Literature Review on "Is Maggot Debridement Therapy Effective for Removal of Necrotic Tissue From Chronic Wounds?"

Literature Review 6 pages (2057 words) Sources: 10

[EXCERPT] . . . .

Maggot Debridement Therapy

Is maggot debridement theory effective for removal of necrotic tissue from chronic wounds? This paper provides a literature review that approaches and answers that question using both qualitative and quantitative analysis of the issue. Thesis: based on the research presented in ten journal articles, maggot debridement procedures do indeed remove necrotic tissue from wounds and ulcers.

(Quantitative) Dr. Ronald Sherman and colleagues sent surveys to more than 350 clinicians who are known to have used (or are currently using) maggot therapy, in order to identify "…off-label uses for maggot therapy that may be worthy" of additional clinical research (Sherman, 2007). Of those 350 surveys, 12 were completed and sent back. Sherman was interested in what applications maggot theory has in addition to the more traditional debridement.

In the article, Sherman reviews the history of maggot applications in North America, explaining that in the late 1930s over a thousand surgeons were regularly using maggots; and "…more than 90% of them were "…satisfied with these wriggling surgical assistants" (602). But in the 1940s, Sherman explains that because of the fact that antibiotics were now available, the use of maggots was cut way back. That having been said, the use of maggots has now become more common, especially since the U.S. Food and Drug Administration (FDA) approved the use of maggots by the company called "Medical Maggots" (in California) in 2004.

As to the dozen responses Sherman received (from 8 surgeons, 2 nurses, 1 internist, and 1 physical therapist), those healthcare professionals used maggots to treat a total of 544 wounds (24% met the criteria for Sherman's study, that they be "off-label" usages). There were three reasons they used maggots (but not in traditional debridement applications): a) the infection or wound did not respond to "conventional surgical and medical therapy"; b) it would have been impractical to use debridement due to the "proximity of vital structures"; and c) the use of anesthesia would have been risky due to patient complications (Sherman 603).

(Qualitative & quantitative) Meanwhile in the peer-reviewed journal Wound Practice and Research Fenn-Smith describes how maggot debridement therapy was effective on a middle-aged woman with a number of serious health issues -- including a serious "black necrotic wound" she had suffered in a fall from a bus (Fenn-Smith, 2008, 169). After the wound had been grafted (and about 5 weeks later) she (Hazel) was discharged from the hospital with the assumption that the grafted skin on the left leg was healing sufficiently, Fenn-Smith explained.

However, a month after going home Hazel's leg was very seriously infected ("…malodorous, highly exudating, and inflamed…with a thick layer of slough" that covered the whole wound, about 20x7cm with a depth of 7mm) (Fenn-Smith, 169). The medical team debated what to do with Hazel's festering leg, and notwithstanding some staff resistance, the team ended up agreeing to maggot debridement therapy (MDT). Because of her past history doctors believed anesthesia would create an undue risk, so a phone call was made to a New South Wales company -- a firm that grows maggots -- and maggots the prescribed size were ordered and in 72 hours they were received and applied.

Three days later the maggots were removed from the wound (after feeding only on dead tissue) and what remained of the graft was "pink and healthy" because the "devitalized tissue" had been removed thanks to the use of MDT; had doctors not used MDT, "Hazel may have lost her leg" (Fenn-Smith, 170).

(Qualitative) Another peer-reviewed journal article presented by Dr. Ronald Sherman discusses the use of maggot therapy on leg and foot ulcers -- after conventional therapy had failed to provide the healing necessary. Eighteen patients were involved in this research; the 18 patients had a total of 20 "non-healing ulcers" (Sherman. 2003. 446). In terms of this study's comparisons, of the 20 ulcers / wounds six were treated with maggot therapy, six were treated with "conventional therapy," and the remaining 8 were treated first with conventional therapy, and that was followed up with maggot treatment (Sherman, 446).

The outcome was very positive in terms of those ulcers that were treated with maggot therapy. Sherman reports that "…during the first 14 days of conventional therapy, there was no significant debridement" of the dead tissue (446). The conventional therapy consisted of "…non-medicated dry dressings or saline-moistened 'wet-to-dry' gauze" that was changed every eight hours; and the topical antimicrobial ointment was applied three times a day.

