The American Journal of Surgery xxx (xxxx) xxx

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The American Journal of Surgery

journal homepage: www.americanjournalofsurgery.com

Original Research Article

Negative pressure wound therapy for emergency laparotomy incisions: A

national database propensity matched study
~o Zamudio, May Abiad, Emanuele Lagazzi, Dias Argandykov,
Wardah Rafaqat, Jefferson A. Proan
Casey M. Luckhurst, George C. Velmahos, Michael P. DeWane, Haytham M.A. Kaafarani,
John O. Hwabejire *
Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA,
USA

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Surgical site infections (SSI) are a common complication of laparotomy incisions. The role of
Negative pressure wound therapy Negative Pressure Wound Therapy (NPWT) in preventing SSIs has not yet been explored in a nationwide analysis.
NPWT We aimed to evaluate the association of the prophylactic use of NPWT with SSIs in patients undergoing an
Emergency
emergency laparotomy procedure.
Laparotomy
Methods: We conducted a retrospective cohort study using the National Surgery Quality Initiative Program
(NSQIP) database from 2013 to 2020. We included patients
18 years undergoing an emergency laparotomy. We
performed a 1:1 propensity matching adjusting for patient age, sex, race, ethnicity, BMI, comorbid conditions,
ASA status, diagnosis, preoperative factors and laboratory variables, procedure type, wound class, and intra-
operative variables. We compared NPWT with standard dressings in two patient populations: 1. patients with
completely closed (skin and fascia) laparotomy incisions and 2. patients with partially closed (fascia only) lap-
arotomy incisions. Our primary outcome was the rate of incisional SSI. Secondary outcomes included the type of
SSI, postoperative 30-day complications, postoperative hospital length of stay, and discharge disposition.
Results: We included 65,803 patients with completely closed incisions of whom 387 patients received NPWT.
There was no significant difference in the rate of total SSIs (13.4 % vs. 11.9 %; p ¼ 0.52) in the matched pop-
ulation of 387 pairs. We included 7285 patients with partially closed incisions of whom 477 patients received
NPWT. There was no significant difference in the rate of total SSIs (3.6 % vs. 4.4 %; p ¼ 0.51) in the matched
population of 477 pairs. Secondary outcomes did not differ significantly in either group.
Conclusion: The rate of SSIs was not significantly different when prophylactic NPWT was used compared to
standard dressings for patients with a closed or partially closed laparotomy incision.

1. Introduction continuous vacuum using a vacuum device to remove excess edema to

Postoperative wound infections contribute to patient distress and
morbidity. Prior research has indicated that patients undergoing intra-
abdominal emergency surgery experience a surgical site infection rate
ranging from 7 % to 32 %.1,2 Recent studies have shown that surgical site
infections (SSI) result in more than $1.6 billion in costs and 1 million
extra hospital days in affected patients in the United States.3
There are several bundles and practices that have been developed to
prevent surgical site infections.4,5 One of the techniques used is pro-
phylactic negative pressure wound therapy (NPWT). NPWT creates a
prevent bacterial growth, and to promote healing through granulation
formation.6–8 However, the evidence for the benefit of NPWT after lap-
arotomy is conflicted. In addition, previous studies rely on data from
single institutions,9–11 underrepresent emergency procedures,9–11 have a
limited sample size,12–15 or do not include a comparison group.13,14
Therefore, our goal was to use a nationally representative cohort to
determine whether the prophylactic use of NPWT after laparotomy in-
cisions is associated with a reduction in SSI rate. We compared NPWT
with standard dressings in two patient populations. For the first com-
parison, we included patients with skin and fascial closure of their

* Corresponding author. Division of Trauma, Emergency Surgery and Surgical Critical Care Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston,
MA, 02114, USA.
E-mail address: jhwabejire@mgb.org (J.O. Hwabejire).

https://doi.org/10.1016/j.amjsurg.2023.10.055
Received 10 August 2023; Received in revised form 29 October 2023; Accepted 30 October 2023
0002-9610/© 2023 Elsevier Inc. All rights reserved.

