Use of Tissue Glue for Surgical Incision Closure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

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.

Bioadhesives with Antimicrobial Properties

Bioadhesives with antimicrobial properties enable easier and safer treatment of wounds as compared to the traditional methods such as suturing and stapling. Composed of natural or synthetic polymers, these bioadhesives seal wounds and facilitate healing while preventing infections through the activity of locally released antimicrobial drugs, nanocomponents, or inherently antimicrobial polers. Although many different materials and strategies are employed to develop antimicrobial bioadhesives, the design of these biomaterials necessitates a prudent approach as achieving all the required properties including optimal adhesive and cohesive properties, biocompatibility, and antimicrobial activity can be challenging. Designing antimicrobial bioadhesives with tunable physical, chemical, and biological properties will shed light on the path for future advancement of bioadhesives with antimicrobial properties. In this review, the requirements and commonly used strategies for developing bioadhesives with antimicrobial properties are discussed. In particular, different methods for their synthesis and their experimental and clinical applications on a variety of organs are reviewed. Advances in the design of bioadhesives with antimicrobial properties will pave the way for a better management of wounds to increase positive clinical outcomes.

Injectable, self-healing hydrogel adhesives with firm tissue adhesion and on-demand biodegradation for sutureless wound closure

Tissue adhesives have garnered extensive interest as alternatives and supplements to sutures, whereas major challenges still remain, including weak tissue adhesion, inadequate biocompatibility, and uncontrolled biodegradation. Here, injectable and biocompatible hydrogel adhesives are developed via catalyst-free o-phthalaldehyde/amine (hydrazide) cross-linking reaction. The hydrogels demonstrate rapid and firm adhesion to various tissues, and an o-phthalaldehyde-mediated tissue adhesion mechanism is established. The hydrogel adhesives show controlled degradation profiles of 6 to 22 weeks in vivo through the incorporation of disulfide bonds into hydrogel network. In liver and blood vessel injury, the hydrogels effectively seal the incisions and rapidly stop bleeding. In rat and rabbit models of full-thickness skin incision, the hydrogel adhesives quickly close the incisions and accelerate wound healing, which exhibit efficacies superior to those of commercially available fibrin glue and cyanoacrylate glue. Thus, the hydrogel adhesives show great potential for sutureless wound closure, hemostasis sealing, and prevention of leakage in surgical applications.

Cyanoacrylate Tissue Adhesives Compared With Sutures on Facial and Neck Wounds: A Meta-analysis

Objective

To compare the effectiveness between cyanoacrylate tissue adhesives (CTAs) and sutures for skin closure on the face and neck.

Data Sources

Embase, Medline, Scopus, Central, Web of Science.

Review Methods

Randomized controlled trials comparing CTAs versus sutures for skin closure on the face and neck were included. Primary outcomes were cosmetic outcomes. Secondary outcomes were scar depth, scar width, pain, closure time, cost, and adverse events. Subgroup analyses were performed by wound locations, type of CTAs, type of sutures, age groups, and type of wounds. Physicians and patients evaluated the cosmetic outcomes.

Results

Eighteen studies (1020 patients) were included. CTAs offered better cosmetic outcomes by Wound Registry Scale at ≤1 month (physician: mean difference [MD]: -1.50, 95% confidence interval, CI: -2.42 to -0.58). The cosmetic outcomes assessed by Visual Analog Scale were comparable at >1 to ≤3 months (physicians: standard mean difference [SMD], -0.01, 95% CI, -0.25 to 0.23, patients: SMD, -0.02, 95% CI, -0.84 to 0.79). The cosmetic outcomes by the Patient and Observer Scar Assessment Scale favored sutures at >3 to 12 months (physician: MD 4.26, 95% CI, 2.02-6.50). Subgroup analyses revealed no differences. CTAs offered less scar depth, scar width, pain, closure time, and total cost of closure. Adverse events were similar.

Conclusion

Based on the wound healing process, the cosmetic outcomes exhibited a favorable inclination toward CTAs at <1 month while demonstrating comparable results between CTAs and sutures at >1 to ≤3 months. Subsequently, sutures exhibited superior cosmetic outcomes compared to CTAs at >3 to 12 months.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most frequent and potentially life-threatening complications following pancreatic surgery. Fibrin sealants have been used in some centres to reduce POPF rate. However, the use of fibrin sealant during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2020.

OBJECTIVES

To evaluate the benefits and harms of fibrin sealant use for the prevention of POPF (grade B or C) in people undergoing pancreatic surgery compared to no fibrin sealant use.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 09 March 2023, together with reference checking, citation searching, and contacting study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 14 RCTs, randomising 1989 participants, comparing fibrin sealant use versus no fibrin sealant use for different locations: stump closure reinforcement (eight trials), pancreatic anastomosis reinforcement (five trials), or main pancreatic duct occlusion (two trials). Six RCTs were carried out in single centres; two in dual centres; and six in multiple centres. One RCT was conducted in Australia; one in Austria; two in France; three in Italy; one in Japan; two in the Netherlands; two in South Korea; and two in the USA. The mean age of the participants ranged from 50.0 years to 66.5 years. All RCTs were at high risk of bias. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included eight RCTs involving 1119 participants: 559 were randomised to the fibrin sealant group and 560 to the control group after distal pancreatectomy. Fibrin sealant use may result in little to no difference in the rate of POPF (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.73 to 1.21; 5 studies, 1002 participants; low-certainty evidence) and overall postoperative morbidity (RR 1.20, 95% CI 0.98 to 1.48; 4 studies, 893 participants; low-certainty evidence). After fibrin sealant use, approximately 199 people (155 to 256 people) out of 1000 developed POPF compared with 212 people out of 1000 when no fibrin sealant was used. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto odds ratio (OR) 0.39, 95% CI 0.12 to 1.29; 7 studies, 1051 participants; very low-certainty evidence) and total length of hospital stay (mean difference (MD) 0.99 days, 95% CI -1.83 to 3.82; 2 studies, 371 participants; very low-certainty evidence). Fibrin sealant use may reduce the reoperation rate slightly (RR 0.40, 95% CI 0.18 to 0.90; 3 studies, 623 participants; low-certainty evidence). Serious adverse events were reported in five studies (732 participants), and there were no serious adverse events related to fibrin sealant use (low-certainty evidence). The studies did not report quality of life or cost-effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included five RCTs involving 519 participants: 248 were randomised to the fibrin sealant group and 271 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF (RR 1.34, 95% CI 0.72 to 2.48; 3 studies, 323 participants; very low-certainty evidence), postoperative mortality (Peto OR 0.24, 95% CI 0.05 to 1.06; 5 studies, 517 participants; very low-certainty evidence), reoperation rate (RR 0.74, 95% CI 0.33 to 1.66; 3 studies, 323 participants; very low-certainty evidence), and total hospital cost (MD -1489.00 US dollars, 95% CI -3256.08 to 278.08; 1 study, 124 participants; very low-certainty evidence). After fibrin sealant use, approximately 130 people (70 to 240 people) out of 1000 developed POPF compared with 97 people out of 1000 when no fibrin sealant was used. Fibrin sealant use may result in little to no difference both in overall postoperative morbidity (RR 1.02, 95% CI 0.87 to 1.19; 4 studies, 447 participants; low-certainty evidence) and in total length of hospital stay (MD -0.33 days, 95% CI -2.30 to 1.63; 4 studies, 447 participants; low-certainty evidence). Serious adverse events were reported in two studies (194 participants), and there were no serious adverse events related to fibrin sealant use (very low-certainty evidence). The studies did not report quality of life. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two RCTs involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. The evidence is very uncertain about the effect of fibrin sealant use on postoperative mortality (Peto OR 1.41, 95% CI 0.63 to 3.13; 2 studies, 351 participants; very low-certainty evidence), overall postoperative morbidity (RR 1.16, 95% CI 0.67 to 2.02; 2 studies, 351 participants; very low-certainty evidence), and reoperation rate (RR 0.85, 95% CI 0.52 to 1.41; 2 studies, 351 participants; very low-certainty evidence). Fibrin sealant use may result in little to no difference in the total length of hospital stay (median 16 to 17 days versus 17 days; 2 studies, 351 participants; low-certainty evidence). Serious adverse events were reported in one study (169 participants; low-certainty evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report POPF, quality of life, or cost-effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealant use may result in little to no difference in the rate of POPF in people undergoing distal pancreatectomy. The evidence is very uncertain about the effect of fibrin sealant use on the rate of POPF in people undergoing pancreaticoduodenectomy. The effect of fibrin sealant use on postoperative mortality is uncertain in people undergoing either distal pancreatectomy or pancreaticoduodenectomy.

