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7th April - Randomized double-blind trial comparing the cosmetic outcome of cutting diathermy versus scalpel for skin incisions

Quote from Tomisin Ashiru on 7th April 2016, 7:25 pm

one thing i notice d about the sample size was that 9 patients withdrew from the trial, bringing the data set to 57 rather than the 66 they seem to focus on. would this not mean that the study was lacking the original power stated to be needed?

I thought the nine patients who withdrew were left out of the analysed data. Maybe could be stated more clearly?

I think on the majority Caucasian point, I think it will be a manifestation of excluding keloid scars.

I think 66 were initially included but only 57 at 6 months but i'm not too sure that the 9 that didn't get followed up at 6 months should have been included in the study at all

I think the skin closure method is an important point and one that may overlap with the point that it may be important to know the grade of the doctor closing the incision?

On that point Nick, a criticism that could be made is that we dont know whether the demographic of the two groups at follow up was balanced as the stated demographics is for all 66 patients

Quote from Rayko Kalenderov on 7th April 2016, 7:29 pm
Quote from Tomisin Ashiru on 7th April 2016, 7:25 pm

one thing i notice d about the sample size was that 9 patients withdrew from the trial, bringing the data set to 57 rather than the 66 they seem to focus on. would this not mean that the study was lacking the original power stated to be needed?

I thought the nine patients who withdrew were left out of the analysed data. Maybe could be stated more clearly?

yes, but it pulls into question whether the data remaining had enough power to draw conclusions from, based on their stated minimum of 60. Or doesn't it?

Is there any reason to think that altering the power setting of the diathermy would have impacted results? The paper talks about a "35-W pure cutting mode diathermy with diathermy blade" but I wasn't 100% sure if this was a reference to the power of the thing or a brand name etc.

 

I think the 60 people required included a 10% addition for drop outs so 57 may be ok?

Quote from Tomisin Ashiru on 7th April 2016, 7:36 pm
yes, but it pulls into question whether the data remaining had enough power to draw conclusions from, based on their stated minimum of 60. Or doesn't it?
Yes, that's what I meant by suggesting the authors could have described it more clearly.

 

I think the diathermy setting would have had a big impact on the results. On that note we dont know how well haemostasis was achieved using this 35W setting and how long it took compared to the scalpel

Quote from william on 7th April 2016, 7:37 pm

Is there any reason to think that altering the power setting of the diathermy would have impacted results? The paper talks about a "35-W pure cutting mode diathermy with diathermy blade" but I wasn't 100% sure if this was a reference to the power of the thing or a brand name etc.

 

I think this is the power and mode the diathermy was set to, i'm not sure if this is the standard settings for making an abdominal incision though or one they have chosen? furthermore could they have tried different powers?

Quote from Nick Ward on 7th April 2016, 7:38 pm

I think the 60 people required included a 10% addition for drop outs so 57 may be ok?

Ah ok, forgot about that bit. Thanks

Cutting through the skin without burning the edges is fine but if inadequate haemostasis is achieved at that setting you havent really saved any operating time

Quote from Daniel Lewis on 7th April 2016, 7:39 pm

I think the diathermy setting would have had a big impact on the results. On that note we dont know how well haemostasis was achieved using this 35W setting and how long it took compared to the scalpel

Forgive my ignorance, but is there a standard for reaching adequate haemostasis using diathermy or is it down to experience/judgement?

Its a good question. In terms of standard time for cutting through the skin, it should be quick - seconds really.  What adds time is coagulating bleeding vessels which in the abdomen are mainly veins dermis and subcutaneous fat. The idea of using a dithermy is that it saves time as you can cut through skin and then straight into the fat, but if the diathermy setting is too low (to avoid skin burns) then its ability to stop every bleeding vessel may be lost

What do people think of the author's conclusions and do they really matter?

And would anyone change their practice based on this paper?

I think the conclusions made were reflective of the results found in the paper, i'm not too sure how much clinical value they will have though and it seems that although with a smaller sample size these conclusions have been found in previous studies

The point about increased safety in the conclusion was a relevant one

The author acknowledges that the results of the study aren't suitable to be extrapolated, so it could be fair to say the impact this study has is quite limited

I agree, scalpels are more dangerous to users. But what about to the patient, especially those with pacemakers?

The discussion section makes effort to evaluate the literature and compare the results of the study to the existing evidence. However, there was little mention of the limitations or suggestions for further research, I felt.

I'm aware that we are coming up towards an hour, has anyone got any further points to make on any of the issues raised or anything they would like to discuss on the paper?

 

the conclusions back up other meta analyses and add to the body of evidence that agrees with those conclusions. However the pain point is over emphasised, there doesn't seem to be any advantage specifically for either technique (possible time-to-haemostasis but that wasnt measured or explored) so no, I dont think its owrth changing clinical practice over. It just seems to suggest either surgical preference or tool available is fine

I think it is quite a bold statement to recommend diathermy over scalpel use based on the results and discussion they presented, the evidence isn't overwhelming either way.