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Staples or sutures for chest and leg wounds following cardiovascular surgery Aliu Sanni and Joel Dunning

Interact CardioVasc Thorac Surg 2007;6:243-246; originally published online Jan 25, 2007; DOI: 10.1510/icvts.2006.151076

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://icvts.ctsnetjournals.org/cgi/content/full/6/2/243

Interactive Cardiovascular and Thoracic Surgery is the official journal of the European Association for Cardio-thoracic Surgery (EACTS) and the European Society for Cardiovascular Surgery (ESCVS). Copyright 2007 by European Association for Cardio-thoracic Surgery. Print ISSN: 1569-9293.

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doi:10.1510/icvts.2006.151076

Interactive CardioVascular and Thoracic Surgery 6 (2007) 243246 www.icvts.org

Best evidence topic - Cardiac general

Staples or sutures for chest and leg wounds following cardiovascular surgery
Aliu Sanni, Joel Dunning*
Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK Received 27 December 2006; accepted 4 January 2007

Summary 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. 2007 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Staples; Sutures; Skin closure; Thoracic surgery; Wounds

1. Introduction A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS w1x. 2. Clinical scenario 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 In wpatients undergoing cardiac operationsx is the use of wstaples or sutures for wound closurex of benefit in reducing the wincidence of wound infectionsx? 4. Search strategy Medline 1966Dec 2006 using OVID interface. wexp Thoracic surgeryy OR cardiac surgery.mp OR thoracic surgery.mp OR exp Coronary Artery Bypassy OR CABG.mp
*Corresponding author. Tel.: q44-780-1548122; fax: q44-780-1548122. E-mail address: joeldunning@doctors.org.uk (J. Dunning). 2007 Published by European Association for Cardio-Thoracic Surgery

OR exp cardiac surgical proceduresyx AND wexp Suture Techniquesy OR skin closure.mp OR wound closure.mp OR intracutanoue.mp OR transcutaneous.mp OR Clip$x AND wwound$.mp OR infection$.mpx 5. Search outcome 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 w24x and Karabay w5x 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 Five randomized controlled trials were identified which investigated sutures and staple techniques for chest and leg wounds following cardiovascular procedures. Angelini et al. w6x 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.

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244 Table 1 Best evidence papers Author, date and country Wolterbeek et al., 2002, Eur J Vasc Endovasc Surg, Holland, w10x PRCT (level 1b) Patient group 170 consecutive patients undergoing femoro-popliteal or femoro-tibial bypass surgery 84 patients were randomized into each group of either continuous polyamide suture wound closure or metallic skin staples wound closure Outcomes Superficial infections Key results Suture group 6y77 (8%) Staple group 2y83 (2%) Psns Suture group 1y77 (1%) Staple group 1y83 (1%) Psns Suture group 6.4 min Staple group 2.7 min P-0.001 Dexon vs. Staples (1.2 vs. 1.6) P-0.05 Dexon vs. Op-site (1.2 vs. 2.2) P-0.001 Wound infection (Median) Cosmetic results Dexon vs. Staples (0 vs. 1) P-0.05 Cosmetic results of subcuticular suture superior to staples Sutures superior for complication rate and cosmesis Weaknesses A total of 10 patients were excluded from the study after randomization No information on cosmetic result No difference between staples and sutures A. Sanni, J. Dunning / Interactive CardioVascular and Thoracic Surgery 6 (2007) 243246

Deep infections

Wound closure time

Angelini et al., 1984, Thorax, UK, w6x PRCT (level 1b)

113 patients undergoing coronary artery bypass surgery were randomized into four groups for closure of leg wounds after saphenous vein harvest: a- Nylon vertical mattress suture (ns27) b- Dexon continuous subcuticular suture (ns29) c- Staples (ns27) d- Op-site sutureless adhesive (ns30)

Wound discharge (Median)

Sutures superior to staples for discharge and cosmesis

Johnson et al., 1997, Ann Surg, USA, w7x PRCT (level 1b)

242 patients undergoing coronary artery bypass graft surgery with sternal and saphenous vein harvest wounds had half of each wound closed with staples and other half with intradermal suture

Wound complications a-Leg wound

Suture group 32.6% Staple group 46.9% Ps0.001 Suture group 3.7% Staple group 14.9% Ps0.00005

b-Chest wound

Infections a-Leg wound

Suture group 9.3% Staple group 8.9% Psns Suture group 0.4% Staple group 2.5% Ps0.06 Leg Sutures 62% Staples 21.1% No Preference 16.9% Chest Suture 61.8% Staples 20.0% Preference 18.2%

b-Chest wound

Patients preference

Chughtai et al., 2000, Can J Cardiol, Canada, w9x PRCT (level1b)

162 patients undergoing CABG equally randomized into having their sternal and leg incisions closed with either suture or skin staples

