Pediatric sutureless circumcision: an effective and cost efficient alternative

INTRODUCTION

Circumcision is the most commonly performed surgical procedures in male children. Maine is one of 18 states in the United States which does not pay for neonatal circumcisions. The aim of this study was to perform outcomes and cost analysis of a sutureless circumcision technique versus circumcision using sutures. Specifically, we evaluated Dermaflex (2-octyl cyanoacrylate, 2-OCA) surgical glue circumcision as a cost effective, faster, and safe alternative to traditional suture circumcision.

MATERIALS AND METHODS

Our study was a non-randomized series. We collected the operative details prospectively, abstracted clinical outcomes retrospectively, and performed data analysis retrospectively. One hundred and twenty-six circumcisions were performed by two pediatric urologists over a 1 year period. Suture circumcisions were performed exclusively during the first 6 months, and 2-OCA glue circumcisions were performed during the second 6 months. Billing charges were analyzed to extrapolate variable costs between the two surgical procedures. The technique used to perform the sutureless circumcision was a modification of the standard sleeve technique, with the use of monopolar diathermy instead of scalpel, and application of 2-OCA glue to approximate tissue edges.

RESULTS

From Jan 2013 to Jan 2014, 72 patients underwent circumcision with suture, and 54 patients underwent circumcision with 2-OCA glue. Mean age in the glue group was 61 months (range 8-202 months), and 50 months in the suture group (range 5-215 months), p = 0.19. All cases were performed under general anesthesia, as outpatient surgery. Mean operative cut time was 18.4 min for the glue group, and 28.6 min for the suture group (p < 0.01). The 10.2 min operative time difference translated to a $378 cost savings per glue circumcision case. Complication rates were not statistically significant between the two groups.

CONCLUSION

The use of 2-OCA tissue adhesive for sutureless circumcision is an alternative to the standard technique. It results in faster operative times, with a significant cost savings, while maintaining comparable complication rates to the standard suture technique. This is a viable, less expensive surgical option for patients whose circumcisions are not covered by Medicaid.

The use of "2-octyl cyanoacrylate" as skin adhesive in pediatric and congenital cardiac surgery

AIM

The aim of this paper was to evaluate the safety and cost-effectiveness of "2-octyl-cyanoacrylate" as skin adhesive in congenital heart surgery.

METHODS

From April 2010 to December 2011, we collected data from 300 patients who underwent cardiac surgery for congenital heart disease. We divided our population into 3 groups: group-1 (N.=100):"2-octyl-cyanoacrylate" has been used to replace the intra-dermal suture line; group-2 (N.=100):"2-octyl-cyanoacrylate" has been utilized as a barrier ("add-on measure") in addition to the intra-dermal suture line, group-3 (N.=100) with a standard intra-dermal suture line.

RESULTS

Median age of patients was 1.36 years. One-hundred and thirty-nine patients were younger than 12 months and 56 older than 16 years. There were 11 wound dehiscence (3.6%) (2 in group-1 and 9 in group-3, P=0.001) and 1 superficial wound infection (group-1). Six patients (2%) required surgical wound revision (2 in group-1 and 4 in group-3, P=NS). Wound complication was significantly associated to delayed sternal closure (3/12 patients, 25% versus 13/288 patients, 4.5%) (P=0.04). Median cost (intra-/postoperative) for wound treatment was lower in group-1 and 2 (19±5.5 and 23.9±7.4 € respectively) when compared to Group-3 (26.7±3.2) (P<0.0001).

CONCLUSION

The use of "2-octyl-cyanoacrylate" proved to be safe and effective; the "add-on measure" strategy provided the best cost-effective solution.

A prospective, randomized, controlled clinical trial of tissue adhesive (2-octylcyanoacrylate) versus standard wound closure in breast surgery

BACKGROUND

Recent studies suggest that the use of tissue adhesive for closure of both traumatic lacerations and incisional surgical wounds leads to cosmetic outcome comparable to conventional sutures. To date, no studies have investigated tissue adhesive in breast surgery and costs. Our aim was to compare the tissue adhesive 2-octylcyanoacrylate (OCA) with standard suture in breast surgery.

METHODS

A prospective randomized study was conducted in which 151 patients were assessed for eligibility, and 133 were randomly allocated to skin closure with OCA adhesive or monofilament suture. Cosmetic outcome with blinded assessment, wound management by the patients, complication rates, and economic outcome were recorded.

RESULTS

There was no difference in cosmetic score in the 2 groups, nor in complications at the early, 6-month, and 1-year follow-up. Patient satisfaction with the wound closed with OCA was rated significantly higher when compared with standard suture (P <.0001). The application of the tissue adhesive was significantly faster than that for standard suture (P <.001). In economic terms total costs were less in the tissue adhesive group, mainly due to lower postoperative costs of physician and assistant services (P <.001).

CONCLUSIONS

OCA is effective and reliable in skin closure for breast surgery, yielding similar cosmetic results to standard suture. OCA is faster than standard wound closure and offers several practical advantages over suture repair for patients. Cost analysis has found that OCA adhesive can significantly decrease health care costs.

N-2-butyl-cyanoacrylate for bleeding gastric varices: a United States pilot study and cost analysis

OBJECTIVES

N-butyl-2-cyanoacrylate has been reported to be effective for bleeding varices but is not available in the United States. We report the initial US experience with cyanoacrylate in this prospective trial and evaluate its safety, efficacy, and relative costs.

METHODS

Patients with active or recent gastric variceal bleeding were eligible. Cyanoacrylate therapy was performed until variceal occlusion was achieved. Rebleeding was assessed at 72 h (acute phase), 6 wk (subacute phase), and 1 yr (chronic phase). Survival was assessed at 3 months and 1 yr. Cost analysis was performed comparing the first 17 patients to historical control patients not treated with cyanoacrylate.

