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9THE USE OF NEGATIVE PRESSURE VACUUM THERAPY IN THE TREATMENT OF SOFT
TISSUE DEFECTS IN THORACIC INJURY
Zarutskyi Ya..
MD, DSci, Professor, Chief of the department of military surgery, Ukrainian military medical academy (Kyiv, Ukraine)
Aslanyan S.
Ph.D., Associate Professor (docent), Associate Professor of the department of military Surgery,
Ukrainian military medical Academy (Kyiv, Ukraine)
Kravchenko K..
PhD, Senior Ordinator of the Clinic of thoracic surgery, National military medical clinical center (Kyiv, Ukraine)
Vovk M.
Adjunct of the department of military surgery, Ukrainian military medical Academy (Kyiv, Ukraine)
Honcharuk V. Tutor of the department of military surgery, Ukrainian military medical Academy (Kyiv, Ukraine)
Abstract
Thoracic injury accounts for 6-8% of all traumatic injuries and belongs to the category of particularly severe lesions of the body. About 90% of victims with thoracic injury are of working age, whose treatment and rehabilitation are quite long due to the large number of purulent-septic complications (up to 20%), which often lead to disability or cause high mortality (17-30%). In peacetime, closed thoracic injuries are more common in the road accidents and in industries that are accompanied by multiple rib fractures and damage to internal organs. The mortality of the closed thoracic injury reaches 5-17%, and with a severe injury - 40%. In modern military armed conflicts, the frequency of combat thoracic injury (CTI) is 8-12% [2]. During the JFO (Joint Forces Operations) in Eastern Ukraine, CTI accounted for 11.7% of the combat casualties of the surgical profile, from which 79.4% were nonpenetrating, and 20.6% were penetrating and usually with damage to internal organs [1]. Severe CTI is accompanied by massive blood loss, traumatic shock, acute respiratory failure, other complications and high mortality to 37% [8]. Large and very large wounds of the chest damages not only skin and hypodermic cellulose, but also fascia, muscles and other important anatomic structures of the chest. In such cases, these are soft tissue defects. Treatment of gunshot wounds of the chest wall complicated by purulent process has a number of features, which are the development of infection in the wound and the occurrence of complex soft tissue defects, which is determined by the phase of the wound process. Peculiarities of the course of the wound process in this category of wounded are the development of traumatic disease, which affects the prolongation of all phases of the wound process and the accession of surgical infection [1,2,6].
During the JFO 9.3% of wounded with CTI, who had significant damage of the chest soft tissues. The peculiarities of combat surgical injury of the chest during the JFO in eastern Ukraine that they were all high-energy, received by bullets with high flight speed. Such injuries were characterized by the formation of a soft tissue defect, multiple fragmentary fractures with a bone defect. Combat surgical injury of the chest, given the different ballistic characteristics by the wounding shells, refers to severe damage of the chest, which in addition to the occurrence of defects in the chest wall causes severe damage of the chest internal organs. Despite the large number of such wounded with significant soft tissue defects, a clear classification of wounds based on their metric parameters has not yet been [3].
In the complex of systemic surgical treatment of wounded and injured with soft tissue defects in thoracic injury an important place is occupied by the treatment of complications both postoperatively and clinically by the chest: the development of purulent-necrotic processes, pleural empyema, broncho-pleural fistulas, infection chest wall wounds. Treatment of such wounds at CTI and a thoracic injury of peace time with soft tissues damage includes primary, repeated and secondary surgical debridements with the subsequent imposing of bandages. Therefore, the purpose of surgical treatment of such patients with soft tissue defects is fast closure in the simplest way with minimal losses, which involves the widespread concept of "reconstructive ladder", which reflects the distribution of plastic wound closure depending on the technical complexity of surgery [5]. This allows to replace small, large soft tissue defects in almost every anatomical area from the imposition of linear sutures to displaced pieces of soft tissue resistant to functional loads.
Modern principles of the treatment of wound defects of soft tissues of the chest are based on the following provisions: reduction of necrobiotic processes in damaged tissues, reduction of infectious complications, reduction of treatment time, reduction of disability of the wounded.
One of the modern world standards in the treatment of chest wounds with large soft tissue defects is the widespread using of VAC therapy (Vacuum Assisted Closure), or more known as NPWT (Negative pressure wound therapy), the treatment of soft tissue wounds by the negative pressure with the formation of vacuum dressings in the wounds (VAC-dressings) [4]. In the complex surgical treatment, this method allows to effectively clean
and prepare to close the wounds of the chest soft tissues by stimulating granulation and reducing the area of the wound defect - dermotension [6]. Therefore, the main purpose of the treatment of such wounds is to reduce the frequency of purulent complications, reduce the duration of treatment and fast returning wounded to service, or to recovering and other working activities. [7].
