Negative pressure wound therapy for surgical site infections: a systematic review and meta-analysis of randomized controlled trials

Perioperative interventions for the prevention of surgical wound infection in adult patients undergoing left ventricular assist devices implantation: A scoping review

BACKGROUND

Surgical wound infection is the most frequent type of care health associated infection. Lack of knowledge about the prevention of surgical wound infection in patients undergoing left ventricular assist device implantation could significantly undermine the potential benefits of surgical intervention.

OBJECTIVES

This study aimed to map the recommendations for adult patients undergoing left ventricular assist device implantation.

DESIGN

This is a scoping review, being registered in the Open Science Framework under DOI https://doi.org/10.17605/OSF.IO/Q76B3 (https://osf.io/q76b3/).

METHOD

Left ventricular assist device coordinators and nurse specialists in dermatology and stomatherapy conducted a scoping review in Scopus, The Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), limited to the period between 2015 and 2022. The results of this scoping review will be discussed and presented in separate articles. This paper will synthesize research evidence on the perioperative topic.

RESULTS

The initial searches resulted in 771 studies. Sixty nine met the eligibility criteria and were included in the scoping review. Eight articles addressing the perioperative topic that answered the question of this article were included.

CONCLUSION

Although this scoping review included heterogeneous, and scarce studies with left ventricular assist device patients. As such, there are many promising future research directions for this topic.

IMPLICATIONS FOR CLINICAL PRACTICE

Infection surveillance should be an integral part of left ventricular assist device implantation programs in health care institutions. Velvet completely buried in subcutaneous tissues reduces transmission system infection. Triple tunnel method reduces transmission system infection risk.

Negative Pressure Wound Therapy in Closed Colorectal Surgical Incisions: A Systematic Review and Meta-Analysis

The utilization of negative pressure wound therapy (NPWT) in lowering the incidence of infections in closed colorectal surgical incisions has not been thoroughly established, and recent trials have had conflicting results. This meta-analysis was conducted to synthesize the findings of available trial data and carefully evaluate the effectiveness of this intervention in colorectal surgery. The databases PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were combed for randomized controlled trials (RCTs) that compared negative pressure wound therapy to standard dressing in closed wounds of patients undergoing colorectal surgery. The incidence of surgical site infections (SSIs) was the primary outcome. Secondary outcomes included the occurrence of seroma and hematoma. The trial results were represented as odds ratios (OR) with a 95% confidence interval (CI), and a fixed-effects model was used. Nine studies found eligible were included, and the pooled results revealed that negative pressure wound therapy significantly reduced the incidence of surgical site infections (OR: 0.70; 95% CI: 0.53, 0.93; P= 0.02). Furthermore, there was a significant reduction in seroma (OR: 0.27; 95% CI: 0.08, 0.95; P = 0.04) and hematoma (OR: 0.20; 95% CI: 0.04, 0.96; P = 0.04). The use of negative pressure wound therapy for primarily closed incisions has been increasing, and our results indicate that it is superior to standard surgical dressings in preventing surgical site infections and other wound complications in colorectal surgeries.

A systematic review with meta-analysis on prophylactic negative pressure wound therapy versus standard dressing for obese women after caesarean section

AIMS

The purpose of this study is to assess the efficacy of prophylactic negative pressure wound therapy (NPWT) in obese women undergoing caesarean section.

DESIGN

An updated review and meta-analysis of randomized controlled trials following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

PubMed, Embase, Medline, Web of Science, and Cochrane Library were searched from inception up to March 2022 without restriction in language. We chose surgical site infection as the primary outcome.

RESULTS

NPWT resulted in a lower surgical site infection rate compared with conventional dressing (risk ratio [RR] = 0.76). The infection rate after low transverse incision was lower comparing the NPWT group with the control group ([RR] = 0.76). No statistically significant difference was detected in blistering([RR] = 2.91). The trial sequential analysis did not support the 20% relative decrease in surgical site infection in the NPWT group. (type II error of 20%).

Incisional negative pressure wound therapy for the prevention of surgical site infection: an up-to-date meta-analysis and trial sequential analysis

Background

The evidence on prophylactic use of negative pressure wound therapy on primary closed incisional wounds (iNPWT) for the prevention of surgical site infections (SSI) is confusing and ambiguous. Implementation in daily practice is impaired by inconsistent recommendations in current international guidelines and published meta-analyses. More recently, multiple new randomised controlled trials (RCTs) have been published. We aimed to provide an overview of all meta-analyses and their characteristics; to conduct a new and up-to-date systematic review and meta-analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment; and to explore the additive value of new RCTs with a trial sequential analysis (TSA).

Methods

PubMed, Embase and Cochrane CENTRAL databases were searched from database inception to October 24, 2022. We identified existing meta-analyses covering all surgical specialties and RCTs studying the effect of iNPWT compared with standard dressings in all types of surgery on the incidence of SSI, wound dehiscence, reoperation, seroma, hematoma, mortality, readmission rate, skin blistering, skin necrosis, pain, and adverse effects of the intervention. We calculated relative risks (RR) with corresponding 95% confidence intervals (CI) using a Mantel-Haenszel random-effects model. We assessed publication bias with a comparison-adjusted funnel plot. TSA was used to assess the risk of random error. The certainty of evidence was evaluated using the Cochrane Risk of Bias-2 (RoB2) tool and GRADE approach. This study is registered with PROSPERO, CRD42022312995.

Findings

We identified eight previously published general meta-analyses investigating iNPWT and compared their results to present meta-analysis. For the updated systematic review, 57 RCTs with 13,744 patients were included in the quantitative analysis for SSI, yielding a RR of 0.67 (95% CI: 0.59-0.76, I2 = 21%) for iNPWT compared with standard dressing. Certainty of evidence was high. Compared with previous meta-analyses, the RR stabilised, and the confidence interval narrowed. In the TSA, the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, confirming the robustness of the summary effect estimate from the meta-analysis.

