Management of complicated gastroschisis with porcine small intestinal submucosa and negative pressure wound therapy

Case Report of a Neonate with Complex Gastroschisis: A Multidisciplinary Approach

Gastroschisis is a congenital anomaly characterized by herniation of abdominal contents via a defect in the anterior abdominal wall. Gastroschisis can manifest as simple or complex, with additional complications such as atresia, perforation, ischemia, necrosis, or volvulus. While prenatal screening and advancements in surgical techniques have improved outcomes, infants with complex gastroschisis cases pose significant challenges in neonatal care. Vanishing gastroschisis, a rare but dreaded complication with a mortality rate ranging from 10 to 70%, occurs when the abdominal wall closes around the herniated bowel, leading to strangulation. We present a case report focusing on the management of neonatal gastroschisis in a 36-week-old female infant with vanishing gastroschisis. The infant's clinical course, including surgical interventions, complications, and multidisciplinary management, is discussed in detail. This case underscores the importance of a multidisciplinary approach in optimizing outcomes for infants with complex gastroschisis. Via this case report, we aim to provide insights into the complexities of neonatal gastroschisis management and advocate for a collaborative approach involving neonatology, pediatric surgery, infectious disease, and palliative care to improve outcomes and quality of life for affected infants.

Acellular Bovine Pericardial Patch for Difficult Abdominal Closure in the Pediatric Population: Our Experience with Review of Literature

Aims

Closure of congenital body wall defects in children can be a challenging task for the pediatric Surgeon. Biological prosthesis has been increasingly used for high-risk wound closure in adult patients with excellent outcomes and use in the pediatric population has also been reported. Here, we aim to study the outcome of abdominal wound repair with a tissue-engineered acellular bovine pericardial patch.

Methods

Over a period of 21 months, a total of 15 children had undergone abdominal wound repair with bioprostheses, i.e., bovine pericardial patch at our institute. Patient demographics, cause of defect, an indication of patch use, rate of infection, postoperative recovery, recurrence, and outcome were studied.

Results

A total of 15 patients underwent abdominal wall closure with acellular bovine pericardial patch. Nine out of 15 patients were neonates, of whom five had gastroschisis, two had a congenital diaphragmatic hernia, and two had ruptured omphalocele major. Of the rest 6 patients, 2 were patients of bladder exstrophy, 2 were older children of congenital diaphragmatic hernia with incisional hernias, and 2 were older children with omphalocele major. Out of the five patients with gastroschisis, two died during the early postoperative period due to sepsis. The wound healed in the rest 13 patients with mild skin dehiscence in two patients. Only one child had a recurrence.

Conclusion

Reconstruction with acellular bovine pericardial patch is a viable option in children with high-risk abdominal wounds as it allows tensionless repair with excellent healing and minimal complications. Recurrence, if any, may disappear with time as remodeling of the prosthesis occurs along with the growth of the body wall of the child.

Abdominal wall hernia repair: from prosthetic meshes to smart materials

Hernia reconstruction is one of the most frequently practiced surgical procedures worldwide. Plastic surgery plays a pivotal role in reestablishing desired abdominal wall structure and function without the drawbacks traditionally associated with general surgery as excessive tension, postoperative pain, poor repair outcomes, and frequent recurrence. Surgical meshes have been the preferential choice for abdominal wall hernia repair to achieve the physical integrity and equivalent components of musculofascial layers. Despite the relevant progress in recent years, there are still unsolved challenges in surgical mesh design and complication settlement. This review provides a systemic summary of the hernia surgical mesh development deeply related to abdominal wall hernia pathology and classification. Commercial meshes, the first-generation prosthetic materials, and the most commonly used repair materials in the clinic are described in detail, addressing constrain side effects and rational strategies to establish characteristics of ideal hernia repair meshes. The engineered prosthetics are defined as a transit to the biomimetic smart hernia repair scaffolds with specific advantages and disadvantages, including hydrogel scaffolds, electrospinning membranes, and three-dimensional patches. Lastly, this review critically outlines the future research direction for successful hernia repair solutions by combing state-of-the-art techniques and materials.

