The Efficacy of NPWT on Primary Closed Incisions
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1 The Efficacy of NPWT on Primary Closed Incisions Pieter Zwanenburg Researcher / PhD Candidate Marja Boermeester Professor of Surgery, Academic Medical Center, Amsterdam
2 Incisional Negative Pressure Wound Therapy NPWT placed on primary closed incision First published in 2006 Promising intervention Fight Against Nosocomial Infections Symposium 2
3 WHO Guidelines Published November preoperative, 16 intra- and postoperative recommendations Allegranzi et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis Dec;16(12):e276-e287. doi: /S (16)30398-X. Epub 2016 Nov 2. Allegranzi et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis Dec;16(12):e288-e303. doi: /S (16) Epub 2016 Nov 2. 3
4 Systematic Review Medline N=1114 EMBASE N=890 Removal of duplicates Records screened Possibly eligible studies Included studies CENTRAL N=1238 N=1238 N=49 N=19 (21 studies) N=9 CINAHL N=129 WHO Excluded based on title/ abstract N=1191 Excluded based on full text N=30 N=2 De Vries et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore) Sep;95(36):e4673
5 15 Observational Studies De Vries et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore) Sep;95(36):e4673 5
6 Stratified by contamination status De Vries et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore) Sep;95(36):e4673 6
7 Stratified by type of surgery De Vries et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore) Sep;95(36):e4673 7
8 GRADE Assessment (obs) De Vries et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore) Sep;95(36):e4673 8
9 6 RCTs De Vries et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore) Sep;95(36):e4673 9
10 6 RCTs De Vries et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore) Sep;95(36):e
11 GRADE Assessment (RCTs) De Vries et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore) Sep;95(36):e
12 : Consider the use of pnpwt on primarily closed surgical incisions in high-risk procedures for the purpose of the prevention of SSI, while taking available resources into account Allegranzi et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis Dec;16(12):e288-e303. doi: /S (16) Epub 2016 Nov 2. 12
13 Paucity of evidence in contaminated surgery Patient Characteristics (own data) NPWT (n=32) Control (n=34) p TPN dependence (%) 14 (44) 15 (47) Previous abdominal operations (IQR) 4 (3-6) 4 (3-6) (range) (1-24) (1-14) Contamination 26 (81) 25 (74) Bowel anastomosis during operation (%) 22 (69) 21 (62) Enterocutaneous fistula present (%) 18 (56) 13 (38) Infected mesh removal (%) 11 (34) 28 (82) De Vries et al. Closed incision prophylactic negative pressure wound therapy in patients undergoing major complex abdominal wall repair. Hernia Aug;21(4): doi: /s Epub 2017 May 23.
14 inpwt in Complex Abdominal Wall Reconstruction - own data - Results NPWT Control p OR (n= 32) (%) (n=34) (%) Surgical site infections (overall) 12 (38) 19 (56) Wound infection (superficial/deep CDC) 7 (24) (n=29) 16 (51) (n=31) (95% CI ) Incisional wound infection 2 (7) 15 (48) < (95% CI ) Subcutaneous abscesses 5 (17) 4 (13) Interventions extra-abdominal Radiologic subcutaneous drainage 7 (22) 8 (24) Opening wound and/or antibiotics 2 (7) (n=29) 15 (48) (n=31) <0.001 De Vries et al. Closed incision prophylactic negative pressure wound therapy in patients undergoing major complex abdominal wall repair. Hernia Aug;21(4): doi: /s Epub 2017 May 23.
15 Paucity of RCTs in contaminated surgery 388 contaminated AWRs inpwt vs gauze-based dressing Postoperative wound complications < 30 days as primary outcome AWR = abdominal wall reconstruction 15
16 But how does it work? 16
17 Less SSIs from Skin Flora A inpwt Acts a barrier against contamination Zwanenburg et al. Working Mechanisms of Incisional Negative Pressure Wound Therapy A Systematic Review. In Progress. 17
18 Enhanced Perfusion Less dead space Less seroma/hematoma fluid Less edema More effective diffusion More effective perfusion Zwanenburg et al. Working Mechanisms of Incisional Negative Pressure Wound Therapy A Systematic Review. In Progress. 18
19 Enhanced Perfusion Increased blood flow Increased lymphatic flow Enhanced perfusion Increased bacterial clearance Zwanenburg et al. Working Mechanisms of Incisional Negative Pressure Wound Therapy A Systematic Review. In Progress. 19
20 Increased Collagen Density & Tensile strength Increased collagen deposition Increased tensile strength Less dehiscence Collagen density inpwt Control Zwanenburg et al. Working Mechanisms of Incisional Negative Pressure Wound Therapy A Systematic Review. In Progress.
21 Cost-effective? Median additional LoS attributable to SSI is 10 days [95% CI: 7-13 days] The median additional cost attributable to SSI is 5,239 (95% CI: 4,622-6,719) Significant reduction of LoS with disposable incisional NPWT (-0.47 days [95% CI to -0.23], p < ) Jenks et al. Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. J Hosp Infect Jan;86(1): doi: /j.jhin Epub 2013 Oct 16. Strugula et al. Meta-Analysis of Comparative Trials Evaluating a Prophylactic Single-Use Negative Pressure Wound Therapy System for the Prevention of Surgical Site Complications. Surg Infect (Larchmt) Oct;18(7): doi: /sur Epub 2017 Sep 8. 21
22 Conclusion / Take Home Message Incisional NPWT is effective in reducing SSIs thereby reducing the need for antibiotics Well grounded by both clinical as preclinical evidence WHO recommends its use Likely cost-effective, especially in high-risk patients Fight Against Nosocomial Infections Symposium 22
23 Thank you!
24 Questions?
25 Preoperative WHO Recommendations Allegranzi et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis Dec;16(12):e276-e287. doi: /S (16) X. Epub 2016 Nov 2. 25
26 Preoperative WHO Recommendations Allegranzi et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis Dec;16(12):e276-e287. doi: /S (16) X. Epub 2016 Nov 2. 26
27 Intra- and Postoperative WHO Recommendations Allegranzi et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis Dec;16(12):e288-e303. doi: /S (16) Epub 2016 Nov 2. 27
28 Intra- and Postoperative WHO Recommendations Allegranzi et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis Dec;16(12):e288-e303. doi: /S (16) Epub 2016 Nov 2. 28
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