Wounds and wound management PDF
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WoundsandWoundManagement Contents Foreword:WoundsandWoundManagement ix RonaldF.Martin Preface:WoundsandWoundManagement xiii MichaelD.Caldwell WoundSurgery 1125 MichaelD.Caldwell Thepurposeofthisarticleistoreviewtheconceptsbehind,andpractice of,woundsurgery.Thetechniquesofwoundsurgery,bornofnecessityin the art of military surgeons, have found their renaissance in the modern ageofwoundcaredrivenbytheeconomicandfunctionalconsiderations inherenttotheoutcome-basedmanagementofchronicdisease.Over300 years of literature on wound healing has shown an innate ability of the wound (in the absence of infection and repeated trauma) to control its progress, largely through the local inflammatory cells. This article dis- cusses several historical works on wound surgery and healing, topical wound therapy, minimal intervention, and emphasizes the closure of chronicwounds. WoundHealingPrimer 1133 StephanieR.GoldbergandRobertF.Diegelmann Surgeonsoftencareforpatientswithconditionsofabnormalwoundheal- ing,whichincludeconditionsofexcessivewoundhealing,suchasfibrosis, adhesions,andcontractures,aswellasconditionsofinadequatewound healing,suchaschronicnonhealingulcers,recurrenthernias,andwound dehiscences.Despitemanyrecentadvancesinthefield,whichhavehigh- lighted the importance of adjunct therapies in maximizing the healing potential,conditionsofabnormalwoundhealingcontinuetocausesignif- icant cost, morbidity, and mortality. To understand how conditions of abnormal woundhealingcanbecorrected, itisimportant tofirstunder- standthebasicprinciplesofwoundhealing. CurrentConceptsRegardingtheEffectofWoundMicrobialEcologyandBiofilms onWoundHealing 1147 CarrieE.BlackandJ.WilliamCosterton Biofilms are a collection of microbes that adhere to surfaces by manufacturing a matrix that shields them from environmental elements. Wound biofilms are difficult to evaluate clinically, and standard culture methods are inadequate for capturing the true bioburden present in the biofilm.Newmoleculartechniquesprovidethemeansforrapiddetection andevaluationofwoundbiofilms,andmayprovetobeusefulintheclinical setting. Studies have shown that many commercial topical agents and wounddressingsinuseareineffectiveagainstthebiofilmmatrix. Atthis stage,mechanicaldebridementappearstobeessentialintheeradication vi Contents ofawoundbiofilm.Topicalantimicrobialagentsandantibioticsmaybeef- fectiveinthetreatmentofthewoundbedafterdebridementinthepreven- tionofbiofilmreformation. UnusualCausesofCutaneousUlceration 1161 JaymiePanuncialmanandVincentFalanga Skinulcerationisamajorsourceofmorbidityandisoftendifficulttoman- age.Ulcerscausedbyaninflammatorycauseormicrovascularocclusion areparticularlychallengingintermsofdiagnosisandtreatment.Theman- agement of such ulcers requires careful assessment of associated sys- temic conditions and a thorough analysis of the ulcer’s clinical and histologic findings. In this article, the authors discuss several examples ofinflammatoryulcersandtheapproachtothediagnosisandtreatment oftheseulcers. ComplexWoundsandTheirManagement 1181 HabeebaPark,CarolCopeland,SharonHenry,andAdrianBarbul Complexwoundspresentachallengetoboththesurgeonandpatientin operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedicbluntorpenetratinginjuries,particularlyintheextremities,as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene,andFourniergangrene.Theprinciplesofmanagementofcom- plexwoundsinvolveassessingthepatient’sclinicalstatusandthewound itself,appropriatetimingofintervention,providingantibiotictherapywhen necessary,andplanningandexecutingsurgicaltherapy,includingthees- tablishmentofacleanwoundbedandclosure/reconstructivestrategies. MedicalandSurgicalTherapyforAdvancedChronicVenousInsufficiency 1195 RonnieWord Venousulcerationisthemostseriousconsequenceofchronicvenousin- sufficiency.Thediseasehasbeenknownformorethan3.5millenniawith wound care centers established as early as 1500 bc. Unfortunately, still todayitisaverypoorlymanagedmedicalcondition bymostphysicians despite that a great deal has been learned about the pathogenesis and treatment for venous