Absorbable vs. Non-absorbable Sutures for Traumatic Laceration
Search Strategy: As with most questions of therapy, you first turn to the Cochrane Database of Systematic Reviews where you see an incomplete protocol addressing this question. Thus, you grit your teeth and decide to pursue the question the “hard” way. Turning to PUBMED, you first conduct a broad/sensitive therapy clinical query using the term “laceration” (2130 citations). Next, you conduct a general PUBMED search of “absorbable suture” (2219 citations). Finally, you combine these two searches to yield 14 citations including the four selections below.
“Please help my baby!” cries the exacerbated mother of a 3-year old who presents to your ED with a 2 cm forehead laceration. After quickly assessing the child to ensure “wellness”, you assure the parents that you’ll take good care of the wound. Dad then declares that the family has a long-planned vacation to Disney World next week. Does the child really need sutures? If so, when will need to be removed and who will remove them in Orlando?
You carefully contemplate Dad’s questions as you begin charting on the child. You convince yourself that the child definitely needs sutures to promote cosmetically effective wound healing while minimizing the risk of wound infection. Would absorbable sutures suffice in place of standard nylon sutures? Do they offer the same long-term cosmetic appearance? Thoughtfully, you turn to the medical literature.
Population: Emergency Department patients with traumatic facial lacerations
Intervention: Wound repair with absorbable sutures
Comparison: Wound repair with non-absorbable sutures
Outcome: Cosmetic outcomes, wound infection or dehiscence rates, patient satisfaction.
First years: A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures, Acad Emerg Med 2004; 11: 730-735. (http://pmid.us/15231459)
Article 1: A Randomized, Controlled Trial Comparing Long-term Cosmetic Outcomes of Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut versus Nonabsorbable Nylon Sutures, Acad Emerg Med 2004; 11: 730-735
Article 2: Cosmetic Outcomes of Facial Lacerations Repaired With Tissue-Adhesive, Absorbable, and Nonabsorbable Sutures, Am J Emerg Med 2004; 22: 254-257
Article 3: Cosmetic Outcomes of Absorbable Versus Nonabsorbable Sutures in Pediatric Facial Lacerations, Ped Emerg Care 2008; 24: 137-142
Article 4: Absorbable Versus Nonabsorbable Sutures in the Management of Traumatic Lacerations and Surgical Wounds: A Meta-Analysis, Ped Emerg Care 2007; 23: 339-344
In general, all of these trials failed to reference or use CONSORT reporting guidelines for RCT’s. Specifically, the all failed to
- blind patient, clinician or nurse outcome assessor to allocation arm increases risk of bias
- provide a clear intention-to-treat statement;
- report upon irrigation methods or prophylactic antibiotic use;
- all were under-powered for their primary outcome and not designed to evaluate therapeutic equivalence;
- most had external validity limited to pediatric patients in pediatrics ED.
Based upon 7 RCT’s (enrolling a total of 702 patients) absorbable sutures appear to be equivalent to non-absorbable sutures for traumatic and non-traumatic wound repair with no significant difference in short- or long-term wound cosmesis, dehiscence or infraction rates for immunocompetent pediatric patients with a wound not amenable to tissue adhesive repair(i.e. wounds > 5 cm length or > 0.5 cm width are not amenable to glue). All of the trials suffer from the confounding variable that they actually had subjects return at 5-10 days whether they had absorbable or non-absorbable sutures. If the benefit of absorbable sutures is to avoid the follow-up visit for suture removal, subsequent trials will need to assess this scenario and not have the absorbable subset return because the return visit itself might alter wound healing or patient satisfaction. Future appropriately powered pragmatic clinical trials should confirm the current findings while assessing cost-effectiveness and actual patient/parent discomfort with suture removal in more general ED populations (obese, elderly, rural, and diabetic).