Feasibility and prognostic significance of ventricular-arterial coupling after myocardial infarction: the RIGID-MI cohort

AIMS

The clinical significance and feasibility of the recently described non-invasive parameters exploring ventricular-arterial coupling (VAC) remain uncertain. This study aimed to assess VAC parameters for prognostic stratification in stable patients with left ventricular ejection fraction (LVEF) ≥40% following myocardial infarction (MI).

METHODS AND RESULTS

Between 2018 and 2021, patients with LVEF ≥40% were evaluated 1 month following MI using transthoracic echocardiography (TTE) and arterial tonometry at rest and after a handgrip test. VAC was studied via the ratio between arterial elastance (Ea) and end-systolic LV elastance (Ees) and between pulse wave velocity (PWV) and global longitudinal strain (GLS). Patients were followed for major adverse cardiovascular events (MACE): all-cause death, acute heart failure, stroke, AMI, and urgent cardiovascular hospitalization. Among the 374 patients included, Ea/Ees and PWV/GLS were obtained at rest for 354 (95%) and 253 patients (68%), respectively. Isometric exercise was workable in 335 patients (85%). During a median follow-up of 32 months (interquartile range: 16-42), 41 (11%) MACE occurred. Patients presenting MACE were significantly older and had a higher prevalence of peripheral arterial disease, lower GLS, higher Ea, PWV, and PWV/GLS ratio. The Ea/Ees ratio and standard TTE parameters during isometric exercise were not associated with MACE. After adjustment, the PWV/GLS ratio was the only VAC parameter independently associated with outcome. Receiver operating characteristic curve analysis identified a PWV/GLS ratio >0.70 (Youden's index = 0.37) as the best threshold to identify patients developing MACE: hazard ratio (95% confidence interval) = 2.2 (1.14-4.27), P = 0.02.

CONCLUSION

The PWV/GLS ratio, assessed 1 month after MI, identifies a group of patients at higher risk of MACE providing additional value on top of conventional non-invasive parameters.

vacuum-assisted wound therapy in soft tissue infections: a retrospective study

PURPOSE

Soft tissue infections can be severe and life-threatening. Their treatment consists currently in radical surgical wound debridement and combined systemic antimicrobial therapy. Different side effects are possible. Local antibiotic therapy represents a new approach to reduce side effects and improve healing. The aim of this study is to assess the effectiveness of the local sprayed use of antibiotics with fibrin sealing compared with negative pressure wound therapy as an established treatment of soft-tissue infections.

METHODS

In this retrospective study, patients with soft tissue infections who underwent surgical treatment were analysed. One group consists of patients, who received local fibrin-antibiotic spray (FAS) (n = 62). Patients treated by vacuum-assisted wound therapy (VAWT) as the established treatment were the control group (n = 57). Main outcomes were differences in the success of healing, the duration until healing and the number of needed operations.

RESULTS

Clinical healing could be achieved for 55 patients (98.21%) in the FAS group vs. 47 patients (92.16%) in the VAWT group (p = 0.19). Time to require this was 10.65 ± 10.38 days in the FAS group and 22.85 ± 14.02 days in the VAWT group (p < 0.001). In the FAS group, patients underwent an average of 1.44 ± 0.72 vs.3.46 ± 1.66 operations in the VAWT group (p < 0.001).

CONCLUSION

Compared to vacuum-assisted wound therapy in soft tissue infections, local fibrin-antibiotic spray shows faster clinical healing and less needed operations. Leading to shorter hospital stays and more satisfied patients. The combination of sprayed fibrin and antibiotics can be seen as a promising and effective method.

Is vacuum-assisted closure therapy the main culprit in right ventricular rupture after deep sternal wound infection?

Right ventricular rupture after deep sternal wound infection (DSWI) is a rare but fatal complication, and can occur with or without vacuum assisted closure (VAC) therapy. There is currently no strong evidence to suggest whether or not VAC therapy is a contributing factor to this complication. In total, 30 articles were retrieved and assessed through a systematic review strategy from 1953 to 2022. The keywords: 'vacuum assisted closure'; 'VAC'; 'negative pressure wound therapy'; 'deep sternal wound infection'; 'DSWI'; 'right ventricular rupture'; and 'cardiac rupture' were used in the search. Overall, 15 of the included articles satisfied the predefined eligibility criteria. Fatal right ventricular ruptures were reported in 18 (36%) out of 50 cases. In this article, the risk factors, mechanisms and management of right ventricular rupture are discussed. A novel view of the mechanism of VAC-associated right ventricular rupture is highlighted, with a focus on both pre- and intraoperative management.

Lessons learned from implementing the parenting Program P in Bolivia to prevent family violence

Parenting programs are an increasingly used strategy to prevent family violence and promote gender equality in the household. Yet, there is limited understanding of the processes and pathways to change through such programs, especially from the Global South. This paper presents key findings of a qualitative evaluation of the parenting 'Program P', which was implemented in El Alto, Bolivia. The study complements and aims to provide additional insights to an experimental evaluation of this program, which found limited impact on the intended objectives, including a reduction in violence against children and women and more gender equitable attitudes among parents. Thirty-six qualitative interviews and 6 focus groups were conducted with men and women that attended Program P, and facilitators of the program. Findings were analyzed thematically and organized around key successes and challenges of the program including motivations and ability to engage with the program, opportunities for supportive group-based processes, addressing hegemonic gender and social norms, and learning and applying skills as a platform to change behaviours. We use these findings to offer implications for more effective design and implementation of gender transformative, parenting programs in Bolivia and globally.

Biodegradable temporising matrix: use of negative pressure wound therapy shows a significantly higher success rate

OBJECTIVE

The purpose of this case series was to evaluate the efficacy of a synthetic biodegradable temporising matrix (BTM; PolyNovo Biomaterials Pty Ltd, Australia) and compare the outcome of BTM patients with and without negative pressure wound therapy (NPWT).

METHOD

A retrospective chart review was conducted on patients admitted with deep full-thickness burns, traumatic or complex wound injuries treated with BTM. Electronic medical records and images were evaluated by a team of clinical professionals. Endpoints included: the measure of successful BTM integration; and comparison between patients treated with and without NPWT. Additional measures were BTM total surface area, BTM sites, timeliness of BTM application and any complications.

RESULTS

A total of 28 patients were evaluated and 23 (82.1%) demonstrated overall successful BTM integration. Patients treated with BTM in conjunction with NPWT (n=16) demonstrated a significantly higher (p=0.046) integration rate compared to patients treated without NPWT (n=12) (93.8% versus 58.3%, respectively). Patients treated with BTM with NPWT continued to successfully integrate and sustain favourable outcomes despite the presence of severe infection or the development of haematomas.

CONCLUSION

A significantly higher integration rate was demonstrated when BTM was used in conjunction with NPWT. The results of this study further support the efficacy of successful integration of BTM as a replacement for tissue loss in the treatment of deep, full-thickness burns, traumatic and complex wound injuries, and particularly favourable outcomes with the use of NPWT. To the best of our knowledge, this is the first reported case series comparing the clinical outcomes of BTM with and without the use of NPWT.

Does prophylactic negative pressure wound therapy prevent surgical site infection in abdominal surgery?

OBJECTIVE

To determine if prophylactic negative pressure wound therapy (pNPWT) allows for the prevention of surgical site infections (SSIs) in abdominal surgery.

METHOD

A non-systematic review assessing the evidence was conducted in 2020.

RESULTS

Retrospectve studies comparing patients with pNPWT with patients receiving standard wound dressing after abdominal surgery showed encouragning results in favour of pNPWT for reducing the incidence of SSIs, but randomised controlled trials have so far reported mixed results.

CONCLUSION

New randomised controlled trials including a sufficient number of patients at risk of SSIs are needed for confirming the results of non-interventional studies.