Please cite this article as: Rafaqat W et al., Negative pressure wound therapy for emergency laparotomy incisions: A national database propensity
matched study, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2023.10.055
W. Rafaqat et al.
laparotomy incision. For the second comparison, we included patients
with only fascial closure of their laparotomy incision. We hypothesized
that use of NPWT would result in fewer wound infections in both patient
populations.
2. Methods
2.1. Data source
We used the American College of Surgeons National Surgical Quality
Improvement Program (ACS-NSQIP) participant user files for the years
2013–2020.16 These files contain procedures from over 700 centers in
the United States.17 The database provides an extensive list of preoper-
ative, intraoperative, and 30-day postoperative variables presented in a
deidentified and HIPAA-compliant manner.
2.2. Patient population
We identified patients who were undergoing emergency general
surgery procedures via a laparotomy incision using a combination of CPT
codes and the ‘emergency’ variable present within the dataset (Supple-
mentary Appendix Table 1). We used categories present in the NSQIP
variable ‘wound_closure’ to identify the level of skin closure after the
laparotomy. The following are the three categories of closure: 1. ‘no
layers of the incision were surgically closed’, 2. ‘only deep layers (fascia)
were surgically closed’, and 3. ‘all layers of the incision (fascia and skin)
were surgically closed’ to classify wound closure.18 We excluded patients
in whom the deep layers (fascia) were not surgically closed.
We also identified patients with a laparotomy for aneurysm repair by
identifying patients undergoing aneurysm repair using the following
codes: 34830 34831 34832 35081 35082 35091 35092 35102 35103
and excluded such patients. We identified the diagnosis for these pro-
cedures using the International Classification of Diseases [ICD] ninth and
tenth revisions. We identified patients receiving NPWT using the
following CPT codes: 97605 97606 97607 97608.
We performed two analyses. Firstly, we compared the impact of
NPWT on SSI rate in comparison to standard dressing in patients with
skin and fascial closure of their laparotomy incision. For this analysis, we
excluded patients in whom only the fascia of their laparotomy incision
was closed. For the second analysis, we compared the impact of NPWT on
SSI rate in comparison to standard dressing in patients with only fascial
closure of their laparotomy incision. For this cohort, we excluded pa-
tients with both skin and fascial closure of their laparotomy incision. We
considered standard dressing to be any variation of gauze, tape, or liquid
adhesive that is typically used on operative wounds.
2.3. Patient characteristics
Analyzed patient characteristics included patient age, sex, race,
ethnicity, BMI, smoking status, comorbid conditions (chronic obstructive
pulmonary disease, hypertension, diabetes, congestive heart failure
functional status, recent weight loss, bleeding disorders, steroid use, as-
cites, disseminated cancer, dialysis, acute kidney injury). Preoperative
patient factors included: transfusion, sepsis, white blood cell count,
bilirubin, hematocrit, and intraoperative variables included: bowel
resection, ASA status, wound class, and type of procedure. We also
assessed the postoperative diagnosis of bowel perforation and return to
the operating room.
2.4. Outcomes
Our primary outcome was the percentage of patients with incisional
SSIs (deep and superficial SSIs). The NSQIP criteria define superficial SSI
as ‘purulent drainage; or positive culture; or pain/tenderness, swelling,
erythema, warm and opened (unless culture negative)’, deep SSI as
‘purulent drainage not from the organ/space component; or a deep
2
The American Journal of Surgery xxx (xxxx) xxx
incision that spontaneously dehisces or is opened with fever or localized
pain/tenderness (unless culture negative); abscess or infection found on
direct exam, reoperation, histology, or imaging.‘, and organ-space SSI as
‘purulent drainage from a drain (not placed during the operative pro-
cedure); positive culture from an aseptically placed drain; abscess or
infection found on direct exam, reoperation, histology, or imaging’.19,20
Secondary outcomes included the type of SSI, postoperative 30-day
complications, postoperative hospital length of stay, organ-space SSI,
and discharge disposition.
2.5. Statistical analysis
We analyzed demographic variables using a t-test or Wilcoxon rank-
sum test for continuous variables and Pearson's χ2 test or Fisher's exact
test for categorical variables. To match a population's nearest neighbor
(1:1) propensity score matching using a caliper width of 0.2 of the
standard deviation of the logit of the propensity score was performed.
For each analysis, the propensity score model incorporated age, sex,
race, comorbidities, pre-operative critical illness (acute kidney injury,
ventilator dependence, sepsis, or septic shock), pre-operative laboratory
values, post-operative diagnosis, ASA physical status, operative time,
performance of bowel resection, type of procedure, and contamination of
the operative field (as indicated by the CDC wound classification).21 We
calculated the standardized difference pre and post matching and a
post-matching value < 0.15 after matching was considered balanced. In
the matched cohorts, we compared outcomes using univariate statistical
analysis. A p-value <0.05 was considered statistically significant. We
performed all analyses using Stata version 17.0 (Stata Corp, College
Station, Texas). This study was deemed exempt from ethical review by
the Mass General Brigham institutional review board since it is a
de-identified database study.
3. Results
3.1. NPWT vs. standard dressing in skin and fascial closure of laparotomy
incisions
3.1.1. Patient characteristics
For this comparison, we included 64,764 patients of whom 354 pa-
tients received NPWT. A significantly greater proportion of patients
receiving NPWT were non-Hispanic, had BMI
40 kg/m2, had smoking,
COPD, diabetes, and dialysis dependency as a comorbidity, and had a
wound class of 4. Patients receiving NPWT were also older than patients
receiving standard dressings. Pre-matching and post-patching charac-
teristics are summarized in Table 1. The patient cohort after matching
consisted of 354 pairs. The covariate balance after matching can be seen
in Fig. 1.
3.1.2. Post-matching outcomes
There was no significant difference in the rate of incisional SSIs, su-
perficial SSIs, deep SSIs, or organ-space SSIs in the matched population.
There was also no significant difference noted in the 30-day readmission
rate, 30-day mortality, postoperative length of stay, discharge disposi-
tion, or other postoperative complications including 30-day sepsis, pul-
monary embolism, and deep vein thrombosis (Table 2).
3.2. NPWT vs. standard dressing in only fascial closure of laparotomy
incisions
3.2.1. Patient characteristics
For this comparison, we included 6222 patients of whom 445 patients
received NPWT. A greater proportion of patients receiving NPWT were
non-Hispanic, had BMI
40 kg/m2, and had diabetes, elevated preop-
erative BUN, and elevated preoperative Creatinine (Table 3). The patient
cohort after matching consisted of 445 pairs. A small proportion of pa-
tients in the matched NPWT group returned to the operating room.
W. Rafaqat et al. The American Journal of Surgery xxx (xxxx) xxx

