MANAGEMENT OF FLAP DEHISCENCE AFTER LıMBERG PROCEDURE FOR RECURRENT PıLONıDAL DıSEASE BY NEGATıVE PRESSURE WOUND THERAPY (NPWT)

Sukru TAS Omer Faruk OZKAN Muzaffer Muazzez OCAKLI Emrah ARSLAN Asli KIRAZ Muammer KARAAYVAZ About the authors

HEADINGS -
Surgical dehiscence; Pilonidal cyst; Surgery.

INTRODUCTION

Sacrococcygeal pilonidal disease is a common inflammatory process affecting young adults. This is mostly seen in sacrococcygeal region. There are multiple factors, which can basically be divided into mainly two, as congenital (such as a result of fusion failure, deeper localized natal cleft) and acquired (such as local infection) factors11 Doll D, Luedi MM, Wysocki AP. Pilonidal sinus disease guidelines: a minefield? Tech Coloproctol 2016; 20: 263-4.,88 de Parades V, Bouchard D, Janier M, Berger A. Pilonidal sinus disease. J Visc Surg 2013; 150: 237-47.. Non-operative and operative strategies are mainly used in management. Local flap use is accepted as the favorite surgical closure method with high success rates, once the lesion is excised. On the other hand, surgical approach occasionally may fail and so several complications are seen such as infection, hemorrhage and flap dehiscence11 Doll D, Luedi MM, Wysocki AP. Pilonidal sinus disease guidelines: a minefield? Tech Coloproctol 2016; 20: 263-4.,44 Humphries AE, Duncan JE. Evaluation and management of pilonidal disease. Surg Clin North Am 2010; 90: 113-24..

When a complication occurs, a precise wound care is needed to manage the wound properly. Herein we present a case with flap dehiscence and infection following a local flap closure in the management of a recurrence of a pilonidal disease usıng a negative pressure wound therapy (NPWT).

CASE REPORT

A 66 year old, disabled female was admitted to general surgery clinic with secretions from an orifice in upper edge of flap and abscess formation localized in sacrococcygeal region. It was noted that the patient had a Limberg flap surgery for pilonidal sinus disease one year ago and a hip protesis five years ago. A surgical drainage was planned and performed. In medical treatment, ceftriaxone and metronidazole were administered.

After no infection was seen, the patient underwent a second rhomboid excision and Limberg flap procedure by preparing left side gluteal flap. At postoperative 7th day, an infection reoccured despite antibiotic administration. Then flap dehissenced (Figure 1A). A new debridement was performed and followed by a negatıve pressure wound therapy (NPWT, Confort-Turkey). NPWT was continued for nine days, with a dressing change every 72 h. The pressure was 60 mmHg, and continued with 5 min on and off intervals with instillation of saline (Figure 1B). At the end of the 10th day, the wound was ready to suture with sufficient granulation formation (Figures 1C and 1D).

FIGURE 1
A) Infection and flap dehiscence prior to treatment; B) replacement of NPWT device; C) wound with granulation tissue after NPWT; D) wound sutured

DISCUSSION

NPWT is one of the treatment approaches to increase healthy granulation tissue for complex wounds77 Ozkan OF, Koksal N, Altinli E, Celik A, Uzun MA, Cikman O, et al. Fournier's gangrene current approaches. Int Wound J 2016; 13: 713-6.. It is also known that NPWT is an effective therapy decreasing bacterial contamination in wounds55 Misteli H, Kalbermatten D, Settelen C. [Simple and complicated surgical wounds]. Ther Umsch 2012; 69: 23-7.. Recently, there are few reports about its successful use in the management of pilonidal sinus disease and recurrent form in addition to surgical treatment22 Dumville JC, Owens GL, Crosbie EJ, Peinemann F, Liu Z. Negative pressure wound therapy for treating surgical wounds healing by secondary intention. Cochrane Database Syst Rev 2015; 4: CD011278.,33 Farrell D, Murphy S. Negative pressure wound therapy for recurrent pilonidal disease: a review of the literature. J Wound Ostomy Continence Nurs 2011; 38: 373-8.. In the literature, there is no study regarding the use of NPWT for the flap dehiscence.

Infection and dehiscence after flap surgery may lead to removal of flap and a secondary surgical intervention is required to close large sized tissue defects99 Sammer DM. Management of complications with flap procedures and replantation. Hand Clin 2015; 31: 339-44.. Prolonged hospital stay, high treatment cost, and late return to work are among disadvantages. When NPWT is used, granulation tissue formation increases with the mechanisms of increased blood flow, and aspiration of infected materials and exudates. NPWT increases blood flow in the applied area and thus works in favor of any flap tissue remaining even though partially lost. This gives an opportunity to use the same flap to close the wound in most cases66 Morisaki A, Hosono M, Murakami T, Sakaguchi M, Suehiro Y, Nishimura S, et al. Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis. Interact Cardiovasc Thorac Surg 2016; 23: 397-402.,1010 Tevanov I, Enescu DM, Balanescu R, Sterian G, Ulici A. Negative Pressure Wound Therapy (NPWT) to Treat Complex Defect of the Leg after Electrical Burn. Chirurgia (Bucur) 2016; 111: 175-9.. So, on the basis of this case, it can be suggested that the usage of NPWT promotes wound healing and contributes to the flap survival in the presence of infection and flap dehiscence in recurrent pilonidal disease.

REFERENCES

  • 1
    Doll D, Luedi MM, Wysocki AP. Pilonidal sinus disease guidelines: a minefield? Tech Coloproctol 2016; 20: 263-4.
  • 2
    Dumville JC, Owens GL, Crosbie EJ, Peinemann F, Liu Z. Negative pressure wound therapy for treating surgical wounds healing by secondary intention. Cochrane Database Syst Rev 2015; 4: CD011278.
  • 3
    Farrell D, Murphy S. Negative pressure wound therapy for recurrent pilonidal disease: a review of the literature. J Wound Ostomy Continence Nurs 2011; 38: 373-8.
  • 4
    Humphries AE, Duncan JE. Evaluation and management of pilonidal disease. Surg Clin North Am 2010; 90: 113-24.
  • 5
    Misteli H, Kalbermatten D, Settelen C. [Simple and complicated surgical wounds]. Ther Umsch 2012; 69: 23-7.
  • 6
    Morisaki A, Hosono M, Murakami T, Sakaguchi M, Suehiro Y, Nishimura S, et al. Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis. Interact Cardiovasc Thorac Surg 2016; 23: 397-402.
  • 7
    Ozkan OF, Koksal N, Altinli E, Celik A, Uzun MA, Cikman O, et al. Fournier's gangrene current approaches. Int Wound J 2016; 13: 713-6.
  • 8
    de Parades V, Bouchard D, Janier M, Berger A. Pilonidal sinus disease. J Visc Surg 2013; 150: 237-47.
  • 9
    Sammer DM. Management of complications with flap procedures and replantation. Hand Clin 2015; 31: 339-44.
  • 10
    Tevanov I, Enescu DM, Balanescu R, Sterian G, Ulici A. Negative Pressure Wound Therapy (NPWT) to Treat Complex Defect of the Leg after Electrical Burn. Chirurgia (Bucur) 2016; 111: 175-9.

  • Fonte de financiamento:

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Publication Dates

  • Publication in this collection
    Jan-Mar 2017

History

  • Received
    19 Jan 2016
  • Accepted
    10 Jan 2017
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