Tissue adhesives for closure of surgical incisions.
BACKGROUND
Sutures, staples and adhesive tapes are the traditional methods of wound closure, whilst tissue adhesives have entered clinical practice more recently. Closure of wounds with sutures enables meticulous closure, but they may show tissue reactivity and can require removal. Tissue adhesives offer the advantages of no risk of needlestick injury and no requirement to remove sutures later. Tissue adhesives have been used primarily in emergency rooms but this review looks at the use of tissue adhesives in the operating room where surgeons are increasingly using these for the closure of surgical skin incisions.


OBJECTIVE
To determine the relative effects of various tissue adhesives and conventional skin closure techniques on the healing of surgical wounds.


METHODS
For this update we searched the Cochrane Wounds Group Specialised Register (Searched 17/11/09); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4 2009; Ovid MEDLINE - 1950 to November Week 1 2009; Ovid EMBASE - 1980 to 2009 Week 46; EBSCO CINAHL - 1982 to 17 November 20098. No date or language restrictions were applied.


METHODS
Only randomised controlled clinical trials were eligible for inclusion.


METHODS
Screening of eligible studies and data extraction were conducted independently and in triplicate whilst assessment of the methodological quality of the trials was conducted independently and in duplicate. Results were expressed as random effects models using mean difference for continuous outcomes and relative risks with 95% confidence intervals for dichotomous outcomes. Heterogeneity was investigated including both clinical and methodological factors.


RESULTS
This update identified an additional six trials resulting in a total of fourteen RCTs (1152 patients) which met the inclusion criteria. Sutures were significantly better than tissue adhesives for minimising dehiscence (10 trials). Sutures were also found to be significantly faster to use. For all other analyses of infection, patient and operator satisfaction and cost there was no significant difference between sutures and tissue adhesives. No differences were found between tissue adhesives and tapes (2 trials) for minimising dehiscence, infection, patients assessment of cosmetic appearance, patient satisfaction or surgeon satisfaction. However a statistically significant difference in favour of using tape was found for surgeons' assessment of cosmetic appearance (mean difference 13, 95% CI 5 to 21). Tapes were also demonstrated to be significantly faster to use than tissue adhesives as were staples (1 trial). No other outcome measures were analysed in this group. 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. In this same trial tissue adhesives were significantly less time consuming to use. For the remaining outcomes of dehiscence and infection no difference was observed between groups. This trial also compared high viscosity with low viscosity adhesives and found that high viscosity adhesives were less time consuming to use than low viscosity tissue adhesives. For all other outcomes of dehiscence, infection, patient satisfaction and operator satisfaction there was no statistically significant difference between high and low viscosity adhesives.


CONCLUSIONS
Sutures were significantly better than tissue adhesives for minimising dehiscence and were found to be significantly faster to use. Although surgeons may consider the use of tissue adhesives as an alternative to other methods of surgical site closure in the operating theatre they must be aware that adhesives may take more time to apply and that if higher tension is needed upon an incision, sutures may minimise dehiscence. There is a need for more well designed randomised controlled trials comparing tissue adhesives and alternative methods of closure. These trials should include people whose health may interfere with wound healing and surgical sites of high tension.
Coulthard
Paul
P
Department of Oral and Maxillofacial Surgery, School of Dentistry, The University of Manchester, Higher Cambridge Street, Manchester, UK, M15 6FH.
Esposito
Marco
M
Worthington
Helen V
HV
van der Elst
Maarten
M
van Waes
Oscar J F
OJ
Darcey
James
J
D001458:Bandages; D003487:Cyanoacrylates; D004659:Enbucrilate; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D013514:Surgical Procedures, Operative; D013529:Surgical Wound Dehiscence / Q000517:prevention & control*; D013530:Surgical Wound Infection / Q000175:diagnosis; D013537:Sutures; D014014:Tissue Adhesives; D014945:Wound Healing
D003487:Cyanoacrylates; D014014:Tissue Adhesives; D004659:Enbucrilate