title: Wound morbidity with staples compared with suture for cesarean skin closure by diabetic status.
abstract: OBJECTIVE
  To determine if the risk of post-cesarean wound morbidity in patients undergoing staple versus suture closure is modified by diabetic status.
  
  
  METHODS
  Secondary analysis of a randomized trial of skin closure with subcuticular 4-0 monocryl suture or surgical staples after cesarean delivery. The primary outcome was a composite of wound disruption or infection within 4-6 weeks. We compared the association between this outcome and skin closure method by diabetic status (also stratified by gestational or pregestational) using the Breslow-Day test for interaction.
  
  
  RESULTS
  Of 350 patients, 179 were randomized to staples and 171 to suture. Of the 67 (19.1%) diabetic patients, 35 were gestational and 32 pregestational. The incidence of composite wound morbidity in non-diabetics was 16.7% for staples and 3.6% for suture (p ≤ 0.001, RR: 4.6, 95% CI: 1.8-11.8); it was 5.7% for staples and 15.6% for sutures in diabetics (p = 0.25, RR: 0.4, 95% CI: 0.1-1.7). The corresponding Breslow-Day p value indicated a significant difference between diabetics and non-diabetics (p = 0.002). Stratified further by gestational and pregestational diabetes, the RRs were 0.3 (95% CI: 0.03-2.4) and 0.5 (95% CI: 0.05-5.0) compared to non-diabetics, respectively. Each diabetic sub-group was significantly different from non-diabetics (Breslow-Day p values for homogeneity p = 0.005 and p = 0.045, respectively).
  
  
  CONCLUSIONS
  The use of staples compared with subcuticular suture for cesarean skin closure is associated with increased wound morbidity. While this is true for non-diabetics, further studies of diabetics are needed to evaluate for a null or opposite effect of closure type.
authors.affiliation: a Department of Obstetrics and Gynecology , Center for Women's Reproductive Health, University of Alabama at Birmingham , Birmingham , AL , USA.
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Fitzwater
authors.affiliation: a Department of Obstetrics and Gynecology , Center for Women's Reproductive Health, University of Alabama at Birmingham , Birmingham , AL , USA.
authors.forename: Victoria C
authors.initials: VC
authors.lastname: Jauk
authors.affiliation: a Department of Obstetrics and Gynecology , Center for Women's Reproductive Health, University of Alabama at Birmingham , Birmingham , AL , USA.
authors.forename: Dana
authors.initials: D
authors.lastname: Figueroa
authors.affiliation: a Department of Obstetrics and Gynecology , Center for Women's Reproductive Health, University of Alabama at Birmingham , Birmingham , AL , USA.
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Biggio
authors.affiliation: a Department of Obstetrics and Gynecology , Center for Women's Reproductive Health, University of Alabama at Birmingham , Birmingham , AL , USA.
authors.forename: William W
authors.initials: WW
authors.lastname: Andrews
authors.affiliation: a Department of Obstetrics and Gynecology , Center for Women's Reproductive Health, University of Alabama at Birmingham , Birmingham , AL , USA.
authors.forename: Alan T N
authors.initials: AT
authors.lastname: Tita
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000379:methods*; D016640:Diabetes, Gestational; D005260:Female; D006801:Humans; D011247:Pregnancy; D013529:Surgical Wound Dehiscence / Q000209:etiology*; D013530:Surgical Wound Infection / Q000209:etiology*; D013537:Sutures / Q000009:adverse effects*; D055815:Young Adult
keywords: Cesarean delivery; diabetes mellitus; gestational diabetes; wound disruption