social pharmacy d-pharm 1st year by Pragati K. Mahajan
Ciprandi, closed incisional npwt
1. 1
Closed
Incisional
NPWT:
Biological
Evidence
for
Clinical
Benefits
Guido
Ciprandi,
MD,
PhD
Bambino
Gesu’
Children’s
Hospital,
Rome
–
Italy
Dpt
of
Surgery,
Division
of
PlasAc
Surger,
Chief
Mario
Zama
WUWHS
Sister
Socie-es
Mee-ng:
ISPeW
2. 2
NPWT
is
a
non-‐invasive
wound-‐closure
device.
It
was
argued
to
help
with
wound
healing
at
a
chronic
or
acute
wound
site
by
using
locally
controlled
NP
Avant-propos
3. 3
closed incision negative pressure therapy (CI-
NPWT) may offer surgeons an additional option to
manage clean, closed surgical incisions
4. 4
CI-NPWT may offer surgeons an additional
option for flap preconditioning avoiding
• Vasodilators drugs
• Vascular reorientation
…and increasing a tissue perfusion
As a result…
Koh
KS,
J
Surg
Res,
2016,204(2):319
Lee
JW,
Arch
Plast
Surg,
2015,
42(2):
6. 6
NPWT
mechanical-‐biological
effects
• Removal
of
dead-‐cells
from
Nhedges
• Removal
of
senescent
cells
• Exposing
cells
from
able-‐to-‐Heal
surfaces
• AcGvaGon
of
quiescent
cells
• Modifying
the
cellular
phenotype
• Inducing
the
cross-‐talks
• GFs
and
homogeneous
hypergranulaGon
7. 7
Why
CI-‐NPWT?
• Decreasing
risk
of
surgical
site
complicaGons
• Wound
breakdown
• Management
of
exudate
• <
Surgical
site
infecGons
(SSIs)
• <
Seroma
formaGon
• <
Haematoma
formaGon
8. 8
• Global
reducGon
of
infecGons
(sSSIs-‐d)
using
CI-‐NPWT
criteria
• Specific
<
of
SSIs
in
criGcal
areas
• Specific
<
of
SSIs
in
babies
• Specific
<
of
SSIs
in
dramaGc
sites
• Hard
reducGon
of
surgical
dehiscences
• <<<Hematomas
and
seromas
confined
to
selected
categories
of
paGents
or
pathologies
or
surgical
techniques
(use
of
microsurgical
techniques
for
manipulaGng
Gssue–
sparing
procedures)
Impact
on
complicaCon
rates?
9. 9
Opportunity to Prevent SSI
• An estimated 40%–60% of SSIs are
preventable
• Overuse, underuse, improper timing, and
misuse of antibiotics occurs in 25%–50%
of operations
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
10. 10
PEDIATRICS:
much
more
aBen-on
have
to
be
paid
to…
1. BMI,
but
not
only:
obesity
and
malnutriGon
2. Remote
InfecGons,
ENT/Theeth
screening
(1.5%
up
to
7%)
3. Test
for
allergy/intolerance:
latex,
silicon,
chlorhexydine,
polyhexanide
(polyhexamethylene
biguanide,
PHMB)
4. DecolonizaGon
for
MRSA
(30%)
5. AB
prophylaxis
guidelines/AB
STOP
before
6. Wash
your
hands
-‐
OR
Traffic
–
Skin
preparaGon
7. Normothermia
and
Glicemia
8. Clean
gloves
before
closing
9. The
microbiology
(polymicrobism)
and
proper
dress
10. Avoid
glues/adhesives
11. Think
about
the
>sebum
producGon/maceraGon
12. Think
about
the
“permeability”
and
the
TEWL
13. CI-‐NPWT
as
a
prac-ce
for
preven-on
Approach
to
prevenCon
11. 11
ComplicaCons
(148
at
risk
sutures)
• Pain
at
the
covered-‐site/
• Mechanical
erythema
and
hyperalgesia
• Skin
blistering
• PyodermiCs,
pyogenic
bacteria
infecGon,
Staphylo/Strepto
• FolliculiCs,
bacterial
or
fungal
infecGon,
Pseudom
• Superficial
InfecCon
• 6.1%
Seroma
1
(3.57%),over
the
fascia
• 5.2%
Hematoma
none
• 7.2%
Deep
InfecCon
1
residual
S-‐SSI
(3
days
of
CI-‐NPWT)
• 6.7%
Dehiscence
1,
infecGon
at
surgical
closure!?