Evaluation of Incisional Wound Healing in Dogs after Closure with Staples or Tissue Glue and Comparison to Intradermal Suture Pattern

The study aimed to monitor the healing process in the canine skin following surgical incision and closure using staples or tissue glue and to compare them with the intradermal suture pattern. Surgically created skin incisions in 10 dogs were apposed with staples, tissue glue (n-butyl cyanoacrylate) and continuous intradermal pattern. The cosmetic appearance of the wounds was blindly evaluated on days 7, 14 and 28 and once a month until the end of the experiment, i.e., one year after the incision. Ultrasonographic and clinical evaluation was performed on days 0-10, 12, 14, 16, 18, 21, 24 and 28, once a week until the end of the 3rd month and once a month until the end of the experiment. Histopathological evaluation was performed on days 7, 14, 28, 180 and 365. The median time required for the performance of each technique differed significantly between techniques; stapling lasted 21 s, glue 2 min 16 s and intradermal 15 min 37 s. Cosmetic appearance with glue was statistically worse than staples and intradermal. The clinical appearance of intradermal was significantly better than glue and staples. No significant differences were found at histological evaluation; however, glue had the worst score throughout the experiment. The overall evaluation of the techniques showed that glue had the worst score compared to intradermal and staples, with the difference being statistically significant in the first postoperative week. Intradermal suture pattern is much better than glue application for skin closure in dogs, whilst is not significantly better than staples. Staples should be preferred when time is an important factor.

Goals, challenges and strategies for wound and bleeding management in total knee arthroplasty: A modified Delphi method

BACKGROUND

Surgical techniques related to soft tissue management play critical roles in optimizing surgical outcomes and patient satisfaction in total knee arthroplasty (TKA). Despite the importance of wound closure and bleeding management approaches, no published guidelines/consensus are available.

METHODS

Twelve orthopedic surgeons participated in a modified Delphi panel consisting of 2 parts (each part comprising two rounds) from September-October 2018. Questionnaires were developed based on published evidence and guidelines on surgical techniques/materials. Questionnaires were administered via email (Round 1) or at a face-to-face meeting (subsequent rounds). Panelists ranked their agreement with each statement on a five-point Likert scale. Consensus was achieved if ≥70% of panelists selected 4/5, or 1/2. Statements not reaching consensus in Round 1 were discussed and repeated or modified in Round 2. Statements not reaching consensus in Round 2 were excluded from the final consensus framework.

RESULTS

Consensus was reached on 13 goals of wound management. Panelists agreed on 38 challenges and 71 strategies addressing surgical techniques or wound closure materials for each tissue layer, and management strategies for blood loss reduction or deep vein thrombosis prophylaxis in TKA. Statements on closure of capsular and skin layers, wound irrigation, dressings and drains required repeat voting or modification to reach consensus.

CONCLUSION

Consensus from Asia-Pacific TKA experts highlights the importance of wound management in optimizing TKA outcomes. The consensus framework provides a basis for future research, guidance to reduce variability in patient outcomes, and can help inform recommendations for wound management in TKA.

Tissue Adhesives in Reconstructive and Aesthetic Surgery—Application of Silk Fibroin-Based Biomaterials

Tissue adhesives have been successfully used in various kind of surgeries such as oral and maxillofacial surgery for some time. They serve as a substitute for suturing of tissues and shorten treatment time. Besides synthetic-based adhesives, a number of biological-based formulations are finding their way into research and clinical application. In natural adhesives, proteins play a crucial role, mediating adhesion and cohesion at the same time. Silk fibroin, as a natural biomaterial, represents an interesting alternative to conventional medical adhesives. Here, the most commonly used bioadhesives as well as the potential of silk fibroin as natural adhesives will be discussed.

Octyl cyanoacrylate skin adhesive with or without subcuticular suture for skin closure after implantable venous port placement for oncology patients: a propensity-score matching analysis

AIM

To compare peri-operative outcomes of skin closure with octyl cyanoacrylate (OCA) skin adhesive (Dermabond) with or without subcuticular sutures after deep dermal suturing for implantable venous port placement closure.

MATERIALS AND METHODS

Seven hundred and ninety-two single-lumen implantable venous port insertions for chemotherapy were reviewed from September 2019 to March 2021 in a retrospective single-centre study. Propensity-score matching by a 1:1 nearest neighbour algorithm was conducted to control for confounding baseline differences. Distances were determined by logistic regression. Propensity-score matching was performed based on the following variables: age at procedure, gender, race, operator's seniority, use of anchoring polypropylene suture (PROLENE), port model, and volume of intra-operative local analgesia. The primary outcome was wound dehiscence at the first follow-up (∼1 week).

