Wound Outcome Following Primary and Delayed Primary Skin Closure Techniques After Laparotomy for Non-Traumatic Ileal Perforation: a Randomized Clinical Trial

Delayed primary skin closure reduce surgical site infection following surgery for gastrointestinal perforation: A systematic review and meta-analysis

BACKGROUND

Following surgery for Gastrointestinal (GI) perforation, there is an increased occurrence of Surgical Site Infections (SSI). The beneficial effect of employing delayed primary skin closure (DPC) on severely contaminated incisions subsequent to surgery for GI perforation remains unverified.

OBJECTIVE

To systematically evaluate the advantages of the DPC management in surgery for GI perforation.

METHODS

A literature search was performed using ClinicalTrials.gov, Pubmed, Embase, Cocharane, and Web of Science identified all eligible English-language studies related to surgery for GI perforation through October 2023. Randomized clinical trials (RCTs) comparing DPC with primary skin closure (PC) in surgery for GI perforation were included. Two investigators independently performed the inclusion work, and a third investigator was consulted for resolving conflicts. Data were extracted by multiple independent investigators and pooled in a random-effects model. The primary outcome was SSI, defined in accordance with the original studies. The secondary outcome was the length of stay (LOS).

RESULTS

Final analysis included 12 RCTs which included a total of 903 patients were randomizing divided into either DPC or PC, including 289 patients with gastroduodenal perforation (32%), 144 patients with small intestine perforation (15.96%), 60 patients with colon perforation (6.64%), and 410 patients with appendix perforation (45.4%). The rates of SSI was significantly decreased after DPC management (OR:0.31, 95%CI:0.15-0.63, p < 0.01), no significant differences were observed between the DPC group and PC group in terms of LOS (MD: - 0.37, 95% CI: - 1.91-1.16, p = 0.63).

CONCLUSION

These results point to the efficacy of DPC management in reducing SSI in patients under surgery for GI perforation, and this strategy did not increase the LOS. This systematic review and meta-analysis may contribute to informed decision-making in the management of severely contaminated wounds associated with GI perforation.

Practical Review on Delayed Primary Closure: Basic Science and Clinical Applications

Wound healing complications present a significant burden on both patients and health-care systems, and understanding wound healing principles is crucial across medical and surgical specialties to help mitigate such complications. One of these longstanding principles, specifically delayed primary closure (DPC), described as mechanically closing a wound after several days of secondary intention healing, lacks clear consensus on its definition, indications, and outcomes. This practical review examines wound healing fundamentals, focusing on DPC, its execution, indications, and comparative outcomes. A PubMed literature search was conducted to retrieve studies on DPC. Inclusion criteria included comparative studies assessing outcomes and complications between DPC and other closure techniques, as well as articles investigating DPC's underlying physiology. Twenty-three comparative studies met inclusion criteria. DPC wounds have significantly higher partial pressure of oxygen, higher blood flow, and higher rates of collagen synthesis and remodeling activity, all of which help explain DPC wounds' superior mechanical strength. DPC seems most beneficial in contaminated wounds, such as complicated appendectomies, postcardiac surgery wounds, and complicated abdominal wall reconstructions, where it has been associated with lower rates of surgical site infections. This practical review provides an evidence-based approach to DPC, its physiology, technique, and indications. Based on the existing literature, the authors recommend that DPC wounds should be dressed in saline/betadine soaks, changed and irrigated daily, with delayed closure lasting between 3 and 5 days or until the infection has resolved. The clearest indications for DPC are in the context of contaminated abdominal surgery and sternal wound dehiscence post cardiac surgery.

Primary Versus Delayed Primary Incision Closure in Contaminated Abdominal Surgery: A Meta-Analysis

BACKGROUND

Debates still exist whether delayed primary incision closure (DPC) could bring more benefits to patients suffering contaminated abdominal surgery. So, we want to determine whether DPC has advantage over primary incision closure (PC) in contaminated abdominal surgery.

METHODS

Embase, Medline, and the Cochrane Library databases were searched for eligible studies from January 1, 1980 to August 6, 2017. Bibliographies of potential eligibility were also retrieved. The primary outcome was the rate of surgical site infection (SSI) and the second outcome was length of hospital stay (LOS). A systematic review and meta-analysis of RCTs were performed.

RESULTS

Twelve studies were included in the final quantitative synthesis. Of the 12 studies included, five were from third world countries (i.e., India and Pakistan), and all of these demonstrated an improvement in SSI rate with DPC. When the fixed-effect model used, compared with PC, SSI was significantly reduced in DPC with a risk ratio of 0.64 (0.51-0.79) (P < 0.0001), and a significant difference in LOS between DPC and PC was also identified with a mean difference of 0.39 (0.17-0.60) (P = 0.0004). Although the random-effect model was used, no significant difference in SSI between DPC and PC was observed with a risk ratio of 0.65 (0.38-1.12) (P = 0.12), and no significant difference in LOS between DPC and PC was found with a mean difference of 1.19 (-1.03 to 3.41) (P = 0.29).

CONCLUSIONS

DPC may be the preferable choice in contaminated abdominal surgeries, especially in patients with high risk of infection, and particularly in resource constrained environments. In addition, more high-quality studies with well design are needed to provide clear evidence.

Outcomes After the Implementation of Practice Management Guidelines for the Treatment of Cardiovascular Implantable Device Pocket Infections

BACKGROUND

Treatment of cardiovascular implantable device pocket infections (CIDPIs) requires a multimodal approach that includes antimicrobials, device explantation, and local wound care. Our institution implemented a practice management guideline (PMG) to standardize the care of CIDPIs and engage our acute care surgeons in 2013. Our PMG includes wound culture, complete capsulectomy, pulse lavage, and the placement of a negative pressure wound therapy appliance at the time of device extraction. Forty-eight hours later, wounds are irrigated and closed in a delayed primary fashion over drains. Our objective was to compare the outcomes of patients who underwent device extraction before and after the implementation of the PMG for the treatment of CIDPIs.

METHODS

An IRB-approved retrospective review of 155 patients at our institution from 2012 to 2015 who underwent device explantation. Evaluated outcomes measured included days from device explant to wound closure, and postoperative complications. Outcomes data were analyzed before (pre-PMG) and after (post-PMG) enactment of the PMG.

RESULTS

Fifty-eight patients (42 males; mean age 68 years) were managed prior to PMG implementation; 97 (72 males; mean age 67) were managed after. Mean days from device explantation to wound closure were compared (pre-PMG 6 ± 3.5 and post-PMG 2.8 ± 1.8), and time to closure was reduced by 3-d post-PMG implementation (P < 0.05). No increase in surgical site infection, hematoma, or unplanned return to operating room was demonstrated between groups (P < 0.05).

CONCLUSIONS

The implementation of a PMG for the management of CIDPIs is effective in reducing the number of days to pocket wound closure; acute care surgeons are well equipped to participate in this practice and improve patient outcomes.