Feridas em pacientes diabéticos

No Brasil, a prevalência do diabetes na população brasileira acima de 40 anos de idade é de 10%, com estimativa de mais de 3,6 milhões de usuários do sistema público. Entre as complicações sérias e onerosas que afetam os pacientes diabéticos, aquelas que ocorrem nos membros inferiores (MMII) representam a maior parte delas (40 a 70%). A microangiopatia atinge os pequenos vasos responsáveis pela irrigação nervosa, os chamados vasa nervorum e é. a desencadeadora da neuropatia periférica, retinopatia e nefropatia diabética. O processo neuropático, pelo fato de favorecer deformidades ósseas no pé, acarreta aumento das pressões plantares. A associação da insensibilidade do pé e do aumento destas pressões resulta em ulceração. Desde 1988, com o desenvolvimento do Pressure Specified Sensory Device™ - PSSD, um só equipamento é capaz de quantificar o limiar de pressão aplicada sobre a pele, necessário para que o paciente sinta o estímulo de um ponto estático e um ponto dinâmico assim como os testes com dois pontos. Consegue-se melhor avaliação do déficit sensitivo nos pés e melhor planejamento de medidas terapêuticas. O tratamento da ferida diabética envolve o controle da isquemia, se necessário e de desbridamento cirúrgico. O sistema a vácuo auxilia na redução do edema, na melhora do aporte sanguíneo ao leito e na formação do tecido de granulação, acelerando o preparo do leito e tornando mais precoce a indicação do tratamento cirúrgico definitivo, através em geral com uso de enxertos de peleDiabetes, in Brasil, affects 10% of the population over 40 years of age Among the serious complications, those on the lower extremities are the majority (40 to 70%). Microangiopathy affects the small vessels the blood supply of nerves, the vasa nervorum and causes the peripheral neuropathy, retinopathy and nephropathy. Neuropathic process enhances osseous deformities on the the foot, which increase plantar pressures in an insensitive foot, ending in ulcerations. Since 1988 the development of the Pressure Specified Sensory Device™ - PSSD turn out to be a single device able to quantify thresholds of pressure, necessary for the patient to feel one or two points tested, statically and in movement. We can now better access the sensitive deficit on the diabetic patients and plan appropriate prevention measures. Treatment of the diabetic wound involves ischemia control, if necessary and surgical debridement in order to remove necrotic tissues. The new developed vacuum system helps the reduction of edema, enhance blood perfusion to the wound and granulation tissue growth providing faster bed preparation and earlier surgical repair usually with skin graft

General treatment and wound management in hereditary epidermolysis bullosa: indication and experience using silver hydrofiber dressing

INTRODUCTION: Hereditary epidermolysis bullosa (EB) is a rare disorder characterized by cutaneomucous fragility, with formation of blisters during minimal trauma. Treatment consists of clinical and nutritional support and management of pain and skin lesions. Silver hydrofiber (Aquacel Ag®) is a type of carboxymethylcellulose fiber dressing with silver that can be used in selected cases of EB. OBJECTIVE: To review the literature on the general treatment and management of cutaneous lesions in congenital EB and evaluate the indication and experience of using silver hydrofiber dressing. METHODS: The review included original articles and systematic reviews published between 2009 and 2014. We also selected two patients with congenital EB treated at the Plastic Surgery Division of Hospital das Clínicas of the Faculty of Medicine of Ribeirão Preto at the University of São Paulo. RESULTS: There is a shortage of scientific evidence related to the treatment of skin lesions in congenital EB, with most recommendations being based on expert opinions. Hydrofiber is indicated in most consensuses for wounds with some exudation and has been shown to be more absorbent than alginate. In our experience, there was apparent improved control of pain, bleeding, and hypothermia with the use of hydrofiber, which has the advantage of not requiring daily changes and can remain on the wound for up to two weeks. CONCLUSIONS: The general and lesion treatments in EB are challenging. Hydrofiber with silver is a treatment option for wounds in hereditary EB, without the need for daily dressing changes

