A Case of Tension Subcutaneous Emphysema Treated With Minimally Invasive Open-Window Thoracostomy Using a Wound Protector/Retractor and Three-Sided Taping

Subcutaneous emphysema is a common complication of thoracic surgery. Tension subcutaneous emphysema that causes airway obstruction is rare but life-threatening. This report presents a patient who developed tension subcutaneous emphysema after recurrent secondary pneumothorax surgery which was treated with minimally invasive open-window thoracostomy. A wound protector/retractor and three-sided taping were successfully used to prevent air from entering the subcutaneous space via the wound while draining trapped air without creating an open pneumothorax. This approach is an option for managing subcutaneous and intrathoracic air leakage in emergency situations.

Minimally invasive intrathoracic negative-pressure therapy and flexible thoracoscopy (FlexVATS) for patients with pleural empyema

To determine whether a new surgical method using a flexible endoscope (FlexVATS) to perform sparing debridement and apply negative-pressure therapy without extensive decortication may be an alternative treatment option for empyema. Surgical treatment of pleural empyema is associated with considerable postoperative complications and mortality rates, and alternative treatment options are being explored to improve patient outcomes. This was a prospective case series. Seventeen consecutive patients treated with FlexVATS between February 2021 and August 2022 were included in the study. Only patients for whom FlexVATS was the first therapeutic intervention for pleural empyema were included. Treatment success, defined as infection resolution, was the primary endpoint of the study. The secondary endpoints were length of hospital stay, 90-day mortality, and empyema cavity volume reduction. Patients who had previously been treated for pleural empyema by either drainage or surgery were excluded. The trial was performed as a single-centre study at a tertiary medical centre in Germany. In total, 17 patients with pleural empyema were included in the study. The median (IQR) duration of vacuum treatment was 15 days (8-35 days). Twelve of the 17 (71%) patients were successfully treated, and a significant reduction in the empyema cavity volume was observed. 41% of the dressing changes were performed outside the operating room. Compared with a historic cohort of conventionally treated patients (decortication via VATS or thoracotomy), the 90-day mortality rates tended to be lower without reaching statistical significance. Three patients (18%) died in hospital during treatment. No negative pressure-therapy-related complications were observed. FlexVATS therapy is a promising alternative therapy for both healthy and debilitated patients with pleural empyema. Larger randomised trials are required to validate this treatment option.

Combined endoscopic-percutaneous treatment of upper gastrointestinal enterocutaneous fistula using vacuum therapy and resorbable plug insertion (Vac-Plug)

After gastrointestinal resections, leakages can occur, persist despite conventional therapy and result in enterocutaneous fistulae. We developed a combination method using flexible endoscopic techniques to seal the enteric orifice with an absorbable plug in addition to a percutaneously and fistuloscopically guided open-pore film drainage (Vac-Plug method). We retrospectively searched our endoscopy database to identify patients treated with the outlined technique. The clinical and pathological data were assessed, the method analyzed and characterized and the technical and clinical success determined. We identified 14 patients that were treated with the Vac-Plug method (4 females, 10 males with a mean age of 56 years, range 50-74). The patients were treated over a time period of 23 days (range 4-119) in between one to thirteen interventions (mean n = 5). One patient had to be excluded due to short follow-up after successful closure. Seventy-seven percent (10/13) were successfully treated with a median follow-up of 453 days (range 35-1246) thereafter. No treatment related complications occurred during the therapy. The data of the analysis showed that the Vac-Plug therapy is safe and successful in a relevant proportion of the patients. It is easy to learn and to apply and is well tolerated. In our opinion, it is a promising addition to the armamentarium of interventional methods of these difficult to treat patients. Of course, its usefulness must be further validated in larger prospective studies.

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.

Use of Negative-Pressure Wound Therapy With Instillation and Dwell Time: An Overview

SUMMARY

The use of negative-pressure wound therapy (NPWT) has become an established therapy for wound management. There have been many advancements in the technology of NPWT including NPWT with instillation and dwell (NPWTi-d). NPWTi-d promotes wound healing by wound cleansing, irrigation, and nonexcisional debridement. NPWTi-d has been shown in comparative clinical studies to decrease the time to definitive wound healing and length of hospitalization. NPWTi-d-using a reticulated open-cell foam dressing with "through" holes (ROCF-CC)-has been postulated to facilitate solubilization, detachment, and elimination of infectious materials, such as slough and thick exudate, before or after operative debridement, and in cases where surgical debridement is not an option. The authors provide an overview on the use of NPWTi-d by reviewing the components of the system, proposed mechanism of action, clinical outcomes, and current consensus guidelines for its utilization.

