1
|
Tsukazaki Y, Enomoto H, Takeuchi N, Ushigome T, Suwa K, Okamoto T, Eto K. Incisional Negative Pressure Wound Therapy for Wounds in Patients with Lower Intestinal Perforations. J Anus Rectum Colon 2024; 8:157-162. [PMID: 39086879 PMCID: PMC11286369 DOI: 10.23922/jarc.2023-059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/29/2024] [Indexed: 08/02/2024] Open
Abstract
Objectives Laparotomy for lower intestinal perforation is associated with a high incidence of surgical site infections. This study aimed to assess whether incisional negative pressure wound therapy (iNPWT) could reduce the incidence of these infections and wound dehiscence in patients with lower intestinal perforation. Methods This single-center prospective study was conducted between September 2019 and July 2022. In the therapy group, wounds were closed with subcuticular sutures, and iNPWT was applied at -120 mmHg for 5 days. A total of 10 days of iNPWT was employed. These patients were compared with a historical control group. The iNPWT group (Group A) comprised 22 patients.The historical control group (Group B) had 65 patients. Table outlines patient characteristics and compares the two study groups. Results Patient characteristics were demographically similar. The incidence of surgical site infections was lower in the therapy group than in the control group (9.1% vs. 52.3%, p < 0.001). Wound dehiscence was not observed in the therapy group but was noted in three patients (4.6%) in the control group. In univariate and multivariate analysis, an application of the therapy device was associated with reduced incidence of surgical site infections (p < 0.001 and p = 0.002, respectively). Conclusions The application of iNPWT in patients with lower intestinal perforation was associated with reduced surgical site infections.
Collapse
Affiliation(s)
- Yuhei Tsukazaki
- Department of Surgery, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Hiroya Enomoto
- Department of Surgery, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Nana Takeuchi
- Department of Surgery, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Takuro Ushigome
- Department of Surgery, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Katsuhito Suwa
- Department of Surgery, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Tomoyoshi Okamoto
- Department of Surgery, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
2
|
Liu Y, Xu M, Wang Z, Zhu X, Xu J. The effect of incisional negative pressure wound therapy on the improvement of postoperative cosmetic suture wounds and scar hyperplasia. Int Wound J 2023; 20:3081-3087. [PMID: 37114415 PMCID: PMC10502242 DOI: 10.1111/iwj.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/29/2023] Open
Abstract
This study aimed to explore the effects of early incisional negative pressure wound therapy (INPWT) on cosmetic suture wounds and postoperative scar hyperplasia. We retrospectively evaluated 120 patients who underwent abdominoperineal resection at the Changhai Hospital between February 2018 and October 2021 and divided them into two groups according to their treatment: the INPWT group (n = 60) and the control group (n = 60). The quality of post-surgical wound healing in the two groups was evaluated. The Patient Scar Assessment Scale (PSAS), the Vancouver Scar Scale (VSS), and the visual analogue scale (VAS) were used to evaluate the surgical incision scar at 1-year follow-up. At this follow-up visit, 115 patients underwent reexamination; five patients were lost to follow-up, including two patients in the INPWT group and three patients in the control group. The INPWT group showed better wound healing than the control group (P < .05). The proportion of patients who received INPWT was significantly higher in the non-surgical site infection (SSI) group than in the SSI group (P < .05). The PSAS, VSS and VAS scores were significantly improved in the INPWT group compared with those in the control group (P < .05). Our results show that INPWT improved the quality of cosmetic suture wounds and reduced the degree of postoperative scar hyperplasia.
Collapse
Affiliation(s)
- Yanjun Liu
- Department of Plastic Surgery, Changhai HospitalSecond Military Medical UniversityShanghaiChina
| | - Mingze Xu
- Department of Plastic Surgery, Changhai HospitalSecond Military Medical UniversityShanghaiChina
| | - Zheng Wang
- Department of Plastic Surgery, Changhai HospitalSecond Military Medical UniversityShanghaiChina
| | - Xiaoshu Zhu
- Department of Plastic Surgery, Changhai HospitalSecond Military Medical UniversityShanghaiChina
| | - Jianguo Xu
- Department of Plastic Surgery, Changhai HospitalSecond Military Medical UniversityShanghaiChina
| |
Collapse
|
3
|
Özkan B, Savran S, Albayati A, Uysal ÇA. Near-total gluteal defect reconstruction with bilateral delayed giant lumbar artery perforator flaps: A case report. Microsurgery 2023; 43:622-626. [PMID: 37464567 DOI: 10.1002/micr.31094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/20/2023]
Abstract
The reconstruction of the near-total or total gluteal defects is challenging. Reconstructive options were restricted when the gluteal flaps were sacrificed. The lumbar artery perforator flap (LAPF) has been recently popularized as an alternative option for sacral and gluteal pressure ulcers. Extension of flap size may be needed in extensive defects. We aim to use the delay phenomenon to increase lumbar artery perforator flap territory to reconstruct near total gluteal defect. A 36-year-old woman was referred to our clinic with defect sizes of 23 × 23 cm and 25 × 17 cm for the right and left gluteal regions. She had a history of multiple surgeries for her paraplegia-related sacrogluteal pressure sores. The reconstruction was started on the left side with delaying incisions to the flap borders. Seven days later, the left gluteal defect was reconstructed with 27 × 19 cm LAPF based on a second lumbar artery perforator. At the same session, the delaying incision was performed to the borders of the right LAPF. On day 14, the right gluteal defect was closed with a 25 × 25 cm-sized right LAPF. No flap loss and early complications were seen. The patient was discharged without complication after 10 days after the last operation. The patient was followed up for 1 year. A right ischial pressure ulcer due to wheelchair use was encountered, which was managed with conservative wound care in the 8th month. Giant-sized lumbar artery perforator flaps may be obtained by delay phenomenon to reconstruct near-total or total gluteal pressure sores.
Collapse
Affiliation(s)
- Burak Özkan
- Department of Plastic Surgery, Baskent University Hospital and Faculty of Medicine, Ankara, Turkey
| | - Süleyman Savran
- Department of Plastic Surgery, Baskent University Hospital and Faculty of Medicine, Ankara, Turkey
| | - Abbas Albayati
- Department of Plastic Surgery, Baskent University Hospital and Faculty of Medicine, Ankara, Turkey
| | - Çağrı A Uysal
- Department of Plastic Surgery, Baskent University Hospital and Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
4
|
Higashi T, Kobayashi N, Ide M, Uchino Y, Inoue T, Inaba Y. The Effect of Local Administration of Vancomycin Suspended in Fibrin Glue for Prevention of Surgical Site Infection After Spinal Instrumentation: Comparison by Probability of Treatment Weighting Model. Spine (Phila Pa 1976) 2023; 48:384-390. [PMID: 36728797 DOI: 10.1097/brs.0000000000004561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/10/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE To compare the surgical site infection (SSI) rate in patients undergoing spinal instrumentation surgery who received vancomycin suspended in fibrin glue at the surgical site and those who did not. SUMMARY OF BACKGROUND DATA The intrawound application of vancomycin powder for preventing SSI after spinal surgery remains controversial. Vancomycin suspended in fibrin glue is another option for local administration that may be effective. The present study assessed whether vancomycin suspended in fibrin glue could prevent SSI after spinal instrumentation surgery. MATERIALS AND METHODS We enrolled patients who underwent posterior spinal instrumentation surgery with or without fusion for degenerative conditions, spinal trauma, or tumor. A multiple logistic regression model with inverse probability of treatment weighting based on propensity score was used to assess the efficacy of vancomycin suspended in fibrin glue and to account for confounding. A secondary multivariate logistic regression analysis was performed to identify the risk factors associated with SSI. RESULTS Of the 264 patients enrolled in this study, 134 underwent application of vancomycin suspended in fibrin glue at the surgical site and 130 did not. The incidence of SSI was lower in patients who were treated with vancomycin suspended in fibrin glue (2.2% vs. 8.5%) even after inverse probability of treatment weighting adjustment (adjusted odds ratio: 0.25; 95% CI, 0.0768-0.91; P =0.03). Multivariate logistic regression analysis showed that the treatment with vancomycin suspended in fibrin glue was significantly associated with a lower odds of SSI (odds ratio: 0.2; 95% CI, 0.05-0.85; P =0.03). CONCLUSIONS The administration of vancomycin suspended in fibrin glue was significantly associated with a lower likelihood of SSI in patients undergoing spinal instrumentation surgery.
Collapse
Affiliation(s)
- Takayuki Higashi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Manabu Ide
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Yosuke Uchino
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Tetsuhiko Inoue
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Yutaka Inaba
- Yokohama City University, Yokohama City, Kanagawa, Japan
| |
Collapse
|
5
|
Sapci I, Camargo M, Duraes L, Jia X, Hull TL, Ashburn J, Valente MA, Holubar SD, Delaney CP, Gorgun E, Steele SR, Liska D. Effect of Incisional Negative Pressure Wound Therapy on Surgical Site Infections in High-Risk Reoperative Colorectal Surgery: A Randomized Controlled Trial. Dis Colon Rectum 2023; 66:306-313. [PMID: 35358097 DOI: 10.1097/dcr.0000000000002415] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Colorectal resections have relatively high rates of surgical site infections causing significant morbidity. Incisional negative pressure wound therapy was introduced to improve wound healing of closed surgical incisions and to prevent surgical site infections. OBJECTIVE This randomized controlled trial aimed to investigate the effect of incisional NPWT on superficial surgical site infections in high-risk, open, reoperative colorectal surgery. DESIGN This was a single-center randomized controlled trial conducted between July 2015-October 2020. Patients were randomly assigned to incisional negative pressure wound therapy or standard gauze dressing with a 1:1 ratio. A total of 298 patients were included. SETTINGS This study was conducted at the colorectal surgery department of a tertiary-level hospital. PATIENTS This study included patients older than 18 years who underwent elective reoperative open colorectal resections. Patients were excluded who had open surgery within the past 3 months, who had active surgical site infection, and who underwent laparoscopic procedures. MAIN OUTCOME MEASURES The primary outcome was superficial surgical site infection within 30 days. Secondary outcomes were deep and organ-space surgical site infections within 7 days and 30 days, postoperative complications, and length of hospital stay. RESULTS A total of 149 patients were included in each arm. The mean age was 51 years, and 49.5% were women. Demographics, preoperative comorbidities, and preoperative albumin levels were comparable between the groups. Overall, most surgeries were performed for IBD, and 77% of the patients had an ostomy fashioned during the surgery. No significant difference was found between the groups in 30-day superficial surgical site infection rate (14.1% in control versus 9.4% in incisional negative pressure wound therapy; p = 0.28). Deep and organ-space surgical site infections rates at 7 and 30 days were also comparable between the groups. Postoperative length of stay and complication rates (Clavien-Dindo grade) were also comparable between the groups. LIMITATIONS The patient population included in the trial consisted of a selected group of high-risk patients. CONCLUSIONS Incisional negative pressure wound therapy was not associated with reduced superficial surgical site infection or overall complication rates in patients undergoing high-risk reoperative colorectal resections. See Video Abstract at http://links.lww.com/DCR/B956 . EFECTO DE LA TERAPIA DE HERIDA INSICIONAL CON PRESIN NEGATIVA EN INFECCIONES DEL SITIO QUIRRGICO EN CIRUGA COLORRECTAL REOPERATORIA DE ALTO RIESGO UN ENSAYO CONTROLADO ALEATORIZADO ANTECEDENTES:Las resecciones colorrectales tienen tasas relativamente altas de infecciones del sitio quirúrgico que causan una morbilidad significativa. La terapia de heridas incisionales con presión negativa se introdujo para mejorar la cicatrización de las heridas de incisiones quirúrgicas cerradas y para prevenir infecciones del sitio quirúrgico.OBJETIVO:El objetivo de este ensayo controlado y aleatorizado fue investigar el efecto de la terapia de herida incisional con presión negativa en infecciones superficiales del sitio quirúrgico en cirugía colorrectal re operatoria, abierta y de alto riesgo.DISEÑO:Ensayo controlado y aleatorizado de un solo centro entre julio de 2015 y octubre de 2020. Los pacientes fueron aleatorizados para recibir tratamiento para heridas incisionales con presión negativa o vendaje de gasa estándar en una proporción de 1:1. Se incluyeron un total de 298 pacientes.AJUSTE:Este estudio se realizó en el departamento de cirugía colorrectal de un hospital de tercer nivel.PACIENTES:Se incluyeron pacientes mayores de 18 años que se fueron sometidos a resecciones colorrectales abiertas, re operatorias y electivas. Se excluyeron aquellos pacientes que tuvieron cirugía abierta en los últimos 3 meses, con infección activa del sitio quirúrgico y que fueron sometidos a procedimientos laparoscópicos.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue infección superficial del sitio quirúrgico dentro de los 30 días. Los resultados secundarios fueron infecciones del sitio quirúrgico profundas y del espacio orgánico dentro de los 7 y 30 días, las complicaciones posoperatorias y la duración de la estancia hospitalaria.RESULTADOS:Se incluyeron un total de 149 pacientes en cada brazo. La edad media fue de 51 años y el 49,5% fueron mujeres. La demografía, las comorbilidades preoperatorias y los niveles de albúmina preoperatoria fueron comparables entre los grupos. En general, la mayoría de las cirugías fueron realizadas por enfermedad inflamatoria intestinal y al 77 % de los pacientes se les confecciono una ostomía durante la cirugía. No hubo diferencias significativas entre los grupos en la tasa de infección del sitio quirúrgico superficial a los 30 días (14,1 % en el control frente a 9,4 % en el tratamiento de herida incisional con presión negativa, p = 0,28). Las tasas de infecciones del sitio quirúrgico profundas y del espacio orgánico a los 7 y 30 días también fueron comparables entre los grupos. La duración de la estancia postoperatoria y las tasas de complicaciones (Clavien-Dindo Graduacion) también fueron comparables entre los grupos.LIMITACIONES:La población de pacientes incluida en el ensayo consistió en un grupo seleccionado de pacientes de alto riesgo.CONCLUSIONES:Video Resumen en http://links.lww.com/DCR/B956 . (Traducción-Dr. Osvaldo Gauto ).
