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BACKGROUND

Postoperative reflux can compromise anastomotic healing after Ivor-Lewis oesophagectomy (ILE). We report on Pre-emptive Active Reflux Drainage (PARD) using a new double-lumen open-pore film drain (dOFD) with negative pressure to protect the anastomosis.

METHODS

To prepare a dOFD, the gastric channel of a triluminal tube (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over 25 cm. The ventilation channel is blocked. The filmcoated segment is placed in the stomach and the intestinal feeding tube in the duodenum. Negative pressure is applied with an electronic vacuum pump (- 125 mmHg, continuous suction) to the gastric channel. Depending on the findings in the endoscopic control, PARD will either be continued or terminated.

RESULTS

PARD was used in 24 patients with ILE and started intraoperatively. Healing was observed in all the anastomoses. The median duration of PARD was 8 days (range 4-21). In 10 of 24 patients (40%) there were issues with anastomotic healing which we defined as "at-risk anastomosis". No additional endoscopic procedures or surgical revisions to the anastomoses were required.

CONCLUSIONS

PARD with dOFD contributes to the protection of anastomosis after ILE. Negative pressure applied to the dOFD (a nasogastric tube) enables enteral nutrition to be delivered simultaneously with permanent evacuation and decompression.

BACKGROUND

Endoscopic vacuum therapy (EVT) has emerged as a novel treatment option for upper gastrointestinal wall defects. The basic principle of action of EVT entails evacuation of secretions, removal of wound debris, and containment of the defect. Furthermore, there is increasing evidence that EVT reduces interstitial edema, increases oxygen saturation, and promotes tissue granulation and microcirculation. Various devices, such as macroporous polyurethane sponge systems or open-pore film drains, have been developed for specific indications. Depending on the individual situation, EVT devices can be placed in- or outside the intestinal lumen, as a stand-alone procedure, or in combination with surgical, radiological, and other endoscopic interventions.

PURPOSE

The aim of this narrative review is to describe the current spectrum of EVT in the upper gastrointestinal tract and to assess and summarize the related scientific literature.

CONCLUSIONS

There is growing evidence that the efficacy of EVT for upper GI leakages exceeds that of other interventional treatment modalities such as self-expanding metal stents, clips, or simple drainages. Owing to the promising results and the excellent risk profile, EVT has become the therapy of choice for perforations and anastomotic leakages of the upper gastrointestinal tract in many centers of expertise. In addition, recent clinical research suggests that preemptive use of EVT after high-risk upper gastrointestinal resections may play an important role in reducing postoperative morbidity.

Amber is 42 jaar en moeder van 3 prachtige kinderen. Van kleins af aan was ze al redelijk gezet en dat bleef zo ondanks veel pogingen om af te vallen. Haar vader is overleden vlak na haar geboorte, ook hij was veel te zwaar en had te hoge cholesterol waarden. Amber dacht: dit gaat mij niet gebeuren en ik ga hulp zoeken om af te vallen. Ze kwam in 2016 in het ziekenhuis in Almelo bij de internist terecht en kreeg daar allerlei onderzoeken inclusief een erfelijkheidsonderzoek in verband met haar vader. Tijdens de tweede afspraak bij de internist werd ze goed met haar neus op de feiten gedrukt. Amber: ‘Hij zei, er moet gauw iets gebeuren want anders wordt u geen 38 jaar oud. Hier schrok ik dus behoorlijk van. Mijn bloeddruk was te hoog, ik rookte, had diabetes en een super hoog cholesterol gehalte.’ Al snel kreeg Amber groen licht voor een gastric bypass. ‘Maar daarvoor moest ik wel een jaar lang een voorbereidend traject volgen’. De operatie vond uiteindelijk plaats in april 2017.

BACKGROUND

Endoscopic vacuum therapy (EVT) has become a standard treatment method for esophageal perforations in adults. However, experience with EVT in infants is scarce. In this retrospective case series, we report on four very young infants who were successfully treated with EVT for esophageal perforations of different etiology.

