Using negative pressure wound therapy to prevent surgical site infection

Prophylactic Use of Negative Pressure Wound Therapy in High-risk Patients Undergoing Oncoplastic and Reconstructive Breast Surgery

Background

Negative pressure wound therapy (NPWT) has emerged as an adjunct to reduce wound complication rates in many surgical domains. This study investigated the prophylactic use of PICO NPWT in high-risk patients undergoing oncoplastic and reconstructive breast surgery.

Methods

This was a prospective multicenter national audit. The findings were compared against Association of Breast Surgery/British Association of Plastic, Reconstructive and Aesthetic Surgeons (ABS/BAPRAS) Oncoplastic Guidelines for best practice.

Results

Data from 267 patients were included from seven centers. All patients had at least one high-risk factor for postoperative wound complications, whereas 78 patients (29.2%) had more than one. Thirty-six patients (13.5%) developed postoperative wound complications. An estimated 16 (6%) developed skin flap necrosis, wound dehiscence occurred in 13 patients (4.9%), and 15 patients (5.6%) developed postoperative wound infection. Eleven patients (4.1%) required further surgery due to wound complications. In total, 158 patients underwent mastectomy with immediate implant reconstruction. Postoperative wound complication rate was comparable in this subgroup (n = 22; 13.9%). Implant loss rate was 3.8%, which was within the 5% target mentioned in the ABS/BAPRAS guidelines. The estimated total cost saving was US $105,600 (£84,613) and US $395.50 (£316.90) per patient. Wound infection rate (5.6%) was much lower than the 25% reported by both iBRA study and National Mastectomy and Breast Reconstruction Audit.

Conclusions

Our study suggests that prophylactic use of NPWT in oncoplastic and reconstructive breast surgery results in low rates of wound-related complications with associated healthcare cost benefits in patients with high-risk factors for wound-related complications. However, a prospective randomized control trial is required.

Efficacy of Strategies Intended to Prevent Surgical Site Infection After Lower Limb Revascularization Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The objective of this study is to evaluate the efficacy of strategies intended to prevent surgical site infection (SSI) after lower limb revascularization surgery.

BACKGROUND

SSIs are common, costly complications of lower limb revascularization surgery associated with significant morbidity and mortality.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 28, 2022). Two investigators independently screened abstracts and full-text articles, extracted data, and assessed the risk of bias. We included randomized controlled trials (RCTs) that evaluated strategies intended to prevent SSI after lower limb revascularization surgery for peripheral artery disease. We used random-effects models to pool data and GRADE to assess certainty.

RESULTS

Among 6258 identified citations, we included 26 RCTs (n=4752 patients) that evaluated 12 strategies to prevent SSI. Preincision antibiotics [risk ratio (RR)=0.25; 95% CI, 0.11-0.57; n=4 studies; I2 statistic=7.1%; high certainty] and incisional negative-pressure wound therapy (iNPWT) (RR=0.54; 95% CI, 0.38-0.78; n=5 studies; I2 statistic=7.2%; high certainty) reduced pooled risk of early (≤30 days) SSI. iNPWT also reduced the risk of longer-term (>30 days) SSI (pooled-RR=0.44; 95% CI, 0.26-0.73; n=2 studies; I2 =0%; low certainty). Strategies with uncertain effects on risk of SSI included preincision ultrasound vein mapping (RR=0.58; 95% CI, 0.33-1.01; n=1 study); transverse groin incisions (RR=0.33; 95% CI, 0.097-1.15; n=1 study), antibiotic-bonded prosthetic bypass grafts (RR=0.74; 95% CI, 0.44-1.25; n=1 study; n=257 patients), and postoperative oxygen administration (RR=0.66; 95% CI, 0.42-1.03; n=1 study) (low certainty for all).

CONCLUSIONS

Preincision antibiotics and iNPWT reduce the risk of early SSI after lower limb revascularization surgery. Confirmatory trials are required to determine whether other promising strategies also reduce SSI risk.

