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Situation

Intellectually disabled 54 year old man with diabetes, obesity and hypertension. The patient has peripheral neuropathy of feet and developed a diabetic foot ulcer. Surgical debridement was performed in OR and wound was initially treated with impregnated gauze ribbon changed twice daily and cleaned with PHMB solution.

Action(s) taken/ treatment provided

A review of treatment regime and dressings was conducted at 5 weeks post-operation due to deterioration of wound, odour and possibility of future amputation of foot. New treatment plan included cleansing and debridement with and monofilament fibre pad and use of biocellulose hydrobalance dressing dipped in PHMB solution to improve rate of healing.

Outcome(s)

After 9 days, wound was granulating with reduced level of exudate and odour. Total cost of dressings over 9 days of treatment was $114.51. Patient was able to be transferred to a rehabilitation facility and avoided amputation.

Lesson(s) learned

After 5 weeks using a wound dressing regime including gauze and time consuming twice-daily dressing changes, the wound had deteriorated, rather than progressed towards healing. The change of dressing plan resulted in granulation and wound progression in just 9 days. Dressings were cost effective and saved time as did not need to be changed so regularly.

The treatment of acute and chronic infected wounds with residing biofilm still poses a major challenge in medical care. Interactions of antimicrobial dressings with bacterial load, biofilm matrix and the overall protein-rich wound microenvironment remain insufficiently studied. This analysis aimed to extend the investigation on the efficacy of a variety of antimicrobial dressings using an in vitro biofilm model (lhBIOM) mimicking the specific biofilm-environment in human wounds. Four wound dressings containing polyhexanide (PHMB), octendine di-hydrochloride (OCT), cadexomer-iodine (C-IOD) or ionic silver (AG) were compared regarding their antimicrobial efficacy. Quantitative analysis was performed using a quantitative suspension method, separately assessing remaining microbial counts within the solid biofilm as well as the dressing eluate (representing the absorbed wound exudate). Dressing performance was tested against P. aeruginosa biofilms over the course of 6 days. Scanning electron microscopy (SEM) was used to obtain qualitative visualization on changes in biofilm structure. C-IOD demonstrated superior bacterial reduction. In comparison it was the only dressing achieving a significant reduction of more than 7 log10 steps within 3 days. Neither the OCT- nor the AG-containing dressing exerted a distinct and sustained antimicrobial effect. PHMB achieved a non-significant microbicidal effect (1.71 ± 0.31 log10 steps) at day 1. Over the remaining course (6 days) it demonstrated a significant microbistatic effect compared to OCT, AG and the control. Quantitative results in the dressing eluate correlate with those of the solid biofilm model. Overall, AG- and OCT-containing dressings did not achieve the expected anti-biofilm efficacy, while C-IOD performed best. Chemical interaction with the biofilms extrapolymeric substance (EPS), visualized in the SEM, and dressing configuration (agent concentration and release pattern) are suspected to be responsible. The unexpected low and diverse results of the tested antimicrobial dressings indicate a necessity to rethink non-debridement anti-biofilm therapy. Focussing on the combination of biofilm-disruptive (for EPS structure) and antimicrobial (for residing microorganisms) features, as with C-IOD, using dehydration and iodine, appears reasonably complementary and an optimal solution, as suggested by the here presented in vitro data.

Objectives

Boerhaave's syndrome is a life-threatening disease with high mortality and morbidity. Endoscopic negative pressure therapy (ENPT) can be used to treat oesophageal perforations.

Case presentation

We report on a case of oesophageal rupture with peritonitis in a 35-year-old male patient. The start of treatment was 11 h after the perforation event. The treatment of the perforation defect was performed exclusively by intraluminal ENPT, the treatment of peritonitis was performed by laparotomy with abdominal lavage. For ENPT we used two different types of open-pore drains. The first treatment cycle of four days was performed with an open-pored polyurethane foam drainage (OPD), which was placed intraluminal to cover the perforation defect and to empty the stomach permanently. The second treatment cycle of nine days was performed with a thin nasogastric tube like double-lumen open-pored film drainage (OFD). For suction OPD and OFD were connected with an electronic vacuum pump (-125 mmHg). OFD enables active gastric emptying with simultaneous intestinal feeding via an integrated feeding tube. Intraluminal ENPT with a total treatment duration of 13 days was able to achieve the complete healing of the defect. Surgical treatment of the perforation defect was not necessary. The patient was discharged 20 days after initial treatment with a non-irritating abdominal wound and a closed perforation.

Conclusions

In suitable cases, endoscopic negative pressure therapy is a minimally invasive, organ-preserving procedure for the treatment of spontaneous oesophageal rupture.

Aims Anastomotic insufficiencies(AI) and perforations of the upper gastrointestinal tract(uGIT) result in high morbidity and mortality. Besides surgical revision and endoscopic stent placement the endoluminal vacuum therapy(EVT) has been established as an additional strategy. So far, the Eso-Sponge is the only licensed EVT system with limitations in very small defects. Therefore, a fistula sponge(FS) was established in our center for the treatment of small defects of the uGIT as a new therapeutic approach. To evaluate success rates, indications and complications of both EVT options in a retrospective, single-center trial.

