title: Tissue adhesives for closure of surgical incisions.
abstract: BACKGROUND
  Sutures (stitches), staples and adhesive tapes have been used for many years as methods of wound closure, but tissue adhesives have entered clinical practice more recently. Closure of wounds with sutures enables the closure to be meticulous, but the sutures may show tissue reactivity and can require removal. Tissue adhesives offer the advantages of an absence of risk of needlestick injury and no requirement to remove sutures later. Initially, tissue adhesives were used primarily in emergency room settings, but this review looks at the use of tissue adhesives in the operating room/theatre where surgeons are using them increasingly for the closure of surgical skin incisions.
  
  
  OBJECTIVE
  To determine the effects of various tissue adhesives compared with conventional skin closure techniques for the closure of surgical wounds.
  
  
  METHODS
  In March 2014 for this second update we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting.
  
  
  METHODS
  Only randomised controlled trials were eligible for inclusion.
  
  
  METHODS
  We conducted screening of eligible studies, data extraction and risk of bias assessment independently and in duplicate. We expressed results as random-effects models using mean difference for continuous outcomes and risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes. We investigated heterogeneity, including both clinical and methodological factors.
  
  
  RESULTS
  This second update of the review identified 19 additional eligible trials resulting in a total of 33 studies (2793 participants) that met the inclusion criteria. There was low quality evidence that sutures were significantly better than tissue adhesives for reducing the risk of wound breakdown (dehiscence; RR 3.35; 95% CI 1.53 to 7.33; 10 trials, 736 participants that contributed data to the meta-analysis). The number needed to treat for an additional harmful outcome was calculated as 43. For all other outcomes - infection, patient and operator satisfaction and cost - there was no evidence of a difference for either sutures or tissue adhesives. No evidence of differences was found between tissue adhesives and tapes for minimising dehiscence, infection, patients' assessment of cosmetic appearance, patient satisfaction or surgeon satisfaction. However there was evidence in favour of using tape for surgeons' assessment of cosmetic appearance (mean difference (VAS 0 to 100) 9.56 (95% CI 4.74 to 14.37; 2 trials, 139 participants). 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. There appeared to be little difference in outcome for different types of tissue adhesives. One study that compared high viscosity with low viscosity adhesives found that high viscosity adhesives were less time-consuming to use than low viscosity tissue adhesives, but the time difference was small.
  
  
  CONCLUSIONS
  Sutures are significantly better than tissue adhesives for minimising dehiscence. In some cases tissue adhesives may be quicker to apply than sutures. Although surgeons may consider the use of tissue adhesives as an alternative to other methods of surgical site closure in the operating theatre, they need to be aware that sutures minimise dehiscence. There is a need for more well designed randomised controlled trials comparing tissue adhesives with alternative methods of closure. These trials should include people whose health may interfere with wound healing and surgical sites of high tension.
authors.affiliation: School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK, M13 9PL.
authors.forename: Jo C
authors.initials: JC
authors.lastname: Dumville
authors.forename: Paul
authors.initials: P
authors.lastname: Coulthard
authors.forename: Helen V
authors.initials: HV
authors.lastname: Worthington
authors.forename: Philip
authors.initials: P
authors.lastname: Riley
authors.forename: Neil
authors.initials: N
authors.lastname: Patel
authors.forename: James
authors.initials: J
authors.lastname: Darcey
authors.forename: Marco
authors.initials: M
authors.lastname: Esposito
authors.forename: Maarten
authors.initials: M
authors.lastname: van der Elst
authors.forename: Oscar J F
authors.initials: OJ
authors.lastname: van Waes
mesh_terms: 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
chemical_list: D003487:Cyanoacrylates; D014014:Tissue Adhesives; D004659:Enbucrilate