Ha s It Ma d e a Re v o l u t i o n in Wo u n d

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1 Al-Shaham AAH, Negative Pressure Wound Therapy Ne g a t i v e Pr e s s u r e Wo u n d Th e r a p y: Ha s It Ma d e a Re v o l u t i o n in Wo u n d Ma n a g e m e n t? *Ali Abbas Hadi Al-Shaham MB.ChB, DSB, CABS Associate Prof and Senior Consultant Plastic Surgeon *Hussein Raad Saadi MB.ChB., DCH, M.Sc.CH, Student, Doctorate of Public Health *Serene Ali Al-Shaham MB.ChB Student, Masters in Family Medicine, UM * Mustafa Jerjess MB.ChB, FIBMS Lecture in Anaesthesiology * Faculty of Medicine Universiti Teknologi MARA Shah Alam, Selangor, Malaysia abstract Conflict of interest: None Negative pressure if applied in topical manner to a wound surface has been reported to enhance wound healing due to increase in local blood flow, reduction of tissue oedema, and by stimulating angiogenesis. An air-tight film covering the wound is connected by suction tube to a control unit by which negative pressure is applied to the surface of the wound in the range of mm Hg. This method has been called negative pressure wound therapy () or vacuum assisted closure (VAC). It has been recommended for virtually all kinds of complex wounds. The duration of the therapy varies from several days to several months. This technology promotes formation of granulation tissue, enhances healing of diabetic foot, and significantly reduces the size of the acute and chronic wounds and ulcers. It lowers the morbidity of Fournier s gangrene, ensures better healing of lower limb wounds and ulcer of ischemic origin, 3

2 Med & Health Rev 2009;1(2):3-14 and can serve as temporary wound cover when no closure technique is available. The limitations to using are presence of dead tissue, exposed vital structures, untreated osteomyelitis, unexplored fistulae and malignant wounds. The cost of the equipment may constitute another factor in limiting the use of this new technology. In conclusion the under certain circumstances is more effective than other available local wound treatments. Keywords: vacuum assisted closure, negative-pressure wound therapy, wound healing. Introduction Patients with massive complex wounds constitute a major therapeutic challenge. Successful management is based on the knowledge of wound pathology as well as adequate skill and expertise of the health care provider. However different kinds of wound care products also have a role in enhancing wound healing process. Clinical randomized controlled trials comparing different wound care products are scarce. The technique of using negative pressure for open wounds was developed in Germany and the United States during the 1990s 1-3 under the name of Vacuum Assisted Closure (VAC) or Negative Pressure Wound Therapy () respectively. applied to a wound surface has many objectives. The following micro and macro-mechanisms are presently valid: increasing local blood flow, reducing oedema, stimulating angiogenesis and hence the formation of granulation tissue, stimulating cell proliferation, reducing cytokines and matrix, reducing bacterial load and reducing the wound size and volume. However, the exact mechanism by which promotes wound closure is not yet fully understood. 4 has been recommended for virtually all kinds of acute and chronic wounds to promote formation of granulation tissue and to accelerate healing in pressure wounds, diabetic leg ulcers, lower 4

3 Al-Shaham AAH, Negative Pressure Wound Therapy leg wounds, surgical wound dehiscence, traumatic wounds, burns, infected wounds, necrotizing fascitis, infected sternal wounds, 5 osteomyelitis, 6 and complex head and neck wounds. 7 The duration of the therapy varies from a few days to months, depending on the treatment aim and the nature of the wound. The aim of this review was to gather the most reliable evidence available on the effectiveness, safety and limitations of in the treatment of acute and chronic wounds. Table 1 lists the major studies that describe the effectiveness and safety of. Many surgeons have considered this new technology as revolution in the wound management protocols. Is it? Table 1: Summary for the uses and effectiveness of the negative pressure wound therapy No. Year Number Authors Wanner Ford Stannard Iianose Armstrong Eto Z Disease studied Decubitus ulcer Decubitus ulcer Soft tissue loss Skin graft to soft tissue lost Diabetic foot ulcer who need amputation Diabetic foot Ulcer 5 Methods Comparative versus Gel products Comparative versus Gel products Effect of on wound exudates Measuring the graft loss in cm2 Comparing versus moist dressing. Effect of on size and granulation in diabetic ulcers Outcome No statically significant difference No statically significant difference Stop earlier with the treatment group () Significantly less in the treatment group () Healing is better in the treatment group () Granulation tissue formation and size reduction are faster.