Keywords: combat surgical injury, combat thoracic injury, soft tissue deffects, negative pressure wound therapy.
Objective: to improve the results of complex surgical treatment of wounded and injured with soft tissue defects (STD) of thoracic wall in thoracic injury by application the negative pressure of vacuum therapy.
Materials and methods. The results of complex surgical treatment of 127 wounded and injured with defects of soft tissues of the chest wall in the period 20142019 were analyzed. Wounds and a closed injury were sustained both by wounded military servicemen during the JFO - combat surgical injury of the chest, and by civilians - a peacetime injury. All patients entered to the treatment facilities with bullet, shrapnel and explosive injuries of the chest, complicated by the inflammatory process and the formation of a defect in the chest soft tissues. Also included in the general study array were civilians who received a severe closed thoracic injury, who were subject to thoracotomy, during the postoperative period, who were also complicated by the purulent-inflammatory process of the wound with formation a defect in the soft tissues of the chest. Criteria for inclusion in the study: wounded and injured in the chest, the course of an injury or wound process in which was accompanied by the formation of a medium, large or extra-large soft tissue defect and violation of the integrity of the chest wall.
Two clinical groups were formed: main and comparison groups. The groups of the wounded and injured were comparable in the age, in the severity of the injury, the character of the wound channel, the number and localization of wounds,
The main group of clinical observation included 54 people with soft tissue defects and violation of the integrity of the chest wall due to injury of the chest in the treatment of which differentiated surgical treatment was used depending on the objective assessment of the severity of the injury, determining the leading injuries, which were used with negative pressure therapy by applying vacuum therapy in combination with different physical and chemical factors.
The comparison group of clinical observations included 73 wounded and injured, who were treated according to the traditional scheme (emergency and planned surgical interventions, daily dressings with antiseptics and ointment components, staged surgical treatments). All patients, depending on the severity of the injury were admitted to the surgical clinic in not heavy, severe and extremely severe severity. The age of the wounded ranged from 18 to 62 years and averaged 40.85 ± 4.29 years in the main group and 40.48 ± 3.50 years in the comparison group.
Table 1
Age Main group Comparison group
n % n %
18-29 12 22,2 15 20,5
30-39 15 27,8 23 31,5
40-49 15 27,8 20 27,4
50-59 3 5,6 4 5,5
More 60 9 16,7 11 15,1
Average age 40,85±4,29* 40, 48±3,50*
Totally 54 100% 73 100%
Characteristics of wounded and injured by age
* - age observation groups are comparable (t Student = 0,07; p = 0,943)
The majority of patients in both groups of clinical not differ. The ratio of gunshot wounds to closed inju-observations related to people of working age. ries was about 50/50 (table 2).
The ratio of patients in the groups of clinical observation of the mechanism of injury of the chest did
Table 2
Characteristics of wounded and injured depending from the mechanism of injury
Main group Comparison group □ 2 / p
n % n %
Gunshot wounds: 28 51,9 33 45,2
- bullets 12 22,2 10 13,7 0,549 / 0,46*
- fragments (multiple) 16 29,6 23 31,5
Closed injury 26 48,1 40 54,8
Totally 54 100 73 100
* - calculation of the value of p by Pearson's criterion x2
In both groups, among the gunshot wounds, the vast majority were multiple shrapnel: 16 (29.6%) in the main group and 23 (31.5%) in the comparison group, which often had the character of an explosive combined wound with primary widespread chest wall damage. Bullet wounds: 12 (22.2%) in the main group and 10 (13.7%) in the comparison group, always had a penetrating nature, also 9 (16.7%) and 9 (12.3%) in the groups accordingly - through wounds. The course of all wounds was complicated by a purulent-inflammatory process in the gunshot wound (exit hole), thoracotomy wound (in cases when thoracotomy was performed for urgent indications) or combined in both wounds. Therefore, the combination of primary defects of gunshot wound and secondary defects as a consequence of purulent-inflammatory and necrotic processes in the wound formed the final defect of the chest wall tissues, as the object of our study and curative effect.
