Reconstruction of cervical necrotizing fasciitis defect with the modified keystone flap technique:Two case reports

BACKGROUND Cervical necrotizing fasciitis(CNF)is a rare,aggressive form of deep neck space infection with significant morbidity and mortality rates.Serial surgical debridement acts as the cornerstone of CNF treatment;however,it often results in defects requiring complex reconstructions.CASE SUMMARY We report two cases in which the keystone flap(KF)was used for CNF defect coverage:Case 1,an 85-year-old patient with CNF in the anterior neck,and Case 2,a 54-year-old patient with CNF in the posterior neck.Both patients received empirical intravenous antibiotic therapy and underwent serial debridement,enabling adequate wound preparation and stabilization.The final defect size measured 5.5 cm×12 cm in Case 1 and 6 cm×11 cm in Case 2.For defect coverage,we employed an 8 cm×19 cm type II KF based on perforators from the superior thyroid artery in Case 1 and a 9 cm×18 cm type II KF based on perforators from the transverse cervical artery in Case 2.Both flaps showed complete survival.No postoperative complications occurred in both cases,and favorable outcomes were observed at 7-and 6-month follow-ups in case 1 and 2,respectively.CONCLUSION We effectively treated CNF-associated defects using the KF technique;KF is viable for covering CNF defects in carefully selected cases.

Early systemic anticoagulation reduces hospital readmission in acute necrotizing pancreatitis patients:A retrospective cohort study

Background:Early systemic anticoagulation(SAC)is a common practice in acute necrotizing pancreatitis(ANP),and its impact on in-hospital clinical outcomes had been assessed.However,whether it affects long-term outcomes is unknown.This study aimed to evaluate the effect of SAC on 90-day readmission and other long-term outcomes in ANP patients.Methods:During January 2013 and December 2018,ANP patients admitted within 7 days from the onset of abdominal pain were screened.The primary outcome was 90-day readmission after discharge.Cox proportional-hazards regression model and mediation analysis were used to define the relationship between early SAC and 90-day readmission.Results:A total of 241 ANP patients were enrolled,of whom 143 received early SAC during their hospitalization and 98 did not.Patients who received early SAC experienced a lower incidence of splanchnic venous thrombosis(SVT)[risk ratio(RR)=0.40,95%CI:0.26-0.60,P<0.01]and lower 90-day readmission with an RR of 0.61(95%CI:0.41-0.91,P=0.02)than those who did not.For the quality of life,patients who received early SAC had a significantly higher score in the subscale of vitality(P=0.03)while the other subscales were all comparable between the two groups.Multivariable Cox regression model showed that early SAC was an independent protective factor for 90-day readmission after adjusting for potential confounders with a hazard ratio of 0.57(95%CI:0.34-0.96,P=0.04).Mediation analysis showed that SVT mediated 37.0%of the early SAC-90-day readmission causality.Conclusions:The application of early SAC may reduce the risk of 90-day readmission in the survivors of ANP patients,and reduced SVT incidence might be the primary contributor.

Timing, distribution, and microbiology of infectious complications after necrotizing pancreatitis

BACKGROUND Acute pancreatitis(AP)is a common acute abdominal disease worldwide,and its incidence rate has increased annually.Approximately 20%of AP patients develop into necrotizing pancreatitis(NP),and 40%to 70%of NP patients have infectious complications,which usually indicate a worse prognosis.Infection is an important sign of complications in NP patients.AIM To investigate the difference in infection time,infection site,and infectious strain in NP patients with infectious complications.METHODS The clinical data of AP patients visiting the Department of General Surgery of Xuanwu Hospital of Capital Medical University from January 1,2014 to December 31,2018 were collected retrospectively.Enhanced computerized tomography or magnetic resonance imaging findings in patients with NP were included in the study.Statistical analysis of infectious bacteria,infection site,and infection time in NP patients with infectious complications was performed,because knowledge about pathogens and their antibiotic susceptibility patterns is essential for selecting an appropriate antibiotic.In addition,the factors that might influence the prognosis of patients were analyzed.RESULTS In this study,539 strains of pathogenic bacteria were isolated from 162 patients with NP infection,including 212 strains from pancreatic infections and 327 strains from extrapancreatic infections.Gram-negative bacteria were the main infectious species,the most common of which were Escherichia coli and Pseudomonas aeruginosa.The extrapancreatic infection time(9.1±8.8 d)was earlier than the pancreatic infection time(13.9±12.3 d).Among NP patients with early extrapancreatic infection(<14 d),bacteremia(25.12%)and respiratory tract infection(21.26%)were predominant.Among NP patients with late extrapancreatic infection(>14 d),bacteremia(15.94%),respiratory tract infection(7.74%),and urinary tract infection(7.71%)were predominant.Drug sensitivity analysis showed that P.aeruginosa was sensitive to enzymatic penicillins,thirdand fourth-generation cephalosporins,and carbapenems.Acinetobacter baumannii and Klebsiella pneumoniae were sensitive only to tigecycline;Staphylococcus epidermidis and Enterococcus faecium were highly sensitive to linezolid,tigecycline,and vancomycin.CONCLUSION In this study,we identified the timing,the common species,and site of infection in patients with NP.

