Outcomes of Skin Graft Take After Use of Vacuum Assisted Closure (VAC) in Diabetic Patients Study

Although the importance of vacuum-assisted wound closure therapy has been well established as road to definitive treatment of trauma wound in the adult population, its use in pediatric patients is not well described in the literature. This study was conducted to evaluate the outcome of vacuum-assisted wound closure therapy in pediatric patients. Twenty-two patients were prospectively treated for soft tissue defect in lower limb using vacuum-assisted wound closure device, as these wounds were not amenable for primary closure. After wound evaluation, thorough wound debridement was done. Vacuum-assisted wound closure dressing was applied once hemostasis was achieved. Dressings were changed as per protocol. After the development of healthy granulation tissue, wound coverage was achieved with skin graft or flaps. Mean age of patients was 9.455 years, ranging from 4 to 14 years. Early, healthy granulation tissue had formed in all patients. The average number of vacuum-assisted closure (VAC) dressings required was 2.682. Average duration of VAC therapy was 8.045 days. The sizes of soft tissue defects reduced from an average 69.18 cm2 to 50.73 cm2 after VAC therapy with a mean decrease of 26.66%. There was no complication because of VAC therapy. Vacuum-assisted wound closure therapy accelerated the process of healthy granulation tissue formation, and thus shortened the healing time. VAC therapy lessens the morbidity and pain associated with large wounds in pediatric patients and brings cheer and smile in growing children.

Vacuum-assisted Closure for Wound Management

Objective To investigate the effect of vacuum-assisted closure(VAC)on the circulating number of endothelia progenitor cell(EPCs)in diabetic patients with mild to moderate degrees of ischemic foot ulcer and their related factors. Methods A total of 84 diabetic patients with foot ulcer duration for at least 4 weeks and ankle brachial index(ABI)0.5~0.9 were selected and divided into and assigned to two groups according to 2∶1 randomization: vacuum-assisted closure(VAC)treatment group(n=56)and Non-VAC treatment group(n=28). The control group(NC) was composed of 18 patients who had normal glucose tolerance and lower extremity ulcer without arteriovenous disease. VAC was performed on the ulcer wound after debridement for 1 week in both VAC group and NC group, and the patients in Non-VAC group received conventional treatment process. The circulating number of EPCs was measured before and after various treatments and the influencing factors of their changes were analyzed. Results After VAC treatment, the circulating number of EPCs significantly increased in both VAC group and NC group [(85.3±18.1)vs(34.1±12.5)/106 cells, (119.9±14.4)vs(66.1±10.6)/106cells, both P 0.05]. In addition, the circulating levels of vascular endothelial growth factor(VEGF)and the protein expressions of VEGF and stromal cell-derived factor-1α(SDF-1α)in the granulation tissue also significantly increased after VAC treatment in both VAC group and NC group, but no significant change in Non-VAC group. Compared with Non-VAC group, the changes of VEGF and SDF-1α levels in the sera and granulation tissue were all significantly higher in both VAC group and NC group(P<0.05 or P<0.01). There were no significant differences in changes of the circulating number of EPCs, and VEGF and SDF-1α in the sera and granulation tissue between VAC group and NC group. Correlation analysis showed that the change of the circulating number of EPCs was correlated with the changes of VEGF and SDF-1α levels in the sera and granulation tissue of VAC group and NC group(P<0.05). Conclusion VAC treatment may increase the circulating number of EPCs in diabetic patients with mild to moderate ischemic foot ulcer as in non-diabetic controls, which may be attributed to the upregulation of systemic and local VEGF and SDF-1α levels. (Chin J Endocrinol Metab, 2017, 33: 816-821) Key words: Diabetic foot ulcer; Endothelia progenitor cell; Vacuum-assisted closure; Cytokine

A comparison of negative pressure wound therapy modalities, VAC versus non-commercial NPWT alternatives: A systematic review of RCTs/CCTs

