Applications of endoscopic vacuum therapy in the lower gastrointestinal tract: Tips and tricks and a review of the literature.

Endoscopic vacuum therapy (EVT) is an established technique for the treatment of rectal wall defects and especially anastomotic leaks. A wide range of EVT devices, both handmade and commercially available, allow for their successful placement even in small defects and difficult localizations. Reported success rates range between 85 and 97 %, while periintervenional morbidity is low and major adverse events are very rare. EVT has proven its effectiveness in the lower gastrointestinal tract and is now considered first line treatment for pelvic anastomotic leaks. This narrative review summarizes the current literature on EVT in the lower gastrointestinal tract, focusing on its indications, technical aspects and results, and offers tips and tricks for its clinical applications.

Is Staged Surgery Always Necessary for Schatzker Type IV-VI Tibial Plateau Fractures? A Comparison Study.

AIMS: This study aims to compare the outcomes of immediate (followed by closed-incision negative-pressure therapy use) versus delayed ORIF in patients with Schatzker type IV-VI TPFs. PATIENTS AND METHODS: A prospective study of patients undergoing ORIF between January 2018 and December 2019 was performed. The inclusion criteria were patients (>18 years) with a closed fracture sent to the emergency room (ER) within 24 h of injury. All the patients underwent preoperative image evaluation. Two senior orthopedic trauma surgeons evaluated the soft tissue condition in the ER by 5P's of the compartment syndrome, judging the timing of the operation of definitive ORIF. Group 1 (n = 16) received delayed ORIF. Group 2 (n = 16) received immediate ORIF and ciNPT use. Patient follow-up occurred after 2 and 6 weeks and 3, 6, and 12 months after surgery. The assessments included the time to definitive fixation, the length of hospital stay, the time to bone union, surgical site complications, and reoperation within 12 months. A universal goniometer was used to measure the postoperative 3 m, 6 m, and 12 m ROM. RESULTS: The patient demographics were similar between the groups (p > 0.05). Group 2 displayed significantly a shorter time to definitive fixation (5.94 ± 2.02 vs. 0.61 ± 0.28, p < 0.0001) and hospital stay (14.90 ± 8/78 vs. 10.30 ± 6.78, p = 0.0016). No significant difference was observed in the time to bone union, surgical site complication incidence, and reoperation rates (p > 0.05). Flexion and flexion-extension knee ROM were demonstrated to be significantly improved in Group 2, 3, 6, and 12 months postoperatively (p < 0.0001). CONCLUSIONS: In this study, early ORIF and ciNPT use resulted in a shorter hospital length of stay, a reduced time to early active motion of the knee, and improved knee ROM. These results suggest that early ORIF with ciNPT for Schatzker type IV-VI TPFs is safe and effective in some patients. However, further research to confirm these findings across larger and more diverse populations is needed.

Medicine's Glass Slipper: The PAVAEX Boot and 20th Century Negative Pressure Therapy.

Before the 20th century, peripheral artery disease (PAD) manifested as extreme pain, chronic wounds, and, eventually, gangrene requiring amputation. Despite this, it was rarely diagnosed. However, at the turn of the century, Western medicine shifted focus from infectious to chronic illnesses, and with this change, physicians' engagement with PAD transformed. Aiming to mitigate long-term injury, physicians now worked to identify and treat vessel disease to restore meaningful blood circulation. This article explores the development and deployment of a new device resulting from this refocus, the PAssive VAscular EXerciser (PAVAEX) Boot, and its role as a creative response to a previously intractable clinical problem. The PAVAEX Boot, designed in 1933 by vascular surgeons Louis G. Herrmann and Mont R. Reid, was one of the few interventions for PAD at the time. Based on the observation that continuous negative pressure results in vasoconstriction, while short bursts transiently increase blood flow, the PAVAEX Boot utilized intermittent negative pressure to enhance peripheral vascular perfusion. Well-marketed and praised throughout the 1930s, it vanished from public writing and academic literature just 20 years later. However, negative pressure wound therapy resurged in the late 20th century, and though its inventors failed to recognize the precedent of the PAVAEX Boot, many of these devices and therapies are rooted in identical theories. We examine why the PAVAEX Boot faded from use and argue that the device remains a crucial advancement in negative pressure therapy.

[Vacuum-assisted laparostomy for advanced peritonitisis]. / Rol' vakuum-assistirovannoi laparostomy v lechenii rasprostranennogo peritonita.

