GENERAL SURGERY NEWS EXTENDED WOUND CARE COVERAGE Column Editors Jarrod P. Kaufman, MD, FACS, and Peter Kim, MD
Can Silver Heal Wounds?
Pressure Injuries: What to Do When Surgery Fails By CHASE DOYLE
Separating Fact From Fiction By ALISON McCOOK
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he patient’s wound was large, complicated and painful. The 68-year-old man came to see wound care expert George J. Koullias, MD, a vascular surgeon at Stony Brook Surgical Associates, in New York, with a large mixed ulcer that had been plaguing him for two years. The bone was exposed, and part of the wound was necrotic. His doctor had referred him to Dr. Koullias for amputation. But Dr. Koullias wanted to try something else. After extensive debridement of the wound, the patient had a series of biofilm control–based dressing applications and placental allografts. Then for the last year, after the wound was in a healing trajectory, he applied—and reapplied—Aquacel Ag (ConvaTec), a hydrofiber dressing that contains silver. For almost one year, the patient reapplied the product every 48 hours. “Gradually, it led to a complete healing of two major wounds,” Dr. Koullias said during a presentation at the
Symposium on Advanced Wound Care 2020 virtual meeting. No amputation was necessary: “We’ve seen him a few weeks ago, and he is doing great.” Clinicians have been using silver, which has strong antimicrobial activity, in wound care for more than 2,000 years. However, it also can impair healing by damaging some cell types, and research about its benefits has produced mixed results (Plast Reconstr Surg Glob Open 2019;7[8]:e2390). So what is fact, and what is fiction?
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dvanced-stage pressure injuries, or pressure ulcers, are a difficult and increasingly common problem whose challenges persist long after the completion of surgery. Meticulous postoperative care and timely management of complications are critical to a successful outcome.
Fact or Fiction: Silver Can Delay Healing Unpublished data from a ConvaTec study that compared Aquacel Ag (both its original and updated versions, Extra and Advantage, respectively) with a wound dressing without silver (Tegaderm, 3M) in an acute porcine wound model found equal rates of healing. Based on these results, David Parsons, PhD, FRSC, the director of science and technology at ConvaTec, in Deeside, Wales, concluded that Aquacel Ag continued on page 14
The Importance of Adequate Debridement By JARROD P. KAUFMAN, MD, FACS Column Editor, Wound Care Premier Surgical & Premier Vein Center, Brick, N.J. Clinical Assistant Professor, Department of Surgery, Temple University School of Medicine, Philadelphia Clinical Affiliated Faculty at the McGowan Institute for Regenerative Medicine, University of Pittsburgh
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elcome to our new section on wound care and tissue management. As section editor, we look forward to presenting you with relevant topics, guidance and information on new products to assist you in caring for this challenging group of patients. We also look forward to your feedback and collaboration on topics that would be of interest to our readers.
the wound and wound bed. Irrigation is defined as using fluids to clean and treat the wound, usually distinguished as low pressure (bulb syringe); intermediate pressure, using a syringe with a gel catheter or blunt needle; or even high pressure, as seen with motorized or pulsed lavage systems. Either of these two aforementioned methods can use varying types of fluids based on the desired response and need of the particular wound bed. Disinfection comes into consideration when wounds are known or presumed to contain significant biofilm and bioburden, which necessitates using antiseptic agents and antimicrobial agents along with removal of devitalized tissue where the microorganisms live and thrive on the necrotic material.
Terminology To begin, it is important to differentiate between cleansing, irrigation and disinfection in distinction to debridement. All of these are important components in the care of acute and chronic wounds. Cleansing is usually taken to mean simply using fluid(s) to remove adherent materials and nonviable tissue from
Types of Debridement Debridement is defined generally and medically as “surgical removal of foreign matter and dead tissue from a wound; [the] removal of dead or contaminated tissue and foreign matter from a wound, especially continued on page 20
Treatment of a pressure ulcer.