4 Med & Health Rev 2009;1(2): Joseph Moues Vuerstaeck Czymek Apostoli Nordmyr Lopez Wagner Chronic wounds Acute and chronic wounds Grafted Leg ulcer Fournier s gangrene Chronic wounds Lower leg wounds Complex abdominal wounds Soft tissue defects Effect of on Size reduction Comparing and moist dressing. Effectiveness in complete healing Effectiveness in recovery Effectiveness on symptoms Effect of on wound healing Effect of on healing of abdominal wounds. Significantly reduction in size in the treatment group. No significant diference in the granulation tissue formation and bact. Count. Significantly better in the treatment group () Longer hospital stay and lower mortality in group Lower pain threshold and loss of patient autonomy Higher healing rate in the treatment group Good healing was accomplished Using Act as good as temporary temporary sealing wound to the wounds closure in which lead to the course of Successful treatment. management. The mechanism of Equipment physics The installment of starts with cover of the open wound with a separate wound dressing (polyurethane or polyvinyl alcohol) 6

5 Al-Shaham AAH, Negative Pressure Wound Therapy and an air-tight film. The wound dressing is connected by means of a set of suction tubes to a control unit by which the primary negative pressure on the surface of the wound can be evenly distributed and easily adjusted. Most commonly mm Hg of negative pressure is used, either continuously or in cycles. The fluid suctioned from the wound is collected into a container in the control unit. 8 Role of topical negative pressure Collected evidence revealed that the principle idea in using the topical negative pressure to the surface of the wound is to create negative pressure inside the wound cavity that will reflect on the vascularity of the wound bed, and enhance the tissue microcirculation. This ultimately improves the formation of new capillary buds and promotes granulation tissue formation, which by itself reduces the wound volume in an ulcer cavity, acute or chronic wound cavity. At the same time it reinforces the tissue circulation even in mild-moderate ischemic ulcers such as diabetic ulcers, or vascular ulcer, arterial, venous and arterio-venous ulcers. 2 Uses of in complex wounds The management of complex wounds is a challenge to the medical care provider. Often it is refractory to the traditional methods of wound management. was introduced in 1995 as one innovative way of improving healing of complex wounds. The following are examples of complex wounds: 1. Diabetic foot In a diabetic ulcer the presence of micro and macro-angiopathy with concomitant neuropathy compounds the problem and alters the mode of healing. Armstrong et al 9 studied 162 patients who had diabetic foot ulcersrequiring transmetatarsal amputation. They compared with moist wound treatment. The foot had adequate blood supply as determined by transcutaneous oxymetry or toe pressure measurement (30 7

6 Med & Health Rev 2009;1(2):3-14 mmhg). Assessment of healing was better in the group than in the control group: 56% vs. 39%. Another study by Eto et al 10 in 24 patients with diabetic foot ulcers showed that the formation of granulation tissue in the group was faster (15.8 vs days), and the size of the ulcer diminished more (20.4 vs. 9.5 cm 2 ) than with patients treated by saline bandages. 2. Fournier s gangrene and necrotizing fasciitis Fournier s gangrene frequently occurs following minor perianal suppuration which ultimately spreads into frank gangrene of the perineum and the lower abdominal skin and fascia. Czymek et al 11 conducted a prospective study in 35 patients to compare two different techniques in the management of Fournier s gangrene after aggressive wound debridement. Treated was carried out with either daily antiseptic (polyhexanide) dressings (group I, n = 16) or VAC therapy (group II, n = 19). VAC group patients were associated with significantly lower mortality. 3. Leg ulcer of vascular origin Ischemic ulcers are among the well-known lesions in the lower limb, and run a protracted healing course. In a Dutch study by Vuerstaeck et al, 12 post operative vs moist dressings were compared in 60 patients with leg ulcers of different etiology - venous, combined venous and arterial, and arterial ulcer for which a skin graft was required. The median time to complete healing was 29 days in the group and 45 days in the control group. On the other hand, both groups were liable to get recurrence in the ulcer in one year follow up. Another multicentric study conducted by Nordmyr J et al 13 used for lower limb wounds in patients with arterial disease at two vascular centers in Uppsala and Malmö, Sweden. One hundred and twenty one patients were included in this study. The follow up period was 12 months. 125 mm Hg negative pressures 8

7 Al-Shaham AAH, Negative Pressure Wound Therapy were applied. 87% of the patients at admission presented with critical lower limb ischemia. The authors concluded that using for complex wounds in the lower limbs in patients with vascular disease was associated with high healing rates. Nonhealed wounds after were predictors for amputation and death. 4. Massive wounds and burst abdomen unsuitable for any closure Occasionally the surgeon faces extensive wounds with soft tissue loss that is not suited for any kind of closure. In a study conducted by Wagner 14 was used as temporary wound closure in 20 patients who had large soft-tissue defects. The wounds required second looks, frequent irrigation and debridement and change of dressing. Definitive wound closure was finally accomplished successfully. Another interesting study by Lopez et al 15 reported promising results in ten applications in 8 neonates during a 3-year period for complex abdominal wounds following laparotomy (7 elective, 3 emergent). Three wounds included intestinal stomas, and 3 included enterocutaneous fistulae. The duration of use was 19.1 ± 15.3 (7-60) days, with complete wound closure in all cases. Using provides a better isolation state to the wounds, inhibit infection. 5. Chronic osteomyelitis All surgeons know how refractory chronic osteomyelitis sinuses and bone infections are to treatment. A study performed by Tan et al 6 used in the management of acute and chronic osteomyelitis successfully. Thirty cases were included in his study, assisted with debridement, autodermoplasty and myo-cutaneous flap surgery. No evidence of relapse was found in all cases treated with negative pressure wound therapy. 9

