Subcuticular sutures following elective hepatobiliary surgery may reduce site infections

1. The use of subcuticular sutures following elective hepatobiliary surgery could reduce the incidence of surgical-site infection compared to skin staples, although this finding was not statistically significant.

Evidence Rating Level: 1 (Excellent)

Study Rundown:  Despite advancements in surgical techniques and novel medications, surgical-site infections within 30 days after surgery continue to be prevalent. A significant portion of these infections stem from abdominal surgeries such as hepatobiliary and pancreatic surgery. Numerous studies have compared infection outcomes between subcuticular sutures and skin staples within various surgical contexts. However, literature in this area specific to elective hepatobiliary and pancreatic surgery continues to be scarce. This randomized controlled study aimed to investigate whether subcuticular suture skin closure compared to regular staples can reduce surgical-site infection in patients undergoing hepatobiliary surgery. A total of 346 participants planned to undergo elective hepatobiliary surgery without the presence of intraabdominal infection prior to surgery were included. Participants were randomly assigned to receive either skin staples for dermal closure, or a subcuticular suture performing a continuous intradermal suture with absorbable monofilament material. The primary outcome assessed in this study was the incidence of surgical-site infection within 30 days post-operatively and involves only skin and tissue at the site of the incision. To be defined as a surgical-site infection, the patient must have either localized pain or tenderness, localized swelling or erythema, and the diagnosis of a superficial surgical-site infection by a trained physician. The results of this study showed that participants belonging to the subcuticular suture group experienced a decrease in surgical-site infection incidence compared to the control group, though this was not a statistically significant finding. While this study does support the use of subcuticular sutures following elective hepatobiliary surgery, more research is required to confirm these results.

Click here to read this study in BMC Surgery.

Relevant Reading: Risk factors for surgical site infection after major hepatobiliary and pancreatic surgery

In-Depth [randomized controlled trial]: The present study used data from adult participants who were planned to undergo elective hepatobiliary surgery without pre-existing intraabdominal infection and did not require an urgent surgery. No restrictions regarding surgical interventions were employed and patients requiring repeat interventions were excluded from the final analyses. Participants were randomly assigned to either the subcuticular suture group or the skin staples group which was the control. Skin staples were used for dermal closure in the control group, and the intervention group used an absorbable monofilament material to perform a continuous intradermal suture. The primary outcome that was assessed in this study was the incidence of surgical-site infection within 30 days of the surgery and involving only the subcutaneous tissue near the incision site. Patients must also have had localized pain or tenderness near the incision site, in addition to swelling and erythema, and required an official diagnosis by a trained physician. Subgroup analyses for outcomes in major hepatic resection, pancreatic resection, bilioenteric reconstruction, and between open versus laparoscopic approaches were performed. Statistical analyses included a single variable Cox proportional hazard model. The results of this study showed that participants belonging to the intervention group experienced a decreased incidence of surgical-site intervention compared to the control group (8 events versus 17 episodes, respectively). These differences between the control and intervention group were not statistically significant. Absolute relative risk reduction was calculated to be 5.2% (95%CI 0.2-10.6%). Of note, the mean time until diagnosis of surgical-site infection was 9.62 days for both groups (95%CI 8.41-11.43). In patients who experienced infection, common organisms were Escherichia coli, Enterococcus faecalis, and Pseudomonas aeruginosa. This study ultimately concludes that the use of subcuticular sutures following elective hepatobiliary surgery could improve surgical infection outcomes post-operatively, but as these results were not statistically significant, more research into this topic is required to make appropriate clinical suggestions. There are several limitations in this study that should be noted, to improve future methodologies. For instance, while this study did consider differences between laparoscopic and open surgeries in its subgroup analyses, the actual surgical procedures employed, and the sizes of the incisions were not taken into consideration. Additionally, a small subset of the study’s participants required antibiotics for infections post-operatively that were not at the surgical site, which may confound these results. As well, subcuticular sutures may present an additional cost and time barrier compared to skin staples, which was not taken into consideration. Nevertheless, future studies investigating the use of subcuticular sutures in improving surgical site infections should be conducted, taking these limitations into consideration.

Image: PD

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