Randomized clinical trial of skin closure by subcuticular suture or skin stapling after elective colorectal cancer surgery

Association between skin suture devices and incidence of incisional surgical site infection after gastrointestinal surgery: systematic review and network meta-analysis

BACKGROUND

Surgical site infections (SSIs) are common complications after abdominal surgery.

AIM

To compare which suture devices could reduce the incidence of incisional surgical site infections (SSIs) after gastrointestinal surgery using a systematic review and network meta-analysis.

METHODS

The CENTRAL, PubMed, and ICHUSHI-Web databases were searched from January 1st, 2000, to December 31st, 2022, for randomized clinical trials (RCTs) comparing the incidence of incisional SSI after gastrointestinal surgery among patients treated with different surgical suture devices, including non-absorbable sutures, absorbable sutures, skin staplers, and tissue adhesives (last searched in August 23th, 2023). The risk of bias was assessed using the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. To estimate the pooled odds ratios (ORs) for each comparison, a fixed-effect inverse-variance model based on the Mantel-Haenszel approach was employed.

FINDINGS

A total of 18 RCTs with 5496 patients were included in this study. The overall SSIs in absorbable sutures were significantly lower than those in skin staplers (OR: 0.77; 95% confidence intervals (CI): 0.63-0.95) and non-absorbable sutures (OR: 0.62; 95% CI: 0.39-0.99), whereas SSIs in absorbable sutures were not significantly different from the SSIs in tissue adhesive. The highest P-score was 0.91 for absorbable sutures. A funnel plot for estimating the heterogeneity of the studies revealed that a publication bias would be minimal (Egger test, P = 0.271).

CONCLUSION

This study showed that absorbable sutures reduced incisional SSIs in gastrointestinal surgical operations compared to any other suture devices.

Development of implantable electrode based on bioresorbable Mg alloy for tissue welding application

An implantable electrode based on bioresorbable Mg-Nd-Zn-Zr alloy was developed for next-generation radiofrequency (RF) tissue welding application, aiming to reduce thermal damage and enhance anastomotic strength. The Mg alloy electrode was designed with different structural features of cylindrical surface (CS) and continuous long ring (LR) in the welding area, and the electrothermal simulations were studied by finite element analysis (FEA). Meanwhile, the temperature variation during tissue welding was monitored and the anastomotic strength of welded tissue was assessed by measuring the avulsion force and burst pressure. FEA results showed that the mean temperature in the welding area and the proportion of necrotic tissue were significantly reduced when applying an alternating current of 110 V for 10 s to the LR electrode. In the experiment of tissue welding ex vivo, the maximum and mean temperatures of tissues welded by the LR electrode were also significantly reduced and the anastomotic strength of welded tissue could be obviously improved. Overall, an ideal welding temperature and anastomotic strength which meet the clinical requirement can be obtained after applying the LR electrode, suggesting that Mg-Nd-Zn-Zr alloy with optimal structure design shows great potential to develop implantable electrode for next-generation RF tissue welding application.

Subcuticular suture and incisional surgical-site infection in elective hepatobiliary and pancreatic surgery: an open-label, pragmatic randomized clinical trial (CLOSKIN trial)

BACKGROUND

Subcuticular suture has proven to reduce superficial incisional SSI (si-SSI) in clean surgery. However, question remains regarding clean-contaminated procedures. The aim of this study is to assess if subcuticular suture is superior to staples in reducing si-SSI incidence in elective HBP surgery.

METHODS

Single-centre, open-label, parallel, pragmatic randomized clinical trial conducted at a referral tertiary Hospital between January 2020 and April 2022. Patients eligible for elective HBP surgery were randomly assigned (1:1) to subcuticular suture or surgical staples wound closure using a minimisation method based on previously confirmed risk factors. The primary endpoint was the incidence of si-SSI. Considered secondary endpoints were major postoperative morbidity in both groups, additional wound complications, median hospital length of stay and need for re-hospitalisation.

RESULTS

Of the 379 patients, 346 patients were randomly assigned to receive skin closure with staples (n = 173) or subcuticular suture (n = 173). After further exclusion of 11 participants, 167 and 168 patients, respectively in the control and the experimental group received their allocated intervention. For the primary endpoint, no significant differences in si-SSI rate were found: 17 (9.82%) staples group vs. 8 (4.62%) in subcuticular suture group (p = 0.062). Subset analysis confirmed absence of significant differences. As for secondary endpoints, overall wound complications did not differ significantly between two procedures: 19 (10.98%) vs. 10 (6.35%) (p = 0.127). There were no treatment related adverse events. However, occurrence of si-SSI contributed to major postoperative morbidity in both groups (p < 0.001 and p = 0.018) and to a substantially prolonged postoperative hospitalization (p = 0.015).

CONCLUSIONS

Subcuticular suture might offer a relative benefit for skin closure reducing incidence of si-SSI after elective HBP surgery, although this was found not to be clinically relevant. Yet, this should not be interpreted as equivalence among both treatments. Therefore, wound closure strategy should not be based only on these grounds.

