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Ann Thorac Surg 2005;79:1196-1200
© 2005 The Society of Thoracic Surgeons
a Department of Thoracic and Vascular Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
b Department of Surgical Critical Care, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
c Department of Wound Healing and Metabolism, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
d Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
Accepted for publication September 21, 2004.
* Address reprint requests to Dr O'Connor, Thoracic and Vascular Surgery, R. Adams Cowley Shock Trauma Center, 22 S Greene Street, Baltimore, MD 21201 (E-mail: joconnor{at}umm.edu).
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Abstract |
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METHODS: This is a retrospective review of trauma registry data from the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine from 2000 to 2003.
RESULTS: Seventeen patients were identified and divided into two groups. Group I consisted of seven patients with primary chest wall processes: four necrotizing soft-tissue infections and three with thoracic trauma resulting in significant loss of chest wall musculature. Group II consisted of ten patients with empyema and varying levels of chest wall extension. Six were postpneumonic and four postoperative. Wound size averaged 16 x 7 cm (range, 7 x 3 cm to 21 x 11 cm). The VAC duration averaged nine days (range, 3 to 21 days) and changed every two to three days. Fourteen wounds were culture positive; nine staphylococcus aureus, two alpha hemolytic streptococcus, and one each with enterococcus, Citrobacter, and anaerobes. Eight were polymicrobial. There were no deaths. All wounds healed without rotational muscle flaps. Ten underwent delayed primary closure, four split-thickness skin graft, and three healed by secondary intention. There was one significant complication: a wound infection after delayed primary closure which required reoperation.
CONCLUSIONS: Closure of complex chest wall wounds can present significant technical challenges. The VAC system is a simple, useful, and novel alternative to conventional wound care even with large, infected wounds.
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Introduction |
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Material and Methods |
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All were operated upon by one of the authors, who reviewed the charts for demographics, preoperative condition, and definitive wound treatment and who saw the patients in postoperative follow-up. Preoperative status included the use and duration of mechanical ventilation, the presence of shock (systolic blood pressure < 90 mm Hg), the use of pressors or inotropic agents, and preexisting comorbid conditions. Data regarding the wound included size, pathogens isolated, length and type of antibiotic therapy, VAC duration, and ultimate wound closure. At the first operation, the length and width of the wounds were measured and all extended to the bony thorax. Mortality, complications, length of stay, and outpatient follow-up comprised the postoperative data. The Institutional Review Board of the University of Maryland School of Medicine approved this retrospective study.
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Results |
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In group I, four patients had necrotizing soft-tissue infections and the remaining three had penetrating trauma resulting in large, contaminated wounds with significant loss of chess wall integrity. All three with penetrating trauma had emergent or urgent thoracotomy, one for absent vital signs but with signs of life.
Group II consisted of ten empyema patients, three of whom had empyema necessitatis. Postpneumonic empyema accounted for six. The remaining four had postoperative empyema, three following penetration thoracoabdominal trauma and one after anterior stabilization of a thoracic spine fracture.
Preoperative Status
Eight patients (two with tracheostomies) required preoperative mechanical ventilation averaging 6.5 days (range, 1 to 17 days) (Table 1). A higher percentage of group II patients were intubated and, on average, intubated longer than group I. Of the seventeen patients, five (29%) were in shock preoperatively, requiring pressors and/or inotropic agents in spite of aggressive volume resuscitation and the use of a pulmonary artery catheter to guide therapy. Two patients in group I were in shock, one with extensive necrotizing fasciitis and one who underwent emergency thoracotomy for traumatic arrest. In group II, all three patients with empyema necessitatis were hemodynamic compromised. The various comorbidities are listed in Table 1 and in general, group II patients had more preexisting disease and demonstrated more preoperative cardiovascular and pulmonary dysfunction.
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GROUP II
All of the patients in this group had empyema, with varying degrees of extension into the chest wall musculature and soft tissue. Six had postpneumonic empyema and half of these had empyema necessitatis. Not unexpectedly, the patients with empyema necessitatis required multiple, extensive debridement, and two had concomitant rib resection. Two others required a pulmonary resection. One patient had a thoracotomy, rib resection, and spinal stabilization performed by the orthopedic surgery service fifteen days prior. At exploration, a portion of the right lower lobe had herniated through a defect in the bony thorax. Predictably, the lung was adherent to the external portion of the chest wall necessitating partial resection of the lower lobe. In all patients the bony thorax could be closed without prosthetic material or muscle flaps. In two there was evidence that chest tubes facilitated extension of the pleural process to the chest wall.
Four of the group I patients and seven of the group II patients required subsequent debridement with an average of three debridements per patient. None required reoperative thoracotomy or placement of additional chest tubes for pleural drainage. In all patients the chest tubes were managed in the usual manner, as they would for any thoracotomy patient, and not influenced by the VAC.
Wound
All of the wounds were managed with the VAC system and, if debridement was not necessary, the dressing was changed at the bedside every two to three days (Table 2). Since the bony thorax was closed in all of these patients, the VAC was never in direct continuity to the plural space or to the parenchyma. The groups were similar with respect to the size of the wound and duration of the VAC dressing but there was variability regarding the isolated pathogen and the technique for ultimate wound closure. The average duration of the VAC was nine days (range, 3 to 21 days). The wound size averaged 16 x 7 cm (range, 7 x 3 cm to 21 x 11 cm).
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GROUP II
All had positive pleural cultures and eight (80%) were staphylococcus aureus. Of these, five were methocillin sensitive and the remaining methicillin resistant. Four of the patients with positive staphylococcus cultures also grew anaerobes. For those who did not culture staphylococcus, enterococcus was isolated in one, and the other had multiple anaerobic organisms. Several techniques were used to accomplish wound closure. Four underwent local advancement of a muscle remnant and delayed primary closure. Two had delayed primary closure alone. A split-thickness skin graft was utilized in two, and two others healed by secondary intention.
Broad-spectrum antibiotic coverage was instituted until operative cultures were obtained. The choice of antibiotics was then dictated by the sensitivity of the isolated pathogen. Twenty-four hours after the wound was closed (delayed primary or split-thickness skin graft) the antibiotics were stopped. For wounds healing by secondary intention, antibiotics were stopped after seven days if the wound was granulating and there were no signs of systemic infection.
Outcome and Follow-Up
There was no mortality. The only complication occurred early in our experience in a patient with empyema necessitatis. Following thoracotomy, decortication, and chest wall debridement, the muscle groups were closed over drains and the skin left open. Four days later, purulent material drained from the wound requiring debridement and application of the VAC dressing. No patient had a postoperative pleural collection requiring drainage, and none required mechanical ventilation upon hospital discharge. In all of the patients but one, the chest tubes were removed before discharge.
Almost 90% required intensive care unit admission with an average length of stay of 15 days (range, 2 to 64 days); the remaining were managed in intermediate care. The total length of hospitalization from the time of surgical intervention until discharge was 23 days (range, 8 to 79 days). These lengths of stay reflect the serious nature of the underlying pathology, the significant premorbid conditions, associated injuries, and the need for ventilatory support. The VAC system did not adversely impact ventilation in any patient, including those breathing spontaneously. Thirteen patients were discharged directly home; one was transferred for inpatient psychiatric treatment and three required inpatient rehabilitation. Eventually all were discharged home. One hundred percent follow-up was achieved with an average length of seven months (range, 3 to 21 months). One of the authors saw each patient and particular attention was paid to respiratory and functional status as well as wound healing. No patient required readmission or operation, and all but two patients had returned to their preoperative status. One was still undergoing rehabilitation after upper extremity amputation. The other, with a distal esophagectomy and gastrectomy, required esophagojejunostomy.
An illustrative case is depicted in the series of photographs in Figures 1 through 4. Figure 1 is an intraoperative photograph taken at the original operation which depicts an extensive empyema with chest wall involvement. The cultures grew polymicrobial organisms. A decortication and pleurectomy were performed and the bony thorax closed. The chest wall required extensive debridement and a VAC system was applied. The duration of the VAC was 15 days, and was changed every three days. No interval debridement was necessary. Figures 2 and 3 are photographs taken on the 6th and 12th days, respectively. Figure 4 is a photograph taken at eight weeks showing the wound completely healed.