RESULTS

The 792 port insertions were conducted in 302 males (38.1%), median age 63 years (IQR: 54-69). Of the 656 wounds closed with subcuticular sutures and skin adhesive, 136 were matched in a 1:1 fashion against procedures closed without a subcuticular suture. No significant differences were demonstrated in pain scores, bleeding, swelling, bruising, fever, wound dehiscence, and discharge at postoperative day 1 (POD1) and at first follow-up between the groups (all p>0.05). Of note, no significant differences in wound dehiscence at first follow-up was found in both unmatched (p=0.133) and matched cohorts (McNemar-Bowker's χ² = 1.167, p=0.761).

CONCLUSION

These findings suggest that the omission of subcuticular sutures during implantable venous port closure may not compromise peri-operative outcomes when OCA skin adhesives were used.

No Additional Benefits of Tissue Adhesives for Skin Closure in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

This systematic review is aimed to compare the performance of tissue adhesives (TA) as an adjunct or closure method with traditional wound closure methods for cutaneous closure in arthroplasty and evaluate whether they have any added benefits in terms of decreasing wound complications and increasing postoperative patient satisfaction.

METHODS

Cochrane Library, PubMed, and EMBASE were searched until February 2021. Randomized controlled trials (RCTs) comparing outcomes of TA with emphasis on skin closure time, in-hospital stay, complication rates, cosmetic scoring systems, and patient satisfaction scores (PSS) compared to subcuticular sutures (SCS) and skin staples (ST) in arthroplasty. The quality of RCTs was assessed using the National Institutes of Health quality assessment tool.

RESULTS

Ten RCTs were included. The pooled and the subgroup analysis revealed no significant difference in the wound infection rates, discharge rates, dehiscence rates, and PSS between TA (as an adjunct or closure method) and SCS or ST. TA (as an adjunct or closure method) was significantly (P < .00001) associated with a longer time to closure compared to ST and a shorter time compared to SCS as a closure method. Length of stay was comparable in all groups.

CONCLUSION

Using TA in combination with subcuticular sutures or ST or as a cutaneous method of closure does not provide additional benefits in terms of decreased hospital stay, decreased infection rates, or wound discharge rates. The PSS and pain scores of the scars also appear to be comparable to standard wound closure methods. No clear conclusion could be drawn regarding cosmetic scoring systems, because of the paucity of data.

LEVEL OF EVIDENCE

Level I (Meta-analysis of RCTs).

Effect of tissue adhesives in repairing perineal trauma during childbirth: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To investigate the effect of tissue adhesives on perineal wound healing and pain relief in women with perineal trauma during childbirth.

BACKGROUND

Due to the high incidence and severe consequences of perineal trauma during childbirth, tissue adhesives are recommended as an alternative to conventional sutures to repair perineal trauma. Although many original studies have explored the effect of tissue adhesives on perineal wound healing and pain relief in women with perineal trauma during childbirth, these studies have differed in participants, interventions and outcomes. Therefore, the effect of tissue adhesives on wound healing and pain relief in perineal trauma during childbirth is inconclusive.

DESIGN

A systematic review and meta-analysis based on PRISMA 2020.

METHODS

A systematic and comprehensive literature search was conducted. Eight electronic databases, three clinical trial registers, and grey literature were searched from inception to 28th April 2021 and reference lists were also retrieved. Randomised controlled trials (RCTs) involving women with first- or second-degree perineal lacerations or women who underwent episiotomy were included. The intervention was the use of tissue adhesives alone or in combination with sutures. For the outcome indicators of perineal wound healing and pain relief, subgroup analyses based on the extent of perineal trauma and measurement time points were conducted, respectively.

RESULTS

A total of 14 RCTs involving 2264 participants were included in this research. The results indicated that for first-degree lacerations, the incidence of wound complications was significantly higher in the tissue adhesives group. In contrast, for episiotomy, the effect of the combination of tissue adhesives and sutures was comparable to that of sutures exclusively. The pooled results revealed that tissue adhesives exerted a positive effect on relieving immediate and short-term perineal pain, but no significant difference was found in the effect of long-term pain relief. Moreover, this review also supported the effect of tissue adhesives in shortening intraoperative repair time and improving clinician-maternal satisfaction.

CONCLUSIONS

The existing evidence illustrates that tissue adhesives effectively promote perineal wound healing and relieve immediate and short-term pain. However, for first-degree lacerations, the increased occurrence of wound complications must be prudently considered when applying tissue adhesives alone, whereas, for episiotomy, the combination of tissue adhesives and sutures may be a promising repair alternative. Future studies are encouraged to adopt long-term effect, adverse effect, and cost-effect analysis as important outcome indicators to comprehensively validate the applicability and generalisability of tissue adhesives.

RELEVANCE TO CLINICAL PRACTICE

For first-degree perineal lacerations, we do not recommend using tissue adhesives alone to repair the wound, given the increased wound complications. While for episiotomy, the combination of tissue adhesives and sutures may be a promising alternative to the use of sutures exclusively. Additionally, the adverse effect and long-term effect of using tissue adhesives alone to repair perineal trauma should be further clarified.

Randomized Controlled Trial of Topical Skin Adhesive vs Nylon Sutures for Incision Closure in Forefoot Surgery

BACKGROUND

There are many options for incision closure in forefoot surgery. The aim of this study was to compare topical skin adhesive (2-octyl-cyanoacrylate) to simple interrupted nylon sutures.

METHODS

A prospective randomized controlled trial comparing topical skin adhesive (TSA) and nylon sutures (NSs) for elective open forefoot surgery. Primary outcome was Hollander Wound Evaluation Scale (HWES) assessed 2 weeks following surgery. Secondary objectives included time taken for wound closure, wound assessment, patient satisfaction with wound cosmesis, incision pain, and infection rate.

RESULTS

Between January and December 2018, 84 feet (70 patients) underwent hallux valgus scarf/Akin osteotomy or first metatarsophalangeal arthrodesis and were randomized to receive either intervention (topical skin adhesive) or control (3/0 nylon sutures). We found worse HWES scores when using TSA compared to NSs (1.07 vs 0.60). Incision closure time was slower for TSA (mean, 272 vs 229 seconds). At 2 weeks postoperatively, wound care was faster for TSA (mean 71 secs) vs NSs (mean 120), and patient-reported pain was less with TSA (visual analog scale: TSA 1.2 vs NSs 2.1). A high degree of overall patient satisfaction was reported in both groups, without significant difference.

