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ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 138-144

Low-cost prophylactic negative pressure wound therapy using central suction device in preventing surgical site infections in patients undergoing emergency laparotomy


Department of General Surgery, Pt. B D Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India

Date of Submission10-May-2021
Date of Acceptance22-Jun-2021
Date of Web Publication19-Jul-2021

Correspondence Address:
Dr. Sanjay Marwah
Senior Professor, Department of General Surgery, Pt. B. D. Sharma PGIMS, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_72_21

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  Abstract 

Background: The surgical site infections (SSIs) are the most common cause of nosocomial infection in surgical patients and are associated with high morbidity, considerable mortality, longer hospital stay, and increased health-care costs. Evidence suggests that incisional negative pressure wound therapy (INPWT) can decrease wound complications, but there is scanty literature regarding INPWT for high-risk laparotomy incisions.
Materials and Methods: A prospective interventional randomized study was conducted over a period of 2 years from May 1, 2018, to April 30, 2020. The enrolled patients were randomized to the study group where INPWT was applied and the control group where patients were subjected to conventional wound dressings.
Results: Out of 85 patients undergoing emergency laparotomy, 36 patients were allocated to the study group and 38 patients to the control group after meeting the exclusion criteria. Baseline demographic characteristics were similar in both the groups. The relative risk (95% confidence interval) of SSI, burst abdomen, and rehospitalization was significantly more in the control group (study versus control group): 0.65 versus 1.4, 0.67 versus 1.33, and 0 versus 2.03, respectively.
Conclusions: Prophylactic use of NPWT is a safe and effective method for preventing SSI and other wound complications in emergency laparotomy for peritonitis, which is a major deciding factor in final wound outcome in such cases.

Keywords: Emergency laparotomy, negative pressure wound therapy, surgical site infections


How to cite this article:
Mandal A, Aggarwal I, Das S, Galhotra A, Marwah S. Low-cost prophylactic negative pressure wound therapy using central suction device in preventing surgical site infections in patients undergoing emergency laparotomy. Saudi Surg J 2020;8:138-44

How to cite this URL:
Mandal A, Aggarwal I, Das S, Galhotra A, Marwah S. Low-cost prophylactic negative pressure wound therapy using central suction device in preventing surgical site infections in patients undergoing emergency laparotomy. Saudi Surg J [serial online] 2020 [cited 2021 Dec 8];8:138-44. Available from: https://www.saudisurgj.org/text.asp?2020/8/3/138/321736


  Introduction Top


Surgical site infections (SSIs) are the infections of incision or organ space that occur after surgery. These are the most common cause of nosocomial infection in surgical patients, accounting for 38% of all hospital-acquired infections.[1],[2] The Centers for Disease Control and Prevention (CDC) wound classification demonstrates that SSI occurs in 15%–30% of contaminated (Class III) and >30% of dirty-infected (Class IV) wounds.[3] SSIs are associated with increased morbidity, prolonged hospital stay, increased readmission, and additional procedures, which lead to increased cost of treatment and poor patient satisfaction.[4],[5]

SSIs continue to be a major problem for patients undergoing laparotomy and its incidence further increases in the setting of contamination when done in emergency setup. In comparison to patients not having postoperative infection, those with SSI are at 2-fold increased risk of death, intensive care unit admission, and more than 5-fold increased risk of readmission.[4] Several patient factors such as smoking, obesity, and comorbidities and also the operative characteristics such as duration of surgery and level of contamination are associated with an increased risk of developing SSI.[5] Several approaches for decreasing SSI in patients undergoing laparotomy have been advocated such as scrubbing, skin preparation, and prophylactic antibiotics.[6],[7] However, no technique has shown any superiority. After the introduction of negative pressure wound therapy (NPWT) in treating wounds of open bone fractures, diabetic ulcers, and the open abdomen, prophylactic NPWT is being suggested as a new method to prevent wound complications by its application on a closed laparotomy wound.[8],[9],[10],[11],[12] NPWT consists of a closed, sealed system connected to a source, which maintains a continuous negative pressure on the wound.[13]

Evidence suggests that NPWT can decrease wound complications, but there is scanty literature regarding its use for high-risk laparotomy incisions. This study was planned to evaluate and compare the efficacy of NPWT with conventional dressing in terms of development of postoperative wound complications and duration of hospital stay in patients undergoing emergency laparotomy. It also aimed to study the drawbacks of NPWT, if any.


  Materials and Methods Top


This prospective interventional randomized study was conducted in the department of general surgery in a tertiary care center of North India over a period of 2 years from May 2018 to April 2020. A total of 74 patients who underwent emergency laparotomy and met the inclusion criteria were analyzed in the study. After getting clearance from the institutional ethical committee, informed written consent regarding the participation in the study was taken from the patients.

Exclusion criteria

  1. Patients requiring reexploration in the postoperative period
  2. Anastomotic leak or fecal fistula in postoperative period
  3. Mortality in postoperative period.


