Negative Pressure Wound Therapy for Surgical-Site Infections

A Randomized Trial

Ammar A. Javed, MD; Jonathan Teinor, BS; Michael Wright, MS; Ding Ding, MD, MS; Richard A. Burkhart, MD; John Hundt, MHS; John L. Cameron, MD; Martin A. Makary, MD, MPH; Jin He, MD, PhD; Frederic E. Eckhauser, MD; Christopher L. Wolfgang, MD, PhD; Matthew J. Weiss, MD

Disclosures

Annals of Surgery. 2019;269(6):1034-1040. 

In This Article

Abstract and Introduction

Abstract

Objective: This study seeks to evaluate the efficacy of negative pressure wound therapy for surgical-site infection (SSI) after open pancreaticoduodenectomy.

Background: Despite improvement in infection control, SSIs remain a common cause of morbidity after abdominal surgery. SSI has been associated with an increased risk of reoperation, prolonged hospitalization, readmission, and higher costs. Recent retrospective studies have suggested that the use of negative pressure wound therapy can potentially prevent this complication.

Methods: We conducted a single-center randomized, controlled trial evaluating surgical incision closure during pancreaticoduodenectomy using negative pressure wound therapy in patients at high risk for SSI. We randomly assigned patients to receive negative pressure wound therapy or a standard wound closure. The primary end point of the study was the occurrence of a postoperative SSI. We evaluated the economic impact of the intervention.

Results: From January 2017 through February 2018, we randomized 123 patients at the time of closure of the surgical incision. SSI occurred in 9.7% (6/62) of patients in the negative pressure wound therapy group and in 31.1% (19/61) of patients in the standard closure group (relative risk = 0.31; 95% confidence interval, 0.13–0.73; P = 0.003). This corresponded to a relative risk reduction of 68.8%. SSIs were found to independently increase the cost of hospitalization by 23.8%.

Conclusions: The use of negative pressure wound therapy resulted in a significantly lower risk of SSIs. Incorporating this intervention in surgical practice can help reduce a complication that significantly increases patient harm and healthcare costs.

Introduction

Surgical-site infections (SSIs) complicate 2% to 5% of all surgical procedures, 8% of major abdominal procedures, and 20% to 40% of pancreaticoduodenectomies (PD).[1–6] Despite multiple infection control initiatives and quality collaboratives, SSIs remain a major concern for reliable safe surgery.[7–9] SSIs are associated with an increased risk of postoperative morbidity, prolonged hospitalization, postponement of chemotherapy, increased healthcare costs, and in some cases poor long-term outcomes.[7,10] In the United States alone, the burden of SSIs is estimated at $10 billion per year.[11]

Several prediction models have been developed for SSI risk prediction for patients undergoing abdominal procedures,[5,7] considering factors such as neoadjuvant chemotherapy and preoperative biliary stenting. The rate of SSIs in patients undergoing PD at Johns Hopkins Hospital has historically been 15% to 20%, which is below the national average reported by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).[8,9,12] Despite SSI rates below the national average, our institution has identified a subgroup of high SSI-risk patients, for whom SSIs remain a clinically relevant problem (>30%).[8]

Negative pressure wound therapy (NPWT) is suggested to reduce risk of SSI by reducing fluid accumulation within the avascular dead space in a closed wound. Recent studies suggest that NPWT can help prevent SSIs after abdominal surgery;[9,12] however, literature is limited to retrospective studies with mixed results. Given these findings, we conducted a randomized, controlled trial of NPWT in high SSI-risk patients undergoing PD.

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