Meat Eaters and Catgut Suture ‘Rejection’ R Narayani*, Geetha Prakash**, M Paul Korath***, K Jagadeesan**** Abstract Although catgut sutures have been used in surgery for many decades, we recently observed that catgut sutures were extruded at times from the wounds, more often in patients who were non-vegetarians when compared to vegetarians. Vicryl or prolene sutures were not extruded in non-vegetarians. This retrospective study consolidated the viewpoint that the extrusion may be a ‘rejection’ phenomenon in persons who were sensitized to sheep protein i.e., mutton eat- ers. Therefore these subjects could not tolerate catgut sutures, which is prepared from sheep intestinal mucosa. The phenomenon of catgut suture extrusion was observed in patients for whom this material was used in the subcutaneous plane. Introduction a rough surface and a tendency to harbour he interfacing of living tissue with a microorganisms that can provoke an Tbiomedical material elicits cell-material inflammatory response. interactions that determine whether the Among synthetic non-absorbable sutures implant will be tolerated or rejected. Sutures polypropylene sutures (prolene) possess high and wound dressings are implants in soft tensile strength and resistance to infections. tissues, which act as scaffolds and ties for But its unique smoothness leads to low knot tissue growth and repair. Therefore they security, which is a limitation. Among the must be prepared from materials that do not natural and absorbable sutures currently in produce any undesirable inflammation or use, catgut sutures which are basically clinically significant changes in the tissues collagen in nature have the highest tensile or fluids of the body.1,2 strength, In the old days, strings of Control over the host responses at the instruments of the violin, fiddle, harp etc were biomedical material-tissue interface is a traditionally made out of a stuff called catgut, paramount problem because several physical, which is a strange name since it was really biological, clinical and technological factors made from sheep intestine. Sutures made are involved.3-6 In terms of tissue response, from sheep intestine but peculiarly called, as it was demonstrated that monofilament ‘catgut’ have been one of the popular suture sutures have a smooth surface that prevents materials for a long time. However the word harbouring of microorganisms and thereby catgut is acutally a misnomer. The Arabic decrease the risk of inflammation. On the word ‘Kit’ means a dancing master’s fiddle, 7 other hand braided and uncoated sutures have but the word catgut has no relation to a cat!. Among synthetic absorbable sutures, vicryl a copolymer of lactide-glycolic acid, *Professor and Head, Biochemistry Department; **Pathologist; ***Chief Physician and Director; polydioxanone (synthetic sutures among PDS) ****Founder and Director, KJ Hospital Research and and polymethylene carbonate (Maxon) are Postgraduate Centre, KJ Research Foundation, widely used. It is reported that original Egmore, Chennai 600 084. uncoated braided sutures from vicryl and 14 Bombay Hospital Journal, Vol. 50, No. 1, 2008 Dexon (a homopolymer of glycolic acid) had Material And Methods rough surfaces and tendency to provoke This is a retrospective study, which 8 inflammation and infection. To overcome consisted of a total of 21 patients between this problem coated sutures like chromic the age group of 10 years to 50 years. These catgut and dexon plus, with better tie down patients were included from our operative characteristics have replaced uncoated records of 2006-2007. These patients sutures. Moreover plain catgut has a life of underwent abdominal surgery for reasons only 3 to 7 days. If treated or coated with like appendicectomy, hernia, hysterectomy chromic salts to form the chromic catgut, it etc. Those cases with wound infections, prior has an increased life up to 20-40 days. Chromic surgery and possibility of spillage were salts enhance the cross linking of collagen excluded from the study. Totally there were and thereby prevent its rapid degradation. 21 patients among whom 9 males and 12 Thus chromic catgut derived from sheep females were present. Vicryl or prolene or intestinal submucosa combines desirable catgut was used as subcutaneous suture aspects like natural origin, smooth surface material in these patients. All sutures were due to coating or chromicisation, good tensile procured from ETHICON division of Johnson strength and absorbability. Since catgut is a and Johnson Ltd. These patients were divided resorbable suture, the material decomposes into 3 groups. Group I consisted of 2 patients in the tissue interfaces and may be replaced in whom prolene was used as suture by regenerating tissues, which again material. Group II had 7 patients in whom augments its biological acceptance. vicryl was used as suture material. Group III But inspite of these favourable aspects of had 12 patients who received catgut as catgut, our experience showed