However, in the same 14 day period using maggots, dead tissue was decreased by "…an average of 4.1cm2 -- but the conventionally treated ulcers were "still covered with necrotic tissue over 33% of their surface" (Sherman, 446). Moreover, four weeks into maggot therapy applications on the leg and foot ulcers those wounds were "completely debrided" (Sherman, 446). The results showed that "Maggot therapy" can be linked to "…faster debridement and wound healing than conventional therapy" (Sherman, 449).

(Qualitative) in another research paper involving ulcers ("diabetic foot ulcers and "pressure ulcers") clearly revealed that as reported earlier in this paper, using maggots on serious wounds creates healing sinner than traditional applications. In this peer-reviewed study, twenty-five patients had "diabetic foot ulcers' and eighteen patients suffered from pressure ulcers following spinal cord injuries; half were treated with traditional medical procedures and half were given maggot treatment (Wang, et al., 2010, 201).

Prior to applying the maggots to the wounds it was assured that the one hundred selected larvae for each procedure were totally disinfected, and a hole was cut in the middle of sterile saline gauze that had been placed over the wound. The maggot larvae went into the wound through that hole in the gauze. The results showed those patients with diabetic foot ulcers "healed completely" and the patients with pressure ulcers also "healed completely" (Wang, 203).

The only complaint from a patient in the maggot therapy group was that he felt some "bearable pain" as the maggots ate away at his dead tissue; as indicated in previous research reported here, the maggots did not damage any healthy tissue as they ate and secreted "some proteolytic enzymes" which helps to "degrade components" (Wang, 204). When their job is completed, the maggots are "…two to three times larger" than when they started (Wang, 204).

(Quantitative). Diabetic foot ulcers are once again the antagonists -- and maggots are the protagonists -- in another peer-reviewed piece, this one published by the International Wound Journal (Paul, et al., 2009, 39). The authors' research in this article did not say that maggot therapy was any better than conventional therapy; only that MDT with L. cuprina (a "tropical blowfly maggot") is "as effective as conventional debridement" when treating diabetic foot ulcers (Paul, 39).

Of the 29 patients that were treated with maggots, 14 wounds were healed, 11 were not healed, and 4 wounds were categorized as "others" (Paul, 39). Meanwhile of the 30 patients in the "control group" (who were treated with conventional debridement), 18 wounds healed and 11 did not heal while 1 was classified "others" (Paul, 39). What makes this particular research different than the previously mentioned projects is that the blowfly "Lucilia cuprina" maggots were used rather than the more commonly applied "Lucilia sericata." Malaysia, where the research took place, is tropical, hence the tropical L. cuprina maggot is available and since its use had not previously been documented, this was experimental and investigative as well.

(Quantitative) Seventy patients in nine British hospitals were used in a research article published in the Journal of the Royal Society of Medicine. The patients were suffering from leg ulcers (16 were arterial, 11 were venous, 11 were diabetic and 9 were of "mixed pathology") (Courtenay, et al., 2000). After all of the patients were exposed to "larva therapy" (LT) for 3 days, in only 2 of the total of 70 cases studied, the larvae did not survive in the wound (Courtenay, 73). When the LT was completed, 30 of the wounds were "fully debrided," twenty of the wounds were "partially debrided," and 8 of the wounds did not change from the time the larvae were applied (Courtenay, 73).

The nurse practitioners that were interviewed after the study, the application of larvae therapy "…reduced hospital stay in 24 (or 34%) of the patients," and the maggots prevented surgery in 19 (27%) of the cases (Courtenay, 73). The use of LT helped 11 (16%) of the patients with ulcers avoid even going into the hospital and in 18 (26%) of those suffering from leg ulcers, the need for antibiotics was reduced (Courtenay, 73). Sixty-three of the 70 patients stated that LT had played "…a major role in management" of their wounds (that is 90% of the cases) (Courtenay, 73).

(Quantitative) a third article featuring the research of Dr. Ronald Sherman shows that of 103 in-patients with a total of 145 pressure ulcers were evaluated based on comparisons between the healing achieved with maggot therapy and more traditional medical care. This is an important research article because it is reported… READ MORE

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