OBJECTIVE: To evaluate the efficacy of negative pressure therapy in patients with peritonitis. MATERIAL AND METHODS: The study included 127 patients with advanced secondary peritonitis between 2019 and 2022. All patients were divided into 2 groups. All ones underwent staged sanitation of the abdominal cavity. In the first group (n=76), re-laparotomies were accompanied by skin suture only and passive abdominal drainage. The second group included patients (n=51) with open abdominal cavity strategy and negative pressure therapy (vacuum-assisted laparostomy). We analyzed the number of surgeries, postoperative complications, duration of hospital-stay and mortality. RESULTS: In the second group, there were significantly lower morbidity, mean number of surgeries and hospital-stay. In addition, incidence of fascial closure of abdominal cavity was higher and mortality rate was lower in the same group. CONCLUSION: Vacuum-assisted laparostomy in patients with advanced peritonitis can reduce the number of secondary purulent complications and mortality, as well as increase the incidence of fascial closure of abdominal cavity. This approach reduces the number of surgical interventions and duration of in-hospital treatment.

Closed-incision negative pressure therapy as a strategy to reduce sternal wound infection in identified high-risk patients: a multicentre propensity matched study.

OBJECTIVES: The premise of this retrospective study was to evaluate the intraoperative use of closed-incision negative pressure therapy (ciNPT) to help reduce the incidence of postoperative sternal wound infections in multimorbid patients with an elevated risk of developing a sternal wound infection post cardiac surgery versus a cohort that received standard-of-care dressings. METHODS: Data for all adult patients were collected from each cardiothoracic surgery unit across 3 hospitals in the United Kingdom. High-risk patients had 2 or more recognized risk factors. Fisher's exact test (two-tailed) and unpaired t-test were used to help analyse categorical and continuous data. Propensity matching was performed to compare the 2 groups. RESULTS: A total of 5,288 patients who had cardiac surgery were included. Propensity matching led to 766 matched cases. There were significantly fewer sternal wound infections in the ciNPT group [43 (5.6%) vs 119 (15.5%) cases; P = 0.0001], as well as fewer deep sternal wound infections [14 (1.8%) vs 31 (4.0%) cases; P = 0.0149] and superficial sternal wound infections [29 (3.8%) vs 88 (11.4%) cases; P = 0.0001]. A higher mean length of stay in the ciNPT group was statistically significant (11.23 ± 13 vs 9.66 ± 10 days; P = 0.0083) as was a significantly higher mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) (11.143 ± 13 vs 8.094 ± 11; P = 0.0001). A statistically significant higher readmission to the intensive care unit due to sternal wound infection was noted for the controls [16 (2.08%) vs 3 (0.39%) readmissions; P = 0.0042]. CONCLUSIONS: The ciNPT appears to be an effective intervention to help reduce the incidence of sternal wound infection in high-risk individuals undergoing cardiac surgery.

The Effects of Negative Pressure Therapy on Hair Growth of Mouse Models.

Negative pressure therapy (NPT) has been shown to facilitate wound healing and promote hair growth in a porcine model. However, there is a paucity of research on the impact of negative pressure on hair growth in murine models. Despite the ability of nude mice to develop hair follicles, the hair they produce is often flawed towing to genetically induced keratin disorders, rendering them a pertinent animal model for assessing hair regeneration. Therefore, this study aims to investigate the effects of negative pressure on hair follicle growth in a nude mouse model. To achieve this, a customized external tissue expansion device was developed to apply negative pressure to the dorsum of nude mice. The mice were subjected to several treatment courses consisting of 15 and 30 min of continuous negative pressure at 10 mmHg, which were repeated 5 and 10 times every other day until sacrifice. Dorsal skin samples were subsequently extracted from the suction and nonsuction areas. The sections were stained with various antibodies to assess the expression of SOX-9, LHX-2, Keratin-15, ß-catenin, CD31, and vascular endothelial growth factor-A, and a TUNEL assay was used to analyze cell apoptosis. The results showed that the number of hair follicles and angiogenesis were significantly higher in the suction area than in the nonsuction area in all groups. Moreover, mice that received NPT for 15 min for 10 times had a higher hair follicle density than the other three groups. Immunofluorescence staining for LHX-2 and Keratin 15 further validated the results of these findings. In conclusion, this study demonstrated that negative pressure effectively promotes hair follicle growth and angiogenesis in nude mice through SOX-9- and LHX-2-mediated follicular regeneration and ß-catenin-mediated hair follicle morphogenesis.

