J Wound Ostomy Continence Nurs. 2013;40(6):641-643. Published by Lippincott Williams & Wilkins
CHALLENGES IN PRACTICE
Rare Complication After VAC Therapy in the Treatment of Tissue Defect Due to Surgical Excision of Pilonidal Sinus Saime Irkoren
Nazan Sivrioglu
■ ABSTRACT BACKGROUND: Pilonidal sinus is frequently managed with surgical incision. If the wound is left open to heal by secondary intention, negative pressure wound therapy (NPWT) is often used to promote healing. CASE: We describe the case of a 60-year-old patient referred after excision of a pilonidal sinus, which was managed postoperatively with NPWT. Unfortunately, the patient developed squamous cell carcinoma, which was undetected postoperatively, as the dressing was left in place for 5 days. CONCLUSION: Guidelines for the use of NPWT should be followed, with dressing intervals at 2 to 3 days. Wounds managed by NPWT should be monitored carefully for malignancy at the time of dressing changes. KEY WORDS: pilonidal sinus, negative pressure wound therapy, squamosal cell carcinoma, tissue defect, vacuumassisted closure
■ Introduction Pilonidal sinus is diagnosed 4 times less frequently in women compared to men and is more commonly seen in dark-skinned people. It is most frequently seen in the sacrococcygeal region.1-3 Principles of treatment include excision of the sinus tract in order to enable the overlying skin to heal and avoid relapse. A surgical wound may be left to heal by secondary intention. Otherwise, the wound may be closed to heal by primary intention. Malignant degeneration is a rare complication of pilonidal disease; there have been 68 cases reported in the literature.1-3 We present a case of a squamous-cell carcinoma after negative pressure wound therapy (NPWT) for tissue defect following surgical excision of pilonidal sinus.
■ Method and Patient We report on a 60-year-old patient, referred to our plastic surgery clinic from a regional hospital presenting with
Hüray Karaca
squamous cell carcinoma (SCC) in a surgical wound that resulted from excision of pilonidal sinus. The pilonidal sinus had been excised by the general surgeon in the hospital, and surgical wound left open for healing with NPWT (VAC; Smith and Nephew, Lohfelden, Germany). Negative pressure wound therapy had been in use for 1 month following surgery. The foam NPWT dressing was changed every 5 days according to the medical records of the hospital. Our clinical examination on admission after removal of the foam dressing revealed necrotic tissue with a suspected tumor, moderate erythema of surrounding tissues, and a strong putrid odor (Figure 1). No other systemic illnesses were noted. A biopsy of the lesion revealed a well-differentiated SCC. Pseudomonas aeruoginosa and Staphylococcus aureus were isolated from the wound culture. The inguinal lymph nodes were not palpable, and lumbosacral spine films revealed no osteomyelitis or destruction of bone. A computed tomographic scan of the pelvis localized the mass to the perianal region in the midline extending into the muscles and subcutaneous fat tissue. Rectosigmoidoscopy was completed and found to be normal. Under general anesthesia, the tumor was excised 2 cm above the induration. It was observed to extend superiorly to the sacrum and anteriorly to the back wall of the rectum. Total excision of the tumor was performed, which included the coccyx bone and the defect reconstructed with gluteal Saime Irkoren, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. Nazan Sivrioglu, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. Hüray Karaca, MD, Assistant, Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. The authors declare no conflict of interest. Correspondence: Saime Irkoren, MD, Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine 09100 Centre, Aydin, Turkey ([email protected]). DOI: 10.1097/WON.0b013e3182a9c2d9
Copyright © 2013 by the Wound, Ostomy and Continence Nurses Society™
J WOCN
■ November/December 2013 641
Copyright © 2013 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
WON200520.indd 641
29/10/13 7:32 PM
642
Irkoren et al
FIGURE 1. After removal of VAC dressing, sacrococcygeal re-
gion showed a nonhealing tissue defect, distinct redness, and hyperthermia of this region, and a strong putrid smell.
rotational flaps (Figure 2). The pathological findings demonstrated well-differentiated SCC with clear skin margins, but there was still tumor invasion to bone margins. Following a further wide local excision, a course of radiotherapy of 5400 rad was given in divided doses over 6 weeks.
