Prophylactic Negative-pressure Dressings Reduce Wound Complications and Resource Burden After Emergency Laparotomies

Enhancing Healing Strategies: Negative-Pressure Wound Therapy and Delayed Primary Closure in Abdominal Wounds Post-emergency Laparotomy for Intestinal Perforation

Background Intestinal perforation is a life-threatening condition requiring immediate surgical intervention. Surgical-site infections (SSIs) and wound dehiscence are common complications associated with emergency laparotomy for intestinal perforation. Finding optimal wound management and postoperative strategies can significantly impact patient outcomes and reduce the risk of complications. Negative-pressure wound therapy (NPWT) is a relatively recent tool employed in the care of wounds to control SSIs and foster healing. Methodology A prospective, observational, cohort study was conducted among 150 patients who underwent emergency exploratory laparotomy due to intestinal perforation at the general surgery department of a tertiary care hospital in New Delhi between July 2022 and December 2023. Preoperatively, all patients underwent initial resuscitation. Intraoperatively, the extent of peritonitis was determined and was categorized according to the Centers for Disease Control and Prevention (CDC) classification. Postoperatively, NPWT dressing was applied to the patient's midline laparotomy wound on postoperative day (POD) two. Negative pressure was set at 75-125 mmHg with suction. The number of NPWT dressing changes required was documented. The wound was closed with vertical mattress sutures under local anesthesia, delayed primary closure (DPC). The incidence of SSIs, the duration for DPC, the incidence of fascial dehiscence, the number of NPWT dressing changes, and the length of hospital stay were documented according to CDC groups. Results The mean age in CDC categories 2, 3, and 4 were 31.789, 28.733, and 42.676 years, respectively. The most common cause of perforation was enteric fever (n = 42, 28%), followed by tuberculosis (n = 36, 24%). Most patients had no known comorbidities (n = 80, 53.3%). Overall, 16% of patients (n = 24) were both alcoholics and smokers. The most frequent bacteria in all CDC categories was Escherichia coli. Fourteen patients developed burst abdomen in the postoperative period and were excluded from the study. The mean duration of DPC increased with higher CDC categories, with CDC category 4 displaying the most extended mean duration at 10.70 days. The number of NPWT dressing changes increases with higher CDC categories, with CDC category 4 exhibiting the highest mean at 2.00 changes. The mean hospital stay increased with higher CDC categories, with CDC category 4 showing the most extended mean stay at 17.324 days. Statistical analysis revealed no significant association between SSI occurrence and CDC categories. Conclusions NPWT followed by DPC is a promising approach to managing gastrointestinal perforations, reducing SSIs, and potentially improving patient outcomes. However, further research is needed to explore the specific benefits of NPWT in conjunction with DPC and its efficacy in various clinical scenarios.

Prophylactic negative pressure wound therapy in patients with closed surgical wound: An integrative review

Surgical site infection is the leading healthcare-associated infection and a major contributor to rising healthcare costs. Implementation of measures to reduce this problem, particularly the prophylactic use of negative pressure wound therapy, may be an effective and promising method to reduce the risk of surgical site infection in patients with closed surgical wounds. The aim of the study was to identify the effectiveness of negative pressure wound therapy as a prophylactic measure in reducing the risk of surgical site infection in patients with a closed surgical wound. Whittemore and Knafl's five-step integrative review framework was carried out using three electronic databases. MEDLINE with Full-text, CINAHL with Full-text and Academic Search Complete were searched through the EBSCOhost Web platform. Articles search publication date was between 2018 and 2022. Nine studies were identified that addressed the effectiveness of prophylactic negative pressure wound therapy in reducing the risk of surgical site infection in the patient with a closed surgical wound. There was also evidence of effectiveness in reducing surgical wound dehiscence, drainage output and drainage time, as well as reducing the incidence of hospital readmissions and the need for wound debridement. Prophylactic negative pressure wound therapy can be an effective treatment option, among others, in reducing the risk of surgical site infection in patients with a closed surgical wound. This evidence promotes improved clinical practice regarding the management of the closed surgical wound, promoting health gains for patients.

ECLAPTE: Effective Closure of LAParoTomy in Emergency-2023 World Society of Emergency Surgery guidelines for the closure of laparotomy in emergency settings

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.

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.

Closed Incision Negative Pressure Therapy versus Standard of Care in Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis

Closed incision negative pressure therapy (ciNPT) has been utilized to help manage closed incisions across many surgical specialties. This systematic review and meta-analysis evaluated the effect of ciNPT on postsurgical and health economic outcomes.

Methods

A systematic literature search using PubMed, EMBASE, and QUOSA was performed for publications written in English, comparing ciNPT to standard-of-care dressings between January 2005 and August 2021. Study participant characteristics, surgical procedure, dressings used, treatment duration, postsurgical outcomes, and follow-up data were extracted. Meta-analyses were performed using random-effects models. Risk ratios summarized dichotomous outcomes. Difference in means or standardized difference in means was used to assess continuous variables reported on the same scale or outcomes reported on different scales/measurement instruments.