PROphylactic closed incision Negative-PRESSure treatment in open incisional hernia repair: Protocol for a multicenter randomized trial (PROPRESS study).

Background: Negative Pressure Therapy in closed incisions (ciNPT) after surgery has shown positive effects including reduction of Surgical Site Infection (SSI) incidence. In patients undergoing elective open incisional hernia repair, however, ciNPT is not standard care, perhaps due to high-quality evidence still not provided. This study hypothesizes that this patient group would benefit from ciNPT by reducing wound complications and improving postoperative quality of life. Method: This is a multicenter Randomized Controlled Trial (RCT) including a total of 110 patients allocated in a 1:1 ratio with one intervention arm and one active control arm receiving ciNPT (i.e., Prevena™) and standard wound dressing, respectively. The primary outcome is the incidence of SSI at 30 days postoperatively and secondary outcomes are 1) pooled incidence of Surgical Site Occurrence (SSO), 2) patient-reported pain and satisfaction with the scar, and 3) hernia-related quality of life. Conclusion: Patients undergoing elective open incisional hernia repair are fragile with a high risk of wound complication development. This multicenter RCT seeks to deliver the high-quality evidence needed to establish the role ciNPT must play for exactly this group with the aim of reducing SSI incidence and health economic costs, and finally improving quality of life. There are no theoretical or clinical experience of unwanted consequences of this treatment.

Negative pressure therapy for ECMO cannula stabilization.

Cannula stabilization for extracorporeal membrane oxygenation (ECMO) is important for patient mobilization and rehabilitation. Limitations to mobilization on ECMO include staff discomfort and cannula instability. We utilized the technique of negative pressure therapy for ECMO cannula stabilization to improve mobilization. Negative pressure therapy for ECMO cannula stabilization can be utilized safely for a variety of cannulation sites in any patient age from newborns to adults. This wound management strategy may facilitate patient mobilization and rehabilitation therapies in addition to extending cannula site duration.

The Role of Open-Pore Film Drainage Systems in Endoscopic Vacuum Therapy: Current Status and Review of the Literature.

Background: Endoscopic vacuum therapy (EVT) is an increasingly popular endoscopic technique used for the treatment of wall defects in the gastrointestinal tract. Open-pore film drainage (OFD) systems are a new addition to the armamentarium of EVT and have shown encouraging results in a wide spectrum of applications. The aim of this review is to summarize the current literature on the applications of OFD systems in the gastrointestinal tract. Summary: Open-pore film drainage (OFD) systems have been used for the treatment of several defects of the gastrointestinal tract. The small size and easy placement of these devices make them very useful, particularly for the treatment of defects that are small in size or difficult to reach. OFDs have been successfully used for both perforations and anastomotic leaks in various locations, with most reports focusing on the treatment of duodenal defects, although successful applications in the esophagus, stomach, and colon have also been reported. Lately, the role of OFDs in preemptive EVT has also been explored. Key Messages: OFD systems are easy to use, particularly for small defects and challenging localizations. The current literature, consisting mainly of small case series and case reports, shows encouraging results, but further prospective studies are needed to explore and verify the indications and technical aspects of this innovative method.

Preclinical Assessments of a Novel Peel and Place Extended-Wear Negative-Pressure Wound Therapy Dressing for up to 35 Days in a Porcine Model.

Objective: While the use of negative pressure wound therapy (NPWT) with reticulated open cell foam (ROCF) is well established, the characteristics of ROCF do not allow for extended-wear use. There is the potential for dressing tissue ingrowth if left in place for greater than the recommended 2-3 days. An easy to use, novel peel and place dressing has been designed for extended wear with the wound management advantages of ROCF while alleviating the challenges of tissue ingrowth. Approach: Paraspinal, full-thickness or deep muscle excisional wounds were created in 11 and 2 swine, respectively, dressings applied with continuous negative pressure at -125 mmHg, and dressings changed weekly. Full-thickness excisional wounds were treated for 13 days and deep muscle wounds for 35 days. Wound dimensions were assessed. Granulation tissue thickness and re-epithelialization were measured via digital morphometry. Tissue quality, fibrinous material prevalence, and dressing removal peel force were analyzed. Results: The peel and place dressing substantially reduces dressing tissue ingrowth, is easy to remove with markedly low dressing peel force and promotes more granulation tissue at day 13 than ROCF with an interface layer. The extended-wear peel and place dressing, when applied to deep muscle wounds with weekly dressing changes, was applied for a total of 35 days. Successful wound closure was evident without any negative impact on wound healing. Innovation: This study assessed the wound management capabilities of an extended-wear peel and place NPWT dressing used until wound closure. Conclusion: The peel and place dressing is a suitable extended-wear NPWT dressing.