The effect of storage method on selected physicochemical and microbiological qualities of wild boar meat

BACKGROUND

This study investigated the influence of the storage method on the physicochemical characteristics and microbial growth of m. longissimus thoracis et lumborum (LTL), m. biceps femoris (BF) and m. vastus lateralis (VL) of wild boar. Muscles were stored in a vacuum (VAC), in a modified high-oxygen atmosphere (MAP) or meat seasoning cabinet (DRY-AGED) for 21 days.

RESULTS

Wild boar meat was characterised by a high protein and low fat content and a good amount of potassium, sodium, calcium, magnesium, zinc and iron. Significantly higher (P < 0.05) pH values were noted for DRY-AGED muscles stored for 21 days (up to 5.89 for VL). On day 21, a significant decrease in pH was noted for all MAP muscles (down to 5.23 for BF). Storage losses due to desiccation and water loss were significantly higher for DRY-AGED samples and ranged from 25.63% to 32.89% on day 21. MAP affected protein and lipid oxidation, which was also reflected in Warner-Bratzler shear force VAC and DRY-AGED had positive results regarding tenderness, whereas on day 21 the MAP-stored meat had toughened significantly (from 35.3 N to 50.7 N in LTL). Lipids were oxidised much faster than proteins during prolonged storage in MAP. Compared to the other methods, DRY-AGED had the best effect on microbial growth.

CONCLUSION

These results indicate that the recommended methods for the storage of wild boar meat are either vacuum packing or dry ageing. The high oxygen content of MAP negatively affected the quality of wild boar meat and carried a risk of increased protein carbonylation. © 2022 Society of Chemical Industry.

Vacuum-assisted staged omphalocele reduction: A preliminary report

INTRODUCTION

Omphalocele represents a rare congenital abdominal wall defect. In giant omphalocele, due to the viscero-abdominal disproportion, gradual reintegration of eviscerated organs is often associated with medical challenges. We report our preliminary experience combining staged gravitational reduction with vacuum (VAC) therapy as a novel approach for treatment of giant omphalocele.

PATIENTS AND METHODS

Retrospective chart review of six patients (five females) born between September 2018 and May 2022 who underwent staged reduction of giant omphalocele in conjunction with VAC therapy was conducted. Treatment was performed at two German third-level Pediatric Surgery Departments. Biometric and periprocedural data were assessed. Main outcome measure was the feasibility of VAC therapy for giant omphalocele. Data are reported as median and interquartile range (Q1-Q3).

RESULTS

Gestational age was 37 (37-38) weeks, and birth weight was 2700 (2500-3000) g. VAC dressing was changed every 3 (3-4) days until abdominal fascia closure at the age of 9 (3-13) days. Time to first/full oral feeds was 3 (1-5)/20 (12-24) days with a hospital stay of 22 (17-30) days. Follow-up was 8 (5-22) months and complications were of minor extent (none: n = 2; Clavien-Dindo I: n = 3; Clavien-Dindo II: n = 1), comprising a delayed neo-umbilical cord rest separation (n = 2) and/or concomitant neo-umbilical site infection (n = 2) with no repeat surgery.

CONCLUSION

In neonates with giant omphalocele, VAC constitutes a promising and technically feasible enhancement of the staged gravitational reduction method. This study shows evidence that VAC may accelerate restoration of the abdominal wall integrity in giant omphalocele, thus minimizing associated comorbidities inherent to a prolonged hospitalization.

Clinical Uses of NPWT with Irrigation of Normal Saline in Diabetic Foot Ulcer: Outcome Assessed by DEPA Score

Introduction

Diabetic foot ulcer (DFU) is a common complication of uncontrolled diabetes. Negative pressure wound therapy (NPWT) with irrigation of normal saline is one of the methods for wound care and dressing techniques in DFU. Wound assessment is another aspect of DFU management for deciding whether the wound is prepared or not for coverage. The present study uses DEPA score as a wound assessment tool in DFU.

Materials and Methods

This case series include 11 patients with DFU who were treated using NPWT with simultaneous irrigation of normal saline.

Results

All 11 patients were male and age more than 60. Most patients have duration of diabetes for less than 10 years. Staphylococcus aureus (n = 5, 45.4%) was most common bacterial flora. Most patients in series presented with DEPA score more than 7 and after application of NPWT instillation therapy significant improvement seen with score in most of the patient with DEPA score below 6. Mean time for NPWT (irrigation) application was 15 days. Mean time of wound preparation was 18.7 days. Final surgical procedures executed in all patients, split skin grafting performed in 7 patients. 4 patients had wound coverage by reverse sural flap (2), medial plantar flap (1) and local flap coverage (1).

Conclusion

NPWT with normal saline irrigation is an effective method of wound preparation in DFU. DEPA score is an important tool for assessment of wound preparation which gives exact information for timing of wound coverage once diabetic foot wound is prepared.

Negative Pressure Wound Therapy: Mechanism of Action and Clinical Applications

Negative pressure wound therapy (NPWT) promotes healing by evenly applying negative pressure on the surface of the wound. The system consists of a sponge, a semiocclusive barrier, and a fluid collection system. Its effectiveness is explained by four main mechanisms of action, including macrodeformation of the tissues, drainage of extracellular inflammatory fluids, stabilization of the environment of the wound, and microdeformation. Rarely will complications linked to NPWT occur, but special care must be taken to prevent events such as toxic shock syndrome, fistulization, bleeding, and pain. New NPWT modalities have been recently developed to make NPWT suitable for a wider variety of wounds. These include NPWT with instillation therapy (NPWTi-d), different cleansing options, and application of NPWT on primarily closed incisions. Finally, vacuum-assisted wound closure therapy has been demonstrated to be efficient for various clinical settings, such as the management of diabetic foot ulcers, pressure ulcerations, chronic wounds, and skin grafts.

Bacterial bioburden of wounds: influence of debridement and negative-pressure wound therapy (NPWT)

OBJECTIVE

To clarify the role of microbiological swabs in surgical decision-making, we investigated the effect of negative-pressure wound therapy (NPWT) and serial surgical debridement on bacterial bioburden in hard-to-heal wounds and ultimately correlated them with the success of surgical closure.

METHOD

All patients were treated with surgical debridement, jet lavage and NPWT before their wounds were finally closed. The treatment effect was assessed by correlating microbiological swabs obtained immediately after intervention with those obtained after removal of the dressings during the following surgical procedures. The result of the last microbiological swab taken before definitive surgical closure was correlated with the requirement for revision surgery.

RESULTS

We included the results of 704 microbiological swabs from 97 patients in 110 wound localisations in this monocentric, retrospective study. NPWT did not improve bacterial bioburden in 77% of cases and the duration of NPWT did not affect the result. Furthermore, no significant effect of NPWT could be found for either anaerobic (p=0.96) or aerobic bacteria (p=0.43). In contrast, surgical debridement decreased bacterial load in approximately 60% of cases. If sterile wound swabs could be obtained at all, it was during the first four surgical debridements in 60% of patients; after that only 10% became sterile.

CONCLUSIONS

Sterile microbiological wound swabs before surgical closure were associated with lower rates of revision surgery, while low or medium bacterial loads did not increase revision rates.