Table 1
Demographics of patients with skin and fascial closure of laparotomy incisions included in study on impact of Negative Pressure Wound Therapy on postoperative
complications.
Characteristics Unmatched patients Matched patients

Standard Dressing NPWT p-value Standard Dressing NPWT p-value

N ¼ 65,416 N ¼ 387 N ¼ 387 N ¼ 387

Age, median (IQR) 65.0 (53.0–76.0) 63.0 (53.0–74.0) 0.10 63.0 (53.0–73.0) 63.0 (53.0–74.0) 0.80
Sex, n (%) 0.74 0.61
Male 30,877 (47.2 %) 186 (48.1 %) 179 (46.3 %) 186 (48.1 %)
Female 34,539 (52.8 %) 201 (51.9 %) 208 (53.7 %) 201 (51.9 %)
Race, n (%) 0.28 0.35
White 53,374 (81.6 %) 315 (81.4 %) 328 (84.8 %) 315 (81.4 %)
Black 9447 (14.4 %) 64 (16.5 %) 51 (13.2 %) 64 (16.5 %)
Asian 1952 (3.0 %) 6 (1.6 %) 3 (0.8 %) 6 (1.6 %)
American Indian or Alaska Native 477 (0.7 %) 2 (0.5 %) 4 (1.0 %) 2 (0.5 %)
Native Hawaiian or Pacific Islander 166 (0.3 %) 0 (0.0 %) 1 (0.3 %) 0 (0.0 %)
Ethnicity, n (%) 0.010 0.84
Non-Hispanic 61,083 (93.4 %) 374 (96.6 %) 373 (96.4 %) 374 (96.6 %)
Hispanic 4333 (6.6 %) 13 (3.4 %) 14 (3.6 %) 13 (3.4 %)
BMI in kg/m2, n (%) <0.001 0.54
< 18.5 kg/m2 3193 (4.9 %) 14 (3.6 %) 9 (2.3 %) 14 (3.6 %)
≥18.5 kg/m2 and < 25 kg/m2 21,395 (32.7 %) 88 (22.7 %) 104 (26.9 %) 88 (22.7 %)
≥ 25 kg/m2 and < 30 kg/m2 18,347 (28.0 %) 100 (25.8 %) 107 (27.6 %) 100 (25.8 %)
≥ 30 kg/m2 and < 35 kg/m2 10,939 (16.7 %) 77 (19.9 %) 67 (17.3 %) 77 (19.9 %)
≥ 35 kg/m2 and < 40 kg/m2 5605 (8.6 %) 48 (12.4 %) 40 (10.3 %) 48 (12.4 %)
≥ 40 kg/m2 5937 (9.1 %) 60 (15.5 %) 60 (15.5 %) 60 (15.5 %)
Current smoker 0.004 0.75
No 50,775 (77.6 %) 277 (71.6 %) 273 (70.5 %) 277 (71.6 %)
Yes 14,641 (22.4 %) 110 (28.4 %) 114 (29.5 %) 110 (28.4 %)
COPD 0.033 0.92
No 59,071 (90.3 %) 337 (87.1 %) 336 (86.8 %) 337 (87.1 %)
Yes 6345 (9.7 %) 50 (12.9 %) 51 (13.2 %) 50 (12.9 %)
Diabetes <0.001 0.74
No 54,750 (83.7 %) 297 (76.7 %) 293 (75.7 %) 297 (76.7 %)
Yes 10,666 (16.3 %) 90 (23.3 %) 94 (24.3 %) 90 (23.3 %)
Hypertension <0.001 0.55
No 30,810 (47.1 %) 142 (36.7 %) 134 (34.6 %) 142 (36.7 %)
Yes 34,606 (52.9 %) 245 (63.3 %) 253 (65.4 %) 245 (63.3 %)
Functional status 0.21 0.99
Independent 60,248 (92.1 %) 347 (89.7 %) 348 (89.9 %) 347 (89.7 %)
Partially dependent 4036 (6.2 %) 31 (8.0 %) 30 (7.8 %) 31 (8.0 %)
Totally dependent 1132 (1.7 %) 9 (2.3 %) 9 (2.3 %) 9 (2.3 %)
CHF 0.88 0.34
No 63,471 (97.0 %) 375 (96.9 %) 370 (95.6 %) 375 (96.9 %)
Yes 1945 (3.0 %) 12 (3.1 %) 17 (4.4 %) 12 (3.1 %)
Dialysis dependent 0.026 0.20
No 63,723 (97.4 %) 370 (95.6 %) 362 (93.5 %) 370 (95.6 %)
Yes 1693 (2.6 %) 17 (4.4 %) 25 (6.5 %) 17 (4.4 %)
Disseminated cancer 0.24 0.86
No 61,446 (93.9 %) 369 (95.3 %) 370 (95.6 %) 369 (95.3 %)
Yes 3970 (6.1 %) 18 (4.7 %) 17 (4.4 %) 18 (4.7 %)
Steroid use 0.16 0.31
No 59,942 (91.6 %) 347 (89.7 %) 338 (87.3 %) 347 (89.7 %)
Yes 5474 (8.4 %) 40 (10.3 %) 49 (12.7 %) 40 (10.3 %)
>10 % weight loss in the last 6 months 0.27 0.22
No 62,157 (95.0 %) 363 (93.8 %) 354 (91.5 %) 363 (93.8 %)
Yes 3259 (5.0 %) 24 (6.2 %) 33 (8.5 %) 24 (6.2 %)
Bleeding disorder 0.39 0.11
No 57,392 (87.7 %) 334 (86.3 %) 318 (82.2 %) 334 (86.3 %)
Yes 8024 (12.3 %) 53 (13.7 %) 69 (17.8 %) 53 (13.7 %)
Preoperative transfusion 0.88 0.16
No 61,983 (94.8 %) 366 (94.6 %) 374 (96.6 %) 366 (94.6 %)
Yes 3433 (5.2 %) 21 (5.4 %) 13 (3.4 %) 21 (5.4 %)
Pre-operative AKI 0.11 0.71
No 63,857 (97.6 %) 373 (96.4 %) 371 (95.9 %) 373 (96.4 %)
Yes 1559 (2.4 %) 14 (3.6 %) 16 (4.1 %) 14 (3.6 %)
Pre-operative serum sodium 0.006 0.51
<135 mEq/L 13,461 (20.6 %) 105 (27.1 %) 98 (25.3 %) 105 (27.1 %)
≥135 mEq/L & < 145 mEq/L 50,371 (77.0 %) 273 (70.5 %) 275 (71.1 %) 273 (70.5 %)
>145 mEq/L 1584 (2.4 %) 9 (2.3 %) 14 (3.6 %) 9 (2.3 %)
Pre-operative BUN
20 mg/dL 0.003 0.71
No 46,459 (%) 248 (%) 243 (%) 248 (%)
Yes 18,957 (%) 139 (%) 144 (%) 139 (%)
Pre-operative creatinine
1.5 mg/dL <0.001 0.74
No 54,076 (82.7 %) 285 (73.6 %) 289 (74.7 %) 285 (73.6 %)
Yes 11,340 (17.3 %) 102 (26.4 %) 98 (25.3 %) 102 (26.4 %)
(continued on next page)

