Alt Ekstremitede Cerrahi Sonrası Kasık Bölgesi Yaraları ve Sekonder Lenfatik Problemlerin Tedavisi

Yıl 2020, , 207 - 211, 30.06.2020

Dilşad Amanvermez Şenarslan , Funda Yıldırım , Mustafa Cerrahoğlu

https://doi.org/10.34087/cbusbed.719024

Öz

Amaç: Kapanması geciken kasık bölgesi yaraları ve sekonder lenfatik problemler hastanede yatış sürelerini uzatmaktadır. Femoral damarlardan girişim, kalp ve periferik vasküler cerrahi için en sık kullanılan erişim yollarındandır. Bu çalışmada femoral damarlara cerrahi girişimler sonrasında iyileşmeyen kasık yaraları ve alt ekstremitedeki sekonder lenfatik problemlerde vakum yardımlı kapatma (VAK) tedavilerinin iyileşme süresine etkisini araştırdık.
Gereç ve Yöntem: Retrospektif özellikteki çalışmada, son iki yılda, kliniğimizdeki majör vasküler cerrahilerde femoral damarlara erişim için kasık insizyonu yapılmış 335 hasta dosyası tarama yapılarak incelenmiştir. Bu hastaların 32’sinde (%9,5) iyileşmeyen kasık yarası ve sekonder lenfore, lenfosel veya lenfödem gibi lenfatik problemler gözlenmiştir. İlk 10 günde yara iyileşmesi yetersiz olan ve ilişkili lenfatik problem gözlenen hastalara öncelikle femoral insizyonun cerrahi debridmanı, lenfatiklerin ligasyonu, lenfoselin çıkarılması uygulanmıştır. Sonrasında 16 hastada yalnızca cerrahi debridman ve yara bakımı (Grup 1) kullanılırken, 16 hastada ek olarak vakum yardımlı kapatma (VAC) cihazı da kullanılmıştır (Grup 2). Her iki gruptaki demografik veriler, risk faktörleri ve yara iyileşmesi için geçen tedavi süreleri karşılaştırılmıştır.
Bulgular: Gruplar arasında demografik özellikler açısından fark bulunmamıştır. Eşlik eden hastalıklar karşılaştırıldığında gruplar arasında fark olmadığı saptandı. Lenfore için etyolojik risk faktörleri kaşılaştırıldığında; tekrarlayan operasyonlar, femoral bölgede prostetik greft bulunması, hipoalbuminemi açısından fark olmadığı ancak VAC kullanılan grupta obesitenin daha fazla olduğu gözlendi. Yara iyileşme süresi Grup 2 de daha kısaydı ancak istatistiksel olarak anlamlı değildi.
Sonuç: Cerrahi sonrası sekonder lenfödem ve kasık yarası iyileşme probleminin temel tedavisi debridman ve optimal cerrahi yara bakımıdır. VAC kullanımı, alt ekstremitede lenfatik akımın drenajını arttırır ve granülasyon dokusu oluşumu ile yara tabanını güçlendirir. VAC tedavisi, alt ekstremite femoral yaralarının ve sekonder lenfatik problemlerin iyileşmesini hızlandırmak için etkili bir tedavi seçeneği olabilir.

Anahtar Kelimeler

Lenfore, sekonder lenfödem

Management of the Postsurgical Lower Extremity Groin Wounds and Secondary Lymphatic Disorders

Öz

Background and Aims: Delayed wound closure and secondary lymphatic problems prolong hospital stay. The femoral exposure is one of the most commonly used access way for the cardiac and peripheral vascular surgery. In this study, we investigated the effect of vacuum-assisted closure (VAK) treatments on the recovery time in non-healing groin wounds after femoral vessel exposure and secondary lymphatic problems in the lower extremity.
Materials and Methods: In this retrospective study, we examined 335 patients hospital records who had groin incision for access to femoral vessels in major vascular surgeries performed in our clinic in the last two years. We observed non healing inguinal wounds and lymphatic problems such as secondary lymphorrhea, lymphocele or lymphedema in 32 of these patiens (9.5%). The patients with insufficient wound healing in the first 10 days postoperatively and associated lymphatic disorders were primarily treated with surgical debridement of the femoral incision, ligation of lymphatics and removal of lymphocele. Afterwards, only surgical debridement and wound care was used in 16 patients (Group 1) and additional to these therapies vacuum assisted closure (VAC) device used in 16 patients (Group 2). Demographic data, risk factors and duration of the treatment for wound healing in both groups were compared.
Results: There was no difference in demographic characteristics between groups. When comorbid diseases were compared, there were no difference between the groups. There was no difference with regard to etiological risk factors for wound site complications such as prosthetic grafts in the femoral region, hypoalbuminemia, recurrent operations. But there was more obese patients in Group 2. The mean wound healing time was shorter in Group 2 but it was not statistically significant.
Conclusion: The basic treatment of postsurgical secondary lymphedema and groin wound healing problem is debridement and optimal surgical wound care. VAC usage enhances the drainage of the lymphatic flow of lower extremity and strengthen wound base by granulation tissue formation. VAC therapy may be an effective therapeutic option to accelerate healing of lower extremity femoral wounds and secondary lymphedema.

