Dr. La Scala

1. University Center of Pediatric Surgery of Western Switzerland
Pediatric Plastic Surgery - Division of Pediatric Surgery
University of Geneva Children’s Hospital
A skin-sparing
approach to necrotizing fasciitis
Giorgio La Scala, MD, PD, FMH(CH)
WUWHS 5th Congress
Florence, September 25-29, 2016

2. Necrotizing fasciitis
•Soft tissues infection
•Rapidly progressing
•Life threatening

3. History
•“... If such an accident was
neglected in the slightest
degree ... great inflammation
took place, and the erysipelas
quickly spread all over ... and
there were great fallings off of
the flesh, tendons, and bones;
and the defluxion which
seated in the part was not like
pus, but a sort of putrefaction
...”
Hippocrates. Of the Epidemics, vol. 2 sect. 3 par. 4 (Translated by Francis Adams)

4. History
Hutchinson. Med Chir Trans 1882, 65:1-11

5. Epidemiology
•0.3-3.5/100’000 annual incidence
•More frequent in winter
•≈ 20% mortality

6. Microbiology
•Type 1: Polymicrobial
•Type 2: Group A Streptococcus (GAS)

7. Risk factors
•Chronic illnesses
•Recent surgery or trauma
•Chickenpox
•No proven link with NSAID use

8. Presentation
•Excruciating pain
•Skin lesions
•Swelling, tenderness
•Progressive, ill-delimited erythema
•Systemic findings
•Fever, tachycardia,
•hypotension, septic shock
Anaya & Dellinger. Clin Infect Dis 2007, 44:705-10
Goh, Goh et al. Br J Surg 2014, 101:e119-25

9. Laboratory Risk Indicator for Necrotizing Fasciitis
(LRINEC) score – for adults
Variable, Unit Score
CRP, mg/L
<150 0
≥150 4
WBC, G/L
<15 0
15–25 1
>25 2
Hemoglobin, g/L
>135 0
110-135 1
<110 2
Variable, Unit Score
Sodium, mmol/L
≥135 0
<135 2
Creatinine, µmol/L
≤141 0
>141 2
Glucose, mmol/L
≤10 0
>10 1
≥ 6 Suspected fasciitis
≥ 8 Highly predictive of fasciitis
Wong, Khin et al., Critical Care Medicine 2004;32:1535-41

10. Final diagnosis: histopathology
•Superficial fascia necrosis
•Polymorphonuclear WBC in deep dermis and fascia
•Fascial arteries and vein fibrinous thrombosis
•Angiitis with arterial and venous walls fibrinoid necrosis
•Bacteria on Gram’s stain of fascia and dermis
•No muscle involvement
Stamenkovic & Lew. N Engl J Med 1984, 310:1689-93

11. Final diagnosis: histopathology

12. Final diagnosis: histopathology

13. Management
•IV Antibiotics
•Wide spectrum antibiotics
•Co-Amoxicillin 50 mg/kg/dose max 2.2 g q6h
•Clindamycin 15 mg/kg, then 10 mg/kg max 600 mg q8h
•If suspected MRSA add Vancomycin 15 mg/kg max 500 mg q6h
•IV Fluids
•Ringer Acetate 20 ml/kg

14. Management
•Emergency surgery
•Diagnosis (frozen sections)
•Wide debridement
•Early surgery: decreases morbidity and mortality
Wong, Khin et al. Crit Care Med 2004, 32:1535-41
Sarani, Strong et al. J Am Coll Surg 2009, 208:279-88

15. Standard management

16. Standard management

17. Standard management
13 months3 weeks

18. The first patient...

19. The first patient...
3 weeks

20. The first patient...
7 weeks

21. The first patient...
28 months

22. Surgery
•Excision of clearly necrotic skin, extended incisions as necessary
•Headlamp, 2.5 × loupes, long retractors
•Deep wound swabs for bacterial cultures and PCR
•Excision until
•Active bleeding
•Glistening fascia adhering to surrounding planes
•Healthy-looking adipose tissue
•Normal marginal biopsies (frozen sections)

23. Management
•Negative pressure wound therapy
•Hyperbaric oxygen if extensive undermining or skin ischemia
•Second look at 24-48h with repeated biopsies as necessary
•Closure when skin and wound well vascularized
•Suction drainage
•Compressive dressing

24. Patients
•2008-2016: n=13; 7 girls, 6 boys
•Incidence (Geneva) 1.4 : 100’000 children ≤ 16 years old
•Median age 4.8 year (1.7-15.1)
•Symptoms duration prior to consultation: 24h (12-72)
•Admission to surgery interval: 6h (1-30)
•Symptoms duration prior to surgery: 49.5h (15-77)