With closed mechanism of injury: 26 (48.1%) in the main group and 40 (54.8%) in the comparison
group, all patients underwent immediate or urgent thor-acotomy according to the relevant clinical indications (massive hemothorax, chest instability, curled hemo-thorax, etc.), and defects in the tissues of the chest wall were the result of complicated by purulent-necrotic process of the thoracotomy wound. As part of the provision of emergency and urgent surgical care, all patients of the study groups in the acute period of traumatic illness underwent surgical operations. In this case, thoracentesis (from one or 2 sides) was performed in all patients. Thoracotomy was performed in 29 (53.7%) patients in the main group and 49 (67.1%) in the comparison group. In cases of gunshot wounds, primary surgical treatment of the inlet and outlet holes was also performed.
Data on the localization of chest wall tissue defects in the wounded and injured were important for effective planning of the treatment process (table 3).
Localization of damage Main group (n=54) Comparison group (n=73) Totally (n=127)
Number % Number % Number %
Anterior surface of the chest 4 7,4 7 9,6 11 8,7
Anterior-lateral surface of the chest 27 50,0 40 54,8 67 52,8
Lateral surface of the chest 9 16,7 10 13,7 19 15,0
The posterior surface of the chest 12 22,2 7 9,6 19 15,0
Two-focus defect - anterior-lateral and posterior surface 2 3,7 9 12,3 11 8,7
In both groups of clinical observation anterolateral defects of a thorax as a result of the complicated course of anterolateral thoracotomies prevailed - 52,8%.
Defects of the anterior, lateral and posterior surfaces were the result of a complicated course of gunshot wounds - 38.7%, and bifocal defects - a synchronous complicated course of anterior-lateral thoracotomy wound and gunshot wound - located at a distance from the thoracotomy. There was an area of undamaged tissue between the wound defects. The greatest difficulty in the treatment of localization were wounds that were located on the posterior surface of the chest: it was due
Characteristics of damage of organs and
to the difficulty of maintaining aseptics, wound care, and also a large array of damaged tissues.
In all victims in our sample thoracic injury was accompanied by damage to the internal organs of the chest. But at the time the inclusion of patients in the study, the acute manifestations of most of these injuries have already been stopped, and did not directly affect the treatment of wound defects of the chest wall. Anatomical and morphological features of these injuries and their specific weight in the subgroup of gunshot wounds differed from the subgroup with a closed mechanism of injury (table 4).
Table 4
Main group Comparison group
n % n %
Gunshot wounds: 28 33
- fractures < 3 ribs 2 7,1 4 12,1
- - fractures> 3 ribs 18 64,3 22 66,7
- - bifocal fractures of the ribs (inlet and outlet holes) 8 28,5 7 22,6
- - lung injury 26 92,9 29 87,9
- - hemothorax 5 17,9 9 27,3
- - hemopneumothorax 23 82,1 24 72,7
Closed injury 26 40
- - fractures> 3 ribs 17 65,4 22 55,0
- - multiple bilateral fractures of the ribs 4 15,4 12 30,0
- - unstable chest 5 19,2 6 15,0
- - lung contusion 24 92,3 40 100
- - heart attack 10 38,4 19 47,5
- - hemothorax 1 3,8 4 10,0
- - hemopneumothorax 25 96,2 36 90,0
Totally 54 - 73 -
Table 3
Distribution of wounded and injured in groups for location of defects in the chest tissues
Most patients in the study group with thoracic in- Table 5 presents the distribution of patients by the
jury had combined character: 46 (85.2%) in the main number of damaged anatomical and functional areas. group and 62 (84.9%) in the comparison group, but the thoracic component was always leading.
Table 5
Characteristics of the study array by the number of damaged anatomical and functional areas (AFA)
AFA damage Main group Comparison group p
n % n %
One 8 14,8 11 15,1 0,969*
Two 27 50,0 38 52,1 0,819*
Three or more 19 35,2 24 32,8 0,786*
Totally 54 100% 73 100
Despite the comparability of groups by the number of damaged AFA, there was a need to compare them by severity of injury. For this, we chose two anatomical scales - based on determining the degree of morphological damage to organs and tissue structures: Anatomic trauma score (ATS) - allows to assess the severity of isolated and combined injury, taking into account the
severity of its individual components, and Injury Severity Score (ISS) - designed to assess mostly combined injuries, but the most widely used anatomical scale of injury severity in the world. The use of two scales increases the reliability of the results. In addition, they have the same number of comparable nominal gradations (tables 6 and 7).
