Cite this article: Obrador LZ, Sanchez MS, Bernardos García LE, García-Ruano A, Fuentes FT (2017) Negative Pressure Therapy with Intermittent Instillation in Deep Wound Infection. Ann Emerg Surg 2(2): 1012.
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*Corresponding authorLeire Zarain Obrador, Department of General and Digestive Surgery, University Hospital Gregorio Marañón, calle Narváez nº7, 3º dcha, Madrid, Spain, Tel: 003-464-7144355; Email:
Negative Pressure Therapy with Intermittent Instillation in Deep Wound InfectionLeire Zarain Obrador*, Mercedes Sanz Sanchez, Luis Enrique Bernardos García, Angela García- Ruano, and Fernando Turégano FuentesDepartment of General and Digestive Surgery, University Hospital Gregorio Marañón, Spain
Abstract
Purpose: Negative Pressure Wound Therapy (NPWT) with intermittent instillation (VAC Veraflo®) is a complement and an effective alternative to surgery in the treatment of abdominal surgical wound dehiscence as a result of a deep infection.
Methods: This is a retrospective and descriptive study. We present the case of three patients, two men and one woman, who underwent abdominal surgery. They were first treated with antibiotics and traditional wound care, but given their torpid evolution, the VAC Veraflo® therapy was initiated.
Results: We present three patients with dehiscence of abdominal surgical wounds because of a deep wound infection with in situ infected prosthetic material -two synthetic meshes and an acelular matrix-, as well as a colostomy in two of the patients, where the VAC Veraflo® therapy was used successfully.
Conclusions: In our experience, despite the complexity of the cases presented here because of the existence of ostomies and infected prosthetic material, the VAC Veraflo® therapy has proved to be superior to conservative management of these complex wounds.
INTRODUCTIONDeep infection and dehiscence of an abdominal surgical
wound is a serious complication, which entails long lasting hospitalizations and prolonged treatments with broad-spectrum antibiotics, frequent wound cures and even emergency surgery sometimes. When fistula, ostomies and prosthetic meshes are associated, the management is even more complex. The healing process is affected by a variety of factors such as the age of the patient, the metabolic diseases, nutritional deficiencies and immuno suppression. It is a complex and dynamic process that involves a sequence of cell migration leading to repair and wound closure. This sequence begins with the removal of debris, followed by the infection control, the decreasing inflammation, angiogenesis, granulation tissue deposition, the shrinkage and remodeling of the connective tissue matrix as well as its maturation. If this sequence is altered, the result is a chronically open wound, without anatomical or functional integrity [1].
Negative pressure wound therapy (NPWT) with intermittent instillation (VAC Veraflo®) offers an alternative to surgery in surgical site infections with in situ prosthetic material, given the fact that it stimulates granulation, reduces bacterial load and has the effect of mechanical debridement. The recent addition of intermittent instillation of topical solutions magnifies such effects and eliminates the bacterial biofilm on prosthetic surfaces, which is why we decided to use NPWT with fluid instillation, since all the cases we present were prosthetic material (mesh) carriers. Up to
now, this therapy has been used successfully for the management of surgical infection with orthopedic prostheses, mainly knee and hip, but its application in abdominal surgical wounds is still an incipient one.
We present three patients with dehiscence of abdominal surgical wounds because of a deep wound infection with in situ infected prosthetic material -two synthetic meshes and an acelular matrix-, as well as a colostomy in two of the patients, where the VAC Veraflo® therapy was used successfully.
METHODSThis is a retrospective and descriptive study. We present the
case of three patients, two men and one woman, who underwent abdominal surgery. They were first treated with antibiotics and traditional wound care, but given their torpid evolution, the VAC Veraflo® therapy was initiated.
