Incisional negative pressure wound therapy for high-risk wounds

The use of incisional negative pressure wound therapy on high-risk breast cancer mastectomy patients

BACKGROUND

The main complications seen in patients who have undergone modified radical mastectomy (MRM) are seroma, surgical site infection, hematoma, wound dehiscence, flap necrosis, and nerve damage. While these complications lead to some problems the most feared effect in the early period is that they cause a delay in adjuvant treatment. Incisional Negative Pressure Wound Therapy (iNPWT) decreases wound dehiscence by reducing oedema and tension, especially in the incision line. This study aim to compare recovery times and wound site complications between patients treated with conventional wound dressings and patients treated with iNPWT after MRM.

METHODS

A retrospective screening was made of the data of 50 patients who underwent MRM because of breast cancer in the General Surgery Clinic of XXX Hospital between 2018 and 2022, and were at high-risk of wound site complications. Two groups were formed as 30 patients applied with iNPWT and 20 patients applied with conventional dressings.

RESULTS

The mean age of the 50 female patients was 53.58 years (range, 30-80 years). The most frequently seen complications were seroma (20 patients) and partial flap ischaemia (14 patients). The mean number of iNPWT applications was 1.30 (range, 1-2), and the mean number of days of application was 4.47 (range, 2-9). Postoperative seroma was observed in 8 patients in the iNPWT group and in 12 patients in the conventional dressings group (p = 0.018). Flap ischaemia and the probability of dehiscence was determined at a statistically significantly higher rate in the patients in the conventional dressings groups (p = 0.005, p = 0.021).

CONCLUSION

The results of this study demonstrated that the use of iNPWT significantly reduced the amount of postoperative drainage, thereby contributing to early drain removal. Furthermore, iNPWT significantly reduced postoperative seroma, flap ischaemia, and flap dehiscence compared to conventional dressings.

Incisional Negative Pressure Wound Therapy for Wounds in Patients with Lower Intestinal Perforations

Objectives

Laparotomy for lower intestinal perforation is associated with a high incidence of surgical site infections. This study aimed to assess whether incisional negative pressure wound therapy (iNPWT) could reduce the incidence of these infections and wound dehiscence in patients with lower intestinal perforation.

Methods

This single-center prospective study was conducted between September 2019 and July 2022. In the therapy group, wounds were closed with subcuticular sutures, and iNPWT was applied at -120 mmHg for 5 days. A total of 10 days of iNPWT was employed. These patients were compared with a historical control group. The iNPWT group (Group A) comprised 22 patients.The historical control group (Group B) had 65 patients. Table outlines patient characteristics and compares the two study groups.

Results

Patient characteristics were demographically similar. The incidence of surgical site infections was lower in the therapy group than in the control group (9.1% vs. 52.3%, p < 0.001). Wound dehiscence was not observed in the therapy group but was noted in three patients (4.6%) in the control group. In univariate and multivariate analysis, an application of the therapy device was associated with reduced incidence of surgical site infections (p < 0.001 and p = 0.002, respectively).

Conclusions

The application of iNPWT in patients with lower intestinal perforation was associated with reduced surgical site infections.

Impact of closed-incision negative pressure wound dressings on surgical site infection following groin incisions in vascular surgery; a single-centre experience

OBJECTIVES

Surgical site infection (SSI) is a common complication in vascular surgery, and is associated with increased patient morbidity, readmission and reintervention. The aim of this study was to assess the impact of closed-incision negative pressure wound therapy (CiNPWT) upon rate of SSI and length of hospital stay.

METHODS

This study was reported in line with the STROBE guidelines. We assessed the baseline incidence of SSI from a 12-month retrospective cohort and, following a change in practice intervention with CiNPWT, compared to a 6-month prospective cohort. The primary endpoint was incidence of SSI (according to CDC-NHSN guidelines) while secondary endpoints included length of hospital stay, readmission, reintervention and Days Alive and Out of Hospital (DAOH) to 90-days.

RESULTS

A total of 127 groin incisions were performed: 76 (65 patients) within the retrospective analysis and 51 (42 patients) within the prospective analysis (of whom 69% received CiNPWT). The primary endpoint of SSI was seen in 21.1% of the retrospective cohort and 9.8% of the prospective cohort (p = .099). Readmission was found to be significantly associated with the retrospective cohort (p = .016) while total admission (inclusive of re-admission) was significantly longer in those in the retrospective cohort (p = .013). DAOH-90 was 83 days (77-85) following introduction of the CiNPWT protocol as compared to the retrospective cohort (77 days (64-83), p = .04).

CONCLUSION

Introduction of CiNPWT was associated with a reduced length of hospital stay and improved DAOH-90. Further trials on CINPWT should include patient-centred outcomes and healthcare cost analysis.

Closed Incision Negative Pressure Therapy Versus Traditional Dressings for Low Transverse Abdominal Incisions Healing by Primary Closure: A Systematic Review and Meta-Analysis

Background: Closed incision negative pressure therapy (ciNPT) devices may reduce wound healing complications when applied to closed surgical incisions. The aim of this review was to assess the effects of ciNPT versus standard dressings in patients undergoing primary closure of high tension, lower transverse abdominal incisions. Methods: This review was registered a priori on PROSPERO (CRD42021252048). A search of the following databases was performed in February 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and nonrandomized studies comparing ciNPT to standard dressings were included. Two independent reviewers performed screening and data extraction. Outcomes evaluated the incidence of wound dehiscence, surgical site infection, total abdominal complications, time to drain removal, and seroma formation. Main Results: Ten studies were included in quantitative and narrative synthesis. Observational study evidence suggests ciNPT likely reduces the incidence of wound dehiscence (odds ratio [OR] 0.57 [0.44-0.96], P = .03) and total abdominal complications (OR 0.34 [0.21-0.54], P < .01). Decreased incidence of seroma formation favored ciNPT (OR 0.65 [0.24-1.76], P = .40); however, this did not achieve significance. Randomized and non-randomized study evidence was very uncertain about the effect of ciNPT on the remaining outcomes. Conclusions: The current best randomized study evidence is very uncertain about the effect of ciNPT on these outcomes. Observational study evidence suggests ciNPT likely results in a statistically significant reduction in abdominal wound dehiscence and total abdominal complications. Additional randomized trials are warranted to limit the impact of bias on the overall certainty of the evidence.

Effects of negative pressure wound therapy on surgical site wound infections after cardiac surgery: A meta-analysis

We conducted a comprehensive analysis to evaluate the benefits of negative pressure wound therapy (NPWT) versus traditional dressings in preventing surgical site infections in patients undergoing cardiac surgery. We thoroughly examined several databases, including PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, Chinese Biomedical Literature Database (CBM) and Wanfang, from inception until July 2023. Two independent researchers were responsible for the literature screening, data extraction and quality assessment; analyses were performed using RevMan 5.4 software. Thirteen studies comprising 8495 patients were deemed relevant. A total of 2685 patients were treated with NPWT, whereas 5810 received conventional dressings. The findings revealed that NPWT was more effective in reducing surgical site infections after cardiac surgery than conventional dressings (4.88% vs. 5.87%, odds ratio [OR]: 0.50, 95% confidence intervals [CIs]: 0.40-0.63, p < 0.001). Additionally, NPWT was more effective in reducing deep wound infections (1.48% vs. 4.15%, OR: 0.36, 95% CI: 0.23-0.56, p < 0.001) and resulted in shorter hospital stays (SMD: -0.33, 95% CIs: -0.54 to -0.13, p = 0.001). However, the rate of superficial wound infections was not significantly affected by the method of wound care (3.72% vs. 5.51%, OR: 0.63, 95% CI: 0.32-1.23, p = 0.180). In conclusion, NPWT was shown to be advantageous in preventing postoperative infections and reducing hospital stay durations in patients undergoing cardiac surgery. Nonetheless, given the limitations in the number and quality of the included studies, further research is recommended to validate these findings.