■ Discussion The etiology of pilonidal disease is not entirely understood, but the most accepted pathogenesis includes loose hairs
FIGURE 2. Intraoperative image.
J WOCN
■ November/December 2013
invading into subcutaneous cysts, aggravating infection, and a leading to a foreign body reaction.1-3 Simple excision of the pilonidal cyst (the tract is laid open to allow healing by secondary intention), curettage, brushing (excision of midline epithelial follicles under local anesthesia and passing a small brush in the track to remove hair within the granulation-lined track), or phenol injection may be used to ablate the sinus. These simple techniques seem to be favorable, but they may require significant healing time and they are associated with a significant recurrence rate.4 Other treatment options include primary closure, marsupialization (excision of the pilonidal sinus, cavity, and lateral tracts; the cavity is then scrubbed and curetted to remove hair and granulation tissue with suturing of the skin edges to the presacral fascia) or leaving the wound open to heal by secondary intention.2,3 Excision with an open wound involves prolonged hospitalization or clinic attendance for multiple dressing changes and may take months to heal. The most generally accepted technique is midline excision with primary closure, this intervention comprises approximately half of all procedures for excision of pilonidal cysts. Malignant degeneration arises in approximately 0.1% of chronic pilonidal disease patients. Preoperative evaluation of patients with carcinoma arising from pilonidal disease includes a thorough physical examination of the inguinal area of the perineum and anus. Patients will require sigmoidoscopy and barium enema to rule out tumor invasion. Abdominal and pelvic computed tomography is beneficial to detect abdominal metastasis and spreading to the para-aortic lymph nodes.1-3 The treatment of choice, if SCC is found or suspected, remains wide excision of the lesion with tumor-free margins including skin, subcutaneous tissue, muscle, and, if indicated, portions of the sacrum and coccyx. Skin grafts and vascularized flaps can be used to close larger tissue defects. Radiotherapy is recommended; it has been shown to decreasing local recurrence by 30%. Radiotherapy should be administered with wide margins as a consequence of the ill-defined extent of the tumor.1-3 Negative pressure wound therapy has been demonstrated to have a positive effect on the healing of surgical wounds of pilonidal sinus in several studies when SCC is not present.5,6 Negative pressure wound therapy involves placement of an open-cell polyurethane foam into the wound, sealing, and then vacuuming to provide subatmospheric pressure. Wound healing is promoted by removal of excess fluid at the wound site which increases blood flow and oxygen delivery to the wound, removal of inflammatory factors, and decreases bacterial colonization.7 The most common complication of NPWT therapy is skin irritation; rare complications are anasarca, arterial erosion, and toxic shock syndrome.5,6 Malignant degeneration of a surgical wound related to pilonidal disease being treated with NPWT has never been described before. Generally, continuous vacuum therapy dressings are left in place for 2 to 3 days.5,6
Copyright © 2013 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
WON200520.indd 642
29/10/13 7:32 PM
J WOCN ■ Volume 40/Number 6
Irkoren et al
Outcomes of this case study suggest that uncritical use of NPWT may have deleterious consequences. Limiting dressing changes to every 5 days in the surgical wound of a pilonidal sinus can cover signs of malignant degeneration. The NPWT technique is safe, easy, and effective in surgical wound care management. However, the rare complication described in this case study should be kept in mind. The relationship between malignant degeneration and NPWT remains unknown. Squamous cell carcinoma may be associated with the vacuum system, which increases blood flow not only to healing cells but also to neoplastic cells. If feasible, similar cases should be examined with changing NPWT dressing every 2 to 3 days, which is consistent with the current standard of care, in order to inspect any changes in the wound or surrounding tissue, and when a suspected lesion or delayed wound healing is noticed, incisional biopsy should be performed immediately.
■ Conclusion Wounds managed by NPWT should be monitored carefully for malignancy at the time of dressing changes. Prompt recognition of this rare complication can lead to
643
rapid diagnosis and management reducing associated morbidity and the potential risk of mortality.