25. Etiology
8
1
1
1
2
Chickenpox
Gingivitis
Insect bite
Wound
No entry point

26. Seasonal distribution
0
1
2
3
4
5
6
7
Dec-Feb Mar-May Jun-Aug Sept-Nov
Other
Chickenpox
n

27. Microbiology
2 11
NF 1 - Polymicrobial
NF 2 - GAS
9
2
GAS alone
GAS polymicrobial

28. Negative Pressure Wound Therapy
•11 patients
•–125 mmHg, continuous mode
•Median duration 5 days (3-15)

29. Hyperbaric oxygen
•7 patients
•Daily 2h dives at 2.5 ATA
•Median 7 dives (3-9)

30. Skin and Fascia Excision
0
3
6
9
12
15
A B C D E F G H I J K L M
Skin Fascia
% TBSA
Median 2
Median 0.1

31. Skin / Fascia Excision
Median skin to fascia excision ratio: 0.1 (0.03-0.5)

32. Surgical interventions to closure
0
3
6
9
12
A B C D E F G H I J K L M
Op (n)
Median 3
n
Median time to closure: 5 days (0-36)

33. Necrotizing fasciitis complications
•Septic shock: 4 patients
•Pneumonia: 1 patient

34. Hospitalization
0
10
20
30
40
50
A B C D E F G H I J K L M
Ward
ICU
ICU-ETT
Median 10
Days

35. Outcome
•Median follow-up 9 months (3-79)
•No mortality
•Morbidity
•1 seroma
•1 nipple loss
•1 hypertrophic scar
•2 contour deformities (thighs)

36. Clinical case 1

37. Clinical case 1
28 months

38. Clinical case 2

39. Clinical case 2
2 days

40. Clinical case 2
13 days6 days

41. Clinical case 2
6 years6 years

42. Clinical case 2
6 years6 years

43. Clinical case 2
6 years6 years

44. Conclusions
•High index of suspicion
•Excruciating pain
•Chickenpox
•Early debridement of non-viable tissues
•Skin preservation is possible
•Median skin to fascia excision ratio: 0.1 (0.03-0.5)

45. Limitations
•Small series
•Effect of hyperbaric oxygen?
•Need for on call pathologist

46. Prevention
•USA: Varicella vaccination program (CDC)
•Two doses, at 12-15 months and 4-6 years
•Canada: Public funded vaccine program since 2004
•114 (2005-2009) annual hospitalizations from 288 (1999 to 2004)
•Switzerland: Recommended in children > 11 years without chickenpox Hx
•Annual hospitalizations of varicella ≈100 (4 × Canada)
Holmes, Reef et al. MMWR Recomm Rep 1996, 45:1-36
Marin, Güris et al. MMWR Recomm Rep 2007, 56:1-40
Varicella-Public Health Agency of Canada, 2012-07-23 (http://tinyurl.com/hclartf)
Bonhoeffer & Heininger. Paediatrica 2008, 19:48-50

47. Prevention
•Varicella vaccination program (CDC)
•Two doses, at 12-15 months and 4-6 years
•Second dose catch-up vaccination for those having received 1 dose only
•Routine vaccination of healthy ≥ 13 years old without immunity
•...
Holmes, Reef et al. MMWR Recomm Rep 1996, 45:1-36
Marin, Güris et al. MMWR Recomm Rep 2007, 56:1-40

48. Prevention (Canada)
•Public funded vaccine programs since 2004
•Annual hospitalizations of varicella down to 114 (2005-2009) from 288 (1999 to 2004)
“Varicella increases the risk of severe invasive group A streptococcal
infection in previously healthy children by 40- to 60-fold”
Varicella-Public Health Agency of Canada, 2012-07-23 (http://tinyurl.com/hclartf)

49. Prevention (Switzerland)
•Recommended for children > 11 years without history of chickenpox
•Annual hospitalizations of varicella ≈100 (4 × Canada)
“the 2% of adults infected with chickenpox have
16 × the complications and 20-40 × the mortality compared to children.”
Bonhoeffer & Heininger. Paediatrica 2008, 19:48-50

50. Publication
•Rüfenacht MS, Montaruli E, Chappuis E, Posfay-Barbe KM, La Scala GC.
•Skin-Sparing Débridement for Necrotizing Fasciitis in Children.
•Plast Reconstr Surg. September 2016; 138: 489e-97e.

51. Giorgio La Scala, MD, PD, FMH(CH)
University Center of Pediatric Surgery of Western Switzerland
Pediatric Plastic Surgery - Division of Pediatric Surgery
University of Geneva Children’s Hospital
giorgio.lascala@hcuge.ch