Endoscopic Vacuum-Assisted Closure (E-VAC) in Septic Shock from Perforated Duodenal Ulcers with Abscess Formations.

This case report underscores the importance of utilizing E-VAC (endoscopic vacuum-assisted closure) in the treatment of a perforated duodenal ulcer complicated by the formation of a subphrenic abscess and septic shock. It showcases how E-VAC can effectively mitigate the risk of further complications, such as leakage, bleeding, or rupture, which are more commonly associated with traditional methods like stents, clips, or sutures. As a result, there is a significant reduction in mortality rates. A perforated duodenal ulcer accompanied by abscess formation represents a critical medical condition that demands prompt surgical intervention. The choice of the method for abscess drainage and perforation closure plays a pivotal role in determining the patient's chances of survival. Notably, in patients with a high ASA (American Association of Anesthesiologists) score of IV-V, the mortality rate following conventional surgical intervention is considerably elevated. The management of perforated duodenal ulcers has evolved from open abdominal surgical procedures, which were associated with high mortality rates and risk of suture repair leakage, to minimally invasive techniques like laparoscopy and ingestible robots. Previously, complications arising from peptic ulcers, such as perforations, leaks, and fistulas, were primarily addressed through surgical and conservative treatments. However, over the past two decades, the medical community has shifted towards employing endoscopic closure techniques, including stents, clips, and E-VAC. E-VAC, in particular, has shown promising outcomes by promoting rapid and consistent healing. This case report presents the clinical scenario of a patient diagnosed with septic shock due to a perforated duodenal ulcer with abscess formation. Following an exploratory laparotomy that confirmed the presence of a subphrenic abscess, three drainage tubes were utilized to evacuate it. Subsequently, E-VAC therapy was initiated, with the kit being replaced three times during the recovery period. The patient exhibited favorable progress, including weight gain, and was ultimately discharged as fully recovered. In the treatment of patients with duodenal perforated ulcers and associated abscess formation, the successful and comprehensive drainage of the abscess, coupled with the closure of the perforation, emerges as a pivotal factor influencing the patient's healing process. The positive outcomes observed in these patients underscore the efficacy of employing a negative pressure E-VAC kit, resulting in thorough drainage, rapid patient recovery, and low mortality rates.

[Local administration of amphotericin B by VAC instillation: Therapeutic aid in the treatment of mucormycosis]. / Application locale d'amphotéricine B par VAC instillation : aide thérapeutique dans le traitement de la mucormycose.

Mucormycosis is a rare and serious fungal infection, occurring mainly in immunocompromised, diabetic, polytrauma or burn patients. Current standard treatments include iterative carcinological surgical trimming, systemic treatment with liposomal amphotericin B and second-line Posaconazole or Isavuconazole. We report the case of a 37-year-old female patient with no previous medical history who developed a disseminated mucormycosis, with an estimated 25 % loss of skin substance and major decay of the chest wall. In addition to standard treatment, local instillations of amphotericin B using the VAC Veraflow® system were performed. We believe that local instillations of amphotericin B by VAC could improve the functional prognosis of patients with skin involvement.

Patient experiences of closed-incision negative pressure therapy on groin incisions after discharge following peripheral arterial surgery: A qualitative study.

BACKGROUND: Closed-incision negative pressure therapy may lower the risk of surgical site infections in patients after peripheral arterial surgery. AIM: To explore patient experience of negative pressure therapy applied to groin incisions after discharge following peripheral arterial surgery, and to study their perception and attitudes toward the self-care information sheet they received at the vascular department. METHODS: A qualitative study underpinned by Gadamer's philosophical hermeneutics was conducted semi-structured interviews by telephone around day seven after therapy ended with ten participants. All had received self-care information sheet at the discharge and been home with closed-incision negative pressure therapy for 3-6 days. The participants had open peripheral arterial surgery in the groin in form of femoral thromboendarterectomy. Kvale and Brinkmann's research guided the data collection, analysis, and interpretation. FINDINGS: Patients found themselves coping with an unfamiliar situation after peripheral arterial surgery and the need arose to conceal the pump and tubing that were part of their incision treatment to protect their self-image. Their treatment became a constant companion, with some patients viewing the equipment as an extension of their bodies and others feeling its impact on activities of daily living. Patients perceived the treatment as providing reassurance, albeit with constraints, leading to feelings of manageability and an increasing sense of control. They viewed the written information as informative but with room for improvement. CONCLUSIONS: Patient experiences of closed-incision negative pressure therapy on groin incisions after discharge following peripheral arterial surgery showed that they perceived it as safe and manageable. Patients need support, however, in learning how to hide the treatment and to expand their own involvement and improve self-care. The study found that patient involvement and individually tailored information is essential to facilitating a healthy transition from hospital to self-care at home and that written information must be improved further.