Acute necrotizing pancreatitis as fi rst manifestation of primary hyperparathyroidism

We report the case of a female patient with severe acute necrotizing pancreatitis associated with hypercalcemia as first manifestation of primary hyperparathyroidism caused by a benign parathyroid adenoma.Initially the acute pancreatitis was treated conservatively.The patient subsequently underwent surgical resection of the parathyroid adenoma and surgical clearance of a large infected pancreatic pseudocyst.Although the association of parathyroid adenoma-induced hypercalcemia and acute pancreatitis is a known medical entity,it is very uncommon.The pathophysiology of hypercalcemia-induced acute pancreatitis is therefore not well known,although some mechanisms have been proposed.It is important to treat the provoking factor.Therefore,the cause of hypercalcemia should be identif ied early.Surgical resection of the parathyroid adenoma is the ultimate therapy.

Usefulness of three-dimensional visualization technology in minimally invasive treatment for infected necrotizing pancreatitis

AIM To explore the value of three-dimensional(3 D) visualization technology in the minimally invasive treatment for infected necrotizing pancreatitis(INP). METHODS Clinical data of 18 patients with INP, who were admitted to the PLA General Hospital in 2017, were retrospectively analyzed. Two-dimensional images of computed tomography were converted into 3 D images based on 3 D visualization technology. The size, number, shape and position of lesions and their relationship with major abdominal vasculature were well displayed. Also, percutaneous catheter drainage(PCD) number and puncture paths were designed through virtual surgery(percutaneous nephroscopic necrosectomy) based on the principle of maximum removal of infected necrosis conveniently.RESULTS Abdominal 3 D visualization images of all the patients were well reconstructed, and the optimal PCD puncture paths were well designed. Infected necrosis was conveniently removed in abundance using a nephroscope during the following surgery, and the median operation time was 102(102 ± 20.7) min. Only 1 patient underwent endoscopic necrosectomy because of residual necrosis. CONCLUSION The 3 D visualization technology could optimize the PCD puncture paths, improving the drainage effect in patients with INP. Moreover, it significantly increased the efficiency of necrosectomy through the rigid nephroscope. As a result, it decreased operation times and improved the prognosis.

Is necrosectomy obsolete for infected necrotizing pancreatitis? Is a paradigm shift needed?

In 1886,Senn stated that removing necrotic pancreatic and peripancreatic tissue would benefit patients with severe acute pancreatitis.Since then,necrosectomy has been a mainstay of surgical procedures for infected necrotizing pancreatitis(NP).No published report has successfully questioned the role of necrosectomy.Recently,however,increasing evidence shows good outcomes when treating walled-off necrotizing pancreatitis without a necrosectomy.The literature concerning NP published primarily after 2000 was reviewed;it demonstrates the feasibility of a paradigm shift.The majority(75%)of minimally invasive necrosectomies show higher completion rates:between 80%and 100%.Transluminal endoscopic necrosectomy has shown remarkable results when combined with percutaneous drainage or a metallic stent.Related morbidities range from 40%to 92%.Single-digit mortality rates have been achieved with transluminal endoscopic necrosectomy,but not with video-assisted retroperitoneal necrosectomy series.Drainage procedures without necrosectomy have evolved from percutaneous drainage to transluminal endoscopic drainage with or without percutaneous endoscopic gastrostomy access for laparoscopic instruments.Most series have reached higher success rates of 79%-93%,and even 100%,using transcystic multiple drainage methods.It is becoming evident that transluminal endoscopic drainage treatment of walledoff NP without a necrosectomy is feasible.With further refinement of the drainage procedures,a paradigm shift from necrosectomy to drainage is inevitable.