Esophageal Perforation and EVAC in Pediatric Patients: A Case Series of Four Children

Introduction: In pediatric patients, esophageal perforation (EP) is rare but associated with significant morbidity and mortality rates of up to 20-30%. In addition to standard treatment options, endoscopic esophageal vacuum-assisted closure (EVAC) therapy has shown promising results, especially in adult patients. Thus far, the only data on technical success and effectiveness of EVAC in pediatric patients were published in 2018 by Manfredi et al. at Boston Children's Hospital. The sparse data on EVAC in children indicates that this promising technique has been barely utilized in pediatric patients. More data are needed to evaluate efficacy and outcomes of this technique in pediatric patients. Method: We reviewed five cases of therapy using EVAC, ArgyleTM Replogle Suction Catheter (RSC), or both on pediatric patients with EP in our institution between October 2018 and April 2020. Results: Five patients with EP (median 3.4 years; 2 males) were treated with EVAC, RSC, or a combination. Complete closure of EP was not achieved after EVAC alone, though patients' health stabilized and inflammation and size of EP decreased after EVAC. Four patients then were treated with RSC until the EP healed. One patient needed surgery as the recurrent fistula did not heal sufficiently after 3 weeks of EVAC therapy. Two patients developed stenosis and were successfully treated with dilatations. One patient treated with RSC alone showed persistent EP after 5 weeks. Conclusion: EVAC in pediatric patients is technically feasible and a promising method to treat EP, regardless of the underlying cause. EVAC therapy can be terminated as soon as local inflammation and C-reactive protein levels decrease, even if the mucosa is not healed completely at that time. A promising subsequent treatment is RSC. An earlier switch to RSC can substantially reduce the need of anesthesia during subsequent treatments. Our findings indicate that EVAC is more effective than RSC alone. In some cases, EVAC can be used to improve the tissues condition in preparation for a re-do surgery. At 1 year after therapy, all but one patient demonstrated sufficient weight gain. Further prospective studies with a larger cohort are required to confirm our observations from this small case series.

The role of vacuum-assisted closure (VAC) therapy in the management of FOURNIER'S gangrene: a retrospective multi-institutional cohort study

PURPOSE

To explore the role of vacuum assisted closure (VAC) therapy versus conventional dressings in the Fournier's gangrene wound therapy.

PATIENTS AND METHODS

This is a retrospective multi-institutional cohort study. Data of 92 patients from nine centers between 2007 and 2018 were retrospectively analyzed. After surgery, patient having a local or a disseminated FG were managed with VAC therapy or with conventional dressings. The 10-weeks wound closure cumulative rate and OS were analyzed.

RESULTS

Of the 92 patients, 62 (67.4%) showed local and 30 (32.6%) a disseminated FG. After surgery, 19 patients (20.7%) with local and 14 (15.2%) with disseminated FG underwent to VAC therapy; 43 (46.7%) with local and 16 (17.4%) with disseminated FG were treated using conventional dressings. The multivariable logistic regression analysis demonstrated that the VAC in patients with disseminated FG led to a higher cumulative rate of wound closure than patients treated with no-VAC (OR = 6.5; 95% CI 1.1-37.4, p = 0.036). The Kaplan-Meier survival curves for the OS showed a significant difference between no-VAC patients with local and disseminated FG (OS rate at 90 days 0.90, 95% CI 0.71-0.97 vs 0.55, 95% CI 0.24-0.78, respectively; p = 0.039). Cox regression confirmed that no-VAC patients with disseminated FG showed the lowest OS (hazard ratio adjusted for sex and age HR = 3.4, 95% CI 1.1-10.4; p = 0.033).

CONCLUSIONS

In this large cohort study, VAC therapy in patients with disseminated FG may offer an advantage in terms of 10-weeks wound closure cumulative rate and OS at 90 days after initial surgery.

Factors influencing the fascial closure rate after open abdomen treatment: Results from the European Hernia Society (EuraHS) Registry : Surgical technique matters

Purpose

Definitive fascial closure is an essential treatment objective after open abdomen treatment and mitigates morbidity and mortality. There is a paucity of evidence on factors that promote or prevent definitive fascial closure.

Methods

A multi-center multivariable analysis of data from the Open Abdomen Route of the European Hernia Society included all cases between 1 May 2015 and 31 December 2019. Different treatment elements, i.e. the use of a visceral protective layer, negative-pressure wound therapy and dynamic closure techniques, as well as patient characteristics were included in the multivariable analysis. The study was registered in the International Clinical Trials Registry Platform via the German Registry for Clinical Trials (DRK00021719).

Results

Data were included from 630 patients from eleven surgical departments in six European countries. Indications for OAT were peritonitis (46%), abdominal compartment syndrome (20.5%), burst abdomen (11.3%), abdominal trauma (9%), and other conditions (13.2%). The overall definitive fascial closure rate was 57.5% in the intention-to-treat analysis and 71% in the per-protocol analysis. The multivariable analysis showed a positive correlation of negative-pressure wound therapy (odds ratio: 2.496, p < 0.001) and dynamic closure techniques (odds ratio: 2.687, p < 0.001) with fascial closure and a negative correlation of intra-abdominal contamination (odds ratio: 0.630, p = 0.029) and the number of surgical procedures before OAT (odds ratio: 0.740, p = 0.005) with DFC.

Conclusion

The clinical course and prognosis of open abdomen treatment can significantly be improved by the use of treatment elements such as negative-pressure wound therapy and dynamic closure techniques, which are associated with definitive fascial closure.

Electronic supplementary material

The online version of this article (10.1007/s10029-020-02336-x) contains supplementary material, which is available to authorized users.

Abdominal wall reconstruction after emergent surgery for fistulizing incarcerated ventral wall hernia in morbidly obese patient

Incarcerated abdominal wall hernias may have a variety of manifestations and the most dreaded consequence is strangulation leading to obstruction and perforation of hollow viscus. Very rarely, such a perforation presents with fistulization into the abdominal wall and skin, which is often not considered but may complicate the management approach. &lt;br/&gt;Case presentation: We reported on presentation and management of a 56-year-old morbidly obese male with a fistulizing incarcerated ventral wall hernia and postoperative abdominal wall necrosis. &lt;br/&gt;Discussion: Contained bowel perforations caused by ventral hernia incarceration are a rare and not well recognized problem and are confined to a handful of case reports in the surgical literature. &lt;br/&gt;Conclusion: The most recognized complications of ventral hernias are incarceration and strangulation leading to obstruction and consequent perforation; however, as the case described below reveals, intestinal perforation and bowel-skin fistulization may occur as unusual incident. Management should involve operative reduction, resection of the involved bowel and staged repair of abdominal wall defect.

"Low cost, modified negative pressure wound therapy in infected orthopaedic wounds: can it be as effective as its costly counterparts?"

BACKGROUND

Infected wounds pose a great financial burden on our healthcare system. Negative pressure wound therapy (NPWT) has brought a paradigm shift in the management of these wounds. However, availability and high cost of a conventional NPWT system remains a challenge. We carried out this study to assess whether we can replicate functioning of the conventional NPWT system using resources which are easily available in most hospitals and determine the clinical efficacy and cost effectiveness of the same.

MATERIAL AND METHODS

A prospective study was conducted in the orthopaedic department at our tertiary care institute from January 2018 to December 2019. Fifty six patients with contaminated or infected orthopaedic wounds were included in the study. Wound dressings were carried out by modified negative pressure therapy and their results were studied.

RESULTS

The study group consisted of 41 males and 15 females. Duration of stay in hospital ranged from 6 to 37 days, with average duration of 14.05 days. Wound closure was achieved by secondary suturing in 18 (32.2%) of the cases and split thickness skin grafting in 38 (67.8%) of the cases. Wound assessment done using the revised Photographic wound assessment tool revealed an average of 60% reduction in scores, post procedure. The average cost of the dressing could be considerably reduced during the study by the use of available material.

CONCLUSION

Through our study we describe a simple and effective method of application of negative pressure dressings which may be beneficial in low resource settings. Our method is easily reproducible and does not require expertise for its application, at the same time it is cost effective and efficient in wound care.

[RETRACTED] Negative pressure wound therapy versus conventional dressing for open fractures in lower extremity trauma

AIMS

It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT.