A Comparison of Negative Pressure and Conventional Therapy in Spine Infections: A Single-Center Retrospective Study

Purpose: To investigate the effectiveness and safety of negative-pressure wound therapy (NPWT) in treating primary spinal infections. Methods: Patients who underwent surgical treatment for primary spinal infection between January 2018 and June 2021 were retrospectively evaluated. They were divided into two groups based on the type of surgery: one that underwent negative-pressure wound therapy (NPWT) and another that underwent conventional surgery (CVSG-Posterior debridement, bone grafting, fusion, and internal fixation in one stage). The two groups were compared in terms of the total operation time, total blood loss, total postoperative drainage, postoperative pain score, time for the postoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to return to normal, postoperative complications, treatment time, and recurrence rate. Results: A total of 43 cases of spinal infection were evaluated, with 19 in the NPWT group and 24 in the CVSG group. The NPWT group had a superior postoperative drainage volume, antibiotic use time, erythrocyte sedimentation rate and CRP recovery times, VAS score at 3 months after the operation, and cure rate at 3 months after operation compared with the CVSG group. There were no significant variations in the total hospital stay and intraoperative blood loss between the two groups. Conclusions: This study supports the use of negative pressure in the treatment of a primary spinal infection and indicates that it has a notably better short-term clinical effect than conventional surgery. Additionally, its mid-term cure rate and recurrence rate are more desirable than those of conventional treatments.

Modulation of Lymphangiogenesis in Incisional Murine Diabetic Wound Healing Using Negative Pressure Wound Therapy

Objective: Despite the significant function of lymphatics in wound healing, and frequent clinical use of Negative Pressure Wound Therapy (NPWT), the effect of mechanical force application on lymphangiogenesis remains to be elucidated. We utilize a murine incisional wound healing model to assess the mechanisms of lymphangiogenesis following NPWT. Approach: Dorsal incisional skin wounds were created on diabetic mice (genetically obese leptin receptor-deficient mice [db/db]; n = 30) and covered with an occlusive dressing (Control, n = 15) or NPWT (-125 mmHg, continuous, 24 h for 7 days; NPWT, n = 15). The wounds were macroscopically assessed for 28 days. Tissue was harvested on day 10 for analysis. Qualitative functional analysis of lymphatic drainage was performed on day 28 using Evans Blue staining (n = 2). Results: NPWT increased lymphatic vessel density (40 ± 20 vs. 12 ± 6 podoplanin [PDPN]⁺ and 25 ± 9 vs. 14 ± 8 lymphatic vessel endothelial receptor 1 [LYVE-1]⁺) and vessel diameter (28 ± 9 vs. 12 ± 2 μm). Western blotting verified the upregulation of LYVE-1 with NPWT. Leukocyte presence was higher with NPWT (22% ± 3.7% vs. 9.1% ± 4.1% lymphocyte common antigen [CD45]⁺) and the leukocytes were predominately B cells clustered within vessels (8.8% ± 2.5% vs. 18% ± 3.6% B-lymphocyte antigen CD20 [CD20]⁺). Macrophage presence was lower in the NPWT group. Lymphatic drainage was increased in the NPWT group, which exhibited greater Evans Blue positivity. Innovation: The lymphangiogenic effects take place independent of macrophage infiltration, appearing to correlate with B cell presence. Conclusion: NPWT promotes lymphangiogenesis in incisional wounds, significantly increasing the lymph vessel density and diameter. This study highlights the potential of NPWT to stimulate lymphatic drainage and wound healing of surgical incisions.

Effects of Different Pressure Levels in Topical Negative Pressure Application—Analysis of Perfusion Parameters in a Clinical Skin Model Using Multimodal Imaging Techniques

The effects of topical negative pressure therapy (TNP) have been a subject of research for many years. In this study, we investigated new imaging devices to detect clinical changes that TNP causes on healthy tissue and identified differences in microcirculation created by different pressure levels. We used near-infrared spectroscopy (NIS), thermography, and a vein illuminator to measure the differences in oxygen saturation, tissue temperature, and vein pattern. A control group (−125 mmHg) and three comparison groups with only TNP dressing (Group 1), −25 mmHg (Group 2), and −175 mmHg (Group 3) were established. Thirty minutes of TNP on intact skin was followed by 30 min of resting. A total of 24 participants were measured by all imaging devices at predetermined time points. Oxygen saturation and skin temperature increased by 8.07% and 1.67 °C for the control group, 4.00% and 1.65 °C for Group 2, and 8.45% and 1.68 °C for Group 3. Group 1 showed a slight increase in oxygen saturation and a 2.7 °C increase in skin temperature. Over the 30 min following removal of TNP, oxygen saturation and temperature decreased gradually for all groups. The vein illuminator did not show significant differences in the venous pattern or flow. Our study showed that higher negative pressure values resulted in higher oxygen saturation and higher tissue temperature.

A Cost-Utility Analysis of the Use of Closed-Incision Negative Pressure System in Vascular Surgery Groin Incisions

OBJECTIVE

Closed-incision negative pressure therapy (CINPT) with the Prevena system has been used and clinically evaluated in high-risk groin incisions to reduce the risk of postoperative complications. We performed a cost-effectiveness analysis evaluating CINPT in femoral-popliteal bypass with prosthetic graft.

METHODS

A literature review looking at prospective randomized trials determined the probabilities and outcomes for femoral-popliteal bypass with and without CINPT. Reported utility scores were used to estimate the quality adjusted life years (QALYs) associated with a successful procedure and postoperative complications. Medicare current procedure terminology and diagnosis-related group codes were used to assess the costs for a successful surgery and associated complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-effectiveness ratio (ICER) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the results, and to accommodate for the uncertainty in the literature.

RESULTS

Femoral-popliteal bypass with CINPT is less costly ($40,138 vs $41,774) and more effective (6.14 vs 6.13) compared to without CINPT. This resulted in a negative ICER of -234,764.03, which favored CINPT, indicating a dominant strategy. In one-way sensitivity analysis, surgery without CINPT was more cost-effective if the probability of successful surgery falls below 84.9% or if the cost of CINPT exceeds $3139. Monte Carlo analysis showed a confidence of 99.07% that CINPT is more cost-effective.

CONCLUSIONS

Despite the added device cost of CINPT, it is cost-effective in vascular surgical operations using groin incisions.

