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Three Part Question

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

Clinical Scenario

You have just seen a patient in clinic who had his saphenous vein harvest incision closed using staples 6 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.

Search Strategy

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]

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 5 RCTs in our own specialty these were regarded as non-contributary to answering the question. The papers by Risnes and Karabay were assessed in full but found not to be relevant in the comparison between sutures and staples thus 5 papers represented the best evidence. These are presented in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Angelini et al, 1984, UK	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(n=27) b- Dexon continuous subcuticular suture (n=29) c- Staples (n=27) d- Op-site sutureless adhesive (n=30)	PRCT (level 1b)	Wound discharge (Median)	Dexon vs. Staples (1.2 vs. 1.6) P<0.05 Dexon vs. Op-site (1.2 vs. 2.2) P<0.001	Sutures superior to staples for discharge and cosmesis.
			Wound infection (Median)	Dexon vs. Staples (0 vs. 1) P<0.05
			Cosmetic result	Cosmetic results of Subcuticular suture superior to staples
Johnson et al, 1997, USA	242 patients undergoing coronary artery bypass graft surgery with sternal & saphenous vein harvest wounds had half of each wound closed with staples and other half with intradermal suture.	PRCT (level 1b)	Wound complications	Leg wound: Suture group 32.6% Staple group 46.9% p=0.001 Chest wound: Suture group 3.7% Staple group 14.9% p=0.00005	Sutures superior for complication rate and cosmesis.
			Infections	Leg wound: suture group 9.3% Staple group 8.9% p=ns Chest wound: Suture group 0.4% Staple group 2.5% p=0.06
			Patients preference	Leg: Sutures 62% Staples 21.1% No preference 16.9% Chest: Suture 61.8% Staples 20.0% No preference 18.2%
Mullen et al, 1999, Canada	77 patients undergoing elective CABG surgery were randomized into four groups: Group 1 (n=20): staples, close immediately Group 2 (n=20): staples, close after protamine Group 3 (n=19): subcuticular sutures, close immediately Group 4 (n=18): subcuticular sutures, close after protamine.	PRCT (level 1b)	Wound quality score of 0-5	Grp1: 4.4±0.2, Grp2: 4.6±0.1, Grp3: 4.2±0.2, Grp4: 4.4±0.2, P=ns	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
			Infection	Group1: 3/20 (15%), Group 2: 3/20 (50%), Group 3:1/17 (6%), Group 4:1/19 (5.3%), p=ns
Chughtai et al, 2000, Canada	162 patients undergoing CABG equally randomized into having their sternal & leg incisions closed with either suture or skin staples.	PRCT (level 1b)	Chest	Superficial Infections: Suture group 1/81(1.2%) Staple group 6/81(7.4%) p=0.05 Deep infections: Suture group 0/81(0%) Staple group 2/81(2.5%) p=0.15 Cosmetic scale: Suture group 74/81 (91%) Staple group 71/81(88%) p=ns	Significantly higher number of diabetics were in the skin clips closure group The skin clips cost three times more than sutures. Sutures had a significantly lower chest infection rate but similar cosmetic results.
			Leg	Infections: Suture group 9/81(11%) Staple group 9/81(11%) p=ns Cosmetic scale: Suture group 65/81(80%) Staple group 69/81(85%) p=ns
Wolterbeek et al, 2002, Holland	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.	PRCT (level 1b)	Superficial infections	Suture group 6/77 (8%), Staple group 2/83 (2%) p=ns	A total of 10 patients were excluded from the study after randomization. No information on cosmetic result. No difference between staples and sutures
			Deep infections	Suture group 1/77 (1%), Staple group 1/83 (1%) p=ns
			Wound closure time	Suture group 6.4mins, Staple group 2.7mins P<0.001

Comment(s)

5 randomized controlled trials were identified which investigated sutures and staple techniques for chest and legs wounds following cardiovascular procedures. Angelini et al 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 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 rate 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. 62% of patients preferred leg closure with sutures compared to 20% preferring staples. Mullen et al 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 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 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 minutes when compared to skin suture which took 6.4 minutes.

Clinical Bottom Line

Of the five randomized controlled trials in cardiovascular surgery that compared staples with suture closure, 3 of the 5 studies found that the complication rate was lower with sutures and the other two found no difference. With regard to cosmesis, 2 of the 5 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

1. 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(6):378-82.
2. 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(2):271-7.
3. 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(5):1587-91.
4. 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(3):277-82.
5. Angelini GD, Butchart EG, Armistead SH, Breckenridge IM. Comparative study of leg wound skin closure in coronary artery bypass graft operations. Thorax 1984;39(12):942-5.
6. 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(5):606-12.
7. 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(1):65-8.
8. 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(11):1403-7.
9. Wolterbeek JH, van Leeuwen AA, Breslau PJ. Skin closure after infrainguinal bypass surgery: a prospective randomised study. Eur J Vasc Endovasc Surg 2002;23(4):321-4.