Influence of advanced wound matrices on observed vacuum pressure during simulated negative pressure wound therapy

Biomaterials and negative pressure wound therapy (NPWT) are treatment modalities regularly used together to accelerate soft-tissue regeneration. This study evaluated the impact of the design and composition of commercially available collagen-based matrices on the observed vacuum pressure delivered under NPWT using a custom test apparatus. Specifically, testing compared the effect of the commercial products; ovine forestomach matrix (OFM), collagen/oxidized regenerated cellulose (collagen/ORC) and a collagen-based dressing (CWD) on the observed vacuum pressure. OFM resulted in an ∼50% reduction in the observed target vacuum pressure at 75 mmHg and 125 mmHg, however, this effect was mitigated to a ∼0% reduction when fenestrations were introduced into the matrix. Both collagen/ORC and CWD reduced the observed vacuum pressure at 125 mmHg (∼15% and ∼50%, respectively), and this was more dramatic when a lower vacuum pressure of 75 mmHg was delivered (∼20% and ∼75%, respectively). The reduced performance of the reconstituted collagen products is thought to result from the gelling properties of these products that may cause occlusion of the delivered vacuum to the wound bed. These findings highlight the importance of in vitro testing to establish the impact of adjunctive therapies on NPWT, where effective delivery of vacuum pressure is paramount to the efficacy of this therapy.

Vacuum-assisted staged omphalocele reduction: A preliminary report

INTRODUCTION

Omphalocele represents a rare congenital abdominal wall defect. In giant omphalocele, due to the viscero-abdominal disproportion, gradual reintegration of eviscerated organs is often associated with medical challenges. We report our preliminary experience combining staged gravitational reduction with vacuum (VAC) therapy as a novel approach for treatment of giant omphalocele.

PATIENTS AND METHODS

Retrospective chart review of six patients (five females) born between September 2018 and May 2022 who underwent staged reduction of giant omphalocele in conjunction with VAC therapy was conducted. Treatment was performed at two German third-level Pediatric Surgery Departments. Biometric and periprocedural data were assessed. Main outcome measure was the feasibility of VAC therapy for giant omphalocele. Data are reported as median and interquartile range (Q1-Q3).

RESULTS

Gestational age was 37 (37-38) weeks, and birth weight was 2700 (2500-3000) g. VAC dressing was changed every 3 (3-4) days until abdominal fascia closure at the age of 9 (3-13) days. Time to first/full oral feeds was 3 (1-5)/20 (12-24) days with a hospital stay of 22 (17-30) days. Follow-up was 8 (5-22) months and complications were of minor extent (none: n = 2; Clavien-Dindo I: n = 3; Clavien-Dindo II: n = 1), comprising a delayed neo-umbilical cord rest separation (n = 2) and/or concomitant neo-umbilical site infection (n = 2) with no repeat surgery.

CONCLUSION

In neonates with giant omphalocele, VAC constitutes a promising and technically feasible enhancement of the staged gravitational reduction method. This study shows evidence that VAC may accelerate restoration of the abdominal wall integrity in giant omphalocele, thus minimizing associated comorbidities inherent to a prolonged hospitalization.

Chronic wounds and novel therapeutic approaches

In the past decade, the frequency of chronic wounds in older population has increased, and their impact on quality of life is substantial. Chronic wounds are a public health problem associated with very high economic and psychosocial costs. These wounds result from various pathologies and comorbidities, such arterial and venous insufficiency, diabetes mellitus and continuous skin pressure. Recently, the role of infection and biofilms in the healing of chronic wounds has been the subject of considerable research. This paper presents an overview of various methods and products used to manage chronic wounds and discusses recent advances in wound care. To decide on the best treatment for any wound, it is crucial to holistically assess the patient and the wound. Additionally, multiple strategies could be used to prevent or treat chronic wounds.

Negative-Pressure Wound Therapy in Infants and Children: A Population-Based Study

BACKGROUND

Although the safety and benefits of negative-pressure wound therapy (NPWT) have been clearly demonstrated in the adult population, studies evaluating the safety and describing the use of NPWT in the pediatric population have been limited. Given this paucity, the goals of this study were to (1) evaluate the literature dedicated to NPWT use in infants and children and (2) leverage a population-level analysis to describe the experience of NPWT use in the pediatric population.

MATERIALS AND METHODS

We performed a literature review and analyzed the Truven Health Analytics MarketScan Commercial Claims Databases from 2006 to 2014 to identify infants and children treated with NPWT. We evaluated patient characteristics, indications, complications before and after NPWT placement, and health care utilization within 30 d of NPWT placement.

