biochemical events that occur exclusively in a living organism.

= Page 1 = WOUND HEALING = Page 2 = WOUND HEALING Jose Ravelo T. Bartolome, MD, FPCS, FPSGS, FPAHNSI Chairman & Assistant Professor Department of Surgery FEU-NRMF Institute of Medicine and Medical Center = Page 3 = Instructional Objectives The students understand the physiology of wound healing and its application in the management of different types of surgical wounds. The students understand the different factors that affects the wound healing process. The student is able to classify different types of surgical wounds and their appropriate management. = Page 4 = Wound Healing Phases of wound healing Heritable diseases of connective tissue Healing of specific tissues Classification of wounds Excess healing Treatment of wounds = Page 5 = Wound / Tissue Injury Disruption of tissue integrity Division of blood vessels Direct exposure of extracellular matrix to platelets = Page 9 = Wound healing All tissues undergo a similar and predictable reparative process. Understanding how the body repairs damage tissues and what factors influence the healing process helps the surgeon ensures and acceptable outcome from surgery... = Page 10 = Wound healing Key point: Although individual tissues may have unique healing characteristics, all tissues heal by similar mechanisms and the process undergoes phases of inflammation, cellular migration, proliferation, matrix deposition and remodeling. = Page 11 = Phases of Wound Healing Predictable pattern of overlapping phases defined by characteristic cellular population and biochemical cativities Phases: Hemostasis and Inflammation Proliferation Maturation and Remodeling = Page 12 = Phases of Wound Healing The cellular, biochemical and mechanical phases of wound healing... = Page 13 = Phases of wound healing - histological GOAL is replacement of normal skin structures with fibroblastic mediated scar tissue... A. The hemostatic/inflammatory phase; B. Latter inflammatory phases reflecting infiltration by mononuclear cells and lymphocytes; C. the proliferative phase, with associated angiogenesis and collagen synthesis = Page 15 = Hemostasis and Inflammation hemostasis precedes and initiates inflammation... exposure of subendothelial collagen to platelets leads to platelet aggregation and activation of coagulation cascade... clot formed for hemostasis as well as scaffolding for inflammatory cell migration...

= Page 6 = Surgical wound... an incision created by surgical instrument - scalpel. = Page 7 = Traumatic wounds resulting from bullet or knife... = Page 8 = Wound healing The response of living tissues to injury... forms the foundation of all surgical practice... Key point: ... is a complex cellular and biochemical cascade that leads to restitution of integrity of function... A highly dynamic, integrated series of cellular and

= Page 16 = Hemostasis and Inflammation CELLULAR INFILTRATION follows a characteristic and predetermined sequence PMNS - first infiltrating cells (24-28 h) Macrophages - second population of infiltrating cells = Page 17 = Polymorphonuclear Cells (PMN) first infiltrating cells in the wound site peaks 24 - 28 hours phagocytosis of bacteria and tissue debris major source of cytokines in early inflammation TNF-a - angiogenesis and collagen synthesis no role in collagen synthesis and acquisition of wound strength release Collagenase - matrix and ground substance degradation = Page 18 = Polymorphonuclear Cells (PMN) STIMULI FOR PMN MIGRATION AND INFILTRATION Complement factors Interleukin-1 Tumor Necrosis Factor - a Tumor Growth Factor - b Platelet factor 4 Bacterial products Fibronectin = Page 19 = Macrophages second population of cells that infiltrate wounds essential in successful healing The Orchestrator peaks by 48-96 h; remains until completion of healing participate in wound debridement via phagocytosis microbial stasis via O2 radicals and NO2 synthesis = Page 20 = Macrophages Most important function: activation and recruitment of other cells using the following mediators Cytokines Growth factors regulate cell proliferation, matrix synthesis, angiogenesis = Page 21 = Enzymes and cytokines secreted by Macrophages COLLAGENASES: debride the wound INTERLEUKIN and Tumor Necrosis Factor (TNF): stimulate fribroblasts formation (produce collagen) and promote angiogenesis

