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Published in: Surgical Endoscopy 3/2018

01-03-2018 | Review

Wound protectors in reducing surgical site infections in lower gastrointestinal surgery: an updated meta-analysis

Authors: Lisa Zhang, Basheer Elsolh, Sunil V. Patel

Published in: Surgical Endoscopy | Issue 3/2018

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Abstract

Background

Surgical site infection (SSI) is a common complication in gastrointestinal surgery. Wound protection devices are being increasingly used in the attempt to reduce infection rates. We performed a meta-analysis to determine if wound protectors reduce the incidence of SSIs in lower gastrointestinal surgery.

Methods

MEDLINE and EMBASE databases were searched between 1946 and 2016. Randomized controlled trials comparing wound protector versus no wound protector in lower gastrointestinal surgery were included. Our primary outcome was surgical site infection. Subgroup analysis was conducted comparing single-ring versus dual-ring wound protectors.

Results

Twelve RCTs with 3029 participants were included. There was a significant decrease in the odds of developing SSI in the wound protector group (OR 0.64, 95% CI 0.45–0.90, P < 0.01, I 2 = 55%). There was evidence of a subgroup effect (P = 0.01) with dual-ring wound protectors associated with significantly lower incidence of SSIs (OR 0.31, 95% CI 0.18–0.52, P < 0.0001, I 2 = 12%), which was not appreciated in the single-ring group (OR 0.84, 95% CI 0.67–1.04, P = 0.11, I 2 = 0%).