Covid-19 and Plastic Surgery: a case report of complex wound treatment

Introduction: The Covid-19 pandemic significantly changed the routine and work of medical specialties. We report the case of a patient treated by Plastic Surgery who contracted the Sars-CoV-2 virus. Case report: A 66-year-old man with a complex wound on his ankle was treated with surgical debridement and negative pressure therapy, and subsequently underwent cutaneous wound coverage with a partial skin graft. In the immediate postoperative period, a dry cough started. That same day a positive examination of the new coronavirus was confirmed in another patient who was in the same room. Therefore, we requested PCR testing, which was also positive for the presence of Sars-CoV-2. The patient evolved well, being discharged on the 5th postoperative day, after the removal of Brown's dressing, and returning after the recommended isolation period (14 days). Discussion: The management of patients who need surgical procedures during a viral pandemic must consider the adoption of preventive measures that reduce the possibility of transmission of the virus. As an example, we mention the reduction in hospital stay, the use of therapies that speed up the therapeutic process, the isolation of the patient on confirmed cases, and the use of personal protective equipment. Conclusion: Despite the infection of this patient by Sars-CoV-2, we emphasize that the Plastic Surgery team must act early during the treatment process. Such actions reduce the possibility of spreading the new coronavirus to other patients and the healthcare team

Reconstructive surgery in the context of Covid-19: complications in the treatment of an inguinal complex wound

Introduction: At the end of 2019, the world saw the emergence of a new respiratory syndrome called Covid-19, caused by a new type of coronavirus, Sars-CoV-2. Classified as a pandemic, it has caused impacts of considerable magnitude. Case Report: A 57-year-old man developed a right inguinal wound after surgical exploration for infection of a prosthesis used in a femur-popliteal bypass. The Plastic Surgery team opted for treatment with surgical debridement associated with negative pressure therapy to prepare the wound bed. In the postoperative period, he had severe acute respiratory syndrome and suspected Covid-19, requiring intubation and intensive care. A sample for RT-PCR of Sars-CoV-2 was collected, and the medications chloroquine and azithromycin were associated with the treatment. Despite intensive treatment, the patient died. The result of the RT-PCR test for the new coronavirus was positive, being released two days after death. Discussion: The analysis of this report allows us to suppose that the patient probably contracted the new coronavirus at the hospital, as he was hospitalized for 35 days before the evolution of respiratory failure. This fact, together with its unfavorable evolution, corroborates the orientation of minimizing hospitalizations and surgical procedures as much as possible to promote more safety for the patient and the health team. Conclusion: Inpatients are susceptible to infection with the new coronavirus and can set up a group at higher risk since many of them are already weakened

Evaluation of cutaneous sensibility of the internal pudendal artery perforator flap in perineal reconstructions

