Limited Access Dressing and Maggots

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Author(s): 
Professor Pramod Kumar, MS, MCh, DNB

Abstract: A case of infected wounds with lymphedema (non-pitting with skin changes) on the left leg showed maggots in the wounds that were covered by slough that extended under the skin edge. The patient had diabetes mellitus and hypertension (on treatment). Removal of the maggots with our routinely practiced method using turpentine oil and closed gauge dressing was tried but failed. After 3 days, closed dressing limited access dressing (LAD) technique was applied, which cleared the wound without allowing the maggots to escape from the dressing. In this case, LAD was a more controlled, hygienic, and effective method of maggot removal. This knowledge may help the surgeon in designing the better-controlled environment for maggot debridement therapy (MDT).





Address correspondence to:
Professor Pramod Kumar, MS, MCh, DNB
Professor and Head of the Department of Plastic Surgery
Kasturba Medical College
Manipal, Karnataka 576 104
India
Phone: +91 (0) 820 257 1201
E-mail: pkumar86@hotmail.com




     Sushruta (600 BC, India), in his surgical treatise Sushruta Samhita, described that flies deposit worms (maggots) onto wounds.1 Like most of its contemporaries, Paré in the 16th century believed that maggots developed spontaneously as a part of the putrefaction process of devitalized tissue.2 Sushruta also described the use of maggots in debridement of tumors.3 English translation of his description is as follows:

      “Nispava, pinyaka (molasses), and paste of kulattha (herbal medicine) added with more meat and water of curd (whey) made a nice paste and was applied on the tumor so that flies shall swarm to it and krimi (worms/maggots) develop there and eat away the tumor. When only a small remnant (of the tumor) remains after the worms have eaten, the area should be scraped and burnt by fire; or if the base (of the tumor) is small it can be kept encircled (for some days) with thin sheets of tin, copper, lead, and iron.”

     Jean Larrey and John Forney Zacharias, recognized that maggots removed only dead tissue, which accelerated the natural healing process.2 William S. Baer (after World War I) used maggots in a cage type dressing for cleaning fowl-smelling, pus-discharging wounds.2 Fleischmann et al2 and Sherman and Shimoda4 found that maggots were effective in debriding many nonhealing wounds, which lead to enhanced wound healing and aided in presurgical wound bed preparation.5

     Maggots debride with their secreted digestive juices,2,5 mouth hooks, and spicules.2 Wound healing improves with maggots because they kill microorganisms (including methicillin-resistant Staphylococcus aureus [MRSA] and pathogenic streptococcus strain) and flush the wound with increased fluid secretion, alter pH (acidic) through secretion of various chemicals, its larval immune system (defensins), and its digestive system. Growing larvae also secret growth factors, which can improve wound healing.2 Maggot therapy, also known as maggot debridement therapy (MDT), larval therapy, or biosurgery, was widely used in controlled and sterile settings2,5 before the discovery of antibiotics, as it serves to clean a wound (human or animal) in order to promote healing.

     Since 1995, the Biosurgical Research Unit in Bridgend, South Wales has distributed sterile larvae commercially. German and Belgian factories have distributed fly larvae in middle Europe since 1998. Since 1996, an annual global meeting on larval therapy (or biosurgery as it was once known) has convened.

References: 

1. Murthy SKR. Cikitsa sthana and Kalpa sthana. Dvivraniya cikitsa [Treatment of two kinds of wounds]. In: Sushrutha Samhita, vol 2. 2nd ed. Chaukhambha Orientalia, India: Varanasi; 2005:3–28.
2. Maggots and Wound Healing. In: Fleischmann W, Grassberger M, Sherman R. Maggot Therapy: A Handbook of Maggot-Assisted Wound Healing. Stuttgart, Germany: Georg Thieme Verlag KG; 2004:16–26.
3. Murthy SKR. Cikitsa sthana and Kalpa sthana. Granthi-apasiarbuda galganda [Benign tumor-Goiter, malignant tumor and cervical lymphadenitis]. In: Sushrutha Samhita, vol 2. 2nd ed. Chaukhambha Orientalia, India: Varanasi; 2005:172–181.
4. Sherman RA, Shimoda KJ. Presurgical maggot debridement of soft tissue wounds is associated with decreased rates of postoperative infection. Clin Infect Dis. 2004;39(7):1067–1070.
5. Whitaker IS, Twine C, Whitaker MJ, Welck M, Brown CS, Shandall A. Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential. Postgrad Med J. 2007;83(980):409–413.
6. Kumar P. Limited access dressing. WOUNDS. 2008;20(2):49–59.
7. Sowani A, Joglekar D, Kulkarni P. Maggots: a neglected problem in palliative care. Indian J Palliat Care. 2004;10(1):27–29.







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