Strength and limitations of the work
This study investigated the association between preoperative TEWL and occurrence of postoperative skin disorders. The clinical significance of these findings and their effects are discussed below.
First, the key finding of increased TEWL in relation to the incidence of postoperative skin disorders and pressure ulcers is significant, as it highlights the measurable and potentially modifiable risk factor for the aforementioned complications. In the context of lateral decubitus surgery under general anesthesia, in which patients are particularly susceptible to skin damage due to prolonged pressure and immobility, identifying TEWL as a predictor offers valuable insights into preventive strategies. This finding contributes to the existing research by providing a more detailed understanding of the condition of the skin and its vulnerability to damage in the perioperative setting [24]. Prior studies have reported various risk factors for pressure ulcers and skin injuries; however, the specific role of TEWL, especially in side-lying surgery, has not been clearly defined [25–27]. By focusing on TEWL, this study offers a novel perspective, which would potentially lead to more targeted and effective interventions for the prevention of postoperative skin disorders and pressure ulcers.
Second, the clinical significance of this study can be delineated as routine evaluation, risk stratification, and early intervention. As a routine assessment, it is imperative to integrate TEWL measurement into the preoperative evaluation of patients undergoing surgery, particularly among those who require prolonged immobilization or are scheduled to undergo procedures in the lateral decubitus position, because of the elevated risk of postoperative skin damage [28–30]. This integration will facilitate the assessment of and intervention for potential postoperative skin damage. Risk stratification involves categorizing patients into risk categories for the development of postoperative skin disorders based on their TEWL values. Specifically, this study necessitates setting a TEWL cut-off value at 19.5 g/m2/h, with higher TEWL values indicating an increased risk. Early intervention in patients with elevated TEWL should include enhanced skin care, hydration management, and nutritional supplementation [31–33]. For patients identified as high-risk, intensive skin care protocols, including the use of barrier creams and regular skin assessments, and adequate preoperative nutritional supplementation are essential. This is attributed to the fact that malnutrition can exacerbate skin fragility. To initiate these early interventions, medical staff, such as nurses, must engage with patients scheduled for surgery, even before hospital admission. Although challenging, preoperative outpatient care in Japan may facilitate this process. Preoperative outpatient care involves a patient awaiting surgery visiting a hospital and being examined by a perioperative nurse before admission. This procedure is typically conducted in the preoperative outpatient clinic [34]. During preoperative outpatient care, TEWL measurements should be taken in high-risk areas for skin damage, and early interventions to reduce TEWL should be initiated for those identified as high risk. Education of healthcare providers is also crucial for early intervention. Training programs for medical staff may be effective in enhancing their understanding of the importance of TEWL in predicting cutaneous complications and the necessity for preventive care. These early interventions have the potential to reduce the risk of postoperative skin disorders.
Third, the use of advanced tools, such as VapoScan and Mobile Moisture HP19-M, in this study to measure TEWL and skin moisture content enhanced the precision of data collection in patients undergoing surgery. These instruments provided accurate and reliable measurements. Previous research across various domains have employed these tools [35, 36], and suggested their potential recommendation for use in the perioperative setting to reduce the incidence of postoperative skin disorders. Although the VapoScan is an advanced tool, any measurement instrument can exhibit inherent variability. The accuracy and calibration of these tools, as well as the consistency of their applications, can influence the outcomes of a study. Therefore, it is essential to educate medical staff on the proper use of devices, such as VapoScan.
This study has some limitations. First, the sample size greatly affected the generalizability of the findings and limited the ability to extrapolate the results to a wider population. This requires consideration of sample diversity in terms of age, sex, comorbidities, and other relevant factors, and is applicable in multicenter studies. Second, as a possible confounding variable, the study design and analysis should have considered these potential confounders to ensure that they truly reflected the relationship between TEWL and postoperative skin conditions. Finally, the follow-up period for postoperative skin disorders was immediately after surgery, which may have affected our ability to fully understand the incidence and severity of skin disorders and pressure ulcers. A longer follow-up period may provide a more comprehensive understanding of the complications, including the aforementioned postoperative skin disorders.
Recommendations for further research
Building on this study, future studies should explore interventions to reduce preoperative TEWL. This involves the implementation and evaluation of various skincare therapies designed to decrease preoperative TEWL, including the use of moisturizers and barrier creams. Additionally, the effect of nutritional supplementation or dietary modifications on preoperative TEWL and skin integrity warrants further investigation. As part of the preventive strategies and patient education, the effectiveness of patient education programs focusing on perioperative skin care and pressure ulcer prevention should be examined. Furthermore, the efficacy of training programs for healthcare professionals on prevention and early detection of postoperative skin disorders needs to be assessed. Furthermore, research evaluating the cost-effectiveness of various preventive and intervention strategies aimed at reducing TEWL and improving postoperative skin conditions are warranted.