437 ORIGINAL SCIENTIFIC ARTICLE Use of vacuum-assisted closure in the treatment of complex intrapleural infections Copyright (c) 2023 Slovenian Medical Journal. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Use of vacuum-assisted closure in the treatment of complex intrapleural infections Uporaba zapiranja ran z vakuumom pri zdravljenju zapletenih intraplevralnih okužb Matic Domjan, Tomaž Štupnik, Matevž Srpčič Abstract Background: Debilitated patients with chronic empyema, who are not fit enough to undergo thoracotomy and decortica- tion due to lung entrapment, may be offered a lower-risk alternative – an open-window thoracostomy. Vacuum-assisted closure (VAC) may accelerate empyema drainage and wound closure. Methods: In this study, we compared two cohorts of patients receiving open-window thoracostomy (OWT) with or without VAC dressing. We included patients with chronic or postresectional empyema with multiple comorbidities or in poor gen- eral condition or on immunosuppression. Results: Delayed wound closure by thoracoplasty was performed in 8 (28%) patients in the OWT group and 8 (53%) pa- tients in the OWT-VAC group (OR 2.54; 95% CI: 0.704-9.168). Time until DWC was significantly shorter (p<0.001) in the OWT- VAC group (48.5, IQR: 27.5 days) compared to the OWT group (316.5, IQR: 102.5 days). Regarding complications, we found no significant differences between the two groups, except for air leak, which was found in 0 (0%) patients in the OWT group and 6 (40%) patients in the OWT-VAC group (OR 1.67; 95% CI: 1.10-2.52; p<0.001). The percentage of patients who required re-do surgery did not differ significantly between the groups - 1 (3%) patient in the OWT group vs. 2 (13%) patients in the OWT-VAC group (OR 7.0; 95% CI: 0.66 – 74.29; p=0.07). Conclusion: Our experience shows that using VAC therapy in OWT can significantly shorten the overall treatment time. It can be safely used at home and in an outpatient setting. Izvleček Izhodišča: Bolnikom s kroničnim empiemom, ki so v slabem splošnem zdravstvenem stanju in niso sposobni za torakoto- mijo in dekortikacijo zaradi ujetih pljuč, lahko ponudimo alternativno možnost z nižjim tveganjem, in sicer torakostomo. Zapiranje rane z vakuumom (VAC) lahko pospeši dreniranje empiema in zapiranje rane. Department of Thoracic Surgery, Division of Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia Correspondence / Korespondenca: Matic Domjan, e: matic.domjan@kclj.si Key words: vacuum-assisted closure; empyema; open window thoracostomy; fenestration; thoracoplasty Ključne besede: zapiranje rane z vakuumom; empiem; torakostoma; fenestracija; torakoplastika Received / Prispelo: 5. 12. 2022 | Accepted / Sprejeto: 13. 7. 2023 Cite as / Citirajte kot: Domjan M, Štupnik T, Srpčič M. Use of vacuum-assisted closure in the treatment of complex intrapleural infections. Zdrav Vestn. 2023;92(11–12):437–41. DOI: https://doi.org/10.6016/ZdravVestn.3406 eng slo element en article-lang 10.6016/ZdravVestn.3406 doi 5.12.2022 date-received 13.7.2023 date-accepted Surgery, orthopaedics, traumatology Kirurgija, ortopedija, travmatologija discipline Original scientific article Izvirni znanstveni članek article-type Use of vacuum-assisted closure in the treat- ment of complex intrapleural infections Uporaba zapiranja ran z vakuumom pri zdravljenju zapletenih intraplevralnih okužb article-title Use of vacuum-assisted closure in the treat- ment of complex intrapleural infections Uporaba zapiranja ran z vakuumom pri zdravljenju zapletenih intraplevralnih okužb alt-title vacuum-assisted closure, empyema, open window thoracostomy, fenestration, thoraco- plasty zapiranje rane z vakuumom, empiem, torakosto- ma, fenestracija, torakoplastika kwd-group The authors declare that there are no conflicts of interest present. Avtorji so izjavili, da ne obstajajo nobeni konkurenčni interesi. conflict year volume first month last month first page last page 2023 92 11 12 437 441 name surname aff email Matic Domjan 1 matic.domjan@kclj.si name surname aff Tomaž Štupnik 1 Matevž Srpčič 1 eng slo aff-id Department of Thoracic Surgery, Division of Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia Klinični oddelek za torakalno kirurgijo, Kirurška klinika, Univerzitetni klinični center Ljubljana, Ljubljana, Slovenija 1 Slovenian Medical