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F ABRAMO,a S ARGIOLAS,b G PISANI,b I VANNOZZIc and V MIRAGLIOTTAd

Objectives To evaluate the efcacy of a hydrocolloid dressing for the treatment of surgical wounds in dogs. Methods Six healthy young female dogs of medium size and different breed underwent ovariohysterectomy. Histological evaluation was performed on biopsies taken from the edges of the wounds at day 7. The dressing was applied on one half of the wound according to manufacturers instructions; the second half served as control. Biopsy specimens were xed in a 10% formalin buffered solution pH 7.4, parafn embedded and stained with haematoxylin and eosin. For clinical assessment, the presence and quality of exudate, erythema of the surrounding area, swelling and correct apposition of the wound margins were evaluated. Results The hydrocolloid dressing was easy to use. The clinical quality of the treated skin wounds was superior to the non-treated ones. Comparison of histological features between treated and untreated wounds showed a more regular organisation of the granulation tissue in the treated wounds, with broblasts being aligned parallel to the overlying epidermis. The number of inammatory cells and the extension of granulation tissue were less prominent and less widespread in treated compared to untreated wounds. Conclusion The dressing performed very well in terms of adhesiveness and exibility. It was useful in the management of surgical wounds to avoid contamination and ameliorate the epithelialisation rate and granulation tissue morphology of the surgical scar. Key words: wound healing, dressing, hydrocolloid, ovariohysterectomy, dog
Aust Vet J 2008;86:9599 doi: 10.1111/j.1751-0813.2007.00243.x

wound temperature is maintained and epithelial healing is improved.3 Cell migration from the wound edges, as well as cell mitosis, are encouraged in such an environment.4 Moist wound healing is now considered the norm for managing surgical wounds in humans.5,6 Bandages and gauzes represent the most commonly used products to manage wounds, especially in veterinary medicine. They are considered passive dressings, that is, they do not perform any activity aside from physical protection of the wound area. Generally, the standard of care for surgical sutured clean wounds is either no dressing or the use of non-adherent or semi-occlusive dressing. Unprotected sutured wounds can undergo desiccation or abrasion, and in animals they can be the target of self-induced trauma due to licking and scratching. Moreover, a non-adherent dressing may stick to the wound surface, causing removal of newly formed epidermis. In recent years, tissue engineering and biomedical research have been aimed at the development of new materials (interactive dressings) for wound management.7 Interactive dressings have the ability to absorb uids, to change their physical state to form a gel, and to maintain a wound bed environment conducive to healing. Among them, polymeric lms, hydrocolloids, hydrogels, polymer alginate, foams and biodressings deserve to be mentioned.8,9,11,19 The main properties of hydrocolloids are to minimise adhesion to the wound, to prevent desiccation and to maintain the moist wound healing environment, thus allowing painless removal of the dressing. They have been studied since the 1960s, especially for the treatment of non-healing decubital ulcers.12 Hydrocolloids are made up of natural or synthetic granular polymer mixtures dipped into an adhesive hydrophobic three-dimensional matrix. When the matrix is structured in a reticular pattern, the hydrocolloidal hydrophilic micro-granules (gelatin, pectin) are embedded in the bres and cannot come out. Micro-granule hydrophily allows a slow and well controlled water uptake, leading to a physical transformation named phase inversion characterised by gel formation13 and colour modication.14 The phase inversion begins at the centre and expands to the periphery, being conned to the injured area (exudative area), whereas in the surrounding normal area, the bandage is adherent and remains unaltered. Several reports show the advantages of using hydrocolloidal bandages in human wounds.15 In domestic animals, less information is available, and the studies performed in humans cannot be directly adapted to wound healing in animals because
Australian Veterinary Journal Volume 86, No 3, March 2008

Introduction
Protection of skin wounds and proper management are important factors for prevention of microbial infection and water loss, thus improving wound repair. The degree of protection required for good healing is related both to the wound features and to the environment in which the animal lives.1 It has already been shown that moist conditions, compared to dry ones, accelerate healing.2 In a moist environment, optimal
a

Department of Animal Pathology, Department of Veterinary Clinic, University of Pisa, 56124 Pisa, Italy. b Ambulatorio Veterinario Associato, 19100 La Spezia, Italy. c Department of Veterinary Clinic, University of Pisa, 56124 Pisa, Italy. d Department of Veterinary Anatomy, Physiology and Biochemistry, University of Pisa, 56124 Pisa, Italy.

