Effect of incisional negative pressure therapy and conventional treatment on wound complications after orthopaedic trauma surgery: A meta-analysis of randomized controlled studies

The results of this meta-analysis were applied to analyse the effects of Negative Pressure Wound Therapy (NPWT) and conventional dressings on post-surgical outcomes after trauma in orthopaedics. Through June 2023, a full review of the literature has been carried out with the help of 4 databases, PubMed, Embase, Cochrane Library, and the Web of Science. The quality of the literature was evaluated according to the classification and exclusion criteria established for this trial, which led to an analysis of 9 related trials. The results included the injury was deeply and superficially infected, and the wound was dehiscence. The 95% confidence interval (CI) and odds ratios (OR) were computed by means of a fixed-effect and a random-effect model. Meta-analyses were conducted with RevMan 5.3. There is no statistical significance between NPWT and routine therapy for deep wound infection (OR, 1.37; 95% CI, 0.82-2.27, p = 0.23); There was no difference in the incidence of inflammation in the wound than with conventional dressings (OR, 1.10; 95% CI, 0.84-1.45, p = 0.49); But NPWT was obviously superior to that of routine therapy in superficial wound infection (OR, 2.07; 95% CI, 1.32-3.25, p = 0.002) and wound dehiscence (OR, 2.44; 95% CI, 1.31-4.57, p = 0.005); But not with respect to wound exudate. therapy group, but no statistically significant difference was found with respect to wound exudation. (OR, 1.16; 95% CI, 0.86-1.57, p = 0.34). Given that some of the chosen trials are too small for this meta-analysis, caution should be exercised when treating their values. More high-quality research with a large sample is required in order to confirm the findings.

The outcome of sutured wounds compared with tissue adhesive for paediatric wound closure: A meta-analysis

A meta-analysis investigation was executed to measure the outcome of sutured wounds (SWs) compared with tissue adhesive (TA) for paediatric wound closure (PWC). A comprehensive literature inspection till February 2023 was applied and 2018 interrelated investigations were reviewed. The 18 chosen investigations enclosed 1697 children with PWC in the chosen investigations' starting point, 977 of them were utilising SWs, and 906 were utilising TA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of SWs compared with TA for PWC by the dichotomous approaches and a fixed or random model. SWs had significantly higher wound cosmetic (WC) scores (mean deviation [MD], 1.70; 95% CI, 0.57-2.84, P = .003), lower wound dehiscence (WD) (OR 0.60; 95% CI, 0.06-0.43, P < .001), and lower cost (MD, -10.22; 95% CI, -10.94 to -9.50, P < .001) compared with those with TA in PWC. No significant difference was found between children utilising SWs and TA in wound infection (WI) (OR, 0.45; 95% CI, 0.15-1.30, P = .14) with no heterogeneity (I2  = 0%) in PWC. SWs had significantly higher WC scores, lower WD, and lower cost, yet, no significant difference was found in WI compared with those with TA in PWC. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations and the low number of selected investigations for the meta-analysis.

Surgical site complications in kidney transplant recipients: incidence, risk factors and outcomes in the modern era

BACKGROUND

Surgical site complications (SSCs) are an important source of morbidity after kidney transplantation. We assessed the incidence, risk factors, outcomes and economic impact of SSCs in a large, diverse population of kidney transplant recipients.

METHODS

We conducted a single-centre, observational cohort study of adult (age ≥ 18 yr) patients who underwent kidney transplantation between Jan. 1, 2005, and Dec. 31, 2015, with a minimum of 1 year of follow-up. Cases of SSC, including infections and wound dehiscence, were determined from patient records. Inpatient and outpatient hospital costs were determined 6 and 12 months after transplantation. We used the Kaplan-Meier product-limit method to determine the cumulative probability of SSCs and other outcomes. We evaluated risk factors and clinical outcomes using Cox proportional hazard ratios. Linear regression models were used to study the effect of SSCs on graft function.

RESULTS

The incidence rate of SSCs within 30 days after transplantation was 4.19 per 100 person-months. The cumulative probability of developing an SSC within 30 days after transplantation was 4.13% (95% confidence interval [CI] 3.23%-5.28%). Increased recipient body mass index (BMI) (hazard ratio [HR] 1.07, 95% CI 1.02-1.11), longer cold ischemic time (HR 1.05, 95% CI 1.01-1.09) and transplantation in 2010-2012 versus 2005-2009 (HR 2.20, 95% CI 1.19-4.04) were risk factors for SSC development. In multivariable stepwise Cox proportional hazard models, SSC was a significant risk factor for death-censored graft failure (HR 3.08, 95% CI 1.60-5.90) and total graft failure (HR 2.09, 95% CI 1.32-3.32). Cumulative median hospital costs were $2238.46 greater for patients with an SSC than for those without.

CONCLUSION

Increased BMI, longer cold ischemic time and the 2010-2012 transplantation period predisposed to SSCs. The development of SSCs was associated with a higher risk of graft failure. Strategies to minimize SSCs may improve outcomes after kidney transplantation and reduce costs.

Surgical Wound Dehiscence Treatment With Low-Level Laser Therapy and Barbatimão: A Case Report

BACKGROUND

Low-level laser therapy (LLLT) and a gel containing an extract of Barbatimão, a native Brazilian tree, have shown promising results in both preclinical and clinical wound healing studies.

PURPOSE

To describe the treatment of surgical wound dehiscence with LLLT and Barbatimão gel.

CASE STUDY

A 54-year-old woman without comorbidities underwent abdominoplasty at another health facility. Three (3) weeks later she presented to the authors' clinic after an episode of syncope, abrupt dyspnea, purulent exudate, and necrotic tissue in the surgical incision. She reported that wound redness, warmth, and swelling started 8 days postoperatively. The patient was admitted; on day 3 of that hospital stay, her condition improved and surgical debridement was performed. Follow-up care of wound dehiscence was provided in the outpatient clinic. The treatment involved daily application of Barbatimão gel and weekly application of LLLT. The wound healed after 84 days.

CONCLUSION

This case report suggests that LLLT may be a beneficial adjunctive therapy, together with Barbatimão gel, for the treatment of surgical wound dehiscence.

Effects of Negative Pressure Wound Therapy on Wound Dehiscence and Surgical Site Infection Following Instrumented Spinal Fusion Surgery-A Single Surgeon's Experience

BACKGROUND

Incisional negative pressure wound therapy (NPWT) is used in many surgical specialties to prevent postoperative dehiscence and surgical site infections (SSIs). However, little is known about the role of incisional NPWT in spine fusion surgery. Therefore, we sought to report a single surgeon's experience using incisional NPWT and describe its effects on dehiscence and SSIs after instrumented spine surgery.

