Sachin Seth DDS
In a meta-analysis of studies not conducted in an oral environment, 14 randomized controlled trials found sutures were faster to use and better than tissue adhesives for minimizing wound break down (dehiscence).
In patients requiring closure of a surgical skin incision of any length, is there a difference in rates of wound dehiscence between tissue adhesives and conventional sutures?
Four reviewers independently screened the titles and abstracts resulting from an electronic database search with no language restrictions. The review included only randomized controlled trials that evaluated adults and children. Only The authors used only studies comparing surgical tissue adhesives to one another or to alternative conventional closure devices such as sutures, staples or adhesive tapes were used. The primary outcome studied was the proportion of wound breakdown (wound dehiscence). Secondary outcomes included: wound infection, cosmetic appearance, patient satisfaction, surgeon satisfaction, relative material costs and closure time. The authors judged the quality of the studies was judged on the methods of randomization, allocation concealment, blind outcome assessment, and completeness of follow-up.
In a meta-analysis updated from 2004, fourteen 14 articles (N=including 1152) subjects fulfilled the predetermined inclusion criteria. Eleven reported the primary outcome of wound dehiscence. Of these studies, nine were parallel-group design and two were split split-body design. Two trials compared tissue adhesive with adhesive tape. There was an oOverall a significant difference was detected in wounds with dehiscence, favoring closure by sutures (RR 4.29 95% CI 1.45 to 12.73), with no evidence of heterogeneity (I2 = 0). One trial compared tissue adhesive with any other skin closure technique including other adhesives, but was the findings were not statistically significant: (RR 0.55 95% CI 0.13 to 2.38).
Sutures were significantly better than tissue adhesives for minimizing dehiscence.
Source of Funding:
Internal support for the review included University of Manchester, UK.; Renier de Graaf Hospital, Netherlands; The Sahlgrenska Academy at Goteborg University, Sweden. One of the authors was a co-author of one of the included studies which was funded by industry.
Importance and Context:
Traditionally, the primary choice for wound closure has been sutures, ; however, alternatives such as staples, adhesive tapes, and tissue adhesives (i.e. cyanoacrylates) have become popular due tobecause of their perceived ease of placement. Tissue adhesives offer a unique and novel means of wound closure since they may result in equivalent tensile strength, improved esthetics of the scar, and lower infection rates when compared with sutures, adhesive tapes and staples. (1). Another advantage of tissue adhesives is that the patient does not need to be seen for removal at a later date, thereby avoiding wound disruption and potential reactivity. Tissue adhesives have been used in various forms over the past 35 years, being used mainly for superficial lacerations in emergency situations. In dentistry, tissue adhesives are used in periodontal surgery applications including post-gingivectomy and free gingival grafts.(2).
Strengths and Weaknesses of the Systematic Review:
The authors conducted a comprehensive search of multiple electronic databases with no language restrictions. However, they did not search the grey literature, nor address publication bias. This could lead to an overestimation of the treatment effect presented. The inclusion criteria were succinct and clear. They excluded studies of patients with health conditions that might impair wound healing, as well as surgical procedures on high-tension sites such as elbows or knees, the inclusion of which could have inappropriately biased the results.
Strengths and Weaknesses of the Evidence:
Blinding of early outcomes in these types of studies is difficult, if not impossible, as tissue adhesive and suture appearance is obvious. However, blinding is possible for later outcomes (e.g. cosmetic appearance) using an independent observer. There was an attempt at blinding in nine studies. In three studies, blinding was unclear and in one there was no blinding for the primary outcome, but all secondary outcomes were blinded. A quality assessment revealed two studies at a high risk of bias, four at low and five at a moderate risk. Allocation concealment was adequate in five studies, inadequate in five and unclear in one. Only one study had conducted an a priori sample size calculation. Four of the studies had industrial sponsorship, four were independent and three were unclear as to funding.
Implications for Dental Practice:
The studies included in this systematic review were not conducted in an oral environment, so all conclusions with respect to dental practice would be extrapolations . For all comparisons, except sutures, there was no difference in dehiscence rates between adhesive and the comparator. However, in the comparison of adhesive with sutures there was a significant difference favoring sutures for minimizing wound dehiscence. Additionally, the evidence suggests that there is no difference in rates of wound infection after surgical incision closure with tissue adhesives, sutures, staples, and tapes or amongst different tissue adhesives. These results favour using sutures over a tissue adhesive over sutures in minimizing wound dehisencs dehiscence in an extra-oral environment. Further trials should be undertaken to examine tissue adhesives in clinical situations that involve the oral environment.