Surgical Wound Dehiscence Treatment With Low-Level Laser Therapy and Barbatimão: A Case Report.

BACKGROUND: Low-level laser therapy (LLLT) and a gel containing an extract of Barbatimão, a native Brazilian tree, have shown promising results in both preclinical and clinical wound healing studies. PURPOSE: To describe the treatment of surgical wound dehiscence with LLLT and Barbatimão gel. CASE STUDY: A 54-year-old woman without comorbidities underwent abdominoplasty at another health facility. Three (3) weeks later she presented to the authors' clinic after an episode of syncope, abrupt dyspnea, purulent exudate, and necrotic tissue in the surgical incision. She reported that wound redness, warmth, and swelling started 8 days postoperatively. The patient was admitted; on day 3 of that hospital stay, her condition improved and surgical debridement was performed. Follow-up care of wound dehiscence was provided in the outpatient clinic. The treatment involved daily application of Barbatimão gel and weekly application of LLLT. The wound healed after 84 days. CONCLUSION: This case report suggests that LLLT may be a beneficial adjunctive therapy, together with Barbatimão gel, for the treatment of surgical wound dehiscence.

Medical grade honey for the treatment of paediatric abdominal wounds: a case series.

OBJECTIVE: Children are at high risk of injuries and wounds. The application of medical grade honey is a promising approach to improving the healing of wounds of various origin and severity. However, the use of medical grade honey in young paediatric patients remains limited. The aim of this study is to show the safety, efficacy and usefulness of medical grade honey in abdominal wounds, of different causes, in paediatric patients. METHOD: This was a prospective, observational case series evaluating five young infants with abdominal wounds at the General Hospital in Thessaloniki. All wounds were treated in the same manner with daily medical grade honey applied to the wound area and closely monitored. RESULTS: All treated wounds rapidly presented granulation tissue formation and underwent re-epithelialisation. Peripheral oedema and inflammation decreased upon initial application. Necrotic tissue was effectively debrided when present. Slough was removed and no signs of infection were detected, irrespective of initial wound presentations. Scar formation was minimal and the full range of motion was preserved in all cases. CONCLUSION: Based on this case study, medical grade honey is safe and effective in treating different abdominal wounds, including infected or dehisced wounds as well as burns. The easy application and broad applicability make medical grade honey recommendable as a first-line treatment in paediatric patients.

The neurosurgical wound and factors that can affect cosmetic, functional, and neurological outcomes.

Surgically accessing pathological lesions located within the central nervous system (CNS) frequently requires creating an incision in cosmetic regions of the head and neck. The biggest factors of surgical success typically tend to focus on the middle portion of the surgery, but a vast majority of surgical complications tend to happen towards the end of a case, during closure of the surgical site incisions. One of the most difficult complications for a surgeon to deal with is having to take a patient back to the operating room for wound breakdowns and, even worse, wound or CNS infections, which can negate all the positive outcomes from the surgery itself. In this paper, we discuss the underlying anatomy, pharmacological considerations, surgical techniques and nutritional needs necessary to help facilitate appropriate wound healing. A successful surgery begins with preoperative planning regarding the placement of the surgical incision, being cognizant of cosmetics, and the effects of possible adjuvant radiation therapy on healing incisions. We need to assess patient's medications and past medical history to make sure we can optimise conditions for proper wound reepithelialisation, such as minimizing the amount of steroids and certain antibiotics. Contrary to harmful medications, it is imperative to optimise nutritional intake with adequate supplementation and vitamin intake. The goals of this paper are to reinforce the mechanisms by which surgical wounds can fail, leading to postoperative complications, and to provide surgeons with the reminder and techniques that can help foster a more successful surgical outcome.

Hyperbaric oxygen therapy as adjuvant for treating wound complications after extensive resection for vulvar malignancy.