RESULTS

We identified 457 articles, 11 of which fit our inclusion criteria. Most studies (65.2%) were case reports or series with less than 10 patients. In addition, we identified 3184 patients aged younger than of 18 y who were treated with NPWT between 2006 and 2014. Serious incident complications within 30 d after NPWT placement were rare (bleeding 0.6%, septicemia 0.5%, and sepsis 0.5%).

CONCLUSIONS

Despite the lack of robust studies, NPWT is widely used for many indications and across different ages and providers. Given the low incidence of serious complications, we conclude that NPWT use in infants and children is safe and can be effectively used by different providers spanning surgical and nonsurgical disciplines.

On the significance of negative-pressure wound therapy with instillation in dermatology

Methods used in the treatment of acute and chronic wounds undergo constant evolution, reevaluation, and innovation. While negative-pressure wound therapy (NPWT) is an established treatment modality, the combination of NPWT and instillation of normal saline as well as solutions with active antiseptic components for topical treatment of the wound bed represents a novel approach. The well-known effects of NPWT may thus be combined with those of local antisepsis. They include a decrease in wound area, induction of granulation tissue, and reduction in bacterial colonization. To date, studies have focused on NPWT with instillation for orthopedic/surgical indications, whereas clinical data in dermatosurgery is limited to case reports or small case series. There are as yet no randomized prospective studies investigating NPWT with instillation in the treatment of skin disorders. The goal of this review is to present the method of NPWT with instillation, to highlight its mode of action as well as possible complications and contraindications, and to review the recent literature. In summary, there is increasing evidence that both simple and complicated wounds may be effectively treated with NPWT with instillation, resulting in markedly accelerated tissue granulation and thus earlier defect closure.

Negative pressure wound therapy in pediatric surgery: How and when to use

INTRODUCTION

Negative pressure wound therapy (NPWT) has been widely adopted to treat laparostomy, abdominal compartment syndrome (ACS) and complicated wounds associated with tissue loss. The method presents specific aspects, advantages and indications in Pediatrics. Our aim is to review the evidence available about NPWT in children.

METHODS

Active search for papers about NPWT in Pediatric patients. Papers referring to orthopedic problems, wound complications after Cardiac Surgery or burns were excluded.

RESULTS

The method shows good results to treat ACS, complicated wounds and abdominal wall malformations in neonates, including prematures. Periwound skin protection, monitoring of fluid losses and fine tuning of negative pressure levels according to age are necessary. Less pain, quicker recovery, less frequent dressing changes, possible recovery of exposed surgical hardware, granulation and shrinkage of the wound are advantages of the method over other kinds of dressing. NPWT is contraindicated over blood vessels and exposed nerves. Debridement is needed before usage over necrotic areas. Enteric fistulae are not contraindications. Complications are rare, mainly foam retention and dermatitis/skin maceration. The possibility of fistulae being caused by NPWT remains debatable.

CONCLUSION

NPWT is widely used in Pediatrics, including neonates and premature, but the evidence available about the method is scarce and low quality. Complications are uncommon and mostly manageable. A possible causal relationship between NPWY and enteric fistula remains unclear. Adult devices and parameters have been adapted to children's use. Extra care is needed to protect the delicate tissues of Pediatric patients. Comparative research to define differential costs, indications and advantages of the method, specific indications and limits of NWTP in Pediatrics is needed.

TYPE OF STUDY

Review.

EVIDENCE LEVEL

IV.

Comparative Cellular Local Response in Abdominal Defect Plastic Surgery with Bovine Pericardium and Bovine Fascia Preserved in Formaldehyde in Experimental Rabbits

In the present paper, we refer to a method of primary closure of congenital defects of the anterior abdominal wall with tensionless viscero-abdominal disproportion. The study group included 10 animals subjected to surgery of the abdominal wall defect closure with bovine pericardium graft preserved in 0.5% formaldehyde, and 5 rabbits of the same breed and weight, in which bovine fascia graft was used as implant, being preserved in 0.5% formaldehyde. The abdominal anterior wall defect was made surgically by excision of the musculo-fascial structures and peritoneum. Bovine pericardium graft and bovine fascia graft were placed and fixed posteriorly to rectus abdominals muscles, having direct contact with the intra-abdominal contents and protected by suturing skin and subcutaneous layer.

The purpose of the study was to perform a comparative postoperative evaluation of local macroscopic and microscopic changes that develop after reconstruction of the major abdominal wall defects experimentally induced in rabbits, using bovine pericardium and bovine fascia grafts preserved in 0.5% formaldehyde.

