Jaco Suijker

Background: Necrotizing soft-tissue infections (NSTIs) present a surgical emergency of increasing incidence, which is often misdiagnosed and associated with substantial mortality and morbidity. A retrospective multicenter (11 hospitals) cohort study was initiated to identify the early predictors of misdiagnosis, mortality, and morbidity (skin defect size and amputation). Methods: Patients of all ages who presented with symptoms and were admitted for acute treatment of NSTIs between January 2013 and December 2017 were included. Generalized estimating equation analysis was used to identify early predictors (available before or during the first debridement surgery), with a significance level of P < 0.05. Results: The median age of the cohort (N = 216) was 59.5 (interquartile range = 23.6) years, of which 138 patients (63.9%) were male. Necrotizing soft-tissue infections most frequently originated in the legs (31.0%) and anogenital area (30.5%). More than half of the patients (n = 114, 54.3%) were initially misdiagnosed. Thirty-day mortality was 22.9%. Amputation of an extremity was performed in 26 patients (12.5%). Misdiagnosis was more likely in patients with a higher Charlson Comorbidity Index (β = 0.20, P = 0.001), and less likely when symptoms started in the anogenital area (β = −1.20, P = 0.003). Besides the established risk factors for mortality (septic shock and age), misdiagnosis was identified as an independent predictor of 30-day mortality (β = 1.03, P = 0.01). The strongest predictors of the final skin defect size were septic shock (β = 2.88, P < 0.001) and a skin-sparing approach to debridement (β = −1.79, P = 0.002). Conclusion: Recognition of the disease is essential for the survival of patients affected by NSTI, as is adequate treatment of septic shock. The application of a skin-sparing approach to surgical debridement may decrease morbidity.

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to a burn center. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three hospitals with a burn center for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centers, usually after survival of the initial septic phase. Those referred from other centers, compared to those primarily admitted to the study hospitals, were more likely to have group A streptococcal involvement (62% vs 35%, p = .02), larger wounds (median 7% vs 2% total body surface area, p < .001), and a longer length of stay (median 49 vs 22 days, p < .001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p < .001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centers’ function as referral centers for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centers provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.

Purpose: Necrotizing soft tissue infections (NSTI) are potentially lethal infections marked by local tissue destruction and systemic sepsis, which require aggressive treatment. Survivors often face a long recovery trajectory. This study was initiated to increase understanding of the long-term impact of NSTI on health related quality of life (HRQoL), and how care may be improved. Methods: Thematic analysis was applied to qualitative data from 25 NSTI-survivors obtained through two focus groups (n = 14) and semi-structured interviews (n = 11). Results: The median age of the participants was 49 years, 14 were female. The median time since diagnosis was 5 years. Initial misdiagnosis was common, causing delay to treatment. Survivors experienced long-term physical consequences (scarring, cognitive impairment, fatigue, sleeping problems, recurrent infections), psychological consequences (traumatic stress symptoms, fear of relapse, adjusting to an altered appearance, sexual issues) and social and relational consequences (changes in social contacts, a lack of understanding). The disease also had a major psychological impact on family members, as well as major financial impact in some. There was a strong desire to reflect on ‘mistakes’ in case of initial misdiagnosis. To improve care, patient and family centered care, smooth transitions after discharge, and the availability of understandable information were deemed important. Conclusion: This study reveals that NSTI have a large impact on physical and psychosocial wellbeing of survivors and their relatives. Except for a few differences (misdiagnosis, fear for re-infection and actual re-infection), the patient experience of patients with NSTI is largely similar to those of burn survivors. Thus, questionnaires to assess HRQoL in burn survivors may be used in future NSTI studies.

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.

Background: Excision of the pectoral fascia (PF) is routinely performed in oncological mastectomies. Preservation of the PF may, however, decrease postoperative complication rates for bleeding, infections, and seroma. It may also improve reconstructive outcomes by better prosthesis coverage, thereby reducing implant extrusion rates and improving cosmetic outcomes. Methods: A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis principles was performed. Studies describing PF preservation were searched in 3 databases. All studies including more than 10 patients were included. The main outcomes were oncological safety (local recurrence, regional and distant metastases, and mortality rates), complication rates (bleeding, infections, seroma), loss of the prosthesis after reconstructive surgery, and cosmetic outcomes following reconstruction. Results: Five studies were included. Three reported on 2 different randomized controlled trials (n = 73, and n = 244), and 2 studies were retrospective case series (n = 203 and n = 256). PF preservation did not affect oncological outcomes in terms of local recurrences, regional and distant metastases, or mortality rates. One study described a significantly lower incidence of seroma in the PF preservation group. No differences were found for bleeding complications and infections. No objective data were provided for reconstructive complications or cosmetic outcomes. Conclusions: The literature on PF preservation is scarce. Based on the current evidence, PF preservation seems oncologically safe while potentially reducing postoperative complication rates. It is expected that reconstructive outcomes will benefit from PF preservation, but these studies lack evidence on this topic. Future studies should provide insight into all aspects of PF preservation.