Journal reading

The impact of negative pressure

wound therapy for closed surgical
incisions on surgical site infection:
A systematic review and
meta-analysis
Oleh: dr. Hannan Khairu Anami

Pembimbing: dr. Hippocrates Kam, SpB (K) V

Abstract
  Background: Surgical site infections cause substantial morbidity and
mortality. Negative pressure wound therapy may reduce the risk of
surgical site infections, but current evidence is unclear. The objective of
this study was to examine whether negative pressure wound therapy
reduces the risk of surgical siteminfections and other wound complications
when compared with conventional dressings in all patients with primarily
closed surgical wounds.
 Methods : A comprehensive systematic review of randomized controlled
trials was conducted. Trials that compared a negative pressure wound
Abstract therapy system to any non-negative pressure wound therapy dressing in
surgical wound(s) intended to heal by primary intention were eligible.
Surgical site infection was the primary outcome, and secondary outcomes
included wound dehiscence, pain, seroma, healing time, length of stay,
device-related complications, cost-effectiveness, and quality of life.
Selection, extraction, and risk of bias steps were done in duplicate, and
data were synthesized using random effects meta-analyses. A priori
sensitivity and subgroup analyses of the primary outcome were
completed. The Grading of Recommendations, Assessment, Development,
and Evaluations framework was used to appraise the quality of the
evidence.
  Results: Forty-four randomized controlled trials with N = 5,693
patients were included. Patients treated with negative pressure
wound therapy experienced nearly a 40% reduction in the risk of
surgical site infections relative to those with conventional
dressings, which was statistically significant: pooled risk ratio 0.61,
95% confidence interval 0.49-0.74, I2=26%. The effect remained
consistent across surgical specialties and brands of negative
Abstract pressure wound therapy devices. A statistically significant
reduction in wound dehiscence and seroma incidence was also
observed.
 Conclusion: There is moderate certainty that negative pressure
wound therapy applied to closed surgical incisions reduces the risk
of surgical site infections across all surgical procedures.
Introduction
 substantial
morbidity
and
mortality
risk of
wound and
reoperation
fascial
dehiscence

SSI

extended
length of unplanned
stay in readmission
hospital

economic
burden
 previously designed for the
treatment of open wounds and first

NPWT
described in the early 1990s

composed of a foam sponge, a

semi-occlusive adhesive barrier,
and a suction pump

provide continuous or intermittent

subatmospheric pressure to the
surface of a wound to promote
granulation tissue formation
Methods
 RCTs that
Open wounds,
compared NPWT
ulcers and skin The population No restrictions
to any standard
grafts, and of interest was according to
of care dressing
wounds closed patients of all surgical
in the context of
after the initial ages across all procedure or
a primarily closed
operation(s) were care settings incision location
surgical incision
excluded
were eligible
 Primary
SSI
outcome

postoperative
wound
complications

Data outcomes
length of stay

adverse
reactions or
device-related
Secondary complications
outcomes
QoL

Healing time

Cost
effectiveness
 A comprehensive search strategy was designed by an experienced
health sciences librarian for the following electronic databases:
MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of
Controlled Trials

Search Searches were executed on November 26, 2018, and were limited
strategy to citations published from 1993

The following clinical trial databases were hand searched to locate

eligible unpublished or ongoing trials: clinicaltrials.gov, the World
Health Organization (WHO) International Clinical Trials Registry
Platform, the ISRCTN register, and Health Canada’s Clinical Trial
Database
 Study Study selection and extraction were conducted using DistillerSR
software
selection,
extraction,
and risk of
bias
Study Extracted data included study characteristics (eg, country, year of
publication, source of funding, total sample size), patient characteristics
selection, (eg, eligibility criteria, age, sex, body mass index), surgical
characteristics (eg, scope of surgery, location of incision, CDC-defined
extraction, and surgical wound classification), intervention details (eg, brand of device,
duration of intervention), and the relevant outcomes of interest.

risk of bias Risk of bias (ROB) was assessed in duplicate using the Cochrane ROB
tool
 Random-effects meta-analyses were
conducted using Review Manager 5.3 software
Mantele Haenszel risk ratios and 95%
confidence intervals (95% CI) were computed
Data Synthesis for dichotomous outcomes, and the mean
difference and 95% CI were computed for
continuous outcomes

Statistical heterogeneity was measured using

the I2 statistic
Result
 107 articles 44 RCTs (and
screening were 3 companion
RESULT 1,001 titles identified for reports) were
and abstracts full-text included and
review abstracted
Study flow
Study and The 44 RCTs included 5,693 participants and 6,061 incisions
patient
characteristics
The majority (84%) were conducted in Europe or North America
and were published between 2006 and 2018

