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Are Tissue Adhesives an Acceptable Alternative for Simple Lacerations?
ANNALS OF EMERGENCY MEDICINE
OCTOBER 2011
Systematic Review Snapshot TAKE-HOME MESSAGE Simple lacerations closed with tissue adhesives have similar cosmetic results compared with those obtained with standard wound closure. METHODS DATA SOURCES The authors searched the Cochrane Wounds Group Specialized Trials Register (October 2007), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 3, 2007), MEDLINE (1950 to 2007), EMBASE (1980 to 2007), CINAHL (1982 to 2007), Web of Science– Science Citation Index (1975 to 2007), 7 clinical trial registries, and reference lists of articles. Experts in the field and product manufacturers were also contacted to retrieve pertinent data from ongoing, unpublished, or published trials not found in the electronic search. STUDY SELECTION All randomized controlled trials were included that compared tissue adhesives with standard wound closure or one tissue adhesive compared with another tissue adhesive for traumatic lacerations in an emergency or primary care setting. Wounds had to be acute, linear lacerations and fewer than 12 hours old, provided that the edges could be approximated with minimal tension after deep sutures were placed, if required. The primary outcome was cosmesis measured by either the Cosmetic Visual Analogue Scale or Wound Evaluation Score.
Are Tissue Adhesives an Acceptable Alternative for Simple Lacerations? EBEM Commentators
Lee Wilbur, MD Rawle Seupaul, MD Department of Emergency Medicine Indiana University School of Medicine Indianapolis, IN
Results Cosmetic outcomes using tissue adhesives versus standard wound closure at 1 to 3 months after repair.
Cosmesis Analysis Cosmetic Visual Analog Score* Wound Evaluation Score
Studies (Total No. of Patients)
RR (95% CI)
7 (549)
NA
4 (364)
0.99 (0.89 to 1.3)
WMD, mm (95% I2, CI) % 1.6 57 (–3.2 to 6.4) NA
0
RR, Relative risk; WMD, weighted mean difference; NA, not applicable. *Cosmetic Visual analog Score: 0 mm (worst) to 10 mm (best).
The search identified 850 potential studies; 13 trials met inclusion criteria, of which 11 contained individual patient data that could be pooled. Three studies were deemed to be adequately concealed, whereas concealment was unclear in the remaining 10.
Commentary Simple traumatic lacerations in adults and children are a common emergency department (ED) presentation. This Cochrane review concludes that there is no difference in cosmesis in Volume , . : October
simple lacerations closed with tissue adhesive compared with standard wound closure. In addition, pain scores (parent visual analog scale weighted mean difference ⫺13.4 mm; 95% CI ⫺20.0 to ⫺6.9 mm) and procedure time (weighted mean difference ⫺4.7 minutes; 95% CI ⫺7.2 to ⫺2.1 minutes) significantly favored tissue adhesives. According to a subgroup analysis in a recent meta-analysis, tissue adhesives were actually found to be superior to standard wound closure at 1 to 3 months postrepair.1
When choosing between a tissue adhesive and standard wound closure, emergency physicians should consider potential complications and cost-effectiveness. Although recent case reports describe foreign body reaction and scar tattooing with tissue adhesives, systematic reviews of randomized controlled trials reported wound dehiscence as the only complication found to be statistically associated with tissue adhesives, with an estimated number needed to harm of 40.1-3 In terms of financial burden, tissue adhesives incur higher institutional cost while generating a lower total patient charge.4 These costs may be offset, however, by increased paAnnals of Emergency Medicine 373
Systematic Review Snapshot
DATA EXTRACTION AND SYNTHESIS Quality of study methodology was assessed independently by 2 investigators. All included trials (13) were randomized controlled trials. Data comparing tissue adhesive with standard wound closure were pooled with a random-effects model, and results were reported as weighted mean difference or a relative risk with 95% confidence intervals (CIs).
tient satisfaction, ED throughput, and a reduced need for procedural sedation in children. Emergency physicians should incorporate the use of tissue adhesives for simple laceration repairs. Compared
374 Annals of Emergency Medicine
with standard wound closure, they result in equivalent cosmesis, less pain, and more rapid wound closure. 1. Beam JW, Beam JW. Tissue adhesives for simple traumatic lacerations. J Athl Train. 2008;43:222-224. 2. Dragu A, Unglaub F, Schwarz S, et al. Foreign body reaction after usage of tissue adhesives for skin closure: a case report and review of the literature. Arch Orthop Trauma Surg. 2009;129:167-169. 3. Swan MC, Descamps MJ, Broadhurst A, et al. Scar tattooing following the use of tissue adhesive. Plast Reconstr Surg. 2006;117:1054-1055. 4. Man SY, Wong EM, Ng YC, et al. Costconsequence analysis comparing 2-octyl cyanoacrylate tissue adhesive and suture for closure of simple lacerations: a randomized controlled trial. Ann Emerg Med. 2009;53:189-197.
