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2-Octyl Cyanoacrylate (Dermabond®) skin adhesive versus polyglactin for skin closure in endoscopic radial artery harvesting
Journal of the Egyptian Society of Cardio-Thoracic Surgery 26 (2018) 37e42
Contents lists available at ScienceDirect
H O S T E D BY
Journal of the Egyptian Society of Cardio-Thoracic Surgery journal homepage: http://www.journals.elsevier.com/journal-ofthe-egyptian-society-of-cardio-thoracic-surgery/
2-Octyl Cyanoacrylate (Dermabond®) skin adhesive versus polyglactin for skin closure in endoscopic radial artery harvesting Ahmed Mostafa Omran a, *, Amir Mohamed b, Yousry Shaheen c, Adel Maher d, Ahmed S. Mahlab a a
National Heart Institute (NHI), Egypt Faculty of Medicine, Alexandria University, Egypt Faculty of Medicine, Benha University, Egypt d Faculty of Medicine, Aswan University, Egypt b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 November 2017 Received in revised form 5 January 2018 Accepted 21 January 2018 Available online 22 February 2018
Background: As the goal of endoscopic conduit harvesting is to decrease pain and better cosmetic appearance, and as the optimal choice of skin closure after endoscopic radial artery harvesting (ERAH) has not yet been determined, we started this study with an aim to compare wound complications, patient satisfaction and scar healing between glue (Dermabond) versus polyglactin intra-cuticular suture for skin closure after ERAH. Methods: This observational study was done at Al Dabbous Cardiac Center, Kuwait, from January 2017 till October 2017 enrolling 40 patients divided into two equal groups (Dermabond group and sutures group). Inclusion criterion was patients underwent coronary artery bypass grafting (CABG) using ERAH, while open technique for radial artery harvesting and Negro race are considered as exclusion criteria. Demographic data were collected, (gender, age, race, body mass index (BMI), preoperative medication and albumin level, as well as diabetes or peripheral vascular disease. Operatively, wound closure time was calculated for all patients. Postoperatively: Cosmetic appearance was assessed using the Hollander scale. Patient satisfaction was recorded at week 6e8 weeks. Results: Demographic and preoperative data were comparable; Dermabond group showed shorter closure time, better scar pigmentation, shape and patient satisfaction. Pain, scar size, infection and hematoma showed no statistical difference. Conclusion: Dermabond can be used safely in closure of skin after ERAH. The excellent results in the small wound of ERAH encouraged us to use it in larger wounds. © 2018 The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Keywords: Dermabond Wound ERAH Skin adhesive OCA
* Corresponding author. E-mail addresses: [email protected], [email protected] (A.M. Omran), [email protected] (A. Mohamed), yousryshaheen2010@ yahoo.com (Y. Shaheen), [email protected] (A. Maher), [email protected] (A.S. Mahlab). Peer review under responsibility of The Egyptian Society of Cardio-thoracic Surgery. https://doi.org/10.1016/j.jescts.2018.01.003 1110-578X/© 2018 The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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A.M. Omran et al. / Journal of the Egyptian Society of Cardio-Thoracic Surgery 26 (2018) 37e42
1. Introduction Since the publication of the first endoscopic great saphenous vein harvesting (EVH) in 1996, EVH increased in popularity and is becoming the preferred method of great saphenous vein graft (SVG) harvesting. A significant number of studies have demonstrated short term advantages of EVH as less wound morbidity, less pain, better cosmetic results, and improved patient satisfaction relative to open technique for SVG harvesting (OVH) [1]. In patients undergoing coronary artery bypass grafting (CABG), radial arteries are the conduit graft of choice after internal thoracic arteries because of their relatively easy harvesting, in addition to the adoption of calcium channel blockers, which prevent vasospasm, enhanced interest in radial arteries, especially in young patients in whom exclusive arterial grafting is desirable [2]. Complications related to conventional open radial artery harvesting (RAH) are usually not negligible when they occur, and the scar of an incision extending longitudinally throughout the forearm is definitely not cosmetically appealing [2]. Nowadays, in an effort to minimize surgical trauma, development and adoption of EVH encourage its application to the radial artery also. Endoscopic radial artery harvesting (ERAH) was associated with better wound appearance, in addition of being safe and effective, with less pain and fewer wound complications than the open surgical technique [3]. As secure skin closure is an important integral step for every surgical procedure, the closure device must provide the strength and the required support for skin tissue, otherwise the wound edges may be gapped or separated, this will provide potential pathway for bacterial contamination, which will lead to infection, as well as suboptimal cosmetic shape, and lower patient satisfaction [4]. Reliable and inexpensive, sutures may take longer time to place, with the additional risk of needle stick injury to the surgeon or the operating staff, in addition to the need for late removal in case of nonabsorbable stitches [5]. Dermabond is a topical skin adhesive that upon contact with a weak base forms a strong polymeric bond across opposed wound edges allowing the normal healing process to occur. It can be used to close easily approximated skin edges of wounds whether they are small surgical incisions or lacerations, with purported advantages over conventional sutures in cosmetic outcomes, cost benefits, and operative times. It provides a protective barrier that adds strength (7-day wound-holding strength in just 3 min) and inhibits bacteria through forming microbial barrier for three days against organisms commonly responsible for surgical site infections. In addition, it affects patient's comfort by providing flexible closure without the pain or anxiety caused by needles as well as fast closure of small incisions and lacerations and eliminating the need for return visits to remove sutures [6].