Results

The literature search identified 84 studies for analysis. Significant reductions in surgical site complication (SSC), surgical site infection (SSI), superficial SSI, deep SSI, seroma, dehiscence, skin necrosis, and prolonged incisional drainage were associated with ciNPT use (P < 0.05). Reduced readmissions and reoperations were significant in favor of ciNPT (P < 0.05). Patients receiving ciNPT had a 0.9-day shorter hospital stay (P < 0.0001). Differences in postoperative pain scores and reported amounts of opioid usage were significant in favor of ciNPT use (P < 0.05). Scar evaluations demonstrated improved scarring in favor of ciNPT (P < 0.05).

Discussion

For these meta-analyses, ciNPT use was associated with statistically significant reduction in SSCs, SSIs, seroma, dehiscence, and skin necrosis incidence. Reduced readmissions, reoperation, length of hospital stay, decreased pain scores and opioid use, and improved scarring were also observed in ciNPT patients.

Prophylactic effect of negative‐pressure wound therapy and delayed sutures against incisional‐surgical site infection after emergency laparotomy for colorectal perforation: A multicenter retrospective cohort study

Aim

The prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after highly contaminated laparotomies has not been sufficiently explored. This study aimed to evaluate the prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after emergency surgery for colorectal perforation.

Methods

This nationwide, multicenter, retrospective cohort study analyzed data from the 48 emergency hospitals certificated by the Japanese Society for Abdominal Emergency Medicine. Patients who underwent an emergency laparotomy for colorectal perforation between April 2015 and March 2020 were included in this study. Outcomes, including the incidence of incisional surgical site infection, were compared between patients who were treated with prophylactic negative-pressure wound therapy and delayed sutures (i.e., negative-pressure wound therapy group) and patients who were treated with regular wound management (i.e., control group) using 1:4 propensity score matching analysis.

Results

The negative-pressure wound therapy group comprised 88 patients, whereas the control group consisted of 1535 patients. Of them, 82 propensity score-matched pairs (negative-pressure wound therapy group: 82; control group: 328) were evaluated. The negative-pressure wound therapy group showed a lower incidence of incisional surgical site infection [18 (22.0%) in the negative-pressure wound therapy group and 115 (35.0%) in the control group, odds ratio, 0.52; 95% confidence interval, 0.30 to 0.92; p = 0.026].

Conclusions

The prophylactic use of negative-pressure wound therapy with delayed sutures was associated with a lower incidence of incisional surgical site infection after emergency surgery for colorectal perforation.

Efficacy of Prophylactic Negative-Pressure Wound Therapy with Delayed Primary Closure for Contaminated Abdominal Wounds

Background. Prophylactic negative-pressure wound therapy (NPWT) to prevent surgical site infection (SSI) may be effective for severely contaminated wounds. We investigated the safety and efficacy of NPWT with delayed primary closure (DPC) for preventing SSI. Methods. For patients with contaminated and dirty/infected surgical wounds after an emergency laparotomy, the abdominal fascia was closed with antibacterial absorbent threads and the skin was left open. Negative pressure (−80 mmHg) was applied through the polyurethane foam, which was replaced on postoperative days 3 and 7. DPC was performed when sufficient granulation was observed. The duration and adverse events of NPWT, the development of SSI, and the postoperative hospital stay were retrospectively reviewed. Results. We analyzed the cases of patients with contaminated (n = 15) and dirty/infected wounds (n = 7). The median duration of NPWT was 7 days (range 5–11 days). NPWT was discontinued in one (4.5%) patient due to wound traction pain. SSI developed in seven patients (31.8%), with incisional SSI in one (4.5%) and organ/space SSI in six (27.3%). The median postoperative hospital stay was 17 days (range 7–91 days). There was no significant relationship between postoperative hospital stay and wound classification ( $P=0.17$ ) or type of SSI ( $P=0.07$ ). Conclusion. Prophylactic NPWT with DPC was feasible and may be particularly suitable for severely contaminated wounds, with a low incidence of incisional SSI.

Prophylactic negative pressure wound dressings reduces wound complications following emergency laparotomies: A systematic review and meta-analysis

BACKGROUND

Wound complications are a common cause of postoperative morbidity and incur significant healthcare costs. Recent studies have shown that negative pressure wound dressings reduce wound complication rates, particularly surgical site infections, after elective laparotomies. The clinical utility of prophylactic negative pressure wound dressings for closed emergency laparotomy incisions remains controversial. This meta-analysis investigated the rates of wound complications after emergency laparotomy when a negative pressure wound dressing was applied.

