Neurosurgical Wound Closure With Porcine Urinary Bladder Matrix: An Interview With the Author

In this video, Dr. Ronaghan provides background and additional details regarding their article, A Novel Approach to Neurosurgical Wound Closure With Porcine Urinary Bladder Matrix: An Illustrative Case Series. Additional authors of the article include Jasmin Rahesh, MD, MS, MBA; and Albin John, MD, MBA. Read the full article here.

Transcript:

I'm Dr. Catherine Ronaghan. I'm a retired professor of surgery, Texas Tech University Health Science Center, where a lot of this work was done over my 7-year period of time there doing emergency general surgery and trauma. Today, I'm very pleased to be able to provide a little video introduction to the paper, which is a short case series of complex neurosurgical wounds which were definitively closed and healed utilizing porcine urinary bladder matrix.

The field of emergency general surgery obviously has a lot of acute wounds. These were both surgical wounds, but the first was related to an elective procedure for a malignancy and the second was a traumatic injury where the patient had a lot of exposed hardware. The first case, actually the wound was almost a month old by the time we got involved, and there were many challenges, including a CSF leak and a really large open wound, lengthwise as well as widthwise, with ischemic dermal edges and such. The second wound, as I said, was an implantation at an infected large cervical, actually, the entire cervical spine and down to about T1, a hardware from an injury sustained in a motor vehicle crash.

Well, neurosurgical wounds can be devastating. Obviously, if you have to remove hardware, or in the case of our first patient, she had an ongoing CSF leak and she'd been in the hospital over a month, and we wanted to approach it in a way that would allow for wound healing without having to remove hardware and, often, neurosurgical wounds are in an odd location, so, for instance, using negative pressure in the first case would be actually contraindicated because of the CSF leak. In the second case, again, you're dealing with a posterior location which is often difficult to maintain the negative pressure, and then also negative pressure is fantastic, but it is not as definitive, and we were able to get these wounds healed literally in a much faster timeline.

Well, actually, both of them were very surprising. The fact that we did a sutureless closure on the first patient, just really we packed a good bit of the porcine urinary bladder matrix powder into the obvious CSF leak, which was near the lumbosacral aspect of the incision, and then just essentially placed the PUBM and just brought the skin edges together with strips of vac tape, it was absolutely sutureless, and the fact that it basically completely healed in under 2 weeks, end of story, I found that quite remarkable.

With the second case, the fact that we got a wound healed with exposed hardware again with one application and actually closure of the wound, and that's been the curious thing and very reproducible thing using the porcine urinary bladder matrix. It is unclear, but these porcine organ products essentially seem to have an antimicrobial properties. Obviously, both of these wounds were infected, yet we implanted material and definitively closed the skin and had no problems in either patient, had complete healing, and the woman retained her hardware, and she was actually a relatively poorly controlled diabetic as well. The properties of this material are really quite remarkable of these porcine, I'm going to call them porcine organ products, because this was porcine urinary bladder matrix, but there's now other products available using different internal organs of pigs.

There's really many opportunities. I think that this can be applied in a preemptive fashion. We have another large series we're working on that were class four wounds essentially that we actually definitively closed again the skin, which is not typically what you would do, and had essentially no infection rate after the closure of an infected wound. You could look at this in the preemptive state where you have a patient with multiple comorbidities and a contaminated wound where you could put this material in at the time of the definitive procedure or the time of the initial procedure and close. I think that there's definitely a role for that in preventing surgical site infections, which is a very expensive and potentially debilitating event for patients.

Just this concept which we have adopted over time of trying to be definitive in closure as soon as possible, so we use a number of modalities, but the end game is to as quickly as possible get some of this material into the wound and close the skin. We do use it in wounds where there has been soft tissue loss, and it does a remarkable job there as well as far as facilitating constructive remodeling and encouraging M2 macrophage recruitment, which is pro-constructive remodeling, versus M1, which is pro-inflammatory and pro-scars. You actually get a more site-specific tissue in the areas where the xenograft is in contact with a living host, and that's actually important as well. It only works if it's properly hydrated and in contact with viable tissues. That's why, in the first patient, the debridement was completed and then the material was implanted at the same time, but it's important to debride a non-viable tissue because it only essentially interacts with live tissue.