Negative Pressure Wound Therapy with Instillation in the Septic Open Abdomen Utilizing a Modified Negative Pressure Therapy System

[Surgical wound closure in advanced peritonitis]

To date, mortality in widespread peritonitis is still high (15-20%) and increased up to 70-80% in case of septic shock. Surgeons actively discuss wound closure technique in these patients considering intraoperative findings and severity of illness. The authors present scientific data and opinions of national and foreign surgeons regarding the methods of laparotomy closure. There are still no generally accepted criteria for choosing the method of laparotomy closure in secondary widespread peritonitis. Indications and clinical efficacy of each procedure require additional research.

Negative Pressure Wound Therapy Devices With Instillation/Irrigation: A Technologic Analysis

PURPOSE

The purpose of this technologic analysis was to critique technologic features of devices designed to deliver negative pressure wound therapy with instillation or irrigation (iNPWT).

APPROACH

Published literature regarding negative pressure wound therapy (NPWT) devices with the added feature of instillation or irrigation was reviewed to provide an overview of iNPWT. Varied features of devices currently available in the United States were described based on instructions published by individual manufacturers. Safety information regarding iNPWT was derived from the Manufacturer and User Facility Device Experience (MAUDE) Database.

CONCLUSIONS

The additional option of instillation or irrigation available with some NPWT devices may provide clinical benefits in carefully selected patients. Advantages may be related to facilitated removal of thick exudate and necrotic tissue. Devices with instillation options are indicated for inpatient settings, with ongoing monitoring of health care professionals. A simpler device with an intermittent irrigation option may be used in the home setting, with proper supervision. More research is needed to demonstrate the clinical effectiveness and cost of the therapy.

A Comparison of Negative Pressure and Conventional Therapy in Infected Open Chest Wounds

Background: The role of negative pressure wound therapy (NPWT) in the management of open chest wounds is unclear. Our aim was to determine the safety and efficacy of NPWT compared with conventional therapy for open chest wounds. Methods: Ten patients with infected open chest wounds were included in a prospective trial of NPWT after surgical debridement. Their outcomes were compared with those of 11 control patients treated during the same period with surgical debridement and open chest packing only. The control group data were obtained by retrospective review of medical records. Results: The median duration of NPWT was eight days (range 2-29 days), with closure in eight patients (80%). Two patients having NPWT had unveiling of occult pleural fistulas leading to early discontinuation. The patients having NPWT had a shorter median time to closure (7 versus 18 days; p = 0.071) and shorter initial (median 6 versus 20 days; p = 0.026) and total (median 6 versus 25 days; p = 0.024) hospital length of stay. Control patients had higher rates of new-onset atrial fibrillation (46% versus 0; p = 0.035) and septic shock (64% versus 10%; p = 0.024). The chest was either closed or healing at the time of the last visit in 100% of the NPWT patients versus 73% of control patients (p = 0.28). The 1-year survival estimates were 90% for the NPWT patients and 80% for the control patients (p = 0.69). Conclusion: Negative pressure wound therapy is feasible and safe for open infected chest wounds in selected patients compared with open packing alone and may reduce hospital stay duration and major complication rates.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Does negative pressure wound therapy with saline instillation improve wound healing compared to conventional negative pressure wound therapy? - A randomized controlled trial in patients with extremity ulcers

BACKGROUND

Wounds are important health problems that cause significant financial burden and loss of time to work, more so in low and lower middle income countries. Negative pressure wound therapy (NPWT) is widely established in managing acute and chronic extremity wounds. We studied the effects of addition of normal saline instillation to NPWT in terms of changes in granulation tissue, bacterial-burden and overall wound healing using readily available means and materials including wall suction for negative pressure, sponge and adhesive transparent sheet for dressing and normal saline for irrigation.

METHODS

All patients with extremity ulcers initially underwent surgical debridement. They were then allotted into two groups, group 1 (NPWT with normal saline instillation- NPWTi) including 25 patients and group 2 (NPWT) including 23 patients. Tissue-bit samples taken on day1 and day 10 were used for bacteriology and for assessing histology. The wound surface-area was measured using the software ImageJ on day 1 and day 10.

RESULTS

Median log difference in colony-count between day1 and day10 was 0.6 (0.2-1.4) in group1 and 0.13 (0.04-0.6) in group 2 (p < 0.05). Mean percentage reduction in wound size was 28.82 and 19.80 in group 1 and group 2 respectively (p < 0.05). Histological parameters of wound healing assessed as surface epithelium, granulation, inflammatory cells, proliferative blood-vessels and fibroblasts were significantly better in group1. A drawback observed with NPWTi was skin maceration around the ulcer which was successfully managed.

CONCLUSION

Our findings suggest that wound healing is significantly better when saline instillation is combined with NPWT. It can aid in complex extremity ulcers management by reducing the size of the wound with healthier looking granulation tissue.

Open Abdomen and Fluid Instillation in the Septic Abdomen: Results from the IROA Study

Background

Open abdomen (OA) is a surgical option that can be used in patients with severe peritonitis. Few evidences exist to recommend the use of intraperitoneal fluid instillation associated with OA in managing septic abdomen.

Materials and methods

A prospective analysis of adult patients enrolled in the International Register of Open Abdomen (trial registration: NCT02382770) was performed.

