A general summary of a few methods used to collect air samples to measure whole animal enteric methane emissions or solely eructated emissions
\r\n\tWithin this scenario, special attention needs to be devoted to financial implications, due to their pervasiveness. Nobody would question the key role that finance plays to complement the real sphere of the economy and that has increasingly attracted both academics and practitioners. As a result, traditional pillars – such as financial markets, products, and institutions – have evolved significantly, with financial innovation fueling further progress over time. The global side of the coin features – among others – financially connected markets, international financial exchanges, and financial conglomerates that provide valuable opportunities in terms of international corporate finance. On the other side, recent advances have involved a wider recourse to ESG factors, allowed forward steps towards a more inclusive financial system, and have made digital finance a must, rather than an option, even though much remains to be accomplished, for instance, to facilitate access to formal financial channels in many underdeveloped regions.
\r\n\r\n\t
\r\n\tThis book aims to examine emerging trends, new perspectives, and empirical applications that deal with globalization and sustainability. The goal is to provide a comprehensive overview of these important concepts as valuable support to successfully meet the challenges and take on the opportunities ahead. At the same time, drawing upon empirical evidence can contribute to bridging the gap between theory and practice, which also fits within the scope of this book.
Ruminant livestock systems contribute significantly to global anthropogenic methane emissions, with about 50% or more of the GHG emissions produced coming from enteric fermentation [1]. The loss of dietary energy in the form of methane has been extensively researched and reviewed [2, 3, 4]. Microorganisms called methanogens produce methane (methanogenesis) in the digestive tract as a by-product of anaerobic fermentation. Briefly, the process of methanogenesis [see 5, 6 for a more detailed summary] consists of:
Glucose equivalents from plant polymers or starch (cellulose, hemicellulose, pectin, starch, sucrose, fructans and pentosans) are hydrolysed by extracellular microbial enzymes to form pyruvate in the presence of protozoa and fungi in the digestive tract:
The fermentation of pyruvate involves oxidation reactions under anaerobic conditions producing reduced co-factors such as NADH. Reduced co-factors such as NADH are then re-oxidised to NAD to complete the synthesis of volatile fatty acids (VFAs) with the main products being acetate, butyrate and propionate (anions of acetic, butyric and propionic VFAs):
The VFAs are then available to be absorbed through the digestive mucosa into the animal’s blood stream. The production of acetate and butyrate production provides a net source of hydrogen or alternatively propionate can utilise any available hydrogen Methanogens eliminate the available hydrogen by using carbon dioxide (CO2) to produce methane:
In ruminants, some 87 to 93% of methane production occurs in the foregut, with the highest rate of production being after eating [7]. In sheep, almost 90% of the methane produced in the hindgut has been found to be absorbed and expired through the lungs, with the remainder being excreted through the rectum [8]. Rectum enteric methane losses have been estimated at 7% [9] and 8% [10] of methane output in dairy cows compared to the 1% found in sheep [8].
Reductions in enteric methane production from ruminants can result from a reduction in rumen fermentation rate (suppression in microbial activity) or a shift in VFA production [11]. An inverse relationship exists between the production of methane in the rumen and the presence of propionate. If the ratio of acetate to propionate was greater than 0.5, then hydrogen would become available to form methane [12]. If the hydrogen produced is not correctly used by methanogens, such as when large amounts of fermentable carbohydrate are fed, ethanol or lactate can form, which inhibits microbial growth, forage digestion, and any further production of VFAs [13]. In practice, ethanol or lactate may form, but any excess hydrogen is simply eructated.
The methods for sampling, measuring and predicting enteric methane production (using studies on dairy cattle as an example), and the influence of dietary components on methane production are reviewed.
Estimates of methane output from livestock can be costly and difficult to make, especially from larger ruminants. Standard methods for measuring the methane concentration in air are by infrared spectroscopy, gas chromatography, mass spectroscopy or a tuneable laser diode. In a controlled and enclosed environment (i.e. chamber) the gas concentration can be calculated directly from the difference between ingoing and outgoing air, but in less contained environments a tracer gas is required as a marker, which is often the inert sulphur hexafluoride (SF6) gas.
Of the methods summarised [from the reviews of 7, 12] in Table 1 that can be used to sample air for its methane concentration, the open-circuit indirect respiration calorimeter (chamber) is acknowledged as currently providing the most reliable and repeatable method of obtaining an estimate of individual whole animal enteric methane emissions (including eructated and flatulence emissions) over a continuous sampling period [7]. If this method becomes less costly to implement, direct selection of animals on methane output could become possible. In some cases, there are suggestions that this technique may affect the behaviour of the animal causing depression of appetite [14, 15], which may be avoided by making the walls of the enclosed environment transparent. A more mobile chamber that has been used is a polythene tunnel. Due to the polythene tunnel being mobile it is adaptable to different feeding systems such as grazing animals [14, 16]. However, difficulties in controlling the tunnel’s temperature and humidity have been found, resulting in a lower estimate of methane production compared to chamber measurements [14, 16].
Method of measurement | Description |
Chamber | Open-circuit indirect respiration calorimeter. Air blown in and extracted out of a chamber. Air concentrations between the incoming and outgoing air are continuously monitored using gas analysers. Chamber conditions are controlled and monitored usually for 48 hours. |
Polythene tunnel | Air blown in and extracted out of tunnel. Air concentrations between the incoming and outgoing air are continuously monitored. |
Room tracer gas | Tracer gas is released into a ventilated room until a steady concentration is reached, after which air samples can be collected. Background air samples are required. |
Mass balance micrometerological | Background air samples and a high precision gas analyser are required. Sampling downwind (and up) of the source. |
Head box, hood or mask | Respired gas volume can be sampled at regular intervals. |
ERUCT (Emissions from ruminants using a calibrated tracer) | Typically using the inert sulphur hexafluoride (SF6) tracer gas. Assumes that the emitted tracer gas from a permeation tube in the rumen simulates the diffusion of any methane emitted. Respired air collected via a capillary tube near the animal\'s nostrils into a vessel. |
A general summary of a few methods used to collect air samples to measure whole animal enteric methane emissions or solely eructated emissions
In comparison to methods that use a controlled and enclosed environment, methods that use a tracer gas such as SF6 as a marker tend to be less costly and more applicable to use on a greater number of animals. The room tracer [17] and mass balance micrometerological methods, where a known amount of gas i.e. a tracer gas or the gas of interest are released from fixed points [18, 19, 20], both require careful monitoring of the sampling environment and diffusion of the gas of interest (in this case methane) needs to be tested prior to commencing sampling. The temperature, air pressure, humidity and air speed should also be monitored for their consistency in a non-enclosed sampling environment. Controlling the sampling environment would make replicating these techniques consistently on commercial farms difficult. Also, in some countries the use of SF6 is not permitted and there may be a withdrawal period on products from animals exposed to the gas [7]. The ERUCT (emissions from ruminants using a calibrated tracer) technique [9, 21] or a head box, hood or mask [22, 23] estimate eructated methane emissions from individual animals. This ignores enteric methane from the rectum, which could be 1 to 8% of total enteric methane production of an animal as previously discussed. The ERUCT technique was devised to allow measurement of methane emissions from free ranging and feedlot animals. The ERUCT technique has been found to be suitable for estimating respired methane emissions from high forage fed animals and not with animals on diets that result in greater post-ruminal digestion [21, 24]. Even though the ERUCT technique is more open to errors in estimates compared to using a chamber, these errors could be reduced by removal of outlying estimates and replicating sampling over several days [10]. More invasive methods of estimating methane production from rumen fluid involve injecting radioactively labelled methane (isotope dilution technique) [8, 25] or ethane [26] into the rumen.