Conclusions

Wound protector use is associated with decreased odds of developing SSI in patients undergoing lower gastrointestinal surgery. There was a subgroup effect when comparing dual-ring to single-ring devices.
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Literature
1.
go back to reference Hubner M, Diana M, Zanetti G, Eisenring MC, Demartines N, Troillet N (2011) Surgical site infections in colon surgery: the patient, the procedure, the hospital, and the surgeon. Arch Surg 146(11):1240–1245CrossRefPubMed Hubner M, Diana M, Zanetti G, Eisenring MC, Demartines N, Troillet N (2011) Surgical site infections in colon surgery: the patient, the procedure, the hospital, and the surgeon. Arch Surg 146(11):1240–1245CrossRefPubMed
2.
go back to reference Blumetti J, Luu M, Sarosi G, Hartless K, McFarlin J, Parker B, Dineen S, Huerta S, Asolati M, Varela E, Anthony T (2007) Surgical site infections after colorectal surgery: do risk factors vary depending on the type of infection considered? Surgery 142(5):704–711CrossRefPubMed Blumetti J, Luu M, Sarosi G, Hartless K, McFarlin J, Parker B, Dineen S, Huerta S, Asolati M, Varela E, Anthony T (2007) Surgical site infections after colorectal surgery: do risk factors vary depending on the type of infection considered? Surgery 142(5):704–711CrossRefPubMed
3.
go back to reference Tang R, Chen HH, Wang YL, Changchien CR, Chen JS, Hsu KC, Chiang JM, Wang JY (2001) Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2809 consecutive patients. Ann Surg 234(2):181–189CrossRefPubMedPubMedCentral Tang R, Chen HH, Wang YL, Changchien CR, Chen JS, Hsu KC, Chiang JM, Wang JY (2001) Risk factors for surgical site infection after elective resection of the colon and rectum: a single-center prospective study of 2809 consecutive patients. Ann Surg 234(2):181–189CrossRefPubMedPubMedCentral
4.
go back to reference Konishi T, Watanabe T, Kishimoto J, Nagawa H (2006) Elective colon and rectal surgery differ in risk factors for wound infection: results of prospective surveillance. Ann Surg 244(5):758–763CrossRefPubMedPubMedCentral Konishi T, Watanabe T, Kishimoto J, Nagawa H (2006) Elective colon and rectal surgery differ in risk factors for wound infection: results of prospective surveillance. Ann Surg 244(5):758–763CrossRefPubMedPubMedCentral
5.
go back to reference Smith RL, Bohl JK, McElearney ST, Friel CM, Barclay MM, Sawyer RG, Foley EF (2004) Wound infection after elective colorectal resection. Ann Surg 239(5):599–605CrossRefPubMedPubMedCentral Smith RL, Bohl JK, McElearney ST, Friel CM, Barclay MM, Sawyer RG, Foley EF (2004) Wound infection after elective colorectal resection. Ann Surg 239(5):599–605CrossRefPubMedPubMedCentral
6.
go back to reference Degrate L, Garancini M, Misani M, Poli S, Nobili C, Romano F, Giordano L, Motta V, Uggeri F (2011) Right colon, left colon, and rectal surgeries are not similar for surgical site infection development. Analysis of 277 elective and urgent colorectal resections. Int J Colorectal Dis 26(1):61–69CrossRefPubMed Degrate L, Garancini M, Misani M, Poli S, Nobili C, Romano F, Giordano L, Motta V, Uggeri F (2011) Right colon, left colon, and rectal surgeries are not similar for surgical site infection development. Analysis of 277 elective and urgent colorectal resections. Int J Colorectal Dis 26(1):61–69CrossRefPubMed
7.
go back to reference Boni L, Benevento A, Rovera F, Dionigi G, Di Giuseppe M, Bertoglio C, Dionigi R (2006) Infective complications in laparoscopic surgery. Surg Infect 7:109–111CrossRef Boni L, Benevento A, Rovera F, Dionigi G, Di Giuseppe M, Bertoglio C, Dionigi R (2006) Infective complications in laparoscopic surgery. Surg Infect 7:109–111CrossRef
8.
go back to reference Nakamura T, Mitomi H, Ihara A, Onozato W, Sato T, Ozawa H, Hatade K, Watanabe M (2008) Risk factors for wound infection after surgery for colorectal cancer. World J Surg 32(6):1138–1141CrossRefPubMed Nakamura T, Mitomi H, Ihara A, Onozato W, Sato T, Ozawa H, Hatade K, Watanabe M (2008) Risk factors for wound infection after surgery for colorectal cancer. World J Surg 32(6):1138–1141CrossRefPubMed
9.
