Effect of the Abdominal Fascial Closure with Triclosan-Coated Sutures in Fecal Peritonitis,on Surgical Site Infection,and Evisceration: A Retrospective Multi-Center Study

Abstract

Background:

Surgical site infection (SSI) is a frequent complication in dirty surgery, reaching rates of up to 40%. The incidence of SSI might be influenced by the suture used for closure of the abdominal fascia. Sutures coated with antibacterial substances may reduce the bacterial load in the incision.

Patients and Methods:

A retrospective study of patients with intra-operative diagnosis of fecal peritonitis undergoing a laparotomy in three Spanish hospitals was performed. Fascial closure consisted in running loop suture of Polyglactin (Vicryl loop^®, Johnson & Johnson, New Brunswick, NY; group 1), running loop suture of triclosan-coated polyglactin (Vicryl plus loop^®; group 2), running loop suture of polydioxanone (PDS loop^® Johnson & Johnson; group 3), and running loop suture of triclosan-coated polydioxanone (PDS plus loop^®; group 4). Incisional SSI and evisceration rates were assessed.

Results:

One hundred four patients were included. There were no differences in age, gender, comorbidities, etiology of peritonitis, and mortality among groups. Surgical site infection rate was 34.6% in group 1; 8% in group 2; 33% in group 3; and 10% in group 4 (p = 0.029). The use of triclosan-coated sutures is associated with lower risk of SSI (risk ratio [RR]: 9; p = 0.003).

Evisceration rate was 0% in groups 1 and 2; 15.2% in group 3; and 10% in group 4 (p = 0.05). All patients suffering from evisceration presented previous SSI. The use of monofilament sutures is associated with higher risk of evisceration (RR: 6.35; p = 0.033).

Conclusion:

Triclosan-coated sutures reduce SSI rate in fecal peritonitis, without differences between braided and monofilament type. The use of monofilament sutures is related to higher risk of evisceration, independent of a triclosan coating.

Surgical site infections (SSIs) are among the most common complications after dirty abdominal surgery. Surgical site infections lead to an increase in morbidity, intensive care unit admissions, mortality, and re-admissions in patients undergoing surgical procedures [1 –3].

A factor that may influence the incidence of SSI is the suture used for closure of the abdominal fascia, because bacteria may adhere to the suture material [4]. There are several sutures that are coated with antibacterial substances, such as triclosan (2,4,4-trichloro-2-hydroxy-diphenylether). Triclosan is an antiseptic substance that in pre-clinical studies has been shown to reduce the bacterial load and bacterial growth in the incision by inhibiting fatty acid synthesis [5]. Triclosan-coated sutures have been tested clinically in different surgical procedures, but most studies have been performed in clean or clean-contaminated surgeries [6]. A previous study by our group demonstrated that in dirty procedures, the use of triclosan-coated polyglactin loop sutures reduces the incisional SSI rate [7]. The World Health Organization has recently published recommendations for the prevention of SSI, including the use of triclosan-coated sutures in all types of surgeries [8].

The goal of this study was to evaluate retrospectively the effect on incisional SSI and evisceration of using different types of triclosan-coated sutures (polyglactin and polydioxanone) in the abdominal fascial closure in patients with fecal peritonitis.

Patients and Methods

A retrospective study was performed in three Spanish hospitals between January 2014 and December 2015. Inclusion criteria were intra-operative diagnosis of fecal peritonitis secondary to acute diverticulitis perforation, neoplastic tumor perforation, or colorectal anastomotic leak of previous elective colorectal resection. Exclusion criteria were laparoscopic approach, a technique performed different than Hartmann procedure, re-operations for reasons other than anastomotic leak, and 30-day post-operative mortality.

The patients were divided into four groups: fascial closure with running loop suture of polyglactin 910 size number 1 (Vicryl loop^®, Johnson & Johnson, New Brunswick, NJ; group 1), running loop suture of triclosan-coated polyglactin 910 size number 1 (Vicryl plus loop^®; group 2), running loop suture of polydioxanone size number 1 (PDS loop^®, Johnson & Johnson; group 3), and running loop suture of triclosan-coated polydioxanone size number 1 (PDS plus loop^®; group 4). Subcutaneous tissue was not sutured in any group. The skin was closed with staples in all patients.

Definitions

Incisional SSI was defined according the U.S. Centers for Disease Control and Prevention (CDC) definitions of SSI (an incisional SSI must have at least one of the following features: purulent drainage; positive culture; pain, tenderness, redness and swelling) [9]. In those patients diagnosed with incisional SSI, the incision was opened deliberately by a surgeon and a microbiologic culture was obtained in all cases. Incisional SSI was evaluated during the hospital stay and 30 days after surgery in the outpatient clinic.

Evisceration was defined as the disruption of the fascial suture and presence of a viscera outside the abdominal cavity. It can be covered by the skin or not.

Variables

The investigated clinical variables were age, gender, comorbidities, etiology of fecal peritonitis, incisional SSI (including deep and superficial), evisceration, mortality, and hospital stay. Microbiologic cultures were obtained.