An Absorbing Improvement for Space Infection Decompression: A Novel Drainage Device

Introduction

Infection of the facial spaces and the associated exudate can often necessitate surgical intervention. Whilst traditional decompression methodologies have reduced the mortality rate from complications such as Ludwig’s Angina, there has been relatively little innovation in the procedure to minimize treatment times and patient distress. Negative pressure wound therapy, which can yield improvements to treatment time, wound healing and patient experience, has gained traction in abscess treatments in other parts of the body but seen limited adoption in maxillofacial surgeries.

Methods

A focused literature review explores the existing treatment methodologies for infected facial space decompression and identifies obstacles to implementing negative pressure wound therapy in maxillofacial surgeries. A novel drainage tool, which features a sleeved sponge over a perforated drainage tube, is proposed. Virtual prototyping and structural analyses of the novel drainage device including a parametric design study are presented.

Results

The parametric study validates the proposed tool’s biocompatibility in terms of overall flexural and axial stiffness between the tool and complex structures in the head and neck. Ultimately, this work presents a necessary first step in the development of specialized drainage tools to promote the adoption of negative pressure wound therapy for infections of facial spaces.

Closed-Incision Negative Pressure Wound management Following Midline Laparotomy in Gynecological Oncology Operations: A Feasibility Pilot Study

Introduction Surgical site infections (SSIs) are a cause of considerable morbidity and mortality in healthcare. Increasingly, closed-incision negative pressure wound therapy (ciNPWT) is being studied as a potential method of reducing incidence of SSI with conflicting results in the literature. Few studies however have looked at its use in the field of gynecological oncology. Objectives We aimed to compare the incidence of SSI when using ciNPWT dressings versus conventional dressings in gynecological oncology patients undergoing midline laparotomies. Methods This was a pilot study involving 14 patients receiving the ciNPWT dressing and 26 control patients. All patients were followed up for a period of 30 days. We used the American College of Surgeons (ACS) risk calculator to estimate each patient's risk of SSI in order to risk stratify the groups. Results The incidence of wound infection was 21% (3/14) in the ciNPWT group and 23% (6/26) in the control group (p=0.886). The ciNPWT group was found to be at significantly higher risk for SSI as calculated by the ACS tool (8.8% ciNPWT, 6% control, p=0.004). After stratifying for this difference in risk, still no significant difference in incidence of SSI was found between the two groups (27% (3/11) ciNPWT, 29% (2/7) control p=0.929). Conclusion The incidence of SSI does not appear to decrease by the prophylactic use of the closed-incision negative pressure wound dressing.

Wound Healing: From Passive to Smart Dressings

The universal increase in the number of patients with nonhealing skin wounds imposes a huge social and economic burden on the patients and healthcare systems. Although, the application of traditional wound dressings contributes to an effective wound healing outcome, yet, the complexity of the healing process remains a major health challenge. Recent advances in materials and fabrication technologies have led to the fabrication of dressings that provide proper conditions for effective wound healing. The 3D-printed wound dressings, biomolecule-loaded dressings, as well as smart and flexible bandages are among the recent alternatives that have been developed to accelerate wound healing. Additionally, the new generation of wound dressings contains a variety of microelectronic sensors for real-time monitoring of the wound environment and is able to apply required actions to support the healing progress. Moreover, advances in manufacturing flexible microelectronic sensors enable the development of the next generation of wound dressing substrates, known as electronic skin, for real-time monitoring of the whole physiochemical markers in the wound environment in a single platform. The current study reviews the importance of smart wound dressings as an emerging strategy for wound care management and highlights different types of smart dressings for promoting the wound healing process.

The use of incisional vacuum-assisted closure system following one-stage incision suture combined with continuous irrigation to treat early deep surgical site infection after posterior lumbar fusion with instrumentation

Background

Previous reports concerning deep surgical site infection (SSI) after posterior spinal instrumentation treated with vacuum-assisted closure (VAC) system indicated that most patients must suffer from a delayed incision suture. To date, there are no published reports about the application of incisional VAC following a one-stage incision suture in the treatment of spinal infections. The purpose of this study was to evaluate the feasibility and efficacy of using an incisional VAC system following a one-stage incision suture combined with continuous irrigation to treat early deep SSI after posterior lumbar fusion with instrumentation.

Methods

Twenty-one patients who were identified as early deep SSI after posterior lumbar fusion with instrumentation were treated by incisional VAC following a one-stage incision suture combined with continuous irrigation at our spine surgery center between January 2014 and March 2020. Detailed data from medical records were collected and analyzed, including age, gender, primary diagnosis, original operation, number of VAC dressing changes, duration of continuous irrigation, hospital stay, risk factors for infection, bacteria type, and laboratory data. Clinical efficacy was assessed using the pre- and postoperative visual analog scale (VAS) for back pain and Kirkaldy-Willis functional criteria by regular follow-up.

Results

All the patients were cured and retained implants with an average of 1.9 times of VAC dressing replacement, and an average of 10.2 days of continuous irrigation. There were significant differences between pre-operation and post-operation in ESR, CRP, and VAS score of back pain, respectively (P < 0.05). The satisfactory rate was 90.5% according to Kirkaldy-Willis functional criteria. One patient developed a back skin rash with itching around the wound because of long-time contact with the VAC dressing. There was no recurrent infection or other complications during follow-up.

Conclusions

Our preliminary results support that the treatment protocol is feasible and effective to treat early deep SSI following posterior lumbar fusion with instrumentation.

Effect of Incisional Negative Pressure Wound Therapy vs Standard Wound Dressing on the Development of Surgical Site Infection after Spinal Surgery: A Prospective Observational Study

BACKGROUND

Use of a closed-incisional negative pressure therapy (ci-NPT) dressing is an emerging strategy to reduce surgical site infections (SSIs) in spine surgery that lacks robust data.

OBJECTIVE

To determine the impact of a ci-NPT, as compared with a standard dressing, on the development of SSIs after spine surgery.

METHODS

This was a prospective observational study over a 2-yr period. Indications for surgery included degenerative disease, deformity, malignancy, and trauma. Exclusion criteria included anterior and lateral approaches to the spine, intraoperative durotomy, or use of minimally invasive techniques. SSIs up to 60 d following surgery were recorded.

RESULTS

A total of 274 patients were included. SSI rate was significantly lower with ci-NPT dressing (n = 118) as compared with the standard dressing (n = 156) (3.4 vs 10.9%, P = .02). There was no statistical difference in infection rate for decompression alone procedures (4.2 vs 9.1%, P = .63), but there was a statistically significant reduction with the use of a negative-pressure dressing in cases that required instrumentation (3.2 vs 11.4%, P = .03). Patients at higher risk (instrumentation, deformity, and malignancy) had less SSIs with the use of ci-NPT, although this did not reach statistical significance. There were no complications in either group.

CONCLUSION

SSI rates were significantly reduced with a ci-NPT dressing vs a standard dressing in patients who underwent spinal surgery. The higher cost of a ci-NPT dressing might be justified with instrumented cases, as well as with certain high-risk patient populations undergoing spine surgery, given the serious consequences of an infection.