Acute necrotizing pancreatitis: Surgical indications and technical procedures

Necrosis of pancreatic parenchyma or extrapancreatic tissues is present in 10%-20% of patients with acute pancreatitis, defining the necrotizing presentation frequently associated with high morbidity and mortality rates. During the initial phase of acute necrotizing pancreatitis the most important pillars of medical treatment are fluid resuscitation, early enteral nutrition, endoscopic retrograde colangiopancreatography if associated cholangitis and intensive care unit support. When infection of pancreatic or extrapancreatic necrosis occurs, surgical approach constitutes the most accepted therapeutic option. In this context, we have recently assited to changes in time for surgery(delaying the indication if possible to around 4 wk to deal with "walledoff" necrosis) and type of access for necrosectomy: from a classical open approach(with closure over large-bore drains for continued postoperative lavage or semiopen techniques with scheduled relaparotomies), trends have changed to a "step-up" philosophy with initial percutaneous drainage and posterior minimally invasive or endoscopic access to the retroperitoneal cavity for necrosectomy if no improvement has been previously achieved. These approaches are progressively gaining popularity and morbidity and mortality rates have decreased significantly. Therefore, a staged, multidisciplinary, step-up approach with minimally invasive or endoscopic access for necrosectomy is widely accepted nowadays for management of pancreatic necrosis.

Negative pressure catheter drainage and jejunal feeding for descending necrotizing mediastinitis by interventional techniques:a retrospective study

Purpose: Descending necrotizing mediastinitis(DNM) is a lethal and acute suppurative disease. This report aimed to summarize our experience in the treatment of DNM with continuous negative pressure catheter drainage and transnasal jejunal feeding by interventional techniques. Materials and Methods: We retrospectively analyzed relevant clinical data of patients with DNM who underwent continuous negative pressure catheter drainage and transnasal jejunal feeding. All drainage catheters and jejunal feeding tubes were inserte d by interventional techniques. Results: In total, 21 patients were diagnosed with DNM by esophagography and computed tomography(CT). Catheters for the drainage of mediastinal abscesses as well as transnasal jejunal feeding tubes were successfully placed in all patients, indicating a 100% success rate. Of all patients, 13 underwent insertion of abscess drainage catheters through percutaneous puncture under DynaCT guidance, while eight had drainage catheter insertion through fistula orifices in the posterior nasopharyngeal wall or esophagus under fluoroscopic guidance. In total, 26 drainage tubes were inserted. One patient with diabetes died of sepsis and diabetic ketoacidosis 5 days postoperatively, while the remaining 20 patients showed good recovery with successful removal of the drainage catheters. Durations of catheterization were 45.2±50.44 days. The overall clinical success rate was 95.2%. Conclusion: The above described methods are non-surgical, minimally invasive and efficacious, and may be alternative therapeutic tools for patients who are not eligible for surgical operation, have a high postoperative risk, or are more likely to choose minimally invasive techniques.

Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach:7 years experience from a single surgical unit

AIM To determine percentage of patients of necrotizing pancreatitis(NP) requiring intervention and the types of interventions performed. Outcomes of patients of step up necrosectomy to those of direct necrosectomy were compared. Operative mortality, overall mortality, morbidity and overall length of stay were determined. METHODS After institutional ethics committee clearance and waiver of consent, records of patients of pancreatitis were reviewed. After excluding patients as per criteria, epidemiologic and clinical data of patients of NP was noted. Treatment protocol was reviewed. Data of patients in whom stepup approach was used was compared to those in whom it was not used. RESULTS A total of 41 interventions were required in 39% patients. About 60% interventions targeted the pancreatic necrosis while the rest were required to deal with the complications of the necrosis. Image guided percutaneous catheter drainage was done in 9 patients for infected necrosis all of whom required further necrosectomy and in 3 patients with sterile necrosis. Direct retroperitoneal or anterior necrosectomy was performed in 15 patients. The average time to first intervention was 19.6 d in the non step-up group(range 11-36) vs 18.22 d in the Step-up group(range 13-25). The average hospital stay in non step-up group was 33.3 d vs 38 d in step up group. The mortality in the step-up group was 0%(0/9) vs 13%(2/15) in the non step up group. Overall mortality was 10.3% while post-operative mortality was 8.3%. Average hospital stay was 22.25 d.CONCLUSION Early conservative management plays an important role in management of NP. In patients who require intervention, the approach used and the timing of intervention should be based upon the clinical condition and local expertise available. Delaying intervention and use of minimal invasive means when intervention is necessary is desirable. The step-up approach should be used whenever possible. Even when the classical retroperitoneal catheter drainage is not feasible, there should be an attempt to follow principles of step-up technique to buy time. The outcome of patients in the step-up group compared to the non stepup group is comparable in our series. Interventions for bowel diversion, bypass and hemorrhage control should be done at the appropriate times.

