Prospective Randomized Trial of Two Wound Management Strategies for Dirty Abdominal Wounds

Abstract

ObjectiveTo determine the optimal method of wound closure for dirty abdominal wounds. Summary Background DataThe rate of wound infection for dirty abdominal wounds is approximately 40%, but the optimal method of wound closure remains controversial. Three randomized studies comparing delayed primary closure (DPC) with primary closure (PC) have not conclusively shown any advantage of one method over the other in terms of wound infection. MethodsFifty-one patients with dirty abdominal wounds related to perforated appendicitis, other perforated viscus, traumatic injuries more than 4 hours old, or intraabdominal abscesses were enrolled. Patients were stratified by cause (appendicitis vs. all other causes) and prospectively randomized to one of two wound management strategies: E/DPC (wound packed with saline-soaked gauze, evaluated 3 days after surgery for closure the next day if appropriate) or PC. In the E/DPC group, wounds that were not pristine when examined on postoperative day 3 were not closed and daily dressing changes were instituted. Wounds were considered infected if purulence discharged from the wound, or possibly infected if signs of inflammation or a serous discharge developed. ResultsTwo patients were withdrawn because they died less than 72 hours after surgery. The wound infection rate was greater in the PC group than in the E/DPC group. Lengths of hospital stay and hospital charges were similar between the two groups. ConclusionA strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC without increasing the length of stay or cost.Dirty surgical wounds are associated with a high rate of wound infection.1 Postoperative wound infections have a significant impact on health resources and costs, 2,3 and the sequelae of wound infections (wound dehiscence and resulting incisional hernias) can result in significant long-term problems. 4 -6 Of the many risk factors influencing postoperative wound infections, the method of skin closure has been implicated as an important factor. Delayed primary closure (DPC) and primary closure (PC) are two commonly used methods, but there is no consensus as to the optimal method. Cruse and Foord 1 found in a retrospective survey a wound infection rate of 40% among 2,093 dirty wounds, but they did not specify how skin closure was performed. Three prospective randomized studies 7-9 performed on appendectomy wounds only showed no advantage to DPC in terms of decreased wound infection compared with PC. We conducted a prospective randomized trial on patients with dirty abdominal wounds and hypothesized that a strategy of DPC of appropriate dirty abdominal wounds would result in a decreased rate of wound infection.

A study on acute surgical abdomen in paediatric age group

“…Wound dehiscence rate was 9.6%, more in malnourished, underweight patients with gastrointestinal emergency surgery and dirty contaminated wound and who had postoperative abdominal distension for longer period. [12][13][14] In our study mortality was higher in operative group (16.67%) as compared to nonoperative (9.25%) and neonatal mortality was higher followed by infants. Mortality was higher in patients with congenital anomalies like gastroschisis and exomphalos than acquired group.…”

Systemic Review and Meta-analysis of Randomized Clinical Trials Comparing Primary vs Delayed Primary Skin Closure in Contaminated and Dirty Abdominal Incisions

“…Adequate details on randomization were only provided by 2 studies 14,20 ; 4 further studies randomized based on hospital number, date of admission, or alternate admission 1 4 , 1 5 , 1 9 , 2 1 ; and 2 prov ided no details of randomization. 16,17 All studies were at high risk of allocation bias. Six studies were at risk of incomplete follow-up and selective reporting because of a lack of details on losses to followup, selective clinical review at 2 weeks only, and reliance on patient-reported adverse events only.…”

“…No study provided detail of blinding of outcome assessors. Two studies provided a definition of SSI in keeping with widely accepted criteria, 16,17 and only 1 study provided no definition; the remainder relied on the authors' own definitions ( Table 2). Funnel plot analysis showed a wide distribution around the mean for all studies and for appendicitis only studies; an asymmetrical distribution of appendicitis only studies indicated potential publication bias.…”

Wound Infection and Length of Hospital Stay with and Without Placement of Drain in Patients With Complicated Appendicitis

“…5 In patients with non-perforated appendicitis the incidence of wound infection is <10%. 7,8 Wound infection increases with perforated appendicitis to 15% to 20% and is highest with diffuse peritonitis, up to 35%.…”