CONCLUSION

Closure of elective forefoot surgery incisions with topical skin adhesive or interrupted nylon sutures offers high satisfaction rates, low pain scores, and low complications. However, topical skin adhesive was associated with more inflammation and areas of wound separation compared to nylon sutures. We recommend the use of sutures for wound closure in forefoot surgery.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Tissue adhesives for bacterial inhibition in extracorporeal membrane oxygenation cannulae

BACKGROUND

One of the most serious complications of extracorporeal membrane oxygenation (ECMO) therapy is ECMO cannulae infection, which can occur at quadruple the rate of central venous catheter infections, and significantly impact morbidity and paediatric mortality. The objective of this in vitro observational study was to assess antimicrobial properties of two n-butyl-2-octyl cyanoacrylate tissue adhesive (TA) formulations for bacterial inhibition at peripheral ECMO cannulae insertion sites.

METHODS

Antimicrobial properties were assessed using modified agar disk-diffusion (n = 3) and simulated agar cannulation insertion site (n = 20) models. Both assays used Staphylococcus epidermidis which was seeded at the edge of the TA or dressing. Microorganism inhibition was visually inspected and evidenced by the presence or absence of a TA bacterial inhibition zone at 24 and 72 h.

RESULTS

Both TAs provided effective barriers to bacterial migration under cannula dressings, to cannula insertion sites and down cannula tunnels. Additionally, both TAs demonstrated distinct zones of inhibition produced when left to polymerise onto agar plates seeded with S. epidermidis.

CONCLUSIONS

N-Butyl-2-octyl cyanoacrylate TA appears to inhibit bacterial growth and migration of S. epidermidis. Application of TA to cannulae insertion sites may therefore be a potential bedside strategy for infection prevention in ECMO cannulae, but requires further testing before being used clinically for this purpose.

In vitro testing of cyanoacrylate tissue adhesives and sutures for extracorporeal membrane oxygenation cannula securement

BACKGROUND

Extracorporeal membrane oxygenation (ECMO), an invasive mechanical therapy, provides cardio-respiratory support to critically ill patients when maximal conventional support has failed. ECMO is delivered via large-bore cannulae which must be effectively secured to avoid complications including cannula migration, dislodgement and accidental decannulation. Growing evidence suggests tissue adhesive (TA) may be a practical and safe method to secure vascular access devices, but little evidence exists pertaining to securement of ECMO cannulae. The aim of this study was to determine the safety and efficacy of two TA formulations (2-octyl cyanoacrylate and n-butyl-2-octyl cyanoacrylate) for use in peripherally inserted ECMO cannula securement, and compare TA securement to 'standard' securement methods.

METHODS

This in vitro project assessed: (1) the tensile strength and flexibility of TA formulations compared to 'standard' ECMO cannula securement using a porcine skin model, and (2) the chemical resistance of the polyurethane ECMO cannulae to TA. An Instron 5567 Universal Testing System was used for strength testing in both experiments.

RESULTS

Securement with sutures and n-butyl-2-octyl cyanoacrylate both significantly increased the force required to dislodge the cannula compared to a transparent polyurethane dressing (p = 0.006 and p = 0.003, respectively) and 2-octyl cyanoacrylate (p = 0.023 and p = 0.013, respectively). Suture securement provided increased flexibility compared to TA securement (p < 0.0001), and there was no statistically significant difference in flexibility between 2-octyl cyanoacrylate and n-butyl-2-octyl cyanoacrylate (p = 0.774). The resistance strength of cannula polyurethane was not weakened after exposure to either TA formulation after 60 min compared to control.

CONCLUSIONS

Tissue adhesive appears to be a promising adjunct method of ECMO cannula insertion site securement. Tissue adhesive securement with n-butyl-2-octyl cyanoacrylate may provide comparable securement strength to a single polypropylene drain stitch, and, when used as an adjunct securement method, may minimise the risks associated with suture securement. However, further clinical research is still needed in this area.

Incisional complications after skin closure with n-butyl cyanoacrylate or stainless-steel skin staples in horses undergoing colic surgery

OBJECTIVE

To compare the prevalence of incisional complications after skin closure with n-butyl cyanoacrylate (NBC) or stainless-steel skin staples (SS) after ventral midline celiotomy for colic surgery in the horse.

STUDY DESIGN

Retrospective study (2014-2018).

ANIMALS

Two hundred eighteen horses.

METHODS

Medical records of horses that underwent exploratory celiotomy for colic were included when the skin was closed with NBC or SS and the horse survived ≥15 days after surgery. Records and a follow-up questionnaire were used to determine in-hospital and posthospital discharge incisional complications. Associations between variables were assessed by using bivariable and multivariable analysis.

RESULTS

The cutaneous incision was closed with SS in 113 of 218 (51.8%) horses and with NBC in 105 of 218 (48.2%) horses. Follow-up information was available in 166 of 218 horses. Five horses with incisional complications prior to discharge but without follow-up were included in the overall analysis. Incisional complications were recorded in 17.5% (30/171) of horses, including 19.1% (17/89) of closures with SS and 15.9% (12/82) of closures with NBC (P = .54). Complications occurred before discharge in 14 of 218 (6.4%) horses and after discharge in 16 of 166 (9.6%) horses. Four horses with in-hospital incisional complications (surgical site infection) developed a second complication after discharge (hernia). Packed cell volume was a risk factor for in-hospital incisional complications (P = .04), and in-hospital incisional complications were associated with posthospital discharge incisional complications (P = .01).

CONCLUSION

Occurrence of incisional complications did not differ between NBC and SS.

CLINICAL SIGNIFICANCE

N-butyl cyanoacrylate is a suitable alternative to SS to close the cutaneous incision for ventral midline celiotomy for colic surgery in the horse.

Three wound-dressing strategies to reduce surgical site infection after abdominal surgery: the Bluebelle feasibility study and pilot RCT

BACKGROUND

Surgical site infection (SSI) affects up to 20% of people with a primary closed wound after surgery. Wound dressings may reduce SSI.

OBJECTIVE

To assess the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of dressing types or no dressing to reduce SSI in primary surgical wounds.

DESIGN

Phase A - semistructured interviews, outcome measure development, practice survey, literature reviews and value-of-information analysis. Phase B - pilot RCT with qualitative research and questionnaire validation. Patients and the public were involved.

SETTING

Usual NHS care.

PARTICIPANTS

Patients undergoing elective/non-elective abdominal surgery, including caesarean section.

INTERVENTIONS

Phase A - none. Phase B - simple dressing, glue-as-a-dressing (tissue adhesive) or 'no dressing'.