In cases of major fascial defects of the anterior abdominal wall, bovine pericardium graft has acceptable strength and biocompatibility, having stabilizing properties of the abdominal wall due to the development of the connective tissue layer located between the implant and the subcutaneous layer. Bovine fascia grafts preserved in formaldehyde have an insignificant irritating and inflammatory action on the intestinal loops compared with bovine pericardium, and do not induce the development of a significant abdominal adhesion process, this allowing their use in the abdominal fascial defects closure with placement in direct contact with the abdominal contents.

Zum Stellenwert der Unterdruck-Instillationstherapie in der Dermatologie

Die Methoden zur Behandlung akuter und chronischer Wunden unterliegen einer steten Weiterentwicklung, Reevaluierung und Anwendung innovativer Therapieformen. Die Vakuumtherapie zur Wundbehandlung gehört zu den etablierten Behandlungsmodalitäten. Ein innovatives Verfahren kombiniert die Vakuumtherapie mit der automatisierten, kontrollierten Zufuhr und Drainage wirkstoffhaltiger Lösungen zur topischen Wundbehandlung im Wundbett und auch wirkstofffrei durch Instillation physiologischer Kochsalzlösung (Unterdruck-Instillationstherapie). Hierdurch können die Effekte der konventionellen Vakuumtherapie mit denen der lokalen Antisepsis kombiniert werden. Hierdurch kommt es zu einer Reduktion der Wundfläche, einer Induktion von Granulationsgewebe sowie einer Reduktion der Keimbesiedelung der Wunden. Bisher publizierte Studien konzentrieren sich auf die Anwendung dieses Therapieverfahrens zur Behandlung orthopädisch-chirurgischer Krankheiten. Die Datenlage bezüglich der Vakuum-Instillationstherapie in der Dermatochirurgie beschränkt sich derzeit auf Fallberichte und Einzelfallerfahrungen. Randomisierte, prospektive Studien zum Vergleich der Vakuum-Instillationstherapie zur Behandlung dermatologischer Krankheitsbilder existieren bislang nicht. Ziele des vorliegenden Artikels sind die Vorstellung der Vakuumtherapie mit Instillation einschließlich ihres Wirkprinzips, deren mögliche Komplikationen, die Diskussion erdenklicher Kontraindikationen sowie eine Übersicht über die aktuell verfügbare Datenlage. Zusammenfassend scheint sich die Evidenz zu verdichten, dass mittels Unterdruck-Instillationstherapie sowohl einfache als auch komplizierte Wunden effizient behandelt werden können, was sich in einer deutlichen Beschleunigung der Wundgranulation mit konsekutiv früher möglichem Defektverschluss äußert.

Vacuum assisted closure for the treatment of complex wounds and enterocutaneous fistulas in full term and premature neonates: a case report

Background

The Vacuum Assisted Closure (VAC) system has become an effective treatment for acute and chronic wound defects. Although its use has been reported in wound care of children and premature infants, the management of the device in this population has not been well established.

Case presentation

We report the satisfactory results in two neonates (one full-term and one preterm) with complex wounds secondary to major abdominal surgery. In the premature baby an enterocutaneous fistula was also present. Complete epithelialization of the wounds was achieved in both patients within a few weeks thus avoiding any further surgical procedure.

Case presentation

The use of VAC system in neonates is safe and effective in the management of complex wounds and should be considered as a first line treatment in the event of a major dehiscence.

Management of a Giant Omphalocele with Non-Cross-Linked Intact Porcine-Derived Acellular Dermal Matrix (Strattice) Combined with Vacuum Therapy

The management of giant omphaloceles at our department is primarily conservative. However, management can be challenging if the omphalocele is ruptured or the sac has to be removed. We report a case in which a giant omphalocele in a newborn female patient was managed by covering the abdominal defect with non-cross-linked intact porcine-derived acellular dermal matrix (Strattice reconstructive tissue matrix, LifeCell Corp., Branchburg, New Jersey, United States) sutured to the fascia combined with vacuum therapy.

Negative pressure wound therapy in infants and children: a single-institution experience

BACKGROUND

Information regarding the use of negative pressure wound therapy (NPWT) in the pediatric population is limited. Because of adverse outcomes in adult patients, the Food and Drug Administration issued a warning in 2011 about the use of NPWT in infants and children.

METHODS

We performed an institutional review board-approved, single-institution, retrospective review of pediatric patients who had undergone NPWT from 2007-2011. We collected the types of wounds for which NPWT was initiated, the NPWT outcomes, and the complications encountered.

