High Anesthetic Risk Research Articles

Cirugía urológica durante la pandemia por SARS-CoV-2. Análisis descriptivo de la experiencia en un Servicio de Urología durante distintas fases epidemiológicas

IntroductionThe SARS-CoV-2 pandemic has changed the urological practice around the world. Our objective is to describe the outcomes presented by patients undergoing surgery in the urology department of a tertiary hospital, across the pandemic phases. MethodsObservational, cohort study including all patients undergoing surgery from March 1 to May 14. According to the hospital organization, we identified three periods: there were no changes during the first two weeks (1st. period), the following seven weeks, when only urgent interventions were carried out after performance of nasopharyngeal swab test (2nd. period), and finally, elective surgery was resumed on May 4, after the implementation of a multidisciplinary screening protocol (3rd. period). Demographic, baseline, surgical and perioperative variables, as well as postoperative outcomes, were obtained in a retrospective (periods 1 and 2) and prospective (period 3) manner. Telephone follow-up was initiated at least 3 weeks after hospital discharge. Results103 urological surgeries were performed, and 11 patients were diagnosed with COVID-19, 8 of them within the 1st. period. The diagnosis was already known in 1 patient, while the other 10 developed the disease in an average of 25 days after the intervention and 16,6 days after discharge. Of seven transplant patients, four got the infection. Three deaths were recorded due to the disease: a 69-year-old woman transplanted and two men over 80 with comorbidities and high anesthetic risk who underwent drainage of retroperitoneal abscess and retrograde intrarenal surgery, respectively. ConclusionsSARS-CoV-2 infection mainly affected renal transplant recipients or elderly patients with high anesthetic risk, during the first 2 weeks of the pandemic. After implementing preoperative PCR tests and a comprehensive screening protocol, cases were substantially reduced, and safe surgical procedures were achieved.

Bipolar radiofrequency thermotherapy treatment of the prostate in urinary catheter-dependent men.

In this study, for the first time in the literature, we evaluated patients with benign prostatic hyperplasia (BPH) who had undergone permanent urinary catheterization for urinary retention and who were treated with radiofrequency (RF) thermotherapy as an alternative method due to their inoperability based on the high risk associated with anesthesia. We aimed to investigate these patients' posttreatment parameters concerning the catheter-free rates, quality of life (QoL) changes, and retrospective treatment efficacy. RF thermotherapy was applied to 62 permanent patients catheterized within the last 3 months due to urinary retention. The follow-up data of the patients were retrospectively analyzed. The patients who were free of catheters and those who required permanent catheterization were determined. The changes in the International Prostate Symptom Score (IPSS), QoL, postvoiding residue (PVR), and maximal flow rate (Qmax ) values were analyzed. A total of 52 patients were evaluated in terms of treatment success in relation to the elimination of the need for a urinary catheter, which was calculated as 73.07%. The Qmax , IPSS, QoL, and PVR values of 38 patients who no longer required a catheter were monitored for 24 months, and statistically significant changes were observed in all parameters. Bipolar RF thermotherapy was found to be beneficial for men dependent on catheters due to BPH. It can be recommended as a safe, minimally invasive treatment method for elderly patients with a high anesthesia risk.

Anesthesia For Total Arthroplasty Of The Joints Of The Lower Extremities In Patients With A High Anesthetic Risk

Purpose: to determine the effect of unilateral spinal anesthesia on systemic and central hemodynamics, to identify its side effects in the elderly and senile, with total hip replacement.
 Materials and methods: 60 patients of geriatric age operated on under unilateral spinal anesthesia were examined. 44 patients underwent total hip arthroplasty (THA), 16 - total knee arthroplasty (TKA). Inclusion criteria: elderly (from 60 to 75 years). For continuous monitoring of the vital functions of the patient, they used the "resuscitation and surgical" monitor UM 300 (LLC UTAS Company Ukraine).
 Conclusion: Unilateral spinal anesthesia is a safe and highly effective technique that can provide full intraoperative pain management for patients with total hip replacement in a high-risk group of patients.