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Table 1 (continued )
Characteristics Unmatched patients Matched patients

Standard Dressing NPWT p-value Standard Dressing NPWT p-value

N ¼ 65,416 N ¼ 387 N ¼ 387 N ¼ 387

Pre-operative albumin 3 g/dL <0.001 0.94

No 49,412 (75.5 %) 263 (68.0 %) 262 (67.7 %) 263 (68.0 %)
Yes 16,004 (24.5 %) 124 (32.0 %) 125 (32.3 %) 124 (32.0 %)
Pre-operative bilirubin
1.2 mg/dL 0.005 0.17
No 54,826 (83.8 %) 304 (78.6 %) 319 (82.4 %) 304 (78.6 %)
Yes 10,590 (16.2 %) 83 (21.4 %) 68 (17.6 %) 83 (21.4 %)
Pre-operative AST
40 U/L 0.007 0.57
No 56,340 (86.1 %) 315 (81.4 %) 321 (82.9 %) 315 (81.4 %)
Yes 9076 (13.9 %) 72 (18.6 %) 66 (17.1 %) 72 (18.6 %)
Pre-operative ALP> 125 U/L 0.095 0.26
No 56,820 (86.9 %) 325 (84.0 %) 313 (80.9 %) 325 (84.0 %)
Yes 8596 (13.1 %) 62 (16.0 %) 74 (19.1 %) 62 (16.0 %)
Pre-operative WBC 0.055 0.46
< 4000/μL 2675 (4.1 %) 16 (4.1 %) 18 (4.7 %) 16 (4.1 %)
≥4000/μL and < 11,000/μL 31,648 (48.4 %) 169 (43.7 %) 154 (39.8 %) 169 (43.7 %)
≥ 11,000/μL and < 15,000/μL 15,213 (23.3 %) 92 (23.8 %) 82 (21.2 %) 92 (23.8 %)
≥ 15,000/μL and < 25,000/μL 13,140 (20.1 %) 83 (21.4 %) 99 (25.6 %) 83 (21.4 %)
≥25,000/μL 2740 (4.2 %) 27 (7.0 %) 34 (8.8 %) 27 (7.0 %)
Pre-operative Hct 35 % 0.010 0.080
No 45,540 (69.6 %) 246 (63.6 %) 269 (69.5 %) 246 (63.6 %)
Yes 19,876 (30.4 %) 141 (36.4 %) 118 (30.5 %) 141 (36.4 %)
Pre-operative platelet count 0.26 0.88
< 100,000/μL 2229 (3.4 %) 19 (4.9 %) 17 (4.4 %) 19 (4.9 %)
≥100,000/μL and < 500,000/μL 60,636 (92.7 %) 354 (91.5 %) 354 (91.5 %) 354 (91.5 %)
≥ 500,000/μL 2551 (3.9 %) 14 (3.6 %) 16 (4.1 %) 14 (3.6 %)
ASA physical status <0.001 0.56
1/2 16,279 (24.9 %) 39 (10.1 %) 29 (7.5 %) 39 (10.1 %)
3 32,041 (49.0 %) 202 (52.2 %) 209 (54.0 %) 202 (52.2 %)
4 15,722 (24.0 %) 131 (33.9 %) 137 (35.4 %) 131 (33.9 %)
5 1374 (2.1 %) 15 (3.9 %) 12 (3.1 %) 15 (3.9 %)
Wound class <0.001 0.25
1 13,241 (20.2 %) 29 (7.5 %) 33 (8.5 %) 29 (7.5 %)
2 19,606 (30.0 %) 81 (20.9 %) 86 (22.2 %) 81 (20.9 %)
3 11,123 (17.0 %) 94 (24.3 %) 71 (18.3 %) 94 (24.3 %)
4 21,446 (32.8 %) 183 (47.3 %) 197 (50.9 %) 183 (47.3 %)

BMI: Basal Metabolic Index, COPD: Chronic Obstructive Pulmonary Disease, CHF: congestive heart failure, AKI: acute kidney injury, AST: Aspartate aminotransferase,
ALP: Alkaline Phosphatase, WBC: white blood cell, Hct: hematocrit, ASA: American Society of Anesthesiologists.