ulcerations. We find that many wound care clinics treatthewoundandnotthecauseoftheproblem.Inthisarticle,wereview thebasicpathophysiologyofadvancedchronicvenousinsufficiencyand review the most up-to-date information with regard to medical therapy anddifferentoptionsofsurgicaltherapytoaddresstheunderlyingvenous pathologyresponsibleforchroniculcers. EndovascularTherapyforLimbSalvage 1215 MichalNawalany Inrecentyearspercutaneoustherapyhasgraduallybeenadoptedasan alternativetoprimaryamputationinpersonsdeemedunsuitableassurgi- calcandidates,andhasestablisheditselfasaprimarymodeoftreatment. Contents vii Therehasbeenanexplosioninendovasculartechnologyandarevolution in revascularization patterns for limb salvage. Open surgery is now fre- quentlyreservedforfailureofendovascularattemptsorpathologyunsuit- able for endovascular revascularization. This article aims to educate the practicinggeneralsurgeonabouttheusefulnessandappropriateapplica- tion of different therapeutic endovascular options as applied to limb salvage. Intra-abdominalHealing:GastrointestinalTractandAdhesions 1227 SanjayMunireddy,SandraL.Kavalukas,andAdrianBarbul Theabdominalcavityrepresentsoneofthemostactiveareasofsurgical activity. Surgical procedures involving the gastrointestinal (GI) tract are among the most common procedures performed today. Healing of the GItractafterremovalofasegmentofbowelandhealingoftheperitoneal surfaceswithsubsequentadhesionformationremainvexingclinicalprob- lems. Interventions to modify both the responses are myriad, yet a full understandingofthepathophysiologyoftheseresponsesremainselusive. DifferentaspectsofGIandperitonealhealing,withassociatedfactors,are discussedinthisarticle. ActiveWoundCoverings:BioengineeredSkinandDermalSubstitutes 1237 Marke´taLı´mova´ Extensiveskinlossandchronicwoundspresentasignificantchallengeto theclinician.Withincreasedunderstandingofwoundhealing,cellbiology, andcellculturetechniques,varioussyntheticdressingsandbioengineered skin substitutes have been developed. These materials can protect the wound, increase healing, provide overall wound coverage, and improve patientcare.Theidealskinsubstitutemaysoonbecomeareality. Index 1257 WoundsandWoundManagement Foreword Wounds and Wound Healing RonaldF.Martin,MD ConsultingEditor TheAccreditationCouncilforGraduateMedicalEducation(ACGME)releaseditsfinal rulingonresidentsupervisionanddutyhourrestrictionstobeenacted1July2011.The fullreportcanbefoundontheirwebsitewww.acgme.org.Youhavenoticedthatthe topic of this issue of the Surgical Clinics of North America is about wound healing andyoumaybewonderingwhatdoestheACGMEreporthavetodowithwoundheal- ing.Inaworddexpectations. NearlyeveryoneinthesurgicaleducationcommunitywithintheUnitedStateshas been grappling with the seemingly endless focus on work regulations for the past several years. This has been a contentious debate that has inflamed passions and been espoused by many groups with varying degrees of interest and self-interest. Many feel the science has been weak, although others argue to the contrary. Some argue that the proposed, now declared, changes are a political necessity to stave off some draconian action from without the body politic of medicine. There may besometruthtoallornoneoftheabovebut,inmyopinion,howtruetheclaimsare ismoreorlessirrelevantasitmissesthefundamentalpoint:arewetryingtomanage expectationswithoutregardtoconsequences? ArecentarticleintheNewYorkTimes,“Whatisitabout20-somethings?”byRobin MarantzHenig(18August2010),reviewed,amongotherthings,someoftheworkof DrArnettonaphaseoflifehecoinedas“emergentadulthood.”Thearticledescribes how the pursuit and achievement of many life goals for younger people have been delayed, or sometimes omitted, compared to similarly aged people in past times. The phenomena of young people graduating from college or graduate school to movebackintotheirparents’homesandthelongerperiodoftimethatparentsprovide tangiblesupportfortheiradultchildrenarediscussedandanumberofobservations are relayed. Perhaps the question alluded to that intrigues me most is whether this phenomenon of delayed achievement of independence (for lack of a better