Enteroatmospheric fistulas in open abdomen in trauma associated with abdominal reintervention and VAC therapy.

BACKGROUND: Open abdomen is an alternative for the management of trauma patient, and negative pressure therapy of the wound using VAC® device is a genuine sort of treatment. Although the device poses technical advantages, risks are present and a critical complication is the enteroatmospheric fistula formation (EAF). OBJECTIVE: To analize the role of negative pressure therapy length and VAC® device number of changes on the EAF formation in trauma patients udergoing open abdomen. METHOD: Cut-off points were calculated using receiver operational characteristics curve. Values were compared with Student's t or Mann-Withney U tests, considering statistically significant p < 0.05. RESULTS: EAF were present in 39 cases (5.9%). A significant difference in the presence of EAF was present in patients with negative pressure therapy of the wound length ≥ 11.2 days (46.9 vs. 1.3%; relative risk [RR]: 3.67; 95% confidence interval [95% IC]: 2.4-6.68; p = 0.017) and when ≥ 2.6 VAC® device changes were performed (34.6 vs. 0.5%; RR: 6.92; 95% IC: 1.1-4.3; p < 0.001). CONCLUSIONS: At our institution, the practice of >3 VAC® device changes and length of therapy > 11 days should be carefully considered leading to reduce the risk of EAF formation.

INTRODUCCIÓN: El abdomen abierto es una alternativa para manejar al paciente traumatizado, y una variante para instituirlo es la terapia de presión negativa de la herida con el dispositivo VAC®. Aunque tiene ventajas técnicas, no está exento de riesgos y una complicación crítica es la formación de fístulas enteroatmosféricas (FEA). OBJETIVO: Analizar el papel de la duración de la terapia de presión negativa y del número de cambios del dispositivo VAC® sobre la aparición de FEA en pacientes traumatizados manejados con abdomen abierto. MÉTODO: Se establecieron puntos de corte con curva de características operacionales del receptor. Los valores se compararon con la prueba t de Student o U de Mann-Whitney, considerando p < 0.05 como valor estadísticamente significativo. RESULTADOS: La FEA se presentó en 39 casos (5.9%). Hubo una diferencia significativa en la aparición de FEA en pacientes con duración de la terapia de presión negativa de la herida ≥ 11.2 días (46.9 vs 1.3%; riesgo relativo [RR]: 3.67; intervalo de confianza del 95% [IC95%]: 2.4-6.68; p = 0.017) y cuando se practicaron ≥ 2.6 cambios del dispositivo VAC® (34.6 vs. 0.5%; RR: 6.92; IC95%: 1.1-4.3; p < 0.001). CONCLUSIONES: En nuestra institución, la práctica de más de tres cambios del dispositivo VAC® y el mantenimiento de la terapia por más de 11 días debe ser cuidadosamente considerado para reducir el riesgo de formación de FEA.

Treatment of Complex Thoracic and Abdominal Trauma Patients: A Review of Literature and Negative Pressure Wound Therapy Treatment Options.

Significance: In trauma care, extensive surgical intervention may be required. Damage control surgery (DCS) is applicable to patients with life or limb-threatening conditions that are incapable of tolerating a traditional surgical approach. Recent Advances: The current resuscitation strategy for complex trauma patients includes limiting crystalloid fluids, balanced mass transfusion protocols, permissive hypotension, and damage control resuscitation. Recent technological advancements in surgical critical care have improved outcomes in these critically ill patients. Critical Issues: DCS, which is often required in patients with trauma injuries, is typically followed by surgical correction of the injury once the immediate patient survival procedures have been completed. However, DCS and the subsequent injury repair procedures have a high risk for postsurgical complication development. Future Directions: Negative pressure therapy modalities can offer clinicians additional adjunctive and cost-effective tools for the management of the trauma care patient, as these systems can be utilized during both the DCS and the postoperative injury management phases of trauma care.

Transnasal negative pressure therapy for accelerating healing and improving the prognosis of pharyngocutaneous fistula.

BACKGROUND: Pharyngocutaneous fistula (PCF) is one of the most common complications of total laryngectomy. This study is to investigate the efficacy of a novel platform called transnasal negative pressure therapy (TNPT) in the management of PCF. METHODS: We retrospectively reviewed 47 patients who underwent total laryngectomy between April 2015 and February 2021 and developed PCF in our hospital. We focused on the healing rate, dressing change frequency, and healing time between the TNPT and non-TNPT groups. The 2 years overall survival (OS) was compared through the log-rank test. RESULTS: There were 18 patients in the TNPT group and 29 in the non-TNPT group. There was no significant between-group difference in the healing rate (chi-square test). However, the frequency of dressing changes was significantly lower (p < 0.001) and the healing time was significantly shorter (p = 0.0194) in the TNPT group than in the non-TNPT group. The 2-year OS rate was significantly higher in the TNPT group (p = 0.0473, log-rank test). CONCLUSION: TNPT promoted wound healing after surgery for PCF and improved the 2-year OS rate. This tool is worthy of clinical application and promotion.

Management of Anastomotic Leakage after Colorectal Resection: Survey among the German CHIR-Net Centers.

(1) Background: A widely accepted algorithm for the management of colorectal anastomotic leakage (CAL) is difficult to establish. The present study aimed to evaluate the current clinical practice on the management of CAL among the German CHIR-Net centers. (2) Methods: An online survey of 38 questions was prepared using the International Study Group of Rectal Cancer (ISREC) grading score of CAL combined with both patient- and surgery-related factors. All CHIR-Net centers received a link to the online questionary in February 2020. (3) Results: Most of the answering centers (55%) were academic hospitals (41%). Only half of them use the ISREC definition and grading for the management of CAL. A preference towards grade B management (no surgical intervention) of CAL was observed in both young and fit as well as elderly and/or frail patients with deviating ostomy and non-ischemic anastomosis. Elderly and/or frail patients without fecal diversion are generally treated as grade C leakage (surgical intervention). A grade C management of CAL is preferred in case of ischemic bowel, irrespective of the presence of an ostomy. Within grade C management, the intestinal continuity is preserved in a subgroup of patients with non-ischemic bowel, with or without ostomy, or young and fit patients with ischemic bowel under ostomy protection. (4) Conclusions: There is no generally accepted therapy algorithm for CAL management within CHIR-Net Centers in Germany. Further effort should be made to increase the application of the ISREC definition and grading of CAL in clinical practice.

Sistema de presión negativa en loxoscelismo cutáneo-visceral. Reporte de un caso

Introducción: Las mordeduras por araña parda pueden manifestarse desde una simple lesión dérmica en el área de la mordedura, hasta formas graves, con falla orgánica múltiple. Caso Clínico: presentamos el caso de una paciente con mordedura por araña parda, quien presenta inicialmente lesiones dérmicas sin necrosis, evolucionando con áreas de necrosis y el desarrollo de síndrome compartimental de extremidad, sepsis, choque séptico y falla renal. Mejora tras manejo intensivo, anti veneno y colocación de terapia de presión negativa (TPN) en herida, conservando la extremidad afectada integra y recuperando la función renal. Discusion: Este caso en particular presenta los tres tipos de manifestaciones que se generan en el loxoscelismo, las cuales son una forma de presentación poco frecuente. El tratamiento con TPN se ha introducido como una terapia poderosa, no farmacológica para ayudar a acelerar el proceso de cicatrización de heridas y puede ser de utilidad en pacientes con mordedura de araña (loxoscelismo).

Introduction: The brown spider bites have the peculiarity of manifesting from a simple skin lesion in the area of the bite, to severe forms, with multiple organic failure. Clinical Case: We present the case of a patient with a brown spider bite, initially presenting dermal lesions without necrosis, evolving with areas of necrosis and the development of compartment syndrome of extremities, sepsis, septic shock and renal failure. Improvement after intensive management and installation in negative pressure therapy wound (NPT), keeping the affected limb integrated and recovering renal function. Discussion: This case in particular presents the three types of manifestations that are generated in loxoscelism, which are a rare form of presentation. The NPT treatment has been introduced as a powerful, non-pharmacological and physical therapy to help accelerate the wound healing process and may be useful in patients with spider bites.

Applications of endoscopic vacuum therapy in the upper gastrointestinal tract.

Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the "piggyback" technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.