Wound dressings for surgical sites

Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews

Background

Caesarean section (CS) is the most performed major surgery worldwide. Surgical techniques used for CS vary widely and there is no internationally accepted standardization. We conducted an overview of systematic reviews (SR) of randomized controlled trials (RCT) to summarize the evidence on surgical techniques or procedures related to CS.

Methods

Searches were conducted from database inception to 31 January 2024 in Cochrane Database of Systematic Reviews, PubMed, EMBASE, Lilacs and CINAHL without date or language restrictions. AMSTAR 2 and GRADE were used to assess the methodological quality of the SRs and the certainty of evidence at outcome level, respectively. We classified each procedure-outcome pair into one of eight categories according to effect estimates and certainty of evidence. The overview was registered at PROSPERO (CRD 42023208306).

Findings

The analysis included 38 SRs (16 Cochrane and 22 non-Cochrane) published between 2004-2024 involving 628 RCT with a total of 190,349 participants. Most reviews were of low or critically low quality (AMSTAR 2). The SRs presented 345 procedure-outcome comparisons (237 procedure versus procedure, 108 procedure versus no treatment/placebo). There was insufficient or inconclusive evidence for 256 comparisons, clear evidence of benefit for 40, possible benefit for 17, no difference of effect for 13, clear evidence of harm for 14, and possible harm for 5. We found no SRs for 7 pre-defined procedures. Skin cleansing with chlorhexidine, Joel-Cohen-based abdominal incision, uterine incision with blunt dissection and cephalad-caudal expansion, cord traction for placental extraction, manual cervical dilatation in pre-labour CS, changing gloves, chromic catgut suture for uterine closure, non-closure of the peritoneum, closure of subcutaneous tissue, and negative pressure wound therapy are procedures associated with benefits for relevant outcomes.

Interpretation

Current evidence suggests that several CS surgical procedures improve outcomes but also reveals a lack of or inconclusive evidence for many commonly used procedures. There is an urgent need for evidence-based guidelines standardizing techniques for CS, and trials to fill existing knowledge gaps.

Funding

UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO).

Topical silver for treating infected wounds

BACKGROUND

Topical silver treatments and silver dressings are increasingly used for the local treatment of contaminated or infected wounds, however, there is a lack of clarity regarding the evidence for their effectiveness.

OBJECTIVES

To evaluate the effects on wound healing of topical silver and silver dressings in the treatment of contaminated and infected acute or chronic wounds.

SEARCH STRATEGY

We sought relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Wounds Group Specialised Register in March 2006 and in MEDLINE, EMBASE, CINAHL, and digital dissertations databases up to September 2006. In addition, we contacted companies, manufacturers and distributors for information to identify relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing the effectiveness of topical silver in the treatment of contaminated and infected acute or chronic wounds.

DATA COLLECTION AND ANALYSIS

Eligibility of trials, assessment of trial quality and data extraction were undertaken by two authors independently. Disagreements were referred to a third author.

MAIN RESULTS

Three RCTs were identified, comprising a total of 847 participants. One trial compared silver-containing foam (Contreet) with hydrocellular foam (Allevyn) in patients with leg ulcers. The second trial compared a silver-containing alginate (Silvercel) with an alginate alone (Algosteril). The third trial compared a silver-containing foam dressing (Contreet)) with best local practice in patients with chronic wounds.The data from these trials show that silver-containing foam dressings did not significantly increase complete ulcer healing as compared with standard foam dressings or best local practice after up to four weeks of follow-up, although a greater reduction of ulcer size was observed with the silver-containing foam. The use of antibiotics was assessed in two trials, but no significant differences were found. Data on pain, patient satisfaction, length of hospital stay, and costs were limited and showed no differences. Leakage occurred significantly less frequently in patients with leg ulcers and chronic wounds treated with a silver dressing than with a standard foam dressing or best local practice in one trial.

AUTHORS' CONCLUSIONS

Only three trials with a short follow-up duration were found. There is insufficient evidence to recommend the use of silver-containing dressings or topical agents for treatment of infected or contaminated chronic wounds.

Systematic review of dressings and topical agents for surgical wounds healing by secondary intention

Background

The best dressing for postoperative wounds healing by secondary intention is unknown.

Methods

A systematic review was conducted to assess the effectiveness of dressings and topical agents on such wounds. Main endpoints were wound healing, pain, patient satisfaction, costs and hospital stay. Systematic methodological appraisal and data extraction were performed by independent reviewers.

Results

Fourteen reports of 13 randomized clinical trials on dressings or topical agents (gauze, foam, bead, alginate and hydrocolloid dressing) for postoperative wounds healing by secondary intention were identified; they were of weak methodological quality. In general, no statistically significant differences in wound healing were found for various dressing comparisons (11 of 13 trials). Patients experienced significantly more pain (four of six trials) and were less satisfied when gauze was used (three of six trials). Gauze was inexpensive, but its use was associated with significantly more nursing time than dressing with foam (two of three trials). No substantial differences in hospital stay were found (four of five trials).

Conclusions

Only small, poor-quality trials exist, rendering the evidence insufficient. Foam is best studied as an alternative to gauze and appears to be preferable in terms of pain reduction, patient satisfaction and nursing time.