Lymphorrhea responds to negative pressure wound therapy

Negative Pressure Wound Therapy: Challenges, Novel Techniques, and Future Perspectives

Significance: Negative pressure wound therapy (NPWT) has been in practice for decades, proving its utility in many applications, ranging from acutely infected wounds to complex combat wounds and skin grafting. It has been routinely demonstrated that NPWT has superior wound healing outcomes compared with previous standard-of-care therapies. However, the technique involves some challenges related to each of the components that comprise the therapy. The purpose of this article is to highlight the challenges, introduce the recent advancements, and discuss about the future directions in NPWT systems. Recent Advances: New techniques and materials have been developed to improve the currently used NPWT systems with promising results when utilized with appropriate indications. Many advancements have been introduced in modes of negative pressure delivery, pumps, interface dressings, adhesive dressings, and tubing technology. Critical Issues: An optimal NPWT system would avoid the common problems such as failure to deliver negative pressure due to loss of an airtight seal or tissue ingrowth into the interface dressing causing painful dressing changes and bleeding. Other challenges include infection control and patient pain and discomfort that may contribute to noncompliance. Future Directions: Many studies have been performed to evaluate the optimal combination of settings and components in various wounds; however, there is still no clear "best" answer for many specific patient-wound scenarios. Novel and emerging tissue engineering and regenerative medicine approaches could potentially be utilized in the future NPWT systems and thus, this review will discuss some novel ideas for future considerations.

Nonoperative Management of a Recurrent Postoperative Inguinal Lymphatic Leak via Negative-Pressure Wound Therapy: A Case Report

ABSTRACT

Lymphatic leaks are common following common femoral vessel exposure for cardiac surgical procedures. The management of this complication can be difficult and is often uncomfortable for the patient. This case report describes the successful nonoperative treatment of a recurrent lymphatic leak from an inguinal surgical wound via negative-pressure wound therapy. Negative pressure may be considered a minimally invasive, effective, and acceptable way to treat postoperative lymphatic leaks at the groin.

Combined internal and external negative pressure wound therapy: breakthrough treatment for lymphocutaneous intractable fistula

PURPOSE

Lymphocutaneous fistula after lymph node dissection is intractable, yet there is no established treatment strategy. This study demonstrates the wound closure time achieved by a new method of combined internal and external negative pressure wound therapy (CIEN) in patients with lymphocutaneous fistula.

METHODS

The subjects of this study were six consecutive patients with lymphocutaneous fistula after lymphatic surgery, who were treated with CIEN between 2018 and 2020. The CIEN technique can be summarized as follows: first, internal foam is inserted into the fistula from the opening of the fenestration. Next, a slightly larger area of external foam is applied above the fistula flap outside the external margin of the foam-filled fistula. After bridging the internal foam and external foam, negative-pressure wound therapy is carried out on this bridging foam block.

RESULTS

CIEN led to rapid and complete wound healing in all six patients. Fistula flap margin ischemia developed in one patient, but adjusting the mode and pressure settings resulted in improvement. Three patients suffered contact dermatitis. There were no signs of tumor or fistula recurrence in any patients after at least 3 months of follow-up.

CONCLUSION

CIEN is an effective and less invasive treatment modality than the conventional method of managing lymphocutaneous fistula.

Lymphaticovenular anastomosis for lymph vessel injury in the pelvis and groin

BACKGROUND

Lymphatic diseases due to lymph vessel injuries in the pelvis and groin require immediate clinical attention when conventional treatments fail. We aimed to clarify the effectiveness of and indications for lymphaticovenular anastomosis (LVA) to treat these lymphatic diseases.

METHODS

We retrospectively evaluated six patients who underwent LVA for lymphatic diseases due to lymph vessel injuries in the pelvis and groin. Specific pathologies included groin lymphorrhea (N = 3), chylous ascites (N = 2), and retroperitoneal lymphocele (N = 1). The maximum lymphatic fluid leakage volume was 150-2600 mL daily. Conventional treatments (compression, drainage, fasting, somatostatin administration, negative pressure wound therapy, or lymph vessel ligation) had failed to control leakage in all cases. We performed lower extremity LVAs after confirming the site of lymph vessel injury using lymphoscintigraphy. We preferentially placed LVAs in thigh sites that showed a linear pattern by indocyanine green lymphography. Postoperative lymphatic fluid leakage volume reduction was evaluated, and leakage cessation was recorded when the drainage volume approached 0 mL.

