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Biosurgical Debridement Facilitates Healing of Chronic Skin Ulcers

Biosurgical Debridement Facilitates Healing of Chronic Skin Ulcers Wound infection and retention of collagenous debris often impede the healing of chronic skin ulcers. We cultivated the fly species Lucilia sericata and used live larvae to debride the ulcer ground of necrotic tissue in 6 cases of refractory skin ulcers. Biosurgery by larvae is a feasible and effective approach for cleansing debris and microbial infestation. Chronic skin ulcers represent a major problem in health care. Before surgical intervention or skin grafting, the ulcers have to be clean in terms both of collagenous debris and of bacterial overgrowth. An interesting alternative to the often ineffective use of fibrinolytic and collagenolytic enzyme preparations1-3 is the application of living fly maggots.4 Larvae of certain fly species digest all necrotic material, but never damage living tissue.5 This application has been termed biosurgery. We describe a case series of 6 patients in whom biosurgery either served as an essential preparation for skin grafting or eliminated the need for surgical intervention at all. To provide a constant supply of live larvae, we temporarily established a simple insectary for the cultivation of L sericata.4 Harvested eggs were soaked in 1% sodium sulfite and in 5% formalin. After being rinsed in sterile saline, the eggs were placed in a sterile flask containing agar with 5% sheep blood to reach their second instar. Sterility was verified by incubating eggs and larvae on trypticase soy agar for 48 hours. After the deposition of 10 maggots per square centimeter, a hydrocolloid dressing (Varihesive Gel Control; ConvaTec, Bristol Meyers Squibb Inc, Princeton, NJ) was applied and fixed with sterile netting.6 The wound dressing was inspected every 6 hours, and excessive fluid was removed. The treatment lasted for 48 hours; thereafter, the maggots were rinsed off with saline. All patients gave written informed consent to the procedure. Within 9 months, we applied maggot therapy to 6 patients (Table 1). The method is painless and was well tolerated by our patients, who just reported some tickling sensations. We found that running a small, low-cost insectary for rearing medical maggots is relatively simple but very time consuming. However, sterile live maggots are also available from international commercial sources. The exact mechanisms of maggot therapy are known only in part; they include enzymatic liquefaction and ingestion of necrotic tissue and destruction of bacteria.7,8 Moreover, the secretions of the maggots can act as tissue growth factors and thus increase the effectiveness of the method.8,9 Biosurgery was very effective in our study (Figure 1 and Figure 2), and its effectiveness was also recently demonstrated in a study involving the treatment of venous ulcers.10 While modern approaches to ulcer management, eg, vacuum-assisted wound closure, are very effective for the treatment of difficult ulcers, they do not provide primary debridement of wound material.11 It appears that ulcer debridement by biosurgery is a feasible, safe, and probably cost-effective approach. View LargeDownload Characteristics of Patients and Outcome of Maggot Debridement Therapy (MDT) Figure 1. View LargeDownload Sloughy ulcer before (A), 48 hours after (B), and 10 weeks after (C) maggot therapy. Figure 2. View LargeDownload Biosurgery cleans wound debris without affecting vital structures (note vena saphena magna crossing the wound field). Ulcer on the distal aspect of the lower part of the leg before (A) and 48 hours after (B) maggot therapy. References 1. Falabella AFCarson PEaglstein WHFalanga V The safety and efficacy of a proteolytic ointment in the treatment of chronic ulcers of the lower extremity. J Am Acad Dermatol. 1998;39737- 740Google ScholarCrossref 2. Mekkes JRZeegelaar JEWesterhof W Quantitative and objective evaluation of wound debriding properties of collagenase and fibrinolysin/desoxyribonuclease in a necrotic ulcer animal model. Arch Dermatol Res. 1998;290152- 157Google ScholarCrossref 3. Mosher BACuddigan JThomas DRBoudreau DM Outcomes of 4 methods of debridement using a decision analysis methodology. Adv Wound Care. 1999;1281- 88Google Scholar 4. Sherman RAPechter EA Maggot therapy: a review of the therapeutic applications of fly larvae in human medicine, especially for treating osteomyelitis. Med Vet Entomol. 1988;2225- 230Google ScholarCrossref 5. Young T Maggot therapy in wound management. Community Nurse. 1997;343- 45Google Scholar 6. Sherman RA A new dressing design for use with maggot therapy. Plast Reconstr Surg. 1997;100451- 456Google ScholarCrossref 7. Vistnes LMLee RKsander GA Proteolytic activity of blowfly larvae secretions in experimental burns. Surgery. 1981;90835- 841Google Scholar 8. Sherman RAHall MJRThomas S Medicinal maggots: an ancient remedy for some contemporary afflictions. Annu Rev Entomol. 2000;4555- 81Google ScholarCrossref 9. Prete P Growth effects of Phaenicia sericata larval extracts on fibroblasts: mechanism for wound healing by maggot therapy. Life Sci. 1997;60505- 510Google ScholarCrossref 10. Wayman KNirojogi VWalker ASowinski AWalker MA The cost-effectiveness of larval therapy in venous ulcers. J Tissue Viability. 2000;1091- 96Google Scholar 11. Webb LXSchmidt U Wound management with vacuum therapy. Unfallchirurg. 2001;104918- 926Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