Interpretation

In this up-to-date meta-analysis, GRADE assessment shows high-certainty evidence that iNPWT is effective in reducing SSI, and uncertainty is less than in previous meta-analyses. TSA indicated that further trials are unlikely to change the effect estimate for the outcome SSI; therefore, if future research is to be conducted on iNPWT, it is crucial to consider what the findings will contribute to the existing robust evidence.

Funding

Dutch Association for Quality Funds Medical Specialists.

A review on circular RNAs and bacterial infections

Bacterial infections and related diseases have been a major burden on social public health and economic stability around the world. However, the effective diagnostic methods and therapeutic approaches to treat bacterial infections are still limited. As a group of non-coding RNA, circular RNAs (circRNAs) that were expressed specifically in host cells and played a key regulatory role have the potential to be of diagnostic and therapeutic value. In this review, we systematically summarize the role of circRNAs in common bacterial infections and their potential roles as diagnostic markers and therapeutic targets.

Prophylactic use of incisional negative pressure wound therapy for the prevention of surgical site occurrences in general surgery: Consensus document

BACKGROUND

Surgical site occurrences pose a threat to patient health, potentially resulting in significant increases in health care spending caused by using additional resources. The objective of this study was to reach a consensus among a group of experts in incisional negative pressure wound therapy to determine the indications for using this type of treatment prophylactically and to analyze the associated risk factors of surgical site occurrences in abdominal surgery.

METHODS

A group of experts in incisional negative pressure wound therapy from Spain and Portugal was formed among general surgery specialists who frequently perform colorectal, esophagogastric, or abdominal wall surgery. The Coordinating Committee performed a bibliographic search to identify the most relevant publications and to create a summary table to serve as a decision-making protocol regarding the use of prophylactic incisional negative pressure wound therapy based on factors related to the patient and type of procedure.

RESULTS

The patient risk factors associated with surgical site occurrence development such as age, immunosuppression, anticoagulation, hypoalbuminemia, smoking, American Society of Anesthesiologists classification, diabetes, obesity, and malnutrition were analyzed. For surgical procedure factors, surgical time, repeated surgeries, organ transplantation, need for blood transfusion, complex abdominal wall reconstruction, surgery at a contaminated site, open abdomen closure, emergency surgery, and hyperthermic intraperitoneal chemotherapy were analyzed.

CONCLUSION

In our experience, this consensus has been achieved on a tailored set of recommendations on patient and surgical aspects that should be considered to reduce the risk of surgical site occurrences with the use of prophylactic incisional negative pressure wound therapy, particularly in areas where the evidence base is controversial or lacking.

Postoperative negative-pressure incision therapy after liver transplant (PONILITRANS study): A randomized controlled trial

BACKGROUND

Postoperative complications of surgical incisions are frequent in liver transplantation. However, evidence justifying the use of incisional negative pressure wound therapy to improve surgical wound outcomes remains limited.

METHODS

Participating patients were randomly assigned to receive incisional negative pressure wound therapy or standard surgical dressing on the closed surgical incision of the liver transplantation. The primary endpoint was surgical site infection incidence 30 days postoperatively. The secondary endpoints included surgical site events (ie, surgical site infection, dehiscence, hematoma, and seroma) and wound quality of life.

RESULTS

Between December 2018 and September 2021, 108 patients (54 in the incisional negative pressure wound therapy group and 54 in the control group) were enrolled in this study. The incidence of surgical site infection at 30 days postoperatively was 7.4% in the treatment group and 13% in the control group (P = .34). The rate of surgical site events was similar in the treatment in the and control group (27.8% vs 29.6%, P = .83). In relation to wound quality of life, the mean score was 75.20 ± 7.27 in the incisional negative pressure wound therapy group and 72.82 ± 10.57 in the control group (P = .23).

CONCLUSION

The prophylactic use of negative pressure wound therapy on primarily closed incisions did not significantly reduce incisional surgical site infection and surgical site event rates after liver transplantation compared with standard surgical dressings.

Cost-Utility Analysis of the Caresyntax Platform to Identify Patients at Risk of Surgical Site Infection Undergoing Colorectal Surgery

BACKGROUND

Surgical site infections (SSIs) account for up to 18% of all healthcare-associated infections (HAIs). The Caresyntax data-driven surgery platform incorporates the most common risk factors for SSI, to identify high-risk surgical patients before they leave the operating theatre and treat them prophylactically with negative pressure wound therapy (NPWT). An economic analysis was performed to assess the costs and health outcomes associated with introduction of the technology in the English healthcare setting.

METHODS

A hybrid decision tree/Markov model was developed to reflect the treatment pathways that patients undergoing colorectal surgery would typically follow, both over the short term (30-day hospital setting) and long term (lifetime). The analysis considered implementation of Caresyntax's platform-based SSI predictive algorithm in the hospital setting, compared with standard of care, from an English National Health Service (NHS) perspective. The base-case analysis presents results in terms of cost per quality-adjusted life-year (QALY) gained, as well as operational impact.

RESULTS

The base-case analysis indicates that the intervention leads to a cost saving of £55.52m across the total NHS colorectal surgery patient population in 1 year. In addition, the intervention has a 98.36% probability of being cost effective over a lifetime horizon. The intervention results in the avoidance of 19,744 SSI events, as well 191,911 excess hospital bed days saved.

CONCLUSION

Caresyntax's platform-based SSI predictive algorithm has the potential to result in cost savings and improved patient quality of life. Additionally, operational gains for the healthcare provider, including reduced infection rates and hospital bed days saved, have been shown through the economic modeling.