During the Symposium on Advanced Wound Care (SAWC) 2020 virtual meeting, John C. Lantis II, MD, the vice chairman and a professor of surgery at Mount Sinai West and St. Luke’s Hospitals/Icahn School of Medicine, in New York City, discussed risk factors associated with recurrence after surgery and presented several nonsurgical options for managing pressure injuries. As Dr. Lantis explained, the standard nonsurgical treatment for a clean, full-thickness pressure ulcer continued on page 15
Wound Care: The ‘Wild Wild West’? Page 16
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IN THE NEWS
GENERAL SURGERY NEWS / OCTOBER 2020
Silver continued from page 13
products “do not hinder the wound healing process.” That may not apply to all wounds and silver products, said Jeffrey E. Janis, MD, a professor of plastic surgery at the Ohio State University Wexner Medical Center, in Columbus. In a 2019 review of nearly 60 studies that examined silver’s benefits in wound care, Dr. Janis found that dosing matters (Plast Reconstr Surg Glob Open 2019;7[8]:e2390). “Not enough ionic silver doesn’t have any benefit, and
too much may be too much of a good thing.” That “sweet spot” seems to be a sustained dose between 30 and 60 ppm, he said; anything above that seems to slow healing, he said, likely by damaging keratinocytes and fibroblasts. “We don’t want major bucket dumps of silver ions.” Answer: fiction (when used properly)
Fact or Fiction: Silver Increases Antimicrobial Resistance Resistance is always a concern with any anti-infective agent, Dr. Parsons said, but there hasn’t been any clinical evidence of
A diabetic foot ulcer at presentation (left). After treatment with Aquacel Ag Advantage (ConvaTec), day 10 (middle) and day 37 (right).
a concern with silver. “When challenged with silver, 100% of tested organisms are eliminated.” ConvaTec has found that the Aquacel Ag Advantage product is effective in vitro against all forms of bacteria,
The next generation in sharp debridement.
including superbugs. “We have yet to find a wound pathogen that can’t be cleared with our silver dressings,” he said. Dr. Janis, also the chief of plastic surgery at Wexner Medical Center, agreed, noting that despite the fact that silver has been around for thousands of years, “I haven’t seen any data that resistance is built up to it.” Answer: fiction
Tips for Using Silver in Wound Healing • Stick to dosages of 30 and 60 ppm, in sustained release. • Use silver in infected wounds, as an adjunct to surgical debridement. • Avoid silver for clean, noninfected wounds and closed surgical incisions. • With burns, sick to dressings that contain nanocrystalline silver. Source: Plast Reconstr Surg Glob Open. 2019;7(8):e2390.
Fact or Fiction: Silver Helps With Wound Care
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In a 2015 paper, more than 100 patients received Aquacel Ag for various types of hard-to-heal wounds; over an average treatment period of four weeks, the majority of wounds (95%) healed or improved, and 17% healed completely (J Wound Care 2015;24[1]:11-22). “That’s quite remarkable,” said Dr. Parsons, who co-authored the study. But some formulations of silver work better than others, he cautioned. “It’s impossible to generalize about silver dressings,” he told meeting attendees. “Silver can definitely be effective,” Dr. Janis said. “And that’s what the literature would say.” He agreed with Dr. Parsons that the metal needs to be in a usable form—ionic—and the data would only support its limited use in specific indications (see “tips”). He said he regularly uses Aquacel Ag and other silvercontaining products to facilitate wound healing in his patients in the appropriate circumstances, specifically around infected wounds for a short period of time. “We see silver is effective when being used correctly.” Answer: fact ■ Disclosures: ConvaTec sells Aquacel Ag, a wound care product that contains silver. Dr. Janis reported no relevant financial conflicts of interest.
