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Original Research (Original Article) 


Hesham Mohammed Ahmed Hamaly et al, 2020;4(3):682–686.

International Journal of Medicine in Developing Countries

Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia

Hesham Mohammed Ahmed Hamaly1, Mohammed Abdu Mohammed Jawahy2, Moath Abdullah Yahya Qadri3, Abdulrahman Yahya Ahmad Alqasem3, Mohammed Ali Jabril Faqihi4*

Correspondence to: Mohammed Ali Jabril Faqihi

*Medical Intern, Department of Medicine, Jazan University, Riyadh, Saudi Arabia.

Email: xfanezz [at] gmail.com

Full list of author information is available at the end of the article.

Received: 22 December 2018 | Accepted: 08 January 2020


ABSTRACT

Background:

Healing of surgical wounds by secondary intention (SWHSI) can be difficult and costly to manage. This survey aimed to assess the prevalence of SWHSI, to characterize the etiology, duration, and management of these secondary wound healings among patients with open surgical wounds, and to investigate the characteristics of patients with SWHSI in Jazan, Saudi Arabia.


Methodology:

A cross-sectional survey was conducted. Our target population was patients older than 17 years in Jazan, Saudi Arabia, with a sampling size of 50. A survey questionnaire consisted of two parts. The respondents have been given a sufficient description of the survey and its objectives.


Results:

In total, 55 patients were recruited. The mean ± SD age of all the study participants was 39.9 ± 20.1 years. The majority of the operation type was laparotomy (16.4%), and the most prevalent location of the wound was abdominal wounds. Most of the patients were treated by a general practitioner (44/55, 80%), and the most commonly used dressing types were saline (n = 37, 67.3%). The mean ± SD of weekly dressing change frequency was 4.7± 1.9 in a range of 1–7 per week.


Conclusion:

We have successfully characterized SWHSI and have been able to describe the characteristics of patients with SWHSI and identify the surgical procedures and surgical specialties that lead to SWHSI. The results from the survey were important and may facilitate the planning of further detailed SWHSI research regarding treatments, outcomes, costs, health resources, improving wound care, and quality of patient’s life.


Keywords:

Surgical wound healing, primary and secondary intentions, dressing type.


Introduction

Most surgical wounds heal by primary intention, whereas the edges of the wound are brought together with sutures, staples, adhesive glue, or clips. Nevertheless, some wounds left open to heal in case there is a risk of infection or if there is a risk of tissue loss, and the healing process occurs through the growth of new tissue from the base of the wound upward, a process described as “surgical wounds healing by secondary intention (SWHSI).” They are estimated to comprise about 28% of all surgical wounds and are often complicated to treat [1]. However, they are under-researched, and little is known about their impact on patients’ lives. SWHSI has various correlated diseases, such as vascular disorders, diabetes, cancer, or other chronic diseases [2]. SWHSI heals slowly and is complex to treat and care [3]. In addition, the previous research suggests that the treatment of complex wounds is costly and consumes healthcare resources, due to the length of duration and intensive care needed [4]. Furthermore, complex wounds are common and affect thousands of individuals every day. It is well documented that complex wounds have a negative impact on patients’ quality of life and are often perceived as horrible, smelly, and painful ones [5]. In the past two decades, wound care has received a lot of attention from researchers. Many studies have aimed to investigate which interventions might be effective in promoting wound healing or preventing wounds [6,7]. While there have been many studies on the prevalence of leg ulcers, diabetic foot ulcers, and pressure ulcers, there are not enough studies about surgical wounds even though many conditions are treated with surgical procedures. Almost ten million surgical operations are performed each year within the United Kingdom (UK) National Health Service (NHS) [8], with estimated 313 million surgical operations being performed globally each year [9]. The majority of surgical wounds heal by primary intention following the apposition of the wound edges with clips, sutures, glue, or adhesive dressings [10]. However, a large number of surgical wounds heal by secondary intention, e.g., when primary closure is not possible or following wound dehiscence. Local audits of hospital and community in UK NHS organizations have estimated that SWHSI comprises approximately 28% of all prevalent surgical wounds receiving care in inpatient or community settings [11]. Despite the potentially large impact of SWHSI, there is a paucity of information regarding the characteristics of patients who have SWHSI, the duration of SWHSI, their surgical etiology, treatment, and management. This lack of information limits our understanding of the clinical and service requirements of this patient population [7] and also makes programmers of research difficult to priorities, plan, and implement. Therefore, providing information on the prevalence, nature, and treatment of SWHSI is important for several reasons including assessing the burden of this condition, care planning in acute settings and the community, health resource management, and informing future intervention studies and qualitative research on living with these wounds and associated symptoms. Therefore, the present study aimed to assess the prevalence of SWHSI and to characterize the etiology, duration, and management of these wounds in Jazan, Saudi Arabia. It is the first study specifically designed to explore patients’ views and experiences of living with SWHSI. Hence, SWHSI affected substantially on daily living, and this impact was particularly crucial for those patients with children or in employment.