Novel imaging methods reveal positive impact of topical negative pressure application on tissue perfusion in an in vivo skin model

The influence of topical negative pressure application (TNPA) on tissue perfusion still remains controversial. TNPA was applied for 30 minutes on intact skin of 21 healthy participants. Measurements of tissue oxygen saturation and tissue temperature as signs of tissue perfusion were performed before application of the TNPA, directly after removal of the TNPA and 5, 10, 15, 20, and 30 minutes after removal of the dressing using the near infrared imaging (NIRI) and a thermal imaging camera. Tissue oxygen saturation showed an increase from 67.7% before applying the TNPA to 76.1% directly after removal of TNPA, followed by a decrease of oxygen saturation 30 minutes after removal of TNPA. The measured temperature of the treated skin area increased from 32.1°C to 36.1°C after removal of TNPA with a consecutive decrease of the temperature 30 minutes after removal. TNPA resulted in both a higher tissue oxygen saturation and a higher skin temperature after 30 minutes compared to the beginning. TNPA increases both tissue oxygen saturation and skin temperature as sign of an increase of tissue perfusion. NIRI and thermal imaging proved to be useful for measuring changes in tissue perfusion.

The impact of closed incisional negative pressure therapy on anterior lateral thigh flap donor site healing and scarring: A retrospective case-control study

BACKGROUND

The objective of this study was to investigate whether closed incisional negative pressure therapy (cINPT) is suitable to improve anterior lateral thigh (ALT) flap donor site healing and scarring.

METHODS

We identified 271 ALT free flaps of widths between 7 and 9 cm and primary donor site closure performed between January 2012 to December 2019. Patients were divided into cases of cINPT versus controls without cINPT as part of this retrospective case-control review. We compared the incidences of postoperative donor site complications (wound dehiscence, infection, seroma, hematoma) and the degree of scarring severity using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS).

RESULTS

A total of 106 ALT donor sites received cINPT (39%), whereas the remaining 165 donor sites received conventional dressings (61%). The distribution of gender, age, body mass index, comorbidities, and mean flap sizes were comparable between both groups. The occurrence of surgical wound dehiscence was significantly lower in the cINPT group (2.8%), when compared to controls (9.0%) (p = 0.04). Furthermore, the mean length of postoperative hospital stay was significantly shorter in the cINPT group (19 ± 8 days versus 21 ± 11 days; p = 0.03). CINPT was associated with a more favorable donor site scar quality when assessed by VSS (p = 0.03) and POSAS (p = 0.002).

CONCLUSION

The use of cINPT was associated with significantly less ALT donor site complications and superior scar quality accelerating patients' postoperative recovery.

The Historical Role of the Plastic Surgeon in Spine Reconstruction

Wound complications occur in up to 19% of patients undergoing complex spine surgery. The role of the plastic surgeon in complex and redo spine surgery is important and evolving. Classically, plastic surgeons have been involved in the management of patients who develop wound complications following surgery. This involves reconstruction of posterior trunk defects with locoregional fasciocutaneous, muscle, and free tissue transfers. There has also been an increasing role for plastic surgeons to become involved in prophylactic closures of complex and/or redo spine surgeries for high-risk populations. Identification of patients with comorbidities and likelihood for multiple reoperations who are prophylactically treated with complex closure with or without local muscle flaps could significantly decrease the postoperative wound complications.

Compromised Flap Salvage With Closed Incision Negative Pressure Therapy Under Real-Time Indocyanine Green Fluorescence Assessment

BACKGROUND

Skin flap transfer is a commonly used technique by surgeons; however, compromised blood flow may result in flap ischemia and necrosis. We describe the use of closed incision negative pressure therapy (ciNPT) to help manage skin flap reconstructions with indocyanine green fluorescence angiography (ICG-FA) to assess perfusion of the flaps before and after ciNPT.

METHODS

Three female and 5 male patients underwent various skin flap reconstructions, including local flaps, pedicled flaps, and propeller flaps, for wound defects related to trauma, infection, or cancer. After flap setting and suturing, ciNPT (-125 mm Hg) was applied to the closed incision for 7 days. Perfusion was assessed using ICG-FA before applying ciNPT and again at 24 hours later. The Shapiro-Wilk test and Wilcoxon signed rank test were used in statistical analysis.

RESULTS

Initial postoperative survival was observed for all skin flaps; however, 1 flap failed after 2 weeks due to uncontrolled infection. The remaining 7 flaps healed well without any surgical revision. All patients were initially determined to have impaired flap perfusion; however, skin flap perfusion was significantly higher after ciNPT than before ciNPT in each case (P = 0.012).

CONCLUSIONS

This study showed good healing outcomes for skin flap reconstructions without complications, despite the fact that each flap had compromised flap perfusion to some extent during the surgery. This case series is novel in that it used laser-assisted ICG-FA to provide a real-time assessment of skin flap perfusion before and after ciNPT.

A new surgical approach of direct perineal wound full-thick closure for perineal wound of abdominoperineal resection for rectal carcinoma: A prospective cohort trial

Perineal wound complications after APR have high morbidity in the colorectal surgical department. Although some approaches have been figured out to solve this clinical focus, the outcomes are still not satisfied. Herein, this prospective comparative clinical trial has been designed to evaluate a new surgical procedure of direct perineal wound full-thick closure (DPWC), compared with conventional perineal wound closure (CPWC), with hopes of making wound healing with less complications. In addition, an evaluation of an incision negative wound pressure therapy, as another focus in this field, was also analysed in the DPWC group. A total of 44 participants in our department were recruited from March 2018 to March 2020, divided into two groups randomly, CPWC group and DPWC group. The patients' characteristics, such as age, gender, BMI, smoking, alcohol consumption, comorbidities, CEA level, and high-risk of invasion, were recorded without statistical significance between the CPWC group and DPWC group. After the same standard abdominal phase, these two groups were performed in different perineal phases. And then, operative and postoperative outcomes were analysed with different statistical methods. Data on wound healing time and length of stay in the DPWC group were shorter than those in the CPWC group (P < .05). Furthermore, cases of wound infection within 30 days in the DPWC group were also less than that in the CPWC group (P < .05). However, no difference was found between the incisional negative pressure wound therapy assisted group (NPA group) and non- incisional negative pressure wound therapy assisted group (non-NPA group). During this study, hypoalbuminemia, as an independent high-risk factor, impacted perineal wound healing. (P = .0271) In conclusion, DPWC is a new surgical approach, which can lead to a better outcome than DPWC, and it can be another surgical procedure for clinicians. In addition, hypoalbuminemia should be interfered for avoiding perineal wound complications.

A Novel Use of Next-Generation Closed Incision Negative Pressure Wound Therapy After Major Limb Amputation and Amputation Revision

We report our experience with next-generation incisional negative pressure wound therapy (iNPWT) applied after major limb amputation or amputation revision. In this high-risk patient population, the need for reliable post-operative soft tissue management is imperative. In both cases reported, healing was uncomplicated. Using the next generation iNPWT in this unique way optimizes the post-operative residual limb by improved incision healing, residual limb edema reduction, and reduced risk of surgical site infection (SSI). This is the first case report of its kind reporting a novel use of next-generation iNPWT, and it demonstrates a need to examine this particular use further.

