The Physicians’ Quarterly Newsletter of the Stamford Health Department of Surgery Winter 2019 A Case Study in Successful Healing of Chronic Refractory Wounds Last May, a 74-year-old female patient with a diseases, podiatry and nursing closely history of Type 2 diabetes, diabetic neuropathy, collaborated to formulate a treatment plan multiple wounds and a trans-metatarsal that was tailored to her complex needs. amputation of her left foot came to the Stamford Health Wound Care and Hyperbaric “Healing wounds in the setting of Charcot Center for a non-healing amputation site neuropathy is particularly challenging because after other surgeries for diabetic ulcers had of the patient’s health and wound-related Before: non-healing transmetatarsal amputation site. failed. “This patient developed wounds due to factors,” explained Dr. Papa. “Diabetes causes Charcot foot, a condition that resulted from a dysregulated inflammatory response, which diabetic neuropathy,” said Joey C. Papa, MD, in turn can result in chronic, low-grade wound General Surgeon and Medical Director of the inflammation because the immune cells that Wound Care Center. “In most cases, it is not only the wound that needs to heal, it is the whole “Healing wounds in the patient. Our goal was to conduct a holistic re-evaluation of this patient to determine the setting of Charcot neuropathy most effective approach to help her recover is particularly challenging and improve her quality of life.” because of the patient’s health At the Wound Care Center, a multidisciplinary and wound-related factors.” team of specialists treats patients suffering from chronic, non-healing wounds. In this patient’s regulate the balance of these factors are not After: normal skin and callus formation, healed case, specialists drawn from general surgery, performing as they should. For this patient, transmetatarsal amputation site. vascular surgery, endocrinology, infectious a coordinated team approach that included aggressive diabetes management, antibiotic The patient was also fitted for a new offloading therapy, targeted wound care with innovative boot to reduce pressure on her foot, and she Highlights products, and patient education with received strict instructions about walking and counseling was vital to her recovery.” limiting time spent on her feet. • Identifying the patient and wound-related factors that contribute to poor healing is The patient’s comprehensive workup included a Over the course of six months, the nursing critical to successful wound treatment. vascular evaluation to determine the adequacy team worked closely with the patient through of blood supply to the left foot. She began every phase of her treatment. “Our nurses excel • Diabetes, malnutrition, obesity and antibiotic therapy that targeted the specific at identifying with patients and helping them cardiovascular disorders can inhibit the microbial colonization within the wound area. navigate through all of the complicated medical immune system’s production and release recommendations,” said Dr. Papa. “Their emotion- of growth factors, macrophages and signal To enhance wound repair, Dr. Papa applied a driven and social approach inspired this patient molecules in the wound bed, which can skin substitute made from a bioactive tissue to accept what she needed to do and ultimately lead to other factors that impede healing, matrix allograft composed of dehydrated take responsibility for her health.” such as microbial colonization and excess human amnion/chorion membrane (dHACM). wound exudate. “The skin substitute lays down growth factors After six months, the patient’s wounds were to encourage repair and reduce the production completely healed. “This patient had suffered • Bioengineered skin substitutes promote of MMPs (matrix metalloproteinases) that can 25 wounds on her left foot over the past 20 wound repair by stimulating host cytokine inhibit wound repair,” said Dr. Papa. “It also years,” said Dr. Papa. “For the first time in as long generation and providing scaffolding cells provides collagen scaffolding that allows the as she could remember, she had no wounds and extracellular matrix (ECM) molecules wound to shift out of its chronic wound phase and was finally able to keep up with her many that affect growth factors. and begin to proliferate healthy tissue.” grandchildren.” StamfordHealth.org Winter 2019 Letter from the Chair of the Department of Surgery I am pleased to present the Winter 2019 issue of Precision, the quarterly newsletter of the Department of Surgery at Stamford Health that highlights our commitment to providing the highest level of comprehensive, patient-centered surgical care. In this issue, we are proud to feature the Stamford Health Wound Care and Hyperbaric Center under the