METHODS

We compared rates of hospital readmission and return to the operating room for dehiscence and SSIs in a consecutive series of patients who underwent spinal fusion surgery with or without NPWT from 2015 to 2018.

RESULTS

A total of 393 patients without and 76 patients with NPWT were included for analysis. Half way through the data collection period, all patients who underwent anterior lumbar fusion received NPWT. Three of 15 (20.0%) of non-NPWT patients who underwent anterior lumbar fusion had dehiscence or SSI compared with zero of 23 (0.0%) of NPWT patients (P = 0.01). NPWT for posterior surgeries was used on a case-by-case basis using risk factors that contribute to SSIs and dehiscence. NPWT patients had higher rates of spinal neoplasia (0.5% vs. 11.3%, P < 0.0001), osteomyelitis/diskitis (1.3% vs. 7.5%, P = 0.02), durotomy (14.9% vs. 28.6%, P = 0.007), revision surgery (32.2% vs. 59.6%, P = 0.0001), and longer fusion constructs (7 vs. 11 levels, P < 0.0001) but had similar rates of dehiscence and SSIs as non-NPWT patients (5.6% vs. 5.7%, P = 0.98).

CONCLUSIONS

NPWT decreases dehiscence and SSIs in patients undergoing lumbar fusion through an anterior approach. When preferentially used in patients at high risk for postoperative wound complications, NPWT prevents increased rates of dehiscence and SSI.

Efficacy of a Urinary Bladder Matrix for Treating Wound Dehiscence With Hardware Exposure in a Patient With Rheumatoid Arthritis

OBJECTIVE

This case report explores an effective treatment modality in a medically complicated patient, with considerable wound dehiscence refractory to treatment with negative pressure wound therapy (NPWT).

CASE REPORT

A 35-year-old woman with a past medical history of hypothyroidism, osteoporosis, and rheumatoid arthritis treated with tumor necrosis factor (TNF) alpha inhibitors and disease-modifying antirheumatic drugs presented to the clinic following right great toe arthrodesis, metatarsal neck osteotomies, extensor tendon lengthening, and capsulotomy of the second, third, fourth, and fifth toes 2 weeks prior, with wound dehiscence of the right great toe and subsequent exposure of surgical hardware, complicated by infection. At the 2-week postop, a urinary bladder matrix was placed on the wound following failed NPWT, which was in place for 10 days. At the 3-month follow-up, the wound was closed and without any drainage. Patient reported a significant reduction in pain (visual analogue scale: 3) with adherence to weight-bearing restrictions.

CONCLUSIONS

Wound healing was accomplished without removal of the exposed deep hardware in a patient with comorbidities and post-surgical wound dehiscence.

Type and Consequences of Short-Term Complications in Colon Cancer Surgery, Focusing on the Oldest Old

BACKGROUND

While the proportion of colon cancer occurring in older patients is expected to increase, these patients may have more complications that may lead to serious consequences. The aim of this study was assess postoperative complications and their short-term consequences in colon cancer surgery according to age.

PATIENTS AND METHODS

Patients undergoing surgery for primary invasive colon cancer in 22 centers between June 2010 and December 2012 were included. Presurgical and surgical variables were analyzed, and in-hospital major postoperative complications and its most serious consequence (no relevant, transfusion, reintervention, admission to the intensive care unit, or death) were estimated according to age group. Chi-square tests were used to analyze the possible associations between variables and age groups.

RESULTS

Data from 1976 patients, mean (range) age 68 (24-97) years, 62% men, were analyzed; 52.2% were aged > 69 years and 17.7% were aged > 79 years. The complication rate was 25.3%, reaching 30.9% in those aged ≥ 80 years. Older age was associated with a higher rate of postoperative infections during the hospital stay. The most common surgical complication in patients aged > 85 years was dehiscence of the anastomosis (11.5%). About 5% of patients with major complications died in the hospital (11.1% of those aged 80-84 years and 14.3% aged > 85 years). Among patients aged > 85 years, 38.1% required transfusions.

CONCLUSION

Older patients should receive appropriate functional preparation before the intervention, and when the risks of the intervention outweigh the potential benefits, a nonsurgical approach may be preferable.

Benefits of a Patient-centered Remote Therapy Monitoring Program Focusing on Increased Adherence to Wound Therapy

INTRODUCTION

Patient nonadherence to wound care protocols may impact the efficacy of modalities, such as negative pressure wound therapy (NPWT). Recently, a remote therapy monitoring (RTM) system has been devised for use with NPWT for home care patients.

OBJECTIVE

Three home care patients receiving NPWT are presented to examine the relationship between patients using the RTM system and Virtual Therapy Specialists (VTS).

MATERIALS AND METHODS

Consent was secured from patients with either multiple comorbidities and/or wounds of varying complexity. Wounds were assessed as per their initial presentation, and all patients were discharged home with an RTM-equipped NPWT system to apply continuous subatmospheric pressure to their wound. Dressings were changed every 2 to 3 days.

RESULTS

All 3 patients were women (age range, 53-72 years), who presented with the following wound types: recalcitrant abdominal wound, acute wound following ventral hernia repair, and dehisced wound following a hysterectomy. Patient 1 was treated with RTM-equipped NPWT for a duration of 88 days (6 nonadherent vs. 82 adherent days) and was adherent to the therapy 93.2% of the time. Patient 2 was treated with RTM-equipped NPWT for a duration of 57 days (8 nonadherent vs. 49 adherent days) and was adherent to the therapy 86.0% of the time. Patient 3 was treated with RTM-equipped NPWT for a duration of 16 days (2 nonadherent vs. 14 adherent days) and was adherent to the therapy 87.5% of the time. Each patient presented with a barrier to therapy adherence (eg, lack of access to residential clinical support, technical issues, or work demands) that was managed by VTS interactions.

CONCLUSIONS

In these 3 cases, RTM-equipped NPWT and the patient-centric exchanges with the VTS through adherence calls helped promote consistent usage of RTM-equipped NPWT to address the patients' therapeutic needs and increase therapy adherence.

Treatment experience for full-thickness wound dehiscence with cerebrospinal fluid leakage following posterior primary spine surgery: Three case reports

RATIONALE

Full-thickness wound dehiscence with cerebrospinal fluid (CSF) leakage following posterior spine surgery is a rare but troublesome complication. In the present study, 3 clinical cases associated with this entity are reported.

PATIENT CONCERNS

The first case developed incision effusion 5 days after posterior decompression and internal fixation for lumbar spinal stenosis. The second case has the same diagnosis and treatment with the first case. She developed intraoperative CSF leak and incision effusion 7 days after the surgery. The third case developed incision effusion 6 days after posterior single door laminoplasty for cervical spondylosis.

