#2 - NPWT for closed breast incisions
Updated: Feb 16, 2020
The Efficacy of Prophylactic Negative Pressure Wound Therapy for Closed Incisions in Breast Surgery: A Systematic Review and Meta-Analysis
David Cagney, Lydia Simmons, Donal Peter O’Leary, Mark Corrigan, Louise Kelly, M. J. O’Sullivan, Aaron Liew, Henry Paul Redmond
World J Surg. 2020 Jan 3. doi: 10.1007/s00268-019-05335-x
I selected this article because of the increased use of prophylactic negative pressure wound therapy (NPWT) to prevent surgical wound complications. Being a wound specialist, I sometimes have been asked about the utility of NPWT in these situations. Because I am not a surgeon, this is not something I have been using with my own patients, but I have been wanting to learn more about it.
This article is a meta-analysis of the use of prophylactic NPWT to prevent surgical complications after breast surgery. The authors noted that complications of surgical wounds include surgical site infection, wound dehiscence, skin necrosis, hematoma, and seroma formation. The goal of this meta-analysis was to assess the efficacy of prophylactic negative pressure wound therapy versus more conventional dressings in closed breast incisions.
The authors reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. PubMed, Embase, CINAHL, and Cochrane Library databases were searched through October 2018 for the relevant search terms. A total of seven studies, which included 904 patients with 1500 close breast incisions were analyzed, and all these included studies were published between 2014 and 2018. Four of the studies compared negative pressure wound therapy utilizing the single use PICOTM NPWT dressing set at 80 mmHg; one for 14 days versus Steri-StripTM, one for 7 days vs Steri-StripTM, one for 6 days compared to an unknown dressing, and one for 7 days compared to a wound contact absorbent dressing. One of the studies used the PICOTM dressing with a mixture of colorectal and breast procedures. Only the breast procedures were included in the meta-analysis. Two of the studies evaluated the PREVENATM NPWT system set to 125 mmHg for seven days compared to Steri-StripTM; one was retrospective and one was prospective. One study did not specify the model of NPWT (125 mmHg) used for 3 days compared to a polyurethane foam and antibacterial ointment. Follow up for the studies ranged from 30 to 365 days.
Out of the 1500 close breast incisions analyzed, 1436 incisions included data on total wound complications. NPWT was associated with a statistically significant lower rate of total wound complications compared to non-NPWT dressings with a pooled odds ratio (OR) of 0.36, confidence interval (CI) 0.19-0.69, P=0.002. The number needed to treat (NNT) to prevent one complication was six.
Four of the studies provided data on surgical site infection (SSI) with a total of 1341 incisions. NPWT was associated with a statistically significant lower rate of SSI compared to non-NPWT dressings with a pooled OR of 0.45, 95% CI 0.24-0.86, P = 0.015, NNT = 50.
The four studies which had data regarding seroma formation (990 incisions) showed a statistically significant lower rate of seroma formation with a pooled OR of 0.28, 95% CI 0.13-0.59, P = 0.001, NNT = 20.
The four studies that had data on wound dehiscence (1175 incisions) showed a statistically significant decrease in wound dehiscence with a pooled OR of 0.49, 95% CI 0.32-0.72, P = 0.000, NNT = 13.
Data on hematoma were included in three studies, 940 incisions, but there was no statistically significant difference.
The authors did determine that the results of their study did provide support for the use of NPWT in the management of closed surgical incisions of the breast. Cost benefit was not reported by any of the included studies so the authors were not able to specifically address this issue in the study results, however, they believe the results suggest that SSI can be reduced by more than 50% in breast incisions with NPWT use and previous studies have estimated that only a 15% reduction in SSI is necessary to make NPWT cost-effective.
My interpretation: I believe the results presented in this meta-analysis are promising for the use of NPWT to prevent wound complications after breast surgery. If indeed the reduction in complications is anywhere near the numbers reported here, I would suspect this intervention was very cost-effective. Last time there was a Cochrane review regarding NPWT in closed incisions, back in 2014, they were not able to determine if there was any clear benefit. The results of this meta-analysis suggest an up-to-date Cochrane review should be performed. I can see why surgeons are excited about the use of prophylactic negative pressure wound therapy to prevent wound complications. It is difficult to imagine any serious complication from the use of NPWT with these kinds of incisions, so if any of my surgical colleagues ask for my opinion on the use of these devices, I will say it appears to be effective with little downside.