Negative Pressure Wound Therapy in Spinal Surgery

Negative pressure wound therapy (NPWT) has demonstrated promise in the management of surgical site infections as well as assisting in surgical wound healing. In this manuscript, we describe the mechanisms and applications of NPWT for surgical wounds and existing evidence for NPWT in cardiac, plastic, and general surgery, followed by a discussion of the emerging evidence base for NPWT in spinal surgery. We also discuss the different applications of NPWT for open wounds and closed incisions, and the promise of newer closed-incision NPWT (ciNPWT) devices. There is nominal but promising prospective evidence on NPWT's efficacy in select at-risk populations for post-operative wound complications after spinal surgery. As there is currently a paucity of robust clinical evidence on its efficacy, rigorous randomized prospective clinical trials are needed.

Negative Pressure Wound Therapy Promotes Wound Healing by Inhibiting Inflammation in Diabetic Foot Wounds: A Role for NOD1 Receptor

Aims: Diabetic foot results in frequent amputation and quality-of-life reduction in diabetes population. These lesions are featured by a prolonged and exaggerated inflammation with a significant impairment in local bacterial invasion. Negative pressure wound therapy (NPWT) attenuates hyperinflammation in the healing of diabetic foot wounds, but the potential mechanism of NPWT down-regulated inflammatory reaction still remains elusive. This study aims to explore the inflammatory signaling involved in the effect of NPWT on diabetic ulcer. Methods: Thirty patients with diabetic foot ulceration were divided into NPWT group (treated with NPWT, n = 10), NPWT + FK565 group (treated with NPWT combined with FK565 which is NOD1 receptor ligand, n = 10) and control group (n = 10). After two weeks treatment, samples were harvested and analyzed by histochemistry for infiltration of inflammatory cells, immunofluorescence stain for NOD1, western blotting for NOD1, RIP2 (Receptor interacting protein 2), IL-1β, TAK1 (Transforming growth factor-β-activated kinase1), p65 and real time-PCR for expression of NOD1 and RIP2. Results: NPWT could notably accelerate the diabetic wound healing through alleviating inflammatory reaction. The immunofluorescence analysis results revealed that NOD1 was mainly expressed in the cytoplasm and noticeably decreased after the NPWT treatment. And NPWT obviously decreased both the mRNA and protein level of NOD1 and RIP2. Moreover, The protein expression of IL-1β, TAK1 and p65 in the NPWT-group were significant decreased. Conclusion: NPWT effectively promotes wound healing by suppressing the wound inflammation in diabetic foot, which is mediated at least in part by suppression of NOD1 receptor.

Generation of Cross-Specialty Consensus Statements on Soft Tissue Management via a Modified Delphi Method

Background

Soft tissue management (STM) training programs for surgeons are largely tradition based, and substantial differences exist among different surgical specialties. The lack of comprehensive and systematic clinical evidence on how surgical techniques and implants affect soft tissue healing makes it difficult to develop evidence-based curricula. As a curriculum development group (CDG), we set out to find common grounds in the form of a set of consensus statements to serve as the basis for surgical soft tissue education.

Methods

Following a backward planning process and Kern’s six-step approach, the group selected 13 topics to build a cross-specialty STM curriculum. A set of statements based on the curriculum topics were generated by the CDG through discussions and a literature review of three topics. A modified Delphi process including one round of pilot voting through a face-to-face CDG meeting and two rounds of web-based survey involving 22 panelists were utilized for the generation of consensus statements.

Results

Seventy-one statements were evaluated, and 56 statements reached the 80% consensus for “can be taught as is.”

Conclusions

Using a modified Delphi method, a set of cross-specialty consensus statements on soft tissue management were generated. These consensus statements can be used as a foundation for multi-specialty surgical education. Similar methods that combine expert experience and clinical evidence can be used to develop specialty-specific consensus on soft tissue handling.

Prophylactic negative pressure wound therapy on wound complications after cesarean delivery in women with obesity: a meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials aimed to assess whether negative pressure wound therapy affects the rate of wound complications when applied to women with obesity after cesarean delivery compared with standard postoperative dressings.

DATA SOURCES

This research used PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials as electronic databases, from the inception of each database to January 2021, with randomized controlled trial as the publication type. There was no restriction applied for language or geographic location.

STUDY ELIGIBILITY CRITERIA

The selection criteria included only randomized controlled trials comparing the effect of negative pressure wound therapy with that of standard dressings on wound complications in women with obesity undergoing cesarean delivery.

METHODS

The primary outcome was a wound complication composite outcome (wound infection, separation or dehiscence, hematoma, seroma, or readmission secondary to a wound concern). The wound complication composite was analyzed by counting events once per patient. The summary measures were reported as relative risk or as mean difference with 95% confidence intervals using the random-effects model of DerSimonian and Laird. An I-squared (Higgins I²) value of >0% was used to identify heterogeneity.

RESULTS

Overall, 11 randomized controlled trials, which included 5746 participants with obesity undergoing cesarean delivery, were included. Of those participants, 2869 (49.9%) were randomized to the intervention group (negative pressure wound therapy), and 2877 (50.1%) were randomized to the control group (standard dressing). Prophylactic negative pressure wound therapy was not associated with a significant change in the rate of wound complications (relative risk, 1.00; 95% confidence interval, 0.81-1.23) compared with standard postoperative dressings. However, the use of negative pressure wound therapy decreased the rate of wound infections (relative risk, 0.79; 95% confidence interval, 0.66- 0.96) and increased the frequency of skin reactions (relative risk, 4.59; 95% confidence interval, 1.29-16.38). Negative pressure wound therapy did not result in a significant difference in the rate of dehiscence, hematoma, seroma, readmission, reoperation, and antibiotic use for wound infection.

CONCLUSION

Compared with standard postoperative incision dressings, negative pressure wound therapy did not affect the rate of wound complications but decreased the frequency of wound infections when applied to women with obesity after cesarean delivery. However, results should be interpreted with caution, as wound infection outcome includes different definitions per the individual trials.