Extended latissimus dorsi chimeric thoracoplasty with a vascular supercharge for Aspergillus empyema

The latissimus dorsi and serratus anterior muscles are available for reconstruction coverage of thoracic defects. We performed extended latissimus dorsi-serratus anterior chimeric thoraco-myoplasty with a vascular supercharge to maintain sufficient blood supply to the flaps because of a deficiency in the distal blood flow to the flap revealed by an intravenous injection of indocyanine green and simultaneous endobronchial embolization for refractory Aspergillus empyema.

EWMA Document: Negative Pressure Wound Therapy

1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies^2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,^4-6 dehisced sternal wounds following cardiac surgery^7,8 and as a valuable agent in complex non-healing wounds.^9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.^12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents^15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.

Negative pressure wound therapy with instillation without open-window thoracostomy for empyema

Treatment of empyema is very challenging. The use of negative pressure wound therapy (NPWT), and NPWT with instillation and dwell time (NPWTi-d) for wound closure have attracted attention. However, they are both limited to use after open-window thoracostomy (OWT) performed to control infection. In some patients with poor general conditions, who cannot undergo surgery, no treatment for empyema is available. Therefore, we devised a new treatment for such patients with NPWTi-d without OWT (non-OWT NPWTi-d). Here we present the cases of two patients with refractory empyema after intrathoracic irrigation and drainage, who underwent non-OWT NPWTi-d using the fistula of the thoracic drain. Both the patients recovered. The first patient was treated for 31 days. As the empyema persisted, he underwent a repeat intrathoracic drainage after which the wound healed. The second patient was treated for 20 days. Non-OWT NPWTi-d may be a new option to treat empyema.

Minimally Invasive Open-Window Thoracostomy Using Wound Edge Protectors

We report the technical details of minimally invasive open-window thoracostomy using wound edge protectors for postoperative pyothorax caused by a bronchopleural fistula with acute exacerbation of idiopathic pulmonary fibrosis under epidural and local anesthesia.

Mini-thoracostomy with vacuum-assisted closure: a minimally invasive alternative to open-window thoracostomy

Thoracostomy is a common treatment option for patients with stage III pleural empyema who do not tolerate pulmonary decortication. However, thoracostomy is considered mutilating because it involves a thoracic stoma, the closure of which can take years or require further surgery. A new, minimally invasive technique that uses the vacuum-assisted closure has been proposed as an alternative to thoracostomy. This study aims to analyze the safety and effectiveness of mini-thoracostomy with vacuum-assisted closure in an initial sample of patients.

Short-term and long-term outcomes of intrathoracic vacuum therapy of empyema in debilitated patients

Background

This retrospective study analyzed the effectiveness of intrathoracic negative pressure therapy for debilitated patients with empyema and compared the short-term and long-term outcomes of three different intrapleural vacuum-assisted closure (VAC) techniques.

Methods

We investigated 43 consecutive (pre)septic patients with poor general condition (Karnofsky index ≤ 50 %) and multimorbidity (≥ 3 organ diseases) or immunosuppression, who had been treated for primary, postoperative, or recurrent pleural empyema with VAC in combination with open window thoracostomy (OWT-VAC) with minimally invasive technique (Mini-VAC), and instillation (Mini-VAC-Instill).

Results

The overall duration of intrathoracic vacuum therapy was 14 days (5–48 days). Vacuum duration in the Mini-VAC and Mini-VAC-Instill groups (12.4 ± 5.7 and 10.4 ± 5.4 days) was significantly shorter (p = 0.001) than in the group treated with open window thoracostomy (OWT)-VAC (20.3 ± 9.4 days). No major complication was related to intrathoracic VAC therapy. Chest wall closure rates were significantly higher in the Mini-VAC and Mini-VAC-Instill groups than in the OWT-VAC group (p = 0.034 and p = 0.026). Overall, the mean postoperative length of stay in hospital (LOS) was 21 days (median 18, 6–51 days). LOS was significantly shorter (p = 0.027) in the Mini-VAC-Instill group (15.1 ± 4.8) than in the other two groups (23.8 ± 12.3 and 22.7 ± 1.5). Overall, the 30-day and 60-day mortality rates were 4.7 % (2/43) and 9.3 % (4/43), and none of the deaths was related to infection.

Conclusions

For debilitated patients, immediate minimally invasive intrathoracic vacuum therapy is a safe and viable alternative to OWT. Mini-VAC-Instill may have the fastest clearance and healing rates of empyema.