RESULTS

The data from 290 consecutive patients were reviewed. Their average age was 9.3 y (range 12 d to 18 y), and their average weight was 46.5 kg (range 1.1-177). Of the wounds, 66% were classified as acute, 10% as chronic, and 24% as traumatic. The two most common indications were surgical wound dehiscence (n = 47) and skin grafting (n = 41). NPWT was used in 15 wounds containing surgical hardware, with 2 devices requiring eventual removal. NPWT was used for a median of 9 d per patient (two dressing changes). Complications occurred in 5 patients (1.7%). Documentation problems were noted in 44 patients. After NPWT, about one-third of the patients (n = 95 patients) were able to undergo delayed primary closure.

CONCLUSIONS

NPWT is an effective adjunct in wound healing and closure in the pediatric population, with no mortality ascribed to NPWT. Also, the complication rates were low.

Combination of tissue expansion and porcine mesh for secondary abdominal wall closure after pediatric liver transplantation

We report the case of a two and a half yr boy hospitalized in our Pediatric Transplantation Unit for portal vein thrombosis following liver transplantation. After performing a meso-Rex shunt, abdominal wall closure was impossible without compressing the portal flow. A combination of two techniques was used to perform the reconstruction of the muscular fasciae and skin layers. The association of tissue expanders and porcine mesh (Surgisis(®)) allowed complete abdominal wall closure with good functional and esthetic results. Use of both techniques is a useful alternative for difficult abdominal closure after liver pediatric transplantation.

Evaluation of Surgisis for patch repair of abdominal wall defects in children

BACKGROUND

Abdominal wall defects in children are not always amenable to primary repair and may require a patch. The ideal material has yet to be established. We sought to evaluate our experience using the bioabsorbable material Surgisis (Cook Surgical, Bloomington, IN) for abdominal closure.

METHODS

A retrospective chart review of abdominal wall defects repaired with Surgisis in our institution from 2000 to 2010 was performed. Data extracted included cause of defect, age at operation, possibility of skin coverage, recurrence, length of follow-up, and rate of wound infection.

RESULTS

Thirteen patients were identified. Cause of defect was gastroschisis (n = 2), ventral hernia after diaphragmatic hernia repair (n = 2), and omphalocele (n = 9). At median follow-up of 60 months (range, 10-90), 5 (38%) of 13 patients recurred, and 1 patient recurred twice. All recurrences required subsequent patch closure. Six instances of wound infection required antibiotics. None required patch removal. There was a trend toward more frequent recurrence among infants undergoing patch repair (3/4 recurrences in this group) than neonates (1/4 recurrences) or children older than 18 months (1/5 recurrences).

CONCLUSION

Our data suggest that Surgisis is moderately successful in the repair of pediatric abdominal wall defects. We noted a trend toward a higher recurrence rate in infants. Further studies investigating timing of repair and alternative biosynthetic materials are warranted.

In vitro and in vivo studies on matrix metalloproteinases interacting with small intestine submucosa wound matrix

Small intestine submucosa (SIS), a bioactive extracellular matrix (ECM) containing critical components of the ECM including collagens, proteoglycans, and glycosaminoglycans, has been widely used for wound healing. The purpose of this study was to investigate the interaction between SIS and matrix metalloproteinases (MMPs). MMP-1, MMP-2, and MMP-9 displayed different binding affinities, indicated by a loss in activity in solution upon incubation with SIS at 53·8%, 85·9%, and 36·9% over 24 hours, respectively. A cell migration study was conducted to evaluate the effects of MMPs and SIS on keratinocytes. The results indicated that MMPs inhibit keratinocyte migration in vitro, and that the inhibition can be significantly reduced by pre-incubating the MMP solution with SIS. To evaluate activity in vivo a diabetic mouse wound healing study was conducted. Biopsy samples were collected on different days for analysis of MMP levels by gelatin zymography. MMP activity was found to be attenuated by SIS treatment on day 3 after wounding. On day 7, the attenuation became less significant indicating that the MMP binding ability of SIS had become saturated. SIS was able to reduce MMP activity immediately, and may reduce the inhibitory effects of MMPs on keratinocyte migration.

