Staples vs. Sutures
                          ===================

       I have no personal experience using tissue adhesives but there
was a discussion on ped-em-l in March about just this issue.  Someone at
that time produced a reference (1) which claimed that the shorter chain
n-alkyl derivatives of cyanoacrylate were more histiotoxic. Both the
n-ethyl (Krazy Glue) and the n-methyl derivatives had been used in
surgery (particularly otolaryngology) but have since been abandoned in
favor of the longer n-butyl derivative (Histoacryl Blue). Compared to
suturing, tissue adhesives appear to have an advantage in terms of a
lower chance of infection, although tensile strength, particularly early
on is not as great (2).

H. Louzon MD

(1)

Toriumi DM, Raslan WF, Friedman M, Tardy ME
Histotoxicity of cyanoacrylate tissue adhesives. A comparative study.
Arch Otolaryngol Head Neck Surg 1990 May;116(5):546-50

Cyanoacrylate derivatives have been used as surgical adhesives for many
years. Shorter-chain derivatives (methyl- and ethyl-cyanoacrylate) have
proved to be histotoxic. Longer-chain derivatives (butyl- and
isobutyl-cyanoacrylate) are much less histotoxic. Many surgeons continue to
use ethyl-2-cyanoacrylate (Krazy Glue) despite the availability of a less
toxic derivative, butyl-2-cyanoacrylate (Histoacryl). In this study, the
histotoxicity and bone graft-cartilage binding ability of Krazy Glue and
Histoacryl were compared. Bone grafts harvested from the anterior wall of
the maxillary sinus were placed in a subcutaneous pocket and glued to
auricular cartilage in the rabbit. Krazy Glue and Histoacryl were used in
opposite ears, harvesting specimens at 1, 2, 4, 12, 24, and 48 weeks. The
Krazy Glue-treated ears developed seromas with histologic evidence of acute
inflammation, tissue necrosis, and chronic foreign body giant cell reaction.
The Histoacryl-treated ears showed mild acute inflammation and mild foreign
body giant cell reaction. The Krazy Glue was completely degraded within 12
months, while some Histoacryl was still present at 1 year. Histoacryl had
minimal histotoxic effect and good bone graft-cartilage binding ability,
whereas Krazy Glue demonstrated severe histotoxicity.

(2)

Noordzij JP, Foresman PA, Rodeheaver GT, Quinn JV, Edlich RF
Tissue adhesive wound repair revisited.
J Emerg Med 1994 Sep-Oct;12(5):645-9

The purpose of this experimental study was to compare the effect of a tissue
adhesive, N-butyl-2-cyanoacrylate, on the wound's ability to resist
infection and gain strength to the effect of percutaneous polypropylene
suture. Percutaneous sutures damaged host defenses, inviting the growth of
bacteria to a level that was significantly greater than that encountered
with the tissue adhesive. Immediately after wound closure, percutaneous
sutures provided a more secure closure, as measured by breaking strength,
than did tissue adhesives. Seven days later, the breaking strengths of
wounds closed by tissue adhesives did not differ significantly from those
repaired with percutaneous sutures. Tissue adhesive closure requires less
psychomotor skills than suture closure and is accomplished more rapidly than
suture closure.