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      VAC® for external fixation of flail chest

      case-report

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          Abstract

          A large aterior chest wall defect following tumor resection was reconstructed with a Gore-Tex® membrane and a combined musculocutaneous rectus femoris and tensor fasciae latae free flap. Subsequent paradoxical respiration impeded weaning from the ventilator. Appliance of Vacuum Assisted Closure® (VAC®) resulted in immediate chest wall stability and a decrease in the patient's need for respiratory support. Shortly thereafter, the VAC® was discontinued and the patient was discharged from the intensive care unit (ICU). This case report is the first to describe the successful use of VAC® as an adjuvant to a one-stage procedure for large thoracic wall reconstruction, allowing sufficient temporary external fixation to eliminate paradoxical respiration and plausibly shorten the stay in the ICU. No adverse effects on flap healing or haemodynamics were recorded. It is likely that external VAC® can improve thoracic stability and pulmonary function in a patient with flail chest and decrease the need for mechanical ventilation.

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          Blood flow responses in the peristernal thoracic wall during vacuum-assisted closure therapy.

          Angelica Wackenfors, Ronny Gustafsson, Johan Sjögren … (2005)
          Vacuum-assisted closure (VAC) therapy is a recently introduced method for the treatment of poststernotomy mediastinitis. The aim of this study was to examine the effects of negative pressure on peristernal soft tissue blood flow and metabolism because the mechanisms by which vacuum-assisted closure therapy promotes wound healing are not known in detail. Microvascular blood flow was examined by laser Doppler velocimetry in an uninfected porcine sternotomy wound model. Microvascular blood flow was examined in the muscular and subcutaneous tissue, at different distances from the wound edge, after the application of -50 to -200 mm Hg. Wound fluid pH, partial pressures of oxygen and carbon dioxide, bicarbonate, and lactate were analyzed after 0, 30, and 60 minutes of continuous negative pressure. Vacuum-assisted closure therapy induced an increase in the microvascular blood flow a few centimeters from the wound edge. In muscular tissue, the distance from the wound edge to the position at which the blood flow was increased was shorter than that in subcutaneous tissue. Close to the wound edge, relative hypoperfusion was observed. The hypoperfused zone was larger at high negative pressures and was especially prominent in subcutaneous tissue. Wound fluid partial pressure of oxygen and lactate levels were increased after 60 minutes of vacuum-assisted closure therapy, which may be the result of changes in the microvascular blood flow. Vacuum-assisted closure therapy induces a change in microvascular blood flow that is dependent on the pressure applied, the distance from the wound edge, and the tissue type. It may be beneficial to tailor the negative pressure used for vacuum-assisted closure therapy according to the wound tissue composition. Wound fluid partial pressure of oxygen and lactate levels increased during vacuum-assisted closure therapy. This combination is known to promote wound healing.
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            Reconstruction of complex chest wall defects by using polypropylene mesh and a pedicled latissimus dorsi flap: a 6-year experience.

            Abdul Hameed, Shaheen Akhtar, Ajmal Naqvi … (2008)
            Reconstruction of full thickness defects of the chest wall is controversial and presents a complicated treatment scenario for thoracic and reconstructive plastic surgeons. It requires close cooperation between the cardiothoracic and reconstructive surgeons to achieve an optimal outcome and reduce the incidence of complications.
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              Hemodynamic effects of the vacuum-assisted closure device on open mediastinal wounds.

              Jonathan W Meadows, William A Wooden, Y Su … (2003)
              Application of the Vacuum-Assisted Closure device (VAC) to open sternal wounds has negative hemodynamic effects. We hypothesized that the interposition of a muscle flap attenuates these negative hemodynamic effects. After institutional approval, monitoring lines were placed in anesthetized, ventilated pigs. Through a median sternotomy, sonometric crystals were strategically positioned around the left ventricle. A rectus flap was rotated over the mediastinal wound, and the VAC was placed over the flap. After baseline measurements, a vacuum of 125 mmHg [Group (GP) 1, n = 5] or 50 mmHg (GP2, n = 6) was initiated. Hemodynamics were recorded every 15 min for 1.5 h, and 15 min after cessation of the vacuum therapy. GP3 (n = 6) underwent intermittent VAC cycling (on 5 min/off 2 min). Significance determined by t test. While non-flapped animals had significant detriment in both left ventricular filling volume and cardiac output, flapped animals had insignificant depression of both parameters. Application of muscle flaps to sternal wounds prior to VAC therapy significantly attenuates the negative hemodynamic effects seen when the VAC is used alone.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clin Pract
                Journal ID (iso-abbrev): Clin Pract
                Journal ID (pmc): CP
                Journal ID (publisher-id): CP
                Title: Clinics and Practice
                Publisher: PAGEPress Publications (Pavia, Italy )
                ISSN (Print): 2039-7275
                ISSN (Electronic): 2039-7283
                Publication date (Electronic): 28 June 2012
                Publication date Collection: 29 May 2012
                Volume: 2
                Issue: 3
                Electronic Location Identifier: e65
                Affiliations
                [1 ]Department of Plastic Surgery and
                [2 ]Department of Anaesthesiology and Intensive Care, Herlev Hospital, University of Copenhagen, Herlev, Denmark
                Author notes
                Correspondence: Rikke Winge, Lynge Bygade 37, DK-3540 Lynge, Denmark. +45.30.26.17.95. winge.research@ 123456micromose.com

                Contributions: RW, JOB, literature research, surgical outcome interpretation, manuscript drafting, critical revision and final approval; RW, discussion writing; JOB, case description; RA, ICU-data analysis and interpretation, critical revision and final approval; CK, conception and design, surgical outcome analysis and interpretation, critical revision and final approval.

                Conflict of interests: the authors declare no potential conflict of interests.

                Article
                Publisher ID: cp.2012.e65
                DOI: 10.4081/cp.2012.e65
                PMC ID: 3981318
                PubMed ID: 24765464
                SO-VID: 162efb1a-79f0-4dbc-8693-f87bb16313f7
                Copyright © ©Copyright R. Winge et al., 2012
                License:

                This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).

                Licensee PAGEPress, Italy

                History
                Date received : 28 December 2011
                Date revision received : 26 April 2012
                Date accepted : 07 May 2012
                Categories
                Subject: Case Report

                Keywords: thoracic wall reconstruction,flail chest.
                Data availability:
                Keywords: thoracic wall reconstruction, flail chest.

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