Collapse
Affiliation(s)
- Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
The Utility of Closed Incision Negative Pressure Wound Therapy following Spinal Fusion: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 168:258-267.e1. [PMID: 36116727 DOI: 10.1016/j.wneu.2022.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 09/11/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine if closed incision negative pressure wound therapy (ciNPWT) decreases surgical site infection (SSI) or wound dehiscence following spinal fusion. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic review and meta-analysis was conducted to identify studies utilizing ciNPWT following spinal fusion. Funnel plots and quality scores of the articles were performed to determine if the articles were at risk of bias. Forest plots were conducted to identify the treatment effect of ciNPWT following spinal fusion. RESULTS A total of 8 studies comprising 1,061 patients who received ciNPWT or a standard postoperative dressing following spinal fusion were included. The rate of SSI [ciNPWT: 4.49% (95% CI: 2.48, 8.00) vs. control: 11.32% (95% CI: 7.51, 16.70), p=0.0103] was significantly lower for patients treated with ciNPWT. A fixed-effects model showed no significant difference between patients who received ciNWPT or a standard postoperative dressing with respect to requiring reoperations for wound debridement (OR: 1.25, 95% CI: 0.64, 2.41). Additionally, wound dehiscence was not significantly different between the two groups although it was non-significantly lower in ciNWPT-treated patients [ciNPWT: 4.59% (95% CI: 2.49, 8.31) vs control: 7.48% (95% CI: 4.38, 12.47), p=0.23]. CONCLUSION Closed incision NPWT may reduce the rates of SSI following spinal fusion. The use of ciNWPT may also significantly reduce the burden associated with postoperative wound complications, but the meta-analysis was insufficiently powered to make this association. Additional, studies may identify a subset of patients who benefit from ciNPWT for other wound-related complications.
Collapse
|
7
|
Sawada G, Kim HM, Ichikawa Y, Hayashi R, Takata A, Murakami M, Fukunaga H, Morita S. Clinical Impact of Two-Week Placement of a Subcutaneous Suction Drain in Preventing Incisional Surgical Site Infection in Open Gastrointestinal Surgery with Class 4 Dirty Wound: A Retrospective Study. Surg Infect (Larchmt) 2022; 23:722-728. [PMID: 36070600 DOI: 10.1089/sur.2022.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Two recent randomized controlled trials demonstrated the beneficial effects of subcutaneous drainage in preventing incisional surgical site infection (SSI) in colorectal surgery. This study aimed to evaluate the efficacy of subcutaneous suction drains (SSDs) compared with primary skin closure (PC) in class 4 dirty wound surgery. Patients and Methods: Eighty-one patients undergoing open gastrointestinal surgery with class 4 dirty wounds were enrolled in this study, 30 of whom underwent SSD insertion, whereas the other 51 were treated with PC. Because several studies have reported that the median onset of the development of incisional SSI was eight to 13 days after surgery, we used a two-week placement of an SSD. Comparison of patients treated with SSD and PC and multivariable analysis were performed to test the ability of SSD in decreasing the SSI rate. Results: No differences were observed between the two groups in terms of gender, body mass index, American Society of Anesthesiology score, steroid use, presence of diabetes mellitus, peri-operative transfusion, and surgery type. Surgical site infection incidence was lower in the SSD group (6.6%; 2/30) than that in the PC group (23.5%; 12/51; p = 0.069). Multivariable analysis revealed that the presence of diabetes mellitus was an important independent risk factor for incisional SSI, and the placement of an SSD has substantial preventive effects on incisional SSI (p = 0.018 and p = 0.014, respectively). Conclusions: This study suggested the potential importance of a two-week placement of an SSD for preventing incisional SSI in class 4 dirty wound surgery.
Collapse
Affiliation(s)
- Genta Sawada
- Department of Surgery, Itami City Hospital, Itami, Japan
| | - Ho Min Kim
- Department of Surgery, Itami City Hospital, Itami, Japan
| | | | - Rie Hayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Akihiro Takata
- Department of Surgery, Itami City Hospital, Itami, Japan
| | | | | | - Shunji Morita
- Department of Surgery, Itami City Hospital, Itami, Japan
| |
Collapse
|
8
|
Agarwal A. Evolution of Negative Pressure Wound Therapy in Orthopaedic Trauma. J Orthop Trauma 2022; 36:S1-S5. [PMID: 35994301 DOI: 10.1097/bot.0000000000002431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 02/02/2023]
Abstract
Negative Pressure Wound Therapy (NPWT) has evolved from open wound management to now include closed incision management. It has been a major advance in the management of open wounds and closed incisional wounds especially in orthopaedic trauma surgery. Because of the success of NPWT in the late 1990s and early 2000s, surgeons began using NPWT with adjuncts on closed incisions as a way to help prevent surgical wound dehiscence especially in at-risk patients for wound problems. It has been well established that obesity, diabetes, and smoking in addition to other comorbidities increase the risk of wound dehiscence and surgical site infections in orthopaedic patients. It is widely used for open wound management, often associated with open fractures, and in the mitigation of risk of surgical site infections over closed incisions (incisional negative pressure wound therapy). Newer systems allow the use of various topical wound solutions to be instilled in conjunction with NPWT, termed NPWTi-d. This has shown promising results in difficult wounds that may be resistant to standard NPWT. This article reviews the evolution and use of NPWT in orthopaedic trauma.
Collapse
Affiliation(s)
- Animesh Agarwal
- Division of Orthopaedic Trauma, University of Texas Health Science Center at San Antonio, Department of Orthopaedics, San Antonio, TX
| |
Collapse
|
9
|
Zhang D, He L. A systemic review and a meta-analysis on the influences of closed incisions in orthopaedic trauma surgery by negative pressure wound treatment compared with conventional dressings. Int Wound J 2022; 20:46-54. [PMID: 35535660 PMCID: PMC9797922 DOI: 10.1111/iwj.13835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 04/21/2022] [Accepted: 04/24/2022] [Indexed: 01/07/2023] Open
Abstract
We performed a meta-analysis to evaluate the influences of closed incisions in orthopaedic trauma surgery (OTS) by negative pressure wound treatment (NPWT) compared with conventional dressings. A systematic literature search up to March 2022 was done and 14 studies included 3935 subjects with OTS at the start of the study; 2023 of them used NPWT and 1912 were conventional dressings. They were reporting relationships between the influences of closed incisions in OTS by NPWT compared with conventional dressings. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the influences of closed incisions in OTS by NPWT compared with conventional dressings using the dichotomous methods with a random or fixed-effect model. NPWT had significantly lower deep surgical site infections (SSIs) (OR, 0.65; 95% CI, 0.48-0.87, P = .004), superficial SSIs (OR, 0.34; 95% CI, 0.19-0.61, P < .001), and wound dehiscence (OR, 0.41; 95% CI, 0.21-0.80, P = .009) compared with conventional dressings in subjects with closed incisions in OTS. NPWT showed a beneficial effect on deep SSIs, superficial SSIs, and wound dehiscence compared with conventional dressings in subjects with closed incisions in OTS. Further studies are required to validate these findings.
Collapse
Affiliation(s)
- Dahua Zhang
- Department of OrthopedicsThe First Affiliated Hospital of Xi'an Medical UniversityXi'anShaanxiChina
| | - Liang He
- Department of OrthopedicsThe First Affiliated Hospital of Xi'an Medical UniversityXi'anShaanxiChina
| |
Collapse
|
10
|
Closed-Incision Negative-Pressure Wound Therapy after Resection of Soft-Tissue Tumors Reduces Wound Complications: Results of a Randomized Trial. Plast Reconstr Surg 2022; 149:972e-980e. [PMID: 35311753 DOI: 10.1097/prs.0000000000009023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wound healing after resection of large soft-tissue tumors is often impaired by large dead space and fluid collection. Recently, the authors were able to show an association of wound complications with worse oncologic outcome in soft-tissue sarcomas. The aim of the study was to examine the value of closed-incision negative pressure wound therapy on postoperative wound drainage and wound complications after soft-tissue tumor resection. METHODS Patients for whom resection is planned of a soft-tissue tumor larger than 10 cm in diameter of the extremities or the trunk were allocated randomly to one of two groups. After wound closure, patients in the study group received closed-incision negative-pressure wound therapy for a duration of 5 days, whereas those in the control group received regular dressings. The amount of drainage fluid, course of wound healing, length of hospital stay, and wound edge perfusion at postoperative day 5 measured by white-light infrared spectroscopy were compared. RESULTS Sixty patients could be included in the study with even distribution to both study arms, meeting the goal. The postoperative course of wound drainage volume was significantly lower in the study group, and hospital stay was significantly shorter, with 9.1 ± 3.8 days versus 13.9 ± 11.8 days. The occurrence of wound complications was significantly lower in the study group on time-to-event analysis (one versus six). Tissue spectroscopy revealed a significantly higher oxygen saturation increase in the wound edge for the study group versus the control group. CONCLUSION Closed-incision negative-pressure wound therapy should be considered for patients undergoing resection of large soft-tissue tumors. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
Collapse
|
11
|
Kabir I, Nguyen T, Heaton J, Peterson K, Martyak M. Incisional Negative Pressure Wound Therapy to Decrease the Incidence of Surgical Site Infections in Trauma Laparotomy Wounds. Am Surg 2022:31348211054529. [PMID: 35384733 DOI: 10.1177/00031348211054529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Surgical site infection (SSI) is a common post-operative complication, especially in trauma laparotomies. Incisional negative pressure wound therapy (iNPWT) is a novel technique in reducing SSIs. We aim to study the rate of wound complications in trauma laparotomy with standard primary closure with staples vs iNPWT. METHODS We had 152 patients meeting inclusion criteria who underwent emergent trauma laparotomies performed at Sentara Norfolk General from 2017 to 2020. We had 79 patients in the standard staple group and 73 patients in the iNWPT group. We then analyzed surgical site infection rates and wound complication rates in both groups within a 30-day period. RESULTS The wound infection rate in the staple vs staple plus iNPWT was 10.0% vs 3.8%, respectively (P = .13). Wound dehiscence rates were 24.1% vs 10.13%, respectively (P = .02). When looking at a subset of patients with hollow viscous injury, the rate of SSIs was statistically lower in the iNPWT group. Prior to the introduction of the incisional vacuum-assisted closure (VAC) to our practice compared to after its introduction, 39.25% of wounds were left open vs 19.51%, respectively (P = .001). CONCLUSION Our data identified a trend toward a decrease in overall SSIs in trauma laparotomies closed with iNPWT. The use of iNPWT demonstrated a decrease in superficial wound dehiscence and a decrease in SSIs in patients with associated full thickness bowel injury. With iNPWT, we are more aggressive with primarily closing trauma laparotomy wounds. This shows promise for increasing primary closure rates while simultaneously decreasing overall superficial surgical site infection rate.