2. Patients and Methods An observational study was done at Al Dabbous Cardiac Center, Kuwait, from January 2017 till October 2017. The study enrolled 40 patients divided into two equal groups the Dermabond group and the sutures group. The inclusion criterion was patients who underwent CABG using radial artery which was harvested endoscopically, while open technique for RAH and Negro race are considered as exclusion criteria. The demographic data were collected, (gender, age, race, body mass index (BMI), preoperative medication and albumin level, as well as diabetes or peripheral vascular disease. Operatively, 2 cm incision was done medial and proximal to the radial styloid process where radial artery was identified and dissected followed by introduction of the endoscope {VASOVIEW HEMOPRO 2 Endoscopic Vessel Harvesting System}.Using the endoscope, radial artery was completely dissected and cut proximally through 5 mm incision. After its cutting radial artery was pulled to be taken through the initial incision, wound was closed in layers using polyglactin while skin was closed using either Dermabond or polyglactin 3-0 on cutting needle. In the Dermabond group, Dermabond was applied in two layers over the edges of the skin after complete drying. A gap of a few seconds occurred between the applications of the two layers. Dermabond (Fig 1) is highly purified 2-octylcyanoacrylate (OCA) monomer, which, after polymerization is stronger, more flexible and less brittle. A chemical initiator in the applicator tip is used to ensure consistent, reliable polymerization times leading to formulation additives to enhance strength, flexibility, and adherence to the skin [6]. All wounds were closed over suction drain to minimize hematoma formation (Fig. 2). The time of closure was calculated for all patients. Postoperative variables included incidence of wound complications, cosmetic results, and patient's pain (according to pain scale) and satisfaction including color, size, thickness, pliability, and visibility as well as overall satisfaction (at 6e8 weeks postoperatively) with the scar compared with normal skin(Fig. 3). Patients were also asked whether the scar was painful or pruritic. The Hollander wound evaluation grading scale was used for postoperative evaluation. Scars were assigned 0 or 1 point each for the presence or absence of the following: width greater than 2 mm, edge elevation or depression, discoloration, suture or staple marks, excessive inflammation and overall poor appearance. A total cosmetic score was then calculated by adding the individual scores on each of the six categories ranging from 0 (worst) to 6 (best) [7]. These data were collected and studied statistically to evaluate any difference between both methods of closure.
A.M. Omran et al. / Journal of the Egyptian Society of Cardio-Thoracic Surgery 26 (2018) 37e42
Fig. 1. Dermabond package and applier.
Fig. 2. Application of Dermabond for skin closure.
Fig. 3. Pain scale for wound postoperative.
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Table 1 Preoperative demographic data. Characters
Dermabond
suture
Number Mean Age Females Mean Preoperative glucose level (mg %) Mean Preoperative albumin level Caucasian race Asian race Body mass index (Kg/m2)
20 67 5 132 3.5 19 1 31
20 62 5 144 3.5 20 0 34
P value 0.2 1 0.4 0.95 0.9 0.3
2.1. Statistical analysis Data were analyzed using SPSS© Statistics version 22 and MedCalc© version 13. The D'Agostino-Pearson test was used to examine the normality of numerical data distribution. Normally distributed continuous variables were presented as mean and SD, and intergroup differences were compared using the independentsamples (unpaired) t-test. Discrete variables and skewed continuous variables were presented as median and interquartile range, and differences were compared using the Mann-Whitney test. Categorical variables were presented as ratio or as number and percentage and differences were compared using the Pearson chi-squared test. Repeated-measures analysis of variance (ANOVA) was used to analyze serial measurements and to examine the effect of time, randomization group, and time-group interaction on the change in the outcome measures. A p-value < 0.05 was considered statistically significant.