Table 6
Criteria for assessing the severity of injuries in patients in the study array
The severity of the injury ATS ISS Forecast for life
not heavy < 24 <15 favorable
heavy 25 - 41 16-25 questionable
extremely heavy > 42 >25 unfavorable
Table 7
Severity of injury and the ratio of groups by severity of injury
The severity of the injury Main group Comparison group P
n % n %
ATS severity 23,1±2,8 24,8±2,1 t = 0,63*; p = 0,49
ISS severity 15,9±1,3 16,8±1,4 t = 0,47*; p = 0,64
Not heavy 22 40,7 26 35,6 x2 = 0,347** p=0,56
Heavy 28 51,9 43 58,9 x2 = 0,625** p=0,43
Extremely heavy 4 7,4 4 5,5 x2 = 0,195** p=0,66
Totally 54 100% 73 100
* Calculation according to Student's t test
** Calculation by criterion x2
The vast majority of patients in the study groups were seriously injured - a total of 71 (55.9%) and victims with not heavy injuries - 48 (37.8%), while there were few victims with extremely severe injuries - 8 (6.3%). This is due to the high mortality of the latter category of patients in the acute period of traumatic illness, and they were simply not included in the study according to the inclusion / exclusion criteria.
Thus, the age, mechanism of injury, the character of defects in the tissues of the chest wall, the consequences and complications of thoracic injury, and also the severity of the injury of the clinical observation group were homogeneous and comparable. That is, the results of their management and surgical treatment can be compared and statistically processed.
Results. The method of treatment with negative pressure in the complex surgical treatment of soft tissue defects of the chest wall is one of the main methods of preparing wounds for closure, which is a set of measures aimed at creating conditions in which the wound defect can be closed with minimal risk of complications and minimal losses in functional terms. The main condition for successful wound healing is the transition of the wound process to the second (reparation) phase. It is established that treatment by vacuum therapy with negative pressure gives some advantages. It improves the course of all stages of the wound process, which is characterized by a decrease in local interstitial soft tissue edema, improved tissue microcirculation, increased local blood and lymph circulation, reduced microbial contamination in the wound, reducing
the severity of wound exudation, which is necessary to stimulate angiogenesis, enhance fibrinolysis and improve the functioning of growth factors for normal wound healing.
Vacuum therapy with negative pressure was performed using devices KCI, HEACO, GomCo, in combination with irrigation with solutions of antiseptics, antibiotics, oxygen insufflation, ultrasonic cavitation for additional stimulation of repair processes. The technique of vacuum therapy is universal and has been used in various phases of the wound process to prevent infection, and in cases of treatment of infectious complications. Also, the method of applying negative pressure was used as a temporary stage for preparation of wound defects for plastic closure and after reconstructive surgery, as a method of wound management in the postoperative period.
All wounded and injured in the comparison group (73 patients) used traditional wound healing tactics. After preoperative preparation, surgical treatment of wounds was performed. It included the opening of wounds, removal of foreign bodies, non-viable tissues, active washing with antiseptic solutions. Wound surfaces of the soft tissues of the chest were tamponade with gauze wipes with solutions of antiseptics. Bandages were replaced 1-2 times a day. Various solutions of antiseptics were used, such as betadine, decasan. When the signs of the inflammatory process were reduced, the wound was cleaned, and the amount of exudate was reduced, the defects were closed with the help of local tissues and skin plasticity methods.
In the main group (54 patients) the method of negative pressure was used. Indications for the use of vacuum therapy for chest injuries were infected chest wall wounds, chest wall defects with open pneumothorax, the presence of a chest wall wound in combination with
pleural empyema and as a stage of temporary wound closure in preparation for thoracoplastic. Contraindications to the application of a vacuum bandage were ne-crotic tissue, bleeding in the wound area, unexamined fistulas. The initial use of this method in the complex surgical treatment of soft tissue wound defects is most effective, in our opinion, in the period that corresponded to the second phase of the wound process (37th day). Carrying out vacuum drainage of wounds once or several times was carried out in a constant or intermittent mode. Repeated sessions of vacuum therapy varied depending on the clinical manifestations. Replacement of bandages was performed in 3-4 days. Criteria for positive use of NPWT were the following factors: reduction local tissue edema, wound cleaning from necrotized tissues, fibrin plaques, purulent contents, formation of young forms of granulation tissue, reduction of purulent secretions from wounds, improvement of clinical blood test.