Studies measuring the methane production of livestock have been carried out for over 80 years (Table 2). In the last 20 years the number of studies globally that have measured enteric methane have increased, as have the range of sampling methods used.
In cattle, the use of high energy dense diets has increased the amount of dry matter (DM) that an animal can consume, as a result of improved efficiencies in rumen fermentation and feed digestibility [42]. The level of intake of feed (more specifically organic matter) influences methane production. Dairy cows ranging in live weight from 385 to 747 kg were found to produce between 45 and 199 kg methane/head/yr (14 to 31 g/kg DM intake) of methane and beef cattle of 364 to 627 kg live weight produced between 40 and 92 kg methane/head/yr (13 to 35 g/kg DM intake), with the difference attributed to the amount of DM consumed [43]. Notably in Table 2 the highest DM intake measured was 29 kg/day in two of the studies [33, 41] and the methane production was also the same at 19 g/kg DM intake. Where a high energy dense diet is formulated to meet the nutrient requirements of a high milk yielding animal, it would appear that the methane output per kg DM intake could average about 19 g/kg, but this would be slightly more for high forage diets where potential intake is lower (0.21 g/kg DM or more [44]). As well as the influence of the composition of the diet, reductions in methane losses per kg DM intake appear to be possible by an incremental increase in the level of feed intake, brought about by increasing the proportion of concentrate feed in the diet. It has been suggested that this decrease in the percentage of dietary GE intake lost as methane occurs at an average of 1.6% per unit increase in feed level [12].
Reference | Dry matter intake (kg/day) | Body weight (kg) | Methane (kg/hd/yr) | Sampling method |
[10] | 18 | 496 | 120 | ERUCT / Chamber |
[17] | 25 | - | 102 | Room tracer (SF6) |
[18] | - | 600 | 142 | Micrometeorological mass balance |
[27] | 1 - 15 | 162 - 655 | 39 | Chamber |
[28] | 9 | - | 79 | Chamber |
[29] | - | - | 40 | Chamber |
[30] | 8 - 18 | - | 68 - 122 | Chamber |
[31] | 18 | 602 | 137 | Micrometeorological mass balance |
[32] | - | 450 - 700 | 112 | Chamber |
[33] | 4 - 29 | 426 - 852 | 24 - 198 | Chamber |
[34] | 13 | 402 - 562 | 96 | ERUCT |
[35] | 13 | 517 | 95 | Chamber |
[36] | 14 - 16 | 595 | 138 | Chamber |
[37] | 14 | - | 109 | ERUCT |
[38] | 12 | 526 | 84 | Chamber / mask / ERUCT / micrometeorological mass balance |
[39] | 20 | 572 | 137 | Chamber |
[40] | 8 - 25 | 379 - 733 | 72 - 210 | Chamber |
[41] | 2 - 29 | 173 - 826 | 13 - 197 | Chamber |
Some of the key experiments globally that have measured methane output from dairy cattle
Prediction methods can be either empirical or mechanistic. Several reviews have studied the use and performance of different methane output prediction equations [11, 12, 33, 38, 45, 46, 47, 48, 49].
Mechanistic equations estimate methane output using mathematical descriptions of rumen fermentation. Even though mechanistic equations at present appear to show the greatest degree of adaptability across diet types and intake level [48, 50, 51], they require detailed and complex dietary input values. Published mechanistic equations are not presented in this review but are described in [52] (recommended in [50] and [46]), [53], [54], [55], [56], [57], [58], [59] (recommended in [50]) and [60].
Empirical equations such as those shown in Table 3 offer a more practical solution to predicting methane output using input variables such as digestibility, carbohydrate content, energy and nitrogen intake, milk production and live weight. Table 3 and Figure 1 present empirical prediction equations for methane output developed using animals that included dairy cattle, with a range of intakes and different diets. Of the empirical prediction equations shown in Table 3, studies have compared the predictions of an equation against methane measurements, with some being recommended such as [29] (recommended in [33]), [61] (recommended in [33], [12], [46] and [47]), [62] (recommended in [63]) and the non-linear equations using DM intake and metabolisable energy (ME) intake by [47] (recommended in [48] and [38]).
Reference | Units | Equation |
[27] | g/day | = 18 + 22.5 × DMI |
[28] | MJ/day | = -2.07 + 2.63 × DMI - 0.105 × DMI2 |
[29] | MJ/day | = [1.3 + 0.112 × D + FL × (2.37 - 0.05 × D)/100] × GEI |
[32] | g/day | = 10.0 + 4.9 × MY + 1.5 × LWGT0.75 |
[37] | g/day | = 17.1 × DMI + 97.4 |
g/day | = 84 + 47 × C + 32 × S + 62 × DS | |
g/day | = 91 + 50 × C + 40 × HC + 24 × S + 67 × DS | |
g/day | = 123 + 84 × C - 30 × HC + 58 × S + 73 × DS - 95 × L | |
[38] | MJ/day | = 8.56 + 0.14 × FP |
MJ/day | = 3.23 + 0.81 × DMI | |
[41] | MJ/day | = 74.43 - (74.43 + 0) × e[−0.0163 × DMI] |
MJ/day | = 74.43 - (74.43 + 0) × e[cx]; cx = -0.0187 + 0.0059 / [1 + exp (S/TADF - 3.1003)]/0.6127 × DMI | |
MJ/day | = (7.16 - 0.101 × DMI)/100 × GEI | |
MJ/day | = 2.6861 + 0.0779 × DEI | |
[47] | MJ/day | = 5.93 + 0.92 × DMI |
MJ/day | = 8.25 + 0.07 × MEI | |
MJ/day | = 7.30 + 13.13 × N + 2.04 TADF + 0.33 × S | |
MJ/day | = 1.06 + 10.27 × FP + 0.87 × DMI | |
MJ/day | = 56.27 - (56.27 + 0) × e[−0.028 × DMI] | |
MJ/day | = 45.89 - (45.89 + 0) × e[−0.003 × MEI] | |
MJ/day | = 45.98 - (45.98 + 0) × e[cx]; cx = -0.0011 × (S/TADF) + 0.0045 × MEI | |
[61] | MJ/day | = 3.38 + 0.51 × NFC + 1.74 × HC + 2.652 × C |
[62] | MJ/day | = DEI × [0.094 + 0.028 × (FADF/TADF)] - 2.453 × (FL-1) |
MJ/day | = DEI × [0.096 + 0.035 × (FDMI/DMI)] - 2.298 × (FL-1) | |
[64] | g/day | = 4.012 × TC + 17.68 |
[65] | % GEI | = 2.898 - 0.0631 × MY + 0.297 × MF - 1.587 × MP + 0.0891 × CP + 0.1010 × [(FADF/DMI) × 100] + 0.l02 × DMI - 0.131 × F + 0.116 × DMD - 0.0737 × CPD |
% GEI | = 2.927 - 0.0405 × MY + 0.335 × MF - 1.225 × MP + 0.248 × CP - 0.448 × [(ADF/DMI) × 100] + 0.502 × [(FADF/DMI) × 100) + 0.0352 × ADFD | |
% GEI | = 227.099 - 2.783 × [(ADFD/DMI) × 100] - 6.0176 × ADFD + 3.607 × CPD + 1.751 × NDSD - 1.423 × CD + 1.203 × HD | |
[66] | g/day | = 41 + 30 × DS + 6 × S + 51 × DCW |
[67] | MJ/day | = 1.36 + 1.21 × DMI - 0.825 × CDMI + 12.8 × NDF |
[68] | L/day | = 38.92 + 26.44 × DMI |
[69] | L/day | = 47.82 × DMI - 0.762 × DMI2 - 41 |
[70] | L/day | = 38.2 + 4.89 × FP × DMI - 0.719 × DMI2 – 20 |
L/day | = 0.666 × LWGT + 2.868 × MY + 75 | |
L/day | = 39.2 × DMI - 0.588 × DMI2 + 0.370 × LWGT - 1.698 × MY – 134 |
Empirical equations from the literature that predict enteric methane output from dietary inputs and production values for dairy cattle