3. Results Demographic data was comparable between both groups where the mean age of the patients in the Dermabond (adhesive) group was 67 years against 62 years in the suture group, while female gender was 5 patients in adhesive group compared to 5 in the Polyglactin group. None of both groups was on preoperative medications that affect wound healing as corticosteroids. The albumin level, BMI and diabetes were comparable to both groups (Table 1). The closure time was significantly shorter in the adhesive group (6 min Vs.11 min P ¼ 0.01). Postoperatively, wounds were evaluated using the Hollander scale, where assessment of edge inversion, margin separation, borders and contour irregularities as well as excessive distortion. Nineteen patients in the Dermabond group scored 0, while the last patient scored 1, on the other hand no patient in the suture group scored 0, six patients scored 1, nine scored 2, four scored 3, and one patient scored 4 (p < 0.001). Pain scale (Fig. 3) was numerically less in adhesive group however it showed no statistical difference. Regarding the incidence of inflammation, hematoma, or exudation from the incision site, there was no statistical significance between the two groups where 1 patient in each group showed signs of inflammation (P ¼ 1). Hyperpigmentation was noted in eighteen patients in the subcuticular suture group while only two patients had this problem in the Dermabond group (p < 0.05) (Fig. 4). Patient satisfaction was assessed 6e8 weeks postoperatively where patients of the adhesive group reported significantly greater satisfaction with the scar, compared with the suture group, especially regarding color, visibility and scar shape while scar size showed no statistical difference (Fig. 5).
Fig. 4. Scar 8 weeks postoperative showing more pigmentation in the suture closure (upper photo) than Dermabond (lower photo).
A.M. Omran et al. / Journal of the Egyptian Society of Cardio-Thoracic Surgery 26 (2018) 37e42
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Fig. 5. Scar 7 weeks postoperative closed by Dermabond with no elevation or hypertrophic scar.
4. Discussion Recently there is a trend for adopting minimally invasive cardiac surgery in a hope to add better results of the surgery, better scar, shorter hospital stay and higher level of patient satisfaction [8]. The patient satisfaction towards his wound is usually related to size, shape, pigmentation, pain and pruritus of the scar [9]. Adhesive skin closure has been used in wound closure as far as 1949; Dermabond is high viscous flexible glue that polymerizes immediately upon exposure to weak bases such as water and blood [10]. The literature reveals the successful use of Octyl Cyanoacrylate (OCA) in wound closure in a variety of surgical settings and specialties [11]. Also previous use of Dermabond was done in cardiac surgery with accepted results [5]. Many reports showed its efficacy regarding limitation of infection as well as better cosmetic appearance especially in delicate tissue like the face or highly mobile skin like knee joint [12,13]. Prolonged exposure during wound closure increases the likelihood of postoperative infections. In this study, Dermabond usage reduced wound closure time associated with better cosmetic appearance and higher patient satisfaction compared with subcuticular sutures [14]. Reduction in wound closure time with OCA may appear more effective with longer incisions. This is due to easier usage and lack of complexity compared with regular suturing techniques [14]. Also although data on the cost-effectiveness is lacking, yet reduction in the overall costs associated with OCA has been reported. This is because of the lower costs of surgeons' consumption regarding less material during the procedure itself and absence of repeat clinic appointments especially when nonabsorbable sutures are being used [15]. Cosmetically, this study provided some data suggesting that Dermabond resulted in better cosmesis after ERAH when compared with traditional subcuticular closure. As cosmetic appearance of a scar depends mainly on surgical proficiency, where the learning curve, (especially in educational centers), take a longer period for the surgeon to achieve optimal cosmesis in wound closure outcomes with standard techniques. The use of tissue adhesives have considerably shorter time for training to bring the same results. This may help to explain the superior results observed in this study. These results are comparable to other studies which were done in traumatic lacerations and incisional surgical wounds as well as after plastic surgery procedures [16e18]. Our observational study reported superior patient satisfaction with the scar postoperatively compared with sutures. This superiority may be due to patient benefits including being able to wash there forearms freely almost immediately after the procedure, decreased risk of allergic reactions associated with sutures as well as the absence of the need to remove the sutures which is sometimes painful for some patients. In other studies, tissue adhesives have gained favor in trauma for their quick and painless closure of lacerations, thus reducing the need for a local anesthetic. In addition, Dermabond sloughs off the incision site after approximately 10 days leaving no risk for formation of suture sinuses due to infected suture material which present a significant problem postoperatively which ein turn-may persists over several months [19]. Complications after CABG, such as superficial or deep wound infections, wound dehiscence and cellulitis, affect patient mobility and may increase re-hospitalization with the resulting increase in direct and indirect costs and sometimes loss of a limb which has also been reported. Dermabond creates a physical antimicrobial barrier that may be advantageous in preventing wound infection [20]. Incidence of inflammation, hematoma, or exudation from the incision site showed no difference with both closure methods. This is the same with the literature, where previous studies demonstrated either a decrease or no difference in the incidence of postoperative infections with Dermabond [20,21]. This signify that less tissue dissection and less spreading wound in addition to better secure closure improve outcomes and minimize postoperative wound complication [22]. 5. Conclusions OCA (Dermabond) can be used safely in closure of skin after ERAH. The excellent results for the usage of Dermabond in the small wound of ERAH encourage us to use it in larger wounds as open harvesting of radial artery and saphenous vein grafts.