Negative pressure wound therapy in the management of neonates with complex gastroschisis

Negative pressure wound therapy (NPWT) is an accepted form of treatment in managing complex wounds in adults and children. It is not as widely used in the neonatal population due to limited clinical experience. We describe the application of the RENASYS™ system (Smith and Nephew, UK) in delivering NPWT to four neonates with complex gastroschisis, all of whom achieved successful outcomes.

Neonatal abdominal wall defects

Gastroschisis and omphalocele are the two most common congenital abdominal wall defects. Both are frequently detected prenatally due to routine maternal serum screening and fetal ultrasound. Prenatal diagnosis may influence timing, mode and location of delivery. Prognosis for gastroschisis is primarily determined by the degree of bowel injury, whereas prognosis for omphalocele is related to the number and severity of associated anomalies. The surgical management of both conditions consists of closure of the abdominal wall defect, while minimizing the risk of injury to the abdominal viscera either through direct trauma or due to increased intra-abdominal pressure. Options include primary closure or a variety of staged approaches. Long-term outcome is favorable in most cases; however, significant associated anomalies (in the case of omphalocele) or intestinal dysfunction (in the case of gastroschisis) may result in morbidity and mortality.

Management of a giant omphalocele with an external skin closure system

BACKGROUND/PURPOSE

The management of neonates with giant omphalocele remains challenging and multiple strategies have been described. We present the case of a 34-week-old neonate with isolated giant omphalocele managed with an external surgical skin closure system as a component of a staged closure strategy.

CASE PRESENTATION

An Inuit boy of 34 weeks gestation was born by urgent Caesarean delivery at an affiliated obstetrical hospital with a giant ruptured omphalocele and loss of abdominal domain. He was transferred to our institution and a silastic silo was fashioned and placed in the operating room. He returned to the operating room several times and was treated by placement of a combined Gore-Tex (WL Gore and Associates, Flagstaff, Ariz)/silastic inlay mesh. An eschar formed over this temporary closure, and we elected to place a dynamic skin closure device to continue gradual bedside reduction. The initial abdominal wall defect was 8.5 cm in transverse diameter and was reduced to 4.5 cm over 3 weeks. Complete closure was subsequently achieved without the need for skin grafting.

DISCUSSION

The use of a dynamic reduction skin closure device has not been documented previously in the pediatric population or in the context of a congenital defect. We describe the use of an external surgical skin closure device in the context of the staged closure of a giant neonatal omphalocele and postulate that such a device may prove useful in the treatment of other congenital tissue defects.

Outcomes of vacuum-assisted closure for the treatment of wounds in a paediatric population: case series of 58 patients

OBJECTIVE

This retrospective case series describes our experiences and outcomes using the vacuum-assisted closure (VAC) Therapy System for the management of difficult acute and chronic wounds in paediatric patients.

SUMMARY BACKGROUND DATA

Difficult wounds that cannot be closed primarily can create major challenges in paediatric patient care. Decreasing the time to wound closure is especially critical when managing paediatric patients.

METHODS

A retrospective review of medical records for 58 consecutive paediatric patients treated with VAC therapy was performed. Demographics, diagnosis, length of therapy, time to closure, time to discharge, type of VAC dressing used, dressing change schedule, therapy settings, and complications were recorded for each patient.

RESULTS

The median age of all 58 patients was 10 years (range, 10 days to 16 years). Fifty-four of the 58 wounds reached full closure. Patients were divided into five different groups according to diagnosis. The median time to closure for each group follows: Group 1 (abdominal wounds) 10 days (range, 3-99 days); Group 2 (surgical soft tissue deficit) 12 days (range, 3-30 days); Group 3 (trauma wounds) 7 days (range, 3-10 days); Group 4 (stage III/IV pressure ulcers) 15 days (range, 14-15 days); Group 5 (fasciotomy wounds) 5 days (range, 5-10 days). No complications were recorded for any of the patients.

CONCLUSIONS

The results demonstrate that VAC therapy may be a viable, safe and effective method of managing this difficult-to-treat population.

V.A.C. Therapy in the management of paediatric wounds: clinical review and experience

Usage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grown exponentially in the past decade. Hundreds of studies have been published regarding outcomes and methods of therapy used for adult wounds. This treatment is increasingly being used to manage difficult-to-treat paediatric wounds arising from congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children, although relatively few studies have been aimed at this population. Given the anatomical and physiological differences between adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use of NPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure (V.A.C. Therapy, KCI Licensing, Inc., San Antonio, TX) for the treatment of paediatric wounds. The primary objectives of the expert advisory panel were to exchange state-of-practice information on paediatric wound care, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of the existing data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposed paediatrics-specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisions could be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequency and use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriate wound care at the time of publication. They are the result of consensus reached by expert advisory panel members based on their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds. Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panel may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the collaborating medical team, including the surgeon and wound care specialist based on available resources, individual patient circumstances and experience with the V.A.C. Therapy System.

