Extraordinary Cases: Abdominal Wounds & Myocutaneous … · Extraordinary Cases: Abdominal Wounds & Myocutaneous Flaps ... Many factors play a role in the development, ... of torso

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Extraordinary Cases: Abdominal Wounds & Myocutaneous Flaps

Matthew J. Finnegan, MD, FACS, FCCWSClinical Associate Professor of Surgery, Rowan

University-SOMChief, Division of General Surgery

Our Lady of Lourdes Medical Center

Abdominal Wounds-Necrotizing Fasciitis



Necrotizing fasciitis: classification, diagnosis, and management.

Lancerotto L, Tocco I, Salmaso R, Vindigni V, Bassetto F. Padova, Italy

Abstract

Necrotizing fasciitis (NF), a life-threatening rare infection of the soft tissues, is a medical and surgical emergency. It is characterized by subtle, rapid onset of spreading inflammation and necrosis starting from the fascia, muscles, and subcutaneous fat, with subsequent necrosis of the overlying skin. Once suspected, immediate and extensive radical debridement of necrotic tissues is mandatory. Appropriate antibiotics and intensive general support avoid massive systemic diffusion of the infective process and are the key for successful treatment. However, early diagnosis is missed or delayed in 85% to 100% of cases in large published series: because of the lack of specific clinical features in the initial stage of the disease, it is often underestimated or confused with cellulitis or abscess. Mortality rates are still high and have shown no tendency to decrease in the last 100 years. Unfortunately, the prevalence of the disease is such that physicians rarely become sufficiently confident with NF to be able to proceed with rapid diagnosis and management. This review covers the literature published in MEDLINE in the period 1970 to December 31, 2010. Particular attention is given to the clinical and laboratory elements to be considered for diagnosis.

A wide variety of diagnostic tools have been described to facilitate and hasten the diagnosis of NF, but the most important tool for early diagnosis still remains a high index of clinical suspicion.

J Trauma Acute Care Surg 2012 Mar(3):560-6



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Necrotizing Fasciitis of the abdomen and chest from axillary abscess secondary to MRSA


Necrotizing Fasciitis of the abdomen and chest from axillary abscess secondary to MRSA



Reconstructive Ladder

a. Radical Debridement of all non-viable tissueb. IV antibiotic therapyc. NPWTd. Rotational Flaps and skin grafts as needed to

obtain wound closure

The reconstructive ladder in necrotizing fasciitis of the chest wallKarsten Knobloch, Joern Redeker and Peter M. Vogt

Interact CardioVasc Thorac Surg 2010;10:484-485

Abdominal Wounds Secondary to Mesh Infections


Case presentation

44y.o. with multtiple chronic abdominal wounds and a large abdominal wall defect s/p multiple

procedures presenting with sepsis secondary to infected Marlex mesh


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Synthetic Mesh Infection




49 year-old female complex past medical history

multiple prior attempts at closure of a recurrent incisional hernia with polypropylene mesh

developed a chronically infected anterior abdominal wound with exposed mesh along with hernia

recurrence

ABDOMINAL WALL WITH MULTIPLE DEFECTS SECONDARY TO PREVIOUSLY DRAINED ABSCESS CAVITIES FROM INFECTED MESH


Excised skin, infected mesh


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RESIDUAL ABDOMINAL WALL DEFECT MANAGED WITH NPWT AS A BRIDGE TO ABDOMINAL WALL RECONSTRUCTION


Extraordinary Cases: Abdominal Wounds & Myocutaneous FlapsFrontiers of Surg. 2016 Jan 8;2:67Evidence for Replacement of an Infected Synthetic by a Biological Mesh in Abdominal Wall Hernia Repair.



