1/3. Acute acalculous cholecystitis after breast reconstruction.Postoperative acute acalculous cholecystitis (AAC) is a potentially lethal complication that presents with a high morbidity and mortality. Some elective plastic surgery patients are at risk to developing this complication, although it has not been previously reported in the plastic surgery population. patients at risk are those affected of ischaemic diseases, artheroschlerotic factors, smoking, diabetes, and patients requiring postoperative intensive care monitoring. The clinical presentation is non-specific and it is usually masked by postoperative pain and by the signs and symptoms of the primary disease. Significant delays in diagnosis result in a high incidence of gangrene, perforation, abscess, and death. Although difficult to prevent, a good preoperative planning, with correction of all physiologic abnormalities prior to surgery may help in minimising the incidence of AAC. Cessation of smoking is essential, and careful monitoring of patients during anaesthesia is crucial to avoid low cardiac output and ischaemic insults to the enteric circulation.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |
2/3. diabetes mellitus and Fournier's gangrene.A case is described in which Fournier's gangrene was the presenting feature of diabetes mellitus and in which extensive subcutaneous emphysema prevented the use of spinal anaesthesia for debridement. In the literature four cases have been reported in which Fournier's gangrene was the presenting feature in patients with diabetic ketoacidosis. Diabetes may predispose to a form of Fournier's gangrene in which subcutaneous gas formation is marked, though subcutaneous emphysema to the degree described in this case has not previously been reported in this condition. diabetes mellitus and subcutaneous emphysema must be sought in patients with Fournier's gangrene as both may have a profound influence on management.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |
3/3. The practical management of Fournier's gangrene.Effective early treatment of this serious condition is necessary to prevent death. Urgent exploration by the most experienced surgeon available should include wide excision of all necrotic or dubious tissue, and adequate drainage of deep fascial planes. Deep and apparently healthy tissues must be exposed and the surgeon must be prepared to proceed to laparotomy, and even diverting colostomy and/or suprapubic cystotomy when necessary. Cross matched blood must be available, and we have found hydrogen peroxide irrigation useful. Pus, tissues, and blood samples for bacteriological culture and sensitivity should always be sent, but broad spectrum antibiotics should be started without delay to prevent systemic complications. In addition to the urgent initial surgery, repeated daily examination of all wounds is necessary, usually under general anaesthesia to allow full inspection, further debridement, irrigation and change of dressings, until the infective process is halted. This is a serious condition with a high mortality which we believe may be reduced by early diagnosis and appropriate aggressive surgery.- - - - - - - - - - ranking = 1keywords = anaesthesia (Clic here for more details about this article) |