Negative pressure wound therapy with instillation, a cost-effective treatment for abdominal mesh exposure

The Effect of Negative-Pressure Wound Therapy with Instillation Compared to Current Standard Care on Wound Closure Time of Infected Wounds: A Systematic Review and Meta-Analysis

BACKGROUND

Infected wounds extend healing time and are associated with higher treatment costs than noninfected wounds. Several observational studies indicate that negative-pressure wound therapy with instillation can effectively reduce bacterial bioburden and improve wound healing. Only a few randomized trials with small sample sizes have been published, and a meta-analysis directly comparing negative-pressure wound therapy with instillation to current standard care is lacking. It is therefore uncertain whether negative-pressure wound therapy with instillation actually improves wound healing. The authors performed a systematic review and hypothesized that negative-pressure wound therapy with instillation reduces wound closure time.

METHODS

The PubMed, Embase, and CENTRAL databases were searched up to December of 2020 for English studies that compare negative-pressure wound therapy with instillation-to either negative-pressure wound therapy without instillation or to other types of wound care-for the treatment of acute or chronically infected wounds. Time to wound closure was analyzed using a random effects meta-analysis in predefined subgroups according to study design and comparative wound care.

RESULTS

The authors identified 14 studies describing 1053 patients. Meta-analysis of three randomized trials shows no significant difference in time to wound closure between negative-pressure wound therapy with instillation and that without (mean difference, 0.48 day; 95 percent CI, -0.70 to 1.65; I ² = 0 percent). Data from eleven observational studies indicate that negative-pressure wound therapy with instillation reduces wound closure time (from 1.6 to 16.8 days; no pooled data). Because of imprecision and risk of bias, the available evidence provides only low-level certainty.

CONCLUSIONS

There is currently insufficient evidence to support or discard the use of negative-pressure wound therapy with instillation for infected wounds. More randomized trials are needed to determine whether a beneficial effect can be substantiated.

[Strategy for maintaining mesh implants in infected postoperative wounds of anterior abdominal wall]

Treatment of infected mesh implants of anterior abdominal wall is a complex problem in the absence of a unified approach. Traditional method involving surgical debridement of the site of infection with removal of mesh implant is associated with many risks and potential complications. This review is devoted to peculiarities of paraprosthetic infection, possible preserving the implant and methods of treating wound infection avoiding removal of endoprosthesis. Requirements for preservation of mesh implant and key role of vacuum therapy are emphasized.

Efficacy of delayed primary closure with intrawound continuous negative pressure and irrigation treatment after surgery for colorectal perforation

AIM

Surgical-site infections (SSIs) often occur after surgery for colorectal perforation. We introduced delayed primary closure (DPC) after intrawound continuous negative pressure and irrigation treatment (IW-CONPIT) to prevent SSIs. We aimed to evaluate the efficacy of DPC after IW-CONPIT compared with primary closure (PC) after surgery for colorectal perforation.

METHODS

We undertook a retrospective study including 22 patients who underwent DPC (DPC group) and 18 patients who underwent PC (PC group) at our hospital between April 2015 and January 2017. The primary outcome was the SSI rate. The secondary outcomes were other complications (<30 days), length of hospital stay, and costs.

RESULTS

The SSI rate was significantly lower in the DPC group than in the PC group (40% vs. 94%, P = 0.0006). Moreover, superficial and deep incisional SSIs, infectious complications, and Clavien-Dindo classification grade ≥ 2 complications were also significantly diminished in the DPC group. Conversely, the length of hospital stay and costs were not significantly different between the two groups. Multivariate analyses revealed that the significant independent protective factor against SSI after surgery for colorectal perforation was DPC after IW-CONPIT (odds ratio 0.04; 95% confidence interval, 0.002-0.25).

CONCLUSION

Delayed primary closure after IW-CONPIT reduced SSIs after surgery for colorectal perforation compared with PC.

Management of abdominal wound dehiscence: update of the literature and meta-analysis

PURPOSE

Abdominal wound dehiscence (AWD) is associated with significant morbidity and mortality. We aimed to provide a contemporary overview of management strategies for AWD.

METHODS

PubMed, EMBASE, the Cochrane library and a clinical trials registry were searched from 2009 onwards using the key words "abdominal wound dehiscence", "fascial dehiscence" and "burst abdomen". Study outcomes included surgical site infection (SSI), recurrence, incisional hernia and 30-day mortality. Studies reported by the EHS clinical guidelines on AWD were included and compared with. OpenMetaAnalyst was used for meta-analysis to calculate statistical significance and odds ratios (OR).

RESULTS

Nineteen studies were included reporting on a total of 632 patients: 16 retrospective studies, one early terminated randomized controlled trial, one review and the European Hernia Society guidelines. Nine studies reported use of synthetic mesh (n = 241), two of which used vacuum-assisted mesh-mediated fascial traction (VAWCM) (n = 19), six without VAWCM (n = 198) and one used synthetic mesh with both VAWCM (n = 6) and without VAWCM (n = 18); two used biological mesh (n = 19). Seven studies reported primary suture closure (n = 299). Three studies reported on an alternative method (n = 91). Follow-up ranged between 1 and 96 months. Meta-analysis was performed to compare the primary suture group with the synthetic mesh group. Heterogeneity was low to moderate depending on outcome. The overall SSI rate in the primary suture group was 27.6% versus 27.9% in the synthetic mesh group, resulting in mesh explantation in five patients; OR 0.65 (95% CI 0.23-1.81). Incisional hernia rates were 11.1% in the synthetic mesh group (19/171) and 30.7% in the primary suture group (67/218); OR 4.01 (95% CI 1.70-9.46). Recurrence rate did not show a statistically significant difference at 2.7% in the synthetic mesh group (3/112), compared to 10.2% in the primary suture group (21/206); OR 1.81 (95% CI 0.18-17.80). Mortality rates varied between 11.2% and 16.7% for primary suture group versus synthetic mesh; OR 1.85 (95% CI 0.91-3.76).