go back to reference Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 20(4):250–278CrossRefPubMed Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 20(4):250–278CrossRefPubMed
10.
go back to reference Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ (1999) The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 20:725–730CrossRefPubMed Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ (1999) The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 20:725–730CrossRefPubMed
12.
go back to reference Gheorghe A, Roberts TE, Pinkney TD, Bartlett DC, Morton D, Calvert M, West Midlands Research Collaborative, ROSSINI Trial Investigators (2014) The cost-effectiveness of wound-edge protection devices compared to standard care in reducing surgical site infection after laparotomy: an economic evaluation alongside the ROSSINI trial. PLoS ONE 9(4):e95595CrossRefPubMedPubMedCentral Gheorghe A, Roberts TE, Pinkney TD, Bartlett DC, Morton D, Calvert M, West Midlands Research Collaborative, ROSSINI Trial Investigators (2014) The cost-effectiveness of wound-edge protection devices compared to standard care in reducing surgical site infection after laparotomy: an economic evaluation alongside the ROSSINI trial. PLoS ONE 9(4):e95595CrossRefPubMedPubMedCentral
13.
go back to reference Mihaljevic AL, Müller TC, Kehl V, Friess H, Kleeff J (2015) Wound edge protectors in open abdominal surgery to reduce surgical site infections: a systematic review and meta-analysis. PLoS ONE 10(3):e0121187CrossRefPubMedPubMedCentral Mihaljevic AL, Müller TC, Kehl V, Friess H, Kleeff J (2015) Wound edge protectors in open abdominal surgery to reduce surgical site infections: a systematic review and meta-analysis. PLoS ONE 10(3):e0121187CrossRefPubMedPubMedCentral
14.
go back to reference Edwards JP, Ho AL, Tee MC, Dixon E, Ball CG (2012) Wound protectors reduce surgical site infection: a meta-analysis of randomized controlled trials. Ann Surg 256(1):53–59CrossRefPubMed Edwards JP, Ho AL, Tee MC, Dixon E, Ball CG (2012) Wound protectors reduce surgical site infection: a meta-analysis of randomized controlled trials. Ann Surg 256(1):53–59CrossRefPubMed
15.
go back to reference Zhang MX, Sun YH, Xu Z, Zhou P, Wang HX, Wu YY (2015) Wound edge protector for prevention of surgical site infection in laparotomy: an updated systematic review and meta-analysis. ANZ J Surg 85(5):308–314CrossRefPubMed Zhang MX, Sun YH, Xu Z, Zhou P, Wang HX, Wu YY (2015) Wound edge protector for prevention of surgical site infection in laparotomy: an updated systematic review and meta-analysis. ANZ J Surg 85(5):308–314CrossRefPubMed
16.
go back to reference Gheorghe A, Calvert M, Pinkney TD, Fletcher BR, Bartlett DC, Hawkins WJ, Mak T, Youssef H, Wilson S, West Midlands Research Collaborative, ROSSINI Trial Management Group (2012) Systematic review of the clinical effectiveness of wound-edge protection devices in reducing surgical site infection in patients undergoing open abdominal surgery. Ann Surg 255(6):1017–1029CrossRefPubMed Gheorghe A, Calvert M, Pinkney TD, Fletcher BR, Bartlett DC, Hawkins WJ, Mak T, Youssef H, Wilson S, West Midlands Research Collaborative, ROSSINI Trial Management Group (2012) Systematic review of the clinical effectiveness of wound-edge protection devices in reducing surgical site infection in patients undergoing open abdominal surgery. Ann Surg 255(6):1017–1029CrossRefPubMed
17.
go back to reference NNIS System (2001) National Nosocomial Infections Surveillance (NNIS) System Report, Data Summary from January 1992 to June 2001, issued August 2001. Am J Infect Control 29(6):404–421CrossRef NNIS System (2001) National Nosocomial Infections Surveillance (NNIS) System Report, Data Summary from January 1992 to June 2001, issued August 2001. Am J Infect Control 29(6):404–421CrossRef
18.
go back to reference Tanner J, Khan D, Aplin C, Ball J, Thomas M, Bankart J (2009) Post-discharge surveillance to identify colorectal surgical site infection rates and related costs. J Hosp Infect 72(3):243–250CrossRefPubMed Tanner J, Khan D, Aplin C, Ball J, Thomas M, Bankart J (2009) Post-discharge surveillance to identify colorectal surgical site infection rates and related costs. J Hosp Infect 72(3):243–250CrossRefPubMed
20.