INTRODUÇÃO: O tratamento das neoplasias malignas anorretais exige ressecções que podem levar ao surgimento de defeitos perineais extensos. Esses defeitos necessitam de reconstrução que deve ser realizada, preferencialmente, com retalhos. Dentre eles, destacamos o retalho perfurante da artéria pudenda interna, localizado no sulco glúteo, vascularizado por vasos perfurantes cutâneos da artéria pudenda interna, e inervado por ramos do nervo pudendo e do nervo cutâneo femoral posterior. Esse retalho apresenta diversas vantagens em comparação com os outros utilizados para reconstrução perineal, e os dados relacionados à avaliação de sua sensibilidade cutânea são escassos, discrepantes e sujeitos a críticas metodológicas. OBJETIVO: Avaliar a sensibilidade cutânea do retalho perfurante da artéria pudenda interna após 12 meses da reconstrução perineal em cirurgias de amputação abdominoperineal de reto, e compará-la com a sensibilidade cutânea pré-operatória do sulco glúteo (área doadora do retalho). MÉTODOS: Estudo prospectivo com 25 pacientes submetidos à amputação abdominoperineal de reto por neoplasias malignas anorretais e reconstruídos com o retalho perfurante da artéria pudenda interna de avanço VY bilateral. As modalidades de sensibilidade tátil, dolorosa, térmica e vibratória foram analisadas em quatro áreas do sulco glúteo no pré-operatório e nas quatro áreas correspondentes do retalho 12 meses após a cirurgia. A avaliação da sensibilidade tátil foi realizada com o Pressure Specified Sensory Device(TM) (PSSD(TM)), aparelho que quantifica a pressão aplicada à pele, estática ou em movimento. As outras modalidades de sensibilidade foram analisadas com o método de escolha forçada, utilizando ponta de agulha para sensibilidade dolorosa, contato quente/frio para sensibilidade térmica e diapasão de 128 Hz para sensibilidade vibratória. RESULTADOS: Os limiares de sensibilidade tátil medidos com o PSSD(TM) no retalho perfurante da artéria pudenda interna após 12 meses da reconstrução perineal foram semelhantes aos limiares de sensibilidade tátil no sulco glúteo no pré-operatório, tanto no teste de pressão estática quanto em movimento. A comparação entre esses limiares não apresentou diferença estatisticamente significante, com valores de p superiores a 0,05 nas quatro áreas avaliadas, para ambos os testes. Todos os pacientes apresentaram sensibilidade dolorosa, térmica e vibratória nas quatro áreas testadas, tanto no sulco glúteo no pré-operatório quanto no retalho após 12 meses da cirurgia. CONCLUSÃO: Nas reconstruções perineais após amputação abdominoperineal de reto, espera-se que a sensibilidade cutânea do retalho perfurante da artéria pudenda interna seja mantidaINTRODUCTION: The treatment of anorectal malignancies requires resection that can lead to extensive perineal defects. These defects require reconstruction which should be performed, preferably, with flaps. Among them, we highlight the internal pudendal artery perforator flap, located on the gluteal fold, vascularized by cutaneous perforator vessels from the internal pudendal artery, and innervated by branches from the pudendal nerve and the posterior femoral cutaneous nerve. This flap has many advantages compared to others used for perineal reconstruction, and data related to the evaluation of its cutaneous sensibility are scarce, discrepant and subject to methodological criticisms. OBJECTIVE: To evaluate cutaneous sensibility of the internal pudendal artery perforator flap 12 months after perineal reconstruction in abdominoperineal resection of rectum, and compare it with the preoperative cutaneous sensibility of the gluteal fold (flap donor area). METHODS: A prospective study of 25 patients undergoing abdominoperineal resection of rectum for anorectal malignancies, and reconstruction with the internal pudendal artery perforator flap, in bilateral VY advancement. The modalities of tactile, pain, thermal and vibration sensibility were analyzed in four areas of the gluteal fold preoperatively and in the four corresponding areas of the flap 12 months after surgery. Tactile sensibility was assessed using the Pressure Specified Sensory Device(TM) (PSSD(TM)), a device that measures the pressure applied to the skin, static or moving. The other types of sensibility were analyzed with the forced-choice method, using a needle for pain sensibility, hot/cold contact for thermal sensibility and 128 Hz tuning-fork for vibration sensibility. RESULTS: The tactile sensibility thresholds measured with PSSD(TM) on the internal pudendal artery perforator flap 12 months after perineal reconstruction were similar to tactile sensibility thresholds of the gluteal fold preoperatively, both in static and moving pressure tests. The comparison between these thresholds showed no statistically significant difference, with p values greater than 0.05 in the four areas evaluated, for both tests. All patients presented pain, thermal and vibration sensibility in all four areas tested, on the both the gluteal fold preoperatively and the flap 12 months after surgery. CONCLUSION: In perineal reconstructions after abdominoperineal resection of rectum, it is expected that the cutaneous sensibility of the internal pudendal artery perforator flap is maintaine

Negative pressure therapy for the treatment of complex wounds

ABSTRACT The objective of this study is to evaluate the effectiveness of negative pressure therapy (NPT) in the treatment of complex wounds, with emphasis on its mechanisms of action and main therapeutic indications. We searched the Pubmed / Medline database for articles published from 1997 to 2016, and selected the most relevant ones. The mechanisms of action of NPT involveboth physical effects, such as increased perfusion, control of edema and exudate, reduction of wound dimensions and bacterial clearance, and biological ones, such as the stimulation of granulation tissue formation, microdeformations and reduction of Inflammatory response. The main indications of NPT are complex wounds, such as pressure ulcers, traumatic wounds, operative wound dehiscences, burns, necrotizing wounds, venous ulcers, diabetic wounds, skin grafts, open abdomen, prevention of complications in closed incisions and in the association with instillation of solutions in infected wounds

