Comment on: Negative-pressure wound therapy in thoracic and abdominal surgery: meta-analysis of randomized trials

Correspondence to: Dr Jeremy Meyer, MD, PhD, PD (email: jeremy.meyer@hug.ch)

Division of Digestive Surgery

Rue Gabrielle-Perret-Gentil 4

1205 Genève

Switzerland

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BJS Open, https://doi.org/10.1093/bjsopen/zrag027, published 20 May 2026

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I read with great interest the meta-analysis by Lakha et al. evaluating prophylactic negative-pressure wound therapy (pNPWT) in thoracic and abdominal surgery, reporting a nearly 50% reduction in surgical site infection (SSI) across 45 (OR 0.53, 95% CI 0.42–0.66)1. I note, however, that this pooled estimate is almost entirely driven by abdominal surgery data, as the three included thoracic RCTs yielded a nonsignificant and imprecise result, precluding any meaningful conclusion in that context. Drawing on our published work specifically in abdominal surgery, I wish to raise two further points.

First, the effect of pNPWT is critically dependent on baseline SSI risk. Our 2021 metaanalysis of 21 studies demonstrated that pNPWT conferred no meaningful benefit in low-risk populations (SSI <20% in the control arm: RD +3%, p=0.23), whereas risk differences of −17% and −19% were observed in medium- and high-risk groups respectively, with significantly lower relative risks in high-risk cohorts2. Given acknowledged publication bias (trim-and-fill : OR 0.70) — further compounded by a small-study effect we previously demonstrated through meta-regression across RCTs3 — the pooled estimate of 0.53 likely overestimates the benefit in unselected populations, and the authors' own recommendation for "selective use in high-risk patients" deserves stronger analytical support.

Second, pNPWT has not achieved wide clinical implementation despite a decade of evidence. Our nationwide Swiss survey found that while 70.7% of abdominal surgeons used pNPWT, 68.6% applied it to fewer than 10% of their patients, driven by cost concerns and uncertainty about patient selection4.This implementation gap will not be resolved by further meta-analyses alone: future guidelines must move beyond confirming efficacy toward defining risk thresholds and cost-effectiveness frameworks that enable rational, equitable adoption — particularly in resource-constrained settings where SSI burden is highest5.