CONDENSATION

Prophylactic negative pressure wound therapy has no effect on overall wound complications in women with obesity after cesarean delivery compared with standard dressings.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain.

OBJECTIVES

To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure.

SEARCH METHODS

In January 2021, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane risk of bias tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. Our primary outcomes were SSI, mortality, and wound dehiscence.

MAIN RESULTS

In this fourth update, we added 18 new randomised controlled trials (RCTs) and one new economic study, resulting in a total of 62 RCTs (13,340 included participants) and six economic studies. Studies evaluated NPWT in a wide range of surgeries, including orthopaedic, obstetric, vascular and general procedures. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Eleven studies (6384 participants) which reported mortality were pooled. There is low-certainty evidence showing there may be a reduced risk of death after surgery for people treated with NPWT (0.84%) compared with standard dressings (1.17%) but there is uncertainty around this as confidence intervals include risk of benefits and harm; risk ratio (RR) 0.78 (95% CI 0.47 to 1.30; I² = 0%). Fifty-four studies reported SSI; 44 studies (11,403 participants) were pooled. There is moderate-certainty evidence that NPWT probably results in fewer SSIs (8.7% of participants) than treatment with standard dressings (11.75%) after surgery; RR 0.73 (95% CI 0.63 to 0.85; I² = 29%). Thirty studies reported wound dehiscence; 23 studies (8724 participants) were pooled. There is moderate-certainty evidence that there is probably little or no difference in dehiscence between people treated with NPWT (6.62%) and those treated with standard dressing (6.97%), although there is imprecision around the estimate that includes risk of benefit and harms; RR 0.97 (95% CI 0.82 to 1.16; I² = 4%). Evidence was downgraded for imprecision, risk of bias, or a combination of these. Secondary outcomes There is low-certainty evidence for the outcomes of reoperation and seroma; in each case, confidence intervals included both benefit and harm. There may be a reduced risk of reoperation favouring the standard dressing arm, but this was imprecise: RR 1.13 (95% CI 0.91 to 1.41; I² = 2%; 18 trials; 6272 participants). There may be a reduced risk of seroma for people treated with NPWT but this is imprecise: the RR was 0.82 (95% CI 0.65 to 1.05; I² = 0%; 15 trials; 5436 participants). For skin blisters, there is low-certainty evidence that people treated with NPWT may be more likely to develop skin blisters compared with those treated with standard dressing (RR 3.55; 95% CI 1.43 to 8.77; I² = 74%; 11 trials; 5015 participants). The effect of NPWT on haematoma is uncertain (RR 0.79; 95 % CI 0.48 to 1.30; I² = 0%; 17 trials; 5909 participants; very low-certainty evidence). There is low-certainty evidence of little to no difference in reported pain between groups. Pain was measured in different ways and most studies could not be pooled; this GRADE assessment is based on all fourteen trials reporting pain; the pooled RR for the proportion of participants who experienced pain was 1.52 (95% CI 0.20, 11.31; I² = 34%; two studies; 632 participants). Cost-effectiveness Six economic studies, based wholly or partially on trials in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in five indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty; coronary artery bypass grafts; and vascular surgery with inguinal incisions. They calculated quality-adjusted life-years or an equivalent, and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the evidence certainty varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed.

AUTHORS' CONCLUSIONS

People with primary closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSIs  than people treated with standard dressings but there is probably no difference in wound dehiscence (moderate-certainty evidence). There may be a reduced risk of death after surgery for people treated with NPWT compared with standard dressings but there is uncertainty around this as confidence intervals include risk of benefit and harm (low-certainty evidence). People treated with NPWT may experience more instances of skin blistering compared with standard dressing treatment (low-certainty evidence). There are no clear differences in other secondary outcomes where most evidence is low or very low-certainty. Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.

A Cost-Utility Analysis of the Use of Closed-Incision Negative Pressure System in Vascular Surgery Groin Incisions

OBJECTIVE

Closed-incision negative pressure therapy (CINPT) with the Prevena system has been used and clinically evaluated in high-risk groin incisions to reduce the risk of postoperative complications. We performed a cost-effectiveness analysis evaluating CINPT in femoral-popliteal bypass with prosthetic graft.

METHODS

A literature review looking at prospective randomized trials determined the probabilities and outcomes for femoral-popliteal bypass with and without CINPT. Reported utility scores were used to estimate the quality adjusted life years (QALYs) associated with a successful procedure and postoperative complications. Medicare current procedure terminology and diagnosis-related group codes were used to assess the costs for a successful surgery and associated complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-effectiveness ratio (ICER) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the results, and to accommodate for the uncertainty in the literature.

RESULTS

Femoral-popliteal bypass with CINPT is less costly ($40,138 vs $41,774) and more effective (6.14 vs 6.13) compared to without CINPT. This resulted in a negative ICER of -234,764.03, which favored CINPT, indicating a dominant strategy. In one-way sensitivity analysis, surgery without CINPT was more cost-effective if the probability of successful surgery falls below 84.9% or if the cost of CINPT exceeds $3139. Monte Carlo analysis showed a confidence of 99.07% that CINPT is more cost-effective.

CONCLUSIONS

Despite the added device cost of CINPT, it is cost-effective in vascular surgical operations using groin incisions.

Closed-Incision Negative Pressure Therapy Decreases Wound Morbidity in Open Abdominal Wall Reconstruction With Concomitant Panniculectomy

INTRODUCTION

Patients undergoing abdominal wall reconstruction (AWR) with concomitant panniculectomy (CP) may be at higher risk for wound complications due to the need for large incisions and tissue undermining. The aim of this study was to evaluate whether the use of closed-incision negative pressure therapy (ciNPT) decreases wound complications in AWR patients undergoing CP.