The success or suitability of an empirical prediction equation for implementation on a data set is dependent on the range of values that the equation was developed on. A comparison of empirical prediction equations from Table 3, which were tested over a range of DM intakes from 1 to 35 kg/d (beyond the range they would have been developed on) for lactating dairy cows fed diets with a high and low proportion of forage content, suggest that the relationship between methane output and intake may be linear up to an average intake of 15 kg DM/d. Above this level of intake, which is more achievable by feeding a higher proportion of concentrates in the diet, the majority of equations showed a decline in methane output per unit intake (due to the increase in the level of intake by feeding a higher proportion of concentrate feed as has been suggested [12]; Fig. 1). This depression in methane lost per kg DM intake at high levels of intake in cattle has also been shown in other studies (reported in [71]). The main difference amongst the performances of methane prediction equations is their ability to give a sensible estimate of methane losses at low (approaching the origin) and high dry matter intakes. Even though some of the variation in the predictive ability of an equation in Figure 1 may be explained by the equation being used on a range of values outside the range it was developed on and the complexity of an equation, there is still considerable variation in methane output for a given level of DM intake [71].
In addition to dynamic and statistical prediction methods, methane output can be estimated based on an animal’s predicted energy requirements, which is the technique used in the Intergovernmental Panel on Climate Change (IPCC) methodology [72, 73]. This energy balance approach is suitable as an estimate over a period of time (as used in national inventories based on IPCC methodology) such as a year or lactation [74]. The IPCC methodology is based on production variables that are generally more easily obtained than those used in empirical or even more dynamic enteric methane prediction equations.
Average methane output polynomial trend lines for methane output predictions by published equations (in
As suggested in Figure 1 and proposed by others [29], increased intake of less digestible feeds such as forage has little effect on methane production per DM intake, whereas an increase in more digestible feeds such as concentrate results in a reduction in methane losses per DM intake. This improvement in the quality of food fed to a ruminant is an effective way to manipulate the diet (particularly in terms of digestible organic matter) to get better animal performance and reduced methane production [40, 45, 70, 75].
Individual feeds can vary considerably in their methanogenic effect based on their chemical composition. An evaluation of chamber measurements of methane from sheep fed different feeds found a range for percentage of GE lost as methane from 3.8% for distillers grains to 12.8% for peas [76]. The authors found that 92% of the variation in methane emission was explained by the equation:
Methane output (% GE) = -10.5 + 0.192 × DE – 0.0567 × EE + 0.00651 × S + 0.00647 × CP + 0.0111 × NDF
where, DE is digestible energy (% of gross energy, GE), EE is ether extract, S is starch, CP is crude protein and NDF is neutral detergent fibre (all in g/kg DM).
The above equation shows the relative response in methane output to each dietary component, with increases in DE, S, CP increasing methane emissions and increasing EE reducing methane. These parameters and their positive or negative effect on methane are common inputs to equations in Table 3. However, this would suggest that high starch feeds such as cereal grain would increase methane emissions. But when fed at an increasing level of intake cereal grains have a curvilinear effect on fibre digestion in mixed rations ([71]; expressed as a ratio of starch to acid detergent fibre content in [41, 47]) and result in a depression in methane per unit DM (as in Fig.1 in [47]) and per unit product.
Diet composition can influence rumen fermentation and reduce methane production as a result of more propionate present or less degradation of food consumed in the rumen. Post-ruminal digestion, particularly in the small intestine, is energetically more efficient with lower methane losses than digestion in the rumen, which can be encouraged by more digestible and higher quality food. The amount and type of dietary carbohydrate fermented affects the fermentation rate and rumen retention time of substrate, in addition to the hydrogen supply due to the ratio of acetate to propionate. The passage rate of substrate and rumen fluid dilution rate (influencing the ratio of acetate to propionate) have been found to explain 28% and 25% of variation in an animal’s methane production [77]. Cellulose ferments more slowly than hemicellulose, but both these structural carbohydrates ferment more slowly than non-structural and more soluble carbohydrates such as starch and sugars [2]. With regard to forages, increasing the digestibility of forage fed by reducing fibre content can reduce methane production. Feeding maize silage [78] or a legume-based silage [45] rather than grass silage has been found to reduce methane production. Also, silage is generally more digestible than hay [45] and adding molasses or urea to straw made it more digestible [79], which in both cases reduced methane production. Forage methane production can be minimised by lower fibre content and high soluble carbohydrate (influenced by maturity), and C3 grasses rather than C4 [2]. The grinding or pelleting of forage to increase its surface area and digestibility could also help reduce methane production [12, 80].
The additions of feed additives to a ruminant’s diet have been and are still being extensively evaluated for their effect on reducing methane emissions. The benefit in animal productivity and reduction in methane production relative to the cost of using different additives is continually being assessed. As previously suggested, the supplementation of diets with additives such as fats can reduce methane production [12, 44, 65, 81, 82, 83, 84] particularly fats with C8 to C16 chain length such as coconut oil [56, 85], however the effect, which is a suppression on fermentation appears to not always last [17, 37]. Suppressing fermentation by supplementing the diet with fat inhibits methanogens and protozoa, and subsequent fibre digestion with a shift towards more propionate present rather than acetate [2]. Likewise, the use of ionophores in feed (particularly monensin and salinomycin) and spices [86] that modify the rumen microflora [87] can reduce methane losses [6, 7, 88, 89] and encourage a shift towards propionogenesis. However eventually the rumen microflora would appear to show some resistance and the suppression ceases [90, 91, 92]. The inconsistent effects of monensin on methane in dairy cattle on forage and grain supplemented diets have also been found [93, 94]. Notably, ionophores are banned within the European Union due to the fears of residues appearing in the milk.
