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Mufty H, Houthoofd S, Daenens K, Maes R, Fourneau I. The Role of the Omniflow II Biosynthetic Graft in Postoperative Wound Problems After Lower Limb Revascularization: A Single Center Prospective Registry. Ann Vasc Surg 2024; 108:179-186. [PMID: 38950853 DOI: 10.1016/j.avsg.2024.04.023] [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: 02/14/2024] [Revised: 04/12/2024] [Accepted: 04/29/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE To investigate the role of the Omniflow II prosthesis in the prevention of vascular graft infection (VGI) in patients with peripheral arterial disease and to report on short-and mid-term graft-related morbidity. MATERIAL AND METHODS Patients were included in prospective registry between October 2019 and March 2023. The primary endpoint was to report infection-related problems, operation-related wound problems, and short- and mid-term graft-related morbidity. Secondary endpoint was to report the bypass patency rates and limb salvage rates. RESULTS A total of 146 Omniflow II grafts were implanted in 125 patients. Sixty-seven patients (45.9%) received a femoral interposition graft, and 77 patients (52.7%) underwent ipsilateral bypass surgery (femoropopliteal or femorocrural). Forty-one patients (28.1%) underwent crural bypass surgery. Seventy-six patients (52.1%) had previous vascular operation in the groin. The mean follow-up time was 352 days (range 0-1108 days). 3.4% of the patients suffered a wound infection limited to the dermis, and in 8.2%, the subcutaneous tissue was involved. Five early VGI (3.4%) and one late VGI (0.7%) occurred. One year primary patency rate of above-the-knee bypass was significantly better compared to the bypass below the knee (74.5% ± 0.131 versus 54% ± 0.126 (P = 0.049)). This difference was not significantly different when below-the-knee bypass surgery was compared with crural bypass surgery (54% ± 0.126 versus 23.8% ± 0.080 (P = 0.098)). CONCLUSIONS The performance of the Omniflow II prosthesis in the preventive setting is highly influenced by the anatomic location of the distal anastomosis. No influence on the incidence of postoperative wound problems could be observed. The rate of Omniflow II VGI in a high-risk population is similar to reported outcomes in other prosthetic grafts.
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Affiliation(s)
- Hozan Mufty
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium.
| | - Sabrina Houthoofd
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
| | - Kim Daenens
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
| | - Raf Maes
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Research Unit of Vascular Surgery, KU Leuven, Leuven, Belgium
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Lok E, Oe T, Ng S. Lower Extremity Traumatic Wound Management: Relative Significance of Negative Pressure Wound Therapy in the Orthopedic Setting. Adv Wound Care (New Rochelle) 2024. [PMID: 39001834 DOI: 10.1089/wound.2023.0133] [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: 07/15/2024] Open
Abstract
Significance: Lower extremity traumatic wounds are associated with numerous perioperative challenges. Their etiologies determine the characteristics and extent of the injury. The timing of subsequent surgical intervention and wound healing optimization after lower extremity trauma are integral to successful perioperative lower extremity wound management. Recent Advances: Managing trauma to the lower extremities uses a multidisciplinary surgical approach. The objective of this review is to summarize lower limb trauma assessment, advancements in lower extremity trauma management, and the clinical applications of advanced wound care in lower limb traumatic wounds. The advent of lower limb reconstruction and the development of advanced wound care modalities have helped to improve the management of these complex injuries. Critical Issues: The extensive involvement of bone, soft tissues, nerves, and blood vessels of severe lower extremity trauma wounds presents a challenge for clinicians in both the acute care setting and during patient rehabilitation. If not properly managed, these injuries may be subject to a decline in limb function and may possibly result in limb loss. To reveal developing limb-threatening conditions, serial examinations should be performed. Future Directions: The majority of lower limb traumatic wound will benefit from the perioperative administration of an appropriate negative pressure wound therapy (NPWT)-based system, which can help to promote granulation tissue and remove wound exudate before definitive closure and/or reconstruction. NPWT should be included as an important adjunct in the surgical management of lower limb traumatic wounds.
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Affiliation(s)
- Evania Lok
- Department of Plastic and Reconstructive Surgery, Austin Health, Melbourne, Australia
| | - Timothy Oe
- Department of Plastic and Reconstructive Surgery, Austin Health, Melbourne, Australia
| | - Sally Ng
- Department of Plastic and Reconstructive Surgery, Austin Health, Melbourne, Australia
- Department of Surgery (Austin Precinct), University of Melbourne, Australia
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Rodríguez Lorenzo L, Salto EA, González Cañas E, Madrazo González Z, Espi MS, Giménez Gaibar A. Incisional Negative Pressure Wound Therapy After Revascularisation Surgery in Patients with Peripheral Arterial Disease: A Randomised Trial (PICO-Vasc Study). Eur J Vasc Endovasc Surg 2024; 68:238-244. [PMID: 38677468 DOI: 10.1016/j.ejvs.2024.04.031] [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: 07/25/2023] [Revised: 04/11/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE This study assessed the potential benefits of using incisional negative pressure wound therapy (iNPWT) for patients undergoing revascularisation due to peripheral arterial disease. METHODS A prospective randomised controlled trial was conducted to compare the inguinal application of iNPWT vs. standard surgical dressings. Patients were enrolled from February 2021 to November 2022. A total of 133 groin incisions were randomised (66 intervention group, 67 control group). The randomisation sequence was carried out by permuted blocks and allocation assigned by opening opaque envelopes once the revascularisation procedure had finished. Wound healing and complication rates were assessed at post-operative days 5, 14, and 30. Primary and secondary endpoints were: 30 day post-operative surgical site infection (SSI) and surgical site occurrence (SSO) rates, defined as a surgical wound complication other than a SSI. Post-operative SSI was defined according to the US Centers for Disease Control and Prevention criteria. SSO included: wound dehiscence, seroma or lymphocele, haematoma, and lymphorrhagia. The study was registered at ClinicalTrials.gov database (NCT04840576) and reported according to the CONSORT guidelines. RESULTS iNPWT did not modify the 30 day inguinal SSI and SSO rates (16.7% vs. 20.9% and 37.9% vs. 44.8%; p = .53, relative risk [RR] 0.999, 95% confidence interval [CI] 0.52 - 1.88 and p = .42, RR 1.29, 95% CI 0.89 - 1.86, respectively). It reduced the early SSO rate (19.7% vs. 35.8%; p = .044, RR 1.45, 95% CI 1.047 - 2.013) and post-operative seroma rate (4.6% vs. 19.4%; p = .014, RR 1.73, 95% CI 1.296 - 2.397). CONCLUSION There were no differences in SSI and SSO rates, although statistically significant reductions in early SSO rates and seroma were found in the intervention group.
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Affiliation(s)
| | - Eduardo Arrea Salto
- Vascular Surgery Department, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - Elena González Cañas
- Vascular Surgery Department, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - Zoilo Madrazo González
- General Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marta Santos Espi
- Vascular Surgery Department, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - Antonio Giménez Gaibar
- Vascular Surgery Department, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
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Shrestha O, Basukala S, Bhugai N, Bohara S, Thapa N, Paudel S, Lahera S, Sah SK, Ghimire S, Kunwor B, Chhetri ST. Comparison of negative pressure wound therapy against normal dressing after vascular surgeries for inguinal wounds: A systematic review and meta-analysis. Surg Open Sci 2024; 19:32-43. [PMID: 38585034 PMCID: PMC10995879 DOI: 10.1016/j.sopen.2024.03.018] [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: 12/18/2023] [Revised: 02/29/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024] Open
Abstract
Background Negative Pressure Wound Therapy (NPWT) is a therapeutic technique of applying sub-atmospheric pressure to a wound to reduce inflammation, manage exudate, and promote the formation of granulation tissue. It aims to optimise the natural physiological processes of wound healing for more effective recovery, and NPWT has emerged as a promising alternative to traditional dressings. Methods The protocol followed in the study was prospectively registered. Appropriate search terms and Boolean operators were used to search electronic databases for relevant articles. Screening of articles was performed, and data extraction was done. The effect measure was chosen according to the nature of the variable, and the effect model was chosen as per heterogeneity. Forest plot was used to give visual feedback. Results This study included 11 randomized controlled trials (13 publications) with a total of 1310 patients (1497 inguinal wounds). The NPWT group had lesser odds of developing surgical site infection (OR: 0.40; 95 % CI: 0.29-0.54; n = 1491; I2 = 20 %; p-value ≤0.00001) and lesser odds of needing surgical wound revision (OR: 0.48; 95 % CI: 0.26-0.91; n = 856; I2 = 0 %; p-value = 0.02) as compared to the normal dressing group. No significant difference was observed in duration of hospital stay, cost of care, wound healing time, or other complications. Conclusion NPWT application in inguinal wounds significantly reduces the surgical site infection and the need for wound revision in patients who have undergone vascular surgery.
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Affiliation(s)
- Oshan Shrestha
- Department of Surgery, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Sunil Basukala
- Department of Surgery, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Nabaraj Bhugai
- Department of Surgery, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Sujan Bohara
- Department of Cardiovascular Surgery, Shahid Gangalal National Heart Centre, Kathmandu 44600, Nepal
| | - Niranjan Thapa
- Department of Surgery, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Sushanta Paudel
- Department of Surgery, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Suvam Lahera
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Sumit Kumar Sah
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Sujata Ghimire
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Bishal Kunwor
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Suchit Thapa Chhetri
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
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Yin R, Gursky A, Falade I, Knox J, Gomez-Sanchez C, Soroudi D, Piper M, Hoffman W, Hansen SL. The Utility of Prevena Negative Pressure Wound Therapy on Groin Incisions for Critical Limb-Threatening Ischemia: A Single Institution Experience. Ann Plast Surg 2024; 92:S331-S335. [PMID: 38689414 DOI: 10.1097/sap.0000000000003802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Incisional negative pressure wound therapy (iNPWT) is an adjunctive treatment that uses constant negative pressure suction to facilitate healing. The utility of this treatment modality on vascular operations for critical limb-threatening ischemia (CLTI) has yet to be elucidated. This study compares the incidence of postoperative wound complications between the Prevena Incision Management System, a type of iNPWT, and standard wound dressings for vascular patients who also underwent plastic surgery closure of groin incisions for CLTI. METHOD We performed a retrospective cohort study of 40 patients with CLTI who underwent 53 open vascular surgeries with subsequent sartorius muscle flap closure. Patient demographics, intraoperative details, and wound complications were measured from 2015 to 2018 at the University of California San Francisco. Two cohorts were generated based on the modality of postoperative wound management and compared on wound healing outcomes. RESULTS Of the 53 groin incisions, 29 were managed with standard dressings, and 24 received iNPWT. Patient demographics, comorbidities, and operative characteristics were similar between the 2 groups. Patients who received iNPWT had a significantly lower rate of infection (8.33% vs 31.0%, P = 0.04) and dehiscence (0% vs 41.3%, P < 0.01). Furthermore, the iNPWT group had a significantly lower rate of reoperation (0% vs 17.2%, P = 0.03) for wound complications within 30 days compared with the control group and a moderately reduced rate of readmission (4.17% vs 20.7%, P = 0.08). CONCLUSIONS Rates of infection, reoperation, and dehiscence were significantly reduced in patients whose groin incisions were managed with iNPWT compared with standard wound care. Readmission rates were also decreased, but this difference was not statistically significant. Our results suggest that implementing iNPWT for the management of groin incisions, particularly in patients undergoing vascular operations for CLTI, may significantly improve clinical outcomes.
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Affiliation(s)
- Raymond Yin
- From the School of Medicine, University of California San Francisco, San Francisco, CA
| | - Alexis Gursky
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY
| | - Israel Falade
- From the School of Medicine, University of California San Francisco, San Francisco, CA
| | | | - Clara Gomez-Sanchez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Daniel Soroudi
- From the School of Medicine, University of California San Francisco, San Francisco, CA
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Tulimieri MT, Callas PW, D'Oria M, Bertges DJ. Effectiveness of Closed Incision Negative Pressure Wound Therapy for Infrainguinal Bypass in the Vascular Quality Initiative. Ann Vasc Surg 2024; 102:47-55. [PMID: 38307232 DOI: 10.1016/j.avsg.2023.11.050] [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: 10/02/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND To analyze surgical site infections (SSIs) after infrainguinal bypass for standard dressings versus closed incision negative pressure wound therapy (ciNPWT) in the Society for Vascular Surgery's Vascular Quality Initiative (VQI). METHODS We retrospectively analyzed SSI after infrainguinal bypass procedures in the VQI from December 2019 to December 2021 comparing ciNPWT and standard dressings. The primary outcome of any superficial or deep wound infection at 30 days was analyzed in a subset of procedures with 30-day follow-up data (cohort A, n = 1,575). Secondary outcomes including in-hospital SSI, return to the operating room (OR) for infection, and length of stay (LOS) were analyzed for all procedures (cohort B, n = 9,288). Outcomes were analyzed in propensity-matched cohorts. RESULTS Patients who received ciNPWT (n = 1,389) were more likely to be female (34% vs. 32%, P = 0.04) with a higher rate of smoking history (90% vs. 86%, P = 0.003), diabetes (54% vs. 50%, P = 0.007), obesity (34% vs. 26%, P < 0.001), prior peripheral vascular intervention (57% vs. 51%, P < 0.001), and to prosthetic conduit (55% vs. 48%, P < 0.001) compared to patients with standard dressings (n = 7,899). After propensity matching of cohort A (n = 1,256), the 30-day SSI rate was 4% (12/341) in the ciNPWT and 6% (54/896) in the standard dressing group (P = 0.07, 95% CI 0.03-1.06). In the propensity-matched in-hospital cohort B (n = 5,435), SSI was 3% (35/1,371) in the ciNPWT group and 2% (95/4,064) in the standard dressing group (P = 0.66). There was no difference in the rate of return to the OR for infection, 1% (36/4,064) vs. 1% (19/1,371) (P = 0.13) or LOS, 9.0 vs. 9.0 days (P = 0.86) for the standard versus ciNPWT groups. CONCLUSIONS In this analysis of the VQI registry, the use of ciNPWT after infrainguinal bypass did not result in a statistically significant decrease in 30-day SSI. We recommend that surgeons consider the use of ciNPWT as part of a bundled process of care for high risk rather than all patients, as it may reduce SSI after infrainguinal bypass.