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Comment |
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The VAC system consists of the application of subatmospheric pressure to polyurethane foam dressing, which conforms to the wound. An evacuation tube is placed in continuity with the foam and the entire area covered with an occlusive, airtight dressing. The evacuation tube is then connected to a vacuum system, where the amount of vacuum applied can be adjusted. Wound healing is postulated to occur as a result of removal of interstitial fluid, decreased bacterial contamination, increased vascularity, and secondary to mechanical forces on the wound itself [1, 8].
In the first and largest experience with the VAC system, Argenta and Morykwas [1] reported 300 wounds, 296 of which responded with increased granulation tissue. Wounds were divided into three categories. There were 175 chronic wounds consisting of venous stasis, vasculitic, and pressure ulcers. A subacute group consisted of 94 patients, including wound dehiscence and wounds with exposed hardware and/or bone. The final group was acute wounds consisting of 31 patients. Attempts were made to place omentum, absorbable mesh, or muscle over exposed viscera. Interestingly, if coverage could not be accomplished, then the VAC was placed directly over thoracic viscera without complication. The authors did not specify the number of patients treated in this fashion. In all three groups, the wounds were closed by granulation, split-thickness skin graft, or muscle flap coverage.
Gratifying results have been obtained using the VAC for sternal wounds, especially after sternotomy. One study reported sternal wound closure solely using the VAC system [4]. Another described primary closure in 45% of patients using the VAC, with the remainder bridged to flap reconstruction [5]. Necrotizing soft-tissue infections of the chest wall are uncommon. Urschel and colleagues [9] reviewed nine of these cases, eight of which were complications of operation or interventional procedures. Spread of infection by tube thoracostomy was implicated in four cases. Delayed diagnosis and incomplete debridement resulted in almost 90% mortality.
Chest wall reconstruction poses specific and significant challenges. Over the past decades, muscle flaps have become the mainstay, and an excellent review can be found in Arnold and Pairlero's report [10] of 500 patients undergoing chest wall reconstruction. While muscle flaps do indeed provide both excellent chest wall stability and good long-term results, there is a substantial problem if the muscle itself is not available to be used for reconstruction. This is precisely the problem when chest wall musculature has been destroyed.
The fundamental principal of adequate operative debridement cannot be overstated and there is no substitute for complete and often multiple operations. Wound debridement was performed in the operating room under general anesthesia. The dressing was changed every two to three days at the bedside with adequate sedation and analgesia. Of those not needing subsequent debridement, a visible bed of granulation tissue was generally present at the first or second VAC change. The duration of the VAC dressing was determined by the rate of wound closure and the patient's overall clinical condition. Independent of the size of the wound, every effort was made to achieve early closure using local muscle advancement, delayed primary closure, and split-thickness skin graft. Wounds were considered suitable for closure when free of infection and nonviable tissue, and with the presence of granulation tissue. Larger wounds often required local muscle advancement, which can be performed even if a portion of the muscle was destroyed, by mobilizing the viable remnant, advancing it, and using it for partial closure. Delayed primary closure was used in smaller wounds. Wound healing by secondary intention was reserved for patients with an unstable or complex clinical course.
Other advantages of the VAC system include the following. It can be changed at the bedside and multiple daily dressing changes are avoided since it is changed every two to three days. Since it is a closed system, there is evacuation of all tissue fluid, and large, cumbersome chest wounds can easily be dressed with this technique.
The management of complex chest wounds represents a significant challenge due to the severity and aggressiveness of the underlying pathologic process, as well as the location and extent of the wound itself. The paradox is the material most suitable for reconstruction, namely a muscle flap, has itself been destroyed. Under these circumstances, the VAC system, coupled with aggressive surgical debridement, offers a strategy to treat complex thoracic wounds.
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Acknowledgments |
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References |
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This article has been cited by other articles:
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  F. Canavese, S. Gupta, J. I. Krajbich, and K. M. Emara Vacuum-assisted closure for deep infection after spinal instrumentation for scoliosis J Bone Joint Surg Br, March 1, 2008; 90-B(3): 377 - 381. [Abstract] [Full Text] [PDF]
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 A. Elackattu, M. Babade, R. T. Brodell, and S. Dewar Bra-Band Wound in an Adolescent Clinical Pediatrics, June 1, 2007; 46(5): 448 - 450. [PDF]
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