SurgClinNAm90(2010)ixexi doi:10.1016/j.suc.2010.10.002 surgical.theclinics.com 0039-6109/10/$eseefrontmatter(cid:1)2010ElsevierInc.Allrightsreserved. x Foreword term)iscausativeoftheprolongationofparentalsupportoristheprolongedsupport ofparentsenablingthedelayof,oreveninhibiting,theyoungerperson’sdevelopment. Thefactthatpeopletendtolivelongerthanweusedtoisconsideredinthisanalysis of observed delayed maturation. It is suggested that perhaps it is a good thing for peopletospendmoretimeexperimentingwithoptionsandexploringself-discovery beforecommittingtoalifecoursethatwilllastlongerthaninpreviouseras.Inmany ways that seems reasonable. If one acknowledges even a fraction of truth in these observations,thenperhapsweshouldseriouslyreconsidermedicaleducationand,in particular,surgicaleducationdatleastasfarasexpectationsovertimeareconcerned. During the time that I have been involved in surgical education, there has been asteadydeclineintheamountoftimethatmedicalstudentswereexpectedtospend “working”ontheireducationandaconcomitantdecreaseintheamountofresponsi- bilitythattheyshouldorcouldassume.OverthatperiodoftimeIwouldsubmitthat firstdaysurgicalresidentshavebecomeprogressivelylessabletofunctionaseffec- tively as their predecessors based on their preparation in medical school. Also, the curve of readiness of individual responsibility has been progressively been shifting towardthe“right”ofthetimelineandnowseemstospillingoverintofellowshipand juniorattending.Andmaybethisisokaytoapoint,ifitisaconsensuschangeamong thosewhoneedmoretimetotrainandthosewhoexpectalevelofindependentcapa- bility.Myobservationhasbeenthatnosuchpervasiveagreementexistsatpresent. Ifthe20-somethings’generaltrendofaslower,moremeanderingpathtowardfull developmentwereatrueculturalchange,thenthisshouldprobablyapplytothegroup ofpeoplewhowetrainaswell.Thereissomeagevarianceinthegroupofresidents nationally,tobesure,buttheconceptprobablystillholds.Ifso,weasanorganization had better address the changing dynamic while we can. Who knows, perhaps next yearwe’llhearaboutthe30-somethingsthatneedmoretimetomakeitto40. TheACGMEdecisiontolimitthehoursandopportunitiesforresidentstolearn,and redefining the work capacity of first year residents as a completely different kind of work schedule, much more akin to the current level of expectation of medical students, is a tacit declaration from our powers-that-be that these young persons are on a different path than those before. We have redefined the expectation of involvement without redefining the expectation of achievement. The amount and typeofinformationtheyneedtolearnarenotdifferent.Theamountoftechnicalprac- ticeandclinicalopportunitiesthatareneededarenolessthanbefore,morelikelythey aregreaterthanpreviouslyrequired.Weareembarkingonapathofchangingexpec- tationsofeffort,opportunity,andcapacitywithout,inmyopinion,properregardtothe consequencesofalteredtraining. Perhapswecanworkthroughthisdisconnect.Wecouldlengthentraining,uniformly dislikedbytrainers,trainees,andthosewhohavetopayforitalike.Wecouldmodula- rizetrainingandcertification,problematicforhistoricalreasonsaswellasitspotential implicationsforexistingorganizationsofconsiderableinfluence.Wecouldseparatethe surgicaleducationworldfromtherestofgraduatemedicaleducation,althoughthat wouldbeaHerculeantaskwithstaunchopposition.Orperhapswecanignorethiswhile weproducetraineeswhoarelessconfidentandperhapslesscompetentastheyenter practice. Every cutting surgeon deals with wounds. Most wounds heal without significant post closure intervention from surgeons, at least, the simple ones. We have largely come to expect that time heals all wounds. Not so. For those wounds that do not healwellorpresentotherchallengessecondarytoinfectionorhostfactors,changing ourexpectationsortryingtolimittheeffortwewillhavetoexpenddoesnotmakethem healbetter.Woundhealingisacomplexbiologicalprocesswithmultipleopportunities Foreword xi to not proceed the way we would hopedmuch like education. One big advantage when comparing wound healing to education is that we have reliable basic science to which we can turn and people who can put the science and clinical information in proper context. Dr