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Effect of a hydrocolloid dressing on rst intention healing surgical wounds in the dog: a pilot study
Blackwell Publishing Asia

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of anatomical, physiological and, above all, behavioural differences. Wound contraction is quicker in animals than in humans and, in the absence of complications, the proliferative phase of wound healing is more efcient and the scarring less optimal.16 An important factor to be considered in veterinary wound management is the greater environmental contamination and the inability to control self-mutilation. A few studies on the efcacy of hydrocolloids have been performed using animal models: contrasting results have been reported on their effects in pigs, rats and dogs.16 19 Matsumuras 199716 experiments were performed on a special dog breed (Mexican Hairless), created to have skin more similar to that of the human while a 1994 study19 did not include histological analyses. The aim of the current investigation was to evaluate the efcacy of a hydrocolloid dressing (Comfeel Plus transparent dressing), already tested in humans,20 in treating surgical wounds in dogs. Clinical and histological features were compared between treated wounds and those healing with no treatment. Since the Pisa University Ethical Committee limited the study to only one biopsy and to those animals subjected to surgery for other reasons, surgical wounds which usually heal quickly and with no major complication were selected. punch served as a control. After ovariohysterectomy the midline incision was closed in three layers: rectus abdominis and its sheaths with a simple continuous poliglactin 910 0 2-0 USP suture; subcutaneous tissue with a simple continuous poliglactin 910 3-0 4-0 USP suture and skin with a simple interrupted 2-0 USP nylon suture. Amoxicillin and clavulanic acid 10 mg/kg SC once, were administered postoperatively. The hydrocolloid dressing was applied to the cranial half of the wound. The caudal half was not dressed and served as the control. Wounds were monitored daily and bandages were changed when necessary (loss of adhesiveness, bleeding), and at the same time the wounds were gently cleaned with sterile physiological saline (0.9% NaCl) solution. The observation period lasted 7 days. Healing wounds were scored macroscopically as: improved, unchanged and worsened. For this clinical assessment the following criteria have been established: presence and quality (serous, sero-sanguineous or purulent) of exudate, erythema of the surrounding area, swelling and correct apposition of the wound margins. The improved score was attributed when treated wounds showed less or no exudate (serous vs sero-sanguineous or purulent), less or no erythema and less or no marginal swelling compared to controls. The unchanged score was attributed when the assessment of the above parameters gave similar results in treated and control wounds. The worsened score was attributed when the treated wounds showed more exudate (sero-sanguineous and purulent vs serous), erythema and margin swelling compared to controls. At day 7, under local anaesthesia with 0.5 mL lidocaine HCl 2%, a second 4 mm biopsy from both the treated and the untreated wounds was taken. Antibiotics and disinfectant solutions were not used topically. Wound biopsy specimens Eighteen biopsies from the six animals were taken: a) six from normal skin; b) six from the edge of treated wounds at day 7 and c) six from the edge of untreated wounds at day 7. Skin biopsies were xed in a 10% formalin buffered solution with pH 7.4 and parafn embedded. Sections with a thickness of about 5 m, taken perpendicular to the surface, were stained with haematoxylin and eosin to evaluate inammation, granulation tissue and re-epithelialisation quality. Inammation was scored with regard to the neutrophil component, focusing at hot spots in the granulation tissue (+ = less than 25% of granulation tissue cells represented by neutrophils; ++ = between 25 and 50%; +++ = more than 50%; = lack of neutrophils).