Statistics

Statistical analysis was performed with the statistical software SPSS 19.0 for Windows (IBM, Armonk, NY). Quantitative variables that followed a normal distribution were defined by the mean and standard deviation. For non-Gaussian variables, the median and range were used. Qualitative variables were defined by number and percentage of cases.

Comparison of variables was performed with analyis of variance (ANOVA) test (Kruskal Wallis test was used for non-Gaussian variables). Comparison of qualitative variables was performed with the χ² test; in those cases with fewer than five observations in the cell, the Fisher exact probability method was used. The effect was quantified with risk ratio (RR). A p < 0.05 was regarded as significant. The study was approved by the local ethics committees.

Results

A total of 104 patients were included in the study, 61 females (58.7%) and 43 males (41.3%), with a mean age of 64.7 ± 15.5 years. Comorbidities included diabetes mellitus (33.6%), high blood pressure (47.1%), dyslipemia (31.7%), cardiopathies (21.1%; 15.4% ischemic cardiopathy and 6.7% atrial fibrillation), and chronic obstructive pulmonary diseases (11.5%).

Fascial closure was performed with Vicryl loop in 26 patients (group 1); Vicryl plus loop in 25 (group 2); PDS loop in 33 (group 3); and PDS plus loop in 20 (group 4). Fecal peritonitis was secondary to anastomotic leak in 43 patients (41.3%), perforated colorectal cancer in 20 patients (19.2%), and perforated acute diverticulitis in 41 (39.4%). There were no differences in age, gender, and etiology of fecal peritonitis between groups (Table 1).

Table 1.

Distribution of Age, Gender, and Etiology of Fecal peritonitis among Groups

	Vicryl loop^{®^}*	Vicryl plus loop^{®^}*	PDS loop^{®^}*	PDS plus loop^{®^}*	p
n	26	25	33	20
Male/female	11/15	10/15	13/20	9/11	NS
Age	65.1 ± 14.2	64.4 ± 13.3	63.9 ± 12.8	65.8 ± 12.9	NS
Anastomotic leak	10	10	14	9	NS
Perforated neoplasm	5	4	7	4	NS
Perforated diverticulitis	11	11	12	7	NS

Johnson & Johnson, New Brunswick, NJ.

PDS = polydioxanone; NS = not significant.

Mortality was 6.7%, affecting two patients in each group, except for group 4, in which there was only one deceased patient (not significant; NS). Mortality cause was multi-organ failure secondary to septic status in all cases. Median hospital stay was 10 days (range, 7–37 d) in group 1; 7.5 days (range, 6–26 d) in group 2; 9.5 days (range,7–64 d) in group 3; and 8 days (range, 5–31 d) in group 4 (p = 0.044). Median hospital stay was shorter in those patients undergoing fascial closure with triclosan-coated sutures (p = 0.013).

The incisional SSI rate was 34.6% in group 1; 8% in group 2; 33% in group 3; and 10% in group 4 (p = 0.029). The use of triclosan-coated sutures is associated with lower risk of SSI (RR: 9; 95% confidence interval [CI] 3.1– 26.4; p = 0.003).

Intra-operatively, microbiologic samples of intra-peritoneal fluids were obtained from all patients. Detected micro-organisms are described in Table 2. There were no significant differences in the microbiologic cultures among groups. A microbiologic sample was also obtained in all patients with incisional SSI. A reduction in the SSIs caused by Escherichia coli and Streptococcus spp. was observed in the patients undergoing fascial closure with triclosan-coated sutures (Table 3).

Table 2.

Microbiologic Cultures of Intra-Peritoneal Fluids in All Patients

	Vicryl loop^{®^}*	Vicryl plus loop^{®^}*	PDS loop^{®^}*	PDS plus loop^{®^}*
n	26	25	33	20
Escherichia coli	23 (88%)	22 (88%)	30 (90.,9%)	17 (85%)
Streptococcus spp.	7 (26.9%)	6 (24%)	9 (27.3%)	5 (25%)
Enterococcus faecalis	10 (38.5%)	9 (36%)	12 (36.4%)	7 (35%)
Pseudomonas aeruginosa	3 (11.5%)	2 (8%)	3 (9.1%)	2 (10%)
Klebsiella spp.	2 (7.7%)	3 (12%)	3 (9.1%)	2 (10%)
Bacteroides fragilis	11 (42,3%)	10 (40%)	13 (39.4%)	8 (40%)

Johnson & Johnson, New Brunswick, NJ.

PDS = polydioxanone.

Table 3.

Microbiologic Cultures of Incision Exudates in Patients with Incisional Surgical Site Infection

	Group 1 (n = 9)	Group 2 (n = 2)	Group 3 (n = 11)	Group 4 (n = 2)	p
Escherichia coli	5 (55.6%)	0	6 (54.5%)	0	0.002
Klebsiella spp.	2 (22.2%)	1 (50%)	3 (27.3%)	1 (50%)	NS
Pseudomonas aeruginosa	1 (11.1%)	0	2 (18.2%)	0	NS
Enterococcus faecalis	0	1 (50%)	1 (9.1%)	1 (50%)	NS
Strptococcus spp.	2 (22.2%)	0	3 (27.3%)	0	0.045

NS = not significant.

