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Aims Anastomotic insufficiencies(AI) and perforations of the upper gastrointestinal tract(uGIT) result in high morbidity and mortality. Besides surgical revision and endoscopic stent placement the endoluminal vacuum therapy(EVT) has been established as an additional strategy. So far, the Eso-Sponge is the only licensed EVT system with limitations in very small defects. Therefore, a fistula sponge(FS) was established in our center for the treatment of small defects of the uGIT as a new therapeutic approach. To evaluate success rates, indications and complications of both EVT options in a retrospective, single-center trial.

Methods Between 01/2018 and 12/2020 all patients undergoing either a FS-EVT or conventional EVT(cEVT) with Eso-Sponge (Braun Melsungen, Germany) due to AI or perforation of the uGIT were recorded. Following criteria were evaluated: indication, diameter of leakage, therapy success and complications. FSs were prepared using a nasogastric tube (6-16Ch diameter) and a porous drainage film (Suprasorb CNP, Lohmann&Rauscher, Germany)(length 1 – 6 cm) sutured to the distal tip.

Results N = 72 patients were included in this analysis (FS-EVT N = 20; cEVT N = 52). FS-EVT was performed in 60 % suffering from AI (cEVT = 68 %) and 40 % from perforation (cEVT = 32 %;p>0.05). After 6.2±3.3d of treatment FSs were exchanged every three days in average, comparable data were obtained for cEVT. The mean diameter of the defect was 9 mm in the FS-EVT group compared to 24 mm in cEVT(p < 0.001), the depth of the leakage showed no significant difference (46 mm for both groups). Therapeutic success (development of granulation tissue, resolution of the leak) was achieved in 90 % (FS-EVT) and 91 % (cEVT) respectively (p > 0.05).

Conclusions EVT comprises an extraordinary treatment option of transmural defects of the uGIT. In clinical practice fistulas <10 mm with large abscess formations exhibit a special challenge, since intraluminal cEVT normally fails. In these cases the concept of extraluminal FS placement is safe and effective.

Die endoskopische Vakuumtherapie (EVT) ist ein fester Bestandteil der Therapie postoperativer Anastomoseninsuffizienzen im Gastrointestinaltrakt. In jüngster Zeit wird die EVT auch bei anderen Indikationen wie Perforationen, endoskopisch zugänglichen Abszessen oder enterokutanen Fisteln mit Erfolg angewendet. Dieser Beitrag erläutert schrittweise den Gebrauch der EVT und zeigt die Möglichkeiten, aber auch Risiken und Grenzen der Therapie auf.

Dressings continue to be a key part of successful wound care, however, choosing the right product for the right patient at the right time can be challenging for the clinician (Hedger, 2014). Modern foam dressings have been widely available since the mid-1970s with the aim to manage light-to-heavy exuding wounds (Hedger et al, 2014). Historically, bordered foam dressings have utilised acrylic-based adhesives; however, these have been associated with increased risk of skin sensitisation and medical adhesive-related skin injuries (MARSI; Meuleneire and Rucknagel, 2013; Hedger et al, 2014; Mestach et al, 2018; Downie and Collier, 2021). A clinical evaluation was undertaken to detail the characteristics and performance of Suprasorb® P sensitive silicone foam dressing (L&R Healthcare). The evaluation comprised a minimum of four dressing changes over at least 2 weeks. Fifty patients (51 wounds) were included in the evaluation. At the final evaluation, 57% (n=29) of the wounds were recorded as improved, 37% (n=19) were recorded as static and 6% (n=3) were recorded as having deteriorated. Of the 27% (n=14) evaluations where patients reported self caring, 71% scored Suprasorb P sensitive as above average for ease of use, suggesting the dressing may be suitable for patients who were self-caring and can apply their own dressing. Suprasorb P sensitive performed well in all the parameters evaluated and may be considered where effective exudate handling, improved patient comfort and ease of handling is required.

A 57-year-old patient underwent emergency laparotomy for an acute abdomen with free intra-abdominal air caused by a perforated distal gastric ulcer. Surgical closure was performed by suture. Histological adenocarcinoma was found Therefore, revision laparotomy with distal gastric resection and Roux-en-y reconstruction was done 3 days later. At 6 days postoperatively, a discharge of biliary secretions via target drainage for duodenal stump insufficiency was seen. Surgical closure was tried in another revision laparotomy. But again biliary secretion occurred proving the persistent duodenal leakage.

Passive drainage via the operative drain was sufficient to avoid development of an acute abdomen, therefore the duodenal secretions were drained passively. Secretion of 100–200 ml daily persisted for 21 days with formation of a duodenal cutaneous fistula channel ([Fig. 1]).

Then, treatment was switched to active drainage management with endoscopic negative pressure using an open-pore film drain. The drain was made by wrapping a strip of thin, double-layered, open-pore film (Suprasorb CNP Drainage Film; Lohmann & Rauscher, Rengsdorf, Germany) around the distal drainage end and fixing it with a suture [1] [2] [3] [4] [5] ([Fig. 2]). This created a small-bore open-pore drainage tube to which negative pressure could be applied. The open-pore film drain used had a diameter of only 5 mm. The length of the drainage element was 10 cm. The drain was simply manually inserted in the cutaneous opening into the pre-existing 12-cm-long fistula channel. Suction of –125 mmHg was applied (ACTIV.A.C; KCI, San Antonio, Texas, USA). The secretion stopped immediately. After 4 days, endoscopic negative pressure treatment was terminated. The open-pore film drain was removed by pulling out the tube ([Fig. 3]). Endoscopic inspection of the fistula channel showed the typical suction effects ([Fig. 4]), with the regular pore structure of the open-pore membrane ([Video 1]). The fistula was closed. The open-pore film drain is a simple device that can be used to achieve duodenal cutaneous fistula closure very easily by negative pressure in appropriate cases.