Caldwell and his collaborators have assembled an excellent collection of articles to help us understand how wounds heal and how we can use that knowledge to impact outcomes positively. The information they have provided will help us reframe expectations of what we must do and how that will affect outcomes. Last,DrCaldwellandIwouldliketodedicatethisissuetoDrGuidoMajno.DrMajno is a true pioneer of wound healing whose contributions to our understanding of the processandhistoryofwoundhealingandinflammationareextraordinary.Ifirstmet himasajuniormedicalstudentwhenhewasProfessorandChairofPathologyatthe University of Massachusetts Medical School. He was one of those teachers whose impactlastedforeveronallhisstudents.Wehadhopedthathecouldhavecontributed tothisissuebut,unfortunately,becauseofhealthreasonshecouldnot.Infact,hehas contributedimmenselytothisissuethroughouthislifebyallthatwehavelearnedfrom him.Wewishhimandhisfamilytheverybest. RonaldF.Martin,MD Departmentof Surgery Marshfield Clinic 1000North Oak Avenue Marshfield,WI 54449,USA E-mail address: [email protected] WoundsandWoundManagement Preface Wounds and Wound Management MichaelD.Caldwell,MD,PhD GuestEditor ThisissueofSurgicalClinicsofNorthAmericaisdesignedtogivethereaderasummary ofimportantconceptsinwoundhealing.Theauthorshavepreparedexcellentarticles that range from the latest information in the basic science of repair to current tech- niquesindifficultwoundmanagement. I appreciate the opportunity to host this issue given to me by Ron Martin. I also greatlyappreciatethecontributionsofeachofthearticleauthorsandIhopethatthe readerwillfindtheireffortstobeasoutstandingasIbelievethemtobe. Wehopethatthisvolumewillprovidethereaderwithnewandintriguingknowledge ofwoundsandwoundhealingdandsurgeonswithanimpetustoovercomethetemp- tationofminimalinterventionandactivelyengageinreducingthemorbidityofchronic wounds. Michael D. Caldwell, MD,PhD Departmentof Surgery Marshfield Clinic 1000North Oak Avenue Marshfield,WI 54449,USA E-mail address: [email protected] SurgClinNAm90(2010)xiii doi:10.1016/j.suc.2010.10.001 surgical.theclinics.com 0039-6109/10/$eseefrontmatter(cid:1)2010ElsevierInc.Allrightsreserved. Wound Surgery Michael D. Caldwell, MD,PhD KEYWORDS (cid:1)Vismedicatrixnaturae (cid:1) Wound (cid:1) Debridement (cid:1)Delayedwoundclosure “JelepansayetDieuleguarit.”1 AmbrosePare,AD1885. “TheChirurgionoughtfortherightcureofwoundstoproposeuntohimselfe,the common and general indication: that is, the uniting of the divided parts, which indication in such a case is thought upon and knowne even by the vulgar: for that which is dis-joyned desires to bee united, because union is contrary to division.”1 Thelossofcontinuityofbodysubstancebyinjuryordiseasewasrecognizedbyour ancestorsasapainful,morbid,andfrequentlyfatalprocess.Consequently,overthe nearly4millenniaofrecordedmedicalhistory,physiciansandsurgeonshaveattemp- tedbyvariousmeanstospeedthehealingofwounds.Thepurposeofthisintroductory article is to review the concepts behind, and practice of, wound surgery. The tech- niquesofwoundsurgery,bornofnecessityintheartofmilitarysurgeons,havefound theirrenaissanceinthemodernageofwoundcaredrivenbytheeconomicandfunc- tionalconsiderationsinherenttotheoutcome-basedmanagementofchronicdisease. Nolongerallowedtorelylargelyonthe“vismedicatrixnaturae”dictathatpopulated minimalintervention-based woundcare,modernwoundcarespecialistsourcurrent arerequiredtooptimizeallaspectsofthewoundbedanditsclosure. VISMEDICATRIXNATURAEANDTHEBIOLOGICPRIORITYOFHEALINGWOUNDS Thetermvismedicatrixnaturaereferstotheintrinsichealingpowerinalivingorganism, by virtue of which it can repair injuries inflicted on itself or resist disease. Although apparently wrongly attributed to Hippocrates, this phrase did encompass much of hisphilosophytowardthehealingarts.Oneoftheearlywritingsrelatingthisconcept towoundswasbyJamesCarrickMoore,2amemberoftheSurgeon’sCompanyofLon- donin1789.InhisdissertationMoorestates:“Whenanyaccidentordiseaseinjuresthe humanframe,itwasearlyobserved,thatthebodypossessedwithinitself,apowerof alleviatingorremedyingtheevil.Inconsequenceofthispowerithappens,thatwhen- everthestructureorfunctionsofanypartofthebodyaredisturbed,suchoperations areimmediatelyexcitedashaveatendencytorestorethemachinetoitsformerstate.” In1794,Hunter3concurred:“Thereisacircumstanceattendingaccidentalinjury,which DepartmentofSurgery,MarshfieldClinic,WI,USA E-mailaddress:[email protected] SurgClinNAm90(2010)1125–1132 doi:10.1016/j.suc.2010.09.001 surgical.theclinics.com 0039-6109/10/$–seefrontmatter(cid:1)2010ElsevierInc.Allrightsreserved. 