Navigating Wound Closure Strategies: Primary Closure vs. Delayed Primary Closure in Digestive Surgery—A Systematic Review and Meta-Analysis on Surgical Site Infections

Authors

Lam Sihardo, Division of Digestive Surgery, Department of Surgery, Faculty of Medicine, Universitas Indonesia, JakartaFollow
Arnetta NL Lalisang, Division of Digestive Surgery, Department of Surgery, Faculty of Medicine, Universitas Indonesia, JakartaFollow
Afid B. Putra, Faculty of Medicine, Universitas Indonesia, JakartaFollow
Bagus A. Suryawiditya, Faculty of Medicine, Universitas Katolik Atma Jaya, JakartaFollow

Abstract

Introduction. Surgical site infection (SSI) is a significant concern following digestive surgery, with varying incidence rates based on wound contamination levels. The choice between Primary Closure (PC) and Delayed Primary Closure (DPC) impacts SSI occurrence, making it essential to evaluate their comparative effectiveness. DPC is hypothesized superior to PC to prevent SSI or wound infection after a contaminated abdominal surgery.

Methods. This systematic review study was carried out through PubMed, Scopus, and Cochrane (CENTRAL). Quality was assessed using Risk of Bias (ROB-2) tool. All results were summarized, and quantitative analysis was performed using a random-effect model. This study is reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Eligibility criteria included adult patients undergoing abdominal gastrointestinal surgery, evaluating SSI and hospital stay, directly comparing PC and DPC, and randomized controlled trials (RCT) study.

Results. Of 447 published studies, there were 10 eligible RCTs, consist of 672 subjects who received DPC and 668 subjects who received PC. We found no significant difference in SSI occurrence between PC and DPC (RR=0.62, 95%CI: 0.38–1.02; p=0.06) with high heterogeneity (I²=74%, p

Conclusion. DPC tend to decrease SSI risk. Our findings revealed that PC is not inferior than DPC to prevent SSI and improve hospital stay in abdominal surgery. The choice between techniques should be individualized, considering patient characteristics and surgical context. Standardized criteria and further research are crucial for refining closure method selection, ultimately enhancing patient outcomes and reducing the burden of SSI.

Bahasa Abstract

Pendahuluan. Infeksi luka operasi (SSI) adalah masalah penting setelah operasi saluran cerna, dengan tingkat kejadian yang bervariasi berdasarkan tingkat kontaminasi luka. Pilihan antara Penutupan Primer (Primary Closure/PC) dan Penutupan Primer Tertunda (Delayed Primary Closure/DPC) memengaruhi kejadian SSI, sehingga penting untuk mengevaluasi efektivitas komparatif keduanya. DPC diduga lebih unggul dibandingkan PC dalam mencegah SSI atau infeksi luka setelah operasi perut yang terkontaminasi.

Metode. Penelitian tinjauan sistematis ini dilakukan melalui PubMed, Scopus, dan Cochrane (CENTRAL). Kualitas penelitian dinilai menggunakan alat Risk of Bias (ROB-2). Semua hasil dirangkum dan analisis kuantitatif dilakukan menggunakan model random-effect. Studi ini dilaporkan sesuai dengan pedoman Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Kriteria inklusi mencakup pasien dewasa yang menjalani operasi saluran cerna abdomen, menilai SSI dan lama rawat inap, membandingkan langsung PC dan DPC, serta merupakan studi uji coba terkontrol secara acak (randomized controlled trials/RCT).

