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To determine whether a new surgical method using a flexible endoscope (FlexVATS) to perform sparing debridement and apply negative-pressure therapy without extensive decortication may be an alternative treatment option for empyema. Surgical treatment of pleural empyema is associated with considerable postoperative complications and mortality rates, and alternative treatment options are being explored to improve patient outcomes. This was a prospective case series. Seventeen consecutive patients treated with FlexVATS between February 2021 and August 2022 were included in the study. Only patients for whom FlexVATS was the first therapeutic intervention for pleural empyema were included. Treatment success, defined as infection resolution, was the primary endpoint of the study. The secondary endpoints were length of hospital stay, 90-day mortality, and empyema cavity volume reduction. Patients who had previously been treated for pleural empyema by either drainage or surgery were excluded. The trial was performed as a single-centre study at a tertiary medical centre in Germany. In total, 17 patients with pleural empyema were included in the study. The median (IQR) duration of vacuum treatment was 15 days (8-35 days). Twelve of the 17 (71%) patients were successfully treated, and a significant reduction in the empyema cavity volume was observed. 41% of the dressing changes were performed outside the operating room. Compared with a historic cohort of conventionally treated patients (decortication via VATS or thoracotomy), the 90-day mortality rates tended to be lower without reaching statistical significance. Three patients (18%) died in hospital during treatment. No negative pressure-therapy-related complications were observed. FlexVATS therapy is a promising alternative therapy for both healthy and debilitated patients with pleural empyema. Larger randomised trials are required to validate this treatment option.

Introduction. Complex wounds require a moist wound healing environment and exudate control. Alginate dressings are highly absorbable and available as sheets for superficial wounds and ropes for deeper wounds. Objective. This study evaluates the real-world performance of a conformable CAD containing mannuronic acid for various wound types. Materials and Methods. The usability and safety of the tested CAD were evaluated in adult patients with various wound types. Further endpoints were clinician satisfaction with dressing application and suitability for wound type and their opinion of the tested CAD compared with other dressings of this type. Results. The study included 83 patients with exuding wounds (42 male [51%]; 41 female [49%]) and a mean age of 74.54 years (SD ± 15.54 years). Thirteen clinicians (76%) (x = 1.24) rated the first CAD application as very easy, 4 (24%) as easy, and 1 (6%) as not easy. The time for dressing application was ranked as very good (x = 1.65) by 8 clinicians (47%), while 7 (41%) rated the time for application as good, and 2 (12%) gave a satisfactory rating. Conclusion. The CAD sheet and rope were safe to use and fit for purpose in wounds of various etiologies. In addition, the dressing was easy to handle and remove, formed a gel faster than other alginates, and outperformed other previous products.

INTRODUCTION

Early postoperative reflux (PR) can compromise anastomotic healing after Ivor Lewis esophagectomy (ILE) and poses a risk for aspiration. Anastomotic insufficiency is the most threatening surgical complication. We present the protective method of pre-emptive active reflux drainage (PARD) with simultaneous enteral feeding. We report our experience with this new safety concept in esophageal surgery in a cohort of 43 patients.

MATERIALS AND METHODS

For PARD we use a double lumen open porous film drainage (dOFD). To create the dOFD, the gastric tube of a Trelumina probe (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore drainage film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over a length of 25 cm. The dOFD is endoscopically inserted into the tubular stomach intraoperatively after completion of the anastomosis. Continuous negative pressure is applied with an electronic pump (-125 mm Hg). The PR is continuously aspirated completely and the stomach and anastomotic region are decompressed. At the same time, nutrition is delivered via an integrated intestinal tube. Depending on the results of the endoscopic control after 5 days, PARD is either continued or terminated.

RESULTS

During the observation period (2017-2023), PARD was used in all patients (n = 43) with ILE. The healing rate under PARD was 100% and healing was observed in all anastomoses. No additional endoscopic procedures or surgical revisions of the anastomoses were required. The median duration of PARD was 8 days (range 4-21). We observed problems in the healing of the anastomosis in 20 of 43 patients (47%) for whom we defined endoscopic criteria for at-risk anastomosis.

