A combination of subcuticular suture and enhanced recovery after surgery reduces wound complications in patients undergoing hepatectomy for hepatocellular carcinoma

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).

The Origin and Development of Interrupted Subcuticular Suture: An Important Technique for Achieving Optimum Wound Closure

BACKGROUND

Subcuticular suture is an important technique for achieving optimum wound closure, and there has been no comprehensive summary of subcuticular sutures to date.

OBJECTIVE

To summarize the origin and development of interrupted subcuticular suture to help clinicians improve their wound closure skills.

MATERIALS AND METHODS

A comprehensive review of subcuticular suture techniques was conducted in PubMed to summarize the advantages and disadvantages of various methods and clinical indications.

RESULTS

Buried suture is the oldest subcuticular suture technique, followed by buried vertical mattress suture, intracutaneous butterfly suture, modified/variant buried vertical mattress suture, intradermal buried vertical mattress suture, buried horizontal mattress suture, wedge-section and modified buried vertical mattress suture, set-back suture, and modified buried horizontal mattress suture, which have gradually been applied in clinical practice. Buried vertical mattress suture is currently the most widely used subcuticular suture technique.

CONCLUSION

Patients can certainly benefit from the appropriate application of subcuticular suture. There is also no single ideal method for achieving optimal results in all cases. Fully understanding the history of subcuticular suture can help doctors improve their wound closure technique.

Comparison of Two Malnutrition Assessment Scales in Predicting Postoperative Complications in Elderly Patients Undergoing Noncardiac Surgery

Background: The present study was designed to investigate the relationship between two malnutrition assessment scales, perioperative nutrition screen (PONS) and Nutritional Risk Screening 2002 (NRS2002), with postoperative complications in elderly patients after noncardiac surgery.

Methods: This was a secondary analysis of a prospective cohort study. Elderly patients (65–90 years) undergoing noncardiac surgery were enrolled in Peking University First Hospital. Malnutrition was screened by PONS and NRS2002 at the day before surgery. Multivariable analysis was employed to analyze the relationship between PONS and NRS2002 and postoperative 30-day complications. Receiver operating characteristic (ROC) curve was generated to evaluate the predictive value of PONS and NRS2002 in predicting postoperative complications.

Results: A total of 915 patients with mean age of 71.6 ± 5.2 years were consecutively enrolled from September 21, 2017, to April 10, 2019. The incidence of malnutrition was 27.3% (250/915) by PONS ≥ 1 and 53.6% (490/915) by NRS2002 ≥ 3. The overall incidence of complications within postoperative 30 days was 45.8% (419/915). After confounders were adjusted, malnutrition by PONS ≥ 1 (OR 2.308, 95% CI 1.676–3.178, P < 0.001), but not NRS2002 ≥ 3 (OR 1.313, 95% CI 0.973–1.771, P = 0.075), was related with an increased risk of postoperative complications. ROC curve analysis showed that the performances of PONS [area under the ROC curve (AUC) 0.595, 95% CI 0.558–0.633] showed very weak improvement in predicting postoperative complications than NRS2002 score (AUC 0.577, 95% CI 0.540–0.614).

Conclusion: The present study found that malnutrition diagnosed by PONS was related with an increased risk of postoperative complications. The performances of PONS and NRS2002 were poor in predicting overall postoperative complications.

Clinical Trial Registration:www.chictr.org.cn, identifier: ChiCTR-OOC-17012734.

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

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

Patient-reported recovery in upper abdominal cancer surgery care: A prospective study

The study aimed to describe and analyse patient-reported recovery in patients after upper abdominal cancer surgery. This study had a quantitative design and patients were consecutively included in a university hospital in southern Sweden. Twenty-four patients answered the Postoperative Recovery Profile (PRP) questionnaire at three measurement points. All five dimensions were affected. In the physical symptoms dimension, the majority of patients reported a lack of energy upon discharge. High levels of anxiety were reported. Over 50% of patients reported some degree of depressed mood at all three measurement points. In the social dimension, the majority of patients reported some degree of being dependent on help from others in everyday life at 4 weeks after discharge. Few patients are fully recovered at 4 weeks after discharge. Individual patient-reported recovery estimates may be valuable in identifying and planning interventions tailored to each patient's needs throughout the care process.

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.