Evisceration rate was 0% in groups 1 and 2; 15.2% in group 3; and 10% in group 4 (p = 0.05). All patients with evisceration presented previous SSIs. The use of monofilament sutures is associated with higher risk of evisceration (RR: 6.35; 95% CI 2.2–19.4; p = 0.033).

Discussion

Suture materials play an important role in the development of SSI by providing a local surface for the adherence of micro-organisms. Accordingly, the strategy of coating sutures with antimicrobial agents to reduce the risk of suture-related SSI has been considered. Triclosan passively dissipates from implanted sutures to the surrounding tissues, creating a barrier against bacterial colonization [4,10]. Although pre-clinical studies have shown that triclosan-coated sutures reduce the growth of gram-positive and gram-negative bacteria [11,12], clinical results have been conflicting for several years. Chang et al. [13] concluded in a systematic review that triclosan-impregnated sutures do not decrease the rate of SSI, but also pointed out that the quality of the studies were moderate. However, the meta-analysis of Wang et al. [14] including 17 randomized controlled trials and involving 3,720 participants, reported that triclosan-coated sutures showed a significant advantage in reducing the SSI rate by 30%. Subgroup analysis revealed consistent results in favor of triclosan-coated sutures in abdominal procedures, but only in clean or clean-contaminated surgical incisions. Furthermore, the actual WHO recommendations include the use of triclosan-coated sutures in all types of surgeries [8].

The greatest heterogeneity in studies is observed in contaminated and dirty surgery. Whereas most authors report no advantage provided by the use of triclosan-coated sutures in these procedures, our previous clinical trial demonstrated an 80% reduction of incisional SSI when using triclosan-coated sutures [7]. The present study even shows a greater effect with a nearly 90% reduction.

In vitro studies have shown that triclosan can reduce the inoculates of Escherichia coli and Staphylococcus aureus by 90%–99.9% [12,17]. However, some bacteria have shown a resistance to triclosan, such as Pseudomonas aeruginosa, which possesses multi-drug efflux pumps that remove triclosan from the cell [16]. These data are confirmed in our patients, presenting a significant reduction in the involvement of Escherichia coli in the incisional SSI in the triclosan group, whereas Pseudomonas aeruginosa shows an insignificant reduction. However, triclosan has been shown to be effective against gram-positive bacteria; although most studies have evaluated only Staphylococcus aureus [12], the bacterostatic efficacy of triclosan can be extrapolated to Streptococcus spp., as in the present study.

Despite the fact that in all cases presenting with evisceration previous incisional SSI was consistent, it is remarkable that monofilament sutures lead to a higher incidence of evisceration. Current evidence supports the use of absorbable monofilament sutures for abdominal fascial closure, mainly based on the fact that braided sutures provide a better surface for the adherence of micro-organisms [17]. Once pathogens have colonized suture materials, a biofilm may form subsequently and promote attachment and reinforce resistance against the attack from the host's immune system and antibiotic treatment, thus predisposing to SSI [4,10]. In our patients, there was no difference in the SSI rate between closures performed with monofilament or with braided sutures. The only significant fact was the triclosan coating, which reduced the SSI rate. We must assume that actual recommendations for abdominal wall closure are based on elective laparotomies and little is still known about emergency surgery, like the present one. Another relevant fact is that in all cases of evisceration, the suture material remained completely unaltered on one side of the fascial section but the opposite site of the fascia was torn. Given that evisceration is clearly associated with incisional SSI, we may hypothesize that an infected fascia could be affected by an inflammatory response and consequently the tissue tends to be edematous and/or infiltrated by inflammatory cells. This infiltration probably leads to a loss of cohesion between the fibers of the fascial tissue, resulting in a dislaceration of the anatomic structures and a suture release. Braided sutures probably have greater friction with the fascial tissue, allowing better anchorage.

Conversely, it is widely known that when knotting monofilament, cuts to the fingers often occur, yet the gloves remain unaltered; this does not happen often when knotting a braided suture. Similarly, the damaged infected fascia can be cut progressively with the monofilament but this might not occur with braided sutures. Future studies must be conducted in dirty or contaminated surgeries to confirm these results.

The main limitation of this study is its retrospective nature. Moreover, the sample size is too small to analyze four groups. However, the relevant results we obtained support this study as a starting point for future prospective randomized clinical trials that focus only on dirty surgeries and analyze the different types of sutures, braided or monofilaments, and uncoated or coated with triclosan.

Conclusion

Triclosan-coated sutures reduce SSI rate in fecal peritonitis with no differences between braided and monofilament ones. The use of monofilament sutures is related to higher risk of evisceration, independent of a triclosan coatin.

Footnotes

Author Disclosure Statement

The authors declare that they have no conflict of interest.

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