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#1
02.04.2010, 16:58
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It's interestng, IMHO.
Редакционные статьи в BMJ, как правило, отражают последнюю "партийную линию". Вопрос занимает место в ежедневных дебатах хирургических коллег, думаю, статья может быть интересна представителям различных хирургических направлений.
Published 16 March 2010 Editorials Staples for skin closure in surgery Are quicker than sutures, but may increase complications About 230 million major surgical procedures are performed worldwide each year,1 and morbidity and mortality after surgery vary widely. Three recent publications highlight the long term implications of surgical complications, both for 30 day survival and "sickness absence."1 2 3 In the linked systematic review (doi:10.1136/bmj.c1199), Smith and colleagues assess clinical outcomes using staples compared with sutures in wound closure in orthopaedic surgery.4 Postoperative infection is a major source of morbidity, mortality, and hospital costs, but it is not completely avoidable because certain factors—such as age, drugs, systemic illness, and type of surgery—cannot be changed. Interventions to reduce infection, such as the use of perioperative antibiotics and clean air operating theatres, are well established. The literature is sparse, however, on the role of skin closure technique on the rates of infection. Wound closure creates the tensile strength that holds the wound edges together and it provides an effective seal until healing takes over. Effective wound healing minimises infection and produces a satisfactory cosmetic result. In orthopaedic surgery, superficial infection can be associated with increased risk of deep infection and reduced implant survival. The preferred method of skin closure varies within and across all branches of surgery. The skin can be closed by continuous subcuticular sutures, interrupted sutures, or skin staples. Data are also now available that compare adhesive and more established techniques.5 Smith and colleagues report the first meta-analysis comparing sutures and staples in orthopaedic wounds. Data from six studies, three of which were randomised, and 683 orthopaedic procedures showed that the risk of infection was three times higher when staples were used (relative risk 3.83, 95% confidence interval 1.38 to 10.68).4 When hip procedures were looked at exclusively, the risk of infection was four times greater when staples were used (relative risk 4.79, 1.24 to 18.47). However, no difference was seen in infection rates when staples were used for total knee replacement.4 Smith and colleagues’ data fit with evidence from other specialties. Three of five randomised controlled trials that compared the use of sutures with staples in the closure of chest and leg wounds in cardiothoracic surgery found a lower complication rate with sutures, and all trials found that sutures produced a better cosmetic result.6 One systematic review compared the use of sutures and staples after elective caesarean section. It found that staples were quicker, but postoperative control of pain was better after sutures. No significant difference was seen in cosmetic appearance or infection rate at six weeks.5 Abdominal wounds closed with sutures have been associated with increased postoperative pain and poorer cosmetic outcomes, but no difference in complications.7 Several studies have shown that using staples to treat scalp lacerations in the emergency department is faster, less expensive, and not associated with an increased rate of complications.8 The most consistent benefit of staples is more rapid skin closure, yet the time saved is rarely more than two to three minutes.9 Although theatre time is estimated at £5 (5.7; $8) to £15 a minute, this represents a relatively small proportion of the total time spent by patients in theatres or operating departments. Secondly, the saving may be reduced by the increased costs of removing the staples (compared with absorbable subcuticular stitches) and reduced even further by the costs of treating the increased number of infections. Studies in orthopaedic and cardiothoracic surgery attribute a higher cost to the use of staples.10 Smith and colleagues acknowledge that only one of the five papers studied in their analysis was appropriately designed and reported. Three studies were randomised but only two studies were adequately blinded, and risk factors for poor wound healing such as steroid use and diabetes were not documented. Furthermore, the observed increase in infection rate seems to have been influenced mainly by the difference in outcomes after hip fractures. Of the four studies of hip surgery, two exclusively included people with hip fracture, who may be more vulnerable to wound infection. Furthermore, because of the lack of random concealed allocation, the most vulnerable of these people may have been allocated staples to minimise time under anaesthesia. Well designed randomised controlled trials are needed to examine further the increased risk of infection risk found by Smith and colleagues. They are also needed to discern whether the risks are exclusive to hip surgery, and to compare the risk of infection with staples in elective hip arthroplasty as opposed to hip fracture. We now have national databases of the outcome of hip and knee arthroplasty and hip fracture, but currently neither records the method of skin closure. These databases could provide the platform to enable comprehensive adequately powered studies. The Medical Journal of Australia has recently updated its guidelines for skin closure in the treatment of hip fractures, and they state that superficial wound complication rates are higher for wounds closed with metallic staples than for wounds closed with subcuticular vicryl.11 The British Orthopaedic Association’s "blue book" for best practice in fragility fractures states that no strong evidence exists to support or condemn the use of either sutures or staples, but that patients should be made aware of which will be used.12 On the best available evidence, it may be more difficult to justify the use of staples in these patients. 
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#3
04.04.2010, 07:42
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Цитата:
 А будущее, имхо, за клеем.
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#4
04.04.2010, 18:29
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В стоматологии не применяются. У нас косметические швы. В своём "музейчике" держу упаковку скобок - очень красивы.
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Линейный вид