Incisional negative pressure wound therapy does not reduce surgical site infections in abdominal midline incisions: a case control study

Purpose: There is evidence from various surgical specialties that incisional negative pressure wound therapy (iNPWT) might reduce postoperative surgical site infections (SSIs). In visceral and general surgery, there is varying evidence of its efficacy in reducing surgical site infections.Methods: A prospectively registered patient cohort of 43 patients with abdominal wall and visceral surgery received treatment with iNPWT and was compared to a matched retrospective cohort to analyze its effects on SSI occurrence and respective risk factors. Groups were matched by procedure, sex, body mass index and age. We used two different systems of iNPWT: (i) PREVENA^TM or (ii) self-made epicutaneous iNPWT from common VAC material.Results: We could not find a total reduction in postoperative SSIs by application of iNPWT. But within the iNPWT cohort, patients with self-made iNPWT suffered more often from SSIs compared to the commercial iNPWT subgroup. No patient specific risk factors could be identified to advocate the use of iNPWT.Conclusion: Our data do not support the use of an incisional negative pressure wound therapy on closed wounds in midline laparotomy incisions. Although, differences exist between the commmercial and self-made systems.

Practical Things You Should Know about Wound Healing and Vacuum-Assisted Closure Management

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the basics of negative-pressure wound therapy and practical uses of various vacuum-assisted closure dressings. 2. Understand the mechanisms of action of negative-pressure therapies and other important adjuncts, such as perfusion imaging. 3. Discuss the evidence for hyperbaric oxygen therapy in wound care.

SUMMARY

Wound healing requires creating an environment that supports the healing process while decreasing inflammation and infection. Negative-pressure wound therapy has changed the way physicians manage acute and chronic wounds for more than 20 years. It contracts wound edges, removes exudate, including inflammatory and infectious material, and promotes angiogenesis and granulation tissue formation. These effects have been consistently demonstrated in multiple animal and human randomized controlled trials. Recent innovations that include instillation therapy and closed incision have further increased our arsenal against difficult-to-treat wounds and incisions at high risk of complications. Instillation of topical wound solutions allows physicians to cleanse the wound without return to the operating room, resulting in fewer debridements, shorter hospital stays, and faster time to wound closure. Other concepts have yielded negative-pressure therapy on top of closed surgical incisions, which holds incision edges together, reduces edema, promotes angiogenesis, and creates a barrier to protect incisions during the critical healing period, thereby reducing surgical-site complications, especially infection. Other practical adjuncts to the modern-day treatment of acute and chronic wounds include indocyanine green angiography, which allows real-time assessment of perfusion, and hyperbaric oxygen treatment, which has been suggested to augment healing in acute, chronic, specifically diabetic foot ulcers and radiation-related wounds.

Incisional negative pressure wound therapy in bilateral breast reductions patients

Introduction: Incisional negative pressure wound therapy (iNPWT) has been applied to bilateral breast reduction patients and shown a reduction in surgical complications. However, its effects on opioid use and hospitalisation length in this patient group has not been investigated.Methods: In this single surgeon retrospective cohort study, 52 patients who underwent bilateral breast reduction were analysed, with 23 patients in the iNPWT cohort and 29 in the standard-of-care (SOC) wound dressing cohort. Hospitalisation length, postoperative opioid use and surgical site complications were compared between cohorts. Mean (range) follow-up time was 369.15 (77-1329) days.Results: Hospitalisation length in days was significantly less in the iNPWT cohort (1.35) than the SOC cohort (2.03). Total ward opioid use was significantly reduced in the iNPWT cohort (45.50mg) compared to the SOC cohort (62.50mg). Discharge opioid prescription was significantly reduced in the iNPWT cohort (125.50mg) compared to the SOC cohort (230.00mg). The number of surgical site complications was significantly different between the groups (p=0.014).Discussion: This study suggests the use of iNPWT in bilateral breast reduction provides significant benefit through the reduction of hospitalisation, complications and opioid use. Conclusion: This is the first study to provide evidence for iNPWT in bilateral breast reduction in reducing postoperative opioid use and hospitalisation. It supports current literature showing a reduction in surgical site complications using iNPWT in bilateral breast reduction.

Negative-Pressure Wound Therapy to Reduce Wound Complications after Abdominoperineal Resection

INTRODUCTION

Abdominoperineal resection is associated with a high rate of wound complications. A high degree of wound tension, a common contributor to wound breakdown and complications, may be mitigated by incisional negative-pressure wound therapy (NPWT). Although NPWT has been shown to reduce complications associated with open and complex wounds, there is a paucity of data regarding its prophylactic use for incisional wounds.

OBJECTIVE

To determine the effect of NPWT use on surgical wound complications of abdominoperineal resection for malignancy.

METHODS

We performed a systematic review by querying the PubMed database for studies from 1990 to 2019 and included English-language studies that used incisional NPWT for closed wounds from abdominoperineal resection in malignancy cases.

RESULTS

Five studies with a total of 76 patients were included. Their findings showed reduced rates of surgical site complications with the use of incisional NPWT. Another 2 studies describing the use of prophylactic NPWT to expedite secondary closure of the surgical wound followed by incisional wound therapy were separately categorized and included 8 patients, none of whom experienced wound wound complications.

DISCUSSION

Additional, prospective research is needed to confirm the benefit of prophylactic incisional NPWT.

Comparison of the Efficacy Between Closed Incisional Negative-Pressure Wound Therapy and Conventional Wound Management After Total Hip and Knee Arthroplasties: A Systematic Review and Meta-Analysis

BACKGROUND

Wound-related problems after total hip arthroplasty (THA) and total knee arthroplasty (TKA) can cause periprosthetic joint infections. We sought to evaluate the effect of closed incisional negative-pressure wound therapy (ciNPWT) on wound complications, skin blisters, surgical site infections (SSIs), reoperations, and length of hospitalization (LOH).

METHODS

Studies comparing ciNPWT with conventional dressings following THA and TKA were systematically searched on MEDLINE, Embase, and the Cochrane Library. Two reviewers performed the study selection, risk of bias assessment, and data extraction. Funnel plots were employed to evaluate publication bias and forest plots to analyze pooled data.

RESULTS

Twelve studies were included herein. The odds ratios (ORs) for wound complications and SSIs indicated a lack of publication bias. ciNPWT showed significantly lower risks of wound complication (OR, 0.44; 95% confidence interval [CI], 0.22-0.9; P = .027) and SSI (OR, 0.39; 95% CI, 0.23-0.68; P < .001) than did conventional dressings. ciNPWT also yielded a significantly lower reoperation rate (OR, 0.38; 95% CI, 0.21-0.69; P = .001) and shorter LOH (mean difference, 0.41 days; 95% CI, -0.51 to -0.32; P < .001). However, the rate of skin blisters was higher in ciNPWT (OR, 4.44; 95% CI, 2.24-8.79; P < .001).

CONCLUSION

Although skin blisters were more likely to develop in ciNPWT, the risks of wound complication, SSI, reoperation, and longer LOH decreased in ciNPWT compared with those in conventional dressings. This finding could alleviate the potential concerns regarding wound-related problems after THA and TKA.

Use of incisional vacuum-assisted closure in the prevention of postoperative infection in high-risk patients who underwent spine surgery: a proof-of-concept study

OBJECTIVE

This proof-of-concept study was conducted to determine whether negative-pressure wound therapy, through the use of incisional vacuum-assisted closure (VAC), is associated with a reduction in surgical site infections (SSIs) when compared to standard wound dressings in patients undergoing open posterior spinal fusion who have a high risk of infection.

