Suturing With U-technique Versus Un-Reapproximated Wound Edges During Removal of Closed Thoracostomy Tube Drain - A Single-centre Open-label Randomized Prospective Trial (SUTURE TRIAL)
Phase: NA
Conditions: Pleural Effusion, Pneumothorax, Chest Trauma, Video-assisted Thoracoscopic Surgery, Thoracotomy, Pleural Diseases, Chylothorax, Empyema, Pyothorax, Thoracic Diseases, Thoracic Injury
Sponsor: University of Ibadan

 
 
 
 
Official Title of the Study: Suturing with U-Technique versus Un-
Reapproximated wound Edges during removal of Closed Thoracostomy-tube 
drain - A single centre Open-label randomized prospective trial (SUTURE 
TRIAL) 
 
 
NCT NUMBER:  Not Yet Assigned 
 
 
 
DATE OF DOCUMENT: January 16, 2019 
 
 
 
 
 
 
 
 
 
 
 
1

STUDY SUMMARY 
Title: Suturing with U-Technique versus Un-Reapproximated wound Edges during removal of Closed 
Thoracostomy-tube drain - A single centre Open-label randomized prospective trial (SUTURE 
TRIAL) 
Background: Closed thoracostomy tube drainage or chest tube insertion is one of the most commonly 
performed procedures in thoracic surgery. There are several published evidence-based guidelines on 
safe performance of a chest tube insertion. However, there is absence of prospective controlled trials 
or systematic reviews indicating the safest technique of closing the wound created at the time of chest 
tube insertion and that best guarantees good wound and overall outcomes, post-chest tube removal. 
The use of a horizontal mattress non-absorbable suture or U- suture which is placed at the time of chest 
tube insertion and used to create a purse-string wound re-approximation at the time of tube removal 
has been an age-long and time-honored practice in most thoracic surgical settings. It has been 
established by a recent study that an occlusive adhesive-absorbent dressing can also be safely used to 
occlude the wound at the time of chest tube removal with good wound and overall outcomes though 
the study focused on tubes inserted during thoracic surgical operations. 
Research Design: The study is an Open-label randomized prospective trial 
Methodology: 142 consenting patients with indication for chest tube insertion, who meet the inclusion 
criteria for enrolment in the study will be randomly assigned into two balanced groups- Group A; that 
will have a Prolene 1 purse-string suture placed around the thoracostomy wound at the time of chest 
tube insertion and which will be used for the thoracostomy wound closure at the time of chest tube 
removal and Group B, that will not have a purse-string suture placement during chest tube insertion 
and will have their wounds covered by an occlusive adhesive-absorbent dressing material 
(Primapore*), at the time of chest tube removal. The procedure for chest tube insertion, indwelling 
chest tube management, post-tube removal care and outpatient follow-up; will be similar for both 
groups and will follow a pre-determined standardized protocol. Specific clinical outcomes while the 
chest tube is indwelling and specific clinical and wound outcomes after the chest tube removal will be 
observed in both Groups for comparison and to determine causal relationships. Observations will be 
recorded in a specially-designed study proforma. 
 
Principal Exposure: For Group A- Purse-string suture (U-suture technique) placement during 
chest tube insertion and purse-string suture closure of thoracostomy 
wound during chest tube removal 
For Group B- Non-placement of purse-string suture during chest tube 
insertion and use of occlusive adhesive-absorbent dressing during chest 
tube removal, for closure of the thoracostomy wound  
 
Outcome variables: - 
Clinical and wound complications with indwelling chest tube 
- 
Early and late wound complications after chest tube removal 
 
 
 
