Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_764_Библиотеки_им_академика_М_И_Перельмана

Surgical debridement changes a chronic wound into an acute one and it is achieved, thanks to sur­gical techniques by the excision, sometimes also in an aggressive way, of all the dead or devital­ized tissues. Surgical debridement can also involve the amputation of a necrotic digit as well as the opening of sinus tracts and wound pockets in order to drain pus or exudate [8, 9]. This pro­cedure can be painful and extensive and requires a skilled surgeon. It is better performed in an operating theater under anesthesia. A local anes­thesia directly inltrated into the wound bed can be enough for some patients in case of smaller wounds. In others, it is better to use a regional anesthesia with a nerve block, spinal, or epidural anesthesia, or in the most extreme cases general anesthesia. We also have to consider that some patients may be insensitive if they have diabetic neuropathy, whereas other neuropathic patients may have hyperesthesia and may be hypersensi­tive [10]. An example of surgical debridement is portrayed in Fig.38.1.

With debridement, it is also possible to reduce the odor of an infected wound, evacuate the pus, and drain unroofed pockets.

To start from a similar starting point at the beginning of the trial, before entering the study, patients with chronic wounds were treated with complete excision. This could have affected the excellent healing rates but, on the other hand, without this step, comparisons between patients may not have been possible. Another limitation of the study was the difference in the age of the wound which could have led to a different heal­ing rate causing a bias in the system.

All patients with necrotic tissue present in their wounds or/and with pus draining from the wound are eligible for debridement. Also, pale granula­tion tissue should be debrided. Some evidence shows how senescent broblasts of chronic wounds are less capable of producing proteins and of replication. In fact, removing granulation tissue from a chronic wound permits the repopu­lation of young broblasts that are capable to control and improve the healing process better than the senescent ones; in addition, it also gives a normal aspect to the wound.

• if the tissue all around the wound is not

In fact, they often are more extensive than they seem at the beginning, from an initial examina­tion and from the appearance of the surface. The best thing to do in this case is to perform an initial debridement in a clinical setting in order to understand the real dimensions of the lesion and to obtain a good tissue sample that can be ana­lyzed for culture. Frequently, in the diabetic foot, over the ulcer we can nd some calluses; only by removing these calluses we can reveal the real extension of the ulcer below, and then we can drain the pus and remove the infected sloughy tissue. With intravenous antibiotics, this kind of infection should heal, but it is necessary to follow the patients every day to detect the evidence of spread. Another useful trick is to draw on the foot an outline of the cellulitis area so that any varia­tion (both extension or reduction) can be easily and quickly detected.

• Osteomyelitis that does not respond to conser­vative measures of therapy.