Background: There is a clear association between hyperglycaemia and surgical-site infection (SSI). Intensive glucose control may involve a risk of hypoglycaemia, which in turn results in potentially severe complications. A systematic review was undertaken of studies comparing intensive versus conventional glucose control protocols in relation to reduction of SSI and other outcomes, including hypoglycaemia, mortality and stroke.Methods: PubMed, Embase, CENTRAL, CINAHL and WHO databases from 1 January 1990 to 1 August 2015 were searched. Inclusion criteria were RCTs comparing intensive with conventional glucose control protocols, and reporting on the incidence of SSI. Meta-analyses were performed with a random-effects model, and meta-regression was subsequently undertaken. Targeted blood glucose levels, achieved blood glucose levels, and important adverse events were summarized.Results: Fifteen RCTs were included. The summary estimate showed a significant benefit for an intensive compared with a conventional glucose control protocol in reducing SSI (odds ratio (OR) 0⋅43, 95 per cent c.i. 0⋅29 to 0⋅64; P < 0⋅001). A significantly higher risk of hypoglycaemic events was found for the intensive group compared with the conventional group (OR 5⋅55, 2⋅58 to 11⋅96), with no increased risk of death (OR 0⋅74, 0⋅45 to 1⋅23) or stroke (OR 1⋅37, 0⋅26 to 7⋅20). These results were consistent both in patients with and those without diabetes, and in studies with moderately strict and very strict glucose control.
Conclusion:Stricter and lower blood glucose target levels of less than 150 mg/dl (8⋅3 mmol/l), using an intensive protocol in the perioperative period, reduce SSI with an inherent risk of hypoglycaemic events but without a significant increase in serious adverse events.
PurposeTo evaluate if incisional prophylactic negative pressure wound therapy (pNPWT) reduces wound infections and other wound complications in high-risk patients undergoing major complex ventral abdominal wall repair.MethodsRetrospective before–after comparison nested in a consecutive series of patients undergoing elective major complex abdominal wall repair. Starting January 2014, pNPWT was applied on the closed incisional wound for a minimum of 5 days. To minimize selection bias, we compared two periods of 14 months before and after January 2014. Wound infections according to the Centre for Disease Control Surgical Site Infection classification as well as other wound complications were recorded.ResultsThirty-two patients were included in the pNPWT group and 34 in the control group. The study group involved clean-contaminated and contaminated operations due to enterocutaneous fistula, enterostomies or infected mesh. Median duration of pNPWT was 5 days (IQR 5–7). Overall wound infection rate was 35%. pNPWT was associated with a significant decrease in postoperative wound infection rate (24 versus 51%; p = 0.029, OR 0.30 (95% CI 0.10–0.90)). Incisional wound infection rates dropped from 48 to 7% (p < 0.01, OR 0.08 (95% CI 0.16–0.39), whereas the number of subcutaneous abscesses was comparable in both groups. Moreover, less interventions were needed in the pNPWT group (p < 0.001).ConclusionsClosed incision pNPWT seems a promising solution to reduce the incidence of wound infections in complex abdominal wall surgery. Randomized controlled trials are needed to estimate more precisely the value and cost-effectiveness of pNPWT in this high-risk setting.
Purpose Complex abdominal wall repair (CAWR) in a contaminated operative field is a challenge. Available literature regarding long-term outcomes of CAWR comprises studies that often have small numbers and heterogeneous patient populations. This study aims to assess long-term outcomes of modified-ventral hernia working group (VHWG) grade 3 repairs. Because the relevance of hernia recurrence (HR) as the primary outcome for this patient group is contentious, the need for further hernia surgery (FHS) was also assessed in relation to long-term survival. Methods A retrospective cohort study with a single prospective follow-up time-point nested in a consecutive series of patients undergoing CAWR in two European national intestinal failure centers. Results In long-term analysis, 266 modified VHWG grade 3 procedures were included. The overall HR rate was 32.3%. The HR rates for non-crosslinked biologic meshes and synthetic meshes when fascial closure was achieved were 20.3% and 30.6%, respectively. The rates of FHS were 7.2% and 16.7%, and occurred only within the first 3 years. Bridged repairs showed poorer results (fascial closure 22.9% hernia recurrence vs bridged 57.1% recurrence). Overall survival was relatively good with 80% en 70% of the patients still alive after 5 and 10 years, respectively. In total 86.6% of the patients remained free of FHS. Conclusions In this study of contaminated CAWR, non-crosslinked biologic mesh shows better results than synthetic mesh. Bridging repairs with no posterior and/or anterior fascial closure have a higher recurrence rate. The overall survival was good and the majority of patients remained free of additional hernia surgery.As 80% of patients are still alive at 5-year follow-up and 86.6% of the patients remained free of additional surgery, the initial higher costs of a non-crosslinked biologic mesh seem trivial.
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