METHODS

This multicentre randomized controlled trial was approved by the ethical review board of a public sector tertiary care institute. Wounds were graded using Gustilo-Anderson (GA) classification, and patients with GA-II to III-C were included in the study. To be eligible, the patient had to present within 72 hours of the injury. The primary outcome of the study was patient-reported Disability Rating Index (DRI) at 12 months. Secondary outcomes included quality of life assessment using 12-Item Short-Form Health Survey questionnaire (SF-12), wound infection rates at six weeks and nonunion rates at 12 months. Logistic regression analysis and independent-samples t-test were applied for secondary outcomes. Analyses of primary and secondary outcomes were performed using SPSS v. 22.0.1 and p-values of < 0.05 were considered significant.

RESULTS

A total of 486 patients were randomized between January 2016 and December 2018. Overall 206 (49.04%) patients underwent NPWT, while 214 (50.95%) patients were allocated to the standard dressing group. There was no statistically significant difference in DRI at 12 months between NPWT and standard dressing groups (mean difference 0.5; 95% confidence interval (CI) -0.08 to 1.1; p = 0.581). Regarding SF-12 scores at 12 months follow-up, there was no significant difference at any point from injury until 12 months (mean difference 1.4; 95% CI 0.7 to 1.9; p = 0.781). The 30-day deep infection rate was slightly higher in the standard gauze dressing group. The non-union odds were also comparable (odds ratio (OR) 0.90, 95% CI 0.56 to 1.45; p = 0.685).

CONCLUSION

Our study concludes that NPWT therapy does not confer benefit over standard dressing technique for open fractures. The DRI, SF-12 scores, wound infection, and nonunion rates were analogous in both study groups. We suggest surgeons continue to use cheaper and more readily available standard dressings. Cite this article: Bone Joint J 2020;102-B(7):912-917.

The Toxoplasma Vacuolar H+-ATPase Regulates Intracellular pH and Impacts the Maturation of Essential Secretory Proteins

Vacuolar-proton ATPases (V-ATPases) are conserved complexes that couple the hydrolysis of ATP to the pumping of protons across membranes. V-ATPases are known to play diverse roles in cellular physiology. We studied the Toxoplasma gondii V-ATPase complex and discovered a dual role of the pump in protecting parasites against ionic stress and in the maturation of secretory proteins in endosomal-like compartments. Toxoplasma V-ATPase subunits localize to the plasma membrane and to acidic vesicles, and characterization of conditional mutants of the a1 subunit highlighted the functionality of the complex at both locations. Microneme and rhoptry proteins are required for invasion and modulation of host cells, and they traffic via endosome-like compartments in which proteolytic maturation occurs. We show that the V-ATPase supports the maturation of rhoptry and microneme proteins, and their maturases, during their traffic to their corresponding organelles. This work underscores a role for V-ATPases in regulating virulence pathways.

Stasic et al. characterize the function of the vacuolar proton ATPase in the life cycle of Toxoplasma gondii, a widespread parasite that infects almost one-third of the world’s population. The work presents molecular evidence of the pump’s role in the synthesis of virulence factors of a highly successful pathogen.

Management of Wounds with Exposed Bones or Tendons in Children by Vacuum-Assisted Closure Therapy: A Prospective Study

Background  The management of complex soft tissue defects with exposed bones/tendons is always a challenging task for the surgeon and the problem becomes more pronounced when it comes to the management of these wounds in children. Though flap procedures are considered the standard for managing the complex soft tissue defects with exposed bones/tendons yet small blood vessels for anastomosis, long operative period, increased chances of perioperative thrombosis, and difficult perioperative management in children add to the difficulty in performing flap procedures in children. The vacuum-assisted closure (VAC) therapy has emerged as a novel modality for the management of the difficult wounds with added advantages, especially in children.

Objective  To evaluate the efficacy of VAC in the management of wounds with exposed bones/tendons in children.

Patients and Method  Forty-six children of complex wounds with exposed bones/tendons were included in the study from July 2016 to June 2018.

Results  Out of 46 patients, 31 were male; the patients had a mean age of 8.4 years. Road traffic accident was the most common mode of injury (54%), with most of the wounds located over extremities. The mean duration of VAC therapy was 12 days. More than 90% coverage of the exposed structure was seen in 89% of patients. The wounds were definitively managed by split-thickness skin graft in 89% of patients and flap cover in 6.5% of patients. The mean cost of the VAC therapy at our government run hospital was 187 Indian rupees per day. No significant major complications were seen during the treatment.

Conclusion  VAC therapy is an efficient, safe, and cost-effective modality of treatment for the management of complex wounds in the pediatric population.

Endoscopic repair of anastomotic leakage after low anterior resection for rectal cancer: A systematic review

INTRODUCTION

Anastomotic leakage (AL) after low anterior resection for rectal cancer is a severe complication. Except for re-operation, several endoscopic options have been proposed for the minimal invasive treatment of AL, including the endoluminal vacuum devices, tissue sealants and Over-The-Scope-Clip (OTSC) technique. The aim of the present review is to evaluate the effect of alternative treatment options for AL repair, by means of endoscopy.

METHOD

A bibliographic search was performed in the international literature. Ten case reports and series were finally included, reporting 75 cases of endoscopic repair of AL. A descriptive statistical analysis and a systematic review were performed.

RESULTS

The patients' mean age was 65.84 ± 9.92 years (95% CI: 61.70-68.76), the male-to-female ratio being 1.5:1. The mean diameter of the cavity was 5.17 ± 3.32 cm (95% CI: 4.03-6.31). The mean time until the diagnosis was 44.15 ± 105.91 days (95% CI: 13.39-74.90). Vacuum-assisted closure therapy was the most common technique (52%), followed by fibrin glue (25.3%) and OTSC (22.7%). As supplementary therapy, OTSC was applied in 8.3%, vacuum-assisted closure in 25%, endoclips in 4.2%, while fibrin glue was the most frequently used (62.5%).

CONCLUSION

Endoscopic management of AL after low anterior resection is considered as an alternative to surgical treatment with promising results.

Tapering pressure of wall vacuum-assisted closure for the treatment of patients with pancreatic fistula in traumatic pancreatic injury: Report of two cases

•

Postoperative pancreatic fistula is a nightmare for digestive surgeons.

•

Requires complex treatment and a long duration of hospitalization of patients with a large cost burden.

•

VAC using wall suction with NPWT principle can be used to treat patients with complex wounds.

•

A simple and easy procedure with good outcomes.

Introduction

Traumatic injury to the pancreas is rare and difficult to diagnose, requiring immediate operative management. It also has high mortality and morbidity rates. Postoperative pancreatic fistula is one of the complications that is considered a nightmare for digestive surgeons. The prevalence of POPF is estimated at 13%–41%, with 28% of mortality rate and the most common cause of death is retroperitoneal sepsis and hemorrhage. It requires complex treatment and a long duration of hospitalization of patients with a large cost burden.

Presentation of case

Here we report 2 cases of POPF after pancreatic injury in abdominal trauma. The patients underwent emergency laparotomy. In the hospital ward, the patients developed wound dehiscence and a clear viscous pancreatic juice came out from the wound with high output. The installation of wall VAC using wall suction with pressure adjustments according to the number of products per day was performed. The patients showed good outcomes, the pancreatic juice output decreased and diminished, and the wound also narrowed and closed.

Discussion

VAC using wall suction is a device that applies the technique of NPWT and an emerging procedure used to treat patients with complex wounds. NPWT can reduce pooling of fluid, while reducing shear stress and tissue hypoxia at the wound edges, and stimulating the release of vascular endothelial growth factor in wound milieu.

Conclusions

Tapering pressure of VAC using wall suction for treatment of pancreatic fistula in post laparotomy pancreatic injury patients is a simple and easy procedure with good outcomes.