go back to reference Review Manager (RevMan) (2014) [Computer program] Version 5.3 Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration Review Manager (RevMan) (2014) [Computer program] Version 5.3 Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration
21.
go back to reference Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, GRADE Working Group (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336(7650):924–926CrossRefPubMedPubMedCentral Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ, GRADE Working Group (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336(7650):924–926CrossRefPubMedPubMedCentral
22.
go back to reference Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700CrossRefPubMedPubMedCentral Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700CrossRefPubMedPubMedCentral
23.
go back to reference Baier P, Kiesel M, Kayser C, Fischer A, Hopt UT, Utzolino S (2012) Ring drape do not protect against surgical site infections in colorectal surgery: a randomised controlled study. Int J Colorectal Dis 27:1223–1228CrossRefPubMed Baier P, Kiesel M, Kayser C, Fischer A, Hopt UT, Utzolino S (2012) Ring drape do not protect against surgical site infections in colorectal surgery: a randomised controlled study. Int J Colorectal Dis 27:1223–1228CrossRefPubMed
24.
go back to reference Cheng KP, Roslani AC, Sehha N, Kueh JH, Law CW, Chong HY, Arumugam K (2012) ALEXIS O-Ring wound retractor vs. conventional wound protection for the prevention of surgical site infections in colorectal resections. Colorectal Dis 14:e346–e351CrossRefPubMed Cheng KP, Roslani AC, Sehha N, Kueh JH, Law CW, Chong HY, Arumugam K (2012) ALEXIS O-Ring wound retractor vs. conventional wound protection for the prevention of surgical site infections in colorectal resections. Colorectal Dis 14:e346–e351CrossRefPubMed
25.
go back to reference Lauscher JC, Grittner F, Stroux A, Zimmermann M, le Claire M, Buhr HJ, Ritz JP (2012) Reduction of wound infections in laparoscopic-assisted colorectal resections by plastic wound ring drapes (REDWIL): a randomized controlled trial. Langenbecks Arch Surg 397:1079–1085CrossRefPubMed Lauscher JC, Grittner F, Stroux A, Zimmermann M, le Claire M, Buhr HJ, Ritz JP (2012) Reduction of wound infections in laparoscopic-assisted colorectal resections by plastic wound ring drapes (REDWIL): a randomized controlled trial. Langenbecks Arch Surg 397:1079–1085CrossRefPubMed
26.
go back to reference Nystrom PO, Broome A, Hojer H, Ling L (1984) A controlled trial of a plastic wound ring drape to prevent contamination and infection in colorectal surgery. Dis Colon Rectum 27(7):451–453CrossRefPubMed Nystrom PO, Broome A, Hojer H, Ling L (1984) A controlled trial of a plastic wound ring drape to prevent contamination and infection in colorectal surgery. Dis Colon Rectum 27(7):451–453CrossRefPubMed
27.
go back to reference Reid K, Pockney P, Draganic B, Smith SR (2010) Barrier wound protection decreases surgical site infection in open elective colorectal surgery: a randomized clinical trial. Dis Colon Rectum 53(10):1374–1380CrossRefPubMed Reid K, Pockney P, Draganic B, Smith SR (2010) Barrier wound protection decreases surgical site infection in open elective colorectal surgery: a randomized clinical trial. Dis Colon Rectum 53(10):1374–1380CrossRefPubMed
28.
go back to reference Horiuchi T, Tanishima H, Tamagawa K, Matsuura I, Nakai H, Shouno I, Tsubakihara H, Inoue M, Tabuse K (2007) Randomized, controlled investigation of the anti-infective properties of the Alexis retractor/protector of incision sites. J Trauma 62(1):212–215CrossRefPubMed Horiuchi T, Tanishima H, Tamagawa K, Matsuura I, Nakai H, Shouno I, Tsubakihara H, Inoue M, Tabuse K (2007) Randomized, controlled investigation of the anti-infective properties of the Alexis retractor/protector of incision sites. J Trauma 62(1):212–215CrossRefPubMed
29.