Journallovenian Medical Journal 438 SURGERY, ORTHOPAEDICS, TRAUMATOLOGY Zdrav Vestn | November – December 2023 | Volume 92 | https://doi.org/10.6016/ZdravVestn.3406 1 Introduction Pleural space infections comprise a broad spectrum of diseases. In the early stages, parapneumonic effusion and thoracic empyema may be treated with chest tube drainage or a video-thoracoscopic procedure. However, failure to do so early may necessitate a more invasive procedure – thoracotomy and decortication due to lung entrapment (1). In a debilitated patient, these proce- dures may carry a substantial risk. Complicated chron- ic empyema in these patients may therefore require a lower-risk alternative - an open window thoracostomy (OWT) (1,2). Fenestration of the thoracic wall allows for a quick resolution of sepsis but also creates a com- plex malodorous wound that can be socially debilitat- ing. Studies have already shown that accelerated OWT empyema drainage may be achieved with the help of vacuum-assisted closure (VAC) (3,4,5,6,7). Additional- ly, VAC treatment seems to facilitate the patient’s return to their daily activities by concealing the wound odour and allowing the dressing changes to be made only weekly (7). 2 Methods 2.1 Patients We designed a study to compare a prospective co- hort with a historical cohort. The historical cohort in- cluded patients with thoracic empyema who received OWT without VAC dressing, and the prospective co- hort included patients who received OWT with VAC dressing (OWT-VAC). After introducing the new treat- ment method in our department in December 2019, its advantages and accelerated healing became apparent with the first few patients. That is why we decided to use only OWT-VAC from then on and to compare the prospective cohort with the historical one. Inclusion criteria for patients with chronic or post- resectional empyema were the following: • poor general condition (Karnoffsky index ≤ 50%) or • multiple comorbidities (≥ 3 organ diseases, such as diabetes mellitus, chronic kidney disease, heart fail- ure, etc. ) or • immunosuppression (induced by medication fol- lowing organ transplantation). We defined the primary outcome as the time until delayed wound closure (time between two procedures - OWT formation and thoracoplasty) and the second- ary outcomes as the percentage of complications (hypo- tension, bleeding, air leak, and re-infection) and re-do surgery. Data were collected prospectively and retrospective- ly for all the patients who received OWT for chronic or postresectional empyema between February 2010 and September 2021. The study was approved by Slovenia’s National Medical Ethics Committee (approval number 0120-230/2020-3; date 14. 07. 2020). Statistical data analysis was performed using the Chi-square test for categorical variables, the indepen- dent samples t-test, and the Mann-Whitney U test for numeric variables. A p-value less than 0.05 (p<0.05) was considered significant. Normally distributed continu- ous variables were presented as mean ± standard devi- ation (SD) and asymmetrically distributed continuous variables as median and interquartile interval (IQR). The odds ratio with a confidence interval of 95% (OR, CI 95%) was used to estimate differences between the treatment groups. Metode: V naši študiji smo primerjali dve kohorti bolnikov, ki so prejeli torakostomo z vakuumsko (VAC) prevezo ali brez nje. Vključili smo bolnike s kroničnim empiemom ali empiemom po resekciji, ki so imeli več bolezni in/ali v slabem splo- šnem zdravstvenem stanju in/ali so jemali imunosupresivna zdravila. Rezultati: Zapiranje rane s torakoplastiko (ZST) je bilo napravljeno pri 8 (28 %) bolnikih v skupini ne-VAC in pri 8 (53 %) bolni- kih v skupini VAC (RO 2,54; 95 % IZ: 0,70-9,17). Čas do ZST je bil pomembno krajši (p<0,001) v skupini VAC (48,5; IQR: 27,5 dni) v primerjavi s skupino ne-VAC (316,5; IQR: 102,5 dni). Pri zapletih nismo našli pomembnih razlik med obema skupinama, razen pri puščanju zraka, ki ni bilo prisotno pri nobenem bolniku v skupini ne-VAC in pri 6 (40 %) v skupini VAC (RO 1,67; 95 % IZ: 1,13-2,52; p<0,001). Delež bolnikov, ki so potrebovali ponovno operacijo, se med skupinama ni pomembno razli- koval – 1 (3 %) bolnik v skupini ne-VAC in 2 (13 %) bolnika v skupini VAC (RO 7,0; 95 % IZ: 0,66 – 74,29; p=0,07). Zaključek: Naše izkušnje kažejo, da lahko uporaba VAC pri torakostomi pomembno skrajša celokupni čas zdravljenja. Lahko se varno uporablja pri bolnikih v ambulanti in v domačem okolju. 