Wound dehiscence after laparotomy remains a severe surgical complication problem and includes 1-3% of patients undergoing abdominal surgery. The occurrence of post-laparotomy wound dehiscence is related to conditions such as anemia, hypoalbuminemia, malnutrition, malignancy, obesity, diabetes, geriatrics, as well as specific surgical procedures such as obstetric and gynecological surgery (obstetrical and gynecological laparotomy) . Current dehiscence management is divided into non-operative or conservative and operative management. Platelet Rich Fibrin (PRF) is a breakthrough for non-operative therapy in patients with surgical dehiscence. PRF contains many growth factors needed for wound healing . PRF contains over 30 bioactive proteins, growth factors, various cytokines, and chemokines that play an essential role in wound healing, acute tissue response to trauma, and involves in some of the physiological processes of the cell, such as growth differentiation, and cell replication . PRF is autologous, so it is relatively safe and does not pose a risk of allergic or infectious disease. This study aimed to determine the effectiveness of wound healing in wound dehiscence of obstetric and gynecologic laparotomy with PRF treatment compared to conventional non-operative methods.
2. Subject and Methods
This was a cross-sectional study conducted in patients who admitted to Obstetric and Gynecology clinic of Dr. Moewardi General Hospital from September to December 2017 and underwent subtotal wound dehiscence following obstetric and gynecological laparotomy in the last 5 years. Subjects were divided into two groups: the control group was given conventional non-operative method while the treatment group was using PRF treatment and all the subjects met inclusion and exclusion criteria. Inclusion criteria including post-obstetric and gynecologic laparotomy dehiscence with a minimum wound length of 3 cm with wound depth up to the fascia of musculus rectus abdominis, while exclusion criteria including post-obstetric and gynecologic, obstetric deformation complications with depth to peritoneum parietal, complications of laparoscopic dehiscence wounds were present such as infection, worsening of the patient's general condition, and also the patient's refusal to continue the study. The sample size was taken with fixed disease sampling method, and Patient has first assessed the condition of the wound then divided into two groups. In the control group using conventional methods, wound dressing was performed by cleaning the wound with 0.9% sterile saline (NaCl) followed by wound closure using sterile gauze. In the PRF therapy group, wound dressing was performed by cleaning the wound with 0.9% sterile saline (NaCl) followed by PRF gel and then wound closure by sterile gauze. Evaluation of wound conditions were 3 days after treatment for each group, followed by the retrieval and data processing and conducted statistical analysis. The difference among 2 groups was considered statistically significant if p value 0.05.
The subjects of the study were patients with subtotal wound dehiscence after obstetric and gynecologic laparotomy in Dr. Moewardi Hospital. Subjects were divided into 2 groups, each group consisted of 15 patients. Each group's characteristics is shown in Table 1 below:
Statistical analysis was done to determine the normality and the homogeneity of the data, continued with bivariate analysis of each characteristic above. We found that all the above variables were homogeneous and there were no significant differences.
The outcome of wound healing between the control group and PRF is seen in the average time of wound healing as shown in Table 2 below:
|Wound healing time||Control group||15||12.60 2.58||0.001*|
|PRF group||15||7.0 3.52|
|* Significance value p 0.05|
Table 2 shows that the average length of wound healing in the control group was longer than PRF group (12.60 2.58 vs 7.0 3.52). Statistical analysis using the normality data test by Saphiro-Wilk test on the duration of wound healing for the control group and the PRF group showed p= 0.050 and p= 0.069 (p sig 0.05), which means that data is normally distributed. The homogeneity test of Lavene showed p= 0.23 (p sig 0.05), meaning that the data is homogeneous. The statistical difference in wound healing time in both groups then analyzed using unpaired t-test. It showed that there was a very significant difference (p= 0.001) between two groups.
F test on double linear regression which aimed to test independent variable (age, BMI, Hb, albumin, blood glucose, PRF) on regression model shows that all independent variables had a simultaneous effect on the dependent variable (wound healing time).
The costs of therapy on patients undergoing wound dehiscence after obstetric and gynecologic laparotomy in Dr. Moewardi Hospital over the past five years (2013-2017) were also analyzed in both control group and PRF group, the cost data obtained from the medical record, with an average cost as follows:
|Variable||Group||N||Average cost (days)||p|
|The average cost of therapy||Conventional||15||IDR 12.540.735 8.227.433||0.001*|
|PRF||15||IDR 4.511.362 2.977.934|
|* Significance value p 0.05|
From Table 3 it was found that the average cost of therapy in conventional group patients was more expensive than the PRF group (12.540.735 8.227.433v s 4.511.362 2.977.934) and it is statistically significant (p=0.001). Thus PRF therapy can be used as a cheaper therapy.
