Approaches to Surgical Debridement in Necrotizing Soft Tissue Infections: Outcomes of an Animated, Interactive Survey

Abstract

Background: Necrotizing soft tissue infections (NSTI) affect long-term quality of life in survivors. Different approaches to debridement may influence quality of life. The aim of this study was to assess the current practice of the debridement of NSTI in the Netherlands.

Methods: An animated, interactive online survey was distributed among general surgeons and plastic surgeons in the Netherlands. Two NSTI-cases were presented, followed by questions regarding the preferred surgical approach. Case one described a woman with a swollen, red leg, with signs of sepsis and without visible necrosis. Case two described an immunocompromised man with septic shock syndrome and extensive necrosis.

Results: In total 232 responses were included (143 general surgeons, 89 plastic surgeons). In case one, 32% chose to preserve all skin, while 17% chose to resect all skin above the affected fascia, including normal-looking skin. In case two, all participants resected necrotic skin, and most (88%) also blue discolored skin. While 32% did not resect more than blue discolored and necrotic skin, 35% also resected red-colored skin, and 21% all skin overlying the affected fascia, including normal colored skin. Respondents working in a hospital with a burn center tended to preserve more skin, whereas plastic surgeons chose more often for skin resection compared to general surgeons.

Conclusions: By using a novel approach to a survey, the authors demonstrate the existence of extensive practice variety regarding the approach to debridement of NSTI among Dutch general and plastic surgeons. Consensus is needed, followed by targeted education of surgeons.

Fig. 1

Slides from the survey demonstrating the course of the questions provided to participants in the two cases, with the different dotted lines indicating different incision patterns. In case one, the first question (a) had three answer possibilities. Depending on the answer provided, the appropriate follow-up question was selected. For example, when answer A was selected the follow-up question was as visible in (b), while when answer C was selected this follow-up question was as visible in (c). This was similar for case two, with the first question displayed in (d), followed by (e) if A was selected, and (f) if D was selected. For all possible slides, see Supplementary material, Appendix A

Fig. 2

Distribution of the approaches chosen for the first and second question for both case one and case two. The different dotted lines indicate different possible incision patterns, and gray continuous line (visible in the second questions) the extent of involved deep tissue layers which were debrided. The percentages, which color math the relevant dotted lines, indicate how many percent of the respondents chose these different incision patterns. Responses to the first questions for case one and case two are displayed in a and c, and to final incision patterns in b and d, respectively