439 ORIGINAL SCIENTIFIC ARTICLE Use of vacuum-assisted closure in the treatment of complex intrapleural infections 2.2 Surgical management All patients underwent the procedure under general anaesthesia. The empyema sac was located according to a preoperative computed tomography scan. A 5 cm in- cision was made, resection of a minimum of one rib was performed, the cavity was opened, and an Eloesser flap was created. OWT group: Saline-soaked gauzes were inserted in- to the cavity and changed daily. Patients were discharged home with the same dressing, which was changed regu- larly by a field nurse at home. OWT-VAC group: Black Granufoam (KCI Medi- cal, San Antonio, TX, USA) was inserted into the cavity, Whitefoam or a silicone membrane was used to cover possibly exposed lung or mediastinum. The suction was typically set to -125 mmHg. In the case of the patient’s hypotension, we reduced the setting to -75 mmHg. After discharge, VAC therapy was continued on an outpatient basis, with the dressing being changed every 5-7 days. In the presence of an air leak due to an alveolopleural fistula (APF), we covered the fistula with polyethylene non-adherent dressing (Eurodressing, Eurofarma SPA, Belpasso, Italy). In this case, VAC dressing required more frequent changing. 3 Results Between February 2010 and September 2021, 44 patients were enrolled in the trial. The first 29 patients received saline-soaked dressing after OWT, and the last 15 received OWT-VAC. There were no significant differ- ences between OWT and OWT-VAC groups regarding age, sex, multimorbidity, immunosuppression, malig- nancy, and postresectional or postpneumonectomy em- pyema (Table 1). There was also no significant difference between the two groups regarding the delayed wound closure (DWC) rate. In the OWT group, DWC was performed in 8 (28%) patients; in the OWT-VAC group, it was done in 8 (53%) patients (OR 2.54; 95% CI: 0.70-9.17). Other patients did not receive DWC because they either died or were lost to follow-up. Time until DWC was much shorter (p<0.001) in the OWT-VAC group (48.5, IQR: 27.5 days) compared to the OWT group (316.5, IQR: 102.5 days) (Table 2). We found no major complications (e.g., severe bleed- ing or shock due to mediastinal shift) in any group. Of 29 patients in the OWT group, 7 (24%) had complications. In 2 (7%) patients, postoperative bleeding was observed, and 5 (17%) patients had re-infection (Table 2). Of 15 patients in the OWT-VAC group, 8 (53%) de- veloped some complications, one patient (7%) experi- enced postoperative hypotension, in 2 (13%) patients, postoperative bleeding was observed, in 6 (40%) patients air leak developed and 3 (20%) patients had re-infection. Regarding complications, we found no significant differ- ences between the two groups, except for air leak, which was observed in 0 (0%) patients in the OWT group and 6 (40%) patients in the OWT-VAC group (OR 1.67; 95% CI: 1.10-2.52; p<0.001). Legend: SD – standard deviation; OR – odds ratio; CI – confidence interval. Characteristic Total n=44 OWT n=29 OWT-VAC n=15 OR (95% CI) p-value Age, mean ± SD (range) 66±9.2 (43-83) 66±10.1 (43-83) 65±7.5 (49-78) 0.75 Sex 0.74 • Female 7 (16%) 5 (17%) 2 (13%) • Male 37 (84%) 24 (83%) 13 (87%) Multiple morbidities (≥3) 29 (44%) 19 (66%) 10 (67%) 1.05 (0.28-3.94) 0.94 Immunosuppression 3 (7%) 2 (7%) 1 (7%) 0.96 (0.08-11.58) 0.98 Malignancy 25 (57%) 16 (55%) 9 (60%) 1.22 (0.34-4.32) 0.76 Postresectional empyema 19 (43%) 11 (38%) 8 (53%) 1.41 (0.40-4.91) 0.59 Postpneumonectomy empyema 7 (16%) 7 (24%) 0 (0%) 0.79 (0.66-0.96) 0.06 Table 1: Baseline characteristics of the patients. 440 SURGERY, ORTHOPAEDICS, TRAUMATOLOGY Zdrav Vestn | November – December 2023 | Volume 92 | https://doi.org/10.6016/ZdravVestn.3406 The percentage of patients who required re-do sur- gery did not differ significantly between the groups (OR 7.0; 95% CI: 0.66 – 74.29; p=0.070). Only one (3%) patient in the OWT group required an additional pro- cedure due to re-infection, and 2 (13%) patients in the OWT-VAC group required additional procedures due to re-infection and bleeding. 