Role of LPS/CD14/TLR4-mediated inflammation in necrotizing enterocolitis:Pathogenesis and therapeutic implications

AIM:To establish the roles of lipopolysaccharide (LPS)/CD14/toll-like receptor 4 (TLR4)-mediated inflammation in a rat model of human necrotizing enterocolitis (NEC).METHODS: Six pairs of intestinal samples from human NEC were collected before and after recovery for histological and molecular analysis of inflammatory cytokines and signaling components. In the rat NEC model, we isolated 10-cm jejunum segments and divided them into six groups (n=6) for sham operation, treatment with LPS, bowel distension, combined bowel distension and LPS stimulation, and two therapeutic groups. The potential eff icacy of a recombinant CD18 peptide and a monoclonal CD14 antibody was evaluated in the latter two groups. The serum and tissue levels of several inflammatory mediators were quantified by real-time polymerase chain reaction, ELISA and immunoblotting.RESULTS: Human acute phase NEC tissues displayed significant increases (P<0.05) in levels of TLR4, CD14, myeloid differentiation protein (MD)-2, tumor necrosis factor (TNF)-α and nuclear factor-κB when compared to those after recovery. The histological and inflammatory picture of human NEC was reproduced in rats that were treated with combined bowel distension and LPS, but not in the sham-operated and other control rats. Serum levels of interleukin-6 and TNF-α were also elevated. The NEC pathology was attenuated by treating the NEC rats with a monoclonal CD14 antibody or an LPS-neutralizing peptide.CONCLUSION:LPS and distension are required to produce the histological and inflammatory features of NEC. A potential treatment option is blocking LPS activation and leukocyte infi ltration.

Necrotizing enterocolitis: A multifactorial disease with no cure

Necrotizing enterocolitis is an inflammatory bowel disease of neonates with significant morbidity and mortality in preterm infants. Due to the multifactorial nature o the disease and limitations in disease models, early diagnosis remains challenging and the pathogenesis elusive. Although preterm birth, hypoxic-ischemic events formula feeding, and abnormal bacteria colonization are established risk factors, the role of genetics and vasoactive/inflammatory mediators is unclear Consequently, treatments do not target the specific underlying disease processes and are symptomatic and surgically invasive. Breast-feeding is the most effective preventative measure. Recent advances in the prevention of necrotizing enterocolitis have focused on bioactive nutrients and trophic factors in human milk. Developmen of new disease models including the aspect of prematurity that consistently predisposes neonates to the disease with multiple risk factors will improve our understanding of the pathogenesis and lead to discovery of innovative therapeutics.

Interventional strategies in infected necrotizing pancreatitis:Indications,timing,and outcomes

Acute pancreatitis(AP)is one of the most common gastrointestinal diseases and remains a life-threatening condition.Although AP resolves to restitutio ad integrum in approximately 80%of patients,it can progress to necrotizing pancreatitis(NP).NP is associated with superinfection in a third of patients,leading to an increase in mortality rate of up to 40%.Accurate and early diagnosis of NP and associated complications,as well as state-of-the-art therapy are essential to improve patient prognoses.The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the“step-up approach”.This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required.Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications.However,the optimal interventional sequence and timing of interventional procedures remain controversial.This review aims to summarize the indications,timing,and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.

Molecular Mechanism of Rice Necrotic Lesion for Optimized Yield and Disease Resistance

How to balance rice resistance and yield is an important issue in rice breeding.Plants with mutated necrotic lesion genes often have persistent broad-spectrum resistance,but this broad-spectrum resistance usually comes at the expense of yield.Currently,many necrotic lesion mutants in rice have been identified,and these genes are involved in disease resistance pathways.This review provides a detailed introduction to the characteristics,classification,and molecular mechanisms of necrotic lesion formation.Additionally,we review the molecular regulatory pathways of genes involved in rice disease resistance.Concurrently,we summarize the relationship between resistance and yield in rice using newly developed gene editing methods.We discuss a rational and precise breeding strategy to better utilize molecular design technology for breeding disease-resistant and high-yield rice varieties.