Other feed additives tested include the use of plant compounds such as tannins (inhibiting methanogens) [95] and saponins (inhibiting protozoa), which reduce the digestibility of dietary fibre [96], and organic acids such as fumarate, malate and acrylate which act as an alternative hydrogen acceptor [97], but results for effects on methane production and animal performance are variable [3]. Probiotics (acetogens and yeast) have been found to reduce methane output, mainly through improving digestion efficiency [88] but not by others [3]. Overall, unless yeast by-products can reliably be used to reduce methane production, the most cost-effective additive for reducing production appears to be the addition of cellulase and hemicellulase enzymes to a ruminant’s diet, which not only improved fibre digestion but also productivity [98].
With the increased importance now attached to enteric methane emissions from ruminants, due its global warming potential, there has been and will continue to be improvements in our understanding of methanogenesis and abatement options. Chamber measurements are costly in comparison to other measurement techniques and prediction methods, and therefore methane predictions using mechanistic models describing rumen fermentation are recognised at present as being more applicable to different feeds and animal species. The methane output from different feeds and animals has been extensively measured, predicted and tested but a robust empirical prediction of enteric methane emissions that can be applied to any ruminant production system is still to be developed. This is partly due to the need for the effect of feeding level to be better defined.
The important variables for predicting enteric methane output are the contents of fermentable carbohydrate, fibre, fat, digestible energy and intake level of a diet. Low enteric methane losses per unit DM appear possible by mechanisms that promote the passage of organic matter to post-rumen digestion and reduce rumen fermentation by high intakes of digestible feed and addition of fats, whilst also reducing emissions per unit product.
AcknowledgementThis work was supported by funding from Dairy Australia, Meat and Livestock Australia and the Australian Government Department of Agriculture, Fisheries and Forestry under its Australia’s Farming Future Climate Change Research Program.
The concept of negative pressure wound therapy (NPWT) was pioneered in 1997 by Morykwas, applying vacuum-assisted closure (VAC) on a pig wound model. Morykwas’ initial methodology involved packing the wound with foam, covering and sealing with an adhesive drape, and applying 125 mm Hg of negative pressure either continuously or intermittently [1]. The rudimentary NPWT led to increased blood f low, granulation tissue, and f lap survival, with decreased bacterial growth [1].
NPWT refers to wound healing technology consisting of three major parts: a wound dressing, covers, and a pump [2]. Wound dressing aids in transferring pressure from the pump to the wound itself, and modern NPWT typically utilizes reticulated open-pore polyurethane foam, intended to equalize the negative pressure across the entire wound surface [2]. The cover creates an airtight seal over an open wound, and the pump applies the negative pressure [2, 3].
There are four major types of NPWT [4]. The first is a large, battery-powered NPWT in the acute inpatient setting, while the second is a portable, battery-powered NPWT designed for outpatient use, but cannot be purchased over the counter and tends to be noisy [4]. The third type is a longer-lasting battery-powered NPWT that can be purchased over the counter and is designed to last 7 days and subsequently discarded, while altered models designed for inpatient use that include additional functions, such as negative pressure wound therapy with instillation-dwelling (NPWTi-d) and incisional negative pressure wound therapy (iNPWT), are the last [4].
By drawing f luid out of the wound, negative pressure increases blood f low, decreases the bacterial burden, cleans the wound, reduces local edema, and removes soluble inf lammatory mediators that may delay wound healing [2, 3, 4]. It has been postulated that NPWT draws antibiotics into the wound, but evidence is lacking [2]. The application of pressure applies forces to the wound, exerting effects macroscopically, through macrodeformation, as well as microscopically, through microdeformation [2, 5]. Naturally, negative pressure on a sealed wound draws the wound edges together [2]. However, it is important to note that the effect is reliant upon tissue parameters such as elasticity and tension, and the strength of the negative pressure does not seem to affect the amount of macrodeformation that occurs [2].
With NPWT, 5–20% of the wound surface experiences tissue stress, and by using a reticulated wound dressing, the action of drawing the wound bed into each pore via negative pressure constitutes the microdeformation that promotes tissue healing processes: increases in cell proliferation, angiogenesis, granulation tissue formation, and epithelialization and decreases in inf lammation [2, 5]. NPWT has the potential to grow granulation tissue over exposed bone, tendon, or devices [4]. Specifically, NPWT increases the concentration of VEGF, TGF-beta, FGF-2, PDGF, and IL-8 in the wound, with IL-10 increasing in the body, and decreased concentrations of TNF-alpha, IL-1 beta, and matrix metalloproteases (MMPs) [2]. In patients with type-2 diabetes, the pro-angiogenic and pro-epithelization proteins GDNF family receptor alpha-2 (GFRA2), which complement C1q binding protein (C1QBP), RAB35, and synaptic inositol 1,4,5-triphosphate 5-phosphatase 1 (SYNJ1), were increased [2].
Traditional NPWT has been utilized for chronic and acute open wounds and has become a mainstay of wound management [4, 6, 7].
Indications for NPWT are as follows [5, 8]:
Acute, chronic, and dehisced surgical wounds
Diabetic, pressure, and venous leg ulcers
Open abdominal wounds
Fasciotomies
Split-thickness skin graft (STSG) recipient sites
Flaps
Partial-thickness burns
Contraindications of NPWT include fistulas, malignancy, osteomyelitis, or infection, and NPWT should never be applied over exposed critical anatomic structures or in wounds with necrotic tissue [4, 5]. Despite the benefits of NPWT, there are several key reminders to remember in order for treatment to be effective. The cover and drainage tube must be assessed carefully as loss of seal or f luid buildup in the tube can lead to skin loss or maceration [5]. It is also important to monitor the pump to minimize the risk of exsanguination.
There is significant variability regarding the application of NPWT that depends on wound characteristics [2, 5]. The wound packing can be foam or gauze [2]. The pump may be mechanically or electrically driven [2]. The strength of negative pressure can vary from −50 mm Hg to −150 mm Hg [2]. The pattern of negative pressure application can be intermittent, continuous, or variable, with a continuous pattern the most common [2]. Selection of parameters is typically at the physician’s discretion, but a recommended pressure is 125 mm Hg applied in a pattern alternating between a 5-minute negative pressure and a 2-minute suction [4, 5]. Although studies suggest intermittent NPWT is the most effective pattern in inducing granulation tissue formation and increasing blood f low, it also increases pain for the patient [4, 5]. As a result, continuous pressure is often used for painful wounds, as well as wounds with overlying skin grafts, and particularly edematous wounds [5]. Beyond wound outcomes, NPWT reduces the number of dressing changes, healthcare labor, time spent in the hospital, and costs, and this is most demonstrated in portable NPWT, which allows treatment to be done at home [5, 9].