CONCLUSIONS

Our results suggest that PARD has a strong protective effect on anastomotic healing and may reduce the risk of anastomotic insufficiency. The integrated feeding tube of the dOFD allows early postoperative enteral feeding while simultaneously applying negative pressure. PARD appears to prevent the negative consequences of impaired anastomotic healing.

ZUSAMMENFASSUNG

EINLEITUNG: Der früh postoperative Reflux (PR) kann die Anastomosenheilung nach Ivor-Lewis-Ösophagektomie (ILE) beeinträchtigen und stellt ein Risiko für Aspirationen dar. Die Anastomoseninsuffizienz ist die bedrohlichste chirurgische Komplikation.Wir stellen die protektive Methode der pre-emptiven aktiven Refluxdrainage (PARD) mit gleichzeitiger enteraler Ernährung vor. Wir berichten über unsere Erfahrungen mit dem neuen Sicherheitskonzept für die Ösophaguschirurgie an einem Patientenkollektiv von 43 Patienten.

MATERIALIEN UND METHODEN

Zur PARD nutzen wir eine doppellumige offenporige Foliendrainage (dOFD). Zur Herstellung der dOFD wird der gastrale Schenkel einer Trelumina Sonde (Freka®Trelumina, Fresenius) über eine Länge von 25 cm mit einer doppellagigen offenporigen Drainagefolie (Suprasorb®CNP Drainagefolie, Lohmann & Rauscher) beschichtet. Die dOFD wird nach Fertigstellung der Anastomose intraoperativ endoskopisch im Schlauchmagen eingeführt. Es wird ein kontinuierlicher Unterdruck mit einer elektronischen Pumpe angelegt (−125 mm Hg). Der PR wird permanent komplett abgesaugt, der Magen und die Anastomosenregion dekomprimiert. Gleichzeitig wird über eine integrierte Intestinalsonde ernährt. Je nach den Ergebnissen der endoskopischen Kontrolle nach 5 Tagen wird PARD entweder fortgesetzt oder beendet.

ERGEBNISSE

Im Beobachtungszeitraum (2017–2023) wurde PARD bei allen Patienten (n = 43) mit ILE eingesetzt. Die Heilungsrate unter PARD betrug 100 %, bei allen Anastomosen wurde eine Abheilung beobachtet. Es wurden keine zusätzlichen endoskopischen Eingriffe oder chirurgische Revisionen an den Anastomosen erforderlich. Die mediane Dauer der PARD betrug 8 Tage (Spanne 4–21). Bei 20 von 43 Patienten (47 %) sahen wir Probleme in der Anastomosenheilung, für die wir endoskopische Kriterien der Risikoanastomose definierten.

SCHLUSSFOLGERUNG

Unsere Ergebnisse legen nahe, dass PARD einen starken protektiven Effekt auf die Anastomosenheilung hat und das Risiko der Anastomoseninsuffizienz reduzieren kann. Die integrierte Ernährungssonde der dOFD ermöglicht simultan zur Unterdruckausübung die frühpostoperative enterale Ernährung. PARD scheint die negativen Folgen einer gestörten Anastomosenheilung zu verhindern.

BACKGROUND

Endoscopic vacuum therapy (EVT) is an increasingly popular endoscopic technique used for the treatment of wall defects in the gastrointestinal tract. Open-pore film drainage (OFD) systems are a new addition to the armamentarium of EVT and have shown encouraging results in a wide spectrum of applications. The aim of this review is to summarize the current literature on the applications of OFD systems in the gastrointestinal tract.

SUMMARY

Open-pore film drainage (OFD) systems have been used for the treatment of several defects of the gastrointestinal tract. The small size and easy placement of these devices make them very useful, particularly for the treatment of defects that are small in size or difficult to reach. OFDs have been successfully used for both perforations and anastomotic leaks in various locations, with most reports focusing on the treatment of duodenal defects, although successful applications in the esophagus, stomach, and colon have also been reported. Lately, the role of OFDs in preemptive EVT has also been explored.

KEY MESSAGES

OFD systems are easy to use, particularly for small defects and challenging localizations. The current literature, consisting mainly of small case series and case reports, shows encouraging results, but further prospective studies are needed to explore and verify the indications and technical aspects of this innovative method.

Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the "piggyback" technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.

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: 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.