Wound Healing & Dehiscence - Department of Surgery at SUNY ... Healing_Dehiscence.pdf · Wound...
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Wound Healing & Dehiscence L. Yuko Shimotake Richmond University Medical Center March 30, 2017
Transcript of Wound Healing & Dehiscence - Department of Surgery at SUNY ... Healing_Dehiscence.pdf · Wound...
Wound Healing & Dehiscence
L.YukoShimotakeRichmondUniversityMedicalCenterMarch30,2017
Case Presenta7on
• HPI:87yomalewithmulCplemedicalproblemspresentedtoED1/26/2017withleJlowerextremityweaknessx1day.PaCentreportedrecentfall8/2016requiringhospitalizaConatOSH,atwhichCme2colonicmasseswerediscoveredonCTA/P.Nofurtherwork-upwasperformedinlightofhisotherco-morbidiCes.
• PMHx:TIA,anemia,GERD,depression,knowncolonicmasses,andfrequentfalls• PSHx:Cholecystectomy• SocialHx:FormercigareZesmokeranddrinker,deniesillicitdruguse• Allergies:NKDA• Medica4ons:Flomax,Citalopram,Finasteride,Omeprazole
Case Presenta7on
• VitalSigns:98F135/677820100%• Exam:
• General–cachecCc,NAD• Abd–soJ,NT/ND• DRE–nogrossblood
• Labs:• 7.7>6.9/25.2<256• 146/4.5/113/25/27/0.9<96• 5.4/2.7/14/12/78/0.2• 14.4/1.1
Case Presenta7on
• CTA/P• CircumferenCalapplecorelesionatcecum• Colo-colonicintussuscepConsathepaCcflexurewithasuspectedleadingmass
Case Presenta7on
• Anemiaà1UpRBCtransfusion• Colonoscopy
• 7-8cmnear-occlusivefungaCngmass75cmfromtheanalverge• Bx–moderatelydifferenCatedadenocarcinoma
• 3.5cmsessilepolyp65cmfromtheanalverge• Bx–tubularadenoma
Case Presenta7on
• OR:Exploratorylaparotomy,righthemicolectomyandileostomycreaCon• Abdominalwallclosure
• #1loopPDSinrunningfashion• RetenConsutures
• EBL100cc,1600ccIVfluids,UOP150cc• Extubated• TransferredtotheSICU
Case Presenta7on
• POD#1-2• NGtuberemoved• Clearliquiddiet• Transferredtofloor
• POD#3-4• Persistentnausea• Midlinewound–serosanginousdrainage
Case Presenta7on
• POD#5• 102.3FHR120’sàfeverworkup
• UTI–Ecoli• CXR–leJ-sidedpatchyparenchyma• CTchest–pneumonia• CTA/P–ileuswithminimalascites
• IVanCbioCcs• NGtubeplaced–500ccbiliousoutput• ReturntoSICU
Case Presenta7on
• POD#6-7• Intubatedforrespiratorydistress• WBC25• Anemia-Hb10to6.8àtransfused3UpRBCand2UFFP• INRof1.9àVitaminK
• POD#8• Bronchoscopy
• BAL–MRSAandyeast• LowdoseLevophed+HydrocorCsone
Case Presenta7on
• POD#10-15• ConCnuedlow-dosepressors+HydrocorCsone
• Highoutputileostomyàfluidbolusreplacements
• Midlinewound–copiousserousdrainage
• POD#16• WBC34• CTchest/A/P
• LeJpleuraleffusionàpigtailcatheterplacement
• LoculatedRUQ13.3x6.6x7.7cmfluidcollecCon• Midlinewound–InferiorretenConappearedischemicàremovedatbedside
Case Presenta7on
• POD#17• Midlinewound–eviceraCon• àbowelreducedandtheskinoverlyingthebowelwasclosedatbedside
Case Presenta7on
• POD#18• OR–Exploratorylaparotomy,abscessdrainage,abdominalwallclosurewithmesh,tracheostomy,andPEGplacement• Abdominalcultures–Acinetobacter• WBCnormalized
Case Presenta7on
• POD#25/7• Coffeeground-likeoutputnotedintheNGtube
• Anemia-Hb9to6àtransfused3UpRBC• Brownsputumfromtracheostomyàbronchoscopy• BAL–Acinetobacter
• POD#27-49/9-31• Sepsis–febrile,WBC11-17• CTchest–largepleuraleffusions
• Pigtail/chesttube• CTA/P–mulCpleintra-abdominalabscesses
• IRdrainage• AnCbioCcs
• JPdrain–feculentoutput
Case Presenta7on
• POD#42/24• PEAàACLSwithROSC• DNR
• POD#49/31• Expired
Case Presenta7on
Wound Healing & Dehiscence
• Terminology• ClinicalPresentaCon• ECology• Woundhealing• PaCentriskfactors• Post-operaCveriskfactors• OperaCveriskfactors• Management
Terminology