METHODS

Beginning in February 2018, all patients at this institution who underwent AWR with CP received ciNPT. These patients were identified from a prospectively maintained institutional database. A standard dressing (non-NPT) group was then created in a 1:1 fashion by identifying patients who had AWR with CP immediately before the beginning of ciNPT use (2016-2018). A univariate comparison was made between the ciNPT and non-NPT groups. The primary outcome was wound complication rate; however, other perioperative outcomes, such as requirement for reoperation, were also tracked. Standard statistical methods and logistic regression were used.

RESULTS

In total, 134 patients met criteria, with 67 patients each in the ciNPT and non-NPT groups. When comparing patients in the ciNPT and non-NPT groups, they were demographically similar, including body mass index, smoking, and diabetes (P < 0.05). Hernias was large on average (289.5 ± 158.2 vs 315.3 ± 197.3 cm2, P = 0.92) and predominantly recurrent (58.5% vs 72.6%, P = 0.14). Wound complications were much lower in the ciNPT group (15.6% vs 35.5%, P = 0.01), which was mainly driven by a decrease in superficial wound breakdown (3.1% vs 19.7%, P < 0.01). Patients in the ciNPT group were less likely to require a return trip to the operating room for wound complications (0.0% vs 13.3%, P < 0.01). In logistic regression, the use of ciNPT continued to correlate with reduced wound complication rates (P = 0.02).

CONCLUSIONS

In AWR with CP, the use of ciNPT significantly decreased the risk of postoperative wound complications, particularly superficial wound breakdown, and lessened the need for wound-related reoperation.

Negative pressure wound therapy versus conventional wound care in cancer surgical wounds: A meta-analysis of observational studies and randomised controlled trials

The application of negative pressure wound therapy (NPWT) in cancer surgical wounds is still controversial, despite its promising usage, because of the risks of increased tumorigenesis and metastasis. This study aimed to review the risks and benefits of NPWT in surgical wounds with the underlying malignant disease compared with conventional wound care (CWC). The first outcome was wound complications, divided into surgical site infection (SSI), seroma, hematoma, and wound dehiscence. The secondary outcome was hospital readmission. We performed a separate meta‐analysis of observational studies and randomised controlled trials (RCTs) with CI 95%. Thirteen observational studies with 1923 patients and seven RCTs with 1091 patients were included. NPWT group showed significant decrease in the risk of SSI (RR = 0.45) and seroma (RR = 0.61) in observational studies with P value <0.05, as well as RCTs but were not significant (RR = 0.88 and RR = 0.68). Wound dehiscence (RR = 0.74 and RR = 1.15) and hospital readmission (RR = 0.90 and RR = 0.62) showed lower risks in NPWT group but were not significant. Hematoma (RR = 1.08 and RR = 0.87) showed no significant difference. NPWT is not contraindicated in cancer surgical wounds and can be considered a beneficial palliative treatment to promote wound healing.

Negative-pressure wound therapy is effective for peritoneal dialysis catheter exit-site management in the early postoperative period

Peritoneal dialysis (PD) catheter exit-site care is critically important for the prevention of catheter-related infections (CRIs) and subsequent peritonitis. The postoperative management of the site is particularly essential because it has an open wound that is always adjacent to a PD catheter tube. This study aimed to examine the effectiveness of negative-pressure wound therapy (NPWT) for postoperative PD catheter exit sites. Thirty patients with end-stage renal disease who underwent simultaneous PD catheter insertion and exit-site formation were randomly assigned to receive NPWT (NPWT group) or conventional dressing (non-NPWT group) for the first seven postoperative days. The exit-site scores on the seventh postoperative day was lower in the NPWT group than in the non-NPWT group (p = 0.0049). Analysis of variance F statistic for the effect of NPWT over 180 days was highly significant (11.482595, p = 0.007). There were no statistically significant differences between the time to first CRI and PD-related peritonitis between the two groups. There was one case of CRI with relapsing peritonitis and catheter loss in the non-NPWT group. These findings demonstrate the association between NPWT and low exit-site score. NPWT can be recommended for the management of PD catheter exit sites in the early postoperative period.

Application of PREVENA (Surgical Incision Protection System) in reducing surgical site infections following reversal of ileostomy or colostomy: the PRIC study protocol

AIM

There is a current lack of evidence in the literature to support the routine use of negative pressure wound therapy (NPWT) to reduce the risk of surgical site infections (SSI) in the setting of ileostomy or colostomy reversal. The aim of this study is to examine whether routine NPWT confers a lower rate of SSI than conventional dressings following reversal of ileostomy or colostomy.

METHODS

The PRIC study is a randomized, controlled, open-label, multi-centre superiority trial to assess whether routine NPWT following wound closure confers a lower rate of SSI following reversal of ileostomy or colostomy when compared to conventional dressings. Participants will be consecutively identified and recruited. Eligible participants will be randomized in a 1:1 allocation ratio, to receive either the NPWT (PREVENA) dressings or conventional dressings which will be applied immediately upon completion of surgery. PREVENA dressings will remain applied for a duration of 7 days. Surgical wounds will then be examined on post-operative day seven as well as during follow-up appointments in OPD for any evidence of SSI. In the interim, public health nurses (PHN) will provide out-patient support services incorporating wound assessment and care as part of a routine basis. Study investigators will liaise with PHN to gather the relevant data in relation to the time to wound healing. Our primary endpoint is the incidence of SSI within 30 days of stoma reversal. Secondary endpoints include measuring time to wound healing, evaluating wound healing and aesthetics and assessing patient satisfaction.

CONCLUSION

The PRIC study will assess whether routine NPWT following wound closure is superior to conventional dressings in the reduction of SSI following reversal of ileostomy or colostomy and ascertain whether routine NPWT should be considered the new standard of care.

