intestinal leakage following VAC therapy caution required?

Rao M, Burke D, Finan PJ, Sagar PM. The use of vacuum-assisted closure of abdominal wounds: a word of caution. Colorectal Dis 2007; 9: 266-68.

in a nutshell
Vacuum-assisted closure (VAC) has been an integral part of open abdominal wound management for the past decade and is supported by a substantial evidence base. Utilising negative pressure wound therapy through a sealed foam dressing, VAC systems protect wounds while promoting perfusion, drawing wound edges together, and removing tissue debris and fluids. Studies examining VAC therapy (V.A.C. Therapy, KCI, San Antonio, Tex) have largely focused on trauma patients. However, as in our hospital, the authors increasingly use this for laparostomy wound management following surgery for intra-abdominal sepsis. This study specifically focused on outcomes in this setting. Over 16 months, 29 patients received VAC therapy for open abdominal wounds. Median age was 60 (range 31-80 years) and median duration of therapy was 26 days (range 2-68). Laparostomy was most frequently indicated for abdominal sepsis, visceral oedema, and raised intra-abdominal pressure. Ten patients died (34%) while receiving VAC therapy and 19 (65.5%) required ICU care. Six patients (20%) developed intestinal fistulation, diagnosed at a median of 20 days (range 2-50) from its commencement. Four of these patients died (66%), all from multi-organ failure, which had been present in five of the six patients prior to VAC therapy.

the verdict
VAC therapy is a well established, evidencedbased treatment for laparostomy wounds Previous studies focus on VAC complications in abdominal trauma rather than sepsis Further research is warranted to investigate whether VAC therapy encourages fistula formation. Edward Fitzgerald edwardfitzgerald@doctors.org.uk Austin G Acheson disease and were therefore predisposed to develop fistulae. Other risk factors put forward include presence of abdominal mesh, abdominal sepsis, and presence of an intestinal anastomosis. Given the increased mortality associated with this complication, further research is required to examine factors contributing to intestinal leakage. In the meantime the authors are right to suggest a cautious approach with a timely reminder that VAC therapy is never completely without risk. austin.acheson@nottingham.ac.uk Nottingham University Hospital

second opinion
There is no doubt VAC therapy has enhanced open abdominal wound management, and, in light of this, its use has spread to other fields including orthopaedic and cardiothoracic surgery. It eases the nursing burden by facilitating wound care, improves healing and reduces sepsis. However, as the authors highlight, it is not risk free. Although development of enterocutaneous fistula in the setting of VAC therapy for laparostomy wound management has not been reported as a significant complication in earlier studies, observations at our hospital support the authors conclusions that the incidence may be higher in relation to its use for abdominal sepsis. However, in this study patients would have suffered significantly compromised bowel function in relation to their multi-organ failure, which largely pre-dated institution of VAC therapy. This would have rendered them more susceptible to intestinal leakage and fistulation. In addition, three patients suffered from inflammatory bowel