Skin closure at cesarean delivery, glue vs subcuticular sutures: a randomized controlled trial

Octyl-2-cyanoacrylate Tissue Adhesive Closure Versus Subcuticular Suture for Post-Auricular Incisions

BACKGROUND

Skin closure techniques in otolaryngology vary based on surgeon preference and wound site. Octyl-2-Cyanoacrylate may be a safe, rapid, and cost-effective option for post-site closure.

AIM

This randomized controlled trial study aimed to compare Octyl-2-Cyanoacrylate and conventional subcuticular sutures in ear surgeries, assessing wound closure results in both case and control groups.

METHODS

This prospective, randomized, controlled, single-blind study was conducted at Ohud Hospital from May 2021 to May 2022. Ear surgery and cochlear implantation in patients were examined, and each group was randomly assigned to receive Dermabond TM and deep layer subcuticular sutures closure. Incisions were assessed at various time points, including 3 weeks, 6 weeks, 6 months, and 1 year post-surgery. The patient and observer Scar Assessment Scale was used, and two independent ear surgeons used the Stony Brook Scar Evaluation Scale for initial scar assessment.

RESULTS

This study involved 126 ear surgery and cochlear implantation patients randomized to use cyanoacrylate tissue adhesive or subcuticular suture for port site closure. The study found that tissue adhesive (OCA) was faster and more efficient than standard sutures, saving an average of 12 min per incision in each ear. Incision cosmesis showed immediate results and significant differences, and patient satisfaction with OCA wound closure was higher than standard sutures.

CONCLUSION

The findings confirmed that cyanoacrylate tissue adhesive significantly reduced the time needed for skin closure during ear surgery and showed immediate cosmetic improvements without any documented instances of bleeding, hematoma, infection, or wound separation.

LEVEL OF EVIDENCE

This is a randomized controlled trial, it follows Level 2 of evidence. Randomized trial or observational study with dramatic effects Laryngoscope, 134:4036-4041, 2024.

Extended-duration antibiotics are not associated with a reduction in surgical site infection in patients with ovarian cancer undergoing cytoreductive surgery with large bowel resection

OBJECTIVE(S)

To evaluate whether extended dosing of antibiotics (ABX) after cytoreductive surgery (CRS) with large bowel resection for advanced ovarian cancer is associated with reduced incidence of surgical site infection (SSI) compared to standard intra-operative dosing and evaluate predictors of SSI.

METHODS

A retrospective single-institution cohort study was performed in patients with stage III/IV ovarian cancer who underwent CRS from 2009 to 2017. Patients were divided into two cohorts: 1) standard intra-operative dosing ABX and 2) extended post-operative ABX. All ABX dosing was at the surgeon's discretion. The impact of antibiotic duration on SSI and other postoperative outcomes was assessed using univariate and multivariable Cox regression models.

RESULTS

In total, 277 patients underwent cytoreductive surgery (CRS) with large bowel resection between 2009 and 2017. Forty-nine percent (n = 137) received standard intra-operative ABX and 50.5% (n = 140) received extended post-operative ABX. Rectosigmoid resection was the most common large bowel resection in the standard ABX (89.9%, n = 124) and extended ABX groups (90.0%, n = 126), respectively. No significant differences existed between age, BMI, hereditary predisposition, or medical comorbidities (p > 0.05). No difference was appreciated in the development of superficial incisional SSI between the standard ABX and extended ABX cohorts (10.9% vs. 12.9%, p = 0.62). Of patients who underwent a transverse colectomy, a larger percentage of patients developed a superficial SSI versus no SSI (21% vs. 6%, p = 0.004).

CONCLUSION(S)

In this retrospective study of patients with advanced ovarian cancer undergoing CRS with LBR, extended post-operative ABX was not associated with reduced SSI, and prolonged administration of antibiotics should be avoided unless clinically indicated.

Skin Reactions Following Primary Total Knee Arthroplasty With an Adhesive Superficial Closure System: A Case Series

BACKGROUND

We investigated a skin adhesive closure device consisting of a self-adhesive polyester mesh placed over the surgical incision, followed by a liquid adhesive that is spread over the mesh and surrounding the skin. It is intended to reduce wound closure times, scarring, and skin complications associated with traditional closure with sutures or staples. The aim of this study was to report on skin reactions in patients who underwent primary total knee arthroplasty (TKA) using the skin adhesive closure system.