INTRODUCTION: Necrosis, wound breakdown, and infection represent major complications associated with radical vulvectomy. We aimed to analyze the feasibility of hyperbaric oxygen (HBO2) therapy as an adjunctive treatment for such complications. METHODS: We performed a retrospective analysis of the medical records, clinical charts, and operative records of vulvar cancer patients who underwent hyperbaric oxygen therapy after extensive surgical resection in our institute between 2012 and 2016, with a comparison of the clinical outcomes of patients with similar surgical procedures andsevere wound complications who did not undergo HBO2. RESULTS: A total of 16 patients were included in the study. In the subgroup treated with HBO2, seven patients were identified. Two patients had primary surgery, while five had recurrent surgery (of these, two had previously undergone radiation therapy). Six patients received reconstructive flaps (five myocutaneous and onefasciocutaneous), while one patient had primary suture. Dehiscence, ischemia and necrosis were estimated to cover 30%-80% of the surgical surface area. Surgical debridement was performed in six patients. Daily 90-minute sessions in the hyperbaric chamber were performed at a pressure of 2.2 atmospheres absolute, with partial oxygen pressure of 1672 mbar. Infection control and satisfactory healing were achieved using 10-61 sessions. All patients in the subgroup who did not receive HBO2 required surgical debridement due to partial or near-total flap necrosis, with two reconstructive interventions required. CONCLUSIONS: Hyperbaric oxygen therapy was an efficient adjuvant for wound healing and infection control in managing wound complications after extensive vulvar resections.

Hyperbaric oxygen therapy for wound breakdown after oronasal fistula and cleft palate repair: four cases.

We offer the first report of hyperbaric oxygen (HBO2) therapy to treat early surgical wound breakdown after oronasal fistula and cleft palate repair in the pediatric population. We present four patients' experiences after undergoing HBO2 therapy. HBO2 was initiated as soon as an oronasal fistula was identified. Three of the children underwent 10 HBO2 treatments with the fourth undergoing 11 treatments. There were no adverse effects during treatment; none of the patients required decompressive myringotomy. Follow-up shows portions of the repair have been salvaged by initiating HBO2 at the first sign of fistula formation. In our case series, the fistulas all decreased in size over the course of treatment and demonstrated granulation tissue at the wound edges. Given the positive outcomes from our preliminary results, our results suggest concurrent usage of HBO2 therapy for wound breakdown after cleft palate repair is an effective treatment option.

Hyperbaric Oxygen Therapy for Wound Dehiscence After Intraoral Bone Grafting in the Nonirradiated Patient: A Case Series.

PURPOSE: In maxillofacial surgery, hyperbaric oxygen treatment is used almost exclusively as adjunctive therapy for osteoradionecrosis of the mandible in irradiated patients. It also is used to prevent the occurrence of osteoradionecrosis in the irradiated patient when dental surgery is indicated. Theoretically, hyperbaric oxygen therapy should benefit the nonirradiated patient in maxillofacial surgery (eg, patients with persistent intraoral wound dehiscences after bone grafting). MATERIALS AND METHODS: Six nonirradiated patients underwent hyperbaric oxygen therapy because of compromised wound healing after intraoral bone grafting of the maxilla as a preimplant procedure. All patients were treated 7 to 26 times with hyperbaric oxygen therapy at 2.5 ATA. RESULTS: All patients healed uneventfully. In retrospect, almost all patients had a history of chronic maxillary sinusitis or trauma to the operated area. CONCLUSION: Hyperbaric oxygen therapy seems to be an effective adjunctive therapy in the treatment of nonirradiated patients with compromised intraoral maxillary bone graft healing. Chronic maxillary sinus problems or a history of trauma could predispose to wound dehiscence after bone grafting.

Autoconjunctival Graft Compromise After Pterygium Surgery in a Patient Receiving Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

PURPOSE: To report on a case of autoconjunctival graft compromise after pterygium surgery in a patient on long-term anti-vascular endothelial growth factor (anti-VEGF) therapy, due to the deleterious effects of anti-VEGF agents on ocular wound healing. METHODS: A white female in her early eighties presented with large right nasal pterygium, first noted 5 years previously. She also had macular degeneration and had been receiving monthly injections of ranibizumab, which was later switched to aflibercept. She proceeded to have a right nasal pterygium excision with a conjunctival autograft, 9 days after her last dose of intravitreal aflibercept. RESULTS: Surgery was uneventful; however, at the week 2 postoperative review, there was conjunctival graft dehiscence with melting of the graft and underlying sclera. The patient was administered hyperbaric oxygen treatments, topical antibiotics, steroids, and lubricating eye drops, and aflibercept injections ceased. The scleral melt slowly resolved and her aflibercept was restarted 3 months later. CONCLUSIONS: This case highlights the potential hazards of performing elective surgery in patients on VEGF inhibitors and the need for an appropriate interval between cessation/subsequent restart of anti-VEGF agents and surgery to be established.