1126 Caldwell doesnotbelongtodisease-namely,thattheinjurydone,hasinallcases,atendencyto produceboththedispositionandthemeansofcure.”Moore2furtherconcludedthat inflammationistheprocessbywhichthevismedicatrixnaturaefillswoundcavities. Moore’sdissertationwasimportantinfocusingtheprocessofwoundhealingonlocal inflammationandtheinflammatorycells.Unfortunately,asknownbyancientsurgeons, woundsexposedtoair,alongwithmanyclosedsurgicalwounds,suppurated.Thus,the mechanism by which inflammatory cells contributed to the healing process was obscured by the participation of these cells in abscess formation. In 1893, Lister4 extendedtheearlierstudiesofKochandPasteuranddemonstratedtheevidencefor bacterialgrowthinwoundsandtheabilityofthisgrowthtoleadtoabscessformation orinvasiveinfection,sepsis,andgangrene.Lister’sworktomitigatebacterialcontam- inationledtoimportantinvestigationsintothebasicelementsoftherepairprocess.For thefirsttime,woundscouldbeexaminedintheabsenceofinfectionandthehistologic responsethatinterrelatedinflammationandwoundrepaircouldbedelineated.There- fore,theworkofVirchow5wasextendedbyMetchnikoff6andthensubsequentlyby SteinandLevenson,7SimpsonandRoss,8andLeibovich9toultimatelydescribethe central role of inflammation and inflammatory cells in tissue repair. Furthermore, by histologicobservation,Metchnikoff6firstintroducedtheconceptofphenotypicinter- conversionbetweenphagocyticandconnectivetissuecells.Thisconcept wassub- sequently addressed by the work of Arlein and colleagues.10 As summarized in a recent review, the finding of Moore that inflammation is the process by which the vismedicatrixnaturaefillsupcavitieshascomefullcircleandmuchofthisprocess canbeattributedtothefunctionsandsecretionsofwound-associatedmacrophages.11 Consistentwiththeintrinsichealingpowerofwoundswastheconceptofthebio- logic priority of healing wounds. The writings of Virchow7 described wound healing as a part of his discussion on the influence of blood vessels on local nutrition. He related that there was not onlyan increase in blood flow to an area of inflammation butalsoanincreaseintheextractionofnutrientsfromthebloodsupplytotheinflamed part.Thisconceptofapriorityofsubstrateusebyaninjuredorinflamedtissuewas best enunciated by Moore.12 Moore’s concept was that because most wounds heal,eveninthefaceofpreinjuryand/orpostinjurystarvation,theremustbeabiologic priorityofahealingwound.MooreandBrennan13furtherproposedthat:“Thegeneral biochemistryofinjuryandconvalescenceandthelocalchangesofwoundhealingare inasensetwobiochemicalpartners.”Thesetwobiochemicalprocessesmaintained themobilizationofleanbodymassafterinjuryandincreasedthesubstratepoolavail- abletothewoundsothat“theinternalbalanceofthewoundispositive,whileformost other cellular tissues—particularly muscle and fat—it is negative.”13 Although the hormonal response to injury results in mobilization of body composition extraneous tothewound,woundmetabolismseemsmuchlessresponsivetocirculatinghormonal changesandmorerelatedtothemetabolismofthewound’sinflammatorycellularinfil- trate.14Thus,atthisjuncture,over300yearsofliteratureonwoundhealinghasshown an innate ability of the wound (in the absence of infection and repeated trauma) to controlitsprogress,largelythroughthelocalinflammatorycells. MINIMALINTERVENTIONINWOUNDCARE Theconceptofminimalinterventioninhealingwounds,datesbacktotheearliestcune- iformwritingsinMesopotamia,15andconfirmedintheEdwinSmithsurgicalpapyrus16 andisreiteratedinmanyofthewritingsofmilitarysurgeons.Thus,woundcleansing, topicalwoundtherapy,andbandagingbecamethemainstayofwoundcareforalmost 5000 years. Most surgeons attribute the basic principles of wound care to Ambrose
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