RESULTS

LVA was performed at an average of 4.3 sites (range, 3-6 sites) in the thigh and 2.7 sites (range, 0-6 sites) in the lower leg. Lymphatic fluid leakage ceased in all cases after a mean of 6 days (range, 1-11 days) postoperatively. No recurrence of symptoms was observed during an average follow-up of 2.9 (range, 0.5-5.5) years.

CONCLUSIONS

LVA demonstrates excellent and rapid effects. We recommend lower extremity LVA for the treatment of lymphatic diseases due to lymph vessel injuries in the pelvis and groin.

A Case of Traumatic Intractable Leg Ulcer with Lymphorrhea Diagnosed Using ICG Lymphography

We report a case of traumatic lower extremity ulcers with lymphorrhea in a 37-year-old woman. She presented intractable ulcers without lymphedema for nearly 6 months after a traumatic injury. She was treated conservatively for 6 months at a referral hospital. Unfortunately, during conservative treatment, cellulitis was developed. Even though the inflammation resolved, the ulcer did not heal. We suspected persistent lymphorrhea as the cause of refractory ulcer, and for that reason, we performed indocyanine green lymphography. The lymphatic vessel damage site was identified; also, a collateral lymphatic vessel connected toward the central side was recognized. The lymph fluid drainage site was selectively ligated. The lymphorrhea and ulcers healed 1 month after ligation. Ulcers with lymphorrhea can be persistent and refractory to treatment. Indocyanine green lymphography can be a feasible diagnostic technique. It can identify the site of leakage and is thus useful for treatment. There are fewer reports on the evaluation of lymphorrhea with video presentation. Here, we report a case with video presentation.

Closed Incisional Negative Pressure Wound Therapy at Flap Suture Line: An Innovative Approach for Improving Outcomes in Suboptimal Wound Conditions

Background  Persistent dead space following flap cover is a frequently encountered challenge following the reconstruction of complex wounds. It may lead to a hematoma, seroma, wound infection, and wound dehiscence. Wound dehiscence could be a devastating complication. Closed incisional negative pressure wound therapy (ciNPWT) over the surgical incisions was found to reduce surgical site infection (SSI) and wound dehiscence. We applied this principle at the closed flap suture line and through this article, we share the indications, technique, and outcomes.

Methods  A retrospective analysis (January 2018–June 2019), in which selected high-risk patients who underwent ciNPWT at the flap suture following complex reconstruction (pedicled or free flap) were included in the study. The indications include deep incisional/organ SSI after debridement and flap coverage, persistent dead space following flap coverage, chronic osteomyelitis. Patients were analyzed in the follow-up period in terms of complications, wound healing.

Results  Nine patients underwent ciNPWT over the flap suture line. The mean age was 32.2 years (range: 10–48 years). The mean duration of the NPWT application was 7.3 days (range: 3–21 days). Three of the nine patients had flap-related minor complications. One patient had marginal flap necrosis and required skin grafting, one patient had minor wound dehiscence (1 cm) which required secondary skin suturing and one patient had chronic discharging sinus related to osteomyelitis of ischium, which subsequently healed with antibiotics and local wound care. None of the patients had NPWT-related complications.

Conclusion  Closed incisional NPWT decreases the untoward effects of dead space following the reconstruction of complex wounds. The incidence of SSI and wound gaping can be reduced.

Lymphatic Leaks of the Thigh and Inguinal Region: Combined Plastic Surgery Approaches for an Effective Treatment Algorithm

BACKGROUND

Surgical procedures interfering with the draining nodes in the inguinal region carry the intrinsic risk of lymphatic complications. Lesions of the inguinal lymphatic network can lead to lymphocele or lymphocutaneous fistulas and can eventually be associated to limb lymphedema with consequent high morbidity.

OBJECTIVES

This article describes a new surgical algorithm based on wound properties to properly address lymphatic complications of the inguinal area. Based on our experience, surgical solutions ranged from selective lymphatic vessel ligation to microsurgical lymphatic fistula treatment and free tissue transfer.

METHODS

Fourteen consecutive patients underwent surgery in our department following failed attempts to address persistent lymphatic leaks. Patient characteristics such as smoking, previous surgeries, comorbidities, and wound properties were considered. Identification of the leak was performed using blue patent dye and indocyanine green fluorescence. Surgical reconstruction occurred, according to our algorithm.