Multivariate test by using confidence interval 95% and α=0.05 showed that total wound healing cost between conventional and PRF group was not affected by external variables where p=0.071 (p 0,05).
From the result of the bivariate test conducted on the research variables in both groups of PRF, it showed that age, BMI, hemoglobin, albumin, and blood glucose are not statistically different (or homogeneous) with p 0.05. The average duration of wound healing appears to be longer in the conventional group (12.60 2.58 days), compared to PRF group (7.00 3.52 days). The unpaired t-test analysis using a 95% confidence interval and α= 0.05 proved that the difference in wound healing among the conventional group and the PRF group was statistically significant (p= 0.001).
The Mann Whitney's test analysis using 95% confidence interval and α= 0.05 proved that there was a very significant difference (p= 0.001) in total cost of wound healing between the conventional group and PRF group. Multivariate test using 95% confidence interval and α = 0.05 showed that the existing external variable did not affect total wound healing cost between conventional group and PRF group (p= 0.071; p 0.05).
Plasma Rich Fibrinogen is a blood plasma contain rich of fibrin and thrombocyte concentration 3-5 times above normal value (platelet concentration in whole blood) . Another literature mentioned that thrombocyte concentrations in PRF were 2-8 times higher compared with average values . The high concentration of platelets and various growth factors in PRF has made this agent applicable in many branches of medicine, i.e., oral surgery, plastic surgery, craniofacial surgery, cardiac surgery, orthopedics, neurology, sports medicine, and dermatology .
Plasma Rich Fibrinogen has various growth factors that are needed in wound healing. When platelets in PRF are activated by thrombin, thrombocytes release growth factors and other substances that serve to accelerate wound healing by increasing cell proliferation, matrix formation, osteoid production, tissue healing, angiogenesis, and collagen synthesis. Plasma Rich Fibrinogen works by degranulation of α-granules present in platelets containing growth factors .
These growth factors help wound healing by attracting cells in a newly formed matrix and trigger cell division. Plasma Rich Fibrinogen has several advantages such as simple, safe, low cost, and clinical effectiveness so that PRF can be an ideal therapy for the treatment of chronic wounds . Plasma Rich Fibrinogen not only releases growth factors in high concentrations but also has antimicrobial properties that can prevent infection because it contains leukocytes .
Plasma Rich Fibrinogen has long been used in healing wounds and soft tissue underneath. The use of PRF in the field of skin surgery and cosmetic dermatology is also proliferating . Wound healing is a complex event involving various cells, and biochemical mediators, one of the critical part were platelets. In response to tissue damage, activated platelets will form platelet plugs and release various growth factors . These growth factors play an essential role in the various phases of wound healing (the inflammatory phase up to the remodeling phase) . Platelets also store other bioactive proteins, such as the enzyme matrix metalloproteinase (MMP), coagulation factors, chemotactic factors, adhesion molecules, vasoactive substances, as well as some bactericidal and fungicidal proteins that also play an active role in the wound healing process. Invitro, there is a relationship between platelet concentration with mesenchymal stem cell proliferation, fibroblast proliferation, and type I collagen production. It supports the role of PRF to accelerate wound healing .
Platelet Derived Growth Factor (PDGF) functions in the stimulation of fibroblasts, chemotactic, TGF-β stimulation, collagen production, increased proteoglycan synthesis. Transforming Growth Factor Beta (TGF-β) functions to modulate the proliferation of fibroblasts, formation of extracellular matrix, increase collagen production by fibroblasts, neutrophil chemotactic factors, and macrophages, while Basic Fibroblast Growth Factor (bFGF) plays a role in collagen production, stimulation of angiogenesis, and myoblast proliferation .
In this study, besides healing wounds more quickly, PRF also has more affordable cost therapy than conventional therapy. Faster healing time affects hospitalization care time in the hospital, thus reducing cost therapy. Thus, PRF can be a practical and cost-effective treatment option.
There was a significant difference in wound healing time of wound dehiscence patients after obstetric and gynecological laparotomy using PRF therapy compared to conventional methods, where PRF group has shorter wound healing time than the control group. Also, PRF therapy is cheaper than conventional therapy.