Retrospective Study on the Clinical Superiority of the Vacuum-Assisted Closure System with a Silicon-based Dressing over the Conventional Tie-over Bolster Technique in Skin Graft Fixation

Background and Objectives: The tie-over bolster technique has been conventionally used for skin graft fixation; however, long operative times and postoperative pain are the main disadvantages of this method. In this study, we introduce a new method using vacuum-assisted closure (VAC) with a silicon-based dressing as an alternative for skin graft fixation. This retrospective study aimed to evaluate the clinical effect of the VAC plus silicon-based dressing method and the conventional tie-over bolster technique for skin graft fixation in terms of pain, operative time, and skin graft take rate. Materials and Methods: Sixty patients who underwent skin graft surgery performed by a single surgeon from January 2017 to October 2018 were included in this clinical study. They were divided into two groups based on the type of treatment: tie-over bolster technique and vacuum-assisted closure (VAC), or silicon-based dressing groups. The operative times were recorded twice (during suturing or stapling of the graft and during removal of the dressing) in the two groups; similarly, pain was assessed using a numeric rating scale (NRS) after surgery and during dressing removal. Skin graft take rate was evaluated two weeks after dressing removal. Results: Twenty-six patients who met the eligibility criteria were enrolled into the study and assigned to one of the two groups (n = 13 each). No significant differences in age, gender, and graft area were noted between the two groups of patients. The VAC plus silicon-based dressing group demonstrated higher skin graft take rates (p < 0.05), shorter operation times (p < 0.05), and lower levels of pain (postoperative pain and pain during dressing removal) compared with the tie-over bolster technique group (p < 0.05). Conclusions: These findings indicate that VAC with silicon-based dressing can be used for skin graft fixation due to its superior properties when compared with the conventional method, and can improve the quality of life of patients undergoing skin graft fixation.

Virtual reality games on accommodation and convergence

Increasing popularity of virtual reality (VR) gaming is causing increased concern, as prolonged use induces visual adaptation effects which disturbs normal vision. Effects of VR gaming on accommodation and convergence of young adults by measuring accommodative response and phoria before and after experiencing virtual reality were measured. An increase in accommodative response and a decrease in convergence was observed after immersion in VR games. It was found that visual symptoms were apparent among the subjects post VR exposure.

Vacuum-assisted closure versus moist dressings in the treatment of diabetic wound ulcers after partial foot amputation: A retrospective analysis in 65 patients

PURPOSE

Changes in weight-bearing patterns after partial foot amputations may lead to new localized high-pressure points and keratosis due to ulcerations in patients with neuropathies and hypovascular limbs. As a result, diabetic foot ulcers (DFUs) after partial foot amputations are very complex. The aim of this study was to compare the effectiveness of vacuum-assisted closure (VAC) therapy with conventional moist wound dressings in the treatment of diabetic wound ulcers after partial foot amputations.

METHODS

Sixty-five diabetic patients with a DFU, who had previously undergone partial foot amputation surgery, were assigned to treatment with VAC (group A: 31 patients) or conventional wound moist dressing (group B: 34 patients). The final results were considered as failed treatment if reamputation was required. Conversely, reaching 90% of wound granulation was considered to be a successful endpoint.

RESULTS

The average time to reach 90% granulation tissue was significantly lower in group A (7.8 ± 1.2 weeks vs. 11.1 ± 1.2 weeks; p < 0.001). However, there was no significant difference regarding the reamputation requirements; 38.7% (12 patients) in group A and 41.2% (14 patients) in group B, ( p = 0.839).

CONCLUSION

The results of this study allowed us to conclude that VAC therapy system appears to be an effective treatment for patients with complex DFUs who had previously undergone partial foot amputation.

Negative pressure wound therapy as a definitive treatment for upper extremity wound defects: A systematic review

Negative pressure wound therapy (NPWT) represents one of the many solutions for complex wounds of the upper extremity. The goal of this study was to investigate the most common indications for definitive treatment of wound defects in the upper extremity with NPWT and to report revision surgery outcomes after its use. A systematic review of the literature was performed. The following keywords and their combinations were used: "upper extremity," "arm," "forearm," "wrist," "hand," "finger" AND "negative-pressure wound therapy," "VAC therapy," "vacuum assisted closure." A total of 45 articles were included, regrouping 404 cases of NPWT in the upper extremity. The forearm was involved in 53% of cases, followed by hand (36%), fingers (10%), and arm (1%). Seventeen different indications were cited, the most common of which were radial forearm flap reconstruction (23%), burn wounds (18%), and compartment syndromes (17%). Of the cases, 90% did not require any subsequent surgical procedure, as opposed to 6% considered partial failures requiring minor revisions and 4% total failures requiring major revisions. Closure of radial forearm flap donor site required the most revision procedures when treated with NPWT. NPWT can be used for several indications pertaining to the reconstruction of the upper extremity. Positive outcomes as a definitive treatment are demonstrated in this systematic review, which reaffirms NPWT as a potent tool for reconstructive endeavours.

Converging drivers of interpersonal violence: Findings from a qualitative study in post-hurricane Haiti

OBJECTIVE

Interpersonal violence affecting women and children is increasingly recognized as a public health priority in humanitarian emergencies. Yet, research and intervention efforts have been fragmented across gender-based violence and child protection sectors. Using data from the Transforming Households: Reducing Incidence of Violence in Emergencies (THRIVE) project, this study sought to qualitatively investigate the intersecting drivers of multiple forms of violence in Côteaux, Haiti, while obtaining insight on how these drivers may be influenced by a humanitarian emergency.

METHODS

This analysis used transcripts obtained using a photo elicitation approach over the course of three sessions per person. Thirty-six individuals participated in the study: eight adult females, ten adult males, eight adolescent females, ten adolescent males. Participants were given cameras to capture images related to family relationships, family safety, and changes to family dynamics due to Hurricane Matthew and its aftermath. In subsequent sessions, these photographs were used as prompts for qualitative interviews.

RESULTS

Multiple and converging drivers of interpersonal violence were identified including the accumulation of daily stressors, loss of power/control, learned behavior (intergenerational cycle of abuse), and inequitable gender norms, all of which were influenced by the humanitarian context caused by Hurricane Matthew.

CONCLUSIONS

Our findings suggest multiple and converging drivers of violence may be exacerbated in times of crises, requiring interdisciplinary responses. In order to comprehensively address the drivers of violence, practitioners and policy makers should consider the needs of individuals and their families holistically, integrating community-led, gender transformative efforts and positive parenting with basic needs provision.

[PRIMARY PROSTATIC RHABDOMYOSARCOMA WITH REPEATING CEREBRAL HEMORRHAGE FROM BRAIN METASTASES IN AN ADULT: A CASE REPORT]

A 28-year-old man visited a nearby doctor with a chief complaint of hematospermia. Magnetic resonance imaging showed a tumor 12-cm in diameter in his pelvis and he was introduced to our hospital. The tumor had replaced the prostate and infiltrated the rectum. He already had multiple lung, pelvic lymph, and bone metastases. He was diagnosed with embryonal rhabdomyosarcoma based on pathological findings after needle tumor biopsy. His disease was stage IV rhabdomyosarcoma according to the Intergroup Rhabdomyosarcoma Study, and he received a VAC (vincristine, actinomycin D, cyclophosphamide) chemotherapy regimen. Despite a partial response with 44% shrinkage in tumor diameter after seven cycles of chemotherapy, he experienced cerebral hemorrhage from small brain metastases during preparation for the eighth course. During gamma knife planning, the cerebral hemorrhage from small brain metastases repeated four times. The patient died 8 months after the introduction of chemotherapy.