Collapse
Affiliation(s)
- Ishraq Kabir
- 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Tuan Nguyen
- 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Julia Heaton
- 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | | | | |
Collapse
|
12
|
Elhage KG, Awad ME, Irfan FB, Lumbley J, Mostafa G, Saleh KJ. Closed-incision negative pressure therapy at -125 mmHg significantly reduces surgical site complications following total hip and knee arthroplasties: A stratified meta-analysis of randomized controlled trials. Health Sci Rep 2022; 5:e425. [PMID: 35229037 PMCID: PMC8865069 DOI: 10.1002/hsr2.425] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Closed-incision negative pressure wound therapy (ciNPT) has shown promising effects for managing infected wounds. This meta-analysis explores the current state of knowledge on ciNPT in orthopedics and addresses whether ciNPT at -125 mmHg or -80 mmHg or conventional dressing reduces the incidence of surgical site complications in hip and knee arthroplasty. METHODS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines and Cochrane Handbook. Prospective randomized controlled trials (RCTs) with ciNPT use compared to conventional dressings following hip and knee surgeries were considered for inclusion. Non-stratified and stratified meta-analyses of six RCTs were conducted to test for confounding and biases. A P value less than .05 was considered statistically significant. RESULTS The included six RCTs have 611 patients. Total hip and knee arthroplasties were performed for 51.7% and 48.2% of the included population, respectively. Of 611 patients, conventional dressings were applied in 315 patients and 296 patients received ciNPT. Two ciNPT systems have been used across the six RCTs; PREVENA Incision Management System (-125 mmHg) (63.1%) and PICO dressing (-80 mmHg) (36.8%). The non-stratified analysis showed that the ciNPT system had a statistically significant, lower risk of persistent wound drainage as compared to conventional dressing following total hip and knee arthroplasties (OR = 0.28; P = .002). There was no difference between ciNPT and conventional dressings in terms of wound hematoma, blistering, seroma, and dehiscence. The stratified meta-analysis indicated that patients undergoing treatment with high-pressure ciNPT (120 mmHg) displayed significantly fewer overall complications and persistent wound drainage (P = .00001 and P = .002, respectively) when compared to low-pressure ciNPT (80 mmHg) and conventional dressings. In addition, ciNPT is associated with shorter hospital stays. (P = .005). CONCLUSION When compared to conventional wound dressing and -80 mmHg ciNPT, the use of -125 mmHg ciNPT is recommended in patients undergoing total joint arthroplasty.
Collapse
Affiliation(s)
- Kareem G. Elhage
- FAJR ScientificNorthvilleMichigan48167USA
- Wayne State University, School of MedicineDetroitMichiganUSA
| | - Mohamed E. Awad
- FAJR ScientificNorthvilleMichigan48167USA
- NorthStar Anesthesia‐Detroit Medical centerDetroitMichiganUSA
- Michigan State University, College of Osteopathic MedicineDetroitMichiganUSA
| | - Furqan B. Irfan
- Michigan State University, College of Osteopathic MedicineDetroitMichiganUSA
| | - Joshua Lumbley
- NorthStar Anesthesia‐Detroit Medical centerDetroitMichiganUSA
| | - Gamal Mostafa
- Wayne State University, School of MedicineDetroitMichiganUSA
- Surgical Outcomes Research Institute, John D. Dingell VA Medical CenterDetroitMichiganUSA
| | - Khaled J. Saleh
- FAJR ScientificNorthvilleMichigan48167USA
- Michigan State University, College of Osteopathic MedicineDetroitMichiganUSA
- Surgical Outcomes Research Institute, John D. Dingell VA Medical CenterDetroitMichiganUSA
| |
Collapse
|
13
|
Xie W, Dai L, Qi Y, Jiang X. Negative pressure wound therapy compared with conventional wound dressings for closed incisions in orthopaedic trauma surgery: A meta-analysis. Int Wound J 2021; 19:1319-1328. [PMID: 34854236 PMCID: PMC9493229 DOI: 10.1111/iwj.13726] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 12/19/2022] Open
Abstract
We performed a meta‐analysis to evaluate the effect of negative pressure wound therapy compared with conventional wound dressings on closed incisions in orthopaedic trauma surgery. A systematic literature search up to October 2021 was done and 12 studies included 3555 subjects with closed incisions in orthopaedic trauma surgery at the start of the study: 1833 of them were provided with negative pressure wound therapy and 1722 were conventional wound dressings. They were reporting relationships about the effect of negative pressure wound therapy compared with conventional wound dressings on closed incisions in orthopaedic trauma surgery. We calculated the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) to assess the effect of negative pressure wound therapy compared with conventional wound dressings on closed incisions in orthopaedic trauma surgery using the dichotomous and continuous methods with a random or fixed‐effect model. Negative pressure wound therapy had significantly lower deep surgical site infection (OR, 0.65; 95% CI, 0.48–0.88, P = .005), superficial surgical site infection (OR, 0.23; 95% CI, 0.11–0.49, P = .31), and wound dehiscence (OR, 0.41; 95% CI, 0.21–0.80, P = .009) compared with conventional wound dressings in subjects with closed incisions in orthopaedic trauma surgery. However, negative pressure wound therapy had no significant effect on the length of hospital stay (MD, 0.29; 95% CI, −2.00‐ 2.58, P = .80) compared with conventional wound dressings in subjects with closed incisions in orthopaedic trauma surgery. Negative pressure wound therapy had significantly lower deep surgical site infection, superficial surgical site infection, and wound dehiscence; however, negative pressure wound therapy had no beneficial effect on the length of hospital stay compared with conventional wound dressings in subjects with closed incisions in orthopaedic trauma surgery. Further studies are required to validate these findings.
Collapse
Affiliation(s)
- Weiwei Xie
- Department of Operation Room, The First People's Hospital of Wenling, Wenling, China
| | - Lingyan Dai
- Ambulatory Surgery Center, Wuhan Children's Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, (Wuhan Maternal and Children's Healthcare Center), Wuhan, China
| | - Yameng Qi
- Department of Dermatology, Second Hospital Affiliated to Tianjin Medical University, Tianjin, China
| | - Xixi Jiang
- Department of Operation Room, The First People's Hospital of Wenling, Wenling, China
| |
Collapse
|
14
|
Modified Incisional Negative Pressure Wound Therapy Increases Seroma Evacuation: An Ex Vivo Model. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5846724. [PMID: 34722767 PMCID: PMC8553466 DOI: 10.1155/2021/5846724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/18/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022]
Abstract
Background Incisional negative wound pressure therapy (iNPWT) is a relatively novel dressing technique with the aim of reducing postoperative wound infections and dehiscence in high-risk wounds after all kinds of surgical procedures. There is a lack of theoretical knowledge about the way those dressing would ameliorate wound healing. One aspect is the reduction of superficial tension, but significant remaining seroma might still cause deep wound infections. The aim of this study was the evaluation of technical modifications of the standard iNPWT dressing to increase seroma evacuation. Methods iNPWT dressings were applied on the porcine abdominal wall, and an incremental pressure ramp from 50 to 200 mmHg was performed. The resulting wound pressures were measured using (i) balloon manometry and (ii) esophageal manometry catheter. Seroma evacuation was analyzed with a seroma model. All measurements were performed with (i) standard iNPWT dressing, (ii) wound gauze diverted through the incision, and (iii) placement of suction drain tube into iNPWT. Results Due to the modifications of the iNPWT dressing, the vacuum applied by the iNPWT dressing could be transferred into the wound and was not only restricted to superficial layers. More importantly, placement of wound gauzes or suction drain tubes led to complete extraction of wound seroma. The placement of the suction drain tube showed the best combination of increased intrawound pressure as well as seroma evacuation. Conclusion Addition of a suction drain tube to the iNPWT dressing leads to an improved function of the iNPWT dressing in our ex vivo model.
Collapse
|
15
|
Garg A, Jayant S, Gupta AK, Bansal LK, Wani A, Chaudhary P. Comparison of closed incision negative pressure wound therapy with conventional dressing for reducing wound complications in emergency laparotomy. POLISH JOURNAL OF SURGERY 2021; 93:1-5. [PMID: 34552028 DOI: 10.5604/01.3001.0014.9759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to compare the post-operative effects of closed incision negative pressure wound therapy with conventional dressing in emergency laparotomy. METHODS This study was conducted from 1st November 2018 to 31st March 2020 in ABVIMS & Dr. R.M.L. Hospital, New Delhi. The potential candidates for the study were patients of 18 years and above who were admitted in surgical emergency and underwent emergency laparotomy by a midline incision. Fifty random patients were alternatively allotted to group A (25 patients) and group B (25 patients). In the patients of group A, closed incision negative pressure wound therapy (ciNPWT) was applied on midline closed wound after an exploratory laparotomy procedure. The patients in group B, standard dry gauze dressing was done. RESULTS The mean age of patients in group A and group B were 46.76±12.20 and 41.96±8.33 years, respectively (p-value-0.11). The wound infection was present in 12% of cases in group A and 32% in group B, but when we calculate the p-value, it was found to be statistically non-significant (p-value-0.08). Similarly, seroma formation and wound dehiscence were found less in group A as compared to group B but not reached up to a statistically significant limit (p-value 0.55 and 0.38 respectively). The frequency of dressing change was 1-2 per week in 92% of cases in group A while it was 3-4 per week in 68% of cases in group B. The mean time of the frequency of dressing change was 1.24±0.72 per week and 4.28±1.90 per week in both the groups respectively (p-value <0.001). There was no significant (p>0.05) difference in the duration of hospital stay between group A (mean hospital stay 8.20±2.34 days) and group B (mean hospital stay 8.21±3.37 days). CONCLUSION Closed incision negative pressure wound therapy has no advantages over conventional dressing in terms of post-operative complications and hospital stay. However, it reduces the frequency of dressing change significantly, which reduces the mental stress of the patient and the burden of changing daily dressing.