Twenty-seven consecutive pediatric patients presenting to the orthopaedic surgery or plastic surgery services were reviewed after completion of wound care with the Vacuum Assisted Closure (V.A.C.) system. Each patient presented with complex soft tissue wounds requiring coverage procedures. Patients with acute wounds and wounds present after nonsuccessful attempts at surgical closure (dehisced incisions and failed flaps) were treated. All soft tissue defects healed without extensive coverage procedures using the V.A.C. system. In the majority of patients, use of the V.A.C. system produced a profuse bed of granulation tissue over all exposed bone, tendon, joint, and/or hardware, which could be covered with split thickness skin graft. Other patients were treated successfully with delayed primary closure, local flap advancement (one patient underwent a pedicled cross-leg flap), or by secondary intention. Use of the V.A.C. device is valuable in increasing the rate of granulation tissue formation and healing of extensive soft tissue injuries in pediatric patients. This vacuum system aids in the debridement of necrotic tissue and local soluble inflammatory mediators that may inhibit the proliferation of granulation tissue. These improvements in the local wound environment seem to accelerate wound healing compared with traditional methods. Before the development of the V.A.C. system, a minimum of nine patients within this group would have required free tissue transfer to obtain adequate coverage. The V.A.C. device seems to permit earlier coverage with local tissue or split-thickness skin grafting techniques, thereby decreasing the need for extensive microvascular tissue transfers in pediatric patients.

To evaluate the results of a vacuum-assisted closure device in patients presenting with open high-energy soft tissue injuries. Consecutive nonrandomized clinical study. From August 1999 through October 2000, 21 patients, with 21 high-energy soft tissue wounds (6 tibial, 10 ankle, and 5 with wounds of the forearm, elbow, femur, pelvis, and a below-knee stump) were treated with a vacuum-assisted closure device at a Level 1 trauma center. A negative atmospheric pressure device used for the management of complex open injuries. Infected wounds had dressings changed every 48 hours, whereas all others had dressings changed every 72 to 96 hours. The duration of vacuum-assisted closure use, final wound closure outcome, costs versus standard dressing changes or free flaps, and a list of all complications were recorded. All patients were followed for 6 months postcoverage. Patients averaged 4.1 sponge changes, 77% performed at bedside, with the device used an average of 19.3 days. Twelve wounds (57%) required either no further treatment or a split-thickness skin graft, and 9 (43%) required a free tissue transfer. The vacuum-assisted closure appears to be a viable adjunct for the treatment of open high-energy injuries. Application can be performed as a bedside procedure but additional soft tissue reconstruction may be needed for definitive coverage. This device does not replace the need for formal debridement of necrotic tissue, but it may avoid the need for a free tissue transfer in some patients with large traumatic wounds.

BackgroundWound management associated with Gustilo grade IIIb open tibia fractures in children often requires muscle flaps, skin grafts, and amputations. The purpose of this study is to report the outcomes and complications of vacuum-assisted closure (VAC) treatment, as well as discuss its role in optimizing value when treating these injuries.MethodsA retrospective review of medical records and imaging studies was performed from 2008-2015. Six pediatric patients with Gustilo grade IIIb fractures managed with the VAC were identified. The time to treatment, frequency of VAC changes, VAC size, and closure attempts, including muscle flaps and skin grafts, were documented. Fracture fixation methods, the incidence of delayed union or nonunion, as well as the occurrence of deep tissue infection and compartment syndrome were detailed.ResultsFive patients were male and one was female with an average age of 12 years (range 8-15 years). All patients sustained a Gustilo IIIb open tibia fracture and were treated with irrigation, debridement, intravenous (IV) antibiotics, fixation, and a VAC as a wound care adjunct. Three patients required both a muscle flap and a skin graft. One patient required a skin graft. There was one case of deep tissue infection. Three patients were treated successfully with the VAC alone and did not require any flap procedures.ConclusionsWound care for Gustilo grade IIIb open tibia fractures in children traditionally involved potentially painful twice-daily dressing changes with solutions such as dilute bleach or iodine. The implementation of VAC markedly reduced the frequency of dressing changes every three days. In the current study, the open wound gradually closed with only a VAC in 50% of Gustilo grade IIIb open pediatric tibia fractures. In summary, the VAC is an adjunct that increases value in the care of pediatric patients with Gustilo grade IIIb open tibia fractures (Value = Outcomes/Cost).Level of evidenceTherapeutic level IV

