We are now using VAC therapy in thoracic/abdominal wounddehiscences after esophagectomy for cancer. Until a few years ago these wounds were treated using sugar in PEG, but the VAC therapy seems to give faster healing results. This is a general impression as we only treated about five patients with VAC therapy, but the good results so far encourage us to further use this technique.

We have used the VAC in the past with a very poor outcome. 2 of our patients who had heel ulcers did not improve with the VAC therapy instead worsen it by decreasing Hb level. Both patients have to receive PRBC.

Dear Krishna

The system negative pressure wound therapy is very used by orthopedists and has several functions: remove fluid from the extravascular space, reduce tissue edema, improve microcirculation and allow a natural debridement in addition to reducing the need for coverage myo-cutaneous.

This article may be useful for you:

Laeknabladid. 2014 Apr;100(4):219-224.

[Negative pressure wound therapy - review.]

Gudmundsdottir I, Steingrimsson S, Valsdottir E, Gudbjartsson T.

Dr Banasiewicz, there are also reports regarding problems in using negative pressure in instances where enterocutaneous fistulae are present. Its interesting to note that you have used negative pressure in leaked gastro pancreatic anastomosis.

One issue with neg pressure is the moistness in the wound encourages nosocomial infections. Does constant irrigation tackle wound colonization with 'difficult to eradicate' organisms like Pseudomonas ?

Dr Banasiewicz, what is the usual negative pressure range you would allow ?

We have used the negative pressure wound systems in difficult to manage thoracic infections such as infected post-pneumonectomy space. The results are amazing! Previously the patients would have needed a long course of dressing changes, irrigation and pedicled muscle grafts to control the problem. With the negative pressure system we were able to close the wounds after only a few changes!

I agree with all those who have brought up the issue of familiarity. I struggle with this at times. Thankfully we only have a few patients who need this in a year. We are currently using a Vac dressing in a kidney pancreas transplant patient who had pancreatectomy for severe pancreatitis. The issue of iatrogenic intestinal fistulae comes up often, it is a genuine concern, which for some clinicians restrains them for using the device. Individual anecdotes on fora like this may reassure clinicians.

For me there are several attraction:

1. the touted benefits of promoting granulation and healing,

2.makes the subsequent management of the wound easier

3. it makes nursing easier

4. often never mentioned, it makes the wound aesthetic hence makes it easier for friends and family.

As Dr Camunas mentioned, negative pressure is useful in post decortication air leaks in empyema, Post eso atresia anast leak

I had an interesting case of a patient almost in extremis with a chronic empyema, high fever, elevated WBC and a large space with an air-fluid level in right chest. The CT scan showed a thick peel on the visceral pleura. He had aspirated and had poor dentition. The empyema developed after a large lung abscess drained into the pleural space. We were very hesitant to do a decortication or any procedure requiring anesthesia because of his precarious condition..

I localized the fluid and removed a portion of a rib. A thoracostomy, an old fashioned treatment. Instead of packing, I placed several large sponges into his chest and had a portion come out to use negaive pressure wound drainage. We changed the sponges in three to four days twice and placed fewer sponges each time. To my surprise the lung expanded and there was minimal air leak. It stopped in a few days.

The big surprise was that the patient had no pain after this procedure! I attributed this to the lack of a chest tube anchored to the skin and going through a tight intercostal space.

After a week, the drainage was minimal and I removed all the sponges with minimal sedation and placed two short segments of a chest tube to maintain the skin aspect of the wound open. I removed those in another week and the wound closed by itself.

I expected he would have needed a decortication once he was in a better condition and could tolerate general anesthesia, but this was not necessary. The chest X-ray and CT scan showed no residual space and complete re-expansion of the lung.

Any similar cases treated with negative pressure wound drainage?

Thanks for your comments and observations.

Dr Camunas, an illustrative case using negative pressure.

3 month old baby boy with Congenital cystic adenomatoid malformation of Rt upper & middle lobe underwent removal of both the lobes with the residual lobe poorly expanding on table. Post operatively, air leak through the chest tube was significant, necessitating re exploration. The bronchial stumps were intact at exploration, but the air leak persisted. At this point of time, negative suction pressure was used through the chest tube, which over a period of time completely sealed the air leak. At follow up after 4 months, the child is thriving well.

I have closed two entero-atmospheric fistulas with wound vac therapy (one was a gastric fistula!). It is very effective in select situations.

As usual, has it limits but very useful in many wound dehiscences or fistulas. can be kept more than a week in some indications, especially in children, limitating then the stress of the dressing change. Be careful, when the dressing has to stay in place for a "long" time to protect the skin around the wound.

Use over all ssg in paediatric burns, and burn scar reconstructions. Acts to stabilise wound in that it prevents shearing, decreases swelling and decreases pain. In the middle of a RCT looking at NPWT in the management of paediatric partial thickness burns. Great for the management of complex gastroschisis patients and ulcerated haemangiomas.

I agree with Prof Kimble's answers above. We have published a number of papers on this modality, and it's uses in complex abdominal wall defect patients, neonates, and burns.

It's not a 'one fix for all' modality. We're coming to realise that the ways you manipulate the variables available (interposition layer, filler, pressure settings, continuous vs intermittent) all have different effects on the wound. As an example - black foam gives a more exuberant granulation layer, but it's not as robust as that which forms under gauze. There are emerging data the eventual scar is not as pliable either. Foam also hurts more when you take it off, as you can get ingrowth into the foam. Experience is the key, and the more you use it the easier it gets.

I can echo Dr. Roife. We have good experiences with using it for entero-atmospheric fistuala if properly installed:

Wirth U, Renz BW, Andrade D, et al. Successful treatment of enteroatmospheric fistulas in combination with negative pressure wound therapy: Experience on 3 cases and literature review. Int Wound J. 2018;15(5):722-730. doi:10.1111/iwj.12916

Another aspect is the successful use of endoscopic vacuum therapy for left-sided colorectal defects:

Kühn F, Wirth U, Zimmermann J, et al. Endoscopic vacuum therapy for in- and outpatient treatment of colorectal defects. Surg Endosc. 2021;35(12):6687-6695. doi:10.1007/s00464-020-08172-5

Kühn F, Schardey J, Wirth U, et al. Endoscopic vacuum therapy for the treatment of colorectal leaks - a systematic review and meta-analysis [published online ahead of print, 2021 Nov 24]. Int J Colorectal Dis. 2021;10.1007/s00384-021-04066-7. doi:10.1007/s00384-021-04066-7