Cirocchi R, Birindelli A, Biffl WL, Mutafchiyski V, Popivanov G, Chiara O, Tugnoli G, Di Saverio S, et al.
The journal of trauma and acute care surgery. Date of publication 2016 Sep 1;volume 81(3):575-84.
1. J Trauma Acute Care Surg. 2016 Sep;81(3):575-84. doi:
10.1097/TA.0000000000001126.
What is the effectiveness of the negative pressure wound therapy (NPWT) in
patients treated with open abdomen technique? A systematic review and
meta-analysis.
Cirocchi R(1), Birindelli A, Biffl WL, Mutafchiyski V, Popivanov G, Chiara O,
Tugnoli G, Di Saverio S.
Author information:
(1)From the Department of General and Oncologic Surgery (R.C.), University of
Perugia, Terni, Italy; General Surgery (A.B.), University of Bologna, Bologna,
Italy; Acute Care Surgery (W.L.B.), Queen's Medical Center, University of Hawaii,
Honolulu, Hawaii; Department of Surgery (V.M.), and Clinic of Endoscopic,
Endocrine Surgery and Coloproctology (G.P.), Military Medical Academy, Sofia,
Bulgaria; Niguarda Hospital Trauma Center (O.C.), Milan, Italy; Trauma Surgery
Unit (G.T., S.D.S.), Maggiore Hospital Regional Emergency Surgery and Trauma
Center, Bologna Local Health District, Bologna, Italy.
BACKGROUND: The open abdomen technique may be used in critically ill patients to
manage abdominal injury, reduce the septic complications, and prevent the
abdominal compartment syndrome. Many different techniques have been proposed and
multiple studies have been conducted, but the best method of temporary abdominal
closure has not been determined yet. Recently, new randomized and nonrandomized
controlled trials have been published on this topic. We aimed to perform an
up-to-date systematic review on the management of open abdomen, including the
most recent published randomized and nonrandomized controlled trials, to compare
negative pressure wound therapy (NPWT) with no NPWT and define if one technique
has better outcomes than the other with regard to primary fascial closure,
postoperative 30-day mortality and morbidity, enteroatmospheric fistulae,
abdominal abscess, bleeding, and length of stay.
METHODS: According to the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of
Interventions, an online literature research (until July 1, 2015) was performed
on MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and Cochrane
Library databases. The MeSH terms and free words used "vacuum assisted closure"
"vac;", "open abdomen", "damage control surgery", and "temporary abdominal
closure". No language restriction was made.
RESULTS: The initial systematic literature search yielded 452 studies. After a
careful assessment of the titles and of the full text was obtained, eight
articles fulfilled inclusion criteria. We analyzed 1,225 patients, of whom 723
(59%) underwent NPWT and 502 (41%) did not undergo NPWT, and performed four
subgroups: VAC versus Bogota bag technique (two studies, 106 participants), VAC
versus mesh-foil laparostomy (two studies, 159 participants), VAC versus
laparostomy (adhesive impermeable with midline zip) (one study, 106
participants), and NPWT versus no NPWT techniques (three studies, 854
participants) in which it is not possible to perform an analysis of the different
types of treatment. Comparing the NPWT group and the group without NPWT, there
was no statistically significant difference in fascial closure (63.5% vs 69.5%;
odds ratio [OR], 0.74; 95% confidence interval [CI], 0.27-2.06; p = 0.57),
postoperative 30-day overall morbidity (p = 0.19), postoperative
enteroatmospheric fistulae rate (2.1% vs 5.8%; OR, 0.63; 95% CIs, 0.12-3.15; p =
0.57), in the postoperative bleeding rate (5.7% vs 14.9%; OR, 0.58; 95% CIs,
0.05-6.84; p = 0.87), and postoperative abdominal abscess rate (2.4% vs 5.6%; OR,
0.42; 95% CI, 0.13-1.34; p = 0.14). On the other hand, statistical significance
was found between the NPWT group and the group without NPWT in the postoperative
mortality rate (28.5% vs 41.4%; OR, 0.46; 95% CI, 0.23-0.91; p = 0.03) and in the
length of stay in the intensive care unit (mean difference, -4.53; 95% CI, -5.46
to 3.60; p < 0.00001).
CONCLUSION: The limitations of the present analysis might be related to the lack
of randomized controlled trials, so there is a risk of selection bias favoring
NPWT. For several outcomes, there were few studies, confidence intervals were
wide, and inconsistency was high, suggesting that although there were no
statistically significant differences between the groups, there was insufficient
evidence to show that the outcomes were similar. We can conclude from the current
available data that NPWT seems to be associated with a trend toward better
outcomes compared to the use of no NPWT. It does reflect the evidence presented
in the current systematic review; however, the data should be interpreted with
substantial caution given a number of weaknesses (in particular, the lack of
statistical significance and heterogeneity between studies, i.e., small sample
size of the included studies, high variability between studies). We highlight the
need for randomized controlled trials having homogeneous inclusion criteria to
assess the use of NPWT for the management of open abdomen.
LEVEL OF EVIDENCE: Systemic review/meta-analysis, level III.
DOI: 10.1097/TA.0000000000001126
PMID: 27257705 [Indexed for MEDLINE]