METHODS

A retrospective review of patients who underwent TKA using adhesive closure between 2016 to 2021 at a single institute was performed. A total of 1,719 cases were analyzed. Patient demographics were collected. The primary outcome was any postoperative skin reaction. Skin reactions were classified as allergic dermatitis, cellulitis, or other. Treatment(s), duration of symptoms, and surgical infections were also collected.

RESULTS

A total of 5.0% (86) of patients were found to have any type of skin reaction following their TKA. Of these 86, 39 (2.3%) had symptoms of allergic dermatitis (AD), 23 (1.3%) had symptoms of cellulitis, and 24 (1.4%) had other symptoms. A total of 27 (69%) allergic dermatitis patients were treated with a topical corticosteroid cream only; their symptoms resolved within an average of 25 days. There was only 1 case of superficial infection (<0.001%). No prosthetic joint infections were observed.

CONCLUSION

Despite skin reactions appearing in 5.0% of cases, the rate of infection was low. A patient-specific preoperative workup and effective treatment strategies can minimize complications associated with adhesive closure system and increase patient satisfaction following TKA.

Prevention of Postoperative Surgical Site Infection Following Cesarean Delivery

Cesarean delivery is the most common major surgical procedure performed among birthing persons in the United States, and surgical-site infection is a significant complication. Several significant advances in preventive measures have been shown to reduce infection risk, while others remain plausible but not yet proven in clinical trials.

Vaginal preparation with different antiseptic solutions before cesarean section for preventing postoperative infections: A systematic review and network meta-analysis

AIMS

We aimed to investigate the effect of various vaginal wash solutions on reducing risks of post-cesarean endometritis, wound infections, fever, and hospital stay duration.

METHODS

Scopus, Web of Science, PubMed, and Cochrane Library were searched for randomized clinical trials that compared different vaginal wash solutions to each other or to "no vaginal cleaning"; without restriction on the age of parturients or site where trials were conducted. We analyzed this frequentist network meta-analysis using the netmeta package in R software version 4.1.2; synthesized data as mean difference or risk ratio with their 95% confidence intervals.

RESULTS

Our network meta-analysis included 29 RCTs with a total sample size of 9311 women undergoing CS. Regarding post-cesarean endometritis, we found that povidone-iodine had the highest significant risk reduction compared to "no vaginal cleaning" (RR = 0.08, 95% CI [0.01, 0.69]). While regarding post-cesarean reduction of wound infection, fever, and hospital stay duration, we found that chlorhexidine 4% (RR = 0.17, 95% CI [0.05, 0.65]), saline 0.9% (RR = 0.12, 95% CI [0.03; 0.48]), and saline 0.9% (MD = -1.29, 95% CI [-2.18; -0.39]), respectively, had the highest significant risk reduction compared to "no vaginal cleaning."

CONCLUSION

Vaginal wash solutions were associated with a significant reduction of post-cesarean endometritis, wound infection, fever, and hospital stay duration. Since povidone-iodine had the highest significant reduction of post-cesarean endometritis, we recommend setting povidone-iodine as the standard practice as pre cesarean vaginal wash solution; consistent practice guidelines of Enhanced Recovery After Surgery (ERAS).

Comparison of the effect of skin closure materials on skin closure during cesarean delivery

Objective

To compare the effect of skin closure materials on skin closure during cesarean delivery.

Methods

We searched EMBASE、PubMed、Scopus、Cochrane CENTRAL for randomized controlled trials (RCTs) on the use of closure materials for skin closing effect during cesarean delivery. The outcomes were time to skin closure of dermal and epidermal layer, skin separation rate and wound complications(wound infection, hematoma,seroma, reclosure, readmission) reported as an odds ratio (OR) and surface under the cumulative ranking curve analysis (SUCRA) score.

Results

Twenty -six RCTs met the inclusion criteria. In the network meta-analysis (NMA) for time to skin closure of dermal and epidermal layer, pooled network OR values indicated that staple (network SMD, -337.50; 95% CrI: -416.99 to -263.18) was superior to absorbable suture. In the Skin separation NMA, pooled network OR values indicated that the absorbable suture (network OR, 0.37; 95% CrI: 0.19 to 0.70) were superior to staple. In the wound complications NMA, pooled network OR values indicated that the no interventions were superior to staple.