This is a systematic review abstract, a regular feature of the Annals’ Systematic Review Snapshots (SRS) series. Each features
an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: Farion KJ, Russel KF, Osmond MH, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev. 2002; (3):CD003326. DOI:10.1002/14651858. CD003326 (assessed as up to date October 1, 2007). The Annals’ EBEM editors assisted in the preparation of the abstract of this Cochrane systematic review. Systematic Review Author Contact Ken J. Farion, MD, FRCPC Department of Pediatrics and Emergency Medicine University of Ottawa, Children’s Hospital of Eastern Ontario Ottawa, Ontario, Canada E-mail: [email protected]
Volume , . : October
OCTOBER 2011
Systematic Review Snapshot TAKE-HOME MESSAGE Simple lacerations closed with tissue adhesives have similar cosmetic results compared with those obtained with standard wound closure. METHODS DATA SOURCES The authors searched the Cochrane Wounds Group Specialized Trials Register (October 2007), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 3, 2007), MEDLINE (1950 to 2007), EMBASE (1980 to 2007), CINAHL (1982 to 2007), Web of Science– Science Citation Index (1975 to 2007), 7 clinical trial registries, and reference lists of articles. Experts in the field and product manufacturers were also contacted to retrieve pertinent data from ongoing, unpublished, or published trials not found in the electronic search. STUDY SELECTION All randomized controlled trials were included that compared tissue adhesives with standard wound closure or one tissue adhesive compared with another tissue adhesive for traumatic lacerations in an emergency or primary care setting. Wounds had to be acute, linear lacerations and fewer than 12 hours old, provided that the edges could be approximated with minimal tension after deep sutures were placed, if required. The primary outcome was cosmesis measured by either the Cosmetic Visual Analogue Scale or Wound Evaluation Score.
Are Tissue Adhesives an Acceptable Alternative for Simple Lacerations? EBEM Commentators
Lee Wilbur, MD Rawle Seupaul, MD Department of Emergency Medicine Indiana University School of Medicine Indianapolis, IN
Results Cosmetic outcomes using tissue adhesives versus standard wound closure at 1 to 3 months after repair.
Cosmesis Analysis Cosmetic Visual Analog Score* Wound Evaluation Score
Studies (Total No. of Patients)
RR (95% CI)
7 (549)
NA
4 (364)
0.99 (0.89 to 1.3)
WMD, mm (95% I2, CI) % 1.6 57 (–3.2 to 6.4) NA
0
RR, Relative risk; WMD, weighted mean difference; NA, not applicable. *Cosmetic Visual analog Score: 0 mm (worst) to 10 mm (best).
The search identified 850 potential studies; 13 trials met inclusion criteria, of which 11 contained individual patient data that could be pooled. Three studies were deemed to be adequately concealed, whereas concealment was unclear in the remaining 10.
Commentary Simple traumatic lacerations in adults and children are a common emergency department (ED) presentation. This Cochrane review concludes that there is no difference in cosmesis in Volume , . : October
simple lacerations closed with tissue adhesive compared with standard wound closure. In addition, pain scores (parent visual analog scale weighted mean difference ⫺13.4 mm; 95% CI ⫺20.0 to ⫺6.9 mm) and procedure time (weighted mean difference ⫺4.7 minutes; 95% CI ⫺7.2 to ⫺2.1 minutes) significantly favored tissue adhesives. According to a subgroup analysis in a recent meta-analysis, tissue adhesives were actually found to be superior to standard wound closure at 1 to 3 months postrepair.1
When choosing between a tissue adhesive and standard wound closure, emergency physicians should consider potential complications and cost-effectiveness. Although recent case reports describe foreign body reaction and scar tattooing with tissue adhesives, systematic reviews of randomized controlled trials reported wound dehiscence as the only complication found to be statistically associated with tissue adhesives, with an estimated number needed to harm of 40.1-3 In terms of financial burden, tissue adhesives incur higher institutional cost while generating a lower total patient charge.4 These costs may be offset, however, by increased paAnnals of Emergency Medicine 373
Systematic Review Snapshot
DATA EXTRACTION AND SYNTHESIS Quality of study methodology was assessed independently by 2 investigators. All included trials (13) were randomized controlled trials. Data comparing tissue adhesive with standard wound closure were pooled with a random-effects model, and results were reported as weighted mean difference or a relative risk with 95% confidence intervals (CIs).
tient satisfaction, ED throughput, and a reduced need for procedural sedation in children. Emergency physicians should incorporate the use of tissue adhesives for simple laceration repairs. Compared
374 Annals of Emergency Medicine
with standard wound closure, they result in equivalent cosmesis, less pain, and more rapid wound closure. 1. Beam JW, Beam JW. Tissue adhesives for simple traumatic lacerations. J Athl Train. 2008;43:222-224. 2. Dragu A, Unglaub F, Schwarz S, et al. Foreign body reaction after usage of tissue adhesives for skin closure: a case report and review of the literature. Arch Orthop Trauma Surg. 2009;129:167-169. 3. Swan MC, Descamps MJ, Broadhurst A, et al. Scar tattooing following the use of tissue adhesive. Plast Reconstr Surg. 2006;117:1054-1055. 4. Man SY, Wong EM, Ng YC, et al. Costconsequence analysis comparing 2-octyl cyanoacrylate tissue adhesive and suture for closure of simple lacerations: a randomized controlled trial. Ann Emerg Med. 2009;53:189-197.
This is a systematic review abstract, a regular feature of the Annals’ Systematic Review Snapshots (SRS) series. Each features
an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: Farion KJ, Russel KF, Osmond MH, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev. 2002; (3):CD003326. DOI:10.1002/14651858. CD003326 (assessed as up to date October 1, 2007). The Annals’ EBEM editors assisted in the preparation of the abstract of this Cochrane systematic review. Systematic Review Author Contact Ken J. Farion, MD, FRCPC Department of Pediatrics and Emergency Medicine University of Ottawa, Children’s Hospital of Eastern Ontario Ottawa, Ontario, Canada E-mail: [email protected]
Volume , . : October