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Materials and methods


Wound dressing The hydrocolloid Comfeel Plus Transparent Dressing (Comfeel Plus Transparent Dressing, Coloplast A/S, Humlebaek, DK.) was used. It consists of a 25 m semi-permeable polyurethane outer membrane with a thin 300 m absorbent and adhesive hydrocolloid interface. The transparency of the dressing allowed inspection of the wound without removal of the dressing, and transforms the absorbed exudate into a gel, gradually becoming opaque, thus signalling when it should be replaced. Animals and procedure The study was authorised by the Ethical Committee of the University of Pisa and the animals were included in the study only after written agreement from their owners. Six healthy young female dogs of medium size, of different breeds, without signs of dermatological or internal diseases, and that were presented to be spayed, were selected for the clinical trial. Complete blood work results were within normal limits. Ovariohysterectomy was performed at the same site for each subject, eliminating anatomical variables that could have invalidated comparative evaluations. Only females were included in the study, thus avoiding possible hormonal variables. Hair was clipped and the surgical sites were aseptically prepared. With the dogs under general anaesthesia (propofol 4 mg/kg IV and isourane 2% in oxygen), 4 cm midline abdominal incisions were created by the same surgeon and with the same protocol. A skin biopsy taken from each animal at the beginning of the surgical procedure on the operative site (day 0) with a 4 mm
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Results
General assessment Complications following anaesthesia and systemic antibiotic therapy were not observed. The dressing was easy to apply, and demonstrated excellent adherence to both the wound and the surrounding skin in all but one patient. In this patient the hydrocolloid bandage was replaced within the rst hours following surgery because of bleeding, with consequent accumulation of sero-haemorrhagic material between the bandage
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and the skin surface. No other medications were needed subsequently. Clinical assessment Five of the six dogs showed an amelioration of the clinical quality of the treated wounds (improved) in respect to the controls. In one dog differences between treated and control wound were not found (unchanged). During the observation period, hydrocolloid treated wounds did not show any evidence of exudate, erythema and or infection. Five of the untreated wounds featured either mild erythema or focal swelling of the wound margin, small crusts close to the suture material and, in one case, incompletely apposed margins. In ve of the six dogs, the bandage was removed easily and painlessly. In the remaining dog the bandage adhered to the wound, although clinico-dermatological signs were not noticed on the skin after removal. Histological assessment Skin biopsies taken at day 0 from all dogs showed normal histological features. In all the biopsies obtained at day 7 from both treated and untreated wounds, epidermal and dermal modications due to the healing process were noticed. These were characterised by re-epithelialisation and the presence of granulation tissue. Re-epithelialisation was complete in all the cases and the new epidermis was irregularly hyperplastic in the untreated wounds and showed a compact hyperkeratotic layer in the treated ones (Figure 1 A, B). In the granulation tissue, neo-angiogenesis, broplasia and a variable number of inammatory cells, mainly neutrophils and macrophages, were present. Comparison of histological features between treated and untreated wounds showed a more regular organisation of the granulation tissue in the treated wounds, with broblasts aligned parallel to the overlying epidermis. In untreated wounds, collagen bundles assumed a non-linear and more woven arrangement (Figure 1 C, D). In untreated wounds, the wound bed was composed of granulation tissue containing a