Necrotizing fasciitis surgery: Difference between revisions

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==Overview==
==Overview==
Surgery is the mainstay of treatment for necrotizing fasciitis. Immediate surgical referral remains the only method of reducing [[mortality]] and [[morbidity]].


==Surgery==
==Surgery==
Surgery is the mainstay of treatment for necrotizing fasciitis.
Surgery is the mainstay of treatment for necrotizing fasciitis.<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>
* Immediate surgical referral remains the only method of reducing mortality and morbidity in necrotizing fasciitis patients.<ref name="pmid22196774">{{cite journal| author=Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J| title=Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. | journal=World J Emerg Surg | year= 2011 | volume= 6 | issue= 1 | pages= 46 | pmid=22196774 | doi=10.1186/1749-7922-6-46 | pmc=3310784 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22196774  }} </ref><ref name="pmid16830885">{{cite journal| author=Mok MY, Wong SY, Chan TM, Tang WM, Wong WS, Lau CS| title=Necrotizing fasciitis in rheumatic diseases. | journal=Lupus | year= 2006 | volume= 15 | issue= 6 | pages= 380-3 | pmid=16830885 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16830885  }} </ref>
*Indications include:<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>
*As the patient's are cardiovascularly unstable, immediate resuscitation with intravenous fluids, colloids and inotropic agents are usually necessary.<ref name="pmid11097546">{{cite journal| author=Baxter F, McChesney J| title=Severe group A streptococcal infection and streptococcal toxic shock syndrome. | journal=Can J Anaesth | year= 2000 | volume= 47 | issue= 11 | pages= 1129-40 | pmid=11097546 | doi=10.1007/BF03027968 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11097546  }} </ref>
:*Patients displaying intense pain and skin color change such as [[edema]] and/or [[ecchymoses]]
*Effects of analgesia can be measured by documenting pain score regularly.
:*Signs of [[ischemia|skin ischemia]] with [[blister|blisters]] and bullae
*Stop the NSAID's on admission of patients.
:*[[Altered mental status]], [[hypotension]], elevated [[band cell|band forms]] in the differential [[WBC]] count and [[metabolic acidosis]].
* Immediate surgical referral remains the only method of reducing [[mortality]] and [[morbidity]] in necrotizing fasciitis patients.<ref name="pmid22196774">{{cite journal| author=Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J| title=Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. | journal=World J Emerg Surg | year= 2011 | volume= 6 | issue= 1 | pages= 46 | pmid=22196774 | doi=10.1186/1749-7922-6-46 | pmc=3310784 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22196774  }} </ref><ref name="pmid16830885">{{cite journal| author=Mok MY, Wong SY, Chan TM, Tang WM, Wong WS, Lau CS| title=Necrotizing fasciitis in rheumatic diseases. | journal=Lupus | year= 2006 | volume= 15 | issue= 6 | pages= 380-3 | pmid=16830885 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16830885  }} </ref>
*As the patient's are cardiovascularly unstable, immediate [[resuscitation]] with [[intravenous fluids]], [[colloids]] and [[inotropes|inotropic agents]] are usually necessary.<ref name="pmid11097546">{{cite journal| author=Baxter F, McChesney J| title=Severe group A streptococcal infection and streptococcal toxic shock syndrome. | journal=Can J Anaesth | year= 2000 | volume= 47 | issue= 11 | pages= 1129-40 | pmid=11097546 | doi=10.1007/BF03027968 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11097546  }} </ref>
*Effects of [[analgesia]] can be measured by documenting pain score regularly.
*Stop the [[NSAID|NSAID's]] on admission of patients.


===Procedure===
====Finger Probe Test====
*Debridement of the tissue is the main surgical procedure.<ref name="pmid22196774">{{cite journal| author=Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J| title=Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. | journal=World J Emerg Surg | year= 2011 | volume= 6 | issue= 1 | pages= 46 | pmid=22196774 | doi=10.1186/1749-7922-6-46 | pmc=3310784 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22196774  }} </ref><ref name="pmid8916882">{{cite journal| author=Elliott DC, Kufera JA, Myers RA| title=Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. | journal=Ann Surg | year= 1996 | volume= 224 | issue= 5 | pages= 672-83 | pmid=8916882 | doi= | pmc=1235444 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8916882  }} </ref>
 
*Wide resection is performed with boundaries at least as wide as the rim of cellulitis including surrounding healthy bleeding tissue.
Finger probe test is useful in the diagnosis of necrotizing fasciitis.
*Re-exploration and serial debridements, spaced 12 to 36 hours, are needed to control the infection.
 