Are biologic grafts effective for hernia repair?: a systematic review of the literature

Biologic grafts for hernia repair are a relatively new development in the world of surgery. A thorough search of the Medline database for uses of various biologic grafts in hernia shows that the evidence behind their application is plentiful in some areas (ventral, inguinal) and nearly absent in others (parastomal). The assumption that these materials are only suited for contaminated or potentially contaminated surgical fields is not borne out in the literature, with more than 4 times the experience being reported in clean fields and the average success rates being higher (93% vs 87%). Outcomes prove to be highly dependent on material source, processing methods and implant scenarios with failure rates ranging from zero to more than 30%. Small intestinal submucosa (SIS) grafts have an aggregate failure rate of 6.7% at 19 months whereas acellular human dermis (AHD) grafts have a failure rate of 13.6% at 12 months. Chemically cross-linked grafts have much less published data than the non-cross-linked materials. In particular, the search found 33 articles for SIS, 32 for AHD, and 13 for cross-linked porcine dermis. Furthermore, the cumulative level of evidence for each graft material was fairly low (2.6 to 2.9), and only 1 material (SIS) had level 1 evidence reported in any hernia type (inguinal and hiatal). Together, biologic grafts have published evidence showing success rates better than 90% overall and more than 2000 years of cumulative implant time. Improvements in materials, techniques, and patient selection are likely to improve these numbers as this field of surgery matures.

Vacuum-assisted closure for complicated neonatal abdominal wounds

BACKGROUND

Neonatal experience in vacuum-assisted closure (VAC) for complex abdominal wounds remains scant.

METHODS

A neonatal VAC protocol was instituted in 2004. The medical records of patients treated with this protocol for the ensuing 3 years were retrospectively reviewed. Continuous data are reported as mean +/- SD (range).

RESULTS

Ten VAC applications occurred in 8 neonates for a 3-year period. Gestational age and age at VAC application were 30 +/- 6.9 (24-40) weeks and 84.5 +/- 51 (21-165) days, respectively. Birth weight and weight at VAC application were 1495 +/- 1118 (615-3415) g and 3515 +/- 2118 (989-7965) g, respectively. All wound complications occurred after laparotomies (7 elective, 3 emergent). Three wounds included intestinal stomas, and 3 included enterocutaneous fistulae. Average wound area at VAC initiation was 13.6 +/- 6.0 (8.5-25) cm(2). Duration of VAC use was 19.1 +/- 15.3 (7-60) days. Vacuum-assisted closure resulted in complete wound closure in all cases and did not result in any local or systemic complications. Five patients (63%) survived to discharge.

CONCLUSIONS

Vacuum-assisted closure for complicated abdominal wounds is safe and successful in neonates of any gestational age and birth weight. It provides effective wound management, even in the presence of stomas or enterocutaneous fistulae.

Negative pressure wound therapy with reticulated open cell foam in children: an overview

This article summarizes the results of a comprehensive review of the literature on the use of negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by V.A.C.(R) Therapy (KCI, San Antonio, TX) in pediatric patients. A review of the literature revealed 20 articles that discussed the use of NPWT/ROCF in exclusively pediatric patients. Nine articles were retrospective reviews, and 11 were case studies. This review discusses the insights from these articles. This review discusses the versatility of NPWT/ROCF for use with pediatric patients with infected wounds; full-thickness burns; open fractures; large soft tissue wounds; surgical wounds of the chest, abdomen, and spine; pilonidal disease; and pressure ulcers. NPWT/ROCF has been used in children as young as a few weeks of age, and in children with comorbidities such as congenital heart disease, immunosuppression, and spina bifida. Wound healing in children can be delayed by impaired perfusion, infection, edema, and poor nutrition. Clinical considerations for using NPWT/ROCF in children can include differences in healing due to higher granulation rates requiring more frequent dressing changes, poor nutritional status, small size, and low weight. With pediatric patients, there is no consensus on foam (white or black) selection, optimum amount of negative pressure, frequency of NPWT/ROCF dressing changes, and interposing contact layer selection. Randomized prospective studies are needed to make recommendations for safe and efficacious clinical practice. Research regarding the effects of dressing types, adjunctive treatment, and wound healing in neonates and children is needed.