OCTOBER 2020 / GENERAL SURGERY NEWS
is wound cleansing followed by topical dressing, pressure redistribution, elimination of drainage, and supportive care. With this approach, six-month healing rates are 40% to 45% for stage III ulcers and 31% to 34% for stage IV ulcers (J Am Geriatr Soc 2004;52[3]:359-367). For patients who undergo flap reconstruction surgery, however, a large retrospective study showed a complication rate of 58.7% (Plast Reconstr Surg Glob Open. 2017;5[1]:e1187). “In patients with low body mass index, ischial pressure ulcers, diabetes and active smoking habits, surgical interventions may have more limited success,” said Dr. Lantis, who noted various perioperative protocols. “It’s important to maximize nutrition, control blood pressure, and utilize off-loading techniques. “For ischial tuberosity pressure injuries, patients should wait at least six weeks before sittings and start with just 10 minutes of sitting at a time,” he added. According to Dr. Lantis, recurrence and nonoperative management of pressure injuries are often identical, and patients who recur after flap reconstruction surgery rarely return to the OR. Dr. Lantis summarized the evidence for several nonsurgical treatment approaches:
4. Transdermal topical oxygen: A single-blind, multicenter, randomized controlled trial found greater wound healing in the experimental group after 12 days of wound oxygen therapy, which suggests this approach may promote wound healing in patients with pressure ulcers (Iran Red Crescent Med J 2015;17[11]:e20211). 5. Stem cell therapy: Preliminary data indicate that cell therapy using
autologous bone marrow mononuclear cells could be a treatment option for stage IV pressure ulcers in patients with spinal cord injury and could help avoid major surgical intervention (J Spinal Cord Med 2011;34[3]:301-307). In 19 patients (86.36%), the pressure ulcers treated with this approach had fully healed after a mean time of 21 days. 6. Anabolic steroids: A trial ended early after interim results demonstrated an unlikely benefit from treatment with oxandrolone (Cochrane Database Syst Rev 2017;6[6]:CD011375). There is
no high-quality evidence to support the use of anabolic steroids in treating pressure ulcers. “Based on a review of the literature, postsurgical dehiscence can be well managed with ongoing sharp debridement, and topical oxygen therapy may help facilitate these closures,” Dr. Lantis ■ concluded. Disclosures: Dr. Lantis has been a consultant to, or a principal investigator for, 3M, Coloplast, Integra, Kerecis, MediWound, Pluristem, Smith & Nephew and TissueTech.
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reduction in wound size versus standard of care alone (J Tissue Viability 2019;28[1)]21-26).
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Pressure Injuries
EXTENDED WOUND CARE COVERAGE
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1. Debridement: A retrospective chart review of sacrum, sacrococcyx, coccyx, ischium and trochanter region pressure injuries showed that bedside surgical debridement using a sharp excisional technique was performed on 190 of 319 (59.5%) of wounds (Wounds 2017;29[7]:215221). Of those 190 wound sites, 138 (73%) had a reduction in square surface area, and there were a total of 43 (23%) wounds that had a square surface area of 0 (reepithelialized), which has a healing rate of 23%. 2. Negative pressure wound therapy: Overall, there is low-quality and inconclusive evidence regarding the clinical effectiveness of negative pressure wound therapy as a treatment for pressure ulcers, who cautioned against routinely offering this treatment unless it is necessary to reduce the number of dressing changes (e.g., in a wound with a large amount of exudate). 3. Cellular and tissue-based therapy: Results of a small randomized study suggest that weekly treatment of chronic pressure ulcers with small intestinal submucosa wound matrix increases the incidence of 90%
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GENERAL SURGERY NEWS / OCTOBER 2020
Wound Care: The ‘Wild Wild West’? his issue I am tackling a new topic for On the Spot: wound care. This topic, which transcends all surgical specialties, is new territory for me. I’d like to thank Christi Cavaliere, MD, for helping me understand some of the current practices and debates in this field. So is wound care practice, as one panelist phrased it, “more style than science”? Is hyperbaric oxygen therapy all it’s cracked up to be? And is wound care really the “Wild Wild West” of patient care? Read on to see what some of the experts think! I would like to thank all of the experts for their contributions to this column. Their hard work and time
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make this a compelling and informative installment for all general surgeons. Don’t forget to check out the Gut Reaction on page 18 as well for some quick candid thoughts from these contributors. Feel free to email me at colleen@cmhadvisors.com with any ideas eas for debate, and look for “Wound Care Part rt 2” in an upcoming issue. Thanks for reading!! —Colleen Hutchinson n Colleen Hutchinson is a medical communications consultant at CMH Media, based in Philadelphia. She can be reached at colleen@cmhadvisors.com.
EXPERT PANELISTS Christi Cavaliere, MD Department of Plastic Surgery, Cleveland Clinic, Cleveland
Venita Chandra, MD, FACS Clinical Associate Professor of Surgery at Stanford University; Co-Medical Director, Stanford Advanced Wound Center; Founder, Stanford Extremity Preservation Program, California Disclosure: Training/Teaching for Smith & Nephew.
