Vacuum-assisted closure therapy with omental transposition for salvage of infected prosthetic femoral–distal bypass involving the femoral anastomosis

Soft tissue reconstruction of complex infra-inguinal wounds following revisionary vascular surgery

INTRODUCTION

Large, full thickness infra-inguinal wounds following revision revascularization procedures of the lower extremity are a challenging complication for reconstructive surgery. Frequently, these patients present with various comorbidities and after several previous reconstructive attempts and therefore no straightforward soft tissue reconstruction is likely.

METHODS

Patients who presented with large, complex inguinal wounds for soft tissue reconstruction were analyzed retrospectively in terms of flap choice, outcome and complication rates. A focus was set on the reconstructive technique and a subgroup analysis was assessed.

RESULTS

19 patients (11 men, 8 women) who received 19 flaps (17 pedicled, two free flaps) were included in this retrospective study. Average patient age was 73.3 years (range: 53-88 years). 10 fascio-cutaneous flaps (ALT, 52.6%) and 9 muscle flaps (47.4%) were applied. Among muscle flaps, 3 pedicled gracilis flaps, 4 pedicled rectus abdominis flaps and two free latissimus dorsi flaps were used. No flap losses were observed except one case of limited distal flap necrosis (gracilis group). Body Mass Index (BMI) ranged from 19 to 37, mean 26.8. Mean surgery time in all patients was 165.9 minutes (range: 105-373 minutes). Revision surgery due to local wound healing problems averaged 1.6 in all patients. In all cases sufficient soft tissue reconstruction was achieved and bypasses were preserved. Lengths of stay averaged 27.2 (14 to 59 days). Mortality was considerably (10.5%) due to systemic complications (One patient died due to a heart attack 4 weeks postoperatively, another patient died due to an extensive pulmonary embolism two weeks postoperatively).

CONCLUSION

Soft tissue reconstruction of complex inguinal wounds after revision vascular surgery is challenging and wound-healing problems are expectable. In addition to the rectus abdominis flap the pedicled ALT flap is feasible in a broad variety of medium to large wounds. Free flap reconstruction is recommended for very large defects. A structured interdisciplinary approach is required for the management of complex wounds after vascular surgery to prevent and to deal with complications and perioperative morbidity.

The Pedicled Omental Flap Technique for Treating Extensive Defects or Soft-Tissue Infection of the Pelvic Area: A Report of 2 Cases

Severe trauma injuries, such as open pelvic fractures and degloving injuries, have recently become salvageable. However, extensive soft-tissue defects often remain and can lead to disuse atrophy of the extremities, prolonged hospital stays, and numerous other problems. Such injuries can be easily and effectively treated by a general trauma surgeon performing the pedicled omental flap technique. We report on 2 highly diverse and complicated cases of soft-tissue defect that were both successfully treated with this technique. One case was an extensive right-sided defect of the pelvic soft-tissue in a 20-year-old woman. The other case was in a 55-year-old man who underwent emergency artificial vessel replacement surgery for a femoral artery tear with severe damage to the surrounding muscle. Although the surgery was successful, a methicillin-resistant Staphylococcus aureus infection developed around the artificial vessel 10 days after surgery. In both cases, the pedicled omental flap technique was successfully performed and yielded epithelization without serious infection and with the infection subsiding with wound-area healing. To our knowledge, the pedicled omental flap technique has rarely been used to treat severe trauma, and our results suggest its usefulness for both preventing infection in large wounds and healing infected wounds.

Retinervus luffae fructus (RLF): a novel material for use in negative pressure wound therapy

OBJECTIVE

To describe a modified negative pressure wound therapy (NPWT) apparatus, made mainly of an environmentally-friendly material derived from the retinervus luffae fructus (RLF; or loofah) plant.

METHOD

We retrospectively reviewed the charts of patients with skin defects on their limbs who underwent treatment with the RLF-NPWT device from September 2012 to October 2012. The endpoint of the study was healing by secondary intention; the time (days) to endpoint was evaluated.

RESULTS

The RLF-NPWT device was used in 16 patients. The age of the patients ranged from 15-82 years, with a mean age of 43 ± 17 years. Six patients sustained crush injuries, nine patients had open limb injuries from motor vehicle accidents and a further patient had a diabetic foot ulcer. The mean time to healing was 8.5 ± 2.4 days. Following RLF-NPWT, fresh granulation tissue was observed in all wound beds, with no evidence of macroscopical necrosis. All 16 patients in the study achieved secondary healing.

CONCLUSION

The environmentally friendly RLF-NPWT apparatus is easy to use and able to provide continual negative pressure for optimal preparation of the wound bed. The cost-effectiveness of RLF-NPWT compared to standard NPWT requires further investigation.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Vacuum-assisted closure therapy for salvaging a methicillin-resistant Staphylococcus aureus-infected prosthetic graft

Infection of a vascular prosthesis after a bypass surgery is relatively rare. However, once developed, serious complications can occur, such as bleeding, sepsis, and organ ischemia, occasionally resulting in leg amputation or even death in some cases. The treatment of a vascular prosthesis infection involves the necessary removal of the infected graft; subsequently, an extra-anatomical bypass surgery is often considered. We herein report a case in which postoperative methicillin-resistant Staphylococcus aureus infection caused dehiscence of the femoral vessels and exposure of the graft vessel and anastomosed area. The infected tissue was surgically removed (debridement), and the patient's condition was successfully treated by the application of a nonadherent dressing and vacuum-assisted closure therapy combined with the bridging technique.