Update on anesthesia for patients undergoing post-bariatric body contouring surgical procedures

Individuals who have undergone bariatric surgery and have lost a considerable amount of weight tend to seek consultation with plastic surgeons for body contouring surgery. This growing population is overweight, and they still have some of the co-morbidities of obesity, such as hypertension, ischemic heart disease, pulmonary hypertension, sleep apnea, iron deficiency anemia, hyperglycemia, among other pathologies. They should be considered as high anesthetic risk and therefore, should be thoroughly evaluated. If more than one surgery is planned, a safe operative plan must be defined. The anesthetic management is adjusted to the physical condition of the patient, the anatomical and physiological changes, the psychological condition, as well as the surgical plan. Anemia is a frequent complication of obesity and bariatric procedures and should be compensated with appropriate anticipation. Pre-anesthetic medications may include benzodiazepines, alpha-2 agonists, anti-emetics, antibiotics, and pre-emptive analgesics. Regional anesthesia should be used whenever possible, especially subarachnoid blockade, since it has few side effects. General anesthesia should be left as the last option and can be combined with regional techniques. It is prudent to use conscious sedation for facial and neck surgery, maintaining strict control, especially with respect to the airway management. Thromboprophylaxis is mandatory and should continue for several days after the operation.

Holmium laser lithotripsy with semirigid ureterorenoscopy in treatment of upper ureteral and renal pelvis stones under spinal anesthesia

Extracorporeal shockwave lithotripsy and especially flexible ureterorenoscopy (URS) are first-choice treatments of upper ureteral and renal pelvis stones. In our study, we aimed to demonstrate that the treatment of upper ureteral and renal pelvis stones smaller than 2 cm could be performed by semirigid URS under spinal anesthesia. The data of 292 patients were retrospectively analyzed. Stones were localized in upper ureter and renal pelvis in 191 (65.4%) and 101 (34.6%) patients, respectively. The stone-free rate was found to be 72.6%. The final stone-free rate was 95.2% after additional treatments administered to 80 patients with residues. While no peri-operative complication was observed, hematuria was observed in three patients during the post-operative period, high fever was observed in 27 patients and sepsis was observed in four patients. It is a well-known fact that flexible URS is the first-choice surgical method in the treatment of upper ureteral and renal pelvis stones. In the current study, we aimed to investigate whether laser lithotripsy with semirigid URS could also be a good and cheap alternative in clinical practice, and if upper urinary tract surgeries could be performed with spinal anesthesia especially in patients with a high risk of general anesthesia. Level of evidence:

Diagnostic challenges in paediatric foreign body aspiration: a case report

Introduction: Foreign body aspiration (FBA) is a potentially fatal paediatric emergency. Our objective was to highlight the importance of a multidisciplinary approach to difficult/doubtful diagnosis.
 Case Report: 34-month-old girl referred for urgent rigid bronchoscopy after suspected metallic blade ingestion (found chewing on it). She had a previous recurrent history of wheezing. The physical examination revealed face/lip wounds, traces of powder on her teeth but no breathing difficulty. The plain X-Ray revealed radiopaque images of the upper pulmonary field and gastric chamber. In the absence of FBA clinical signs but considering a previous history of bronchial hyperresponsiveness, a direct digital radiographic study was performed. There were no images compatible with foreign bodies: the results were interpreted as artefacts and no bronchoscopy was performed.
 Conclusions: A careful pre-anaesthetic evaluation, a high level of suspicion and excellent multidisciplinary communication led to the recognition of false radiologic findings. A conservative approach was followed and invasive procedures in a remote location, with high anaesthetic risk for the paediatric population were avoided.

Évaluation par tomodensitométrie thoracique d’un traitement de la trachéobronchomalacie par pression positive continue dans le cadre d’un syndrome de Mounier–Kuhn

Tracheobronchomegaly disease is often associated with a tracheobronchomalacia which is responsible for recurrent lower respiratory tract infections. Currently there is no evidence to support any specific treatment for the condition. We report the case of a 79 years old patient presenting with tracheobronchomegaly in the context of Mounier-Kuhn syndrome complicated by a tracheobronchomalacia responsible for her symptomatology. The diagnosis of tracheobronchomalacia had been confirmed by high-resolution chest computed tomography (CT) with expiratory slices and virtual bronchoscopy. Treatment with continuous positive airway pressure (CPAP) was proposed, and we confirmed its efficacy using high-resolution chest CT, which showed a decrease in tracheobronchial collapse and a reduction in air trapping. Three-dimensional virtual bronchoscopy is an interesting tool and a noninvasive method to diagnose tracheobronchomegaly for patients who are at a high anesthetic risk. It is also possible to use it demonstrate the effect of CPAP in tracheobronchomalacia.

Feasibility of In-office Fine-Needle Aspiration for Base of Tongue Tumors.