Results

A total of 387 patients were enrolled in two groups: 84 with peritoneal fluid instillation (FI) and 303 without (NFI). The groups were homogeneous for baseline characteristics. Overall complications were 92.9% in FI and 86.3% in NFI (p = 0.106). Complications during OA were 72.6% in FI and 59.9% in NFI (p = 0.034). Complications after definitive closure were 70.8% in FI and 61.1% in NFI (p = 0.133). Entero-atmospheric fistula was 13.1% in FI and 12% in NFI (p = 0.828). Fascial closure was 78.6% in FI and 63.7% in NFI (p = 0.02). Analysis of FI in negative pressure wound therapy (NPWT) showed: Overall morbidity in NPWT was 94% and in non-NPWT 91.2% (p = 0.622) and morbidity during OA was 68% and 79.4% (p = 0.25), respectively. Definitive fascial closure in NPWT was 87.8% and 96.8% in non-NPWT (p = 0.173). Overall mortality was 40% in NPWT and 29.4% in non-NPWT (p = 0.32) and morality during OA period was 18% and 8.8% (p = 0.238), respectively.

Conclusion

We found intraperitoneal fluid instillation during open abdomen in peritonitic patients to increase the complication rate during the open abdomen period, with no impact on mortality, entero-atmospheric fistula rate and opening time. Fascial closure rate is increased by instillation. Fluid instillation is feasible even when associated with nonnegative pressure temporary abdominal closure techniques.

Cost evaluation of temporary abdominal closure methods in abdominal sepsis patients successfully treated with an open abdomen. Should we take temporary abdominal closure methods at face value? Health economic evaluation

Background

Many commercial and artisanal devices are utilized for temporary abdominal closure in patients being managed with an open abdomen for abdominal sepsis. The costs of materials required to treat patients with an open abdomen varies drastically. In Costa Rica, due to the lack of accurate information relating to the actual cost to manage a patient entails that the method with the least expensive materials is usually selected.

Study design

A single-center retrospective review of 46 patients diagnosed with abdominal sepsis and successfully treated with an open abdomen and one of the three temporary abdominal closure methods during the year 2018 in a tertiary hospital was evaluated using a gross-cost pricing model developed by the authors. The three temporary abdominal closure methods were a locally manufactured Bogota Bag, and commercial abdominal negative pressure therapy dressing and negative pressure therapy with 0.9% saline solution instillation. The per-unit-costs were hospital day and intensive care day, number of surgical procedures per patient, cost negative pressure therapy kits.

Results

Statistically significant cost reduction was observed in the cohort treated with negative pressure therapy with instillation as compared to the other temporary abdominal closure methods. The reduction of hospital length of stay, as well as fewer number of surgeries were the main contributing factors in diminishing costs. On average, the costs to treat a patient utilizing negative pressure therapy with instillation was nearly 50% lower than using the other two temporary abdominal closure methods.

Conclusions

The costs relating to managing abdominal sepsis in the septic open abdomen vary greatly according to the temporary abdominal closure utilized. If the hospital length of stay, intensive care unit length of stay and number of surgeries required are the main parameters used in determining costs, the use of negative pressure therapy with 0.9% saline solution instillation reduces costs by nearly 50% in comparison to conventional negative pressure wound therapy and Bogota Bag. In this instance, the more expensive method at first glance, obtained a considerable cost reduction when compared to therapies that utilize less expensive materials.

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The costs of materials required to treat patients with an OA varies drastically. In Costa Rica, due to the lack of accurate information relating to the actual cost to manage a patient entails that the method with the least expensive materials is usually selected.

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Statistically significant cost reduction was observed in the cohort treated with negative pressure therapy with instillation as compared to the other TAC methods.

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On average, the costs to treat a patient utilizing negative pressure therapy with instillation was up to 50% lower than using the other two TAC methods.

Application of Negative Pressure Wound Therapy with Instillation and Dwell Time of the Open Abdomen: Initial Experience

Recent therapeutic advances in the management of severe abdominal sepsis (SAS) have improved patient mortality and morbidity. However, SAS and its impact on multiple organ failure remain a serious, life-threatening condition with a high mortality rate. The open abdomen (OA) technique has become an effective alternative to repeat laparotomy. The use of OA negative pressure wound therapy (OA NPWT) has been a significant advancement in the management of the open abdomen. Similarly, negative pressure wound therapy (NPWT) with instillation and dwell time (NPWT-i) has been used in patients with multiple comorbidities, with an American Society of Anesthesiology Classification ≥ 2, severe traumatic wounds, diabetic foot infections, and wounds complicated by invasive infection or extensive biofilm. Controlled instillation of saline during NPWT-i may further enhance healing by facilitating automatic and contained volumetric wound irrigation and cleansing and diluting local levels of inflammatory cytokines, improving the local as well as the systemic response to infection. Although the soft tissue and intra-abdominal compartments differ anatomically, they share very similar biologic responses to infections. Therefore, from a biologic and physiologic aspect, intraperitoneal instillation therapy may play a role as an adjunctive treatment of abdominal compartment inflammation from trauma or infection. The addition of saline solution instillation to OA NPWT (OAI) in a programmed, controlled manner may offer the clinician an effective adjunctive therapy for the treatment of the complex septic abdomen. The technical aspects of instillation into the OA and a pooled multicenter case study cohort utilizing OAI with saline solution, bacitracin, or hypochlorous acid in the management of the septic abdomen is presented.