The impact of surgical site occurrences and the role of closed incision negative pressure therapy

Prospective evaluation of a closed-incision negative pressure wound therapy system in kidney transplantation and its association with wound complications

Introduction

Wound complications can cause considerable morbidity in kidney transplantation. Closed-incision negative pressure wound therapy (ciNPWT) systems have been efficacious in reducing wound complications across surgical specialties. The aims of this study were to evaluate the use of ciNPWT, Prevena™, in kidney transplant recipients and to determine any association with wound complications.

Material and methods

A single-center, prospective observational cohort study was performed in 2018. A total of 30 consecutive kidney transplant recipients deemed at high risk for wound complications received ciNPWT, and the results were compared to those of a historical cohort of subjects who received conventional dressings. Analysis for recipients with obesity and propensity score matching were performed.

Results

In total, 127 subjects were included in the analysis. Of these, 30 received a ciNPWT dressing and were compared with 97 subjects from a non-study historical control group who had conventional dressing. The overall wound complication rate was 21.3% (27/127). There was no reduction in the rate of wound complications with ciNPWT when compared with conventional dressing [23.3% (7/30) and 20.6% (20/97), respectively, p = 0.75]. In the obese subset (BMI ≥30 kg/m2), there was no significant reduction in wound complications [31.1% (5/16) and 36.8% (7/19), respectively, p = 0.73]. Propensity score matching yielded 26 matched pairs with equivalent rates of wound complications (23.1%, 6/26).

Conclusion

This is the first reported cohort study evaluating the use of ciNPWT in kidney transplantation. While ciNPWT is safe and well tolerated, it is not associated with a statistically significant reduction in wound complications when compared to conventional dressing. The findings from this study will be used to inform future studies associated with ciNPWT in kidney transplantation.

Efficacy of incisional negative pressure therapy in preventing post-sternotomy wound complications

BACKGROUND

Sternal wound infections represent a source of significant morbidity and mortality following median sternotomy. The use of incisional negative pressure wound therapy in prevention has yet to be elucidated.

METHODS

A retrospective study was conducted before and after a universal wound care protocol was implemented including the prophylactic use of negative pressure wound therapy (NPWT). The primary endpoint was sternal infections within 90 days of the index operation.

RESULTS

In the control period, there was a 3.0% rate of sternal infection within 90 days compared to 0.8% in the intervention period (p < 0.001). An odds ratio of 0.25 (95% confidence interval 0.11, 0.57; p < 0.001) in the intervention period as compared to the control period was demonstrated.

CONCLUSIONS

The use of a standardized wound care protocol including the universal application of NPWT for patients undergoing cardiac surgery with median sternotomy was an independent predictor of decreased rates of sternal infection.

Complication rates in very low and extremely low birth weight infants following laparotomy: a prospective study

INTRODUCTION

Surgical site occurrences (SSO), including surgical site infection, dehiscence, and incisional hernia, are complications following laparotomy. SSO rates in premature neonates are poorly understood. We hypothesize that SSO rates are higher among extremely low birth weight (ELBW) infants compared to very low birth weight (VLBW) infants and strive to determine the optimal abdominal closure method for these infants.

METHODS

We conducted a prospective observational study of infants < 1.5 kg (kg) undergoing laparotomy at two institutions from 1/1/2020 to 5/1/2022. Patients were grouped by weight and closure; SSO rates were computed and the association tested using Fisher's exact test.

RESULTS

We identified 59 patients and 104 total operations. At initial surgery, 37 patients weighed < 1 kg (ELBW); 22 patients weighed 1-1.5 kg (VLBW). Complication rate for ELBW was 6(16%) vs. 2(9%) in VLBW, but not significant (p = 0.45). More complications followed a single-layer compared to a two-layer closure (18 vs. 2), but not significant (p = 0.30).

CONCLUSIONS

SSO rates are higher for ELBW infants undergoing laparotomy, and fewer complications follow two-layer closure. However, these findings did not reach statistical significance. Further studies are needed to identify modifiable factors to reduce postoperative complications in these infants.

Effect of stapled versus layered skin closure on surgical site occurrences after abdominal wall reconstruction

BACKGROUND

The effect of skin closure technique on surgical site occurrences (SSO) after open abdominal wall reconstruction (AWR) with retromuscular polypropylene mesh placement is largely unknown. We hypothesize that layered subcuticular skin closure with cyanoacrylate skin adhesive is protective of surgical site infection compared to standard stapled closure.

METHODS

A retrospective review utilizing the Abdominal Core Health Quality Collaborative (ACHQC) database of all patients at Prisma Health-Upstate. All patients with open abdominal wall reconstruction (AWR) of midline incisional hernia defects with retromuscular polypropylene mesh placement from January 2013 to February 2020 were included. Patient demographics, comorbidities, type of hernia repair with mesh location, method of skin closure, and SSOs were collected. Skin closure method was divided into two groups, reflecting a temporal change in practice: staples (historical control group) versus subcuticular suture with cyanoacrylate skin adhesive with/without polymer mesh tape (study group). Primary endpoint was SSI and SSO. Secondary endpoints were SSO or SSI requiring procedural intervention (SSOPI/SSIPI). Standard statistical methods were utilized.

