Low-Level Laser Therapy Prevents Prodromal Signal Complications on Saphenectomy Post Myocardial Revascularization

Abstract

Background and objective: One of the most frequent treatments for ischemic heart disease is myocardial revascularization, often applying the saphenous vein as a coronary graft. However, postoperative complications may occur, such as saphenous dehiscence. According to the literature, low-level laser therapy (LLLT) has been used in the treatment of several inflammatory processes in patients. Recently, its uses have expanded to include LLLT preventive therapy and postoperative treatment. Despite our department's successful application of LLLT in the treatment of saphenectomy incisions, many colleagues are still uncertain as to laser theraphy's benefits. Therefore, the study's purpose was to evaluate tissue repair of prodromal surgical incisions after the administration of LLLT. Materials and methods: The pilot study included 14 patients, divided into two groups. Both groups of patients received the traditional treatment; additionally, the Laser Group (n=7) received diode laser treatment (λ=780 nm, fluence=19 J/cm², pulse=25 mW, time=30 sec, energy=0.75 J, irradiance=625 mW/cm², beam spot size 0.04 cm²), which was applied on the edges of the saphenectomy incision. The Control Group (n=7) received conventional treatment exclusively. Results: In the Laser Group: all seven patients showed significant improvement, whereas the Control Group had twice as many complications, including critical rates of incisional dehiscence . Conclusions: LLLT was valuable in preventing prodromal complications in saphenectomy post myocardial revascularization.

Introduction

Approximately 17,000,000 people died from cardiovascular diseases (CVDs) in 2008; >80% of CVD deaths occur in low to middle-income countries. It is the leading cause of death in Brazil (300,000 deaths/year), as well as worldwide.¹ By 2030, almost 23,600,000 people will be dying from CVDs.²

Cardiovascular surgery has evolved in the last three decades, particularly regarding the treatment of coronary heart disease, and especially in the surgical treatment of myocardial ischemia caused by coronary artery obstruction.³ In Brazil, the first studies on myocardial revascularization (MR) were pioneered by Zerbini et al.⁴ During the first half of 2011, an average of 208 monthly cardiac procedures were performed at The Heart Institute, The General Hospital at Medical School of University of São Paulo (InCor/HC-FMUSP).

Jatene et al.⁵ were the first to perform MR using internal saphenous vein bypass. Nonetheless, saphenectomy site complications can lead to postoperative morbidity, as a result of coronary artery bypass grafting. Moreover, significant incisional complications occur following lower extremity bypass procedures.⁶ Saphenectomy dehiscence after MR causes 10% of patients' health debilitation, and increases length and cost of hospital stays.⁷

Studies performed in patients undergoing MR showed that several factors are associated with morbidity, changing the normal healing process. Among them are diabetes mellitus (DM), hypertension (HBP), dyslipidemia (DLP), older age, and cardiopulmonary bypass.^7
–9

Low-level laser therapy (LLLT) is one of advanced healing tools, accelerating and optimizing the tissue repair process.^10
–12 There is evidence that LLLT advances tissue repair by enhancing RNA, DNA,¹³ and adenosine triphosphate (ATP) synthesis,¹⁴ facilitating angiogenesis,¹⁵ fibroblast proliferation,¹⁶ collagen, and other tissue component synthesis,^17
–19 as well as promoting immunologic action.²⁰ Although there are few studies detailing LLLT in surgical prevention,²¹ Chavantes²² has shown positive results, avoiding dehiscence in sternotomy as well as in saphenectomy,⁷ which presented a significant reduction in morbidity rates. By preventively applying LLLT, Pinto et al.²³ found a decline in the incidence of surgical wound dehiscence in neonates who underwent surgical repair of congenital myelomeningocele.

The purpose of the study was to evaluate tissue repair in prodromal saphenectomy incisions applying LLLT in patients undergoing MR.

Materials and Methods

Patients

This work was a pilot study with 14 patients (5 women and 9 men), who presented prodromal signals on the saphenous incision post MR were selected. Patients were divided equally into two groups:

The Laser Group (G1) – conventional therapy plus laser irradiation on surgical incision (n=7)

The Control Group (G2) – conventional therapy only (n=7)

All patients were evaluated within the first 12 h (immediate postoperative [IPO]), 48 and 72 h post-surgery, subsequently on the 7th day (prior to hospital discharge), and subsequently on the 15th, 30th, 60th, and 180th days following the surgery.