Transforming Growth Factor (TGF): stimulate keratinocytes

= Page 22 = T - Lymphocytes routinely seen infiltrating wound less numerous than macrophages peaks at day 7 bridge transition from inflammatory to proliferative phase essential but role not fully defined = Page 23 = T - Lymphocytes hypothesis: play an active role in the modulation of wound environment depletion of T-lymphocytes - decrease wound strength and collagen content; decrease in CD8+ suppressor cell - enhance healing decrease CD4+ helper cell - no effect downregulation of fibroblast collagen synthesis by cell associated interferon-gamma, TNF-a and IL-1 = Page 24 = Inflammatory phase of healing fighting infection induction of proliferative phase of healing a necessary part of healing result to tissue damage if prolonged may last as long as there are wound associated debris the presence of dirt or other foreign objects can extend the inflammatory phase = Page 25 = Inflammatory phase of healing surgical wound debridement to remove necrotic tissues and foreignbodies/dirts = Page 26 = PROLIFERATIVE PHASE 4th - 12th day tissue continuity re-established Fibroblasts and Endothelial Cells infiltrate the wound PDGF - strongest chemotactic factor for fibroblasts = Page 27 = PROLIFERATIVE PHASE ANGIOGENESIS occurs during proliferation as a product of endothelial cell infiltration activity of fibroblasts and epithelial cells requires O2 this step is imperative for other stages of healing to proceed

= Page 28 = Endothelial Cells participate in angiogenesis stimulated by hypoxia and lactic acid in the wound collagenase and plasminogen activator needed to degrade the clot and be part of the extracellular matrix (ECM) zinc-dependent metalloproteinases digest basement membrane and ECM to allow cell proliferation and angiogenesis = Page 29 = Fibroblasts proliferates and activated to carry out primary function of matrix synthesis remodeling mediated by cytokines and growth factors released from wound macrophages proliferation starts as early as 2 - 5 days from wounding; peaks at 2 weeks post-wounding the main cells in the wound at end of 7 days fibroplasia ends 2 - 4 weeks after wounding = Page 30 = Fibroblasts in the wound site... synthesize more collagen than fibroblasts elsewhere proliferate less deposit ground substance into the wound bed actively carry-out wound contraction and remodeling = Page 31 = PROLIFERATIVE PHASE GRANULATION TISSUE FORMATION needed to fill the cavity that was left by a large, open wound new blood vessels fibroblasts inflammatory cells endothelial cells myofibroblasts components of a new, provisional ECM = Page 32 = PROLIFERATIVE PHASE PROVISIONAL ECM its main components are fibronectin and HYALURONAN which create a very hydrated matrix and facilitate cellular migration MATRIX SYNTHESIS - COLLAGEN most abundant protein in the body critical role in wound healing essential for the functional integrity of the wound = Page 33 = COLLAGEN TYPES OF COLLAGEN (18 described)

TYPE I collagen - major component of extracellular matrix in skin most abundant in scar tissues ; the end product when tissue heals by repair TYPE III collagen - more prominent and important during repair process collagen of granulation tissue produced quickly by young fibroblasts before the tougher Type I collagen is synthesized = Page 34 = Collagen synthesis Release of protocollagen into the endoplasmic reticulum hydroxylation of proline to hydroxyproline and lysine to hydroxylysine hydroxylation requires O2 and Fe as co-factors a- ketoglutarate as co-substrate Ascorbic acid (vitamin C) as electron donor

= Page 35 = Factors affecting collagen synthesis Highly dependent on: adequate oxygenation sufficient nutrients amino acids co-factors vitamins and trace minerals

= Page 36 = Factors affecting collagen synthesis Other systemic factors: smoking nutrition metabolic disease immunosupression connective tissue disorders

= Page 37 = Factors affecting collagen synthesis Local wound environment vascular supply lack of infection others topical agents ionizing radiation foreign bodies

sebaceous (oil) glands = Page 38 = Proteoglycan synthesis Glycosaminoglycan - ground substance that makes up granulation tissue; Combine with proteins to form proteoglycans participate in matrix synthesis dirty traumatic wounds healing by granulation tissue formation

= Page 44 = EPITHELIALIZATION marginal basal cells near the cut edges undergo a series of rapid mitotic divisions migration by moving over one another in a leap-frog fashion once defect is covered, cells transform from flat to columnar the formation of granulation tissue in an open and deep wound allows epithelialization to proceed

= Page 39 = Glycosaminoglycans Major glycosaminoglycans present in wounds DERMATAN SULFATE CHONDROITIN SULFATE increased conc. during the 1st 3 weeks of healing

= Page 40 = Matrix synthesis ASSEMBLY OF COLLAGEN SUB-UNITS + LATTICE OF SULFATED PROTEOGLYCANS SCAR FORMATION

= Page 45 = EPITHELIALIZATION Healing primarily by Superficial Partial re-epithlialization without fibroplasia Thickness Burns and granulation tissue formation

= Page 41 = EPITHELIALIZATION migration of epithelial cells from wound edges across provides intact barrier against infection begins at 12th h and completed at 24th h with a watersealed edges; longer in open wounds with significant epidermal/dermal defects at 5th day, uncomplicated and normally healing skin wound will have the same resistance to infection as an intact skin

= Page 46 = Keratinocyte migration move over granulation tissue underneath the scab; separating the scab from underlying tissues requires dissolution of scabs formed; migration is best enhanced by a moist environment; dry environment leads to formation of bigger and tougher scab

= Page 42 = EPITHELIALIZATION

= Page 47 = Wound Contraction wound closure by decreasing surface area; usually needed in open wounds One week after wounding; fibroblasts differentiated int MYOFIBROBLASTS wound edges begin to contract can lest fro several weeks even after complete reepithelialization

= Page 43 = EPITHELIALIZATION the thickening in the edges of a healing wound Cells responsible for epithelialization: Basal keratinocytes Dermal appendages hair follicles sweat glands

= Page 48 = Wound Contraction long period of wound contraction can lead to disfigurement and loss of function a large wound may be 40 - 80% smaller after wound contraction wound contraction can be at speef of 0.75 mm/day

= Page 49 = Wound Maturation and Remodeling begin during the phase of Fibroplasia reorganization of previously Change in the matrix synthesized collagen composition over time constant turnover of extracellular Extracellular matrix matrix both in the healing wound Collagen and during normal tissue homeostasis Scar

healing may progress inappropriately to either a chronic wound such as venous ulcer or pathological scarring such as a Kelloid scar...

= Page 54 = Wound Healing - physiologic events FIBROPLASIA - the creation of scar Inflammation and Hemostasis phase Proliferation phase Maturation phase EPITHELIALIZATION WOUND CONTRACTION

= Page 55 = Cytokines and Growth Factors in wound healing = Page 50 = COLLAGEN Matrix Metalloproteins MMP Serine Proteases COLLAGEN SYNTHESIS COLLAGEN SYNTHESIS = ACELLULAR COLLAGEN-RICH SCAR

= Page 56 = Cytokines and Growth Factors in wound healing

= Page 57 = Cytokines and Growth Factors in wound healing

= Page 51 = Wound Maturation and Remodeling strictly controlled by cytokines and growth factors balance between collagen synthesis and lysis is the determinant of wound strength and integrity amount of collagen in wound reches a plateau tensile strength of wound continues to increase for several months (6 - 12 months); also the time that scar appearance is more or less final

= Page 58 = Heritable diseases affecting wound healing Connective tissue disease EHLER-DANLOS syndrome MARFAN syndrome OSTEOGENESIS IMPERFECTA EPIDERMOLYSIS BULLOSA ACRODERMATATIS ENETROPATHICA

= Page 52 = Wound Maturation and Remodeling The Mechanical Strength of the Scar never achieves thatof the uninjured tissue wounded tissue strength is 50% of unwounded tissue at 3 months from injury; usually reaches 80% at end of maturation and remodeling

= Page 59 = Ehler-Danlos Syndrome defect in connective tissue formation friable skin with prominent veins easy bruising recurrent hernias platelet abnormality low coagulation factors level

= Page 53 = The phases of wound healing normally progress in a predictable, timely manner. If they do not proceed as such,

= Page 60 = Ehler-Danlos Syndrome poor wound healing forms cigarette paper scars joints that are unusually flexible

GIT problems - bleeding, hiatel hernia, rectal prolapse

Brain and Nerves Gastrointestinal tract Bone and Cartilage Fetal wound healing

= Page 61 = Marfan SYndrome tall stature; arachnodactyly lax ligaments; myopia pectus excavatum asecnding aortic aneurysms defect is in extracellular protein Lens subluxation FIBRILLIN (elastic fibers) NO actual delay in wound healing

= Page 66 = Brain and Nerves brain heals largely by connective tissue scar formation peripheral nerves - grows at a rate of 1 mm/day terminal nerves degenerates; axon sheaths reconnects randomly

= Page 62 = Osteogenesis Imperfecta failure in maturation and organization of collagen fibers; mutation in TYPE I Collagen brittle bone; osteopenia low-muscle mass; ligament and joint laxity easy bruising scarring is normal and skin not hyperextensible

= Page 67 = Gastrointestinal Tract healing begins with reapproximation of bowel ends rate of repair varies from location in the tract anastomotic strength regained rapidly in 1 week; can resist bursting stronger than surrounding tissues colon and esophagus - prone to leak (lacks serosa)

= Page 63 = Epidermolysis Bullosa impairment of tissue adhesions within the epidermis, basement membrane or dermis separation and blistering with minimal trauma; ulceration oral erosions and esophageal obstruction dressing with non-adhesive pads

= Page 68 = Gastrointestinal Tract healing failures - leaks and fistula dehiscence excessive healing stricture and stenosis

= Page 64 = Acrodermatitis Enteropathica autosomal recessive; in children inability to absorb ZINC from breast milk or food Zinc - necessary co-factor for DNA polymerase and reverse transcriptase inhibition of cell proliferation impaired granulation tissue formation

= Page 69 = Gastrointestinal Tract submucosal layer is the strongest; imparts greatest tensile strength and suture holding capacity same healing sequence as cutaneous wound serosal and mucosal healing - without scar collagenase activity occur early (first 3 - 5 days: breakdown exceeds synthesis)

= Page 65 = Healing of Specific Tissues

= Page 70 = Gastrointestinal Tract suture-line usually holds anastomosis in 3 - 5 days Important technical aspects of repair: tension-free adequate blood-supply receive adequate nutrition free of sepsis

= Page 71 = Bone Healing depends on connective tissue synthesis Unique process: Condensation of Hydroxyapatite Crystals Pronounced remodelling: CALLUS formation Bone repair can also be primary (reduced) or secondary Non-union a disastrous complication

= Page 72 = Bone Factors affecting bone healing TYPE OF FRACTURE IMMOBILIZATION FIXATION MECHANICAL STRESS

= Page 76 = Fetal wound healing Wound environment : sterile, temperature stable fluid environment Inflammatory responses : immaturity of the fetal immune system reduced fetal inflammation Differential growth factor profiles : absence of TGF-beta significant role in scarring Wound matrix : due to excessive and extended hyaluronic acid production aid in the orderly organization of collagen

= Page 73 = Bone Three to four days post fracture soft tissue forms a bridge between the fracture bone fibrocartilagenous union The next phase is callus stage mineralization of soft callus formation of bone In 2-3 months, there is complete bone union

= Page 77 = Categories of wound closure Primary wound healing healing by first intention Secondary wound healing Delayed primary wound healing Epithelialization

= Page 78 = Primary wound healing occurs within hours of repairing a full-thickness surgical incision involves closure of a wound within hours of its creation This surgical insult results in the mortality of a minimal number of cellular constituents

= Page 74 = Cartilage Very avascular and depends on diffusion for nutrition across the matrix Healing power is often inadequate and overall regeneration is incomplete Often results in persistent structural defect

= Page 79 = Primary wound healing

= Page 75 = Fetal wound healing Fetal wounds achieve integrity without evidence of scarring Main distinguishing characteristic of fetal wound from adult Environment Inflammatory response Differential growth factor profiles Wound matrix

= Page 80 = Secondary wound healing healing by granulation a full-thickness wound often with bacterial infection is allowed to close and heal inflammatory response is more intense than with primary wound healing larger quantity of granulomatous tissue is produced need for wound closure healing results in pronounced contraction of wounds

= Page 81 = Secondary wound healing Fibroblastic differentiation into myofibroblasts

resemble contractile smooth muscle contribute to wound contraction are maximally present in the wound from the 10th-21st days

HYPOXIA/ANEMIA Hypoxia/hypoperfusion/Anemia Low oxygen tension has a profound deleterious effect on all aspect of wound healing

= Page 82 = Delayed primary wound healing wound edges are not reapproximated immediately contaminated wounds By the fourth day phagocytosis of contaminated tissues processes of epithelization collagen deposition maturation

= Page 87 = Factors affecting wound healing STEROIDS/CHEMOTHERAPEUTIC DRUGS Large doses or chronic usage of glucocorticoids reduce collagen synthesis and wound strength inhibit the inflammatory phase of wound healing and the release of lysosomeal enzymes. used 3 or 4 days post injury does not affect the healing. inhibit epithelialization and contraction contribute to increase rate of wound infection

= Page 83 = Delayed primary wound healing Foreign materials are walled off by macrophages wound is closed surgically at this time Healing by tertiary intention Combination of the first two Placement of suture Allow wound to stay open for a few days Closure of the sutures

= Page 88 = Factors affecting wound healing METABOLIC DISORDERS Uncontrolled diabetes results in reduced inflammation, angiogenesis and collagen synthesis. Increase rates of wound infection and failure. Diseased large and small vessel (hallmark of advanced diabetes) contributes to local hypoxemia

= Page 84 = Factors affecting wound healing Advanced age Hypoxia/hypoperfusion Steroids/ chemotherapeutic drugs Metabolic disorders Nutrition Infections

= Page 85 = Factors affecting wound healing ADVANCED AGE Advanced age Possible source of impaired wound healing in the elderly: Increase incidence of: cardiovascular disease, metabolic dis., (malnutrition, D. M., Vit. Deficiency), cancer, and the prevalent use of drugs that impair wound healing

= Page 89 = Factors affecting wound healingNUTRITION Deficiency in Vit. A result in Decreased inflammatory response Decreased collagen synthesis Decreased fibroblast proliferation Supplemental Vitamin A reverse the inhibitor effects of corticosteroids. Deficiency in Vitamin C results in Electron donor in the hydroxylation process Increased rates of infection and if infection occurs, it tends to be severe due to decreased walling-off bacteria. Zinc is used empirically in dermatologic cases. Zinc deficiency results in decrease collagen synthesis, impaired overall wound strength, and delayed epithelialization.

= Page 86 = Factors affecting wound healing -

= Page 90 = Factors affecting wound healing INFECTIONS can weaken an abdominal closure or hernia repair and result in wound dehiscence and recurrence of the

hernia. can cosmetically lead to disfiguring, unsightly, scars and delayed closure. Prophylactic antibiotics should be given to all patients

= Page 91 = Anatomical classification of wound infection Superficial or Suprafascial involving the skin and subcutaneous tissue only Deep infection involves the fascia, muscle Cavity/space

= Page 95 = Chronic wounds Ischemic arterial ulcers Venous stasis ulcers Diabetic wounds Decubitus/ pressure ulcers

= Page 92 = Anatomical classification of wound infection Necrotizing fascitis- the most dangerous of deep infections Results in high mortality especially in the elderly It is an invasive process that involves the fascia and leads to secondary skin necrosis. It is a septic thrombosis of the vessels between skin and the deep layers.

