Randomized controlled trial comparing subcuticular absorbable suture with conventional interrupted suture for wound closure at elective operation of colon cancer

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

AIM

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

METHODS

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

RESULTS

A total of 18 RCTs with 5,496 patients were included in this study. The overall SSIs in absorbable sutures were significantly lower than the ones in skin staplers (OR: 0.77; 95% confidence intervals (CI): 0.63-0.95) and non-absorbable sutures (OR: 0.62; 95% CI: 0.39-0.99). On the other hand, SSIs in absorbable sutures were not statistically different from the SSIs in tissue adhesive. The highest P-score was 0.91 for absorbable sutures. A funnel plot for estimating the heterogeneity of the studies revealed that a publication bias would be minimal (Egger test, P = 0.271).

CONCLUSION

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

Clinical Equivalence of Monoglyde® and Monocryl® Absorbable Poliglecaprone-25 Sutures: A Single-Blind, Randomized Study

OBJECTIVES

Poliglecaprone-25 is a synthetic monofilament suture commonly used for post-cesarean subcuticular skin closure. The present study was designed to assess the effect of subcuticular skin closure using Monoglyde® vs. Monocryl® poliglecaprone-25 absorbable sutures on the risk of wound composite outcomes in the first 30 days post-partum [surgical site infection (SSI), wound dehiscence, hematoma or seroma].

STUDY DESIGN

This is a prospective, single-blind, randomized (1:1), multicentric, two-arm study performed between September 2020 and December 2021 at two different centers across India. Women (18-40 years) with a singleton pregnancy requiring cesarean delivery were randomized to Monoglyde® (n=62) or Monocryl® (n=62) suture groups. The primary endpoint is the incidence of wound composite outcomes in the first 30 days post-partum (SSI, wound dehiscence, seroma, or hematoma). In addition, the secondary outcomes, incidence of wound composite outcome at all visits (till four months), suture extrusion and loosening, suture removal and evaluation of microbial deposits on sutures (in case not absorbed or infection), operative time, intraoperative suture handling, postoperative pain, return to normal day-to-day activities, modified Hollander cosmesis score, subject satisfaction score, and adverse events were noted.

RESULTS

Non-significant difference between the groups regarding demographic characteristics and primary endpoint; the incidence of wound composite outcome was observed. Moreover, no significant difference in suture extrusion and loosening, suture removal and evaluation of microbial deposits on sutures, operative time, intraoperative suture handling, pain, return to normal day-to-day activities, modified Hollander cosmesis, and subject satisfaction score were registered between the groups.

CONCLUSIONS

This study establishes the clinical equivalence of Monoglyde® and Monocryl® poliglecaprone-25 sutures, and both sutures can be used for subcuticular skin closure following cesarean delivery with minimal risk for wound complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

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

Comparing running vs interrupted sutures for skin closure: A systematic review and meta-analysis

Continuous sutures and interrupted sutures have been widely applied to skin closure after non-obstetric surgery or traumatic wounds. Usually, continuous sutures were divided into transdermal or subcuticular sutures according to whether the stitches were placed through or below the epidermal layer. Interrupted sutures, on the other hand, involved penetration of the loose connective tissue beneath the skin layers, with stitches placed through the external skin layer. Complications including infection, dehiscence, and poor cosmetic appearance were not rare after suturing. Whether a suture method is a suitable option for rapid wound healing and long-term cosmetic appearance remains controversial. To examine the potential benefits and harms of continuous skin sutures vs interrupted skin sutures in non-obstetric surgery or traumatic wounds. Searching websites such as PubMed, the Cochrane Central Library, Web of Science and Embase, and ClinicalTrials.gov were systematically searched up to 5 January 2022 and were assessed and guided by Preferred Reporting Items for Systematic Reviews and Meta-analysis rules as well as guidelines. All relevant randomised controlled studies comparing continuous sutures with interrupted sutures of skin closure were analysed. The suture techniques and material used in each trial were recorded. The transdermal and subcuticular continuous sutures were separately compared with interrupted sutures in the subgroup analysis of dehiscence and cosmetic appearance because the visual appearance of these two continuous suturing techniques was significantly different. Ten studies including 1181 participants were analysed. Subcuticular continuous sutures had comparatively higher visual analogue scale (VAS) scores among patients and doctors than interrupted sutures (OR = 0.27, 95% Confidence Intervals [CI] = 0. 07-0.47, P < .01). Similarly, priority was found regarding transdermal continuous sutures and interrupted sutures (OR = 0.40, 95% CI = 0.21-0.60, P < .01). Five randomised controlled trials (RCTs) demonstrated relevant data about dehiscence events. The incidence of continuous suture was significantly lesser than that of interrupted suture (OR = 0.16, 95% CI = 0.07-0.37, P < .01). There was no significant difference between the infection events rates of two suture methods (OR = 0.69, 95% CI = 0.40-1.21, P = .62, I²  = 0%). This systematic review indicated the superiority of both transdermal and subcutaneous continuous sutures over interrupted sutures in skin closure in terms of wound healing and cosmetic appearance.