• Incisionalhernia• SeparaConoffasciaaJerskiniswell-healed
• Dehiscence• Tosplitalonganaturalorsurgicalline;separaConofanyorall3layersbeforeskiniswell-healed
• EvisceraCon• Todisembowel;toprotrudethroughasurgicalincisionorsufferprotrusionofapartthroughanincision
Clinical Presenta7on
• 7-14dayspost-op• Salmonpinkserousdrainage85%• ReportsrippingsensaCon• Increasedintra-abdominalpressure–coughing,vomiCng,stooling
E7ology
• Failureofwoundhealing
Wound Healing
Wound Healing – Hemostasis
• 5-10minutes• CapillarydilaContoincreasebloodflowtowound• ThenconstricConofvessel• PlateletaggregaConandfibrinclotformaCon• Complementcascade–CKandGF
Wound Healing – Inflamma7on
• Plateletgranules• Alpha–PF4,beta-thrombomodulin,PDGF,TGF-beta• Dense–adenosine,serotonin,calcium
• PMNaggregaCon–day0-2• MacrophageaggregaCon–day3-4
Wound Healing – Prolifera7on
• Day3-60• NeovascularizaCon• EpithelializaCon• Collagensynthesis
• Fibroblasts• CollagentypeIII• Peaksatday21• Requiresoxygen,vitaminC,iron,alpha-KG
• Myofibroblast• ContracCon• AbundantacCnmicrofilaments
Wound Healing – Matura7on
• Day7–1year• ConCnuouscollagendeposiConandreplacement• CollagentypeIIIàtypeI
• 4:1raCo• Sametotalcollagenoverall
• Improvetensilestrength
Wound Healing
Wound Healing
• Strength• At6weeks
• 80%ofmaximalstrength• At8weeks
• 80%oforiginalstrength• 100%maximalstrength
• RetrospecCvemulC-centerreview• 429,906operaCons1985-2005
• Excluded–appendectomy,non-surgicaloperaCons• 363casesofdehiscence• 1089selectedcontrolcases• Management
• 61treatedwithNOM• 302treatedoperaCvely
• Results• Occurrence
• Mean-day9(0-32days)• 90%priorto15days
• ECologies• Suturestearing29%• InfecCon9%• Brokensuture8%• NecroCcfascia6%• Looseknots4%• Unknown44%
• Outcomes• Prolongedhospitalstay–36v16d• Higherincidenceofincisionalhernias• Mortality–22v9%
• Independentriskfactors• Age• Gender• Hypertension• COPD• Ascites• Uremia• Jaundice
• Anemia• Emergencysesng• Typeofsurgery• OperaCveCme• Post-operaCvecoughing• WoundinfecCon• Sepsis• Steroids
• Riskmodel
• Riskmodel–EP• 1.1+0.7+1.5+0.7+1.4+1.9• Total(x)=7.3• P=ex/(1+ex)x100%• P=e(-8.37+(1.085*7.3))/(1+e(-8.37+(1.085*7.3))x100%• P=61%riskofdehiscence
Risk Factors – Pa7ent
• Age• <45yo1.3%versus>45yo5.4%
• Gender• Malesx2>females
• MalnutriCon• Albumin<3mg/dl• VitaminCdeficiency-8-foldrisk
• Anemia• COPD
Risk Factors – Pa7ent
• Uncontrolleddiabetes• ControlledDMisnotariskfactor
• Malignancy• Sepsis• Renalfailure• MedicaCons• Chemotherapy• RadiaCon–fibroblastfuncCon• Steroids• Immunomodulators–azathioprine
Risk Factors – Pa7ent
• Steroids• InhibiConofinflammatoryphase• InhibitepithelializaConandcontracCon• Reducecollagensynthesis• Reducewoundstrength
• RadiaCon• Acuteocclusionofsmallbloodvessels• PermanentalteraConoffibroblastfuncCon• Dose-dependent
• <300cGy–insignificant• >1000cGy–impairshealing• >4500cGy–complicaCons
• Time-dependent• Pre-opWITHIN1week–insignificant• Post-op–acceptable
Risk Factors – Post-opera7ve
• WoundinfecCon• Woundhematoma• Intra-abdominalinfecCon
• Intra-abdominalpressure• AggressiveresuscitaCon• Coughing• VomiCng• Straining• UrinaryretenCon• Ileus• Edema
Risk Factors – Opera7ve
• Intra-abdominalspillage/infecCon• Incision• Closure
Risk Factors – Opera7ve
• Intra-abdominalspillage/infecCon• Incision• Closure
• Prolongedinflammatoryphaseofwoundhealing• ConCnuouscytokinerelease
Risk Factors – Opera7ve
• Intra-abdominalspillage/infecCon• Incision• Closure
• Lessanalgesiarequired• LesspulmonarydysfuncCon• Fewerwounddehiscence• Fewerincisionalhernias• Transverselaparotomy?
