Suture support: Is it advantageous?

Henrik K. Kjaergard, M.D.Department of Cardiothoracic Surgery, Gentofte University Hospital, Niels Andersens Vej 65, 2900 Hellerup, Denmark

Abstract

Sutures have been used to facilitate and enhance wound closure and healing throughout the course of medical history. Suturing is stillthe most common method of wound closure, but in some surgical situations suture support can improve clinical outcomes. Sutures providemechanical support to a wound and help create the optimal environment for wound healing. However, suturing can give rise to suchcomplications as bleeding from suture holes and air and fluid leakage. In the last 25 years, fibrin sealants have been used increasingly inthe clinical setting to assist in the sealing of surgical wounds and to give additional mechanical support to a range of wounds during theearly phases of wound healing. The use of fibrin sealants in addition to sutures has a direct effect on hemostasis and blood loss. Fibrinsealants also reduce the volume of fluid drained and air leakage postoperatively in head, neck, and thoracic surgery, in some cases resultingin a reduced length of hospital stay. The use of fibrin sealant as suture support can also reduce the number of sutures and the length ofoperations for intricate or complex procedures. The aim of this article is to provide an overview of how fibrin sealants acting as an adjunctto sutures affect surgical outcomes. © 2001 Excerpta Medica, Inc. All rights reserved.

The use of sutures to aid wound closure dates back to 3500BC, when it was first alluded to in an Egyptian scroll [1].Today, suturing is still the most common method of woundclosure, and recent advances in suture materials now allowsurgeons to select the most appropriate suture for the par-ticular wound or surgical intervention. Ideally, the chosensuture should provide mechanical support to a wound andcreate the optimal environment for wound healing until thetissue is sufficiently healed to withstand normal physicalstress. In choosing an appropriate suture type for woundclosure and healing, surgeons need to consider the strengthof the suture, the type of tissue being held, and the absorb-ability of the sutures, because healing rates vary betweentissues [2]. It is well known that tissue healing rates varydepending on the tissue; for example, skin heals much morequickly than fascia [2]. It has also been shown that skinwounds regain 85% of their original strength by day 15 [2].However, many sutures start to lose their strength from day3 to day 9, contributing little or no mechanical support fromday 9 [3]. Furthermore, it has been reported that sutures failto provide significant mechanical support for abdominalwounds between postoperative days 15 and 28 [4,5].

Complications associated with suturing in a variety ofsurgical interventions include mainly bleeding from sutures

and also air and fluid leakage. Bleeding from suture holes isa frequent occurrence in cardiothoracic and vascular surgeryand may impact on postoperative morbidity and mortality[6]. The spray application of fibrin sealant may reduceperioperative hemorrhage during cardiac operations [6]. Re-section of some parenchymal tissue may also lead to pro-longed bleeding, and fibrin sealant has been used as aneffective hemostat in diffuse bleeding organs where sutur-ing is difficult or impossible [7]. Occasionally, fluid leakagemay be a problem in gastrointestinal anastomosis (eg,esophageal and colorectal anastomosis), and in these diffi-cult cases the application of fibrin sealants can reduce bothfluid leakage and the potential risk of infection resultingfrom leakage.

Suturing is the method of choice for wound closure.Inflammatory reactions and occasionally infections may oc-cur as a result of sutures. However, the inflammation asso-ciated with sutures is not usually a problem for either thepatient or the surgeon. A review of the literature indicatesthat reduced-suture fibrin sealant anastomosis and suturelessfibrin sealant anastomosis may be performed with less in-flammation and necrosis compared with conventional sutur-ing techniques [8].

Although many technologic advances have been made insurgical procedures and surgical materials (such as suturematerials), reducing the incidence of complications is stillof importance to surgeons. For many years, surgeons havebeen using fibrin sealant in conjunction with sutures (or

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The American Journal of Surgery 182 (2001) 15S–20S

0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved.PII: S0002-9610(01)00910-X

alone) to improve the integrity of wound closure in terms ofreduced hemorrhage from the suture line and suture holes[9–13]. Indeed, in some surgical procedures a reduction inthe number of stitches required to maintain wound closure isobserved after the use of fibrin sealants. Some delicatetissues, such as lung parenchymal tissue, can also be closedwith fibrin sealant. In addition, fibrin sealants do not initiate/exacerbate an undue inflammatory response.

The aim of this review is to compare the clinical outcomeof the use of fibrin sealants as an adjunct to sutures insurgical practice to aid wound closure and healing.

