma surgery. The results of parastomal hernia repair however are poor, showing an high incidence of postoperative recurrences. In the last years, hernia repair with prosthetic mesh has given better postoperative results. ⋯ According literature and the authors' results, the parastomal hernia might be considered an incisional hernia and, therefore, a sing of diffuse abdominal wall disease. The Rives' surgical technique might be the gold standard for treatment of parastomal hernia, even if not associated to incisional hernia. The more complexity of Rives' technique compared to local fascial mesh repair is compensated by the result of total abdominal wall reinforcement.
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Infectious mononucleosis is an acute, viral, illness associated with a high incidence of splenomegaly. Spontaneous splenic rupture is a rare but life-threatening complication of infectious mononucleosis. The authors report the case of a 19-year-old patient with an infectious mononucleosis causing a spontaneous splenic rupture. ⋯ In this patient ultrasound and Rutkow's criteria may aid in establishing the diagnosis. In patients with infectious mononucleosis suspected of having rupture of the spleen, a rapid but thorough assessment and prompt implementation of appropriate management should minimize the associated morbidity and mortality. On the basis of review of the medical literature and of our own experience, we advocate emergent splenectomy for spontaneous splenic rupture in patients with infectious mononucleosis.