RESULTS

A total of 834 patients were analyzed, with 263 treated with stapled skin closure and 571 with subcuticular and adhesive closure. On univariate analysis, the incidence of SSI was significantly lower in the study group (11.8 vs 6.8%; p = 0.002), as was the need for SSIPI (11.8 vs 6.7%; p = 0.015). Rate of SSO was not significantly different between groups (28.1 vs 27.2%), but the rate of SSO requiring intervention was lower in the study group (14.1 vs 9.3%; p = 0.045).

CONCLUSION

Layered skin closure technique, including subcuticular closure and adhesive, may reduce the risk of surgical site infection after open AWR. A prospective randomized trial is planned to confirm these findings.

"Closed Incision Negative Pressure Therapy (ciNPT) reduces abdominal donor site surgical wound dehiscence in Deep Internal Epigastric Perforator (DIEP) flap breast reconstructions: DEhiscence PREvention Study II (DEPRES II) - a Randomized Clinical Trial"

BACKGROUND

In breast reconstruction surgeries, surgical wound dehiscence is a serious complication which generates a significant burden on patients and healthcare systems. There are indications that postoperative treatment with closed incision negative pressure therapy (ciNPT) has been associated with reduced wound dehiscence rates. This randomized clinical trial examines the effect of ciNPT application on abdominal donor site surgical wound dehiscence in low- and high-risk patients undergoing a breast reconstruction with a deep internal epigastric perforator (DIEP) flap.

METHODS

Eighty eligible women, stratified as low- or high-risk patients, were included and were randomized for treatment with either ciNPT or adhesive strips (AS) by drawing sealed, opaque envelopes. All surgeons were kept blind for allocation. Primary outcomes were surgical wound dehiscence and surgical site infection at the abdominal donor site upon follow-up after 12 weeks. Secondary outcomes were seroma and hematoma formation. Five patients were excluded from the study due to non-sufficient exposure to the study treatment (n=4) or major protocol deviation (n=1).

RESULTS

A total of 75 women, low-risk (n=38) and high-risk (n=37), received either ciNPT (n=36) or AS (n=39). Patients' demographics did not differ significantly. Donor-site surgical wound dehiscence occurred in 23 patients; the Absolute Risk Reduction was statistically significant (21.6%, 95% Confidence Interval [1.5-41.7]). No statistically significant differences were found in surgical site infection or secondary outcomes.

CONCLUSIONS

In this randomized clinical trial, postoperative treatment with ciNPT decreased the incidence of surgical wound dehiscence at the abdominal donor site in low- and high-risk DIEP flap breast reconstruction patients.

Negative Pressure Wound Therapy in children: A 25 cases series

Negative Pressure Wound Therapy is a device applied to a wound that causes local depression. There are a few series showing the effectiveness of this treatment in Pediatric. The objective of this work is to try to clarify the indications in children. This is a retrospective series of 25 children between 2004 and 2019. The inclusion criteria were all children with a wound treated with Negative Pressure Wound Therapy. The characteristics retained were their age, the context of occurrence, the treatment time, the depression applied, the technique of skin covering wound and the average healing time. We included 25 patients. The average age was 8.8 years. The context of the wound occurrence was mainly a road (44%) or a domestic (36%) accident. Substance losses were mainly located in the lower limb (84%). The depression applied was -90mmHg. The healing time was 18.4 days. Thin skin grafting was the main method chosen (88%). No complications related to Negative Pressure Wound Therapy equipment have been identified. Despite the weakness of the literature and the lack of consensus regarding its use, Negative Pressure Wound Therapy is an essential therapy in pediatric. It is a simple and effective technique in children. It can reduce the need for flaps coverage, even in the event of exposure of noble elements. The flaps should not, however, be excluded from the decision-making algorithm, on pain of complications or sequelae.

Evaluation of closed incision negative pressure therapy systems on the closure of incisional space model

OBJECTIVE

The objective of this study was to compare the ability of foam dressing-based and non-foam-based closed incision negative pressure therapy (ciNPT) systems to close isolated incisional deficits in a tissue model.

METHODS

Similarly sized foam-based and non-foam-based absorbent ciNPT dressings were applied to ~36cm long, ~3mm and ~6mm wide simulated incisions in gel sheets covered with drape (n=6 dressings/group/experimental condition spread over three respective therapy units). Changes in incision widths were measured directly or with overlying solid gel sheeting (to mimic tissue resistance), at five equally spaced locations before, immediately upon and one hour after initiating negative pressure using associated therapy units.