Strategies to Minimize Surgical Scarring: Translation of Lessons Learned from Bedside to Bench and Back

Significance: An understanding of the physiology of wound healing and scarring is necessary to minimize surgical scar formation. By reducing tension across the healing wound, eliminating excess inflammation and infection, and encouraging perfusion to healing areas, surgeons can support healing and minimize scarring. Recent Advances: Preoperatively, newer techniques focused on incision placement to minimize tension, skin sterilization to minimize infection and inflammation, and control of comorbid factors to promote a healing process with minimal scarring are constantly evolving. Intraoperatively, measures like layered closure, undermining, and tissue expansion can be taken to relieve tension across the healing wound. Appropriate suture technique and selection should be considered, and finally, there are new surgical technologies available to reduce tension across the closure. Postoperatively, the healing process can be supported as proliferation and remodeling take place within the wound. A balance of moisture control, tension reduction, and infection prevention can be achieved with dressings, ointments, and silicone. Vitamins and corticosteroids can also affect the scarring process by modulating the cellular factors involved in healing. Critical Issues: Healing with no or minimal scarring is the ultimate goal of wound healing research. Understanding how mechanical tension, inflammation and infection, and perfusion and hypoxia impact profibrotic pathways allows for the development of therapies that can modulate cytokine response and the wound extracellular microenvironment to reduce fibrosis and scarring. Future Directions: New tension-off loading topical treatments, laser, and dermabrasion devices are under development, and small molecule therapeutics have demonstrated scarless wound healing in animal models, providing a promising new direction for future research aimed to minimize surgical scarring.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

The online version of this article (10.1007/s00595-020-02181-6) contains supplementary material, which is available to authorized users.

Comprehensive literature review of randomized clinical trials examining novel treatment advances in patients with colon cancer

The treatment of colon cancer has had numerous recent advances, in terms of surgical approach, adjuvant therapies, and more. In this review, the authors examine randomized clinical trials comparing open surgery to laparoscopic surgery (including total mesocolic excision), and also examine the role of robotic surgery. Novel surgical techniques including the no-touch technique, side-to-side anastomosis, suture technique, complete mesocolic excision (CME) with central vascular ligation (CVL), and natural orifice transluminal endoscopic surgery (NOTES) are outlined. The role of placing endoscopic self-expandable metal stents (SEMS) for colonic obstruction is compared and contrasted with the surgical approach, and the effect that the anti-VEGF inhibitor bevacizumab may have on this side effect profile is further explored. The role of the resection of the primary tumor in the setting of metastatic disease is examined with respect to survival benefit. Pathways of perioperative care which can accelerate post-surgical recovery, including enhanced recovery after surgery (ERAS) are examined. The role of adjuvant chemotherapy in patients with high-risk stage II and patients with stage III disease is examined, along with the role on circulating tumor DNA (ctDNA) as well as with the biologic targeted agents cetuximab and bevacizumab. Lastly, the authors detail the postoperative surveillance schedules after surgical resection with respect to survival outcomes.

Subcuticular sutures for skin closure in non-obstetric surgery

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Subcuticular interrupted versus continuous skin suturing in elective cesarean section in obese women: a randomized controlled trial

