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Staples or sutures for chest and leg wounds following cardiovascular surgery

Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK

Received 27 December 2006; accepted 4 January 2007

*Corresponding author. Tel.: +44-780-1548122; fax: +44-780-1548122.

E-mail address: joeldunning{at}doctors.org.uk (J. Dunning).

	Abstract

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Results 7. Conclusion References

 
A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question asked was whether the use of skin sutures or skin staples for chest and leg wounds in patients following cardiovascular surgery reduces the incidence of wound infections. Altogether 119 abstracts were found using the reported search, of which five randomized controlled trials, represented the best evidence on this topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We concluded in the five randomized controlled trials in cardiovascular surgery that compared staples with suture closure, three out of five found that the complication rate was lower with sutures and the other two found no difference. With regard to cosmesis, two of the five studies found sutures to be superior and the remaining papers found no difference. We conclude that sutured skin closure for leg and chest wounds is superior to stapled closure.

Key Words: Staples; Sutures; Skin closure; Thoracic surgery; Wounds

	1. Introduction

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Results 7. Conclusion References

 
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].

	2. Clinical scenario

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Results 7. Conclusion References

 
You have just seen a patient in clinic who had his saphenous vein harvest incision closed using staples six weeks ago. You see that there are two series of staple marks either side of the incision which looks ugly to you. You mention it to the surgeon who performed the harvest and he states that actually the incidence of infection is much lower with staples compared to sutures as you can take single ones out in local areas, and they hold better also. You resolved to look up the evidence to back up these comments.

	3. Three-part question

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Results 7. Conclusion References

 
In [patients undergoing cardiac operations] is the use of [staples or sutures for wound closure] of benefit in reducing the [incidence of wound infections]?

	4. Search strategy

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Results 7. Conclusion References

 
Medline 1966–Dec 2006 using OVID interface.

[exp Thoracic surgery/ OR cardiac surgery.mp OR thoracic surgery.mp OR exp Coronary Artery Bypass/ OR CABG.mp OR exp cardiac surgical procedures/] AND [exp Suture Techniques/ OR skin closure.mp OR wound closure.mp OR intracutanoue.mp OR transcutaneous.mp OR Clip$] AND [wound$.mp OR infection$.mp]

	5. Search outcome

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Results 7. Conclusion References

 
A total of 119 abstracts were found of which nine seemed relevant. Several papers in general surgery, obstetrics and plastic surgery were also found but as there were five RCTs in our own specialty these were regarded as non-contributary to answering the question. The papers by Risnes [2–4] and Karabay [5] were assessed in full but found not to be relevant in the comparison between sutures and staples, thus five papers represented the best evidence. These are presented in Table 1.

	6. Results

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Results 7. Conclusion References

Angelini et al. [6] in 1984 performed a PRCT separating 113 patients into four groups. The leg wounds were either closed with continuous nylon vertical mattress suture (Ethicon), continuous subcuticular absorbable suture (Dexon), metal skin staples (Premium) or adhesive sutureless skin closure material (Op-site). The use of continuous subcuticular suture (Dexon) resulted in significantly less wound infection when compared to any of the other modalities. In addition, the cosmetic results of the subcuticular sutures were superior to staples.

Johnson et al. [7] in 1997 prospectively compared 242 patients with sternal and saphenous vein harvest wounds. These wounds were closed half way with staples and the other half with intradermal sutures. Wound infection rates were found to be similar using either staples or intradermal sutures in chest and leg wound closure. There was, however, a significantly higher complication rate (defined as drainage, erythema, separation, necrosis, seroma or infection) using staple closure for either chest or leg wounds. Sixty-two percent of patients preferred leg closure with sutures compared to 20% preferring staples.

Mullen et al. [8] in 1997, using a PRCT, allocated 77 patients into one of four leg wound closure groups: Staples, close immediately; staples, close after protamine administration; subcuticular sutures, close immediately; subcuticular sutures, close after protamine administration. None of the above stated techniques were found to be superior in terms of wound infection rates or cosmetic results.