MAIN OUTCOME MEASURES

Phase A - pilot RCT design; SSI, patient experience and wound management questionnaires; dressing practices; and value-of-information of a RCT. Phase B - participants screened, proportions consented/randomised; acceptability of interventions; adherence; retention; validity and reliability of SSI measure; and cost drivers.

DATA SOURCES

Phase A - interviews with patients and health-care professionals (HCPs), narrative data from published RCTs and data about dressing practices. Phase B - participants and HCPs in five hospitals.

RESULTS

Phase A - we interviewed 102 participants. HCPs interpreted 'dressing' variably and reported using available products. HCPs suggested practical/clinical reasons for dressing use, acknowledged the weak evidence base and felt that a RCT including a 'no dressing' group was acceptable. A survey showed that 68% of 1769 wounds (727 participants) had simple dressings and 27% had glue-as-a-dressing. Dressings were used similarly in elective and non-elective surgery. The SSI questionnaire was developed from a content analysis of existing SSI tools and interviews, yielding 19 domains and 16 items. A main RCT would be valuable to the NHS at a willingness to pay of £20,000 per quality-adjusted life-year. Phase B - from 4 March 2016 to 30 November 2016, we approached 862 patients for the pilot RCT; 81.1% were eligible, 59.4% consented and 394 were randomised (simple, n = 133; glue, n = 129; no dressing, n = 132); non-adherence was 3 out of 133, 8 out of 129 and 20 out of 132, respectively. SSI occurred in 51 out of 281 participants. We interviewed 55 participants. All dressing strategies were acceptable to stakeholders, with no indication that adherence was problematic. Adherence aids and patients' understanding of their allocated dressing appeared to be key. The SSI questionnaire response rate overall was 67.2%. Items in the SSI questionnaire fitted a single scale, which had good reliability (test-retest and Cronbach's alpha of > 0.7) and diagnostic accuracy (c-statistic = 0.906). The key cost drivers were hospital appointments, dressings and redressings, use of new medicines and primary care appointments.

LIMITATIONS

Multiple activities, often in parallel, were challenging to co-ordinate. An amendment took 4 months, restricting recruitment to the pilot RCT. Only 67% of participants completed the SSI questionnaire. We could not implement photography in theatres.

CONCLUSIONS

A main RCT of dressing strategies is feasible and would be valuable to the NHS. The SSI questionnaire is sufficiently accurate to be used as the primary outcome. A main trial with three groups (as in the pilot) would be valuable to the NHS, using a primary outcome of SSI at discharge and patient-reported SSI symptoms at 4-8 weeks.

TRIAL REGISTRATION

Phase A - Current Controlled Trials ISRCTN06792113; Phase B - Current Controlled Trials ISRCTN49328913.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 39. See the NIHR Journals Library website for further project information. Funding was also provided by the Medical Research Council ConDuCT-II Hub (reference number MR/K025643/1).

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants have been used in some centers to reduce postoperative pancreatic fistula. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2018.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched trial registers and the following biomedical databases: the Cochrane Library (2019, Issue 2), MEDLINE (1946 to 13 March2019), Embase (1980 to 11 March 2019), Science Citation Index Expanded (1900 to 13 March 2019), and Chinese Biomedical Literature Database (CBM) (1978 to 13 March 2019).

SELECTION CRITERIA

We included all randomised controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included 12 studies involving 1604 participants in the review. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included seven studies involving 860 participants: 428 were randomised to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence) or length of hospital stay (MD 0.99 days, 95% CI -1.83 to 3.82; 371 participants; two studies; very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included four studies involving 393 participants: 186 were randomised to the fibrin sealant group and 207 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (16.7% versus 11.7%; RR 1.14, 95% CI 0.28 to 4.69; 199 participants; two studies; very low-quality evidence). We are uncertain whether fibrin sealants reduce postoperative mortality (0.5% versus 2.4%; Peto OR 0.26, 95% CI 0.05 to 1.32; 393 participants; four studies; low-quality evidence) or length of hospital stay (MD 0.01 days, 95% CI -3.91 to 3.94; 323 participants; three studies; very low-quality evidence). There is probably little or no difference in overall postoperative morbidity (52.6% versus 50.3%; RR 1.04, 95% CI 0.87 to 1.24; 323 participants; three studies; moderate-quality evidence) between the groups. We are uncertain whether fibrin sealants reduce reoperation rate (5.2% versus 7.7%; RR 0.74, 95% CI 0.33 to 1.66; 323 participants; three studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two studies involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (median 16 to 17 days versus 17 days; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study (169 participants; low-quality evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.

Tissue adhesive for vascular access devices: who, what, where and when?

Despite vascular access devices (VADs) being vital for patient care, device failure rates are unacceptably high with around 25% of central venous devices, and 30-40% of peripheral venous devices, developing complications that result in VAD failure. The use of tissue adhesive is a novel method of securing VADs and is gaining popularity, however the evidence base guiding its clinical use is still emerging. This article aims to review the types and properties of tissue adhesives, provide an overview of the existing evidence base, and discuss how tissue adhesives may be used in clinical practice.

Robot-assisted laser tissue soldering system

Fast and reliable incision closure is critical in any surgical intervention. Common solutions are sutures and clips or adhesives, but they all present difficulties. These difficulties are especially pronounced in classical and robot-assisted minimally-invasive interventions. Laser soldering methods present a promising alternative, but their reproducibility is limited. We present a system that combines a previously reported laser soldering system with a robotic system, and demonstrate its feasibility on the incision-closure of ex-vivo mice skins. In this demonstration, we measured tearing forces of ~2.5N, 73% of the tearing force of a mouse skin without an incision. This robot-assisted laser soldering technique has the potential to make laser tissue soldering more reproducible and revolutionize surgical tissue bonding.

Bioadhesives for internal medical applications: A review

Bioadhesives such as tissue adhesives, hemostatic agents, and tissue sealants have gained increasing popularity in different areas of clinical operations during the last three decades. Bioadhesives can be categorized into internal and external ones according to their application conditions. External bioadhesives are generally applied in topical medications such as wound closure and epidermal grafting. Internal bioadhesives are mainly used in intracorporal conditions with direct contact to internal environment including tissues, organs and body fluids, such as chronic organ leak repair and bleeding complication reduction. This review focuses on internal bioadhesives that, in contrast with external bioadhesives, emphasize much more on biocompatibility and adhesive ability to wet surfaces rather than on gluing time and intensity. The crosslinking mechanisms of present internal bioadhesives can be generally classified as follows: 1) chemical conjugation between reactive groups; 2) free radical polymerization by light or redox initiation; 3) biological or biochemical coupling with specificity; and 4) biomimetic adhesion inspired from natural phenomena. In this review, bioadhesive products of each class are summarized and discussed by comparing their designs, features, and applications as well as their prospects for future development.