8 Med & Health Rev 2009;1(2): Decubitus Ulcer (bed sore, pressure sore) The decubitus ulcer is the result of pressure necrosis of the skin and soft tissue which is sandwiched between a bony prominence and a pressure site. Two studies compared the use of with traditional wound care such as gel product or moist bandages. The first study concluded that no significant difference was noted in the outcome of 22 patients. 16 Ford et al, 17 in another study of 28 patients, noted that healing was accomplished in 8 patients (4 vs. 4) during the 6 week study period using and the gel product. In the other 20 patients, a 42% reduction in ulcer size with gel products and 52% with were accomplished. One can conclude that no significant difference is obtainable by using in decubitus ulcers. The explanation is that the presence of bursa lining the bed sore makes the wound refractory to healing by any method. Debridement of the decubitus ulcer is of paramount importance in the healing process. Limitations of is contraindicated in wounds with dead tissue, exposed vital structures, untreated osteomyelitis, unexplored fistulae and malignant wounds. Factors such as poor nutritional status, uncontrolled diabetes, corticosteroid therapy, immunosuppressant therapy, anticoagulant therapy or bleeding tendency may adversely influence the decision to apply, as these may significantly delay or prevent wound healing. 8 Furthermore one study revealed that using the decreases patient compliance to pain and loss of patient autonomy. 18 This may lead to diminished ambulation and increased the incidence of thrombo-embolic phenomena. The cost of the equipment may be another factor limiting the use of this new technology. 10

9 Al-Shaham AAH, Negative Pressure Wound Therapy Conclusions This therapy under certain circumstances appears to be more effective than other available local wound treatments especially in complex wounds of variable etiology. There is evidence supporting the use of this technology in promoting angiogenesis, enhancing granulation tissue formation and reducing the volume of ulcer and wound in difficult wounds which otherwise have a protracted healing course. does not replace surgical wound debridement. Caution is also warranted if there is a risk of bleeding from the wound. Address for correspondence: Ali Abas Al-shaham. Faculty of Medicine, Universiti Teknologi MARA, Shah Alam, Selangor, Malaysia. alialshaham@yahoo.com, alialshaham@ salam.uitm.edu.my REFERENCES 1. Fleischmann W, Lang E, Russ M. Treatment of infection by vacuum sealing. Unfallchirurg 1997; 100: Morykwas MJ, Argenta LC, Shelton-Brown EI, et al.vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997; 38: Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38: Mendonca DA, Papini R, Price PE. Negative-pressure wound therapy: a snapshot of the evidence.international Wound Journal. 2006; 3: Vikatmaa P, Juutilainen V, Kuukasjärvi P, Malmivaara A. Negative Pressure Wound Therapy: a Systematic Review on Effectiveness and Safety. Eur J Vasc Endovasc Surg 2008; 3:

10 Med & Health Rev 2009;1(2): Tan YB, Li H, Pan ZJ, Treatment of acute and chronic osteomyelitis with negative pressure wound therapy. Zhonghua Wai Ke Za Zhi 2008; 46: Dhir K,Reubi AJ,Lipana J. Vacuum-assisted closure therapy in the management of head and neck wounds. Laryngoscope 2009: 119: Hunter JE, Teot L, Horch R, Evidence-based medicine: vacuumassisted closure in wound care management. Int Wound J 2007; 4: Armstrong DG, Lavery LA. Diabetic Foot Study Consortium: negative pressure wound therapy after partial diabetic foot amputation: a multicentre randomized controlled trial. Lancet 2005; 366: Etöz A, Özgenel Y, Özcan M. The use of negative pressure wound therapy on diabetic foot ulcers: a preliminary controlled trial. Wounds 2004; 16: Czymek R, Hamori C, Bergman S, et al.a prospective randomized trial of Vacuum Assisted Closure versus standard therapy of fournier s wounds. Wounds 2000; 12: Vuerstaek JD, Vainas T, Wuite J, State-of-the-art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuumassisted closure (V.A.C.) with modern wound dressings. J Vasc Surg 2006; 44: Nordmyr J, Svensson S, Björck M, Vacuum assisted wound closure in patients with lower extremity arterial disease. The experience from two tertiary referral-centres. Int Angiol 2009; 28: Wagner A. Use of vacuum-assisted closure therapy for the conditioning of soft-tissue defects. Oper Orthop Traumatol 2008; 20: Lopez G, Clifton-Koeppel R, Emil S. Vacuum-assisted closure for complicated neonatal abdominal wounds. J Pediatr Surg 2008; 43:

11 Al-Shaham AAH, Negative Pressure Wound Therapy 16. Wanner MB, Schwarzl F, Strub B, Vacuum assisted wound closure for cheaper and more comfortable healing of pressure sores: a prospective study. Scand J Plast Reconstr Surg Hand Surg 2003; 37: Ford CN, Reinhard ER, Yeh D, Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the health point system in the management of pressure ulcers. Ann Plast Surg 2002; 49: Apostoli A, Caula C. Pain and basic functional activites in a group of patients with cutaneous wounds under V.A.C. therapy in hospital setting. Prof Inferm 2008; 61: