Grand Rounds

Paper of the week

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Subcuticular sutures versus staples for skin closure after open gastrointestinal surgery: a phase 3, multicentre, open-

label, randomised controlled trial

Tsujinaka et al, The Lancet 28 September-04 October, 2013

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Introduction-1

• Post op wound complications are common problem

• Sub-cuticular suture (SCS) is an attractive way of skin closure in most types of surgery

• Many ASA class 1 (clean surgery) studies with SCS found– Low wound complications– Good cosmetic appearance

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Introduction-2

• However in ASA class 2 (clean-contaminated) wounds the usefulness of one over the other is not know

• Staples are preferred – Convenience of use– Speed of use

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Study aims

• To investigate differences in prevention of wound complications between sub-cuticular sutures and staples after elective upper and lower gastrointestinal open surgery

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The Fight

Vs

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Study design-1

• Large-scale multi-centre phase 3 randomised control trial

• B/t June 1, 2009 and Feb 28, 2012• Superiority trial

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Study design-2

• Inclusion criteria– Pt undergoing Upper or lower GI surgery– Age >20– Adequate organ function

• Exclusion criteria (among others)– Emergency or laparoscopic surgery– Pervious history of midline incision– Long term corticosteroids use– Active infections– Uncontrolled DM

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Study arms

• Subcuticular suture group – Interrupted subcuticular sutures with 3-0 or 4-0 monofilament

absorbable suture – The interval of the sucuticular sutures was 15–25 mm and the

length of the bite of sutures was 15–25 mm from the edge of the skin.

– ± Use of sterile strips or skin glue for epidermal approximation (an institutional choice)

• Staples group – Metallic skin staples, which were the choice of individual

institutions, 10–15 mm apart were used. – Before the trial, investigators from participating institutions were

instructed on how to do subcuticular sutures during the trial

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Randomisation

• Randomisation by a computer-generated permuted-block sequence

• Patients were randomly assigned (1:1) to either subcuticular sutures or staples arms and

• Balanced according to institution, sex, and type of surgery (ie. upper or lower gastrointestinal open surgery)

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Study outcomes

• Primary outcome – Incidence of wound complications within 30

days of surgery. • Secondary outcome

– Incidence of hypertrophic scar formation 6 months after surgery

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Results-2Types of diseases and surgical procedures in patients undergoing

upper gastrointestinal surgery  Subcuticular sutures (n=385) Staples (n=417)

Diseases    

Gastric cancer 375 (97.4%) 403 (96.6%)

Gastric submucosal tumour 6 (1.6%) 9 (2.2%)

Other 4 (1.0%) 5 (1.2%)

Procedures    

Total gastrectomy 149 (38.7%) 143 (34.3%)

Distal gastrectomy 186 (48.3%) 219 (52.5%)

Proximal gastrectomy 19 (4.9%) 16 (3.8%)

Exploratory laparotomy 4 (1.0%) 4 (1.0%)

Other 27 (7.0%) 35 (8.4%)13

Results-3Types of diseases and surgical procedures in patients undergoing

lower gastrointestinal surgery

  Subcuticular sutures (n=177) Staples (n=101)

Diseases    

Colon cancer 98 (55.4%) 51 (50.5%)

Rectal cancer 71 (40.1%) 48 (47.5%)

Anal cancer 2 (1.1%) 1 (1.0%)

Other 6 (3.4%) 1 (1.0%)

Procedures    

Right hemicolectomy 41 (23.2%) 28 (27.7%)

Left hemicolectomy 44 (24.9%) 8 (7.9%)

Low anterior resection 61 (34.5%) 38 (37.6%)

Abdominoperineal resecti 11 (6.2%) 10 (9.9%)

Partial resection of colon 9 (5.1%) 10 (9.9%)

Other 11 (6.2%) 7 (6.9%) 14

Results-4  All patients

 Subcuticular suture

(n=558)Staples (n=514)

Odds ratio (95% CI) p

Primary outcome        

Wound complication rate* 47 (8.4%) 59 (11.5%) 0.7 (0.4-1.0) 0.12

Component outcomes        

Surgical site infection (superficial incisional) 36 (6.4%) 36 (7.0%) 0.9 (0.5-1.5) 0.81

