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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Saturday, March 02, 2013
March Journal Club
Moderator: Dr. Adrian Barbul
 
Article: Negative Pressure Wound Therapy for At-Risk Surgical Closures in Patients With Multiple Comorbidities: A Prospective Randomized Controlled Study. Masden, Derek; Goldstein, Jesse; Endara, Mathew; Xu, Kyle; Steinberg, John; Attinger, Christopher. Annals of Surgery. 255(6):1043-1047, June 2012.
 
Summary: This is a randomized study of the effect of negative pressure wound therapy (NPWT) on the healing of wounds of the lower extremity and abdomen closed primarily or by delayed primary means. The study included high risk patients with many co-morbidities such as low serum albumin (~2.3g/Dl), diabetes (>70%), hypertension, peripheral vascular disease and renal failure. In the OR, the patient was assigned to a treatment arm using block randomization. Controls received a silver-impregnated dressing. Treatment was for three days. A total of 81 patients completed the study and were analyzed.

All wounds were evaluated after three days and in subsequent clinic visits by providers blinded to the randomization. All groups were well matched in terms of operations and risk factors. No differences were found in rates of infection (6.8% for NPWT vs 13.5% for controls) or time to diagnosis of infection, dehiscence (36.4% vs 29.7%) or time to dehiscence. The authors conclude that the use of NPWT in high risk wounds, primarily of the lower extremities, does not offer any advantage over standard dressings. 

The use of NPWT in many surgical situations has undergone explosive growth. Its use, however, is often driven by ease of use, advantage as an adjunct in wound care, and suggestions of enhanced wound healing.  The authors are to be commended for rigorously studying the effectiveness of NPWT in the population described.  The authors themselves were surprised by the findings, having felt that surely NPWT would be advantageous. Such studies conducted with similar open mindedness are needed to fully understand the role of NPWT in modern wound care.

 

Questions:

1. Is the widespread use of NPWT well supported by a large number of randomized, blinded, well-designed studies in different surgical situations?

2. Does the current study demonstrate any bias?  Are you ready to apply its findings into your own practice?

3. Do you believe that NWPT improves wound healing? How do you use it in your current practice?

 

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers.

 

 

 

 

 

 

 

About the Author

Dr. David T Efron
Dr. Efron is an Associate Professor of Surgery, Anesthesiology & Critical Care Medicine and Emergency Medicine at the Johns Hopkins School of Medicine. He is the Director of Trauma and Chief of the Division of Acute Care Surgery (encompassing Trauma, Emergency Surgery and Surgical Critical Care) in The Johns Hopkins Hospital Department of Surgery. He is currently the Vice-Chair of the Maryland State Committee on Trauma. Dr. Efron’s current research interests are within the realm of regulation of inflammatory mediators of septic and post-injury states, particularly focusing on the role that statins play in this milieu. Dr. Efron carries additional interest in traumatic injury from interpersonal violence, measures of violence intensity, and trauma recidivism with an eye to prevention strategies.

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