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Publisher
American Medical Association
Copyright
Copyright © 2002 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.162.16.1906
Publisher site
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Abstract

Wound infection and retention of collagenous debris often impede the healing of chronic skin ulcers. We cultivated the fly species Lucilia sericata and used live larvae to debride the ulcer ground of necrotic tissue in 6 cases of refractory skin ulcers. Biosurgery by larvae is a feasible and effective approach for cleansing debris and microbial infestation. Chronic skin ulcers represent a major problem in health care. Before surgical intervention or skin grafting, the ulcers have to be clean in terms both of collagenous debris and of bacterial overgrowth. An interesting alternative to the often ineffective use of fibrinolytic and collagenolytic enzyme preparations1-3 is the application of living fly maggots.4 Larvae of certain fly species digest all necrotic material, but never damage living tissue.5 This application has been termed biosurgery. We describe a case series of 6 patients in whom biosurgery either served as an essential preparation for skin grafting or eliminated the need for surgical intervention at all. To provide a constant supply of live larvae, we temporarily established a simple insectary for the cultivation of L sericata.4 Harvested eggs were soaked in 1% sodium sulfite and in 5% formalin. After being rinsed in sterile saline, the eggs were placed in a sterile flask containing agar with 5% sheep blood to reach their second instar. Sterility was verified by incubating eggs and larvae on trypticase soy agar for 48 hours. After the deposition of 10 maggots per square centimeter, a hydrocolloid dressing (Varihesive Gel Control; ConvaTec, Bristol Meyers Squibb Inc, Princeton, NJ) was applied and fixed with sterile netting.6 The wound dressing was inspected every 6 hours, and excessive fluid was removed. The treatment lasted for 48 hours; thereafter, the maggots were rinsed off with saline. All patients gave written informed consent to the procedure. Within 9 months, we applied maggot therapy to 6 patients (Table 1). The method is painless and was well tolerated by our patients, who just reported some tickling sensations. We found that running a small, low-cost insectary for rearing medical maggots is relatively simple but very time consuming. However, sterile live maggots are also available from international commercial sources. The exact mechanisms of maggot therapy are known only in part; they include enzymatic liquefaction and ingestion of necrotic tissue and destruction of bacteria.7,8 Moreover, the secretions of the maggots can act as tissue growth factors and thus increase the effectiveness of the method.8,9 Biosurgery was very effective in our study (Figure 1 and Figure 2), and its effectiveness was also recently demonstrated in a study involving the treatment of venous ulcers.10 While modern approaches to ulcer management, eg, vacuum-assisted wound closure, are very effective for the treatment of difficult ulcers, they do not provide primary debridement of wound material.11 It appears that ulcer debridement by biosurgery is a feasible, safe, and probably cost-effective approach. View LargeDownload Characteristics of Patients and Outcome of Maggot Debridement Therapy (MDT) Figure 1. View LargeDownload Sloughy ulcer before (A), 48 hours after (B), and 10 weeks after (C) maggot therapy. Figure 2. View LargeDownload Biosurgery cleans wound debris without affecting vital structures (note vena saphena magna crossing the wound field). Ulcer on the distal aspect of the lower part of the leg before (A) and 48 hours after (B) maggot therapy. References 1. Falabella AFCarson PEaglstein WHFalanga V The safety and efficacy of a proteolytic ointment in the treatment of chronic ulcers of the lower extremity. J Am Acad Dermatol. 1998;39737- 740Google ScholarCrossref 2. Mekkes JRZeegelaar JEWesterhof W Quantitative and objective evaluation of wound debriding properties of collagenase and fibrinolysin/desoxyribonuclease in a necrotic ulcer animal model. Arch Dermatol Res. 1998;290152- 157Google ScholarCrossref 3. Mosher BACuddigan JThomas DRBoudreau DM Outcomes of 4 methods of debridement using a decision analysis methodology. Adv Wound Care. 1999;1281- 88Google Scholar 4. Sherman RAPechter EA Maggot therapy: a review of the therapeutic applications of fly larvae in human medicine, especially for treating osteomyelitis. Med Vet Entomol. 1988;2225- 230Google ScholarCrossref 5. Young T Maggot therapy in wound management. Community Nurse. 1997;343- 45Google Scholar 6. Sherman RA A new dressing design for use with maggot therapy. Plast Reconstr Surg. 1997;100451- 456Google ScholarCrossref 7. Vistnes LMLee RKsander GA Proteolytic activity of blowfly larvae secretions in experimental burns. Surgery. 1981;90835- 841Google Scholar 8. Sherman RAHall MJRThomas S Medicinal maggots: an ancient remedy for some contemporary afflictions. Annu Rev Entomol. 2000;4555- 81Google ScholarCrossref 9. Prete P Growth effects of Phaenicia sericata larval extracts on fibroblasts: mechanism for wound healing by maggot therapy. Life Sci. 1997;60505- 510Google ScholarCrossref 10. Wayman KNirojogi VWalker ASowinski AWalker MA The cost-effectiveness of larval therapy in venous ulcers. J Tissue Viability. 2000;1091- 96Google Scholar 11. Webb LXSchmidt U Wound management with vacuum therapy. Unfallchirurg. 2001;104918- 926Google ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Sep 9, 2002

Keywords: debridement,skin ulcer

References