Fig. 1. Covariate balance pre- and post-matching for use of NPWT in patients with skin and fascial closure of laparotomy incisions.

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Table 2
Outcomes in matched patients with skin and fascial closure and fascial closure only of laparotomy incisions included in a study on the impact of Negative Pressure
Wound Therapy on postoperative complications.
Outcomes Skin and Fascial Closure Fascial Closure Only

Standard Dressing NPWT p-value Standard Dressing NPWT p-value

N ¼ 387 N ¼ 387 N ¼ 477 N ¼ 477

Incisional SSIs, n (%) 0.52 0.51

No 341 (88.1 %) 335 (86.6 %) 456 (95.6 %) 460 (96.4 %)
Yes 46 (11.9 %) 52 (13.4 %) 21 (4.4 %) 17 (3.6 %)
Organ Space SSI, n (%) 0.48 0.51
No 357 (92.2 %) 362 (93.5 %) 12 (2.5 %) 9 (1.9 %)
Yes 30 (7.8 %) 25 (6.5 %) 465 (97.5 %) 468 (98.1 %)
Deep Incisional SSI, n (%) 0.050 0.51
No 377 (97.4 %) 384 (99.2 %) 12 (2.5 %) 9 (1.9 %)
Yes 11 (2.6 %) 4 (0.8 %) 465 (97.5 %) 468 (98.1 %)
Superficial SSI, n (%) 0.050 0.81
No 377 (97.4 %) 384 (99.2 %) 468 (98.1 %) 469 (98.3 %)
Yes 11 (2.6 %) 4 (0.8 %) 9 (1.9 %) 8 (1.7 %)
30-day Mortality, n (%) 0.75 0.26
No 367 (94.8 %) 365 (94.3 %) 406 (85.1 %) 418 (87.6 %)
Yes 20 (5.2 %) 22 (5.7 %) 71 (14.9 %) 59 (12.4 %)
30-day Sepsis, n (%) 0.30 0.94
No 327 (84.5 %) 337 (87.1 %) 369 (77.4 %) 368 (77.1 %)
Yes 60 (15.5 %) 50 (12.9 %) 108 (22.6 %) 109 (22.9 %)
30-day PE, n (%) 0.41 0.37
No 383 (99.0 %) 385 (99.5 %) 465 (97.5 %) 469 (98.3 %)
Yes 4 (1.0 %) 2 (0.5 %) 12 (2.5 %) 8 (1.7 %)
30-day DVT, n (%) 0.19 0.66
No 369 (95.3 %) 376 (97.2 %) 454 (95.2 %) 451 (94.5 %)
Yes 18 (4.7 %) 11 (2.8 %) 23 (4.8 %) 26 (5.5 %)
30-day Readmission, n (%) 0.21 0.43
No 338 (87.3 %) 349 (90.2 %) 422 (88.5 %) 414 (86.8 %)
Yes 49 (12.7 %) 38 (9.8 %) 55 (11.5 %) 63 (13.2 %)
Discharge disposition, n (%) 0.63 0.25
Home 242 (62.5 %) 227 (58.7 %) 247 (51.8 %) 257 (53.9 %)
Acute Care 7 (1.8 %) 7 (1.8 %) 4 (0.8 %) 12 (2.5 %)
Skilled care 75 (19.4 %) 71 (18.3 %) 116 (24.3 %) 105 (22.0 %)
Rehab 24 (6.2 %) 33 (8.5 %) 43 (9.0 %) 44 (9.2 %)
Hospice 4 (1.0 %) 6 (1.6 %) 8 (1.7 %) 8 (1.7 %)
Unskilled facility 0 (0.0 %) 1 (0.3 %) 2 (0.4 %) 1 (0.2 %)
Left AMA 1 (0.3 %) 0 (0.0 %) 0 (0.0 %) 3 (0.6 %)
Died 34 (8.8 %) 42 (10.9 %) 57 (11.9 %) 47 (9.9 %)
Postoperative LOS (days), median (IQR) 85–14 96–14 0.094 107–15 106–15 0.91

SSI: surgical site infection, PE: pulmonary embolism, DVT: deep venous thrombosis, Rehab: rehabilitation, AMA: Against Medical Advice, LOS: length of stay.