TRIAL REGISTRATION NUMBER

ISRCTN Registry number ISRCTN37315612 (registration date: 14/01/2020).

Skin closure following abdominal wall reconstruction: three-layer skin suture versus staples

Skin closure following abdominal wall reconstruction (AWR) has received little attention, even though these patients have demonstrated insufficient wound healing. This study assessed the postoperative wound-related complications and patient-reported outcomes after skin closure using single- or triple layer closure following AWR. This was a retrospective study at a University Hospital from 2016 to 2018. Patients were grouped into a single-layer cohort (SLC) and a triple-layer cohort (TLC). Skin incisions closed with either technique were compared. Postoperative complications were registered from chart review (SLC: n = 48, TLC: n = 40). Patient reported-outcomes were assessed through the Patient Scar Assessment Questionnaire (PSAQ) and the Hernia Related Quality of Life survey. A total of 51 patients were included (SLC: n = 26, TLC: n = 25). There was no difference in wound complications after single- or triple-layer skin closure; seroma (SLC: 16.7% vs. TLC: 15%, p = 1.00), surgical site infection (SLC: 4.2% vs. TLC: 7.5%, p = .834), hematoma (SLC: 6.2% vs. TLC: 2.5%, p = .744) and wound rupture (SLC: 2.1% vs. TLC: 2.5%, p = 1.00). Patients who had incisions closed using single-layer closure were more satisfied; PSAQ satisfaction with scar symptoms (SLC: 6.7 points (IQR 0.0-18.3) vs. TLC: 26.7 points (IQR 0.0-33.3), p = .039) and scar aesthetics (SLC 25.9 points (IQR 18.5-33.3) vs. TLC: 37.0 (IQR 29.6-44.4), p = .013). There was no difference in 30-day wound complications after either skin closure technique. The results favoured the single-layer closure technique regarding the cosmetic outcome.Abbreviations: AWR: abdominal wall reconstruction; SLC: single-layer cohort; TLC: triple-layer cohort; PSAQ: patient scar assessment questionnaire; IH: incisional hernia; QOL: quality of life; BMI: body mass index; HerQLes: hernia-related quality of life; ASA: American Society of Anesthesiologists; SSO: surgical site occurence; SSI: surgical site infection; LOS: length of stay; RCT: randomized controlled trial.

Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery

BACKGROUND

Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS).

STUDY DESIGN

In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement.

RESULTS

In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds.

CONCLUSIONS

Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.

Risk Stratification for Superficial Surgical Site Infection after Emergency Trauma Laparotomy

Background: Superficial surgical site infections (S-SSIs) are common after trauma laparotomy, leading to morbidity, increased costs, and prolonged length of stay (LOS). Opportunities to mitigate S-SSI risks are limited to the intra-operative and post-operative periods. Accurate S-SSI risk stratification is paramount at the time of operation to inform immediate management. We aimed to develop a risk calculator to aid in surgical decision-making at the time of emergency laparotomy. Methods: A retrospective cohort study of patients requiring emergency trauma laparotomy between 2011 and 2017 at a single, level 1 trauma center was performed. Operative factors, skin management strategy, and outcomes were determined by chart review. Bayesian multilevel logistic regression was utilized to create a risk calculator with variables available upon closure of the laparotomy. Models were validated on a 30% test cohort and discrimination reported as an area under the receiver operating characteristics curve (AUROC). Results: Of 1,322 patients, the majority were male (77%) with median age of 33 years, injured by blunt mechanism (54%), and median injury severity score of 19. Eighty-eight (7%) patients developed an S-SSI. Patients who developed S-SSI had higher final lactate, blood loss, transfusion requirements, and wound classification. Patients with S-SSI more frequently had mesenteric or large bowel injury than those without S-SSI. Superficial SSI was associated with increased complications and prolonged length of stay (LOS). The S-SSI predictive model demonstrated moderate discrimination with an AUROC of 0.69 (95% confidence interval [CI], 0.56-0.81). Parameters contributing the most to the model were damage control laparotomy, full-thickness large bowel injury, and large bowel resection. Conclusion: A predictive model for S-SSI was built using factors available to the surgeon upon index emergency trauma laparotomy closure. This calculator may be used to standardize intra- and post-operative care and to identify high-risk patients in whom to test novel preventative strategies and improve overall outcomes for patients requiring emergency trauma laparotomy.

A meta-analysis on continuous versus interrupted skin closure following appendicectomy

BACKGROUND

The aim of this review was to analyse RCTs comparing wound-related outcomes between continuous subcuticular and interrupted transdermal wound closures for open appendicectomies in all age groups.