Establish diagnosis

Patient perioperative condition

Define the anatomy/understand the defect

Indications/limitations of prosthetics/ bioprosthetics

Wound preparation and control of infection

Distinguish contamination from infection and treat appropriately

Management of complications (including prosthetic -related)

Account for concomitant disease processes which relate to the

abdominal wall

Postoperative management


Enterocutaneous Fistula


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Albumin = 1.8 g/dl

Proximal Diversion of the Small or large bowel if possible can Facilitate enteral nutrition support which is key to the management of enterocutaneousfistulae and anastomotic leak.


Eradication of sepsis, appropriate wound management, establishment of nutritional support, and restoration of normal physiology were attempted.

Definitive surgical management was deferred for at least 6 months after the last abdominal surgical intervention.

Dis Colon Rectum 2010; 53: 192–199

Challenging Wounds and the Use Negative Pressure Wound Therapy Open abdomen

Open abdomen

Control of viscera with allowance for drainage

Treatment of primary underlying disease

Complicated by respiratory and renal failure and sepsis

Severe protein calorie malnutrition

Managing the open abdomen with meshed biologic graft

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Managing the open abdomen

Myocutaneous Flaps


Extraordinary Cases: Abdominal Wounds & Myocutaneous FlapsSurgical treatment of pressure ulcers: an 11-year experience at

the Department of Plastic and Reconstructive Surgery of Hospital of Kaunas University of Medicine

Kestutis Maslauskas, Donatas Samsanavic ̌ius, Rytis Rimdeika, VygintasKaikarisDepartment of Plastic and Reconstructive Surgery, Kaunas University of Medicine, Lithuania

In patients with paraplegia, the first pressure ulcer occurs after 74.79±61.34 months from the onset of the disease. Pressure ulcers most commonly occur

over tuber ischial area. The most effective surgical treatment of pressure ulcers is closure of the wound using myocutaneous flaps (use of the hamstrings); fasciocutaneous flaps

were the most commonly used method in patients who underwent surgery for the second time. Medicina (Kaunas) 2009; 45(4)


2015 Apr;24(4):S12-4, S16-21, A 9-year retrospective evaluation of 102 pressure ulcer reconstructions., Kenneweg KA, et al

Many factors play a role in the development, course and treatment of PUs. It is vital to understand the role of patient risk factors in the development of PUs, to direct subsequent management and reconstruction, and to prevent future recurrences.

“IT TAKES A VILLAGE AND YOU HAVE TO HAVE A PROGRAMATIC APPROACH”

TeamCo-morbid ConditionsContraindicationsContracts


Extraordinary Cases: Abdominal Wounds & Myocutaneous FlapsThe Team Approach

Patient / Significant others

Surgeon

Nurse Practitioner/CWOCN/CWS

Internist / Pulmonary/ Cardiology/Infectious Disease

PMR/Psychiatry/ Pain Management/ Holistic Nursing

Nutrition Support

Nursing Staff –across the continuum of care

Social Services /Case Management

Peer Counseling/ Support Groups

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2010 Jun;125(6):1725-34, Multivariate predictors of failure after flap coverage of pressure ulcers, Keys KA1, et al.

The authors propose that operative management should be approached with trepidation, if at all, in young patients with recurrent ischial ulcers.


Factors affecting decision for Flap closure

Wound BedMalnutritionExtent of osteo> time on IV antibioticsCo MorbiditiesSpasticity/ contractures Patient Compliance

Contraindications:Tabacco abuse

Medical & Mental In-Stability



THE FACTS:

Am J Med. 1992 Jul 15;93(1A):22S-24S, Smoking and wound healing, Silverstein P1.,-Smokers should be advised to stop smoking prior to elective surgery or when recovering from wounds resulting from trauma, disease, or emergent surgery.

Wound Repair Regen. 2009 May-Jun;17(3):347-53, Effect of smoking, abstention, and nicotine patch on epidermal healing and collagenase in skin transudate.Sørensen LT1,et al, We conclude that smoking attenuates epidermal healing and may enhance extracellular matrix degradation. Three months of abstinence from smoking does not restore epidermal healing, whereas 4 weeks of abstinence normalizes suction blister MMP-8 levels. These findings suggest sustained impaired wound healing in smokers and potential reversibility of extracellular matrix degradation.