A causa dos divertimentos

Texto justificativo para a atribuição da Menção Especial da Crítica 2011 ao actor Miguel Guilherme pela sua interpretação em O senhor Puntilla e o seu criado Matti, de Bertolt Brecht (enc. João Lourenço / Teatro Aberto, 2010).ABSTRACT - Explanatory text for the Critic's Special Award 2011 attributed to the actor Miguel Guilherme for his interpretation in the performance O senhor Puntilla e o seu criado Matti, de Bertolt Brecht (dir. João Lourenço / Teatro Aberto, 2010)

Bronchial fistula closure with negative pressure wound therapy: a feasible and cost-effective treatment

ABSTRACT Treatment of bronchial fistula (BF) after pulmonary lobectomy is a challenge. Often, patients require long hospital stay, have recurrent empyema and pneumonia, are susceptible to sepsis, often need broad-spectrum antibiotics, as well as various surgical approaches. With the advent and growing evidence of the benefits of negative pressure therapy (NPT), its use in some patients with BF has been reported with encouraging results concerning its feasibility and cost-effectiveness. The aim of this study was to demonstrate the application of NPT as a resource for BF treatment and comparatively analyze the overall cost of treatment

Tratamento cirúrgico das feridas complexas: experiência da cirurgia plástica no Hospital das Clínicas da FMUSP

OBJETIVO: Relatar o tratamento das feridas complexas pela Cirurgia Plástica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP). MÉTODO: Em um período de 4 anos (2006 a 2009), foi realizada análise retrospectiva dos pacientes com feridas complexas atendidos pela Cirurgia Plástica no HC-FMUSP, pelas solicitações de consulta. RESULTADOS: 1.569 pacientes foram atendidos, com média de 32,7 consultas por mês. A idade média foi 45,9 anos, predominando o sexo masculino (62%). Das 1.569 consultas, 899 foram solicitadas por especialidades cirúrgicas (57%) e 670 por especialidades clínicas (43%). A distribuição por tipo de ferida foi: 533 por pressão (34%), 471 traumáticas (30%), 235 cirúrgicas complicadas (15%), 157 necrotizantes (10%), 63 venosas (4%), 62 por vasculite (4%), 31 diabéticas (2%) e 17 pós-radiação (1%). O tratamento foi operatório em 1.145 pacientes (73%) e não-operatório em 424 casos (27%). Nos pacientes operados, foram realizadas 2.263 cirurgias: 759 desbridamentos com terapia por pressão negativa (34%), 679 desbridamentos (30%), 293 enxertos de pele (13%), 213 enxertos de pele com terapia por pressão negativa (9%), 186 retalhos pediculados (8%), 80 reimplantes digitais (4%) e 53 retalhos microcirúrgicos (2%). CONCLUSÃO: A Cirurgia Plástica mostrou ser especialidade com papel fundamental no tratamento das feridas complexas, por adotar uma conduta cirúrgica mais precoce para a resolução dos casos, reduzindo o período de cura e de internação hospitalarObjective: To report the treatment of complex wounds by the division of Plastic Surgery, “Hospital das Clínicas, Faculty of Medicine, University of São Paulo (HC-FMUSP). Method: Over a period of 4 years (2006-2009), it was performed a retrospective analysis of patients with complex wounds treated by Plastic Surgery at HC-FMUSP, through requests for consultation. Results: 1,569 patients were treated, with a mean of 32.7 consultations per month. The mean age was 45.9 years, predominantly male (62%). From 1,569 consultations, 899 were requested by the surgical specialties (57%) and 670 for clinical specialties (43%). The distribution by type of wound was: 533 pressure sores (34%), 471 traumatic wounds (30%), 235 complicated surgical wounds (15%), 157 necrotizing wounds (10%), 63 venous ulcers (4%), 62 wounds by vasculitis (4%), 31 diabetic wounds (2%) and 17 post-radiation wounds (1%). There were surgical treatment in 1,145 patients (73%) and non-surgical management in 424 cases (27%). In operated patients, there were 2,263 surgeries: 759 debridements with vacuum therapy (34%), 679 debridements (30%), 293 skin grafts (13%), 213 skin grafts with vacuum therapy (9%), 186 pedicle flaps (8%), 80 digital replantation (4%) and 53 free flaps (2%). Conclusion: Plastic Surgery has an important role in the treatment of complex wounds, by adopting an earlier surgical treatment to cure definitively these cases, reducing the healing time and hospital sta