Objective: To compare the interrupted subcuticular skin closure with continuous one in obese women undergoing cesarean delivery.Materials and methods: A randomized controlled study conducted on 169 obese women with term uncomplicated singleton pregnancy who underwent elective cesarean delivery. They were randomized to either skin closure through continuous subcuticular sutures using vicryl 3/0 or interrupted subcuticular suturing using vicryl 3/0. The primary outcome parameter was occurrence of wound infection. Secondary outcomes included other skin complications, postoperative pain, operative duration and hospital stayResults: There was a statistically higher number of cases with wound hematoma (20 vs. 10, p = .04), infection (30 vs. 15, p = .008) and those who needed reclosure of wound (8 vs. 0, p = .004) in the continuous when compared to women in the interrupted subcuticular group, respectively. Healing with secondary intension was significantly higher in women in the continuous subcuticular group (52 vs. 26, respectively, p < .001). The number of cases with wound seroma and keloid formation was not statistically different between the two groups (25 vs. 19, p = .272 and 12 vs. 5, p = .069 in the continuous vs. interrupted groups, respectively). The duration of CS was longer in those who underwent interrupted closure when compared to continuous ones. However, that was statistically insignificant (40.95 + 6.376 vs. 37.05 + 6.455, p = 0.14).Conclusions: Most surgical wound complications were reduced if skin closure with continuous subcuticular sutures is replaced with interrupted one.

A Prospective Comparative Study Between Subcuticular and Sutureless Technique of Skin Closure Following External Dacryocystorhinostomy

PURPOSE

To compare the cosmetic outcome of the surgical scar of external dacryocystorhinostomy by the subcuticular versus sutureless technique.

METHODS

This was a prospective interventional randomized control study conducted at tertiary level hospital. Fifty patients of primary-acquired nasolacrimal duct obstruction were included in this study. The control group patients underwent the technique of wound closure in 2 layers, subcutaneous interrupted suture with 6-0 vicryl and superficial skin with 6-0 prolene continuous subcuticular sutures. In the case group, interrupted subcutaneous sutures with 6-0 vicryl with Steristrip for skin apposition was used. The surgical scars were assessed and graded by still photographs on a computer screen by 2 independent observers unaware of the surgical technique used at 2, 6 and 12 weeks postoperatively.

RESULTS

The mean scar assessment score by the 2 observers were 2.60 (0.57), 2.04 (0.64), and 1.16 (0.89) in control group and 2.02 (0.65), 1.44 (0.70), and 0.44 (0.61) in case group at 2, 6, and 12 weeks, respectively. Scar grades were analyzed using chi-square test between the 2 group and Wilcoxon signed rank test within the group. The difference between the 2 groups were found to be statistically significant at 2, 6, and 12 weeks (P < 0.05). Thus, the technique of wound closure with steristrip lead to comparatively less scarring as compared with subcuticular technique.

CONCLUSION

The authors recommend the sutureless technique of wound closure using steristrip in Ext DCR as it has superior cosmetic results as compared with subcuticular technique of external dacryocystorhinostomy.

Appendectomy Skin Closure Technique, Randomized Controlled Trial: Changing Paradigms (ASC)

BACKGROUND

Appendectomy is the most frequent and urgent gastrointestinal surgery. Overtime, the surgical techniques have been improved upon, in order to reduce complications, get better cosmetic results, and limit the discomfort associated with this procedure, by its high impact in the surgery departments. The traditional skin closure is associated with a poor cosmetic result and it requires stitches removal, alongside the pain associated with this procedure, and no benefits were demonstrated in the literature regarding separated stitches over intradermic stitch. This is a randomized controlled trial, and our objective is to compare two different skin closure techniques in open appendectomy.

METHODS

A prospective randomized trial method was used, with a total number of 208 patients participating in the study, after acute appendicitis diagnosis in the emergency department. They were randomized into two groups: patients who would receive skin closure with a unique absorbable intradermic stitch (Group A) and another group that would receive the traditional closure technique, consistent in non-absorbable separated stitches (Group B). General characteristics like gender, age, Body Mass Index (BMI), comorbidities, and allergies were registered. Days of Evolution (DOE) until surgery, previous use of antibiotics, complicated or uncomplicated appendicitis, surgical time, and wound complications like skin infection, dehiscence, seroma or abscess were also registered in each case.

RESULTS

8 patients were excluded due to negative appendicitis during surgery and lack of follow-up. Two groups, each containing 100 patients, were formed. General characteristics and parity were compared, and no statistically significant differences were observed. Difference in the surgical time (Group A: 47.35 min vs Group B: 54.13 min, p < .001) and cases with complicated appendicitis (Group A: 58 and Group B:38, p = .005) were found to be statistically significant. Four wound complications were reported, and the incidence of seroma (Group A:0 and Group B:5, p = .02) and abscess (Group A:2 and Group B:8, p = .05) were found to have some statistical significant difference. In a multivariate analysis, a relationship was observed between BMI > 25 kg/m² and seroma (p = .006), BMI > 25 kg/m² and abscess (p = .02), surgical time >50 min and seroma (p < .001), >2 DOE and abscess (p = .001), and complicated appendicitis with seroma development (p = .03).