Subjects and Methods

A cross-sectional survey was conducted. Our target population was patients older than 17 years with open surgical wounds in the first and secondary care facilities in Jazan, Saudi Arabia, with a sampling size of 50. A survey questionnaire consisted of two parts: one to collect sociodemographic criteria and another one to assess wound care findings. At the end of the questionnaire, an e-mail was provided for any inquiries from the participants about any unclear questions. The socio-economic variables that were in the questionnaire were included participants’ age, gender, ethnicity, level of education, and marital status. The characteristics of their wound (the type of operation, location of the wound, and wound bed condition) and current wound management (how many consultations, treatment objectives, and wound treatment given) were also evaluated through the questionnaire. The proportion of SWHSI, which was intentional or resulted from the dehiscence of a wound closed primarily. The surgery type that caused the SWHSI (e.g., elective vs. emergency, surgical specialty, and surgical procedure), in addition to the duration of SWHSI, and the types of treatments were assessed. Numbers and percentages were used to present all the categorical variables, whereas the mean ± standard deviation was used to summarize all the continuous variables. Confidentiality was assured to all the participants who agreed to participate in the study. An ethical approval was obtained before starting data collection. The respondents have been given a sufficient description of the survey and its objectives.

Table 1. Demographic findings.

Description
(n = 55)
Age
Range 7–90
Mean ± SD 39.9 ± 20.1
Age  
<20 8 (14.5)
20–40 26 (47.3)
>40 21 (38.2)
Gender  
Male 39 (70.9)
Female 16 (29.1)
Educational level  
Illiterate 17 (30.9)
Primary 5 (9.1)
Intermediate 6 (10.9)
Secondary 21 (38.2)
University 6 (10.9)
Marital status  
Married 39 (70.9)
Not married 16 (29.1)