Chughtai et al. [9] in 2000 performed a PRCT comparing outcomes between subcuticular suture technique and skin stapling technique for closure of sternal and leg incisions in 162 CABG patients. There was a tendency towards increased wound infections when staples were used for both chest and leg incision closure. Cosmetic outcomes were similar but the staples cost three times as much as the sutures.

Wolterbeek et al. [10] in 2002 performed a randomized control trial on 170 patients undergoing infrainguinal bypass surgery. These patients were allocated into a skin staple or skin suture wound closure group. There was no significant difference in the occurrence of superficial or deep infections following the use of either material in wound closure. However, using staples for wound closure this took only 2.7 min when compared to skin suture which took 6.4 min.

	7. Conclusion

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Results 7. Conclusion References

 
Of the five randomized controlled trials in cardiovascular surgery that compared staples with suture closure, three of the five studies found that the complication rate was lower with sutures and the other two found no difference. With regard to cosmesis, two of the five studies found sutures to be superior and the remaining papers found no difference. We conclude that sutured skin closure for leg and chest wounds is superior to stapled closure.

	References

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Results 7. Conclusion References

 

1. Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interactive CardioVasc Thorac Surg 2003; 2:405–409.[Abstract/Free Full Text]
2. Risnes I, Abdelnoor M, Lundblad R, Baksaas ST, Svennevig JL. Leg wound closure after saphenous vein harvesting in patients undergoing coronary artery bypass grafting: a prospective randomized study comparing intracutaneous, transcutaneous and zipper techniques. Scand Cardiovasc J 2002; 36:378–382.[CrossRef][Medline]
3. Risnes I, Abdelnoor M, Lundblad R, Baksaas ST, Svennevig JL. Sternal wound closure in patients undergoing open-heart surgery: a prospective randomized study comparing intracutaneous and zipper techniques. [see comment]. Eur J Cardiothorac Surg 2002; 22:271–277.[Abstract/Free Full Text]
4. Risnes I, Abdelnoor M, Baksaas ST, Lundblad R, Svennevig JL. Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques. [see comment]. Ann Thorac Surg 2001; 72:1587–1591.[Abstract/Free Full Text]
5. Karabay O, Fermanci E, Silistreli E, Aykut K, Yurekli I, Catalyurek H, Acikel U. Intracutaneous versus transcutaneous suture techniques: comparison of sternal wound infection rates in open-heart surgery patients. Tex Heart Inst J 2005; 32:277–282.[Medline]
6. Angelini GD, Butchart EG, Armistead SH, Breckenridge IM. Comparative study of leg wound skin closure in coronary artery bypass graft operations. Thorax 1984; 39:942–945.[Abstract]
7. Johnson RG, Cohn WE, Thurer RL, McCarthy JR, Sirois CA, Weintraub RM. Cutaneous closure after cardiac operations: a controlled, randomized, prospective comparison of intradermal versus staple closures. Ann Surg 1997; 226:606–612.[CrossRef][Medline]
8. Mullen JC, Bentley MJ, Mong K, Karmy-Jones R, Lemermeyer G, Gelfand ET, Koshal A, Modry DL, Penkoske PA. Reduction of leg wound infections following coronary artery bypass surgery. Can J Cardiol 1999; 15:65–68.[Medline]
9. Chughtai T, Chen LQ, Salasidis G, Nguyen D, Tchervenkov C, Morin JF. Clips versus suture technique: is there a difference? Can J Cardiol 2000; 16:1403–1407.[Medline]
10. Wolterbeek JH, van Leeuwen AA, Breslau PJ. Skin closure after infrainguinal bypass surgery: a prospective randomised study. Eur J Vasc Endovasc Surg 2002; 23:321–324.[CrossRef][Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joel Dunning Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sanni, A. Articles by Dunning, J. Search for Related Content PubMed PubMed Citation Articles by Sanni, A. Articles by Dunning, J. Related Collections Education Cardiac - other Coronary disease Related Article