METHODS

A systematic literature search was conducted in April 2020 (MEDLINE, Embase, CENTRAL, Web of Science, PROSPERO, Google Scholar, WHO International Clinical Trials Registry Platform). RCTs without restrictions on study language, year, status of publication, and patient age were included. The risk of bias was assessed using the risk-of-bias tool for RCTs. Pooled risk ratios (RRs) and mean differences (MDs) for binary and continuous variables were calculated using random-effects models. A summary-of-findings table was generated to assess the level of evidence.

RESULTS

Eleven trials were included (1781 patients analysed, 891 in continuous and 890 in interrupted groups). The overall rate of wound infection was 7.1 per cent. There was no significant difference in the risk of wound infection (11 trials, 1781 patients; RR 1.13, 95 per cent c.i. 0.77 to 1.66; P = 0.530) or wound exploration (7 trials, 1129 patients; RR 0.74, 0.41 to 1.34, P = 0.320) between the two groups. Continuous wound closure had a significantly reduced risk of wound dehiscence (6 trials, 865 patients; RR 0.16, 0.05 to 0.50; P = 0.002) and smaller wound scar (3 trials, 417 patients; MD -2.11 (95 per cent c.i. -2.57 to -1.66) mm; P < 0.001). The absolute risk reduction and number needed to treat for wound dehiscence were 6.1 per cent and 16 respectively. There was no significant statistical heterogeneity for all outcomes (I2 0-15 per cent, χ2 P > 0.100). Most RCTs had a high risk of bias.

CONCLUSION

Continuous subcuticular open appendicectomy wound closure is not associated with an increased risk of wound infection and exploration. This method of closure has a reduced risk of wound dehiscence and better cosmetic outcomes.

Subcuticular Sutures versus Staples in Reducing Surgical Site Infections after Open Abdominal Digestive Surgery: A System Review and Meta-Analysis of Randomized Controlled Trials

Background: Wound complications, primarily surgical site infections (SSIs), impose heavy a heavy burden on public health. This study aimed to compare the difference in the abilities of subcuticular sutures and staples to prevent SSIs after open abdominal surgery on the digestive system. Methods: A comprehensive search in Ovid-MEDLINE, Embase, Web of Science, and Cochrane Library (Central Register of Controlled Trials) was performed in January 2021. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PICOS (population, intervention, control, outcome, study type) model was applied to guide study selection and data extraction. Results: Six studies including 3,863 participants were included. According to analysis of SSI incidence, there was no obvious difference between the incidence of SSI when subcuticular sutures and staples were used (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.61-1.08; p = 0.15). In the subsequent subgroup analysis of different operation procedures, the pooled results also failed to show significance for upper gastrointestinal surgery (OR, 1.09; 95% CI, 0.63-1.9; p = 0.75), lower gastrointestinal surgery (OR, 0.77; 95% CI, 0.56-1.05; p = 0.1), or hepatobiliary-pancreatic surgery (pooled OR, 0.72; 95% CI, 0.34-1.54; p = 0.4). Conclusions: Subcuticular sutures and staples did not show differences in their ability to prevent SSI incidence after open abdominal operation. These results require further verification by large-scale, high-quality randomized controlled trials.

Subcuticular sutures versus staples for skin closure in patients undergoing abdominal surgery: A meta-analysis of randomized controlled trials

Background

Surgical site infections (SSIs) are common postoperative complications. Whether the use of staples or sutures makes a difference in abdominal surgery’s infection rate remains elusive.

Methods

A systematic review was performed to identify randomized clinical trials comparing staples and sutures after abdominal surgeries. Eligibility criteria involved the SSI occurrence as the primary outcome and the incidence of wound dehiscence, closure time, cosmesis, and patient satisfaction as the secondary outcomes.

Results

Of the 278 studies identified, seven randomized controlled trials representing 3705 patients were included in this review. There was no significant difference in SSI rates between sutures and staples in general (OR = 0.98, 95% CI = 0.79–1.22, I² = 44%, P = 0.1) or in a subgroup of gastrointestinal surgery, where subcuticular suturing was found with a comparable SSI risk with skin stapling (OR = 0.85, 95% CI = 0.66–1.09). Staple closure was associated with a shorter surgery duration, whereas sutures appeared to provide better cosmesis and patient satisfaction. Sutures and staples achieved a comparable incidence of dehiscence. There was no significant between-study publication bias.

Conclusion

Our study demonstrated similar outcomes in SSI rate between subcuticular sutures and staples for skin closure in patients undergoing abdominal surgery.

Real-World Outcomes of Patients Undergoing Open Colorectal Surgery with Wound Closure Incorporating Triclosan-Coated Barbed Sutures: A Multi-Institution, Retrospective Database Study

Purpose

Open colorectal surgery is associated with a high rate of postoperative wound complications. This is a single-arm study of real-world outcomes of triclosan-coated barbed suture (Ethicon's STRATAFIX^TM Symmetric PDS^TM Plus Knotless Tissue Control Device [SSPP]) used in open colorectal surgery.