Conclusion

In conclusion, our network meta-analysis showed that the risk of skin separation with absorbable suture after cesarean delivery was reduced compared with staple, and does not increase the risk of wound complications, but the wound closure time would slightly prolonged.

Effect of Closure of Anterior Abdominal Wall Layers on Early Postoperative Findings at Cesarean Section: A Prospective Cross-sectional Study

OBJECTIVE

 To investigate the effect of closure types of the anterior abdominal wall layers in cesarean section (CS) surgery on early postoperative findings.

METHODS

 The present study was designed as a prospective cross-sectional study and was conducted at a university hospital between October 2018 and February 2019. A total of 180 patients who underwent CS for various reasons were enrolled in the study. Each patient was randomly assigned to one of three groups: Both parietal peritoneum and rectus abdominis muscle left open (group 1), parietal peritoneum closure only (group 2), and closure of the parietal peritoneum and reapproximation of rectus muscle (group 3). All patients were compared in terms of postoperative pain scores (while lying down and during mobilization), analgesia requirement, and return of bowel motility.

RESULTS

 The postoperative pain scores were similar at the 2^nd, 6^th, 12^th, and 18^th hours while lying down. During mobilization, the postoperative pain scores at 6 and 12 hours were significantly higher in group 2 than in group 3. Diclofenac use was significantly higher in patients in group 1 than in those in group 2. Meperidine requirements were similar among the groups. There was no difference between the groups' first flatus and stool passage times.

CONCLUSION

 In the group with only parietal peritoneum closure, the pain scores at the 6^th and 12^th hours were higher. Rectus abdominis muscle reapproximations were found not to increase the pain score. The closure of the anterior abdominal wall had no effect on the return of bowel motility.

Prolonged Usage of an Adhesive Wound Closure Device in Postoperative Facial Scar Management: A Split-Wound Randomized Controlled Trial

Background: Additional skin support is promising in scar management, especially for wounds under high tension. Options for effective skin support are limited. This study aimed to determine whether prolonged use of an adhesive wound closure (AWC) device prevents scar spread and improves final appearance. Patients and Methods: This is a split-wound randomized evaluator-blinded study of 14 patients with facial wounds under high tension. After surgical closure, one half of each wound was randomly allocated to receive either standard care or additional 3-month treatment with an AWC device. Scar width, scar scale, and side effects were evaluated 12 months after surgery. Results: A significant difference was observed in scar width between the treated and nontreated sites at 12-month, with a mean difference of 1.024 (95% confidence interval, 0.347-1.700) mm in favor of the treated group. Scar widths in both groups increased rapidly in the first month after surgery and gradually increased until the sixth month. Scale for vascularization and relief were significantly lower in the treated sites. No significant differences were found in complications between two groups. Conclusions and Relevance: Prolonged usage of the AWC device prevented scar spread at 12 months and improved final scar scores in vascularization and relief. Clinical Trial Registration number: ChiCTR1900027155.

When is the right time to remove staples after an elective cesarean delivery?: a randomized control trial

Objective: To determine if there are differences in scar healing and cosmetic outcome between early and late metal staples removal after cesarean delivery.Study design: Randomized controlled trial, in which patients undergoing a scheduled nonemergent cesarean delivery were randomly assigned to early staples removal versus late staples removal. Outcome assessors were blinded to group allocation. Scars were evaluated 8 weeks after cesarean delivery. Primary outcome measures were Patient and Observer Scar Assessment Scale (POSAS) scores. Secondary outcome measures included surgical site infection, wound disruption, hematoma, or seroma.Results: During the study period, 104 patients were randomized. There were no between-group differences in maternal demographics. Both groups had similar indications for cesarean delivery and similar rate of previous one or more cesarean delivery. Patient and Observer Scar Assessment Scale were similar for patients (p = .932) and for physician observer (p = .529). No significant differences were demonstrated between the groups in the rate of surgical site infection or wound disruption.Conclusions: Removal of stainless steel staples on postoperative 4 versus postoperative 8 after cesarean delivery showed similar outcome without significant effect on incision healing. Therefore, timing of removal staples after cesarean delivery could be performed based on patients and surgeon preference.