Among these patients, the reoperation was related to the laparotomy in
45 (84.9 %) patients, and the most common procedure was the reopening
of their laparotomy incision (11 patients; 21 %). The covariate balance
after matching can be seen in Fig. 2. Characteristics in the matched
population for both groups are summarized in Table 3.
3.2.2. Post-matching outcomes
There was no significant difference in the primary outcome: rate of
incisional SSIs or the secondary outcomes including superficial SSIs, deep
SSIs, organ-space SSI, 30-day sepsis, 30-day readmission, discharge
disposition, postoperative length of stay, or 30-day mortality in the
matched population (Table 2).
4. Discussion
The results of our study showed no reduction in the rate of SSIs when
patients with complete or partial closure of laparotomy incisions received
prophylactic NPWT.
Previous literature has shown conflicting results about the benefit of
NPWT in patients with skin and fascial closure of laparotomy incisions. In
a meta-analysis based on 5 randomized controlled trials, Kuper et al.,
concluded that there was no significant difference in the rate of SSIs
among those patients who had NPWT compared to standard dressings
after a laparotomy incision.22 Similarly, Sonia et al. conducted a
meta-analysis based on six RCTs and 14 observational studies and rec-
ommended against the routine use of NPWT for SSI prophylaxis
following abdominal surgery. In the meta-analysis by Sonia et al., a
combined analysis of all studies showed that NPWT reduced rates of SSIs,
but the analysis had significant heterogeneity. When data from only RCTs
was pooled, the difference in the rate of SSIs became non-significant.10 In
another meta-analysis, Sahebally et al. concluded that the risk of SSIs
after laparotomy was reduced with the use of NPWT compared to stan-
dard dressings.11 However, this study combined data from observational
studies and randomized controlled trials. In addition, the authors
included a study comparing the use of NPWT in patients with only fascial
closure of their laparotomy incision.13
Our results did not show a difference in outcomes in patients who
received NPWT after only fascial closure of laparotomy incisions. The use
of NPWT after partial closure has not been well-explored in previous
literature. Ota et al. conducted a multicentered prospective study that
enrolled 56 patients with lower gastrointestinal perforation who received
NPWT after partial closure. The authors concluded that the use of NPWT
was associated with a low incidence of infectious complications.14
Similarly, Sato et al. used NPWT in patients with contaminated (n ¼ 15)
or dirty/infected wounds (n ¼ 7). The authors found that prophylactic
NPWT was feasible and resulted in a low incidence of incisional SSIs.
However, these studies only had a single arm as they did not compare
with a group of patients without NPWT.15 Lozano-Balderas et al. con-
ducted a three-arm randomized controlled trial including patients with
primary skin closure (n ¼ 27), fascial closure with delayed skin closure
(n ¼ 29), and fascial closure with NPWT-assisted delayed skin closure (n
¼ 25). The authors found a significant decrease in the rate of SSIs in the

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Table 3
Demographics of patients with only fascial closure of laparotomy incisions included in study on impact of Negative Pressure Wound Therapy on postoperative
complications.
Characteristics Unmatched patients Matched patients