Methods

Retrospective cohort study using the Premier Healthcare Database. The study included patients who underwent an inpatient open colorectal surgery with wound closure using SSPP (size 0 or 1 to increase the likelihood the suture was used in fascia) between October 2015-September 2019 (N=593). Wound complications, hospital length of stay, total hospital costs (2019 US$), and all-cause readmissions post-discharge were measured. Post-hoc multivariable analyses compared wound complications between non-elective admissions and elective.

Results

The overall incidence of wound complications within 30-days post-procedure was 7.1%, with the majority of those being surgical site infections (SSI) (6.0%). Mean operation time was 190 (standard deviation [SD]=64.4) mins, postoperative length of stay was 8.1 (SD=11.9) days, 30-day readmission rate was 11.8%, and total hospital costs were $31,693 (SD=$40,076). As compared with published literature on the rate of SSI in colorectal surgery, the 30-day rate of SSI in the present study (6.0%) fell within the range of 5.4% to 18.2% for open colorectal surgery and from 4.3% to 21.5% for combined open and minimally invasive procedures. Multivariable-adjusted incidence proportions of wound complications were slightly lower for non-elective admissions and did not differ significantly from those of elective admissions.

Conclusion

The rate of wound complications observed in the present study falls within the range of rates previously reported in the literature, suggesting a safe and effective role for SSPP in open colorectal surgery. In post hoc analyses, the adjusted rate of wound complications was similar between non-elective and elective admissions. Head-to-head studies are required to determine comparative advantages or disadvantages for SSPP versus other sutures.

Subcuticular sutures reduce surgical site infection after repeat liver resection: a matched cohort analysis

Liver cancer frequently requires repeated liver resections due to the high recurrence rate. The aim of this study was to clarify whether subcuticular sutures reduce wound complication rates following repeat incisions. Data from 382 repeated liver resections in 1,245 consecutive patients were assessed. Patients were divided into a Subcuticular sutures group and a Skin staples group on the basis of the wound-closure method. To avoid bias in analysing wound complications, data were matched to adjust for patient background and operation variables. After matching, 82 matched, paired patients with subcuticular sutures or skin staples were compared. Total wound complication rate was significantly lower with subcuticular sutures than with skin staples (8.5% vs. 20.7%, p = 0.027). Incisional surgical site infection was also lower with subcuticular sutures than with skin staples (6.1% vs. 17.1, p = 0.028). Univariate analysis revealed 4 factors associated with wound complications: body mass index; serum albumin concentration; wound length; and closure with skin staples. Multivariate analysis revealed closure with skin staples (odds ratio, 2.91; 95% confidence interval, 1.07-7.94; p = 0.037) as the only independent factor negatively associated with wound complications. Subcuticular sutures appear to reduce wound complications compared to skin staples following repeat incision for liver resection.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018

BACKGROUND

The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide.

METHODS

We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies.

RESULTS

There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese.

CONCLUSIONS

The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Subcuticular Sutures Versus Staples for Wound Closure in Open Liver Resection: A Randomised Clinical Trial

BACKGROUND

Subcuticular sutures reduce wound complication rates only in clean surgeries. Repeat resection is frequently required in liver surgery, due to the high recurrence rate (30-50%) of liver cancers. The aim of this study is to assess that subcuticular sutures is superior to staples in liver surgery.

METHODS

This single-centre, single-blinded, randomised controlled trial was conducted at a university hospital between January 2015 and October 2018. Patients were randomly assigned (1:1) to receive either subcuticular sutures or staples for skin closure. Three risk factors (repeat resection, diabetes mellitus and liver function) were matched preoperatively for equal allocation. The primary endpoint was the wound complication rate, while secondary endpoints were surgical site infection (SSI), duration of postoperative hospitalisation and total medical cost. Subset analyses were performed only for the 3 factors allocated as secondary endpoints.

RESULTS

Of the 581 enrolled patients, 281 patients with subcuticular sutures and 283 patients with staples were analysed. As the primary outcome, the wound complication rate with subcuticular sutures (12.5%) did not differ from that with staples [15.9%; odds ratio (OR), 1.33; 95% confidence interval (CI), 0.83-2.15; p = 0.241]. As secondary outcomes, no significant differences were identified between the two procedures in the overall cohort while overall wound complications [7 patients (8.5%) vs. 17 patients (20.0%); OR, 2.68; 95% CI, 1.08-7.29; p = 0.035] with repeat incision were significantly less frequent with subcuticular sutures.

CONCLUSION

Subcuticular sutures were not shown to reduce wound complications compared to staples in open liver resection, but appear beneficial for repeat incisions.

Evaluation of negative-pressure wound therapy for surgical site infections after ileostomy closure in colorectal cancer patients: a prospective multicenter study

PURPOSE

Surgical site infection (SSI) occurs at a high rate after ileostomy closure. The effect of preventive negative-pressure wound therapy (NPWT) on SSI development in closed wounds remains controversial. We conducted a prospective multicenter study to evaluate the usefulness of preventive NPWT for SSI after ileostomy closure.

