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ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

Print version ISSN 0102-6720

ABCD, arq. bras. cir. dig. vol.25 no.1 São Paulo Jan./Mar. 2012

http://dx.doi.org/10.1590/S0102-67202012000100018 

LETTER TO EDITOR

 

Some considerations on "synthesis of large wounds of the body wall with rubber elastic band"

 

 

Rafael Denadai

Faculty of Medicine, University of Marilia, SP, Brazil. email: silva.rdp@hotmail.com

 

 

To the Editor:

I have read with great interest the article by Dr. Petroianu1. In this letter, besides applauding the excellent technical innovation, I include some considerations on the subject.

1. Concomitant to the use of negative pressure therapy (simple handling and easy acquisition2) with elastic strips1, similar to that proposed by other groups3-5 (partial approximation of the fascia of the rectus abdominalis associated with vacuum system), can potentiate the effects of each technique, reducing the time spent to early healing and reducing stress on the edges of the wound and, so, improving the results.

2. Although not being the scope of the article1, the 21 abdominal wounds could be classified into sub-groups5 in order to facilitate both the conduction of comparative measurements between the different groups (for example, healing time) and the comparison of the results for future studies (using straps or other sustention treatments) and improving the patients care6.

3. As the technical knowledge based on recent number of cases described this technique as a disadvantage compared to other methods7, after the initial proposal of author8, the increase in the number of cases operated on 1, 9.10, resulted in improvement of the technical performance, and therefore the results? What were the differences and / or similarities in the results presented subsequently?

4. In the literature, the aesthetic results and patients' perceptions of their scars have been measured through numerous assessment tools previously validated11, objectively or subjectively12. There is also a quantitative method described by the Dr. Petroianu group13. Once the objective and subjective measurement of the scars is essential for clinical practice (evaluating the results of studies), and facilitates communication among surgeons, enabling a comparison between studies12 (using elastic bands or not)14, witch were the criteria used in evaluation of the results of the study (described as "excellent") and perceptions of patients (shown as "all happy")?

 

 

1. Petroianu A. Síntese de grandes feridas da parede corpórea com tira elástica de borracha. ABCD Arq Bras Cir Dig 2010;23:16-18.         [ Links ]

2. Campbell AM, Kuhn WP, Barker P. Vacuum-assisted closure of the open abdomen in a resource-limited setting. S Afr J Surg 2010;48:114-115.         [ Links ]

3. Cothren CC, Moore EE, Johnson JL, Moore JB, Burch JM. One hundred percent fascial approximation with sequential abdominal closure of the open abdomen. Am J Surg 2006;192:238-242.         [ Links ]

4. Navsaria PH, Bunting M, Omoshoro-Jones J, Nicol AJ, Kahn D. Temporary closure of open abdominal wounds by the modified sandwich-vacuum pack technique. Br J Surg 2003;90:718-722.         [ Links ]

5. Hilliard ST, Chew KY, Chung AY, Tan B. Improving vacuum-assisted closure of widely open abdomens with improvised elastic sutures. Eur J Plast Surg 2011; [Article in Press]         [ Links ]

6. Björck M, Bruhin A, Cheatham M, Hinck D, Kaplan M, Manca G, Wild T, Windsor A. Classification-important step to improve management of patients with an open abdomen. World J Surg 2009;33:1154-1157.         [ Links ]

7. van As AB, Navsaria P, Numanoglu A, McCulloch M. Modified sandwich vacuum pack technique for temporary closure of abdominal wounds: an African perspective. Acta Clin Belg Suppl 2007;(1):215-219.         [ Links ]

8. Petroianu A. Opção técnica para a síntese de grandes feridas da parede corpórea. Rev Col Bras Cir 2009;36:353-355.         [ Links ]

9. Petroianu A. Closure of large wounds of the body wall with elastic rubber strip. Am Surg 2010;76:E168-169.         [ Links ]

10. Petroianu A. Synthesis of large wounds of the body wall with rubber elastic band. Acta Med Port 2011;24:427-430.         [ Links ]