RESULTS

Foam-based ciNPT closed simulated incisions more often than non-foam-based ciNPT in all tested conditions (p<0.05). While foam-based ciNPT almost completely closed the ~3mm wide incisional spaces, unlike non-foam-based ciNPT, the biggest differences between the two groups were observed with the ~6mm incisional width, which allowed maximal inward-stretching of the appositional faces without complete closure. The additional gel layer blunted closure in both groups, but much more with non-foam-based ciNPT. There was minimal impact of negative pressure duration on these results.

CONCLUSION

Foam-based ciNPT closed incisional widths in simulated tissue significantly more compared with non-foam-based ciNPT. Different ciNPT systems should not be considered necessarily equivalent in performance.

Experience using closed incision negative pressure wound therapy in sternotomy patients

OBJECTIVE

Postoperative delayed wound healing, surgical site infections (SSIs), and other wound complications are associated with increased morbidity and health-care costs. In cardiothoracic surgery, wound complications can have life-threatening consequences. In recent years, negative pressure wound therapy (NPWT) has been applied over closed surgical incisions to help reduce tension and protect from external contamination. We report our initial experiences using a closed incision negative pressure therapy (ciNPT) over clean, closed sternotomy incisions at an Irish tertiary referral centre.

METHOD

A retrospective record review identified 10 patients (4 females, 6 males) where ciNPT was used following sternotomy for cardiac surgery or other mediastinal surgery between January 2012 and March 2013.

RESULTS

The patients had an average age of 71.5±14.18 years (range: 44-89 years). Patient comorbidities included obesity, hypertension, active tobacco use, chronic obstructive pulmonary disease, and diabetes mellitus. Patients underwent coronary artery bypass grafting (CABG), aortic valve replacement (AVR), AVR and CABG, or removal of a thymic mass or mediastinal cyst. ciNPT was left in place for an average of 6±0.82 days. All incisions healed without complications.

CONCLUSION

ciNPT use should be considered for patients at risk for postoperative SSI development or other wound complications.

The Effect of Ultrasound-Assisted Debridement Combined with Vacuum Pump Therapy in Deep Sternal Wound Infections

Purpose: To assess whether a combined treatment of low-frequency (25 kHz) ultrasonic-debridement systems followed by vacuum-assisted wound closure (VAC) produces a better outcome in deep sternal wound infections (SWIs) compared to that of VAC alone.

Methods: We evaluated 45 consecutive patients (25 males) between January 2013 and December 2016, in whom deep SWI was treated with a combination of low-frequency ultrasonic debridement system followed by vacuum-assisted closure (group A, n = 23) or with only vacuum-assisted closure therapy (group B, n = 22). Our final step in both groups was a secondary wound closure with a musculocutaneous flap.

Results: In both groups, a similar variety of bacteria were isolated. The time between eradication and secondary wound closure was significantly shorter in group A (7.3 ± 4.8 vs. 19.9 ± 17.2 days, p = 0.001). After a third debridement session, 95.7% of microbiological cultures were negative in group A versus 54.5% in B ( p = 0.001). Duration of antibiotic treatment (p = 0.003) and hospitalization time ( p = 0.0001) were significantly shorter in group A.

Conclusion: The use of low-frequency ultrasonic debridement system is an effective, less invasive technique to combat wound infection. In combination with vacuum-assisted closure therapy, we documented good mid-term results in our patients.

Closed-incision negative pressure therapy to reduce groin wound infections in vascular surgery: a randomised controlled trial

Groin wound infections pose a major problem in vascular surgery. Closed-incision negative pressure therapy (ciNPT) was especially designed for the management of incisions at risk of surgical site infections. The aim of this study was to investigate whether ciNPT is able to reduce the incidence of wound infections after vascular surgery. Data on 132 consecutive patients, scheduled for vascular surgery with a longitudinal femoral cutdown, were collected prospectively. All patients were randomised either to the ciNPT group (n = 64) or the control group (n = 68) with conventional dressing. In the ciNPT group, the foam dressing was applied intraoperatively and removed after 5 days. The control group received an absorbent dressing. All wounds were evaluated after 5 and 42 days. Infections were graded according the Szilagyi classification (I-III°). There were no significant differences between both groups considering patient characteristics. Indications for surgery were peripheral arterial disease in 95% (125/132) and aneurysm in 5% (7/132). The overall infection rates were 14% (9/64) in the ciNPT group and 28% (19/68) in the control group (P = 0·055). Early infections were observed in 6% (4/64) of the ciNPT group and 15% (10/68) of the control group (P = 0·125). ciNPT did not reduce infection rates associated with different risk factors for infection. While the experiences with the ciNPT device were encouraging, the study fails to provide evidence of the efficacy of the device to reduce groin wound infections after vascular surgery. It illustrates far more that larger multicentre studies are required and appear promising to provide further evidence for the use of ciNPT.