Minimally Invasive Surgery for Necrotizing Pancreatitis: A Case Report

Introduction: Necrotizing pancreatitis management is complex and varies significantly among clinicians. Minimally invasive approaches like transgastric necrosectomy via laparoscopy are emerging as effective treatment options. This case report underscores the technique’s efficacy, clinical outcomes, and role in reducing complications. Clinical Observation: A 59-year-old male with a history of smoking and alcoholism presented with severe abdominal pain, nausea, and vomiting. Over the following weeks, he developed symptoms including asthenia, weight loss, and melena. Diagnostic workup revealed severe anemia and Balthazar E necrotizing pancreatitis, with significant intra-abdominal fluid collections and signs of infection. After initial conservative management, the patient underwent transgastric necrosectomy via laparoscopy due to deteriorating clinical status. The procedure involved removing necrotic tissue and performing a cystogastroanastomosis and jejunostomy. Postoperative care included fasting, parenteral nutrition, broad-spectrum antibiotics, and enzymatic replacement. The patient recovered well, with reduced necrotic tissue on follow-up imaging, and was discharged twelve days post-surgery [1]. Conclusion: Transgastric necrosectomy by laparoscopy is a valuable first-line surgical option for patients with symptomatic necrotizing pancreatitis, particularly in cases without prior interventions. This minimally invasive technique helps reduce major complications and mortality, offering a less invasive alternative to traditional open necrosectomy. The multidisciplinary approach and careful postoperative management were crucial to the patient’s favorable outcome. The case highlights the potential of transgastric necrosectomy as an effective treatment strategy in managing complex pancreatitis cases, including those with associated duodenal perforation [2].

Dietary Macleaya cordata extract supplementation improves the growth performance and gut health of broiler chickens with necrotic enteritis

Background The poultry industry needs effective antibiotic alternatives to control outbreaks of necrotic enteritis(NE)caused by Clostridium perfringens.Methods The aim of this study was to investigate the effects of dietary supplementation with Macleaya cordata extract(MCE)on the immune function and gut microbiota of broilers with NE.A total of 2881-day-old broiler chicks were randomly assigned to a 2×2 factorial arrangement with two concentrations of dietary MCE supplementation(0 or 350 mg/kg of diet)and two disease challenge statuses(control or NE).Results The results revealed that NE significantly increased the feed conversion rate(FCR),mortality,intestinal lesion score,the levels of IL-1β,IL-17 and IFN-γ/IL-4 in serum and IL-17/IL-10 in the jejunal mucosa,m RNA levels of TLR2,IFN-γand p Ig R in the jejunum,and Clostridium perfringens concentrations in the cecum.NE significantly decreased the body weight(BW),body weight gain(BWG),jejunal villus height,V/C,m RNA level of AMPK-α1 in jejunum,IL-4 level in the jejunal mucosa and lactic acid bacteria abundance in the cecum.MCE significantly increased BW,BWG,jejunal villus height,V/C,m RNA levels of occludin,ZO-1 and AMPK-α1 in the jejunum,the levels of Ig A and Ig G in serum and IL-10 in the jejunal mucosa and m RNA levels of NF-κB,IL-10 and MHC-II in the jejunum.Additionally,MCE significantly decreased the FCR,mortality,intestinal lesion score,jejunal crypt depth,the levels of IFN-γand IL-17 in serum and IL-17/IL-10 in the jejunal mucosa,Clostridium perfringens concentrations in the cecum,and m RNA levels of IL-17/IL-10 in the jejunum.Moreover,NE significantly increased the abundance of bacteria that are associated with inflammation,obesity and depression(Alistipes,Barnesiella,Intestinimonas,RF39 and UCG-005)and significantly decreased the abundance of short-chain fatty acid(SCFA)-producing bacteria(Anaerotruncus,Butyricicoccus and Bacteroides)in the cecum.MCE significantly increased the abundance of SCFA-producing bacteria(Streptococcus,Ruminococcus_torques_group and Lachnospiraceae_NK4A136_group)and significantly reduced the abundance of bacteria that are associated with inflammation and obesity(Alistipes,Barnesiella and UCG-010)in the cecum.In the cecum of broilers with NE,the relative abundance of Barnesiella and Alistipes was higher and that of Lachnoclostridium and Shuttleworthia was lower.Interestingly,these trends were reversed by the addition of MCE to the diet.Spearman correlation analysis showed that Barnesiella and Alistipes were associated with enhanced intestinal inflammation and inhibited growth performance,whereas Lachnoclostridium and Shuttleworthia were associated with anti-inflammatory effects.Conclusions MCE ameliorated the loss of growth performance in broiler chickens with NE,probably by regulating the intestinal barrier,immune function,and gut microbiota.

