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BACKGROUND

Adjustable compression wraps (ACWs) may represent the future of compression for the treatment of the most severe stages of chronic venous diseases and lymphedema. We tested in five healthy subjects: Coolflex® from Sigvaris®; Juzo wrap 6000®, Readywrap® from Lohmann Rauscher®; Juxtafit® and Juxtalite® from Medi®, Compreflex® from Sigvaris®. The objective of this pilot study was to study the stretch, interface pressures, and Static Stiffness Index (SSI) of the six ACWs applied to the leg.

METHODS

The stretch was evaluated by stretching the ACWs to their maximum length. Interface pressure measurements were performed using a PicoPress® transducer and a probe placed at point B1. Interface pressures were measured in the supine resting position and in the standing position. We calculated the SSI. We started the measurements at 20 mmHg in the supine position and increased the pressures by 5 mmHg to 5 mmHg.

RESULTS

Coolflex® (inelastic ACW) cannot exceed a maximum pressure of 30 mmHg at rest with a maximum SSI of approximately 30 mmHg. Juzo wrap 6000® (a 50% stretch) and Readywrap® (a 60% stretch) have a profile of stiffness very near one to the other. The optimal stiffness for Juzo is from 16 mmHg to of 30 mmHg for a resting pressure between 25 mmHg and 40 mmHg. For Readywrap, the optimal stiffness is from 17 mmHg to 30 mmHg with a maximum SSI of 35mmHg. The optimal application zone of this wrap at rest is 30 to 45 mmHg. Juxtafit®, Juxtalite® and Compreflex® (respectively 70%, 80%, 124% stretch) can be applied with pressures above 60 mmHg but with maximum SSI of 20 mmHg for Circaid® and>30 mmHg for Compreflex®.

CONCLUSIONS

This pilot study allows us to propose a classification of wraps according to their stretch: inelastic ACW and short or long stretch ACW (50-60% and 70%, 80%, and 124% stretch). Their stretch and stiffness could help to better determine what could be expected of ACWs in clinical practice.

Situation

A 65-year-old male bed bound patient with a BMI of 16 kg/m², a schizoid personality disorder, former strong alcoholism and an MCA stroke in 2019 with low rehabilitation potential, was presented with a sacral pressure injury to the District Nursing Service.

Action(s) taken/ treatment provided

The pressure injury was subjected to sharp debridement to remove the hard necrotic tissue. For further autolytic debridement, the wound was treated with a hydrogel wound dressing*. For exudate management, a superabsorbent wound dressing** was used as a secondary association. In the first week, the wound was additionally debrided mechanically. However, since this resulted in more arterial bleeding, treatment completely switched to autolytic debridement. Dressing changes were completed daily by Rest Home staff with weekly input from the District Nurse.

Outcome(s)

After 5 days of autolytic debridement, dark eschar started to soften. Further maceration of the peri wound skin was prevented by the superabsorbent dressing via absorbing high quantities of exudate. After 15 days, the necrotic areas were starting to lift up. Granulation on some areas of the wound bed developed. After 28 days, some edges of the wound bed had partially healed. After 43 days the wound had healed to such an extent that autolytic debridement was no longer indicated and application of a dermal template commenced.

Lesson(s) learned

The hydrogel wound dressing in combination with the superabsorbent dressing were able to debride and prepare the wound bed for the next step of application with a dermal template.

Aim:

We report on the case of a 14-year-old girl with extensive soft tissue defects on the right lower extremity up to the right hip following a traffic accident. The patient suffered a subtotal amputation of the right lower extremity with a rupture of the external iliac artery and the iliac vein.

Method:

After CTA, the pulseless, ischemic leg was treated with autologous arterial und venous vascular graft. Perfusion resumed 4 hours post-accident. Osteosynthesis was carried out using an external fixator. Despite fasciotomy, extensive soft tissue necrosis occurred on the right lower extremity. Due to pre-terminal multiple organ failure caused by SIRS, a large-area necrosectomy was performed and NPWT started. The occlusive dressing was applied to the entire right lower extremity including the anogenital area up to the iliac crest using a tubular bandage*.

Results / Discussion:

This method allowed for sufficient negative pressure on the entire hip area and the entire right lower extremity. Septic condition improved immediately. After stimulating wound granulation, the secondary, serial split skin coverage of the defects was possible.

Conclusion:

In the case of extensive soft tissue defects on the lower extremity with deep substance defects in the area of the hip and simultaneous external fixation on the pelvic ring as well as cystofix and colostoma creation, the establishment of an NPWT system typically is difficult and time-consuming. With the tubular bandage it was possible to use a reliable, reproducible, time-saving occlusive and elastic system for the NPWT.

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.

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.

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.