American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Negative Pressure Wound Therapy May Reduce Risk of Surgical Site Infection

Shiroky J, Lillie E, Muaddi H, Sevigny M, Choi WJ, Karanicolas PJ. The impact of negative pressure wound therapy for closed surgical incisions on surgical site infection: A systematic review and meta-analysis. Surgery. 2020;167(6):1001-1009.

Stewart DB. Commentary: Negative pressure wound therapy for closed incisions—the new standard wound care? Surgery. 2020;167(6):1010-1011.

Surgical site infection (SSI) is diagnosed in 2.8 percent of all surgical procedures performed annually in the U.S.; patients who undergo colorectal procedures have SSI risk that approaches 30 percent. SSI is associated with increased rates of other costly wound complications such as incisional hernia; thus, SSI may be the most expensive of all hospital-acquired infections. The article by Shiroky and coauthors reports results of a systematic review of randomized controlled clinical trials to assess the impact of negative pressure wound therapy (NPWT) on the risk for SSI. The authors analyzed 44 randomized trials that included nearly 6,000 patients. The analysis showed that use of NPWT reduced the risk for SSI by 40 percent, and this benefit was consistent across wound classes 2 and above and all surgical specialties. The analysis concluded that 16 patients would have to be treated to prevent one SSI.

In the editorial that accompanies the article, Stewart stressed that the data necessary to confirm cost-effectiveness of NPWT are not yet available and that newer types of NPWT devices that can be managed at home by patients could conceivably lead to reduced overall cost. Although additional data are needed, the evidence supporting use of NPWT is strong.

Deimplementation of Choosing Wisely Recommendations Has Varying Results on Low-Value Breast Procedures

Wang T, Baskin AS, Dossett LA. Deimplementation of the Choosing Wisely Recommendations for low-value breast cancer surgery: A systematic review. JAMA Surg. 2020.

This article reports results of a systematic review of the literature designed to determine the success of efforts to reduce usage of breast surgery procedures that were deemed to be of low value on the basis of data from randomized trials and consensus from the Choosing Wisely campaign. The procedures evaluated included axillary lymph node dissection in patients with limited nodal involvement who received lumpectomy and radiation therapy, re-excision for lumpectomy for invasive cancer with close but negative margins, contralateral prophylactic mastectomy for average-risk patients with unilateral cancer, and sentinel lymph node biopsy in patients aged 70 years or older with hormone receptor-positive breast cancer. The analysis showed that rates of axillary dissection and re-excisions for close margins had dropped by 50 percent and 40 percent, respectively.

Of note was the finding that performance of contralateral prophylactic mastectomy continues to increase; the procedures cluster in younger, white patients who have health insurance and access to breast reconstruction. The data suggest that counseling by surgeons and other health care professionals significantly influences patient decisions to undergo contralateral mastectomy. Rates of sentinel node biopsy in older patients remain stable at 80 percent; the data were too limited to explain this observation. The authors concluded that results of deimplementation of low-value breast procedures have been variable and that efforts to address surgeon and patient biases will be necessary for increased success of future deimplementation efforts.

Additional Readings

COVID-19 Collective Sacrifices: Not for the Individual, but for Protection of the Whole Line

A recent issue of the Daily Stoic (@Daily Stoic) e-newsletter focused on the collective sacrifice surgeons, other health care professionals, and patients have made during the coronavirus disease (COVID-19) pandemic. The newsletter highlights several previously published articles noting that the pandemic has asked a great deal of physicians and nurses in particular, but of members of the general public as well.

In another article, Steven Pressfield (interviewed here) spoke about how the Spartans would have responded to this kind of collective sacrifice. He quotes Plutarch, who explained why the Spartans punished with death the soldier who dropped his shield but not his other protective gear: “Because helmet and breastplate are worn to protect the individual alone, but the shield is borne to protect the whole line.”

“Why are we asked to wear surgical or face masks in public, to practice social distancing, and to observe self-quarantining?” Mr. Pressfield asked. “Answer: Because these practices are not for the individual alone but for the protection of the whole line.”

As John Brownstein noted, “The mask is not for you. Social distancing is not for you. It’s for the grandmother of the person you never met. It’s for the chemo patient. It’s because you might be a carrier and not know it, and so in wearing a mask, you protect the strangers you see and the strangers they see too.”