A sutureless technique using cyanoacrylate adhesives when creating a stoma for extremely low birth weight infants

As intestinal perforation in ELBW infants is likely to result in mortality or long-term
serious consequences, and the surgical treatment of intestinal perforation in ELBW
infants is still challenging (Eicher et al. 2012]; Rees et al. 2007]; Murthy et al. 2014]). Although the standard approach for patients with an intestinal perforation is surgical
resection of the involved bowel with the creation of intestinal stomas, several authors
have suggested that primary peritoneal drainage under local anesthesia is better than
laparotomy in ELBW infants. These studies used peritoneal drainage based on the belief
that these infants could not tolerate laparotomy (Michel et al. 2004]; Gollin et al. 2003]). While peritoneal drainage may offer some initial advantages because it is relatively
easy to perform and less invasive than surgery, a subsequent laparotomy is required
for clinical deterioration and bowel trouble in 28–74 % of cases (Moss et al. 2006]; Rees et al. 2008]; Hunter et al. 2008]; Sola et al. 2010]). The special problems related to a laparotomy in ELBW infants include an increased
susceptibility to infection, water and heat loss from the exposed bowel, and postoperative
ventilator difficulties due to abdominal distension (Lai et al. 2010]). The key factor associated with a successful abdominal surgery in ELBW infants includes
the use of a minimally invasive technique. It has been reported that 2-octyl cyanoacrylate,
a tissue adhesive, can be safely and effectively used as a superficial wound closure
alternative (Singer and Thode 2004]; Coulthard et al. 2004]; Farion et al. 2002]). Experimental intestinal anastomosis for the bowel using 2-octyl cyanoacrylate has
been reported (Paral et al. 2011]; Irkorucu et al. 2009]; Kanellos et al. 2002]). Cyanoacrylate adhesives allow for a shorter operation and resulted in greater satisfaction
for both patients and surgeons in comparison to sutures (Farion et al. 2002]). Furthermore, their use is associated with fewer infections, easier wound management,
and subsequently, is more cost-effective (Wong et al. 2011]; Aslam and Hunter 2009]).

The complications of intestinal stomas in ELBW infants are often caused by the surgical
techniques used. The thickness of the bowel wall in ELBW infants is similar to the
diameter of the needles commonly used, which is 70 ?m for 6-0, and 100 ?m for 5-0
(Faingold et al. 2005]; Epelman et al. 2007]). It is therefore understandable that a needle stick can easily lead to a penetration
of the bowel wall (Rygl et al. 2009]; Faingold et al. 2005]; Epelman et al. 2007]). Tissue adhesives do not require needles, and thus eliminate the risk of breaking
the bowel wall. Indeed, the present study showed no complications associated with
stoma creation in our cases. The appearance of the stoma was relatively good, and
it was easy to manage the skin around the stomas.

In this study, the use of cyanoacrylate adhesive did not reduce the length of the
operation compared to the prior cases where sutures were used (data not shown). The
length of the operation is affected not only by surgical procedures, including inspection
of the affected bowel and stoma creation, but also the degree of intraperitoneal adhesion
due to peritonitis. Thus, given the complicated nature of the procedure and the poor
general health of ELBW infants, it was not surprising that there was no significant
decrease in the length of the operation. The mortality of affected patients is associated
with various factors, such as sepsis, peritonitis, the general condition and the degree
of existing IVH (intraventricular hemorrhage) at the time of the surgery. This study
demonstrated that the use of the liquid tissue adhesive for creating a stoma in ELBW
infants could reduce the incidence of postoperative complications related to stoma
creation, thus improving the outcome for the patients. Cyanoacrylate adhesives can
simplify the surgical techniques, and thus make such patients easier to manage.

In conclusion, this study demonstrated that the use of cyanoacrylate adhesives in
ELBW infants may have the potential to reduce the length of the operation and the
incidence of complications related to the stoma. Although accumulation and analysis
of large numbers of ELBW infants and cumulative data of using this sutureless technique
are needed to verify this safety observation, this pilot study showed the use of cyanoacrylate
tissue adhesives is recommended as alternative for stoma creation in these premature
infants.