The Case for Standardizing Cesarean Delivery Technique: Seeing the Forest for the Trees

In this Commentary, we explain the case for a standardized cesarean delivery surgical technique. There are three strong arguments for a standardized approach to cesarean delivery, the most common major abdominal surgery performed in the world. First, standardization within institutions improves safety, efficiency, and effectiveness in health care delivery. Second, surgical training among obstetrics and gynecology residents would become more consistent across hospitals and regions, and proficiency in performing cesarean delivery measurable. Finally, standardization would strengthen future trials of cesarean delivery technique by minimizing the potential for aspects of the surgery which are not being studied to bias results. Before 2013, more than 155 randomized controlled trials, meta-analyses or systematic reviews were published comparing various aspects of cesarean delivery surgical technique. Since 2013, an additional 216 similar studies have strengthened those recommendations and offered evidence to recommend additional cesarean delivery techniques. However, this amount of cesarean delivery technique data creates a forest for the trees problem, making it difficult for a clinician to synthesize this volume of data. In response to this difficulty, we propose a comprehensive, evidence-based and standardized approach to cesarean delivery technique.

Randomized clinical trial comparing skin closure with tissue adhesives vs subcuticular suture after robotic urogynecologic procedures

BACKGROUND

Skin closure techniques during minimally-invasive gynecologic surgery is largely based on surgeon preference. The optimum technique would theoretically be safe, rapid, inexpensive, and result in good cosmetic appearance. Cyanoacrylate tissue adhesive (Dermabond) may be a comparable and safe option for port site closure as compared with subcuticular suture. In this randomized clinical trial, we hypothesized that operative time for skin closure would be less than subcuticular suture during robotic urogynecologic procedures.

AIM

To compare skin closure during robotic urogynecologic surgeries for tissue adhesives and subcuticular suture.

METHODS

Fifty female subjects > 18 years of age undergoing robotic urogynecologic procedures were randomized to have port site closure with either cyanoacrylate tissue adhesive (n = 25) or subcuticular suture (n = 25). All procedures and postoperative evaluations were performed by the same board certified Female Pelvic Medicine and Reconstructive Surgeon. Incisional closure time was recorded. Each subject was followed for 12-wk postoperatively. Incision cosmesis was evaluated using the Stony Brook Scar Evaluation Scale.

RESULTS

A total of 47 subjects (cyanoacrylate group, n = 23; suture group, n = 24) completed the 12-wk postoperative evaluation. Closure time was significantly less (P < 0.0005) using cyanoacrylate tissue adhesive (5.4 ± 2.0 min) than subcuticular suture (24.9 ± 5.6 min). Cosmesis scores were significantly higher in the cyanoacrylate tissue adhesive group than subcuticular suture (P = 0.025). No differences were found between bleeding, infection, or dehiscence (P = 1.00, P = 0.609, P = 0.234, respectively). No statistical demographical differences existed between the two study arms.

CONCLUSION

Our study supported our original hypothesis that cyanoacrylate tissue adhesive for port site closure during robotic urogynecolgic procedures uses less time than with subcuticular suture. Our study also supports that tissue adhesive is comparable to cosmetic outcome while not jeopardizing rates of bleeding, infection, or dehiscence.

Octyl-2-cyanoacrylate tissue adhesive without subcuticular suture for wound closure after total hip arthroplasty: a prospective observational study on thirty-two cases with controls for 3 months follow-up

BACKGROUND

Whether using tissue adhesive alone after subcutaneous suture can close the skin incision with safety as well as cosmetic appearance after total hip arthroplasty was not clear.

METHODS

A prospective study was conducted. The same surgical methods were consistent throughout the entire study. After implanting prosthesis, the joint capsule was reconstructed. Fascial and subcutaneous layer were respectively closed by continuous running barbed suture. Patients were randomized allocated to group A with octyl-2-cyanoacrylate tissue adhesive alone, to group B with tissue adhesive after continuous subcuticular suture, or to group C with skin staples. Time of closure, drainage, pain, wound complications, and cosmesis were compared. All data were analyzed statistically.

RESULTS

There was no significant difference in drainage, Visual Analog Scale score or early wound complications between the three groups. However, there was significant difference in time of closure (P = 0.013). In pairwise comparison, time of closure in groups A and B was significantly longer than those in group C (P = 0.001 and P = 0.023, respectively); time of closure in group A was significantly shorter than those in group B (P = 0.003). Patient and Observer Scar Assessment Scale total scores were not significantly different at 6 weeks and 3 months postoperatively (P = 0.078 and P = 0.284, respectively).