The present study was conducted at The Laser Medical Center, The Nursing Department and The Cardiovascular and Thoracic Surgery Department of The Heart Institute, General Hospital, Medical School, University of São Paulo (InCor-HC/FMUSP). Data were collected after the approval of the Ethics Research Committee of The Heart Institute (InCor-HC/FMUSP). Patients read and signed the written informed consent. All groups were randomly sorted.

Exclusion criteria

Criteria for excluding potential research subjects included: (1) immunosuppression; (2) infection; (3) respiratory, kidney, or liver failure; or (4) class III or IV obesity.

Treatment

A continuous wave (CW) diode laser (GaAlAs–780 nm) with beam area=0.04 cm² (Twin Laser from MM Optics, São Carlos-SP, Brazil) was used under the following specifications: fluence=19 J/cm², output power=25 mW, exposure time=30 sec, spot size=0.04 cm², irradiance=625 mW/cm², energy=0.75 J, were applied surrounding the entire surgical perimeter wound edge (each 2 cm). Dosimetry was kept even with the incision reduction. The points' numbers were changed for each patient, according to wound's size. Laser irradiation applied at the following intervals: 2nd PO and 4th PO day in the intensive care unit (ICU). All patients received conventional treatment in the ICU, where cleaning was performed using saline solution (SS) at 0.9% and gauze occlusive dressing every 24 h.

Surgical incision

The suture closed material used was synthetic absorbable poly (glycolide E-caprolactone) monofilament, 4350-40XF (4-0, MONOFYL^®).

A single, independent, experienced investigator documented and compared the surgical incisions. Regardless of the absence or presence of any alterations, all patients were examined, with the investigator taking particular care to report on the progression of inflammatory processes. The data were evaluated and categorized into the following: erythema, edema, blister, hematoma, transudation, and dehiscence on saphenectomy. A A visual analogue scale (VAS) was used to evaluate incision pain, and it was classified from zero (no pain) to 10 (maximum pain).

Statistical analysis

A nonparametric test to compare and to evaluate proportions was performed, to verify qualitative variables A χ² test was performed, and significant statistical variables up to 5% (p value<0.05) were used.

Results

Patients were homogenous and similar. Regarding gender, 71.4% were male in G1, and 100% were male in G2. The same percentage in both groups (71.4%) had dislipidemy. In G1, 100% had hypertension compared with 71.4% in G2. Approximately 71.4% of the patients in G1 had diabetes compared with 57.4% in G2. Around 71.4% of the patients in G1 developed wounds on the left leg compared with 85.6% in G2 (Fig. 1).

FIG. 1.

Population characteristics in both groups.

Mean age was 63 years (range 39–84). Upon examination, the following assessment was made regarding the presence of inflammatory signs: in G1, seven patients had erythema, four had edema and hematoma, six had blisters, and two indicated pain; in G2, six patients had erythema and blisters, three had edema, one had hematomas, and none indicated pain (Fig. 2).

FIG. 2.

Prodromal signs in saphenectomy incision, initial (immediate postoperative <12 h) and final assessment (7th postoperative day).

It is noteworthy that, before treatment, G1 patients exhibited conditions that were more acute than those experienced by patients in G2.

All patients were assessed prior to discharge. The patients' distribution according to inflammatory signs was as follows: in G1, only two patients had erythema and edema, one had decreased blisters and hematomas, and none reported pain. In G2, five had erythema, four had edema and blisters, and two had hematomas (Fig. 2), all without pain. Altogether, G1 showed significant improvement of the prodromal signs, whereas G2 exhibited a worsening in the inflammatory process. It is noteworthy that, before treatment, G1 patients exhibited worse conditions than those experienced by patients in G2.

Five patients (71.4%) from G1 had saphenectomy repair following hospital discharge. From this group, only two cases (28.5%) presented a small dehiscence (length=1 cm). On the other side, four patients (57.1%) from G2 developed saphenectomy dehiscence. Two patients (28.5%) experienced uniform and continuous healing. We were unable to contact one of the patients after discharge.

The presence of erythema, edema, hematomas, and transudate in the surgical incision can be noted in Fig. 3a. Figure 4a shows an incision with signs of edema and erythema. In G1, post laser therapy treatment, it was possible to observe hematoma reabsorption (Fig. 3b), without secretion. In the Control Group, prodromal signs worsened over time (Fig. 4b). All patients were discharged 7 days after the surgery.