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A.M. Omran et al. / Journal of the Egyptian Society of Cardio-Thoracic Surgery 26 (2018) 37e42
Dermabond may help to reduce operative time, increase patient satisfaction, and improve cosmetic appearance compared with traditional suturing. It may also assist in reducing the overall infection risk. 5.1. Study limitations The number of patients enrolled in the study limits its explanatory power, the more number of patients can clearly emphasize the benefit of Dermabond in wound closure is true or just a myth. Also the usage of endoscopic wounds, which is smaller and cleaner than conventional wounds, can affect the results when compared to other larger wounds as in the leg for OVH. Another criticism could be made that the wounds were not monitored for long enough, however, it has been reported previously that there was strong agreement between wound shape at 2 months and 1 year. The results of the present study were, thus, representative of cosmetic outcome [19]. Conflicts of interest None. Funds None. References [1] Zenati Marco A, Laurie Shroyer A, Collins Joseph F, Hattler Brack, Ota Takeyoshi, Hossein Almassi G, et al. Impact of endoscopic versus open saphenous vein harvest technique on late coronary artery bypass grafting patient outcomes in the ROOBY (Randomized On/Off Bypass) Trial. J Thorac Cardiovasc Surg 2011-02-01;141(2):338e44. L, Olivares Gabriel, Ehasz Paul, Marc Gillinov A, Svensson Lars G, Brozzi Nicolas, et al. Endoscopic radial artery harvesting procedure for [2] Navia Jose coronary artery bypass grafting. Ann Cardiothorac Surg 2013 Jul;2(4):557e64. [3] Navia JL, Brozzi N, Chiu J, Blackstone EH, Atik FA, Svensson LG, et al. Endoscopic versus open radial artery harvesting for coronary artery bypass grafting. J Cardiovasc Surg (Torino) 2012;53:257e63. [4] Rushbrook Jeremy L, White Grace, Kidger Lizi, Marsh Philip, Taggart Thomas FO. The antibacterial effect of 2-octyl cyanoacrylate (Dermabond®) skin adhesive. J Infect Prev 2014 Nov;15(6):236e9. [5] Krishnamoorthy Bhuvaneswari, Najam Osman, Khan Ursalan A, Waterworth Paul, Fildes James E, Yonan Nizar. Randomized prospective study comparing conventional subcuticular skin closure with Dermabond skin glue after saphenous vein harvesting. Ann Thorac Surg 2009;88:1445e50. [6] Bruns Thomas B, Mack Worthington J. Using tissue adhesive for wound repair: a practical guide to Dermabond. Am Fam Physician 2000 Mar 1;61(5): 1383e8. [7] Singer AJ1, Arora B, Dagum A, Valentine S, Hollander JE. Development and validation of a novel scar evaluation scale. Plast Reconstr Surg 2007 Dec; 120(7):1892e7. [8] Shawky Fareed, Ashraf Bassiony. Early outcome of mini aortic valve replacement surgery. J Egypt soc cardiothorac surg In Press, Corrected Proof, Available online 12 July 2017. [9] Quinn JV, Wells GA. An assessment of clinical wound evaluation scales. Acad Emerg Med 1998;5:583e6. [10] Anderson JM, Gibbons DF. The new generation of biomedical polymers. Biomater Med Devices Artif Organs 1974;2:235. [11] Toriumi Dean M, Grady O', Desai Kevin, et al. Use of octyl-2-cyanoacrylate for skin closure in facial plastic surgery. Plast Reconstr Surg 1998;102: 2209e19. [12] Handschel JGK, Depprich RA, Dirksen D, Runte C, Zimmermann A, Kubler NR. A prospective comparison of octyl-2-cyanoacrylate and suture in standardized facial wounds. Int J Oral Maxillofac Surg 2006;35:318e23. [13] El-Gazzar Yaser, Smith Daniel C, Kim Sun Jin, Hirsh David M, Blum Yossef, Marcie Cobelli FNP, et al. The use of Dermabond® as an adjunct to wound closure after total knee arthroplasty: examining immediate post-operative wound drainage. J Arthroplasty 2013;28:553e6. [14] Bovill ES, Boulton R, Wharton S. Use of Dermabond as a dressing for prominent ear correction: a sound alternative to head dressings. J Plast Reconstr Aesthetic Surg 2010 Jun;63(6):1065e6. [15] Osmond MH, Klassen TP, Quinn JV. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr 1995; 126:892e5. [16] Singer AJ, Hollander JE, Valentine SM, Thode Jr HC, Henry MC. Association of training level and short-term cosmetic appearance of repaired lacerations. Acad Emerg Med 1996;3:378e83. [17] Hollander JE, Singer AJ. Application of tissue adhesives: rapid attainment of proficiency. Stony Brook Octylcyanoacrylate Study Group. Acad Emerg Med 1998;5:1012e7. [18] Nipshagen MD, Hage JJ, Beekman WH. Use of 2-octylcyanoacrylate skin adhesive (Dermabond) for wound closure following reduction mammaplasty: a prospective, randomized intervention study. Plast Reconstr Surg 2008;122:10e8. [19] Quinn J, Maw J, Ramotar K, Wenckebach G, Wells G. Octylcyanoacrylate tissue adhesive versus suture wound repair in a contaminated wound model. Surgery 1997;122:69e72. [20] TA1 Thomas, Taylor SM, Crane MM, Cornett WR, Langan 3rd EM, Snyder BA, et al. An analysis of limb-threatening lower extremity wound complications after 1090 consecutive coronary artery bypass procedures. Vasc Med 1999;4:83e8. [21] KJ1 Farion, Osmond MH, Hartling L, Russell KF, Klassen TP, Crumley E, et al. Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trials. Acad Emerg Med 2003;10:110e8. [22] Fareed Shawky, Senna Waleed Abou, Sewielam Mohamed, Fouad Ahmed, Sabry Ayman, Bassiony Ashraf. Early outcome of minimally invasive mitral valve surgery. J Egypt Soc Cardiothorac Surg 2016;24:173e80.
Contents lists available at ScienceDirect
H O S T E D BY
Journal of the Egyptian Society of Cardio-Thoracic Surgery journal homepage: http://www.journals.elsevier.com/journal-ofthe-egyptian-society-of-cardio-thoracic-surgery/
2-Octyl Cyanoacrylate (Dermabond®) skin adhesive versus polyglactin for skin closure in endoscopic radial artery harvesting Ahmed Mostafa Omran a, *, Amir Mohamed b, Yousry Shaheen c, Adel Maher d, Ahmed S. Mahlab a a
National Heart Institute (NHI), Egypt Faculty of Medicine, Alexandria University, Egypt Faculty of Medicine, Benha University, Egypt d Faculty of Medicine, Aswan University, Egypt b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 November 2017 Received in revised form 5 January 2018 Accepted 21 January 2018 Available online 22 February 2018
Background: As the goal of endoscopic conduit harvesting is to decrease pain and better cosmetic appearance, and as the optimal choice of skin closure after endoscopic radial artery harvesting (ERAH) has not yet been determined, we started this study with an aim to compare wound complications, patient satisfaction and scar healing between glue (Dermabond) versus polyglactin intra-cuticular suture for skin closure after ERAH. Methods: This observational study was done at Al Dabbous Cardiac Center, Kuwait, from January 2017 till October 2017 enrolling 40 patients divided into two equal groups (Dermabond group and sutures group). Inclusion criterion was patients underwent coronary artery bypass grafting (CABG) using ERAH, while open technique for radial artery harvesting and Negro race are considered as exclusion criteria. Demographic data were collected, (gender, age, race, body mass index (BMI), preoperative medication and albumin level, as well as diabetes or peripheral vascular disease. Operatively, wound closure time was calculated for all patients. Postoperatively: Cosmetic appearance was assessed using the Hollander scale. Patient satisfaction was recorded at week 6e8 weeks. Results: Demographic and preoperative data were comparable; Dermabond group showed shorter closure time, better scar pigmentation, shape and patient satisfaction. Pain, scar size, infection and hematoma showed no statistical difference. Conclusion: Dermabond can be used safely in closure of skin after ERAH. The excellent results in the small wound of ERAH encouraged us to use it in larger wounds. © 2018 The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Keywords: Dermabond Wound ERAH Skin adhesive OCA