Collapse
Affiliation(s)
- Arun Garg
- Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Sneh Jayant
- Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Arun Kumar Gupta
- Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Lalit Kumar Bansal
- Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Abid Wani
- Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Poras Chaudhary
- Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| |
Collapse
|
16
|
Closed Incisional Negative Pressure Wound Therapy (ciNPWT) in Oncological Orthopedic Surgery: Preliminary Report. Surg Technol Int 2021. [PMID: 33755942 DOI: 10.52198/21.sti.38.os1429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This report presents the authors' experience with surgical wound-healing using a negative-pressure wound therapy (NPWT) device in a population of oncological orthopedic patients. Two groups of 26 oncological patients each underwent surgical excision. After surgery, the control group received standard dressings and the closed incisional NPWT (ciNPWT) group was treated with a ciNPWT system on the sutured wound area for 14 days. As a primary endpoint, the percentage of post-surgery wound-site complications using ciNPWT devices was compared to that with standard patch dressings. Overall, 30.7% of the control group and 7.7% of the ciNPWT group manifested wound-site complications within 2 weeks after surgery. As a secondary endpoint, final wound healing was compared between the groups: delayed wound healing was observed in 4 (15.4%) patients in the control group and in none (0%) of those in the ciNPWT group. Finally, the length of stay (LOS) was 6.3 days in the control group and 5.1 days in the ciNPWT group. These results suggest that the ciNPWT device could be beneficial in minimizing the incidence of short-term surgical-site complications and decreasing length of stay in high-risk patients, such as those undergoing oncological orthopedic surgery.
Collapse
|
17
|
Miura T, Yamamoto Y, Murao N, Maeda T, Osawa M, Hayashi T, Funayama E. Combined internal and external negative pressure wound therapy: breakthrough treatment for lymphocutaneous intractable fistula. Surg Today 2021; 51:1630-1637. [PMID: 33993364 DOI: 10.1007/s00595-021-02283-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/31/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Lymphocutaneous fistula after lymph node dissection is intractable, yet there is no established treatment strategy. This study demonstrates the wound closure time achieved by a new method of combined internal and external negative pressure wound therapy (CIEN) in patients with lymphocutaneous fistula. METHODS The subjects of this study were six consecutive patients with lymphocutaneous fistula after lymphatic surgery, who were treated with CIEN between 2018 and 2020. The CIEN technique can be summarized as follows: first, internal foam is inserted into the fistula from the opening of the fenestration. Next, a slightly larger area of external foam is applied above the fistula flap outside the external margin of the foam-filled fistula. After bridging the internal foam and external foam, negative-pressure wound therapy is carried out on this bridging foam block. RESULTS CIEN led to rapid and complete wound healing in all six patients. Fistula flap margin ischemia developed in one patient, but adjusting the mode and pressure settings resulted in improvement. Three patients suffered contact dermatitis. There were no signs of tumor or fistula recurrence in any patients after at least 3 months of follow-up. CONCLUSION CIEN is an effective and less invasive treatment modality than the conventional method of managing lymphocutaneous fistula.
Collapse
Affiliation(s)
- Takahiro Miura
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuhei Yamamoto
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Naoki Murao
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Taku Maeda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Masayuki Osawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Toshihiko Hayashi
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Emi Funayama
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
| |
Collapse
|
18
|
Canbek U, Dibek E, Akgun U, Col B, Canbek TD, Aydogan NH, Usmanov N, Kasap M, Akpinar G. Analysis of the fluid biochemistry in patients with prolonged wound drainage after hip hemiarthroplasty. Injury 2021; 52:918-925. [PMID: 33059924 DOI: 10.1016/j.injury.2020.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The origin and content of prolonged wound drainage (PWD) after arthroplasty remain uncertain. In this study, we performed the biochemical, biological and advanced proteomic analysis of the drainage fluid collected from PWD patients following hip hemiarthroplasty (HA). METHODS Data of 28 patients who developed PWD after HA were prospectively analyzed. After examining the biochemical content of the drainage fluid collected on postoperative day 6, to find out if the drainage fluid was transudate or exudate, it was compared with the patient's serum values according to the Light criteria. Subsequently, biological and proteomic analyzes of both drainage fluid and serum were performed. The similarities and differences in terms of protein concentrations, protein identities were examined. In the drainage fluid, we analyzed lymph-specific proteins. RESULTS 16 patients with PWD were male (61.1%), 12 were female (38.9%), and the mean age of all patients was 79.64 ± 8.44 (65-95). Biochemical test results of the drainage fluid / serum were as follows: Total protein: 2.1 / 5.2 g/dl, albumin: 1.3 / 3.1 g/dl, lactate dehydrogenase (LDH): 121/324 U/l, cholesterol: 28/160 mg/dl, triglyceride: 37/122 mg/dl, sodium (Na): 140/ 140mg/dl, potassium (K): 4.1/ 4.1 mg/dl. pH of the drainage fluid was 7.6. According to these biochemical values, drainage fluid was classified as transudate. As a result of protein identification, fibrinogen beta chain, keratin type 1, creatine kinase M-type protein were detected in drainage fluid. Subsequent western analysis revealed that, gliseraldehyde-3-phosphate dehydrogenase (GAPDH) and beta actin antibody were detected in the drainage fluid but not in serum. CONCLUSION Despite the similarity in serum and transudative PWD fluid in terms of biochemical content, we found that when we carried out further proteomic analysis, PWD contains lymph-specific proteins. Unlike PWD, these proteins were not determined in serum. PWD fluid can be also called as lymphorrhea. PWD fluid with abundant proteins may also provide an appropriate environment for the growth of microorganisms.
Collapse
Affiliation(s)
- Umut Canbek
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey.
| | - Esra Dibek
- Mugla Sıtkı Koçman University, Faculty of Science, Department of Biology, Mugla, Turkey
| | - Ulas Akgun
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey
| | - Bekir Col
- Mugla Sıtkı Koçman University, Faculty of Science, Department of Biology, Mugla, Turkey
| | - Tugba Dubektas Canbek
- Mugla Sitki Kocman University Training and Research Hospital, Department of Internal Medicine, Mugla, Turkey
| | - Nevres Hurriyet Aydogan
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey
| | - Nosirzhon Usmanov
- Mugla Sitki Kocman University, Faculty of Medicine, Department of Orthopaedics and Traumatology Mugla, Turkey
| | - Murat Kasap
- Kocaeli University, Medical School Department of Medical Biology, Kocaeli, Turkey
| | - Gurler Akpinar
- Kocaeli University, Medical School Department of Medical Biology, Kocaeli, Turkey
| |
Collapse
|
19
|
Closed Incisional Negative Pressure Therapy Significantly Reduces Early Wound Dehiscence after Reduction Mammaplasty. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3496. [PMID: 33968556 PMCID: PMC8099400 DOI: 10.1097/gox.0000000000003496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/08/2021] [Indexed: 11/25/2022]
Abstract
Background: Closed incisional negative pressure therapy (ciNPT) has been shown to improve surgical outcomes. Functional reduction mammaplasty has a wound dehiscence rate of 25% and higher in most series, requiring extra care and delayed secondary healing. We aimed to determine if shifting from standard care dressings to ciNPT reduced early dehiscence after breast reduction. Methods: This multisurgeon retrospective study compared consecutive patients undergoing primary breast reduction dressed with ciNPT to similar patients with standard dressing materials. Perioperative management was otherwise unchanged. Early dehiscence was defined as incisional disruption requiring wound care within the first 30 postoperative days. Statistical analyses were performed using t-test and Fisher exact test. Results: We analyzed 79 patients with 158 breasts (114 standard and 44 ciNPT). Both groups were similar. Mean ages were 35 and 34 years; body mass index, 28.5 and 27.4 kg/m2; and reduction volumes, 565 and 610 g, respectively. None were active smokers, and 9.5% were former smokers. Wise pattern skin incisions were used in all, and parenchymal resections mostly utilized superomedial pedicles. Median ciNPT treatment was 6 days. Early dehiscence was significantly lower with ciNPT, occurring in only 1 of 44 (2%) breasts, compared to 16 of 114 in the standard group (14%), P = 0.003, a relative risk reduction of 84%. Two control patients required debridement, whereas none of the ciNPT patients did. Conclusion: Application of ciNPT markedly decreased early dehiscence requiring wound care, compared to using standard dressings, in otherwise similarly risk-stratified breast reduction patients.
Collapse
|
20
|
Mehdorn M, Niebisch S, Scheuermann U, Gockel I, Jansen-Winkeln B. Incisional negative pressure wound therapy does not reduce surgical site infections in abdominal midline incisions: a case control study. Acta Chir Belg 2020; 120:250-256. [PMID: 30975040 DOI: 10.1080/00015458.2019.1599180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Purpose: There is evidence from various surgical specialties that incisional negative pressure wound therapy (iNPWT) might reduce postoperative surgical site infections (SSIs). In visceral and general surgery, there is varying evidence of its efficacy in reducing surgical site infections.Methods: A prospectively registered patient cohort of 43 patients with abdominal wall and visceral surgery received treatment with iNPWT and was compared to a matched retrospective cohort to analyze its effects on SSI occurrence and respective risk factors. Groups were matched by procedure, sex, body mass index and age. We used two different systems of iNPWT: (i) PREVENATM or (ii) self-made epicutaneous iNPWT from common VAC material.Results: We could not find a total reduction in postoperative SSIs by application of iNPWT. But within the iNPWT cohort, patients with self-made iNPWT suffered more often from SSIs compared to the commercial iNPWT subgroup. No patient specific risk factors could be identified to advocate the use of iNPWT.Conclusion: Our data do not support the use of an incisional negative pressure wound therapy on closed wounds in midline laparotomy incisions. Although, differences exist between the commmercial and self-made systems.
Collapse
Affiliation(s)
- Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Uwe Scheuermann
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| |
Collapse
|
21
|
Boland PA, Kelly ME, Donlon NE, Bolger JC, Mehigan BJ, McCormick PH, Larkin JO. Prophylactic negative pressure wound therapy for closed laparotomy wounds: a systematic review and meta-analysis of randomised controlled trials. Ir J Med Sci 2020; 190:261-267. [PMID: 32588378 PMCID: PMC7315908 DOI: 10.1007/s11845-020-02283-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/16/2020] [Indexed: 12/16/2022]
Abstract
Surgical site infections are a common source of post-operative morbidity and contribute significantly to healthcare costs. Patients undergoing emergency laparotomy and/or bowel surgery are particularly at risk. Prophylactic negative pressure wound therapy (NPWT) has been shown to reduce wound infection. However, to date, there has been a lack of consensus around its use for closed laparotomy wounds. We conducted a systematic review of randomised controlled trials comparing the use of prophylactic negative pressure wound therapy with standard dressings for closed laparotomy incisions. The primary outcome was incidence of incisional surgical site infection (SSI) at 30 days post-operatively. Secondary outcomes included superficial and deep SSI, skin dehiscence, fascial dehiscence and length of stay. A total of 2182 publications were identified, of which, following review of titles, abstracts and full texts, five studies met the criteria for inclusion. Across these studies, 467 patients were randomised to NPWT and 464 to standard dressings. Overall SSI rate was 18.6% (n = 87/467) versus 23.9% (n = 111/464) in the NPWT and standard dressing groups, respectively (Odds ratio 0.71, 95% CI 0.52–0.99, p = 0.04*). Deep SSI incidence was the same in both groups (2.6%). Both skin dehiscence and fascial dehiscence were slightly higher in the standard dressing group ((4.2%, n = 11/263 versus 3.1% (n = 8/261) and (0.9% (n = 3/324) versus 0.6% (n = 2/323)), respectively. This study observed that NPWT reduces the overall SSI for closed laparotomy wounds. It supports data recommending the use of prophylactic NPWT dressings, especially in high-risk patients in both emergency and elective circumstances.