Anahtar Kelimeler

Lymphorrhea, Secondary lymphedema, Vacuum assisted closure

Kaynakça

• 1. Inui T, Bandyk DF, Vascular surgical site infection: risk factors and preventive measures, Seminars in Vascular Surgery, 2015, 28(3–4), 201–7. https://linkinghub.elsevier.com/retrieve/pii/S0895796716000065.
• 2. Kwon J, Staley C, McCullough M, Goss S, Arosemena M, Abai B, et al, A randomized clinical trial evaluating negative pressure therapy to decrease vascular groin incision complications, Journal of Vascular Surgery, 2018, 68(6), 1744–52.
• 3. Bennett KM, Levinson H, Scarborough JE, Shortell CK, Validated prediction model for severe groin wound infection after lower extremity revascularization procedures, Journal of Vascular Surgery, 2016, 63(2), 414–9.
• 4. Jorgensen MG, Toyserkani NM, Hyldig N, Chakera AH, Hölmich LR, Thomsen JB, et al, Prevention of seroma following inguinal lymph node dissection with prophylactic, incisional, negative-pressure wound therapy (SEROMA trial): study protocol for a randomized controlled trial, Trials, 2018, 15, 19(1), 441.
• 5. Moody JA, Botham SJ, Dahill KE, Wallace DL, Hardwicke JT, Complications following completion lymphadenectomy versus therapeutic lymphadenectomy for melanoma - A systematic review of the literature, European Journal of Surgical Oncology, 2017, 43(9), 1760–7.
• 6. Labanaris AP, Polykandriotis E, Horch RE, The effect of vacuum-assisted closure on lymph vessels in chronic wounds, Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS, 2009,62,1068-1075. 7. Yadav S, Rawal G, Baxi M, Vacuum assisted closure technique: a short review, The Pan African Medical Journal, 2017, 28, 246.
• 8. Fernandez LG, Matthews MR, Sibaja Alvarez P, Norwood S, Villarreal DH, Closed Incision Negative Pressure Therapy: Review of the Literature, Cureus, 2019, 21, 11(7), Se5183.
• 9. Frazee R, Manning A, Abernathy S, Isbell C, Isbell T, Kurek S, et al, Open vs Closed Negative Pressure Wound Therapy for Contaminated and Dirty Surgical Wounds: A Prospective Randomized Comparison, Journal of the American College of Surgeons, 2018, 226(4), 507–12. http://dx.doi.org/10.1016/j.jamcollsurg.2017.12.008
• 10. Willy C, Engelhardt M, Stichling M, Grauhan O, The impact of surgical site occurrences and the role of closed incision negative pressure therapy, International Wound Journal, 2016, 13(3), 35–46.
• 11. Lee K, Murphy PB, Ingves MV, Duncan A, DeRose G, Dubois L, et al, Randomized clinical trial of negative pressure wound therapy for high-risk groin wounds in lower extremity revascularization, Journal of Vascular Surgery, 2017, 66(6), 1814–9.
• 12. Blum KS, Karaman S, Proulx ST, Ochsenbein AM, Luciani P, Leroux J-C, et al, Chronic high-fat diet impairs collecting lymphatic vessel function in mice, PLoS ONE, 2014, 9(4), Se94713.
• 13. Ma Z, Li Z, Shou K, Jian C, Li P, Niu Y, et al, Negative pressure wound therapy: Regulating blood flow perfusion and microvessel maturation through microvascular pericytes, International Journal of Molecular Medicine, 2017, 40(5), 1415–25.
• 14. Yuan Y, Niu Y, Xiao W, Qi B, Hu X, Yu A, The Effect and Mechanism of Negative Pressure Wound Therapy on Lymphatic Leakage in Rabbits, The Journal of Surgical Research, 2019, 235, 329–39.
• 15. Glass GE, Murphy GF, Esmaeili A, Lai L-M, Nanchahal J, Systematic review of molecular mechanism of action of negative-pressure wound therapy, The British Journal of Surgery, 2014, 101(13), 1627–36.
• 16. Jorgensen MG, Toyserkani NM, Thomsen JB, Sørensen JA, Prophylactic incisional negative pressure wound therapy shows promising results in prevention of wound complications following inguinal lymph node dissection for Melanoma: A retrospective case-control series, Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS, 2019, 72(7), 1178–83.
• 17. Willy C, Agarwal A, Andersen CA, Santis GD, Gabriel A, Grauhan O, et al, Closed incision negative pressure therapy: international multidisciplinary consensus recommendations, International Wound Journal, 2017, 14(2), 385–98.
• 18. Koetje JH, Ottink KD, Feenstra I, Fritschy WM, Negative Pressure Incision Management System in the Prevention of Groin Wound Infection in Vascular Surgery Patients, Surgery Research and Practice, 2015, Epub. doi: 10.1155/2015/303560.
• 19. Matatov T, Reddy KN, Doucet LD, Zhao CX, Zhang WW. Experience with a new negative pressure incision management system in prevention of groin wound infection in vascular surgery patients. Journal of Vascular Surgery, 2013, 57(3), 791–5.