Contemporary postnatal surgical management strategies for congenital abdominal wall defects

Early definitive closure of abdominal wall defects is possible in most cases. Staged reduction does offer distinct advantages, and mortality and morbidity may be better. Risk stratification may produce outcome and tailor management of difficult cases in the form of a clinical pathway. Stem cell technology may, in the future, offer the ideal allogenic prosthesis in complex cases.

Negative pressure wound therapy with instillation: a pilot study describing a new method for treating infected wounds

This data review reports the results of 15 patients who were treated with Vacuum-Assisted Closure (VAC) negative pressure therapy system in addition to the timed, intermittent delivery of an instilled topical solution for management of their complex, infected wounds. Prospective data for 15 patients treated with negative pressure wound therapy (NPWT)-instillation was recorded and analysed. Primary endpoints were compared to a retrospective control group of 15 patients treated with our institution's standard moist wound-care therapy. Culture-specific systemic antibiotics were prescribed as per specific patient need in both groups. All data were checked for normality of distribution and equality of variance and appropriate parametric and non parametric analyses were conducted. Compared with the standard moist wound-care therapy control group, patients in the NPWT-instillation group required fewer days of treatment (36.5 +/- 13.1 versus 9.9 +/- 4.3 days, P < 0.001), cleared of clinical infection earlier (25.9 +/- 6.6 versus 6.0 +/- 1.5 days, P < 0.001), had wounds close earlier (29.6 +/- 6.5 versus 13.2 +/- 6.8 days, P < 0.001) and had fewer in-hospital stay days (39.2 +/- 12.1 versus 14.7 +/- 9.2 days, P < 0.001). In this pilot study, NPWT instillation showed a significant decrease in the mean time to bioburden reduction, wound closure and hospital discharge compared with traditional wet-to-moist wound care. Outcomes from this study analysis suggest that the use of NPWT instillation may reduce cost and decrease inpatient care requirements for these complex, infected wounds.

The use of Surgisis for abdominal wall reconstruction in the separation of omphalopagus conjoined twins

Abdominal wall reconstruction in omphalopagus twins poses a difficult reconstructive challenge, as separation often results in a large abdominal wall defect. A number of options are available for closure, including tissue flaps, expanders and patches made of foreign material. Surgisis is a new biodegradable small intestine scaffolding substrate that permits tissue in-growth and results in a permanent durable scar. We describe its use in abdominal wall reconstruction after separation of a set of conjoined twins. A set of omphalopagus conjoined twins shared liver and abdominal wall. After separation at 6 months of age, Twin A's abdomen could be closed primarily, but Twin B could not. A 4-ply Surgisis mesh was used in the upper abdominal closure, and a skin flap was created, to completely cover the patch. Both twins survived the operation. A small portion of the skin flap over the Surgisis broke down, healing by secondary intention. In follow up of over 18 months post procedure, there have been no wound infections and the abdominal wall is intact with no evidence of a hernia. Surgisis can be successfully used for the reconstruction of complex abdominal wall defects in the pediatric patient, including reconstruction after separation of conjoined twins.

The novel use of small intestinal submucosal matrix for chest wall reconstruction following Ewing's tumour resection

Chest wall reconstruction following major tumour resection remains a challenging problem in the paediatric population due to the need for growth and development following the repair. Synthetic non-biodegradable grafts and materials have led to asymmetrical growth and significant functional and cosmetic compromise. The ideal graft material should be biological non-immunogenic which enables natural healing and facilitates further growth. Ewing's sarcoma is an uncommon primitive neuroectodermal tumour which rarely occurs in the ribs. However, recent improvements in management have produced a significantly improved survival; increasing the importance of chest wall reconstruction. We prospectively assessed the utilisation of Surgisis (an acellular collagen matrix) as a replacement graft in two children undergoing primary chest wall reconstruction following tumour resection. Surgisis is derived from porcine small intestinal submucosa (SIS) that serves as a template for tissue reconstruction and remodeling. The graft was well tolerated; there was no herniation and it allowed normal symmetrical chest movement and growth to occur. The properties of SIS allows natural collagen growth and compares favourably with marlex mesh and other forms of chest wall reconstruction. We believe its unique properties allow it to act as a suitable framework for chest wall reconstruction allowing chest wall growth and development.