Circular RNA Expression Profiles Following Negative Pressure Wound Therapy in Burn Wounds with Experimental Pseudomonas aeruginosa Infection

Infections of burn wounds, especially those caused by Pseudomonas aeruginosa, could trigger sepsis or septic shock, which is the main cause of death after burn injury. Compared with traditional saline-wet-to-dry dressings, negative pressure wound therapy (NPWT) is more effective for the prevention and treatment of wound infections. However, the mechanism by which NPWT controls infection and accelerates wound healing remains unclear. Accordingly, in this study, the molecular mechanisms underlying the effects of NPWT were explored using a murine model of P. aeruginosa-infected burn wounds. NPWT significantly reduced P. aeruginosa levels in wounds, enhanced blood flow, and promoted wound healing. Additionally, NPWT markedly alleviated wound inflammation and increased the expression of wound healing–related molecules. Recent evidence points to a role of circular RNAs (circRNAs) in wound healing; hence, whole-transcriptome sequencing of wound tissues from NPWT and control groups was performed to evaluate circRNA expression profiles. In total, 12 up-regulated and 25 down-regulated circRNAs were identified between groups. Among these, five significant differentially expressed circRNAs acting as microRNA sponges were identified, and their predicted targets were verified by reverse transcription-quantitative polymerase chain reaction. These results further support the roles of circRNAs in wound healing by NPWT and the prevention of P. aeruginosa infection, providing key molecular targets for further functional analyses.

Incisional negative pressure wound therapy for clean-contaminated wounds in abdominal surgery: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The role of incisional negative-pressure wound therapy (iNPWT) in preventing surgical site infections (SSIs) in clean-contaminated abdominal wounds is still controversial. This meta-analysis was performed to evaluate whether the use of iNPWT could reduce SSIs and other complications in clean-contaminated abdominal surgery.

METHODS

The authors searched PubMed, EMBASE, Cochrane library, and Web of Science from database inception to 23 January 2021 for randomized controlled trials (RCTs). They assessed the risk of bias using the Cochrane Collaboration risk of bias tool and conducted a meta-analysis using RevMan 5.4.

RESULTS

Eleven RCTs, including 4112 patients, were analyzed, of which 2057 were treated with iNPWT and 2055 with standard dressings. The SSI rates (OR = 0.76, 95% CI = 0.61-0.94, P = 0.01), in patients undergoing an iNPWT intervention were significantly lower than those in patients receiving standard dressings. There was no statistically significant difference between the rates of incision dehiscence, seroma, and readmission between groups.

CONCLUSIONS

Application of iNPWT for clean-contaminated wounds in abdominal surgery reduced SSI rates but showed similar rates of wound dehiscence, seroma, and readmission compared with standard dressings.

Prophylactic Single-use Negative Pressure Dressing in Closed Surgical Wounds After Incisional Hernia Repair: A Randomized, Controlled Trial

OBJECTIVE

A randomized controlled trial (RCT) was undertaken to evaluate whether the prophylactic application of a specific single-use negative pressure (sNPWT) dressing on closed surgical incisions after incisional hernia (IH) repair decreases the risk of surgical site occurrences (SSOs) and the length of stay.

BACKGROUND

The sNPWT dressings have been associated to several advantages like cost savings and prevention of SSOs like seroma, hematoma, dehiscence, or wound infection (SSI) in closed surgical incisions. But this beneficious effect has not been previously studied in cases of close wounds after abdominal wall hernia repairs.

METHODS

An RCT was undertaken between May 2017 and January 2020 (ClinicalTrials.gov registration number NCT03576222). Participating patients, with IH type W2 or W3 according to European Hernia Society classification, were randomly assigned to receive intraoperatively either the sNPWT (PICO)(72 patients) or a conventional dressing at the end of the hernia repair (74 patients). The primary endpoint was the development of SSOs during the first 30 days after hernia repair. The secondary endpoint included length of hospital stay. Statistical analysis was performed using IBM SPSS Statistics Version 23.0.

RESULTS

At 30 days postoperatively, there was significatively higher incidence of SSOs in the control group compared to the treatment group (29.8% vs 16.6%, P < 0.042). There was no SSI in the treatment group and 6 cases in the control group (0% vs 8%, P < 0.002). No significant differences regarding seroma, hematoma, wound dehiscence, and length of stay were observed between the groups.

CONCLUSION

The use of prophylactic sNPWT PICO dressing for closed surgical incisions following IH repair reduces significatively the overall incidence of SSOs and the SSI at 30 days postoperatively.

The use of closed incision negative pressure therapy for incision and surrounding soft tissue management: Expert panel consensus recommendations

As the use of closed incision negative pressure therapy (ciNPT) becomes more widespread, dressing designs have evolved to address implementation challenges and meet surgeon demand. While traditional application of ciNPT was limited to the immediate suture line, a novel dressing that covers the incision and additional surrounding tissues has become available. To expand upon previous ciNPT recommendations and provide guidance on this new dressing, an expert panel of plastic surgeons convened to review the current literature, identify challenges to the implementation and sustainability of ciNPT, and use a modified Delphi technique to form a consensus on the appropriate use of ciNPT with full‐coverage dressings. After three rounds of collecting expert opinion via the Delphi method, consensus was reached if 80% of the panel agreed upon a statement. This manuscript establishes 10 consensus statements regarding when ciNPT with full‐coverage foam dressings should be considered or recommended in the presence of patient or incision risk factors, effective therapeutic settings and duration, precautions for use, and tools and techniques to support application. The panel also discussed areas of interest for future study of ciNPT with full‐coverage dressings. High‐quality, controlled studies are needed to expand the understanding of the benefits of ciNPT over the incision and surrounding tissues.