In-hospital low-cost custom made VAC: Effective method for reducing infection in late presenting Open lower limb fractures in overburdened Indian hospitals

BACKGROUND

Open fractures are still associated with troublesome rates of infection. Thorough debridement irrigation and antibiotic cover are of paramount importance irrespective of the fixation method. VAC therapy is a well known method of accelerating the wound healing and decreasing the infection in non healing ulcers. The main drawback of VAC therapy is requirement of a special equipment and high cost. We in our hospital are using low cost custom made VAC therapy for non healing ulcers in lower socio-economic people and have seen extremely good results in wound healing and infection control.

OBJECTIVE

To evaluate the role of pre operative low cost custom made VAC therapy as an adjunctive method of decreasing the rates of infection in late presenting lower limb open fractures.

METHODS

A retrospective study of 26 open femur and tibia fractures for which low cost VAC therapy was used between January 2014 to January 2017.

RESULTS

2 out of 26 cases (7.4%) ended up with deep infection.

CONCLUSION

Pre operative in-hospital low cost custom made VAC therapy is a useful adjunctive method of reducing infection rates in late presenting open fractures.

Serial Reduction of an Extremely Large Gastroschisis using Vacuum-Assisted Closure

We herein describe a case of serial reduction of an extremely large and complex gastroschisis using vacuum-assisted closure (VAC) therapy in a boy born at 35 ^5/7 weeks' gestation. A spring-loaded silicone silo was placed at birth. By day of life (DOL) 22, minimal visceral contents had been reduced, and the silo was difficult to maintain due to the size of the fascial defect and loss of abdominal domain. A bespoke VAC dressing was constructed, and biweekly dressing changes allowed gradual reduction of the gastroschisis until the viscera were consolidated. By DOL 50, the viscera were completely reduced, and VAC therapy was discontinued. Feeds were commenced on DOL 57 and increased to goal by DOL 86. The baby was discharged home on DOL 115. We conclude that VAC dressings can be used to aid gradual reduction of an extremely large gastroschisis, particularly in medical fragile infants.

Vacuum-assisted closure combined with a closed suction irrigation system for treating postoperative wound infections following posterior spinal internal fixation

BACKGROUND

Wound infections after posterior spinal surgery are a troublesome complication; patients are occasionally forced to remove the internal fixation device, which can lead to instability of the spine and injury to the spinal cord. The purpose of this study was to evaluate the efficacy of modified vacuum-assisted closure (VAC) for treating an early postoperative spinal wound infection.

METHODS

We conducted a retrospective study of 18 patients with wound infections after posterior spinal surgery from 2014 to 2017 at a single tertiary center. All patients included in the study received modified VAC treatment (VAC combined with a closed suction irrigation system, CSIS) until the wound satisfied the secondary closure conditions. Detailed information was obtained from the medical records.

RESULTS

Wound size decreased significantly after 1 week of the modified VAC treatment. Three patients were treated with VAC three times and one patient received the VAC treatment four times; the remaining patients received the VAC treatment twice. The patients had excellent wound beds after an average of 8 days. The wound healed completely after an average of 17 days, and the average hospital stay was 33 days. There was no recurrence of infection at the 1-year follow-up.

CONCLUSIONS

This study demonstrates that VAC combined with a CSIS is a safe, reliable, and effective method to treat a wound infection after spinal surgery. This improved VAC procedure provides an excellent wound bed to facilitate wound healing and shorten the hospital stay.

Integrative approach for diabetic foot management- a case report

Non-healing diabetic foot has always demanded more attention from the surgeon due to the distinct problem it possesses. There is a constant need for the evolvement in the management and this case is one such attempt. A 62-year-old male patient with a history of diabetes mellitus since 10 years presented with a non-healing foot ulcer since 1 month. He was managed with Ayurveda internal and external interventions for dusta vrana combined with contemporary methods like vacuum assisted wound suction and skin grafting. The patient who presented with non-healing diabetic foot was found to have better wound healing with combined intervention. The current approach indicates the better outcome with multi-dimensional approach towards diabetic foot.

[Posttraumatic Osteomyelitis: Improvement in Outcome by Negative Pressure Wound Therapy with Instillation Technique]

Posttraumatic Osteomyelitis: Improvement in Outcome by Negative Pressure Wound Therapy with Instillation Technique Abstract. Surgical treatment of post-traumatic (fistula) osteomyelitis can be difficult and is associated with an increased risk of later recurrence. Very often osteomyelitis is accompanied by a soft tissue (defective) wound. After surgical debridement, the use of the vacuum sealing technique can stimulate wound healing and improve local blood circulation. In particular, the introduction of the innovative instillation technique for wound sponges can increase the effectiveness of the treatment of the infection. By regularly rinsing the sponges with an antiseptic polyhexanide solution, the duration of treatment, the number of operations, the in-patient stay and the recurrence rate in this patient group can be statistically significantly reduced.

The application of incisional negative pressure wound therapy for perineal wounds: A systematic review

Impaired perineal wound healing is a major source of morbidity after abdominoperineal resection. Incisional negative pressure wound therapy can improve healing, prevent infections, and decrease the frequency of dehiscence. Our objective was to summarise existing evidence on the use of incisional negative pressure wound therapy on perineal wounds after abdominoperineal resection and to determine the effect on perineal wound complications. Electronic databases were searched in January 2017. Studies describing the use of incisional negative pressure wound therapy on primarily closed perineal wounds after abdominoperineal resection were included. Of the 278 identified articles, 5 were retrieved for inclusion in the systematic review (n = 169 patients). A significant decrease in perineal wound complications when using incisional negative pressure wound therapy was demonstrated, with surgical site infection rates as low as 9% (vs 41% in control groups). The major limitation of this systematic review was a small number of retrieved studies with small patient populations, high heterogeneity, and methodological issues. This review suggests that incisional negative pressure wound therapy decreases perineal wound complications after abdominoperineal resection. Further prospective trials with larger patient populations would be needed to confirm this association and delineate which patients might benefit most from the intervention.

The use of vacuum-assisted closure for the treatment of deep sternal wound defects: a centre-specific technique

The objective is to describe the 'Two Bridges Technique' (TBT), which has proven to be successful and has been the standard technique at our centre for vacuum-assisted closure (VAC) of post-sternotomy mediastinitis. An extensive literature search was performed in four databases to identify all published articles concerning VAC for post-sternotomy mediastinitis. Several VAC methods have been used; however, no article has described our specific technique. TBT consists of a two-bridges construction using two types of foam with different pore sizes, which ensures an equally divided negative pressure over the wound bed and stabilisation of the chest. This guarantees a continuous treatment of the sternal defect and prevents foam displacement. It maintains an airtight seal that prevents skin maceration and provides enough protection to avoid right ventricular rupture. The main advantage of TBT is the prevention of shifting or tilting of the foam during chest movements such as breathing or couching. Along with targeted antibiotic treatment, this alternative VAC technique can be an asset in the sometimes cumbersome treatment of post-sternotomy mediastinitis.

Vacuum-assisted closure therapy of paradoxical reaction in tuberculous lymphadenopathy caused by Mycobacterium africanum

A 26-year-old HIV-negative male from Ghana was treated for cervical, intrathoracic and abdominal lymph node tuberculosis (TB) and tuberculous hepatitis. Penetration of the thoracic trachea by a mediastinal lymph node had caused bronchomucosal TB. Sputum culture grew M. africanum, sensitive to all first-line antituberculous drugs. Four weeks after the beginning of directly observed treatment with isoniazid, rifampin, pyrazinamide and ethambutol, the right cervical lymph node increased in size, liquefied and caused a spontaneous fistula. A biopsy of the necrotized lymph node revealed rare acid-fast bacilli with a positive PCR for Mycobacterium tuberculosis complex. After debridement, vacuum-assisted closure therapy was performed for 6 weeks. Five months after the beginning of antituberculous therapy, a second paradoxical reaction occurred, with painful swelling of two contralateral supraclavicular lymph nodes. Extirpation of one node yielded a positive PCR for M. tuberculosis complex; the culture was negative. Antituberculous treatment was continued, and additional treatment with oral prednisolone 20 mg daily for 1 month tapering over 10 weeks was introduced, resulting in a decrease in lymphadenopathy. Antituberculous treatment was continued for a total of 9 months. The outcome was favorable, no further lymphadenopathy occurred over the following 6 months.