Risk Factors – Opera7ve
• Intra-abdominalspillage/infecCon• Incision• Closure
• Bitesize• Suturetechnique• Suturematerial• Suturelength–Jenkin’srule• Layers• RetenConsutures
Closure
• Bitesize–STITCHtrial• Large1cmbites21%• Small0.5cmbites13%
• Suturetechnique–INSECTtrial• Interruptedvicryl15.9%• ConCnuousmonoplus12.5%• ConCnuousPDS8.4%
Closure – Suture Material
• AbdominalwallhealingCme• 42days–50%originalstrength• 120days–70-80%originalstrength• 140days–73-93%originalstrength
• Non-absorbable• Morepainandsuturesinuses
• Absorbable–180days• HigherinfecConrates
• Nodifferenceinoutcome
Closure – Jenkin’s Rule
• Lengthofsuturemustaccommodatetoincisionsize• Increasepost-operaCvely
• 4:1raCosuture-to-woundlength• Donottug!
• 1cmbites–1cmapart…..
Closure – Layers
• Massclosure–1%dehiscence• Layeredclosure–11%dehiscence• Moreadhesions• LongeroperaCveCme• Tensiononeachlayer
• Peritonealclosure• Nodifference
Closure – Reten7on Sutures
• Wideinterruptedbites• Heavynon-absorbablesuture• 3cmfromwoundedge–3cmintervals• PlasCc/rubbertubingtopreventsutureerosion• NottooCght!• Leavefor3weeks
Closure – Reten7on Sutures
• Outcomes• NodifferenceinwoundinfecCon• Nodifferenceinincisionalhernia• PreventsevisceraConinhigh-riskpaCents
Management of Dehiscence
Stable+evisceraCon OR
Unstable+evisceraCon OR
Unstable,noevisceraCon
Gauzeandsterileocclusivedressing,binder
Delayedherniarepair
Stable,noevisceraCon Noproblem
Summary
• 4phasesofwoundhealingarehemostasis,inflammaCon,proliferaConandremodeling.• Firstcelltoappearinwoundhealingisplatelet.• FirstinflammatorycelltoappearinwoundhealingisPMN.• Woundhealingiscomplexanddelicateprocessandaffectedbymanyfactors,includingpaCents’condiConsandsurgicaldecisions.• BitesizemaZers• SuturetechniquemaZers• Suturetypedoesnot
Which of the following statements about the effects of radia7on therapy on wound healing is NOT true? • A–RadiaContherapyinanoperaCvefieldgiveoneweekpost-operaCvelyincreasestheincidenceofwounddehiscence.• B–previouslyirradiatedskinwillblisterifthepaCentistreatedwithDoxorubicin/Adriamycin• C–singledoseof300cGygivenpreoperaCvelydoesnotsignificantlyaffectwoundhealing• D–radiaConcausesocclusionofsmallbloodvesselsandpremanentlyaltersfibroblastfuncCon.• E–paCentstreatedpre-operaCvelywith4500cGyhaveagreaterriskofwoundcomplicaConthannon-irradiatedpaCentsundergoingAPR.
Which of the following has been shown to reverse the cor7costeroid-induced inhibi7on of wound healing? • A–VitaminA• B–Bromelian• C–Eicosapentaenoicacid• D–Garlic• E–VitaminE
Thank you!
References
• VanRamshort,etal“AbdominalWoundDehiscenceinAdults:developmentandvalidaConofariskmodel”WorldJournalofSurgery(2010)34:20-27