METHODS

A total of 64 patients were examined; 21 patients received incisional VAC application (VAC group) versus 43 diagnosis-matched patients who received standard wound dressings (control group). Patients in the VAC group were prospectively enrolled in a consecutive series between March 2013 and March 2014 if they met the following diagnostic criteria for high risk of infection: posterior open surgery across the cervicothoracic junction; thoracic kyphosis due to metastatic disease; high-energy trauma; or multilevel revision reconstructive surgery. Patients in the VAC group also met one or more comorbidity criteria, including body mass index ≥ 35 or < 18.5, diabetes, previous radiation at surgical site, chemotherapy, steroid use, bedridden state, large traumatic soft-tissue disruption, or immunocompromised state. Consecutive patients in the control group were retrospectively selected from the previous year by the same high-risk infection diagnostic criteria as the VAC group. All surgeries were conducted by the same surgeon at a single site. The primary outcome was SSI. All patients had 1 year of follow-up after their surgery. Baseline demographics, intraoperative parameters, and postoperative wound infection rates were compared between groups.

RESULTS

Patient demographics including underlying comorbidities were similar, with the exception that VAC-treated patients were malnourished (p = 0.020). VAC-treated patients underwent longer surgeries (p < 0.001) and required more postoperative ICU admissions (p = 0.039). The median length of hospital stay was not different between groups. In total, 9 control patients (21%) developed an SSI, versus 2 VAC-treated patients (10%).

CONCLUSIONS

Patients in this cohort were selected to have an increased risk of infection; accordingly, the rate of SSI was high. However, negative-pressure wound therapy through VAC application to the postoperative incision resulted in a 50% reduction in SSI. No adverse effects were noted secondary to VAC application. The preliminary data confirm the authors' proof of concept and strongly support the need for a prospective randomized trial.

Incisional Negative Pressure Wound Therapy: An Effective Tool for Major Limb Amputation and Amputation Revision Site Closure

Objective: To evaluate our institutional experience of incisional negative pressure wound therapy (iNPWT) applied immediately after major limb amputation closure or amputation revision closure. Approach: A retrospective review was performed on 25 patients who underwent major limb amputation or amputation revision and had iNPWT placed intraoperatively upon incision closure. Results: Twenty-one patients underwent lower extremity amputation and four underwent upper extremity amputation. Seventeen were primary amputations and eight were amputation revisions. No patients developed dehiscence, seroma, or hematoma. One patient developed a surgical site infection (4%) that was treated with oral antibiotics. The average time to eligibility for prosthetic fitting for lower extremity amputations was 6.3 weeks. Innovation: Amputee patients have increased wound healing demands that can impact prosthetic wear and ambulation status. Stump incisions are located at the distal end of their extremities and often are in areas that have had prior surgical procedures performed. Thus, blood supply to the incision site may not be optimal. iNPWT is an effective incision management technique to promote healing and decrease postoperative complications in this patient population, which can lead to increased mortality. Conclusion: iNPWT is an effective technique of minimizing wound complications in the amputee and should be considered in this high-risk patient population.

A Novel Tube-Drainage Technique of Negative Pressure Wound Therapy for Fistulae after Reconstructive Surgery

Background:

Patients with head and neck or esophageal cancer who undergo resection and reconstructive surgery sometimes develop fistulae that exhibit delayed wound healing. We developed a novel negative pressure wound therapy (NPWT) that employs a Penrose drain. This case series report describes its effect on the wound healing and treatment duration of cancer patients with postoperative fistulae.

Methods:

This consecutive case series consisted of all patients from February 2014 to February 2017 who underwent resection and reconstruction for head and neck or esophageal cancer and who then developed a fistula that was treated with either NPWT or a second flap that did not resolve the fistula or led to fistula recurrence and was then treated with NPWT. A Penrose drainage tube was inserted into the fistula, and a NPWT device was applied.

Results:

Eleven patients (10 males, 1 female; mean age, 67.4 years) underwent NPWT for fistulae that arose after tumor resection and reconstruction (n = 6) or after fistula reconstruction (n = 5). The resection was for esophageal (n = 4), laryngeal (n = 3), oral (n = 2), and hypopharyngeal (n = 2) cancer. In 9 cases, 1 week of NPWT led to rapid and complete wound healing. In 2 cases, complete healing occurred after 3–4 weeks of NPWT.

Conclusions:

Our NPWT applies continuous negative pressure inside the fistula only and dramatically promoted fistula healing. This approach may work by cleaning the fistula and promoting mucosal surface adhesion. It is particularly effective when the tissue surrounding the fistula is soft due to fresh tissue transfer.

Negative pressure wound treatment with computer-controlled irrigation/instillation decreases bacterial load in contaminated wounds and facilitates wound closure

Microbial wound contamination is known to be a hindrance to wound healing. Negative pressure wound therapy (NPWT) with or without irrigation is known to optimise conditions in problem wounds. The aim of this study was to investigate the influence of computer-controlled wound irrigation with NPWT on the bacterial load in contaminated wounds. A total of 267 patients were treated with NPWT with automated instillation because of problematic wounds using an antiseptic instillation solution. In 111 patients, a minimum of 4 operative procedures were necessary, and swabs were taken at least at the first and at the fourth operation in a standardised procedure. The number of different bacteria and the amount of bacteria were analysed during the course. In a subgroup of 51 patients, swabs were taken at all 4 operative procedures and analysed separately. In an overall analysis, the number of different bacteria and the amount of bacteria significantly decreased independent of wound localisation and diagnosis. NPWT with automated instillation demonstrates a positive influence in the reduction of bacterial load in problem wounds. Thus, it may help to optimise wound conditions before definite wound closure.

Early Closure of Infected Laparotomy Wound with Negative-Pressure Wound Therapy: Safety and Efficacy in 42 Consecutive Cases

Postoperative surgical site infections (SSIs) are one of the most common complications. SSIs after laparotomy have a high incidence and are complicated and expensive to heal. The aim of this study was to evaluate the safety and efficacy of a novel therapy of early closure of open abdominal SSIs wound combining wound irrigation with negative pressure wound therapy (NPWT). Open abdominal SSIs wounds were closed with sutures in 42 consecutive patients. Topical NPWT was applied over a closed wound with a deep drain to allow dynamic drainage and wound irrigation. CT scan with contrast medium injected through the deep drain was performed in patients with suspicious tracts detected during debridement surgery three days after surgery to identify a potential fistula. Wound healing and safety of the therapy was evaluated during an average six months follow-up. Closed wounds healed successfully in all the patients without recurrence of wound infection. Fistulas were easily diagnosed in all four fistula patients by using CTscan with contrast medium injection through the wound. Fistula was confirmed in these four patients at re-exploration. All the drain tube wounds healed spontaneously after drain removal. No severe adverse event occurred during therapy in any patients. With the aid of topical NPWT and deep drainage and irrigation, early closure of open SSIs wound can be done safely. We were also able to diagnose gastrointestinal fistulas at an early stage with the use of CTscan imaging after contrast injection into the wound.