Application of prolonging small feeding volumes early in life to prevent of necrotizing enterocolitis in very low birth weight preterm infants

Objective:To study the effects of prolonging small feeding volumes early in life on the incidence of necrotizing enterocolitis(NEC)in very low birth weight(VLBW)preterm infants.Methods:A total of 128 VLBW infants who could not be breastfed were assigned into the experimental group(63 cases)and the control group(65 cases)using a random number table.The experiment group was fed 12 mL/(kg·d)on day 1 which was increased to 24 mL/(kg·d)for the first 10 study days.The control group was fed 12 mL/(kg·d)for the first 14e48 hours.Then,the feeding volume increased by 24-36 mL/(kg·d)up to 140e160 mL/(kg·d)and maintained until the 10th day after birth.The incidence of feeding intolerance and NEC,duration of hospitalization,time to full enteral feedings,incidence of intrahepatic cholestasis,and the levels of gastrin and motilin in serum were assessed.Results:The incidence of feeding intolerance was significantly lower in the experimental group compared with the control group(15.87% vs.33.84%).There was a significant reduction in the incidence of NEC between the experimental and control groups(7.9% vs.16% in the control group).Conclusion:A protocol that prolongs small feeding volumes early in life can reduce the incidence and severity of NEC,but still warrants further study.

Suspected coexistence of perianal necrotizing sweet syndrome in chronic myelomonocytic leukemia:A case report

BACKGROUND Chronic myelomonocytic leukemia(CMML)complicated with Sweet syndrome(SS)is a rare hematological neoplasm.However,cases of concomitant development of perianal necrotizing SS(NSS)have not been reported.CASE SUMMARY We report a case of a 49-year-old male patient who underwent sequential procedures for hemorrhoids and perianal abscess.He developed postoperative incision infection and was referred to the department where the authors work.Initially,perianal necrotizing fasciitis secondary to incision infection after perianal abscess surgery was suspected.Despite receiving antibiotic therapy and undergoing surgical debridement,deeper necrotic areas formed in the patient’s perianal wounds,accompanied by persistent high fever.Blood and fungal cultures yielded negative results.The final diagnosis was corrected to be CMML with suspected concomitant perianal NSS.CONCLUSION CMML with perianal NSS is a rare condition,often misdiagnosed as perianal abscess or perianal necrotizing fasciitis.Conventional antibiotic therapy and surgical debridement are ineffective in managing this condition.

Umbilical cord mesenchymal stem cell exosomes alleviate necrotizing enterocolitis in neonatal mice by regulating intestinal epithelial cells autophagy

BACKGROUND Necrotizing enterocolitis(NEC)is a severe gastrointestinal disease that affects premature infants.Although mounting evidence supports the therapeutic effect of exosomes on NEC,the underlying mechanisms remain unclear.AIM To investigate the mechanisms underlying the regulation of inflammatory response and intestinal barrier function by umbilical cord mesenchymal stem cell(UCMSCs)exosomes,as well as their potential in alleviating NEC in neonatal mice.METHODS NEC was induced in 5-d-old C57BL/6 pups through hypoxia and gavage feeding of formula containing lipopolysaccharide(LPS),after which the mice received human UCMSC exosomes(hUCMSC-exos).The control mice were allowed to breastfeed with their dams.Ileal tissues were collected from the mice and analyzed by histopathology and immunoblotting.Colon tissues were collected from NEC neonates and analyzed by immunofluorescence.Molecular biology and cell culture approaches were employed to study the related mechanisms in intestinal epithelial cells.RESULTS We found that autophagy is overactivated in intestinal epithelial cells during NEC,resulting in reduced expression of tight junction proteins and an increased inflammatory response.The ability of hUCMSC-exos to ameliorate NEC in a mouse model was dependent on decreased intestinal autophagy.We also showed that hUCMSC-exos alleviate the inflammatory response and increase migration ability in intestinal epithelial cells induced by LPS.CONCLUSION These results contribute to a better understanding of the protective mechanisms of hUCMSC-exos against NEC and provide a new theoretical and experimental foundation for NEC treatment.These findings also enhance our understanding of the role of the autophagy mechanism in NEC,offering potential avenues for identifying new therapeutic targets.

Effectiveness of negative pressure wound therapy in complex surgical treatment of necrotizing fasciitis of the upper limb

BACKGROUND Necrotizing fasciitis(NF)of the upper extremities is a severe surgical pathology,and the incidence of this disease has been steadily increasing in recent decades.Surgical treatment is accompanied by the formation of extensive wounds,which can be treated with significant difficulties.In recent years,negative pressure wound therapy(NPWT)has proven to be highly effective.It is also promising for the treatment of NF.AIM To explore the effectiveness of NPWT in the treatment of NF of the upper extremities.METHODS The results of the treatment of 36 patients with NF of the upper extremities in two groups(NPWT group and control group;2022−2023)were retrospectively analyzed.In the NPWT group,the NPWT method(120 mmHg;constant mode)was used after surgical treatment.The number of vacuum-assisted dressings in patients ranged from 1 to 3,depending on the dynamics of the wound process.The duration of fixation of one bandage was up to 2−3 d.In the control group,conventional methods of local wound treatment were used.The following indicators were analyzed:The treatment delay,the prevalence of inflammation,the microbial landscape,the number of debridements,the duration of wound preparation for surgical closure,and the nature of skin plastic surgery.RESULTS Most patients experienced a significant treatment delay[4 d,interquartile range(IQR):2–7 d],which led to the spread of the pathological process to the forearm and shoulder.The most common pathogens were Staphylococcus aureus(14;38.9%)and Streptococcus pyogenes(22;61.1%).The average number of debridements per patient was 5(IQR:3–7),with no difference between groups.The average time to prepare wounds for surgical closure was 11±4 d in the NPWT group and 29±10 d(P=0.00001)in the control group.In the NPWT group,the wounds were more often closed with local tissues(15;83.3%),and in the control group,split-thickness skin grafts were more often used(4;50%).CONCLUSION The predominant isolation of Staphylococcus aureus and/or Streptococcus pyogenes from the lesions allowed us to classify these patients as NF type II.Multiple debridement procedures have become a feature of this disease treatment.The use of NPWT has significantly reduced the time required to prepare wounds for surgical closure.Early closure of wounds allows for more frequent use of local tissue repair,which ensures better results.NPWT is a highly effective way to prepare wounds for early surgical closure in patients with upper extremity NF.

Early endoscopic management of an infected acute necrotic collection misdiagnosed as a pancreatic pseudocyst: A case report

BACKGROUND Infected acute necrotic collection(ANC)is a fatal complication of acute pancre-atitis with substantial morbidity and mortality.Drainage plays an exceedingly important role as the first step in invasive intervention for infected necrosis;however,there is great controversy about the optimal drainage time,and better treatment should be explored.CASE SUMMARY We report the case of a 43-year-old man who was admitted to the hospital with severe intake reduction due to early satiety 2 wk after treatment for acute pancre-atitis;conservative treatment was ineffective,and a pancreatic pseudocyst was suspected on contrast-enhanced computed tomography(CT).Endoscopic ultra-sonography(EUS)suggested hyperechoic necrotic tissue within the cyst cavity.The wall was not completely mature,and the culture of the puncture fluid was positive for A-haemolytic Streptococcus.Thus,the final diagnosis of ANC in-fection was made.The necrotic collection was not walled off and contained many solid components;therefore,the patient underwent EUS-guided aspiration and lavage.Two weeks after the collection was completely encapsulated,pancreatic duct stent drainage via endoscopic retrograde cholangiopancreatography(ERCP)was performed,and the patient was subsequently successfully discharged.On repeat CT,the pancreatic cysts had almost disappeared during the 6-month fo-llow-up period after surgery.CONCLUSION Early EUS-guided aspiration and lavage combined with late ERCP catheter drainage may be effective methods for intervention in infected ANCs.