conspicuous number of diffusely distributed inammatory inltrate in the interstices, mainly neutrophils, while in treated wounds, wound beds contained few if any inammatory cells (Figure 1 E, F). The neutrophil content score is shown in Table 1. The wound bed appeared to be more widespread and irregular in the untreated compared to the treated wounds as shown in Figure 1 A, B. In the latter, the granulation tissue projected downwards into the deep dermis in a narrow linear fashion. It is well established in humans that chronic wounds heal better2 and more quickly in moist conditions. The hydrocolloid layer of the dressing used creates a moist environment between the polyurethane membrane and the surface of the wound. Benets
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have also been demonstrated in surgical wounds from the use of both conventional and modern dressings, especially to control contamination21 and to enhance the repair process. In particular, hydrocolloid dressings have been found to be signicantly more comfortable than conventional ones,22 cost-effective, and time-saving.23 While avoiding contamination is a main goal in veterinary medicine wound care, the use of hydrocolloid dressings has not been thoroughly investigated. In 1994, Morgan et al19 reported their use in acute full-thickness wounds in dogs, but the present study is the rst to report the use of hydrocolloid dressings in surgical wounds in this species. In our study the hydrocolloid dressing was easy to use, performed well in terms of adherence and exibility, was well-tolerated and did not induce allergic reactions. Because of the transparency of the bandage, it was possible to supervise the clinical evolution of the wounds, controlling possible bleeding (as occurred in one patient), contamination, or other complications. The adhesive power of this product makes it particularly suited to use in animals. It has been shown in humans20 that this dressing can be left in place for up to 7 days without the need for a secondary dressing, thereby saving time and materials. Hair clipping and correct application of the bandage appear to be important in wound management. If hair clipping is not done properly there could be pain during the healing process or during bandage removal, since the growing hair adheres to the bandage.24 Moreover, the operator has to be careful to avoid bubble formation that might create non-adherent areas, with subsequent detachment. Histological evaluation allowed evaluation of healing tissue in both treated and untreated wounds, and, in all cases, reepithelialisation over the granulation tissue was complete at day 7. The hyperplastic epidermis was covered by a layer of compact keratin rather than the normal basket weave organisation of keratinocytes. The compact appearance of the stratum corneum might have been due to compression by the bandage. Inammatory cells were fewer in number in the treated wounds compared to untreated ones. Acute inammation in the proliferative phase of wound healing is considered essential to the proper outcome of a repairing wound. Its role is to inactivate inciting stimuli and restore normal microvascular permeability in order to prevent continued passage of blood cells into the wound space.25 Inammation is also necessary for the release of mediators required for the repair phase, however, the secretory activity of inammatory cells must be halted and macrophages and neutrophils must be cleared from the wound bed in order for the inammatory response to resolve and the remodelling phase to proceed.25 This mechanism prevents chronic inammation and resultant healing disorders. The paucity of inammatory cells found in the treated wounds may have been a positive response of the tissue to prevent healing disorders in the subsequent remodelling phase. In treated wounds, regular organisation of the granulation tissue scaffold was observed histologically, and may have represented an attempt to restore the normal mechanical properties of the
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Discussion