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Affiliation(s)
| | - Peter W Callas
- Medical Biostatistics, University of Vermont, Burlington, VT
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Daniel J Bertges
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT.
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Rezk F, Åstrand H, Svensson-Björk R, Hasselmann J, Nyman J, Butt T, Bilos L, Pirouzram A, Acosta S. Multicenter parallel randomized trial evaluating incisional negative pressure wound therapy for the prevention of surgical site infection after lower extremity bypass. J Vasc Surg 2024; 79:931-940.e4. [PMID: 38042513 DOI: 10.1016/j.jvs.2023.11.043] [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: 10/16/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Incisional negative pressure wound therapy (iNPWT) applied over all incisions after lower extremity bypass in the prevention of surgical site infections (SSIs) is unclear. The primary and secondary aims of this study were to investigate if prophylactic iNPWT after the elective lower extremity bypass prevents SSI and other surgical wound complications. METHODS This was a multicenter, parallel, randomized controlled trial. Patients undergoing elective lower extremity bypass in 3 hospitals were randomized to either iNPWT or standard dressings. SSIs or other wound complications were assessed within the first 90 days by wound care professionals blinded to the randomized result. The validated Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, and Stay (ASEPSIS) score was used to objectively assess the wounds. ASEPSIS score ≥21 is defined as an SSI. Unilateral and bilateral groups were analyzed with the Fisher exact test and the McNemar test, respectively. RESULTS In the unilateral group (n = 100), the incidence of SSI in the iNPWT group was 34.9% (15/43), compared with 40.3% (23/57) in the control group, according to the ASEPSIS score (P = .678). In the bilateral group (n = 7), the SSI rate was 14.3% (1/7) in the iNPWT group compared with 14.3% (1/7) in the control group (P = 1.00). In the unilateral group, there was a higher wound dehiscence rate in the control group (43.9%) compared with the iNPWT group (23.3%) (P = .0366). No serious iNPWT-related adverse events were recorded. CONCLUSIONS There was no reduction of SSI rates in leg incisions with iNPWT compared with standard dressings in patients undergoing elective lower extremity bypass, whereas iNPWT reduced the incidence of wound dehiscence.
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Affiliation(s)
- Francis Rezk
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Surgery, Region Jönköping County, Jönköping, Sweden.
| | - Håkan Åstrand
- Department of Surgery, Region Jönköping County, Jönköping, Sweden
| | | | | | - Johan Nyman
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Talha Butt
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Linda Bilos
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Artai Pirouzram
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
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Sexton FC, Soh V, Yahya MS, Healy DA. Effectiveness of negative-pressure wound therapy to standard therapy in the prevention of complications after vascular surgery. Minerva Surg 2024; 79:48-58. [PMID: 37930087 DOI: 10.23736/s2724-5691.23.10096-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Wound complications are common after vascular surgery and many may be preventable. Negative pressure wound therapy (NPWT) dressings may be able to reduce wound complications relating to closed incisions following vascular surgery and several devices are currently available along with a large body of literature. This review article will describe the use of NPWT dressings in vascular surgery. We will summarize the currently available systems, the likely mechanism of action of NWPT, the published studies to date and we will give our recommendations regarding the priorities for future research on this topic.
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Affiliation(s)
- Fiona C Sexton
- Department of Dermatology, Beaumont Hospital, Dublin, Ireland
| | - Vernie Soh
- Department of Vascular Surgery, Belfast Health and Social Care Trust, Belfast, UK
| | - Muhammad S Yahya
- Department of Vascular Surgery, Belfast Health and Social Care Trust, Belfast, UK
| | - Donagh A Healy
- Department of Vascular Surgery, Belfast Health and Social Care Trust, Belfast, UK -
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Loanzon RS, Kim Y, Voit A, Cui CL, Southerland KW, Long CA, Williams ZF. Risk factors and consequences of wound complications following sartorius flap reconstruction. J Vasc Surg 2024; 79:323-329.e2. [PMID: 37802403 DOI: 10.1016/j.jvs.2023.09.033] [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: 07/06/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE Groin wound complications are common following vascular surgery and can lead to significant patient morbidity. Sartorius muscle flap coverage may help to prevent vascular graft infection in the setting of wound dehiscence or infection. However, risk factors and consequences of wound complications following sartorius flap reconstruction remain incompletely investigated. METHODS We retrospectively queried all patients who underwent sartorius flap reconstruction at a tertiary academic medical center. Data collected included patient demographics, medical comorbidities, surgical indication, index vascular procedure, and postoperative outcomes. The primary outcome was wound complication following sartorius flap procedure, which was defined as groin wound infection, dehiscence, or lymphocutaneous fistula. RESULTS From 2012 to 2022, a total of 113 patients underwent sartorius flap reconstruction. Of these, 66 (58.4%) were performed after the development of a prior groin complication, and 47 (41.6%) were prophylactic. A total of 88 patients (77.9%) had a prosthetic bypass graft adjacent to the flap. Twenty-nine patients (25.7%) suffered a wound complication following sartorius flap reconstruction, including 14 (12.4%) with wound dehiscence, 13 (11.5%) with wound infection, and two (1.8%) with lymphocutaneous fistula. Patients with wound complications had a higher body mass index (28.8 vs 26.4 kg/m2; P =.03) and more frequently active smokers (86.2% vs 66.7%; P = .04). Additionally, patients with wound complications had a higher unplanned 30-day hospital readmission rates (72.4% vs 15.5%; P < .001), reintervention rates (75.9% vs 8.3%; P < .001), and re-do flap reconstruction rates (13.8% vs 2.4%; P = .02). On multivariable analysis, higher body mass index was independently associated with post-flap wound complications (adjusted odds ratio [aOR], 1.01; 95% confidence interval [CI], 1.001-1.03; P = .037). Consequently, wound complications were associated with both surgical reintervention (aOR, 35.4; 95% CI, 9.9-126.3; P < .001) and unplanned hospital readmission (aOR, 17.8; 95% CI, 5.9-54.1; P < .001). CONCLUSIONS Sartorius flap reconstruction is an effective adjunct in facilitating wound healing of groin wounds. However, wound complications are common following sartorius flap reconstruction and may be associated with reintervention and unplanned hospital readmission. These data support the judicious and thoughtful utilization of sartorius flap procedures among high-risk patients.
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Affiliation(s)
- Roberto S Loanzon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Antanina Voit
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Kevin W Southerland
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC
| | - Zachary F Williams
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC.
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Meng X, Xie X, Liu Y, Huang C, Wang L, Fang X, Chen X. Effect of closed incision negative pressure wound treatment in vascular surgery: A meta-analysis. Int Wound J 2024; 21:e14392. [PMID: 37722871 PMCID: PMC10788581 DOI: 10.1111/iwj.14392] [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: 08/16/2023] [Revised: 08/27/2023] [Accepted: 08/31/2023] [Indexed: 09/20/2023] Open
Abstract
The meta-analysis aimed to assess and compare the effect of closed-incision negative pressure wound (NPW) treatment in vascular surgery. Using dichotomous or contentious random or fixed effect models, the outcomes of this meta-analysis were examined, and the odds Ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. Ten examinations from 2017 to 2022 were enrolled for the present meta-analysis, including 2082 personals with vascular surgery. Closed-incision NPW treatment had significantly lower infection rates (OR, 0.39; 95% CI, 0.30-0.51, p < 0.001), grade I infection rates (OR, 0.33; 95% CI, 0.20-0.52, p < 0.001), grade II infection rates (OR, 0.39; 95% CI, 0.21-0.71, p = 0.002), and grade III infection rates (OR, 0.31; 95% CI, 0.13-0.73, p = 0.007), and surgical re-intervention (OR, 0.49; 95% CI, 0.25-0.97, p = 0.04) compared to control in personal with vascular surgery. However, no significant differences were found between closed-incision NPW treatment and control in the 30-day mortality (OR, 0.54; 95% CI, 0.29-1.00, p = 0.05), antibiotic treatment (OR, 0.53; 95% CI, 0.24-1.19, p = 0.12), and length of hospital stay (MD, -0.02; 95% CI, -0.24-0.19, p = 0.83) in personnel with vascular surgery. The examined data revealed that closed-incision NPW treatment had significantly lower infection rates, grade I infection rates, grade II infection rates, and grade III infection rates, surgical re-intervention, however, there were no significant differences in 30-day mortality, antibiotic treatment, or length of hospital stay compared to control group with vascular surgery. Yet, attention should be paid to its values since some comparisons had a low number of selected studies.
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Affiliation(s)
- Xiaohu Meng
- Department of Vascular Surgery, Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineZhejiangChina
| | - Xupin Xie
- Department of Vascular Surgery, Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineZhejiangChina
| | - Yongchang Liu
- Department of Vascular Surgery, Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineZhejiangChina
| | - Changpin Huang
- Department of Vascular Surgery, Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineZhejiangChina
| | - Linjun Wang
- Department of Vascular Surgery, Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineZhejiangChina
| | - Xin Fang
- Department of Vascular Surgery, Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineZhejiangChina
| | - Xumei Chen
- Department of Wound Prosthesis, Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineZhejiangChina
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Barry IP, Turley LP, Gwilym BL, Bosanquet DC, Richards T. Impact of closed-incision negative pressure wound dressings on surgical site infection following groin incisions in vascular surgery; a single-centre experience. Vascular 2023; 31:1128-1133. [PMID: 35759405 DOI: 10.1177/17085381221111007] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Surgical site infection (SSI) is a common complication in vascular surgery, and is associated with increased patient morbidity, readmission and reintervention. The aim of this study was to assess the impact of closed-incision negative pressure wound therapy (CiNPWT) upon rate of SSI and length of hospital stay. METHODS This study was reported in line with the STROBE guidelines. We assessed the baseline incidence of SSI from a 12-month retrospective cohort and, following a change in practice intervention with CiNPWT, compared to a 6-month prospective cohort. The primary endpoint was incidence of SSI (according to CDC-NHSN guidelines) while secondary endpoints included length of hospital stay, readmission, reintervention and Days Alive and Out of Hospital (DAOH) to 90-days. RESULTS A total of 127 groin incisions were performed: 76 (65 patients) within the retrospective analysis and 51 (42 patients) within the prospective analysis (of whom 69% received CiNPWT). The primary endpoint of SSI was seen in 21.1% of the retrospective cohort and 9.8% of the prospective cohort (p = .099). Readmission was found to be significantly associated with the retrospective cohort (p = .016) while total admission (inclusive of re-admission) was significantly longer in those in the retrospective cohort (p = .013). DAOH-90 was 83 days (77-85) following introduction of the CiNPWT protocol as compared to the retrospective cohort (77 days (64-83), p = .04). CONCLUSION Introduction of CiNPWT was associated with a reduced length of hospital stay and improved DAOH-90. Further trials on CINPWT should include patient-centred outcomes and healthcare cost analysis.
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Affiliation(s)
- Ian Patrick Barry
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Luke P Turley
- Department of General Surgery, Sir Charles Gardiner Hospital, Nedlands, WA, Australia
| | - Brenig L Gwilym
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
| | - David C Bosanquet
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
| | - Toby Richards
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, WA, Australia
- University of Western Australia, Perth, WA, Australia
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12
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Graversen CB, Missel M, Jakobsen S. Patient experiences of closed-incision negative pressure therapy on groin incisions after discharge following peripheral arterial surgery: A qualitative study. JOURNAL OF VASCULAR NURSING 2023; 41:171-179. [PMID: 38072569 DOI: 10.1016/j.jvn.2023.06.006] [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: 03/02/2023] [Revised: 05/30/2023] [Accepted: 06/27/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Closed-incision negative pressure therapy may lower the risk of surgical site infections in patients after peripheral arterial surgery. AIM To explore patient experience of negative pressure therapy applied to groin incisions after discharge following peripheral arterial surgery, and to study their perception and attitudes toward the self-care information sheet they received at the vascular department. METHODS A qualitative study underpinned by Gadamer's philosophical hermeneutics was conducted semi-structured interviews by telephone around day seven after therapy ended with ten participants. All had received self-care information sheet at the discharge and been home with closed-incision negative pressure therapy for 3-6 days. The participants had open peripheral arterial surgery in the groin in form of femoral thromboendarterectomy. Kvale and Brinkmann's research guided the data collection, analysis, and interpretation. FINDINGS Patients found themselves coping with an unfamiliar situation after peripheral arterial surgery and the need arose to conceal the pump and tubing that were part of their incision treatment to protect their self-image. Their treatment became a constant companion, with some patients viewing the equipment as an extension of their bodies and others feeling its impact on activities of daily living. Patients perceived the treatment as providing reassurance, albeit with constraints, leading to feelings of manageability and an increasing sense of control. They viewed the written information as informative but with room for improvement. CONCLUSIONS Patient experiences of closed-incision negative pressure therapy on groin incisions after discharge following peripheral arterial surgery showed that they perceived it as safe and manageable. Patients need support, however, in learning how to hide the treatment and to expand their own involvement and improve self-care. The study found that patient involvement and individually tailored information is essential to facilitating a healthy transition from hospital to self-care at home and that written information must be improved further.
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Affiliation(s)
- Camilla Borch Graversen
- Department of Vascular Surgery, Copenhagen University Hospital - Rigshospitalet, Inge Lehmanns vej 5, 2100 Copenhagen, Denmark
| | - Malene Missel
- Department of Cardiothoracic Surgery, Copenhagen University Hospital - Rigshospitalet, Inge Lehmanns vej 5, 2100 Copenhagen, Denmark
| | - Sally Jakobsen
- Department of Vascular Surgery, Copenhagen University Hospital - Rigshospitalet, Inge Lehmanns vej 5, 2100 Copenhagen, Denmark.