We aim to demonstrate the feasibility of in-office transcervical ultrasound (TCUS)-guided fine-needle aspiration (FNA) of base of tongue (BOT) tumors in a single-institution. Retrospective chart review was performed and 3 patients met criteria, with BOT tumors ≥3 cm . Two patients had no cervical adenopathy, while FNA of a cervical lymph node was inconclusive in patient 3. Two patients had multiple medical comorbidities rendering them high risk for general anesthesia, and 1 patient had a BOT tumor obscuring visualization of the glottis, which would have precluded intubation and potentially required tracheostomy to proceed. All patients underwent successful in-office TCUS-guided FNA, with results showing squamous cell carcinoma. There were no related complications. In-office TCUS-guided FNA can be used for diagnosis of BOT lesions that are evident on ultrasound. This is beneficial in cases where general anesthesia is considered high risk. Additionally, 1 patient safely continued anticoagulation, and another was able to avoid tracheostomy. This technique is cost-effective as it avoids the expenses associated with operative intervention.

Spinal anesthesia in surgical treatment of lumbar spine tumors

ObjectiveThis study aims to show the feasibility of spinal anesthesia in lumbar spinal tumor surgery; share our data and experience. Patients and methods: A retrospective review of 14 patients with high risk for general anesthesia due to severe comorbidities was carried out. Patients who underwent surgeries under spinal anesthesia for lumbar vertebral column or spinal cord tumors at a single center between 2007–2019 were evaluated. The final pathological diagnosis, operation time, and surgical procedures were analyzed. Also, preoperative and postoperative advantages and disadvantages were determined. A comparison was performed with other 184 patients who were operated for spinal tumors in the same period under general anesthesia. ResultsMaximum operation time was found 220 min, and the average operation time was 166 min. The most primary diagnosis was vertebral column metastasis. The mean age was 65.5 years. None of the patients required general anesthesia during surgery; however, two patients needed additional spinal anesthesia preoperatively, which was performed by the surgeon. Lumbar decompression and fusion were the most performed procedures. ConclusionSpinal anesthesia is a feasible and useful method of anesthesia in lumbar spinal tumor surgery for especially elderly patients with American Society of Anesthesiologists (ASA) 3 or 4 score and high risk of general anesthesia.

Laparoscopic surgery for recurrent inguinal hernias

The OBJECTIVE was to evaluate the technical feasibility of endoscopic hernioplasty in recurrent inguinal hernia. METHODS AND MATERIALS. Personal experience of the authors covers more than 10 000 laparoscopic inguinal hernioplasties operated in 1996-2018. This paper analyzes the results of 127 patients treated for recurrent inguinal hernias after primary laparoscopic approach, reoperated using minimally-invasive surgical techniques. RESULTS. Possible causes of relapses after primary hernioplasty, both after TAPP and TEP techniques, were analyzed. The technical features of performing repeated laparoscopic interventions in this group of patients were considered. The developed and implemented technical methods, the tactics of the surgical treatment, the choice of the prostheses' type and size used in patients with various kinds of recurrent inguinal hernias were described. Results of the study included an analysis of the treatment while recommendations on the technique of repeated surgical intervention of recurrent hernias were formulated. The safety and effectiveness of the laparoscopic repeated surgery for recurrent inguinal hernias were shown. CONCLUSION. Laparoscopic approach to hernioplasty in recurrent inguinal hernia is equally effective after open and endoscopic primary repair. An increase in the number of hernioplasty for recurrent inguinal hernias with non-adhesive mesh grafts is promising. Contraindications to redo laparoscopic intervention may include high risk of general anesthesia and severe scarring in the lower abdomen.

Hemodynamic changes after spinal anesthesia in preeclamptic patients undergoing cesarean section at a tertiary referral center in Ethiopia: a prospective cohort study