RESULTS
Case presentation 1
78 year old woman who underwent a single-port laparoscopic left hemicolectomy for colonic adenocarcinoma, stage IIB. Her past medical history included diabetes, dyslipidemia, vitiligo, and hypothyroidism. During the postoperative period she suffered an anastomotic dehiscence and deep wound infection, and a Hartmann’s procedure was carried out. A year later she was admitted for reconstruction of her GI tract and repair of
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an incisional hernia with a polipropilene mesh placed over the posterior fascia of rectus abdominis muscles. On the eleventh postoperative day a new anastomotic dehiscence was diagnosed, and a new Hartmann’s procedure was performed, together with closure of abdominal wall using a dual synthetic mesh (polipropilene + PTFE, Prim®); this was placed again over the posterior fascia of rectus abdominis muscles, given the fact that the patient presented with peritonitis at the moment of surgery and that she had already gone through a number of abdominal surgeries. Postoperatively she developed a deep wound infection with partial detachment of the mesh (Figure 1a) and some exposure of bowel. The culture results showed Staphylococcus aureus, enterococcus faecium and bacteroide uniformis. Given the torpid evolution of the wound with conservative management with antibiotics and conventional dressings, it was decided to start the VAC Veraflo® therapy (Figure 1b).
Dressing changes were performed every three days, placing a polyvinyl alcohol foam in contact with the mesh. Continuous negative pressure of 100 mmHg was applied, with instillation every 3 hours initially, then every 5 hours, and finally every 8 hours. During the first 3 days an instillation of 100 mg of tobramycin diluted in 500 cc of saline according to the antibiogram was used, followed by instillation of 100 cc of saline. The mesh was totally removed after 13 days of therapy since it was detached and not fulfilling its function. Two days later the device was removed, with complete resolution of the infection, as well as epithelialization and healing of the wound (Figure 1c).
Case presentation 2
81 year old man who underwent an abdominoperineal resection for a rectal adenocarcinoma, stage T3N2a. His past medical history included Parkinson´s disease, dyslipidemia, glaucoma, arthritis, and benign prostatic hyperplasia. On the fifteenth postoperative day he had an evisceration which was repaired with a synthetic mesh (Vicryl®) placed over the posterior fascia of rectus abdominis muscles. Five days later he developed a wound infection with partial dehiscence (Figure 2a) and, subsequently, infection and dehiscence of the perineal wound. The culture results were enterobacter aerogenes and staphylococcus aureus.
A conservative management was undertaken during six days, consisting of conventional dressings and systemic antibiotic
therapy, but with poor results. VAC Veraflo® therapy was then established with instillation of 30 ml of saline every 3 hours at a negative pressure of 100 mmHg, placing polyvinyl alcohol foam below the polyurethane sponge (Figure 2b). The VAC therapy was maintained for 26 days, the result being a small abdominal defect with granulation tissue in the wound bed that was managed by conventional dressings (Figure 2c).
Given the outcome of the VAC therapy, and after two months of conventional unsuccessful dressings of the infected perineal wound, another VAC was placed in on the perineum with a Y connection. It was removed one month later, once the wound was almost fully healed with only a small defect to cover; there was granulation tissue in the wound bed that could be managed with
Figure 1a Dehiscence of the suprainfraumbilical laparotomy wound and detachment of the dual synthetic mesh, with colostomy on the right flank.
Figure 1b The VAC Veraflo ® place.
Figure 1c Laparotomy wound healed after the VAC Veraflo ® therapy.
Figure 2a Dehiscence of the wound with a mesh on the wound bed and a colostomy on the right flank.
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conventional dressings until complete healing (Figure 2d).
Case presentation 3
A 75 year old man who underwent surgery for a giant midline abdominal hernia, a chronic ulcer in his abdomen, and an entero-cutaneous fistula (Figure 3a). His past medical history included hypertension, dyslipidemia, obesity, COPD, atrial fibrillation, multinodular goiter, and urethral stenosis. He had a surgical history of a right aortoiliac bypass and a left aortofemoral bypass for a ruptured aneurysm of the infrarenal aorta. During the hernia repair a bowel resection was performed, with placement of a biologic mesh (Strattice®). On the ninth postoperative day dermal necrosis was observed overlying the surgical wound, with exposure of the biological mesh (Figure 3b). The culture results showed escherichia coli and enterococcus sp. After conservative wound debridement, a VAC device was placed, with intermittent instillation of 10 ml of hypertonic saline every 3 hours, at a negative pressure of 100 mmHg. A polyvinyl alcohol sponge was placed in contact with the mesh. During VAC replacements further wound debridements were performed. After 36 days of VAC Veraflo® therapy, the instillation therapy was suspended and a negative pressure therapy established at 125 mmHg. Six weeks after initiation of NPWT the VAC device was removed, observing improvement and contraction of the wound, without slough or necrotic exudate, as well as increased granulation tissue on the bed of the wound. Abdominal defect coverage was subsequently performed with a split skin graft in order to cover the exposed biological mesh in the right paraumbilical region. The mesh did remain in situ (Figure 3c).