* Corresponding author. E-mail addresses: [email protected], [email protected] (A.M. Omran), [email protected] (A. Mohamed), yousryshaheen2010@ yahoo.com (Y. Shaheen), [email protected] (A. Maher), [email protected] (A.S. Mahlab). Peer review under responsibility of The Egyptian Society of Cardio-thoracic Surgery. https://doi.org/10.1016/j.jescts.2018.01.003 1110-578X/© 2018 The Egyptian Society of Cardio-thoracic Surgery. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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A.M. Omran et al. / Journal of the Egyptian Society of Cardio-Thoracic Surgery 26 (2018) 37e42
1. Introduction Since the publication of the first endoscopic great saphenous vein harvesting (EVH) in 1996, EVH increased in popularity and is becoming the preferred method of great saphenous vein graft (SVG) harvesting. A significant number of studies have demonstrated short term advantages of EVH as less wound morbidity, less pain, better cosmetic results, and improved patient satisfaction relative to open technique for SVG harvesting (OVH) [1]. In patients undergoing coronary artery bypass grafting (CABG), radial arteries are the conduit graft of choice after internal thoracic arteries because of their relatively easy harvesting, in addition to the adoption of calcium channel blockers, which prevent vasospasm, enhanced interest in radial arteries, especially in young patients in whom exclusive arterial grafting is desirable [2]. Complications related to conventional open radial artery harvesting (RAH) are usually not negligible when they occur, and the scar of an incision extending longitudinally throughout the forearm is definitely not cosmetically appealing [2]. Nowadays, in an effort to minimize surgical trauma, development and adoption of EVH encourage its application to the radial artery also. Endoscopic radial artery harvesting (ERAH) was associated with better wound appearance, in addition of being safe and effective, with less pain and fewer wound complications than the open surgical technique [3]. As secure skin closure is an important integral step for every surgical procedure, the closure device must provide the strength and the required support for skin tissue, otherwise the wound edges may be gapped or separated, this will provide potential pathway for bacterial contamination, which will lead to infection, as well as suboptimal cosmetic shape, and lower patient satisfaction [4]. Reliable and inexpensive, sutures may take longer time to place, with the additional risk of needle stick injury to the surgeon or the operating staff, in addition to the need for late removal in case of nonabsorbable stitches [5]. Dermabond is a topical skin adhesive that upon contact with a weak base forms a strong polymeric bond across opposed wound edges allowing the normal healing process to occur. It can be used to close easily approximated skin edges of wounds whether they are small surgical incisions or lacerations, with purported advantages over conventional sutures in cosmetic outcomes, cost benefits, and operative times. It provides a protective barrier that adds strength (7-day wound-holding strength in just 3 min) and inhibits bacteria through forming microbial barrier for three days against organisms commonly responsible for surgical site infections. In addition, it affects patient's comfort by providing flexible closure without the pain or anxiety caused by needles as well as fast closure of small incisions and lacerations and eliminating the need for return visits to remove sutures [6].
