The vacuum-assisted closure (V.A.C®) system for surgical site infection with involved vascular grafts

Esophageal Perforation and EVAC in Pediatric Patients: A Case Series of Four Children

Introduction: In pediatric patients, esophageal perforation (EP) is rare but associated with significant morbidity and mortality rates of up to 20-30%. In addition to standard treatment options, endoscopic esophageal vacuum-assisted closure (EVAC) therapy has shown promising results, especially in adult patients. Thus far, the only data on technical success and effectiveness of EVAC in pediatric patients were published in 2018 by Manfredi et al. at Boston Children's Hospital. The sparse data on EVAC in children indicates that this promising technique has been barely utilized in pediatric patients. More data are needed to evaluate efficacy and outcomes of this technique in pediatric patients. Method: We reviewed five cases of therapy using EVAC, ArgyleTM Replogle Suction Catheter (RSC), or both on pediatric patients with EP in our institution between October 2018 and April 2020. Results: Five patients with EP (median 3.4 years; 2 males) were treated with EVAC, RSC, or a combination. Complete closure of EP was not achieved after EVAC alone, though patients' health stabilized and inflammation and size of EP decreased after EVAC. Four patients then were treated with RSC until the EP healed. One patient needed surgery as the recurrent fistula did not heal sufficiently after 3 weeks of EVAC therapy. Two patients developed stenosis and were successfully treated with dilatations. One patient treated with RSC alone showed persistent EP after 5 weeks. Conclusion: EVAC in pediatric patients is technically feasible and a promising method to treat EP, regardless of the underlying cause. EVAC therapy can be terminated as soon as local inflammation and C-reactive protein levels decrease, even if the mucosa is not healed completely at that time. A promising subsequent treatment is RSC. An earlier switch to RSC can substantially reduce the need of anesthesia during subsequent treatments. Our findings indicate that EVAC is more effective than RSC alone. In some cases, EVAC can be used to improve the tissues condition in preparation for a re-do surgery. At 1 year after therapy, all but one patient demonstrated sufficient weight gain. Further prospective studies with a larger cohort are required to confirm our observations from this small case series.

Negative-Pressure Wound Therapy for Managing Complicated Wounds at Extracorporeal Membrane Oxygenation Sites

OBJECTIVE

To evaluate the effectiveness of negative-pressure wound therapy (NPWT) for management of wound complications at extracorporeal membrane oxygenation (ECMO) removal sites.

METHODS

The authors retrospectively reviewed patients who underwent NPWT at ECMO removal sites followed by the development of wound complications including skin necrosis, lymphorrhea, and femoral vessel exposure. A nonadhesive bacteria-binding mesh was used as a wound contact layer of NPWT application. Patient characteristics and clinical outcomes were evaluated.

RESULTS

Nine patients underwent NPWT for complicated wounds at ECMO sites. The mean age of patients was 49.2 years (range, 14-64 years). All patients exhibited wound complications with lymphorrhea and skin necrosis. Seven of nine patients had wound cultures that were positive for microorganisms, but culture conversion to negative was achieved after NPWT application for a mean period of 21.2 days (range, 12-30 days). Lymphorrhea was successfully managed, and formation of fresh granulation tissue was observed in all patients. Wound healing either by primary closure, skin graft, or secondary healing was achieved without recurrence of wound complications. There were no cases of femoral vessel injury or aneurysm during NPWT application.

CONCLUSIONS

Negative-pressure wound therapy appears to be a safe and effective treatment option in the management of complicated wounds at ECMO sites.

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 for prevention and treatment of surgical-site infections after vascular surgery

BACKGROUND

Indications for negative-pressure wound therapy (NPWT) in vascular surgical patients are expanding. The aim of this review was to outline the evidence for NPWT on open and closed wounds.

METHODS

A PubMed, EMBASE and Cochrane Library search from 2007 to June 2016 was performed combining the medical subject headings terms 'wound infection', 'abdominal aortic aneurysm (AAA)', 'fasciotomy', 'vascular surgery' and 'NPWT' or 'VAC'.

RESULTS

NPWT of open infected groin wounds was associated with shorter duration of wound healing by 47 days, and was more cost-effective than alginate dressings in one RCT. In one RCT and six observational studies, NPWT-related major bleeding and graft preservation rates were 0-10 and 83-100 per cent respectively. One retrospective comparative study showed greater wound size reduction per day, fewer dressing changes, quicker wound closure and shorter hospital stay with NPWT compared with gauze dressings for lower leg fasciotomy. NPWT and mesh-mediated fascial traction after AAA repair and open abdomen was associated with high primary fascial closure rates (96-100 per cent) and low risk of graft infection (0-7 per cent). One retrospective comparative study showed a significant reduction in surgical-site infection, from 30 per cent with standard wound care to 6 per cent with closed incisional NPWT.