RESULTS

Lymphatic leaks were visualized in 11 of 14 patients. Direct closure of the wound after leak ligation could be performed in 4 of 14 patients. Multilymphatic into vein anastomosis was performed in 3 of 14 patients, and the remaining patients benefited from flap surgery based on the wound defects. All 14 patients had successful outcomes (100%) with early drain removal (average, 6 [SD, 6] days) and definitive wound healing 2 weeks postoperatively. After a mean follow-up of 12 (SD, 2.9) months, no clinical infection, lymphatic complication, or wound breakdown occurred. One patient had a partial recurrence that did not require surgical intervention.

CONCLUSIONS

A stepwise approach, combining lymphatic surgery principles and plastic surgery flap techniques, can lead to an effective treatment algorithm where surgical options are wound tailored to guarantee the best functional outcomes.

Supermicrosurgical Lymphaticovenous Anastomosis as an Alternative Treatment Option for Patients with Lymphorrhea

BACKGROUND

Lymphorrhea is probably the most appalling form of lymphedema and is difficult to treat. Intractable lymphorrhea is prone to infection because of skin breakdown. It is believed that supermicrosurgical lymphaticovenous anastomosis is unsuitable for treating such severe disease. Only a few lymphorrhea patients treated with lymphaticovenous anastomosis have been reported. Whether it can be used to treat lymphorrhea has remained inconclusive.

METHODS

From September of 2015 to June of 2018, 105 patients underwent supermicrosurgical lymphaticovenous anastomosis (n = 746) in the authors' hospital. These patients are divided into the nonlymphorrhea group (three male and seven female patients) and the nonlymphedema group (lymphedema patients without lymphorrhea) (11 male and 84 female patients). Retrospective chart review with demographic data and intraoperative findings were recorded and analyzed. Post-lymphaticovenous anastomosis outcomes for lymphorrhea patients were also recorded.

RESULTS

No significant differences were found in patient age, sex, or affected limbs between these two groups. As for intraoperative findings, no differences were found in the percentage of indocyanine green-enhanced lymphatic vessels (52.7 ± 41.1 percent versus 67.3 ± 36.7 percent; p = 0.227) or the pathologic changes of lymphatic vessels based on the normal, ectasis, contraction, and sclerosis type classification (2.2 ± 1.0 versus 2.1 ± 1.0; p = 0.893) between the lymphorrhea and nonlymphorrhea groups, respectively. The average follow-up period was 14.5 months (range, 3 to 31 months). Five lymphorrhea patients (50 percent) showed complete recovery without relapse; significant lymphorrhea reduction was found in three patients (30 percent), and two patients showed minimal improvements (20 percent).

CONCLUSION

With comparable functional lymphatic vessels identified in lymphorrhea patients, supermicrosurgical lymphaticovenous anastomosis is a viable option for lymphorrhea treatment, with satisfactory results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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.

[Management of lymphatic fistulas in the groin from a surgeon's perspective]

BACKGROUND

The postoperative occurrence of lymph fistulas in the groin is a complication that should be taken seriously. These fistulas cause an increase in morbidity and can support local and ascending infections. The treatment of this complication ranges from conservative procedures, such as compression dressings and bed rest to operative treatment with detection of the fistulas and ligation, negative pressure wound therapy (NPWT) or even muscle flaps. This review provides an overview of current therapeutic modalities.

MATERIAL AND METHODS

On the basis of a current literature search via PubMed, we identified possible treatment options, which are described in this article.

RESULTS

The conservative treatment options presented still have an importance in treating groin fistulas. A selection of safe and effective interventional and operative treatments is presented.

CONCLUSION

If there are indications for an interventional or operative treatment a variety of safe and effective therapies are available, which can significantly reduce the length of hospital stay. The option of treatment using a muscle flap is of value as a last resort in the treatment of infected vascular prosthesis in the groin of Szilagyi type III and should be used when necessary.

Treatment of postoperative high-volume lymphatic complications using isosulfan blue

BACKGROUND

Lymphocele (LC) and lymphocutaneous fistula (LF) are infrequent but serious complications that occur when lymphatics are disrupted during a vascular procedure. Conservative management with bed rest, extremity elevation, aspiration, and pressure dressing is often ineffective. This study evaluated the effectiveness of isosulfan blue (ISB) to identify disrupted lymphatics for ligation.