CONCLUSION

Tissue adhesive without subcuticular suture was similar with a combination of subcuticular suture and tissue adhesive as well skin staples in terms of safety and cosmetic appearance after total hip arthroplasty.

Study To Reduce Infection Prior to Elective Cesarean Deliveries (STRIPES): a randomized clinical trial of chlorhexidine

BACKGROUND

Surgical site infections after cesarean delivery are a cause of maternal morbidity and are typically caused by skin microbial flora. Preadmission application of chlorhexidine gluconate using impregnated cloths may decrease surgical site infections by decreasing the abundance of microbial flora.

OBJECTIVE

To determine whether the application of chlorhexidine gluconate cloths the night before and the morning of scheduled cesarean delivery decreases the risk of surgical site infections by 6 weeks postoperatively compared with placebo.

STUDY DESIGN

In this single-center, double-blind, placebo-controlled trial, patients were randomized (1:1) to receive either Sage 2% chlorhexidine cloths or Sage Comfort Bath fragrance-free cloths (placebo) to apply to 6 skin sites on the body (neck, shoulders and chest, armpits, arm and hands, abdomen and groin, left leg and foot, right leg and foot, back and buttocks) the night before and after a shower the morning of scheduled cesarean delivery. Routine clinical and operative procedures were followed. The primary outcome was surgical site infections (superficial or deep incisional with or without organ space endometritis) by 6 weeks after cesarean delivery. The secondary outcomes were surgical site infections by 2 weeks and other wound-related complications by 2 and 6 weeks after cesarean delivery.

RESULTS

From April 2015 to August 2019, 1356 patients were enrolled: 682 were assigned to the chlorhexidine group and 674 to the placebo group. The groups were similar in demographic and medical characteristics. A total of 14 patients were lost to follow-up before cesarean delivery (10 in chlorhexidine and 4 in placebo) and 33 were lost to follow-up after cesarean delivery (10 in chlorhexidine and 23 in placebo). Among the remaining 1309 (97%), no difference was found in surgical site infections by 6 weeks between the 2 groups (2.6% in chlorhexidine vs 3.7% in placebo; P=.24). There were no differences in secondary outcomes at 2 or 6 weeks and no differences in primary outcome in a per-protocol analysis.

CONCLUSION

Preadmission use of chlorhexidine gluconate cloths compared with placebo does not reduce the risk of surgical site infection after scheduled cesarean deliveries. Following the standard of care guidelines results in a low risk of surgical site infections in this group of patients.

Povidone-iodine 1% is the most effective vaginal antiseptic for preventing post-cesarean endometritis: a systematic review and network meta-analysis

BACKGROUND

Direct comparison metaanalyses have reported benefits with presurgical vaginal preparation before cesarean delivery for the reduction of endometritis. These reports did not perform a multitreatment comparison of the various antiseptic solutions assessed in previous studies.

OBJECTIVE

The purpose of this study was to review the literature systematically and quantitate and summarize indirectly the comparative efficacy of antiseptic formulations and their concentrations that are used for the preparation of the vagina before cesarean delivery in the prevention of endometritis and other infectious complications.

STUDY DESIGN

We used MEDLINE, EMBASE (from their inception to November 2018) and Cochrane databases, biographies, and conference proceedings. We used randomized clinical trials of patients who underwent surgical preparation of the vagina with antiseptic formulations before cesarean delivery with the aim of reducing the risk of infectious morbidity. Our systematic review was registered and followed the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for network meta-analysis guidelines. Network meta-analysis was performed with computerized software and used user-written programs to assess consistency, inconsistency, ranking probabilities, and graphing results. Direct and indirect pairwise comparisons of the various formulations and their concentrations were performed with the use of multivariate random-effects models and metaregression. A frequentist inference method was employed for the fitted model to estimate the ranking probabilities. Subgroup analyses for patients in labor, not in labor, and with ruptured membranes were conducted.