FIG. 3.

(a) Laser Group immediately postoperative, initial evaluation, and (b) Laser Group on the 7th postoperative day after treatment, final evaluation.

FIG. 4.

(a) Control Group immediately postoperative, initial evaluation, and (b) Control Group on the 7th postoperative day after treatment, final evaluation.

No statically significant signs of inflammation were observed between the Laser and the Control Groups (p=0.10), with the exception of erythema (p=0.05).

Discussion

Cardiovascular surgeries are complex procedures. Therefore, postoperative morbidities—frequently experienced by patients undergoing saphenectomy—are not only dreaded because of possible complications, but they can also manifest in increased hospital stay and cost both for patients and institutions. The Heart Institute InCor- Medicine Faculty of University Hospital performs almost 3000 cardiovascular procedures/year. It is important to note that this number has been increasing at staggering rates. MR accounted for 856 cardiovascular operations/year in the 1980s. Nowadays this figure has increased to 1106 operations/year.²⁴

As we face a considerable number of MRs performed at InCor and the risk of saphenectomy dehiscence occurs, the fundamental importance of this study—preventing such morbidity—becomes clear. Complications in surgical incisions are common when wound dehiscence occurs. Any complications incurred by saphenectomy are predicated on the surgical techniques employed in the procedure, as well as on the patients' overall health.

Dalman et al. observed in their study that metabolic conditions are a significant predictor of wound complications.⁶ We observed in this pilot study that most patients who developed dehiscence had hypertension and diabetes, although this were not statistically significant. Cardiovascular literature reports that metabolic disorders increase risks of postoperative complications, and this was encountered in our work as a key factor.²⁵ Factors such as diabetes, dyslipidemia, being elderly and female, and vascular disease may contribute to wound infection and delayed wound healing,^26,27 as we observed in our groups.

Most researchers report that LLLT is an effective tool to accelerate the tissue repair process, as well as to treat pain that does not respond to conventional medical treatments.^28
–30

In our study, only erythema was found to present a statically significant difference (p=0.05) when comparing G1 and G2. Laser therapy has proven to be beneficial in the management of saphenectomy incisions. The present data and findings indicated that there was no statistically significant divergence (p=0.10) between the Laser and the Control Groups for prodromal signs—most likely because of the small size of sample groups in this pilot study.

Minatel et al. showed that the combination of 660 and 890 nm lights promoted tissue granulation and rapid healing of diabetic ulcers, particularly when these failed to respond to other forms of treatment.²⁸ According to Mester et al. and Medrado et al., groups receiving fluence=4 J/cm² always presented better cicatrization. They concluded that LLLT reduced the inflammatory process, increased collagen deposition, and induced greater proliferation of myofibroblasts in cutaneous wounds.^30,31

Regarding the parameters of our study in the Laser Group (G1), the infrared laser was applied only twice, and it is possible that the low energy administered to patients was insufficient to completely heal all patients' wounds effectively, as later on in G1, one patient progressed to a small dehiscence. Nonetheless, all patients in the Control Group developed significant dehiscences, as well as twice as many complications as those in the Laser Group.

Campana et al. suggests that the laser action on the tissue is related to the possibility of inhibiting the occurrence of chemotactic factors during the initial stages of inflammation.^32,33 It is believed that applying LLLT in the early inflammatory phase is essential to obtaining good results,¹⁵ as we found. In the Control Group (G2), all patients developed a posteriori saphenectomy dehiscence.

As observed during follow-up examinations, >50% of patients with total wound healing, following only two LLLT applications, belonged to the Laser Group. Only one patient in Laser Group presented a small dehiscence. It is possible that patients in the Control Group experienced a greater number of complications because of risk factors and, possibly, the absence of LLLT's adjuvant therapy.

In consonance with the results established by this study, it can be asserted that patients treated with LLLT, including those with diabetes and other metabolic disorders, undergo an effective healing process, especially in the prevention of post-saphenectomy dehiscence, although the study does not evince a significant statistical response. Another factor to be credited is the patients' financial burden; those patients who develop dehiscence had higher costs because of prescribed medicines.

Further study is required to determine the actual efficacy of LLLT, and its potential and value in the management of saphenectomy incisions.