= Page 96 = Decubitus ulcer Localized area of tissue necrosis that develops when soft tissue is compressed between a bony prominence and an external surface Due to capillary collapse secondary to excessive pressure impeding the delivery of nutrients to body tissue

= Page 97 = Decubitus ulcer

= Page 98 = Decubitus ulcer

= Page 93 = Anatomical classification of wound infection The most common organisms responsible for wound infection in the order of frequency are: Streptococcus Enterococci Escherichia coli

= Page 99 = Decubitus ulcer stage I stage II stage III stage IV

= Page 94 = Chronic wounds Failed to proceed through the orderly process that produces satisfactory anatomic and functional integrity or that have proceeded through the repair process without producing an adequate anatomic and functional result Wounds that have not healed in three (3) months Repeated trauma, poor perfusion or oxygenation and excessive inflammation causes chronicity of the wound Malignant transformation of chronic ulcers can occur in any long standing wound (Marjolins ulcer) squamous or basal cell carcinoma

= Page 100 = Venous stasis ulcers Due to venous stasis and back pressure Venous stasis is due to incompetence of either the superficial on the deep venous system The wound is shallow with irregular margins Surrounding skin is pigmented

= Page 101 = Venous stasis ulcers

= Page 102 = Ischemic arterial ulcers These are due to lack of blood supply and painful Associated with other symptoms of peripheral vascular disease Intermittent Claudication Rest pain Night pain

Color changes Dryness of skin Hair loss Sealing

Rise above the skin level but stay within the confines of the original wound and often regress overtime Occur across areas of tension and flexor surface

= Page 103 = Ischemic arterial ulcers

= Page 104 = Excess healing Excess dermal scarring Keloids Hypertropic scars Peritoneal scarring

= Page 110 = Excess Healing In Hypertropic scars and keloids the goals of treatment are: restoration of function of the area relief of symptoms prevention of recurrence

= Page 105 = Excess healing Hypertropic scar Keloidal scar

= Page 106 = Keloids

= Page 111 = Peritoneal Scarring Peritoneal adhesions are fibrous bands of tissues formed between organs that are normally separated between organs and the internal body wall Most peritoneal adhesions are a result of peritoneal injury a prior surgical procedure (65%) intra-abdominal infection (28%) 65 75% of small bowel obstruction (ileum) is due to intraabdominal adhesions

= Page 107 = Keloids rise above the skin level and extend beyond the original wound and rarely regress spontaneously occur after trauma to the skin, tender, pruritic, and causes a burning sensation composed of excessive amounts of collagen, elastin, and ground substance site of predilection are: Earlobes, deltoid, presternal, and upper back reg

= Page 112 = Peritoneal Scarring

= Page 113 = Wound classification Class I (clean wound) <2% infection rate; clean surgical incision Does not enter GIT, GUT, Resp tract Class II (clean- contaminated) 2 5 % infection rate; GIT, GUT and resp tract entered Prophylactic antibiotic

= Page 108 = Keloids Surgical excision is combined with: Intralesional corticosteroid injection Topical application of silicon sheets Pressure

= Page 109 = Hypertropic Scars An over abundance of fibroplasias in the dermal healing process.

= Page 114 = Wound classification Class III (contaminated) 50% infection rate; gross contamination Therapeutic antibiotics Class IV (dirty wounds) Infected or traumatic wounds Surgical debridement part of treatment

= Page 115 = Clean wounds

= Page 116 = Clean contaminated wounds

= Page 117 = Contaminated wounds

= Page 118 = Dirty wounds

= Page 119 = Treatment of Wounds

= Page 120 = Antiobiotics Empirical Culture and Sensitivity - based

= Page 121 = Wound Care Absorbent dressings Nonadherent dressings Occlusive and Semi-occlusive dressings Hydrophillic and Hydrophobic dressing Hydrocolloid and Hydrogel dressings Alginates dressings Absorbable materials Medicated dressings Mechanical devices - drains, suctions

= Page 122 = THANK YOU