Oncologic feasibility for negative pressure wound therapy application in surgical wounds: A meta-analysis

Negative pressure wound therapy (NPWT) decreases postoperative complications of various surgeries. However, the use of NPWT for oncological surgical wounds remains controversial. To evaluate the association of NPWT with oncologic recurrence in surgical wounds without residual malignancy, we analysed studies that compared NPWT with conventional non‐pressure dressings for cancer surgical wounds without residual tumour by August 12, 2020. We compared tumour recurrence rates and postoperative complications between the two procedures. The six studies included 118 patients who received NPWT, and 149 patients who received conventional non‐pressure wound care. The overall quality of the included studies was high based on the Newcastle–Ottawa scale score of 7.5. Tumour recurrence after NPWT was not significantly different compared with conventional non‐negative pressure wound care (9.3% versus 11.4%, P = 0.40). There was no significant heterogeneity between the studies (I² = 3%). Although NTWT was associated with a lower complication rate compared with the control group, the result was non‐significant (P = 0.15). Application of NPWT in oncologic resection wounds without residual malignancy revealed no difference in local recurrence and may reduce the risk of postoperative complications compared with conventional non‐negative pressure dressings. NPWT can be considered an alternative method for reconstruction in challenging cases.

Negative-pressure wound therapy for III/IV pressure injuries: A meta-analysis

This meta-analysis was conducted to identify the potential benefits and the efficacy of negative-pressure wound therapy (NPWT) for III/IV pressure injuries (PIs) compared with standard wound care (SWC). Sixteen RCTs with 629 patients were included in our analysis. The methodological quality was assessed by the Cochrane Collaboration Tool. The outcomes included complete ulcer healing rate, wound healing time, pain score, the frequency of dressing change, hospitalization cost, the condition of the exudate, and the wound improvement. The percentage of healing rate was 61.45% for the NPWT group and 36.90% for SWC (95% CI: 1.32-1.70). There were significant differences in wound healing time (WMD = -16.47 days, 95% [CI (-22.36, - 10.59) days, P ≤ .001]). The pain score and hospitalization cost in NPWT was lower compared with SWC group (WMD = -2.39, 95% CI [-3.47, -1.30], P ≤ .001); (SMD = -2.55, 95% CI [-4.07, -1.03], P < .01). The frequency of dressing change in both NPWT groups was greatly reduced (SMD = -3.61, 95% [CI (-4.57, - 2.66) times, P ≤ .001]). Our meta-analysis indicated that NPWT was associated with greater improvements in improving PIs and shorting healing time for III/IV PIs. However, this conclusion needs to be confirmed by high-quality multicenter RCTs.

Necrotizing Fasciitis of the Breast: A Review of the Literature

Background: Necrotizing fasciitis (NF) is a rare, rapidly progressing, and potentially fatal tissue infection involving subcutaneous tissue, superficial fascia, and the overlying skin. Breast NF is often misdiagnosed because of the thick breast tissue between the skin and deep fascia. Only early diagnosis followed by prompt antibiotic treatment and surgical therapy can prevent disastrous consequences. There are many case reports on breast NF, but a systematic review is lacking. Methods: Using PubMed and Scopus we performed a systematic review of the literature covering a period of 20 years. We reviewed articles with predisposing comorbidities (risk factors), triggering factors, laboratory examinations, culture of organisms, antibiotic treatment, surgical interventions, the presence of septic shock, and final outcome. We also performed statistical tests of all these factors in relation to death. Results: Forty cases identified from 38 articles were included in our literature review. Twenty-one cases (52.5%) were primary, whereas 15 cases (37.5%) occurred after surgery. In 15 cases (37.5%), the single organism responsible for NF was Streptococcus pyogenes, whereas mixed organisms were found in 17 cases (42.5%). Surgical debridement was performed in 39 (97.5%) cases. Septic shock was found in all five (12.5%) deceased cases and was associated with patient's mortality (p < 0.001). Conclusions: Breast NF is a rare, severe, and easily misdiagnosed complication. Breast NF could differ from that in other body regions in etiology pattern and clinical manifestations. Confirmed diagnosis of breast NF is based on the combination of clinical, cultural, laboratory, and imaging findings. Urgent subsequent treatments, including surgical debridement, antibiotic therapy, and reconstructive surgery, are critical for better prognosis and survival of patients.

Cost-effectiveness analysis of negative pressure wound therapy dressings after open inguinal vascular surgery - The randomised INVIPS-Trial

AIM

While the scientific evidence in favour of negative pressure wound therapy (NPWT) dressings on sutured incisions in the prevention of surgical site infections (SSIs) has increased, the cost-effectiveness after vascular surgery has not been evaluated. The aim of this study was to evaluate the cost-effectiveness of NPWT compared to standard dressings for the prevention of SSIs after open inguinal vascular surgery.

MATERIALS AND METHODS

Patient data were retrieved from the randomised INVIPS-trial's open arm, which included patients randomised to either NPWT or standard dressings. The patients were surveyed for SSIs for 90 days postoperatively. The patients' individual cost data were included and analysed from a healthcare perspective. The patients' quality of life was measured using the Vascuqol-6 questionnaire pre- and 30 days postoperatively. Cost-effectiveness of NPWT was determined by decreased or equal total costs and a significant reduction in SSI incidence.

RESULTS

The mean vascular procedure-related costs at 90 days were €16,621 for patients treated with NPWT (n = 59) and €16,285 for patients treated with standard dressings (n = 60), p = 0.85. The SSI incidence in patients treated with NPWT was 11.9% (n = 7/59) compared to 30.0% (n = 18/60) with standard dressings, p = 0.015. This corresponds to an increased mean cost of €1,853 per SSI avoided. The cost-effectiveness plane of incremental vascular procedure-related costs and difference in Vascuqol-6 score showed that 42% of estimates were in the quadrant where NPWT was dominant.

CONCLUSION

NPWT is considered cost-effective over standard dressings in patients undergoing open inguinal vascular surgery due to reduced SSI incidence at no higher costs.