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Apaydin EA, Woo K, Rollison J, Baxi S, Motala A, Hempel S. Enhanced recovery after surgery (ERAS) for vascular surgery: an evidence map and scoping review. Syst Rev 2023; 12:162. [PMID: 37710325 PMCID: PMC10500918 DOI: 10.1186/s13643-023-02324-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/15/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) interventions aim to improve patient outcomes. Vascular surgery patients have unique requirements and it is unclear which ERAS interventions are supported by an evidence base. METHODS We conducted a scoping review to identify ERAS randomized controlled trials (RCTs) published in the biomedical or nursing literature. We assessed interventions for applicability to vascular surgery and differentiated interventions given at preadmission, preoperative, intraoperative, and postoperative surgery stages. We documented the research in an evidence map. RESULTS We identified 76 relevant RCTs. Interventions were mostly administered in preoperative (23 RCTs; 30%) or intraoperative surgery stages (35 RCTs; 46%). The majority of studies reported mortality outcomes (44 RCTs; 58%), but hospital (27 RCTs; 35%) and intensive care unit (9 RCTs; 12%) length of stay outcomes were less consistently described. CONCLUSION The ERAS evidence base is growing but contains gaps. Research on preadmission interventions and more consistent reporting of key outcomes is needed.
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Affiliation(s)
- Eric A Apaydin
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- RAND Health Care, RAND Corporation, Santa Monica, CA, USA.
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Karen Woo
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Sangita Baxi
- RAND Health Care, RAND Corporation, Santa Monica, CA, USA
| | - Aneesa Motala
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- RAND Health Care, RAND Corporation, Santa Monica, CA, USA
| | - Susanne Hempel
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- RAND Health Care, RAND Corporation, Santa Monica, CA, USA
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Hong J, Xie L, Fan L, Huang H. The wound adjuncts effect of closed incision negative pressure wound therapy on stopping groin surgical site wound infection in arterial surgery: A meta-analysis. Int Wound J 2023; 20:2726-2734. [PMID: 36977282 PMCID: PMC10410315 DOI: 10.1111/iwj.14146] [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: 02/13/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/30/2023] Open
Abstract
A meta-analysis study was conducted to assess the influence of the wound adjuncts therapy of closed incision negative pressure wound therapy (ciNPWT) on stopping groin site wound infection (SWSI) in arterial surgery. A comprehensive literature examination till January 2023 was implemented and 2186 linked studies were appraised. The picked studies contained 2133 subjects with groin surgical wounds of arterial surgery in the picked studies' baseline, 1043 of them were using ciNPWT, and 1090 were using standard care. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of the wound adjuncts therapy of ciNPWT on stopping groin SWSI in arterial surgery by the dichotomous and continuous styles and a fixed or random model. The ciNPWT had a significantly lower SWSI (OR, 0.42; 95% CI, 0.33-0.55, P < .001), superficial SWSI (OR, 0.46; 95% CI, 0.33-0.66, P < .001), and deep SWSI (OR, 0.39; 95% CI, 0.25-0.63, P < .001) compared with the standard care in groin surgical wound of arterial surgery. The ciNPWT had a significantly, lower SWSI, superficial SWSI, and deep SWSI compared with the standard care in groin surgical wounds of arterial surgery. Although precautions should be taken when commerce with the consequences because some of the picked studies for this meta-analysis was with low sample sizes.
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Affiliation(s)
- Jin Hong
- Department of Vascular Hernia SurgeryAffiliated Hospital of Shaoxing UniversityZhejiangChina
| | - Licheng Xie
- Department of Vascular Hernia SurgeryAffiliated Hospital of Shaoxing UniversityZhejiangChina
| | - Libin Fan
- Department of Vascular Hernia SurgeryAffiliated Hospital of Shaoxing UniversityZhejiangChina
| | - Haiyan Huang
- Department of Vascular Hernia SurgeryAffiliated Hospital of Shaoxing UniversityZhejiangChina
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Groenen H, Jalalzadeh H, Buis DR, Dreissen YE, Goosen JH, Griekspoor M, Harmsen WJ, IJpma FF, van der Laan MJ, Schaad RR, Segers P, van der Zwet WC, de Jonge SW, Orsini RG, Eskes AM, Wolfhagen N, Boermeester MA. Incisional negative pressure wound therapy for the prevention of surgical site infection: an up-to-date meta-analysis and trial sequential analysis. EClinicalMedicine 2023; 62:102105. [PMID: 37538540 PMCID: PMC10393772 DOI: 10.1016/j.eclinm.2023.102105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/19/2023] [Accepted: 06/30/2023] [Indexed: 08/05/2023] Open
Abstract
Background The evidence on prophylactic use of negative pressure wound therapy on primary closed incisional wounds (iNPWT) for the prevention of surgical site infections (SSI) is confusing and ambiguous. Implementation in daily practice is impaired by inconsistent recommendations in current international guidelines and published meta-analyses. More recently, multiple new randomised controlled trials (RCTs) have been published. We aimed to provide an overview of all meta-analyses and their characteristics; to conduct a new and up-to-date systematic review and meta-analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment; and to explore the additive value of new RCTs with a trial sequential analysis (TSA). Methods PubMed, Embase and Cochrane CENTRAL databases were searched from database inception to October 24, 2022. We identified existing meta-analyses covering all surgical specialties and RCTs studying the effect of iNPWT compared with standard dressings in all types of surgery on the incidence of SSI, wound dehiscence, reoperation, seroma, hematoma, mortality, readmission rate, skin blistering, skin necrosis, pain, and adverse effects of the intervention. We calculated relative risks (RR) with corresponding 95% confidence intervals (CI) using a Mantel-Haenszel random-effects model. We assessed publication bias with a comparison-adjusted funnel plot. TSA was used to assess the risk of random error. The certainty of evidence was evaluated using the Cochrane Risk of Bias-2 (RoB2) tool and GRADE approach. This study is registered with PROSPERO, CRD42022312995. Findings We identified eight previously published general meta-analyses investigating iNPWT and compared their results to present meta-analysis. For the updated systematic review, 57 RCTs with 13,744 patients were included in the quantitative analysis for SSI, yielding a RR of 0.67 (95% CI: 0.59-0.76, I2 = 21%) for iNPWT compared with standard dressing. Certainty of evidence was high. Compared with previous meta-analyses, the RR stabilised, and the confidence interval narrowed. In the TSA, the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, confirming the robustness of the summary effect estimate from the meta-analysis. Interpretation In this up-to-date meta-analysis, GRADE assessment shows high-certainty evidence that iNPWT is effective in reducing SSI, and uncertainty is less than in previous meta-analyses. TSA indicated that further trials are unlikely to change the effect estimate for the outcome SSI; therefore, if future research is to be conducted on iNPWT, it is crucial to consider what the findings will contribute to the existing robust evidence. Funding Dutch Association for Quality Funds Medical Specialists.
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Affiliation(s)
- Hannah Groenen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
| | - Hasti Jalalzadeh
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
| | - Dennis R. Buis
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Yasmine E.M. Dreissen
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Neurosurgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Jon H.M. Goosen
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Orthopedic Surgery, Sint Maartenskliniek, Ubbergen, Netherlands
| | - Mitchel Griekspoor
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Dutch Association of Medical Specialists, Utrecht, Netherlands
| | - Wouter J. Harmsen
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Dutch Association of Medical Specialists, Utrecht, Netherlands
| | - Frank F.A. IJpma
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Division of Trauma Surgery, Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Maarten J. van der Laan
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Roald R. Schaad
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Anesthesiology, Leiden University Medical Centre, Leiden, Netherlands
- Dutch Association of Anesthesiology (NVA), Netherlands
| | - Patrique Segers
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Wil C. van der Zwet
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
- Department of Medical Microbiology, Infectious Diseases and Infection Prevention, Maastricht University Medical Center, Maastricht, Netherlands
| | - Stijn W. de Jonge
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Ricardo G. Orsini
- Department of Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Anne M. Eskes
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Faculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
- Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, Gold Coast, Australia
| | - Niels Wolfhagen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, Netherlands
- Dutch National Guideline Group for Prevention of Postoperative Surgical Site Infections, Netherlands
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Zhu Y, Dai L, Luo B, Zhang L. Meta-analysis of prophylactic negative pressure wound therapy for surgical site infections (SSI) in caesarean section surgery. Wideochir Inne Tech Maloinwazyjne 2023; 18:224-234. [PMID: 37680737 PMCID: PMC10481433 DOI: 10.5114/wiitm.2023.125913] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/06/2023] [Indexed: 09/09/2023] Open
Abstract
Introduction Negative pressure wound therapy (NPWT) has been used in reducing the incidence of surgical site infections (SSIs) and wound complications across various surgical categories. SSIs are a common post-surgical complication following caesarean section (CS) births, making it necessary to use prophylactic interventions to reduce SSI and wound complication incidences. Aim To conduct an updated meta-analysis on randomized controlled trials (RCTs) comparing SSI incidence and wound complications in women undergoing C-sections receiving NPWT or standard dressings after wound closure. Material and methods A systematic literature review was conducted using MEDLINE and CENTRAL databases, and clinical trial registries for RCTs that involved NPWT versus standard dressings in participants undergoing C-section procedures. The primary outcome was surgical site infection (SSI) and other wound complications (haematoma, dehiscence, seroma. Results A total of 11 RCTs were included in the meta-analysis with information from 5,693 patients. A reduction in overall SSI incidence (RR = 0.79, 95% CI: 0.66-0.95, p = 0.01, I2 = 0%) and wound complication rate (RR = 0.86, 0.75 to 0.98, p = 0.02, I2 = 5%) was found with all studies pooled together. Subgroup analyses showed that NPWT did not significantly reduce SSI incidence when stratified by the type of C-section (emergency/elective) whereas the type of NPWT device had a differential effect on SSI reduction, with PICO NPWT systems showing a beneficial effect (RR = 0.72, 0.58 to 0.91, p = 0.006, I2 = 0%) in comparison to the PREVENA closed-incision device (RR = 0.94, 0.68 to 1.29, p = 0.73, I2 = 0%). Conclusions Prophylactic NPWT is useful in reducing the incidence of SSIs in women undergoing C-sections based on synthesis of results from RCTs in obese women (BMI > 30 kg/m2).
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Affiliation(s)
- Yi Zhu
- Department of Burn Plastic Surgery, Taizhou School of Clinical Medicine, Nanjing Medical University. Taizhou City, Jiangsu Province, China
| | - Lingyan Dai
- Ambulatory Surgery Center, Wuhan Children’s Hospital (Wuhan Maternal and Children’s Healthcare Center), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Binjie Luo
- Department of Burn Plastic Surgery, Taizhou School of Clinical Medicine, Nanjing Medical University. Taizhou City, Jiangsu Province, China
| | - Lin Zhang
- Department of Emergency, the First People’s Hospital of Jiangxia District, Wuhan city, Hubei Province, China
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Cooper HJ, Singh DP, Gabriel A, Mantyh C, Silverman R, Griffin L. Closed Incision Negative Pressure Therapy versus Standard of Care in Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4722. [PMID: 36936465 PMCID: PMC10019176 DOI: 10.1097/gox.0000000000004722] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/26/2022] [Indexed: 03/18/2023]
Abstract
Closed incision negative pressure therapy (ciNPT) has been utilized to help manage closed incisions across many surgical specialties. This systematic review and meta-analysis evaluated the effect of ciNPT on postsurgical and health economic outcomes. Methods A systematic literature search using PubMed, EMBASE, and QUOSA was performed for publications written in English, comparing ciNPT to standard-of-care dressings between January 2005 and August 2021. Study participant characteristics, surgical procedure, dressings used, treatment duration, postsurgical outcomes, and follow-up data were extracted. Meta-analyses were performed using random-effects models. Risk ratios summarized dichotomous outcomes. Difference in means or standardized difference in means was used to assess continuous variables reported on the same scale or outcomes reported on different scales/measurement instruments. Results The literature search identified 84 studies for analysis. Significant reductions in surgical site complication (SSC), surgical site infection (SSI), superficial SSI, deep SSI, seroma, dehiscence, skin necrosis, and prolonged incisional drainage were associated with ciNPT use (P < 0.05). Reduced readmissions and reoperations were significant in favor of ciNPT (P < 0.05). Patients receiving ciNPT had a 0.9-day shorter hospital stay (P < 0.0001). Differences in postoperative pain scores and reported amounts of opioid usage were significant in favor of ciNPT use (P < 0.05). Scar evaluations demonstrated improved scarring in favor of ciNPT (P < 0.05). Discussion For these meta-analyses, ciNPT use was associated with statistically significant reduction in SSCs, SSIs, seroma, dehiscence, and skin necrosis incidence. Reduced readmissions, reoperation, length of hospital stay, decreased pain scores and opioid use, and improved scarring were also observed in ciNPT patients.
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Affiliation(s)
- H. John Cooper
- From the Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, N.Y
| | - Devinder P. Singh
- Department of Plastic Surgery, University of Miami Health System and Miller School of Medicine, Miami, Fla
| | | | | | - Ronald Silverman
- Department of Plastic Surgery, University of Maryland School of Medicine, Baltimore, Md
- Medical Solutions Division, 3M, St Paul, Minn
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Systematic Review of Groin Incision Surgical Site Infection Preventative Measures in Vascular Surgery. J Vasc Surg 2023; 77:1835-1850.e2. [PMID: 36804782 DOI: 10.1016/j.jvs.2023.01.209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/09/2023] [Accepted: 01/30/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Groin surgical site infections (SSIs) after open revascularization can lead to devastating consequences in patients. As a result, prevention has been crucial in minimizing the rate of SSIs. This review aims to evaluate the current body of literature regarding prevention techniques including: prophylactic flaps, incision technique, topical antibiotic use, closed-incision negative pressure wound therapy and adhesive drapes METHODS: This review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic review was conducted utilizing the Google Scholar ©, PubMed, and Cochrane Review databases regarding the five prevention topics. The authors identified 1,371 potential studies with 33 studies selected and analyzed after systematic review regarding the five preventative topics. RESULTS The primary outcome of interest was how the rate of SSI was affected with each preventative technique. As a result, the recommendations are: - We suggest prophylactic flaps be considered in high-risk surgical patients undergoing open arterial exposure of the groin. [Grade 2C] - We suggest consideration of transverse incisions for open arterial exposure of the groin as a means of SSI prevention. [Grade 2C] - Given the lack of data regarding topical antibiotics no recommendation can be made regarding its use. - We suggest closed-incision negative pressure wound therapy be utilized in groin surgical incisions at high risk for SSI. [Grade 2B] - Given the paucity of data regarding adhesive drapes, such as Ioban ®, no recommendation can be made regarding its use. CONCLUSIONS This review highlights the effects of various preventative techniques and their potential benefit in prevention of SSI in the groin. However, there is a glaring deficit in the available data emphasizing the need for additional robust studies to better delineate their effectiveness and implementation into surgical practice. While the use of endovascular techniques continues to increase thus limiting the amount of open arterial procedures and the potential for further studies to be conducted. In order to provide the high-quality studies needed to better evaluate these prevention techniques, large multi-institutional collaboration will likely be necessary to provide the appropriate number of patients to evaluate true effectiveness.