leadership of Joey C. Papa, MD. Drawing on the collective experience of specialists from many fields, the Center offers the latest leading-edge David Yuh, MD, products and advanced technologies such as bioengineered skin substitutes that improve patients’ wound healing and FACS, FACC their overall well-being. This is an exciting time for the Department of Surgery as we continue our mission to provide outstanding care for our patients. I am pleased to share the following articles and updates with you: • A case study of a 74-year-old woman with Type 2 diabetes and non-healing wounds due to Charcot foot neuropathy underwent comprehensive, holistic treatment at the Wound Care Center that resulted in complete resolution of her wounds. • A conversation with Joey C. Papa, MD, about the latest developments and challenges in the chronic wound healing field. • A warm welcome to Mohamad Zanbrakji, MD, general, trauma and critical care surgeon. It is an honor to work with so many outstanding surgeons and staff to provide exceptional care to our patients. David Yuh, MD, FACS, FACC Chair of the Department of Surgery, Stamford Health Introducing Mohamad Zanbrakji, MD General, Trauma and Critical Care Surgeon, Stamford Health Medical Group appendicitis, bowel obstruction and gallbladder Board-certified in both general surgery and issues, as well as elective surgery for hernia surgical critical care, Dr. Zanbrakji enjoys applying repair, soft tissue masses and abdominal wall his intensive clinical training to caring for the reconstruction. sickest patients who often present with multiple comorbidities. “I was drawn to the field of trauma Dr. Zanbrakji received his medical degree and surgical critical care because it enables me to from Ross University School of Medicine. He combine my knowledge and technical skills,” he Mohamad Zanbrakji, MD then completed a general surgery internship said. “In the ICU, I find it most gratifying to care for and residency at Stamford Hospital, Columbia severely ill patients and help them return to their The Stamford Health Department of Surgery is normal lives by the time they leave the hospital.” proud to welcome Mohamad Zanbrakji, MD, a general, trauma and critical care surgeon with “I was drawn to the field of trauma As he builds his practice here in Fairfield County, special interest and expertise in emergency and surgical critical care because it Dr. Zanbrakji strongly believes that everyone general surgery, trauma surgery, laparoscopic enables me to combine my knowledge deserves access to healthcare. He also joined and robotic surgery. a global surgery group and is planning his first and technical skills.” trip to Uganda to educate and train doctors and At Stamford Health, Dr. Zanbrakji provides general provide surgical care to people with dire needs. and minimally invasive surgery services including University College of Physicians and Surgeons, the latest laparoscopic and robotic approaches followed by a fellowship in trauma and surgical to a wide range of surgical disorders such as critical care at Yale University School of Medicine. StamfordHealth.org Innovative and Compassionate Care at the Letter from the Chair of the Stamford Health Wound Care and Hyperbaric Center Department of Surgery In a field of rapidly advancing techniques care by keeping abreast of emerging products restricted lifestyle, loss of mobility, powerlessness, and technologies, the Stamford Health Wound and technologies and providing comprehensive and a variety of coping challenges,” said Dr. Papa. Care and Hyperbaric Center is one step ahead services that enable our patients to seamlessly “Our physicians and veteran nursing staff excel of the curve in its collaborative approach to transition from the Center to home for the at helping our patients navigate their health wound repair, offering the latest procedures, best outcomes.” and wound-specific issues as well as any socio- products and supportive care that empower economic barriers to healing.” patients to heal and return to optimal health. At the Wound Care Center, specialists in general, vascular, colorectal and trauma surgery, infectious Patients are referred to the Wound Care Center For four consecutive years the Wound Care diseases and podiatry work with physician for any acute wound (including large cuts, skin Center has received the Robert A. Warriner III assistants, nurses and social workers to provide a tears and chronic wounds) that has not healed in Center of Distinction Award for meeting the comprehensive range of state-of-the-art services: 30 days (commonly experienced in people with highest standards set by Healogics, Inc., the wound evaluation with diagnostic assessment; diabetes or vascular disease), a surgical wound nation’s largest provider of advanced