METHODS

A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, Cochrane Registry, Web of Science, and Clinialtrials.gov databases were searched from January 1, 2005, to April 1, 2022. All studies comparing negative pressure wound dressings to standard dressings on closed emergency laparotomy incisions were included.

RESULTS

A total of 1,199 (negative pressure wound dressings: 566, standard dressing: 633) patients from 7 (prospective: 4, retrospective: 3) studies were identified. Overall, the surgical site infection (superficial/deep) rate was 13.6% (77/566) vs 25.1% (159/633) in the negative pressure wound dressing versus standard dressing groups, respectively (odds ratio 0.43, 95% confidence interval 0.30-0.62). Wound breakdown (skin/fascial dehiscence) was significantly lower in the negative pressure wound dressing (7.7%) group compared to the standard dressing (16.9%) group (odds ratio 0.36, 95% confidence interval 0.19-0.72). The incidence of overall wound complications was significantly lower in the negative pressure wound dressing (15.9%) group compared to the standard dressing (30.4%) group (odds ratio 0.41, 95% confidence interval 0.28-0.59). No significant differences were found in hospital length-of-stay and readmission rates.

CONCLUSION

Prophylactic negative pressure wound dressings for closed emergency laparotomy incisions were associated with a significant reduction in surgical site infections, wound breakdown, and overall wound complications, thus supporting its clinical use.

Closed incision negative pressure wound therapy is associated with reduced surgical site infection after emergency laparotomy: A propensity matched-cohort analysis

BACKGROUND

Surgical site infection contributes to a significant proportion of postoperative morbidity in patients undergoing emergency laparotomy. Surgical site infections cause significant patient burden, increase duration of stay, and have economic implications. Closed incision negative pressure therapy has been shown to reduce surgical site infection rates in patients undergoing elective laparotomy; however, there is limited evidence for their use in the emergency setting. This study aims to compare rates of surgical site infection between patients receiving closed incision negative pressure therapy and standard surgical dressing after emergency laparotomy through a propensity matched analysis.

METHODS

A registry-based, prospective cohort study was undertaken using data from the National Emergency Laparotomy Audit database at our center. The primary outcome measure was surgical site infection as defined by the Centers for Disease Control criteria. Secondary outcomes included 30-day postoperative morbidity and grade, duration of stay, 30-day mortality, and readmission rates. A propensity-score matching was performed in a 1:1 ratio to mitigate for selection bias.

RESULTS

A total of 1,484 patients were identified from the National Emergency Laparotomy Audit data set, and propensity-score matching resulted in 2 equally matched cohorts with 237 patients in each arm. The rate of surgical site infection was significantly lower in the closed incision negative pressure therapy cohort (16.9% vs 33.8%, P < .001). There were no overall differences in 30-day morbidity, Clavien-Dindo grade, Comprehensive Complication Index severity, length of hospital stay, reoperation rates, and 30-day mortality between the 2 groups.

CONCLUSIONS

Prophylactic closed incision negative pressure therapy in emergency laparotomy patients is associated with a reduction in surgical site infection rates.

Pharyngeal Pouch Surgery in Octo- and Nonagenarians is Safe and Effective: A Multicentre Comparative Cohort Study

BACKGROUND

Surgery is the only effective treatment strategy for a symptomatic pharyngeal pouch. However, octo- and nonagenarians are often denied referral to a surgeon because of perceived increased risks. Here, we compare the outcomes of pharyngeal pouch surgery in octo- and nonagenarians with patients under 80 years-of-age and determine the factors which predict post-operative complications and improvement in swallowing.

METHODS

Analysis of a prospectively maintained database of patients who underwent pharyngeal pouch surgery across seven hospitals over 15 years.

RESULTS

In total, 113 patients (≥80 years-of-age: 27, <80 years-of-age: 86) underwent endoscopic or open pharyngeal pouch surgery. Despite more comorbidities and a longer hospital stay (median: one extra day), patients ≥80 years-of-age had comparable operative time, complication profile, intensive care admission, emergency reoperation, and revisional pouch surgery as their younger counterparts. Furthermore, the severity of complications was not significantly different between the two age cohorts. No surgical mortality was recorded. Multivariate analysis demonstrated that diverticulectomy combined with cricopharyngeal myotomy independently predicted higher rates of complications (OR: 4.53, 95% CI: 1.43-14.33, p = 0.010), but also greater symptomatic improvement (OR: 4.36, 95% CI: 1.50-12.67, p = 0.007). Importantly, a greater proportion of octo- and nonagenarians experienced improved swallowing than patients <80 years-of-age (96.3% vs. 74.4%, p = 0.013). Moreover, advanced age was not predictive of post-operative complications on multivariate analysis.

CONCLUSIONS

Pharyngeal pouch surgery in octo- and nonagenarians is safe and effective. Surgical correction in this age group alleviates symptoms and improves quality-of-life for most patients. These patients should not be denied surgery on the basis of advanced age alone.