METHODS

Between 1998 and 2016, there were 33 lymphatic complications treated with ISB-directed ligation in 32 patients. The patients' records were retrospectively reviewed, recording demographics, comorbid conditions, index vascular operation causing the lymphatic complication, details of the procedure done to treat the lymphatic complication, and outcomes. In each patient, between 1 and 3 mL of ISB was injected in the subcutaneous tissue of the interdigital web space. The wound associated with the lymphatic complication was opened. The appearance of dye within the wound identified disrupted lymphatic ducts for suture ligation.

RESULTS

The lymphatic complications were either LC (11 [33%]) or LF (22 [66%]) and were associated with femoral vein harvest (9), great saphenous vein harvest (8), exposure of femoral arteries (13), creation of an upper extremity fistula (1), repeated femoral access for coronary angiography, or excision of an LC (1). Most patients were male (66%), and the mean age was 56.8 ± 13.1 years. In comparing patients with LF and LC, the diagnosis of LF was made earlier (13.8 ± 7.0 days vs 23.4 ± 14.1 days; P = .02), and treatment occurred sooner for LF than for LC (22.1 ± 8.1 days vs 48.8 ± 51.2 days; P = .02). In all patients, ISB identified one or more disrupted lymphatics. The appearance of the ISB dye within the wound after injection was rapid, often within 5 to 10 minutes. After ligation of the lymphatics, most wounds were closed primarily (26 [79%]), but a muscle flap (5 [15%]), negative pressure dressing (1 [3%]), and dressing changes (1 [3%]) were also used. Wound healing was achieved in all patients on average 32.5 ± 21.5 days after lymphatic ligation.

CONCLUSIONS

The current series is one of the largest reported experiences using ISB to identify injured lymphatics responsible for LC or LF. Lymphatic complications after a vascular procedure usually occur within 3 weeks of the index vascular procedure, with LF being identified and treated earlier than LC. ISB injection rapidly identifies disrupted extremity lymphatics. Ligation of these lymphatics results in reliable resolution of the lymphatic complication.

Lymphaticovenous Anastomoses for Lymphedema Complicated by Severe Lymphorrhea Following Resection of Soft-Tissue Sarcomas of the Adductor Compartment: A Report of Two Cases

CASE

Lymphedema and lymphorrhea are major causes of wound complications after the resection of soft-tissue sarcomas in the adductor compartment of the thigh. We report 2 cases of successful treatment of lymphedema and lymphorrhea, which had been refractory to nonoperative treatment, with use of lymphaticovenous anastomosis (LVA) and intraoperative indocyanine green lymphography after the resection of a sarcoma in the adductor compartment.

CONCLUSION

These 2 cases highlight that LVA can be a useful and minimally invasive alternative to myocutaneous flaps for the treatment of wound complications caused by lymphedema and lymphorrhea after surgery for soft-tissue sarcomas in the adductor compartment of the thigh.

A review of the postoperative lymphatic leakage

Lymphatic complications are rare, but well-known phenomena, and have been described by many researchers. However, many diagnoses of lymphatic complications are found confusing due to different definition. A literature search in Pubmed was performed for studies postoperative lympatic complications. These complications divided into two parts: lymphatic leakage and lymphatic stasis. This review is about lymphatic leakage, especially, postoperative lymphatic leakage due to the injury of lymphatic channels in surgical procedures. According to polytrophic consequences, many types of postoperative lymphatic leakage have been presented, including lymph ascites, lymphocele, lymphorrhea, lymphatic fistula, chylous ascites, chylothorax, chyloretroperitoneum and chylorrhea. In this review, we focus on the definition, incidence and treatment about most of these forms of lymphatic complications to depict a comprehensive view of postoperative lymphatic leakage. We hold the idea that the method of treatment should be individual and personal according to manifestation and tolerance of patient. Meanwhile, conservative treatment is suitable and should be considered first.

Knee lymphocutaneous fistula secondary to knee arthroplasty

Lower limb lymphorrhea secondary to a surgical procedure is a rare but difficult-to-solve complication. In lower limb, this entity is frequently associated with vascular procedures around the inguinal area. We report on a case of a knee lymphocutaneous fistula secondary to a knee revision arthroplasty. To our knowledge, no previous reports regarding this complication have been published.

Utility of indocyanine green fluorescence lymphography in identifying the source of persistent groin lymphorrhea

SUMMARY

Surgical manipulation of the groin can result in lymphatic injury in a significant number of patients leading to poor wound healing or infectious complications. Surgical repair of lymphatic injury is greatly aided by the precise and prompt intraoperative localization of the injured lymphatic vessels. We assessed and identified lymphatic leaks in 2 cases of surgical wound lymphorrhea occurring after instrumentation of the groin using laser-assisted indocyanine green lymphography paired with isosulfan blue injection. Both cases healed without complication, and no lymphatic leak recurrence was observed during postoperative follow-up. Laser-assisted indocyanine green lymphography is a useful adjunct in the management of lymphatic leaks after surgery of the groin and may have potential for prophylactic evaluation of high-risk groin wounds.

Lymphatic complications after vascular interventions

Introduction

Lymphorrhea due to classical and mini-invasive surgical interventions on femoral and popliteal arteries is a serious hindrance to patient treatment. Depending on the experience of a particular center, the incidence and frequency of this type of complication may constitute a serious clinical problem. While the level of lymphorrhea intensity and its duration result in certain foreseeable consequences, their treatment can be a time-consuming and multistep procedure.

Aim

To compare different types of vascular interventions with lymphorrhea occurrence.

Material and methods

The authors conducted a retrospective analysis of lymphatic complications based on the material collected between 2005 and 2012 at the Department of Vascular and Endovascular Surgery of the Military Institute of Medicine in Warsaw and in the Department of Interventional Cardiology and Angiology of the Institute of Cardiology in Anin, Warsaw, in 2009–2012.

Results

Maintaining due thoroughness when dissecting tissues and treating the cutting line in this area with ligatures and tissue puncture are the most reliable methods of minimizing the risk of lymphatic leakage after surgical procedures performed in a classical way. The lymphatic complication under analysis is far less likely to occur when procedures are performed as planned and an endovascular technique is used – statistical significance p < 0.05. Minimally invasive and fully percutaneous procedures performed via needle puncture, including the use of the fascial closure technique to close the femoral artery, eliminate the likelihood of the occurrence of this vascular complication – statistical significance was found with p value less than 0.05.

Conclusions

We concluded that in every case by minimizing the vascular approach we protected the patient against lymphatic complications.

Therapeutic efficacy of vacuum-assisted-closure therapy in the treatment of lymphatic complications following peripheral vascular interventions and surgeries

Objectives

Lymphatic complications, lymphocele and lymphorrhea being the leading, are generally encountered after vascular interventions and surgeries. The present study aimed to evaluate the outcomes of vacuum-assisted-closure (VAC) therapy, which we frequently prefer as the first-choice treatment for such complications.

Materials and methods

Among patients undergoing peripheral vascular intervention or surgery between January 2008 and February 2012, the medical files of 21 patients who received VAC therapy or other treatment due to symptomatic lymphatic complications were retrospectively analyzed and the results were discussed.

Results

Group I consisted of 10 patients (three with lymphocele and seven with lymphorrhea) who underwent VAC therapy as the first-choice treatment, Group II consisted of 11 patients of which 7 patients received various therapies before VAC therapy and 4 patients received other treatments alone. The patients who received VAC therapy as the primary therapy demonstrated more rapid wound healing, early drainage control, and shorter hospital stay. The mean hospital medical cost was €1038 (range, €739–1826) for the patients who primarily underwent VAC therapy; it was calculated to be €2137 (range, €1610–3130) for the other patients ( p = 0.001).

Conclusion

In addition to its safety and good clinical outcomes, VAC therapy also has economic advantages and should be the primary method for the treatment of lymphatic complications.

Negative pressure wound therapy for inguinal lymphatic complications in critically ill patients

Purpose

In this study, we investigated the therapeutic potential of regulated negative pressure vacuum-assisted wound therapy for inguinal lymphatic complications in critically ill, liver transplant recipients.

Methods

The great saphenous vein was harvested for hepatic vein reconstruction during liver transplantation in 599 living-donor liver transplant recipients. Fourteen of the recipients (2.3%) developed postoperative inguinal lymphatic complications and were treated with negative pressure wound therapy, and they were included in this study.

Results

The average total duration of negative pressure wound therapy was 23 days (range, 11 to 42 days). Complete resolution of the lymphatic complications and wound healing were achieved in all 14 patients, 5 of whom were treated in hospital and 9 as outpatients. There was no clinically detectable infection, bleeding or recurrence after an average follow-up of 27 months (range, 7 to 36 months).