Beyond its indications listed previously, the use of NPWT has been expanding into newer wound types, including tunneling wounds and avascular tissue, and new published case series have demonstrated the use of NPWT in wounds such as necrotizing fasciitis [4, 5, 10]. Alterations to traditional NPWT led to negative wound pressure therapy with installation (NPWT-i) and incisional negative pressure wound therapy (iNPWT), the latter of which is utilized on closed wounds.
Incisional NPWT (iNPWT) has been used since 2006, as an adjunct treatment to augment wound healing and prevent surgical site infections (SSI) and wound complications.
Surgical incisions are a break in the skin and its defenses in avoiding translocation of infectious pathogens into the deeper tissues. It’s imperative to cover and isolate these incisions by a sterile protective dressing in the sterile environment of the operating room. Advances in these sterile protective dressings have taken place over decades and, in the present form, are made up of a nonadherent, antimicrobial-containing dressing covered with sterile gauze or abdominal pads, which are held in place by tapes or transparent film.
In the 1990s, NPWT demonstrated promising results in the management of acute and chronic open wounds, and Argenta and Morykwas proposed improved perfusion and wound contraction, which had a profoundly positive effect on the success of wound healing [1].
Gomoll et al., in 2006, pioneered the idea of incisional NPWT and described the application of NPWT on 35 orthopedic trauma patients, considered high-risk for infections [11]. A permeable nonadherent dressing was applied over the incision and covered with standard VAC sponge cut into 1-inch wide strips and then sealed with conventional VAC adhesive material. The negative pressure was maintained for 3 days, and patients were followed up for SSI for a minimum of 3 weeks. None of these 35 patients reported infections, which led to heightened interest in application of NPWT for surgical incisions.
Efficacy of NPWT depends on a number of factors, namely, foam width, foam thickness, magnitude of negative pressure, and its duration and frequency.
To achieve reproducible and standardized results, the NPWT dressing includes a skin interface layer, which is directly placed over the incision site, over which reticulated foam dressing is secured with occlusive drape. The VAC pump along with the canister is then connected via tubes attached through the foam dressing and secured underneath the occlusive drape to maintain an airtight seal. It’s imperative to secure and maintain an airtight seal, in order to achieve efficacy and prevent complications like maceration of peri-wound skin.
Several studies and trials have proposed these mechanisms of iNPWT (Figure 1):
Physical barrier to external contamination
Microdeformation of the wound edges and release of local growth factors
Approximation of wound edges and minimizing lateral tension and dead space
Fluid egress and exudate removal
Cross-sectional depiction of an incision closed with sutures without incisional NPWT (a). Application of incisional NPWT decreases lateral tissue tension and increases incisional apposition (b), reducing dead space. The applied pressure causes microdeformation and release of local growth factors, promoting healing of the surgical incision (reprinted with permission from Ref. [
The negative pressure is commonly used
Another alternative, to bridge the gap between continuous and interrupted pressure, is
The role of foam width and thickness is important, as it’s proportional to the lateral tension attenuation, as described later in the chapter. Hence, a standard foam width of 60 mm is recommended. Cutting thin strips of the foam and using as a construction dressing are also discouraged, as it limits the efficacy and benefits of the iNPWT.
The optimum negative pressure has been a debatable aspect of NPWT. A lot of research focused on negative pressure of −80 mm Hg with positive results, followed by a paper published by Morykwas et al., using −125 mm Hg. The results of this trial were promising as it demonstrated improved healing and granulation as compared to the earlier results published by the same team and others. Recent literature and guidelines recommend a pressure of −125 mm Hg; however, pressures ranging from −80, −100, and −125 mm Hg have been employed, and encouraging results have been published.
Application of iNPWT on perineal wounds, following abdominoperineal resection (APR) for colonic and anal lesions, demonstrated improved wound healing and reduced complications and infection rates, while using pressure of −80 mm Hg. The increase in negative pressure beyond −125 mm Hg does not demonstrate improved wound outcomes, either in open or closed wounds.
As the uses and application of the NPWT system develop for closed incision surgical wounds, results of various large-scale clinical trials would emerge, and further modifications would evolve to maximize the clinical benefits of this promising therapeutic modality for postoperative surgical wounds.
Several studies have described the benefits of incisional NPWT (iNPWT) in general, colorectal, cardiac, vascular, plastic, and orthopedic surgeries. These benefits have been classified as immediate, intermediate, and long-term effects and result from the sterile isolation of the incision; mechanical stabilization and reduction in the tensile forces; obliteration of dead space; reduction of local edema, hematoma, and seroma; and increased perfusion and lymphatic f low.
Nam et al. proposed benefits of iNPWT [12], as
Immediate effects
Protection of incision from external contamination
Decreased lateral tension on the incision
Increased appositional strength
Normalized stress distribution
Increased skin perfusion
Intermediate effects
Decreased edema
Decreased hematoma/seroma formation
Increased lymphatic f low
Long-term effects
Improved Incision quality
Mechanical strength
Histology
Gene expression
Surgical site infections (SSIs) result in significant morbidity and increased healthcare costs, accounting for 21.8% of the 721,800 healthcare-associated infections recorded annually in the United States [13].
SSIs are estimated to increase average hospital stay by 9.6 days, resulting in an added cost of $38,656 and around $10 billion in direct and indirect costs annually [14].
With emphasis on lowering healthcare costs and advancing quality of care, SSIs pose a major physical, psychological, and economic burden.
Incisional NPWT immediately provides protection and isolation of the incision from external contamination. Multiple studies in trauma surgery, general surgery, and plastic surgery have attributed decreased local edema, f luid egress, lower hematoma/seroma rates, lower time to healing, and improved genomic profile, in terms of reduction of pro-inf lammatory cytokines and chemokines in surgical incisions covered with NPWT. An international expert panel in 2017 recommended ciNPWT for patients at high risk for surgical site complications [15]. Notable high-risk features include diabetes, ASA score ≥ 3, obesity (BMI ≥ 30 kg/m2), tobacco use, hypoalbuminemia, corticosteroid use, high-tension wounds and revision surgery.
Multiple studies across different specialties reported a threefold to fivefold reduction in the surgical site infection risk, following the use of ciNPWT [16, 17, 18].
Notably, Grauhan and team reported findings of a prospective study of 150 obese patients who underwent cardiac surgery via a median sternotomy. A significant reduction of fourfold in the incidence of wound infection was seen in the iNPWT group compared to conventional dressings, at 1 week of surgery [19]. Similar findings were reported by Matatov in groin infections covered with iNPWT, after vascular procedures (6 vs. 30%, p = 0.0011) [20]. Bonds described a reduction in the rate of SSIs in the iNPWT group, after open colectomy (12.5 vs. 29.3%, p < 0.05) [21].
Contrastingly, a study analyzing 398 patients concluded incisional NPWT improved short-term wound complications but had no effect on long-term infection rate following knee and hip arthroplasty. A higher proportion of iNPWT patients reported wound drainage at day 7, though similar increase was not seen at different time intervals. This study is the largest RCT comparing outcomes of NPWT dressing in elective lower extremity arthroplasty and supporting improved soft tissue healing response and lower wound-related complications, but no effect on the risk of late superficial or deep infections [22].
Evidence supporting the use of iNPWT in hand and spine surgery is new and fewer. SSIs occur is 0.4–20% of patients undergoing spine surgery and contribute to increased morbidity, hospitalization, and costs [23, 24, 25, 26]. Various treatment modalities such as drains, copious irrigation, and prophylactic antibiotics are employed. Adogwa et al. reported a 30% reduction in wound infection rate and 50% reduction in wound dehiscence rates in patients after long-segment thoracolumbar spine fusion and suggested ciNPWT as a safe and effective means of wound management for high-risk spine incisions.
Recent literature suggests incisional NPWT as a safe and effective method in preventing SSIs and wound complications in high-risk patients.
As modern healthcare strives to deliver quality and efficient yet cost-effective care, continued efforts are warranted to evaluate economic viability of NPWT use and its application in various specialties.
An estimated cost of $100 per day was associated with the use of the PREVENA (V.A.C therapy, KCI, San Antonio, TX) system, which showed significant reduction in SSI risk [27]. With a typical use of 5–7 days, cost of ciNPWT is estimated around $500–700. When used in high-risk populations and higher-cost wound management modality, such additional costs of the NPWT system are validated, as they lead to overall reduction in total healthcare expenditure. SSIs prolong hospital stay, on an average of 9 days, and are associated with an increase in costs up to $20,000 [28].
When compared with indirect costs associated with treatment of wound dehiscence and complications, and direct costs such as daily dressing changes, the economic viability of the iNPWT system in high-risk population seems justified. Chopra et al. found an estimated cost saving of $1456 with ciNPWT use in abdominal wall surgeries. Raymund Horch and his team proposed a cost saving of $163 in obese patients and $203 in morbidly obese patients employing iNPWT in post-bariatric patients undergoing abdominal and thigh dermolipectomy. The authors determined that a 28 and 25% reduction in SSIs’ rate in the obese and morbidly obese patients, respectively, was needed to achieve cost savings with iNPWT. Lewis et al. proposed cost savings with iNPWT if wound complications are reduced by one-third in patients undergoing laparotomy for gynecological malignancies [29]. Further evaluation of the applicability of the NPWT system and its costs is warranted in diverse patient population (high vs. low risk), healthcare setups (inpatient vs. at-home), and specialties.
NPWT has been applied successfully as a therapeutic modality to treat open wounds for decades, which led to heightened interest in the scientific community to use it over closed wounds, incisions, and skin grafts. Many trials and studies have proposed the following mechanisms of incisional NPWT:
Foam dressing protects wound from external mechanical stress.
Decrease wound tension and tensile forces in deeper dermal layers.
Continuous removal of exudate and f luids.
Decrease local edema improving physiologic adaptation of the wound.
Increase in local perfusion, oxygenation, and lymphatic f low.
Decrease hematoma/seroma rates.
Decrease in time-to-heal duration.
On a molecular level, iNPWT has been hypothesized to remove toxic inf lammatory mediators and increase the concentration of local tissue growth factors, via microdeformation [30].
An immediate benefit of the iNPWT is the foam dressing that protects the incision/wound from external contamination as well as its ability to minimize the lateral tension around the suture line by 50%. It also normalizes tensile forces in the deep dermal tissue to decrease dead space, which aids in wound healing and reduced seroma/hematoma rates. In wound mechanics, study conducted on an incision made on silicon surface found when iNPWT was applied, 51% more force was required to pull apart a sutured incision, and 43% more force was required to pull apart a stapled incision than non-iNPWT-treated incisions. An interesting correlation was the proportional association between the width of the foam dressing and the force required to pull the incision apart. The study concluded that a foam width of 60 mm is required to increase the tensile strength of the incision.
Studies on earlier techniques of NPWT discouraged the construction method (dressing of the incision by cutting foam into thin strips) as it likely decreased the positive effect of reduced lateral tension on the incision [1].
Early application of iNPWT on pig wound model demonstrated improved healing in terms of mechanical, histomorphometric, and gene expression properties. These incisions showed significantly improved mechanical properties (strain energy density, peak strain) and a narrower scar, extending in the deep dermis [31].
Long-term genomic analysis on surgical wounds reveals pro-inf lammatory chemokine and cytokine signals in conventional dressing (sterile absorbent abdominal dressing)-treated incisions compared to iNPWT-treated incisions. Thus, the latter seemed superior in wound strength and wound maturity compared to conventional dressing-covered incisions [31].
Early application of iNPWT promotes f luid egress and continuous removal of exudates. This leads to reduction in local edema, reduced hematoma/seroma rates, improved time to hematoma resolution, decreased time to wound healing, and with split-thickness skin grafts (STSG), improved survival with NPWT [12]. When used with grafts and skin substitutes, the f luid egress with iNPWT minimizes sheer stress and provides tight apposition to the underlying recipient wound bed, which promotes incorporation of the graft or skin substitutes and reepithelialization of graft interstices [32, 33, 34]. Maruccia et al. described faster healing, fewer dressing changes, and quicker maturity of mesh skin grafts when combined with NPWT. This combined treatment provides higher integration, better immobilization of the graft, expulsion of f luids, and a moist clean wound bed [35].
The reduction in local edema and removal of f luids in sites such as the abdomen and breast help in reducing the need for postoperative drainage. There is renewed interest in analyzing results to conclude reduced need and duration for postoperative drains. Several studies in general surgery, plastic surgery, and orthopedic surgery have demonstrated reduced drainage with iNPWT-covered incisions. Raymund Horch and his team, in 2014, demonstrated the benefits of iNPWT in a post-bariatric patient population undergoing dermolipectomy of the abdomen and who presented with reduced exudate formation, earlier drain removal, and decreased length of hospitalization [36].
Pain relief with iNPWT has been reported rarely, as very few studies have focused on reporting pain scores with this modality. Maruccia et al., in 2016, reported a statistically significant reduction in pain scores and wound area in skin graft patients. This could be explained by faster healing and improved uptake of the graft, along with less frequent need for dressing changes [35].
Recent literature shows
An important aspect of iNPWT is its ability to alter
Timmers et al. found a fivefold increase in perfusion, assessed with Doppler probes, after application of NPWT over the forearms of healthy volunteers [38].
In a study on iNPWT published in 2016 from the University of Chicago, comprising of 228 patients undergoing immediate expander-based breast reconstruction (study and control groups of 45 and 183, respectively), it was concluded that the application of iNPWT significantly decreased the rate of major mastectomy f lap necrosis rate (requiring operative intervention), overall mastectomy f lap necrosis rates, and overall complication rates [39].
An important supplement to the improved perfusion is
Kilpadi and Cunningham reported 63% reduced hematoma/seroma rates with iNPWT and injected isotope-labeled nanospheres in the subcutaneous tissue to discover their highest concentration in lymph nodes closest to, draining the incision site [40]. Recent literature is overwhelmingly in favor of reduced seroma/hematoma rates, across various surgical procedures covering different surgical specialties and incision sites. To name a few, iNPWT and reduced seroma/hematoma have been demonstrated at f lap donor sites, like scapular and latissimus dorsi free f lap harvest sites, total hip and knee arthroplasty, over abdominal (e.g., cesarean, laparotomy, and abdominoplasty), thoracic incisions (e.g., sternotomy), breast incisions (expander-based and autologous reconstruction), lower extremity (trauma and fractures), and groin incisions (vascular procedures involving femoral vessels) [40, 41, 42, 43].
Reduced hospital stay with iNPWT use has been demonstrated extensively, via reduced time-to-heal duration, as well as decreased SSI and wound dehiscence and complication rates. A recent systematic review on abdomen procedures estimates reduction of ICU stay but required more extensive clinical RCT and research [44]. Though, it’s difficult to quantify this reduction in hospital stay across various procedures, NPWT as an incision management tool has been demonstrated to optimize and accentuate the wound healing process.
These rates have been assessed in a recent meta-analysis comparing efficacy of NPWT in high-risk patients undergoing abdominal wall reconstruction. Both outcomes were low in the iNPWT group as compared to control [9 vs. 14% and 3 vs. 14%, respectively; RR = 0.68 CI (0.46–0.99)].
Wound dehiscence and complications are lowered with the use of iNPWT and its aforementioned benefits. Recent literature estimates a reduction of ~50% reduction in wound dehiscence rates, across various surgical specialties [23, 45, 46, 47, 48, 49, 50].
The proposed mechanism of improved wound healing, increased perfusion, decreased infection rates, decreased hematoma/seroma rates, decreased lateral and deep wound tension, improved wound maturity, and strength and obliteration of dead space augurs well for low wound dehiscence and complication rate.
Besides the cost-benefit analysis, an incision management tool with these benefits and improved scar appearance definitely requires further clinical trials and recommendations for use, especially in high-risk patients.
Interest in the use of iNPWT has been peaking in the last few years as favorable outcomes seem promising and with easy adaptability and application of at-home single-use canister-based NPWT. This single-use NPWT can be used for 7 days and improves patient acceptability and compliance. A lot of research has been invested in the safety of these systems and to identify complications impeding its widespread use.
The risk of hemorrhage, especially in patients on anticoagulants and with clotting disorders, has been described with the use of iNPWT. Any evidence of fistulas or communication to visceral cavities needs further imaging and management before the application of negative pressure. Allergic reaction to the dressings is a contraindication to the use of iNPWT. Minor skin irritation and ecchymosis are the most frequently encountered complications.
The earliest description of the use of negative pressure in wound healing was in the management of soft tissue injury associated with open fractures. The beneficial outcomes seen in various animal models spurred the development of a wide range of clinical indications including abdominal, breast, orthopedic, vascular, cardiac, and plastic surgeries (e.g., skin graft, burns, muscle f lap) [51].
The use of incisional NPWT in high-risk patients undergoing abdominal surgeries decreased wound complications such as surgical site infections and wound healing complications. The primary goals of incisional NPWT wound management include active removal of exudates, estimation of third-space f luid loss, and avoidance of mechanical contamination of the abdominal viscera [51].
With the help of the dressing, NPWT applies negative pressure uniformly, thus promoting healing by reducing edema, approximating the wound, and removing infectious material and exudates [52].
Some studies showed that NPWT improves the removal of abdominal f luid, which helps in early fascial closure. The removal of f luids is especially beneficial in reducing inf lammatory responses that may occur [53, 54]. This is supported by the septic/hemorrhagic shock porcine model, which showed that NPWT efficacy was partially due to a reduction in the anti-inf lammatory response [55].
On a recent comparative study on incisional NPWT and conventional dressing following abdominal wall reconstruction, the authors demonstrated a statically significant reduction in the incidence of skin dehiscence and overall wound complications in the incisional NPWT group compared with the conventional dressing group [30].
In a study comparing the rates of SSI of patients who underwent surgery for pancreatic, colorectal, or peritoneal surface malignancies between incisional NPWT and conventional dressings, the incidence of SSI was significantly lower in the incisional NPWT group than the conventional group [56].
The use of incisional NPWT as an effective prophylactic tool has been examined in studies from various surgical specialties. The results show that its use facilitates healing of incisional wounds and reduces the incidence of wound healing disorders [57].
Breast reconstruction using the expander-/implant-based breast reconstruction is usually performed after mastectomy and plays a crucial role in psychosocial and oncological outcomes in breast cancer patients.
One of the most common and significant complications in the immediate expander-based breast reconstruction is mastectomy f lap necrosis, which has been reported to occur in up to 30% of the patients [58]. Authors of a recent study evaluated the incidence of mastectomy f lap necrosis in patients with incisional NPWT after immediate expander-based breast reconstruction compared with the incidence in patients with conventional dressing.
The incisional NPWT group had a lower overall complication rate, overall mastectomy f lap necrosis rate, and major mastectomy f lap necrosis than the conventional dressing group [59].
Besides oncological breast surgery, the use of incisional NPWT was also assessed in a multicenter study on reduction mammoplasty. The results have shown that incisional NPWT applied to closed incision appeared to be most effective on dehiscence in the higher BMI categories and benefit most in preventing complications in the higher tissue resection weight categories [60] (Figure 2). The results thus suggest applying incisional NPWT devices in reduction mammoplasty where the BMI is over 25 or resection weight is above 500 mg [60] (Figure 3).
Progression of incisions in patient treated with iNPWT and standard wound care after bilateral reduction mammaplasty. Wound complications and dehiscence are reduced with iNPWT (reprinted with permission from Ref. [
Relation of body mass index (BMI) on wound dehiscence rates in patients undergoing reduction mammaplasty. The NPWT group shows lower wound dehiscence rates than standard wound care (reprinted with permission from Ref. [
The safety and efficacy of incisional NPWT in elderly patients undergoing breast surgery were studied previously. The results of the study suggest that the rates of infections and surgical site events (SSE) were lower with the use of incisional NPWT. The use of incisional NPWT is thus highly recommended in elderly patients, who have significant increased risk of developing SSE when compared with younger patients [61]. Other studies have concluded that incisional NPWT applied to closed surgical incisions on healthy patients after breast reduction surgery prevented postsurgical wound complications significantly [62].
