Absorbable Sutures in General Surgery

review article

Absorbable sutures in general surgery – review, available materials, and optimum choices Marcin Gierek1, Katarzyna Kuśnierz2, Paweł Lampe2, Gabriela Ochała3, Józef Kurek1, Bartłomiej Hekner4, Katarzyna Merkel5, Jakub Majewski1 1Department of General, Endocrine and Oncological Surgery, Multispecialty Hospital, Jaworzno; Head: Józef Kurek MD PhD 2Department of Gastrointestinal Tract Surgery, Medical University of Silesia, Katowice2 Head: Prof. Paweł Lampe MD PhD 3Department of Skin and Venereal Diseases, Municipal Hospital, Sosnowiec; Head: Anita Lenartowska-Białek MD 4Silesian University of Technology, Katowice; Head: Prof. Jerzy Myalski PhD 5Department of Material Engineering, Central Mining Institute, Katowice; Head: Henryk Rydarowski PhD

Article history: Received: 17.01.2016 Accepted: 01.03.2017 Published: 30.04.2018

Abstract: Sutures are the most versatile materials used in surgery. Despite recent technological advances and availability of novel materials such as tissue cements, it appears that surgical sutures will continue to be used for many years to come. The objective of this study was to provide an overview of the most common absorbable sutures used in general surgery. The appropriate suture choice for a particular procedure is of key importance for the success of that procedure. Keywords: Absorbable sutures, Polydioxanone, Polyglecaprone, Polyglactin

INTRODUCTION cenna (980-1037).

Appropriate suture choice for a particular procedure is a pre- The 19th century was an era of catgut. Catgut is a biodegradable requisite for the success of that procedure. Sutures inappro- fiber characterized by good mechanical properties. priate for a particular organ may have tragic consequences for patients, as shown by Allan Oldfather Whipple in 1934 [1]. In 1868, Joseph Lister made the first attempt to use sutures coated Whipple used catgut as the suturing material in his first ampulla with an antibacterial agent. Two types of fibers were used to that of Vater resection surgeries. However, anastomotic dehiscence end, one was obtained from bovine peritoneum and the other was leading to patient’s death was observed on the second day after made of traditional catgut. Both types of sutures were coated with the procedure as the suture had been degraded by the pancre- an antiseptic phenol solution. atic juice enzymes. After five months, Wipple replaced catgut with silk sutures and thus defined a new standard for this pro- With time, the use of catgut became less and less popular due to cedure at the time [2,3]. the increasing availability of synthetic absorbable sutures. First absorbable synthetic sutures were developed in the US in 1962, and the Dexon suture was introduced into the market in the late HISTORICAL PERSPECTIVE 1960s [4]. The Dexon material continued to be improved, and new generations of the suture were introduced [33]. Currently, other Needles with a small orifice for threading sewing materials were synthetic sutures are available, such as Vicryl or PDS, that are cha- known as early as 50,000 years BC. About 20,000 years BC, bone racterized by better tissue tone retention properties. was the standard needle material [4]. It is very likely that such needles were threaded with sutures for stitching wounds as a number of preserved skulls from the Neolithic period featured signs GENERAL CHARACTERISTICS OF SUTURES of trepanation. This procedure was often successful since healing took place after trepanation, and the wounds must have been clo- Sutures are either absorbable or non-absorbable. Most sutures sed in some way [4]. are manufactured as atraumatic sutures. Some are manufactured as conventional threads for attachment to surgical needles According to Sushruta, surgical sutures used to be made of hair, (ligatures). Basic suture characteristics are provided on packa- flax, or hemp fibers. Interestingly, Sushruta also described mate- ges. Suture thickness should match the type of anastomosis to rials used by surgeons in training who mastered stitching techni- be performed. ques; among others, these included melons and animal hides [4]. Sutures are available in a variety of sizes, and different sizes are Around 150 AD, Galen of Pergamum became renowned for his used for various applications. Two types of gauges are used to in- ability to heal tendon ruptures in gladiators, thus offering them dicate the suture thickness: 1) the metric gauge (in tenths of a mil- a chance for a quick comeback to the arena. His work, titled “De limeter), and 2) the surgical gauge (Tab. I). Methodo Medendi”, mentions for the first time catgut – a suturing material made of sheep’s or goat’s bowels. The metric gauge, accepted in the European and US Pharmacopo- eia, defines suture thickness in tenths of a millimeter. The surgical Traditional sutures, mainly made of flax, were also used by Avi- gauge is used more commonly in the clinical setting. 34 doi: 10.5604/01.3001.0010.5632 WWW.PPCH.PL review article

Tab. I. Metric and surgical gauges of absorbable and non-absorbable sutures.

METRIC GAUGE SURGICAL GAUGE

0,2 10 - 0

0,3 9 - 0

0,4 8 - 0

0,5 7 - 0

0,7 6 - 0

1 5 - 0 Fig. 1. Chemical formula of Polyglactin 910: x – number of lactic acid residues; y – number of glycolic acid residues. 1,5 4 - 0

2 3 - 0

3 2 - 0

3,5 0

4 1

5 2

6 3 / 4

7 5 Fig. 2. Chemical formula of polydioxanone (n = polymer length)

CHARACTERISTICS OF ABSORBABLE MATERIALS POLYGLECAPRONE 25

POLIGLACTIN 910 This material was first used in surgery in 1993. The sutures are made of glycolide and ε-caprolactone copolymer, and are a syn- The full name of this material is poly(glycolide-co-L-lactide) [5]. This po- thetic equivalent of catgut that causes no tissue reactions. The for- lyester material is used for production of absorbable stitching materials mula of the polymer is (C2H2O2)m(C6H10O2)m. Polyglecaprone (sutures) and absorbable meshes used, for instance, for hernia repair. 25 was found to be non-antigenic and apyrogenic.