Collapse
Affiliation(s)
| | - Michael E Kelly
- Department of Colorectal Surgery, St James's Hospital, Dublin, 8, Ireland
| | - Noel E Donlon
- Department of Colorectal Surgery, St James's Hospital, Dublin, 8, Ireland
| | - Jarlath C Bolger
- Department of Colorectal Surgery, St James's Hospital, Dublin, 8, Ireland
| | - Brian J Mehigan
- Department of Colorectal Surgery, St James's Hospital, Dublin, 8, Ireland
| | - Paul H McCormick
- Department of Colorectal Surgery, St James's Hospital, Dublin, 8, Ireland
| | - John O Larkin
- Department of Colorectal Surgery, St James's Hospital, Dublin, 8, Ireland
| |
Collapse
|
22
|
Kwaadu KY. Charcot Reconstruction: Understanding and Treating the Deformed Charcot Neuropathic Arthropathic Foot. Clin Podiatr Med Surg 2020; 37:247-261. [PMID: 32146981 DOI: 10.1016/j.cpm.2019.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
With worsening diet and increasing prevalence of diabetes, patient encounters with Charcot neuropathic arthropathy (CNA) are expected to increase. Without intervention, the pathology progresses with further subluxation/dislocation and fracture, placing soft tissues at risk of preulceration or formal ulceration, infection, and potentially major amputation. The need to avoid amputation is of paramount importance. Although a formal single eradicating tool for CNA is lacking, there is capacity to intervene in ways that may curtail the pace of destruction. This article reviews understanding of the disease process and provides guidance to surgical reconstruction of the deformity.
Collapse
Affiliation(s)
- Kwasi Y Kwaadu
- Department of Surgery, Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107, USA.
| |
Collapse
|
23
|
De Simone B, Sartelli M, Coccolini F, Ball CG, Brambillasca P, Chiarugi M, Campanile FC, Nita G, Corbella D, Leppaniemi A, Boschini E, Moore EE, Biffl W, Peitzmann A, Kluger Y, Sugrue M, Fraga G, Di Saverio S, Weber D, Sakakushev B, Chiara O, Abu-Zidan FM, ten Broek R, Kirkpatrick AW, Wani I, Coimbra R, Baiocchi GL, Kelly MD, Ansaloni L, Catena F. Intraoperative surgical site infection control and prevention: a position paper and future addendum to WSES intra-abdominal infections guidelines. World J Emerg Surg 2020; 15:10. [PMID: 32041636 PMCID: PMC7158095 DOI: 10.1186/s13017-020-0288-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/01/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Surgical site infections (SSI) represent a considerable burden for healthcare systems. They are largely preventable and multiple interventions have been proposed over past years in an attempt to prevent SSI. We aim to provide a position paper on Operative Room (OR) prevention of SSI in patients presenting with intra-abdominal infection to be considered a future addendum to the well-known World Society of Emergency Surgery (WSES) Guidelines on the management of intra-abdominal infections. METHODS The literature was searched for focused publications on SSI until March 2019. Critical analysis and grading of the literature has been performed by a working group of experts; the literature review and the statements were evaluated by a Steering Committee of the WSES. RESULTS Wound protectors and antibacterial sutures seem to have effective roles to prevent SSI in intra-abdominal infections. The application of negative-pressure wound therapy in preventing SSI can be useful in reducing postoperative wound complications. It is important to pursue normothermia with the available resources in the intraoperative period to decrease SSI rate. The optimal knowledge of the pharmacokinetic/pharmacodynamic characteristics of antibiotics helps to decide when additional intraoperative antibiotic doses should be administered in patients with intra-abdominal infections undergoing emergency surgery to prevent SSI. CONCLUSIONS The current position paper offers an extensive overview of the available evidence regarding surgical site infection control and prevention in patients having intra-abdominal infections.
Collapse
Affiliation(s)
- Belinda De Simone
- Department of General Surgery, Azienda USL-IRCSS di Reggio Emilia, Guastalla Hospital, Via Donatori di sangue 1, 42016 Guastalla, RE Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, 62100 Macerata, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, 56124 Pisa, Italy
| | - Chad G. Ball
- Department of Surgery and Oncology, Hepatobiliary and Pancreatic Surgery, Trauma and Acute Care Surgery, University of Calgary Foothills Medical Center, Calgary, Alberta T2N 2T9 Canada
| | - Pietro Brambillasca
- Anesthesia and Critical Care Department, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Massimo Chiarugi
- Emergency Surgery Unit and Trauma Center, Cisanello Hospital, Pisa, Italy
| | | | - Gabriela Nita
- Unit of General Surgery, Castelnuovo ne’Monti Hospital, AUSL, Reggio Emilia, Italy
| | - Davide Corbella
- Anesthesia and Critical Care Department, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University Hospital Meilahti, Helsinki, Finland
| | - Elena Boschini
- Medical Library, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health and University of Colorado, Denver, USA
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps memorial Hospital, La Jolla, CA USA
| | - Andrew Peitzmann
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Gustavo Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | | | - Dieter Weber
- Trauma and General Surgery, Royal Perth Hospital, Perth, Australia
| | - Boris Sakakushev
- University Hospital St George First, Clinic of General Surgery, Plovdiv, Bulgaria
| | - Osvaldo Chiara
- State University of Milan, Acute Care Surgery Niguarda Hospital, Milan, Italy
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, USA
| | | | - Micheal D. Kelly
- Department of General Surgery, Albury Hospital, Albury, NSW 2640 Australia
| | - Luca Ansaloni
- Department of Emergency and Trauma Surgery, Bufalini Hospital, 47521 Cesena, Italy
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, University Hospital of Parma, 43100 Parma, Italy
| |
Collapse
|
24
|
Horch RE, Ludolph I, Müller-Seubert W, Zetzmann K, Hauck T, Arkudas A, Geierlehner A. Topical negative-pressure wound therapy: emerging devices and techniques. Expert Rev Med Devices 2020; 17:139-148. [PMID: 31920139 DOI: 10.1080/17434440.2020.1714434] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: The treatment of chronic wounds constitutes a massive financial burden to society and our health-care system. Therefore, efficient wound care is of great importance to all kinds of medical fields. The implementation and modification of negative-pressure wound therapy can be seen as a major improvement in wound healing. Many different NPWT applications evolved trying to address various wound etiologies.Areas covered: This review aims to give an overview of various NPWT applications, show its effects on wound healing, and discuss future modifications.Expert opinion: NPWT as a delivery device for cold plasma, growth factors, or targeted stem cells to the wound bed and the ability to monitor the inflammatory activity, bacterial load and wound healing factors can be seen as possible future steps to individualized wound care. In addition, it requires high-quality experimental studies to develop the ideal foam in terms of microstructure, pore size, and material properties.
Collapse
Affiliation(s)
- Raymund E Horch
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Wibke Müller-Seubert
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Katharina Zetzmann
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Theresa Hauck
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Alexander Geierlehner
- Department of Plastic and Hand Surgery, Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nuernberg FAU, Erlangen, Germany
| |
Collapse
|
25
|
|
26
|
Gök MA, Kafadar MT, Yeğen SF. Comparison of negative-pressure incision management system in wound dehiscence: A prospective, randomized, observational study. J Med Life 2019; 12:276-283. [PMID: 31666831 PMCID: PMC6814883 DOI: 10.25122/jml-2019-0033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Wound dehiscence is a significant problem faced by surgeons after major abdominal surgery. In this study, it was aimed to select the best incision management system to keep the incision edges together and prevent wound opening, and infection by protecting the incision. In this study, 60 patients who underwent abdominal surgery were evaluated regarding their risk of wound dehiscence. In our clinic, high-risk cases of abdominal surgery are performed, the risk factors being ischemia along the incision line, dirty and contaminated wound, obesity, tension on the suture line, traumatization of the wound site, age at onset (> 65), body mass index (BMI) > 30, diabetes mellitus, chronic obstructive pulmonary disease (COPD), immunosuppressive drug users. A prospective study protocol was planned after ASA (American Society of Anesthesiologists) physical status class assignment. Patients were divided into three groups: patients who underwent a postoperative negative-pressure therapy dressing, patients who underwent subcutaneous aspiration drainage, and patients who received standard dressing. The aim of this study was to evaluate the decompensation, surgical site infection, seroma, hospital stay and costs and to evaluate the results in the postoperative period. Sixty patients were randomized (n = 20, for each group). Thirty-one (51%) of the patients were male, and the mean age was 64.3 ± 8.9 (46-85). The mean BMI was 30.45 ± 7.2. There was no statistically significant difference (p≥0.05) between groups in terms of sex, age, and BMI. The ASA score and surgical interventions were similar between the groups. Wound dehiscence rate was 25% (n = 8), 20% (n = 6) and 3% (n = 1) for the Standard Dressing (SD), Aspiration Drainage (AD) and Negative-Pressure (NP) groups, respectively (p <0.017). Duration of hospitalization was 16.45 ± 6.6, 14.3 ± 7.4 and 8.95 ± 2.8 days (p <0.001) for SD, AD and NP groups, respectively. No statistically significant difference was found between the groups regarding other variables (p≥0.05 for all variables). Negative-pressure wound treatment is an easy, fast and practical technique which reduces lateral tension and swelling. It provides perfusion support and helps to protect the surgical field against external sources of infection.
Collapse
Affiliation(s)
- Mehmet Ali Gök
- Clinic of General Surgery, Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Mehmet Tolga Kafadar
- Clinic of General Surgery, Health Sciences University, Mehmet Akif İnan Training and Research Hospital, Şanlıurfa, Turkey
| | - Serkan Fatih Yeğen
- Clinic of General Surgery, Ali Osman Sönmez Oncology Hospital, Bursa, Turkey
| |
Collapse
|
27
|
Wang C, Zhang Y, Qu H. Negative pressure wound therapy for closed incisions in orthopedic trauma surgery: a meta-analysis. J Orthop Surg Res 2019; 14:427. [PMID: 31829217 PMCID: PMC6907184 DOI: 10.1186/s13018-019-1488-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/26/2019] [Indexed: 12/19/2022] Open
Abstract
Background This meta-analysis was performed to determine the efficacy of negative pressure wound therapy (NPWT) versus conventional wound dressings for closed incisions in orthopedic trauma surgery. Methods A systematic search was performed in PubMed, Embase, and the Cochrane Library databases. The outcome measures included deep surgical site infection (SSI), superficial SSI; wound dehiscence and length of hospital stay. Cochrane collaboration’s tool and the Newcastle–Ottawa Scale (NOS) were used to evaluate literature qualities. Meta-analysis was performed using RevMan 5.3 software. Results A total of 6 studies including 2 randomized controlled trials (RCTs) and 4 cohort studies met our inclusion criteria. NPWT resulted in a significantly lower incidence of deep SSI, superficial SSI, and wound dehiscence than conventional wound dressings. However, no statistically significant difference was found in the length of hospital stay. Conclusions NPWT appeared to be an efficient alternative to help prevent SSIs and wound dehiscence on closed incisions in orthopedic trauma surgery. Rational use of NWPT should be based on the presence of patient’s condition and risk factors.
Collapse
Affiliation(s)
- Cong Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China
| | - Yiwen Zhang
- Operating Room, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China
| | - Hao Qu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China.
| |
Collapse
|
28
|
Fowler AL, Barry MK. Closed incision negative pressure therapy: Results of recent trials and recommendations for clinical practice. Surgeon 2019; 18:241-250. [PMID: 31822387 DOI: 10.1016/j.surge.2019.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Open abdominal surgery is associated with high rates of wound complications . Surgical site infection (SSI) is associated with prolonged length of stay, delayed treatment and high rates of readmission (1, 3, 4). Negative pressure wound therapy over closed incisions (ciNPWT) is a novel approach to prevention of SSI. We reviewed the outcomes of studies comparing ciNPWT and standard therapy in open abdominal wounds to assess the efficacy of the current evidence base. AIM To assess the effect of negative pressure wound therapy used over closed incisions in open abdominal surgery. METHODS Search of relevant terms was conducted on PubMed, Scopus and Cochrane to identify studies published between Jan 2006-Feb 2019. Studies were chosen based on specific inclusion criteria. Articles were screened to assess demographics, study design and outcomes. RESULTS Seven retrospective and six prospective randomised controlled trials were identified for inclusion, totalling 3048 participants. 967 received ciNPWT and 2081 received standard treatment. Studies assessed a mix of surgeries (colorectal n = 6, pancreaticoduodenectomy n = 1, gynaecologic n = 1, acute care surgery n = 1, mixed open n = 2). ciNPWT was statistically significant in reducing SSI in 9 of 13 studies. CONCLUSION ciNPWT in open abdominal surgery has demonstrated promising results for reducing SSI rate in some trials however, patient selection remains unclear. Recent randomized controlled trials have failed to demonstrate benefit overall with use of ciNPWT in open abdominal surgery. Further multicentre prospective trials are needed for cost-benefit analysis and appropriate patient-selection.