Daniel Eiferman, MD, MBA, FACS Associate Professor of Surgery, Division of Critical Care, Trauma and Burn at the Ohio State University Wexner Medical Center, Columbus
Jeffrey E. Janis, MD, FACS Director of Emergency Surgery and Trauma Unit, Department of Surgery, Humanitas Clinical and Research Hospital, IRCCS, Milan; Professor of Plastic Surgery, Neurosurgery, Neurology and Surgery and Chief of Plastic Surgery, the Ohio State University Wexner Medical Center, Columbus
iWn
iWn
A specialised news source in the wounds arena A trusted provider of latest news, review of cutting-edge research, congress coverage and opinion from thought leaders
Disclosure: Consultant to Allergan/LifeCell; royalties from Springer Publishing and Thieme.
Jarrod P. Kaufman MD, FACS Surgeon and Founding Member, Premier Surgical & Premier Vein Center, Brick, N.J.; Clinical Assistant Professor, Department of Surgery, Temple University School of Medicine, Philadelphia; Clinical Affiliated Faculty, McGowan Institute for Regenerative Medicine at the University of Pittsburgh Disclosure: Consultant to Geistlich, MBOT-MTF and MTF.
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Hayato Kurihara, MD, FACS, FEBS Director of Emergency Surgery and Trauma Unit, Department of Surgery, Humanitas Clinical and Research Hospital, IRCCS, Milan Disclosure: Smith & Nephew (invited speaker on surgical site infection prevention and negative pressure wound therapy in open abdomen management in 2019 and 2020).
Martin I. Newman, MD, FACS Interim Chair and Residency Program Director, Department of Plastic Surgery, Cleveland Clinic Florida, Weston
OCTOBER 2020 / GENERAL SURGERY NEWS
Negative pressure wound therapy using Prevena (3M/ KCI) can prevent wound complications in certain wound categories. DR. CAVALIERE: AGREE The Prevena nega-
tive pressure wound therapy device can be a very useful tool for incision management. I generally consider use with high-risk wounds associated with tension and edema. I have found the device helpful for some patients undergoing complex closure of spine, sternal, knee and breast wounds. It is important to review patient- and wound-related factors when considering use. The device adds moderate cost and can be beneficial in high-risk patients; however, broad application in low-risk patients would not be cost-effective.
EXTENDED WOUND CARE COVERAGE
to vacuum-assisted closure (VAC) 15 or 20 years ago, front-line surgeons and physicians seem to recognize certain benefits of using this branded negative pressure wound dressing without possessing a complete understanding of why. And, like the VAC, I am anxious to see what peer-reviewed literature reports in the decades ahead. A recent PubMed search using the keyword “Prevena” yielded only 50 results. In contrast, a search of the same database returns close to 7,000 hits for the keyword “VAC” and over 4,000 hits for “negative pressure wound therapy.”
DR. EIFERMAN/DR. JANIS: AGREE There have
been substantial data to support its use (and cost-effectiveness) in certain patient subpopulations. It’s not an appropriate treatment for all, but for those at higher risk for incisional complications. DR. KAUFMAN: AGREE These types of
NPWT devices have greatly assisted us in managing incisional wound complications and do help in their prevention. I have seen this particularly after complex abdominal wall procedures.
DR. NEWMAN: DISAGREE I cannot support a
statement that includes the phrase “can prevent wound complications.” Having said that, the Prevena may help to reduce the incidence of some of the more common undesirable outcomes following surgery. This appears to be much examined in wounds of the lower anterior abdomen following gynecologic or contaminated colorectal procedures. Similar
many devices for prevention of SSI and the use of pNPWT already confirmed positive results, but it’s important to underline that the ideal use of NPWT should be considered if integrated in a specific bundle for SSI. Post-incisional infection after surgery is multifactorial and, according to international guidelines, surgeons, anesthesiologists and nurses should focus on preoperative, intraoperative and postoperative stages where specific strategies must be implemented (e.g., no hair removal strategy, perioperative oxygenation, glucose level
DR. KURIHARA: AGREE Nowadays there are
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FOR COMPLEX HERNIA REPAIRS
DR. CHANDRA: ON THE FENCE Prevena is used
in the closed wound operative setting as a prophylaxis with the goal of decreasing seromas, wound infections and dehiscences. The use of negative pressure is clearly well established for use in open wounds; the concept of use in closed wounds is an interesting one. There is a mixture of data in terms of which patients may benefit most from prophylactic negative pressure wound therapy (pNPWT). The issue, of course, is the balance of cost over benefit. In my practice, I use pNPWT in high-risk patients for surgical site infections (obese, diabetic, groin wounds, etc.) but not as a standard for all of my procedures. The World Health Organization published guidelines on recommendations relating to SSIs (Lancet Infect Dis 2016;16[12]:e288-e303). They reviewed the publications on the topic and overall recognized that there was only lowquality evidence available. They found abdominal and cardiac surgery demonstrated benefit with the use of pNPWT, while it was not statistically significant in orthopedic or trauma surgery. Ultimately, they suggested the use of pNPWT on closed surgical incisions in highrisk conditions. They defined high-risk conditions to include patients with significant surrounding soft tissue or skin damage suggesting poor tissue perfusion, decreased blood flow, dead spaces or intraoperative contamination.