• 2.8%
Sepsis
and
Death
due
to
a
deepSSI
none
CSI
=
Closed
Surgical
Incision
28
CI-‐NPWT
effect
of
CI-‐NPWT
on
surgical
sites
healing
by
primary
inten-on
Closed
Incisional-‐NPWT
for
High-‐Risk
Wounds
P
<
0.0009
12. 12
CI-‐NPWT
in
Children
• Effects
on
“wound”
and
perilesional
Gssues
• Protect
against
external
infecGon
• Help
in
holding
incision
edges
together
• Decrease
lateral
Gssue
tension
• Exudate
and
fluids
removal
and
drainage
• Cellular
and
molecular
ac-ons
Kilpadi
DV,
AestheCc
Plast
Surg,
2014,
38(4):767-‐78
13. 13
…The lesson learned from normal tissues
1
2
3
4
Macroscopical areas
1.Normal skin
2.Boundary line
3.Suction area
4.Hypergranulating area
14. 14
Measuring
CI-‐NPWT
effects:
the
study
• Laser
Doppler
imaging
system
(Gssue
perfusion)
• Histological
analysis
(HE,
CD31,
Masson-‐t)
• Ultrastructural
examinaCon
(TEM)
Increased
microvascular
density
in
the
subdermal
plexus
Organized
collagen
producCon
Muscle’s
hypertyrophy
Increased
amount
of
fibers
IV
15. 15
TEM:
Histobiological
acCons
of
CI-‐NPWT
1. Extracellular
juncGonal
pamern
2. Fibroblast
3. Collagen
fibers
organizaGon
4. Endocellular
structures
(RER)
5. Nuclear
pamern
(courtesy
of
Dr
Renata
Boldrini,
The
Research
Lab
of
Hystopathology
&
Molecular
Sciences,
SEM
and
TEM
secCon,
Bambino
Gesu’
Children’s
Hospital,
Rome,
Italy)
17. 17
AcGvated
fibroblasts
with
an
evident
ectaGc
RER
CI-NPWT sampled tissues
Rough
Endoplasmic
reCculum
(RER),
is
a
conCnuous
membrane
system
that
forms
a
series
of
flafened
sacs
within
the
cytoplasmof
eukaryoCc
cell
and
serves
mulCple
funcCons,
being
important
parCcularly
in
the
synthesis,
folding,
modificaCon,
and
transport
of
proteins
Rough…studded with ribosomes
18. 18
Increasing
number
of
normal-‐shaped
intracellular
organules
Perinuclear
fine
chromaCn
dispersion
Morphofunctional expression of tissue viability after CI-NPWT in children
CI-NPWT sampled tissues
19. 19
Collagen fibers
• ConnecGve
Gssue
• Extracellular
matrix
• Triple
helix
arrangement
(normal
shape)
• Tipe
IV,
two-‐dimensional
• reGculum
*Three-‐stranded
helical
segments,
fibrils
type
I,II,III
20. 20
Conclusion
1.
CI-‐NPWT
Promotes
“granula-on”
but
what
does
it
mean
exactly?
• Enhances
Cell-‐to-‐Cell
adherence
• Induces
normal
arrangement
of
collagen
fibers
• Produces
an
ectaGc
RER
• Turn
on
fibroblasts
21. 21
Effects of Ultrastructural Granulation:
patient and cost benefits
1. < hospital readmission
2. <additional minor/major surgical procedures
3. <additional anesthesiological procedures
4. <hospital stay
5. <the number of stress related procedures
6. <the pain-related procedures
7. <drugs administrations
8. <loss of school-days
9. <loss of working days for parents and > Family costs
10. <admission upgrading and emergencies
11. <deaths (d-SSIs – related)
12. >number of Graft/Devices/Electrical tools-preservation strategies
13. Softer scars (stem-cells/like effect)
26. 26
NUMBERS:
january
2008-‐december
2015
322
pts,
426
wounds
(61%
F/39%M
-‐
mean
age
6.7yrs)
Department of Surgery – Plastic and Maxillofacial Surgery Unit
• 328 children submitted to NPWT
• 426 wounds treated with NPWT
• 25.8% of Complex Wounds were submitted to NPWT
• 49.2% considering the last 3 yrs
• 222pts Traditional NPWT 67,6%
• 78pts Simplified Canisterless NPWT 23,7%
• 28pts Closed Incisional-NPWT 8,55%
NUMBERS
27. 27
…during the last 3 years
0
10
20
30
40
2013 2014 2015
Traditional
Simplified
Incisional
28. 28
About
pafern
of
lesions
and
different
features
and
comorbidiCes
• We
are
reasonably
sure
about
the
so
called
“at
risk
incisions”
and
paGents
to
submit
to
a
CI-‐NPWTherapy
29. 29
About
pafern
of
lesions
and
different
features
and
comorbidiCes
• We
are
not
everyday
sure
about
wounds
and
paGents
to
submit
to
a
NPWTherapy
in
terms
of
type
of
filler,
pression
regimen,
modality…it’s
not
so
easy…
30. 30
What
is
the
best
NPWT-‐choice?
DEHISCENCE
AFTER
BACK
SURGERY
31. 31
What
is
the
best
NPWT-‐choice?
DEHISCENCE
POST
ONCOLOGICAL
SURGERY
32. 32
What
is
the
best
NPWT-‐choice?
CONGENITAL
MELANOCYTIC
NEVUS/INTEGRA
33. 33
What
is
the
best
NPWT-‐choice?
TROCHANTERIC
PRESSURE
ULCER
46. 46
Conclusion
and
Future
2.
DysregulaGon
of
cell
division
orientaGon
could
lead
to
abnormal
Gssue
development
and
funcGon
with
a
negaGve
influence
on
skin
repair
and
regeneraGon
Shaowei
Y
et
al,
Biosci
Rep,
2015
How
to
guide
nega-ve
pressure
inside
-ssues
and
how
to
choose
the
proper
linear
interac-on
with
oriented
cells
47. 47
Conclusion
and
Future
3.
Division
plane
is
crucial
for
cell
fate.
Only
a
stretch
inducing
division
along
the
long
cell
axis
can
induce
the
minimal
energy
difference.
Guang-‐Kui
X
et
al,
J
Biomech,
2016
Goal:
studying
the
interac-on
between
the
stretch
and
tridimensional
cultured
blocks
of
oriented
cells
mimicking
the
effect
of
a
CI-‐NPWT
on
underlying
-ssues