DIAGNOSIS

All cases developed CSF leak, incision effusion and finally full-thickness wound dehiscence on the postoperative period.

INTERVENTIONS

Bed rest, drainage, vacuum sealing drainage (VSD), and reoperations were applied in all of the patients. Trapezius flap transfer was applied to the third case. One lumbar patient developed deep infection and meningitis; thus, the internal fixation and bone graft were removed.

OUTCOMES

All of the patients received wound healing finally and were followed up for >6 months. No incision complications reoccurred, and preoperative symptoms significantly relieved.

LESSONS

Several techniques can be adopted to minimize the incidence of complications and proper surgical repair is the most important. Lumbar cistern drainage and VSD are recommended. Some other available options of management will also help.

Use of an Extracellular Matrix Patch for Sternal Wound Dehiscence after Cardiac Surgery in a Neonate

Management of sternal wound dehiscence in newborns after cardiac operations can be a slow and lengthy process, during which the risk of progression to deep sternal wound infection and mediastinitis remains a concern. We report the case of a neonate born with single-ventricle physiology who underwent a Damus-Kaye-Stansel procedure as first-stage palliation toward creating Fontan circulation. The postoperative period was characterized by sterile wound dehiscence of the subcutaneous layers. We used a CorMatrix extracellular matrix patch as an adjunct to repair the wound defect. After 7 weeks, the wound had healed with excellent results. To our knowledge, this is the first report of extracellular matrix patch implantation for sternal wound reconstruction in a neonate.

Effect of a New Purified Collagen Matrix With Polyhexamethylene Biguanide on Recalcitrant Wounds of Various Etiologies: A Case Series

INTRODUCTION

The management of chronic, nonhealing wounds in patients with multiple comorbidities continues to be a challenge for health care practitioners. Chronic wounds typically do not progress through the normal phases of wound healing and generally remain stagnant during the inflammatory phase, resulting in an increase in proteolytic enzymes with degradation of the extracellular matrix. Bacterial biofilm has been documented to be one of the main factors delaying wound healing, resulting in the prolongation of the inflammatory phase.

OBJECTIVE

In order to control biofilm formation, sequester proteolytic enzymes, and provide a biocompatible scaffold to support healing, the investigators utilize a purified collagen matrix containing polyhexamethylene biguanide (PCMP) in a case series of 9 wounds on 8 patients with multiple comorbidities who did not respond to previous conventional or adjuvant therapy.

MATERIALS AND METHODS

Wound etiologies included 3 pressure ulcers, 1 diabetic foot ulcer, 1 venous leg ulcer, 2 postsurgical wound dehiscences, 1 ulcer secondary to calciphylaxis, and 1 traumatic wound secondary to hematoma. The average wound size at the first PCMP application was 34.0 cm2, and the wounds were present for an average of 9.2 weeks prior to the first PCMP application.

RESULTS

Patients received an average of 5.8 PCMP applications. Of the 6 wounds that healed, average time to closure from the first PCMP application was 10 weeks. The remaining 3 wounds demonstrated improved wound appearance with 100% granulation tissue and an average area reduction during PCMP treatment of 61.4%.

CONCLUSIONS

This case series demonstrated that PCMP along with good wound care supported both wound closure and improvements in wound bed condition and area reduction on recalcitrant, nonhealing wounds of various etiologies.

Hyperbaric oxygen therapy as adjuvant for treating wound complications after extensive resection for vulvar malignancy

INTRODUCTION

Necrosis, wound breakdown, and infection represent major complications associated with radical vulvectomy. We aimed to analyze the feasibility of hyperbaric oxygen (HBO₂) therapy as an adjunctive treatment for such complications.

METHODS

We performed a retrospective analysis of the medical records, clinical charts, and operative records of vulvar cancer patients who underwent hyperbaric oxygen therapy after extensive surgical resection in our institute between 2012 and 2016, with a comparison of the clinical outcomes of patients with similar surgical procedures andsevere wound complications who did not undergo HBO₂.

RESULTS

A total of 16 patients were included in the study. In the subgroup treated with HBO₂, seven patients were identified. Two patients had primary surgery, while five had recurrent surgery (of these, two had previously undergone radiation therapy). Six patients received reconstructive flaps (five myocutaneous and onefasciocutaneous), while one patient had primary suture. Dehiscence, ischemia and necrosis were estimated to cover 30%-80% of the surgical surface area. Surgical debridement was performed in six patients. Daily 90-minute sessions in the hyperbaric chamber were performed at a pressure of 2.2 atmospheres absolute, with partial oxygen pressure of 1672 mbar. Infection control and satisfactory healing were achieved using 10-61 sessions. All patients in the subgroup who did not receive HBO₂ required surgical debridement due to partial or near-total flap necrosis, with two reconstructive interventions required.

CONCLUSIONS

Hyperbaric oxygen therapy was an efficient adjuvant for wound healing and infection control in managing wound complications after extensive vulvar resections.

Hyperbaric oxygen therapy for wound breakdown after oronasal fistula and cleft palate repair: four cases

We offer the first report of hyperbaric oxygen (HBO₂) therapy to treat early surgical wound breakdown after oronasal fistula and cleft palate repair in the pediatric population. We present four patients' experiences after undergoing HBO₂ therapy. HBO₂ was initiated as soon as an oronasal fistula was identified. Three of the children underwent 10 HBO₂ treatments with the fourth undergoing 11 treatments. There were no adverse effects during treatment; none of the patients required decompressive myringotomy. Follow-up shows portions of the repair have been salvaged by initiating HBO₂ at the first sign of fistula formation. In our case series, the fistulas all decreased in size over the course of treatment and demonstrated granulation tissue at the wound edges. Given the positive outcomes from our preliminary results, our results suggest concurrent usage of HBO₂ therapy for wound breakdown after cleft palate repair is an effective treatment option.

