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Biosurgery the Future of non Healing Wounds

Article  in  Polish Journal of Surgery · June 2010

DOI: 10.2478/v10035-010-0054-5

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POLSKI
PRZEGLĄD CHIRURGICZNY 10.2478/v10035-010-0054-5
2010, 82, 6, 371–375
Biosurgery the future of non healing wounds
Hubert Arasiewicz, Benita Szubryt, Mariola Wylędowska-Kania
Department of Dermatology and Venerology, Medical University of Silesia in Katowice
Kierownik: prof. dr hab. L. Brzezińska-Wcisło
As our society is ageing the number of pa-
tients suffering from chronic wounds arising
from diabetes and peripheral vascular disease
is constantly growing. It places an enormous
burden on our health care system. Chronic
wounds require long-term treatment, what
results in the increasingly higher costs. Bio-
surgery, as an alternative to a classic wound
dressing, proved to be a very effective and
quick method of wound cleansing. It hastens
the healing process, and hence lowers the
overall cost of the treatment (1). It uses sterile
maggots Lucilia sericata. The simplicity and
limited number of side effects makes it a very
promising method of chronic wound dressing.
This article aims to present a current practical
and theoretical understanding of biosurgery.
History
The history of biosurgery dates back to the
times of native tribes of New South Wales,
Burmese highlanders as well as ancient Maya
people. The first physician to observed a posi-
tive influence of maggots on the process of
chronic wounds healing was a French surgeon,
Ambroise Paré (1510-1590). The turning point
of his experience with biosurgery was during
an observation of a patient with a severe head
wound, where maggots significantly contrib-
uted to the recovery. Thereafter Paré allowed
maggots to live in the open wounds, as a factor
enhancing healing process. The first docu-
mented example of applying maggots at an
open wound was a publication by a military
physician, Forney Zacharias (1837-1901), who
described it during The Civil War. A real
breakthrough however transpired in 1928,
when William Baer, an American orthopedist
from John Hopkins University applied faculta-
tive parasitism principles in a bone inflamma-
tion treatment of four children. In those days
the therapy was deemed the quickest and the
most effective method of bone inflammation
treatment. In the thirties over three hundred
American hospitals were using biosurgery as
a standard in chronic wounds treatment, and
over one hundred papers were published on
the subject. However, an advent of sulfon-
amides and industrial technology of penicillin
production in the forties ousted biosurgery
from the heath care. Present renaissance of
the method is caused by a growing antibiotic
resistance and constantly increasing cost of
the chronic wounds treatment.
A significant contribution to the revival of
biosurgery is attributed to Ronald Sherman,
employee of the University of California Irvine
Medicine School, USA. Together with his co-
worker, he conducted research that helped
biosurgery back to the academic medicine. In
1996 International Biotherapy Society, an
entity examining role of the living organisms
in the wound healing process, was estab-
lished.
Nowadays, utilization of maggots Lucilia
sericata for healing purposes is getting a grow-
ing number of supporters. The comeback of
maggots therapy is an effect of a progressive
ageing of the society. This demographic trans-
formation prompts the increase of illnesses
causing intractable wounds, and in effect im-
poses heavy costs on the overloaded health care
system (2-6).
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372 H. Arasiewicz i wsp.
Mechanics
Cornerstone of the intractable wounds
treatment is a proper debridement, sustaining
moist environment and preventing infection.
Using maggots in the treatment helps to
change the course of healing from chronic to
to severe (normal wound healing phases)(7).
During the process maggots devour bacteria
along with liquid dead tissue, and subsequent-
ly bacteria are destroyed within their digestive
system. The whole process is so efficient, that
maggots are able to change the wound from
rank and infected to clean and healthy within
just few days. Numerous authors divide the
mechanics into three stages: debridement,
disinfection and stimulation of healing.
Debridement
Debridement is a stage thanks to which we
gain control over an inflammation, limit bad
odour and expose healthy vascularized tissue.