Management of a Dehisced Hand Wound Using Hydrogen Peroxide, Electrical Stimulation, Silver-containing Dressings, and Compression: A Case Study.

Wound dehiscence is the separation of a wound along surgical sutures. A 57-year-old, otherwise healthy mechanic presented with a large open wound of >1 month duration on his left hand. His wound had dehisced after treatment that involved cleansing, surgical sutures, and oral antibiotics. He presented with a 5.0 cmx0.7 cmx0.3 cm lesion through the palmar creases of the hand with edema around the fourth and fifth digits and a callous formation around the distal portion of the wound. The wound had scant serosanguinous drainage and some induration at the periwound area, as well as a moderate foul odor. Tendons were not affected, but function was limited, the hand was painful, and the patient had been unable to work. Treatment was initiated with twice-a-week immersion of the hand in hydrogen peroxide diluted with water subjected to high-voltage pulsed current electric stimulation (HVPC). The wound was dressed with silver-containing dressings secured with stretch gauze and a compression garment. The wound was completely closed after 9 visits (35 days). No functional limitations of the hand or fingers, no cosmetic defect, and no wound recurrence were noted 9 months after healing. Although uncommon, dehisced wounds, especially in certain anatomical locations such as the hand, can be difficult to heal and may cause long-term problems with functioning. The treatment combination facilitated expedient healing of this dehisced hand wound. Research is needed to help elucidate the observations from this case study.

Clinical experience with Leptospermum honey use for treatment of hard to heal neonatal wounds: case series.

Preterm, critically ill neonates represent a challenge in wound healing. Many factors predispose infants to skin injuries, including decreased epidermal-dermal cohesion, deficient stratum corneum, relatively alkaline pH of skin surface, impaired nutrition and presence of multiple devices on the skin. We present a case series describing the use of medical-grade honey-Leptospermum honey (Medihoney), for successful treatment of slowly healing neonatal wounds, specifically stage 3 pressure ulcer, dehiscent and infected sternal wound, and full-thickness wound from an extravasation injury.

Anaphylactic shock during hyperbaric oxygen therapy.

A case of a 38-year-old woman is reported who was treated with hyperbaric oxygen therapy to cure a dehiscent wound. She suffered from "oral-allergy syndrome" (OAS) while eating certain fruits, and from itching when wearing latex gloves to handle hair dyes. Fifteen minutes after the start of compression, malaise, anxiety, dyspnoea, tachycardia, cold sweating and laryngeal stridor occurred. Despite intensive care treatment, face angioedema persisted for several days. On the basis of history, radioallergosorbent test (RAST) and prick tests, latex was assumed to be responsible for the anaphylactic reaction. To our knowledge, this is the first extensive report of an anaphylactic reaction to latex in a hyperbaric chamber. The lesson drawn from this case record can be summarized as follows: 1) never fail to collect a thorough history; 2) set up a latex-safe hyperbaric chamber when needed; 3) have an emergency kit always near at hand.

Successful treatment of an infected wound in infants by a combination of negative pressure wound therapy and arginine supplementation.

OBJECTIVE: Wound dehiscence caused by surgical site infection (SSI) presents a complicated problem. Negative pressure wound therapy (NPWT) was developed to treat wound dehiscence. Nutritional treatment using arginine has also been recently shown to be effective for the treatment of pressure ulcers. Therefore, wound complications due to SSI were treated using NPWT combined with nutritional therapy with an arginine-rich supplement (ARS). METHODS: Six pediatric patients with wound dehiscence due to SSI received this combined therapy. RESULTS: The average age of the patients was 12.2 mo. The operations that these patients underwent included laryngotracheal separation, radical operation for spinal bifida, gastrostomy, colostomy, anorectoplasty, and tumor extirpation. A local wound infection induced wound dehiscence in all patients. Therefore, NPWT was introduced with an enteral administration of ARS. All wounds completely healed within 1 mo after the introduction of this combined therapy without any other complications from the NPWT or ARS. A follow-up study at 6 mo after this therapy was completed showed no complications associated with the wounds. CONCLUSION: This combination therapy using NPWT and ARS administration was effective in inducing early healing of infected wound complications after surgery.