CONCLUSION

Open appendectomy skin closure with a unique absorbable intradermic stitch is safe, with a reduced seroma and abscess incidence, compared to traditional closure, and an equivalent dehiscence and superficial infection incidence, allowing a lower hospital attention cost and length of hospital stay for treatment of complications. The relative risk of complications with traditional skin closure is 2.91 higher, compared to this new technique.

Randomized Clinical Trials in Colon and Rectal Cancer

Surgery remains the mainstay of treatment for colon and rectal cancers. Colon cancer outcomes have improved with laparoscopic techniques, enhanced recovery pathways, and adjuvant chemotherapy. Adjuvant 5-fluorouracil with or without oxaliplatin in stage III and possibly high-risk stage II colon cancer is associated with improved survival. Multimodality management of rectal cancer continues to evolve; total mesorectal excision is the cornerstone. Oncologic results do not support the use of laparoscopic resection in rectal cancer. Preoperative short- or long-course radiation for stage II or III rectal cancer is the standard of care. Long course chemoradiation is recommended for bulky tumors.

Alternatives to antibiotics for prevention of surgical infection

BACKGROUND

Surgical-site infection (SSI) is still the second most common healthcare-associated infection, after respiratory tract infection. SSIs are associated with higher morbidity and mortality rates, and result in enormous healthcare costs. In the past decade, several guidelines have been developed that aim to reduce the incidence of SSI. Unfortunately, there is no consensus amongst the guidelines, and some are already outdated. This review discusses the recent literature regarding alternatives to antibiotics for prevention of SSI.

METHODS

A literature search of PubMed/MEDLINE was performed to retrieve data on the prevention of SSI. The focus was on literature published in the past decade.

RESULTS

Prevention of SSI can be divided into preoperative, perioperative and postoperative measures. Preoperative measures consist of showering, surgical scrubbing and cleansing of the operation area with antiseptics. Perioperative factors can be subdivided as: environmental factors, such as surgical attire; patient-related factors, such as plasma glucose control; and surgical factors, such as the duration and invasiveness of surgery. Postoperative measures consist mainly of wound care.

CONCLUSION

There is a general lack of evidence on the preventive effectiveness of perioperative measures to reduce the incidence of SSI. Most measures are based on common practice and perceived effectiveness. The lack of clinical evidence, together with the stability of the high incidence of SSI (10 per cent for colorectal procedures) in recent decades, highlights the need for future research.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Protective Effect of a Synbiotic against Multidrug-Resistant Acinetobacter baumannii in a Murine Infection Model

This study investigated the ability of the probiotic Bifidobacterium breve strain Yakult (BbY) to protect against infection, as well as the potentiation of BbY activity by the synbiotic combination of BbY and prebiotic galactooligosaccharides (GOS). The study employed a mouse model of lethal intestinal multidrug-resistant Acinetobacter baumannii (MDRAb) infection. The endogenous intestinal microbiota was disrupted by the administration of multiple antibiotics, causing the loss of endogenous Bifidobacterium Oral infection of these mice with MDRAb resulted in marked growth of this organism. Additional treatment of the infected mice with a sublethal dose of 5-fluorouracil (5-FU) induced systemic invasion by MDRAb and subsequent animal death. The continuous oral administration of BbY increased the survival rate and inhibited the intestinal growth and invasion by MDRAb in the infection model. Disruptions of the intestinal environment and barrier function in the infected mice were attenuated by BbY. Protection against the MDRAb infection was markedly potentiated by a synbiotic combination of BbY and GOS, although GOS by itself did not provide protection. Negative correlations were observed between intestinal MDRAb and BbY counts or acetic acid levels; positive correlations were observed between acetic acid levels and intestinal epithelium expression of tight-junction-related genes. These results demonstrated that the probiotic and synbiotic markedly potentiated protection against fatal intestinal infection caused by a multidrug-resistant bacterium. Probiotics and synbiotics are presumed to provide protection by compensation for the disrupted indigenous populations, thereby maintaining the intestinal environments and barrier functions otherwise targeted during opportunistic infection by MDRAb.