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Original Investigation |

Systemic Review and Meta-analysis of Randomized Clinical Trials Comparing Primary vs Delayed Primary Skin Closure in Contaminated and Dirty Abdominal Incisions

Aneel Bhangu, MBChB, MRCS1; Prashant Singh, BSc1; Jonathan Lundy, MD2; Douglas M. Bowley, FRCS1
[+] Author Affiliations
1Royal Centre for Defence Medicine, Birmingham, England
2Department of Trauma and Acute Care Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
JAMA Surg. 2013;148(8):779-786. doi:10.1001/jamasurg.2013.2336.
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Importance  Surgical site infection remains a major challenge in surgery. Delayed primary closure of dirty wounds is widely practiced in war surgery; we present a meta-analysis of evidence to help guide application of the technique in wider context.

Objective  To determine using meta-analysis whether delayed primary skin closure (DPC) of contaminated and dirty abdominal incisions reduces the rate of surgical site infection (SSI) compared with primary skin closure (PC).

Data Sources  A systematic review of the literature published after 1990 was conducted of the Medline, PubMed, Current Controlled Trials, and Cochrane databases. The last search was performed on October 6, 2012. No language restrictions were applied.

Study Selection  Randomized clinical trials comparing PC vs DPC were included.

Data Extraction and Synthesis  Two of us independently selected studies based on quality assessment using the Cochrane Collaboration tool for assessing risk of bias in randomized trials. Data were pooled using fixed- and random-effects models.

Main Outcome and Measure  Rate of SSI, as defined by the individual study.

Results  The final analysis included 8 studies randomizing 623 patients with contaminated or dirty abdominal wounds to either DPC or PC. The most common diagnosis was appendicitis (77.4%), followed by perforated abdominal viscus (11.5%), ileostomy closure (6.5%), trauma (2.7%), and intra-abdominal abscess/other peritonitis (1.9%). The time to first review for DPC was provided at between 2 and 5 days postoperatively. All studies were found to be at high risk of bias, with marked deficiencies in study design and outcome assessment. When SSI was assessed across all studies using a fixed-effect model, DPC significantly reduced the chance of SSI (odds ratio, 0.65; 95% CI, 0.40-0.93; P = .02). However, heterogeneity was high (72%), and using a random-effects model, the effect was no longer significant (odds ratio, 0.65; 95% CI, 0.25-1.64; P = .36).

Conclusions and Relevance  Delayed primary skin closure may reduce the rate of SSI, but current trials fail to provide definitive evidence because of poor design. Well-designed, large-numbered randomized clinical trials are warranted.

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Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-analysis Flowchart of Included Studies
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Figure 2.
Forest Plots Illustrating Meta-analysis of Surgical Site Infections by Delayed Primary Closure (DPC) vs Primary Closure (PC)

The effects are shown using fixed-effects (A) and random-effects (B) models. M-H indicates Mantel-Haenszel.

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