DISCUSSIONThe impact of surgical site infection (SSI) is of great importance
in terms of mortality, prolonged hospitalizations and costs. It has been shown that patients who develop SSI have longer and more expensive hospitalizations. Their mortality is double compared to patients without this complication. They have a 60% chance
Figure 2b VAC Veraflo® placement on the open wound.
Figure 3a Giant midline hernia and an entero-cutaneous fistula on the right flank.
Figure 3b Dermal necrosis on the surgical wound, with exposure of the biologic mesh.
Figure 3c Abdominal defect properly healed after 45 days of VAC therapy and a split skin graft.
Figure 2cd the abdominal and perineal wounds with progressive healing with the VAC Veraflo® therapy.
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of requiring admission to an ICU, and they are five times more likely to be readmitted at a hospital [2]. Therefore, all measures to prevent SSI and improve their management can make a significant reduction in morbidity and mortality, as well as the economic costs associated with this condition.
During normal healing process [3], a series of molecular actions allow the hemostasis, the removal of cellular debris, the cell proliferation, the angiogenesis, and development of a new extracellular matrix and the remodeling of the scar. The succession of these actions leads to the closure of the wound. Proper healing requires precise coordination and communication between various cells that produce a set of cytokines, growth factors and collagen.
Previous studies show that mechanical stress exerted on the wound could activate signal transduction and simulate cell proliferation. The study by Jacobs S. et al., shows that the negative pressure applied by the VAC stimulates the production of pro-angiogenic growth factors leading to enhanced angiogenesis and granulation tissue formation, accelerating healing [3].
Factors that affect wound healing can be divided into systemic and local [4]. Among the systemic factors we can find malnutrition, metabolic diseases, advanced age and immuno suppression. Among the local factors there are infection, edema, ischemia, topical medications, low oxygen levels because of vasoconstriction of the capillary bed in the area, excessive tension on the tissues and inadequate arterial supply.
Likewise, there are various factors that relate to the abdominal wound dehiscence [5]. Some of the most important risk factors are age greater than 65 years, male gender, tobacco, obesity, chronic steroid treatment, anemia, jaundice, uremia, diabetes, hypoalbuminemia, COPD, neoplastic diseases, wound infection and emergency surgery. Among the factors directly related to the surgery are the location of the incision, the technique and type of closure, the degree of postoperative hypothermia, oxygenation and blood supply. Of all these factors, the most decisive for the abdominal wound dehiscence is the SSI. It is associated with the flow of bacterial metaloproteinases and endotoxins – which stimulate the colagenases production-, which causes the degradation of collagen, the extension of the inflammatory condition and the fibroblast activation.
In the present study, the three patients had multiple risk factors for proper wound healing, also associated with an increased risk of surgical wound dehiscence.
The abdominal wound dehiscence related to deep infection is difficult to manage, particularly when associated to fistulas, ostomies or infected meshes, as in our cases. Because of the patient’s condition, surgery may not be feasible, leaving an “open abdomen” which requires complex wound care and extended hospital stays. NPWT is an option in the open abdomen: it stimulates granulation, reduces bacterial load and has the effect of mechanical debridement. The recent addition of intermittent instillation of topical solutions maximizes such effects and eliminates bacterial biofilm on prosthetic surfaces.
Despite the fact that randomized controlled trials should be conducted in order to establish the utility of this new system,
case series are important to report since RCT in these challenging cases are extremely difficult to conduct.
Since its approval by the FDA in 1995, the use of subatmospheric pressure for the care of wounds has expanded significantly in the last two decades [6]. Applying subatmospheric pressure to wounds can accelerate the rate of granulation tissue production. The rapid growth of granulation tissue allows a faster wound closure, either by secondary intention, or as a bridge to surgery for definitive wound closure [7].
The VAC device promotes wound healing through the following actions: - the elimination of third space edema, thus improving the supply of oxygen and nutrients to cells; - the removal of waste products by continuously applying negative pressure; - the reduction of bacterial colonization and promotion of granulation tissue; - promotion of angiogenesis and, finally, the evacuation of inhibitory wound factors [8].
