Incisional Application of Negative Pressure for Nontraumatic Lower Extremity Amputations: A Review

In the environment of diabetes and peripheral vascular disease (PVD), there is a high risk of incisional complications following amputation, including seroma, hematoma, infection, and dehiscence. Incisional negative-pressure wound therapy (iNPWT) is a novel application of negative-pressure wound therapy (NPWT) that may be able to mitigate these complications and reduce the need for revisional surgery (including higher-level major lower-extremity amputations). It may also facilitate an increased rate of healing and earlier return to function. iNPWT has been used successfully in high-risk patients to decrease complications. In highly comorbid patients receiving iNPWT for primary closure of abdominal wall reconstruction, incisional infection rates were reduced from 48% to 7% (p=0.029). Furthermore, the need for revisional surgery was significantly decreased in those treated with iNPWT (48% vs.7%, p<0.001), as was the rate of dehiscence (10.68% vs. 5.32%, p<0.001). Major lower-extremity amputations in the multi-comorbid patient have a 16% incidence of incisional dehiscence. Additionally, the rate of infection has been reported to be as high as 22%. Five-year mortality following major lower-extremity amputation is reported to be 50% or higher. This high mortality rate is due, in part, to wound-healing complications. iNPWT can potentially reduce these healing complications and mortality. As of yet, no prospective, randomized trial has shown reduced morbidity, earlier return to function, or reduced mortality with the use of iNPWT after a lower-extremity amputation. This review presents recent findings regarding the use of iNPWT. Further studies on this topic are needed.

Conserving nephrons in cholesteatoma

A case of cholesteatoma, clearly delineated by preoperative air contrast retrograde pyelography, was treated like stone disease by removal of the obstructing material from the renal pelvis and pelvic ureter. A 7-year followup suggests that conservative surgical management may be the preferred treatment, since there is no evidence to date that cholesteatoma is a pre-malignant lesion nor necessarily a recurrent condition.