Owing to its biodegradability and biocompatibility, polyglactin 910 It is a biodegradable polymer belonging to aliphatic polyesters ob- has been registered by the FDA (Food and Drug Administration) tained from caprolactone in a ring-opening polymerization pro- for use in therapeutic applications. In the course of its synthesis, cess. In the human body, it undergoes degradation due to hydro- monomeric fragments, comprised of glycolic acid or lactic acid, lysis of ester bonds [8]. are joined by ester bonds, which results in an aliphatic polyester as the final product. The empirical formula of Polyglactin 910 is The retention period is 21-28 days. C2H2O2)m (C3H4O2)n. Polyglactin 910 undergoes degradation due to hydrolysis of the ester bonds [6]. The retention profile, as expressed by approximate percentage of initial retention strength, is as follows [46,48]: The retention period of Polyglactin 910 sutures is 28-35 days [46,48]. • 60% after 7 days The retention profile, as expressed by approximate percentage of • 30 % after 14 days initial retention strength, is as follows [5,7]: Polyglecaprone 25 suture absorption rate is in the range of 90- • 75% after 14 days 120 days [5,7]. • 50% after 21 days Polyglecaprone 25 sutures are used for bringing together and/or The absorption rate is 56-70 days [5,7]. ligating soft tissues when absorbable suture stitching is required.

Polyglactin 910 sutures are manufactured synthetically as absor- POLYDIOXANONE bable, braided, and monofilament sutures. This material was first used in surgery in 1982. Polydioxanone Polyglactin 910 sutures are used for bringing together and/or li- sutures are used when absorbable materials are indicated. Due to gating soft tissues, including in eye surgery, for connecting peri- their longer strength retention, polydioxanone sutures are indi- pheral nerves, as well as for microsurgical procedures on blood cated for the management of slower-healing wounds and tissues. vessels with diameters smaller than 2 mm. Polyglactin 910 sutures These monofilament sutures are made of the poly(p-dioxanone) are widely used in gastrointestinal tract surgeries. polyester. The empirical formula of the polymer is C4H6O3 [5,7]. POL PRZEGL CHIR, 2018: 90 (2), 34-37 35 review article

Polydioxanone is a polymer made of recurring sets of ether and hundreds of procedures performed worldwide over the centuries. The ester groups (Figure 3). The synthesis of polydioxanone requires development of suturing techniques is closely related to the scientific heat and catalysis using zinc compounds. Polydioxanone sutures progress. Until several decades ago, the most common suture mate- undergo biodegradation via hydrolysis, and the degradation me- rial was catgut, known for centuries [4]. Today, it has been replaced tabolites are excreted mainly in urine [9]. by newer materials, such as genetically engineered sutures produced by recombinant E.coli strains (MIT Boston, USA, 2007) or sutures Effective retention period is up to 90 days [5,7]. made by transgenic spiders [10]. Novel types of sutures are being developed. For instance, there are absorbable sutures made of magne- The retention profile, as expressed by approximate percentages of sium alloys [11,12,13] that have not yet been introduced for wider use. initial retention strength, is as follows: Choosing appropriate sutures is often based on the surgeon’s expe- • 70% – 14 days rience, preference, or economic aspects. The manufacturers pro- • 50% – 28 days vide information regarding the retention strengths of individual • 25% – 42 days products; this parameter is often decisive for the choice of suture during surgical procedures. Appropriate suture choice for a parti- Poilydioxanone suture absorption rate is in the range of 180 to 210 days. cular procedure is of key importance for the success of that procedure. No studies that might help to optimize this choice have been Poilydioxanone sutures are used for bringing together soft tissues. conducted in recent years. There is a lack of studies on the dyna- The sutures may be used in gastrointestinal tract surgery (e.g. for mics of strength profiles in various environments. Elucidation of intestinal anastomoses), pediatric cardiovascular surgery, micro- microstructures as well as Fourier-transformed infrared (FT-IR) surgery, and eye surgery. spectra of the most common materials presented above, following exposure to different biological environments, might markedly contribute to optimization of suture choices. Novel materials are SUMMARY also important, such as absorbable zinc/magnesium sutures that may find use in surgery in the future. It seems very important to The currently available wide selection of sutures and surgical proce- broaden the scope of research to include objective studies of the- dures that surgeons can take advantage is based on observations and se materials, particularly in in vitro settings.

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Word count: 1340 Page count: 4 Tables: 1 Figures: 2 References: 13

DOI: 10.5604/01.3001.0010.5632 Table of content: https://ppch.pl/issue/10631

Competing interests: The authors declare that they have no competing interests.

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Corresponding author: Marcin Gierek MD PhD, Department of General, Endocrine and Oncological Surgery, Multispecialty Hospital, ul. Chełmońskiego 26, 43-600 Jaworzno, Poland; E-mail: [email protected]

Cite this article as: Gierek M., Kuśnierz K., Lampe P., Ochała G., Kurek J., Hekner B., Merkel K., Majewski J.; Absorbable sutures in general surgery – review, available materials, and optimum choices; Pol Przegl Chir 2018: 90 (2): 34 - 37

POL PRZEGL CHIR, 2018: 90 (2), 34-37 37