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Journal Club Department of Surgery Prince of Wales Hospital

Wound Closure Technique and Acute Wound Complication in Gastric Surgery for Morbid Obesity Dezie AJ, Silvestri F, Liriano E, Benotti P American College of Surgeons, September 2000. Journal Club Department of Surgery Prince of Wales Hospital. Study Design.

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Journal Club Department of Surgery Prince of Wales Hospital

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  1. Wound Closure Technique and Acute Wound Complication in Gastric Surgery for Morbid ObesityDezie AJ, Silvestri F, Liriano E, Benotti P American College of Surgeons, September 2000 Journal Club Department of Surgery Prince of Wales Hospital

  2. Study Design • Prospective, randomized study of midline fascial closure technique in gastric bariatric patient • Conducted between 1991-1998 • 331 consecutive morbidly obese patients • 2 groups randomized: • Group 1: Continuous fascial closure (n=172) • Group 2: Interrupted fascial closure (n=159)

  3. Study Design • Patients randomized intraoperatively by odd/even MRN at time of fascial closure • Randomized suture material (Nylon vs PDS) • 4 different surgeons performing surgery • Wounds monitored for 30 days post-op • End points • superficial wound complications (superficial infections, seromas and haematomas) • Deep wound complications (deep surgical infections and fascial dehiscence)

  4. Fascial Closure Technique Sutures 1cm apart and between 1-2cm from fascial edge

  5. Table 1

  6. Conclusions • No significant differences between techniques in incidences of superficial complications • Continuous fascial closure were associated with fewer deep complications • Similar outcomes were observed with both monofilament suture materials • Continuous fascial closure reduces major acute wound complications in morbidly obese patients undergoing gastric operations

  7. Strengths • Reasonable patient numbers • Prospective randomized trial • Comparing surgical technique and suture material • Clear endpoints • Weakness • Inclusion criteria not stately clearly • Randomization method (not double blinded) • Ordered categories to show adequacy of randomization technique (patient factors, co-morbidities) • Identification of complications by surgeons (bias) • Data collection ?independent source

  8. Meta-analysis of techniques for closure of midline abdominal incisions • Date of Most Recent Update: 2004 • NHS Centre for Reviews and Dissemination. University of York, York, U.K. • Abstract and Commentary for: van't Riet M, Steyerberg E W, Nellensteyn J, Bonjer H J, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. • British Journal of Surgery. 2002; 89(11):1350-1356. • 15 studies reviewed (6566 patients)

  9. Results of the Review • Continuous closure using rapidly absorbable versus non-absorbable sutures (1 RCT, n=751): rapidly absorbable sutures resulted in significantly more incisional hernias (P=0.001), but less suture sinuses (P<0.001) and prolonged wound pain (P=0.003) • NO statistically-significant difference between the two suture types for any other outcome measure. • Continuous closure using slowly absorbable versus non-absorbable sutures (5 RCTs, n=2,669): non-absorbable sutures resulted in significantly more wound pain (P<0.005) and suture sinuses (P<0.02) • NO statistically-significant difference between the two types for the incidence of hernias, wound dehiscence or infection.

  10. Results of the Review • Interrupted rapidly absorbable versus continuous slowlyabsorbable (4 RCTs, n=1,992): there was no statistically- significant difference between the groups for any of the outcome measures • Interrupted non-absorbable versus continuous rapidlyabsorbable (1 RCT, n=105): there was no statistically-significant difference between the groups for the incidence of hernias, wound dehiscence, or wound infection

  11. Results of the Review • Continuous versus interrupted (any suture type): the pooled analysis did NOT show any significant difference between the two techniques for incisional hernias (odds ratio 0.9, 95% confidence interval: 0.6, 1.2, P=0.40), or the incidence of wound dehiscence or wound infection (no results presented). • Analysis of the suture length to wound length ratio (3 RCTs): two studies reported that an increased suture length to wound length ratio of 4:1 or even 6:1 resulted in a significant decrease in the incidence of incisional hernia.

  12. Author's conclusions • To reduce the incidence of incisional hernia without increasing wound pain or suture sinus frequency, slowly absorbable continuous sutures appear to be the optimal method of fascial closure. • Adequate suture length (suture length to wound length ratio of at least 4:1)

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