go back to reference Mihaljevic AL, Schirren R, Ozer M, Ottl S, Grun S, Michalski CW, Erkan M, Jager C, Reiser-Erkan C, Kehl V, Schuster T, Roder J, Clauer U, Orlitsch C, Hoffmann TF, Lange R, Harzenetter T, Steiner P, Michalski M, Henkel K, Stadler J, Pistorius GA, Jahn A, Obermaier R, Unger R, Strunk R, Willeke F, Vogelsang H, Halve B, Dietl KH, Hilgenstock H, Meyer A, Kramling HJ, Wagner M, Schoenberg MH, Zeller F, Schmidt J, Friess H, Jorg K (2014) Multicenter double-blinded randomized controlled trial of standard abdominal wound edge protection with surgical dressings versus coverage with a sterile circular polyethylene drape for prevention of surgical site infections: a CHIR-Net Trial (BaFO; NCT01181206). Ann Surg 260(5):730–739CrossRefPubMed Mihaljevic AL, Schirren R, Ozer M, Ottl S, Grun S, Michalski CW, Erkan M, Jager C, Reiser-Erkan C, Kehl V, Schuster T, Roder J, Clauer U, Orlitsch C, Hoffmann TF, Lange R, Harzenetter T, Steiner P, Michalski M, Henkel K, Stadler J, Pistorius GA, Jahn A, Obermaier R, Unger R, Strunk R, Willeke F, Vogelsang H, Halve B, Dietl KH, Hilgenstock H, Meyer A, Kramling HJ, Wagner M, Schoenberg MH, Zeller F, Schmidt J, Friess H, Jorg K (2014) Multicenter double-blinded randomized controlled trial of standard abdominal wound edge protection with surgical dressings versus coverage with a sterile circular polyethylene drape for prevention of surgical site infections: a CHIR-Net Trial (BaFO; NCT01181206). Ann Surg 260(5):730–739CrossRefPubMed
30.
go back to reference Pinkney TD, Calvert M, Bartlett DC, Gheorghe A, Redman V, Dowswell G, Hawkins W, Mak T, Youssef H, Richardson C, Hornsby S, Magill L, Haslop R, Wilson S, Morton D, West Midlands Research Collaborative, ROSSINI Trial Management Group (2013) Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial). BMJ 347:f4305CrossRefPubMedPubMedCentral Pinkney TD, Calvert M, Bartlett DC, Gheorghe A, Redman V, Dowswell G, Hawkins W, Mak T, Youssef H, Richardson C, Hornsby S, Magill L, Haslop R, Wilson S, Morton D, West Midlands Research Collaborative, ROSSINI Trial Management Group (2013) Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial). BMJ 347:f4305CrossRefPubMedPubMedCentral
31.
go back to reference Psaila JV, Wheeler MH, Crosby DL (1977) The role of plastic wound drapes in the prevention of wound infection following abdominal surgery. Br J Surg 64(10):729–732CrossRefPubMed Psaila JV, Wheeler MH, Crosby DL (1977) The role of plastic wound drapes in the prevention of wound infection following abdominal surgery. Br J Surg 64(10):729–732CrossRefPubMed
32.
go back to reference Williams JA, Oates GD, Brown PP, Burden DW, McCall J, Hutchison AG, Lees LJ (1972) Abdominal wound infections and plastic wound guards. Br J Surg 59(2):142–146CrossRefPubMed Williams JA, Oates GD, Brown PP, Burden DW, McCall J, Hutchison AG, Lees LJ (1972) Abdominal wound infections and plastic wound guards. Br J Surg 59(2):142–146CrossRefPubMed
33.
go back to reference Silva A, Vargas G, Moreno A, Becerra P (2008) Use of an elastic wall retractor during appendectomy to reduce wound infection. Rev Chil Cir 60(6):527–533 Silva A, Vargas G, Moreno A, Becerra P (2008) Use of an elastic wall retractor during appendectomy to reduce wound infection. Rev Chil Cir 60(6):527–533
34.
go back to reference Lee P, Waxman K, Taylor B, Yim S (2009) Use of wound-protection system and postoperative wound-infection rates in open appendectomy: a randomized prospective trial. Arch Surg 144(9):872–875CrossRef Lee P, Waxman K, Taylor B, Yim S (2009) Use of wound-protection system and postoperative wound-infection rates in open appendectomy: a randomized prospective trial. Arch Surg 144(9):872–875CrossRef
35.
go back to reference Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, Nyquist AC, Saiman L, Yokoe DS, Maragakis LL, Kaye KS (2014) Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 35(6):605–627CrossRefPubMedPubMedCentral Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, Nyquist AC, Saiman L, Yokoe DS, Maragakis LL, Kaye KS (2014) Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 35(6):605–627CrossRefPubMedPubMedCentral
Metadata
Title
Wound protectors in reducing surgical site infections in lower gastrointestinal surgery: an updated meta-analysis
Authors
Lisa Zhang
Basheer Elsolh
Sunil V. Patel
Publication date
01-03-2018
Publisher
Springer US
Published in
Surgical Endoscopy / Issue 3/2018
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-017-6012-0

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