Chest Superficial Infections

Suture group 1y81 (1.2%) Staple group 6y81 (7.4%) Ps0.05

Significantly higher number of diabetics were in the skin clips closure group

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A. Sanni, J. Dunning / Interactive CardioVascular and Thoracic Surgery 6 (2007) 243246 Table 1 (Continued) Author, date and country Patient group Outcomes Deep Infections Key results Suture group 0y81 (0%) Staple group 2y81 (2.5%) Ps0.15 Suture group 74y81 (91%) Staple group 71y81 (88%) Psns Weaknesses The skin clips cost three times more than sutures Sutures had a significantly lower chest infection rate but similar cosmetic results 245

Cosmetic scale

Leg Infections

Suture group 9y81 (11%) Staple group 9y81 (11%) Psns Suture group 65y81 (80%) Staple group 69y81 (85%) Psns Group Group Group Group Psns Group Group Group Group Psns 1: 2: 3: 4: 4.4"0.2 4.6"0.1 4.2"0.2 4.4"0.2 1 and 2 patients excluded from the initial 20 patients enrolled into groups 4 and 3, respectively No differences between sutures and staples No cosmetic differences

Cosmetic scale

Mullen et al., 1999, Can J Cardiol, Canada, w8x PRCT (level 1b)

77 patients undergoing elective CABG surgery were randomized into four groups: Group 1 (ns20): staples, close immediately Group 2 (ns20): staples, close after protamine Group 3 (ns19): subcuticular sutures, close immediately Group 4 (ns18): subcuticular sutures, close after protamine

Wound quality score of 05

Infection

1: 2: 3: 4:

3y20 3y20 1y17 1y19

(15%) (50%) (6%) (5.3%)

In addition, the cosmetic results of the subcuticular sutures were superior to staples. Johnson et al. w7x 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. w8x 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. w9x 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. w10x 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 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.

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246 A. Sanni, J. Dunning / Interactive CardioVascular and Thoracic Surgery 6 (2007) 243246 w9x Chughtai T, Chen LQ, Salasidis G, Nguyen D, Tchervenkov C, Morin JF. Clips versus suture technique: is there a difference? Can J Cardiol 2000;16:14031407. w10x Wolterbeek JH, van Leeuwen AA, Breslau PJ. Skin closure after infrainguinal bypass surgery: a prospective randomised study. Eur J Vasc Endovasc Surg 2002;23:321324.

References
w1x Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interactive CardioVasc Thorac Surg 2003;2:405409. w2x 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;36:378382. w3x 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. wsee commentx. Eur J Cardiothorac Surg 2002;22:271277. w4x 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. wsee commentx. Ann Thorac Surg 2001;72:15871591. w5x 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;32:277282. w6x Angelini GD, Butchart EG, Armistead SH, Breckenridge IM. Comparative study of leg wound skin closure in coronary artery bypass graft operations. Thorax 1984;39:942945. w7x 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;226:606612. w8x 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;15:6568.

ICVTS on-line discussion A


Title: Advantages of suture closure of sternotomy incision wound Author: Anand Sachithanandan, Birmingham Heartlands Hospital, Birmingham B9 5SS, UK doi:10.1510/icvts.2006.151076A eComment: The authors conclude that subcuticular suture closure of leg and sternal skin incisions is superior in comparison with stapled closure in that the former is more cosmetic and has a lower infection rate w1x. There are two other benefits of sternal wound suture closure. Firstly, this provides the most junior trainee (often delegated with skin closure) further opportunity to develop suturing skills. Second as noted, stapled closure is quicker than suture closure however ironically re-opening of the sternal closure is much quicker if subcuticular sutures are used instead of staples. This may be important when rapid and expeditious re-opening of the sternotomy wound is required in an emergent situation in the intensive care unit. Reference w1x Sanni AO, Dunning J. Staples or sutures for chest and leg wounds following cardiovascular surgery. Interact CardioVasc Thorac Surg 2007; 6:243246.

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Staples or sutures for chest and leg wounds following cardiovascular surgery Aliu Sanni and Joel Dunning Interact CardioVasc Thorac Surg 2007;6:243-246; originally published online Jan 25, 2007; DOI: 10.1510/icvts.2006.151076 This information is current as of June 14, 2011
Updated Information & Services References Citations Subspecialty Collections including high-resolution figures, can be found at: http://icvts.ctsnetjournals.org/cgi/content/full/6/2/243 This article cites 10 articles, 4 of which you can access for free at: http://icvts.ctsnetjournals.org/cgi/content/full/6/2/243#BIBL This article has been cited by 3 HighWire-hosted articles: http://icvts.ctsnetjournals.org/cgi/content/full/6/2/243#otherarticles This article, along with others on similar topics, appears in the following collection(s): Cardiac - other http://icvts.ctsnetjournals.org/cgi/collection/cardiac_other Education http://icvts.ctsnetjournals.org/cgi/collection/education Coronary disease http://icvts.ctsnetjournals.org/cgi/collection/coronary_disease Requests to reproducing this article in parts (figures, tables) or in its entirety should be submitted to: icvts@ejcts.ch For information about ordering reprints, please email: icvts@ejcts.ch

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