Conclusions

This pilot study reports an effective response applying laser therapy in the early stage dehiscence (prodromal signals) immediately after surgery, which then avoids several complications. Our work indicates that it is possible to prevent morbidity in patients undergoing saphenectomy post MR, with cost effectiveness, by using LLLT.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

Cardiovascular diseases USA: World Health Organization (WHO). (2012). Available at: http://www.who.int/media. (Accessed April 8, 2012 ).

Godoy

M.F.

, Lucena

J.M.

, Miquelin

A.R.

, Paiva

F.F.

, Oliveira

D.L.Q.

, Augustin Junior

J.L.

, and Neto

F.C.

(2007). Cardiovascular mortality and its relation to socioeconomic levels among inhabitants of São Jose do Rio Preto, São Paulo state, Brazil. Arq. Bras. Cardiol., 88, 200–206.

Rojas

S.S.O.

, Veiga

V.C.

, Souza

J.M.

, Berlinck

M.S.

, Iasbech

J.A.

, Magna

L.A.

, Vieira

R.W.

, and Oliveira

S.A.

(2003). Surgical myocardial revascularization without extracorporeal circulation. Arq. Bras. Cardiol., 80, 502–508.

Zerbini

E.J.

, Souza

J.E.M.R.

, Jatene

, Bittencourt

, Pillegi

, and Campos Filho

C.M.

(1968). Surgical treatment of coronary insufficiency. Arq. Bras. Cardiol., 2, 33–40.

Jatene

A.D.

, Paulista

P.P.

, and Souza

L.C.B.

(1970). Surgical treatment of coronary insufficiency with bypass. Arq. Bras. Cardiol., 23, 85–90.

Dalman

R.L.

, Abbruzzese

, Bushnik

, and Harris

E.J.

Jr . (2000). Open saphenectomy complications following lower extremity revascularization. Cardiovasc. Surg., 8, 51–57.

Pinto

N.C.

, Pereira

M.H.C.

, Stolf

N.A.G.

, and Chavantes

M.C.

(2009). Low level laser therapy in acute dehiscence saphenectomy: therapeutic proposal. Rev. Bras. Cir. Cardiovasc., 24, 88–91.

Almeida

A.S.

, and Manfroi

W.C.

(2007). Peculiarities of ischemic heart disease treatment in the elderly. Rev. Bras. Cir. Cardiovasc., 22, 476–483.

Basaran

, Selimoglu

, Ozcan

, Ogus

, Kafali

, Ozcelebi

, et al. (2007). Being an elderly woman: is it a risk factor for morbidity after coronary artery bypass surgery?. Eur. J. Cardiothorac. Surg., 32, 58–64.

10.

Rocha Junior

A.M.

, Vieira

B.J.

, Andrade

L.C.F.

, and Aarestrup

F.M.

(2007). Effects of low-level laser therapy on the progress of wound healing in humans: the contribution of in vitro and in vivo experimental studies. J Vasc. Bras., 6, 257–265.

11.

Medrado

A.R.A.P.

, Pugliese

L.S.

, Reis

S.R.A.

, and Andrade

Z.A.

(2003). Influence of low level laser therapy on wound healing and its biological action upon myofibroblasts. Lasers Surg. Med., 32, 239–244.

12.

Minatel

D.G.

, Frade

M.A.C.

, França

S.C.

, and Enwemeka

C.S.

(2009). Phototherapy promotes healing of chronic diabetic leg ulcers that failed to respond to other therapies. Lasers Surg. Med., 41, 433–441.

13.

Smol'yaninova

N.K.

, Karu

T.I.

, Fedoseeva

G.E.

, and Zelenin

A.V.

(1991). Effects of He-Ne Laser irradiation on chromatin properties and synthesis of nucleic acids in human peripheral blood lymphocytes. Biomed. Sci., 2, 21–126.

14.

Pazos

(2008). Photobiology of laser interaction with animal cell. in: Laser in Biomedicine. Chavantes

M.C.

(ed.). São Paulo: Atheneu, pp. 73–100.

15.

Bjordal

J.M.

, Johnson

M.I.

, Iversen

, Aimbire

, and Lopes–Martins

R.A.B.

(2006). Low-level laser therapy in acute pain: a systematic review of possible mechanisms of action and clinical effects in randomized placebo-controlled trials. Photomed. Laser Surg., 24, 158–168.

16.