*The extent and depth of debridement is so extensive that it may involve group of muscles which requires removal of all the muscles.
*'''Procedure'''
:*This test is carried out in the ward, emergency room, or in the theater under [[Anesthesia|local or general anesthesia]].
:*After infiltrating the area, a 2cm [[incision]] is made down to the [[fascia|deep fascia]].
:*[[Fascia]] will be swollen and grey on gross inspection.
:*Gentle probing with index finger is performed at the level of deep fascia and if the tissue dissects with the minimal resistance, then finger probe test is considered positive.
:*Signs suggesting necrotizing fasciitis include:
:**Lack of bleeding
:**Lack of normal tissue resistance on finger probe
:**Oozing of malodorous "dish water fluid"
 
===Extremities===
*[[Debridement]] of the tissue is the main surgical procedure.<ref name="pmid22196774">{{cite journal| author=Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J| title=Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. | journal=World J Emerg Surg | year= 2011 | volume= 6 | issue= 1 | pages= 46 | pmid=22196774 | doi=10.1186/1749-7922-6-46 | pmc=3310784 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22196774  }} </ref><ref name="pmid8916882">{{cite journal| author=Elliott DC, Kufera JA, Myers RA| title=Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. | journal=Ann Surg | year= 1996 | volume= 224 | issue= 5 | pages= 672-83 | pmid=8916882 | doi= | pmc=1235444 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8916882 }} </ref>
*To achieve better surgical wound healing and less [[scar|scarring]], incisions are performed parallel to [[Langer's lines]].<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960 }} </ref>
*Wide resection is performed with boundaries at least as wide as the rim of [[cellulitis]] until surrounding healthy bleeding tissue found.
*After drainage of [[pus]] and/or hemorrhagic fluid, ventricle incisions are made, keeping the wound open which allows drainage and removal of additional [[necrotic tissue]]. 
*Patients should be closely monitored after surgery and re-exploration with serial debridements, spaced 12 to 36 hours, may be needed to control the infection.
*The extent and depth of [[debridement]] is so extensive that it may involve group of muscles which requires removal of all the muscles.
 
====Amputation====
Indications for amputation include:<ref name="pmid15723996">{{cite journal| author=Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E| title=Predictors of mortality and limb loss in necrotizing soft tissue infections. | journal=Arch Surg | year= 2005 | volume= 140 | issue= 2 | pages= 151-7; discussion 158 | pmid=15723996 | doi=10.1001/archsurg.140.2.151 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15723996  }} </ref><ref name="pmid11476311">{{cite journal| author=Tang WM, Ho PL, Fung KK, Yuen KY, Leong JC| title=Necrotising fasciitis of a limb. | journal=J Bone Joint Surg Br | year= 2001 | volume= 83 | issue= 5 | pages= 709-14 | pmid=11476311 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11476311  }} </ref>
*Extensive [[soft tissue]] [[necrosis]] with involvement of the underlying muscles
*ASA (American Society of Anaesthesiologists) score III and above<ref name="pmid21712864">{{cite journal| author=Daabiss M| title=American Society of Anaesthesiologists physical status classification. | journal=Indian J Anaesth | year= 2011 | volume= 55 | issue= 2 | pages= 111-5 | pmid=21712864 | doi=10.4103/0019-5049.79879 | pmc=3106380 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21712864  }} </ref>
*[[Shock]]


===Perineal, perianal or scrotal infection===
===Perineal, perianal or scrotal infection===
*A temporary diverting colostomy should be considered to facilitate decrease the need for frequent change of dressings, protect the skin graft for reconstruction and wound hygiene.
*A temporary diverting [[colostomy]] should be considered to facilitate the decrease need for frequent change of dressings, protect the [[skin graft]] for reconstruction and [[wound hygiene]].
*After scrotal resection, the testes are treated
*After scrotal resection, the [[testes]] are treated by placing them in pockets in the medial aspects of the thighs.
 
===Abdominal wall infection===
Incision:<ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue=  | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960  }} </ref>
*Skin incision is made in the longitudinal direction along the muscle-fascial layers of the inner abdominal wall until healthy tissue is found.
Postoperative management:
*Serial dressing changes until the wound is free of ongoing or recurrent infection.
*In the case of progression of infection, aggressive surgical [[debridement]] should be repeated.
Extension of infection into the [[bowel]]:
*In cases of extension of infection into the bowel, an exploratory [[laparotomy]] is required.
*Radical surgical debridement at the site of infection and [[retroperitoneal]] site is performed followed by partial bowel excision depending on the part of the bowel involved.
*A diverting [[colostomy]] with multiple drainages's of infected abdominal fluid collections is required.
*Hartmann’s resection is the procedure of choice in patients with perforated colon with [[peritonitis]] and in elderly patients with multiple co-morbidities.
 