Suture support

To date, suture support has been described widely in theliterature with varying definitions. Here we use suture sup-port to describe the use of fibrin sealant as an adjunct tosutures after surgical intervention, resulting in additionalmechanical support, prevention/reduction of needle holeand suture line bleeding, and an aid to healing.

Fibrin sealant in clinical practice

Fibrin sealants were developed some 25 years ago asbiologic tissue adhesives. The utility of fibrin sealants incardiovascular surgery was recognized as early as the late1970s [14]. Since then, fibrin sealants have been used in awide range of surgical procedures, including cardiothoracic,head and neck surgery, thyroid surgery, neurosurgery, andvascular surgery to provide suture support.

Hemostasis

Postoperative blood loss after cardiac surgery requiresre-operation in 4.4% of patients [15]. Fibrin sealants have

been used successfully in conjunction with sutures in car-diothoracic surgery to produce hemostasis. Indeed, fibrinsealant to support suture has been reported to be 94% ormore effective at reducing blood loss after cardiovascularand thoracic surgery [16,17]. Control of blood loss fromsuch sites as the mediastinum, specific sites at coronaryartery bypass graft anastomoses, and long suture lines wasachieved with the use of fibrin sealant [16]. This observationsupports the earlier finding by Spotnitz et al [6] that peri-operative hemorrhage from the mediastinum was signifi-cantly reduced by suture support. Blood loss in proceduresusing fibrin sealant as suture support at 12 and 24 hours was461 mL and 714 mL, respectively, compared with 731 mLand 1,016 mL, respectively, for the control group (Fig. 1)[6].

The volume of blood lost during surgery is dependent ona number of factors, including use of intraoperative heparin,complexity of the surgery being performed, and the timetaken to induce hemostasis. The use of fibrin sealants insurgery has been shown to significantly reduce the time tohemostasis with a beneficial effect on blood loss. In arandomized study in 17 patients undergoing surgery forcarotid endarterectomy, suture support reduced suture linebleeding by 130 mL compared with the blood loss frompatients who did not receive fibrin sealant [18]. In addition,the time to hemostasis in the suture support group wassignificantly lower at 5.5 minutes compared with 19 min-utes in the control group (P #0.005; Table 1). Furthermore,100% of patients in the control group required oxidizedcellulose gauze to aid hemostasis compared with only 13%in the suture support group [18].

The observation that hemostasis was achieved morequickly in patients after suture support has been confirmedin another randomized study of peripheral vascular surgery.Hemostasis was achieved in 0.5 minutes in the suture sup-port group compared with 4 minutes in the control group(P ,0.014; Table 1) [19]. Moreover, immediate hemostasis

Fig. 1. Perioperative blood loss from the mediastinum is reduced after suture support [6]. *P ,0.05, unpaired Student’st test.

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was achieved on release of the clamps in 62% of patients inthe suture support group compared with 22% in the controlgroup [19]. These observations indicate that suture supportcan also be used as successfully in peripheral vascularsurgery as it has been in cardiovascular surgery.

Fibrin sealants have also been used successfully for he-mostasis in neurosurgery for such procedures as arterio-venous malformation, middle cerebral artery aneurysm,orbital tumor, oligodendroglioma, meningioma, and oph-thalmic aneurysm [20]. Indeed, suture support in patientsundergoing surgery for intracranial artery aneurysm (n511) has been shown to be effective with no recurrent bleed-ing of the aneurysm in 100% of patients during the 25-month follow-up period [20]. In most cases, local hemosta-sis was achieved within 1 minute of application of fibrinsealant [20].

The use of electrocautery, particularly in neurosurgery,is currently under review. In such sensitive tissues as thebrain, where tissue damage can cause irreparable damage,electrocautery is used with caution. In these situations theuse of fibrin sealant and sutures can reduce the need for thisdestructive technique.

Blood loss associated with head and neck surgery is ofconcern to surgeons, especially as the rest (minimal move-ment of the head and neck) that is necessary to facilitatewound healing may not be taken for granted. Conservativeor radical neck surgery performed for resection of malignantneoplasms of the oral cavity can leave large areas of rawtissue that can exude blood. The unavoidable rotation andflexion–extension movement of the neck may, in somecases, cause renewed bleeding. Fibrin sealant used in con-junction with suction drainage not only produced hemosta-sis, but also significantly reduced the volume of woundsecretion after either radical or conservative neck surgery,during the first 2 postoperative days (P #0.05) [21]. Al-though the volume of wound secretion was greater afterradical surgery compared with conservative surgery, thedifference in secretory volume after the use of commercialfibrin sealant was not significantly different [21].