The relationship between preoperative nutritional state and adverse outcome following abdominal and thoracic surgery in children: Results from the NSQIP database

INTRODUCTION

Anthropometric measurements can be used to define pediatric malnutrition. Our study aims to: (1) characterize the preoperative nutritional status of children undergoing abdominal or thoracic surgery, and (2) describe the associations between WHO-defined acute (stunting) and chronic (wasting) undernutrition (Z-scores <-2) and obesity (BMI Z-scores >+2) with 30-day postoperative outcomes.

METHODS

We queried the Pediatric NSQIP Participant Use File and extracted data on patients' age 29days to 18years who underwent abdominal or thoracic procedures. Normalized anthropometric measures were calculated, including weight-for-height for <2years, BMI for ages ≥2years, and height for age. Logistic regression models were developed to assess nutritional outlier status as an independent predictor of postoperative outcome.

RESULTS

23,714 children (88% ≥2y) were evaluated. 4272 (18%) were obese, while 2640 (11.1%) and 904 (3.8%) were stunted and wasted, respectively, after controlling for gender, ASA/procedure/wound classification, preoperative steroid use, need for preoperative nutritional support, and obese children had higher odds of SSIs (OR 1.29, 95% CI 1.1-1.5, p=0.001), while stunted children were at increased risk of any 30-day postoperative complication (OR 1.16, 95% CI 1.0-1.3, p=0.036).

CONCLUSION

Children who are stunted or obese are at increased risk of adverse outcome after abdominal or thoracic surgery.

LEVEL OF EVIDENCE

III.

Incisional Negative-Pressure Wound Therapy for Perineal Wounds After Abdominoperineal Resection for Rectal Cancer, a Pilot Study

Objective: Abdominoperineal resection (APR) is associated with high incidence of surgical wound infections. The use of incisional negative-pressure wound therapy (iNPWT) is known to reduce wound infections for several surgical indications. The aim of this pilot study was to investigate the potential of a new portable negative-pressure therapy device on perineal wound healing in patients undergoing APR. Approach: A new single-use incisional negative-pressure therapy device was applied in 10 patients. A negative pressure of -80 mmHg was continued for 7 days postsurgery. Incidence of wound complications and time to wound healing were compared with a historical control group of 10 patients undergoing APR in 2014, treated with conventional wound care. Results: Patient characteristics were comparable in both groups. Mean 1.6 dressings were used per patient. A wound complication was diagnosed in seven patients versus six in the control group. Wound infections were diagnosed median 11.5 days after surgery, compared with 10.5 days in the control group. Duration of wound healing was shorter in the study group (median 8.5 weeks vs. 13 weeks). Innovation: This is the first study to report on the use of this iNPWT device for patients who underwent APR for rectal cancer. Conclusion: In this study, iNPWT did not reduce wound complications. Wound infections occurred slightly later and seemed to have a less severe clinical course. After treatment with iNPWT, the duration of wound healing was shorter.

Closed Incision Negative Pressure Therapy Effects on Postoperative Infection and Surgical Site Complication After Total Hip and Knee Arthroplasty

BACKGROUND

The aim of this study is to determine whether negative pressure wound therapy, used prophylactically in clean surgical incisions, reduces surgical site infection, hematoma, and seroma after total joint replacement.

METHODS

A single center, open-label study with a prospective cohort of patients undergoing primary total knee arthroplasty or total hip arthroplasty treated with closed incision negative pressure therapy (ciNPT) of clean surgical wounds was conducted. One hundred ninety-six incisions treated with ciNPT in 192 patients were compared with a historical control group of 400 patients treated with traditional gauze dressing. The rates of clinically significant hematoma, seroma, dehiscence, surgical site infection, and complication were compared using univariate analyses and multiple logistic regression.

RESULTS

The rate of deep infection was unchanged in the ciNPT group compared with control (1.0% vs 1.25%); however, the overall rate of infection (including superficial wound infection) decreased significantly (3.5% vs 1.0%, P = .04). Overall complication rate was lower in the ciNPT group than controls (1.5% vs 5.5%, P = .02). Upon logistic regression, only treatment group was associated with complication; patients treated with ciNPT were about 4 times less likely to experience a surgical site complication compared with control (P = .0277, odds ratio 4.251, 95% confidence interval 1.172-15.414).

CONCLUSION

ciNPT for total knee arthroplasty and total hip arthroplasty in a comprehensive patient population reduced overall incidence of complication, but did not significantly impact the rate of deep infection. Further research to determine clinical and economic advantages of routine use of ciNPT in total joint arthroplasty is warranted.

Reduction of groin wound complications in vascular surgery patients using closed incision negative pressure therapy (ciNPT): a prospective, randomised, single-institution study

Groin wound infections in patients undergoing vascular procedures often cause a lengthy process of wound healing. Several clinical studies and case reports show a reduction of surgical site infections (SSIs) in various wound types after using closed incision negative pressure therapy (ciNPT). The aim of this prospective, randomised, single-institution study was to investigate the effectiveness of ciNPT (PREVENA™ Therapy) compared to conventional therapy on groin incisions after vascular surgery. From 1 February to 30 October 2015, 100 patients with 129 groin incisions were analysed. Patients were randomised and treated with either ciNPT (n = 58 groins) or the control dressing (n = 71 groins). ciNPT was applied intraoperatively and removed on days 5-7 postoperatively. The control group received a conventional adhesive plaster. Wound evaluation based on the Szilagyi classification took place postoperatively on days 5-7 and 30. Compared to the control group, the ciNPT group showed a significant reduction in wound complications (P < 0·0005) after both wound evaluation periods and in revision surgeries (P = 0·022) until 30 days postoperatively. Subgroup analysis revealed that ciNPT had a significant effect on almost all examined risk factors for wound healing. ciNPT significantly reduced the incidence of incision complications and revision procedures after vascular surgery.

Preliminary result with incisional negative pressure wound therapy and pectoralis major muscle flap for median sternotomy wound infection in a high-risk patient population

Deep sternal wound infection (DSWI) represents a dangerous complication that can follow open-heart surgery with median sternotomy access. Muscle flaps, such as monolateral pectoralis major muscle flap (MPMF), represent the main choices for sternal wound coverage and infection control. Negative pressure incision management system has proven to be able to reduce the incidence of these wounds' complications. Prevena™ represents one of these incision management systems and we aimed to evaluate its benefits. A total of 78 patients with major risk factors that presented post-sternotomy DSWI following cardiac surgery was selected. Thrity patients were treated with MPMF and Prevena™ (study group). Control group consisted of 48 patients treated with MPMF and conventional wound dressings. During the follow-up period, 4 (13%) adverse events occurred in the study group, whereas 18 complications occurred (37·5%) in the control group. Surgical revision necessity and mean postoperative time spent in the intensive care unit were both higher in the control group. Our results evidenced Prevena™ system's ability in improving the outcome of DSWI surgical treatment with MPMF in a high-risk patient population.

5th Congress of WUWHS Abstract book Florence, Italy September 25–29 2016

The abstract book contains the abstracts of keynote lectures, focus sessions, symposia, workshops, AIUC annual meeting, AISLEC annual meeting, EPUAP annual meeting, ETRS special session, sponsor symposia, oral presentations, poster presentations and the subject index.