BackgroundSpinal anesthesia-induced maternal hypotension is the most frequent complication associated with maternal morbidity and mortality during Cesarean section. The aim of this study was to compare the incidence and magnitude of hemodynamic changes in preeclamptic and non-preeclamptic parturients undergone Cesarean section under spinal anesthesia.MethodA prospective cohort study was conducted from 01 February to 28 May 2019 in preeclamptic and non-preeclamptic parturients. We hypothesized preeclamptic parturients are at high risk of spinal anesthesia induced hypotension than non preeclamptics. A total of 122 ASA II and ASA III parturients were recruited consecutively and assigned to two groups (81non-preeclamptics, and 41 preeclamptics). Parturients with cardiac disease, twin pregnancy, chronic hypertension, gestational hypertension, superimposed hypertension, renal disease, diabetes mellitus, coagulopathy (platelet count < 80 × 109/L), active labor, eclampsia, abruptio placentae, placenta praevia, any adjuvant added with local anesthetics were excluded. The data analysis was done using SPSS version 22 statistical software. Student t test, MannWhitney U test and Fisher exact test were used to compare the data. All P values < 0.05 were considered statistically significant.ResultThe incidence of spinal anesthesia-induced hypotension was higher in non-preeclamptic parturients than preeclamptic parturients (55.6% vs. 34.1%, respectively) and the degree of blood pressure drop was significantly greater in the non-preeclamptic parturients compared to those with preeclampsia; As well intraoperative fluid consumption was significantly greater in the non-preeclamptics parturients compared to those with preeclamptics.ConclusionThe incidence and magnitude of spinal anesthesia-induced hypotension in parturients undergone Cesarean section were less in preeclamptic parturients than in non-preeclamptic parturients.. Based on the data from this study we recommended spinal anesthesia for preeclamptic patients, unless there is a contra indication based on preeclampsia.

Rectal perforation following endorectal prostate MRI: an unexpected complication

BackgroundProstate cancer is a common cancer among men in developed countries. Prostate magnetic resonance imaging (MRI) has been widely employed for early diagnosis of prostate cancer and recommending a treatment plan. The incidence of rectal perforation during endorectal prostate MRI is rare and has never been reported before. Herein, we present a case of rectal perforation after a prostate MRI examination that was subjected to emergency surgical intervention because of the acute presentation of generalized peritonitis. Patients with systemic comorbidities are reportedly at greater risks of encountering colonoscopic perforation. Endorectal prostate MRI is a safe diagnostic modality, but inadequate lubrication of the endorectal coil or over-insufflation of the balloon during the procedure may also lead to serious complications such as hollow organ perforation. Early surgery will be necessary should peritoneal symptoms persist.Case presentationIn 2015, a 56-year-old man came to our ER due to acute abdominal pain after he finished his MRI exam. The exam indicated diffuse tenderness over his abdomen and at the ER, his abdominal CT (computerized tomography) was checked. The images revealed extraluminal air in the perirectal fat and the pneumoperitoneum. In response, exploratory laparotomy, simple closure of rectal perforation, and loop-S colostomy were performed and the patient was discharged 1 month after operation.ConclusionsProstate MRI is a secure procedure with few complications. Clinicians must keep in mind the possibility of perforation when using ultrasound probe. Hollow organ perforation can result in serious morbidity or death. As a result, patients need to be informed of the complications of prostate MRI. When performing the procedure, clinicians must be cautioned about the potential problems for patients with high-anesthetic risk.

Awake, Endoscopic Revision Surgery for Lumbar Pseudarthrosis After Transforaminal Lumbar Interbody Fusion: Technical Notes

We sought to evaluate the feasibility for awake, endoscopic treatment of lumbar pseudarthrosis after a transforaminal lumbar interbody fusion (TLIF). A 71-year-old male with severe cardiac disease, determined to be high risk for general anesthesia, presented with mechanical back pain and a L3-4 pseudarthrosis and L3 pedicle screw loosening after a L3-5 TLIF. An awake, transforaminal endoscopic redo diskectomy and TLIF procedure were performed by removing residual disk material adjacent to the previous "PEEK" (polyetheretherketone) interbody spacer and placing allograft, bone morphogenetic protein, and an expandable titanium interbody device adjacent to the PEEK cage. At 1-year follow-up, preoperative visual analog scale for back pain and Oswestry disability index improved from 7 and 38% to 1 and 2%. The 1-year follow-up radiograph showed stable interbody placement and no further screw loosening. A minimally invasive, awake procedure is presented for the treatment of pseudarthrosis after TLIF.

Awake office based trans nasal flexible endoscopicdiode laser assisted posterior cordotomy for bilateral vocal fold paralysis

