Surgical Management of Hidradenitis Suppurativa: A Narrative Review

ObjectiveHidradenitis suppurativa (HS) is a debilitating, chronic, dermatological inflammatory skin disease that affects apocrine gland bearing skin in the axillae, groin, and inframammary regions. It is underdiagnosed and its pathogenesis incompletely understood. This paper provides a comprehensive review of the existing literature on the surgical management of HS, focusing upon outcomes of definitive surgery. MethodsA literature search was conducted according to PRISMA guidelines. PubMed and EMBASE databases were searched for original studies pertaining to the surgical management of HS published from January 1970 to July 2020. A total of 33 papers were included for analysis.ResultsManagement options include risk factor modification, pharmacological agents, and surgical intervention. Many surgical management techniques exist, including incision and drainage, CO₂ laser therapy, deroofing, wide local excision, and reconstructive surgery. Incision and drainage is commonly utilized for symptom relief of sepsis. While data on curative surgical management are lacking, studies on surgical approaches have shown favorable outcomes in highly selected cases.Wide excision with flap reconstruction results in high patient satisfaction rates, good cosmesis, and reduced disease recurrence.Limitations A small number of suitable papers met our specific focus and inclusion and exclusion criteria. Novel techniques described in case studies were missed. Additionally, this study examined HS management as a whole, but region-specific management was not reviewed closely.ConclusionThe success of surgical management is dependent on multiple factors. Thus far, the precise role of surgery in elective treatment of refractory HS requires further analysis and reporting of outcomes.     

A prospective microbiologic surveillance program to detect and prevent the transfusion of bacterially contaminated platelets

After two patients received bacterially contaminated platelet transfusions, a prospective surveillance program was instituted to perform Gram staining and microbiologic culturing of platelets at the time of transfusion. In 12 months, 3141 random-donor platelet pools (prepared from 14,481 units) and 2476 single-donor apheresis units were cultured. All single-donor apheresis units were sterile, but 6 (0.19%) of the random-donor pools were found to be bacterially contaminated, with 1 unit of 5 in the pool being the source in each case. Contaminants were Staphylococcus epidermidis (4 cases), Bacillus cereus (1), and Staphylococcus aureus (1) at counts of 0.5 × 10(2) to 10(11) colony-forming units per mL in platelet pools and 10(3) to 10(13) colony-forming units per mL in source units. The contamination rate for units transfused at < or = 4 days (1.8/10,000) was significantly lower than that at 5 days (11.9/10,000; p < 0.05), as was the magnitude of contamination (p < 0.05). Use of the pretransfusion Gram stain on 4- and 5-day-old platelet pools was 100 percent sensitive (4/4 true positives) and 99.93 percent specific (1 false positive) in detecting contaminated pools. These data define the extent and magnitude of platelet bacterial contamination and demonstrate the efficacy of the pretransfusion Gram stain on platelet units stored for 4 and 5 days in preventing the transfusion of heavily contaminated units. It is concluded that the risk of platelet contamination is related to the duration of component storage.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of dietary supplementation with marine fish oil on leukocyte lipid mediator generation and function in rheumatoid arthritis

Twelve patients with active rheumatoid arthritis supplemented their usual diet with 20 gm of Max-EPA fish oil, daily, for 6 weeks. Following this supplementation, the ratio of arachidonic acid to eicosapentaenoic acid in the patients' neutrophil cellular lipids decreased from 81:1 to 2.7:1, and the mean generation of leukotriene B₄ (with calcium ionophore stimulation) significantly declined by 33%. The mean neutrophil chemotaxis to both leukotriene B₄ and FMLP significantly increased toward the normal range at week 6. The generation of 5-lipoxygenase products by calcium ionophore-stimulated monocytes was not significantly suppressed, but a significant decline (37%) in plateletactivating factor generation was noted at week 6. The modulation of these measures of leukocyte inflammatory potential suggests that fish oil supplementation may have an antiinflammatory effect.     

Ultrasonographic evidence of Gatekeeper™ prosthesis migration in patients treated for faecal incontinence: a case series

Background

Faecal incontinence (FI) is both a medical and social problem, with an underestimated incidence. For patients with internal anal sphincter damage, implantation of biomaterial in the anal canal is a recognised treatment option. One such material, Gatekeeper?, has previously shown promising short- and medium-term results without any major complications, including displacement. The main aim of the present study is to assess the degree to which displacement of Gatekeeper prostheses may occur and to determine whether this is associated with patient outcomes.

Methods

Seven patients (six females) with a mean age of 55.6 years [50.5–57.2] and a mean FI duration of 6 ± 2 years were prospectively enrolled in the study. Each subject was anaesthetised and underwent implantation of six prostheses in the intersphincteric region, guided by endoanal 3D ultrasound (3D-EAU). Follow-up was performed at post-interventional months 1, 3, and 12 (median 12 ± 4 months), during which data were obtained from a defaecation diary, Wexner scale assessment, anorectal manometry (ARM), 3D-EAU, and a health status and quality of life questionnaire (FIQL).

Results

At 3-month follow-up, 3D-EAU revealed displacement of 24/42 prostheses in 5/7 patients. Of these, 15 had migrated to the lower portion and 9 to the upper portion of the anal canal and rectum. Despite this migration, treatment was considered successful in 3/7 patients. In one patient, it was necessary to remove a prosthesis due to spontaneous extrusion.

Conclusions

We have shown that displacement of the Gatekeeper? prosthesis occurs, but is not associated with poorer clinical outcomes.

     

Guidelines for practical use of MAL‐PDT in non‐melanoma skin cancer

Methyl aminolaevulinate photodynamic therapy is increasingly practiced in the treatment of actinic keratoses, Bowen’s disease and basal cell carcinomas. This method is particularly suitable for treating multiple lesions, field cancerization and lesions in areas where a good cosmetic outcome is of importance. Good treatment routines will contribute to a favourable result. The Norwegian photodynamic therapy (PDT) group consists of medical specialists with long and extensive PDT experience. With support in the literature, this group presents guidelines for the practical use of topical PDT in non‐melanoma skin cancer.     

Identifying problematic severe asthma in the individual child – does lung function matter?*

Aim: Measures of lung function (usually FEV₁ <80% predicted) are used to classify asthma severity in both adults and children, despite evidence that lung function impairment is less pronounced in the paediatric asthma population. The present study assesses the relevance of lung function measurements as discriminators of severe childhood asthma. Methods: Fifty‐one school‐aged children with problematic severe asthma, 37 mild‐to‐moderate asthmatics and 29 healthy controls underwent a comprehensive clinical work‐up. Problematic severe asthma was defined in patients exhibiting poor asthma control despite high‐dose inhaled corticosteroid treatment and at least one other asthma controller drug. Mild‐to‐moderate asthmatic children used low‐dose inhaled steroids and reported minimal asthma symptoms. Results: Baseline FEV₁ values were significantly reduced in children with problematic severe asthma, yet FEV₁ <80% predicted showed a low sensitivity (41%) for discriminating severe vs. mild‐to‐moderate asthma. Receiver‐operated characteristic analysis estimated the optimal cut‐off of FEV₁ to be 90% predicted in this population (sensitivity 61%, specificity 83%). Baseline FEV₁/FVC and FEF_25–75 values were not superior to FEV₁ in discriminating problematic severe asthma, and neither exhaled nitric oxide levels nor bronchial hyperresponsiveness differentiated between the two asthmatic study populations. Conclusion: Spirometric measurements are insensitive discriminators of problematic severe asthma in childhood.