Approaches to Surgical Debridement in Necrotizing Soft Tissue Infections: Outcomes of an Animated, Interactive Survey

Abstract

Background Necrotizing soft tissue infections (NSTI) affect long-term quality of life in survivors. Different approaches to debridement may influence quality of life. The aim of this study was to assess the current practice of the debridement of NSTI in the Netherlands. Methods An animated, interactive online survey was distributed among general surgeons and plastic surgeons in the Netherlands. Two NSTI-cases were presented, followed by questions regarding the preferred surgical approach. Case one described a woman with a swollen, red leg, with signs of sepsis and without visible necrosis. Case two described an immunocompromised man with septic shock syndrome and extensive necrosis. Results In total 232 responses were included (143 general surgeons, 89 plastic surgeons). In case one, 32% chose to preserve all skin, while 17% chose to resect all skin above the affected fascia, including normal-looking skin. In case two, all participants resected necrotic skin, and most (88%) also blue discolored skin. While 32% did not resect more than blue discolored and necrotic skin, 35% also resected red-colored skin, and 21% all skin overlying the affected fascia, including normal colored skin. Respondents working in a hospital with a burn center tended to preserve more skin, whereas plastic surgeons chose more often for skin resection compared to general surgeons. Conclusions By using a novel approach to a survey, the authors demonstrate the existence of extensive practice variety regarding the approach to debridement of NSTI among Dutch general and plastic surgeons. Consensus is needed, followed by targeted education of surgeons.

Contemporary strategies for diagnosis and management of necrotizing soft tissue infections: Α review

“…Subtle differences may distinguish one entity from another, but the clinical approach to diagnosis and treatment is similar. The disease includes also "subtypes", based on the tissue layers affected (NF, necrotizing myositis, necrotizing cellulitis), and on the anatomic region (Fournier's gangrene, Ludwig's angina) [7,18,19].…”

“…NSTIs remain associated with a heavy mortality and significant morbidity despite the improvement in clinical care, usage of broad spectrum and targeted antibiotics, and the aggressive surgical debridement [12,14,19,22,28]. Average mortality rates remained high (around 20%) over the past 20 years [3,7,[11][12][13][14][15]19]. However, the mortality appears recently to be declining, which should be attributed to increasing awareness, improved recognition and earlier institution of more effective therapies [11,12,14,28].…”

“…Necrotizing soft tissue infection (NSTI) includes a heterogeneous group of potentially lethal infections of the soft tissue compartment (dermis, subcutaneous fat, superficial and deep fascia, and/or muscle), characterized by rapid spread though fascial planes, progressive tissue destruction due to toxins released from virulent bacteria, and causing systemic toxicity [1][2][3][4][5][6][7]. Initially, local signs can be minimal and become more prominent only as the disease progresses [3].…”

“…Necrotizing fasciitis (NF), the worst and most fulminant form of the NSTIs, has a reported incidence of 0.4 cases per 100000 adults every year [1]. Unfortunately, a stagnant and high and unacceptable average mortality rate of around 20% has been recorded worldwide over the past 20 years [3,7,[11][12][13][14][15]. The interval between the onset of symptoms and initiation of treatment has been recognized as the crucial determinant for outcome [4,6].…”

“…The basic principles of improved awareness for timely diagnosis, the synchronous intensive resuscitation/supporting, the prompt administration of broad-spectrum antimicrobial therapy, and the aggressive surgical debridement (necrectomy), which basically is a damage control surgery (DCS), as well as the required secondary surgical procedures, remain unchanged for the last decades, and they are still the pillars of therapy, aiming at reducing morbidity and mortality [2,4,6]. However, better compliance of physicians with the existing guidelines as well as innovative therapeutics are still needed to combat this persistently lethal disease [4,7].…”