“I will take glue with stitches”: A comparison of skin closure techniques in pancreaticoduodenectomy

Abstract

Background: Surgical site complications are one of the most closely monitored and prevalent post-operative problems, occurring in as many as 15 to 28% of patients that undergo pancreaticoduodenectomy. Wound complications not only affect patient recovery and quality of life, but also negatively impact quality metrics like cost and hospital length of stay. With many closure techniques available, we sought to determine if any closure method (subcuticular stitch vs. subcuticular stitch + skin sealant vs. staples) provided a benefit of reduced post-pancreatoduodenectomy wound complications. Methods: All patients that underwent open pancreatoduodenectomy from June 2015 to June 2018 were reviewed and grouped based on wound closure (subcuticular stitch vs. subcuticular stitch + skin sealant vs. staples). We performed a retrospective review of our institution’s prospective ACS-NSQIP database and augmented it through medical record review for wound closure method and superficial surgical site complications (SSSC). These included cellulitis, seroma, abscess, fat necrosis, and other. Closure groups were compared using independent samples t-test/analysis of variance and chi-square test for continuous and categorical variables respectively. Univariable analysis and multivariable regression models were used to examine the effect of wound closure method on the various post-operative outcomes, while controlling for pre-operative and peri-operative covariables. Results: A total of 418 pancreatoduodenectomies were included on study (N=74 subcuticular stitch, N= 205 subcuticular stitch + skin sealant, N=139 stapled). Operative time did not differ between groups. There was a significant difference in the incidence of SSSC between wound closure methods. Patients with subcuticular stitch + skin sealant (9.8%) were significantly less likely to develop a SSSC compared to patients with stapled closure (20.1%) on univariable (p=0.009) and multivariable analyses (p=0.016; OR 0.37). A similar though insignificant trend was seen for patients with subcuticular stitch + skin sealant (9.8%) compared to suture alone closure (16.2%) on univariable (p=0.142) analysis. Unadjusted length of stay was significantly longer for stapled closure (11.9 days) compared to subcuticular stich + skin sealant (9.6 days) and subcuticular stitch alone (9.8 days) (p<0.05), but did not reach significance on multivariable analysis. Conclusion: Subcuticular suture with skin sealant after pancreaticoduodenectomy appears to be the preferred method for skin closure to reduce the risk of superficial surgical site complications. A change of practice and prospective study of this technique is warranted in light of this data.