CONCLUSION

NPWT has a central role in open and infected wounds after vascular surgery; the results of prophylactic care of closed incisions are promising.

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.

Prosthetic Vascular Graft Infections: Bacterial Cultures from Negative-Pressure-Wound-Therapy Foams Do Not Improve Diagnostics

We analyzed the diagnostic value of microorganisms cultured from negative-pressure-wound-therapy (NPWT) foam samples compared to that of microorganisms cultured from deep tissue samples from patients with vascular graft infections. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 58%, 86%, 81%, and 66%, respectively. The diagnostic value of microbiological cultures from NPWT foams was poor.

Leg for life? The use of sartorius muscle flap for the treatment of an infected vascular reconstructions after VA-ECMO use. A case report

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Use of VA-ECMO systems may be encumbered by severe vascular complications.

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Infections developed after femoral arterial surgery cause significant morbidity.

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Coverage of vascular structures with a muscle flap can achieve site sterilization.

Introduction

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO1) systems are a life-saving option in the treatment of acute respiratory distress syndrome (ARDS2), but may be encumbered by severe vascular complications in the groin.

Presentation of case

A pregnant woman was admitted with respiratory failure due to H1N1 influenza. VA-ECMO was inserted percutaneously by the intensivists and then accidentally removed by the patient after 8 days. 24 h later VA-ECMO was reinstalled with surgical denudation of femoral vessels in another department. 2 h later, due to active bleeding and signs of limb ischemia, the patient was referred to our department and emergency trombectomy and patch angioplasty with PTFE were performed. Evolution was further bad with wound infection (Pseudomonas, Proteus), which imposed large debridement, replacing the PTFE patch with 2 parallel venous patches and wound reconstruction through sartorius muscle rotation. The wound underwent negative pressure therapy for 10 days and was skin grafted. The patient recovered under systemic antibiotic and virostatic therapy.

Discussion

Major complications of using VA-ECMO devices are related to vascular access, most common bleeding at the puncture site and acute limb ischemia. In the groin, sartorius muscle flap is the most used for vascular coverage and small tissue defect reconstruction because of the ease in harvesting and low donor-site complications.

Conclusion

Although ischemic complications associated with VA-ECMO are accepted by intensivists under the slogan “leg for life”, for the repair of the femoral artery in the presence of groin infection the sartorius muscle remains an efficient solution for limb salvage.

Efficacy and safety of negative pressure wound therapy for Szilagyi grade III peripheral vascular graft infection

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether it is safe and effective to use negative pressure wound therapy (NPWT) for Szilagyi grade III (i.e. the arterial implant proper involved in the infection) peripheral vascular graft infection. Altogether, 69 papers were found using the reported search. From the search results, reference lists of potentially eligible studies and related citations in PubMed, seven papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In the only randomized, controlled trial that compared NPWT (n = 10) and alginate dressing change (n = 10), the NPWT group demonstrated shorter time to full skin epithelialization (median 57 vs 104 days; P = 0.026). In the other six case series, the recruited case number ranged from 12 to 72. The mode of NPWT varied among the included studies, with the majority using a continuous negative pressure of 125 mmHg. One study combined NPWT and sartorius myoplasty, another used sartorius myoplasty in selected cases and others did not. The mean duration of using NPWT ranged from 14.2 to 43 days. The mean duration to achieve complete wound healing ranged from 24 (the study with sartorius myoplasty) to 51 days. The NPWT treatment failure rate ranged from 0 (the study with sartorius myoplasty) to 25%. The major complication of NPWT was bleeding and the incidence rate was reported to be <10%. We conclude that the amount of evidence for recommending NPWT alone as the first-line treatment for Szilagyi grade III peripheral vascular graft infection is small with only one small-sized randomized controlled trial demonstrating that NPWT alone is superior to alginate dressing change in shortening the time to complete wound healing by 2 months. Limited evidence (case series with >1 year of follow-up) showed that NPWT with a continuous negative pressure of 125 mmHg, or combined NPWT and sartorius myoplasty, may shorten the time to complete wound healing by 2 months, have a >70% success rate, and have a <10% NPWT-related complication rate.