Ann Plast Surg. 2014 Apr;72(4):463-6, Effect of side-stream smoking on random-pattern skin flap survival in rats, Gazzalle A1, et al, In conclusion, this study suggests increased risk of random-pattern skin flap necrosis after side stream exposure to cigarette smoke.


Trunk, abdomen, and pressure sore reconstruction.Rubayi S, Chandrasekhar BS. Department of Surgery, Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242, USA.

. SUMMARY: Chest wall reconstruction is indicated following tumor resection, radiation wound breakdown, or intrathoracic sepsis. Principles of wound closure and chest wall stabilization, where indicated, are discussed. Principles of abdominal wall reconstruction continue to evolve with the introduction of newer bioprosthetics and the application of functional concepts for wound closure. The authors illustrate these principles using commonly encountered clinical scenarios and guidelines to achieve predictable results.Pressure ulcers continue to be devastating complications to patients' health and a functional hazard when they occur in the bedridden, in patients with spinal cord injuries, and in patients with neuromuscular disease. Management of pressure ulcers is also very expensive. The authors describe standard options to treat defects of the chest, abdomen, and back and pressure ulcers in all anatomical areas. A comprehensive understanding of principles and techniques will allow practitioners to approach difficult issues of torso reconstruction and pressure sores with a rational confidence and an expectation of generally satisfactory outcomes. With pressure ulcers, prevention remains the primary goal. Patient education and compliance coupled with a multidisciplinary team approach can reduce their occurrence significantly. Surgical management includes appropriate patient selection, adequate débridement, soft-tissue coverage, and use of flaps that will not limit future reconstructions if needed.

Postoperatively, a strict protocol should be adapted to ensure the success of the flap procedure.Plast Reconstr Surg 2011 Sep;128(3):201e-215e

Perioperative Counseling/ComplianceCo-morbid Conditions:

OsteomyelitisMalnutrition


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Successful Truncated Osteomyelitis Treatment for Chronic Osteomyelitis

Secondary to Pressure Ulcers in Spinal Cord Injury PatientsRobert Marriott, MD, and Salah Rubayi, MD, FACS

In cases of pressure ulcer management with bony involvement, bone pathologic

diagnosis of chronic osteomyelitis allows for a shorter antibiotic course with

better results when the offending tissue has been adequately debrided and

closed with viable tissue flap coverage, than simple long-term (4–6 weeks)

antibiotic treatment. Because of the extreme contaminated nature of these

wounds, if such therapy works in these patients, it may be applicable to chronic

osteomyelitis in more varied contaminated surgical cases involving bone.

Annals of Plastic Surgery • Volume 61, Number 4, October 2008

CRITICAL STUDY BECAUSE THIS SUBSET OF PATIENTS NEED TO BE OUT OF

BED TO COMPLETE REHAB, AND IMPROVE QUALITY OF LIFE


OSTEOMA/OSTEOMYELITIS OF THE ALIEN TYPE


Dtsch Arztebl Int. 2012 Apr;109(14):257-64, Treatment algorithms for chronic osteomyelitis, Walter G1, CONCLUSION: Surgery combined with anti-infective chemotherapy leads to long-lasting containment of infection in 70% to 90% of cases. Suitable drugs are not yet available for the eradication of biofilm-producing bacteria.

Open Forum Infect Dis. 2015 Aug 6;2(3): Pressure Ulcer-Related Pelvic Osteomyelitis: A Neglected Disease? Bodavula P1, et alConclusions: This is one of the largest cohort studies of pressure ulcer-related pelvic osteomyelitis to date. Significant variations existed in diagnostic approach. Most patients received antibiotics; those treated with a combined medical-surgical approach had fewer hospital readmissions.

