Topical negative pressure effects on coronary blood flow in a sternal wound model

Several studies have suggested that mediastinitis is a strong predictor for poor long‐term survival after coronary artery bypass surgery (CABG). In those studies, several conventional wound‐healing techniques were used. Previously, we have shown no difference in long‐term survival between CABG patients with topical negative pressure (TNP)‐treated mediastinitis and CABG patients without mediastinitis. The present study was designed to elucidate if TNP, applied over the myocardium, resulted in an increase of the total amount of coronary blood flow. Six pigs underwent median sternotomy. The coronary blood flow was measured, before and after the application of TNP (?50 mmHg), using coronary electromagnetic flow meter probes. Analyses were performed before left anterior descending artery (LAD) occlusion (normal myocardium) and after 20 minutes of LAD occlusion (ischaemic myocardium). Normal myocardium: 171·3 ± 14·5 ml/minute before to 206·3 ± 17·6 ml/minute after TNP application, P < 0·05. Ischaemic myocardium: 133·7 ± 18·4 ml/minute before to 183·2 ± 18·9 ml/minute after TNP application, P < 0·05. TNP of ?50 mmHg applied over the LAD region induced a significant increase in the total coronary blood flow in both normal and ischaemic myocardium.     

Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds

Over the past two decades, topical negative pressure (TNP) wound therapy has gained wide acceptance as a genuine strategy in the treatment algorithm for a wide variety of acute and chronic wounds. Although extensive experimental and clinical evidence exists to support its use and despite the recent emergence of randomised control trials, its role and indications have yet to be fully determined. This article provides a qualitative overview of the published literature appertaining to the use of TNP therapy in the management of acute wounds by an international panel of experts using standard methods of appraisal. Particular focus is applied to the use of TNP for the open abdomen, sternal wounds, lower limb trauma, burns and tissue coverage with grafts and dermal substitutes. We provide evidence-based recommendations for indications and techniques in TNP wound therapy and, where studies are insufficient, consensus on best practice.     

Treatment of anticoagulated patients with negative pressure wound therapy

There is a paucity of evidence surrounding the use of negative pressure wound therapy (NPWT) in patients receiving anticoagulant medication. Guidelines generally recommend caution regarding the use of NPWT in anticoagulated patients in general, but areas of particular risk are frequently not highlighted. The US Food and Drug Authority (FDA) reported six mortalities between 2009 and 2011 in patients receiving NPWT. These mortalities were associated with the use of NPWT over vascular graft sites. The coagulation status of these patients was not reported. It is the authors' recommendation that guidelines regarding the use of NPWT in anticoagulated patients highlight specific clinical situations of risk, although there is insufficient evidence to support the avoidance of NPWT in anticoagulated patients in general.     

Topical negative pressure therapy: mechanisms and indications

Topical negative pressure (TNP) therapy has emerged as a high-technology, microprocessor-controlled physical wound-healing modality. Complex effects at the wound-dressing interface following application of a controlled vacuum force have been documented. These include changes on a microscopic, molecular level and on a macroscopic, tissue level: interstitial fluid flow and exudate management, oedema reduction, effects on wound perfusion, protease profiles, growth factor and cytokine expression and cellular activity, all leading to enhanced granulation tissue formation and improved wound-healing parameters. Primary indications for clinical use have been documented and include traumatic wounds, open abdominal wounds, infected sternotomy wounds, wound bed preparation, complex diabetic wounds and skin-graft fixation. Whilst this therapy now forms an essential part of the wound healing armamentarium, extensive clinical trials are recommended to confirm efficacy and delineate its optimum use.     

Rigenera protocol in the treatment of surgical wound dehiscence

The effective management of post‐operative wounds is important to prevent potential complications such as surgical‐site infections and wound dehiscence. The purpose of this study was to treat wound dehiscence in elderly patients who were subjected to orthopaedic surgical interventions. The dehisced wounds were treated with autologous micro‐grafts obtained using a promising CE‐certified medical device called Rigeneracons. This instrument is a biological disruptor of human tissues able to specifically select progenitor cells that, as already reported in previous studies, maintain high cell viability but mainly have a high regenerative potential, allowing the repair of damaged tissues. Autologous micro‐grafts obtained by Rigeneracons are ready to use and can be applied alone or in combination with biological scaffolds directly on the injured area. We observed in our patients a complete remission of dehisced wounds, on average, after 30 days from micro‐grafts application and a total wound re‐epithelialisation after 1 year from the surgical intervention. In conclusion, although we reported only three patients, autologous micro‐grafts can be considered a promising approach for the treatment of dehisced wounds, improving the wound‐healing process and in general the patient's quality of life without using other dressings.     

Topical negative pressure and military wounds—A review of the evidence

Background

Topical negative pressure (TNP) has been used as a method of wound management for some years. Use of TNP is accepted best practice at Role 4. There are advocates of using TNP after initial wound surgery at Role 3 or 2E. The evidence to support forward use of TNP is not comprehensive, especially when considering this narrow cohort of patients and injury pattern. It is the aim of this review to evaluate the current evidence for the use of TNP in all wounds, and to find what evidence there is that may be applicable to military wounds.

Methods

A literature search of Cinahl, Embase, Medline, ProQuest and the Cochrane Library was conducted; references were cross-referenced. All Randomised Controlled Trials (RCTs) were included in all languages over a comprehensive time period. An interim review was conducted by the Wound Management Working Group of the Academic Department of Military Surgery and Trauma. A further literature review was conducted to find all papers relating to the use of TNP on military wounds.

Results

17 reports were reviewed relating to 14 studies including 662 patients. Of these 131 were reported to have had traumatic injuries. Significant results were reported with respect to time to wound healing, patient comfort and reduction in wound volumes. Bacterial load was not affected, in the 3 trials which commented on this, but in 1 there was a significant reduction in wound infections in the TNP group. Several of the trials were small, methodology was not consistent therefore no meta-analysis was possible. 2 papers were found describing case series of military patients being treated with TNP.

Conclusions

There is very little published evidence in the form of RCTs to support the use of TNP in the acute traumatic military setting. This review supports the requirement for further investigation to evaluate whether this method of wound management has a place forward of Role 4.     

粘贴式负压冲吸器在治疗结直肠术后切口感染中的应用研究

目的 探讨应用粘贴式负压冲吸器治疗结直肠术后切口感染的效果.方法 将2010年1月-2011年11月南京军区福州总医院普通外科收治的48例结直肠手术后出现切口感染的患者,按照抽签随机分组的方法,随机分为实验组和对照组,实验组24例,采用粘贴式负压冲吸器治疗;对照组24例,采用传统处理方法治疗.对比2种方法的人均伤口处理时间、换药次数和换药总费用.结果 实验组自开始处理感染切口至二期缝合所需要的人均伤口处理时间(6.12±1.19)d短于对照组(8.54 ±2.98)d,差异有统计学意义(P＜0.05),人均换药次数[(1.44±0.51)次]明显少于对照组[(9.42±2.92)次],差异有统计学意义(P＜0.01),人均换药总费用也少于对照组,差异有统计学意义(P＜0.05).结论 应用粘贴式负压冲吸器治疗结直肠术后切口感染,能缩短伤口处理时间,减少了换药次数和换药总费用,具有较高的临床应用价值.     

Topical negative pressure coupled with split‐thickness skin grafting for the treatment of hidradenitis suppurativa: a case report

Hidradenitis suppurativa is a cutaneous, chronic, recurrent inflammatory disease. Here, we report the case of a 66‐year‐old man who had hidradenitis suppurativa in the buttocks. He suffered from diabetes mellitus. In the past, he had perianal abscesses. Because of improper treatment of furuncle infections in the buttocks, skin ulcers formed, which worsened and resulted in multiple fistulas. The skin lesion surface was large and the infection was severe. After wound debridement treatment, topical negative pressure and nutritional support were given. After one and a half months, the wound healed with split‐thickness skin grafting. In a 2‐year follow‐up, there was no evidence of hidradenitis suppurativa recurrence.     

Influence on pressure transduction when using different drainage techniques and wound fillers (foam and gauze) for negative pressure wound therapy

Pressure transduction to the wound bed in negative pressure wound therapy (NPWT) is crucial in stimulating the biological effects ultimately resulting in wound healing. In clinical practice, either foam or gauze is used as wound filler. Furthermore, two different drainage techniques are frequently employed. One involves the connection of a non‐perforated drainage tube to the top of the dressing, while the other involves the insertion of perforated drains into the dressing. The aim of this study was to examine the efficacy of these two different wound fillers and drainage systems on pressure transduction to the wound bed in a challenging wound (the sternotomy wound). Six pigs underwent median sternotomy. The wound was sealed for NPWT using different wound fillers (foam or gauze) and drainage techniques (see earlier). Pressures between 0 and ?175 mmHg were applied and the pressure in the wound was measured using saline‐filled catheters sutured to the bottom of the wound (over the anterior surface of the heart) and to the side of the wound (on the thoracic wall). The negative pressure on the wound bed increased linearly with the negative pressure delivered by the vacuum source. In a dry wound, the pressure transduction was similar when using the different wound fillers (foam and gauze) and drainage techniques. In a wet wound, pressure transduction was better when using a perforated drainage tube inserted into the wound filler than a non‐perforated drainage tube connected to the top of the dressing (?116 ± 1 versus ?73 ± 4 mmHg in the wound at a delivered pressure of ?125 mmHg for foam, P < 0·01), regardless of the type of wound filler. Gauze and foam are equally effective at delivering negative pressure to the wound bed. Perforated drainage tubes inserted into the wound filler are more efficient than a non‐perforated drainage tubes connected to the top of the dressing. The choice of drainage technique may be particularly important in wounds with a large volume of exudate.     

Initial multi‐centre observations upon the effect of a new topical negative pressure device upon patient and clinician experience and the treatment of wounds

Topical Negative Pressure (TNP) has become an accepted intervention in wound healing with a growing body of scientific literature supporting the effectiveness of TNP across a wide variety of wound aetiologies. The range of TNP devices has also increased with perhaps the primary distinction being between those TNP devices that employ gauze or foam as a wound dressing. This study reports preliminary multi‐centre observations upon the use of a new gauze based TNP device in the treatment of wounds. Across 3 study centres twenty‐nine subjects were recruited to the study with 8 presenting with leg ulcers, 8 with pressure ulcers, 12 with acute or surgical wounds and 1 with a non‐healing burn injury. Wounds were then treated with the new TNP therapy for a maximum of 17 days (range 2–17 days). There appeared to be a trend for subjects with leg ulcers to be treated for longer (mean duration 12.9 days) compared to subjects with pressure ulcers (mean duration 6.5 days) or those with surgical wounds (mean duration 8.2 days). Given the relatively short duration of the TNP therapy no wound completely healed although 22/29 (75.9%) showed reductions in surface area per day of treatment with all but 1 pressure ulcer and 1 leg ulcer responding positively to treatment. While not an RCT, this and similar cohort studies may be central to the future selection of TNP devices given the increasing importance of the role of the user interface to reduce the likelihood of incorrect use and sub‐optimal outcomes.     

The effectiveness of topical negative pressure in the treatment of pressure ulcers: a literature review

The objective of the study was to gain insight into the effectiveness of vacuum-assisted closure (VAC) therapy or, more particularly, topical negative pressure (TNP) in the treatment of pressure ulcers. We carried out a systematic search in Medline, Embase and Cinahl for Randomized Clinical Trials (RCTs) involving topical negative pressure in pressure ulcers over the period 1992–2007. Five RCTs were included. Two studies dealt exclusively with pressure ulcers. No significant differences in wound healing were found in these studies. Three other studies (mixed etiology of wounds) did show significant differences in wound healing, in the decrease of wound treatment time, and in the decrease in number of bacteria. The quality of these studies, both in terms of methodology and otherwise, did not always match with the scientific standard. Moreover, these studies lacked subgroup analyses. The analyzed studies described positive effects of TNP, although both the control treatment and the end points varied in these studies. On the basis of the systematic assessment of these five RCTs, the conclusion is that TNP has not proven to be more effective than various control interventions. The differences between and within the studies in terms of control interventions, the differences in randomization and a number of weaknesses in the analyses do not allow a good comparison. The main recommendations for follow-up studies include: randomization of patients rather than of wounds, a homogeneous patient population, the use of a single well-defined and procedurally documented control intervention, and prior calculation of the random sample size.     

Simple pectoralis major myocutaneous advancement flaps for closure after sternal wound dehiscence

Between October 1994 and March 1996, 14 consecutive patients with a wound dehiscence after median sternotomy for cardiac surgery were treated with pectoralis major myocutaneous advancement flaps. After thorough sternal wound debridement, the sternal edges were contoured to create a shallow defect. This was to enable the obliteration of dead space between the mediastinum and the flaps. The pectoralis muscle was then elevated off the chest wall, its humeral attachment, the thoraco-acromial pedicle and the connection with the skin were left intact. Next, the bilateral myocutaneous flaps were advanced medially and approximated to each other in the midline. The mean operation time was 140 min and the mean follow-up time was 10 months. Four patients developed minor complications. The advantage of this technique is its simplicity and the reduction in mean operation time. Received: 30 December 1999 / Accepted: 3 February 2000     

The influence of different sizes and types of wound fillers on wound contraction and tissue pressure during negative pressure wound therapy

Negative pressure wound therapy (NPWT) contracts the wound and alters the pressure in the tissue of the wound edge, which accelerates wound healing. The aim of this study was to examine the effect of the type (foam or gauze) and size (small or large) of wound filler for NPWT on wound contraction and tissue pressure. Negative pressures between --20 and --160 mmHg were applied to a peripheral porcine wound (n = 8). The pressure in the wound edge tissue was measured at distances of 0·1, 0·5, 1·0 and 2·0 cm from the wound edge and the wound diameter was determined. At 0·1 cm from the wound edge, the tissue pressure decreased when NPWT was applied, whereas at 0·5 cm it increased. Tissue pressure was not affected at 1·0 or 2·0 cm from the wound edge. The tissue pressure, at 0·5 cm from the wound edge, was greater when using a small foam than when using than a large foam. Wound contraction was greater when using a small foam than when using a large foam during NPWT. Gauze resulted in an intermediate wound contraction that was not affected by the size of the gauze filler. The use of a small foam to fill the wound causes considerable wound contraction and may thus be used when maximal mechanical stress and granulation tissue formation are desirable. Gauze or large amounts of foam result in less wound contraction which may be beneficial, for example when NPWT causes pain to the patient.     

An inexpensive method of negative pressure wound therapy for extremities

Negative pressure wound therapy (NPWT) is an established method for the faster wound healing of chronic non‐healing wounds. It is also used for laparostomy wounds and healing of split skin grafts. The commercially available machine and the consumables for NPWT are very expensive and economically not feasible in developing and underdeveloped countries. So, we devised a NPWT system for wounds of the extremity using inexpensive, readily available materials in any hospital. The materials used are sterile glove, autoclaved sponge, Foley catheter, and a wall suction unit. The sponge was placed over the wound, and a sterile glove was pulled over it. A Foley catheter was placed over the sponge and taken out through one of the fingers of the glove. Adhesive plaster was used to air‐seal the glove. The Foley catheter was fixed with silk ties and connected to wall suction. Granulation and wound healing was faster in this system. This system was safe and inexpensive for the treatment of wounds of the extremity.     

Factors affecting postmusculoskeletal tumour surgery wound problem treatment with negative pressure wound therapy

The aim of the study is to investigate the risk factors identified in literature that have been associated with prolonged Negative Pressure Wound Therapy (NPWT). Our study included patients who developed local wound problems after bone or soft tissue sarcoma surgery with negative margin at our clinic between 2012 and 2018 and treated with NPWT. All patients were followed up of at least 6 months. Sex, albumin level, skin infiltration, type of wound problem, postoperative intensive care unit (ICU) requirement, and intraoperative blood loss were found to be influential factors on NPWT > 10 sessions. We conclude that treatment may be prolonged and the necessary precautions need to be taken in patients with an impaired preoperative nutritional condition, with intraoperative high amount of blood loss, and with long postoperative stays in the ICU as well as if the underlying cause for wound problem is an infection.     

Management of a complex hind foot war injury with negative pressure wound therapy: A case study

We report the use of Negative Pressure Wound Therapy (NPWT) in a 39 year old patient with a complex open hind foot injury. The patient sustained an open calcaneal fracture with extensive soft tissue damage following the detonation of an explosively formed penetrating round in a confined space. A remarkable recovery was made following surgical debridement, internal fixation of the fracture and use of NPWT over the soft tissue injury. The patient returned to his normal level of function, without complications within a few months.     