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ON THE SPOT
GENERAL SURGERY NEWS / OCTOBER 2020
Wound Care continued from page 17
control). Due to economic costs, accurate patient selection for correct use of the NPWT device should be mandatory; this might be challenging since a dedicated protocol to identify those patients who might benefit from NPWT for a specific surgical intervention ideally needs a scoring system. For this reason, periodic audit meetings in the different surgical areas should be set in place.
The discipline of wound care, compared with most other disciplines and specialties, is basically the “Wild Wild West” of patient care. DR. CAVALIERE: AGREE Wound care as a dis-
cipline is unique in that there is no distinct training program recognized by the Accreditation Council for Graduate Medical Education (ACGME), and there are a variety of certification options, although distinct wound care certification is not required. Dressings, woundrelated devices, and cell and tissue-based products have multiplied severalfold over the past decade; however, largescale outcome studies are often lacking, making wound care practice more style than science. Wounds are typically associated with other medical issues, such as diabetes, immunosuppression, rheumatologic diseases and neurologic diseases. Controlling for these comorbidities also complicates evaluation of
best practices and outcomes. Standardizing training requirements would help to build a more systematic approach to patient care. Development of an acceptable wound healing model against which new dressings and devices could be tested would also promote evidence-based care. Efforts are underway through various wound organizations to develop a curriculum and best practices, but there is more work to be done.
includes optimization of many factors, including local wound care and debridement, infection control, edema control, off-loading, perfusion management, nutrition management, revascularization or reconstruction, and management of patients’ underlying medical issues. All of these factors need to be considered and factored in at every evaluation; thus, systematic and organized multidisciplinary approaches to these patients work best.
DR. KURIHARA: ON THE FENCE Historically, surgeons’ awareness of wound healing, especially in terms of infection prevention, has been quite low; this is probably due to the fact that wound healing, although an important part of patient recovery, is not perceived as an important and desirable end point, since it is timeconsuming and distracting from focusing on new surgical cases and more attractive techniques. Nevertheless, the number of publications on wound management and prevention of SSIs has been remarkably increasing in recent years, showing a new interest in this topic. Many hospitals all over the world are creating specific pathways on SSI and dedicated multidisciplinary wound management teams, and we are already on our way to assist with a more structured approach to wound care.
DR. EIFERMAN/DR. JANIS: DISAGREE Wound
DR. CHANDRA: DISAGREE The discipline of
wound care is absolutely not the “Wild Wild West” of patient care. The challenge with wound care is the complexity of patients, and the importance of taking a multidisciplinary and wholistic approach to patients. Good wound care
healing underpins all surgical specialties. While much is known, there are still gaps that require more research. As long as we use the best available evidence and continue to investigate what we don’t know, I would not consider that the Wild West. However, it is our collective obligation to stay on top of the latest relevant literature. Otherwise, one’s practice never matures since training, despite advances in the field. DR. NEWMAN: ON THE FENCE Although I am not a fan of the term “Wild Wild West,” I certainly understand the frustration of the person who applies it to the discipline of wound care. “Wound care” taken as a whole, represents a multi-billion-dollar industry. As such, it attracts not only well-motivated health care teams, but it also draws those with purely financial goals. The aggressive nature of industry, as well, may play a role in promoting the use of less than well-proven adjuncts to the discipline of wound care. In addition, the willingness of certain health care providers to try something new before it is Treatment tool, device or therapy that you can’t live without
supported by well-designed studies may reflect a growing impatience on part of the patient and provider. Thus, the combination of a chronic disease, a potentially large financial benefit, aggressive industry promotion, and impatient patients and providers may result in less vigilant respect for the scientific method. Ultimately, it is up to the individual or team providing care to determine whether a particular adjunct is effective in healing wounds and supported by independent, nonsponsored literature. DR. KAUFMAN: ON THE FENCE The field has gotten better over the years that I have been in practice. But due to the variety of specialties and varied training of those who participate in wound care treatment, it is true that some would agree with this statement. For the most part, there is a paucity of prospective randomized controlled trials to support clinical decision making. The critiques are that most of the evidence that exists consists of small case series and is largely anecdotal.