In the study by Joseph E. et al., comparing traditional wound care with wet compresses against the use of VAC therapy, it was observed that the most significant difference between them was the change in depth of the wound in 66% of patients treated with VAC therapy versus 20% of patients being treated with traditional dressings [1]. Histological differences were also observed: in 81% of patients treated with traditional wound care both inflammation and fibrosis were observed, while the main feature in the group treated with VAC therapy was the formation of granulation tissue in 64 % of cases [1]. This study also demonstrates a shorter hospital stay and a more favorable outcome of patients treated with VAC therapy by reducing the healing time of their wounds compared to patients treated with conventional cures.
Some groups have analyzed as well the effectiveness and efficiency of commercial negative pressure systems against “home-made” negative pressure devices (Barker´s technique) in the management of the open abdomen, and they have observed a much higher success rate with commercial devices. The conclusion would be then that the higher cost involving commercial devices is offset by better results and the economic savings related to a successful closure of the abdominal wall [9].
The instillation improves the wound healing process since it combines the advantages of topic solutions for treating wounds with the benefits of negative pressure therapy. The VAC Veraflo® device offers the possibility of scheduling a retention time as well as the automatic volumetric administration, and it differs therefore from other systems available on the market that provide instillation solutions with a continuous flow (without hold time). This treatment also differs in the use of specifically designed dressings that are less hydrophobic than the current VAC Ganu Foam® dressings, which provide a better distribution and the subsequent removal of fluid from the wound bed.
In the clinical cases presented, NPWT with intermittent instillation was employed by using the VAC Veraflo® device. Under the polyurethane foam sponge, another sponge of polyvinyl alcohol was placed in contact with the mesh. The reason for placing this sponge of polyvinyl alcohol was the presence of intra-abdominal viscera under the mesh used for the abdominal wall reconstruction, thus avoiding direct contact of viscera with
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Obrador LZ, Sanchez MS, Bernardos García LE, García-Ruano A, Fuentes FT (2017) Negative Pressure Therapy with Intermittent Instillation in Deep Wound Infection. Ann Emerg Surg 2(2): 1012.
Cite this article
the polyurethane foam. In the first case described the mesh was partly unanchored, which conditioned increased exposure of intra-abdominal organs. In the third case the prosthesis used was a biological mesh (Strattice®), meaning a more complex management in case of deep wound infection. A continuous negative pressure of 100 mmHg was used, with periodical saline instillation throughout the day. In one of the cases, an antibiotic therapy diluted in saline according to the antibiogram results was instilled during the first 3 days, followed by instillation of 100 cc of saline.
As detailed in the description of the cases, the duration of the VAC therapy in our patients (15, 26, and 45 days, respectively), exceeded in two of them the 3 weeks initially recommended.
The indications for VAC therapy at the time of its approval by the FDA in 1995 did not include abdominal dehiscent wounds, and in fact its use in these cases is still incipient, especially in complex circumstances as described herein, given the comorbidity of patients as well as the presence of synthetic mesh in the first two cases, and an acellular matrix in the third. The first two patients also had ostomies adjacent to the abdominal wound, which was an added difficulty. Given the failure of conservative treatment, it was decided to use the VAC Veraflo® therapy. It was thus possible to avoid surgical treatment, not recommended given the comorbidity of these patients and their hemodynamic status. Infection control and a faster healing were achieved, as well as a more comfort for the patients and reduction of hospital stay.
Despite the economic cost of this therapy, this reduction of hospital stay and the improved results compared to those of conventional cures and “home-made” negative pressure devices, make the VAC Veraflo® therapy cost-effective.
When faced with complex cases such as dehiscent abdominal surgical wounds in relation with deep wound infection, with presence of prosthesis, it is important to individualize each case and work with different services in a multidisciplinary approach. The Plastic and Reconstructive Surgery Service of our hospital was directly involved in the care of the patients.
CONCLUSION NPWT with intermittent instillation (VAC Veraflo®) is a
complement and an effective alternative to surgery in the treatment of abdominal surgical wound dehiscence as a result
of a deep infection. In our experience, despite the complexity of the cases presented here because of the presence of stomas and infected prosthetic material, the VAC Veraflo® therapy has proved to be successful in allowing us to maintain both synthetic and biological meshes, avoiding surgery in these high-risk patients. Undoubtedly, management must be individualized and multidisciplinary.
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