Young

, Bolton

, Dyson

, Harvey

, and Diamantopoulos

(1989). Macrophage responsiveness to light therapy. Lasers Surg. Med., 9, 497–505.

17.

Pugliese

L.S.

, Medrado

A.L.

, Reis

S.R.A.

, and Andrade

Z.A.

(2003). The influence of low-level laser therapy on biomodulation of collagen and elastic fibers. Pesqui. Odontol. Bras., 17, 307–313.

18.

Tuner

, and Hode

(2002). Laser Therapy: Clinical Practice and Scientific Background. Grängesberg: Prima Books.

19.

Toyokawa

, Matsui

, Uhara

, Tsuchiya

, Teshima

, Nakanishi

, et al. (2003). Promotive effects of far-infrared ray on full-thickness skin wound healing in rats. Exp. Biol. Med., 228, 724–729.

20.

Höfling

D.B.

, Chavantes

M.C.

, Juliano

A.G.

, Cerri

G.G.

, Romão

, Yoshimura

E.M.

, and Chammas

M.C.

(2010). Low level laser therapy in chronic auto immune thyroiditis: a pilot study. Lasers Surg. Med., 42, 589–596.

21.

Chavantes

M.C.

(2005). Pilot study: new treatment applying LLLT in tracheal stenosis, using biomodulated effect. 5th Congress of the World Association for Laser Therapy, November 25, São Paulo, Brazil. Photomed. Laser Surg., 23, 113.

22.

Chavantes

M.C.

(2008). Laser in cardiorespiratory problems, in: Laser em Biomedicina. Chavantes

M.C.

(ed.). São Paulo: Atheneu, pp. 149–181.

23.

Pinto

F.C.G.

, Chavantes

M.C.

, Pinto

N.C.

, Alho

, Yoshimura

E.M.

, Krebs

V.L.J.

, and Teixeira

M.J.

(2010). Novel treatment immediately after myelomeningocele repair applying low-level laser therapy in newborns: a pilot study. Pediatr. Neurosurg., 46, 249–254.

24.

Braile

D.M.

, and Gomes

W.J.

(2010). Evolution of cardiovascular surgery. the brazilian saga. A history of work, pioneering experience and success. Arq. Bras. Cardiol., 94, 141–142.

25.

Chavantes

M.C.

, and Jatene

A.D.

(1990). Laser application in cardiovascular field. Arq. Bras. Cardiol, 54, 63–68.

26.

Morain

W.D.

, and Colen

L.B.

(1990). Wound healing in diabetes mellitus. Clin. Plast. Surg., 17, 493–501.

27.

Rosenberg

C.S.

(1990). Wound healing in the patient with diabetes mellitus. Nurs. Clin. North Am., 25, 247–261.

28.

Minatel

D.G.

, Frade

M.A.C.

, França

S.C.

, and Enwemeka

C.S.

(2009). Phototherapy promotes healing of chronic diabetic leg ulcers that failed to respond to other therapies. Lasers Surg. Med., 41, 433–441.

29.

Fulop

A.M.

, Dhimmer

, Deluca

J.R.

, Johanson

D.D.

, Lenz

R.V.

, Patel

K.B.

, Douris

P.C.

, and Enwemeka

C.S.

(2009). A meta-analysis of the efficacy of phototherapy in tissue repair. Photomed. Laser Surg., 27, 695–702.

30.

Mester

, Mester

A.F.

, and Mester

(1985). The biomedical effects of laser application. Lasers Surg. Med., 5, 31–39.

31.

Medrado

A.R.A.P.

, Pugliese

L.S.

, Reis

S.R.A.

, and Andrade

Z.A.

(2003). Influence of low level laser therapy on wound healing and its biological action upon myofibroblasts. Lasers Surg. Med., 32, 239–244.

32.

Campana

, Moya

, Gavoto

, Juri

, and Palma

J.A.

(1998). Effects of diclofenac sodium and HeNe laser irradiation on plasmatic fibrinogen levels in inflammatory processes. J. Clin. Laser Med. Surg., 16, 317–320.

33.

Campana

, Moya

, Gavoto

, Soriano

, Juri

H.O.

, Spitale

L.S.

, Simes

J.C.

, and Palma

J.A.

(1999). The relative effects of HeNe laser and meloxican on experimentally induced inflammation laser therapy. J. Clin. Laser Med. Surg., 11, 6–10.