RESULTS

For the prevention of endometritis, we identified 23 studies that comprised 7097 women who were allocated to the following treatments: povidone-iodine (1%, 5%, 10%), chlorhexidine (0.2%, 0.4%), metronidazole gel, cetrimide, or normal saline solution/no treatment. Direct and indirect pairwise comparisons indicated that, when compared with saline solution or no treatment, all antiseptic formulations decreased rates of endometritis (5.2% vs 9.1%; odds ratio, 0.48; 95% confidence interval, 0.35-0.65; 22 studies/6994 women). Individually, povidone-iodine (odds ratio, 0.43; 95% confidence interval, 0.28-0.64; 16 studies/5968 women), cetrimide (odds ratio, 0.34; 95% confidence interval, 0.13-0.90; 1 study/200 women), and metronidazole (odds ratio, 0.38; 95% confidence interval, 0.16-0.90; 1 study/224 women) significantly reduced the risk of endometritis. Rankings of vaginal preparations indicated that povidone-iodine 1% had the highest probability (72.7%) of being the most effective treatment for the prevention of endometritis. For the secondary outcomes of postoperative wound infection and fever, a significant reduction was found only with povidone-iodine (odds ratio, 0.61; 95% confidence interval, 0.48-0.78; 16 studies/5968 women; and odds ratio, 0.58; 95% confidence interval, 0.40-0.83; 12 studies/4667 women). Subgroup analyses also found that povidone-iodine significantly reduced risk of endometritis for women in labor (odds ratio, 0.42; 95% confidence interval, 0.20-0.88; 5 studies/1211 women), with ruptured membranes(odds ratio, 0.21; 95% confidence interval, 0.10-0.44; 4 studies/476 women), and undergoing planned cesarean delivery (odds ratio, 0.39; 95% confidence interval, 0.27-0.57; 8 studies/1825 women).

CONCLUSION

Among patients who underwent cesarean delivery, presurgical vaginal irrigation with povidone-iodine had the highest probability of reducing the risk of endometritis, postoperative wound infections, and fever.

Clinical and economic outcomes of cesarean deliveries with skin closure through skin staples plus waterproof wound dressings versus 2-octyl cyanoacrylate plus polymer mesh tape

PURPOSE

To compare clinical and economic outcomes of cesarean deliveries with skin closure through skin staples plus waterproof wound dressings (SSWWD) versus 2-octyl cyanoacrylate plus polymer mesh tape (2OPMT). We hypothesized that cesarean deliveries with skin closure through 2OPMT may be associated with a lower rate of wound complications and infections as compared with skin closure through SSWWD; we also hypothesized that, accordingly, 2OPMT may be associated with lower hospital length of stay (LOS), hospital costs, and all-cause readmissions as compared with SSWWD.

METHODS

Retrospective, observational study using a research database derived from administrative records routinely contributed by hundreds of hospitals in the USA. We queried the database for patients aged 18-49 years who had an in-hospital low transverse cesarean delivery between 1 January, 2012 and 31 March, 2017. Using records of medical supplies used during deliveries, we identified deliveries for which skin closure was performed by either SSWWD (SSWWD group) or 2OPMT (2OPMT group). Our primary study outcome was a composite endpoint of infection/wound complication diagnosis during the hospital stays in which the deliveries were performed. Our secondary outcomes included: length of stay (LOS) and total hospital costs for the hospital stays in which the deliveries were performed, and all-cause readmissions (30/60/90 days post discharge) to the same hospital in which the delivery was performed. We compared outcomes between propensity-score matched groups using regressions accounting for hospital-level clustering and non-Gaussian empirical outcome distributions.

RESULTS

Each group comprised 2133 patients (4266 total patients; mean age = 30.3 years [SD = 4.6]). Compared with the SSWWD group, the 2OPMT group had statistically significant lower rates of complications (infection, 0.7 versus 1.6%, p = .011; wound complication, 0.6 versus 1.3%, p = .036; composite, 0.9 versus 2.0%, p = .002), shorter LOS (mean = 3.5 days [SD = 1.6] versus 3.7 days [SD = 1.8], p = .007), and lower total hospital costs (mean = $8879 [SD = $3157] versus $9313 [SD = $3311], p = .025). Between-group differences for 30/60/90-day all-cause readmissions were statistically insignificant.

CONCLUSIONS

This large observational study is the first of its kind and provides evidence that cesarean delivery skin closure with 2OPMT is associated with lower rates of in-hospital infection and wound complications, lower LOS, lower total hospital costs as compared with SSWWD.