STATEMENT OF SIGNIFICANCE

Despite the emergence of numerous novel bioadhesive formulations in recent years, thus far, the classification of internal and external bioadhesives has not been well defined and universally acknowledged. Many of the formulations have been proposed for treatment of several diseases even though they are not applicable for such conditions. This is because of the lack of a systematic standard or evaluation protocol during the development of a new adhesive product. In this review, the definition of internal and external bioadhesives is given for the first time, and with a focus on internal bioadhesives, the criteria of an ideal internal bioadhesive are adequately discussed; this is followed by the review of recently developed internal bioadhesives based on different gluing mechanisms.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2016.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched trial registers and the following biomedical databases: the Cochrane Library (2018, Issue 4), MEDLINE (1946 to 12 April 2018), Embase (1980 to 12 April 2018), Science Citation Index Expanded (1900 to 12 April 2018), and Chinese Biomedical Literature Database (CBM) (1978 to 12 April 2018).

SELECTION CRITERIA

We included all randomized controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).

MAIN RESULTS

We included 11 studies involving 1462 participants in the review.Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomyWe included seven studies involving 860 participants: 428 were randomized to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence). There is probably little or no difference in length of hospital stay between the groups (12.1 days versus 11.4 days; MD 0.32 days, 95% CI -1.06 to 1.70; 755 participants; four studies; moderate-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomyWe included three studies involving 251 participants: 115 were randomized to the fibrin sealant group and 136 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (1.6% versus 6.2%; RR 0.25, 95% CI 0.01 to 5.06; 57 participants; one study; very low-quality evidence). Fibrin sealants may lead to little or no difference in postoperative mortality (0.1% versus 0.7%; Peto OR 0.15, 95% CI 0.00 to 7.76; 251 participants; three studies; low-quality evidence) or length of hospital stay (12.8 days versus 14.8 days; MD -1.58 days, 95% CI -3.96 to 0.81; 181 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (33.7% versus 34.7%; RR 0.97, 95% CI 0.65 to 1.45; 181 participants; two studies; very low-quality evidence), or reoperation rate (7.6% versus 9.2%; RR 0.83, 95% CI 0.33 to 2.11; 181 participants; two studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomyWe included two studies involving 351 participants: 188 were randomized to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (17.0 days versus 16.5 days; MD 0.58 days, 95% CI -5.74 to 6.89; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study: more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.

Developing outcome measures assessing wound management and patient experience: a mixed methods study

OBJECTIVES

To develop outcome measures to assess practical management of primary surgical wounds and patient experience.

DESIGN

Mixed methods, including qualitative interviews and data extraction from published randomised controlled trials (RCTs).

SETTING

Two university-teaching NHS hospitals and three district NHS hospitals in the South West and Midlands regions of England.

PARTICIPANTS

Sixty-four patients and 15 healthcare professionals from abdominal general surgical specialities and obstetrics (caesarean section).

METHODS

Measures were developed according to standard guidelines to identify issues relevant to patients' experiences of surgical wounds and dressings, including analysis of existing RCT outcomes and semi-structured interviews. These were written into provisional questionnaire items for a single outcome measure. Cognitive interviews with patients and healthcare professionals assessed face validity, acceptability and relevance. Findings from interviews were regularly shared with the study team who suggested amendments to modify and reword items to improve understanding before further iterative testing with patients and healthcare professionals.

RESULTS

Analyses of existing RCT outcomes and interviews produced a total of 69 issues. Pretesting and iterative revision established the need for two separate measures. One measure addresses healthcare professionals' experience of wound management in two key areas: exudate and its impact, and allergic reactions to the dressing. The other measure addresses patients' experience of wounds in seven key areas: wound comfort, dressing removal, dressings to protect the wound, impact on daily activities, ease of movement, anxiety about the wound and satisfaction with dressing. Each measure took less than five min to complete and both were understood and acceptable to patients and healthcare professionals.

CONCLUSION

This in-depth study has developed two measures to assess practical management of primary surgical wounds and patient experience. Further work to test their validity, reliability and application to other settings is now required.

TRIAL REGISTRATION NUMBER

HTA - 12/200/04; Pre-results.

Scarless Wound Closure by a Mussel-Inspired Poly(amidoamine) Tissue Adhesive with Tunable Degradability

Burn, trauma, and various medical conditions including bacterial infection, diabetes complication, and surgery could lead to an acute cutaneous wound and scar formation. Application of tissue glues instead of sutures could minimize the additional trauma and scar formation. Despite the countless efforts devoted to the development of high-strength tissue glues, little attention has been paid to their influence on the scar formation. Here, we report the development of a new tissue glue with excellent biocompatibility and tunable degradability for scarless wound closure. A series of catechol-containing poly(amidoamine) (CPAA) polymers were synthesized via the one-step Michael addition of dopamine and bisacrylamide. The tertiary amino group in the polymer backbone was used to introduce a zwitterionic sulfobetaine group by one-step ring-opening polymerization. The introduction of the zwitterionic sulfobetaine group could easily tune the hydrophilicity and the degradability of CPAA without influencing the density of the catechol group in the polymer. Lap-shear tests on the porcine skin demonstrated a high adhesion strength of 7 kPa at 1 h, rising to 24 kPa by 12 h. Addition of silica nanoparticles could further enhance the adhesion strength by 50%. In vivo studies further confirmed that the CPAA tissue glue could effectively accelerate the healing process of incisional wounds on the back of Sprague Dawley rats compared with suture and reduce the scar formation.

Septal Deviation Treatment Using Bone or Cartilage Grafts Fixed with Cyanoacrylate Tissue Adhesive

BACKGROUND

This paper presents a method in which bone or cartilage grafts are fixed to the septal cartilage with cyanoacrylate-based tissue adhesive for the treatment of septal deviation. A prospective study was designed to show the effectiveness of the technique.

METHODS

Cyanoacrylate-based tissue adhesive was used to fix the cartilage or bone grafts onto the septal cartilage to straighten deviated septal cartilage in 77 patients. Regarding the patients' preoperative and postoperative nasal respiration, the following were assessed: (1) Nasal Obstruction Symptom Evaluation (NOSE) scales, (2) patient satisfaction with postoperative nasal respiration using visual analog scoring, and (3) computerized tomographic images.