Hyperbaric oxygen therapy (HBOT), generally speaking, is not worth the time and cost. DR. CHANDRA: DISAGREE I am cautious
about singing the praises of HBOT, as this is a costly and cumbersome treatment; however, there definitely are scenarios and patients who really serve to benefit. In fact, my gut feeling is that we don’t typically do HBOT on some patients who could serve to benefit from it, as I describe below.
GUT REACTION
Best wound care meeting
Christi Cavaliere, MD
American College of Wound Healing and Tissue Repair
Increasing number of wounds due to abnormal soft tissue calcification
Any plastic surgery textbook; it’s important to understand surgical options for reconstruction
Debridement in the OR
Bill Kuzon
Compression stockings that patients can’t put on
Daniel Eiferman, MD
Symposium on Advanced Wound Care
Missed bladder perforation
“Talent Is Overrated,” by Geoffrey Colvin
LigaSure (Medtronic)
R. Anthony Perez-Tamayo
Inappropriate use of technologies and products
Martin I. Newman, MD
Symposium on Advanced Wound Care
Necrotizing fasciitis
“Textbook of Chronic Wound Care: An EvidenceBased Approach for Diagnosis and Treatment”
Vacuum-assisted closure
Dr. Smith
Nonproven adjuncts
Venita Chandra, MD
Because wound care is so multidisciplinary, I usually go to my specialty conferences (vascular surgery) and participate in the wound care/limb salvage section
Mixed arterial venous wound; patient was compressed without addressing her underlying arterial insufficiency first
Anything they like; it is important to take a break and relax a bit from this intense work we do
A 15 blade
I have many, from different walks of my life
Any of the expensive “skin substitutes” if used in a patient who is not medically optimized and whose wound is not properly prepared
Jeffrey E. Janis, MD
Symposium on Advanced Wound Care
Any of Dr. Eiferman’s surgeries
“Wound Care Practice”
Either the VAC or VersaJet (Smith & Nephew)
Chris Attinger
Inappropriate use of technologies and products
Hayato Kurihara, MD
European Wound Management Association
Enteroatmospheric fistula in open abdomen
“Wound Care Essentials: Practice Principles” (Lippincott, Williams and Wilkins; 2011 [3rd ed.])
Negative pressure wound therapy systems
The nurses of my hospital!
Long-term hospitalization
European Wound Management Association is the best by far
Accidental radiofrequency ablation of superficial femoral artery
“QBQ! The Question Behind the Question,” by John G. Miller, and “Good to Great,” by James C. Collins
Advanced wound care grafts (CTP)
All who taught me how to adequately debride, and especially Dr. Alex Uribe
Allografts or xenografts that require wasting material (that don’t come in a variety of sizes)
Jarrod P. Kaufman, MD
Worst complication I’ve seen recently
Good book for residents and fellows to read
My mentor
Biggest waste of money in wound care
OCTOBER 2020 / GENERAL SURGERY NEWS
It is important to recognize that HBOT is not a magic wand, and all the other factors in terms of wound care, including management of patients underlying medical issues, infection control, off-loading, etc., need to be optimized before proceeding with HBOT. I believe HBOT is most helpful in patients with relative wound bed ischemia, such as the Wagner 3 diabetic foot ulcers and radiation wounds. My theory—and this has not been validated—is that in patients with extreme chronic wounds of nearly all types, such as a 10-year-old venous stasis ulcer, the significant peri–wound scar results in relative wound bed ischemia and HBOT could potentially be beneficial in these patients as well. This is an area in which I hope we will see more data/research in the future. DR. NEWMAN: DISAGREE The benefits of
HBOT are well documented for certain applications. Other applications may not have as much support. The statement “not worth the time and cost,” however, appears to leave the patient out of the equation. Instead, it appears to focus on the dollars and cents of wound care as a business. From a purely economic point of view—for example, how much money will it cost to heal a particular wound—it is generally recognized that HBOT consumes significant resources. However, it is impossible to quantify the human benefits of successful HBOT, for example, reduction in the incidence and severity of decompression sickness, preservation of a limb or an appendage in a diabetic or previously irradiated patient, and the treatment of some burn patients.