CONCLUSION

Included studies were of low to very low quality. The use of synthetic mesh results in a significantly lower rate of incisional hernia, whereas SSI rate was comparable to primary suture repair.

Surgical Site Infections Complicating the Use of Negative Pressure Wound Therapy in Renal Transplant Recipients

Surgical site infections (SSI) of the abdominal wall in renal transplant recipients can on occasion require management with negative pressure wound therapy (NPWT). This is often successful, with a low risk of further complications. However, we describe three cases in which persistent or recurrent surgical site sepsis occurred, whilst NPWT was being deployed in adults with either wound dehiscence or initial SSI. This type of complication in the setting of NPWT has not been previously described in renal transplant recipients. Our case series demonstrates that in immunosuppressed transplant recipients, there may be ineffective microbial or bacterial bioburden clearance associated with the NPWT, which can lead to further infections. Hence recognition for infections in renal transplant patients undergoing treatment with NPWT is vital; furthermore, aggressive management of sepsis control with early debridement, antimicrobial use, and reassessment of the use of wound dressing is necessary to reduce the morbidity associated with surgical site infections and NPWT.

Negative pressure wound therapy with instillation: International consensus guidelines update

The use of negative pressure wound therapy with instillation and dwell time (NPWTi‐d) has gained wider adoption and interest due in part to the increasing complexity of wounds and patient conditions. Best practices for the use of NPWTi‐d have shifted in recent years based on a growing body of evidence and expanded worldwide experience with the technology. To better guide the use of NPWTi‐d with all dressing and setting configurations, as well as solutions, there is a need to publish updated international consensus guidelines, which were last produced over 6 years ago. An international, multidisciplinary expert panel of clinicians was convened on 22 to 23 February 2019, to assist in developing current recommendations for best practices of the use of NPWTi‐d. Principal aims of the meeting were to update recommendations based on panel members' experience and published results regarding topics such as appropriate application settings, topical wound solution selection, and wound and patient characteristics for the use of NPWTi‐d with various dressing types. The final consensus recommendations were derived based on greater than 80% agreement among the panellists. The guidelines in this publication represent further refinement of the recommended parameters originally established for the use of NPWTi‐d. The authors thank Karen Beach and Ricardo Martinez for their assistance with manuscript preparation.

Negative Pressure Wound Therapy with Instillation and Dwell Time in the Surgical Management of Severe Hidradenitis Suppurativa

Background: Hidradenitis suppurativa (HS) is a physically debilitating disease that greatly impairs the quality of life of affected individuals. Advanced disease is often difficult to treat with topical and systemic therapies. Surgical resection of diseased skin has become paramount in HS management but proposes challenges of wound care and closure.

Methods: Four patients with a total of 12 complex wounds were treated over a three year period. All of the patients were males between the ages of 28 and 61 years. The lesions were located on the buttocks (n=5), chest (n=1), perianal (n=2), perineal (n=2), and axillary regions (n=2). A protocol of wide local excision, followed by negative pressure wound therapy with instillation and dwell time (NPWTi-d) to decrease bioburden and promote angiogenesis of the exposed base, and subsequent skin grafting was used. Patients remained hospitalized between procedures.

Results: The original wound area ranged from 210-540 cm². Skin grafts of comparable sizes were taken from donor sites. The average duration of NPWTi-d placement was 3.5 days and the average time from excision to wound coverage was 4.3 days. The percent of graft uptake ranged from 70%-90%. All patients were resolved of their local disease with no complications.

Conclusions: Surgical management of HS can be complicated by difficult closures. This case series demonstrates that wide local excision followed by NPWTi-d and skin grafting is able to achieve local resolution of disease in HS patients who have failed multiple minimally invasive therapies.

Negative pressure wound treatment with computer-controlled irrigation/instillation decreases bacterial load in contaminated wounds and facilitates wound closure

Microbial wound contamination is known to be a hindrance to wound healing. Negative pressure wound therapy (NPWT) with or without irrigation is known to optimise conditions in problem wounds. The aim of this study was to investigate the influence of computer-controlled wound irrigation with NPWT on the bacterial load in contaminated wounds. A total of 267 patients were treated with NPWT with automated instillation because of problematic wounds using an antiseptic instillation solution. In 111 patients, a minimum of 4 operative procedures were necessary, and swabs were taken at least at the first and at the fourth operation in a standardised procedure. The number of different bacteria and the amount of bacteria were analysed during the course. In a subgroup of 51 patients, swabs were taken at all 4 operative procedures and analysed separately. In an overall analysis, the number of different bacteria and the amount of bacteria significantly decreased independent of wound localisation and diagnosis. NPWT with automated instillation demonstrates a positive influence in the reduction of bacterial load in problem wounds. Thus, it may help to optimise wound conditions before definite wound closure.