Results

In total, 55 patients were recruited. Thirty-nine of the patients were male (70.09%), and sixteen (29.1%) were female. The mean ± SD age of all the study participants was 39.9 ± 20.1 years. Approximately, two-thirty of the patients (71%) were married. Concerning educational level, the majority was from who has secondary level (38.2%) or illiterates (31%) as shown in Table 1. Of 55 participants, 26 patients had a closed wound intended opened (47.3%), 16 patients had an opened wound (29.1%), and 13 remaining patients had a closed wound but not intended opened (23.6%) as shown in Table 2. Furthermore, patients were asked about the type of the operation; the plurality was laparotomy (16.4%); and 60% were differentiated as fracture fixation (12.7%), hernia repair (7.3%), sleeve gastrectomy (7.3%), wound exploration (7.3%), laparoscopic cholecystectomy (7.3%), open appendectomy (5.5%), limb amputation (5.5%), and the little two types of operations: open cholecystectomy (3.6%) and chest tube insertion (3.6%), whereas 23.6% were a miscellaneous type of surgery as shown in Table 2. Concerning the site of the wound, abdominal wounds were the most prevalent location (n = 28/55, 50.9%), with other common locations being the lower limb (n = 13/55, 23.6%), back (n = 5/55, 9.1%), chest (n = 5/55, 9.1%), upper limb (n = 3/55, 5.5%), and head area (n = 1/55, 1.8%). As detailed in Table 2, general surgery clinic was the most frequent treatment site at baseline (n = 42/55, 76.4%); however, 8 (14.5%) participants were being treated at critical care hospital, whereas four (7.3%) participants were being treated at community care units, and only one case was reported to have been treated at a wound care clinic. Most of the patients were treated by general practitioner (44/55, 80%); a smaller proportion of patients (n = 6, 10.9%) have been treated by nurse, followed by four (7.3%) patients who have been treated by medical students; and one patient has been treated by nurse assistant (1.8%) (Table 2). As detailed in Table 2, the most commonly used dressing types for SWHSI across the whole survey period were saline (n = 37, 67.3%), followed by using swab with Ringer (n = 8, 14.5%) and alcohol with Bovidon
(n = 6, 10.9%), whereas the little two types of dressing were saline solution (n = 2, 3.6%) and polyurethane (n = 2, 3.6%). Furthermore, a survey questionnaire asked about how long the wound care consultation had taken for each patient; dressings were changed most commonly every 4–6 days (23/55, 41.8%). The mean ± SD of weekly dressing change frequency was 4.7± 1.9 in a range of 1–7 per week. Fourteen (25.5%) patients were changed dressing every 1–3 days per week, whereas 18 (32.7%) patients were changed dressing daily (7 days).

Table 2. Wound care findings.

Description
(n = 55)
Wound type  
Closed wound intendedly opened 26 (47.3)
Closed wound not intendedly opened 13 (23.6)
Open wound 16 (29.1)
Operation type  
Laparotomy 9 (16.4)
Fracture fixation 7 (12.7)
Hernia repair 4 (7.3)
Sleeve gastrectomy 4 (7.3)
Wound exploration 4 (7.3)
Laparoscopic cholecystectomy 4 (7.3)
Open appendectomy 3 (5.5)
Limb amputation 3 (5.5)
Open cholecystectomy 2 (3.6)
Chest tube insertion 2 (3.6)
Miscellaneous 13 (23.6)
Wound site  
Abdomen 28 (50.9)
Lower limb 13 (23.6)
Back 5 (9.1)
Chest 5 (9.1)
Upper limb 3 (5.5)
Head 1 (1.8)
Treatment location  
General surgery clinic 42 (76.4)
Critical care hospital 8 (14.5)
Community care units 4 (7.3)
Wound care clinic 1 (1.8)
Assigned HCW  
Medical student 4 (7.3)
Nurse assistant 1 (1.8)
Nurse 6 (10.9)
GP 44 (80)
Dressing type  
Dressing with saline 37 (67.3)
Swab with Ringer 8 (14.5)
Alcohol with Bovidon 6 (10.9)
Saline solution 2 (3.6)
Polyurethane 2 (3.6)
Weekly dressing change frequency
Range 1–7
Mean ± SD 4.7 ± 1.9
Weekly dressing change frequency  
1–3 days 14 (25.5)
4–6 days 23 (41.8)
Daily (7 days) 18 (32.7)