Conclusion

Negative pressure wound therapy is an effective, readily-available treatment option that is less invasive than exploration and ligation of leaking lymphatics and provides good control of drainage and rapid wound closure in critically ill patients.

Low-invasive lymphatic surgery and lymphatic imaging for completely healed intractable pudendal lymphorrhea after gynecologic cancer treatment

Lower limb lymphedema and an accompanying lymphatic fistula (lymphorrhea) occur as complications after gynecologic surgery to treat cancer. Herein, we report the case of a 68-year-old woman who underwent resection and radiotherapy because of uterine cervical cancer (stage 2a) 20 years previously. Left lower limb and pudendal lymphedema and continuous lymphorrhea developed soon after surgery. Conservative treatment was administered; however, the edema increased, and a pudendal lymphatic fistula and cellulitis developed repeatedly. Lymphovascular anastomosis (LVA) and lymph vessel ligation were performed after preoperative evaluation via lymphoscintigraphy and indocyanine green (ICG) lymphography. A radioisotope injected into the first interdigit pedal region flowed into the pudendal region via the inguinal lymph nodes at preoperative lymphoscintigraphy. Linear patterns were observed up to the half level of the crus, and stardust patterns occurred over the lower abdominal and pudendal regions at ICG lymphography. During surgery, ICG lymphography was also used to identify the site of the fistula. With the patient under local anesthesia, LVA was applied in the half crus and left inguinal regions, followed by ligation and division of lymph vessels flowing into the fistula. The region around the fistula was excised as a 1 × 3-cm tissue block. As of 5 months after surgery, no recurrence of lymphatic fistula or exacerbation of lymphedema has occurred. This case shows the effectiveness of preoperative ICG lymphography and lymphoscintigraphy followed by treatment via lymph vessel ligation and LVA for curative resolution of a lymphatic fistula.

Clinical evaluation of gauze-based negative pressure wound therapy in challenging wounds

The aim of this randomised clinical study was to evaluate the effectiveness and safety of gauze-based negative pressure wound therapy (NPWT) in patients with challenging wounds. A total of 50 consecutive patients who had wound drainage for more than 5 days, required open wound management and had existence of culture positive infection were included the study. In this study, gauze-based NPWT was compared with conventional dressing therapy in the treatment of patients with difficult-to-heal wounds. The patients were randomly divided into two groups. Group I (n = 25) was followed by conventional antiseptic (polyhexanide solution) dressings, and group II (n = 25) was treated with saline-soaked antibacterial gauze-based NPWT. The wounds' sizes, number of debridement, bacteriology and recurrence were compared between group I and group II. The mean age of the patients was 59·50 years (range 23-97). In group I, average wound sizes of pre- and post-treatment periods were 50·60 ± 55·35 and 42·50 ± 47·92 cm(2), respectively (P < 0·001). Average duration of treatment was 25·52 ± 16·99 days, and average wound size reduction following the treatment was 19·99% in this group. In group II, the wounds displayed considerable shrinkage, accelerated granulation tissue formation, decreased and cleared away exudate. The average wound sizes in the pre- and post-treatment periods were 98·44 ± 100·88 and 72·08 ± 75·78 cm(2) , respectively (P < 0·001). Average duration of treatment was 11·96 ± 2·48 days, and average wound size reduction following the treatment was 32·34%. The patients treated with antibacterial gauze-based NPWT had a significantly reduced recurrence (2 wounds versus 14 wounds, P = 0·001), and increased number of the culture-negative cases (22 wounds versus 16 wounds, P < 0·047) in a follow-up period of 12 months. There was a statistically significant difference between two groups in all measurements. As a result, we can say that the gauze-based NPWT is a safe and effective method in the treatment of challenging infective wounds when compared with conventional wound management.

Update on negative-pressure wound therapy

BACKGROUND

Over the last 15 years, negative-pressure wound therapy has become commonly used for treatment of a wide variety of complex wounds. There are now several systems marketed, and additional products will be available in the near future. Many clinicians have noted a dramatic response when negative-pressure wound therapy technology has been used, prompting a number of scientific investigations related to its mechanism of action and clinical trials determining its efficacy.

METHODS

The peer-reviewed literature within the past 5 years was reviewed, using an evidence-based approach.

RESULTS

Negative-pressure wound therapy works through mechanisms that include fluid removal, drawing the wound together, microdeformation, and moist wound healing. Several randomized clinical trials support the use of negative-pressure wound therapy in certain wound types. Serious complications, including bleeding and infection, have recently been reported by the U.S. Food and Drug Administration in a small number of patients.