Methods Between 01/2018 and 12/2020 all patients undergoing either a FS-EVT or conventional EVT(cEVT) with Eso-Sponge (Braun Melsungen, Germany) due to AI or perforation of the uGIT were recorded. Following criteria were evaluated: indication, diameter of leakage, therapy success and complications. FSs were prepared using a nasogastric tube (6-16Ch diameter) and a porous drainage film (Suprasorb CNP, Lohmann&Rauscher, Germany)(length 1 – 6 cm) sutured to the distal tip.

Results N = 72 patients were included in this analysis (FS-EVT N = 20; cEVT N = 52). FS-EVT was performed in 60 % suffering from AI (cEVT = 68 %) and 40 % from perforation (cEVT = 32 %;p>0.05). After 6.2±3.3d of treatment FSs were exchanged every three days in average, comparable data were obtained for cEVT. The mean diameter of the defect was 9 mm in the FS-EVT group compared to 24 mm in cEVT(p < 0.001), the depth of the leakage showed no significant difference (46 mm for both groups). Therapeutic success (development of granulation tissue, resolution of the leak) was achieved in 90 % (FS-EVT) and 91 % (cEVT) respectively (p > 0.05).

Conclusions EVT comprises an extraordinary treatment option of transmural defects of the uGIT. In clinical practice fistulas <10 mm with large abscess formations exhibit a special challenge, since intraluminal cEVT normally fails. In these cases the concept of extraluminal FS placement is safe and effective.

A 57-year-old patient underwent emergency laparotomy for an acute abdomen with free intra-abdominal air caused by a perforated distal gastric ulcer. Surgical closure was performed by suture. Histological adenocarcinoma was found Therefore, revision laparotomy with distal gastric resection and Roux-en-y reconstruction was done 3 days later. At 6 days postoperatively, a discharge of biliary secretions via target drainage for duodenal stump insufficiency was seen. Surgical closure was tried in another revision laparotomy. But again biliary secretion occurred proving the persistent duodenal leakage.

Passive drainage via the operative drain was sufficient to avoid development of an acute abdomen, therefore the duodenal secretions were drained passively. Secretion of 100–200 ml daily persisted for 21 days with formation of a duodenal cutaneous fistula channel ([Fig. 1]).

Then, treatment was switched to active drainage management with endoscopic negative pressure using an open-pore film drain. The drain was made by wrapping a strip of thin, double-layered, open-pore film (Suprasorb CNP Drainage Film; Lohmann & Rauscher, Rengsdorf, Germany) around the distal drainage end and fixing it with a suture [1] [2] [3] [4] [5] ([Fig. 2]). This created a small-bore open-pore drainage tube to which negative pressure could be applied. The open-pore film drain used had a diameter of only 5 mm. The length of the drainage element was 10 cm. The drain was simply manually inserted in the cutaneous opening into the pre-existing 12-cm-long fistula channel. Suction of –125 mmHg was applied (ACTIV.A.C; KCI, San Antonio, Texas, USA). The secretion stopped immediately. After 4 days, endoscopic negative pressure treatment was terminated. The open-pore film drain was removed by pulling out the tube ([Fig. 3]). Endoscopic inspection of the fistula channel showed the typical suction effects ([Fig. 4]), with the regular pore structure of the open-pore membrane ([Video 1]). The fistula was closed. The open-pore film drain is a simple device that can be used to achieve duodenal cutaneous fistula closure very easily by negative pressure in appropriate cases.

Since the introduction of negative pressure therapy of the abdomen, care has been taken to protect the intestine from the effects of negative pressure in order to avoid impairments of abdominal organs. As an alternative to the widespread AB-Thera^R system (KCI, San Antonio, Texas, USA), the different concept of Suprasorb CNP^R (Lohmann & Rauscher, Austria-Germany) was introduced by the producer with the premise of achieving a better therapeutic effect. Due to numerous pores of the film, the effects of the negative pressure are brought to the surface of the intestinal organs and these effects were tested on seven experimental animals. Particular attention was paid to the small intestine, colon, liver, and pancreas. Over 8 h continuously, three animals were tested with −80 mmHg, 4 with −60 mmHg. The results showed no macroscopic pathological changes. The histological results showed borderline changes in the small intestine and colon with −80 mmHg application, minimal or none with −60 mmHg. The liver and pancreas were found free of pathological changes. For use on human organs, the intra-abdominal application of −60 mmHg for the Suprasorb CNP system is proposed as the standard.

Die endoskopische Vakuumtherapie (EVT) ist ein fester Bestandteil der Therapie postoperativer Anastomoseninsuffizienzen im Gastrointestinaltrakt. In jüngster Zeit wird die EVT auch bei anderen Indikationen wie Perforationen, endoskopisch zugänglichen Abszessen oder enterokutanen Fisteln mit Erfolg angewendet. Dieser Beitrag erläutert schrittweise den Gebrauch der EVT und zeigt die Möglichkeiten, aber auch Risiken und Grenzen der Therapie auf.