Complex Wound Management Using Negative Pressure Wound Therapy With Instillation and Dwell Time in a Cancer Care Setting

Introduction. Unresolved wound healing represents a major health care cost with a negative impact on patient quality of life, especially among oncology patients who exhibit a delay in the wound healing cascade due to chemotherapy and radiation. In order to address this problem, the author utilized negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) to cleanse wounds of debris and help promote healing. Objective. The author examines the impact of NPWTi-d on multiple indicators of wound healing progress in 6 cancer patients with complex wounds and multiple comorbidities. Materials and Methods. The NPWTi-d was initiated with instillation of normal saline or 0.125% hypochlorite solution, which was allowed to dwell for 3 to 20 minutes, followed by 2 to 3.5 hours of -125 mm Hg continuous negative pressure. Dressing changes were performed every 2 to 3 days. Debridements, incision and drainage, and antibiotics were administered as necessary. Results. A total of 1 woman and 5 men (average age, 62 years; range, 53–78 years) presented with the following wounds: surgical dehiscence (n = 3), pressure injury (n = 1), chronic seroma (n = 1), and abdominal wall abscess (n = 1). Malignancy was not detectable in any wounds. Patient comorbidities included diabetes, hypertension, and past treatment for cancers. The NPWTi-d was applied for 1 to 2 weeks, after which the wounds exhibited a reduction in slough, an improvement in granulation tissue, and a decrease in wound volume. Wounds were closed with a flap or transitioned to conventional NPWT prior to discharge home or to a rehabilitation facility for outpatient recovery. Conclusions. As shown in this case series, NPWTi-d was a beneficial tool for cleansing the wound bed, thus creating a moist, closed wound environment conducive to healing. Using NPWTi-d supported the formation of a healthy wound bed and contributed to rapid, positive outcomes in this patient population.

In patients undergoing necessary oncology therapies, the normal wound healing cascade is often interrupted, affected by both the malignancy itself and the course of treatment.¹ A stalled wound can postpone a patient’s discharge from the hospital, delay recovery, and have an overall negative impact on quality of life.² To address this problem, advanced wound care may be necessary to stimulate wound progression to a healthier stage, such as by the removal of nonviable tissues and cleansing the wound bed. Negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) is a closed, automated system that supports healing by delivering topical solutions to the wound surface to moisten, solubilize, and remove debris while providing cyclic intervals of negative pressure. In this case series, the author aimed to overcome barriers to wound healing using NPWTi-d in the management of 6 complex, recalcitrant wounds in patients receiving treatment at a comprehensive cancer center. 

All wounds were free of detectable malignancy prior to the initiation of any negative pressure therapy. A total of 3 patients had received prior treatment with conventional NPWT (V.A.C. Therapy; KCI+3M). The NPWTi-d (V.A.C. VERAFLO Therapy; KCI+3M) was initiated with instillation of normal saline (n = 3) or 0.125% hypochlorite solution (n = 3; Table). In all cases, the standard reticulated open cell foam dressing (V.A.C. VERAFLO Dressing; KCI+3M) was used. In 2 patients, instillation with hypochlorite solution was discontinued after 1 week, per hospital policy, and replaced with normal saline in the second week of therapy. After instillation, the solutions were allowed to dwell for 3 to 20 minutes, followed by 2 to 3.5 hours of -125 mm Hg continuous negative pressure. Dressing changes were performed every 2 to 3 days. Debridements and incision and drainage were performed as necessary. During therapy, 3 patients received antibiotics.

A total of 1 woman and 5 men (average age, 62 years; range, 53–78 years) presented with the following wounds: surgical dehiscence (n = 3), pressure injury (n = 1), chronic infected seroma (n = 1), and infected abdominal wall abscess (n = 1). Patient comorbidities included obesity, diabetes, hypertension, and past cancer treatment. For all cases, the wounds had been resistant to prior therapies, which included conventional NPWT, debridements, moist dressings, and incision and drainage. The NPWTi-d was applied with the primary goal of clearing the wound of nonviable tissue with alternating cycles of negative pressure and soaks with cleansing solutions. After 1 to 2 weeks, NPWTi-d was discontinued, and the wounds exhibited a reduction in slough, an improvement in granulation tissue, and a decrease in wound volume (Table). Wounds were closed with a flap or transitioned to conventional NPWT. All patients were discharged from the hospital to a rehabilitation clinic or home for outpatient recovery. There are 3 representative cases described below.

Case 1
The first case was a 78-year-old frail man with neurofibromatosis, macular degeneration with near complete blindness, and hypertension. Medical history included treatment of cutaneous melanoma, low anterior resection surgery for rectal cancer, and multiple skin excisions for superficial skin cancers. The patient had recently been diagnosed with a pulmonary embolism, though he was asymptomatic, and began taking enoxaparin sodium (LOVENOX; Sanofi Aventis). The patient underwent an emergency right hemicolectomy for obstructing stage II (T3N0M0) rectal cancer. The procedure was complicated by an anastomotic leak and fascial dehiscence, requiring reoperation for end ileostomy, creation of a mucous fistula, and closure of the abdominal fascia with a vicryl mesh. The abdominal cutaneous layer remained open, and a NPWT unit was placed in the operating room. The wound measured 22 cm x 14 cm x 1 cm (Figure 1A). At 3-weeks postoperatively, NPWTi-d was initiated with instillation of normal saline, followed by a 3-minute dwell time and 2 hours of continuous negative pressure at -125 mm Hg. After 2 weeks of NPWTi-d, the mesh was covered by a layer of granulation tissue and the wound size had reduced to 15 cm x 8 cm x 0.5 cm (39% reduction) (Figure 1B). The patient transitioned to conventional NPWT and was discharged to a rehabilitation center 1 week after discontinuing NPWTi-d.