Negative Pressure Wound Therapy for a Complicated Abdominal Laparotomy in Neonatal Necrotizing Enterocolitis: A Case Report

Necrotizing enterocolitis (NEC) is the most common surgical emergency in neonatal intensive care units, and patients who require surgery have high mortality and morbidity rates. The utility of negative pressure in the management of adults with complicated abdominal wounds has been documented, but there are few reports describing the use of negative pressure wound therapy (NPWT) in children or following neonatal surgery. The case of a 6 day old, 5-weeks premature neonate with NEC is presented. An exploratory midline laparotomy was performed on day 3 of life owing to rectal bleeding and abdominal distension that did not respond to gastric decompression, bowel rest, and intravenous antibiotics. Ten (10) cm of necrosis in the distal ileum were noted and resected; in addition, an ileostomy was performed, and a Penrose drain was left in the surgical site. On postoperative day 5, the laparotomy dehisced. Continuous NPWT (50 mm Hg) was initiated and changed owing to patient tolerance to intermittent therapy (5 minutes on, 30 seconds off) at 80 mm Hg. By postoperative day 11, granulation tissue formation was complete. No surgical procedures were required for the complete closure of the abdominal wall, and no adverse reactions were noted. The baby was discharged from the hospital on postop day 15. In this patient, the use of negative pressure was found to be safe and facilitated management of a complicated abdominal wound in the presence of a stoma and the formation of healthy granulation tissue. Additional research is needed to help clinicians provide optimal, evidence-based care for dehisced wounds in this vulnerable population.

Abdominal Cavity Eventration Treated by Means of the "Open Abdomen" Technique Using the Negative Pressure Therapy System--Case Report and Literature Review

Wound dehiscence is a surgical complication in which the wound ruptures along the surgical suture with abdominal cavity bowel displacement. It is observed in 0.2-6% of operated patients. The extensive wound is a gateway for infection. Moreover, increased secretion of serous fluid induces a hygienic problem and may lead to secondary skin infections or bedsores. The negative pressure wound therapy (NPWT) system is an innovative therapeutic method. It perfectly executes the TIME strategy, receiving more and more recognition. The study presented a case of a 62-year old male patient after several consecutive wound dehiscence episodes who was primarily treated for rectal cancer by means of low anterior resection of the rectum. Due to acute respiratory insufficiency after several operations, wound necrosis with dehiscence was observed. Considering the high risk of perioperative death we abandoned surgical treatment and introduced conservative management using negative pressure wound therapy until the patient's health improved. Literature regarding the above-mentioned issue was also reviewed.

Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a nested qualitative study

OBJECTIVE

To explore women's lived experiences of a dehisced perineal wound following childbirth and how they felt participating in a pilot and feasibility randomised controlled trial (RCT).

DESIGN

A nested qualitative study using semistructured interviews, underpinned by descriptive phenomenology.

PARTICIPANTS AND SETTING

A purposive sample of six women at 6-9 months postnatal who participated in the RCT were interviewed in their own homes.

RESULTS

Following Giorgi's analytical framework the verbatim transcripts were analysed for key themes. Women's lived experiences revealed 4 emerging themes: (1) Physical impact, with sub-themes focusing upon avoiding infection, perineal pain and the impact of the wound dehiscence upon daily activities; (2) Psychosocial impact, with sub-themes of denial, sense of failure or self-blame, fear, isolation and altered body image; (3) Sexual impact; and (4) Satisfaction with wound healing. A fifth theme 'participating in the RCT' was 'a priori' with sub-themes centred upon understanding the randomisation process, completing the trial questionnaires, attending for hospital appointments and acceptability of the treatment options.

CONCLUSIONS

To the best of our knowledge, this is the first qualitative study to grant women the opportunity to voice their personal experiences of a dehisced perineal wound and their views on the management offered. The powerful testimonies presented disclose the extent of morbidity experienced while also revealing a strong preference for a treatment option.

TRIAL REGISTRATION NUMBER

ISRCTN05754020; results.

Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a pilot and feasibility randomised controlled trial

OBJECTIVE

To establish the feasibility of conducting a definitive randomised controlled trial (RCT) comparing the effectiveness of resuturing versus expectant management for dehisced perineal wounds.

DESIGN

A multicentre pilot and feasibility RCT.

SETTING

Ten UK maternity units from July 2011 to July 2013.

POPULATION

Eligible women with a dehisced perineal wound within 2 weeks of childbirth.

METHODS

The interventions were resuturing or expectancy. Randomisation was via web or telephone, stratified by participating centre. Blinding was not possible due to the nature of the interventions. Analysis was by intention-to-treat.

OUTCOME

The primary outcome measure was wound healing at 6-8 weeks.

RESULTS

The study revealed a number of feasibility issues, particularly strong patient and clinician preference for treatment options at recruiting centres and the timing of the primary outcome measure. Thirty-four women were randomised (17 in each arm). Data from 33 women were analysed on an intention-to-treat analysis to obtain preliminary estimates of effect size. There was a difference in wound healing at 2 weeks favouring resuturing (OR 20.00, 95% CI 2.04 to 196.37, p=0.004). However, by 6-8 weeks all but one wound in both groups had healed.

CONCLUSIONS

PREVIEW revealed a number of feasibility issues, which impacted on recruitment rate. These will have to be taken into account in the design of any future definitive study. In this feasibility study, resuturing was associated with quicker wound healing and women reported higher satisfaction rates with the outcome at 3 months.

TRIAL REGISTRATION NUMBER

ISRCTN05754020.

Treatment of Oncological Post-surgical Wound Dehiscence with Autologous Skin Micrografts

BACKGROUND/AIM

The closure of postoperative wounds is essential in order to prevent surgical site infections or wound dehiscence, mainly in oncological patients. We aimed to demonstrate the efficacy of autologous micrografts in the management of wound dehiscence in an oncology patient undergoing decompressive spinal laminectomy.

CASE REPORT

A 57-year-old man with IgG multiple myeloma and medullary plasmocytoma C7-T3, was to undergo decompressive spinal laminectomy and vertebral fixation leading to a wound dehiscence with exposed instrumentation. Autologous micrografts were obtained by Rigenera protocol and directly applied to the dehisced wound. After 60 days of negative pressure wound therapy, we observed reduction of the diameter and depth of wound dehiscence, with a coverage of instrumentation, without complete re-epithelialization, that instead was reached by application of autologous micrografts after 70 days.

CONCLUSION

The Rigenera protocol may be the solution for complex wounds in oncological and immune-compromised patients where other treatments are contraindicated.

Complications of Elbow Trauma

The elbow is a highly congruent trochoginglymoid joint allowing motion in both flexion-extension and pronosupination across 3 articulations. Therefore, treatment of fractures of the elbow can be technically challenging to manage, even after initial surgery. The posttraumatic elbow is prone to complications such as stiffness associated with heterotopic ossification, instability or subluxation (posterolateral rotatory instability and varus posteromedial instability patterns), and wound complications. This article discusses the pathoanatomy, prevention, and treatment of these complications.