RESULTS

A total of 44 patients were enrolled, 37 with cirrhosis and seven with noncirrhotic portal hypertension (NCPH). In cirrhotic patients, rebleeding was seen in two of 37 (5%) at 72 h, one of 30 (3%) at 6 wk, and five of 28 (18%) at 1 yr. Survival without shunt at 3 months was 30 of 34 (88%) and at 1 yr was 24 of 31 (77%). In NCPH patients, rebleeding was seen in two of seven (29%) at 72 h. These patients received definitive therapy for NCPH after diagnosis. Mortality and costs were substantially higher in the non-cyanoacrylate group. The odds of death were greater by 7-fold in the non-cyanoacrylate group than within the cyanoacrylate group (95% CI = 1.18-41.36, p = 0.0318). At 3 months, there was a 3.18-fold difference (95% CI = 1.05-9.64, p = 0.0411) in accrued costs; at 1 yr, the difference was 2.55-fold (95% CI = 0.96-6.94, p = 0.0585). The cost-effective ratio was estimated as 108,237 US dollars/death averted, reflecting marked cost reduction with improved survival in the cyanoacrylate-treated group. This is believed to result largely from avoidance of shunt interventions.

CONCLUSIONS

Cyanoacrylate treatment of gastric varices is safe, clinically effective, and cost effective.

Prospective randomized trial of skin adhesive versus sutures for closure of 217 laparoscopic port-site incisions

BACKGROUND

The purpose of this study is to determine whether closure of laparoscopic port-site incisions using octylcyanoacrylate (OCA) is feasible, whether it is faster than traditional subcuticular suturing, whether the number and length of incisions impact on closure time, and to determine wound morbidity and patient satisfaction outcomes.

STUDY DESIGN

A prospective randomized trial was performed on adult patients scheduled for elective laparoscopic surgery in three surgical specialties at a tertiary referral center. Patients were randomized to have closure of laparoscopic port sites using either OCA or sutures. Patients were followed up 2 to 3 weeks postoperatively. At 2 months patients were mailed a questionnaire regarding their satisfaction with the method of closure and the appearance of their scars.

RESULTS

A total of 175 incisions in 50 patients were closed with OCA, and 142 incisions in 42 patients were closed with subcuticular sutures. Time to close was significantly faster for OCA (median 2.5 minutes versus 6 minutes, p < 0.001). OCA was faster than traditional subcuticular suturing for cases involving three or more port sites (median 2.5 minutes versus 6 minutes, p < 0.001), and for cases with total length of incisions >4 cm (median 2.6 minutes versus 7 minutes, p < 0.001). OCA and subcuticular suturing groups did not differ significantly on patient acceptance or assessment of scars.

CONCLUSIONS

Closure of laparoscopic port-site incisions is feasible with OCA. Closure with OCA requires significantly less operative time than subcuticular suturing, particularly in cases when three or more port sites are used or when total incision length is greater than 4 cm. OCA appears to have equivalent adverse wound outcomes and patient acceptance rates as subcuticular suturing.

Randomized study of the effectiveness of closing laparoscopic trocar wounds with octylcyanoacrylate, adhesive papertape or poliglecaprone

BACKGROUND

Several methods for skin closure are used, i.e. sutures, adhesive papertape and tissue adhesives. Little is known about the efficacy of these techniques in laparoscopic surgery. This study was performed to analyse the efficacy of octylcyanoacrylate, a new tissue adhesive, adhesive papertape and poliglecaprone for wound closure in laparoscopy.

METHODS

From May 2000 to September 2001, 140 patients were included in a prospective randomized trial. Wounds were closed with octylcyanoacrylate (n = 48), adhesive papertape (n = 42) or poliglecaprone (n = 50). Closing time, wound infection, cosmetic results and costs were evaluated. A time-motion analysis was also performed.

RESULTS

The patients in the three groups were well matched for age, gender and body mass index. Closing times per wound were 26, 33 and 65 s respectively for adhesive papertape, octylcyanoacrylate and poliglecaprone (P < 0.001). Cosmetic results, as scored by the patients, were no different. The number of actions required to close each wound was 5.7, 8.3 and 21.0 for octylcyanoacrylate, adhesive papertape (P = 0.05 versus octylcyanoacrylate) and poliglecaprone (P < 0.01 versus octylcyanoacrylate and adhesive papertape) respectively. Octylcyanoacrylate was significantly more expensive than poliglecaprone and adhesive papertape.

CONCLUSION

Closure with adhesive papertape was the fastest method. The smallest number of actions required to close a wound was with octylcyanoacrylate. Adhesive papertape was the most cost-effective.

Biological tissue adhesive for multiple use in the accident and emergency department

OBJECTIVE

To assess the strength of the glue and microbial contamination over 28 days from opening a vial of tissue adhesive in the accident and emergency setting, and to quantify cost savings of repeated use of the vials.

METHOD

(1) Strips of reinforced nylon and a specially constructed piece of apparatus designed to measure the force at which the glue gave way were used to measure the strength of the tissue adhesive at various times after the glue was opened to assess if the glue strength deteriorated over time. (2) Microbial contamination of the glue was assessed.

RESULTS

There was no deterioration in the glue strength over time. There was no evidence of microbial contamination of the glue.

CONCLUSION

Cyanoacrylate tissue adhesive can safely be reused for a period of 28 days after opening with no risk of degradation of glue strength or contamination with micro-organisms. In our department this represents a potential saving of ł5400 per year.