Effects of Incisional Negative-Pressure Wound Therapy on Primary Closed Defects after Superficial Circumflex Iliac Artery Perforator Flap Harvest: Randomized Controlled Study

BACKGROUND

Prolonged hematoma or seroma after primary closure is a causative element in wound complications. This study evaluated the effects of negative-pressure wound therapy on primary closed wounds after superficial circumflex iliac artery perforator flap harvest.

METHODS

This study was a prospective, randomized, clinical trial comparing conventional dressing against a single application of negative-pressure wound therapy for 5 days after primary closure. A total of 100 patients who had superficial circumflex iliac artery perforator flap harvest were enrolled.

RESULTS

There was no statistical difference between the incisional negative-pressure wound therapy and conventional dressing groups in the distribution of risk factors. Significant findings were noted for duration and amount of closed suction drainage: 6.12 ± 4.99 days (median, 4 days; range, 3 to 8 days) and 100.47 ± 140.69 cc (median, 42 cc) for wounds treated with conventional dressing versus 3.34 ± 1.35 days (median, 3 days; range, 2 to 4 days) and 23.28 ±18.36 cc (median, 20 cc) for wounds in treatment group (p = 0.0077 and p = 0.0004), respectively. After closure, an increase in skin perfusion were noted on day 5 in the treatment group (p = 0.0223). There was one case of wound dehiscence in the conventional dressing group.

CONCLUSION

The incisional negative-pressure wound therapy has a positive effect over primary closed surgical defects by significantly reducing the amount of fluid collected by closed suction drains, allowing earlier removal of drains and enhancing the skin perfusion on the repaired skin.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Treatment of standardised wounds with pure epidermal micrografts generated with an automated device

In this study, we analysed the effects of pure epidermal micrografts generated with an automated device in a standardised human wound model. Epidermal micrografts were harvested using an automated device. Micrografts were then transplanted onto split-skin donor sites. The target area was only partially covered with transplants to create an intra-individual control area. Wounds were evaluated by subjective assessment as well as measurements with combined laser and white light spectroscopy and cutometry. The epidermal graft sites remained completely stable, whereas control sites offered partially unstable and blistering areas. Statistically, no measurable difference in the speed of initial reepithelialisation could be shown. However, there was an increased pliability and softness of the treated areas that correlated with the subjective impression of both investigators and patients. There was a significantly higher relative haemoglobin concentration, measurable in treated and untreated areas at 4 weeks and 6 months. Cutometry showed no differences in skin properties between treated and untreated areas. This study shows an effect of epidermal micrografts in a standardised human wound model and supports the positive impact of keratinocytes on early wound healing as described in literature. Long-term effects of epidermal grafting deserve further studies.

Evidence based review of negative pressure wound therapy

Vacuum-assisted closure, sometimes referred to as microdeformational wound therapy or most commonly negative pressure wound therapy (NPWT), has significantly improved wound care over the past two decades. NPWT is known to affect wound healing through four primary mechanisms (macrodeformation, microdeformation, fluid removal, and alteration of the wound environment) and various secondary mechanisms (including neurogenesis, angiogenesis, modulation of inflammation, and alterations in bioburden) which are described in this review. In addition, the technique has many established uses, for example in wound healing of diabetic and pressure ulcers, as well as burn and blast wounds. This therapy also has many uses whose efficacy has yet to be confirmed, for example the use in digestive surgery. Modifications of the traditional NPWT have also been established and are described in detail. This therapy has various considerations and contraindications which are summarized in this review. Finally, future perspectives, such as the optimal cycling of the treatment and the most appropriate interface material, are touched upon in the final segment. Overall, despite the fact that questions remain to be answered about NPWT, this technology is a major breakthrough in wound healing with significant potential use both in the hospital but also in the community.

Impact of incisional negative pressure wound therapy on perineal wound healing after abdominoperineal rectum extirpation

INTRODUCTION

Perineal wound healing disorders are one of the major complications following abdominoperineal rectum extirpation.

METHODS AND RESULTS

We evaluated the impact of an "incisional negative pressure wound therapy" (iNPWT) system after abdominoperineal rectum extirpation in six patients. All patients had a neoadjuvant radiochemotherapy with 50.4 Gy and 5-FU. Five of the six patients (83%) experienced complication-free healing of the perineal wound after 5 to 12 days of iNPWT. One patient developed a wound healing disorder 8 days after abdominoperineal rectum extirpation during current iNPWT.

DISCUSSION

Use of an iNPWT system can be of favor after abominoperineal rectum extirpation.

Negative pressure wound therapy in orthopaedic surgery

Negative pressure wound therapy (NPWT) consists in applying subatmospheric pressure to a wound that is sealed off by a specially designed dressing and connected by a tube to a suction pump and drainage collection system. Skin defects are extremely common in orthopaedic and trauma surgery. NPWT is valuable across a range of indications. Proven effects include an increase in blood flow, stimulation of angiogenesis, and a decrease in wound surface area. NPWT can be used to treat post-traumatic and surgical wounds, burns, and chronic wounds such as pressure sores and ulcers. The lower frequency of dressing changes with NPWT lightens the staff workload. The French high authority for health (HAS) has issued good practice guidelines for the use of NPWT in specific and limited indications. NPWT has benefited from the introduction of several technological improvements such as silicone interfaces, foam dressings with various densities and pore sizes, and irrigation systems. The result is greater adaptability to each specific situation. Nevertheless, NPWT is not appropriate in every case and cannot replace a necessary surgical procedure. The goal of this work is to review the principles, practical modalities, and indications of NPWT.

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Management of extremely hard-to-heal extremity wounds with severe life-threatening complications

The introduction of neoadjuvant radiotherapy has allowed limb-preserving surgical treatment in patients with extremity soft tissue sarcoma, and the overall prognosis of this approach is similar to that of limb amputation. The benefits of this treatment, however, are often accompanied with a higher risk of major complications and blood vessel damage because of radiation-induced inflammation and necrosis of the vessel wall. In particular, it is associated with the rupture of large vessels like the femoral artery and more severe complications of wounds located in the proximal lower extremity. We present a series of four patients with soft tissue sarcoma of the thigh undergoing tumour removal and reconstruction of the defect after neoadjuvant radiotherapy. The post-operative outcome depended on the total dose of radiation used as well as the closing technique of the resulting wound. Major wound complications occurred when the irradiated skin was closed directly over the resection cavity or when local skin flaps were used. In one case, severe radiation-induced life-threatening multiple bleeding events occurred, which led to multiple flap failures. Even if the skin cover is not a problem, we propose a combined interdisciplinary approach involving immediate plastic surgical transfer of healthy, well-vascularised tissue into a defect resulting from oncological resection of sarcoma of the lower extremity following neoadjuvant radiotherapy in order to avoid secondary wound breakdown and severe bleeding complications.

Practical Approaches to Definitive Reconstruction of Complex Abdominal Wall Defects

With advances in abdominal surgery and the management of major trauma, complex abdominal wall defects have become the new surgical disease, and the need for abdominal wall reconstruction has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question. While most surgeons use native abdominal wall whenever possible, evidence suggests that synthetic or biologic mesh needs to be added to large ventral hernia repairs. One particular group of patients who exemplify "complex" are those with contaminated wounds, enterocutaneous fistulas, enteroatmospheric fistulas, and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this article, I outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain.