Effectiveness of negative pressure wound therapy in complex surgical treatment of necrotizing fasciitis of the upper limb

BACKGROUND Necrotizing fasciitis(NF)of the upper extremities is a severe surgical pathology,and the incidence of this disease has been steadily increasing in recent decades.Surgical treatment is accompanied by the formation of extensive wounds,which can be treated with significant difficulties.In recent years,negative pressure wound therapy(NPWT)has proven to be highly effective.It is also promising for the treatment of NF.AIM To explore the effectiveness of NPWT in the treatment of NF of the upper extremities.METHODS The results of the treatment of 36 patients with NF of the upper extremities in two groups(NPWT group and control group;2022−2023)were retrospectively analyzed.In the NPWT group,the NPWT method(120 mmHg;constant mode)was used after surgical treatment.The number of vacuum-assisted dressings in patients ranged from 1 to 3,depending on the dynamics of the wound process.The duration of fixation of one bandage was up to 2−3 d.In the control group,conventional methods of local wound treatment were used.The following indicators were analyzed:The treatment delay,the prevalence of inflammation,the microbial landscape,the number of debridements,the duration of wound preparation for surgical closure,and the nature of skin plastic surgery.RESULTS Most patients experienced a significant treatment delay[4 d,interquartile range(IQR):2–7 d],which led to the spread of the pathological process to the forearm and shoulder.The most common pathogens were Staphylococcus aureus(14;38.9%)and Streptococcus pyogenes(22;61.1%).The average number of debridements per patient was 5(IQR:3–7),with no difference between groups.The average time to prepare wounds for surgical closure was 11±4 d in the NPWT group and 29±10 d(P=0.00001)in the control group.In the NPWT group,the wounds were more often closed with local tissues(15;83.3%),and in the control group,split-thickness skin grafts were more often used(4;50%).CONCLUSION The predominant isolation of Staphylococcus aureus and/or Streptococcus pyogenes from the lesions allowed us to classify these patients as NF type II.Multiple debridement procedures have become a feature of this disease treatment.The use of NPWT has significantly reduced the time required to prepare wounds for surgical closure.Early closure of wounds allows for more frequent use of local tissue repair,which ensures better results.NPWT is a highly effective way to prepare wounds for early surgical closure in patients with upper extremity NF.

Devastating complication of negative pressure wound therapy after deep inferior epigastric perforator free flap surgery:A case report

BACKGROUND Thermal injuries on free transferred or replanted tissues resulting from loss of sensibility are an infrequent occurrence.They require immediate and appropriate management before they progress to an irreversible condition.Although negative pressure wound therapy(NPWT)can prevent wound progression by increasing microcirculation,the inappropriate application of NPWT on complicationthreatened transferred and replanted tissues can induce an adverse effect.CASE SUMMARY A 48-year-old woman who underwent immediate breast reconstruction with a deep inferior epigastric artery perforator free flap.While applying a heating pad directly to the flap site,she sustained a deep second to third-degree contact burn over 30%of the transferred flap on postoperative 7 d.As the necrotic changes had progressed,we applied an NPWT dressing over the burned area after en-bloc debridement of the transferred tissues on postoperative 21 d.After 4 d of NPWT application,the exposed fatty tissues of the flap changed to dry and browncolored necrotic tissues.Upon further debridement,we noted that the wound gradually reached total necrosis with a collapsed vascular pedicle of deep inferior epigastric artery.CONCLUSION Although NPWT has been shown to be successful for treating various wound types,the significant risk of NPWT application in short-lasting reconstructed flap wounds after thermal injury should be reminded.

Application of negative pressure wound therapy after skin grafting in the treatment of skin cancer:A case report

BACKGROUND Skin cancer is a common malignant tumor in dermatology.A large area must be excised to ensure a negative incisal margin on huge frontotemporal skin cancer,and it is difficult to treat the wound.In the past,treatment with skin grafting and pressure dressing was easy to cause complications such as wound infections,subcutaneous effusion,skin necrosis,and contracture.Negative pressure wound therapy(NPWT)has been applied to treat huge frontotemporal skin cancer.CASE SUMMARY Herein,we report the case of a 92-year-old woman with huge frontotemporal skin cancer.The patient presented to the surgery department complaining of ruptured bleeding and pain in a right frontal mass.The tumor was pathologically diagnosed as highly differentiated squamous cell carcinoma.The patient underwent skin cancer surgery and skin grafting,after which NPWT was used.She did not experience a relapse during the three-year follow-up period.CONCLUSION NPWT is of great clinical value in the postoperative treatment of skin cancer.It is not only inexpensive but also can effectively reduce the risk of surgical effusion,infection,and flap necrosis.

Utilizing Instilling Negative Pressure Wound Therapy with Vashe Wound Solution for an Infected Sternal Dehiscence: A Case Report

Utilization of negative pressure wound therapy with instillation (NPWTi) for sternal dehiscence wounds secondary to sternal wound infection after surgery has become an accepted therapy. NPWTi accelerates wound healing through macrostrain, microstrain, and cyclic fluid instillation. Wounds benefit from additional superficial infection control with the removal of microorganisms, the release of proinflammatory mediators, stimulation of angiogenesis, as well as mechanical debridement. However, very few cases of utilizing NPWTi in the treatment of sternal wound infections have been reported in the literature. This case study describes the use of NPWTi with hypochlorous acid for the treatment of a sternal wound infection.

Pre-placement of adhesive tape around wound sites can prevent air leakage in negative pressure wound therapy procedures

The introduction of negative pressure wound therapy has revolutionized the management of complicated wounds.However,the maintenance of an effective negative pressure environment is difficult in some instances,such as wounds in close proximity to an intestinal stoma or wounds surrounded by external fixations.We found that adhesive tape adheres more easily to itself than to wet skin or uneven surfaces.Therefore,we placed adhesive tape around surgical wounds prior to covering them with foam and sealing them with more tape.As a result of the strong adhesive force between pieces of tape,this method could provide a better environmental seal,even in situations where space is limited.Pre-placed adhesive tape around the wound site prior to foam placement could provide sufficient adhesion to maintain a continuous negative pressure environment during treatment.

Incisional Negative Pressure Wound Therapy in the Prevention of Surgical Site Infection after Vascular Surgery with Inguinal Incisions: Rationale and Design of a Randomized Controlled Trial (INVIPS-Trial)

Background/Aims: Inguinal incisions are a common route of access in vascular surgery. Due to anatomical challenges and a diverse bacterial flora in this area, surgical site infections (SSI) represent a common, debilitating and sometimes life-threatening complication. The INVIPS-Trial evaluates the role of Negative Pressure Wound Therapy (NPWT) on closed inguinal incisions in elective vascular surgery to prevent SSI and other wound complications. Methods: This randomized controlled trial (RCT) registered at ClinicalTrials.gov (Identifier: NCT01913132) compares the effects of a NPWT dressing (PICO, Smith & Nephew, UK) and the center’s standard wound dressing (Vitri Pad, ViTri Medical, Sweden) on postoperative wound complications, especially SSI. The study includes two distinct vascular procedures with different SSI risk profiles: endovascular aortic repair (EVAR) and open surgical approaches involving the common femoral artery (OPEN). Results: Four hundred ninety-five groin incisions in both treatment arms are anticipated to be included in the EVAR group and 147 inguinal incisions in both treatment arms in the OPEN group. Since a large percentage of inguinal vascular procedures in both groups but especially in the EVAR group are performed bilaterally, many patients can serve as their own control by randomly receiving NPWT on one and the standard dressing on the contralateral inguinal incision. Conclusions: This ongoing RCT attempts to elucidate the potential benefit of NPWT on closed inguinal incisions after different vascular procedures. Outcome and conclusions of this trial could have implications on postoperative wound care of patients in both vascular surgery and other surgical specialties.

Management of Complex Wounds with Dermal Substitute Assisted by a Negative Pressure System

Introduction: The standard treatment for complex wound care is autografting. The advent of dermal substitutes has provided a novel tool for the preparation of the bed to be grafted. However, most types of dermal matrices require the application of a skin graft a second time. Currently, other strategies have been developed to improve the vascularization process, such as negative pressure wound therapy (NPWT), which has been reported to reduce the time required for vascular growth and dermal matrix integration and thus achieve a shorter waiting period for autologous graft application. The present study aims to evaluate the effectiveness and safety of dermal matrix management associated with NPWT in the treatment of complex wounds. Methods: Seven patients with a diagnosis of complex wounds were enrolled in this study between July 1, 2015, and June 31, 2016. After debridement and having an adequate wound bed, patients who met the criteria for the application of combined therapy were treated with dermal substitutes and a negative pressure system. The percentage of graft integration into the wound bed, complications, length of hospital stay, and duration of therapy were analyzed. Results: The mean age was 42.5 ± 16 (39 - 54) years old;three women and four men were included in the study. The approximate size of skin loss was 120.7 ± 75 cm2 (25 - 250 cm2). The combined therapy of dermal matrix plus NPWT was instituted in all cases for a period of 14 days. There were no complications, with 100% graft integration in 6 of 7 cases. Patients were discharged after a mean hospital stay of 5.4 days. Conclusions: This study demonstrates that the utilization of combined dermal matrix plus NPWT therapy can be performed safely and effectively in patients with complex wounds with low complication rates and a short hospital stay.

Consensus on the application of negative pressure wound therapy of diabetic foot wounds

Because China is becoming an aging society,the incidence of diabetes and diabetic foot have been increasing.Diabetic foot has become one of the main health-related killers due to its high disability and mortality rates.Negative pressure wound therapy(NPWT)is one of the most effective techniques for the treatment of diabetic foot wounds and great progress,both in terms of research and its clinical application,has been made in the last 20 years of its development.However,due to the complex pathogenesis and management of diabetic foot,irregular application of NPWT often leads to complications,such as infection,bleeding and necrosis,that seriously affect its treatment outcomes.In 2020,under the leadership of Burns,Trauma and Tissue Repair Committee of the Cross-Straits Medicine Exchange Association,the writing group for‘Consensus on the application of negative pressure wound therapy of diabetic foot wounds’was established with the participation of scholars from the specialized areas of burns,endocrinology,vascular surgery,orthopedics and wound repair.Drawing on evidence-based practice suggested by the latest clinical research,this consensus proposes the best clinical practice guidelines for the application and prognostic evaluation of NPWT for diabetic foot.The consensus aims to support the formation of standardized treatment schemes that clinicians can refer to when treating cases of diabetic foot.

Consensus on the health education of home-based negative pressure wound therapy for patients with chronic wounds:a modified Delphi study

Background:The study aimed to develop consensus on the components of health education of home-based negative pressure wound therapy(NPWT)for patients with chronic wounds.Methods:A Delphi method was used to achieve consensus on the components of health education and 75%agreement and coefficient of variation(CV)<0.25 were used as cutoff.Sixteen experts were recruited purposefully to finish this study.Results:Two rounds of consultation were implemented.Consensus was achieved on 36 of the 42 statements.The final agreed list of statements represented three domains:health education before carrying out home-based NPWT,health education for the treatment day of NPWT at hospital and health education for NPWT at home.Conclusions:This study was the first attempt to develop consensus on the comprehensive components of health education of home-based NPWT for patients with chronic wounds.According to the established framework and components of health education,wound professionals can safely and effectively implement health education of home-based NPWT for patients with chronic wounds and improve their self-care ability and treatment experience at home.

Preliminary evidence using negative pressure wound therapy to achieve limb salvage for the ischemic diabetic foot

Aim:Negative pressure wound therapy(NPWT)in diabetic foot ulcers(DFU)has been discussed in several studies,but without a focus on peripheral arterial disease(PAD),which is a common comorbidity.This study aims to investigate the feasibility of NPWT in the treatment of DFU with PAD in regards to limb salvage and the clinical course.Methods:The authors retrospectively collected patients with DFU and PAD diagnosed with either Doppler ultrasound or angiography as the PAD study group.Patients with DFU but no PAD were enrolled as the non-PAD comparison group.NPWT was applied to both PAD and non-PAD subjects.Results:There were 10 patients in the PAD group and 3 patients in the non-PAD group.In the PAD group,there was a 70%limb salvage rate with 14.70(±10.33)treatment days.The non-PAD comparison group had a higher limb salvage rate(100%vs.70%,respectively),but a longer treatment time(30.00 vs.14.70 days,P<0.05,respectively)when compared to the PAD group.The 3 patients in the PAD group who failed limb salvage all had issues related to uncontrolled infection.Conclusion:NPWT is a feasible adjuvant therapy for DFU in patients with PAD,with a 70%limb salvage rate.Prolonged treatment time was due to the initial severity of the subjects with multiple comorbidities.The main reason for limb loss was intractable infection.

Use of negative pressure wound therapy in pediatric oncology patients:a single-center review of 66 patients

Aim:Negative pressure wound therapy(NPWT)has been studied extensively in adult patients,but less is known about pediatric patients.This study assesses the efficacy and safety of vacuum-assisted closure®usage in pediatric oncology patients.Methods:Retrospective data on all patients treated with NPWT at a single pediatric oncology hospital were collected between April 2005 and September 2013.Details on pre-treatment factors,treatment course,and post-treatment events were collected.No control group was available for comparison.Results:Sixty-six patients were identified,with a total of 74 wounds.Median age at the time of NPWT application was 13 years(range,10 months-23 years).Median duration of treatment was 21 days(range,3-236 days).NPWT therapy was started with continuous high negative pressures(125 mmHg)in most patients.Sixty-nine percent of patients had their wounds healed without intervention,and 20%of patients required surgical closure.NPWT was discontinued temporarily secondary to skin maceration or cellulitis in 12%of patients.NPWT was used in a number of non-standard clinical situations,including primarily-closed incisional wound NPWT and bridging NPWT through adjuvant chemotherapy.Conclusion:In pediatric oncology patients,NPWT is safe,effective,and well-tolerated.Although this study is retrospective in nature,and there was no control group for comparison,these data are important for clinicians to guide therapy as device monitoring agencies and payors increasingly require outcomes data for the approval of therapeutic decisions.

A Control System Design to Establish Dose-Response Relationships in Wound Healing Therapy

Advanced biophysical wound healing therapies can apply mechanical, electrical, or light energy to re-stimulate healing processes in chronic wounds. Despite the growing evidence of the clinical efficacy of these therapies, the optimal treatment stimulation parameters remain unknown and there are no standard treatment protocols. We introduce a closed-loop control design as an experimental system to study the dose-response of wound healing therapy treatment within a prescribed multidimensional and multimodal stimulation parameter space. Systems engineering approaches are applied to the control problem for estimation of a transfer function and model equations derived for use in optimal model-based control. The experimental control system design consisted of simultaneous application of biophysical energies inputted into a wound system. A study design set up including the use of negative pressure wound therapy, electrical stimulation therapy, and photobiomodulation device systems was described. Treatment stimulation parameters were selected from experimental ranges used in the scientific literature. Classical control methods and model-based control were suggested for model selection and evaluation and design of the overall control system. An experimental design for multimodal biophysical wound healing therapy control system is introduced to establish the dose-response interactions for development of therapeutic applications and device design.

Histopathological study of chronic wounds modulated by intermittent negative pressure therapy under limited access dressing

Aim:Negative pressure wound therapy(NPWT)has achieved widespread success in the treatment of chronic wounds.However,its effects have been only partially explored,and investigations have generally concentrated on the wound-dressing interface;a detailed histopathological description of the evolution of wounds under NPWT is still lacking.The present study was performed to investigate the effect of a limited access dressing(LAD)which exerts intermittent NPWT in a moist environment on chronic wounds.Methods:A total of 140 patients were randomized into 2 groups:LAD group(n=64)and conventional dressing group(n=76).By histopathological analysis of the granulation tissue,the amount of inflammatory infiltrate,necrotic tissue,angiogenesis,and extracellular matrix(ECM)deposition was studied and compared to determine healing between the 2 groups.Results:After 10 days of treatment,histopathological analysis showed a significant decrease in necrotic tissue with LAD compared to the conventional dressing group(mean±standard error,11.5±0.48 vs.10.1±0.30,P=0.007),the number of inflammatory cells(12.6±0.60 vs.8.63±0.35,P=0.018),a significant increase in new blood vessels(12.8±0.58 vs.9.3±0.29,P=0.005)and ECM deposit(13.3±0.50 vs.9.6±0.24,P=0.001).Conclusion:LAD exerts its beneficial effects on chronic wound healing by decreasing the amount of necrotic tissue and inflammatory cells while increasing the amount of ECM deposition and angiogenesis.

The Use of the V.A.C. RX-4 for Multiple Soft Tissue Wound Application in the Single Patient: A Case Report

Contact burn injuries account for a considerable proportion of admissions that frequently require debridement. Such debridements of these multiple open wounds might benefit from the application of negative pressure wound therapy (NPWT) for the removal of proinflammatory mediators and to promote granulation tissue with macrostrain and microstrain. Having four or more Vacuum Assist Closure (V.A.C.) Ulta devices connected to the same patient for adequate wound coverage is cumbersome in the management of the patient’s wound care and tethers the patient to the bed. The V.A.C. RX-4 is a multichannel device that can deliver NPWT with a smaller footprint. In addition, the V.A.C. RX-4 has a weight of 16 lbs. versus one V.A.C Ulta which is 7.4 lbs. Therefore, collectively, four V.A.C. Ultas would equal 29.6 lbs. or almost double the weight of a single V.A.C. RX-4. Use of the V.A.C. RX-4 by healthcare providers can mean greater mobility for the patient and easier transport between patient destinations within the hospital. This case report demonstrates the utility of the V.A.C. RX-4 for open and freshly debrided, large soft tissue wounds in a burn patient.

Strategies and challenges in the treatment of chronic venous leg ulcers

Evaluating patients with chronic venous leg ulcers(CVLUs)is essential to find the underlying etiology.The basic tenets in managing CVLUs are to remove the etiological causes,to address systemic and metabolic conditions,to examine the ulcers and artery pulses,and to control wound infection with debridement and eliminating excessive pressure on the wound.The first-line treatments of CVLUs remain wound care,debridement,bed rest with leg elevation,and compression.Evidence to support the efficacy of silver-based dressings in healing CVLUs is unavailable.Hydrogen peroxide is harmful to the growth of granulation tissue in the wound.Surgery options include a high ligation with or without stripping or ablation of the GSVs depending on venous reflux or insufficiency.Yet,not all CVLUs are candidates for surgical treatment because of comorbidities.When standard care of wound for 4 wk failed to heal CVLUs effectively,use of advanced wound care should be considered based on the available evidence.Negative pressure wound therapy facilitates granulation tissue development,thereby helping closure of CVLUs.Autologous split-thickness skin grafting is still the gold standard approach to close huge CVLUs.Hair punch graft appears to have a better result than traditional hairless punch graft for CVLUs.Application of adipose tissue or placenta-derived mesenchymal stem cells is a promising therapy for wound healing.Autologous platelet-rich plasma provides an alternative strategy for surgery for safe and natural healing of the ulcer.The confirmative efficacy of current advanced ulcer therapies needs more robust evidence.

Management protocol for Fournier’s gangrene in sanitary regime caused by SARS-CoV-2 pandemic:A case report

BACKGROUND Fournier's gangrene(FG)is a serious,aggressive and often deadly polymicrobial infection of the soft tissues of the perineum,the rectum and the external genital organs.It is an anatomical subcategory of necrotizing fasciitis,which has a similar etiology and treatment strategy.CASE SUMMARY A 60-year-old man was admitted to the hospital during severe acute respiratory syndrome coronavirus 2 pandemic with complaints of fever up to 38.9°C,abdominal pain,and edema of the scrotum,the penis,the perineum,and the right gluteal region for 2 d.Computed tomography of the abdomen and the pelvis revealed extensive inflammatory infiltrations of the subcutaneous tissue of the hypogastrium,and the penis;along with liquefaction and presence of gas in the subcutaneous tissues of the scrotum,the perineum,and the right gluteal region.The patient was diagnosed with FG,and was urgently qualified to undergo surgery in the Department of Urology.After performing the necessary examinations,a resection of the necrotic tissues with bilateral orchiectomy and excision of the penile and scrotal skin was performed.After surgery,he was transferred to the intensive care unit for further management.CONCLUSION Early management prevents the resection of the other organs by inhibiting the contiguous spread of infection.

Endoscopic vacuum assisted closure of esophagogastric anastomosis dehiscence:A case report

BACKGROUND Esophagogastric leakage is one of the most severe postoperative complications.Partial disruption of the anastomosis,can be successfully treated with an endoscopic vacuum assisted closure(E-VAC).The advantage of that method of treatment is the ability to adjust a vacuum dressing individually to the size of the dehiscence and thus to reduce the risk of a secondary fistula or abscess.The authors present two patients with postoperative gastroesophageal leakage treated successfully with E-VAC.CASE SUMMARY Two male patients developed a potentially life threatening esophagogastric leakage.Patient A underwent resection of the distal half of the esophagus and upper part of the stomach due to Siewert type II adenocarcinoma of the gastroesophageal junction.Proximal resection of the stomach was performed in the patient B after massive bleeding from Mallory-Weiss tears.Both patients were treated successfully with an individually adapted E-VAC with concomitant correction of fluid and electrolyte disturbances,and treatment of sepsis with appropriate antibiotics.CONCLUSION Endoscopic vacuum closure is an effective alternative to endoscopic stenting or relaparotomy.Through individual approach it allows a more accurate assessment of healing.

Effect of limited access dressing on surface pH of chronic wounds

Aim:Changes in the pH of chronic wounds can inhibit the optimal activity of various enzymes in the wound environment,thereby delaying wound healing.The aim of the present study is to monitor the effect of limited access dressing(LAD)on the pH on the surface of chronic wounds.Methods:A total of 140 patients with chronic wounds of more than 4 weeks duration were divided into two groups by simple randomization:a LAD group(n=64)and a conventional dressing group(n=76).Fifty-six participants(22 in the LAD group and 34 in the conventional dressing group)were lost to follow-up or withdrawn from the study.Results:In the LAD group(n=42),the mean age was 38.3±10.56 years(range:12-60 years),and the mean wound size at the time of admission was 28 cm^(2)(range:19-40 cm^(2)).In the conventional dressing group(n=42),the mean age was 35.3±14.0 years(range:17-65 years),and the mean wound size at the time of admission was 26 cm^(2)(range:18-39 cm^(2)).Patients treated with LAD showed a significant decrease in the mean±standard deviation pH when compared with the conventional dressing group(0.83±0.52 vs.0.41±0.26,P=0.048).Conclusion:LAD reduces the chronic wound surface pH to a level required for the optimal function of various enzymes.This could be a factor that exerts a beneficial effect on wound healing.