Management of a Dehisced Hand Wound Using Hydrogen Peroxide, Electrical Stimulation, Silver-containing Dressings, and Compression: A Case Study

Wound dehiscence is the separation of a wound along surgical sutures. A 57-year-old, otherwise healthy mechanic presented with a large open wound of >1 month duration on his left hand. His wound had dehisced after treatment that involved cleansing, surgical sutures, and oral antibiotics. He presented with a 5.0 cmx0.7 cmx0.3 cm lesion through the palmar creases of the hand with edema around the fourth and fifth digits and a callous formation around the distal portion of the wound. The wound had scant serosanguinous drainage and some induration at the periwound area, as well as a moderate foul odor. Tendons were not affected, but function was limited, the hand was painful, and the patient had been unable to work. Treatment was initiated with twice-a-week immersion of the hand in hydrogen peroxide diluted with water subjected to high-voltage pulsed current electric stimulation (HVPC). The wound was dressed with silver-containing dressings secured with stretch gauze and a compression garment. The wound was completely closed after 9 visits (35 days). No functional limitations of the hand or fingers, no cosmetic defect, and no wound recurrence were noted 9 months after healing. Although uncommon, dehisced wounds, especially in certain anatomical locations such as the hand, can be difficult to heal and may cause long-term problems with functioning. The treatment combination facilitated expedient healing of this dehisced hand wound. Research is needed to help elucidate the observations from this case study.

Results of a retrospective comparative study: material cost for managing a series of large wounds in subjects with serious morbidity with a hydrokinetic fiber dressing or negative pressure wound therapy

This retrospective observational study analyzed lesions with regard to healing trends and cost of materials.

MATERIALS AND METHODS

The observed lesions were mostly postsurgical or stage IV pressure ulcers in patients with serious morbidity. The wounds were treated with a hydrokinetic fiber dressing (sorbion Sachet S, sorbion Gmbh & Co, a BSN medical company, Senden, Germany) (n = 26) or negative pressure wound therapy (NPWT) (n = 16).

RESULTS

Primary healing trends (ie, reduction of wound size, change from necrosis to granulation tissue, and change from granulation tissue to epithelium) and secondary healing trends (ie, periwound conditions) were similar for wounds treated with the hydrokinetic dressing when compared to wounds treated with NPWT. Cost of materials was substantially lower for wounds treated with the hydrokinetic fiber dressing compared to the NPWT, with cost reductions of $1,640 (348%) to $2,242 (1794%) per wound, depending on the criteria used for the analysis.

CONCLUSION

In this set of wounds, the hydrokinetic fiber dressing was shown to lead to similar healing results while providing substantial reductions of the cost of materials. For the types of wounds presented in this observational study, the hydrokinetic fiber dressing seems to be an effective substitution for negative pressure wound therapy.

Postoperative care in pediatric liver transplantation

In the last 25 years, liver transplantation in children has become an effective, definitive, and universally accepted treatment for terminal liver diseases. Long-term survival exceeds 80% and improves each year as the result of constant technical advancements and improvements in immediate postoperative intensive care and clinical control.

Management of open wounds: lessons from orthopedic oncology

The management of complex wounds remains a challenge, and although there have been many promising advances, patients often undergo a morbid and lengthy process to obtain sufficient, satisfactory healing. Sarcoma patients are especially vulnerable to soft tissue wound-healing complications. These patients are often treated with neoadjuvant radiation and/or chemotherapy and have compromised local vascularity to healing tissue. The advent and refinement of wound vacuum-assisted closure technology have been shown to have a tremendous impact. This article reviews the benefits of some novel technologies currently undergoing investigation in orthopedic oncology that will likely have applications in wound management from other causes.

NEGATIVE PRESSURE WOUND THERAPY (NPWT) FOR THE MANAGEMENT OF LAPAROSTOMY WOUNDS: CASE SERIES

Laparostomy or the open abdomen can be a lifesaving intervention in surgical emergencies for abdominal compartment syndrome, wound dehiscence, trauma and intra-abdominal sepsis. However, the open abdomen imposes a significant burden on nursing staff caring for these critically ill patients due to the large volume of exudate and fluid loss.To achieve mechanical containment of abdominal viscera and active removal of exudate, we used NPWT to manage five patients with complex intra-abdominal sepsis laparostomy wounds. It took between 12 to 28 days to achieve full granulation for secondary closure of the wounds. The series shows that in the management of laparostomy wounds, NPWT provides an easier way to manage the large volumes of exudates and reduces the frequency of dressings changes required with traditional wound dressings.

Vacuum with mesh is a feasible temporary closure device after fascial dehiscence

INTRODUCTION

The open abdomen is a challenging condition and a temporary abdominal closure device is required in order to protect the intra-abdominal viscera. We aimed to evaluate the feasibility of a recent device: vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) after fascial dehiscence focusing on fascial closure rate, mortality and procedure-related complications.

MATERIAL AND METHODS

We performed a retrospective study on 18 patients treated with VAWCM after fascial dehiscence who were consecutively admitted to the Department of Surgery, Slagelse Hospital, between October 2008 and October 2012.

RESULTS

The 18 patients had a median age of 64 (29-90) years. 80% (12/15) obtained delayed primary abdominal closure. The in-hospital mortality was 17% (3/18). The median treatment period with VAWCM and vacuum-assisted wound closure were 18 (7-34) and 21 (7-53) days, respectively, with a median of six (1-11) tightenings. One patient developed an intra-abdominal abscess. Three patients survived until discharge without having obtained delayed primary closure. In two of these patients, the fascial edges were adapted with a prosthetic mesh and one patient was left with a planned ventral hernia. We performed a retrospective follow-up with a median duration of 21 months 21% developed an incisional hernia. Two patients died within 60 days after closure of the abdomen.

CONCLUSION

We found and that VAWCM is a safe and useful technique for delayed primary closure of the open abdomen after fascial dehiscence. We stress the need for more studies on temporary abdominal closure devices in selected groups of patients.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

[Vacuum assisted closure therapy in dehiscence of abdominal wound after cesarean section treated in a hospital-at-home]

The Hospital at Home is a range of hospital care provided to patients in the comfort of their own homes, so patient and family can actively participate in the process. Cesarean section is a surgical procedure that requires a short hospital stay. However if complications arise during the process, such as a dehiscence of surgical wound, the hospital stay is prolonged, delaying mother-child bonding, which is very important for the growth of the child. Nursing care in wound healing by secondary intention is a priority for the patient's recovery. VAC therapy (vacuum assisted closure) promotes a rapid recovery, although it requires dressings and active medical surveillance, as well as training by the nursing staff for carrying it out at home. We describe the outcome and the process of the healing of a surgical wound after cesarean section, not only because of a complex wound, but the previously mentioned factors that make us consider the Hospital at Home as the best alternative care.