===Breast and axilla===
*As the axillary region is rich in [[blood]] and [[lymphatic]] supply, this enables the infection to spread rapidly to distant sites. Hence the delay in surgical debridement proves to be lethal.<ref name="pmid23131384">{{cite journal| author=Adachi K, Tsutsumi R, Yoshida Y, Watanabe T, Nakayama B, Yamamoto O| title=Necrotizing fasciitis of the breast and axillary regions. | journal=Eur J Dermatol | year= 2012 | volume= 22 | issue= 6 | pages= 817-8 | pmid=23131384 | doi=10.1684/ejd.2012.1838 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23131384  }} </ref>
*Care must be taken to avoid [[contractures]].<ref name="pmid22211460">{{cite journal| author=Yamasaki O, Nagao Y, Sugiyama N, Otsuka M, Iwatsuki K| title=Surgical management of axillary necrotizing fasciitis: a case report. | journal=J Dermatol | year= 2012 | volume= 39 | issue= 3 | pages= 309-11 | pmid=22211460 | doi=10.1111/j.1346-8138.2011.01456.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22211460  }} </ref><ref name="pmid19952603">{{cite journal| author=Netscher DT, Baumholtz MA, Bullocks J| title=Chest reconstruction: II. Regional reconstruction of chest wall wounds that do not affect respiratory function (axilla, posterolateral chest, and posterior trunk). | journal=Plast Reconstr Surg | year= 2009 | volume= 124 | issue= 6 | pages= 427e-35e | pmid=19952603 | doi=10.1097/PRS.0b013e3181bf8323 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19952603  }} </ref>


===Amputation===
===Vacuum-assisted closure device===
Amputation is considered if the infection is rapidly spreading towards the trunk despite aggressive debridement or if the infection includes the joint.<ref name="pmid15723996">{{cite journal| author=Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E| title=Predictors of mortality and limb loss in necrotizing soft tissue infections. | journal=Arch Surg | year= 2005 | volume= 140 | issue= 2 | pages= 151-7; discussion 158 | pmid=15723996 | doi=10.1001/archsurg.140.2.151 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15723996 }} </ref>
*Vacuum assisted closure device is used for faster and  effective wound closure.<ref name="pmid18470279">{{cite journal| author=Silberstein J, Grabowski J, Parsons JK| title=Use of a Vacuum-Assisted Device for Fournier's Gangrene: A New Paradigm. | journal=Rev Urol | year= 2008 | volume= 10 | issue= 1 | pages= 76-80 | pmid=18470279 | doi= | pmc=2312348 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18470279  }} </ref><ref name="pmid25593960">{{cite journal| author=Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A| title=Current concepts in the management of necrotizing fasciitis. | journal=Front Surg | year= 2014 | volume= 1 | issue= | pages= 36 | pmid=25593960 | doi=10.3389/fsurg.2014.00036 | pmc=4286984 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25593960 }} </ref>
*Helps wound healing by absorbing excess [[exudates]], reducing localized [[edema]], and finally drawing wound edges together.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Emergency mdicine]]
[[Category:Disease]]
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[[Category:Dermatology]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]
[[Category:Rheumatology]]
[[Category:Surgery]]
[[Category:Orthopedics]]

Latest revision as of 22:56, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]

Overview

Surgery is the mainstay of treatment for necrotizing fasciitis. Immediate surgical referral remains the only method of reducing mortality and morbidity.

Surgery

Surgery is the mainstay of treatment for necrotizing fasciitis.[1]

  • Indications include:[1]

Finger Probe Test

Finger probe test is useful in the diagnosis of necrotizing fasciitis.

  • Procedure
  • This test is carried out in the ward, emergency room, or in the theater under local or general anesthesia.
  • After infiltrating the area, a 2cm incision is made down to the deep fascia.
  • Fascia will be swollen and grey on gross inspection.
  • Gentle probing with index finger is performed at the level of deep fascia and if the tissue dissects with the minimal resistance, then finger probe test is considered positive.
  • Signs suggesting necrotizing fasciitis include:
    • Lack of bleeding
    • Lack of normal tissue resistance on finger probe
    • Oozing of malodorous "dish water fluid"

Extremities

  • Debridement of the tissue is the main surgical procedure.[2][5]
  • To achieve better surgical wound healing and less scarring, incisions are performed parallel to Langer's lines.[1]
  • Wide resection is performed with boundaries at least as wide as the rim of cellulitis until surrounding healthy bleeding tissue found.
  • After drainage of pus and/or hemorrhagic fluid, ventricle incisions are made, keeping the wound open which allows drainage and removal of additional necrotic tissue.
  • Patients should be closely monitored after surgery and re-exploration with serial debridements, spaced 12 to 36 hours, may be needed to control the infection.
  • The extent and depth of debridement is so extensive that it may involve group of muscles which requires removal of all the muscles.