To evaluate the effect of vacuum-assisted closure (VAC) therapy on wound management by measuring the graft take, wound healing time, need for any re-grafting and duration of hospitalization. Single blinded randomized controlled trial. This study was carried out in the Department of Plastic and Reconstructive Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from October 2007 to December 2009. A total of 100 adult patients of either gender with acute traumatic wounds were included. Patients who needed flap coverage as the primary intervention, and those with Diabetes, malignancy, bleeding diathesis were excluded. Half of the patients were randomly assigned to the intervention group and the rest to the control group with lottery method. All wounds were initially subjected to thorough excision. Wound bed preparation for STSG (split thickness skin graft) was achieved using 10 days pre-treatment with VAC dressings in the intervention group while employing normal saline gauzes in the control group. All patients were subsequently treated with STSG. The primary outcome measure was graft take while the secondary outcome measures included wound healing time, need for any re-grafting and duration of hospital stay. Results were compared in both groups using chi-square test. Marked differences were found in favour of the VAC therapy group with respect to the various wound management outcome measures studied. i.e. graft take (greater than 95% graft take in 90% of VAC therapy group vs. 18% of controls), wound healing time (2 weeks postgrafting in 90% of VAC therapy group vs. 18% of controls), need for regrafting (none among VAC therapy group vs. 8% of controls) and duration of hospital stay (less than 3 weeks in 90% of VAC therapy group vs. 18% of controls). VAC therapy should be employed in the pre-treatment of wounds planned to be reconstructed with STSG, since it has marked advantages in the wound bed preparation compared with the traditional normal saline gauze dressings.

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Introduction: Wound healing is a complex, dynamic process and delayed wound healing significant health problem in India. Various type of surgical methods have been developed for wound healing such as Advanced Wound Care Therapies (AWCT)/ Vacuum-Assisted Closure (VAC) and myo-cutaneous or fascio-cutaneous tissue transfers, Stander dressing therapy etc. VAC Therapy is a Non-Invasive therapy. This therapeutic technique using for the management of large chronically infected wounds more recently used in the treatment of traumatic wounds and non-healing wounds. Aim: Aim of this study is to evaluate functional outcome of vacuum-assisted closure (VAC) dressing therapy for the management of non-healing wounds and traumatic wounds. Materials and methods: Our study was conducted on 30 patients in the Department of Orthopaedics, Kamineni Hospital, LB Nagar Hyderabad from May 2017 to June 2018. Out of 30 patients 18 male and 12 females, Mean age ranging from 19 to 58 for males and 20 to 60 for females. In our study, maximum cases were reported Road traffic accident 20 (67%) patients, followed by machinery injury in 6 (20%) patients and 4 (13%) patients had a fall from height. Vacuum Assisted Closure (VAC) dressing therapy applied for non-healing wounds and traumatic wounds. Results: Out of 30 wounds taken in the study, 20 wounds reduced in area & were resurfaced with split thickness skin grafting and 5 wounds showed reduction in area & were subjected to secondary closure. During start of VAC dressing therapy, all wounds were infected. At the end of VAC dressing, all wounds became swab negative during course of VAC dressing therapy, no patient required surgical debridement and there was gradual decrease in size of wound. Discussion: Our study showed that in VAC dressing therapy after day 3, there were 40% of patients who had no bacterial growth, and on day 7 there were 88% of patients who growth, whereas in saline-wet-to-moist patients only 10% of patients had no bacterial growth on the 8th day. Our study showed that VAC dressing therapy increases the vascularity and rate of granulation tissue formation compared to standard wound dressing therapy. Conclusion: VAC dressing provides sterile and controlled environment to large, educating wound surfaces by controlled application of sub-atmospheric pressure and prepares wounds for closure through split skin grafting and secondary closure in short time leading to less overall morbidity with decreased hospital stay.