Fluid and air leakage

Fibrin sealants have also been used in other surgicalprocedures, such as head and neck surgery and thoracic

surgery, with success. In thyroid surgery, suture supportsignificantly reduced the volume of fluid drained during thefirst postoperative night by approximately 50% (18 mLcompared with 39 mL for suture alone;P #0.0001) [22].Furthermore, the mean time to drain removal was 1.6 daysin the fibrin sealant group and 2.2 days in the control group.This meant that patients in the fibrin sealant group weredischarged from hospital after a mean of 2.8 days, with mostpatients leaving the day after drain removal. Overall, pa-tients in the suture support group were discharged fromhospital 0.9 days earlier than the control group. In this seriesof 30 patients, this translated to a saving of 27 bed days orthe equivalent of approximately seven additional thyroidec-tomies. The cost difference between the two arms of thestudy was approximately $260 per patient in favor of fibrinsealant treatment or $7,900 per study group. Cost estimateswere current for 1991 [22].

In 1990, Matthew et al [16] reported that the use of fibrinsealant in various thoracic and cardiovascular procedureswas 100% (14 of 14 patients) successful in reducing fluidloss.

Cerebrospinal fluid leakage is associated with complexneurosurgical procedures. Fibrin sealant has been used withsuccess to prevent or stem cerebrospinal fluid leakage frompituitary tumor, metastatic tumors, oligodendroglioma, andcerebrospinal fluid rhinorrhea [20]. However, some cere-brospinal leakage was observed after the use of fibrin seal-ant in a few neurosurgical procedures [20].

In pulmonary resections, fibrin sealant has been shown toreduce blood loss from cut lung surfaces and bronchialanastomoses and to reduce air leakage with a success rate of88% [16]. Fibrin sealant, in addition to reducing the inci-dence of air leakage, also reduced the frequency of postop-erative air leakage with an estimated risk reduction of 41%.Furthermore, an improvement rate of 81% was obtained inthe airway tolerance–pressure test in patients after suturesupport [23]. Mouritzen [23] also reported a significantreduction in length of hospital stay and a reduction in thenumber of patients in the fibrin sealant group with compli-cations compared with controls. There was no estimate ofcost saving reported for this study.

Surgical time

Surgical procedures that are intricate and/or complex, forexample, vascular/microvascular surgery for digital replan-tation, can be time consuming. However, in the case ofdigital replantation, it is important to re-establish blood flowas soon as possible to reduce the ischemia induced byamputation. Techniques that shorten the operative time con-tribute to the success of digit replantation. Fibrin sealant hasbeen used successfully as suture support in microvascularanastomoses in digit replantation surgery. The survival rateof digit replantation surgery after suture support (89%) wascomparable with that reported for conventional microvas-cular surgery [24]. In addition, fibrin sealant–assisted mi-

Table 1Time to hemostasis (mean range) after carotid endarterectomy andperipheral vascular surgery with or without fibrin sealant suture support

Procedure Study Control(mins)

Fibrinsealant(mins)

P value

Carotidendarterectomy

Milne et al,1995 [18]

19 (10–47) 5.5 (4–31) 0.005

Peripheral vascularsurgery

Milne et al,1996 [19]

4 (0–21) 0.5 (0–11) 0.014

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crovascular anastomosis did reduce the operative time byapproximately 1.3 hours. This was a direct consequence ofthe reduced number of microsutures required at each anas-tomosis [24]. The development of safe, effective proceduresthat reduce operating times compared with conventionaltechniques has a positive impact on direct health-care costs.

Adverse events

Fibrin sealant is a product that uses blood-derived fibrin-ogen as one of its main constituents. The potential risk oftransmission of blood-borne infection, such as hepatitis andhuman immunodeficiency virus, by fibrin sealants has beenof concern to surgeons. However, to date there have been nodocumented reports of transmission of hepatitis or HIVinfection from the use of fibrin sealant [25]. Indeed, at 6months there was no serologic evidence of hepatitis A, B, orC, and no patients developed abnormal liver function testsduring follow-up visits [18]. There is a rare but elevated riskof hypersensitivity reactions at re-exposure to aprotinin andimmunization and bleeding from re-exposure to bovinethrombin. Most manufacturers have therefore switched overto human thrombin [26,27]. With appropriate precautions,re-exposure to aprotinin in patients, particularly those witha high risk of bleeding, is reported to be justified, and thebenefits of aprotinin treatment are thought to outweigh therelative risk of a serious allergic reaction [28].