Amputation

Indications for amputation include:[6][7]

  • Extensive soft tissue necrosis with involvement of the underlying muscles
  • ASA (American Society of Anaesthesiologists) score III and above[8]
  • Shock

Perineal, perianal or scrotal infection

  • A temporary diverting colostomy should be considered to facilitate the decrease need for frequent change of dressings, protect the skin graft for reconstruction and wound hygiene.
  • After scrotal resection, the testes are treated by placing them in pockets in the medial aspects of the thighs.

Abdominal wall infection

Incision:[1]

  • Skin incision is made in the longitudinal direction along the muscle-fascial layers of the inner abdominal wall until healthy tissue is found.

Postoperative management:

  • Serial dressing changes until the wound is free of ongoing or recurrent infection.
  • In the case of progression of infection, aggressive surgical debridement should be repeated.

Extension of infection into the bowel:

  • In cases of extension of infection into the bowel, an exploratory laparotomy is required.
  • Radical surgical debridement at the site of infection and retroperitoneal site is performed followed by partial bowel excision depending on the part of the bowel involved.
  • A diverting colostomy with multiple drainages's of infected abdominal fluid collections is required.
  • Hartmann’s resection is the procedure of choice in patients with perforated colon with peritonitis and in elderly patients with multiple co-morbidities.

Breast and axilla

  • As the axillary region is rich in blood and lymphatic supply, this enables the infection to spread rapidly to distant sites. Hence the delay in surgical debridement proves to be lethal.[9]
  • Care must be taken to avoid contractures.[10][11]

Vacuum-assisted closure device

  • Vacuum assisted closure device is used for faster and effective wound closure.[12][1]
  • Helps wound healing by absorbing excess exudates, reducing localized edema, and finally drawing wound edges together.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A (2014). "Current concepts in the management of necrotizing fasciitis". Front Surg. 1: 36. doi:10.3389/fsurg.2014.00036. PMC 4286984. PMID 25593960.
  2. ↑ 2.0 2.1 Roje Z, Roje Z, Matić D, Librenjak D, Dokuzović S, Varvodić J (2011). "Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs". World J Emerg Surg. 6 (1): 46. doi:10.1186/1749-7922-6-46. PMC 3310784. PMID 22196774.
  3. ↑ Mok MY, Wong SY, Chan TM, Tang WM, Wong WS, Lau CS (2006). "Necrotizing fasciitis in rheumatic diseases". Lupus. 15 (6): 380–3. PMID 16830885.
  4. ↑ Baxter F, McChesney J (2000). "Severe group A streptococcal infection and streptococcal toxic shock syndrome". Can J Anaesth. 47 (11): 1129–40. doi:10.1007/BF03027968. PMID 11097546.
  5. ↑ Elliott DC, Kufera JA, Myers RA (1996). "Necrotizing soft tissue infections. Risk factors for mortality and strategies for management". Ann Surg. 224 (5): 672–83. PMC 1235444. PMID 8916882.
  6. ↑ Anaya DA, McMahon K, Nathens AB, Sullivan SR, Foy H, Bulger E (2005). "Predictors of mortality and limb loss in necrotizing soft tissue infections". Arch Surg. 140 (2): 151–7, discussion 158. doi:10.1001/archsurg.140.2.151. PMID 15723996.
  7. ↑ Tang WM, Ho PL, Fung KK, Yuen KY, Leong JC (2001). "Necrotising fasciitis of a limb". J Bone Joint Surg Br. 83 (5): 709–14. PMID 11476311.
  8. ↑ Daabiss M (2011). "American Society of Anaesthesiologists physical status classification". Indian J Anaesth. 55 (2): 111–5. doi:10.4103/0019-5049.79879. PMC 3106380. PMID 21712864.
  9. ↑ Adachi K, Tsutsumi R, Yoshida Y, Watanabe T, Nakayama B, Yamamoto O (2012). "Necrotizing fasciitis of the breast and axillary regions". Eur J Dermatol. 22 (6): 817–8. doi:10.1684/ejd.2012.1838. PMID 23131384.
  10. ↑ Yamasaki O, Nagao Y, Sugiyama N, Otsuka M, Iwatsuki K (2012). "Surgical management of axillary necrotizing fasciitis: a case report". J Dermatol. 39 (3): 309–11. doi:10.1111/j.1346-8138.2011.01456.x. PMID 22211460.
  11. ↑ Netscher DT, Baumholtz MA, Bullocks J (2009). "Chest reconstruction: II. Regional reconstruction of chest wall wounds that do not affect respiratory function (axilla, posterolateral chest, and posterior trunk)". Plast Reconstr Surg. 124 (6): 427e–35e. doi:10.1097/PRS.0b013e3181bf8323. PMID 19952603.
  12. ↑ Silberstein J, Grabowski J, Parsons JK (2008). "Use of a Vacuum-Assisted Device for Fournier's Gangrene: A New Paradigm". Rev Urol. 10 (1): 76–80. PMC 2312348. PMID 18470279.
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