Hasil.Dari 447 penelitian yang diterbitkan, terdapat 10 RCT yang memenuhi syarat, terdiri dari 672 subjek yang menerima DPC dan 668 subjek yang menerima PC. Tidak ditemukan perbedaan signifikan dalam kejadian SSI antara PC dan DPC (RR=0,62, 95%CI: 0,38–1,02; p=0,06) dengan heterogenitas tinggi (I2=74%, p

Kesimpulan. DPC cenderung mengurangi risiko SSI. Temuan kami mengungkapkan bahwa PC tidak lebih buruk dibandingkan DPC dalam mencegah SSI dan memperbaiki lama rawat inap pada operasi abdomen. Pemilihan antara kedua teknik ini harus disesuaikan secara individual, dengan mempertimbangkan karakteristik pasien dan konteks pembedahan. Kriteria yang distandardisasi dan penelitian lebih lanjut diperlukan untuk menyempurnakan pemilihan metode penutupan, sehingga pada akhirnya meningkatkan hasil pasien dan mengurangi beban SSI.

References

1. Alkaaki A, Al-Radi OO, Khoja A, Alnawawi A, Alnawawi A, Maghrabi A, et al. Surgical site infection following abdominal surgery: a prospective cohort study. Canadian Journal of Surgery. 2019;62(2):111–7.

2. Mawalla B, Mshana SE, Chalya PL, Imirzalioglu C, Mahalu W. Predictors of surgical site infections among patients undergoing major surgery at Bugando Medical Centre in Northwestern Tanzania. BMC Surg. 2011;11(1):21.

3. Legesse Laloto T, Hiko Gemeda D, Abdella SH. Incidence and predictors of surgical site infection in Ethiopia: prospective cohort. BMC Infect Dis. 2017;17(1):119.

4. Aga E, Keinan-Boker L, Eithan A, Mais T, Rabinovich A, Nassar F. Surgical site infections after abdominal surgery: incidence and risk factors. A prospective cohort study. Infect Dis. 2015;47(11):761–7.

5. Aga E, Keinan-Boker L, Eithan A, Mais T, Rabinovich A, Nassar F. Surgical site infections after abdominal surgery: incidence and risk factors. A prospective cohort study. Infect Dis. 2015;47(11):761–7.

6. Syaiful RA, Mazni Y, Prasetyo ML, Lalisang TJM. Surgical site infection after digestive surgery in a single tertiary hospital in Indonesia: six years of data. Medical Journal of Indonesia. 2020;29(3):310–5.

7. Hepburn HH. Delayed primary suture of wounds. BMJ. 1919;1(3033):181–3.

8. Wilkie DPD. Observations on mortality in acute appendicular disease. BMJ. 1931;1(3658):253–5.

9. Coller FA, Valk WL. The delayed closure of contaminated wounds: a preliminary report. Ann Surg. 1940;112(2):256–70.

10. Cohn SM, Giannotti G, Ong AW, Esteban Varela J, Shatz D V., McKenney MG, et al. Prospective Randomized Trial of Two Wound Management Strategies for Dirty Abdominal Wounds. Ann Surg. 2001;233(3):409–13.

11. Wilson H. Secondary Suture of War Wounds: A Clinical Study of 305 Secondary Closures. Ann Surg. 1945;121(2):152–6.

12. ElHawary H, Covone J, Abdulkarim S, Janis JE. Practical Review on Delayed Primary Closure: Basic Science and Clinical Applications. Plast Reconstr Surg Glob Open. 2023;11(8):e5172.

13. Inyang A, Usang U, Talabi A, Anyanwu LJ, Sowande O, Adejuyigbe O. Primary versus delayed primary closure of laparotomy wounds in children following typhoid ileal perforation in Ile-Ife, Nigeria. African Journal of Paediatric Surgery. 2017;14(4):70.

14. Putra AB, Suryawiditya BA, Lalisang ANL, Sihardo L. Comparison of primary closure and delayed closure to surgical site infection in adult abdominal surgery: a systematic review and meta-analysis. OSF Registries [Internet]. 2023 [cited 2024 Dec 12]; Available from: https://doi.org/10.17605/OSF.IO/68QK3

15. McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): An R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods [Internet]. 2020 Apr 26; Available from: https://doi.org/10.1002/jrsm.1411

16. Lahat G, Tulchinsky H, Goldman G, Klauzner JM, Rabau M. Wound infection after ileostomy closure: a prospective randomized study comparing primary vs. delayed primary closure techniques. Tech Coloproctol. 2005;9(3):206–8.