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Na S, Mazzaferro N, Xia W, Greenberg P, Beckerman W. Risk Factors for Surgical Site Infections After Lower Extremity Open Revascularization. Ann Vasc Surg 2023; 89:251-260. [PMID: 36404450 DOI: 10.1016/j.avsg.2022.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/01/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a serious complication of lower extremity open revascularization and is associated with increased morbidity, increased healthcare costs, and decreased postoperative quality of life. The objective of this study was to determine factors associated with an increased risk of developing postoperative SSI in patients undergoing lower extremity revascularization. Associations between SSI and postoperative complications were also identified. METHODS Patients who underwent lower extremity open revascularization from 2014-2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). A multivariate logistic regression analysis was used to determine risk factors associated with SSIs within 30 days of the operation and postoperative complications. Odds ratios (ORs) were adjusted for demographics, preoperative comorbidities, procedure type, and intraoperative variables. RESULTS Ten thousand nine hundred ten patients who underwent lower extremity open revascularization were identified, with a mean age of 67.24 years and of whom 7,318 (67%) were male. Of the 10,910 patients, 922 (8.45%) had an SSI within 30 days of the operation. Risk factors associated with developing SSI included body mass index 25-29.9 (OR, 1.34; 95% confidence interval [CI], 1.08-1.67), body mass index ≥ 30 (OR, 2.12; 95% CI, 1.71-2.62), history of severe chronic obstructive pulmonary disease (OR, 1.47; 95% CI, 1.18-1.84), preprocedural beta-blocker use (OR, 1.25; CI 95%, 1.05-1.49), procedure time > 214 minutes (OR, 1.44; 95% CI, 1.22-1.70), and creatinine > 1.2 (OR 1.03; 95% CI, 0.87-1.21). One factor associated with a decreased risk of developing SSI was male gender (OR, 0.71; 95% CI, 0.60-0.84). Patients who developed an SSI were more likely to have adverse outcomes such as myocardial infarction/stroke, major amputation, bleeding requiring transfusion or secondary procedure, or require a reintervention in the treated segment. CONCLUSIONS There are various patient-related and operative factors that increase the likelihood of developing an SSI after lower extremity open revascularization. These findings indicate that addressing modifiable perioperative SSI risk factors may be beneficial in decreasing rates of SSI and improving postoperative outcomes.
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Affiliation(s)
- Sungshin Na
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ.
| | - Natale Mazzaferro
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ
| | - Weiyi Xia
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ
| | - Patricia Greenberg
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ
| | - William Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
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Nicolazzo D, Rusin E, Varese A, Galassi M. Negative Pressure Wound Therapy and Traditional Dressing: An Italian Health Technology Assessment Evaluation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20032400. [PMID: 36767767 PMCID: PMC9915998 DOI: 10.3390/ijerph20032400] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/13/2023] [Accepted: 01/21/2023] [Indexed: 05/27/2023]
Abstract
This evaluation shows the main advantages related to the introduction of negative pressure wound therapy (NPWT) in Italian clinical practice for the management of incisions in vascular surgery in patients suffering from peripheral arterial disease (PAD) and at risk of postoperative complications, compared to treatment with traditional dressings. A health technology assessment (HTA) activity was conducted assuming the hospital perspective, within a 12-month time horizon. The nine EUnetHTA Core Model dimensions were deeply explored, using scientific evidence on the topic, real-life data, and healthcare professionals' perceptions. The evaluation shows that the use of NPWT has had a positive impact in terms of higher clinical effectiveness and safety profile. The process mapping highlights how NPWT allows a reduction of 2.5 hospitalization days compared with standard dressing, with the consequent benefits considering economic, organizational, and social aspects. A significant economic saving per patient emerged, with an overall optimization of the patient's clinical pathway, impacting positively on the hospital's capacity. The budget impact analysis shows that the higher number of patients treated with NPWT, the higher the economic advantages. Furthermore, assuming the patient's perspective, it would generate an overall reduction in social costs of 28%. In conclusion, the results of this study provide helpful evidence-based information to policymakers through examinations of the relative values of intervention, thus supporting the overall hospital and institutional decision-making process to define appropriate areas of investments, leading to the achievement of not only higher clinical outcomes, but also important social, economic, and organizational advantages.
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Affiliation(s)
| | | | - Alessandra Varese
- A.O.U Città dalla Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Margherita Galassi
- Istituto Nazionale per lo Studio e la Cura dei Tumori, 20133 Milan, Italy
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McMillan H, Vo UG, Moss JL, Barry IP, Bosanquet DC, Richards T. Controlling the controls: what is negative pressure wound therapy compared to in clinical trials? Colorectal Dis 2022; 25:794-805. [PMID: 36579358 DOI: 10.1111/codi.16465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 12/30/2022]
Abstract
AIM Surgical site infections (SSIs) are common following colorectal operations. Clinical trials suggest that closed incision negative pressure wound therapy (ciNPWT) may reduce SSIs compared to a 'standard of care' group. However, wound management in the standard of care group may vary. The aim of this review was to assess the control arms in trials of ciNPWT for potential confounding variables that could influence the rates of SSI and therefore the trial outcomes. METHODS A mapping review of the PubMed database was undertaken in the English language for randomized controlled trials that assessed, in closed surgical wounds, the use of ciNPWT compared to standard of care with SSI as an outcome. Data regarding wound care to assess potential confounding factors that may influence SSI rates were compared between the ciNPWT and standard of care groups. Included were the method of wound closure, control dressing type, frequency of dressing changes and postoperative wound care (washing). RESULTS Twenty-seven trials were included in the mapping review. There was heterogeneity in ciNPWT duration. There was little control in the comparator standard of care groups with a variety of wound closure techniques and different control dressings used. Overall standard of care dressings were changed more frequently than the ciNPWT dressing and there was no control over wound care or washing. No standard for 'standard of care' was apparent. CONCLUSION In randomized trials assessing the intervention of ciNPWT compared to standard of care there was considerable heterogeneity in the comparator groups and no standard of care was apparent. Heterogeneity in dressing protocols for standard of care groups could introduce potential confounders impacting SSI rates. There is a need to standardize care in ciNPWT trials to assess potential meaningful differences in SSI prevention.
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Affiliation(s)
- Hayley McMillan
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, Western Australia, Australia
| | - Uyen G Vo
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, Western Australia, Australia.,Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jana-Lee Moss
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, Western Australia, Australia.,Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Ian P Barry
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - David C Bosanquet
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, UK
| | - Toby Richards
- Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, Western Australia, Australia
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Pagani NR, Moverman MA, Puzzitiello RN, Menendez ME, Kavolus JJ. The Cost-Effectiveness of Closed Incisional Negative Pressure Wound Therapy for Infection Prevention after Revision Total Knee Arthroplasty. J Knee Surg 2022; 35:1301-1305. [PMID: 33511588 DOI: 10.1055/s-0041-1724137] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent investigations have shown that closed incisional negative pressure wound therapy (ciNPWT) decreases the rate of postoperative wound complications following revision total knee arthroplasty (TKA). In this study, we used a break-even analysis to determine whether ciNPWT is a cost-effective measure for reducing prosthetic joint infection (PJI) after revision TKA. The cost of ciNPWT, cost of treatment for PJI, and baseline infection rates following revision TKA were collected from institutional data and the literature. The absolute risk reduction (ARR) in infection rate necessary for cost-effectiveness was calculated using break-even analysis. Using our institutional cost of ciNPWT ($600), this intervention would be cost-effective if the initial infection rate of revision TKA (9.0%) has an ARR of 0.92%. The ARR needed for cost-effectiveness remained constant across a wide range of initial infection rates and declined as treatment costs increased. The use of ciNPWT for infection prevention following revision TKA is cost-effective at both high and low initial infection rates, across a broad range of treatment costs, and at inflated product expenses.
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Affiliation(s)
- Nicholas R Pagani
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Michael A Moverman
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | | | - Mariano E Menendez
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Joseph J Kavolus
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
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How Can Negative Pressure Wound Therapy Pay for Itself?-Reducing Complications Is Important. J Orthop Trauma 2022; 36:S31-S35. [PMID: 35994307 DOI: 10.1097/bot.0000000000002427] [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: 06/06/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Orthopaedic trauma demonstrates a relatively high rate of surgical site infections (SSI) as compared with other surgical specialties. SSIs provide significant clinical challenges and create significant health care costs. Incisional negative pressure wound therapy (iNPWT) has reduced the risk of SSI in orthopaedic surgery and other surgical specialties. PURPOSE The purpose of this study is to investigate potential cost savings with the use of iNPWT (3M Prevena Therapy, 3M, St. Paul, MN) in high-risk orthopaedic trauma patients with closed OTA/AO 41C and 43C fractures. METHODS This is a retrospective cohort study performed at a single, level-1 trauma center using data from a lower extremity fracture registry. Using the results from the registry and baseline infection rates derived from the literature, a health economic model was developed to evaluate the potential cost savings. RESULTS A total of 79 patients included in the registry underwent open reduction and internal fixation of OTA/AO 41C and 43C fractures. A total of 10.1% developed a SSI. For those who received iNPWT, the rate of SSI was 7.4%. A health economic model suggests that the use of iNPWT may reduce the costs per patient by approximately $1381 to $4436 per patient. CONCLUSIONS This health economic assessment and model suggests that judicious use of iNPWT may reduce health care costs in patients undergoing open reduction and internal fixation of OTA/AO 41C and 43C fractures. LEVEL OF EVIDENCE Economic Level IV.
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Xie R, Li B, Wen F. Effect of prophylactic negative pressure treatment for post-surgery groin wounds management in vascular surgery: A meta-analysis. Int Wound J 2022; 20:269-277. [PMID: 35818744 PMCID: PMC9885472 DOI: 10.1111/iwj.13870] [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: 05/26/2022] [Revised: 05/29/2022] [Accepted: 06/04/2022] [Indexed: 02/03/2023] Open
Abstract
We performed a meta-analysis to evaluate the effect of prophylactic negative pressure treatment for post-surgery groin wounds management in vascular surgery. A systematic literature search up to April 2022 was performed and 1537 total number of groin vascular surgery incisions at the baseline of the studies; 729 of them were using the prophylactic negative pressure treatment, and 808 were using control. Odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated to assess the effect of prophylactic negative pressure treatment for post-surgery groin wounds management in vascular surgery using the dichotomous, and contentious methods with a random or fixed-effect model. The prophylactic negative pressure treatment subjects had a significantly lower surgical site wound infection (OR, 0.26; 95% CI, 0.16-0.42, P < .001) in subjects after vascular surgery compared with control. However, prophylactic negative pressure treatment did not show any significant difference in revision surgery (OR, 0.73; 95% CI, 0.52-1.00, P = .05), readmission (OR, 0.93; 95% CI, 0.66-1.32, P = .69), mortality in hospital (OR, 0.54; 95% CI, 0.29-1.01, P = .05), and length of hospital stay (MD, -0.24; 95% CI, -0.91-0.44, P = .49) compared with control in subjects after vascular surgery. The prophylactic negative pressure treatment subjects had a significantly lower surgical site wound infection and no significant difference in revision surgery, readmission, mortality in hospital, and length of hospital stay compared with control in subjects after vascular surgery. The analysis of outcomes should be with caution because of the low sample size of 2 out of 10 studies in the meta-analysis and a low number of studies in certain comparisons.
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Affiliation(s)
- Rui Xie
- Department of Thyroid Breast Vascular SurgeryBanan Hospital of Chongqing Medical UniversityChongqingChina
| | - Bo Li
- Department of Thyroid Breast Vascular SurgeryBanan Hospital of Chongqing Medical UniversityChongqingChina
| | - Fei Wen
- Department of Thyroid Breast Vascular SurgeryBanan Hospital of Chongqing Medical UniversityChongqingChina
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Norman G, Shi C, Goh EL, Murphy EM, Reid A, Chiverton L, Stankiewicz M, Dumville JC. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 2022; 4:CD009261. [PMID: 35471497 PMCID: PMC9040710 DOI: 10.1002/14651858.cd009261.pub7] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain. OBJECTIVES To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure. SEARCH METHODS In January 2021, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting. SELECTION CRITERIA We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane risk of bias tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. Our primary outcomes were SSI, mortality, and wound dehiscence. MAIN RESULTS In this fourth update, we added 18 new randomised controlled trials (RCTs) and one new economic study, resulting in a total of 62 RCTs (13,340 included participants) and six economic studies. Studies evaluated NPWT in a wide range of surgeries, including orthopaedic, obstetric, vascular and general procedures. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Eleven studies (6384 participants) which reported mortality were pooled. There is low-certainty evidence showing there may be a reduced risk of death after surgery for people treated with NPWT (0.84%) compared with standard dressings (1.17%) but there is uncertainty around this as confidence intervals include risk of benefits and harm; risk ratio (RR) 0.78 (95% CI 0.47 to 1.30; I2 = 0%). Fifty-four studies reported SSI; 44 studies (11,403 participants) were pooled. There is moderate-certainty evidence that NPWT probably results in fewer SSIs (8.7% of participants) than treatment with standard dressings (11.75%) after surgery; RR 0.73 (95% CI 0.63 to 0.85; I2 = 29%). Thirty studies reported wound dehiscence; 23 studies (8724 participants) were pooled. There is moderate-certainty evidence that there is probably little or no difference in dehiscence between people treated with NPWT (6.62%) and those treated with standard dressing (6.97%), although there is imprecision around the estimate that includes risk of benefit and harms; RR 0.97 (95% CI 0.82 to 1.16; I2 = 4%). Evidence was downgraded for imprecision, risk of bias, or a combination of these. Secondary outcomes There is low-certainty evidence for the outcomes of reoperation and seroma; in each case, confidence intervals included both benefit and harm. There may be a reduced risk of reoperation favouring the standard dressing arm, but this was imprecise: RR 1.13 (95% CI 0.91 to 1.41; I2 = 2%; 18 trials; 6272 participants). There may be a reduced risk of seroma for people treated with NPWT but this is imprecise: the RR was 0.82 (95% CI 0.65 to 1.05; I2 = 0%; 15 trials; 5436 participants). For skin blisters, there is low-certainty evidence that people treated with NPWT may be more likely to develop skin blisters compared with those treated with standard dressing (RR 3.55; 95% CI 1.43 to 8.77; I2 = 74%; 11 trials; 5015 participants). The effect of NPWT on haematoma is uncertain (RR 0.79; 95 % CI 0.48 to 1.30; I2 = 0%; 17 trials; 5909 participants; very low-certainty evidence). There is low-certainty evidence of little to no difference in reported pain between groups. Pain was measured in different ways and most studies could not be pooled; this GRADE assessment is based on all fourteen trials reporting pain; the pooled RR for the proportion of participants who experienced pain was 1.52 (95% CI 0.20, 11.31; I2 = 34%; two studies; 632 participants). Cost-effectiveness Six economic studies, based wholly or partially on trials in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in five indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty; coronary artery bypass grafts; and vascular surgery with inguinal incisions. They calculated quality-adjusted life-years or an equivalent, and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the evidence certainty varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed. AUTHORS' CONCLUSIONS People with primary closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSIs than people treated with standard dressings but there is probably no difference in wound dehiscence (moderate-certainty evidence). There may be a reduced risk of death after surgery for people treated with NPWT compared with standard dressings but there is uncertainty around this as confidence intervals include risk of benefit and harm (low-certainty evidence). People treated with NPWT may experience more instances of skin blistering compared with standard dressing treatment (low-certainty evidence). There are no clear differences in other secondary outcomes where most evidence is low or very low-certainty. Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - En Lin Goh
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Elizabeth Ma Murphy
- Ward 64, St. Mary's Hospital, Manchester Foundation NHS Trust, Manchester, UK
| | - Adam Reid
- School of Biological Sciences, Faculty of Biology, Medicine & Health, Manchester, UK
| | - Laura Chiverton
- NIHR Clinical Research Facility, Great Ormond Street Hospital, London, UK
| | - Monica Stankiewicz
- Chermside Community Health Centre, Community and Oral Health Directorate, Brisbane, Australia
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Bloom JA, Tian T, Homsy C, Singhal D, Salehi P, Chatterjee A. A Cost-Utility Analysis of the Use of Closed-Incision Negative Pressure System in Vascular Surgery Groin Incisions. Am Surg 2022:31348221087395. [PMID: 35392664 DOI: 10.1177/00031348221087395] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Closed-incision negative pressure therapy (CINPT) with the Prevena system has been used and clinically evaluated in high-risk groin incisions to reduce the risk of postoperative complications. We performed a cost-effectiveness analysis evaluating CINPT in femoral-popliteal bypass with prosthetic graft. METHODS A literature review looking at prospective randomized trials determined the probabilities and outcomes for femoral-popliteal bypass with and without CINPT. Reported utility scores were used to estimate the quality adjusted life years (QALYs) associated with a successful procedure and postoperative complications. Medicare current procedure terminology and diagnosis-related group codes were used to assess the costs for a successful surgery and associated complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-effectiveness ratio (ICER) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the results, and to accommodate for the uncertainty in the literature. RESULTS Femoral-popliteal bypass with CINPT is less costly ($40,138 vs $41,774) and more effective (6.14 vs 6.13) compared to without CINPT. This resulted in a negative ICER of -234,764.03, which favored CINPT, indicating a dominant strategy. In one-way sensitivity analysis, surgery without CINPT was more cost-effective if the probability of successful surgery falls below 84.9% or if the cost of CINPT exceeds $3139. Monte Carlo analysis showed a confidence of 99.07% that CINPT is more cost-effective. CONCLUSIONS Despite the added device cost of CINPT, it is cost-effective in vascular surgical operations using groin incisions.
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Affiliation(s)
- Joshua A Bloom
- Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Tina Tian
- Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Christopher Homsy
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Payam Salehi
- Division of Vascular Surgery, Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Abhishek Chatterjee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
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Livingston KA, Koh E, Adlouni M, Hassan A, Gan W, Yijun zhang M, Falohun T, Peden EK, Rahimi M. Vasculink iPhone Application and Risk Prediction Model for Groin Complication in Vascular Surgery. Ann Vasc Surg 2022; 85:237-245. [DOI: 10.1016/j.avsg.2022.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/27/2022] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
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Boll G, Callas P, Bertges DJ. Meta-analysis of prophylactic closed-incision negative pressure wound therapy for vascular surgery groin wounds. J Vasc Surg 2022; 75:2086-2093.e9. [PMID: 34999218 DOI: 10.1016/j.jvs.2021.12.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Previous meta-analysis of randomized control trials evaluating the efficacy of closed incision negative pressure wound therapy (ciNPWT) on vascular surgery groin wounds reported a reduction in surgical site infections (SSI). Our aim was to perform a comprehensive, updated meta-analysis after the largest multicenter randomized control trial (RCT) on the subject to date reported no benefit of ciNPWT. METHODS A systematic review identified RCTs that compared the primary outcome of incidence of postoperative SSIs of groin incisions treated with ciNPWT or standard dressings. Secondary outcomes included wound dehiscence, composite incidence of seroma / lymph leak / hematoma, need for reoperation, in-hospital mortality, need for readmission and hospital length of stay. Odds ratios were compared across studies using random effects meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias tool, Harbord test and trim-and-fill analysis. RESULTS Eight RCTs comprised of 1125 incisions (n = 555 [49.3%] ciNPT, n = 570 [50.7%] control) were included. RCTs included 3 studies inside and 5 outside of the United States. ciNPWT was associated with a significant reduction in rate of SSIs (OR 0.39; 95% CI 0.24-0.63; p < 0.001). There was no significant difference in rate of wound dehiscence (OR 1.11, 95% CI 0.67-1.83, p = 0.68), composite incidence of seroma, lymph leak or hematoma (OR 0.49, 95% CI 0.13-1.76, p= 0.27), need for reoperation (OR 0.68, 95% CI 0.40-1.16, p = 0.16), or need for readmission (OR 0.60, 95% CI 0.30-1.21, p = 0.15). It was not possible to quantitatively evaluate in-hospital mortality or hospital length of stay. Risk of bias assessment identified high risk of bias regarding participant blinding in all studies, low risk in randomization and outcome reporting, and variability between studies in other methodologies. There was no evidence of publication bias. CONCLUSIONS Meta-analysis of pooled data suggest prophylactic use of ciNPWT for vascular groin incisions is associated with reduced rates of SSIs, with the greatest benefits seen in trials with higher baseline rates of infection in the control group.
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Affiliation(s)
- Griffin Boll
- Department of Surgery, University of Vermont Medical Center, Burlington, VT
| | - Peter Callas
- Medical Biostatistics, University of Vermont, Burlington, VT
| | - Daniel J Bertges
- Department of Surgery, University of Vermont Medical Center, Burlington, VT.
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van Dam MA, Strietman M, van Eps RG, Wever JJ, Veger HT. Clinical Relevance of Closed-Incision Negative Pressure Therapy (ciNPT) for SSI-Risk Reduction in Vascular Surgery Through a Groin Incision. Ann Vasc Surg 2022; 78:93-102. [PMID: 34537352 DOI: 10.1016/j.avsg.2021.06.035] [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: 04/02/2021] [Revised: 06/16/2021] [Accepted: 06/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vascular surgery, especially lower limb revascularization surgery, has one of the highest rates of surgical complications, predominantly surgical site infections (SSI). Resulting in a significant burden of additional costs due to longer hospital stays, re-admissions and re-interventions, mainly attributable to deep incisional SSIs. Closed incisional negative pressure therapy (ciNPT) is a relatively new strategy in the postoperative management surgical wounds, aiming to reduce surgical wound complications. When discussing the clinical relevance of ciNPT, it is crucial to take into account the outcome of therapy as well as the additional costs related to ciNPT. Since, the additional costs must be justified by an associated decrease in the morbidity and costs associated with groin wound complications, which are particularly attributable to deep incisional SSIs. The current literature evaluating the beneficial effect of ciNPT in groin incisional vascular surgery, predominantly focusses on the decrease in superficial SSIs. Whereas this study aims to address and discuss the clinical relevance of ciNPT over conventional wound dressings, by separately evaluating and comparing the incidence of superficial and deep SSIs and their related re-admissions and re-interventions. METHODS In this single center prospective cohort study performed in a non-academic hospital in The Netherlands, 59 consecutive patients (67 incisions) were included between January and October 2019. All underwent elective vascular surgery with groin (access) incisions for either lower limb revascularization surgery or abdominal aortic aneurysm surgery. The study group was treated with six days ciNPT (PREVENA Incision Management System; KCI/3M, San Antonio, TX, USA) and matched for equal comparison to a historical retrospectively analysed cohort of 54 consecutive patients (60 incisions), all of whom have undergone elective vascular surgery for equal indications with groin (access) incisions in our center between January and October 2018. The standard-care group was treated following standard surgical wound care protocol with conventional surgical self-adhesive plaster (10 × 15cm, Mepore, Mölnlycke Health Care AB, Gothenburg, Sweden). RESULTS Study groups were comparable at baseline, except for Body Mass Index (BMI), which was significantly higher in the ciNPT-group (P =.021). No significant differences for formation of seroma, hematoma, as well as wound dehiscence and SSIs were found between both groups. Groin SSIs were seen in 12.1% of the patients in the ciNPT-group and in 13.0% in the Standard-care group (OR 0.80, CI ((0.26, 2.48)), deep SSI contributed for 4 out of 7 patients of total SSIs in the ciNPT-group and for 2 out of 7 patients in the standard of care group (P-value >0.05). Analysis for incidence of hospital re-admission and re-intervention in both study groups showed no significant difference. Subset analysis in both study groups for SSIs differentiated in superficial and deep SSIs showed that only deep SSIs resulted in re-interventions. CONCLUSIONS Based on the findings in the population of our single center study, we conclude that routine use of ciNPT was not effective in reducing groin wound complications, and therefore could not replicate the promising findings from some previous studies. Furthermore, we did not find a reduction in the incidence of deep SSIs, which comprise the highest morbidity and costs. Considering our findings as well as the associated additional expenses related to ciNPT, it might be superfluous at this stage to use ciNPT as the new standard of post-operative groin incision care for all lower limb revascularization and abdominal aortic aneurysm surgeries. In our opinion further research is warranted for establishing a risk-factor based model for determination of the indication of ciNPT. To be able to achieve a more substantiated decision for utilizing ciNPT compared to standard surgical wound care in groin incisional vascular surgical interventions.
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Affiliation(s)
- Martijn A van Dam
- Department of Vascular Surgery, Hagaziekenhuis, Els Borst-Eilersplein 275, 2455AA, The Hague, The Netherlands
| | - Merel Strietman
- Wound Expertise Center, Hagaziekenhuis, Els Borst-Eilersplein 275, 2455AA, The Hague, The Netherlands
| | - Randolph Gs van Eps
- Department of Vascular Surgery, Hagaziekenhuis, Els Borst-Eilersplein 275, 2455AA, The Hague, The Netherlands
| | - Jan J Wever
- Department of Vascular Surgery, Hagaziekenhuis, Els Borst-Eilersplein 275, 2455AA, The Hague, The Netherlands
| | - Hugo Tc Veger
- Department of Vascular Surgery, Hagaziekenhuis, Els Borst-Eilersplein 275, 2455AA, The Hague, The Netherlands
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Zhao AH, Kwok CHR, Jansen SJ. How to Prevent Surgical Site Infection in Vascular Surgery: A Review of the Evidence. Ann Vasc Surg 2021; 78:336-361. [PMID: 34543711 DOI: 10.1016/j.avsg.2021.06.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 06/16/2021] [Accepted: 06/20/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND This review aims to identify and review the current evidence for preventing postoperative surgical site infections in abdominal aortic aneurysm surgery or infrainguinal arterial surgery. METHODS Extended literature review of clinical trials that examined the prevention of postoperative surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. Searches were conducted on Ovid MEDLINE (1950 - 13 March 2020) using key terms for vascular surgery, surgical site infections and specific preventative techniques. Articles were included if they discussed a relationship between a preventative technique and surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. The GRADE guidelines were used to assess the quality of evidence. RESULTS 21 techniques and 81 studies were included. Prophylactic antibiotics and negative pressure wound therapy have a high quality of evidence for the prevention of surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. A moderate quality evidence base was identified for gentamicin containing collagen implant (confined to high surgical site infection risk centers). Currently, there is a low or very low quality of evidence to suggest a reduction in the surgical site infection rate for combination therapy, glycaemic control, Methicillin-resistant Staphylococcus aureus screening and absorbable suture. Evidence suggests no beneficial effect for nutritional supplementation, chlorhexidine bath, hair removal therapy, Staphylococcus aureus nasal eradication, cyanoacrylate microsealant, silver grafts, rifampicin bonded grafts, triclosan coated suture and postoperative wound drains. Endoscopic saphenous vein harvest may reduce surgical site infection rate (very low quality of evidence) but may lower long-term patency. Autologous vein grafts may increase surgical site infections (very low quality of evidence) but may provide better long-term patency rates in above-knee infrainguinal bypass surgery. There was no identified evidence for perioperative normothermia, electrosurgical bipolar vessel sealer or Dermabond and Tegaderm for surgical site infection prevention in vascular surgery. CONCLUSIONS Prophylactic antibiotics and postoperative negative pressure wound therapy are effective in the prevention of postoperative surgical site infection in abdominal aortic aneurysm or infrainguinal arterial surgery. There exists a significant risk of bias in the literature for many preventative techniques and further studies are required to investigate the efficacy of gentamicin containing collagen implant, and specific combination therapies.
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Affiliation(s)
- Adam Hanting Zhao
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia; Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Western Australia, Nedlands, Western Australia, Australia.
| | - Chi Ho Ricky Kwok
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Western Australia, Nedlands, Western Australia, Australia
| | - Shirley Jane Jansen
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia; Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Western Australia, Nedlands, Western Australia, Australia; Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia; Heart and Vascular Research Institute, Harry Perkins Institute for Medical Research, Nedlands, Western Australia, Australia
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Prophylactic Single-use Negative Pressure Dressing in Closed Surgical Wounds After Incisional Hernia Repair: A Randomized, Controlled Trial. Ann Surg 2021; 273:1081-1086. [PMID: 33201116 DOI: 10.1097/sla.0000000000004310] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE A randomized controlled trial (RCT) was undertaken to evaluate whether the prophylactic application of a specific single-use negative pressure (sNPWT) dressing on closed surgical incisions after incisional hernia (IH) repair decreases the risk of surgical site occurrences (SSOs) and the length of stay. BACKGROUND The sNPWT dressings have been associated to several advantages like cost savings and prevention of SSOs like seroma, hematoma, dehiscence, or wound infection (SSI) in closed surgical incisions. But this beneficious effect has not been previously studied in cases of close wounds after abdominal wall hernia repairs. METHODS An RCT was undertaken between May 2017 and January 2020 (ClinicalTrials.gov registration number NCT03576222). Participating patients, with IH type W2 or W3 according to European Hernia Society classification, were randomly assigned to receive intraoperatively either the sNPWT (PICO)(72 patients) or a conventional dressing at the end of the hernia repair (74 patients). The primary endpoint was the development of SSOs during the first 30 days after hernia repair. The secondary endpoint included length of hospital stay. Statistical analysis was performed using IBM SPSS Statistics Version 23.0. RESULTS At 30 days postoperatively, there was significatively higher incidence of SSOs in the control group compared to the treatment group (29.8% vs 16.6%, P < 0.042). There was no SSI in the treatment group and 6 cases in the control group (0% vs 8%, P < 0.002). No significant differences regarding seroma, hematoma, wound dehiscence, and length of stay were observed between the groups. CONCLUSION The use of prophylactic sNPWT PICO dressing for closed surgical incisions following IH repair reduces significatively the overall incidence of SSOs and the SSI at 30 days postoperatively.
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Meiler LJ, Beach EC, Chavan B, Conrad-Schnetz KJ, Stanley JA, Ramon ND. Benefit of Negative Pressure Dressings in Vascular Surgery Patients with Infra-Inguinal 1 Incisions after short-term followupAssessing the Benefit of Incisional Negative Pressure 2 Dressings in Community-Based Vascular Surgery Patients with Infra-Inguinal Incisions. J Vasc Surg 2021; 74:1668-1672. [PMID: 34019988 DOI: 10.1016/j.jvs.2021.04.058] [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: 07/22/2020] [Accepted: 04/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Within the vascular patient population there is increased risk of developing wound complications especially in infra-inguinal incisions. There has been increasing interest in using closed incisional negative pressure dressings to decrease the risk of wound complications. To assess the efficacy of these incisional wound dressings we studied surgical site infections and seroma rates of infrainguinal incisions in our vascular patient population. METHODS This was a multi-institutional, retrospective study from July 2015- June 2019. In 2017 our institution began using the Prevena incisional wound system. Wound complication rates were compared to the non Prevena group prior to 2017. There was a total of 100 infrainguinal incisions (left and right combined) that received the Prevena wound system and 138 infrainguinal incisions that had not. The primary endpoint was to assess for wound complication rates including surgical site infections and seroma formation. Surgical site infections were graded based on the ACS-NSQIP SSI criteria. Seroma formation was diagnosed based on clinical diagnosis, imaging studies (ultrasound, CT) or needle aspiration of fluid collection. RESULTS Analysis showed a statistically significant decrease in the rate of SSIs in the Prevena group when compared to the non Prevena group (p=0.012). There was no statistical difference between the two groups in the rate of seroma formation (p=0.155). Of the 100 incisions that received the Prevena wound system 1.2% (1/82) had a femoral SSI and 22% (4/18) had a popliteal SSI. For seroma formation 24.4% (20/82) had a femoral seroma and 11.1% (2/18) had a popliteal seroma. Of the 138 incisions that did not have the Prevena wound system, 9.6% (10/104) had a femoral SSI, and 8.8% (3/34) had a popliteal SSI. For seroma formation 24.0% (25/104) had a femoral seroma and 8.8% (3/34) had a popliteal seroma. Comorbid conditions were assessed in the two study groups and there was no statistical significance regarding rates of surgical site infections between the groups. CONCLUSIONS The use of an incisional negative pressure dressing decreases the rate of surgical site infections in infrainguinal incisions. Regarding the use of these wound systems for seromas; our study did not show a statistical significance in decreasing seroma rates.
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Affiliation(s)
- Laura J Meiler
- South Pointe Hospital - Cleveland Clinic, Warrensville Heights, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Elsworth C Beach
- South Pointe Hospital - Cleveland Clinic, Warrensville Heights, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Bhakti Chavan
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Kristen J Conrad-Schnetz
- South Pointe Hospital - Cleveland Clinic, Warrensville Heights, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Jeffrey A Stanley
- South Pointe Hospital - Cleveland Clinic, Warrensville Heights, OH; Western Reserve Hospital - Summa Health Systems, Cuyahoga Falls, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH
| | - Nicole D Ramon
- South Pointe Hospital - Cleveland Clinic, Warrensville Heights, OH; Western Reserve Hospital - Summa Health Systems, Cuyahoga Falls, OH; Ohio University Heritage College of Osteopathic Medicine, Athens, OH.
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Bertges DJ, Smith L, Scully RE, Wyers M, Eldrup-Jorgensen J, Suckow B, Ozaki CK, Nguyen L. A multicenter, prospective randomized trial of negative pressure wound therapy for infrainguinal revascularization with a groin incision. J Vasc Surg 2021; 74:257-267.e1. [PMID: 33548422 DOI: 10.1016/j.jvs.2020.12.100] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/29/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Wound complications after open infrainguinal revascularization are a frequent cause of patient morbidity, resulting in increased healthcare costs. The purpose of the present study was to assess the effects of closed incision negative pressure therapy (ciNPT) on groin wound complications after infrainguinal bypass and femoral endarterectomy. METHODS A total of 242 patients who had undergone infrainguinal bypass (n = 124) or femoral endarterectomy (n = 118) at five academic medical centers in New England from April 2015 to August 2019 were randomized to ciNPT (PREVENA; 3M KCI, St Paul, Minn; n = 118) or standard gauze (n = 124). The primary outcome measure was a composite endpoint of groin wound complications, including surgical site infections (SSIs), major noninfectious wound complications, or graft infections within 30 days after surgery. The secondary outcome measures included 30-day SSIs, 30-day noninfectious wound complications, readmission for wound complications, significant adverse events, and health-related quality of life using the EuroQoL 5D-3L survey. RESULTS The ciNPT and control groups had similar demographics (age, 67 vs 67 years, P = .98; male gender, 71% vs 70%, P = .86; white race, 93% vs 93%, P = .97), comorbidities (previous or current smoking, 93% vs 94%, P = .46; diabetes, 41% vs 48%, P = .20; renal insufficiency, 4% vs 7%, P = .31), and operative characteristics, including procedure type, autogenous conduit, and operative time. No differences were found in the primary composite outcome at 30 days between the two groups (ciNPT vs control: 31% vs 28%; P = .55). The incidence of SSI at 30 days was similar between the two groups (ciNPT vs control: 11% vs 12%; P = .58). Infectious (13.9% vs 12.6%; P = .77) and noninfectious (20.9% vs 17.6%; P = .53) wound complications at 30 days were also similar for the ciNPT and control groups. Wound complications requiring readmission also similar between the two groups (ciNPT vs control: 9% vs 7%; P = .54). The significant adverse event rates were not different between the two groups (ciNPT vs control: 13% vs 16%; P = .53). The mean length of the initial hospitalization was the same for the ciNPT and control groups (5.2 vs 5.7 days; P = .63). The overall health-related quality of life was similar at baseline and at 14 and 30 days postoperatively for the two groups. Although not powered for stratification, we found no differences among the subgroups in gender, obesity, diabetes, smoking, claudication, chronic limb threatening ischemia, bypass, or endarterectomy. On multivariable analysis, no differences were found in wound complications at 30 days for the ciNPT vs gauze groups (odds ratio, 1.4; 95% confidence interval, 0.8-2.6; P = .234). CONCLUSIONS In contrast to other randomized studies, our multicenter trial of infrainguinal revascularization found no differences in the 30-day groin wound complications for patients treated with ciNPT vs standard gauze dressings. However, the SSI rate was lower in the control group than reported in other studies, suggesting other practice patterns and processes of care might have reduced the rate of groin infections. Further study might identify the subsets of high-risk patients that could benefit from ciNPT.
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Affiliation(s)
- Daniel J Bertges
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, Vt.
| | - Lisa Smith
- Office of Clinical Trials Research, University of Vermont College of Medicine, Burlington, Vt
| | - Rebecca E Scully
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Mark Wyers
- Division of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | - Bjoern Suckow
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Louis Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
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Chien YC, Lin YH, Chen CC, Lin HC. Compromised Flap Salvage With Closed Incision Negative Pressure Therapy Under Real-Time Indocyanine Green Fluorescence Assessment. Ann Plast Surg 2021; 86:S96-S101. [PMID: 33438958 DOI: 10.1097/sap.0000000000002653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Skin flap transfer is a commonly used technique by surgeons; however, compromised blood flow may result in flap ischemia and necrosis. We describe the use of closed incision negative pressure therapy (ciNPT) to help manage skin flap reconstructions with indocyanine green fluorescence angiography (ICG-FA) to assess perfusion of the flaps before and after ciNPT. METHODS Three female and 5 male patients underwent various skin flap reconstructions, including local flaps, pedicled flaps, and propeller flaps, for wound defects related to trauma, infection, or cancer. After flap setting and suturing, ciNPT (-125 mm Hg) was applied to the closed incision for 7 days. Perfusion was assessed using ICG-FA before applying ciNPT and again at 24 hours later. The Shapiro-Wilk test and Wilcoxon signed rank test were used in statistical analysis. RESULTS Initial postoperative survival was observed for all skin flaps; however, 1 flap failed after 2 weeks due to uncontrolled infection. The remaining 7 flaps healed well without any surgical revision. All patients were initially determined to have impaired flap perfusion; however, skin flap perfusion was significantly higher after ciNPT than before ciNPT in each case (P = 0.012). CONCLUSIONS This study showed good healing outcomes for skin flap reconstructions without complications, despite the fact that each flap had compromised flap perfusion to some extent during the surgery. This case series is novel in that it used laser-assisted ICG-FA to provide a real-time assessment of skin flap perfusion before and after ciNPT.
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Affiliation(s)
- Yi-Chun Chien
- From the Shin-Kong Memorial Hospital, Taipei, Taiwan
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Gwilym BL, Dovell G, Dattani N, Ambler GK, Shalhoub J, Forsythe RO, Benson RA, Nandhra S, Preece R, Onida S, Hitchman L, Coughlin P, Saratzis A, Bosanquet DC. Editor's Choice - Systematic Review and Meta-Analysis of Wound Adjuncts for the Prevention of Groin Wound Surgical Site Infection in Arterial Surgery. Eur J Vasc Endovasc Surg 2021; 61:636-646. [PMID: 33423912 DOI: 10.1016/j.ejvs.2020.11.053] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/03/2020] [Accepted: 11/30/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Groin incision surgical site infections (SSIs) following arterial surgery are common and are a source of considerable morbidity. This review evaluates interventions and adjuncts delivered immediately before, during, or after skin closure, to prevent SSIs in patients undergoing arterial interventions involving a groin incision. DATA SOURCES MEDLINE, EMBASE, and CENTRAL databases were searched. REVIEW METHODS This review was undertaken according to established international reporting guidelines and was registered prospectively with the International prospective register of systematic reviews (CRD42020185170). The MEDLINE, EMBASE, and CENTRAL databases were searched using pre-defined search terms without date restriction. Randomised controlled trials (RCTs) and observational studies recruiting patients with non-infected groin incisions for arterial exposure were included; SSI rates and other outcomes were captured. Interventions reported in two or more studies were subjected to meta-analysis. RESULTS The search identified 1 532 articles. Seventeen RCTs and seven observational studies, reporting on 3 747 patients undergoing 4 130 groin incisions were included. A total of seven interventions and nine outcomes were reported upon. Prophylactic closed incision negative pressure wound therapy (ciNPWT) reduced groin SSIs compared with standard dressings (odds ratio [OR] 0.34, 95% CI 0.23 - 0.51; p < .001, GRADE strength of evidence: moderate). Local antibiotics did not reduce groin SSIs (OR 0.60 95% CI 0.30 - 1.21 p = .15, GRADE strength: low). Subcuticular sutures (vs. transdermal sutures or clips) reduced groin SSI rates (OR 0.33, 95% CI 0.17 - 0.65, p = .001, GRADE strength: low). Wound drains, platelet rich plasma, fibrin glue, and silver alginate dressings did not show any significant effect on SSI rates. CONCLUSION There is evidence that ciNPWT and subcuticular sutures reduce groin SSI in patients undergoing arterial vascular interventions involving a groin incision. Local antibiotics did not reduce groin wound SSI, although the strength of this evidence is lower. No other interventions demonstrated a significant effect.