The options for abdominal coverage after damage control laparotomy or abdominal compartment syndrome vary by institution, surgeon preference, and type of patient. Some advocate polyglactin mesh (MESH), while others favor vacuum-assisted closure (VAC). We performed a single institution prospective randomized trial comparing morbidity and mortality differences between MESH and VAC. Patients expected to survive and requiring open abdomen management were prospectively randomized to either MESH or VAC. After randomization, an enteral feeding tube was inserted and the closure device placed. VAC patients returned to the operating room every 3 days for a total of three changes at which time polyglactin mesh was placed if closure was not possible. The MESH group had twice daily assessments for the possibility of bedside mesh cinching and closure. Both groups underwent split thickness skin grafting when granulation tissue was evident, if delayed primary closure was not possible. Fifty-one patients were randomized. Both cohorts were matched for Injury Severity Scale score, gender, blunt/penetrating/abdominal compartment syndrome and age. Three patients died within 7 days and were excluded from closure rate calculation. There were no differences between delayed primary fascial closure rates in the VAC (31%) or MESH (26%) groups. The fistula rate in the VAC group was 21% but not statistically different from the 5% rate for MESH. Intraabdominal rates were not statistically different. All VAC fistulas were related to feeding tubes and suture line areas; the MESH fistula followed a retroperitoneal colon leak remote from the mesh. MESH and VAC are both useful methods for abdominal coverage, and are equally likely to produce delayed primary closure. The fistula rate for VAC is most likely due to continued bowel manipulation with VAC changes with a feeding tube in place-enteral feeds should be administered via nasojejunal tube. Neither method precludes secondary abdominal wall reconstruction.

E dwina Paolo, 68, is hospitalized with a nonhealing saphenous vein donor site on her left leg three months after a coronary artery bypass graft. The distal portion of her wound is covered with fibrin, and bone is exposed. After several weeks of traditional wound care and moist dressings, vacuumassisted closure (VAC) therapy is initiated to prepare the wound bed for a skin graft. The nurse caring for Ms. Paolo cuts a piece of sterile polyurethane foam sponge to fit the wound cavity. She places a tube with end and side ports inside the sponge and connects it to a disposable canister loaded into a programmable vacuum pressure pump.1.2 She covers the foam dressing and the embedded evacuation tube with a transparent film to hold the sponge and tubing in place, to ensure an airtight seal and to maintain a moist environment. X Negative suction pressure-pressure lower i than that of the atmosphere at sea level-is applied by the VAC pump at 75 mmHg, increasing in increments of 25 mmHg (to prevent pain during therapy) to a target pressure of 125 mmHg. The device can be programmed to deliver an amount of negative pressure appropriate to a patient's comfort level and the characteristics of the wound. Continuous negative pressure is applied for 48 hours; then the sponge is changed and treatment is continued. For two weeks, Ms. Paolo receives therapy with intermittent negative pressure-suction is turned on for five minutes and off for two minutesto remove excess fluids, promote formation of granulation tissue, and restore capillary flow.