RESULTS

The patients were followed up for 29 months on average. Patients' respiration-related problems resulting from septal deviation were relieved in all but four patients. Clinically and radiologically, the straightened septums preserved their new forms, and it was detected with computerized tomography that the bone grafts had acquired permanency. In addition, the NOSE scores improved significantly compared to their preoperative levels.

CONCLUSIONS

In cases in which the use of bone or cartilage grafts is chosen to straighten the deviated septal cartilage, fixation of grafts with cyanoacrylate (CA) tissue adhesive is a quick, instantly effective, and reliable method. CA, which enables the subsurface of the graft to have complete contact with the septal cartilage, provides extra benefit by transferring all of the reformative forces of the grafts to the septal cartilage.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Systematic Review and Meta-Analysis of Surgical Zipper Technique versus Intracutaneous Sutures for the Closing of Surgical Incision

BACKGROUND

It is controversial whether surgical zipper technique (SZT), a non-invasive method of surgical wound closure, achieves a better outcome of incision healing than intracutaneous sutures (IS) in the surgery. This meta-analysis was performed to systematically analyze whether surgical zipper is superior to suture material for the incision closure.

METHODS

Databases and reference lists were searched for randomized controlled trials (RCTs) comparing SZT with IS for the incision closure.

RESULTS

Four RCTs with 678 patients were identified and analyzed. Compared with IS, SZT achieved similar incidence of postoperative complications, less time for incision closure, less cost of both surgeons' time and operating room time, no need for removing sutures and more comfort for the patients. Besides, SZT achieved perfect aesthetic results in various types of incisions with the exception of those with substantial curvatures, those with secretions, in obese patients or those under high tension.

CONCLUSION

The non-invasive zipper technique may be a more attractive option of incision closure in a wide spectrum of surgical areas.

Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial.

OBJECTIVES

To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.

SEARCH METHODS

We searched The Cochrane Library (2015, Issue 7), MEDLINE (1946 to 26 August 2015), EMBASE (1980 to 26 August 2015), Science Citation Index Expanded (1900 to 26 August 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 26 August 2015).

SELECTION CRITERIA

We included all randomized controlled trials that compared fibrin sealant group (fibrin glue or fibrin sealant patch) versus control group (no fibrin sealant or placebo) in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

We included nine trials involving 1095 participants who were randomized to the fibrin sealant group (N = 550) and the control group (N = 545) after pancreatic surgery. All of the trials were at high risk of bias. There was no evidence of differences in overall postoperative pancreatic fistula (fibrin sealant 29.6%; control 31.0%; RR 0.93, 95% CI 0.71 to 1.21; P = 0.58; nine studies; low-quality evidence), postoperative mortality (3.1% versus 2.1%; Peto OR 1.29, 95% CI 0.59 to 2.82; P = 0.53; eight studies; very low-quality evidence), overall postoperative morbidity (29.6% versus 28.9%; RR 1.04, 95% CI 0.82 to 1.32; P = 0.77; five studies), reoperation rate (8.7% versus 10.7%; RR 0.80, 95% CI 0.53 to 1.21; P = 0.29; five studies), or length of hospital stay (12.9 days versus 13.1 days; MD -0.73 days, 95% CI -2.20 to 0.74; P = 0.331; six studies) between the groups. The proportion of postoperative pancreatic fistula that was clinically significant was not mentioned in most trials. On inclusion of trials that clearly distinguished clinically significant fistulas, there was inadequate evidence to establish the effect of fibrin sealants on clinically significant postoperative pancreatic fistula (9.4% versus 13.4%; RR 0.72, 95% CI 0.42 to 1.21; P = 0.21; three studies). Quality of life and cost effectiveness were not reported in any of the trials.

AUTHORS' CONCLUSIONS

Based on the current available evidence, fibrin sealants do not seem to prevent postoperative pancreatic fistula in people undergoing pancreatic surgery.

Clinical applications of surgical adhesives and sealants

In the United States and Europe, the number of topical adhesives, surgical sealants, and hemostats approved for use in the surgical setting is ever expanding although no single device fills all medical and surgical needs to replace sutures. As more surgical procedures are performed through laparoscopic and robotic approaches, these devices are becoming more important, and current research is focused on solving the limitations of conventional wound treatments. This review article discusses clinical applications of various biologically derived and synthetic products that are currently available to surgeons and those that are in development.

Synthesis and properties of temperature-sensitive and chemically crosslinkable poly(ether-urethane) hydrogel

The PEU-MA solutions can gelate at physiological temperature, and be further crosslinked by UV light.

Tissue adhesives for closure of surgical incisions

BACKGROUND

Sutures (stitches), staples and adhesive tapes have been used for many years as methods of wound closure, but tissue adhesives have entered clinical practice more recently. Closure of wounds with sutures enables the closure to be meticulous, but the sutures may show tissue reactivity and can require removal. Tissue adhesives offer the advantages of an absence of risk of needlestick injury and no requirement to remove sutures later. Initially, tissue adhesives were used primarily in emergency room settings, but this review looks at the use of tissue adhesives in the operating room/theatre where surgeons are using them increasingly for the closure of surgical skin incisions.

OBJECTIVES

To determine the effects of various tissue adhesives compared with conventional skin closure techniques for the closure of surgical wounds.

SEARCH METHODS

In March 2014 for this second update we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting.

SELECTION CRITERIA

Only randomised controlled trials were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We conducted screening of eligible studies, data extraction and risk of bias assessment independently and in duplicate. We expressed results as random-effects models using mean difference for continuous outcomes and risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes. We investigated heterogeneity, including both clinical and methodological factors.

MAIN RESULTS

This second update of the review identified 19 additional eligible trials resulting in a total of 33 studies (2793 participants) that met the inclusion criteria. There was low quality evidence that sutures were significantly better than tissue adhesives for reducing the risk of wound breakdown (dehiscence; RR 3.35; 95% CI 1.53 to 7.33; 10 trials, 736 participants that contributed data to the meta-analysis). The number needed to treat for an additional harmful outcome was calculated as 43. For all other outcomes - infection, patient and operator satisfaction and cost - there was no evidence of a difference for either sutures or tissue adhesives. No evidence of differences was found between tissue adhesives and tapes for minimising dehiscence, infection, patients' assessment of cosmetic appearance, patient satisfaction or surgeon satisfaction. However there was evidence in favour of using tape for surgeons' assessment of cosmetic appearance (mean difference (VAS 0 to 100) 9.56 (95% CI 4.74 to 14.37; 2 trials, 139 participants). One trial compared tissue adhesives with a variety of methods of wound closure and found both patients and clinicians were significantly more satisfied with the alternative closure methods than the adhesives. There appeared to be little difference in outcome for different types of tissue adhesives. One study that compared high viscosity with low viscosity adhesives found that high viscosity adhesives were less time-consuming to use than low viscosity tissue adhesives, but the time difference was small.