METHODS

From January 2018 to November 2018, 50 patients who underwent closure of ileostomy created after surgery for colorectal cancer participated in this study. An NPWT device was applied to each wound immediately after surgery and then treatment was continued for 3 days. The primary endpoint was 30-day SSI, and the secondary endpoints were the incidence of seroma, hematoma, and adverse events related to NPWT.

RESULTS

No patients developed SSI, seroma, or hematoma. Adverse events that may have been causally linked with NPWT were contact dermatitis in two patients and wound pain in one patient, and there were no cases of discontinuation or decompression of NPWT.

CONCLUSION

The use of NPWT following ileostomy closure may be useful for reducing the development of SSI in colorectal cancer patients. This is a prospective multicenter pilot study and we are planning a comparative study based on these successful results.

TRAIL REGISTRATION

Registration number: UMIN000032053 ( https://www.umin.ac.jp/ ).

Surgical wound closure by staples or sutures?: Systematic review

AIM

To compare the effects of sutures and staples for skin closure of surgical wounds.

MATERIAL AND METHODS

We included published and unpublished randomized controlled trials (RCTs) and cluster-randomized trials comparing staples with sutures. Patients were adults (aged 18 years or over) who had undergone any type of surgery. The primary outcomes were risk of overall and severe wound infection. Secondary outcomes included length of hospital stay, readmission rate, adverse events, patient satisfaction with cosmetic results, postoperative pain.

RESULTS

Forty-two very low to low quality RCTs with a total of 11,067 patients were included. Sutures resulted in slightly fewer overall wound infections (4.90%) compared to staples (6.75%) but it is uncertain whether there is a difference between the groups (risk ratio [RR] 1.20, 95% confidence intervals [CI] 0.80-1.79; patients = 9864; studies = 34; I = 70%). The evidence was also insufficient to state a difference in terms of severe wound infection (staples 1.4% vs sutures 1.3%; RR 1.08, 95% CI 0.61-1.89; patients = 3036; studies = 17; I = 0%), grade of satisfaction (RR 0.99, 95% CI 0.91-1.07; patients = 3243; studies = 14; I = 67%) and hospital stay. Staples may increase the risk of adverse events (7.3% for staples vs 3.5% for sutures; RR 2.00, 95% CI 1.44-2.79; patients = 6246; studies = 21; I = 33%), readmission rate (RR 1.28, 95% CI 0.18-9.05; patients = 2466; studies = 5; I = 66%) and postoperative pain (standardized mean difference [SMD] 0.41,95%CI -0.35 to 1.16; I = 88%, patients = 390 patients, studies = 5).

CONCLUSIONS

Due to the lack of high quality evidence, we could not state if sutures are better than staples in terms of wound infection, readmission rate, adverse events, and postoperative pain. With a low quality of evidence, sutures reduce postoperative pain and improve grade of satisfaction with the cosmetic outcome.

Subcuticular sutures for skin closure in non-obstetric surgery

BACKGROUND

Following surgery, surgical wounds can be closed using a variety of devices including sutures (subcuticular or transdermal), staples and tissue adhesives. Subcuticular sutures are intradermal stitches (placed immediately below the epidermal layer). The increased availability of synthetic absorbable filaments (stitches which are absorbed by the body and do not have to be removed) has led to an increased use of subcuticular sutures. However, in non-obstetric surgery, there is still controversy about whether subcuticular sutures increase the incidence of wound complications.

OBJECTIVES

To examine the efficacy and acceptability of subcuticular sutures for skin closure in non-obstetric surgery.

SEARCH METHODS

In March 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

All randomised controlled trials which compared subcuticular sutures with any other methods for skin closure in non-obstetric surgery were included in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials, extracted data and carried out risk of bias and GRADE assessment of the certainty of the evidence.