4 Discussion Treatment of complex chronic intrapleural infections in patients with poor general condition and multiple morbidities remains challenging. In the last decade, vac- uum-assisted closure use in treating chronic empyemas has increased in thoracic surgery (6). Our study indicates that using VAC in OWT can sig- nificantly accelerate healing and shorten overall treat- ment time in patients with chronic empyema. This ob- servation confirms the results of earlier retrospective studies (4,5,6,7). Additionally, VAC provides a hermet- ically tight dressing that conceals the wound odour and prevents discharge spillage. Another significant advan- tage is the possibility of using VAC therapy in an outpa- tient setting, which allows for early discharge, although dressing changes might present additional strain for the outpatient clinic. Early-on fears of mediastinal traction with possible catastrophic hypotension and shock after using VAC in- trapleurally have proven unnecessary (3). Although our VAC series contained no patients with postpneumonec- tomy empyema, studies have already demonstrated that VAC therapy can be used safely and effectively in such patients, even in the presence of bronchopleural fistula (BPF) (8). During the SARS-CoV-2 pandemic, Konagaya et al. have shown the efficacy and advantages of OWT-VAC in treating a COVID-19-related empyema with prolonged air leak due to an unresolved alveolopleural fistula (APF) (9). This finding might indicate that neither BPF nor APF is a contraindication for VAC therapy. A good alternative for treating chronic pleural em- pyema might also be using VAC with the instillation of a local antiseptic solution. In 2014, Hofman et al. first reported the polyhexanide solution flushing application in patients with OWT-VAC (10). Nevertheless, one must be cautious in choosing suitable patients. The use of an- tiseptic instillation in a patient with BPF or APF might lead to severe chemical pneumonitis. Because some of the patients presented with air leak at the time of OWT creation and some developed it later during treatment, we decided against using local antiseptic solution instil- lation in this cohort of patients. To our knowledge, no randomized trials have in- vestigated the use of VAC for intrathoracic infections. Because of the small number of patients, such studies would be difficult to conduct, and considering the ap- parent benefits of VAC and significantly accelerated healing, designing such a study would not be justified. 4.1 Study limitations The main limitations of our study are the limited number of patients and its design - it is a retrospec- tive study with two cohorts. The relatively small sample Legend: DWC – delayed wound closure; IQR – interquartile range; OR – odds ratio; CI – confidence interval. Outcome OWT n=29 OWT-VAC n=15 OR (95% CI) p-value DWC by thoracoplasty - no. of patients (%) 8 (28%) 8 (53%) 2.54 (0.70-9.17) 0.15 Time until DWC – no. of days, median (IQR) 316.5 (102.5) 48.5 (27.5) <0.001 Complications – no. of patients (%) 7 (24%) 8 (53%) 5.11 (1.28-20.49) 0.02 • Hypotension 0 1 (7%) 1.07 (0.94-1.23) 0.16 • Bleeding 2 (7%) 1 (7%) 0.96 (0.08-11.58) 0.98 • Air leak 0 6 (40%) 1.67 (1.10-2.52) <0.001 • Re-infection 5 (17%) 3 (20%) 1.20 (0.25-5.89) 0.82 Re-do surgery – no. of patients (%) 1 (3%) 2 (13%) 7.00 (0.66-74.29) 0.07 Table 2: Primary and major secondary outcomes. 441 ORIGINAL SCIENTIFIC ARTICLE Use of vacuum-assisted closure in the treatment of complex intrapleural infections References 1. Hofmann HS. Modern management of empyema thoracis. Semin Thorac Cardiovasc Surg. 2013;25(4):287-91. DOI: 10.1053/j.semtcvs.2013.07.006 PMID: 24673957 2. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. 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Minimally Invasive Vacuum-Assisted Closure Therapy With Instillation (Mini-VAC-Instill)for Pleural Empyema. Surg Innov. 2015;22(3):235-9. DOI: 10.1177/1553350614540811 PMID: 25049317 might be the reason for some of the non-significant out- come results. 5 Conclusion Our experience shows that VAC therapy in OWT can significantly shorten the overall treatment time. It might be a safe and effective treatment for complex intrathoracic infections, and it can be safely used at home and in an outpatient setting. Conflict of interest None declared.