Tissue Adhesive Compared With Sterile Strips After Cesarean Delivery: A Randomized Controlled Trial

OBJECTIVE

To assess whether tissue adhesive after closure of Pfannenstiel incision for cesarean delivery lowers the risk of wound complications when compared with sterile strips.

METHODS

In this multicenter randomized controlled trial, women undergoing cesarean delivery using Pfannenstiel skin incision were randomized to receive tissue adhesive (2-octyl cyanoacrylate) compared with sterile strips after closure of the skin incision. The primary outcome was a composite of wound complications (drainage, cellulitis, abscess, seroma, hematoma, or isolated wound separation) within 8 weeks of delivery. Secondary outcomes included operative time, readmission, office or emergency department visits, or antibiotic use for wound complications, and patient satisfaction with the cesarean scar. With 80% power and a 95% CI, a sample size of 432 per group (n=864) was required to detect a 50% reduction in the primary outcome. A planned interim analysis was performed after 500 patients delivered. A conditional power analysis revealed that the probability of showing a benefit with tissue adhesive was extremely low (6.2%), and the study was halted owing to futility.

RESULTS

Between November 2016 and April 2018, 504 patients were randomized, and follow-up was achieved in 479 (95%). Wound complications occurred in 18 out of 238 patients (7.6%) in the tissue adhesive group and 19 out of 241 patients (7.9%) in the sterile strips group (relative risk 0.96; 95% CI 0.51-1.78). There were no significant differences with regard to types of wound complications, operative time, readmission, office or emergency department visits, antibiotics prescribed for wound complications, or patient scar assessment scores of pain, stiffness, and irregularity between the two groups. However, tissue adhesive performed slightly better in regard to itchiness of scar and overall scar satisfaction.

CONCLUSION

Compared with sterile strips, tissue adhesive after closure of Pfannenstiel incision for cesarean delivery is unlikely to lower the risk of wound complications.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02838017.

Infections complicating cesarean delivery

PURPOSE OF REVIEW

Cesarean sections are common surgical procedures performed in a healthy population and are unique because of a relatively high rate of postoperative infection. There have been many important advances in understanding the pathogenesis of infection and evaluation of interventions to prevent post cesarean section infections in the last few years. Our purpose in this review is to analyze these new data, discuss unanswered questions, and propose changes in standard of care.

RECENT FINDINGS

Wound closure techniques including subcuticular sutures and subcutaneous suturing have been shown to be effective at reducing surgical site infections. Wound dressings including negative pressure dressings likely do not decrease infection rates. The type, timing, and duration of preoperative prophylactic antibiotics, including adjunctive azithromycin for laboring women and multidose antibiotics in obese women, have also yielded mixed results. Our understanding of normal uterine microbiome and the impact of intrapartum antibiotics on the newborn is emerging.

SUMMARY

The pathogenesis of surgical site infections after Cesarean section is complex and multifactorial. Many interventions to reduce infections have been studied with varying degrees of effectiveness. Despite advances in the area, important questions remain unanswered.

n-Butyl-2-cyanoacrylate tissue adhesive (Histoacryl) vs. subcuticular sutures for skin closure of Pfannenstiel incisions following cesarean delivery

BACKGROUND

Tissue adhesives are now routinely used for skin closure in various surgeries. This study aimed to evaluate the safety and efficacy of n-butyl-2-cyanoacrylate (NBCA) tissue adhesive in cesarean delivery by comparing it with the safety and efficacy of subcuticular suture closure.

METHODS AND FINDINGS

A retrospective chart review was undertaken of all patients who underwent cesarean delivery via Pfannenstiel skin incision. During the study period, a total of 209 patients had NBCA (Histoacryl®) closure and 208 patients had suture closure. Wound complications and Vancouver scar scale (VSS) scores were compared between the 2 groups.

RESULTS

There were no significant differences between the two groups in indications for cesarean deliveries or number of previous cesarean deliveries. Incidences of wound disruption and infection were also similar between the two closure groups (p = 0.322 and 0.997, respectively). The rate of wound complications was 3.4% in the NBCA group and 5.3% in the suture group. All complications healed uneventfully with topical antibiotics or closure strips. VSS scores at 6-8 weeks after operation were not significantly different between the two groups (p = 0.858). These results were corroborated by propensity score-matching analysis.

CONCLUSIONS

NBCA may be a useful skin closure of Pfannenstiel skin incisions after cesarean delivery.