Vacuum-assisted closure therapy for a complicated, open, above-the-knee amputation wound

Negative-pressure wound therapy (NPWT) with a vacuum-assisted closure system has been successfully used in the management of various wounds on the trunk and distal extremities, including diabetic foot ulcers. However, reported successful NPWT cases have involved distal wounds that were below the knee. The authors report a case of an elderly diabetic patient with recalcitrant wounds in his left lower extremity from an above-the-knee amputation. The patient had undergone 27 surgical débridement or revision procedures over the course of 3 months. On entering rehabilitation, the patient had a full-thickness wound in his residual limb that measured 9 × 8 cm. The patient received NPWT with a vacuum-assisted closure system, which resulted in a fully healed residual limb. After 120 days, the patient was ready to begin prosthetic restoration.

[Dehiscence of laparotomy after hysterectomy - wound management]

Authors of the paper present prospective case report about nursing process and healing of extensive dehiscence of middle lower laparotomy wound in patient after surgical procedure for endometrial carcinoma. The aim of the paper is to describe, analyse and evaluate the process of complicated postoperative wound healing using negative pressure and moist therapy. They emphasize importance of cooperation between particular departments in complicated postoperative wound therapy management. They point out using new and easily available techniques and methods, risk factors elimination and maintenance of the factors that have a positive influence on wound healing.Key words: postoperative wound dehiscence, negative pressure wound therapy, moist therapy, case report.

Promising results after vacuum-assisted wound closure and mesh-mediated fascial traction

INTRODUCTION

Patients with an open abdomen (OA) present a major challenge to the surgeon. High mortality and associated complication rates have been reported depending on the specific method of temporary abdominal closure, the primary disorder and any co-morbidity. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) is a novel technique recently introduced for late fascial closure of the OA. In previous studies, the disease aetiologies were mainly vascular and visceral surgical disease and trauma. We report our results using VAWCM in a non-trauma patient population treated with an OA due to visceral surgical disease.

MATERIAL AND METHODS

Medical records of all patients in our department treated with VAWCM during the period from 1 August 2009 to 31 May 2011 were reviewed. All sixteen patients were non-trauma patients. The initial treatment was vacuum-assisted closure (VAC) (Abdominal Dressing System KCI, San Antonio, Texas, USA). VAWCM treatment was initiated if complete fascial closure could not be obtained with VAC.

RESULTS

Two patients died of multiple organ failure that was not associated with the VAWCM treatment. In one patient, treatment was terminated due to a very short life expectancy. We achieved a complete fascial closure rate in seven out of 16 patients. One patient had a pancreatic fistula at discharge that was not associated with the VAWCM treatment. No enteric fistulas occurred.

CONCLUSION

It seems that VAWCM can improve the rate of complete fascial closure after treatment with OA without increasing the mortality or the occurrence of enteric fistula compared with other kinds of temporary abdominal closure.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Conservative management of minor anastomotic leakage after open elective colorectal surgery

INTRODUCTION

The utility of prophylactic drainage in colorectal surgery is controversial. The aim of the present article is to study the role of drainage tubes on the management of minor anastomotic dehiscences.

PATIENTS AND METHODS

We retrospectively review clinical reports of 18 consecutive patients with anastomotic dehiscence after open elective colorectal surgery. The mean age was 63 years and the male - female ratio was 5:1. Nine (50%) patients underwent re-operation for fecal peritonitis (group A) while the remaining nine (50%) were managed conservatively (group B). The parameters evaluated in both groups were: time of the anastomotic breakdown, clinical findings, amount of fluid drained the day of the dehiscence, diagnostic means used, length of stay and mortality.

RESULTS

Anastomotic leakages were observed medially after 3, 6 days from surgery in group A and after 5.6 days in group B. The most frequent clinical manifestations were: fecal material through the tubes (88.9%), pelvic pain (88.9%) and fever (77.8%). Patients in group A had a median faecal fluid flow of 235cc the day of the dehiscence and 130cc those in group B. Imaging was employed only in three cases in group A and in all cases in group B. The length of hospital stay was longer in patients treated surgically: 37 days versus 29 in those treated conservatively.

CONCLUSIONS

Minor anastomotic leakages generally occur later than greater ones, they have a milder clinical presentation and can be managed conservatively with the use of drain tubes.

Anaphylactic shock during hyperbaric oxygen therapy

A case of a 38-year-old woman is reported who was treated with hyperbaric oxygen therapy to cure a dehiscent wound. She suffered from "oral-allergy syndrome" (OAS) while eating certain fruits, and from itching when wearing latex gloves to handle hair dyes. Fifteen minutes after the start of compression, malaise, anxiety, dyspnoea, tachycardia, cold sweating and laryngeal stridor occurred. Despite intensive care treatment, face angioedema persisted for several days. On the basis of history, radioallergosorbent test (RAST) and prick tests, latex was assumed to be responsible for the anaphylactic reaction. To our knowledge, this is the first extensive report of an anaphylactic reaction to latex in a hyperbaric chamber. The lesson drawn from this case record can be summarized as follows: 1) never fail to collect a thorough history; 2) set up a latex-safe hyperbaric chamber when needed; 3) have an emergency kit always near at hand.

Management of fasciotomy wounds--does the dressing matter?

Fasciotomy is a limb-saving procedure in the management of ischemic extremities. Little evidence exists as to the best method of fasciotomy wound management. We hypothesized that the use of vacuum dressing (VAC) or creation of dynamic tension (DYN) would increase rates of primary closure, reducing the need for split thickness skin grafting (STSG). The records of a large urban Level I trauma center were used to identify fasciotomy recipients over a 10-year period and were retrospectively analyzed. Data collected included injury characteristics, wound management, and outcomes. Wound management was dictated by surgeon preference, and categorized as gauze packing, DYN, or VAC. The primary outcome was primary closure versus need for STSG. Wound management cohorts were compared using logistic regression. Fisher's exact test and χ(2) were performed to compare proportions and categorical variables respectively. From 2000 to 2009, 227 patients had a fasciotomy performed. Mechanism, age, and incidence of fracture were different between the groups. There was a trend towards increased primary closure with DYN (83%). Average length of stay (LOS) was 21 days for those receiving primary closure and 27 days for STSG. There was a significant decrease in LOS for the DYN group (average 16 days) when compared with gauze packing and VAC. In this series of 227 patients who underwent fasciotomy, no technique of wound management produced a significant improvement in primary closure rate. A trend toward more primary closure was seen in the DYN group. LOS was longer for patients receiving STSG. The DYN cohort had a significantly shorter LOS.