Collapse
Affiliation(s)
- Amy Lee Fowler
- Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgical Affairs, Royal College of Surgeons in Ireland, 121-122 St Stephen's Green Dublin 2, Ireland
| | - Michael Kevin Barry
- Discipline of Surgery, National University of Ireland, Galway, Ireland; Department of Surgical Affairs, Royal College of Surgeons in Ireland, 121-122 St Stephen's Green Dublin 2, Ireland.
| |
Collapse
|
29
|
Kim JH, Kim HJ, Lee DH. Comparison of the Efficacy Between Closed Incisional Negative-Pressure Wound Therapy and Conventional Wound Management After Total Hip and Knee Arthroplasties: A Systematic Review and Meta-Analysis. J Arthroplasty 2019; 34:2804-2814. [PMID: 31288945 DOI: 10.1016/j.arth.2019.06.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 05/20/2019] [Accepted: 06/10/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Wound-related problems after total hip arthroplasty (THA) and total knee arthroplasty (TKA) can cause periprosthetic joint infections. We sought to evaluate the effect of closed incisional negative-pressure wound therapy (ciNPWT) on wound complications, skin blisters, surgical site infections (SSIs), reoperations, and length of hospitalization (LOH). METHODS Studies comparing ciNPWT with conventional dressings following THA and TKA were systematically searched on MEDLINE, Embase, and the Cochrane Library. Two reviewers performed the study selection, risk of bias assessment, and data extraction. Funnel plots were employed to evaluate publication bias and forest plots to analyze pooled data. RESULTS Twelve studies were included herein. The odds ratios (ORs) for wound complications and SSIs indicated a lack of publication bias. ciNPWT showed significantly lower risks of wound complication (OR, 0.44; 95% confidence interval [CI], 0.22-0.9; P = .027) and SSI (OR, 0.39; 95% CI, 0.23-0.68; P < .001) than did conventional dressings. ciNPWT also yielded a significantly lower reoperation rate (OR, 0.38; 95% CI, 0.21-0.69; P = .001) and shorter LOH (mean difference, 0.41 days; 95% CI, -0.51 to -0.32; P < .001). However, the rate of skin blisters was higher in ciNPWT (OR, 4.44; 95% CI, 2.24-8.79; P < .001). CONCLUSION Although skin blisters were more likely to develop in ciNPWT, the risks of wound complication, SSI, reoperation, and longer LOH decreased in ciNPWT compared with those in conventional dressings. This finding could alleviate the potential concerns regarding wound-related problems after THA and TKA.
Collapse
Affiliation(s)
- Jun-Ho Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun-Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Dae-Hee Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| |
Collapse
|
30
|
Donlon NE, Boland PA, Kelly ME, Schmidt K, Cooke F, Neary PM, Barry KM, Reynolds JV. Prophylactic negative wound therapy in laparotomy wounds (PROPEL trial): randomized controlled trial. Int J Colorectal Dis 2019; 34:2003-2010. [PMID: 31529194 DOI: 10.1007/s00384-019-03398-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Superficial surgical site infections are a common post-operative complication. They also place a considerable financial burden on healthcare. The use of prophylactic negative pressure wound therapy has been advocated to reduce wound infection rates. However, there is debate around its routine use. The purpose of this trial is to determine if prophylactic negative pressure wound therapy reduces post-operative wound complications in patients undergoing laparotomy. METHODS/DESIGN This multi-centre randomised controlled trial will compare standard surgical dressings (control) to two competing negative pressure wound therapy dressings (Prevena™ and PICO™). All patients will be over 18 years, who are undergoing an emergency or elective laparotomy. It is intended to enrol a total of 271 patients for the trial. DISCUSSION The PROPEL trial is a multi-centre randomised controlled trial of patients undergoing laparotomy. The comparison of standard treatment to two commercially available NPWT will help provide consensus on the routine management of laparotomy wounds. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov (NCT number NCT03871023).
Collapse
Affiliation(s)
| | - P A Boland
- Department of Surgery, St James Hospital, Dublin 8, Ireland
| | - M E Kelly
- Department of Surgery, St James Hospital, Dublin 8, Ireland
| | - K Schmidt
- Department of Surgery, Wexford General Hospital, Wexford, Ireland
| | - F Cooke
- Department of Surgery, University Hospital Waterford, Waterford, Ireland
| | - P M Neary
- Department of Surgery, University Hospital Waterford, Waterford, Ireland
| | - K M Barry
- Department of Surgery, Mayo University Hospital, Mayo, Ireland
| | - J V Reynolds
- Department of Surgery, St James Hospital, Dublin 8, Ireland
| |
Collapse
|
31
|
Zayan NE, West JM, Schulz SA, Jordan SW, Valerio IL. Incisional Negative Pressure Wound Therapy: An Effective Tool for Major Limb Amputation and Amputation Revision Site Closure. Adv Wound Care (New Rochelle) 2019; 8:368-373. [PMID: 31346491 DOI: 10.1089/wound.2018.0935] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/20/2019] [Indexed: 12/17/2022] Open
Abstract
Objective: To evaluate our institutional experience of incisional negative pressure wound therapy (iNPWT) applied immediately after major limb amputation closure or amputation revision closure. Approach: A retrospective review was performed on 25 patients who underwent major limb amputation or amputation revision and had iNPWT placed intraoperatively upon incision closure. Results: Twenty-one patients underwent lower extremity amputation and four underwent upper extremity amputation. Seventeen were primary amputations and eight were amputation revisions. No patients developed dehiscence, seroma, or hematoma. One patient developed a surgical site infection (4%) that was treated with oral antibiotics. The average time to eligibility for prosthetic fitting for lower extremity amputations was 6.3 weeks. Innovation: Amputee patients have increased wound healing demands that can impact prosthetic wear and ambulation status. Stump incisions are located at the distal end of their extremities and often are in areas that have had prior surgical procedures performed. Thus, blood supply to the incision site may not be optimal. iNPWT is an effective incision management technique to promote healing and decrease postoperative complications in this patient population, which can lead to increased mortality. Conclusion: iNPWT is an effective technique of minimizing wound complications in the amputee and should be considered in this high-risk patient population.
Collapse
Affiliation(s)
- Nichole E. Zayan
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julie M. West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Steven A. Schulz
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sumanas W. Jordan
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Division of Plastic Surgery, Northwestern University, Chicago, Illinois
| | - Ian L. Valerio
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
32
|
Wang L, Xu X, Cao JG, Liu J. Negative pressure wound therapy in total hip and knee arthroplasty: a meta-analysis. J Comp Eff Res 2019; 8:791-797. [PMID: 31397173 DOI: 10.2217/cer-2019-0009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Aim: To assess the efficiency and safety of negative pressure wound therapy (NPWT) in the total hip and knee arthroplasty, we conducted a meta-analysis from randomized controlled trials. Methods: Potential academic articles were identified from the Cochrane Library, PubMed, Embase, Springer and ScienceDirect. Secondary sources were identified from the references of the included literature. RevMan 5.1 was used to analyze the pooled data. Results: Six randomized controlled trials met the inclusion criteria. Meta-analysis showed more superficial surgical site infection and blisters in patients with total knee arthroplasty. There were no significant differences between two groups in total infection and total complications. Conclusion: NPWT decreased the incidence of superficial surgical site infection. More blisters were noticed in patients with NPWT after total knee arthroplasty.
Collapse
Affiliation(s)
- Lei Wang
- Department of Joint Surgery, Tianjin Hospital, Tianjin, 300211, PR China
| | - Xin Xu
- Department of Imaging, Tianjin Hospital of ITCWM, Nankai Hospital, Tianjin, 300100, PR China
| | - Jian-gang Cao
- Department of Sport Medicine, Tianjin Hospital, Tianjin, 300211, PR China
| | - Jun Liu
- Department of Joint Surgery, Tianjin Hospital, Tianjin, 300211, PR China
| |
Collapse
|
33
|
Negative Pressure Wound Therapy Use to Decrease Surgical Nosocomial Events in Colorectal Resections (NEPTUNE). Ann Surg 2019; 270:38-42. [DOI: 10.1097/sla.0000000000003111] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
34
|
Garcia‐Pertierra S, Vizcaino Reves N, Calvo Aguado A. Negative‐pressure wound therapy for high‐risk surgical incision wounds using an ultra‐portable device: 11 cases. VETERINARY RECORD CASE REPORTS 2019. [DOI: 10.1136/vetreccr-2018-000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
35
|
Incisional wound VAC and risk-adjusted SSI rates in colorectal surgery: A tertiary centre experience. Am J Surg 2019; 217:948-953. [DOI: 10.1016/j.amjsurg.2018.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 12/16/2022]
|
36
|
Management of Closed Incisions Using Negative-Pressure Wound Therapy in Orthopedic Surgery. Plast Reconstr Surg 2019; 143:21S-26S. [DOI: 10.1097/prs.0000000000005308] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
37
|
Hyldig N, Joergensen JS, Wu C, Bille C, Vinter CA, Sorensen JA, Mogensen O, Lamont RF, Möller S, Kruse M. Cost-effectiveness of incisional negative pressure wound therapy compared with standard care after caesarean section in obese women: a trial-based economic evaluation. BJOG 2018; 126:619-627. [PMID: 30507022 DOI: 10.1111/1471-0528.15573] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of incisional negative pressure wound therapy (iNPWT) in preventing surgical site infection in obese women after caesarean section. DESIGN A cost-effectiveness analysis conducted alongside a clinical trial. SETTING Five obstetric departments in Denmark. POPULATION Women with a pregestational body mass index (BMI) ≥30 kg/m2 . METHOD We used data from a randomised controlled trial of 876 obese women who underwent elective or emergency caesarean section and were subsequently treated with iNPWT (n = 432) or a standard dressing (n = 444). Costs were estimated using data from four Danish National Databases and analysed from a healthcare perspective with a time horizon of 3 months after birth. MAIN OUTCOME MEASURES Cost-effectiveness based on incremental cost per surgical site infection avoided and per quality-adjusted life-year (QALY) gained. RESULTS The total healthcare costs per woman were €5793.60 for iNPWT and €5840.89 for standard dressings. Incisional NPWT was the dominant strategy because it was both less expensive and more effective; however, no statistically significant difference was found for costs or QALYs. At a willingness-to-pay threshold of €30,000, the probability of the intervention being cost-effective was 92.8%. A subgroup analysis stratifying by BMI shows that the cost saving of the intervention was mainly driven by the benefit to women with a pre-pregnancy BMI ≥35 kg/m2 . CONCLUSION Incisional NPWT appears to be cost saving compared with standard dressings but this finding is not statistically significant. The cost savings were primarily found in women with a pre-pregnancy BMI ≥35 kg/m2 . TWEETABLE ABSTRACT Prophylactic incisional NPWT reduces the risk of SSI after caesarean section and is probably dominant compared with standard dressings #healtheconomics.