New Treatment Strategy for a Delayed Skin Necrosis Related to a Calcaneal Fracture

In calcaneal avulsion fractures, skin necrosis as a result of pressure from the underlying fragment is a fairly common and serious complication. In spite of proper treatment, skin healing complication may occur. We report a calcaneal fracture case complicated by skin necrosis and managed with a novel treatment strategy including application of Platelet Rich Plasma (PRP) and Vacuum Assisted Closure (VAC). This is the first application of combined PRP and VAC treatment in a calcaneal fracture complicated by skin necrosis and was accompanied with very favorable outcomes while avoiding other more complex treatment modalities.

Vacuum assisted closure technique: a short review

The management of difficult to heal wounds has always been a cause of concern for the treating clinicians. There has been a tremendous increase in the number patients presenting with difficult to heal wounds. The conventional techniques have been in use since the long time for the management of these wounds, yet desired results are not achieved always. Thus a newer novel technique which might be useful in the difficult to heal wounds and delivering at par or better results as compared to the conventional techniques is the need of the hour.

Negative Pressure Wound Therapy for Burns

Negative pressure wound therapy (NPWT) has become a widely used treatment for acute and chronic wounds. NPWT is indicated for a variety of complex wounds, and some studies validate its use for certain aspects of burn care. Although further research is needed to explore the benefits for burns, NPWT has proven beneficial in its use as a dressing that bolsters skin grafts, promotes integration of bilaminate dermal substitutes, promotes re-epithelialization of skin graft donor sites, and potentially reduces the zone of stasis. This article reviews the literature on NPWT in burns, based on indication/application, and describes our experience with the use of modified NPWT for large burns.

Experimental comparison of abdominal drainage systems

BACKGROUND

In an experimental study the performance of different closed abdominal drainage systems was tested.

METHODS

A vacuum bottle designed for Redon Drainage, a flexible plastic bulb designed for Jackson-Pratt drains and a V.A.C.^® Negative Pressure Wound Therapy System were used. In a porcine cadaveric study mimicking the abdominal cavity the intrinsic pressure (IP) at one and three minutes (T0, T3) and the amount of evacuated fluid were measured.

RESULTS

The Redon and Jackson drainage displayed a rapid decline to IP values of almost zero comparing T0 and T3. Only the V.A.C.^® system was able to preserve constant values of negative IP values measured at both time points. Only the V.A.C.^® system was able to remove almost the whole amount of inserted fluid.

CONCLUSIONS

In an experimental setting the V.A.C.^® system was superior to the other two tested systems in delivering constant negative IP and the amount of evacuated fluid.

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.

Evaluation of Vacuum Assisted Closure Therapy for Soft Tissue Injury in Open Musculoskeletal Trauma

INTRODUCTION

The application of controlled levels of negative or sub atmospheric pressure for a prolonged period of time on a wound had shown to accelerate removal of excess fluid and promote hyperaemia, which eventually promote wound healing.

AIM

The study was conducted with the aim to evaluate the effectiveness of Vacuum Assisted Closure (VAC) therapy for soft tissue injury in open musculoskeletal trauma.

MATERIALS AND METHODS

Twenty cases of complex musculoskeletal wound involving different parts of body were included in this progressive randomized study. In patients, aggressive debridement was done before the application of VAC therapy. Controlled negative pressure was uniformly applied to the wound. Dressings were changed after every 4 to 5 days. The evaluation of results included healing rate of the wound, eradication of infection, complication rate, and number of secondary procedures.

RESULTS

VAC therapy over the wound was administered for an average of 20.4 days ±6.72 days (range 14 to 42 days). There was decrease in wound size attained by VAC therapy ranged from 2.6 to 24.4cm(2), with an average reduction of 10.55 cm(2). Three wounds were infected at the start of VAC therapy. However, all patients were cleared of bacterial infection by the end of VAC therapy.

CONCLUSION

VAC therapy using negative pressure promote Wound healing by increasing local capillary perfusion and increased rate of granulation tissue formation, decreases the duration of wound healing and requires fewer painful dressing change.

Long-term outcomes of sandwich ventral hernia repair paired with hybrid vacuum-assisted closure

BACKGROUND

Sandwich ventral hernia repair (SVHR) may reduce ventral hernia recurrence rates, although with an increased risk of surgical site occurrences (SSOs) and surgical site infections (SSIs). Previously, we found that a modified negative pressure wound therapy (hybrid vacuum-assisted closure [HVAC]) system reduced SSOs and SSIs after ventral hernia repair. We aimed to describe our outcomes after SVHR paired with HVAC closure.

METHODS

We conducted a 4-y retrospective review of all complex SVHRs (biologic mesh underlay and synthetic mesh overlay) with HVAC closure performed at our institution by a single surgeon. All patients had fascial defects that could not be reapproximated primarily using anterior component separation. Descriptive statistics were used to report the incidence of postoperative complications and hernia recurrence.

RESULTS

A total of 60 patients (59.3 ± 11.4 y, 58.3% male, 75% American Society of Anesthesiologists class ≥3) with complex ventral hernias being underwent sandwich repair with HVAC closure. Major postoperative morbidity (Dindo-Clavien class ≥3) occurred in 14 (23.3%) patients, but incidence of SSO (n = 13, 21.7%) and SSI (n = 4, 6.7%) was low compared with historical reports. Median follow-up time for all patients was 12 mo (interquartile range 5.8-26.5 mo). Hernia recurrence occurred in eight patients (13.3%) after a median time of 20.6 months (interquartile range 16.4- 25.4 months).

CONCLUSIONS

Use of a dual layer sandwich repair for complex abdominal wall reconstruction is associated with low rates of hernia recurrence at 1 year postoperatively. The addition of the HVAC closure system may reduce the risk of SSOs and SSIs previously reported with this technique and deserves consideration in future prospective studies assessing optimization of ventral hernia repair approaches.

Negative pressure therapy is effective in abdominal incision closure

BACKGROUND

CDC wound classification demonstrates surgical site infection (SSI) occurs in 15%-30% of contaminated (class III) and >30% of dirty-infected (class IV) wounds. Several techniques have been used to decrease SSI rates in midline laparotomy incisions; however, no technique has shown superiority. Evidence suggests incisional negative pressure wound therapy (INPWT) can decrease wound complications, but no literature exists regarding INPWT for high-risk laparotomy incisions. We sought to analyze the efficacy of INPWT in the management of high-risk midline laparotomy incisions.

METHODS

Retrospective review of adult patients who underwent laparotomy between January 2013 and June 2014 with midline closure using INPWT. Only class III or IV wounds were included. Laparotomy incisions were loosely closed. INPWT set at 125 mm Hg is placed over oil emulsion impregnated gauze. INPWT is removed after 5 d and the wound left open to air. Records were reviewed for immediate and/or delayed surgical site complications. Primary end point was 30-d incisional SSI. Secondary end points included other surgical site complications.

RESULTS

One class III and 12 class IV wounds were treated with INPWT for a median of 5 d. The class III wound developed a small skin dehiscence with no evidence of superficial or deep SSI. Among class IV wounds, the rate of superficial and deep incisional SSI was 25% and 0%, respectively. The overall surgical site complication rate was 41.7%.

CONCLUSIONS

INPWT in closure of high-risk midline laparotomy incisions is a safe, effective method of wound closure with equivalent SSI rates to previously described methods.

Ovarian Malignant Mixed Germ Cell Tumor: A Case of Unusual Presentation as Molar Pregnancy

BACKGROUND

This research was conducted to introduce a patient with rare ovarian mixed germ cell tumor, presented as molar pregnancy.