Data classification: Range of surgical specialties, type of

procedures (elective/emergency), type of device, duration of
intervention, age of patients, risk of SSI

Risk of bias Nearly 75% of trials were at a high ROB regarding blinding of
within studies participants and personnel
 Vascular
urology (1
surgery (6
trial, N=50),
trials, N=742)
General cardiothoracic
surgery (7 surgery (4
trials, N=983) trials, N=232)

Obstetrics (8
neurosurgery
trials,
(1 trial, N=19)
N=1,977)

Orthopedic Range of plastic surgery

surgery (13
trials, surgical (3 trials,
N=515)
N=1,493) specialties
 SSI Wound dehiscence Pain
• Incidence of SSI was • A total of 18trials (N= • Eight trials (N=585)
reported in 32 trials 3,339) reported on reported pain
(N=4,704) wound dehiscence. outcomes, but the
• There was a • NPWT significantly data could not be
statistically significant reduced the risk of pooled.
decreased risk of SSI wound dehiscence • In 5 of the trials
in patients who compared with (N=273), pain scores
received NPWT standard dressings were similar
compared with (pooled RR 0.76, 95% • In the 3 remaining
conventional dressing CI 0.62-0.92, I2=0%, studies (N=312),
(pooled risk ratio [RR] moderate certainty) significantly fewer
0.61, 95% CI 0.49- NPWT patients
0.74, I2=26%, reported pain or
moderate certainty) recorded significantly
lower pain scores
relative to the control
patients
Incidence of wound seroma and hematoma
• The incidence of seroma and hematoma was captured in 8 trials (N=875) and 7
trials (N=927), respectively.
• A statistically significant reduction in favor of NPWT was identified for the
former outcome (pooled RR 0.64, 95% CI 0.42-0.98, I2=0%, moderate certainty)

Length of stay (LOS)

• Only 4 studies could be pooled
• Meta-analysis results demonstrated a significant reduction in LOS among NPWT
patients (mean difference -1.17 days, 95% CI -2.19 to -0.16, n=576, I2=43%)

Adverse reactions and skin blisters

• Three trials reported on adverse skin reactions (n=2 were unspecified, and n=1
was an allergic reaction) (n=294), and 6 RCTs (n=617) recorded the incidence of
skin blisters.
• No significant difference was identified with respect to the latter (pooled RR 3.45,
95% CI 0.82-14.48, I279%, low certainty)
 QoL and Cost-
healing time effectiveness cost-effectiveness of NPWT
in 87 obese women
Lee et al (N= 54) reported
undergoing elective
significantly improved QoL
caesarean sections 
in the NPWT arm at
lightly more costly and
discharge
more effective than
standard care

NPWT versus standard care

In a trial of over 800 in the prevention of
patients, no significant complications after total
difference in QoL was hip and knee replacement
observed at 30 days surgery in 220 patients
between the study groups revealed savings of over
£1,000 ($1,420) per patient
Discussion
• The application of NPWT on all closed
wound incisions reduces the risk of SSI by
approximately 40% and appears to reduce
the incidence of wound dehiscence and
seroma

• WHO issued a conditional

recommendation, given the low quality of
evidence, to use NPWT in adults on
primarily closed high-risk wounds
 Predominantly Key patient and Practitioners could
studied in the operation-related use their
context of high-risk risk factors, institution’s rate of
populations or including BMI, SSI, ideally
wounds where it is smoking status, stratified by wound
most likely to diabetes, and class or surgical
provide the prolonged procedure, and
greatest benefit. operation time, calculate the
have been number needed to
proposed as treat to help
indications for the determine whether
use of NPWT NPWT should be
applied as a
postoperative SSI
prophylaxis
The optimal Further study of
protocol for the the economic
application of the considerations of
NPWT device NPWT would be
remains unclear pertinent to
inform decision-
making and help
define the
subgroups in
which it is most
cost effective
Strength
Strengths of this systematic
review include representation
of clinical and methodological
expertise on the team,
rigorous review conduct, a
focus on RCTs across all
surgical specialties, and
additional analyses to evaluate
the robustness of the primary
outcome.
This study not specifically
designed to capture
costeffectiveness studies, so
some may have been missed.
Thi stsudy included
unpublished studies, which are
less detailed than published
trials and not subject to formal
review.
Limitations
Thank you