Collapse
Affiliation(s)
- N Hyldig
- Department of Plastic Surgery, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,OPEN Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - J S Joergensen
- Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - C Wu
- Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - C Bille
- Department of Plastic Surgery, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - C A Vinter
- Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - J A Sorensen
- Department of Plastic Surgery, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - O Mogensen
- Division of Pelvic Cancer, Karolinska University Hospital, and the Karolinska Institute, Stockholm, Sweden
| | - R F Lamont
- Department of Gynaecology and Obstetrics, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Division of Surgery, University College London, London, UK
| | - S Möller
- OPEN Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - M Kruse
- Department of Public Health, Danish Centre for Health Economics (DaCHE), University of Southern Denmark, Odense, Denmark
| |
Collapse
|
38
|
Introduction to "Management of Surgical Incisions Utilizing Closed-Incision Negative-Pressure Therapy". Plast Reconstr Surg 2018; 143:4S-5S. [PMID: 30586095 DOI: 10.1097/prs.0000000000005304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
39
|
Sahebally SM, McKevitt K, Stephens I, Fitzpatrick F, Deasy J, Burke JP, McNamara D. Negative Pressure Wound Therapy for Closed Laparotomy Incisions in General and Colorectal Surgery: A Systematic Review and Meta-analysis. JAMA Surg 2018; 153:e183467. [PMID: 30267040 DOI: 10.1001/jamasurg.2018.3467] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance Surgical site infections (SSIs) are common after laparotomy wounds and are associated with a significant economic burden. The use of negative pressure wound therapy (NPWT) has recently been broadened to closed surgical incisions. Objective To evaluate the association of prophylactic NPWT with SSI rates in closed laparotomy incisions performed for general and colorectal surgery in elective and emergency settings. Data Sources The PubMed, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases were searched without language restrictions for relevant articles from inception until December 2017. The latest search was performed on December 31, 2017. The bibliographies of retrieved studies were further screened for potential additional studies. Study Selection Randomized clinical trials and nonrandomized studies were included. Unpublished reports were excluded, as were studies that examined NPWT (or standard nonpressure) dressings only without a comparator group. Studies that evaluated the use of NPWT in open abdominal incisions were also excluded. Disagreement was resolved by discussion, and if the question remained unsettled, the opinion of the senior author was sought. A total of 198 citations were identified, and 189 were excluded. Data Extraction and Synthesis This meta-analysis was conducted according to PRISMA guidelines. Data were independently extracted by 2 authors. A random-effects model was used for statistical analysis. Main Outcomes and Measures The primary outcome measure was SSI, and secondary outcomes included seroma and wound dehiscence rates. These outcomes were chosen before data collection. Results Nine unique studies (3 randomized trials and 2 prospective and 4 retrospective studies) capturing 1266 unique patients were included. Of these, 1187 patients with 1189 incisions were included in the final analysis (52.3% male among 7 studies reporting data on sex; mean [SD] age, 52 [15] years among 8 studies reporting data on age). Significant clinical and methodologic heterogeneity existed among studies. On random-effects analysis, NPWT was associated with a significantly lower rate of SSI compared with standard dressings (pooled odds ratio [OR], 0.25; 95% CI, 0.12-0.52; P < .001). However, no difference in rates of seroma (pooled OR, 0.38; 95% CI, 0.12-1.23; P = .11) or wound dehiscence (pooled OR, 2.03; 95% CI, 0.61-6.78; P = .25) was found. On sensitivity analysis, focusing solely on colorectal procedures, NPWT significantly reduced SSI rates (pooled OR, 0.16; 95% CI, 0.07-0.36; P < .001). Conclusions and Relevance Application of NPWT on closed laparotomy wounds in general and colorectal surgery is associated with reduced SSI rates but similar rates of seroma and wound dehiscence compared with conventional nonpressure dressings.
Collapse
Affiliation(s)
| | - Kevin McKevitt
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Ian Stephens
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joseph Deasy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - John Patrick Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Deborah McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
40
|
Giannini S, Mazzotti A, Luciani D, Lullini G, Tedesco G, Andreoli I, Cadossi M, Faldini C. Postoperative wound management with negative pressure wound therapy in knee and hip surgery: a randomised control trial. J Wound Care 2018; 27:520-525. [DOI: 10.12968/jowc.2018.27.8.520] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Sandro Giannini
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy
| | - Antonio Mazzotti
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy, Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Deianira Luciani
- Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giada Lullini
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy, Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Tedesco
- Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Isabella Andreoli
- Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Matteo Cadossi
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy, Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cesare Faldini
- Biomedical and Neuromotorial Science Department, University of Bologna, Italy, Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna, Italy
| |
Collapse
|
41
|
Abstract
Wound complications and surgical site infections after orthopaedic procedures result in substantial morbidity and costs. Traditional postoperative wound care consists of applying sterile, dry gauze and abdominal pads to the surgical site, with more frequent dressing changes performed in cases in which wound drainage is excessive. Persistent incisional drainage is of particular concern because it increases the risk of deep infection. The use of closed incision negative-pressure wound therapy (ciNPWT) to manage delayed wound healing was first reported a decade ago, and the benefits of this treatment modality include wound contraction with diminished tensile forces, stabilization of the wound environment, decreased edema and improved removal of exudate, and increased blood and lymphatic flow. Numerous trauma, plastic surgery, and general surgery studies have demonstrated that ciNPWT improves wound healing. In orthopaedic surgery, ciNPWT has been shown to be clinically effective for incisions at high risk for perioperative complications. However, specific indications for ciNPWT continue to be defined.
Collapse
|
42
|
Cooper HJ, Roc GC, Bas MA, Berliner ZP, Hepinstall MS, Rodriguez JA, Weiner LS. Closed incision negative pressure therapy decreases complications after periprosthetic fracture surgery around the hip and knee. Injury 2018; 49:386-391. [PMID: 29174454 DOI: 10.1016/j.injury.2017.11.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 11/14/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Periprosthetic fractures (PPFXs) are becoming increasingly common following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients sustaining PPFXs face considerable perioperative morbidity, with relatively increased rates of surgical site infection. We sought to evaluate the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing perioperative wound complications following lower extremity periprosthetic fracture surgery. METHODS We performed a retrospective review of 69 consecutive patients who underwent surgery to address lower extremity periprosthetic fractures around hip or knee implants performed over a 6.5-year period. The population was divided into two groups based on the surgical dressing used at the conclusion of the procedure: (1) a sterile, antimicrobial hydrofiber dressing, or (2) ciNPT. There were no baseline demographic differences between the two groups. Rates of wound complications, surgical site infection, and reoperation related to the surgical site were compared between groups. Continuous variables were analyzed using a student's t-test, and categorical variables using either chi-square or fisher's exact test. RESULTS Patients treated with ciNPT developed fewer wound complications (4% vs. 35%; p=0.002), fewer deep infections (0% vs. 25%; p=0.004), and underwent fewer reoperations related to the surgical site (4% vs. 25%; p=0.021) compared to patients treated with standard of care. CONCLUSIONS Our findings suggest that ciNPT may reduce wound complications, SSIs, and reoperations in patients undergoing lower extremity periprosthetic fracture surgery. This is the first study to investigate ciNPT as a treatment for periprosthetic fracture surgery, and has the potential to change the postoperative management of these patients.
Collapse
Affiliation(s)
- H John Cooper
- Division of Hip and Knee Reconstruction, Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, United States.
| | - Gilbert C Roc
- Center for Joint Preservation & Reconstruction, Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, United States
| | - Marcel A Bas
- Center for Joint Preservation & Reconstruction, Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, United States
| | - Zachary P Berliner
- Center for Joint Preservation & Reconstruction, Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, United States
| | - Matthew S Hepinstall
- Center for Joint Preservation & Reconstruction, Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, United States
| | - José A Rodriguez
- Adult Reconstruction and Joint Replacement Service, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, United States
| | - Lon S Weiner
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health System, New York, NY, United States
| |
Collapse
|
43
|
Redfern RE, Cameron-Ruetz C, O'Drobinak SK, Chen JT, Beer KJ. Closed Incision Negative Pressure Therapy Effects on Postoperative Infection and Surgical Site Complication After Total Hip and Knee Arthroplasty. J Arthroplasty 2017; 32:3333-3339. [PMID: 28705547 DOI: 10.1016/j.arth.2017.06.019] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/22/2017] [Accepted: 06/08/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of this study is to determine whether negative pressure wound therapy, used prophylactically in clean surgical incisions, reduces surgical site infection, hematoma, and seroma after total joint replacement. METHODS A single center, open-label study with a prospective cohort of patients undergoing primary total knee arthroplasty or total hip arthroplasty treated with closed incision negative pressure therapy (ciNPT) of clean surgical wounds was conducted. One hundred ninety-six incisions treated with ciNPT in 192 patients were compared with a historical control group of 400 patients treated with traditional gauze dressing. The rates of clinically significant hematoma, seroma, dehiscence, surgical site infection, and complication were compared using univariate analyses and multiple logistic regression. RESULTS The rate of deep infection was unchanged in the ciNPT group compared with control (1.0% vs 1.25%); however, the overall rate of infection (including superficial wound infection) decreased significantly (3.5% vs 1.0%, P = .04). Overall complication rate was lower in the ciNPT group than controls (1.5% vs 5.5%, P = .02). Upon logistic regression, only treatment group was associated with complication; patients treated with ciNPT were about 4 times less likely to experience a surgical site complication compared with control (P = .0277, odds ratio 4.251, 95% confidence interval 1.172-15.414). CONCLUSION ciNPT for total knee arthroplasty and total hip arthroplasty in a comprehensive patient population reduced overall incidence of complication, but did not significantly impact the rate of deep infection. Further research to determine clinical and economic advantages of routine use of ciNPT in total joint arthroplasty is warranted.
Collapse
Affiliation(s)
| | | | - Simone K O'Drobinak
- Department of Orthopedic Surgery, Wildwood Orthopedic and Spine Institute, ProMedica Toledo Hospital, Toledo, Ohio
| | - John T Chen
- Department of Mathematics and Statistics, Bowling Green State University, Bowling Green, Ohio
| | - Karl J Beer
- Department of Orthopedic Surgery, Wildwood Orthopedic and Spine Institute, ProMedica Toledo Hospital, Toledo, Ohio
| |
Collapse
|
44
|
Pleger SP, Nink N, Elzien M, Kunold A, Koshty A, Böning A. Reduction of groin wound complications in vascular surgery patients using closed incision negative pressure therapy (ciNPT): a prospective, randomised, single-institution study. Int Wound J 2017; 15:75-83. [PMID: 29068153 PMCID: PMC7950196 DOI: 10.1111/iwj.12836] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 09/02/2017] [Accepted: 09/08/2017] [Indexed: 01/08/2023] Open
Abstract
Groin wound infections in patients undergoing vascular procedures often cause a lengthy process of wound healing. Several clinical studies and case reports show a reduction of surgical site infections (SSIs) in various wound types after using closed incision negative pressure therapy (ciNPT). The aim of this prospective, randomised, single-institution study was to investigate the effectiveness of ciNPT (PREVENA™ Therapy) compared to conventional therapy on groin incisions after vascular surgery. From 1 February to 30 October 2015, 100 patients with 129 groin incisions were analysed. Patients were randomised and treated with either ciNPT (n = 58 groins) or the control dressing (n = 71 groins). ciNPT was applied intraoperatively and removed on days 5-7 postoperatively. The control group received a conventional adhesive plaster. Wound evaluation based on the Szilagyi classification took place postoperatively on days 5-7 and 30. Compared to the control group, the ciNPT group showed a significant reduction in wound complications (P < 0·0005) after both wound evaluation periods and in revision surgeries (P = 0·022) until 30 days postoperatively. Subgroup analysis revealed that ciNPT had a significant effect on almost all examined risk factors for wound healing. ciNPT significantly reduced the incidence of incision complications and revision procedures after vascular surgery.