METHODS

Four infants were diagnosed with esophageal perforations on day 7, 32, 35 and 159 of life, respectively. The youngest one was prematurely born in the 31st week of pregnancy weighing 980 g only. Three infants had perforations due to foreign body insertion (nasogastric tube or pulling through of percutaneous endoscopic gastrostomy (PEG) tube through the esophagus). One child had an anastomotic dehiscence after Foker's surgery for atresia. In three children EVT was applied as first-line therapy for perforation, in one child EVT was a rescue therapy due to persisting leakage after surgical closure involving thoracotomy. Depending on the esophageal diameter, either an open-pore drainage film or polyurethane sponge was attached to a single-lumen 8 Fr suction catheter, endoscopically (or fluoroscopically by wire-guidance) placed into the esophagus (intraluminal EVT) and supplied with continuous negative pressure (ranging between 75 and 150 mmHg). The EVT system was exchanged twice per week.

RESULTS

Complete closure of the perforation/leakage could be achieved in all four infants (100%) after 22 days of continuous EVT (median value; range 7-39) and 4.5 EVT exchanges (median value; range 1-12). No serious adverse events occurred.

CONCLUSIONS

EVT is an effective and safe addition to our therapeutic armamentarium in the management of esophageal perforations irrespective of its etiology. Here we prove the feasibility of EVT even in very young infants. The use of an extra thin vacuum open-pore drainage film is helpful to cope with the small esophageal diameter. EVT settings and exchange rates similar to those known from adult treatment were used.

Background: Gentle skin cleansing and exfoliation and the use of moisturizers as an adjunct to medical treatment should be part of the prevention, treatment, and maintenance of cutaneous conditions such as acne vulgaris (acne) psoriasis, and xerosis. A monofilament fiber debriding technology (MFDT) is used for effective, safe, and rapid skin cleansing and exfoliation and debris, slough, and biofilm removal. The current review addresses the clinical experience using MFDT for various cutaneous conditions that require cleansing or exfoliation or both and how to combine it with medical treatment.

Methods: A literature review explored clinical insights into the role of skin cleansing and exfoliation for patients with various dermatological conditions.

The searches yielded 29 publications, 7 guidelines/algorithms, 13 reviews, 8 clinical studies, and one in vitro study.

Results: Mechanical cleansing using a device can be helpful; however, avoid injury of the skin as it may result in thickening of the epidermis leading to hyperkeratosis and disruption of the skin barrier. Clinical experience with MFDT for acne, psoriasis, atopic dermatitis, and xerosis is discussed. Additionally, MFDT was used to exfoliate hyperkeratosis, actinic keratosis, and traumatic skin tattoos.

Conclusions: Mechanical cleansing using MFDT was shown to be safe and beneficial for skin cleansing and exfoliation of various cutaneous conditions; however, only anecdotal evidence or small studies are available to support its use for these conditions.

AIM

Lymphoedema is associated with dysfunctional lymphatics, tissue fibrosis and inflammatory changes in the skin and local tissue. Ensuring compression supports tissue health is crucial to managing lymphoedema. Providing patients with safe compression which enhances their tissue health is paramount when supporting their 24-hour self-management regimens. This case study explores the use of a new compression garment in two sitting positions in an adult with primary lymphoedema.

METHOD

An 18-year-old female (body mass index 25.2 kg/m2) with Milroy's disease was recruited. She attended two separate 1-hour sessions to evaluate tissue oxygenation (StO2) in chair-sitting and long-sitting (sitting up with a supported back and legs horizontal) positions. Following removal of her usual class 2 (20-30 mmHg) flat-knit compression hosiery, StO2 was recorded for 20 minutes: pre-, during and post the application of an adjustable compression garment (Lohmann & Rauscher) to the right leg.