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Affiliation(s)
- Brenig L Gwilym
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, UK. https://twitter.com/VascResearchNet
| | | | | | | | - Joseph Shalhoub
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Rachael O Forsythe
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Sandip Nandhra
- Northern Vascular Centre, Institute of population health sciences, Newcastle University, Newcastle, UK
| | | | - Sarah Onida
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, London, UK
| | | | - Patrick Coughlin
- Cardiovascular Interdisciplinary Research Centre, University of Cambridge, Cambridge, UK
| | - Athanasios Saratzis
- NIHR Leicester Biomedical Research Centre, University of Leicester Department of Cardiovascular Sciences, Leicester, UK
| | - David C Bosanquet
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, UK
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Siegwart LC, Sieber L, Fischer S, Maraka S, Kneser U, Kotsougiani-Fischer D. Influence of closed incision negative-pressure therapy on abdominal donor-site morbidity in microsurgical breast reconstruction. Microsurgery 2020; 42:32-39. [PMID: 33201541 DOI: 10.1002/micr.30683] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 08/06/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Closed incision negative-pressure therapy (CINPT) has been shown to shorten the time to heal in post-bariatric abdominoplasty and to lower seroma rates in cosmetic abdominoplasty. The objective of this study was to assess the effect of CINPT on donor-site morbidity following abdominal-based free-flap breast reconstruction. PATIENTS AND METHODS We reviewed medical records from 225 women who had undergone 300 microsurgical free-flap breast reconstructions from the abdomen from November 1, 2007 to March 31, 2019. Patients were grouped according to wound therapy, including 127 patients in the standard of care group and 98 patients in the CINPT group. Primary outcomes were minor (non-operative) and major (operative) surgical site complications. Secondary outcomes were time to drain removal, in-hospital length, and scar quality. RESULTS Analysis of patient demographics showed an equal distribution with regard to the age, smoking status, prevalence of diabetes mellitus, preoperative chemotherapy, and previous abdominal surgery in both groups. Significantly more patients with obesity (29.6 vs. 15.8%; p = .01) and bilateral breast reconstruction (40.8 vs. 27.6%; p = .04) were included in the CINPT group. Compared to standard of care, the CINPT group had a lower incidence of major surgical site complications (26.0 vs. 11.2%; p = .001). There was no difference in minor surgical site complications and secondary outcomes between groups. CONCLUSION The CINPT represents a reliable tool to reduce surgical site complications on the abdominal donor-site in abdominal-based free-flap breast reconstruction.
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Affiliation(s)
- Laura C Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
| | - Laura Sieber
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Department of Medicine, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA.,Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
| | - Dimitra Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center BG Clinic Ludwigshafen, Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Heidelberg, Germany
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Rasheed H, Diab K, Singh T, Chauhan Y, Haddad P, Zubair MM, Vowels T, Androas E, Rojo M, Auyang P, McFall R, Gomez LF, Mohamed A, Peden E, Rahimi M. Contemporary Review to Reduce Groin Surgical Site Infections in Vascular Surgery. Ann Vasc Surg 2020; 72:578-588. [PMID: 33157243 DOI: 10.1016/j.avsg.2020.09.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022]
Abstract
Surgical site infection (SSIs) in lower extremity vascular procedures is a major contributor to patient morbidity and mortality. Despite previous advancements in preoperative and postoperative care, the surgical infection rate in vascular surgery remains high, particularly when groin incisions are involved. However, successfully targeting modifiable risk factors reduces the surgical site infection incidence in vascular surgery patients. We conducted an extensive literature review to evaluate the efficacy of various preventive strategies for groin surgical site infections. We discuss the role of preoperative showers, preoperative and postoperative antibiotics, collagen gentamicin implants, iodine impregnated drapes, types of skin incisions, negative pressure wound therapy, and prophylactic muscle flap transposition in preventing surgical site infection in the groin after vascular surgical procedures.
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Affiliation(s)
- Haroon Rasheed
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Kaled Diab
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Tarundeep Singh
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Yusuf Chauhan
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Paul Haddad
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - M Mujeeb Zubair
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Travis Vowels
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Edward Androas
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Manuel Rojo
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Phillip Auyang
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Ross McFall
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Luis Felipe Gomez
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Ahmed Mohamed
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Eric Peden
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Maham Rahimi
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX.
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Abstract
Summary
Background
Wound healing deficits and subsequent surgical site infections are potential complications after surgical procedures, resulting in increased morbidity and treatment costs. Closed-incision negative-pressure wound therapy (ciNPWT) systems seem to reduce postoperative wound complications by sealing the wound and reducing tensile forces.
Materials and methods
We conducted a collaborative English literature review in the PubMed database including publications from 2009 to 2020 on ciNPWT use in five surgical subspecialities (orthopaedics and trauma, general surgery, plastic surgery, cardiac surgery and vascular surgery). With literature reviews, case reports and expert opinions excluded, the remaining 59 studies were critically summarized and evaluated with regard to their level of evidence.
Results
Of nine studies analysed in orthopaedics and trauma, positive results of ciNPWT were reported in 55.6%. In 11 of 13 (84.6%), 13 of 15 (86.7%) and 10 of 10 (100%) of studies analysed in plastic, vascular and general surgery, respectively, a positive effect of ciNPWT was observed. On the contrary, only 4 of 12 studies from cardiac surgery discovered positive effects of ciNPWT (33.3%).
Conclusion
ciNPWT is a promising treatment modality to improve postoperative wound healing, notably when facing increased tensile forces. To optimise ciNPWT benefits, indications for its use should be based on patient- and procedure-related risk factors.
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Price A, Contractor U, White R, Williams I. The use of vascularised muscle flaps for treatment or prevention of wound complications following arterial surgery in the groin. Int Wound J 2020; 17:1669-1677. [PMID: 32744430 PMCID: PMC7949366 DOI: 10.1111/iwj.13449] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 12/01/2022] Open
Abstract
Wound complications following arterial surgery in the groin are relatively common and can result in significant morbidity and mortality. Vascularised muscle flaps (VMF) may be used as an adjunct to aid healing, either to manage complications or prophylactically. This series describes 46 patients who received sartorius or gracilis muscle flaps, of which 70% were performed as a salvage procedure to treat complications ranging from wound breakdown to vascular graft infection. The remaining 30% were performed at the time of the arterial surgery in patients with risk factors such as re‐do surgery or immunosuppression. The peri‐operative mortality rate was 9% and the major amputation rate was 26%, reflecting the complexity of patients that require intervention. Overall, 85% achieved successful healing in the groin without the need for further treatment following VMF. Only one case of flap necrosis occurred. Wound healing complications occurred more commonly after sartorius muscle flaps. The gracilis muscle offers a bulkier mass and greater mobility and so may be preferable, particularly for larger groin defects. This series has shown that VMF offer a safe and reliable option for selected cases to achieve wound healing in the groin in patients with often significant co‐morbidities.
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Affiliation(s)
- Annie Price
- Department of Wound Healing, University Hospital of Wales, Cardiff, UK
| | - Ummul Contractor
- Regional Vascular Unit, University Hospital of Wales, Cardiff, UK
| | - Richard White
- Regional Vascular Unit, University Hospital of Wales, Cardiff, UK
| | - Ian Williams
- Regional Vascular Unit, University Hospital of Wales, Cardiff, UK
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Practical Things You Should Know about Wound Healing and Vacuum-Assisted Closure Management. Plast Reconstr Surg 2020; 145:839e-854e. [PMID: 32221237 DOI: 10.1097/prs.0000000000006652] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Understand the basics of negative-pressure wound therapy and practical uses of various vacuum-assisted closure dressings. 2. Understand the mechanisms of action of negative-pressure therapies and other important adjuncts, such as perfusion imaging. 3. Discuss the evidence for hyperbaric oxygen therapy in wound care. SUMMARY Wound healing requires creating an environment that supports the healing process while decreasing inflammation and infection. Negative-pressure wound therapy has changed the way physicians manage acute and chronic wounds for more than 20 years. It contracts wound edges, removes exudate, including inflammatory and infectious material, and promotes angiogenesis and granulation tissue formation. These effects have been consistently demonstrated in multiple animal and human randomized controlled trials. Recent innovations that include instillation therapy and closed incision have further increased our arsenal against difficult-to-treat wounds and incisions at high risk of complications. Instillation of topical wound solutions allows physicians to cleanse the wound without return to the operating room, resulting in fewer debridements, shorter hospital stays, and faster time to wound closure. Other concepts have yielded negative-pressure therapy on top of closed surgical incisions, which holds incision edges together, reduces edema, promotes angiogenesis, and creates a barrier to protect incisions during the critical healing period, thereby reducing surgical-site complications, especially infection. Other practical adjuncts to the modern-day treatment of acute and chronic wounds include indocyanine green angiography, which allows real-time assessment of perfusion, and hyperbaric oxygen treatment, which has been suggested to augment healing in acute, chronic, specifically diabetic foot ulcers and radiation-related wounds.
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Norman G, Goh EL, Dumville JC, Shi C, Liu Z, Chiverton L, Stankiewicz M, Reid A. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 2020; 6:CD009261. [PMID: 32542647 PMCID: PMC7389520 DOI: 10.1002/14651858.cd009261.pub6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain. OBJECTIVES To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure. SEARCH METHODS In June 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting. SELECTION CRITERIA We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. MAIN RESULTS In this third update, we added 15 new randomised controlled trials (RCTs) and three new economic studies, resulting in a total of 44 RCTs (7447 included participants) and five economic studies. Studies evaluated NPWT in the context of a wide range of surgeries including orthopaedic, obstetric, vascular and general procedures. Economic studies assessed NPWT in orthopaedic, obstetric and general surgical settings. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Four studies (2107 participants) reported mortality. There is low-certainty evidence (downgraded twice for imprecision) showing no clear difference in the risk of death after surgery for people treated with NPWT (2.3%) compared with standard dressings (2.7%) (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.50 to 1.47; I2 = 0%). Thirty-nine studies reported SSI; 31 of these (6204 participants), were included in meta-analysis. There is moderate-certainty evidence (downgraded once for risk of bias) that NPWT probably results in fewer SSI (8.8% of participants) than treatment with standard dressings (13.0% of participants) after surgery; RR 0.66 (95% CI 0.55 to 0.80 ; I2 = 23%). Eighteen studies reported dehiscence; 14 of these (3809 participants) were included in meta-analysis. There is low-certainty evidence (downgraded once for risk of bias and once for imprecision) showing no clear difference in the risk of dehiscence after surgery for NPWT (5.3% of participants) compared with standard dressings (6.2% of participants) (RR 0.88, 95% CI 0.69 to 1.13; I2 = 0%). Secondary outcomes There is low-certainty evidence showing no clear difference between NPWT and standard treatment for the outcomes of reoperation and incidence of seroma. For reoperation, the RR was 1.04 (95% CI 0.78 to 1.41; I2 = 13%; 12 trials; 3523 participants); for seroma, the RR was 0.72 (95% CI 0.50 to 1.05; I2 = 0%; seven trials; 729 participants). The effect of NPWT on occurrence of haematoma or skin blisters is uncertain (very low-certainty evidence); for haematoma, the RR was 0.67 (95% CI 0.28 to 1.59; I2 = 0%; nine trials; 1202 participants) and for blisters the RR was 2.64 (95% CI 0.65 to 10.68; I2 = 69%; seven trials; 796 participants). The overall effect of NPWT on pain is uncertain (very low-certainty evidence from seven trials (2218 participants) which reported disparate measures of pain); but moderate-certainty evidence suggests there is probably little difference between the groups in pain after three or six months following surgery for lower limb fracture (one trial, 1549 participants). There is also moderate-certainty evidence for women undergoing caesarean sections (one trial, 876 participants) and people having surgery for lower limb fractures (one trial, 1549 participants) that there is probably little difference in quality of life scores at 30 days or 3 or 6 months, respectively. Cost-effectiveness Five economic studies, based wholly or partially on trials included in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in four indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty and coronary artery bypass graft surgery. They calculated quality-adjusted life-years for treatment groups and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the grade of the evidence varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed. AUTHORS' CONCLUSIONS People experiencing primary wound closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSI than people treated with standard dressings (moderate-certainty evidence). There is no clear difference in number of deaths or wound dehiscence between people treated with NPWT and standard dressings (low-certainty evidence). There are also no clear differences in secondary outcomes where all evidence was low or very low-certainty. In caesarean section in obese women and surgery for lower limb fracture, there is probably little difference in quality of life scores (moderate-certainty evidence). Most evidence on pain is very low-certainty, but there is probably no difference in pain between NPWT and standard dressings after surgery for lower limb fracture (moderate-certainty evidence). Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - En Lin Goh
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Zhenmi Liu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Laura Chiverton
- NIHR Clinical Research Facility, Great Ormond Street Hospital, London, UK
| | - Monica Stankiewicz
- Chermside Community Health Centre, Community and Oral Health Directorate, Brisbane, Australia
| | - Adam Reid
- School of Biological Sciences, Faculty of Biology, Medicine & Health, Manchester, UK
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The impact of negative pressure wound therapy for closed surgical incisions on surgical site infection: A systematic review and meta-analysis. Surgery 2020; 167:1001-1009. [DOI: 10.1016/j.surg.2020.01.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/08/2020] [Accepted: 01/26/2020] [Indexed: 01/03/2023]
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Norman G, Goh EL, Dumville JC, Shi C, Liu Z, Chiverton L, Stankiewicz M, Reid A. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 2020; 5:CD009261. [PMID: 32356396 PMCID: PMC7192856 DOI: 10.1002/14651858.cd009261.pub5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain. OBJECTIVES To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure. SEARCH METHODS In June 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting. SELECTION CRITERIA We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. MAIN RESULTS In this third update, we added 15 new randomised controlled trials (RCTs) and three new economic studies, resulting in a total of 44 RCTs (7447 included participants) and five economic studies. Studies evaluated NPWT in the context of a wide range of surgeries including orthopaedic, obstetric, vascular and general procedures. Economic studies assessed NPWT in orthopaedic, obstetric and general surgical settings. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Four studies (2107 participants) reported mortality. There is low-certainty evidence (downgraded twice for imprecision) showing no clear difference in the risk of death after surgery for people treated with NPWT (2.3%) compared with standard dressings (2.7%) (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.50 to 1.47; I2 = 0%). Thirty-nine studies reported SSI; 31 of these (6204 participants), were included in meta-analysis. There is moderate-certainty evidence (downgraded once for risk of bias) that NPWT probably results in fewer SSI (8.8% of participants) than treatment with standard dressings (13.0% of participants) after surgery; RR 0.66 (95% CI 0.55 to 0.80 ; I2 = 23%). Eighteen studies reported dehiscence; 14 of these (3809 participants) were included in meta-analysis. There is low-certainty evidence (downgraded once for risk of bias and once for imprecision) showing no clear difference in the risk of dehiscence after surgery for NPWT (5.3% of participants) compared with standard dressings (6.2% of participants) (RR 0.88, 95% CI 0.69 to 1.13; I2 = 0%). Secondary outcomes There is low-certainty evidence showing no clear difference between NPWT and standard treatment for the outcomes of reoperation and incidence of seroma. For reoperation, the RR was 1.04 (95% CI 0.78 to 1.41; I2 = 13%; 12 trials; 3523 participants); for seroma, the RR was 0.72 (95% CI 0.50 to 1.05; I2 = 0%; seven trials; 729 participants). The effect of NPWT on occurrence of haematoma or skin blisters is uncertain (very low-certainty evidence); for haematoma, the RR was 0.67 (95% CI 0.28 to 1.59; I2 = 0%; nine trials; 1202 participants) and for blisters the RR was 2.64 (95% CI 0.65 to 10.68; I2 = 69%; seven trials; 796 participants). The overall effect of NPWT on pain is uncertain (very low-certainty evidence from seven trials (2218 participants) which reported disparate measures of pain); but moderate-certainty evidence suggests there is probably little difference between the groups in pain after three or six months following surgery for lower limb fracture (one trial, 1549 participants). There is also moderate-certainty evidence for women undergoing caesarean sections (one trial, 876 participants) and people having surgery for lower limb fractures (one trial, 1549 participants) that there is probably little difference in quality of life scores at 30 days or 3 or 6 months, respectively. Cost-effectiveness Five economic studies, based wholly or partially on trials included in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in four indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty and coronary artery bypass graft surgery. They calculated quality-adjusted life-years for treatment groups and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the grade of the evidence varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed. AUTHORS' CONCLUSIONS People experiencing primary wound closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSI than people treated with standard dressings (moderate-certainty evidence). There is no clear difference in number of deaths or wound dehiscence between people treated with NPWT and standard dressings (low-certainty evidence). There are also no clear differences in secondary outcomes where all evidence was low or very low-certainty. In caesarean section in obese women and surgery for lower limb fracture, there is probably little difference in quality of life scores (moderate-certainty evidence). Most evidence on pain is very low-certainty, but there is probably no difference in pain between NPWT and standard dressings after surgery for lower limb fracture (moderate-certainty evidence). Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.