Standard Dressing NPWT p-value Standard Dressing NPWT p-value

N ¼ 6808 N ¼ 477 N ¼ 477 N ¼ 477

Age, median (IQR) 64.0 (54.0–74.0) 62.0 (53.0–73.0) 0.011 63.0 (53.0–72.0) 62.0 (53.0–73.0) 0.56
Sex, n (%) 0.43 0.36
Male 3255 (47.8 %) 237 (49.7 %) 251 (52.6 %) 237 (49.7 %)
Female 3553 (52.2 %) 240 (50.3 %) 226 (47.4 %) 240 (50.3 %)
Race, n (%) 0.24 0.45
White 5718 (84.0 %) 408 (85.5 %) 412 (86.4 %) 408 (85.5 %)
Black 842 (12.4 %) 60 (12.6 %) 52 (10.9 %) 60 (12.6 %)
Asian 144 (2.1 %) 4 (0.8 %) 9 (1.9 %) 4 (0.8 %)
American Indian or Alaska Native 80 (1.2 %) 5 (1.0 %) 4 (0.8 %) 5 (1.0 %)
Native Hawaiian or Pacific Islander 24 (0.4 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %)
Ethnicity, n (%) 0.021 0.21
Non-Hispanic 6424 (94.4 %) 462 (96.9 %) 468 (98.1 %) 462 (96.9 %)
Hispanic 384 (5.6 %) 15 (3.1 %) 9 (1.9 %) 15 (3.1 %)
BMI in kg/m2, n (%) <0.001 0.93
< 18.5 kg/m2 270 (4.0 %) 11 (2.3 %) 15 (3.1 %) 11 (2.3 %)
≥18.5 kg/m2 and < 25 kg/m2 1929 (28.3 %) 101 (21.2 %) 106 (22.2 %) 101 (21.2 %)
≥ 25 kg/m2 and < 30 kg/m2 1849 (27.2 %) 117 (24.5 %) 107 (22.4 %) 117 (24.5 %)
≥ 30 kg/m2 and < 35 kg/m2 1310 (19.2 %) 104 (21.8 %) 102 (21.4 %) 104 (21.8 %)
≥ 35 kg/m2 and < 40 kg/m2 694 (10.2 %) 60 (12.6 %) 64 (13.4 %) 60 (12.6 %)
≥ 40 kg/m2 756 (11.1 %) 84 (17.6 %) 83 (17.4 %) 84 (17.6 %)
Current smoker 0.57 0.71
No 5014 (73.6 %) 357 (74.8 %) 362 (75.9 %) 357 (74.8 %)
Yes 1794 (26.4 %) 120 (25.2 %) 115 (24.1 %) 120 (25.2 %)
COPD 0.52 0.69
No 6004 (88.2 %) 416 (87.2 %) 420 (88.1 %) 416 (87.2 %)
Yes 804 (11.8 %) 61 (12.8 %) 57 (11.9 %) 61 (12.8 %)
Diabetes 0.037 0.69
No 5623 (82.6 %) 376 (78.8 %) 371 (77.8 %) 376 (78.8 %)
Yes 1185 (17.4 %) 101 (21.2 %) 106 (22.2 %) 101 (21.2 %)
Hypertension 0.31 0.69
No 3059 (44.9 %) 203 (42.6 %) 197 (41.3 %) 203 (42.6 %)
Yes 3749 (55.1 %) 274 (57.4 %) 280 (58.7 %) 274 (57.4 %)
Functional status 0.14 0.62
Independent 6173 (90.7 %) 445 (93.3 %) 450 (94.3 %) 445 (93.3 %)
Partially dependent 504 (7.4 %) 24 (5.0 %) 18 (3.8 %) 24 (5.0 %)
Totally dependent 131 (1.9 %) 8 (1.7 %) 9 (1.9 %) 8 (1.7 %)
CHF 0.24 0.68
No 6551 (96.2 %) 464 (97.3 %) 466 (97.7 %) 464 (97.3 %)
Yes 257 (3.8 %) 13 (2.7 %) 11 (2.3 %) 13 (2.7 %)
Dialysis dependent 0.053 0.67
No 6547 (96.2 %) 467 (97.9 %) 465 (97.5 %) 467 (97.9 %)
Yes 261 (3.8 %) 10 (2.1 %) 12 (2.5 %) 10 (2.1 %)
Disseminated cancer 0.80 1.00
No 6259 (91.9 %) 437 (91.6 %) 437 (91.6 %) 437 (91.6 %)
Yes 549 (8.1 %) 40 (8.4 %) 40 (8.4 %) 40 (8.4 %)
Steroid use 0.17 1.00
No 5871 (86.2 %) 422 (88.5 %) 422 (88.5 %) 422 (88.5 %)
Yes 937 (13.8 %) 55 (11.5 %) 55 (11.5 %) 55 (11.5 %)
>10 % weight loss in the last 6 months 0.61 0.45
No 6398 (94.0 %) 451 (94.5 %) 456 (95.6 %) 451 (94.5 %)
Yes 410 (6.0 %) 26 (5.5 %) 21 (4.4 %) 26 (5.5 %)
Bleeding disorder 0.66 0.86
No 5774 (84.8 %) 401 (84.1 %) 403 (84.5 %) 401 (84.1 %)
Yes 1034 (15.2 %) 76 (15.9 %) 74 (15.5 %) 76 (15.9 %)
Preoperative transfusion 0.92 0.67
No 6430 (94.4 %) 450 (94.3 %) 453 (95.0 %) 450 (94.3 %)
Yes 378 (5.6 %) 27 (5.7 %) 24 (5.0 %) 27 (5.7 %)
Pre-operative AKI 0.86 0.60
No 6540 (96.1 %) 459 (96.2 %) 462 (96.9 %) 459 (96.2 %)
Yes 268 (3.9 %) 18 (3.8 %) 15 (3.1 %) 18 (3.8 %)
Pre-operative serum sodium 0.77 0.44
<135 mEq/L 1902 (27.9 %) 135 (28.3 %) 129 (27.0 %) 135 (28.3 %)
≥135 mEq/L & < 145 mEq/L 4695 (69.0 %) 330 (69.2 %) 341 (71.5 %) 330 (69.2 %)
>145 mEq/L 211 (3.1 %) 12 (2.5 %) 7 (1.5 %) 12 (2.5 %)
Pre-operative BUN
20 mg/dL 0.034 0.22
No 4178 (%) 316 (%) 298 (%) 316 (%)
Yes 2630 (%) 161 (%) 179 (%) 161 (%)
Pre-operative Cr
1.5 mg/dL 0.033 0.31
No 5068 (74.4 %) 376 (78.8 %) 363 (76.1 %) 376 (78.8 %)
Yes 1740 (25.6 %) 101 (21.2 %) 114 (23.9 %) 101 (21.2 %)
(continued on next page)

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W. Rafaqat et al. The American Journal of Surgery xxx (xxxx) xxx