Innovation and management of diabetic foot wounds.

Recent innovations in the field of wound healing have created numerous advanced therapies from which clinicians may now choose. The challenge for the reconstructive surgeon is to ensure that these adjunct technologies are used according to an evidence-based protocol to ensure optimal healing. Critical to successful outcomes is that new modes of therapy do not supplant, but are used in tandem with, core principles of wound management: establishing a correct diagnosis, ensuring a good local blood supply, debriding the wound to a clean base, correcting the biomechanical abnormality, and nurturing the wound until it shows signs of healing. Debridement should be performed as often as necessary until the wound is deemed clean and ready for reconstruction. Useful adjuncts in debridement include hydrotherapy and ultrasonic therapy. The majority of reconstructions are accomplished through simple techniques. If a wound is not meeting the expected healing trajectory, management adjuncts such as negative pressure wound therapy, growth factor, cultured skin, and hyperbaric oxygen can then reactivate or expedite the process toward achieving a healed wound.

Hyperbaric oxygen on the healing of ischemic colonic anastomosis--an experimental study in rats.

The aim of the present study was to evaluate the effect of hyperbaric oxygen therapy (HBO2) on the healing process of ischemic colonic anastomoses in rats. Forty Wistar rats were divided into four groups: control (Group I), control and HBO2 (Group II), ischemia (Group III), ischemia and HBO2 (Group IV). Ischemia was achieved by clamping four centimeters of the colonic arcade. On the eighth therapy day, the anastomotic region was removed for quantification of hydroxyproline and immunohistochemical determination of metalloproteinases 1 and 9 (MMP1, MMP9). The immunohistochemical studies showed significantly larger metalloproteinase-labeled areas in Group IV compared with Group III for both MMP1 and MMP9 (p < 0.01). This finding points to a higher remodeling activity of the anastomoses in this experimental group. Additionally, animals subjected to hyperbaric oxygen therapy showed both a reduction in interstitial edema and an increase in hydroxyproline concentrations [at the anastomotic site]. Therefore, we conclude that HBO2 is indeed beneficial in anastomotic ischemia.

The role of hyperbaric oxygen therapy in the treatment of sternal wound infection.

Sternal wound dehiscence and infection are major problems for patients and health care providers. A range of risk factors, including diabetes, obesity and internal thoracic artery harvest, has been implicated. Several pathophysiological mechanisms, which may account for the development of infection, have been proposed. There is a growing body of evidence which suggests that sternal ischaemia may play a significant role in the initiation of wound infection, and that this may be exacerbated by harvest of the internal thoracic artery. Current treatments for infection include wound debridement, irrigation and tissue flap reconstruction. In addition, several novel therapies such as negative pressure dressings have been shown to be safe and useful. Hyperbaric oxygen therapy - the administration of 100% oxygen at pressures greater than atmospheric pressure - is widely used in the treatment of various chronic wounds. The mechanism whereby hyperbaric oxygen exerts its effects is being elucidated and there is a growing body of clinical evidence that supports its use. It has been suggested that there may be a role for hyperbaric oxygen therapy in the treatment of sternal infection. The theoretical mechanisms would seem plausible, but at present there is only limited evidence to support its use. This review addresses the theory and evidence supporting the role of hyperbaric oxygen therapy in the treatment of sternal wound infection.

[Effects of hyperbaric oxygen therapy (HBO) during treatment of infected free bone transplants. A Case report]. / Effekte der Hyperbaren Sauerstofftherapie (HBO) bei der Behandlung infizierter freier Knochentransplantate.