Non-surgical-site infection 11 (2.0%) 23 (4.5%) 0.4 (0.1-0.9) 0.02

Wound separation 3 (0.5%) 8 (1.6%) 0.3 (0.0-1.4) 0.13

Seroma 5 (0.9%) 12 (2.3%) 0.3 (0.1-1.1) 0.09

Haematoma 1 (0.2%) 2 (0.4%) 0.4 (0.0-8.9) 0.61

Other 2 (0.4%) 1 (0.2%) 1.8 (0.0-1.3) 115

Results-5  Upper gastrointestinal surgery

 

Subcuticular sutures (n=176)

Staples (n=101)

Odds ratio (95% CI) p

Primary outcome        

Wound complication rate* 18 (10.2%) 20 (19.8%) 0.4 (0.2-0.9) 0.03

Component outcomes        

Surgical site infection (superficial incisional) 13 (7.4%) 16 (15.8%) 0.4 (0.1-0.9) 0.03

Non-surgical-site infection 5 (2.8%) 4 (4.0%) 0.7 (0.1-3.6) 0.73

Wound separation 2 (1.1%) 2 (2.0%) 0.5 (0.0-7.9) 0.62

Seroma 2 (1.1%) 1 (1.0%) 1.1 (0.0-1.4) 1

Haematoma 1 (0.6%) 1 (1.0%) 0.5 (0.0-4.3) 1

Other 0 (0.0%) 0 (0.0%) .. ..16

Results-6  Lower gastrointestinal surgery

 

Subcuticular sutures (n=382)

Staples (n=413)

Odds ratio (95% CI) p

Primary outcome        

Wound complication rate* 29 (7.6%) 39 (9.4%) 0.7 (0.4-1.3) 0.38

Component outcomes        

Surgical site infection (superficial incisional) 23 (6.0%) 20 (4.8%) 1.2 (0.6-2.4) 0.53

Non-surgical-site infection 6 (1.6%) 19 (4.6%) 0.3 (0.1-0.8) 0.01

Wound separation 1 (0.3%) 6 (1.5%) 0.1 (0.0-1.4) 0.13

Seroma 3 (0.8%) 11 (2.7%) 0.2 (0.0-1.1) 0.06

Haematoma 0 (0.0%) 1 (0.2%) .. ..

Other 2 (0.5%) 1 (0.2%) 2.1 (0.1-1.1) 0.6117

Results-7Secondary outcomes in the modified intention-to-treat population

Hypertrophic scar formation n Odds ratio (95% CI) p

All patients   0.7 (0.5-0.9) 0.04

Subcuticular sutures 558 93 (16.7%)  

Staples 514 111 (21.6%)  

Upper gastrointestinal   0.6 (0.4-0.9) 0.02

Subcuticular sutures 382 66 (17.3%)  

Staples 413 98 (23.7%)  

Lower gastrointestinal   1.2 (0.5-2.7) 0.72

Subcuticular sutures 176 27 (15.3%)  

Staples 101 13 (12.9%)  

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Discussion 1

• Strengths– Level 1 evidence (RCT)– Simple methodology– Large study and long duration– Surgeon well trained to put suture/staples– Information about surgery at upper vs lower

GI– Cant be double/single blinded

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Discussion 2

• Weakness– No data on number of patients approached or

assessed for eligibility– Third arm with skin glue could be used– Did not include hepatobiliary or pancreatic

surgery – No data on duration of surgery, patients'

satisfaction, patients' preference

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Conclusions

• Unlike in ASA class 1 surgery this trial failed to prove subcuticular sutures were a new standard procedure for skin closure after gastrointestinal surgery;

• The formation of hypertrophic scars was significantly reduced with subcuticular sutures compared with staples

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Take home message Like/Unlike

Suture Staples

Wound complication

Overall

Upper

Lower

Scar formation

Overall

Upper

Lower 22

Future??

Upper GI

Lower GI

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Thank you

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