Evaluation of wound healing effects of micronized acellular dermal matrix in combination with negative pressure wound therapy: In vivo study

Acellular dermal matrix (ADM) grafts can provide coverage for full-thickness skin defects and substitute for dermal defects. We tested the effectiveness of micronized ADM (mADM) as a dressing material, combined with negative pressure wound therapy (NPWT), for managing superficial wounds. We compared the wound healing effect of mADM in combination with NPWT with those of gelatin and mADM applied with a foam dressing. These therapeutic materials were applied to 36 cm² excisional wounds in a porcine full-thickness skin defect model. Wound healing kinetics and new tissue formation were assessed 10 days after the initial treatment by measuring the wound area. Collagen deposition and neovascularization were histologically evaluated. Compared with the other two groups, mADM plus NPWT combination group had a significantly larger wound area at the baseline (P = .0040), but the smallest on the 7th day (P = .0093). In addition, collagen formation and neovascularization were more histologically promoted than in the other two groups. mADM showed better results than the gelatin group but less collagen and revascularization than the combination group, and there was no significant difference in wound area. Our results show that the combination of mADM and NPWT has a synergistic wound healing effect.

Prevention of Orthopedic Prosthetic Infections Using Evidence-Based Surgical Site Infection Care Bundles: A Narrative Review

Background: The number of primary/revision total joint replacements (TJR) are expected to increase substantially with an aging population and increasing prevalence of comorbid conditions. The 30-day re-admission rate, in all orthopedic specialties, is 5.4% (range, 4.8%-6.0%). A recent publication has documented that the surgical site infection (SSI) infection rate associated with revision total knee (rTKR, 15.6%) and revision total hip (rTHR, 8.6%) arthroplasties are four to seven times the rate of the primary procedures (2.1%-2.2%). These orthopedic infections prolong hospital stays, double re-admissions, and increase healthcare costs by a factor of 300%. Methods: A search of PubMed/MEDLINE, EMBASE and the Cochrane Library publications, which reported the infection risk after TKR and THR, was undertaken (January 1, 1995 to December 31, 2021). The search also included documentation of evidence-based practices that lead to improved post-operative outcomes. Results: The evidence-based approach to reducing the risk of SSI was grouped into pre-operative, peri-operative, and post-operative periods. Surgical care bundles have existed within other surgical disciplines for more than 20 years, although their use is relatively new in peri-operative orthopedic surgical care. Pre-admission chlorhexidine gluconate (CHG) showers/cleansing, staphylococcal decolonization, maintenance of normothermia, wound irrigation, antimicrobial suture wound closure, and post-operative wound care has been shown to improve clinical outcome in randomized controlled studies and meta-analyses. Conclusions: Evidence-based infection prevention care bundles have improved clinical outcomes in all surgical disciplines. The significant post-operative morbidity, mortality, and healthcare cost, associated with SSIs after TJR can be reduced by introduction of evidence-based pre-operative, intra-operative, and post-operative interventions.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Negative pressure wound therapy does not decrease postoperative wound complications in patients undergoing mastectomy and flap fixation

Patients and breast cancer surgeons are frequently confronted with wound complications after mastectomy. Negative pressure wound therapy (NPWT) is a promising technique for preventing wound complications after skin closure in elective surgery. However, a clinical study evaluating postoperative complications following the use of NPWT, focusing solely on closed incisions in patients undergoing mastectomy, has yet to be performed. Between June 2019 and February 2020, 50 consecutive patients underwent mastectomy with NPWT during the first seven postoperative days. This group was compared to a cohort of patients taking part in a randomized controlled trial between June 2014 and July 2018. Primary outcome was the rate of postoperative wound complications, i.e. surgical site infections, wound necrosis or wound dehiscence during the first three postoperative months. Secondary outcomes were the number of patients requiring unplanned visits to the hospital and developing clinically significant seroma (CSS). In total, 161 patients were analyzed, of whom 111 patients in the control group (CON) and 50 patients in the NPWT group (NPWT). Twenty-eight percent of the patients in the NPWT group developed postoperative wound complications, compared to 18.9% in the control group (OR = 1.67 (95% CI 0.77–3.63), p = 0.199). The number of patients requiring unplanned visits or developing CSS was not statistically significant between the groups. This study suggests that Avelle negative pressure wound therapy in mastectomy wounds does not lead to fewer postoperative wound complications. Additionally, it does not lead to fewer patients requiring unplanned visits or fewer patients developing clinically significant seromas.