Collapse
Affiliation(s)
- Sebastian P Pleger
- Department of Vascular Surgery, Jung-Stilling Hospital, Siegen, Germany.,Department of Cardiovascular Surgery, University Hospital, Justus Liebig University, Giessen, Germany
| | - Nadine Nink
- Department of Vascular Surgery, Jung-Stilling Hospital, Siegen, Germany
| | - Meshal Elzien
- Department of Vascular Surgery, Jung-Stilling Hospital, Siegen, Germany
| | - Alexander Kunold
- Department of Vascular Surgery, Jung-Stilling Hospital, Siegen, Germany
| | - Ahmed Koshty
- Department of Vascular Surgery, Jung-Stilling Hospital, Siegen, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital, Justus Liebig University, Giessen, Germany
| |
Collapse
|
45
|
Negative Pressure Wound Therapy on Closed Surgical Wounds With Dead Space: Animal Study Using a Swine Model. Ann Plast Surg 2017; 76:717-22. [PMID: 25003432 PMCID: PMC4890833 DOI: 10.1097/sap.0000000000000231] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Closed incisional wound surgery frequently leaves dead space under the repaired skin, which results in delayed healing. The purpose of this study was to evaluate the effect of negative pressure wound therapy (NPWT) on incisional wounds with dead space after primary closure by evaluating the fluid volume through the suction drain, blood flow of the skin, tensile strength, and histology of the wounds. Methods Bilateral 25-cm-long incisional wounds with dead space were created on the back of 6 pigs by partially removing the back muscle and then suturing the skin with nylon sutures. NPWT (experimental group) or gauze dressing (control group) was applied over the closed incision for 7 days. Analysis of the wound included monitoring the amount of closed suction drain, blood perfusion unit, tensile strength of the repaired skin, and histology of the incision site. Results The drainage amount was significantly reduced in the experimental group (49.8 mL) compared to the control group (86.2 mL) (P = 0.046). Skin perfusion was increased in the experimental group with statistical significance compared to the control group (P = 0.0175). Collagen staining was increased in the experimental group. The tensile strength of the incision site was significantly higher in the experimental group (24.6 N at 7 days, 61.67 N at 21 days) compared to the control group (18.26 N at 7 days, 50.05 N at 21 days) (P = 0.02). Conclusion This study explains some of the mechanism for using NPWT in closed incision wounds with dead space. It demonstrates that NPWT significantly reduces drainage amount, increases skin perfusion, increases tensile strength, and has the tendency to promote collagen synthesis for closed wound with dead space indicating enhanced healing.
Collapse
|
46
|
Kong R, Shields D, Bailey O, Gupta S, Mahendra A. Negative Pressure Wound Therapy for Closed Surgical Wounds in Musculoskeletal Oncology Patients - A Case-Control Trial. Open Orthop J 2017; 11:502-507. [PMID: 28694889 PMCID: PMC5481620 DOI: 10.2174/1874325001711010502] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/14/2017] [Accepted: 02/23/2017] [Indexed: 01/26/2023] Open
Abstract
Following excision of musculoskeletal tumours, patients are at high risk of wound issues such as infection, dehiscence and delayed healing. This is due to a multitude of factors including the invasive nature of the disease, extensive soft tissue dissection, disruption to blood and lymphatic drainage, residual cavity and adjuvant therapies. The use of negative pressure wound therapy (NPWT) has a growing body of evidence on its beneficial effect of wound healing such as promoting cell differentiation, minimising oedema and thermoregulation. Traditionally, these dressings have been used for open or dehisced wounds; however recent research has investigated its role in closed wounds. Aim: To evaluate the effect of NPWT in patients with closed wounds, either primarily or with flap coverage, in our high risk group. Consecutive patients who had a NPWT dressing applied were selected, and a control group was established by a blinded researcher with matching for tissue diagnosis, surgical site, gender and age. The primary outcome measured was documented for wound complications, with secondary data collected on radiotherapy and wound drainage. Results: Patients were well matched between the intervention (n=9) and control (n=9) groups for gender, age and tissue diagnosis. Both groups had 1 patient who underwent preoperative radiotherapy. A total of 3 wound infections occurred in the control group and none in the NPWT group. Overall there was a trend towards lower drain output and statistically significantly reduced infection rate in the NPWT group. Conclusion: In this short series, despite the NPWT patients having more additional risk factors for wound issues, they resulted in fewer infections. The sample size is not sufficient to have statistically significant reduction. Further evaluation on the value of NPWT in this patient group should be prospectively evaluated.
Collapse
Affiliation(s)
- Roderick Kong
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0ET Scotland, United Kingdom
| | - David Shields
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0ET Scotland, United Kingdom
| | - Oliver Bailey
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0ET Scotland, United Kingdom
| | - Sanjay Gupta
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0ET Scotland, United Kingdom
| | - Ashish Mahendra
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0ET Scotland, United Kingdom
| |
Collapse
|
47
|
Effects of Incisional Negative-Pressure Wound Therapy on Primary Closed Defects after Superficial Circumflex Iliac Artery Perforator Flap Harvest: Randomized Controlled Study. Plast Reconstr Surg 2017; 138:1333-1340. [PMID: 27879604 DOI: 10.1097/prs.0000000000002765] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prolonged hematoma or seroma after primary closure is a causative element in wound complications. This study evaluated the effects of negative-pressure wound therapy on primary closed wounds after superficial circumflex iliac artery perforator flap harvest. METHODS This study was a prospective, randomized, clinical trial comparing conventional dressing against a single application of negative-pressure wound therapy for 5 days after primary closure. A total of 100 patients who had superficial circumflex iliac artery perforator flap harvest were enrolled. RESULTS There was no statistical difference between the incisional negative-pressure wound therapy and conventional dressing groups in the distribution of risk factors. Significant findings were noted for duration and amount of closed suction drainage: 6.12 ± 4.99 days (median, 4 days; range, 3 to 8 days) and 100.47 ± 140.69 cc (median, 42 cc) for wounds treated with conventional dressing versus 3.34 ± 1.35 days (median, 3 days; range, 2 to 4 days) and 23.28 ±18.36 cc (median, 20 cc) for wounds in treatment group (p = 0.0077 and p = 0.0004), respectively. After closure, an increase in skin perfusion were noted on day 5 in the treatment group (p = 0.0223). There was one case of wound dehiscence in the conventional dressing group. CONCLUSION The incisional negative-pressure wound therapy has a positive effect over primary closed surgical defects by significantly reducing the amount of fluid collected by closed suction drains, allowing earlier removal of drains and enhancing the skin perfusion on the repaired skin. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
Collapse
|
48
|
Zaidi A, El-Masry S. Closed-incision negative-pressure therapy in high-risk general surgery patients following laparotomy: a retrospective study. Colorectal Dis 2017; 19:283-287. [PMID: 27416813 DOI: 10.1111/codi.13458] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/08/2016] [Indexed: 12/23/2022]
Abstract
AIM Surgical site infection (SSI) and wound dehiscence are dreaded complications following laparotomy in general surgical patients, and can potentially occur more often in various comorbid states. Negative-pressure wound therapy (NPWT) has a positive effect of on open and complicated wounds and so has been used for at-risk surgical incisions with the aim of redistributing lateral tension and holding incision edges together. The aim of the present study was to compare the rate of wound complications following laparotomy in high-risk general surgical patients with a clean incision treated with closed-incision negative-pressure therapy (ciNPT) with those receiving conventional care. METHOD A retrospective review was performed of the hospital medical records of patients who underwent laparotomy between 1 October 2010 and 31 March 2012. Records of 69 patients who received ciNPT and 112 who were managed by adherent gauze dressings were included in the final analysis. RESULTS Two (2.9%) patients in the ciNPT group and 23 (20.5%) in the non-NPWT group developed a wound complication following laparotomy (P < 0.0009). The relative risk (RR) was 0.14 (0.03-0.58), suggesting that infection is less likely to occur in ciNPT-treated incisions, compared with gauze dressings. CONCLUSION ciNPT was associated with a positive clinical outcome and was a safe and effective method of postsurgical management in our general surgery patients considered to have risk of developing wound complications following laparotomy.
Collapse
Affiliation(s)
- A Zaidi
- Surgery, North Tees and Hartlepool NHSFT, Stockton on Tees, UK
| | - S El-Masry
- Surgery, Our Lady Of Lourdes, Drogheda, Louth, Ireland
| |
Collapse
|
49
|
Is Intraoperative Local Vancomycin Powder the Answer to Surgical Site Infections in Spine Surgery? Spine (Phila Pa 1976) 2017; 42:267-274. [PMID: 28207669 DOI: 10.1097/brs.0000000000001710] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a retrospective cohort comparative study of all patients who underwent instrumented spine surgery at a single institution. OBJECTIVE To compare the rate of surgical site infection (SSI) between the treatment (vancomycin) and the control group (no vancomycin) in patients undergoing instrumented spine surgery. SUMMARY OF BACKGROUND DATA SSI after spine surgery is a dreaded complication associated with increased morbidity and mortality. Prophylactic intraoperative local vancomycin powder to the wound has been recently adopted as a strategy to reduce SSI but results have been variable. METHODS In the present study, there were 117 (30%) patients in the treatment group and 272 (70%) patients in the comparison cohort. All patients received identical standard operative and postoperative care procedures based on protocolized department guidelines. The present study compared the rate of SSI with and without the use of prophylactic intraoperative local vancomycin powder in patients undergoing various instrumented spine surgery, adjusted for confounders. RESULTS The overall rate of SSI was 4.7% with a decrease in infection rate found in the treatment group (0.9% vs. 6.3%). This was statistically significant (P = 0.049) with an odds ratio of 0.13 (95% confidence interval 0.02-0.99). The treatment group had a significantly shorter onset of infection (5 vs. 16.7 days; P < 0.001) and shorter duration of infection (8.5 vs. 26.8 days; P < 0.001). The most common causative organism was Pseudomonas aeruginosa (35.2%). Patient diagnosis, surgical approach, and intraoperative blood loss were significant risk factors for SSI after multivariable analysis. CONCLUSION Prophylactic Intraoperative local vancomycin powder reduces the risk and morbidity of SSI in patients undergoing instrumented spine surgery. P. aeruginosa infection is common in the treatment arm. Future prospective randomized controlled trials in larger populations involving other spine surgeries with a long-term follow-up duration are recommended. LEVEL OF EVIDENCE 3.
Collapse
|
50
|
Scalise A, Calamita R, Tartaglione C, Pierangeli M, Bolletta E, Gioacchini M, Gesuita R, Di Benedetto G. Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature. Int Wound J 2016; 13:1260-1281. [PMID: 26424609 PMCID: PMC7950088 DOI: 10.1111/iwj.12492] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 06/20/2015] [Accepted: 08/07/2015] [Indexed: 01/01/2023] Open
Abstract
Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.
Collapse
Affiliation(s)
- Alessandro Scalise
- Department of Plastic and Reconstructive SurgeryUniversità Politecnica delle MarcheAnconaItaly
| | - Roberto Calamita
- Department of Plastic and Reconstructive SurgeryUniversità Politecnica delle MarcheAnconaItaly
| | - Caterina Tartaglione
- Department of Plastic and Reconstructive SurgeryUniversità Politecnica delle MarcheAnconaItaly
| | - Marina Pierangeli
- Department of Plastic and Reconstructive SurgeryUniversità Politecnica delle MarcheAnconaItaly
| | - Elisa Bolletta
- Department of Plastic and Reconstructive SurgeryUniversità Politecnica delle MarcheAnconaItaly
| | - Matteo Gioacchini
- Department of Plastic and Reconstructive SurgeryUniversità Politecnica delle MarcheAnconaItaly
| | - Rosaria Gesuita
- Interdepartmental Centre of EpidemiologyBiostatistics and Medical Informatics (EBI Centre), Università Politecnica delle MarcheAnconaItaly
| | - Giovanni Di Benedetto
- Department of Plastic and Reconstructive SurgeryUniversità Politecnica delle MarcheAnconaItaly
| |
Collapse
|