MAIN RESULTS

We included 66 studies (7487 participants); 11 included trials had more than two arms. Most trials had poorly-reported methodology, meaning that it is unclear whether they were at high risk of bias. Most trials compared subcuticular sutures with transdermal sutures, skin staples or tissue adhesives. Most outcomes prespecified in the review protocol were reported. The certainty of evidence varied from high to very low in the comparisons of subcuticular sutures with transdermal sutures or staples and tissue adhesives; the certainty of the evidence for the comparison with surgical tapes and zippers was low to very low. Most evidence was downgraded for imprecision or risk of bias. Although the majority of studies enrolled people who underwent CDC class 1 (clean) surgeries, two-thirds of participants were enrolled in studies which included CDC class 2 to 4 surgeries, such as appendectomies and gastrointestinal surgeries. Most participants were adults in a hospital setting. Subcuticular sutures versus transdermal sutures There may be little difference in the incidence of SSI (risk ratio (RR) 1.10; 95% confidence interval (CI) 0.80 to 1.52; 3107 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce wound complications (RR 0.83; 95% CI 0.40 to 1.71; 1489 participants; very low-certainty evidence). Subcuticular sutures probably improve patient satisfaction (score from 1 to 10) (at 30 days; MD 1.60, 95% CI 1.32 to 1.88; 290 participants; moderate-certainty evidence). Wound closure time is probably longer when subcuticular sutures are used (MD 5.81 minutes; 95% CI 5.13 to 6.49 minutes; 585 participants; moderate-certainty evidence). Subcuticular sutures versus skin staples There is moderate-certainty evidence that, when compared with skin staples, subcuticular sutures probably have little effect on SSI (RR 0.81, 95% CI 0.64 to 1.01; 4163 participants); but probably decrease the incidence of wound complications (RR 0.79, 95% CI 0.64 to 0.98; 2973 participants). Subcuticular sutures are associated with slightly higher patient satisfaction (score from 1 to 5) (MD 0.20, 95% CI 0.10 to 0.30; 1232 participants; high-certainty evidence). Wound closure time may also be longer compared with staples (MD 0.30 to 5.50 minutes; 1384 participants; low-certainty evidence). Subcuticular sutures versus tissue adhesives, surgical tapes and zippers There is moderate-certainty evidence showing no clear difference in the incidence of SSI between participants treated with subcuticular sutures and those treated with tissue adhesives (RR 0.77, 95% CI 0.41 to 1.45; 869 participants). There is also no clear difference in the incidence of wound complications (RR 0.62, 95% CI 0.35 to 1.11; 1058 participants; low-certainty evidence). Subcuticular sutures may also achieve lower patient satisfaction ratings (score from 1 to 10) (MD -2.05, 95% CI -3.05 to -1.05; 131 participants) (low-certainty evidence). In terms of SSI incidence, the evidence is uncertain when subcuticular sutures are compared with surgical tapes (RR 1.31, 95% CI 0.40 to 4.27; 354 participants; very low-certainty evidence) or surgical zippers (RR 0.80, 95% CI 0.08 to 8.48; 424 participants; very low-certainty evidence). There may be little difference in the incidence of wound complications between participants treated with subcuticular sutures and those treated with surgical tapes (RR 0.90, 95% CI 0.61 to 1.34; 492 participants; low-certainty evidence). It is uncertain whether subcuticular sutures reduce the risk of wound complications compared with surgical zippers (RR 0.55, 95% CI 0.15 to 2.04; 424 participants; very low-certainty evidence). It is also uncertain whether it takes longer to close a wound with subcuticular sutures compared with tissue adhesives (MD -0.34 to 10.39 minutes; 895 participants), surgical tapes (MD 0.74 to 6.36 minutes; 169 participants) or zippers (MD 4.38 to 8.25 minutes; 424 participants) (very low-certainty evidence). No study reported results for patient satisfaction compared with surgical tapes or zippers.

AUTHORS' CONCLUSIONS

There is no clear difference in the incidence of SSI for subcuticular sutures in comparison with any other skin closure methods. Subcuticular sutures probably reduce wound complications compared with staples, and probably improve patient satisfaction compared with transdermal sutures or staples. However, tissue adhesives may improve patient satisfaction compared with subcuticular sutures, and transdermal sutures and skin staples may be quicker to apply than subcuticular sutures. The quality of the evidence ranged from high to very low; evidence for almost all comparisons was subject to some limitations. There seems to be no need for additional new trials to explore the comparison with staples because there are high-quality studies with large sample sizes and some ongoing studies. However, there is a need for studies exploring the comparisons with transdermal sutures, tissue adhesives, tapes and zippers, with high-quality studies and large sample sizes, including long-term assessments.

Subcuticular sutures in laparoscopic colorectal surgery: a comparative study to evaluate wound infection rates and cosmetic results

Laparoscopic colorectal surgery is categorized as clean-contaminated surgery. It is important to prevent incisional surgical site infections (SSIs), because SSIs can prolong hospital stays, increase medical costs and produce negative cosmetic outcomes for patients. The aim of this study is to evaluate the efficacy of subcuticular skin sutures following colorectal laparoscopic surgery in terms of wound infection rates and aesthetic results. A retrospective analysis on a database of a consecutive series of unselected patients was conducted. Patients underwent elective colorectal laparoscopic surgery in a single center between October 1st of 2016 and October 30th of 2017. Data on patients' demographics, operative details, short-term and long-term outcomes and aesthetic satisfaction were prospectively recorded. A total of 100 patients were selected and divided in 2 groups: 43 patients who had received subcuticular sutures, 57 patients who had received separate stitch sutures. Wound infection rates were lower, with no statistical significance in the subcuticular suture group (6.9% versus 15.8%, p = 0.182), but the patient-reported cosmetic results were superior in the subcuticular suture group (1.9 versus 2.9, p < 0.001). Multivariate analyses identified high BMI and low preoperative hemoglobin level as possible risk factors associated with wound infection after colorectal laparoscopic surgery. Subcuticular sutures could improve cosmetic results in patients undergoing elective laparoscopic surgery for colorectal cancer with comparable risks of wound infection. In this population, high BMI and low preoperative hemoglobin levels appear to be risk factors associated with wound infections.