Purpose: The purpose of this retrospective study is to describe our experiencewith the new technique of Awake office based flexible endoscopic diode laser assisted posterior cordotomy for bilateral vocal fold paralysis. The technique was primarily designed as an alternative to traditional micro suspension CO2 posterior cordotomy for patients of bilateral vocal fold paralysis when associated with co morbidity leading to either difficulty for suspension laryngoscopy or high risk for general anesthesia. Material and methods: The study was carried out on 20 patients of Bilateral Vocal Fold Paralysis associated with co morbidity with limitations for Micro suspension cordotomy. 12 patients were females and 8 patients were males in the age group of 25 and 75 years, attending Sri Sathya Sai E.N.T Hospital and Research Center for Voice Disorders, India from January 2012 to January 2017. All the patients were operated by posterior cordotomy done in office based setup under local anesthesia using Fiberoptic fiberoptic flexible laryngoscope and diode fiberlaser.. Results: Results proved the efficacy of the procedure based on the pre and postoperative Pulmonary Function Tests and Voice Handicap Index scores which were statistically significant. Conclusion: The new technique was proved as safe and perfect alternative to traditional micro suspension cordotomy in patients of bilateral vocal fold paralysis associated with comorbities leading to either difficulty for suspension laryngoscopy or high risk for general anesthesia. The study also described it’s advantages such as conservation of voice by avoiding the over correction of glottic space by monitoring the voice intraoperatively and feasibility for revision cordotomy in the Office basis.

Bernard–Soulier syndrome and anesthetic management

Bernard–Soulier syndrome (BSS) is a rare autosomal recessive disease with bleeding diathesis due to platelet dysfunction secondary to the absence of the von Willebrand factor receptor on the platelet surface called glycoprotein Ib–V–IX. The deficiency results in prolonged bleeding time and spontaneous bleeds and may be with high risk for anesthesia and surgery. Here, we report a case of BSS coming for trabeculectomy.

Postoperative follow up in the management of intertrochanteric fractures of femur a comparative study using dynamic hip screw and proximal femoral nail

Background: Intertrochanteric fractures have the highest postoperative fatality rate amongst surgically treated fractures, they have become an important health issue and thus it is very important to study and compare different surgical options available for these fractures. So purpose of the study to compare postoperative follow up in the management of intertrochanteric fractures of femur a comparative study using dynamic hip screw and proximal femoral nail. Material & Methods: Patients with pathologic fractures, patients with multiple fractures, patients with old neglected, fractures, fractures in paediatric age group, fractures in elderly patient with high medical risk for anesthesia and surgery, reverse intertrochanteric fractures were included in the study. The post-operative pain was also assessed as per the Harris Hip Score criteria at the end of 1 year and the post-operative gait was also assessed at the end of 1 year. Union was decided on the basis of obliteration of fracture line with bridging callus so as to allow unprotected function of the limb.Observation & Results: At 1 year follow up, 9 patients had no pain, 5 had minimal pain, 6 had moderate pain and only 1 patient had severe pain post operatively in the DHS group, while 12 patients had no pain, 8 had minimal pain and 3 had moderate pain post operatively in the PFN group. The functional outcome was better for PFN than for DHS however, the difference was not statistically significant (p value >0.05). Conclusion: Thus it was concluded from this study that P.F.N. has the following advantages over D.H.S. in the treatment of intertrochanteric fractures (especially unstable fractures). Lesser operative time, lesser blood loss, early post-operative rehabilitation of the patients, better functional outcome. However, the difference in the functional outcome is not statistically significant and thus we require a larger group of study to prove the significance.

ОСОБЕННОСТИ ТАКТИКИ ЛЕЧЕНИЯ БОЛЬНЫХ ОСТРЫМ ОБТУРАЦИОННЫМ ХОЛЕЦИСТИТОМ «ВЫСОКОГО РИСКА»

To improve the results of surgical treatment of patients with high operational and anesthetic risk, the suffering of acute obstructive cholecystitis (AOC), by improving two-stage tactics.

TECHNOLOGY OF PALLIATIVE SURGICAL TREATMENT OF PATIENTS WITH UNRESECTABLE CANCER OF THE HEAD OF THE PANCREAS, COMPLICATED BY MECHANICAL JAUNDICE