Since the introduction of negative pressure therapy of the abdomen, care has been taken to protect the intestine from the effects of negative pressure in order to avoid impairments of abdominal organs. As an alternative to the widespread AB-Thera^R system (KCI, San Antonio, Texas, USA), the different concept of Suprasorb CNP^R (Lohmann & Rauscher, Austria-Germany) was introduced by the producer with the premise of achieving a better therapeutic effect. Due to numerous pores of the film, the effects of the negative pressure are brought to the surface of the intestinal organs and these effects were tested on seven experimental animals. Particular attention was paid to the small intestine, colon, liver, and pancreas. Over 8 h continuously, three animals were tested with −80 mmHg, 4 with −60 mmHg. The results showed no macroscopic pathological changes. The histological results showed borderline changes in the small intestine and colon with −80 mmHg application, minimal or none with −60 mmHg. The liver and pancreas were found free of pathological changes. For use on human organs, the intra-abdominal application of −60 mmHg for the Suprasorb CNP system is proposed as the standard.

Objectives

Boerhaave's syndrome is a life-threatening disease with high mortality and morbidity. Endoscopic negative pressure therapy (ENPT) can be used to treat oesophageal perforations.

Case presentation

We report on a case of oesophageal rupture with peritonitis in a 35-year-old male patient. The start of treatment was 11 h after the perforation event. The treatment of the perforation defect was performed exclusively by intraluminal ENPT, the treatment of peritonitis was performed by laparotomy with abdominal lavage. For ENPT we used two different types of open-pore drains. The first treatment cycle of four days was performed with an open-pored polyurethane foam drainage (OPD), which was placed intraluminal to cover the perforation defect and to empty the stomach permanently. The second treatment cycle of nine days was performed with a thin nasogastric tube like double-lumen open-pored film drainage (OFD). For suction OPD and OFD were connected with an electronic vacuum pump (-125 mmHg). OFD enables active gastric emptying with simultaneous intestinal feeding via an integrated feeding tube. Intraluminal ENPT with a total treatment duration of 13 days was able to achieve the complete healing of the defect. Surgical treatment of the perforation defect was not necessary. The patient was discharged 20 days after initial treatment with a non-irritating abdominal wound and a closed perforation.

Conclusions

In suitable cases, endoscopic negative pressure therapy is a minimally invasive, organ-preserving procedure for the treatment of spontaneous oesophageal rupture.

Aim: Foam dressings are thought to aid in the establishment of a beneficial moist wound environment as they exhibit excellent fluid management capacity by absorbing as well as donating fluid. Therefore, a scratch wound healing model using human fibroblasts and keratinocytes was developed depending on the donation of fluid by the applied dressings. The effect on cell proliferation and migration of NFD* and cotton gauze was investigated.

Methods: Human dermal fibroblasts (DF) and human epidermal keratinocytes (HaCaT) were seeded into 6-well-plates and cultivated for 48h before scratching. NFD and gauze were cut aseptically (d=3.5cm), soaked in medium and applied directly on the cell scratches without further medium addition. Cells were stained with hematoxylin/eosin after 1, 6, 24, and 48h. Scratches were photographed using a digital microscope and evaluated using the Image J program.

Results: It was found that NFD supported the scratch healing in vitro by promoting fibroblast and keratinocyte proliferation and migration through establishing a moist wound environment. Results were almost comparable to the medium control. In contrast, scratches covered with gauze remained open, probably due to the loss of moisture by drying of the wound dressing.

Conclusions: It could be shown that NFD is able to promote wound healing by effectively creating humid conditions favouring wound closure while gauze was not able to maintain the moist environment resulting in non-healing cell scratch wounds in vitro.

*NFD - Suprasorb® P sensitive (Lohmann&Rauscher)

Background and Aims

In the management of leg ulcers and hyperkeratosis of the surrounding skin, it is not uncommon for them to affect very large areas of the leg. The large size also leads to an increase in the level of exudate and the amount of devitalised tissue. As a result, a larger amount of material is needed to loosen and remove the devitalised tissue than is the case with smaller wounds. To evaluate the performance of this debridement pad optimised for larger wounds and the surrounding skin, a small case series was performed.

Methods

For the case series leg ulcers of various origins that needed debridement were treated once or over a longer period of time with the larger pad when indicated. The treatment was documented both photographically and in writing.

Results

Five patients between the ages of 64 and 83 were treated. All of them suffered from chronic ulcers covering a big area on their legs. At least some of the wounds were colonised with bacteria/biofilm. Two patients were suffering from hyperkeratosis, too. The debridement with the debridement pad was well tolerated by the patients. Biofilm as well as devitalised tissue were removed effectively. All wounds were healed or becoming better.

Conclusions

Most of the time one pad was sufficient, even for ulcers spreading to cover the entire gaiter area. A much larger area could be treated efficiently and quicker than it would have been possible with a smaller device. In addition, the enlargement of the device is accompanied by an increase in the absorption capacity for exudate, slough and debris.