Intraoperative surgical site infection control and prevention: a position paper and future addendum to WSES intra-abdominal infections guidelines

BACKGROUND

Surgical site infections (SSI) represent a considerable burden for healthcare systems. They are largely preventable and multiple interventions have been proposed over past years in an attempt to prevent SSI. We aim to provide a position paper on Operative Room (OR) prevention of SSI in patients presenting with intra-abdominal infection to be considered a future addendum to the well-known World Society of Emergency Surgery (WSES) Guidelines on the management of intra-abdominal infections.

METHODS

The literature was searched for focused publications on SSI until March 2019. Critical analysis and grading of the literature has been performed by a working group of experts; the literature review and the statements were evaluated by a Steering Committee of the WSES.

RESULTS

Wound protectors and antibacterial sutures seem to have effective roles to prevent SSI in intra-abdominal infections. The application of negative-pressure wound therapy in preventing SSI can be useful in reducing postoperative wound complications. It is important to pursue normothermia with the available resources in the intraoperative period to decrease SSI rate. The optimal knowledge of the pharmacokinetic/pharmacodynamic characteristics of antibiotics helps to decide when additional intraoperative antibiotic doses should be administered in patients with intra-abdominal infections undergoing emergency surgery to prevent SSI.

CONCLUSIONS

The current position paper offers an extensive overview of the available evidence regarding surgical site infection control and prevention in patients having intra-abdominal infections.

Bartsch D. Superficial Surgical Site Infection Following the Use of Intracutaneous Sutures Versus Staples

BACKGROUND

Superficial wound infections after gastrointestinal surgery markedly impair the affected patients' quality of life. As it is still unknown which method of skin closure is best for the reduction of wound infections in elective gastrointestinal sur- gery, we compared the frequency of wound infections after intracutaneous suturing versus skin stapling.

METHODS

In a prospective, randomized, single-center study, patients undergoing elective gastrointestinal surgery were intraoperatively randomized to skin closure either with an intracutaneous suture or with staples. The primary endpoint-the occurrence of a grade A1 wound infection within 30 days of surgery-was evaluated according to the intention-to-treat principle.

RESULTS

Out of a total of 280 patients, 141 were randomized to intracutaneous suturing and 139 to stapling. The groups did not differ significantly with respect to age, sex, or ASA classification. 19 of the 141 patients in the intracutaneous suturing group (13.5%) had a grade A1 wound infection, compared with 23 of 139 in the stapling group (16.6%) (odds ratio [OR]: 0.79; 95% confidence interval: [0.41; 1.52]; p = 0.47). A multiple regression analysis revealed that the type of surgery (colorectal vs. other), the approach, and the incision length were independent risk factors for a grade A1 wound infection. When wound dehiscences were additionally considered, wound complications were found to have arisen significantly more often in the stapling group than in the intracutaneous suturing group (16.3% [23/141] versus 30.2% [42/139], OR: 0.45 [0.25; 0.80]; p = 0.006).

CONCLUSION

In elective gastrointestinal surgery, intracutaneous suturing was not found to be associated with a lower rate of superficial wound infections than skin stapling, but fewer wound dehiscences occurred in the intracutaneous suturing group.

Compliance with preoperative care measures reduces surgical site infection after colorectal operation

BACKGROUND

Surgical site infections (SSIs) are a major cause of morbidity complicating colorectal operations. Several evidence-based preoperative strategies are associated with decreased SSI rates. We hypothesize that compliance with multiple strategies is associated with lower incidence of SSI after the elective colorectal operation.

METHODS

Preoperative care measure compliance before colorectal operations were assessed. Measures included antiseptic wash the night before and day of operation, oral antibiotic, and mechanical bowel preparation, antibiotic prophylaxis, Chloraprep skin preparation, and hair clipping. Rates of SSI after colectomy and other pertinent outcomes were stratified by full and partial compliance with preoperative measures. Exclusion criteria included bowel perforation, ischemia, complete obstruction, intra-abdominal abscess, and no intraoperative skin closure.

RESULTS

Eight hundred twenty-six subjects underwent colectomy between 2010 and 2016; 469 met inclusion criteria. Compliance with all measures occurred in 214 (46%) and was independently associated with lower postoperative infection rates (odds ratio [OR], 0.37; confidence interval [CI], 0.16-0.85; P = 0.02). SSI occurred in 51 (11%): was superficial in 35 (7%); deep in 5 (1%); and organ space in 11 (2%). SSI rates were reduced from 16% (partial or no compliance group) to 5% (full compliance group). No stand-alone intervention was independently associated with decreased SSI rate. Multivariate analysis found the following factors associated with a lower risk of SSI: full compliance with all five process measures, lower BMI, nonsmoker, and minimally invasive operation.