When the wound defects of the soft tissues of the chest wall were temporarily closed, liquid sutures were applied, which were covered on the outside with a gauze napkin, and the skin was protected with a tread. A polyurethane sponge was applied on top, which was sutured to the edges of the wound for more secure fixation. In the presence of large and deep vast defects of the soft tissues of the chest wall, the sponge was laid in several layers for completely closure them. In the presence of non-viability of the ribs with signs of osteomyelitis at the bottom of the wound defects of the chest, they were perforated, or according to the indications, the outer cortical plate of the rib was removed and soft tissue defects were closed with a polyurethane sponge. This accelerated the elimination of osteomyelitis, stimulated regional blood flow and growth of granulation tissue.
Picture 1.
Infected wound with a defect in the soft tissues of the front of the chest. Osteomyelitis V-VI ribs on the left.
Picture 2. Surgical treatment of the wound with resection of the V rib on the left.
Picture 3. Imposition of a functioning VAC bandage on the wound defect of soft tissues at treatment of a gunshot
fragment wound at CTI.
After autodermoplastic in some cases, in order to fully closure the defects of the soft tissues of the chest and secure fixation of the split autodermograft with a complex relief of the wound surface used the application of polyvinyl alcohol vacuum dressings with absorbent and bacteriostatic effect with negative pressure. It is helped to heal wound defects, evacuate wound exudate and prevent graft injury. A feature of the application of vacuum therapy with negative pressure on the chest was the constant monitoring of its implementation, as there was a risk of bleeding.
All patients in both groups of clinical observation underwent general drug therapy, which was aimed at compensating for general disorders. Antibacterial therapy was performed in all patients with an antibiotico-gram.
The study found that the course of wound healing in wounded with defects of the soft tissues of the chest wall in thoracic injury had significant differences depending from microbial contamination (clean, contaminated, purulent wounds), the mechanism of injury and its location. Already in the first sessions of vacuum therapy in the main group there were significant changes, manifested by increase in exudation from the wound and changes the character of secretions from purulent to serous. For 5-7 days during which vacuum therapy was performed, in most patients the elimination of the intoxication syndrome was observed, the wound was cleared from purulent and necrotic secretions. In
addition, to a large extent the process of eliminating intoxication contributed to the rapid reduction of micro-bial contamination of the wound [10].
In contrast to the comparison group in the main group at the local level, the characteristic features were the appearance of active forms of granulation on the surface of the wound defect on average 6-8 days of treatment, which meant reducing the duration of phase I inflammation and its faster transition to phase II of the wound process.
Characteristic changes occurred on the part of blood parameters, which were initially manifested by leukocytosis with a shift of the leukocyte formula to the left and the appearance of young forms of neutrophils, then the number of leukocytes to 7-9 days decreased to normal.
This positive dynamics of these indicators in the shortest possible time of complex treatment of wound defects of soft tissues of the chest wall using VAC therapy was characterized by cleaning the wound surface, removing the causative agent of purulent infection, and early appearance of active granulations, followed by signs of marginal epithelialization. Characteristic signs of stoping the using NPWT were the change of the exudation phase to the phase of proliferation, wound cleaning, reduction of microbial contamination and improvement of microcirculation, which was characterized by improved local circulation.
During the second week of treatment there was also a further normalization of clinical blood counts -decreased white blood cell count and the percentage of
rod neutrophils. As a result of the favorable development of the treatment process, the length of stay of patients of the main group in the hospital was (15.75 ± 4.27) bed-day.
Thus, based on research and treatment results, the data indicate significant advantages in the positive and effective treatment of patients with large defects of the soft tissues of the chest wall with thoracic injury using VAC dressings, characterized by reduced duration of treatment, accelerated reduction of bacterial wound contamination, reduction of local tissue edema, improvement of local lymph and blood circulation.
Conclusiones.
1. The use of negative pressure vacuum therapy in complex surgical treatment of soft tissue defects of the chest wall as a result of gunshot wounds and injuries leads to improvement of microcirculation in soft tissues, fluid evacuation and reducing interstitial edema, reduction of wound defect and its preparation for the plastic closure of tissues.
2. The use of vacuum therapy for closure wound defects of the thoracic injury, and also postoperative wounds has a positive curative effect not only on the wound defect, but also on the internal organs of the thoracic cavity.
3. Thus, the success in the treatment of patients with wound defects of the soft tissues of the chest wall of various etiologies is due not only to high-quality surgery with plastic closure, but also the constant use of comprehensive surgical treatment with adequate antibacterial therapy and active involvement and constant monitoring NPWT, which allows in the shortest terms to reduce the duration of treatment, the number of complications and improve the functional results of the wounded and injured at the level of medical care.
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