Nutrition Support


Cell mitosis

Pro-inflammatory cytokines

MMPs

Growth factors

Cells capable of rapid response

mitogenic activity

Pro-inflammatory cytokines

MMPs

Varied levels of growth factors

Senescent cells

Healing Wounds Chronic Ulcers

17Schultz GS & Mast BA (1998)


Biochemical Differences Chronic inflammation/stress

Increased oxidative stress = altered and increased nutrient utilization:ARG, GLN, Cystine, Protein, calories, Vit A, B, C, & E; Cu, Zn, Mg, & more

Heavy Exudate = protein, calories, fluid & micronutrient/zinc losses

Chronic wound drainage has 8 x the amount of matrix metallo-proteases. MMPs contain protein and zinc

1. Bergstrom N, Bennett MA, Carlson CE, et al. Pressure Ulcer Treatment. Clinical Practice Guidelines. No.15.

Rockville, MD: U.S. Dept. of Health & Human Service, AHCPR. AHCPR Pub. No. 95-0653. Dec.1994. 2. Ovington L, Cullen B. Matrix metalloprotease modulation and growth factor protection. OWM 2002;48(6):2-

15.

Increased needs to support healing and offset nutrient losses and altered nutrient

utilization


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Loss of LBMArginine & Glutamine

Become essential amino acids

Loss of Lean Body Mass/Malnutrition Due To Illness

Inflammatory Response Increase in catecholamine Increase in cortisol Decrease in insulin Decrease/Increase in growth

hormone Decrease in testosterone

•Decreased ability to perform self

pressure relief

•Loss of GI Integrity

•Loss of appetite

•Malabsorption

•Diarrhea

•Poor Wound Healing

•Spontaneous Pressure Ulcers

•100% Mortality with a 40% Loss

of LBM

• Insulin resistance• Oxidative stress• Altered nutrient

utilization – proteinfor energy

20% loss of body protein

Significantly impair physiologic functions.

An IWL of 15% or more is associated

with a 20% loss of body protein (Hill, 1992).

Surgical Management of Pressure Ulcers During Inpatient Neurologic Rehabilitation: Outcomes for Patients With Spinal Cord Disease

Abhishek Srivastava, MD et al, Department of Psychiatric and Neurological Rehabilitation, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

J Spinal Cord Med. Apr 2009;32(2):125–131

TENSOR FASCIA LATA ROTATIONAL FLAP CLOSURE OF TROCHANTERIC DECUBITUS

ULCER WITH OSTEOMYELITIS

A proposed protocol for the surgical treatment of pressure sores based on a study of 337 cases. A.Margara , et al

We compare outcomes in period 1985–1992 with that since 1992, when our present protocol was adopted The latter protocol is based on rigorous assessment of the preoperative general and specific conditions, the use of specific flaps for each involved region, and appropriate domiciliary medical assistance [3, 5, 17]. The choice of a specific myocutaneous flap depends on two factors:

(a) a flap which is specifically indicated for the area involved, and(b) the ability of the chosen flap to be re-harvested if the decubitus recurs.

The rigorous use of these criteria has improved the results in terms of initial healing and thus significantly reduced the recurrence rate.

Eur J Plast Surg (2003) 26:57–61



LARGE VOLUME NECROTIC SACRAL WOUND

LARGE VOLUME SACRAL WOUND S/P DEBRIDEMENT

V - Y ADVANCEMENT FLAP CLOSURE


Round two for this 50y.o. paraplegic who presented with recurrent sacral &bilateral Trochanteric decubitii &osteomyelitis, 8 years after primary flap

reconstruction of both hips.