Relevance. It is relevant to develop new technological solutions for palliative surgical treatment of patients with unresectable pancreatic head cancer (UPHC), since the incidence of postoperative complications in such patients reaches 25 %, and mortality – 20 %.&#x0D; Objective. To improve the diagnosis and immediate results of palliative surgical treatment of patients with UPHC complicated by obstructive jaundice, duodenal obstruction, and carcinomatous pancreatitis.&#x0D; Materials and methods. At the first stage of the study, criteria for the diagnosis of PHC complications, tactics and methods for their surgical correction were evaluated (group I, 159 patients). After analyzing the results, a new technology for the surgical treatment of patients is formulated, the clinical testing of which was carried out in the second stage. An open, prospective, randomized study included 112 patients with UPHC complicated by obstructive jaundice (group II), who underwent palliative surgical treatment using patented surgical procedures. A comparative analysis of the results of surgical treatment of patients of both groups was carried out.&#x0D; Results. The safety and effectiveness of the simultaneous implementation with biliodigestive gastrodigestive shunting has been proven. The advantages of the tactics of two-stage surgical treatment of patients with signs of liver failure are shown. In patients with high anesthetic and surgical risk, the replacement of open surgery with endoscopic prosthetics of the biliary system and duodenal obstruction is justified. In severe forms of carcinomatous pancreatitis with expansion of the main pancreatic duct, a technique for combined bilio- and pancreatodigestive shunting is proposed. When multiple organ dysfunctions with hepatic-renal, hemorrhagic syndromes are formed in patients with obstructive jaundice, decompression of the biliary system by minimally invasive techniques is shown in the first stage, and the main stage of surgical intervention in the second. As a result, the incidence of postoperative complications was 9,8 %, mortality – 3,7 %.&#x0D; Conclusions. In patients with UPHC cancer complicated by obstructive jaundice, performing instead of traditional biliodigestive bypass surgery combined bilioastrodigestive bypass surgery is a safe procedure that does not increase the frequency of postoperative complications, prevents the need for repeated gastro-digestive interventions, improves the quality of life of patients in the long-term postoperative period. The operation of choice in the surgical treatment of patients with UPHC complicated by obstruction of the biliary system and duodenum with high surgical and anesthetic risk is endoscopic interventions with endoscopic prosthetics of the bile ducts and duodenum.

Novel Endovascular Neck Reconstruction and Coiling Technique for the Treatment of a Large Wide-Necked Basilar Apex Aneurysm Through a Radial Artery Approach: 2-Dimensional Operative Video.

Herein, we demonstrate a case of a large, wide-necked, basilar apex aneurysm (BAA) that was treated with neck reconstruction-assisted coil embolization using the PulseRider device (PulsarVascular, Los Gatos, California), a novel neck-reconstruction device. A 68-yr-old man was found to have large BAA during work-up for sinusitis. Computed tomography angiogram revealed an 11×10-mm BAA. Patient has history of coronary artery disease, atrial fibrillation (currently taking Warfarin), recent left hip replacement and right femoral bypass. Treatment of the aneurysm was advised due to its location and size. Microsurgical clip reconstruction was high risk for general anesthesia due to his medical comorbidities and anticoagulation. Wide-necked bifurcation aneurysms are challenging to treat with traditional balloon- or stent-assisted techniques. To mitigate these challenges, novel neck-reconstruction devices have been developed. The Pulsar is one of these neck-reconstruction devices that removes the need to selectively catheterize branch arteries; it is available in a "Y" and "T" configuration. Under conscious sedation and through a radial artery approach, the patient underwent endovascular reconstruction of BAA with Pulsar device and coils. A 6-Fr guide catheter, a 0.021" microcatheter for the Pulsar device and a 0.017" microcatheter for coil delivering were used. A 3×8.6 mm Pulsar device was selected based on aneurysm neck and basilar artery measurements. Complete embolization (Raymond-Roy 1 obliteration) of the aneurysm was successfully achieved with no complications. The patient remained neurologically intact and was discharged on postoperative day 1. Parts of this video were published in Intracranial Aneurysms (1st Edition), Ringer (Ed), online companion to chapter 33B, Copyright Elsevier (2018).

Negative pressure wound therapy in the management of complex lower limb wounds: a case series highlighting outpatient care with small single-use devices

Background: Traditionally, the treatment of exposed tendon has required vascularised tissue coverage, usually with complex surgical intervention. The introduction of negative pressure wound therapy (NPWT) has challenged this traditional reconstructive concept. Unfortunately, standard NPWT units are usually bulky, noisy and curtail the mobility and lifestyle of patients. The introduction of small, modern, lightweight, portable, single-use NPWT units have therefore revitalised the use of NPWT and provided a solution to the many problems encountered with the larger devices. Case series: This study highlights three cases of patients with complex lower limb wounds with tendon exposure who were successfully treated with single-use NPWT in an outpatient setting. The median time for complete wound granulation was 5–10 weeks. Minor sharp debridement of wounds was required to encourage granulation tissue formation and this was well tolerated in the outpatient setting. Conclusion: Portable NPWT units provide an alternative to surgical reconstruction in patients with lower limb wounds with exposed tendon. These devices can be utilised in a purely outpatient setting, thus avoid long-term hospitalisation. Older patients with high anaesthesia risk or who lack alternative reconstructive options due to vascular co-morbidities are the most appropriate candidates for this treatment option.