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Affiliation(s)
- Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - En Lin Goh
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Zhenmi Liu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Laura Chiverton
- NIHR Clinical Research Facility, Great Ormond Street Hospital, London, UK
| | - Monica Stankiewicz
- Chermside Community Health Centre, Community and Oral Health Directorate, Brisbane, Australia
| | - Adam Reid
- School of Biological Sciences, Faculty of Biology, Medicine & Health, Manchester, UK
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Chan KS, Arunaachalam M, Hong Q, Yong EM, Lingam P, Zhang L, Chandrasekar S, Tan GWL, Lo ZJ. Outcomes of incisional negative pressure wound therapy following brachiobasilic transposition arteriovenous fistula creation: A 1:2 propensity score matched study. Int Wound J 2020; 17:1231-1238. [PMID: 32347016 DOI: 10.1111/iwj.13376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 12/22/2022] Open
Abstract
Incisional negative wound pressure therapy (iNPWT) use on closed incisions has been shown to improve wound outcomes, but no studies have evaluated the use of iNPWT following brachiobasilic transposition arteriovenous fistula (BBT-AVF). We aim to investigate the efficacy of iNPWT vs conventional wound therapy in reducing surgical site infections (SSIs) for BBT-AVF incisions. This is a retrospective cohort study of patients who underwent BBT-AVF creation between January 2010 and December 2017. A 1:2 propensity score matching (PSM) was performed to reduce selection bias and address for confounding factors. Study outcomes included SSI and haematoma incidence, 30-day readmission, and 30-day mortality. A total of 154 patients were reviewed in this study: 47 (30.5%) had iNPWT and 107 (69.5%) had conventional wound therapy. The overall median age was 60.5 (interquartile range 54-69). PSM with a 1:2 ratio resulted in a total of 117 patients (39 iNPWT and 78 conventional wound therapy). In the unmatched cohort, SSI incidence was lower in the iNPWT group (n = 1/47 [2.1%] vs n = 14/107 [13.1%], P = .035). However, incidence of SSI was comparable between iNPWT and conventional wound therapy after matching (n = 1/39 [2.6%] vs n = 9/78 [11.5%], P = .102). There was no significant difference in 30-day readmission and 30-day mortality. Within our study population of patients with BBT-AVF incisions, there is a non-statistically significant reduction in SSI incidence for patients who received iNPWT as compared with conventional wound therapy. Further prospective randomised controlled studies should be conducted to validate these findings.
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Affiliation(s)
- Kai Siang Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Muthaiah Arunaachalam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Qiantai Hong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - En Ming Yong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Pravin Lingam
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Li Zhang
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Glenn Wei Leong Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Zhiwen Joseph Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Sexton F, Healy D, Keelan S, Alazzawi M, Naughton P. A systematic review and meta-analysis comparing the effectiveness of negative-pressure wound therapy to standard therapy in the prevention of complications after vascular surgery. Int J Surg 2020; 76:94-100. [DOI: 10.1016/j.ijsu.2020.02.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/20/2020] [Accepted: 02/24/2020] [Indexed: 12/18/2022]
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Chang B, Sun Z, Peiris P, Huang ES, Benrashid E, Dillavou ED. Deep Learning-Based Risk Model for Best Management of Closed Groin Incisions After Vascular Surgery. J Surg Res 2020; 254:408-416. [PMID: 32197791 DOI: 10.1016/j.jss.2020.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/13/2020] [Accepted: 02/16/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Reduced surgical site infection (SSI) rates have been reported with use of closed incision negative pressure therapy (ciNPT) in high-risk patients. METHODS A deep learning-based, risk-based prediction model was developed from a large national database of 72,435 patients who received infrainguinal vascular surgeries involving upper thigh/groin incisions. Patient demographics, histories, laboratory values, and other variables were inputs to the multilayered, adaptive model. The model was then retrospectively applied to a prospectively tracked single hospital data set of 370 similar patients undergoing vascular surgery, with ciNPT or control dressings applied over the closed incision at the surgeon's discretion. Objective predictive risk scores were generated for each patient and used to categorize patients as "high" or "low" predicted risk for SSI. RESULTS Actual institutional cohort SSI rates were 10/148 (6.8%) and 28/134 (20.9%) for high-risk ciNPT versus control, respectively (P < 0.001), and 3/31 (9.7%) and 5/57 (8.8%) for low-risk ciNPT versus control, respectively (P = 0.99). Application of the model to the institutional cohort suggested that 205/370 (55.4%) patients were matched with their appropriate intervention over closed surgical incision (high risk with ciNPT or low risk with control), and 165/370 (44.6%) were inappropriately matched. With the model applied to the cohort, the predicted SSI rate with perfect utilization would be 27/370 (7.3%), versus 12.4% actual rate, with estimated cost savings of $231-$458 per patient. CONCLUSIONS Compared with a subjective practice strategy, an objective risk-based strategy using prediction software may be associated with superior results in optimizing SSI rates and costs after vascular surgery.
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Affiliation(s)
| | - Zhifei Sun
- KelaHealth, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Erich S Huang
- KelaHealth, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ehsan Benrashid
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ellen D Dillavou
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Benrashid E, Youngwirth LM, Guest K, Cox MW, Shortell CK, Dillavou ED. Negative pressure wound therapy reduces surgical site infections. J Vasc Surg 2020; 71:896-904. [DOI: 10.1016/j.jvs.2019.05.066] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/25/2019] [Indexed: 12/16/2022]
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Gombert A, Dillavou E, D'Agostino R, Griffin L, Robertson JM, Eells M. A systematic review and meta-analysis of randomized controlled trials for the reduction of surgical site infection in closed incision management versus standard of care dressings over closed vascular groin incisions. Vascular 2020; 28:274-284. [PMID: 31955666 PMCID: PMC7294533 DOI: 10.1177/1708538119890960] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Surgical site infection after groin incision is a common complication and a financial burden to patients and healthcare systems. Closed incision negative pressure therapy (ciNPT) has been associated with decreased surgical site infection rates in published literature. This meta-analysis examines the effect of ciNPT (PREVENA™ Incision Management System; KCI, San Antonio, TX) versus traditional postsurgical dressing use in reducing surgical site infection rates over closed groin incisions following vascular surgery. METHODS A systematic literature search using PubMed, OVID, EMBASE, and QUOSA was performed on 3 January 2019, by two independent researchers and focused on publications between 1 January 2005 and 31 December 2018. The review conformed to the statement and reporting check list of the Preferred Reporting Items for Systematic Reviews and Meta Analyses. Inclusion criteria included abstract or manuscript written in English, published studies, conference abstracts, randomized controlled trials (RCTs), ciNPT usage over closed groin incisions in vascular surgery, comparison of ciNPT use and traditional dressings, study endpoint/outcome of surgical site infection, and study population of >10. Characteristics of study participants, surgical procedure, type of dressing used, duration of treatment, incidence of surgical site infection, and length of follow-up were extracted. Weighted odds ratios and 95% confidence intervals were calculated to pool study and control groups in each publication for analysis. Treatment effects were combined using Mantel-Haenszel risk ratios, and the Chi-Square test was used to assess heterogeneity. Overall, high-risk patients, normal-risk patients, and Szilagyi I, II, III outcomes were assessed between ciNPT and control groups. The Cochrane Collaboration tool was utilized to assess the risk of bias for all studies included in the analysis. RESULTS A total of 615 articles were identified from the literature search. After removal of excluded studies and duplicates, six RCT studies were available for analysis. In these studies, a total of 362 patients received ciNPT, and 371 patients received traditional dressings (control). Surgical site infection events occurred in 41 ciNPT patients and 107 control patients. The heterogeneity test was nonsignificant (p > 0.05). The overall RCT meta-analysis showed a highly significant effect in favor of ciNPT (OR = 3.06, 95% CI [2.05, 4.58], p < 0.05). High-risk, normal-risk, Szilagyi I, and Szilagyi II meta-analyses were also statistically significant in favor of ciNPT use (p < 0.05). The varying RCT inclusion/exclusion criteria, such as differences in procedure types, and patient populations form the major limitations of this study. CONCLUSIONS A statistically significant reduction in the incidence of surgical site infection was seen following ciNPT usage in patients undergoing vascular surgery with groin incisions.
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Affiliation(s)
- Alexander Gombert
- Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany
| | - Ellen Dillavou
- Vascular Surgery, Duke Regional Hospital, Duke University Medical Center, Durham, NC, USA
| | - Ralph D'Agostino
- Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Anderson J, King R, Brothers T, Robison J, Veeraswamy R, Wooster M, Mukherjee R, Ruddy JM. Discharge to a Post-Acute Care Facility after Emergent Femoral Artery Repair is Not Protective Against Wound Complications. Ann Vasc Surg 2020; 66:400-405. [PMID: 31917226 DOI: 10.1016/j.avsg.2019.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 12/24/2019] [Accepted: 12/28/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Access site complication is the most common adverse event after endovascular intervention, and when emergent operative repair of the common femoral artery (CFA) is needed, patient morbidity can be significantly increased. The intent of this project was to identify predictors of wound events after emergent operative repair of the CFA due to an access site complication. It was hypothesized that patients discharged to a facility would benefit from an ongoing relationship with healthcare professionals as evidenced by more consistent follow-up and lower wound complication rates. METHODS Patients who had a percutaneous CFA access complication and required emergent open CFA repair at an academic medical institution between 2015 and 2018 were included, and the charts were reviewed retrospectively. Primary outcomes included wound complication and outpatient compliance with vascular surgery clinic visit. Dichotomous groups were evaluated by the chi-squared test, and continuous variables were evaluated by Student's t-test. Univariate and multivariate regression analyses were completed to assess risk factors contributing to wound event or failure of clinic follow-up. RESULTS Forty-four patients were identified with emergent CFA repair due to an access complication between July 2015 and June 2018. Among this population, 33% of patients had wound complications and 27% were discharged to a facility. Among those discharged to a facility, the rate of follow-up to the vascular surgeon's clinic was significantly lower than those discharged to home (40% vs. 85%, P < 0.05), and the incidence of wound complications appeared greater but did not reach statistical significance (50% vs. 27%, P = 0.11). Univariate analysis indicated that kidney disease, albumin <3 g/dL, and current smoking were predictive of wound complication, whereas on multivariate analysis, only kidney disease remained predictive (P < 0.05, odds ratio = 22). The modified frailty index (mFI) was not predictive of wound complications or compliance with follow-up. However, mFI did approach statistical significance when predicting discharge to a facility. CONCLUSIONS Despite the availability of medical personnel to arrange transportation and provide wound care in post-acute care facilities, patients who were discharged to a facility after CFA injury requiring emergent repair experienced lower compliance with clinic follow-up and may have suffered more wound complications. Strategies to improve compliance with patient follow-up and wound healing in patients sent to post-acute care facilities are warranted.
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Affiliation(s)
- Joseph Anderson
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Ryan King
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Thomas Brothers
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Surgery Section, Ralph H. Johnson Department of Medical Affairs Medical Center, Charleston, SC
| | - Jacob Robison
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Ravi Veeraswamy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Mathew Wooster
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Rupak Mukherjee
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Jean Marie Ruddy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Surgery Section, Ralph H. Johnson Department of Medical Affairs Medical Center, Charleston, SC.
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Inguinal Vascular Surgical Wound Protection by Incisional Negative Pressure Wound Therapy. Ann Surg 2020; 271:48-53. [DOI: 10.1097/sla.0000000000003364] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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