DISCUSSION AND CONCLUSION

Compliance with preoperative care strategies reduces rates of SSI after colectomy with a cumulative effect more pronounced than any single intervention reinforcing the need for protocol-driven and evidence-based care for patients undergoing colorectal operations.

Wound Closure and Management

BACKGROUND

The management of incisions and decisions on closure techniques for surgical wounds are driven by expected incisional morbidity and the severity of the potential morbidity for the patient.

METHODS

This article reviews current literature on the potential strategies to be considered in closing the skin and fascia of incisions.

RESULTS

The review of the literature indicates that low-risk wounds for infection should be closed primarily with subcuticular suture, and adjunctive local measures should be avoided. Adjunctive measures of irrigation, topical antimicrobial agents, and negative pressure incisional therapy may have a role in high-risk wounds. Surgeons should strongly consider primary closure of contaminated wounds.

CONCLUSIONS

The overall literature on adjuncts of wound irrigation, topical antimicrobials, and negative pressure wound therapy have potential to be of benefit but additional investigation is necessary since they do impact cost, patient experience, and antibiotic stewardship.

Randomized Comparison of Subcuticular Sutures Versus Staples for Skin Closure After Open Abdominal Surgery: a Multicenter Open-Label Randomized Controlled Trial

BACKGROUND

The incisional surgical site infection (SSI) is an extremely common complication following open abdominal surgery and imposes a considerable treatment and cost burden.

METHOD

We conducted a multicenter open-label randomized controlled trial at three Tokyo Metropolitan medical institutions. We enrolled adult patients who underwent either an elective or an emergency open laparotomy. Eligible patients were allocated preoperatively to undergo wound closure with either subcuticular sutures or staples. A central Web-based randomization tool was used to assign participants randomly by a permuted block sequence with a 1:1 allocation ratio and a block size of 4 before mass closure to each group. The primary endpoint was the occurrence of a superficial SSI within 30 days after surgery in accordance with the Centers for Disease Control and Prevention criteria. This trial was registered with UMIN-CTR as UMIN 000004836 ( http://www.umin.ac.jp/ctr ).

RESULTS

Between September 1, 2010 and August 31, 2015, 401 patients were enrolled and randomly assigned to either group. One hundred and ninety-nine patients were allocated to the subcuticular suture and 202 patients to the staple groups (hereafter the "suture" and "staple" group, respectively). Three hundred and ninety-nine were eligible for the primary endpoint. Superficial SSIs occurred in 25 of 198 suture patients and in 27 of 201 staple patients. Overall, the rate of superficial SSIs did not differ significantly between the suture and staple groups.

CONCLUSION

Subcuticular sutures did not increase the occurrence of superficial SSIs following open laparotomies mainly consisting of clean-contaminated surgical procedures. The applicability of the wound closure material and method is likely to depend on individual circumstances of the patient and surgical procedure.

Randomized clinical trial of oral and intravenous versus intravenous antibiotic prophylaxis for laparoscopic colorectal resection

Background

The use of oral prophylactic antibiotics for the prevention of surgical-site infection (SSI) in patients undergoing laparoscopic surgery for colorectal cancer is controversial. The aim of this RCT was to evaluate whether intravenous perioperative antibiotics are inferior to combined preoperative oral and perioperative intravenous antibiotics in this setting.

Methods

Patients undergoing elective laparoscopic colorectal resection in a single cancer centre were assigned randomly to combined preoperative oral antibiotics (metronidazole and kanamycin) and perioperative intravenous antibiotics (cefmetazole) (oral/IV group) or to perioperative intravenous antibiotics (cefmetazole) alone (IV-only group). Patients were stratified for the analyses based on type of operation (colonic surgery, anterior resection or abdominoperineal resection), preoperative use of mechanical bowel preparation, preoperative chemoradiotherapy and the presence of diabetes mellitus. The primary endpoint was the overall rate of SSI. Secondary endpoints were the rates of incisional site infection, organ/space infection, anastomotic leakage, intra-abdominal abscess, adverse events and postoperative complications.

Results

Of 540 patients offered participation in the trial in 2013–2014, 515 agreed to take part and were randomized. Some 256 patients in the IV-only group and 255 in the oral/IV group completed the treatment per protocol. The overall rate of SSI was 7·8 per cent (20 of 256) in the IV-only group and 7·8 per cent (20 of 255) in the oral/IV group, confirming that perioperative administration of intravenous antibiotics alone was not inferior to the combined regimen (P = 0·017). There were no differences in rates of incisional site infection (5·5 versus 5·9 per cent respectively), organ/space infection (2·3 versus 2·0 per cent) or other secondary endpoints between the two groups.

Conclusion

Intravenous perioperative antimicrobial prophylaxis alone is not inferior to combined preoperative oral and intravenous perioperative prophylaxis with regard to SSI in patients with colorectal cancer undergoing elective laparoscopic resection. Registration number: UMIN000019339 (http://www.umin.ac.jp/ctr/).