RESULTS

In the long-sitting position, StO2 levels started high at baseline (94.5%), and were relatively maintained both during and post-a short 20-minute intervention (94.1%). In the chair-sitting position, StO2 levels were significantly lower at baseline (52%), showing a 77% increase during the intervention (92%), followed by a small 9% decrease post-intervention (83.7%).

CONCLUSION

This compression garment significantly increased StO2 levels in the chair-sitting position, while maintaining the effects of the patient's compression stockings, in the long-sitting position. Similar to non-lymphoedematous limbs, the patient's normal prescription hosiery maintains StO2. Through implementation of the short intervention sessions, night compression garments may have the potential to improve tissue health in individuals with primary lymphoedema, encouraging self-management and offering a potential night compression solution where the need arises in a 24-hour management plan.

Introduction: According to the European guidelines, the first step for local wound preparation is debridement, which stands for removing of devitalized tissue such as slough or necrosis. There are numerous types of debridement, but not all of them can be performed by non-specialists. Most of the research investigating efficiency of novel debridement products are carried out or funded by pharmaceutical companies.

Aim: To compare the efficacy of relative necrotic tissue removal after 30 days on patients subjected to debridement with sterile sponge, monofilament fibre cloth, non-woven cloth impregnated with sodium hyaluronate and phospholipids and traditional sterile gauze.

Material and methods: By use of photographic documentation at 7 days’ intervals and planimetry methods, the total wound surface area and sloughy tissue area was measured.

Results: Results have shown that monofilament cloth was the most effective, removing on average 63.44 ±32.91% of necrotic tissue after the first procedure and 74.65 ±30.95% within 30 days of application, in comparison to the sterile gauze group that had on average only 23.53 ±19.16% of necrotic tissue removed at day 0 and 44.95 ±31.47% removed at day 30. Moreover, patients using all 3 products tested reported higher satisfaction with that treatment than those treated with gauze.

Conclusions: Results imply that all those methods could be considered as they are well accepted by patients and cause less pain during the procedure, which is essential for good compliance and complete resolution of the lesions.

In recent years, the impact of biofilms on non-healing wounds has gained increasing interest and it has been reported that between 80% to 100% of non-healing wounds have a biofilm associated with them that impedes wound healing (Bjarnsholt et al, 2017; Malone et al, 2017). Biofilms consist of a complex community of microorganisms, which tend to attach to surfaces, and are encased within a matrix consisting of extracellular polymeric substances (EPS) (Malone et al, 2017). This matrix provides

the microorganisms with protection against antimicrobial treatment and an individual’s immune system. There is an increasing focus and awareness around the use of biofilm based wound care (BBWC) pathways, and they are recommended in several consensus documents (Bianchi et al, 2016; Shultz et al, 2017; Murphy et al, 2020; International Wound Infection Institute (IWII), 2022), This article will discuss the evidence behind BBWC and the potential for introduction of a BBWC pathway into the community setting.

After gastrointestinal resections, leakages can occur, persist despite conventional therapy and result in enterocutaneous fistulae. We developed a combination method using flexible endoscopic techniques to seal the enteric orifice with an absorbable plug in addition to a percutaneously and fistuloscopically guided open-pore film drainage (Vac-Plug method). We retrospectively searched our endoscopy database to identify patients treated with the outlined technique. The clinical and pathological data were assessed, the method analyzed and characterized and the technical and clinical success determined. We identified 14 patients that were treated with the Vac-Plug method (4 females, 10 males with a mean age of 56 years, range 50-74). The patients were treated over a time period of 23 days (range 4-119) in between one to thirteen interventions (mean n = 5). One patient had to be excluded due to short follow-up after successful closure. Seventy-seven percent (10/13) were successfully treated with a median follow-up of 453 days (range 35-1246) thereafter. No treatment related complications occurred during the therapy. The data of the analysis showed that the Vac-Plug therapy is safe and successful in a relevant proportion of the patients. It is easy to learn and to apply and is well tolerated. In our opinion, it is a promising addition to the armamentarium of interventional methods of these difficult to treat patients. Of course, its usefulness must be further validated in larger prospective studies.