Biosurgery enables debridement on the micro-
scopic level, with minimal damage to a healthy
tissue – the quality that gives biosurgery an
upper hand over traditional methods. Maggots
Lucilia sericata are necrophagous organisms
feeding on dead tissue and ooze coming from
the wound (3). As an organism, maggot is de-
void of teeth, and hence digest extracorporealy
by secreting a number of enzymes including:
carboxypeptidases A and B, leucine aminopep-
tidase, collagenase and serine proteases (tryp-
sin-like and chymotripsin-like), aspartyl pro-
teinase and metalloproteinase (8). Digested
tissue is subsequently painlessly consumed by
the maggot. One maggot consume approxi-
mately 0.15 gram of dead tissue a day. Depend-
ing on the number of maggots used and the
time over which the dressing is applied, it
enables to clean the wound to a substantial
extent (9). Approximately 5 to 10 maggots a
cm2 is suggested (10).
Disinfection
Apprehension of the mechanics by which
maggots can bring infection under control in
scope of the wound was altering alongside the
development of the research methods. The first
theory implied that maggots activity intensify
the oozing, and hence cause mechanical rinsing
of the wound. Rich with proteolytic enzyms
ooze was supposed to contribute to digestion
of bacteria. It was also proved that bacteria
consumed by the maggot die in its digestive
system. Excreting ammoniac and calcium
carbonate, maggots increase pH index of the
wound, what constrains expansion of the bac-
teria and broadens an activity of the proteo-
lytic enzyms (6, 8, 11). The antiseptic mechan-
ics is not completely intelligible. Due to the
ambiguous results of the research, the direct
antiseptic in vitro effect could not be proved (12).
Nevertheless, presence of at least two active
antiseptic agents, characterized by a broad
spectrum of activity G(+), G(-) including
MRSA, has been proved. Modern methods of
isolation allowed approximate stipulation of
the antiseptic substances nature as thermo-
stable and protease resistant (size <500 Da
and 0,5-3-kDa) (13, 14, 15). Last researches
indicate that maggots play a key role in break-
ing bacterial biofilm with Pseudomonas aeru-
ginosa, what additionally promotes its usage
for infected wounds (16).
Stimulation of healing
Maggots stimulate healing by draining a
tissue, what enables better access to oxygen and
enzymes. They excrete allantoin and urea,
which are ingredients of numerous healing
ointments (6). Experimental tests confirmed
that maggots’ excretions/secretions (ES) causes
increased activeness of fibroblasts in vitro (17,
18, 19), and also inhibits pro-inflammatory
function of neutrophiles (20) and monocytes
(21), without suppressing phagocytosis. De-
scribed was also immuno-moduling effect based
on decreasing the production of TNF-a, IL-
12p40 (pro-inflammatory function) and increas-
ing IL-10 (anti-inflammatory function). The
latest research enabled isolation of IFN-gamma
and beta-FGF from the ES maggots. Those
agents have a fundamental role in philological
healing processes (19). Wang and assoc. showed
that ES induces human microvascular endothe-
lial cell migration through AKT1 (22). More-
over, authors are unanimous regarding its
beneficial effect on wound remodeling.
Indications and contraindications for
biosurgeral debridement
Biosurgery is very effective with intractable
wounds. Physicians all over the world use this
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 Biosurgery the future of non healing wounds
method especially willingly with diabetic wounds
and other wounds with large amount of dead
tissue, and get good clinical results (23-28). Some
the applications of “living wound dressings”
described in the literature (6) are as follows:
– diabetic ulcers,
– ulceration (venous, arterial, venous-arte-
rial, naturopathic),
– pressure sores,
– thromboangiitis obliterans,
– tumour-related wounds,
– necrotizing fasciitis,
– pyoderma gangrenosum,
– osteomyelitis,
– burns,
– severe wounds,
– mastoiditis,
– pilonidal sinus,
– wound infected after breast operation,
– wounds after a knee joint endoprosthesis,
– non-healing wounds after surgeries,
– MRSA infected wounds,
– condition after removing medial malleolus
abscess,
– infected gun shot wound.
A few of them were not long ago disadvised,
due to a problematic location of the dressing
(what caused difficulties during disposal of
maggots). This includes: cleansing of perito-
neal cavity, glans penis or pleural space (29).