Case 2
The next case was a 54-year-old man with a second and third portion duodenectomy with primary anastomosis complicated by a biliary obstruction. The patient underwent an extrahepatic bile duct reconstruction to the distal stomach and placement of a percutaneous endoscopic gastrostomy tube. The patient remained with a persistent fistula from the right duodenum to the stomach, persistent biliary drainage from a right upper quadrant surgical drain, and an abdominal abscess after removal of drains for interventional radiology. At this time, the patient acquired a stage IV sacral pressure injury, which was debrided and covered with moist dressings. The wound measured 5.5 cm x 5 cm x 3 cm with undermining (Figure 2A). The wound bed was covered with 25% slough and 75% granulation tissue. No odor was present, but serous drainage was noted. After 2 days, wound management with NPWTi-d with 0.125% sodium hypochlorite was initiated, which was allowed to dwell for 10 minutes, followed by 2 hours of continuous negative pressure at -125 mm Hg. After 1 week, the instillation solution was changed to normal saline, with all other NPWTi-d settings remaining the same. After the second week, the wound reduced in size (Figure 2B), and therapy was transitioned to 1 month of conventional NPWT. At 3 months after initial treatment of the pressure injury, the wound was closed (Figure 2C).

Case 3
The third case is a 59-year-old woman with diabetes and hypertension. She underwent an abdominal perineal resection with colostomy for anal cancer, resulting in a large midline incision. At 1-month postop, the patient was readmitted for dehiscence of the cutaneous layer, revealing a wound over the intact abdominal fascia. The wound emitted a foul odor; tunneling was present without extension to the peritoneal cavity. Wound management was initiated with 1 week of conventional NPWT; however, the wound appeared stalled (Figure 3A). The decision was made to transition the patient to NPWTi-d with 0.125% sodium hypochlorite. The solution was allowed to dwell for 5 minutes, followed by a 3.5-hour cycle of continuous negative pressure at -125 mm Hg. After the first week, the instillation solution was changed to normal saline, with all other settings remaining unchanged. After 2 weeks of NPWTi-d, the wound had decreased in depth and was covered in granulation tissue (Figure 3B). The patient was discharged home to continue wound management with conventional NPWT at week 3. 

In patients undergoing treatment for cancer, elimination of the tumor is the primary goal of therapy. However, some of these interventions may result in surgical incisions, abscesses, or other wounds, such as hospital-acquired pressure injuries, which must be addressed before the patient can be discharged from the hospital. Furthermore, some oncological therapies have a direct negative impact on wound healing. Studies of various chemotherapeutic agents suggest impaired wound healing in recipient patients,^3,4 and complications arising from wounds in irradiated tissues are a common clinical problem.^5-7 The impact of oncologic therapy on the wound healing cascade depends on the specific treatment strategy and can vary from patient to patient.^8,9 Therefore, there is a need for a supportive therapy that can enable wound healing in this population. Negative pressure therapies represent one such option, having been found to be effective in managing nonhealing wounds in various patient populations.^10-12

According to the manufacturer’s instructions for use, NPWT and NPWTi-d are contraindicated for wounds in which a malignancy can be detected. However, once tumor resection has been achieved, negative pressure therapies can be applied to support wound healing. Indeed, this case series is supported by other published cases in which NPWT devices have been applied to enable wound bed preparation and closure.^13-19 In a study of patients receiving NPWT (n = 6) versus conventional wound care (n = 10) after inguinal lymphadenectomy for penile cancer,¹⁷ the NPWT group had a significantly reduced median time to complete closure (P < .001). In a comparison of NPWT (n=16) and conventional dressings (n = 13) for free flap donor sites in patients with head and neck cancer,¹⁶ the researchers found a lower mean graft loss rate (19% and 37%, respectively) and shorter mean total healing time (P = .02) in the NPWT group. Another examination of patients with head and neck cancer receiving NPWT (n = 31) or conventional wound care (n = 27) after tumor ablation and neck reconstruction found the NPWT group had a lower rate of complications (P = .025).¹³ While these studies support the use of NPWT in patients with cancer, to the author’s knowledge, the present case series is the first to describe the use of NPWTi-d to provide additional cleansing required to advance the wound healing cascade and facilitate closure in the oncological population. In this patient group, the primary goal of NPWTi-d had been achieved: the quality of the wound bed was improved via the removal of debris and increased coverage with granulation tissue. In each case after NPWTi-d, the wound had decreased in size, and the patient was able to be discharged with a closed wound or a stable, healing wound suitable for outpatient therapy.

This study is limited in that it is a retrospective case series with a limited sample size. This study does not include a control group, and the outcomes reported here reflect the author’s experience and may not be observed under differing circumstances. 

As shown in these cases, NPWTi-d was beneficial in the delivery, soak, and removal of topical wound solutions to cleanse the wound bed, thus creating a moist, closed wound environment conducive to healing.¹⁶ Using NPWTi-d supported the formation of a healthy wound bed and contributed to rapid, positive outcomes in this patient population. Hence, NPWTi-d presents an effective option for managing complex wounds in the oncology setting. 

Author: Dona Lyndhia Isaac, RN, MSN/ED, CWON

Affiliation: Memorial Sloan Kettering Cancer Center, New York City, NY

Correspondence: Dona Lyndhia Isaac, RN, MSN/ED, CWON, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York City, NY; isaacd@mskcc.org 

Disclosure: Ms. Isaac is a consultant for KCI+3M. Data were presented at the Symposium on Advanced Wound Care in May 2019.