2. Patients and Methods An observational study was done at Al Dabbous Cardiac Center, Kuwait, from January 2017 till October 2017. The study enrolled 40 patients divided into two equal groups the Dermabond group and the sutures group. The inclusion criterion was patients who underwent CABG using radial artery which was harvested endoscopically, while open technique for RAH and Negro race are considered as exclusion criteria. The demographic data were collected, (gender, age, race, body mass index (BMI), preoperative medication and albumin level, as well as diabetes or peripheral vascular disease. Operatively, 2 cm incision was done medial and proximal to the radial styloid process where radial artery was identified and dissected followed by introduction of the endoscope {VASOVIEW HEMOPRO 2 Endoscopic Vessel Harvesting System}.Using the endoscope, radial artery was completely dissected and cut proximally through 5 mm incision. After its cutting radial artery was pulled to be taken through the initial incision, wound was closed in layers using polyglactin while skin was closed using either Dermabond or polyglactin 3-0 on cutting needle. In the Dermabond group, Dermabond was applied in two layers over the edges of the skin after complete drying. A gap of a few seconds occurred between the applications of the two layers. Dermabond (Fig 1) is highly purified 2-octylcyanoacrylate (OCA) monomer, which, after polymerization is stronger, more flexible and less brittle. A chemical initiator in the applicator tip is used to ensure consistent, reliable polymerization times leading to formulation additives to enhance strength, flexibility, and adherence to the skin [6]. All wounds were closed over suction drain to minimize hematoma formation (Fig. 2). The time of closure was calculated for all patients. Postoperative variables included incidence of wound complications, cosmetic results, and patient's pain (according to pain scale) and satisfaction including color, size, thickness, pliability, and visibility as well as overall satisfaction (at 6e8 weeks postoperatively) with the scar compared with normal skin(Fig. 3). Patients were also asked whether the scar was painful or pruritic. The Hollander wound evaluation grading scale was used for postoperative evaluation. Scars were assigned 0 or 1 point each for the presence or absence of the following: width greater than 2 mm, edge elevation or depression, discoloration, suture or staple marks, excessive inflammation and overall poor appearance. A total cosmetic score was then calculated by adding the individual scores on each of the six categories ranging from 0 (worst) to 6 (best) [7]. These data were collected and studied statistically to evaluate any difference between both methods of closure.
A.M. Omran et al. / Journal of the Egyptian Society of Cardio-Thoracic Surgery 26 (2018) 37e42
Fig. 1. Dermabond package and applier.
Fig. 2. Application of Dermabond for skin closure.
Fig. 3. Pain scale for wound postoperative.
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Table 1 Preoperative demographic data. Characters
Dermabond
suture
Number Mean Age Females Mean Preoperative glucose level (mg %) Mean Preoperative albumin level Caucasian race Asian race Body mass index (Kg/m2)
20 67 5 132 3.5 19 1 31
20 62 5 144 3.5 20 0 34
P value 0.2 1 0.4 0.95 0.9 0.3
2.1. Statistical analysis Data were analyzed using SPSS© Statistics version 22 and MedCalc© version 13. The D'Agostino-Pearson test was used to examine the normality of numerical data distribution. Normally distributed continuous variables were presented as mean and SD, and intergroup differences were compared using the independentsamples (unpaired) t-test. Discrete variables and skewed continuous variables were presented as median and interquartile range, and differences were compared using the Mann-Whitney test. Categorical variables were presented as ratio or as number and percentage and differences were compared using the Pearson chi-squared test. Repeated-measures analysis of variance (ANOVA) was used to analyze serial measurements and to examine the effect of time, randomization group, and time-group interaction on the change in the outcome measures. A p-value < 0.05 was considered statistically significant.
3. Results Demographic data was comparable between both groups where the mean age of the patients in the Dermabond (adhesive) group was 67 years against 62 years in the suture group, while female gender was 5 patients in adhesive group compared to 5 in the Polyglactin group. None of both groups was on preoperative medications that affect wound healing as corticosteroids. The albumin level, BMI and diabetes were comparable to both groups (Table 1). The closure time was significantly shorter in the adhesive group (6 min Vs.11 min P ¼ 0.01). Postoperatively, wounds were evaluated using the Hollander scale, where assessment of edge inversion, margin separation, borders and contour irregularities as well as excessive distortion. Nineteen patients in the Dermabond group scored 0, while the last patient scored 1, on the other hand no patient in the suture group scored 0, six patients scored 1, nine scored 2, four scored 3, and one patient scored 4 (p < 0.001). Pain scale (Fig. 3) was numerically less in adhesive group however it showed no statistical difference. Regarding the incidence of inflammation, hematoma, or exudation from the incision site, there was no statistical significance between the two groups where 1 patient in each group showed signs of inflammation (P ¼ 1). Hyperpigmentation was noted in eighteen patients in the subcuticular suture group while only two patients had this problem in the Dermabond group (p < 0.05) (Fig. 4). Patient satisfaction was assessed 6e8 weeks postoperatively where patients of the adhesive group reported significantly greater satisfaction with the scar, compared with the suture group, especially regarding color, visibility and scar shape while scar size showed no statistical difference (Fig. 5).
Fig. 4. Scar 8 weeks postoperative showing more pigmentation in the suture closure (upper photo) than Dermabond (lower photo).