that plain and sutures. Each of these groups contained chromic catgut caused inflammation and vegetarians and non vegetarians. ultimately were ‘rejected’ in a sizable number Results of patients who received these sutures. It was interesting to note that all the patients who Out of the 7 patients in whom vicryl was extruded the catgut sutures were non- used as suture material, 6 were non- vegetarians. This observations of extrusion vegetarians and one of them was vegetarian. of catgut during the wound healing process Wounds healed well in about one week post by some individuals who were non- surgery in both non-vegetarians as well as in vegetarians gave the idea that the extrusion the vegetarian who received vicryl sutures. may be a ‘rejection’ phenomenon in people No adverse reaction such as serosanguinous who were sensitized to mutton. Therefore a discharge, pus or infection was observed at retrospective study was made to consolidate the wound site in any of them. In 2 patients this thought process. where prolene was used as suture material Table 1 : Tissue response to suture materials Suture Total No of Tolerated Rejected Statistical Material patients Veg Non-veg Veg Non-veg significance Prolene group I 2 1 1 0 0 I vs II 1.000 Vicryl group II 7 1 6 0 0 II vs III 0.010 Catgut group III 12 2 3 0 7 III vs I 0.363 Bombay Hospital Journal, Vol. 50, No. 1, 2008 15 it was observed that wounds healed well by wound site on 8th postoperative day. Although the fourth to seventh post operative day the wound was healthy without signs of without any adverse reaction at the site of infection around 12th to 14th postoperative day, the wound. Out of the 2 patients, one was the patient passed the catgut stitch per vagina vegetarian and another was non-vegetarian. on the 22nd postoperative day, which also was But out of 12 patients in whom catgut was infected. The catgut material was found to used as suture material, 5 patients tolerated be culture positive for staphylococcus the sutures very well and their wounds were epidermis and klebsiella. healthy and healed within 1 week. Among Another patient with chromic catgut these 5 patients, 2 were vegetarians and 3 suture showed serosanguinous discharge from were non vegetarians. Although non 8th postoperative day onwards at wound site. vegetarians these 3 patients consumed little On the 42nd postoperative day, purulent pus or no mutton in their diet. One patient had was aspirated from the wound and found to never taken mutton but has the habit of be positive for staphylococcus epidermis. eating only fish and chicken. The other 2 Wound discharge lasted from 16th patients said that they very rarely consumed postoperative day to 40 post operative day in mutton. They consumed chicken and beef yet another patient with chromic catgut. predominantly among non vegetarian food. Histopathological examination of sections of Among the other 7 patients in group III the catgut suture material revealed fibrous adverse reactions at the wound site like pain, tissue formation along with neutrophil and oozing, serosanguinous discharge and lymphocyte infiltration in to the sutures. In infection were seen along with ultimate the patient who received plain catgut suture, rejection of catgut sutures. Among these 7 small blood droplets were noticed at the edge patients, in whom rejection of catgut suture of the operated site on 23rd postoperative day. was seen 6 had chromic catgut and 1 had plain The catgut was rejected on 25th postoperative catgut as suture material. In all of them, day following which it was removed. oozing followed by blood stained serous The results obtained were analysed by discharge from wound site was noticed Fisher’s exact test. The results were not between seventh and tenth postoperative day. statistically significant when group I was Most of them complained of pain at the site compared with group II and group I was of wound. Interestingly all these seven compared with group III. When group II was patients were non-vegetarians. Another compared with group III the results were feature common to all these non vegetarians found to be statistically significant at the level was that they were all mutton eaters who of P < 0.05. consumed mainly mutton than any other non vegetarian items. Discussion In one patient with chromic catgut the The response of the tissues to an implant discharge from the wound and pus formation like a suture material may be only slightly lasted up to 33 days and the catgut material different from normal postoperative healing was eventually extruded on the 45th if the material is chemically and physically postoperative day. Thereafter the wound inert.9 On the other hand healing is delayed healed well. In another female patient, pus if the material is less inert or highly ‘irritant.’ and blood tinged discharge was seen on 7th Foreign body giant cells are produced along postoperative day and pus was drained from with eventual scar or fibrous layer 16 Bombay Hospital Journal, Vol.