Effect of Prophylactic Negative Pressure Wound Therapy vs Standard Wound Dressing on Surgical-Site Infection in Obese Women After Cesarean Delivery: A Randomized Clinical Trial

IMPORTANCE

Obesity increases the risk of both cesarean delivery and surgical-site infection. Despite widespread use, it is unclear whether prophylactic negative pressure wound therapy reduces surgical-site infection after cesarean delivery in obese women.

OBJECTIVE

To evaluate whether prophylactic negative pressure wound therapy, initiated immediately after cesarean delivery, lowers the risk of surgical-site infections compared with standard wound dressing in obese women.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter randomized trial conducted from February 8, 2017, through November 13, 2019, at 4 academic and 2 community hospitals across the United States. Obese women undergoing planned or unplanned cesarean delivery were eligible. The study was terminated after 1624 of 2850 participants were recruited when a planned interim analysis showed increased adverse events in the negative pressure group and futility for the primary outcome. Final follow-up was December 18, 2019.

INTERVENTIONS

Participants were randomly assigned to either undergo prophylactic negative pressure wound therapy, with application of the negative pressure device immediately after repair of the surgical incision (n = 816), or receive standard wound dressing (n = 808).

MAIN OUTCOMES AND MEASURES

The primary outcome was superficial or deep surgical-site infection according to the Centers for Disease Control and Prevention definitions. Secondary outcomes included other wound complications, composite of surgical-site infections and other wound complications, and adverse skin reactions.

RESULTS

Of the 1624 women randomized (mean age, 30.4 years, mean body mass index, 39.5), 1608 (99%) completed the study: 806 in the negative pressure group (median duration of negative pressure, 4 days) and 802 in the standard dressing group. Superficial or deep surgical-site infection was diagnosed in 29 participants (3.6%) in the negative pressure group and 27 (3.4%) in the standard dressing group (difference, 0.36%; 95% CI, -1.46% to 2.19%, P = .70). Of 30 prespecified secondary end points, 25 showed no significant differences, including other wound complications (2.6% vs 3.1%; difference, -0.53%; 95% CI, -1.93% to 0.88%; P = .46) and composite of surgical-site infections and other wound complications (6.5% vs 6.7%; difference, -0.27%; 95% CI, -2.71% to 2.25%; P = .83). Adverse skin reactions were significantly more frequent in the negative pressure group (7.0% vs 0.6%; difference, 6.95%; 95% CI, 1.86% to 12.03%; P < .001).

CONCLUSIONS AND RELEVANCE

Among obese women undergoing cesarean delivery, prophylactic negative pressure wound therapy, compared with standard wound dressing, did not significantly reduce the risk of surgical-site infection. These findings do not support routine use of prophylactic negative pressure wound therapy in obese women after cesarean delivery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03009110.

Prophylactic Use of Negative Pressure Wound Therapy Reduces Surgical Site Infections in Elective Colorectal Surgery: A Prospective Cohort Study

Background: The main purpose was to assess the efficacy of negative pressure wound therapy (NPWT) for surgical site infection (SSI) in elective open and laparoscopic open-assisted colorectal surgery. The primary end point was to establish SSI within 30 days post-operatively. The secondary aim was hospital stay and to assess SSI predictors in a multivariable analysis. Patients and Methods: A prospective cohort study was undertaken between January 2017 and December 2018 in patients undergoing elective colorectal surgery, both through open and minimally invasive approaches, to whom NPWT or fully occlusive dressing were applied. Baseline data were compared between the two groups and multivariable analysis was performed to identify SSI risk factors. Results: Two hundred patients were included: 100 NPWT patients and 100 closed dressing patients. No differences between the two groups were found. The incidence of SSI in the control dressing group was 19% versus 9% in the NPWT group, which was substantially different (odds ratio [OR] 0.30; 95% confidence interval [CI] 0.11-0.83; p = 0.02). No differences were found in hospital length of stay (12.33 d in NPWT group vs. 12.39 d in the control group; p = 0.82). A body mass index (BMI) of 30-35 (p = 0.04), BMI >35 (p = 0.03), and midline wound (p = 2.68) were found to be predictors of SSI in multivariable analysis. Conclusion: The prophylactic use of NPWT in laparotomy incisions for patients undergoing elective colorectal surgery (both through open and laparoscopic approach) is associated with a reduction in SSI rates.

Improved Perioperative Seroma and Complication Rates Following the Application of a 2-Layer Negative Pressure Wound Therapy System After Inguinal Lymphadenectomy for Metastatic Cutaneous Melanoma

Background

Perioperative complications following inguinal lymphadenectomy, including seroma formation, are frequent. We have employed a 2-layer negative pressure wound therapy (2-LNPWT) as a method to reduce seroma rate and perioperative complications. We present the outcome of our initial experience with 2-LNPWT and compare the outcomes of its use with traditional closed suction drains (CSDs).

Materials and methods

A non-randomised retrospective case–control series was analysed. Surgeons performing inguinal lymphadenectomy for metastatic cutaneous melanoma utilised either the 2-LNPWT therapy or traditional CSDs according to their practice preference.

Results

The study included 111 patients. The cohorts were well matched for gender, disease burden, body mass index and comorbidities. The 2-LNPWT technique was associated with significantly better postoperative outcomes than CSD, in terms of incidence of seroma formation (26.9% vs 49.4%; p < 0.03), period of drainage (15 days vs 20 days; p = 0.005) and return to theatre rate (0% vs 15.3%; p = 0.03). The overall seroma rate was 44.1%. The only significant association with seroma initiation was the type of drainage system used (2-LNPWT 31.2% vs CSD 58.3%; p < 0.03; OR 3.0). The method of drainage did not alter the course of an established seroma. There was no significant difference in overall or disease-specific survival detected between the 2 groups.

Conclusion

This retrospective non-randomised case control study has demonstrated the safe use of a novel application of negative pressure wound therapy that significantly reduced the incidence of seroma formation and postoperative complication rate for inguinal lymphadenectomy for melanoma.