Trial registration: ClinicalTrials.gov number, NCT03942575. Date of registration: 08/05/2019.

Negative Pressure Wound Therapy Versus Closed Suction Irrigation System in the Treatment of Deep Surgical Site Infection After Lumbar Surgery

OBJECTIVE

We compared the efficacy of a closed suction irrigation system (CSIS) and negative pressure wound therapy (NPWT) for deep surgical site infection (SSI) after lumbar surgery with instrumentation.

METHODS

We included 31 patients (NPWT group, n =16; CSIS group, n = 15) with deep SSIs after lumbar surgery with instrumentation from 2007 to 2017. The medical records were reviewed and patient characteristics, laboratory results, infection details, and treatment interventions were recorded. The Japanese Orthopaedic Association score and Oswestry disability index were used to assess pain and functional outcomes preoperatively and 3 and 12 months postoperatively. The cost of SSIs were compared between the NPWT and CSIS groups.

RESULTS

No significant differences were found in the baseline characteristic data between the NPWT and CSIS groups. Implants were retained in all patients in the CSIS group, but required removal from 2 patients with late infections in the NPWT group. The average hospital stay was 36.8 ± 10.5 days and 33.4 ± 18.9 days in the NPWT and CSIS groups, respectively. The cost was greater in the NPWT group than in the CSIS group. Both NPWT and CSIS significantly reduced the Oswestry disability index and improved the Japanese Orthopaedic Association scores, but no significant difference was found between the 2 groups.

CONCLUSIONS

Our results have shown that both NPWT and CSIS are efficient techniques for the management of deep SSI after lumbar surgery with instrumentation. CSIS was more economical and the NPWT system was portable and easier for postoperative nursing care.

Application of a paste-type acellular dermal matrix for coverage of chronic ulcerative wounds

BACKGROUND

Chronic wounds occur due to failure of the normal healing process, associated with a lack of deposition of cellular components and a suitable microenvironment such as the extracellular matrix (ECM). Acellular dermal matrix (ADM) is viewed as an ECM substitute, and a paste-type ADM has recently been introduced. We hypothesized that CGPaste, an injectable paste-type ADM, could serve as a scaffold and promote wound healing.

METHODS

We retrospectively studied seven patients in whom CGPaste was applied between 2017 and 2018, who had pressure ulcers, necrotizing fasciitis, diabetic foot ulcers, traumatic defects, and osteomyelitis. The goal of applying CGPaste was to achieve complete wound healing with re-epithelialization or growth of granulation tissue, depending upon the wound bed status. CGPaste was injected based on the wound size along with the application of a dressing.

RESULTS

Four of the seven patients showed granulation tissue on their wound bed, while the other three patients had a bony wound bed. The mean wound area was 453.57 mm2 and the depth was 10.71 mm. Wound healing occurred in five of the seven patients (71.43%). The mean duration of complete healing was 2.4 weeks. Two patients showed failure due to paste absorption (29.57%); these patients had wound beds comprising bone with relatively large and deep wounds (40×30 and 30×20 mm2 in area and 15 and 10 mm in depth).

CONCLUSIONS

CGPaste is an effective option for coverage of small and deep chronic wounds for which a flap operation or skin grafting is unfeasible.