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Extraordinary Cases: Abdominal Wounds & Myocutaneous FlapsFailed Flap Protocols

22 y.o. patient s/p MVA with slow recovery from anoxic brain injury, did not receive adequate care in a local SNIF

NPWT: a Bridge to Flap, Control Large Wound, and/or Promote Primary Wound

Healing

Colostomy

Urostomy


2013 Aug;10(4):455-60., Improvisations in classic and

modified techniques of flap surgery to improve the success rate for pressure ulcer healing in patients with spinal cord injury. Singh R1, et al.

good in 4 (10·81%) patients and poor in 1 (2·7%) patient. Partial flap necrosis (2·7%), low incidence of PrU recurrence rate at flap site (5·4%) and overall PrUrecurrence (11·4%) were the complications observed. Improvisation of classic and modified techniques of flap surgeries along with reinforcement of general care principles of paraplegia can be effective in minimising complications often associated with PrU reconstructive surgery thus improving the ultimate outcome.


Matthew J. Finnegan, MD, FACS, FCCWSClinical Associate Professor of Surgery,

Rowan University-SOMChief, Division of General Surgery

Our Lady of Lourdes Medical [email protected]

All patients must be on complete bed rest on a Kreg low air loss mattress or its equivalent for a minimum of four to six weeks!

Patients with multiple co -morbidities should have a medical consult in hospital and appropriate follow up. They need close medical attention in the SNIF or Rehab facility that they choose.

All patients are required to move from side to side on a standard 2 hour rotating schedule that nursing will remind and instruct you to do.

No extra padding/sheets to bed. This may cause additional pressure .

Patients need Foley catheters for 4-6 weeks to prevent urine contamination of flap.

If they do not have a colostomy, fecal bag or aggressive care to prevent any stool contact with the flap is mandatory .

Cleanse incision and drain sites (if applicable) with NSS or wound cleanser. Apply Bacitracin lightly, Adaptic & dry dressing for two weeks post-flap. Bacitracin may be discontinued for maceration. Medipore tape should be used. No silk tape.

After four weeks for sacral flap and six weeks for an ischial flap, Dr. Finnegan or his nurse practitioner will decide on your sitting protocol.

IV antibiotics will be ordered for all patients. Most patients require at least 14 days of IV antibiotics. Patients with boney infections or osteomyelitis will need 4-6 weeks of IV antibiotics. All patients will have an Infectious Disease consult to review cultures from surgery and adjust antibiotics accordingly. Any changes in the antibiotics will be called directly to the facility.

PERIOPERATIVE FLAP CLINICAL PATHWAY

Almost all patients will have a PICC line for IV antibiotics. They will need routine PICC line care.

Please review all existing medications with the patient, to comply with current medication reconciliation regulations. Screening for medications that may adversely affect wound healing is very important.

Do not raise head of bed greater than 30 degrees. No hip flexion greater than 30 degrees. This prevents recurrence or injury to the flap.Log rolling and careful turns and repositioning will limit shearing injury to the flap and surrounding skin.

Please notify the surgical office if the patient develops: fever, increased drainage, redness/warmth at surgical site, open incision lines, and odor.

Patients should not be transported off of the off-loading surface prescribed for them unless emergent circumstances arise. Any transfer in the first 3-4weeks can lead to flap failure.

Nutrition support is key to flap success. All patient need a dietary consult at the hospital and SNIF/Rehab. They need a weekly pre-albumin level. The nutrition support regiment should include; total daily protein of 1.0 to 1.5gms/kg(this includes meals and supplemental protein intake), a multivitamin, vitamin C, zinc, glutamine and arginine.

Patients should call the office at 856-546-3900 for follow up appointment 8-10 weeks post-op. Patients will be followed by a Nurse Practitioner, who is trained to care for patients who have had reconstructive flap surgery. They will provide expert bedside care and communicate with the surgical team on a regular basis.

Patients do have a choice in post flap care. The Case Manager will provide a list of recommended facilities that our flap patients may choose from. We do not recommend nor do we usually proceed with surgery in patients who do not wish to remain in our system for postoperative care.

PERIOPERATIVE FLAP CLINICAL PATHWAY

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Extraordinary Cases: Abdominal Wounds & Myocutaneous … · Extraordinary Cases: Abdominal Wounds & Myocutaneous Flaps ... Many factors play a role in the development, ... of torso