Open thoracic window: a useful alternative for retained infected pleural collections in critically ill trauma patients.

Historically, tube thoracostomy, image-guided drainage, or an open thoracotomy has been indicated as the standard procedure for the management of patients with retained infected pleural collections (RIPC). These infections can be a debilitating and potentially lethal complication in already critically ill trauma patients. The purpose of this review was to evaluate the usefulness of an open thoracic window (OTW) as definitive therapy for the management of RIPC refractory to conventional therapies. The medical records of patients who underwent an OTW for RIPC were reviewed for the following: demographic data, primary diagnosis, clinical findings that explained the failure of the conventional management, bacteriology of the retained collection, and final outcome. Over a 3-year period, eight critically ill trauma patients who had sustained multiple system trauma and developed a RIPC were identified (six males and two females; average age, 47 years). Of the eight patients identified, six collections were in the right and two in the left pleural cavity. Staphylococcus aureus and Acinetobacter were the two most common bacterial isolates from these collections. All patients had undergone multiple and unsuccessful drainage attempts by thoracostomy tubes. Additionally, two of the patients also underwent image-guided drainage procedures, which proved to be unsuccessful. After creation of the OTW, all patients had complete resolution of the RIPC, and all were discharged alive from the hospital. During outpatient follow up, the OTW was found to have completely healed and required no further surgical intervention. The creation of long-term pleural drainage, with an OTW, facilitates and expedites the resolution of persistent infected pleural collections by providing more efficient surgical drainage and mechanical débridement. Our experience also shows this uncommon operation to be an effective alternative when conventional measures have failed.

Wound healing in patients with cancer.

OBJECTIVE: The treatment of patients with cancer has advanced into a complex, multimodal approach incorporating surgery, radiation, and chemotherapy. Managing wounds in this population is complicated by tumor biology, the patient's disease state, and additional comorbidities, some of which may be iatrogenic. Radiation therapy, frequently employed for local-regional control of disease following surgical resection, has quantifiable negative healing effects due to local tissue fibrosis and vascular effects. Chemotherapeutic agents, either administered alone or as combination therapy with surgery and radiation, may have detrimental effects on the rapidly dividing tissues of healing wounds. Overall nutritional status, often diminished in patients with cancer, is an important aspect to the ability of patients to heal after surgical procedures and/or treatment regimens. METHODS: An extensive literature search was performed to gather pertinent information on the topic of wound healing in patients with cancer. The effects that surgical procedures, radiation therapy, chemotherapy, and nutritional deficits play in wound healing in these patients were reviewed and collated. RESULTS: The current knowledge and treatment of these aspects of wound healing in cancer patients are discussed, and observations and recommendations for optimal wound healing results are considered. CONCLUSION: Although wound healing may proceed in a relatively unimpeded manner for many patients with cancer, there is a potential for wound failure due to the nature and effects of the oncologic disease process and its treatments.

Dermatofibrosarcoma protuberans of the forehead and scalp with involvement of the outer calvarial plate: multistaged repair with the use of skin expanders.

BACKGROUND AND OBJECTIVE: Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive and infiltrative tumor that requires Mohs' micrographic surgery or wide excision to treat. Adequate excision often leaves a cosmetic disfiguring defect, particularly if the tumor is located on the head and neck. Complex defects of the face present special problems, such as distortion, ectropion, and retraction of normal tissues. PATIENT AND METHODS: We present a case of an infiltrating DFSP of the forehead and scalp in a young woman. The tumor was removed, and the defect was reconstructed with multistaged repair, which included bone coverage, local and regional flaps, and the use of expanders. RESULTS: A multistaged repair was performed with good clinical outcome and satisfactory cosmetic results. CONCLUSION: Multistaged repair of the face is a viable alternative surgical approach to preserve facial contours and minimize distortion in the treatment of DFSP. This case illustrates the degree of complexity that the treatment of DFSP may involve.