AUTHORS' CONCLUSIONS

Sutures are significantly better than tissue adhesives for minimising dehiscence. In some cases tissue adhesives may be quicker to apply than sutures. Although surgeons may consider the use of tissue adhesives as an alternative to other methods of surgical site closure in the operating theatre, they need to be aware that sutures minimise dehiscence. There is a need for more well designed randomised controlled trials comparing tissue adhesives with alternative methods of closure. These trials should include people whose health may interfere with wound healing and surgical sites of high tension.

Comparison of 2 methods of incision closure in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery

STUDY DESIGN

A prospective, randomized, and controlled clinical trial.

OBJECTIVE

To compare surgical zipper with subcuticular Monocryl sutures in terms of incision closure time, cosmetic results, and the complication rate in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) surgery.

SUMMARY OF BACKGROUND DATA

In previous literatures, the application of surgical zipper to incision closure has been reported to be associated with a favorable outcome. However, in the PSF surgery of patients with AIS, the use of surgical zipper has not been described.

METHODS

Ninety female patients with AIS undergoing PSF were assigned randomly to 2 incision closure groups either using surgical zipper or using the 4-0 absorbable subcuticular suture. The incision outcome was evaluated with the Hollander Incision Evaluation Score at 7 days, 2 weeks, 6 months, and 1 year after surgery, respectively. Besides, a visual analogue scale was allocated to each patient to rate the cosmetic result of the incision. The 2 groups were compared to determine the differences in terms of incision closure time, the complication rate, and cosmetic results.

RESULTS

The incision closure using surgical zipper consumed significantly less time than that using subcuticular suture (45.3 vs. 540.5 s, P < 0.001). As for the cosmetic results, no significant differences of Hollander Incision Evaluation Score scores between the 2 suturing groups were found. Besides, patients' satisfaction with cosmetic outcome on a linear visual analogue scale also revealed similar results between the 2 groups. As for postoperative complications, we found 1 case of mild blister due to allergy to the tape of the dressings and 2 cases of incisional pain in the Monocryl suture group.

CONCLUSION

The application of surgical zipper in PSF surgery is a safe and effective method. The ease and the speed of application make surgical zipper an attractive option for incision closure in patients with AIS undergoing PSF.

LEVEL OF EVIDENCE

4.

Clinical and histological effects of the temporary occlusion of the rabbit nasolacrimal duct and point using cyanoacrylate adhesives

The objective of this study was to evaluate the clinical and histological effects of occluding the nasolacrimal ducts and points of rabbits. For this study, 20 adult New Zealand rabbits, both males and females, weighing 3.2±0.4kg were allocated into two groups for n-butyl-cyanoacrylate occlusion (GB, n=10) or 2-octyl-cyanoacrylate occlusion (GO, n=10). The contralateral eyes served as the controls. The persistence of tears was evaluated daily using the Schirmer I test. Discomfort, eye discharge, epiphora, and conjunctival hyperemia were assessed prior to the procedure (T0) and during the 14 subsequent days (T1-T14). On days seven and 14, five animals from each group were euthanized, and their nasolacrimal ducts were collected, processed and analyzed by histology. In the GB group, the Schirmer test values differed from that at T0 at all of the subsequent time points, whereas there was no difference in the values observed from the GO group. Compared with the corresponding controls, the GO and GB groups differed significantly at almost all of the time points. When comparing the treatment groups, differences were found at T6, T7, T9, T10, T11, T12 and T14, with higher Schirmer values in the GB group. Epiphora was observed in the GB group from T1 to T8 and in the GO group from T1 to T6. Within seven days post-occlusion, histology revealed a moderate foreign body reaction, with marked necrosis and sloughing of the canalicular epithelium, in the GO group, which was absent at day 14. In the GB group, a marked inflammatory reaction and a mild foreign body reaction were found at day seven, and the foreign body reaction was prevalent at day 14. This study demonstrated that both adhesives were effective in obstructing the nasolacrimal ducts and points of rabbits and that their application and handling are easy and free of complications. However, both adhesives promoted inflammatory and foreign body reactions that evolved to repair and regeneration at day 14 of evaluation.

LiquiBand® Surgical S topical adhesive versus sutures for the closure of laparoscopic wounds. A randomized controlled trial

Cyanoacrylate adhesives offer the surgeon and patient an alternative to subcuticular suturing. LiquiBand® Surgical S (LBSS) is a new formulation with a blend of monomeric n-butyl and 2-octyl cyanoacrylates. In this study, the effectiveness, safety, and clinical utility of LBSS was compared to Vicryl^™ sutures for the closure of laparoscopic incisions. This was a prospective randomized study of LBSS skin adhesive versus Vicryl^™ sutures for the topical closure of laparoscopic surgical incisions. Subjects were asked to return at 2 weeks postsurgery to report complications and adverse events. Wounds were evaluated for apposition and cosmesis using a modified Hollander Wound Evaluation Scale (HWES). The Shapiro-Wilk test of normality was done. Independent-samples T test, Mann Whitney U test, and chi-square test were used to compare variables between the two wound closure methods. A total of 114 subjects participated in this trial completing all aspects of the study. Fifty-five subjects received sutures for topical wound closure, with 59 subjects receiving LBSS. Surgeons were found to be satisfied with 100 % of all applications using the LBSS device. One hundred percent of wounds closed with sutures and 98.9 % wounds closed with LBSS achieving an optimal HWES of 0. There was no statistical difference in cosmesis or complications for either method. Closure with LBSS was significantly faster by a mean of 2 min. LiquiBand® Surgical S is as good as sutures for the closure of laparoscopic wounds in terms of cosmesis and complications with the added benefit of being significantly faster.

Absorbable cyanoacrylate surgical sealant in kidney transplantation

As the proportion of older recipients increases, the vascular anastomoses can be challenging with significant atherosclerosis, and patients with comorbidities may be on an anticoagulation therapy, potentially increasing the risk of hemorrhagic complications. We report a case of kidney transplantation in which an absorbable cyanoacrylate surgical sealant was used. A 32-year-old white male received a kidney transplant from his wife. Two renal arteries of the donor's left kidney were reconstructed on the back table and anastomosed to the right iliac artery of the recipient. After the sealant was applied to the suture lines, the vascular clamps were released without significant bleeding from the anastomoses. The recipient demonstrated a stable graft function without an immediate complication. This case illustrates the potential benefits of the cyanoacrylate sealant in selected kidney transplant recipients.