11. Durani P, McGrouther DA, Ferguson MW. Current scales for assessing human scarring: a review. J Plast Reconstr Aesthet Surg 2009;62:713-720.         [ Links ]

12. Verhaegen PD, van der Wal MB, Middelkoop E, van Zuijlen PP. Objective scar assessment tools: a clinimetric appraisal. Plast Reconstr Surg 2011;127:1561-1570.         [ Links ]

13. Vidigal FM, Petroianu A. Avaliação de cicatrizes cutâneas: apresentação de um método quantitativo. Rev Col Bras Cir 2010;37:121-127.         [ Links ]

14. Barkun JS, Aronson JK, Feldman LS, Maddern GJ, Strasberg SM; Balliol Collaboration, Altman DG, Barkun JS, Blazeby JM, Boutron IC, Campbell WB, Clavien PA, Cook JA, Ergina PL, Flum DR, Glasziou P, Marshall JC, McCulloch P, Nicholl J, Reeves BC, Seiler CM, Meakins JL, Ashby D, Black N, Bunker J, Burton M, Campbell M, Chalkidou K, Chalmers I, de Leval M, Deeks J, Grant A, Gray M, Greenhalgh R, Jenicek M, Kehoe S, Lilford R, Littlejohns P, Loke Y, Madhock R, McPherson K, Rothwell P, Summerskill B, Taggart D, Tekkis P, Thompson M, Treasure T, Trohler U, Vandenbroucke J. Evaluation and stages of surgical innovations. Lancet 2009;374:1089-1096.         [ Links ]

 


 

The author's reply

 

 

Andy Petroianu

Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil. (31) 8884-9192. e-mail: petroian@gmail.com

 

 

To the Editor:

I read with great satisfaction the kind letter of Dr. Rafael Dendai, referring to the article I wrote on the synthesis of large wounds using gummy to close its borders. I appreciate the teachings of Prof. Dendai and finesse of Mr. Editor to allow my response to that letter.

With respect to four considerations, please consider my opinions.

1 - There is no doubt about the advantages and effectiveness of treating wounds with negative pressure. However, this procedure is performed in abdominal wounds and depends on special equipment to maintain continuous suction at a constant and predetermined pressure. While the patient is subjected to this procedure must remain at rest, preferably on the bed. Moreover, the use of only the rubber straps allows wide mobilization of the patient, that does not even need to remain hospitalized. These gummy can be used with good results in most parts of the body surface, except the region of the head and neck. In the region of the skull skin has low mobility, while in the face and neck the discomfort was expected to be too big, to the point that was not thought to be tried.

2 - Our desire was to have patients enough to make a comparative study with various techniques. However, we only had 26 consecutive patients in whom we used only the gummy. If we have had subgroups, in order to compare techniques, we would have a small number of patients in each group, not permitting a comparative study. We are experimentally studying this technique comparing with other types of synthesis of large wounds and, soon, we may have answers to some questions about these procedures.

3 - Until we get the technique presented here, we tried different approaches to the edges of the wounds, with gummy suture circumferentially around the wound, but the results were more time-consuming and less effective. Then, was tried to suture the gummy to aponeurotic and muscular layers, but the results were not good. The gummy was also sutured to the subcutaneous tissue, without success. Instead of single points of nylon holding the gummy to the skin, we put small pieces of tubular nelaton to avoid pulling the skin, but this intermediation caused decubitus ulcers. Until we figure out a better way, will stay with the method described in our article, since its results have been very rewarding.

4 - We kept the same published criteria for evaluation of aesthetic results in the synthesis of these wounds. We ask the aid of a plastic surgeon, who examined the wound at baseline and after its total closing. Patients also responded in an interview about their opinions on the closure of the wound, asking them to note. I believe that the suffering that went with their prior large complicated wounds (figures on the article), contributed to patients' satisfaction with the final result of the synthesis. The scores of both the surgeon and patient were 8, 9 and 10. For this reason, we consider the excellent results, confirming the satisfaction of all patients and their physicians, including plastic surgeon.

I appreciate the opportunity to write a bit more about this operative alternative to the synthesis of large wounds and clarify issues that were not well presented in our article. I put myself available for other explanations when needed.

Best regards.