Patients presenting in emergency with features of acute abdomen were resuscitated and appropriate preoperative investigations were done before exploration. Charlson comorbidity index and APACHE II scores were recorded based on the clinical and biochemical parameters. The patients underwent emergency laparotomy through midline incision for adequate source control. After completion of the operative procedure, the rectus sheath was closed in a single layer using continuous delayed absorbable suture followed by skin closure with interrupted silk sutures. At the time of laparotomy wound closure, the patients were divided into NPWT group and conventional wound dressing group with computer-generated randomization.

Study group

Patients subjected to NPWT.

Control group

Patients subjected to conventional wound dressing.

In the NPWT group, one 16 F negative suction drain having multiple side holes was placed in the subcutaneous plane after closure of rectus sheath and taken out through a separate stab incision followed by skin closure [Figure 1]a and [Figure 1]b. The drainage tube was connected to central suction unit with negative pressure continuously maintained at 125 mm of Hg [Figure 2]a and [Figure 2]b. All the patients were given injection ceftriaxone, amikacin, and metronidazole in standard doses during perioperative period and changed according to the culture report. In postoperative period, monitoring of clinical parameters was done. In the NPWT group, the volume and nature of discharge collected was recorded daily and the drain was kept for minimum 72 h or until output was <10 ml over 24 h. The wound dressing was changed at the time of drain removal or when dressing got soaked. In the conventional dressing group, the wound dressing was changed daily as per our standard practice. Periodic monitoring of development of SSIs was done by signs and symptoms and by culture sensitivity of wound drain fluid (in NPWT group) and wound discharge, if any (in conventional dressing group).
Figure 1: (a) Showing placement of wound drain in subcutaneous plane, (b) Skin closure over wound drain

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Figure 2: (a) Installation of NPWT, (b) Central suction unit

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Statistical analysis

At the end of the study, the collected data were analyzed using SPSS software (version 27.0 for Microsoft Windows; SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistically significant.


  Observations and Results Top


A total of 85 patients presented in emergency and underwent emergency laparotomy during the study period. Seven patients in the study group and four patients in the control group were excluded based on the exclusion criteria [Figure 3]. In total, 36 patients in the study group and 38 patients in the control group completed the study protocol and were included in analysis. As per the CDC wound classification, all the patients had Class III and Class IV wounds at the time of laparotomy wound closure.
Figure 3: Consort chart

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There were no significant differences in patient demographics between the two groups [Table 1]. Seven (19.4%) patients in the study group developed SSIs, compared with 13 (34.2%) in the control group. Three (8.3%) and two (5.6%) patients in the study group developed superficial wound dehiscence and deep wound infections (burst abdomen), respectively, compared to 8 (21.1%) and 4 (10.5%) in the control group, respectively [Figure 4]a and [Figure 4]b. The relative risk for development of SSI, superficial wound dehiscence, and burst abdomen in the study group compared with the control group was 0.65 versus 1.4, 0.52 versus 1.53, and 0.67 versus 1.33, respectively, at 95% confidence interval [Table 2]. One patient in the study group had accidental drain removal due to loosening of the stitch on third postoperative day but had no wound complications. Another patient in the study group had blockage of the drainage tube due to blood clot that remained undetected leading to failure of NPWT and subsequent deep wound infection. The mean hospital stay was 10.97 ± 6.49 days for the study group and 12.74 ± 7.74 days for the control group; however, the difference was not statistically significant.
Table 1: Demographic profile

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Figure 4: (a) Superficial surgical site infection, (b) Deep surgical site infection

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Table 2: Postoperative complications

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For delayed wound complications, none of the patient in the study group required rehospitalization, whereas three patients (7.9%) in the control group were rehospitalized due to wound dehiscence. Three (8.3%) patients in the study group and four patients (10.5%) in the control group developed incisional hernia [Table 3].
Table 3: Delayed complications

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  Discussion Top


SSIs and other wound complications are associated with high morbidity, considerable mortality, longer hospital stay, increased health-care costs, adverse psychological outcomes, and reduced quality of life.[4],[5],[14] Therefore, any strategy by which SSI may be reduced is of great interest for both health-care providers and patients. Some authors have advocated the inclusion of NPWT to prevent SSI on closed laparotomy incisions, based on preliminary evidence of its efficacy in the prevention of SSIs.[12]

The precise mechanism of prophylactic NPWT is unknown. Current hypothesis is that prophylactic NPWT keeps a moist wound that promotes healing, drains out exudates, reduces tissue edema, contracts the wound margins, mechanically stimulates the wound bed, and increases blood perfusion at the wound edge, which may lead to angiogenesis and granulation tissue formation. Moreover, the sealed system protects against microorganisms from outside entering the wound, thus reducing bacterial colonization.[13] The improved blood flow and oxygenation to the compromised tissue also increases the area's resistance to infection, allowing faster healing.[15],[16],[17]

Earlier studies analyzed the use of NPWT in preventing SSIs in elective operations. In recent years, it has also been used in emergency surgeries as risk of developing SSIs is more in such cases [Table 4]. The occurrence of SSI was monitored up to 30 days in all the previous as well as the present study. It was found to be significantly less in the study group cases in all earlier studies. However, the difference was not significant statistically in the present study possibly due to smaller number of cases. In comparison to the present study, O'Leary et al.[18] and Zaidi and El-Masry[19] had much lower incidence of postoperative SSI possible because they included mix of elective and emergency cases whereas the present study had only emergency laparotomy cases. Similarly, Schurtz et al.[20] had much lower incidence of SSI because they included cases with Class I, II, and III wounds (clean, clean contaminated, and contaminated wounds). However, Kugler et al.[21] as well as the present study cases had much higher incidence of SSI due to the fact that majority of the patients had Class IV (dirty) wounds. In a recent meta-analysis by Wells et al.,[22] NPWT has shown to reduce the overall incidence of SSI in closed abdominal incisions but has no effect on deep SSI. In this meta-analysis, more than 50% of cases were of cesarean section and remaining studies were mix of emergency and elective laparotomies. These findings indicate that although NPWT helps in decreasing SSI, the incidence of SSI is largely dependent on the class of wound [Table 4].
Table 4: Surgical site infections

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Duration of hospital stay was also less in the study group cases in all the studies including the present study, although not significant statistically. However, O'Leary et al.[18] observed that duration of stay in the study group cases was almost half in comparison to other studies with statistically significant difference. It was possibly due to inclusion of elective as well as emergency cases in their study [Table 5].
Table 5: Hospital stay (days)

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The studies have shown that controlled negative pressure assists in wound healing by various mechanisms.[15],[16],[17],[23] This wound healing parameter was analyzed by Seidel et al.[24] where they used NPWT in already open or dehiscence wound. They observed that wound closure, reduction in wound surface area, and reduction in wound volume were significantly shorter in the NPWT group compared to the conventional wound treatment group. In the present study as well as all previous studies, indicators of wound healing were duration of hospital stay, SSI, and readmission for wound complications that were found to be lesser in the NPWT group.

Various studies related to use of NPWT for the prevention of SSIs in emergency setting have used different devices having variable specifications and cost [Table 6].
Table 6: Technical specifications and cost of therapy

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In majority of the previous studies including the present study, the pressure range used in NPWT was between − 75 mm of Hg and − 125 mm of Hg. Most of earlier studies used some expensive devices or incision management system for NPWT, leading to high cost of the treatment [Table 6]. In developing countries, cost of treatment is a major factor deciding the patient management. The technique used in the present study for creating NPWT utilized already installed central suction points in the surgical wards that had no additional financial burden for the treatment. This simple technique was found to be as effective as other devices as observed by the final outcome of the patients. Hence, this technique should be recommended for use in third world countries to cut down the cost of therapy.

Drawbacks of negative pressure wound therapy and their management in our study

Difficult ambulation

The study group patients had difficulty in ambulation since NPWT was attached to the central suction unit. However, the patients were made ambulatory a couple of times in the day by detaching the central suction unit temporarily and attaching the NPWT with negative pressure collection chamber for maintaining negative pressure. This was aimed at preventing postoperative complications such as deep vein thrombosis and hypostatic pneumonia. This problem has not been encountered in previous studies since devices used by them allowed patients to move with NPWT in situ.

Drain blockage

The functioning of negative pressure wound drain was regularly confirmed in the study group cases by checking the patency of the drainage tube twice in a day by aspiration and clearing the clots in the tube, if any. However, in one case, the drainage tube remained blocked due to retention of blood clots and fatty tissue, leading to failure of NPWT.

Wound discharge

Twenty-two percent of cases (8/36) in the study group had discharge from the wound, following removal of the wound drain despite having NPWT. This indicated that although NPWT helped in decreasing the wound complications, the class of wound is a major factor deciding the final outcome in such cases.


  Conclusions Top


Management strategies for the prevention of SSI continue to evolve, and NPWT is emerging as another novel strategy in an attempt to decrease wound infection rate. As observed in the present as well as previous similar studies, the prophylactic use of NPWT is a safe and effective method for preventing SSI, especially in the setting of wound contamination, which is a major deciding factor in final wound outcome. NPWT significantly reduces the incidence of SSI which lead to decreased hospital stay, less morbidity, decreased cost of treatment, and increased patient satisfaction. In our study, installation of NPWT was done using central suction unit and no special devices were used, thus significantly reducing the cost of therapy. Its results were at par with that of previous studies with minimal drawbacks. However, more similar prospective studies need to be conducted with larger number of cases to establish its benefits.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Seidel D, Diedrich S, Herrle F, Thielemann H, Marusch F, Schirren R, et al. Negative pressure wound therapy vs conventional wound treatment in subcutaneous abdominal wound healing impairment: The SAWHI randomized clinical trial. JAMA Surg 2020;155:E1-10.  Back to cited text no. 24
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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