BACKGROUND: Hyperbaric oxygen therapy (HBO) leads to a significant increase of oxygen supply in poorly perfused tissue. Several physiological mechanisms of this treatment modality are suitable for having a positive effect on infected large autologous free bone transplants. CASE REPORT: In a 49-year-old male with a metastasized squamous cell carcinoma of the floor of the mouth radical tumour surgery with subsequent radiation was performed. Nine years later an infected osteoradionecrosis of the mandible emerged which required a continuity-resection with simultaneously performed reconstruction of the mandible using an autologous free transplanted iliac bone graft. Four days post surgery wide intraoral dehiscence with complete denuding of the bone graft occurred. For this reason initiation of an adjuvant hyperbaric oxygen therapy in addition to high dose antibiotic therapy and local wound care. Combined therapy led to granulation tissue on the surface of the transplanted bone with subsequent epithelization. Complete incorporation and conversion of the bone transplant with full rehabilitation concerning function and aesthetics was noted. DISCUSSION: Without HBO treatment the large volume infected autologous free bone transplant would have been lost. Beside other capabilities of HBO the induction of rapid neovascularisation and increasing oxygen diffusion radius are the reasons that the infected transplant was saved. Only under these conditions it was possible to erradicate the bacterial infection effectively with antibiotics.

Treatment of surgical wound dehiscence.

Surgical exploration of cavities, sinuses, and specific antibiotic therapy are fundamental for the control fo cutaneous infection. Topical treatment will vary based on evaluation of the lesion, experience of the health care team, and the environment.

[The "open abdomen" as one of the possible therapeutic alternatives in postoperative complications]. / "Open abdomen" jedna z mozných liecebných alternatív pooperacných komplikácií.

The authors discuss the important problem of healing, infection of surgical wounds and causes of healing per secundam. Despite efforts on the part of surgeons to close the surgical wound, in particular in old people with polymorbidity, hypoproteinaemia and anaemia, disintegration of the surgical wound may occur which cannot be closed and healing must proceed while the abdomen is open.

Is hyperbaric oxygen a useful adjunct in the management of problem lower extremity wounds?

Hyperbaric oxygen (HBO) is currently being used in the treatment of nonhealing or "problem" wounds of the lower extremities. In an attempt to evaluate the efficacy of HBO in problem wounds, a retrospective study of the HBO experience at Orlando Regional Medical Center was conducted. From 1989 to 1994, fifty-four patients with nonhealing lower extremity wounds resulting from underlying peripheral vascular disease and/or diabetes mellitus were treated with HBO. Wounds were grouped into the following five categories: (1) diabetic ulcers (n = 17 [31%]); (2) arterial insufficiency (n = 8 [15%]); (3) gangrenous lesions (n = 6 [11%]); (4) nonhealing amputation stumps (n = 13 [24%]); and (5) nonhealing operative wounds (n = 10 [19%]). Each patient received an average of 30 treatments. Outcomes for all 54 patients treated with HBO in this study were dismal. None of the patients experienced complete healing, six (11%) showed some improvement, 43 (80%) showed no improvement, and in five cases (9%) results were inconclusive because these patients underwent concomitant revascularization or amputation. Thirty-eight of the 43 patients who showed no improvement (88%) ultimately required at least one surgical procedure to treat their wounds. Thirty-four patients (63%) developed complications, most commonly barotrauma to the ears, which occurred in 23 patients (43%). The average cost of 30 HBO treatments was $14,000 excluding daily inpatient charges. Based on the experience with HBO therapy at Orlando Regional Medical Center and the paucity of good supporting literature, it is difficult to justify such an expensive, ineffective complication-prone treatment modality for problem extremity wounds.

Bleb rupture following filtering surgery with mitomycin-C: clinicopathologic correlations.

A 91-year-old woman with a complete rupture of her mitomycin-C filtration bleb associated with eye rubbing while crying was examined. An 18mm soft contact lens was placed preoperatively to re-form the anterior chamber and the patient underwent a conjunctival advancement. Histopathology of the free conjunctival specimen revealed a stratified squamous epithelium with marked attentuation of the subepithelial tissue in the area treated with mitomycin-C. Bleb rupture may be associated with minimal physical trauma following guarded filtration surgery. Successful visual rehabilitation is possible with conjunctival advancement, yet long-term survival of the bleb is poor.