CONCLUSIONS

Negative-pressure wound therapy has dramatically changed the way complex wounds are treated. The rapid introduction of this technology has occurred faster than large-scale randomized controlled studies or registry studies have been conducted. Further clinical studies and basic science studies will help surgeons to better understand the evidence and use this technology in the future.

Lymphocutaneous fistulas: pre-therapeutic evaluation by magnetic resonance lymphangiography

OBJECTIVE

Lymphocutaneous fistulas with intractable lymphatic leakage represent a serious clinical condition leading to a severe impairment of quality of life for the affected patients. To date, no adequate diagnostic imaging modality is in existence to allow selection of the correct treatment option. The aim of this study was to perform a pre-therapeutic evaluation of the lymphatic system in patients with lymphocutaneous fistulas by magnetic resonance lymphangiography (MRL).

METHODS

Eight lower extremities in four patients with lymphocutaneous fistulas were examined by MRL. Three locations were examined: first, the lower leg and foot regions; second, the upper leg and the knee region; and third, the pelvic and retroperitoneal regions. A T(1) weighted three-dimensional (3D) spoiled gradient echo and a heavily T(2) weighted 3D turbo spin echo (3D-TSE) sequence were utilised to undertake MRL.

RESULTS

In all four patients (100%), the clinically suspected lymphocutaneous fistulas (groin and forefoot) were exactly delineated by MRL. In two patients (50%) adjacent diffuse lymphangiomatous changes were detected, extending into the upper leg, pelvis, retroperitoneum, abdomen and abdominal walls. In one patient (25%) with primary lymphoedema of the right lower extremity, MRL revealed an aplasia of the lymphatic collectors at the levels of the lower and upper leg. All patients (100%) suffered from an ipsilateral lymphoedema of the lower extremity, whereby in two patients with diffuse lymphangiomatosis the lymphatic vessels were consecutively enlarged up to a diameter of 6 mm.

CONCLUSION

MRL is a safe and accurate imaging modality for a comprehensive evaluation of the lymphatic system in patients suffering from lymphocutaneous fistulas.

Use of gauze-based negative pressure wound therapy in a pediatric burn patient

Negative pressure wound therapy (NPWT) is described as it is used in the treatment of an infant burn victim. This case highlights the ability and techniques used to maintain an airtight dressing seal in the perirectal region. Use of this dressing type post-skin grafting allowed for 100% graft adhesion and no bacterial contamination despite close proximity to the rectum. Favorable experience and outcome with this patient are strong indicators that NPWT should be considered as a viable treatment in pediatric populations and that situations where body contour or fluids may make NPWT difficult to administer should not be a deterrent to therapy.

Treatment of a groin lymphatic fistula with negative pressure wound therapy

INTRODUCTION

Groin lymphatic fistulas are a troublesome finding after limb revascularization surgery. Its management represents a difficult task for the clinician.

REPORT

We report our experience in the treatment of such a condition with negative-pressure wound therapy (NPWT) in a 70-year-old man which benefited from extra-anatomic prosthetic axillofemoral bypass. After a week of treatment, the fistula dried up and closure was obtained with simple suture under local anaesthesia. Follow-up at 9 months showed stable coverage without any sign of leakage.

DISCUSSION

This study depicts NPWT as an effective non-invasive treatment in the management of groin lymphocutaneous fistula.

The Effect of Negative Pressure Therapy on the Femoral Vein Blood Flow and Wall Structure

Negative pressure therapy has been recently used for managing lymphatic or infective groin complications. The aim of this study was to investigate any possible association between application of negative pressure therapy in the groin area and deep-vein thrombosis. Acute surgical wounds were created at the inguinal areas in 7 pigs. Different negative pressures ranging from −50 to −200 mmHg were applied directly over the femoral vessels, and blood flow alterations were studied using a Doppler ultrasound. Femoral vein specimens were also removed for histological examination after 12 hours of therapy. It has been demonstrated that negative pressure therapy does not significantly alter the baseline lower limb venous return. Histology demonstrated several changes, which are associated with vein thrombogenesis. The hemodynamic and pathological findings still leave a potential for thrombogenic effects of negative pressure therapy and warrant care to protect the femoral veins, with the use of thrombosis prophylaxis measures.