Vacuum-assisted closure versus closure without vacuum assistance for preventing surgical site infections and infections of chronic wounds: a meta-analysis of randomized controlled trials.

OBJECTIVES: We sought to examine whether vacuum-assisted closure (VAC) is associated with fewer surgical site infections (SSIs) or infections of chronic wounds than other management procedures for surgical wounds. METHODS: The PubMed and Scopus databases were searched systematically. Randomized controlled trials (RCTs) comparing the development of SSIs or infections of chronic wounds between patients treated with VAC for acute or chronic wounds and those whose wounds were treated without VAC were considered eligible for inclusion in the study. RESULTS: Eight RCTs met the inclusion criteria for the study. Four of the studies included chronic or diabetic lower extremity wounds and four included fractures. In three of four studies reporting on fractures, the wounds were not closed post-operatively, whereas in one study primary closure of the wound was performed. With regard to wounds left open after the stabilization of fractures, patients whose wounds were treated with VAC developed fewer SSIs than those whose wounds were treated without VAC ([367 patients (196 with VAC; 171 without VAC) relative risk [RR], 0.47; 95% CI 0.28-0.81]). On the contrary, no difference in the development of SSIs occurred among patients with chronic or diabetic lower-extremity wounds treated with VAC and those whose wounds were treated without VAC ([638 patients (320 with VAC; 318 without VAC) RR 1.67; 95% CI: 0.71-3.94]). CONCLUSION: The available evidence suggests that the development of infections in wounds treated with VAC depends on the type of wound being treated.

Laparoscopy for acute small bowel obstruction: indication or contraindication?

BACKGROUND: Acute small bowel obstruction (SBO) is a relatively common cause of emergency hospital admission, most frequently due to postoperative adhesions. With increased experience and technical advances in laparoscopic surgery, the laparoscopic management of acute SBO has become feasible and potentially superior to the open approach. This retrospective study presents the authors' experience with laparoscopic treatment of SBO over a 6-year period to assess the feasibility, efficacy, and clinical outcome of this therapeutic method and to present the author's methodology. METHODS: From April 2003 to January 2009, 32 patients hospitalized in the author's department for acute SBO underwent elective laparoscopic treatment after failure of conservative measures. Standard laparoscopic techniques and instruments were used. RESULTS: Postoperative adhesions were identified in 62.5% of patients (n=20) as well as tumor (n=3), incarcerated ventral hernia (n=4), incarcerated femoral hernia (n=3), internal hernia (n=1), and Crohn's disease (n=1). The conversion rate was 18.7% (n=6), and the postoperative complication rate was 3.25% (n=1). The mean operative time was 78 min. Bowel function returned after a mean of 3.2 days, and the mean hospital stay was 4.6 days. CONCLUSIONS: The laparoscopic treatment of acute SBO is an attractive alternative to the open approach. However, it must be kept in mind that surgery longer than 120 min is a significant predictor of postoperative morbidity, that bowel injury may be missed at the time of operation and can be avoided with improved surgical techniques and appropriate instrumentation, that lysis of all intraabdominal adhesions is unnecessary, and that a low threshold for conversion should be maintained, especially in cases of severe, dense, extensive adhesions.