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Figure 1. Photomicrographs of skin biopsies taken at day 7 in untreated (A, C, E) and treated (B, D, F) wounds. A, B: the width of the healing tissue was greater in the untreated (A) than in the treated (B) wounds (Bar = 300 m). C, D: treated wounds showed regularly arranged broblasts, mostly in parallel bundles (Bar = 100 m) while control wounds showed haphazardly organised collagen bundles and broblasts. E, F: treated wounds showed few inammatory cells compared to the untreated ones (Bar = 50 m).

skin, leading to improved tissue quality (in terms of strength and resistance). The dressing might have contributed some mechanical property to the skin/wound interface, thus preventing the detachment of the wound margins. Reduction in the number of inammatory cells at day 7, together with a more regular collagen bre organisation in the treated wounds, suggests that the hydrocolloid dressing properly guided the healing process.
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Unfortunately, ethical concerns allowed the inclusion in the study of only six subjects, thus necessitating the use of each dog as its own control and precluding the randomisation of the cranial and caudal wound halves to the treatment group. Performing treated and control wounds in the same subject, however, may have reduced the inuence of confounding variables. Ethical concerns also precluded further biopsies, limiting histological evaluation to the early postoperative period.
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Table 1. Assesment of inammation in the granulation tissue of untreated wounds and wounds treated by the application of a hydrocolloid dressing Case 1 Group nt t 2 nt t 3 nt t 4 nt t 5 nt t 6 nt t nt = non treated wounds, t = treated wounds + = less than 25% of granulation tissue cells represented by netrophils; ++ = between 25 and 50%; +++ = more than 50%; = lack of neutrophils Score +++ + +++ + +++ + +++ + ++ ++ + 3. Wu P, Nelson EA, Reid WH, Ruckley CV, Gaylor JD. Water vapour transmission rates in burns and chronic leg ulcers: inuence of wound dressings and comparison with in vitro evaluation. Biomaterials 1996;17:1373 1377. 4. Lawrence JC. Dressings and wound infection. Am J Surg 1994;167:21 24. 5. Bruin P, Jonkman MF, Meijer HJ, Pennings AJ. A new porous polyetherurethane wound covering. J Biomed Mater Res 1990;24:217 226. 6. Williams C. Hydrocoll: a new breed of hydrocolloid wound dressing. Br J Nurs 1998;7:13371340. 7. Turner TD. Interactive dressing used in the management of human soft tissue injuries and their potential in veterinary practice. Vet Dermatol 1997;8:235 242. 8. Turner TD. Semipermeable lms as wound dressings. Schweiz Rundsch Med Prax 1984;73:950952. 9. Schmidt RJ, Spyratou O, Turner TD. Biocompatibility of wound management products: the effect of various monosaccharides on L929 and 2002 broblast cells in culture. J Pharm Pharmacol 1989;41:781 784. 10. Cockbill SME, Turner TD. Management of veterinary wounds. Vet Rec 1995;136:362365. 11. Ramsey DT, Pope ER, Wagner-Mann C, Berg JN, Swaim SF. Effects of three occlusive dressing materials on healing of full-thickness skin wounds in dogs. Am J Vet Res 1995;56:941949. 12. Spence WR, Burk RD, Rae JW. Gel support for prevention of decubitus ulcers. Arch Phys Med Rehabil 1967;48:283 288. 13. Lanel B, Barthes Biesel D, Renier C, Chauve T. Swelling of hydrocolloid dressings. Biorheology 1997;34:139153. 14. Holtz JH, Asher SA. Polymerized colloidal crystal hydrogel lms as intelligent chemical sensing materials. Nature 1997;389:829 832. 15. Eisenbud D, Hunter H, Kessler L, Zulkowski K. Hydrogel wound dressings: where do we stand in 2003? Ostomy Wound Manage 2003;49:52 57. 16. Matsumura H, Yoshizawa N, Kimura T et al. A burn wound healing model in the hairless descendant of the Mexican hairless dog. J Burn Care Rehabil 1997;18:306312. 17. Agren MS, Everland H. Two Hydrocolloid dressings evaluated in experimental full-thickness wounds in the skin. Acta Derm Venereol 1997;77:127 131. 18. Agren MS, Mertz PM, Franzen L. A comparative study of three occlusive dressings in the treatment of full-thickness wounds in pigs. J Am Acad Dermatol 1997;36:5358. 19. Morgan PW, Binnington AG, Miller CW et al. The effect of occlusive and semi-occlusive dressings on the healing of acute full-thickness skin wounds on the forelimbs of dogs. Vet Surg, 1994;23:494 502. 20. Goodhead A. Clinical efcacy of Comfeel Plus Transparent Dressing. Br J Nurs 2002;11:284287. 21. Noe JM, Keller M. Can stitches get wet? Plast Reconstr Surg 1988;81:82 84. 22. Rasmussen H, Larsen MJ, Skeie E. Surgical wound dressing in outpatient paediatric surgery. A randomised study. Dan Med Bull 1993;40:252 254. 23. Hulten L. Dressings for surgical wounds. Am J Surg. 1994;167:42S 45S. 24. Cockbill SME. Evaluation in vivo and in vitro of the performance of interactive dressings in the management of animal soft tissue injuries. Vet Dermatol 1998;9:8798. 25. Theoret CL. The pathophysiology of wound repair. Vet Clin North Am Equine Pract 2005;21:113.

In conclusion, this pilot study provides some evidence that hydrocolloid dressings may be of benet in the management of rst intention healing wounds in veterinary patients. Although preliminary, our histological ndings suggest the possibility of using hydrocolloid dressings to guide the wound healing process.

Acknowledgments
We acknowledge the Italian Education University and Scientic Research Ministry for funding this work.

References
1. Tanaka A, Nagate T, Matsuda H. Acceleration of wound healing by gelatin lm dressings with epidermal growth factor. J Vet Med Sci 2005;67:909913. 2. Horncastle J. Wound dressings. Past, present, and future. Med Device Technol 1995;6:3036.

(Accepted for publication: 27 August 2007)

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