Discussion

Most of the surgical wounds were healed by primary intention; the wound is closed with sutures, clips, or glue. However, some surgical wounds are either left open to heal from the bottom up (“healing by secondary intention”) or break open partially or fully after primary closure. In general, there is a little basic knowledge about the occurrence of SWHSI. This survey is one of the first in Jazan, Saudi Arabia, to provide insight into the prevalence, characteristics, and management of SWHSI. We have willingly collected data among Saudi Arabian patients who were older than 17 years with open surgical wounds in the first and secondary care facilities. This study provided the important data on patient demographics, number, duration, surgical and clinical details, and dressing type of SWHSI. We found that the prevalence of SWHSI was more common in men than women which may simply reflect the fact that some diseases that are associated with SWHSI (e.g., peripheral vascular disease, pilonidal sinus disease, and non reconstructable critical lower limb ischemia) are more common in men than in women; this is in a harmony with the result of Chetter et al. [12,13]. Furthermore, more than two-thirds of the patients with SWHSI were treated in the general surgery clinic who received care from GP surgeries and a little number of patients were treated at care settings; this is different to results from previous studies [12] at which more half of the patients were treated at primary care settings. We have shown a variety of primary and secondary dressing types in use and some concerns about practice. For example, saline, alcohol, and dry swabs were used as a primary dressing for SWHSI and it was documented that their use is associated with more pain [14]. This variation in the treatment might be due to insufficient knowledge about wound management in community care in Saudi Arabia, and there are no specialized wound care services there, as well as no specialist wound care courses for nurses or nursing assistants. Moreover, a variation in dressing change time was identified in the present study: frequencies of change ranged from daily, 1–3 days per week, or from 4 to 6 days per week. This might be due to some wounds which need more frequent dressings or might be a sign of uncertainty among healthcare personnel about treatment selection and wound care regimen; there is a lack of good evidence on the clinical effectiveness of wound dressings or other topical agents for healing SWHSI [1518]. The median duration (in days) of SWHSI was higher than that reported by Chetter [12], which was three times per day; this variation in the duration might be the type of surgery which was different. The wide range of dressings used and the number of treatment changes observed likely reflect the limited randomized controlled trial data on treatments for SWHSI, and hence, there was the uncertainty regarding the clinical and cost-effective treatments for these wounds [1517). Further randomized controlled trial evidence for wound dressings is, therefore, required, which can subsequently inform wound management plans, including the use of dressings where effectiveness in relation to wound healing has been demonstrated by Chetter et al. [13]. The present results were in a semi-similar trend to the results obtained by Paden et al. [18], who conducted a cross-sectional survey of patients with open surgical wounds in Slovenia, but differ in dressing type; hence, a systemic antibiotic therapy was applied to people whose wounds were left open at the time of surgery, such as abdominal and colorectal surgeries to decrease the risk of wound infection. Data from this survey can be used to inform the design of future research studies. Information on the care settings where SWHSI is likely to be encountered and common surgical specialties (within secondary care) which lead to SWHSI is useful for targeting patient recruitment. The number of patients captured during this survey period provides an approximation of potential recruitment rates. Data on SWHSI duration can be used to estimate how long patients in the cohort study need to be followed up to capture healing events. This survey also highlights the areas for more detailed data collection, e.g., the types of dressings’ patients with SWHSI receive. This study has a number of strengths. First, it provides insight into the prevalence of SWHSI, including group age older than 17 years, in Jazan, Saudi Arabia. This paper makes a particular contribution in outlining the types of dressings and treatments used for SWHSI. Furthermore, this study also highlights the need for future studies on wound management uncertainties, assessing patients’ quality of life. On the other hand, the cross-sectional nature of this survey had some limitations, we were unable to record the time of healing, we were also unable to collect information on the level of nonresponse to survey questionnaires, and thus, it is possible to draw the conclusions that only represent patients who were under the care of those who responded to the survey. Another limitation, in this survey, was the little number of patients who responded to the questionnaire, so we need to extend a future survey among more number of patients also in different areas in Saudi Arabia.


Conclusion

This survey is the first to provide essential information about the extent, nature, and treatment of SWHSI in Saudi Arabia. Furthermore, we have successfully characterized SWHSI and have been able to describe the characteristics of patients with SWHSI and identify the surgical procedures and surgical specialties that lead to SWHSI. The locations where patients with SWHSI are treated are also described. The prevalence data from this survey are similar to results from the previous studies; it seems that SWHSI is a common type of complex wound. Most of the people with SWHSI are treated in primary care settings with a variety of wound dressings and other topical treatments. The results from the survey are important and may facilitate the planning of further detailed SWHSI research regarding treatments, outcomes, costs, health resources, improving wound care, and quality of patient’s life.


