Using advanced wound care and hyperbaric oxygen to manage wound complications following treatment of vulvovaginal carcinoma

Pelvic Necrosis with Formation of a Pelvic "Cloaca" and Necrotizing Soft Tissue Infection After Radiation for Anal Squamous Cell Carcinoma

BACKGROUND Anal squamous cell carcinoma (SCC) is a rare cancer commonly treated with the Nigro protocol, which combines chemotherapy and radiation. Patients who received radiation therapy prior to modern advances, such as computer-based tumor targeting, volumetric planning, and intensity-modulated radiation therapy, experience more acute and chronic adverse effects. Though exceedingly rare, radiation necrosis is of particular concern, as it can result in significant morbidity and mortality, including complex pelvic fistula formation and predisposition to potentially life-threatening necrotizing soft-tissue infections. CASE REPORT Here, we present a case of a 66-year-old woman with a prior history of anal SCC stage T3N×M0 who was treated with the Nigro protocol. Her treatment course was complicated by radiation proctitis, necessitating fecal diversion and ureteral strictures, requiring frequent stent exchanges. She presented 18 years after her cancer treatment, with widespread necrosis of her pelvic organs and surrounding soft tissue, resulting in formation of a large pelvic "cloaca", with a superimposed necrotizing soft-tissue infection. She was successfully treated by expedited resuscitation, septic source control, using multiple extensive debridements, and complete urinary diversion, utilizing a multidisciplinary team. CONCLUSIONS This case highlights the importance of monitoring patients for signs of radiation toxicity, particularly in patients who received radiation prior to the latest technological advancements, as they are at increased risk of developing severe, late adverse effects decades after treatment. When these complications are recognized, early and aggressive intervention is required to spare the patient significant morbidity and mortality.

Clinical effects of high-intensity laser therapy on patients with chronic refractory wounds: a randomised controlled trial

OBJECTIVE

To investigate the effectiveness of high-intensity laser therapy (HILT) on chronic refractory wounds.DesignRandomised controlled trial.

SETTING

The outpatient wound care department of the Affiliated Jiangsu Shengze Hospital of Nanjing Medical University from August 2019 to June 2020.

PARTICIPANTS

Sixty patients were enrolled in this study and were randomised into control (n=30) and treatment (n=30) groups.

INTERVENTIONS AND OUTCOME MEASURES

The control group was treated only with conventional wound dressing, whereas the treatment group received irradiation with HILT in addition to standard wound care, such as debridement, wound irrigation with normal saline solution and application of dressing and sterile gauze. Patient scores on the Bates-Jensen Wound Assessment Tool (BWAT) and Pressure Ulcer Scale for Healing (PUSH) were evaluated before and after 1, 2 and 3 weeks of treatment.

RESULTS

One patient was excluded from the control group, and a total of 59 subjects completed the trial. The BWAT scores significantly decreased in the treatment group compared with the control group at the end of 3-week treatment (difference=-3.6; 95% CI -6.3 to-0.8; p<0.01). Similarly, patients in treatment group showed a significant reduction of PUSH scores compared with the control group (difference=-5.3; 95% CI -8.1 to -2.6; p<0.01).

CONCLUSIONS

The therapeutic effects of HILT on chronic refractory wounds are significant and far more superior to those of conventional wound dressing.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry; ChiCTR1900023157. URL: http://www.chictr.org.cn/showproj.aspx?proj=38866.

Integration of microbubbles with biomaterials in tissue engineering for pharmaceutical purposes

Tissue engineering with the aid of biomaterials is a novel and promising knowledge aiming at improving human life expectancy. Besides, microbubbles are increasingly employed in biomedical applications due to their capability as a reservoir of therapeutic agents and oxygen molecules. In the present study, Microbubbles as the backbone of the research are produced as one of the potent devices in tissue engineering approaches, including drug delivery, wound healing, 3D printing, and scaffolding. It was shown that microbubbles are capable of promoting oxygen penetration and boosting the wound healing process by supplying adequate oxygen. Microbubbles also demonstrated their strength and potency in advancing drug delivery systems by reinforcing mass transfer phenomena. Furthermore, microbubbles developed the mechanical and biological characteristics of engineered scaffolds by manipulating the pores. Increasing cell survival, the biological activity of cells, angiogenesis, cell migration, and also nutrient diffusion into the inner layers of the scaffold were other achievements by microbubbles. In conclusion, the interest of biomedical communities in simultaneous usage of microbubbles and biomaterials under tissue engineering approaches experiences remarkable growth in Pharmaceutical studies.

Therapeutic Effects of Hyperbaric Oxygen in the Process of Wound Healing

Chronic and non-healing wounds, especially diabetic foot ulcers and radiation injuries, imply remarkable morbidity with a significant effect on the quality of life and a high sanitary cost. The management of these wounds requires complex actions such as surgical debris, antibiotic treatment, dressings and even revascularization. These wounds are characterized by poor oxygen supply resulting in inadequate oxygenation of the affected tissue. The adjuvant treatment with hyperbaric oxygen therapy (HBOT) may increase tissue oxygenation favoring the healing of wounds which do not respond to the usual clinical care. The increase in the partial pressure of oxygen contributes to cover the energy demands necessary for the healing process and reduces the incidence of infections. Moreover, the increase in oxygen leads to the production of reactive species with hormetic activity, acting on signaling pathways that modulate the synthesis of inflammation mediators, antioxidants and growth factors which can contribute to the healing process. Studies performed with cell cultures and in animal models seem to demonstrate the beneficial effects of HBOT. However, clinical trials do not show such conclusive results; thus, additional randomized placebo-controlled studies are necessary to determine the real efficacy of HBOT and the mechanism of action for various types of wounds.

Dose-Dependent Effect of Hyperbaric Oxygen Treatment on Burn-Induced Neuropathic Pain in Rats

Hyperbaric oxygen treatment (HBOT) has been used to reduce neuropathic pain. Melatonin and opioid receptors are involved in neuropathic pain, but it is not known if HBOT works through these pathways to achieve its antinociceptive effect. We divided anesthetized rats into two treatment and three sham groups. The two treatment groups received third-degree burns on their right hind paws, one treated in a hyperbaric chamber for a week and the other for two weeks. We evaluated the mechanical paw-withdrawal threshold (MWT) and expression of melatonin receptor 1 (MT1), melatonin receptor 2 (MT2), μ (MOR) and κ (KOR) opioid receptor, brain-derived neurotrophic factor (BDNF), Substance P, and calcitonin gene-related peptide (CGRP) in cuneate nucleus, dorsal horn, and hind paw skin by immunohistochemical, immunofluorescence assays and real-time quantitative polymerase chain reaction (RT-PCR). The group receiving one-week HBOT had increased expressions of MT1, MT2, MOR and KOR and decreased expressions of BDNF, Substance P, and CGRP. Their mechanically measured pain levels returned to normal within a week and lasted three weeks. This anti-allodynia effect lasted twice as long in those treated for two weeks. Our findings suggest that increasing the duration of HBOT can reduce burn-induced mechanical allodynia for an extended period of time in rats. The upregulation of melatonin and opioid receptors observed after one week of HBOT suggests they may be partly involved in attenuation of the mechanical allodynia. Downregulation of BDNF, substance P and CGRP may have also contributed to the overall beneficial effect of HBOT.