■ References 1. Malek MM, Emanuel PO, Divino CM. Malignant degeneration of pilonidal disease in an immunosuppressed patient: report of a case and review of the literature. Dis Colon Rectum. 2007;50: 1475-1477. 2. Chatzis I, Noussios G, Katsourakis A, Chatzitheoklitos E. Squamous cell carcinoma related to long standing pilonidaldisease. Eur J Dermatol. 2009;19:408-409. 3. Citak M, Backhaus M, Meindl R, Muhr G, Fehmer T. Rare complication after VAC-therapy in the treatment of deep sore ulcers in a paraplegic patient. Arch Orthop Trauma Surg. 2010;130: 1511-1514. 4. Nessar G, Kayaalp C, Seven C. Elliptical rotation flap for pilonidal sinus. Am J Surg. 2004;187(2):300-303. 5. Kiessling AH, Lehmann A, Isgro F, Moritz A. Tremendous bleeding complication after vacuum-assisted sternal closure. J Cardiothorac Surg. 2011;9:16. 6. Farrell D, Murphy S. Negative pressure wound therapy for recurrent pilonidal disease: a review of the literature. J Wound Ostomy Continence Nurs. 2011;38:373-378. 7. Baharestani MM. Negative pressure wound therapy: an examination of cost-effectiveness. Ostomy Wound Manage. 2004;50(11A) (suppl):29S-33S. Review.
Call for Authors: Challenges in Practice Our Challenges in Practice Section Editor invites case studies or multiple cases series that illustrate the importance of critical thinking or provide alternative or novel approaches to WOC management. This section is ideal for the novice author who has not published platform articles in JWOCN or other journals. Potential cases discussed on the WOC Web Forum that would translate into excellent Challenges in Practice articles include: • Perineal erythema in a frail elderly patient nonresponsive to urinary stream diversion with an indwelling catheter • Rationale for selecting a particular debriding technique based on wound type, care setting, and expertise within the facility • Case studies or case series focusing on initial experiences with novel mattresses, wound care dressings, wound care devices, or other topical wound care therapies • Case studies or case series focusing on unusual stomal or peristomal complications
Copyright © 2013 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
WON200520.indd 643
29/10/13 7:32 PM
CHALLENGES IN PRACTICE
Rare Complication After VAC Therapy in the Treatment of Tissue Defect Due to Surgical Excision of Pilonidal Sinus Saime Irkoren
Nazan Sivrioglu
■ ABSTRACT BACKGROUND: Pilonidal sinus is frequently managed with surgical incision. If the wound is left open to heal by secondary intention, negative pressure wound therapy (NPWT) is often used to promote healing. CASE: We describe the case of a 60-year-old patient referred after excision of a pilonidal sinus, which was managed postoperatively with NPWT. Unfortunately, the patient developed squamous cell carcinoma, which was undetected postoperatively, as the dressing was left in place for 5 days. CONCLUSION: Guidelines for the use of NPWT should be followed, with dressing intervals at 2 to 3 days. Wounds managed by NPWT should be monitored carefully for malignancy at the time of dressing changes. KEY WORDS: pilonidal sinus, negative pressure wound therapy, squamosal cell carcinoma, tissue defect, vacuumassisted closure
■ Introduction Pilonidal sinus is diagnosed 4 times less frequently in women compared to men and is more commonly seen in dark-skinned people. It is most frequently seen in the sacrococcygeal region.1-3 Principles of treatment include excision of the sinus tract in order to enable the overlying skin to heal and avoid relapse. A surgical wound may be left to heal by secondary intention. Otherwise, the wound may be closed to heal by primary intention. Malignant degeneration is a rare complication of pilonidal disease; there have been 68 cases reported in the literature.1-3 We present a case of a squamous-cell carcinoma after negative pressure wound therapy (NPWT) for tissue defect following surgical excision of pilonidal sinus.
■ Method and Patient We report on a 60-year-old patient, referred to our plastic surgery clinic from a regional hospital presenting with
Hüray Karaca
squamous cell carcinoma (SCC) in a surgical wound that resulted from excision of pilonidal sinus. The pilonidal sinus had been excised by the general surgeon in the hospital, and surgical wound left open for healing with NPWT (VAC; Smith and Nephew, Lohfelden, Germany). Negative pressure wound therapy had been in use for 1 month following surgery. The foam NPWT dressing was changed every 5 days according to the medical records of the hospital. Our clinical examination on admission after removal of the foam dressing revealed necrotic tissue with a suspected tumor, moderate erythema of surrounding tissues, and a strong putrid odor (Figure 1). No other systemic illnesses were noted. A biopsy of the lesion revealed a well-differentiated SCC. Pseudomonas aeruoginosa and Staphylococcus aureus were isolated from the wound culture. The inguinal lymph nodes were not palpable, and lumbosacral spine films revealed no osteomyelitis or destruction of bone. A computed tomographic scan of the pelvis localized the mass to the perianal region in the midline extending into the muscles and subcutaneous fat tissue. Rectosigmoidoscopy was completed and found to be normal. Under general anesthesia, the tumor was excised 2 cm above the induration. It was observed to extend superiorly to the sacrum and anteriorly to the back wall of the rectum. Total excision of the tumor was performed, which included the coccyx bone and the defect reconstructed with gluteal Saime Irkoren, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. Nazan Sivrioglu, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. Hüray Karaca, MD, Assistant, Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey. The authors declare no conflict of interest. Correspondence: Saime Irkoren, MD, Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine 09100 Centre, Aydin, Turkey ([email protected]). DOI: 10.1097/WON.0b013e3182a9c2d9
Copyright © 2013 by the Wound, Ostomy and Continence Nurses Society™
J WOCN
■ November/December 2013 641
Copyright © 2013 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
WON200520.indd 641
29/10/13 7:32 PM
642
Irkoren et al
FIGURE 1. After removal of VAC dressing, sacrococcygeal re-
gion showed a nonhealing tissue defect, distinct redness, and hyperthermia of this region, and a strong putrid smell.
rotational flaps (Figure 2). The pathological findings demonstrated well-differentiated SCC with clear skin margins, but there was still tumor invasion to bone margins. Following a further wide local excision, a course of radiotherapy of 5400 rad was given in divided doses over 6 weeks.
■ Discussion The etiology of pilonidal disease is not entirely understood, but the most accepted pathogenesis includes loose hairs
FIGURE 2. Intraoperative image.
J WOCN
■ November/December 2013
invading into subcutaneous cysts, aggravating infection, and a leading to a foreign body reaction.1-3 Simple excision of the pilonidal cyst (the tract is laid open to allow healing by secondary intention), curettage, brushing (excision of midline epithelial follicles under local anesthesia and passing a small brush in the track to remove hair within the granulation-lined track), or phenol injection may be used to ablate the sinus. These simple techniques seem to be favorable, but they may require significant healing time and they are associated with a significant recurrence rate.4 Other treatment options include primary closure, marsupialization (excision of the pilonidal sinus, cavity, and lateral tracts; the cavity is then scrubbed and curetted to remove hair and granulation tissue with suturing of the skin edges to the presacral fascia) or leaving the wound open to heal by secondary intention.2,3 Excision with an open wound involves prolonged hospitalization or clinic attendance for multiple dressing changes and may take months to heal. The most generally accepted technique is midline excision with primary closure, this intervention comprises approximately half of all procedures for excision of pilonidal cysts. Malignant degeneration arises in approximately 0.1% of chronic pilonidal disease patients. Preoperative evaluation of patients with carcinoma arising from pilonidal disease includes a thorough physical examination of the inguinal area of the perineum and anus. Patients will require sigmoidoscopy and barium enema to rule out tumor invasion. Abdominal and pelvic computed tomography is beneficial to detect abdominal metastasis and spreading to the para-aortic lymph nodes.1-3 The treatment of choice, if SCC is found or suspected, remains wide excision of the lesion with tumor-free margins including skin, subcutaneous tissue, muscle, and, if indicated, portions of the sacrum and coccyx. Skin grafts and vascularized flaps can be used to close larger tissue defects. Radiotherapy is recommended; it has been shown to decreasing local recurrence by 30%. Radiotherapy should be administered with wide margins as a consequence of the ill-defined extent of the tumor.1-3 Negative pressure wound therapy has been demonstrated to have a positive effect on the healing of surgical wounds of pilonidal sinus in several studies when SCC is not present.5,6 Negative pressure wound therapy involves placement of an open-cell polyurethane foam into the wound, sealing, and then vacuuming to provide subatmospheric pressure. Wound healing is promoted by removal of excess fluid at the wound site which increases blood flow and oxygen delivery to the wound, removal of inflammatory factors, and decreases bacterial colonization.7 The most common complication of NPWT therapy is skin irritation; rare complications are anasarca, arterial erosion, and toxic shock syndrome.5,6 Malignant degeneration of a surgical wound related to pilonidal disease being treated with NPWT has never been described before. Generally, continuous vacuum therapy dressings are left in place for 2 to 3 days.5,6
Copyright © 2013 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
WON200520.indd 642
29/10/13 7:32 PM
J WOCN ■ Volume 40/Number 6
Irkoren et al
Outcomes of this case study suggest that uncritical use of NPWT may have deleterious consequences. Limiting dressing changes to every 5 days in the surgical wound of a pilonidal sinus can cover signs of malignant degeneration. The NPWT technique is safe, easy, and effective in surgical wound care management. However, the rare complication described in this case study should be kept in mind. The relationship between malignant degeneration and NPWT remains unknown. Squamous cell carcinoma may be associated with the vacuum system, which increases blood flow not only to healing cells but also to neoplastic cells. If feasible, similar cases should be examined with changing NPWT dressing every 2 to 3 days, which is consistent with the current standard of care, in order to inspect any changes in the wound or surrounding tissue, and when a suspected lesion or delayed wound healing is noticed, incisional biopsy should be performed immediately.
■ Conclusion Wounds managed by NPWT should be monitored carefully for malignancy at the time of dressing changes. Prompt recognition of this rare complication can lead to
643
rapid diagnosis and management reducing associated morbidity and the potential risk of mortality.
■ References 1. Malek MM, Emanuel PO, Divino CM. Malignant degeneration of pilonidal disease in an immunosuppressed patient: report of a case and review of the literature. Dis Colon Rectum. 2007;50: 1475-1477. 2. Chatzis I, Noussios G, Katsourakis A, Chatzitheoklitos E. Squamous cell carcinoma related to long standing pilonidaldisease. Eur J Dermatol. 2009;19:408-409. 3. Citak M, Backhaus M, Meindl R, Muhr G, Fehmer T. Rare complication after VAC-therapy in the treatment of deep sore ulcers in a paraplegic patient. Arch Orthop Trauma Surg. 2010;130: 1511-1514. 4. Nessar G, Kayaalp C, Seven C. Elliptical rotation flap for pilonidal sinus. Am J Surg. 2004;187(2):300-303. 5. Kiessling AH, Lehmann A, Isgro F, Moritz A. Tremendous bleeding complication after vacuum-assisted sternal closure. J Cardiothorac Surg. 2011;9:16. 6. Farrell D, Murphy S. Negative pressure wound therapy for recurrent pilonidal disease: a review of the literature. J Wound Ostomy Continence Nurs. 2011;38:373-378. 7. Baharestani MM. Negative pressure wound therapy: an examination of cost-effectiveness. Ostomy Wound Manage. 2004;50(11A) (suppl):29S-33S. Review.
Call for Authors: Challenges in Practice Our Challenges in Practice Section Editor invites case studies or multiple cases series that illustrate the importance of critical thinking or provide alternative or novel approaches to WOC management. This section is ideal for the novice author who has not published platform articles in JWOCN or other journals. Potential cases discussed on the WOC Web Forum that would translate into excellent Challenges in Practice articles include: • Perineal erythema in a frail elderly patient nonresponsive to urinary stream diversion with an indwelling catheter • Rationale for selecting a particular debriding technique based on wound type, care setting, and expertise within the facility • Case studies or case series focusing on initial experiences with novel mattresses, wound care dressings, wound care devices, or other topical wound care therapies • Case studies or case series focusing on unusual stomal or peristomal complications
Copyright © 2013 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
WON200520.indd 643
29/10/13 7:32 PM