CASE PRESENTATION

The patient was a 16 year old woman admitted with diagnosis of molar pregnancy. Abdominal enlargement was the only complaint. She had a large pelvic mass in physical examination. The first diagnosis was molar pregnancy due to previous ultrasonic reports and positive βeta HCG. Urine pregnancy test was positive. As suction curettage was performed for her, surprisingly, the size of uterus was normal and no molar tissue was found in pathologic examination. At intraoperative ultrasound exam, an extra-uterine heterogeneous mass was found. Extra-uterine mass was confirmed by CT and MRI done after suction curettage. Mixed germ cell tumor was confirmed by histological examination after laparatomy and removing tumoral mass. Finally, she received Bleomycin, Etoposide and Cisplatin (BEP) regimen in four courses and Vincristine, Actinomycin D (Dactinomycin) and Cyclophosphamide (VAC) regimen in two courses and Diphereline for saving the other ovary.

CONCLUSION

Some young patients misinterpret the early symptoms of an ovarian neoplasm as those of pregnancy which can lead to a delay in the diagnosis.

Delayed primary closure in open abdomen with stoma using dynamic closure system

BACKGROUND

The situation of abdominal sepsis secondary to colonic perforation sometimes forces treat the patient with multiple interventions in the open abdomen (OA) context. Correct management of OA is important to restore the patient's clinical situation and to avoid further complications of the abdominal wall. Delayed primary closure of the abdomen using a dynamic and progressive traction is a relatively new technique for treating the OA.

CASE PRESENTATION

We report the case of a 50 year old woman with history of malnutrition and chronic obstructive pulmonary disease, affects for an OA after several surgical interventions. Two previous interventions (right colectomy, ileostomy and laparotomy with Bogotá bag) for disseminated peritonitis and abdominal compartment syndrome were performed. Six days after the Bogota bag the of the dynamic closure system ABRA(®) system was placed to delayed primary closure of the abdomen with excellent result results of the contingency of the abdominal wall.

DISCUSSION

The most common technique in the current management of OA is the placement of vacuum-assisted closure or the use of a mesh. These systems generally require several operations to restore the integrity of the abdominal wall. However, the dynamic closure of the abdominal wall makes it possible to restore it into the same process.

CONCLUSIONS

ABRA system allows delayed primary closure of the abdominal wall in an OA by sepsis secondary to colonic perforation. The stoma was not a problem with this technique. The final closure of the abdomen was at 16 days after the ABRA placement. The abdominal wall has not alterations in the follow up after 3 years.

Acute tonsillar cerebellar herniation in a patient with traumatic dural tear and VAC therapy after complex trauma

BACKGROUND CONTEXT

Cases of cerebral hypotension and tonsillar herniation after accidental lumbar cerebrospinal fluid (CSF) drainage or chest tube drainage with intrathoracic CSF leaks have been reported. To the authors' knowledge, this case presents the first report of severe intracranial hypotension because of suction of CSF by a Vacuum-Assisted Closure (VAC) device.

PURPOSE

The purpose of this study was to report a life-threatening intracranial hypotension in a polytraumatized patient after VAC therapy.

STUDY DESIGN

This study is a case report.

METHODS

A 23-year-old woman suffered of a Grade 3 open pelvic fracture after a motor vehicle accident. After a VAC therapy, the patient became nonresponsive. A cranial computer tomography (CCT) showed signs of intracranial hypotension with narrowing of the basal cisterns and sagging of the cerebellar tonsils. The VAC was removed. Further neuroradiological diagnostic showed a tear in the dural sac at the L5-S1 level. The patient consequently underwent neurosurgery. After a dural patch, she was oriented postoperatively and the CCT improved to a normal state.

RESULTS

Fifteen days after admission, the patient was discharged without neurologic sequelae.

CONCLUSIONS

Severely injured patients undergoing VAC therapy with secondary neurologic deterioration not because of head injury should be appropriately diagnosed to rule out dural laceration and cranial hypotension.

Vacuum-assisted closure for open perineal wound after abdominoperineal resection

INTRODUCTION

In colorectal cancer surgery, surgical site infection (SSI) is a common complication, and especially, perineal wound complications after abdominoperineal resection (APR) remain to be serious clinical problems. Vacuum-assisted closure (VAC) therapy was first reported in another surgical field in 1997, and it is useful for treating complex wounds because it promotes granulation. VAC therapy has been recently used for open abdominal wounds. We introduced VAC for treating open perineal wound of APR and report the usefulness of it.

PRESENTATION OF CASE

We treated four patients. Firstly, in cases 1 and 2, we introduced VAC therapy to the management of SSI of the perineal wound after APR, and it was useful to control postoperative perineal wound infection. And also, in cases 3 and 4, we introduced VAC therapy to prevent perineal wound infection. Perineal wound infection did not happen.

DISCUSSION

A vertical rectus abdominis myocutaneous flap has been reported to decrease perineal wound complications including pelvic abscess and open perineal wound; however it results in significant operative blood loss, increased operative time, and additional surgical complications. In our cases, there were no complications relating to VAC therapy and it promoted rapid wound healing. Our results suggested that it is an effective treatment for APR in a high-risk case of an open perineal wound.

CONCLUSION

VAC therapy is a less invasive method and a useful treatment for open perineal wound of APR.

Uses of negative pressure wound therapy in orthopedic trauma

Negative pressure wound therapy (NPWT) is a useful management tool in the treatment of traumatic wounds and high-risk incisions after surgery. Since its development nearly 2 decades ago, uses and indications of NPWT have expanded, allowing its use in a variety of clinical scenarios. In addition to providing a brief summary on its mechanism of action, this article provides a focused, algorithmic approach on the use of NPWT by reviewing the available data, the appropriate clinical scenarios and indications, and the specific strategies that can be used to maximize outcomes.

Staging resection and reconstruction with temporary wound VAC coverage in a case of giant cystosarcoma phyllodes of the breast

•

We report a rare case of malignant cystosarcoma phyllodes invading the chest wall.

•

The patient presented with systemic toxicity and hematologic/electrolyte disarray.

•

Surgical resection and reconstruction were staged with temporary wound VAC coverage.

•

Definitive histopathologic tumor margins were assessed between procedures.

•

Adjuvant medical/radiotherapy were administered resulting in long-term remission.

Introduction

Cystosarcoma phyllodes (CP) is a rare breast tumor occurring most often in females in their fifth decade. While usually benign, some CP tumors exhibit aggressive growth patterns and extensively invade chest wall structures; resecting these tumors to negative surgical margins can be challenging. We present a case of malignant CP involving the chest wall where using a negative pressure vacuum-assisted closure (VAC) system after resection enabled complete histopathologic margin assessment prior to reconstruction. This is the first known report of staged breast tumor resection and reconstruction with interim VAC coverage.

Case presentation

A 48 year-old woman presented with rapidly increasing left breast size, fevers, and fatigue. On examination, the left breast was massively enlarged with engorged vessels and skin necrosis. Lab analyses revealed unusual metabolic abnormalities requiring preoperative hospitalization. We performed a left modified radical mastectomy with partial resection of pectoralis major and minor muscles, temporarily sealing the wound with a VAC due to concern for deeper tumor extension that could require further resection. Pathology revealed malignant CP with a negative deep margin. The 38 cm defect was then repaired with latissimus myocutaneous flap plus skin graft. At three-year follow up the patient remains free of disease.

Conclusion

In cases of malignant CP involving the chest wall, minimizing the extent of chest wall resection is critical for reducing morbidity, while completely clearing tumor margins is essential for reducing recurrence risk. Using temporary wound VAC coverage enables cautious debulking followed by histopathologic margin assessment prior to definitively reconstructing the breast.