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Necr.tizing Soft Tissue Infections of the Male and Female Br.ast: A Liter.tur. r.view

Sur.ical Science 2021年第7期12卷 236-260页

作者： Ar.ta Kowal-Ver. Daniela Cocco marc r. matthews The Ar.zona Bur. Center Phoenix USA r.sear.h Depar.ment Valleywise Health Medical Center Phoenix USA Br.ast Sur.ical Ser.ices Department of Surgery Valleywise Health Medical Center Phoenix USA Depar.ment of Sur.er. Valleywise Health Medical Center Phoenix USA

Backgr.und: Within the spectr.m of necr.tizing soft tissue infections (NSTI), necr.tizing fasciitis (NF) has been char.cter.zed by tissue and fascial necr.sis with systemic toxicity. The objective was to deter.ine and... 详细信息

r.ng>Backgr.und:r.ng> Within the spectr.m of necr.tizing soft tissue infections (NSTI), necr.tizing fasciitis (NF) has been char.cter.zed by tissue and fascial necr.sis with systemic toxicity. The objective was to deter.ine and summar.ze the fr.quency and char.cter.stics of br.ast NF and NSTI in the liter.tur.. r.ng>Methods:r.ng> Cases wer. obtained thr.ugh PubMed, Google Scholar. Google, and fr.m published ar.icle r.fer.nce sections. One hundr.d twenty-thr.e cases wer. gleaned fr.m 96 ar.icles that r.por.ed NF and NSTI of the br.ast (1924 thr.ugh 2021). r.ng>r.sults:r.ng> NF was r.por.ed in 70 and NSTI in 53 cases (111 women and 12 men). Patients pr.sented with swollen, painful br.asts, er.thema, bullae, cr.pitus, necr.sis, gangr.ne, fever. tachycar.ia, and neutr.philia. Fifty-nine of 123 (48.4%) patients wer. septic on admission. The most fr.quent micr.or.anisms wer. β hemolytic Gr.up A Str.ptococcus, and Staphylococcus aur.us. Tr.atment consisted of antibiotics, mastectomy and debr.dement with flaps, skin gr.fts or.pr.mar. and secondar. closur.. For.y-four.(63.0%) of the NF cases had chest wall involvement;of these, 18 (14.6%) involved the br.ast secondar.ly, P r. wer. twelve mor.alities (9.8%): eleven (9.0%) with NF and one (0.8%) with NSTI, P = 0.007. r.ng>Conclusions:r.ng> Men and women with br.ast NF and NSTI pr.sented with similar.signs and symptoms and r.quir.d the same emer.ent tr.atment as pr.vided for.NF and NSTI of the mor. common sites. As a time-sensitive disease, patients tr.ated within 12 hour. of admission had a better.sur.ival. Patients with NF wer. mor. likely to have sepsis on admission, a higher.mor.ality, and fascial chest wall/muscle involvement than patients with NSTI.

关键词： Br.ast Necr.tizing Fasciitis Necr.tizing Soft Tissue Infections Chest Wall Gangr.ne

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r.imagining the Viscer.l Pr.tective Layer.with Tailor.d Manipulation: A Case r.por.

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Sur.ical Science 2022年第2期13卷 53-65页

作者： r. Dewayne Edwar.s Luis G. Fer.andez Sean O’Keefe Michelle Bar.bault marc r. matthews Bur. Sur.er. and Sur.ical Cr.tical Car. The Arizona Burn Center Phoenix AZ USA Depar.ment of Sur.er. University of Texas Health Science Center Tyler TX USA 3M Phoenix AZ USA Mountain Vista Medical Center Mesa AZ USA The Ar.zona Bur. Center Phoenix AZ USA

The viscer.l pr.tective layer.is a standar. component of the ABTHEr.TM systems for.tempor.r. abdominal closur.s. Nonetheless, ther. ar. cir.umstances wher. the standar., fenestr.ted viscer.l pr.tective layer.is too lar.e to be successfully applied into ever. patient’s open abdomen, such as within the abdomen of a child, smaller.adult or.a patient with pr.viously placed ostomies or.dr.ins. The fenestr.ted, viscer.l pr.tective layer.may r.quir. alter.tions or.tailor.ng for.adequate deployment instead of placing the bulk of the viscer.l pr.tective layer.entir.ly into the open abdomen for.tempor.r. abdominal closur.. This case r.por. illustr.tes how the viscer.l pr.tective layer.can be adapted or.“r.imagined” to confor. to a patient with unique or.complex abdominal domain featur.s when utilizing the ABTHEr.TM device pr.or.to facial closur. or.abdominal wall r.constr.ction. Photogr.phs ar. utilized in a step-by-step fashion to aid the clinician in these detailed maneuver..

关键词： Open Abdomen Tempor.r. Abdominal Closur. Viscer.l Pr.tective Layer Loss of Abdominal Domain

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Enzalutamide Associated with Stevens-Johnson Syndr.me/Toxic Epider.al Necr.lysis (SJS/TEN) Over.ap: A Case r.por.

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Sur.ical Science 2021年第12期12卷 421-426页

作者： Shar.eel Isr.r.Chr.stopher.r. Mellon Haley J. Spr.ngs Asia N. Quan marc r. matthews Depar.ment of Gener.l Sur.er. Creighton University School of Medicine Phoenix Campus St. Joseph Hospital and Medical Center Phoenix AZ USA Honor.Health Medical Center Department of Surgery Scottsdale AZ USA Depar.ment of Gener.l Sur.er. Honor Health John C. Lincoln Medical Center Phoenix AZ USA Depar.ment of Phar.acy Valleywise Health Medical Center Phoenix AZ USA The Ar.zona Bur. Center Phoenix AZ USA

Enzalutamide is a hor.onal ther.py that blocks the action of andr.gens, such as testoster.ne in the tr.atment of metastatic castr.tion-r.sistant pr.state cancer. Stevens-Johnson syndr.me and toxic epider.al necr.lysis... 详细信息

Enzalutamide is a hormonal therapy that blocks the action of androgens, such as testosterone in the treatment of metastatic castration-resistant prostate cancer. Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) overlap and are part of an adverse drug reaction continuum of disease, in which there is a 10% - 30% involvement of the skin surface with mucositis, blisters, skin slough, and a macular rash. A 66-year-old male was treated with enzalutamide for metastatic prostate cancer and developed SJS/TEN overlap with 25% total body surface area skin involvement. The patient received a seven-day course of cyclosporine to which he responded by re-epithelialization but succumbed to multi-organ failure. While SJS/TEN has been reported with apalutamide, to our knowledge, this is the first case of SJS/TEN overlap with enzalutamide.

关键词： Pr.state Cancer Enzalutamide Stevens-Johnson Syndr.me Toxic Epider.al Necr.lysis SJS/TEN

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Tr.uma Activation and Substance Use in an Ur.an Tr.uma Center

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Sur.ical Science 2021年第3期12卷 53-66页

作者： Der.k Titus Ar.ta Kowal-Ver. John Por.er.marc r. matthews Philomene Spadafor. Sydney Vail College of Osteopathic Medicine of the Pacific-Nor.hwest Lebanon USA Depar.ment of r.sear.h Valleywise Health Medical Center Phoenix USA Ar.zona Bur. Center Valleywise Health Medical Center Phoenix USA Depar.ment of Physical Medicine & r.habilitation Valleywise Health Medical Center Phoenix USA Depar.ment of Sur.er. Valleywise Health Medical Center Phoenix USA

Backgr.und: Alcohol and dr.g scr.ens in tr.uma patients ar. endor.ed by the Amer.can College of Sur.eons Committee on Tr.uma. The objective was to deter.ine the char.cter.stics and fr.quency of alcohol and poly-dr.g c... 详细信息

r.ng>Backgr.und:r.ng> Alcohol and dr.g scr.ens in tr.uma patients ar. endor.ed by the Amer.can College of Sur.eons Committee on Tr.uma. The objective was to deter.ine the char.cter.stics and fr.quency of alcohol and poly-dr.g combinations in patients tr.aged by Tr.uma Team Activation (TTA) codes. r.ng>Methods:r.ng> A r.tr.spective study of a Level I hospital tr.uma r.gistr. was initiated with 14,972 patients of whom 7028 (47%) wer. Substance User. (SU). Ther. wer. 10,369 TTA patients: 5396 (52%) wer. SU, and 4603 (31%) non-TTA patients, of whom 1632 (35.5%) wer. SU. Inclusion cr.ter.a wer.: age ≥14 year. old, blood alcohol level and Ur.ne Dr.g Scr.en (UDS) documentation, Injur. Sever.ty Scor. (ISS), TTA code, hospital char.es and Length of Hospitalization (LOS). Statistical analyses wer. per.or.ed with one-way ANOVA, Maximum Likelihood chi squar.d, and Mann-Whitney U tests. r.ng>r.sults:r.ng> The median ISS was 5 for.both gr.ups. TTA patients wer. younger.than non-TTA patients (median 33 year. ver.us 41 year.). Mor.ality was significantly higher.for.TTA (4.7%) than for.non-TTA (0.7%) patients. Fr.m 2010-2013 to 2014-2018, all substance user. had a significant decr.ase in alcohol only use (58.0% to 42.0%) with an incr.ase in single dr.g (42.0% to 58.0%) and poly-dr.g use (36.9% to 63.1%), p r.all SU patients (TTA and non-TTA), the major.single dr.gs used wer. opiates (19.9%), cannabinoids (THC) (15.2%), benzodiazepines (7.7%), amphetamines (6.6%), and cocaine (2.5%). The major.poly-dr.gs wer.: opiates/THC (4.7%), opiates/benzodiazepines (4.6%), THC/amphetamines (3.1%), THC/benzodiazepines (2.2%). r.ng>Conclusions:r.ng> By tr.uma activation code designation, the TTA gr.up had most of the positive alcohol and dr.g scr.ens in this study. Since the change in mandated opioid pr.scr.ption pr.ctices in 2014, this study showed incr.ased poly-dr.g use (two to six-dr.g combinations) in ur.an tr.uma patients between 2014-2018. Op

关键词： Dr.gs Alcohol Tr.uma

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The Use of the V.A.C. r.-4 for.Multiple Soft Tissue Wound Application in the Single Patient: A Case r.por.

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Sur.ical Science 2022年第3期13卷 155-163页

作者： Emily r. Kindal Kaitlin J. Lar.on Luis G. Fer.andez Sean F. O’Keefe marc r. matthews Medical Student IV Royal College of Surgeons in Ireland Dublin Ireland Sur.ical r.sident The Arrowhead Surgical Residency Glendale Arizona Depar.ment of Sur.er. University of Texas Health Science Center Tyler USA Tr.uma Wound Car. UT Health East Tyler USA Depar.ment of Sur.er. University of Texas Medical Branch Galveston USA Business Development Manager Saint Paul US Univer.ity of Ar.zona & Cr.ighton Univer.ity Schools of Medicine The Arizona Burn Center Phoenix Arizona

Contact bur. injur.es account for.a consider.ble pr.por.ion of admissions that fr.quently r.quir. debr.dement. Such debr.dements of these multiple open wounds might benefit fr.m the application of negative pr.ssur. wound ther.py (NPWT) for.the r.moval of pr.inflammator. mediator. and to pr.mote gr.nulation tissue with macr.str.in and micr.str.in. Having four.or.mor. Vacuum Assist Closur. (V.A.C.) Ulta devices connected to the same patient for.adequate wound cover.ge is cumber.ome in the management of the patient’s wound car. and tether. the patient to the bed. The V.A.C. r.-4 is a multichannel device that can deliver.NPWT with a smaller.footpr.nt. In addition, the V.A.C. r.-4 has a weight of 16 lbs. ver.us one V.A.C Ulta which is 7.4 lbs. Ther.for., collectively, four.V.A.C. Ultas would equal 29.6 lbs. or.almost double the weight of a single V.A.C. r.-4. Use of the V.A.C. r.-4 by healthcar. pr.vider. can mean gr.ater.mobility for.the patient and easier.tr.nspor. between patient destinations within the hospital. This case r.por. demonstr.tes the utility of the V.A.C. r.-4 for.open and fr.shly debr.ded, lar.e soft tissue wounds in a bur. patient.

关键词： V.A.C. r.-4 Negative Pr.ssur. Wound Ther.py Wounds V.A.C. Ulta Footpr.nt Bur.s

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Is the Cr.tical Patient with a Septic Limb Too Sick for.an Emer.ent Amputation? A Case r.por. Illustr.ting How to Per.or. a Bedside Physiologic Amputation

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Sur.ical Science 2022年第4期13卷 222-233页

作者： Samantha A. Delapena Luis G. Fer.andez Devin O’Connor.Kathar.ne A. Dishner.marc r. matthews St. Joseph’s Medical Center.Valleywise Health Medical Center Creighton University Phoenix Arizona USA Univer.ity of Texas Health Science Center Tyler Texas USA Dar.mouth College Hanover New Hampshire USA Univer.ity of Ar.zona and Cr.ighton Univer.ity Schools of Medicine Phoenix Arizona USA

A physiologic amputation is an impor.ant option for.the cr.tically ill patient who has ir.ever.ible limb disease with necr.tic wounds but who would have a low pr.bability of sur.iving a standar. open amputation, without effective pr.oper.tive r.suscitation, antibiotics, and cor.ection of metabolic der.ngements. An open amputation may be r.quir.d secondar. to vascular.ischemic disease, necr.tizing fasciitis, or.ther.al injur. that has led to the cr.tical and unstable condition. The physiologic amputation stabilizes the patient while pr.venting fur.her.metabolic deter.or.tion. The cr.oamputation is intended to r.scue the patient’s life and is not meant for.limb salvage. While physiologic amputation has been descr.bed for.over.a centur., it is uncommonly per.or.ed. This case r.por. descr.bes a physiologic amputation in a step-by-step fashion for.the sur.eon attempting to save a cr.tically ill patient’s life who might not other.ise sur.ive an open amputation.

关键词： Physiologic Amputation Cr.oamputation Cr.tically Ill Sepsis Septic Shock Cr.oanesthesia Amputation Medical Amputation

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Complex Limb Salvage with Placental-Based Allogr.fts: A Pilot Study

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Sur.ical Science 2021年第3期12卷 76-94页

作者： Danielle A. Thor.bur. Ar.ta Kowal-Ver. William H. Tettelbach Kevin N. Foster.marc r. matthews Mayo Clinic Ar.zona Department of Plastic and Reconstructive Surgery Phoenix AZ USA Depar.ment of r.sear.h Valleywise Health Medical Center Phoenix AZ USA The Ar.zona Bur. Center Phoenix AZ USA Wester. Peak Specialty Hospital Bountiful UT USA MiMedx Gr.up Inc. Marietta Georgia USA Depar.ment of Sur.er. Valleywise Health Medical Center Phoenix AZ USA

Backgr.und: Commer.ially available human placental amnion/chor.on tissue allogr.fts have been successfully used as pr.tective tr.atment bar.ier. for.wounds and diabetic ulcer.. Bur. and tr.umatic limb injur.es with ex... 详细信息

r.ng>Backgr.und: r.ng>Commer.ially available human placental amnion/chor.on tissue allogr.fts have been successfully used as pr.tective tr.atment bar.ier. for.wounds and diabetic ulcer.. Bur. and tr.umatic limb injur.es with exposed bone or.tendon gener.lly r.quir. sur.ical flaps or.amputations for.healing. The pur.ose of this study was to deter.ine if dehydr.ted human amnion/ chor.on membr.ne allogr.fts (dHACM) with decellular.zed human collagen matr.x (dHCM) could be used to salvage injur.d human extr.mities. r.ng>Methods and Mater.als:r.ng> dHACM/dHCM was topically applied to the wounds after.debr.dement. Negative Pr.ssur. Wound Ther.py (NPWT) was concur.ently initiated, pr.mar.ly to bolster.the tissue with moistur. and contamination contr.l. Appr.ximately ever. seven days, wounds wer. r.-evaluated for.gr.nulation tissue gr.wth r.sponse. As needed, patients r.ceived dHACM/ dHCM and NPWT in the outpatient or.home car. settings after.dischar.e. r.ng>r.sults:r.ng> Fifteen males and two females (26 extr.mities) wer. tr.ated for.four.een bur. and thr.e Necr.tizing Soft Tissue Infections (NSTI) injur.es. Closur. was obser.ed in patients after.two to five dHACM/dHCM applications. The dHACM/dHCM tr.atment was initiated: (median) 17-days after.injur.;NPWT for.17-days;autogr.ft or.pr.mar. closur. after.21-days;dischar.e 25-days after.the fir.t application. r.ng>Conclusion:r.ng> Tr.atment with human placental-der.ved allogr.fts pr.vided a pr.tective cover.ng that enabled the healing cascade to gener.te gr.nulation tissue for.ation in extr.mity wounds with exposed tendon and/or.bone. In select limb salvage cases, dHACM/dHCM tr.atment may be a pr.mising alter.ative to amputations, tissue r.ar.angements, fr.e tissue flaps or.other.techniques for.r.solution of extr.mity wounds with bone and tendon exposur..

关键词： Bur.s Tr.uma Placental Tissue Amnion Chor.on Bur.s Necr.tizing Soft Tissue Infections (NSTI)

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Limb Salvage Using Human Placental Allogr.fts: Adding to the r.constr.ctive Ladder.Par.digm

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Sur.ical Science 2022年第1期13卷 1-8页

作者： Stephanie Y. Ohar. Samantha A. Delapena William H. Tettelbach Lor. Whooley Sean F. O’Keefe marc r. matthews Valleywise Health Medical Center Creighton University Phoenix AZ USA Wester. Peak Specialty Hospital Bountiful UT USA MIMEDX Gr.up Inc. Marietta GA USA Depar.ment of Anesthesiology School of Medicine Duke University Durham NC USA 3M St. Paul MN USA Ar.zona Bur. Center Department of Surgery Valleywise Health Medical Center Phoenix AZ USA

Human placental allogr.fts ar. the latest tr.atment modalities for.diabetic ulcer., chr.nic wounds, limbs, and tendons for.healing cascade and pr.moting gr.nulation tissue cover.ge. Pur.on&r.g pr.cessed dehydr.ted hum... 详细信息

Human placental allografts are the latest treatment modalities for diabetic ulcers, chronic wounds, limbs, and tendons for healing cascade and promoting granulation tissue coverage. Purion® processed dehydrated human amnion/chorion membrane allografts (dHACM), decellularized human collagen matrix (dHCM), dehydrated umbilical cord (dHUC) and micronized dehydrated human amnion/chorion membrane allografts (mdHACM) have been the newest modality used to salvage injured human extremities with tendon and bone exposure. A 53-year-old male was assaulted and sustained second and third degree burns to both legs. The left extremity had a 9.5% total body surface area (%TBSA) burned. The right extremity had a 5.5% TBSA and three exposed tendons (Achilles/flexor digitorum longus/tibialis anterior), muscles, talar and tibial bones. Bilateral extremity pedal pulses were present, and all toes had less than two second capillary refill. Sensation, motor, and strength were normal. During the 48-day-hospital stay, the patient had eight operations: tangential excisional debridements of necrotic tissue with weekly wound dressing applications of dHACM and dHCM, on both legs. In addition, dHUC was applied over the exposed tendons on weeks 2 - 5. The exposed tendons were injected with mdHACM on weeks 4 and 5. Negative pressure wound therapy was applied at 125 mmHg for

关键词： Limb Salvage Placental Membr.nes Amnion Chor.on Umbilical Cor. Allogr.ft Bur.s Tr.uma

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Der.vation of a Standar.ized Method to Identify the Anter.or.Compar.ment of the Lower.Extr.mity Using Point-of-Car. Ultr.sonogr.phy

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Sur.ical Science 2021年第4期12卷 107-118页

作者： Levi T. Filler.Daniel Or.sco Car. E. Mitchell John C. Por.er.Philomene Spadafor. Kar.n J. r.chey Bikash Bhattar.i marc r. matthews Depar.ment of Emer.ency Medicine Valleywise Health System Phoenix Arizona USA Depar.ment of Emer.ency Medicine St. John’s Regional Medical Center Oxnard California USA Depar.ment of Physical Medicine and r.habilitation Valleywise Health Medical Center Phoenix Arizona USA Depar.ment of Sur.er. Valleywise Health Medical Center Phoenix Arizona USA Depar.ment of Medicine Valleywise Health Medical Center Phoenix Arizona USA Ar.zona Bur. Center Valleywise Health Medical Center Phoenix Arizona USA

Intr.duction: Anter.or.compar.ment syndr.me (ACS) of the lower.extr.mity is a well-r.cognized sur.ical emer.ency. The anter.or.compar.ment is the most fr.quently missed of the four.compar.ments dur.ng lower.extr.mity ... 详细信息

r.ng>Intr.duction:r.ng> Anter.or.compar.ment syndr.me (ACS) of the lower.extr.mity is a well-r.cognized sur.ical emer.ency. The anter.or.compar.ment is the most fr.quently missed of the four.compar.ments dur.ng lower.extr.mity fasciotomy. This study descr.bes a novel appr.ach that combines sonogr.phic measur.ments and physical examination landmar.s to accur.tely identify the anter.or.compar.ment. r.ng>Mater.als and Methods:r.ng> This study was conducted as a pr.spective anatomical study of 94 volunteer. at a single institution. Physical exam and sonogr.phic methods wer. utilized to der.ve measur.ments of the anter.or.compar.ment, followed by biometr.c and validation data. r.ng>r.sults:r.ng> Volunteer. for.the der.vation and validation phases of study wer. similar.r.gar.ing gender. height and weight, age, and BMI. The der.vation set r.vealed the distance to the anter.or.compar.ment to be 2.77 cm (median 2.6 cm, r.nge 1.5 - 5.4 cm) fr.m the mid-axial line and r.sulted in identification of the anter.or.compar.ment 100% of the time (p r. r.pr.ducible in the inter.al validation set with 100% accur.cy. r.ng>Conclusion:r.ng> The fascial planes of the anter.or.compar.ment can be identified with 100% accur.cy when utilizing physical examination and sonogr.phic methods. This can ser.e as a foundation for.futur. studies evaluating ways to r.duce of the number.of missed anter.or.compar.ment fasciotomies in the setting of ACS.

关键词： Acute Compar.ment Syndr.me Point-of-Car. Ultr.sound Missed Injur. Fasciotomy

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Necr.tizing Fasciitis Secondar. to Emphysematous Cholecystitis and Cholecystocutaneous Fistula: A r.r. Case r.por. Pr.sentation

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Sur.ical Science 2023年第5期14卷 388-397页

作者： Alexandr. N. Dominianni Samantha A. Delapena Luis G. Fer.andez Mostaffa T. Jabassini Sean F. O’Keefe r.chel L. Villanueva marc r. matthews College of Medicine-Phoenix University of Arizona Phoenix AZ USA Cr.ighton Univer.ity Ar.zona Health Education Alliance Phoenix AZ USA Depar.ment of Sur.er. Division of Trauma Surgery/Surgical Critical Care The University of Texas Health Science Center Tyler TX USA The Univer.ity of Texas-Tyler.School of Medicine Bill Bar.ett Endowed Chair.in Tr.uma Sur.er. Tyler TX USA Tr.uma Wound Car. UT Health East Tyler TX USA Depar.ment of Sur.er. University of Texas Medical Branch Galveston TX USA Adjunct Clinical Pr.fessor.of Medicine and Nur.ing University of Texas Arlington TX USA Past Commanding Gener.l TXSG Medical Br.gade Austin TX USA Sur.ical r.sident Abrazo Health Network General Surgery Residency Glendale AZ USA Ar.a Sales Manager Miach Orthopedics Sur.ical Acute Account Manager 3M Minneapolis MN USA Clinical Pr.fessor.of Sur.er. Banner University of Arizona/University Medical Center Tucson AZ USA

Emphysematous cholecystitis is a r.r. subtype of acute cholecystitis char.cter.zed by the pr.sence of gas in the gallbladder.wall secondar. to ischemia. Typically, this is a r.sult of cystic ar.er. vascular.compr.mise with a concomitant infection fr.m gas-for.ing or.anisms such as Clostr.dium species, Klebsiella species, or.Escher.chia coli. The mor.ality r.te of acute emphysematous cholecystitis is 15% - 20% compar.d with 1.4% in uncomplicated acute cholecystitis. The subsequent development of a cholecystocutaneous fistula, an abnor.al connection between the gallbladder.and the skin, is also a r.r. complication of gallbladder.disease. We descr.be a case of a 77-year.old male who pr.sented with r.ght flank necr.tizing fasciitis which developed fr.m a cholecystocutaneous fistula secondar. to emphysematous cholecystitis. Once the necr.tic tissues wer. adequately debr.ded, the lar.e open wound was tr.ated with negative pr.ssur. wound ther.py with instillation (NPWT-i) utilizing hypochlor.us acid (HOCL). The wound was closed with a split-thickness skin gr.ft.

关键词： Emphysematous Cholecystitis Gangr.nous Cholecystitis Cholecystocutaneous Fistula Necr.tizing Fasciitis Sepsis

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