List of Abbreviations

NHS National Health Services
SWHSI Surgical wounds healing by secondary intention
UK United Kingdom

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

An informed consent was obtained from all the participants.


Ethical approval

Online Survey Was Done Afrer Verbal Approval Of Jazan University.


Author details

Hesham Mohammed Ahmed Hamaly1, Mohammed Abdu Mohammed Jawahy2, Moath Abdullah Yahya Qadri3, Abdulrahman Yahya Ahmad Alqasem3, Mohammed Ali Jabril Faqihi4

  1. Medical Intern, Department of Medicine, Jazan University, Samtah, Jazan, Saudi Arabia
  2. Medical Intern, Department of Medicine, Jazan University, Baish, Jazan, Saudi Arabia
  3. Medical Intern, Department of Medicine, Jazan University, Abu Arish, Jazan, Saudi Arabia
  4. Medical Intern, Department of Medicine, Jazan University, Riyadh, Saudi Arabia

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How to Cite this Article
Pubmed Style

Hamaly HMA, Jawahy MAM, Qadri MAY, Alqasem AYA, Faqihi MAJ. Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia. IJMDC. 2020; 4(3): 682-686. doi:10.24911/IJMDC51-1577049614


Web Style

Hamaly HMA, Jawahy MAM, Qadri MAY, Alqasem AYA, Faqihi MAJ. Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia. http://www.ijmdc.com/?mno=79005 [Access: March 28, 2020]. doi:10.24911/IJMDC51-1577049614


AMA (American Medical Association) Style

Hamaly HMA, Jawahy MAM, Qadri MAY, Alqasem AYA, Faqihi MAJ. Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia. IJMDC. 2020; 4(3): 682-686. doi:10.24911/IJMDC51-1577049614



Vancouver/ICMJE Style

Hamaly HMA, Jawahy MAM, Qadri MAY, Alqasem AYA, Faqihi MAJ. Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia. IJMDC. (2020), [cited March 28, 2020]; 4(3): 682-686. doi:10.24911/IJMDC51-1577049614



Harvard Style

Hamaly, H. M. A., Jawahy, . M. A. M., Qadri, . M. A. Y., Alqasem, . A. Y. A. & Faqihi, . M. A. J. (2020) Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia. IJMDC, 4 (3), 682-686. doi:10.24911/IJMDC51-1577049614



Turabian Style

Hamaly, Hesham Mohammed Ahmed, Mohammed Abdu Mohammed Jawahy, Moath Abdullah Yahya Qadri, Abdulrahman Yahya Ahmad Alqasem, and Mohammed Ali Jabril Faqihi. 2020. Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (3), 682-686. doi:10.24911/IJMDC51-1577049614



Chicago Style

Hamaly, Hesham Mohammed Ahmed, Mohammed Abdu Mohammed Jawahy, Moath Abdullah Yahya Qadri, Abdulrahman Yahya Ahmad Alqasem, and Mohammed Ali Jabril Faqihi. "Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia." International Journal of Medicine in Developing Countries 4 (2020), 682-686. doi:10.24911/IJMDC51-1577049614



MLA (The Modern Language Association) Style

Hamaly, Hesham Mohammed Ahmed, Mohammed Abdu Mohammed Jawahy, Moath Abdullah Yahya Qadri, Abdulrahman Yahya Ahmad Alqasem, and Mohammed Ali Jabril Faqihi. "Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia." International Journal of Medicine in Developing Countries 4.3 (2020), 682-686. Print. doi:10.24911/IJMDC51-1577049614



APA (American Psychological Association) Style

Hamaly, H. M. A., Jawahy, . M. A. M., Qadri, . M. A. Y., Alqasem, . A. Y. A. & Faqihi, . M. A. J. (2020) Prevalence and characteristics of secondary wound healing among patients with open surgical wounds in Jazan, Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (3), 682-686. doi:10.24911/IJMDC51-1577049614