Complications related to high-risk lower extremity fractures such as calcaneal, pilon, and tibial plateau are particularly common. Common complications include infection and wound healing problems. In a prospective randomized multicenter clinical trial evaluating the use of NPWT after calcaneus, pilon, or tibial fractures, the authors have found a significant reduction of infection in the NPWT group [48]. The beneficial effects of NPWT on wounds after total ankle replacement or calcaneus fractures were recognized in a study that showed decreased total time required to achieve complete healing, decreased risk of infections, and decreased pain and swelling [63]. Several retrospective studies showed positive effects of incisional NPWT on wounds after open reduction and internal fixation of acetabular fractures. The NPWT group showed reduced rates of wound dehiscence, deep wound infections, and infection rates [64, 65].
A prospective randomized clinical study examined the wounds of patients after total hip arthroplasty using ultrasound examination to evaluate for the development of potential seroma, a possible risk factor for wound infections. The study showed a significant reduction in the seroma size when compared to standard wound dressing and positive effects on wound healing and complication rate [42].
Despite the use of prophylactic antibiotics, the increasing incidence of postoperative sternal wound infections continues to be a serious problem after surgical cardiac procedures. Sternal wound infections are associated with additional expenses, increased length of stay in the hospital, increased mortality during the first year, and a significant reduction in quality of life [66].
Risk factors that increase the risk of sternal wound infections include smoking, diabetes, increasing number of grafts, peripheral vascular disease, chronic pulmonary disease, obesity, increased duration of mechanical ventilation, preoperative malnutrition, and harvesting of bilateral internal mammary arteries [67].
The use of incisional NPWT on sternal surgical incisions in patients with multiple comorbidities and consequently a high risk for wound complications was evaluated. Results have shown no wound complications in this high-risk group of patients at least 30 days after surgery and complete wound and surrounding skin healing with the absence of skin lesion due to negative pressure after removal of the dressing [68]. Results from another study also concluded that applying incisional NPWT over clean, closed incisions for the first 6–7 postoperative days reduced the likelihood of postoperative wound infections after median sternotomy not only in high-risk patients but also in a comprehensive patient population [45].
Vascular surgical site infections (SSI) occur as a result of perioperative events that lead to the colonization of the wound and underlying graft with bacterial species. Patients undergoing vascular procedures are at an increased risk of developing an SSI of up to 5% of clean procedures and 30% of clean-contaminated procedures [69]. Severe complications that arise after vascular surgery including leg amputation and death prompted the use of incisional NPWT postoperatively to prevent complications associated with such surgeries. Results of different studies have shown a potential reduction in wound complications and no observed increase in hemorrhage in high-risk patients with severe comorbidities undergoing vascular surgeries [70].
Recent retrospective study on lower leg fasciotomy supports faster wound closure and daily wound size reduction, fewer dressing changes, and shorter hospital stay with NPWT. These factors contribute to significant reduction in surgical site infections, from 30 per cent with standard wound care to 6 per cent with closed incisional NPWT [71].
In plastic surgery, the use of NPWT is particularly important in patients who experienced complications associated with skin graft rejection and its associated partial necrosis. It’s also used after excision of large scalp f laps due to injuries and lack of opportunities to cover it with the patient’s own skin. NPWT resulted in faster healing and granulation of wounds and a reduction of the overall size [72]. The use of NPWT in large wound surfaces with large amounts of mucus, observed in skin burns, resulted in a significant acceleration in the time taken for patients’ healing and rehabilitation. Additional outcomes included wounds that healed better, fewer infection rates, and more elastic tissue preservation [73]. Results from a multicenter, prospective randomized controlled, within-patient study involving our center and senior author (RDG) provided high-level evidence supporting significantly reduced wound complications following application of iNPWT in susceptible patients [60].
Advances in surgical and sterilization techniques have largely mitigated risk of wound complications and SSI rates; however, these complications till date pose a major physical, financial, and psychological challenge in the postoperative phase of treatment. Incisional NPWT presents a promising treatment modality for surgical wounds and incisions, with its proposed benefits in reducing infections, preventing wound dehiscence and optimizing wound healing and scarring. Randomized controlled trials and further clinical research are warranted to develop guidelines to the safe, effective, and routine use of iNPWT. However, in the present economic model of healthcare, efficacy of a treatment modality alone does not justify its use, and a large-scale cost-benefit analysis is warranted to rationalize its use in high-risk and low-risk postoperative patients.
The authors would like to thank Abbas Hassan, Rou Wan, and Dr. Jing Liu for their valuable inputs and contribution.
The authors declare no conf lict of interest.
The first author CJJ would like to immensely thank senior author RDG for his unending support, guidance, and inspiration to strive to be perfect.
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This includes, but is not limited to: single-neuron modeling, sensory processing, motor control, memory, and synaptic plasticity, attention, identification, categorization, discrimination, learning, development, axonal patterning, guidance, neural architecture, behaviors, and dynamics of networks, cognition and the neuroscientific basis of consciousness. 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Novel computational algorithms for image analysis, scene understanding, biometrics, deep learning and their software or hardware implementations for natural and medical images, robotics, VR/AR, applications are some research directions relevant to this topic.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",keywords:"Image Analysis, Scene Understanding, Biometrics, Deep Learning, Software Implementation, Hardware Implementation, Natural Images, Medical Images, Robotics, VR/AR"},{id:"25",title:"Evolutionary Computation",scope:"Evolutionary computing is a paradigm that has grown dramatically in recent years. This group of bio-inspired metaheuristics solves multiple optimization problems by applying the metaphor of natural selection. It so far has solved problems such as resource allocation, routing, schedule planning, and engineering design. Moreover, in the field of machine learning, evolutionary computation has carved out a significant niche both in the generation of learning models and in the automatic design and optimization of hyperparameters in deep learning models. This collection aims to include quality volumes on various topics related to evolutionary algorithms and, alternatively, other metaheuristics of interest inspired by nature. 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It has become a massive part of our daily lives, making predictions based on experience, making this a fascinating area that solves problems that otherwise would not be possible or easy to solve. This topic aims to encompass algorithms that learn from experience (supervised and unsupervised), improve their performance over time and enable machines to make data-driven decisions. It is not limited to any particular applications, but contributions are encouraged from all disciplines.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/26.jpg",keywords:"Intelligent Systems, Machine Learning, Data Science, Data Mining, Artificial Intelligence"},{id:"27",title:"Multi-Agent Systems",scope:"Multi-agent systems are recognised as a state of the art field in Artificial Intelligence studies, which is popular due to the usefulness in facilitation capabilities to handle real-world problem-solving in a distributed fashion. 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\r\n\tPollution is caused by a wide variety of human activities and occurs in diverse forms, for example biological, chemical, et cetera. In recent years, significant efforts have been made to ensure that the environment is clean, that rigorous rules are implemented, and old laws are updated to reduce the risks towards humans and ecosystems. However, rapid industrialization and the need for more cultivable sources or habitable lands, for an increasing population, as well as fewer alternatives for waste disposal, make the pollution control tasks more challenging. Therefore, this topic will focus on assessing and managing environmental pollution. It will cover various subjects, including risk assessment due to the pollution of ecosystems, transport and fate of pollutants, restoration or remediation of polluted matrices, and efforts towards sustainable solutions to minimize environmental pollution.
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