EXTENDED WOUND CARE COVERAGE
associated with relative ischemia, such as radiation-related wounds, small vessel disease in diabetic foot ulcers, and compromised flaps. Evidence to support use is limited for some wound types such as pressure ulcers. HBOT requires approximately two-hour sessions five days per week for six weeks. This is a significant time commitment, and many patients face issues arranging transportation. HBOT has applications in the acute care setting, such as acute ischemia and necrotizing soft tissue infections; however, due to reimbursement structure and location of chambers in outpatient
wound centers, HBOT is less likely to be used for these acute diagnoses. Further research is needed to better define the role of HBOT in treating various wound types and to determine the optimal treatment duration. DR. EIFERMAN/DR. JANIS: DISAGREE HBOT has specific indications for which it is effective (gas gangrene, osteoradionecrosis, decompression sickness, etc.). When used outside of evidence-based indications, then the value equation may be more questionable.
DR. KAUFMAN: DISAGREE For the correct
and indicated applications, this is a very safe and effective treatment. Some of the indications that are generally accepted include gas gangrene, central retinal artery occlusion, crush injuries, compartment syndrome after decompression, acute peripheral arterial ischemia, decompression sickness, exceptional blood loss anemia, necrotizing soft tissue infections, chronic osteomyelitis, delayed radiation injury (bowel and bladder and bone necrosis), air or gas embolism, compromised skin grafts and flaps, severe anemia, and carbon monoxide poisoning. ■
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DR. KURIHARA: AGREE The role of HBOT
is also still very controversial in case of life-threatening necrotizing soft tissue infections. So far, evidence of the therapeutic concept of HBOT is still limited to positive experiences only in case studies and animal studies. Moreover, it’s not yet available in most hospitals, and at the moment, it might be considered as an adjunctive treatment only in selected cases and not as a standard of treatment. It also should be underlined that under no circumstances should HBOT delay surgical debridement, if indicated, especially in case of necrotizing soft tissue infection. Furthermore, the additional costs for any HBOT are very high ranging in Europe, from 8,000 to 25,000 euros; therefore, the combination of lack of evidence and economic impact, at the moment, does not seem to justify extended use of this approach.
Download a PDF or request free hard copy reprints
DR. CAVALIERE: DISAGREE HBOT is one of
ormanagement.net/VitalEdge
many tools in the wound care toolbox. Broad application in all wound categories is not appropriate. Increasing oxygen delivery makes sense for wounds
ormanagement.net/download/BB1914_WM.pdf
Supported by
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GENERAL SURGERY NEWS / OCTOBER 2020
Debridement continued from page 13
by excision.”1 There are multiple types of debridement that can be used, and these are critical in transitioning the chronic wound which is stalled in the inflammatory phase through all of the phases of wound healing to a fully epithelialized healed wound. The most commonly used types of debridement in clinical practice include: • mechanical, also known as “sharp” or surgical; • hydrodebridement; • thermal/laser debridement; • ultrasonic debridement; • enzymatic debridement; • maggot debridement therapy; • autolytic debridement; and • whirlpool therapy.
Figure. Phases of wound healing.
Some therapies are combined or blended modalities from the above list and others combine them independently to achieve optimal clinical results. The time-tested and most efficient method is debridement with surgical instruments (scalpel, scissors, dermatomes, sharp curettes, bone rongeurs, forceps). This is not always practical based on the wound site and the location for the debridement (office, wound care clinic, nursing home or OR).2 Hydrosurgical debridement can be accomplished with a variety of commercially available devices (Table). These devices allow for use of pressurized fluid that actually can cut and remove tissue at various depths based on the settings used.
