# The Clinical and Economic Value of Triclosan-Coated Surgical Sutures in Abdominal Surgery
## 4 Discussion  
SSIs primarily result from the disruption of the equilibrium between the quantity of inoculated microorganisms, their virulence, and the ability of the immune system to clear them. TCS, which are coated in a broad-spectrum antimicrobial agent, reduce the bacterial load at the wound site, thereby potentially helping to reduce the risk of SSIs. Meta-analysis is a useful tool in that it allows for data pooling from multiple trials and thus provides a more comprehensive estimation of treatment effects. However, this approach only partially restricted the confounding effect of the differences and heterogeneity among the included studies  
Figure 3: Boxplot of the annual budget impact (savings) according to the probabilistic sensitivity analysis. Figure 2: Histogram of the number of avoided SSI episodes according the probabilistic sensitivity analysis. Abbreviations: SSI, surgical site infection. and populations. Among the available meta-analyses and in accordance with the defined inclusion criteria, we assessed and estimated the results of the 2017 meta-analysis reported by [PERSON] et al. [28] as the most recently available evidence that fulfilled our clinical focus. The authors included all RCTs that evaluated the effect of TCS in patients who underwent abdominal surgery. The effect of TCS was evaluated in several studies that enrolled subjects with distinct patient-related and operation-related risk factors. There was heterogeneity between trials in terms of surgery type which included elective colorectal surgeries, elective procedures through midline laparotomy, elective and emergency laparotomyies for any type of target organ, emergency surgery for fecal peritonitis, and open appendectomy. The pooled results yielded a significant 33% reduction in the odds of having an SSI after surgery for patients who received a wound closure with TCS versus CS. However, it should be noted that intervention type (elective versus emergency), target organs, and the lack of implementation of recognized peri-operative strategies to reduce SSI likely limit the ability to define the true effect of TCS, adding high heterogeneity and possible confounders. Two additional RCTs [40; 41] that were published afterwards did not contribute to solving these uncertainties. The effect of TCS should, ideally, be evaluated in a population with a fixed risk of SSI and, importantly, in a setting where all the WHO recommendations [16] (Table 4) are fulfilled to assess the true \"over the top\" protective effect of this strategy. The heterogeneity of studies' settings in terms of adherence to SSI prevention guidelines can therefore be considered as an additional bias; however, these limitations notwithstanding, all nine published meta-analyses reported a consistent decrease in the risk of having an SSI with the use of the used TCS (Table 2). Despite the fact that some of the available meta-analyses did not demonstrate significant differences compared to the control arms, the decrease in the SSI rate can still be considered important as it may result in a net financial saving even if the cost of TCS is higher than CS.