17. Khan KI, Mahmood S, Akmal M, Waqas A. Comparison of rate of surgical wound infection, length of hospital stay and patient convenience in complicated appendicitis between primary closure and delayed primary closure. J Pak Med Assoc. 2012;62(6):596–8.

18. Ahmad M, Ali K, Latif H, Naz S, Said K. Comparison of primary wound closure with delayed primary closure in perforated appendicitis. J Ayub Med Coll Abbottabad. 2014;26(2):153–7.

19. Agrawal V, Joshi MK, Gupta AK, Jain BK. Wound Outcome Following Primary and Delayed Primary Skin Closure Techniques After Laparotomy for Non-Traumatic Ileal Perforation: a Randomized Clinical Trial. Indian Journal of Surgery. 2017;79(2):124–30.

20. Nasib G, Shah SI, Bashir EA. Laparotomy for peritonitis: primary or delayed primary closure? J Ayub Med Coll Abbottabad. 2015;27(3):543–5.

21. Siribumrungwong B, Chantip A, Noorit P, Wilasrusmee C, Ungpinitpong W, Chotiya P, et al. Comparison of Superficial Surgical Site Infection Between Delayed Primary Versus Primary Wound Closure in Complicated Appendicitis. Ann Surg. 2018;267(4):631–7.

22. Baksi A, Chatterjee S, Ray U, Nilima N, Firoz Khan W, Banerjee N. A randomized trial analyzing the effects of primary versus delayed primary closure of incision on wound healing in patients with hollow viscus perforation. Turk J Surg. 2020;36(4):327–32.

23. Ahmad M, Faiz A, Ramzan K, Baker MQA, Malik MH, Jamahed M, et al. The Comparison Of The Frequency Of Surgical Site Infections in patients With Primary Closure Vs Delayed Primary Closure In Contaminated Abdominal surgeries. Pakistan Journal of Medical and Health Sciences. 2022;16(8):21–3.

24. Tofigh AM, Family S. Primary versus delayed primary skin closure in operated patients due to perforated peptic ulcer disease: a randomized controlled clinical trial. Langenbecks Arch Surg. 2022;407(4):1471–8.

25. Hackam DJ, Rotstein OD. Stoma closure and wound infection: an evaluation of risk factors. Can J Surg. 1995;38(2):144–8.

26. Alkaaki A, Al-Radi OO, Khoja A, Alnawawi A, Alnawawi A, Maghrabi A, et al. Surgical site infection following abdominal surgery: a prospective cohort study. Canadian Journal of Surgery. 2019;62(2):111–7.

27. Zhang J, Xue F, Liu SD, Liu D, Wu YH, Zhao D, et al. Risk factors and prediction model for inpatient surgical site infection after elective abdominal surgery. World J Gastrointest Surg. 2023;15(3):387–97.

28. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97–132; quiz 133–4; discussion 96.

29. Berard F, Gandon J. Postoperative wound infections: the influence of ultraviolet irradiation of the operating room and of various other factors. Ann Surg. 1964;160(Suppl 2):1–192.

30. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13(10):606–8.

31. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309–32.

32. Siribumrungwong B, Srikuea K, Thakkinstian A. Comparison of superficial surgical site infection between delayed primary and primary wound closures in ruptured appendicitis. Asian J Surg. 2014;37(3):120–4.

Recommended Citation

Sihardo, Lam; Lalisang, Arnetta NL; Putra, Afid B.; and Suryawiditya, Bagus A. (2024) "Navigating Wound Closure Strategies: Primary Closure vs. Delayed Primary Closure in Digestive Surgery—A Systematic Review and Meta-Analysis on Surgical Site Infections," The New Ropanasuri Journal of Surgery: Vol. 9: No. 2, Article 2.
DOI: 10.7454/nrjs.v9i2.1204
Available at: https://scholarhub.ui.ac.id/nrjs/vol9/iss2/2