Traumatic wound breakdown following baha™ implant

OBJECTIVES

To highlight the importance of recognizing and managing severe peri-operative and post-operative soft tissue complications of baha™ osseointegrated implants. To discuss a patient with severe post-traumatic peri-operative and post-operative scalp complications following baha™ surgery, including management options.

STUDY DESIGN

Case report and literature review of post-operative soft tissue complications of baha™ osseointegrated implants. METHODS (CASE SUMMARY): A patient presented with a severe right sided mixed hearing loss and was treated with a baha™ osseointegrated implant. Post-operatively, the patient suffered trauma to the site and developed a severe traumatic wound infection, with complete dehiscence of the split thickness skin graft. The patient was treated with oral antibiotics and meticulous, aggressive local wound care. Operative management was considered but not implemented. Full healing with ability to use the device successfully was achieved.

RESULTS

The patient healed completely and did not require revision surgery. He now has serviceable hearing after benefiting from the baha™ implant.

CONCLUSIONS

Although post-operative complications following baha™ surgery are infrequent and commonly mild, the surgeon will rarely be encountered by a severe soft tissue complication as described. Aggressive local wound care included culture-guided antibiotic therapy is indicated prior to performing revision surgery.

Airway dehiscence after lung transplantation in a patient with cystic fibrosis

The presence of resistant pathogens in the lower airways of patients with cystic fibrosis (CF) is not an absolute contraindication for lung transplantation. We describe a case in which a patient with CF died as a result of an anastomotic dehiscence, ischemia, and infection with linezolid-resistant methicillin-resistant Staphylococcus aureus. We review infection issues during the post-lung-transplant period and related anastomotic dehiscence in CF.

Medical devices; general and plastic surgery devices; classification of tissue adhesive with adjunct wound closure device intended for topical approximation of skin. Final rule

The Food and Drug Administration (FDA) is classifying the tissue adhesive with adjunct wound closure device intended for topical approximation into class II (special controls). The special control that will apply to the device is the guidance document entitled ``Guidance for Industry and FDA Staff; Class II Special Controls Guidance Document: Tissue Adhesive With Adjunct Wound Closure Device Intended for the Topical Approximation of Skin.'' The agency is classifying the device into class II (special controls) in order to provide reasonable assurance of safety and effectiveness of the device. Elsewhere in this issue of the Federal Register, FDA is announcing the availability of a guidance document that will serve as the special control for this device type.

Hyperbaric oxygen on the healing of ischemic colonic anastomosis--an experimental study in rats

The aim of the present study was to evaluate the effect of hyperbaric oxygen therapy (HBO2) on the healing process of ischemic colonic anastomoses in rats. Forty Wistar rats were divided into four groups: control (Group I), control and HBO2 (Group II), ischemia (Group III), ischemia and HBO2 (Group IV). Ischemia was achieved by clamping four centimeters of the colonic arcade. On the eighth therapy day, the anastomotic region was removed for quantification of hydroxyproline and immunohistochemical determination of metalloproteinases 1 and 9 (MMP1, MMP9). The immunohistochemical studies showed significantly larger metalloproteinase-labeled areas in Group IV compared with Group III for both MMP1 and MMP9 (p < 0.01). This finding points to a higher remodeling activity of the anastomoses in this experimental group. Additionally, animals subjected to hyperbaric oxygen therapy showed both a reduction in interstitial edema and an increase in hydroxyproline concentrations [at the anastomotic site]. Therefore, we conclude that HBO2 is indeed beneficial in anastomotic ischemia.

Innovation and management of diabetic foot wounds

Recent innovations in the field of wound healing have created numerous advanced therapies from which clinicians may now choose. The challenge for the reconstructive surgeon is to ensure that these adjunct technologies are used according to an evidence-based protocol to ensure optimal healing. Critical to successful outcomes is that new modes of therapy do not supplant, but are used in tandem with, core principles of wound management: establishing a correct diagnosis, ensuring a good local blood supply, debriding the wound to a clean base, correcting the biomechanical abnormality, and nurturing the wound until it shows signs of healing. Debridement should be performed as often as necessary until the wound is deemed clean and ready for reconstruction. Useful adjuncts in debridement include hydrotherapy and ultrasonic therapy. The majority of reconstructions are accomplished through simple techniques. If a wound is not meeting the expected healing trajectory, management adjuncts such as negative pressure wound therapy, growth factor, cultured skin, and hyperbaric oxygen can then reactivate or expedite the process toward achieving a healed wound.

The bridge stent technique for salvage of pancreaticojejunal anastomotic dehiscence

OBJECTIVES

Although infrequent, Grade C postoperative pancreatic fistulae (POPF) following pancreaticoduodenectomy (PD) are morbid and potentially lethal. Traditional management of a disrupted pancreaticojejunostomy (PJ) anastomosis consists of either wide external drainage or completion pancreatectomy. The aim of this study is to describe an alternative management approach to PJ dehiscence after PD.

METHODS

A bridge stent technique is employed in the setting of a disrupted PJ anastomosis. Upon re-exploration, a 5-Fr or 8-Fr silastic feeding tube stent is placed across a gap between the jejunal enterotomy and the pancreatic duct, and secured with an absorbable suture at both ends. Depending upon the degree of local inflammation, this may be externalized by coursing the stent downstream through the pancreaticobiliary drainage limb in a Witzel fashion.

RESULTS

Over 8 years and 357 PDs with duct-to-mucosa PJ reconstruction, seven ISGPF (International Study Group on Pancreatic Fistula) Grade C fistulae occurred (2%). Two patients ultimately died secondary to POPF (neither anastomosis was dehisced). The described technique was used in the other five patients, all of whom had evidence of a dehisced PJ anastomosis. All originally had at least two or three recognized risk factors for POPF development (high-risk pathology, soft gland, duct diameter ≤ 3 mm, estimated blood loss ≥ 1000 ml). All patients survived this complication and were discharged from hospital. There have been no longterm external fistulae, nor any recognized PJ strictures or remnant atrophy (median follow-up: 10.7 months).

CONCLUSIONS

In the context of a dehisced pancreaticojejunal anastomosis, the bridge stent technique is a safe and effective method of management that contributes to diminished mortality and helps to salvage pancreatic function.

Proximal-releasing stent insertion under transnasal endoscopic guidance in patients with postoperative esophageal leakage

BACKGROUND

Covered metallic or plastic stent placement has become an important treatment for postoperative esophageal leakage; however, fluoroscopic guidance is also required. Here we present a novel stent insertion technique with a newly designed proximal-releasing, self-expanding metallic stent (PR-SEMS) and transnasal endoscope that can enable stent insertion without fluoroscopy as a new method to prevent stent migration.