A.M. Omran et al. / Journal of the Egyptian Society of Cardio-Thoracic Surgery 26 (2018) 37e42
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Fig. 5. Scar 7 weeks postoperative closed by Dermabond with no elevation or hypertrophic scar.
4. Discussion Recently there is a trend for adopting minimally invasive cardiac surgery in a hope to add better results of the surgery, better scar, shorter hospital stay and higher level of patient satisfaction [8]. The patient satisfaction towards his wound is usually related to size, shape, pigmentation, pain and pruritus of the scar [9]. Adhesive skin closure has been used in wound closure as far as 1949; Dermabond is high viscous flexible glue that polymerizes immediately upon exposure to weak bases such as water and blood [10]. The literature reveals the successful use of Octyl Cyanoacrylate (OCA) in wound closure in a variety of surgical settings and specialties [11]. Also previous use of Dermabond was done in cardiac surgery with accepted results [5]. Many reports showed its efficacy regarding limitation of infection as well as better cosmetic appearance especially in delicate tissue like the face or highly mobile skin like knee joint [12,13]. Prolonged exposure during wound closure increases the likelihood of postoperative infections. In this study, Dermabond usage reduced wound closure time associated with better cosmetic appearance and higher patient satisfaction compared with subcuticular sutures [14]. Reduction in wound closure time with OCA may appear more effective with longer incisions. This is due to easier usage and lack of complexity compared with regular suturing techniques [14]. Also although data on the cost-effectiveness is lacking, yet reduction in the overall costs associated with OCA has been reported. This is because of the lower costs of surgeons' consumption regarding less material during the procedure itself and absence of repeat clinic appointments especially when nonabsorbable sutures are being used [15]. Cosmetically, this study provided some data suggesting that Dermabond resulted in better cosmesis after ERAH when compared with traditional subcuticular closure. As cosmetic appearance of a scar depends mainly on surgical proficiency, where the learning curve, (especially in educational centers), take a longer period for the surgeon to achieve optimal cosmesis in wound closure outcomes with standard techniques. The use of tissue adhesives have considerably shorter time for training to bring the same results. This may help to explain the superior results observed in this study. These results are comparable to other studies which were done in traumatic lacerations and incisional surgical wounds as well as after plastic surgery procedures [16e18]. Our observational study reported superior patient satisfaction with the scar postoperatively compared with sutures. This superiority may be due to patient benefits including being able to wash there forearms freely almost immediately after the procedure, decreased risk of allergic reactions associated with sutures as well as the absence of the need to remove the sutures which is sometimes painful for some patients. In other studies, tissue adhesives have gained favor in trauma for their quick and painless closure of lacerations, thus reducing the need for a local anesthetic. In addition, Dermabond sloughs off the incision site after approximately 10 days leaving no risk for formation of suture sinuses due to infected suture material which present a significant problem postoperatively which ein turn-may persists over several months [19]. Complications after CABG, such as superficial or deep wound infections, wound dehiscence and cellulitis, affect patient mobility and may increase re-hospitalization with the resulting increase in direct and indirect costs and sometimes loss of a limb which has also been reported. Dermabond creates a physical antimicrobial barrier that may be advantageous in preventing wound infection [20]. Incidence of inflammation, hematoma, or exudation from the incision site showed no difference with both closure methods. This is the same with the literature, where previous studies demonstrated either a decrease or no difference in the incidence of postoperative infections with Dermabond [20,21]. This signify that less tissue dissection and less spreading wound in addition to better secure closure improve outcomes and minimize postoperative wound complication [22]. 5. Conclusions OCA (Dermabond) can be used safely in closure of skin after ERAH. The excellent results for the usage of Dermabond in the small wound of ERAH encourage us to use it in larger wounds as open harvesting of radial artery and saphenous vein grafts.
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Dermabond may help to reduce operative time, increase patient satisfaction, and improve cosmetic appearance compared with traditional suturing. It may also assist in reducing the overall infection risk. 5.1. Study limitations The number of patients enrolled in the study limits its explanatory power, the more number of patients can clearly emphasize the benefit of Dermabond in wound closure is true or just a myth. Also the usage of endoscopic wounds, which is smaller and cleaner than conventional wounds, can affect the results when compared to other larger wounds as in the leg for OVH. Another criticism could be made that the wounds were not monitored for long enough, however, it has been reported previously that there was strong agreement between wound shape at 2 months and 1 year. The results of the present study were, thus, representative of cosmetic outcome [19]. Conflicts of interest None. Funds None. 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