Vacuum-assisted closure (VAC)

has been an integral part of open

abdominal wound management

for the past decade and is sup-

ported by a substantial evidence

base. Utilising negative pressure

wound therapy through a sealed

foam dressing, VAC systems

protect wounds while promoting

perfusion, drawing wound edges

together, and removing tissue

debris and fluids.

Studies examining VAC

therapy (V.A.C.® Therapy™,

KCI, San Antonio, Tex) have

in a nutshell

second opinion

the verdict

There is no doubt VAC therapy

has enhanced open abdominal

wound management, and,

in light of this, its use has

spread to other fields including

orthopaedic and cardiothoracic

surgery. It eases the nursing

burden by facilitating wound

care, improves healing and

reduces sepsis. However, as

the authors highlight, it is not

risk free.

Although development of

enterocutaneous fistula in

the setting of VAC therapy for

laparostomy wound manage-

ment has not been reported

largely focused on trauma

patients. However, as in our

hospital, the authors increasingly

use this for laparostomy wound

management following surgery

for intra-abdominal sepsis. This

study specifically focused on

outcomes in this setting.

Over 16 months, 29 patients

received VAC therapy for open

abdominal wounds. Median

age was 60 (range 31-80 years)

and median duration of therapy

was 26 days (range 2-68). Lap-

arostomy was most frequently

indicated for abdominal sepsis,

visceral oedema, and raised

intra-abdominal pressure.

Ten patients died (34%) while

receiving VAC therapy and 19

(65.5%) required ICU care.

Six patients (20%) developed

intestinal fistulation, diagnosed

at a median of 20 days (range

2-50) from its commencement.

Four of these patients died

(66%), all from multi-organ

failure, which had been present

in five of the six patients prior to

VAC therapy.

as a significant complication in

earlier studies, observations at

our hospital support the authors’

conclusions that the incidence

may be higher in relation to

its use for abdominal sepsis.

However, in this study patients

would have suffered significantly

compromised bowel function

in relation to their multi-organ

failure, which largely pre-dated

institution of VAC therapy. This

would have rendered them

more susceptible to intestinal

leakage and fistulation. In

addition, three patients suffered

from inflammatory bowel

disease and were therefore

predisposed to develop fistulae.

Other risk factors put forward

include presence of abdominal

mesh, abdominal sepsis,

and presence of an intestinal

anastomosis.

Given the increased mortality

associated with this complica-

tion, further research is required

to examine factors contributing

to intestinal leakage. In the

meantime the authors are right

to suggest a cautious approach

with a timely reminder that VAC

therapy is never completely

without risk.

intestinal leakage following VAC therapy – caution required?Rao M, Burke D, Finan PJ, Sagar PM. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis 2007; 9: 266-68.

• VAC therapy is a well

established, evidenced-

based treatment for

laparostomy wounds

• Previous studies focus on

VAC complications in

abdominal trauma rather

than sepsis

• Further research is

warranted to investigate

whether VAC therapy

encourages fistula

formation.

Edward Fitzgerald

edwardfitzgerald@doctors.org.uk

Austin G Acheson

austin.acheson@nottingham.ac.uk

Nottingham University Hospital