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Friday, July 14, 2017

From the SIR Residents and Fellows Sections (SIRRFS)

Teaching Topic: Randomized Controlled Trial of Octyl Cyanoacrylate Skin Adhesive versus Subcuticular Suture for Skin Closure after Implantable Venous Port Placement

Martin JG, Hollenbeck ST, Janas G, Makar RA, Pabon-Ramos WM, Suhocki PV, Miller MJ, Sopko DR, Smith TP, Kim CY. J Vasc Interv Radiol. 2017 Jan;28(1):111-116.

Click here for abstract

Implanting central venous port catheters has become an everyday occurrence for most interventional radiologists. In 1992, interventional radiologists implanted slightly less than 13 thousand central venous port catheters per Medicare claims data. By 2011, this number had exploded to over 83 thousand. [1] Likewise, the proportion placed by radiologists compared to other specialists increased from 17% to 27% in the same period. While port placement has become an essential tool in every interventional radiologist’s armamentarium, it remains one of the few procedures that require large incisions and full thickness skin closure. Traditionally, skin closure is performed with a deep dermal suture layer and a superficial subcuticular suture layer. The use of tissue adhesives made from octyl cyanoacrylate, such as Sure+Close II (Chemence Medical) and Dermabond (Ethicon), have been studied extensively in other specialties’ literature as an alternative for subcuticular suture closure. In this study, Martin et al. at Duke University conducted a randomized controlled trial comparing tissue adhesives and subcuticular sutures in port placement.

The authors randomly assigned 109 subjects after initial port placement and deep dermal suture closure to either receive subcuticular suture closure or adhesive closure. Subjects were followed up for infection, dehiscence, and photographs were obtained at 3-months post-procedure. Photographs were then examined by a blinded plastic surgeon and rated for cosmetic appearance on a validated 10-point scale. Additionally, each closure was timed by handheld stopwatch. There was no significant difference between groups in infection and dehiscence rates or cosmetic scores. However, using tissue adhesive was much faster taking only 1.4 minutes compared to the 8.6 minutes suturing required

Clinical Pearls

What is the purpose of superficial skin closure?

It is important to keep in mind that the ideal superficial skin closure is intended to appose epidermal edges with a slight eversion to prevent unsightly scar depression. The deep dermal stitches are used to minimize dead-space and should bear the nearly all the tension required for closure. The superficial tissues lack the strength to hold the incision closed and tension on the superficial layer causes scar widening. This is a particularly important consideration in port placement since the bulk of the port increases the tension across the incision.

How do these results compare to the use of skin adhesives in other procedures?

Skin adhesives have not shown statistically significant differences in cosmetic outcome in traumatic wound and surgical incision closure in many different procedures on various body parts. Perhaps the most relevant of these studies comes from the Plastic Surgery literature, where Nahas et al. compared the two methods side to side in mammoplasty and along the same incision in abdominoplasty. They found no significant cosmetic difference in 3, 6, and 12 month follow up. [2] This study design helps control for patient factors by using side to side or same wound comparison. Abdominoplasty incisions are usually closed under large amounts of tension and usually require various tension reducing techniques like quilting sutures and patient positioning to reduce the risk of dehiscence. Mammoplasty closure bears some similarities to port placement closure in that they are both on the chest and over and implanted foreign bodies. However, port placement is unique in that the implant is very superficial and the patients are theoretically at higher risk for poor wound healing secondary to the diseases which the port is intended to be used to treat.

Questions to Consider

How does radiation therapy affect your decision for skin closure?

Radiation can cause skin atrophy, fibrosis, ulceration, and vessel rupture. In radiated skin, all phases of the wound healing process are disrupted to some degree. [3] Fibroblasts and keratinocytes have have reduced production of crucial growth factors as well as disorganized collagen production. This study excluded patients with prior radiation therapy to the chest or plans for radiation. There is no RCT specifically comparing the different superficial closure techniques in radiated skin, but the safe use of tissue glues has been described in breast reconstruction after radiation. [4] It is likely that radiation increases the complication risks in both tissue glue and subcuticular suture closure.

What is the role of antibiotics in port placement?

The authors of this study prophylactically administered intravenous antibiotics (cefazolin 1g or clindamycin 600 mg) and irrigated the port pocket with a saline solution containing cefazolin or clindamycin. The use of antibiotic prophylaxis in implanted central venous access ports is somewhat controversial. While many retrospective studies have found decreased infection rates, the most recent Cochrane systematic review found that prophylactic antibiotics did not reduce Gram positive infection rates in RCT’s of long-term central venous catheters in oncology patients. However, flushing and locking the catheter with a combined antibiotic and heparin solution reduced the risk of Gram positive catheter-related sepsis. [5] The 2011 Guidelines for the Prevention of Intravascular Catheter-related Infections from the CDC recommend against prophylactic antibiotics. [6]

Additional Sources

1. Duszak R Jr, Bilal N, Picus D, Hughes DR, Xu BJ. Central venous access: evolving roles of radiology and other specialties nationally over two decades. J Am Coll Radiol. 2013 Aug;10(8):603-12. doi: 10.1016/j.jacr.2013.02.002. Epub 2013 Jun 14. PMID: 23770064.

2. Nahas FX, Solia D, Ferreira LM, Novo NF. The use of tissue adhesive for skin closure in body contouring surgery. Aesthetic Plast Surg. 2004 May-Jun;28(3):165-9. Epub 2004 Jul 30. PMID: 15383885.

3. Haubner F, Ohmann E, Pohl F, Strutz J, Gassner HG. Wound healing after radiation therapy: review of the literature. Radiat Oncol. 2012 Sep 24;7:162. doi: 10.1186/1748-717X-7-162.

4. Colwell AS. Current strategies with 1-stage prosthetic breast reconstruction. Gland Surgery. 2015;4(2):111-115. doi:10.3978/j.issn.2227-684X.2015.02.05.

5. van de Wetering MD, van Woensel JB, Lawrie TA. Prophylactic antibiotics for preventing Gram positive infections associated with long-term central venous catheters in oncology patients. Cochrane Database Syst Rev. 2013 Nov 25;(11):CD003295. doi: 10.1002/14651858.CD003295.pub3. PubMed PMID:24277633.

6. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the Prevention of Intravascular Catheter-related Infections. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 2011;52(9):e162-e193. doi:10.1093/cid/cir257.

Post Author:
Charles Hyman, MS4
Warren Alpert Medical School of Brown University

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