OBJECTIVE

To describe our experience with 7 patients who underwent PR-SEMS insertion with the direct-vision technique and our use of the transnasal endoscope without fluoroscopy.

DESIGN

Prospective outcome study.

SETTING

A tertiary-care referral university hospital.

PATIENTS

This study involved all patients at our center who experienced postoperative esophageal leakage after esophagectomy, primary closure, or total gastrectomy.

INTERVENTION

PR-SEMS insertion with the direct vision technique and use of transnasal endoscopy without fluoroscopy.

MAIN OUTCOME MEASUREMENTS

Success rate of stent insertion, healing rate of postoperative esophageal leaks, and stent migration rate.

RESULTS

All stents were placed at the expected location without complications. One patient had massive hematemesis and underwent surgery. The bleeding focus was the splenic artery, which was damaged during gastrectomy. A significant marginal ulcer occurred in one patient, and the stent was immediately retrieved with an endoscope. After stent removal, 4 postoperative leakages were completely healed, and 2 lesions were not occluded. The 2 remaining minimal lesions became completely occluded with conservative management after stent removal. Stent migration did not occur.

LIMITATIONS

A small number of patients. Further prospective, randomized, controlled trials are needed.

CONCLUSION

PR-SEMS insertion under transnasal endoscopic guidance is a feasible, safe, and effective treatment for postoperative esophageal leakage, and it can be performed as a bedside procedure. Our anchoring method is effective for the prevention of migration from nonobstructed lesions.

[A complicated case of spontaneous oesophageal rupture managed by transgastric drainage]

Spontaneous rupture of the oesophagus is an extremely serious condition with high morbidity and mortality. Primary surgical repair may be followed by numerous complications. A 29-year-old man had undergone primary surgical repair due to spontaneous rupture of the lower third of the oesophagus. After the operation he developed suture insufficiency, which could not have been stented, and transgastric drainage was performed therefore. After a slow healing of the fistula, we could avoid another operation and his oesophagus was preserved. Fortunately, a stricture did not develop either. Transgastric drainage of the oesophagus could be a good therapeutic choice in selective and complicated cases.

Gastric leak after laparoscopic-sleeve gastrectomy for obesity

BACKGROUND

One of the most serious complications after laparoscopic sleeve gastrectomy (LSG) is gastric leak. Few publications exist concerning the treatment of gastric leak. We sought to determine by way of a prospective study the clinical presentation, postoperative course, and treatment of gastric leak after LSG for obesity.

METHODS

From October 2005 to August 2008, 214 patients with different degrees of obesity underwent LSG. During surgery, each patient received saline with methylene blue by way of nasogastric tube and had a drain placed. All patients underwent radiologic study with liquid barium sulphate on postoperative day 3.

RESULTS

Seven patients developed gastric leak. Leak in two patients (28.6%) was diagnosed by upper gastrointestinal tract (UGI) study. Two patients had type I leak (28.6%), and five patients had type II leak (71.4%). Four patients underwent reoperation. Three patients were managed medically with enteral or parenteral feeding; the drain was maintained in situ; and collections were drained by percutaneous punctions guided by computed axial tomography. Mean hospital length of stay was 28.8 days, and time to leakage closure was 43 days after surgery.

CONCLUSION

Different ways exist to manage gastric leak, depending on the magnitude of the collection and the clinical repercussions. When treatment necessitates reintervention and is performed early, suture repair is more likely to be successful. Leakage closure time will vary.

Therapeutic alternatives for burst abdomen

Burst abdomen is a postoperative complication associated with significant morbidity and mortality. The risk factors for burst abdomen are patient- and surgery-related. The management of this complication is a relatively unexplored area within the field of surgery. Relevant surgical outcomes include recurrence, mortality, and incisional hernia. A total number of 27 studies are identified that reported on at least one surgical outcome (recurrence, mortality, or incisional hernia rate) of at least 10 patients with burst abdomen. None of the identified studies were designed prospectively, and only a minority of studies reported surgical outcomes of considerable numbers of patients with burst abdomen. Reported conservative management options included use of saline-soaked gauze dressings and negative pressure wound therapy. Operative management options included temporary closure options (open abdomen treatment), primary closure with various suture techniques, closure with application of relaxing incisions, use of synthetic (nonabsorbable and absorbable) and biological meshes, and the use of tissue flaps. The treatment of burst abdomen is associated with unsatisfactory surgical outcome. Randomized controlled clinical trials are needed to provide the surgical community with a greater level of evidence for the optimal treatment strategy for burst abdomen and the various subtypes.

Vacuum-assisted closure and bilateral pectoralis muscle flaps for different stages of mediastinitis after cardiac surgery

PURPOSE

To assess the results of bilateral pectoralis major muscle flaps (BPMMF) and vacuum-assisted closure (VAC) at different stages of postcardiac surgery mediastinitis.

METHODS

Of 65 patients with a deep sternal wound infection (DSWI) after cardiac surgery, 33 with a stable sternum were treated with VAC (59.3 +/- 11.7 years of age) and 32 with an unstable sternum or osteomyelitis (63.3 +/- 9.8 years of age) were treated with early BPMMF and continuous irrigation. Delayed BPMMF reconstruction was necessary in six VAC patients.

RESULTS

The overall incidence of DSWI was 1.04% within the study period. Deep sternal wound infection was diagnosed 15.9 +/- 10.8 days (range 5-62 days) after surgery. Diabetes was more common in the BPMMF group than in the VAC group (P = 0.046). Hospital mortality after treatment was 4.6% (n = 3) overall. Causes of death were septic multiorgan failure and respiratory failure. The infective pathogens were methicillin-resistant Staphylococcus aureus (MRSA; n = 2) and Acinetobacter species (n = 1). The median hospital stay was 29 days (range 15-110 days). After 6 months, only one recurrent sternal infection had occurred in the VAC group.

CONCLUSIONS

Early BPMMF is an effective surgical treatment for DSWI in patients with an unstable sternum and osteomyelitis. VAC may be considered for patients without osteomyelitis but a stable sternum, or as adjuvant therapy in patients with comorbidity.

Closure of pneumonectomy stump fistula using custom Y and cuff-link-shaped silicone prostheses

Large postpneumonectomy stump fistulas pose a significant problem for thoracic surgeons and interventional bronchoscopists. We present a case of successful rigid bronchoscopic repair of a complete right pneumonectomy stump dehiscence using a custom-built stent made of a sculpted silicone Y stent sutured to a new cuff-link-shaped DJ-Fistula stent. This resulted in rapid symptom resolution, weaning from mechanical ventilation and discharge home in a patient with bronchogenic carcinoma, respiratory failure, and significant other comorbidities that precluded repeat thoracotomy.