Complex injuries of the upper extremity remain a therapeutic challenge. The prognosis of the damaged extremity is often limited by soft tissue defects. Vacuum Assisted Closure (V.A.C.) therapy facilitates temporary coverage of soft tissue defects prior to surgical reconstruction. In a retrospective study all patients with complex defect injuries of the upper extremity that were treated by V.A.C. prior to reconstruction between August 2003 and September 2005 were analyzed. 7 patients (6 male, 1 female, 14-70 years) were included in the study. The patients suffered from subtotal upper arm (n = 1) and forearm (n = 1) amputation, complex multilevel amputation injury of the forearm (n = 1), slash wound of the forearm with skin defect and discontinuity of all volar structures (n = 1), complex open forearm fractures with skin and soft tissue defects (n = 2), and almost complete necrosis of the flexor compartment following distal radius and proximal ulnar fracture and compartment syndrome (n = 1). Stabile defect coverage was achieved in all patients following V.A.C. therapy by myocutaneous free flaps (n = 2), split thickness skin grafts (STSG) (n = 2), sequential secondary suture (n = 1), and STSG + secondary suture (n = 2). Wound conditions improved significantly under V.A.C. therapy. 5 patients reported pain relief following induction of V.A.C. therapy. Due to reduction of tissue oedema secondary suture was facilitated in 3 patients. V.A.C. therapy represents an essential tool for treatment of complex injuries of the upper extremity with extended soft tissue defects. Decreased frequency of dressing changes as well as reduced tissue oedema considerably improved patient's comfort. Posttraumatic compartment syndrome or skin necrosis, which are often associated with macro amputations of the upper extremity, are efficiently treated with V.A.C., and secondary sutures may be performed despite initial skin defects.

Objective: Vacuum assisted closure is a reported technique to manage complex wounds. We have utilized this technique by using simple locally available material in the management of our patients on outpatient basis. The objective of this study is to present our experience.Methods:This study was conducted from June 2011 to June 2013 at Dow University Hospital and Aga Khan University Hospital, Karachi. There were 38 patients managed with vacuum assisted closure. Mean age was 56±7.8 years. Twenty three patients presented with necrotizing fasciitis and 15 patients with gangrene. Lower limbs were involved in majority of the patients. Debridement or amputations were done. Vacuum dressing was changed twice weekly in outpatient department. Wounds were closed secondarily if possible or covered with split thickness skin graft in another admission.Results:All the wounds were successfully granulated at the end of vacuum therapy. Mean hospital stay was 7.5 days. Vacuum dressing was applied for a mean of 20 days. There was reduction in the size of the wound. Thirteen patients underwent secondary closure of the wound under local anesthesia, 18 patients required coverage with split thickness skin graft and 7 patients healed with secondary intention.Conclusion:Vacuum assisted closure appeared to be an effective method to manage complex diabetic wounds requiring sterile wound environment.

Head and neck wounds can present a reconstructive challenge for the plastic surgeon. Whether from skin cancer, trauma, or burns, there are many different treatment modalities used to dress and manage complex head and neck wounds. Vacuum-assisted closure (VAC) therapy has been used on wounds of nearly every aspect of the body but not routinely in the head and neck area. This study was conducted to demonstrate our results using the VAC in the treatment of complex head and neck wounds. This is an IRB-approved, retrospective review of 69 patients with 73 head and neck wounds that were managed using the VAC between 1999 and 2008. The wound mechanism, location, and size, length of VAC therapy, patient comorbidities, use of radiation, complications, and ultimate outcome were assessed. In this patient population, the VAC was utilized because the standard reconstructive ladder was not a good option or had previously failed. Sixty-nine patients with complex head and neck wounds were treated with the wound VAC. The mean age of the patients was 66 years, with a range of 5-96 years. Males outnumbered females in this study nearly 2:1. Eighty-six percent of patients had wounds secondary to cancer, 8% secondary to trauma, 3% secondary to infection, and 3% secondary to burns. The VAC was used as a dressing over skin grafts in 50%, over Integra in 21%, and over open debrided wounds in 29%. Wounds healed without complication in 44% of the skin grafts, 67% of Integra-covered wounds, and 71% of debrided wounds. Minor complications included failure of complete graft take, failure of granulation tissue formation in open debrided wounds, infection, and hematoma formation under skin grafts. Major complications included positive cancer margins requiring reexcision and death secondary to pulmonary embolism, sepsis, and metastatic cancer. Most complications resolved with dressing changes, repeat grafting, or the administration of antibiotics. Our results demonstrate that the wound VAC provides a reliable, effective, and durable dressing for a multitude of complex head and neck wounds. Additionally, it is a valuable tool when traditional surgical procedures are not a viable option.