Wound Debridement in the Literature Multiple studies in the literature demonstrate that the frequency and extent of adequate debridement leads to more rapid wound healing. Clinical judgment and experience lead to the knowledge of “how much to debride” so that vital tissue is not removed. General principles of this practice include removal of all grossly necrotic tissue as well as removal of tissue down to healthy-appearing tissue with visible signs of bleeding signifying adequate blood supply. This process was studied in chronic venous leg ulcers and diabetic foot ulcer wounds by Cardinal et al, in 2009. and their results suggested that frequent debridement of these types of wounds may increase wound healing and closure rates.3 Wilcox et al, in 2013, retrospectively studied the frequency of debridement and time to healing in 312,744 wounds. This four-year study in 525 wound care centers showed
that only 70.8% of wounds healed with debridement alone. Further, they concluded that the more frequently wounds were debrided, the better was the healing outcome. Gordon et al espoused a contrary view in 2012, noting that the rationale is valid for the debridement of diabetic foot ulcers, but finding insufficient data supporting debridement for venous ulcers and pressure ulcers.4 A similar conclusion was reached by the Cochrane review performed by Gethin et al, in 2015.5 These investigators concluded that there is limited evidence to indicate that repetitive debridement of venous leg ulcers has a clinically significant impact on wound healing. Further critiques included the small number of participants, low number of studies, and lack of meta-analysis which precluded any strong conclusions for the benefit of debridement in these types of wounds.
Conclusion Table. Commonly Used Hydrosurgical and Ultrasonic Devices for Debridementa Device
Versajet 2
Debritom
Manufacturer
Smith & Nephew
Medaxis
Selected Benefits
Indication(s)
• Preserves viable tissue and reduces debridement procedures • Creates a smooth wound bed • Removes bacteria • Reduces time to closure
• Wound debridement (acute and chronic wounds, burns) • Soft tissue debridement • Cleansing of the surgical site for sharp debridement and/or pulsed lavage irrigation
• Different debridement options • Tissue-preserving option that creates bleeding but avoids excessive debridement
• • • •
• Tissue-selective ultrasonic debridement • Removes bioburden • Reduces blood loss
• Debridement of wounds (burns, diabetic ulcers, pressure injuries, soft tissue injury) • Using an ultrasonic aspirator for sharp debridement, fragmentation and aspiration of tissue
• No-touch selective debridement • Portable, battery-operated, closed debridement system
• • • • • •
Venous and arterial leg ulcers Diabetic foot ulcers Pressure wounds Acute wounds and burns
Debridement is a time-honored method that still has immense value for patients with acute and chronic wounds. When performed correctly and with appropriate frequency, debridement clearly leads to increased healing rates and closure in most types of wounds. Care needs to be taken, however, to clearly define the type of wound being cared for to ensure that the appropriate adjunctive methods are used in special wounds like venous ulcers or pyoderma gangrenosum. ■
References 1. Dictionary.com
SonicOne
Pulsar II
UltraMIST
a
Misonix
Sanara
Cellularity
• Non-contact, low-frequency ultrasound • Pain-free delivery through a fluid mist that acts as the medium to deliver energy to the wound
Partial- and full-thickness wounds Pressure ulcers Surgical wounds Diabetic ulcers Arterial and venous insufficiency wounds Traumatic wounds
• To promote wound healing through wound cleansing and maintenance debridement (removal of fibrin, yellow slough, tissue exudates and bacteria)
Not an exhaustive list. The devices included in this table are those most commonly used in practice in the author’s experience.
2. Wilcox JR, Carter MJ, Covington S. Frequency of debridements and time to heal: a retrospective cohort study of 312,744 wounds. JAMA Dermatol. 2013;149(9):1050-1058. 3. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen. 2009;17(3):306-311. 4. Gordon KA, Lebrun E, Tomic-Canic M, et al. The role of surgical debridement in healing of diabetic foot ulcers. Skinmed. 2012;10(1):24-26. 5. Gethin G, Cowman S, Kolbach DN. Debridement for venous leg ulcers. Cochrane Database Syst Rev. 2015;2015(9):CD008599.