Immuno-modulating mechanics described
above justify treatment of pyoderma gangreno-
sum and other skin alterations with autoim-
munologic background. Another thesis empha-
size antiseptic property of maggots which
contribute to good clinical results in infected
wounds dressing MRSA (14). Another ex-
tremely important aspect is a tumour-related
wounds treatment, where cleansing has a pal-
liative character. It helps to eliminate an un-
pleasant odour, which is often embarrassing
for a patient. Nowadays maggots are more
willingly used for non-chronic severe wounds
(29). Relative contraindications include dry
wounds (maggots require humid environment),
opening abdominal cavity and neighborhood
of large blood vessels (Difficult disposal of mag-
gots). There is also one strict contraindication
– allergy to maggots (6).
Side effects
Biosuregeral therapy is considerably safe
and entails few possible side effects. One of the
373
most dangerous is an infection transmitted by
non-sterile maggots. However, ensuring prop-
er breeding conditions and sterility minimize
the problem considerably (30). In case of large
amount of dead tissue a disagreeable oduor
caused by engaging the wound is likely, but
this can be mostly eliminated after first change
of dressing. Very important factor is a tech-
nique and thoroughness of dressing applica-
tion, as it determines the stability of dressing
and prevent maggots from getting out, what
could discourage patients and medical person-
nel alike from using the therapy. Pain rarely
accompany the therapy and is easily subjected
to pharmacotherapy (31, 32). Mentions about
bleeding from biosurgeraly cleansed wound
seldom occur (33).
Biosurgeral dressing
Correctly applied dressing is a significant
element of the biosurgeral therapy. Its main
purpose is to keep maggots within the limits
of the wound. It has to be thigh enough lest
“little surgeons” escape, and airy enough to
enable them their work. During the process of
debridement wound usually become more
soggy and oozy, hence extra gauze should be
applied. Biosurgeral dressing should be ap-
plied for approximately 3-4 days. However, it
is not possible to stipulate the exact time, as
it is individually tailored to each patient. A
good yardstick is a size of maggots. While ap-
plying, they are the size of a rice grain, and
provided the debridement proceeds success-
fully, they grow 1 cm long. Varied techniques
of “living dressing” application, depending on
the location of the wound, are available. They
all consist in constructing a “cage” which re-
strict maggots to the area of the wound. There
is an alternative dressing called Biofoam, in
which sterile maggots are mixed up with
scraps of foam and put into a handy bag, what
keeps them out of sight. Cage dressing is
cheaper and more available than biofoam, and
being equally effective, it is more frequently
in use(9). General rules of cage dressing
preparation boils down to four simple steps,
which are:
I. Covering healthy skin → II. Applying
maggots → III. Securing maggots with cage →
IV. Applying outer dressing.
It must be remembered that biosurgeral
dressing, by virtue of its living nature, requires
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374 H. Arasiewicz i wsp.
exceptional precautions. Wetting, drying or
squashing is strongly disadvised as it can dis-
turb the debridement (30, 31).
Costs
Economic aspect of biosurgery was compre-
hensively described in British conditions.
Among the publications we can find calcula-
tions unambiguously in favour of biosurgery,
as well as those regarding it financially com-
parable with classic therapy. Wayman and
assoc. presented result ranging from £79 to
£136, whereas Thomas and assoc. put it be-
tween £82 and £503 (adding up nursing care
cost) respectively for patients treating with
biosurgeral and classic dressing (34, 35). Dum-
ville and assoc. indicated that the time of
wound debridement was considerable short-
ened, but it didn’t entail lower cost of the
therapy (36). As for polish conditions, breeding
of sterile maggots Lucilia sericata is getting
more and more common, what entails its mar-
ket price drop. Appearance of local sellers has
broken the barrier of expensive import. Some
of the authors encourage hospitals to breed
maggots independently in specially appointed
spaces, what should additionally lower costs
of the therapy (37).
Discussion
Nowadays, maggots are used in hospital as
well as ambulatory treatment all over the
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