Table 3 (continued )
Characteristics Unmatched patients Matched patients

Standard Dressing NPWT p-value Standard Dressing NPWT p-value

N ¼ 6808 N ¼ 477 N ¼ 477 N ¼ 477

Pre-operative albumin 3 g/dL 1.00 0.35

No 4025 (59.1 %) 282 (59.1 %) 296 (62.1 %) 282 (59.1 %)
Yes 2783 (40.9 %) 195 (40.9 %) 181 (37.9 %) 195 (40.9 %)
Pre-operative bilirubin
1.2 mg/dL 0.19 0.31
No 5354 (78.6 %) 363 (76.1 %) 376 (78.8 %) 363 (76.1 %)
Yes 1454 (21.4 %) 114 (23.9 %) 101 (21.2 %) 114 (23.9 %)
Pre-operative AST
40 U/L 0.092 0.46
No 5603 (82.3 %) 378 (79.2 %) 387 (81.1 %) 378 (79.2 %)
Yes 1205 (17.7 %) 99 (20.8 %) 90 (18.9 %) 99 (20.8 %)
Pre-operative ALP >125 U/L 0.94 0.15
No 5633 (82.7 %) 394 (82.6 %) 410 (86.0 %) 394 (82.6 %)
Yes 1175 (17.3 %) 83 (17.4 %) 67 (14.0 %) 83 (17.4 %)
Pre-operative WBC 0.61 0.76
< 4000/μL 421 (6.2 %) 32 (6.7 %) 29 (6.1 %) 32 (6.7 %)
≥4000/μL and < 11,000/μL 2397 (35.2 %) 157 (32.9 %) 173 (36.3 %) 157 (32.9 %)
≥ 11,000/μL and < 15,000/μL 1582 (23.2 %) 124 (26.0 %) 114 (23.9 %) 124 (26.0 %)
≥ 15,000/μL and < 25,000/μL 1862 (27.4 %) 124 (26.0 %) 127 (26.6 %) 124 (26.0 %)
≥25,000/μL 546 (8.0 %) 40 (8.4 %) 34 (7.1 %) 40 (8.4 %)
Pre-operative Hct 35 % 0.17 0.59
No 4297 (63.1 %) 316 (66.2 %) 308 (64.6 %) 316 (66.2 %)
Yes 2511 (36.9 %) 161 (33.8 %) 169 (35.4 %) 161 (33.8 %)
Pre-operative platelet count 0.53 0.39
< 100,000/μL 273 (4.0 %) 21 (4.4 %) 14 (2.9 %) 21 (4.4 %)
≥100,000/μL and < 500,000/μL 6079 (89.3 %) 430 (90.1 %) 441 (92.5 %) 430 (90.1 %)
≥ 500,000/μL 456 (6.7 %) 26 (5.5 %) 22 (4.6 %) 26 (5.5 %)
ASA physical status 0.049 0.98
1–2 1028 (15.1 %) 64 (13.4 %) 67 (14.0 %) 64 (13.4 %)
3 3048 (44.8 %) 243 (50.9 %) 239 (50.1 %) 243 (50.9 %)
4 2437 (35.8 %) 156 (32.7 %) 158 (33.1 %) 156 (32.7 %)
5 295 (4.3 %) 14 (2.9 %) 13 (2.7 %) 14 (2.9 %)
Wound class 0.32 0.92
1 85 (1.2 %) 10 (2.1 %) 10 (2.1 %) 10 (2.1 %)
2 568 (8.3 %) 45 (9.4 %) 48 (10.1 %) 45 (9.4 %)
3 835 (12.3 %) 61 (12.8 %) 67 (14.0 %) 61 (12.8 %)
4 5320 (78.1 %) 361 (75.7 %) 352 (73.8 %) 361 (75.7 %)

BMI: Basal Metabolic Index, COPD: Chronic Obstructive Pulmonary Disease, CHF: congestive heart failure, AKI: acute kidney injury, Cr: creatinine, AST: Aspartate
aminotransferase, ALP: Alkaline Phosphatase, WBC: white blood cell, Hct: hematocrit, ASA: American Society of Anesthesiologists.

Fig. 2. Covariate balance pre- and post-matching for use of NPWT in patients with only fascial closure of laparotomy incisions.

NPWT-assisted group compared to the other two arms.13 However, the In our study, the percentage of patients utilizing NPWT (1.2 %) was
study had a limited sample size and was based in a single institution so lower compared to the rate reported in previous retrospective studies
the results may not be generalizable. that used chart review to identify patients receiving NPWT following

7
W. Rafaqat et al.
colectomy or laparotomy procedures.23,24 However, these studies
included patients at high risk for SSIs so the rate of NPWT may have been
higher in their study populations compared to that expected in the gen-
eral population. In addition, the lower utilization of NPWT in our dataset
may be partly attributed to the limited availability of NPWT across
hospitals in the US during the earlier years included in our study. Finally,
NPWT may have been under-coded in the NSQIP database which could
be a limitation of our study. In addition, while the NSQIP database has
clinical granularity, information was not available for certain variables
such as the duration of use of NPWT or the type or pressure of the device.
Moreover, the database does not indicate the method of skin closure such
as whether staples or sutures were used. The insurance status of the pa-
tient is also not available. Due to the cost of NPWT, the insurance status
of the patient may determine whether they receive the therapy and could
be a potential confounder in this study. Another limitation of the study is
that we assumed that a standard dressing was used in patients in whom
NPWT was not coded. Despite these limitations, this study provides a
valuable perspective on the use of NPWT in patients undergoing a lap-
arotomy using a nationally representative cohort.
5. Conclusion
Based on a propensity-matched sample from a national database, the
use of NPWT did not reduce the rate of SSIs when compared to standard
dressings for patients with skin and fascial closure or only fascial closure
of their laparotomy incision. In addition, the use of NPWT was not
associated with any difference in morbidity or discharge disposition
when compared to a standard dressing.
Funding
No funding was received for this study.
Author contributions
Conception: WR, JOH. Design: JOH and WR. Data Acquisition: WR
and JAPZ. Data analysis and interpretation: WR and JAPZ. Draft writing:
WR. Writing, review, and editing: WR and JOH Supervision and valida-
tion: MA, EL, DA, HMAK, GCV, CML, and MPD.
Ethical statement
Ethical exemption was granted to this study since it is a retrospective
study conducted using de-identified data.
Declaration of competing interest
There is no conflict of interest that the authors wish to report.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.amjsurg.2023.10.055.
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