In vitro optimisation of topical negative pressure regimens for angiogenesis into synthetic dermal replacements

BACKGROUND: The use of synthetic dermal replacements (SDRs) in the treatment of large wounds, which have associated morbidity and mortality, has attracted great interest. However, because of poor outcome, SDRs have limited use. The addition of topical negative pressure (TNP) has increased their success, but little research has focused on the underlying mechanisms. This paper studies the in vitro effects of TNP on commonly used SDRs to identify the most effective TNP regimen and optimum SDR for encouraging endothelial cell ingress. METHODS: Endothelial cells were co-cultured in vitro on four SDRs with or without TNP. Negative pressure (125mmHg) was applied intermittently, continuously, for 4h per day, or not at all. Endothelial ingress was measured for each condition. RESULTS: In the collagen controls, cell migration was minimal. Integratrade mark gave the greatest endothelial cell migration (p<0.05, n=3). TNP increased endothelial cell migration, intermittent application being the optimum regimen. CONCLUSIONS: Integratrade mark has an open sponge structure which may account for greater angiogenicity than Allodermtrade mark, Permacoltrade mark and Xenodermtrade mark. In vitro intermittent TNP stimulates the greatest angiogenic response. The majority of clinical studies investigating SDR success with TNP have used continuous regimens; this study suggests a change in clinical practice to intermittent application.     

Use of negative pressure wound therapy after infection and flap dehiscence in radical vulvectomy: A case report

IntroductionVulvar cancer has a lower incidence in high income countries, but is rising, in part, due to the high life expectancy in these societies. Radical vulvectomy is still the standard treatment in initial stages. Wound dehiscence contitututes one of the most common postoperative complications.Presentation of caseA 76 year old patient with a squamous cell carcinoma of the vulva, FIGO staged, IIIb is presented. Radical vulvectomy and bilateral inguinal lymph node dissection with lotus petal flaps reconstruction are performed as the first treatment. Wound infection and dehiscence of lotus petal flaps was seen postoperatively. Initial management consisted in antibiotics administration and removing necrotic tissue from surgical wound. After this initial treatment, negative wound pressure therapy was applied for 37 days with good results.DiscussionWound dehiscence in radical vulvectomy remains the most frequent complication in the treatment of vulvar cancer. The treatment of this complications is still challenging for most gynecologic oncologist surgeons.ConclusionThe utilization of the negative wound pressure therapy could contribute to reduce hospitalization and the direct and indirect costs of these complications.     

Quality of life and scar evolution after negative pressure or conventional therapy for wound dehiscence following post‐bariatric abdominoplasty

No studies have examined scars and quality of life after different treatments of wound dehiscence in patients undergoing post‐bariatric abdominoplasty. Scars and quality of life of patients with postoperative wound dehiscence managed with negative pressure wound therapy (group A) and conventional wound therapy (group B) were reviewed 6 months after wound healing. Of 38 patients undergoing treatment for wound dehiscence after 203 abdominoplasty, 35 (group A = 14 versus group B = 21) entered the study. Wound healing in group A was significantly faster than group B (P = 0·001). Patients (P = 0·0001) and observers (P = 0·0001) reported better overall opinions on a scar assessment scale for group A. Better overall quality of life and general health satisfaction were observed in group A (P < 0·05). A significant correlation was observed between the World Health Organization Quality of Life scores and Patient and Observer Scar Assessment Scale scores (r=−0·68, P < 0·0001) in all 35 patients. Negative pressure wound therapy is feasible and effective in patients with wound dehiscence following post‐bariatric abdominoplasty. An adequate post‐treatment outcome is achieved compared with conventional wound therapy in light of a strong association found between worse patient scar self‐assessment and poor overall quality of life, regardless of the received treatment.     

Management of negative pressure wound therapy in the treatment of diabetic foot ulcers

Diabetic foot (DF) is a common complication of diabetes and the first cause of hospital admission in diabetic patients. In recent years several guidelines have been proposed to reinforce the the management of DF with a notable increase in diabetes knowledge and an overall reduction of amputations. Significant improvements have been reached in the treatment of diabetic foot ulcers (DFUs) and nowadays clinicians have several advanced medications to apply for the best local therapy. Among these, negative pressure wound therapy (NPWT) is a useful adjunct in the management of chronic and complex wounds to promote healing and wound bed preparation for surgical procedures such as skin grafts and flap surgery. NPWT has shown remarkable results although its mechanisms of action are not completely understood. In this paper, we offer a complete overview of this medication and its implication in the clinical setting. We have examined literature related to NPWT concerning human, animal and in vitro studies, and we have summarized why, when and how we can use NPWT to treat DFUs. Further we have associated our clinical experience to scientific evidence in the field of diabetic foot to identify a defined strategy that could guide clinician in the use of NPWT approaching to DFUs.