Animal studies

The mechanical support offered by sutures with andwithout suture support with fibrin sealant cannot be deter-mined in human subjects for obvious ethical reasons. Con-sequently, these studies are performed in animal models,

because it is important to determine the bursting pressure ofsutures with and without suture support.

Suture support

Gastrointestinal anastomoses may occasionally leak, andcolonic, low rectal, and esophageal anastomoses are moresusceptible to leakage than other anastomoses despite goodsurgical technique. The option to use fibrin sealant gives thesurgeon additional suture support and can reduce the poten-tial risk of leakage in successful surgery. The leakage ofcolonic contents into the peritoneum can lead to peritonitisor sepsis with a fatal outcome.

Fibrin sealant has been used experimentally to assess thesuitability of suture support in colon anastomoses in anexperimental rat model. Bursting pressures of 94 and 131mm Hg were obtained for colonic anastomoses closed withsuture support compared with 68 and 92 mm Hg for colonicanastomoses closed with sutures alone (1 mm Hg5 1.36 cmH2O) [29,30]. This additional firmness lasted for the dura-tion of the 3-week observation period [29]. These findingsare further supported by results in porcine stapled smallbowel where suture support resulted in anastomoses that didnot leak and showed only a mild inflammatory responsecompared with sutures alone [31].

Similar observations have been reported for skin woundsclosed with sutures and suture support. Suture support re-sulted in watertight sutures immediately after surgery andincreased the hydrostatic pressure resistance of skin suturesby 17.2 cm H2O (Fig. 2) [32]. At days 3 and 6, skin suturessupported with fibrin sealant were able to withstand in-creased hydrostatic pressures of 23.1 and 16.8 cm H2O,respectively (Fig. 2; 0.05, P , 0.10) [32]. Similar resultswere reported for bladder sutures supported with fibrinsealant. These results suggest that the watertightness of

Fig. 2. Hydrostatic leak pressure (cm H2O) for skin tubes as a function of time (days) after suturing alone and with fibrin sealant treatment [32].*0.05 , P , 0.10.

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conventional suturing can be improved with suture support.This could have clinical implications in urology, where awatertight suture may prevent urine extravasation in thewound and reduce or eliminate the associated complicationof postoperative infection and the need for urinary diver-sion.

As observed in the clinical setting, suture support hasbeen shown to produce hemostasis in experimental models.Fibrin sealant has been reported to minimize blood loss aftermicrovascular repair in hypertensive rats with no leakage orloss of patency of the anastomoses [33]. More recently,suture support was shown to significantly (P #0.05) reducehemorrhage from carotid vascular grafts in a porcine model.The mean blood loss was 9.2 mL in the suture support groupcompared with 178.8 mL in the control group [34]. Theseresults suggest that suture support would prevent leakage ofblood after vascular and/or microvascular repair surgery,even in cases of high blood pressure.

Suture support has also been used successfully in exper-imental delayed vasovasostomy in a rat model with resultscomparable to conventional suturing. However, after suturesupport only three sutures instead of the usual six sutureswere required to produce similar anatomical results in vasalanastomoses. Furthermore, the mean operative time withfibrin sealant–assisted vasovasostomy was significantlyshorter (P #0.001) than conventional suturing and wastechnically less demanding [35].

Conclusion

The use of suture support in a broad spectrum of surgicalprocedures provides several advantages to the patient. Thebenefits of suture support include hemostasis, resulting inreduced blood loss from needle hole and suture line wounds,thus reducing the need for blood transfusion after suchprolonged and complex surgical procedures as cardiovascu-lar surgery; and a reduction in the drain volume and airleakage during thoracic and cardiac surgery, thereby short-ening the time required for a chest drain, resulting in fewerdays of discomfort for patients and in some cases a signif-icant shortening of hospital stay. Suture support may alsoimprove the success rate of some surgical procedures byreducing the complexity of the procedures, as has beenobserved in digit replantation surgery. Furthermore, suturesupport is safe and well tolerated by patients with no indi-cation of viral infection from the fibrin sealant and fewadverse reactions.

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