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Conclusion: 
Data obtained from the prospective trial will provide general guideline for managing 
chest tube/thoracostomy wounds after chest tube removal. It will also be employed in the design of  
institutional protocol for chest tube insertion. 
Keywords: Chest tube insertion, Purse-string suture, occlusive adhesive-absorbent dressing, 
thoracostomy wound closure, wound complications 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER ONE 
INTRODUCTION/BACKGROUND 
Closed thoracostomy tube drain insertion also referred to as tube thoracostomy, intercostal drainage or 
simply chest tube insertion is the most commonly performed surgical procedure in thoracic surgery 
(1). It is often performed routinely as part of the treatment of many thoracic diseases (2). This 
procedure largely involves placing a hollow and flexible drainage tube into the pleural space to remove 
an abnormal collection of air or fluid so as to permit re-expansion of the lung (3,4). It can also be used 
to infuse agents into the pleural space. 
The wide use of chest drains became popular during the 1918 flu pandemic but they were first 
documented for the treatment of empyema by Hippocrates (5). Around the fourth century B.C, while 
using rudimentary skills of incision and cautery, he described the process of incising the chest and 
inserting a metal tube for pleural drainage (5,6).  
Generally, the indications for inserting a closed thoracostomy tube drain include-pneumothorax, 
malignant pleural effusion, empyaema and complicated parapneumonic pleural effusion, traumatic 
haemopneumothorax; postoperatively after thoracotomy, pulmonary lobectomy, oesophagectomy, 
cardiac surgery; treatment with sclerosing agents or pleurodesis and post-pneumonectomy 
bronchopleural fistula (4,5,7,8,9). Table 1 below clearly summarizes these indications. The procedure 
is relatively contraindicated in patients with lung adherence to the chest wall and uncorrected 
coagulopathy (4). 
The chest tubes inserted can be classified based on size or calibre into small-bore chest tubes and large 
bore chest tubes (9). The small-bore chest tubes (<20Fr) are indicated for spontaneous pneumothorax, 
free flowing pleural effusions or empyema while the large-bore chest tubes (>20Fr) are indicated for 
hemothorax, acute trauma, open thoracostomy, after most cardiothoracic, oesophageal or spine surgery 
(10).  
The insertion of a chest tube and the ongoing care of patients with indwelling chest tubes carries the 
potential for significant morbidity and mortality if not properly done (10). Also, the safe closure of a 
chest tube insertion wound has been of great interest to surgeons for many years (11). Since chest tube 
insertion is considered a mandatory skill for different physicians including general and thoracic 
surgeons, interventional pulmonologists, intensivists and emergency medical specialists worldwide, 
there is an ever pressing need to develop a standard algorithm for removal of chest tubes (12). 
 
 
PROBLEM STATEMENT 
In spite of the ubiquitous placement of chest drains for different purposes, there is still a lack of high- 
quality prospectively-designed evidence-based guideline for post-placement management of the chest  
tubes making current management of patients with chest tubes to be largely reliant on protocols of  
individual institutions and personal idiosyncrasies mostly borne out of anecdotal experience (13, 14)  
Several national and international thoracic societies’ guidelines exist as well as published literatures  
that give clear advice on when to consider inserting chest drains (5,7,9). Also, there is a litany of  
procedural guidelines detailing how to safely perform chest tube insertion. However, there is a paucity  
of major guidelines or scientifically-proven standard methodology of closing the wound made during  
the process of chest tube insertion at the time of removal of the chest tube (9,11,15). The conventional 
method of managing a thoracostomy wound at the time of chest tube insertion is to use an anchoring 
4

suture to fix the chest tube to the wound edge thereby preventing it from spontaneously extruding 
while also placing a purse-string suture around the wound that would be used to close the wound at 
the time of chest tube removal (2,11). This purse-string suture can also be used as an additional means 
of securing the chest tube in position with the added advantage of preventing air or pleural fluid from 
entering or egressing the pleural space (i.e. air and water tightness) during the tube removal process 
(2). It has been reported that though beneficial for the most parts, this purse-string suture placement at 
the time of tube insertion has its inherent burden of suture-related pain, irritation and increased rates 
of wound infection following its placement and retention, an experience reported by patients during 
the course of the tube drainage and which may persist even after tube removal (11). It means this 
conventional method can be associated with higher drain removal pain scores and in addition, more 
frequent outpatient wound dressings after hospital discharge, need for suture removal after the wound 
has healed and the long-term development of an unsightly thoracostomy scar (2, 11,16). Skin staplers 
and simple interrupted skin sutures have also been used with equally unsatisfactory wound outcomes 
(2). 
It has been noted that when petroleum gauze or any other adhesive and impermeant dressing material 
was used for air and water tight occlusion of the thoracostomy wound after chest tube removal 
(implying nonuse of a purse-string or any other type of suture), the incidence of iatrogenic 
pneumothorax and wound dehiscence was higher (2). Other more sophisticated suture techniques such 
as the use of knotless sutures, using a two-layer method with triclosan-coated sutures; appear to be 
more expensive to perform and require experience and uncommon expertise (15). 
From the foregoing, it is clear that both the conventional suturing method as well as the alternative use 
of impermeant occlusive dressing of the thoracostomy wound after chest tube removal have their 
attendant problems. Studies that directly and deliberately compare outcomes and benefits of these two 
prominent thoracostomy wound management approaches are non-existent in medical literature. 
 
 
RATIONALE FOR THE STUDY 
The lack of evidence to support choice of thoracostomy wound closure at the time of removal of chest 
tube underscores the need for this study. There is no shortage of publications establishing an 
association between chest tube insertion as an invasive procedure and the occurrence of specific 
intervention-related early and late complications with variable degrees of impact on immediate and 
long-term outcomes of the disease indicating the tube insertion in the first place (4,6,7,9,11-16). 
Nonetheless, there are a few studies suggesting different techniques of closing a thoracostomy wound 
at the time of tube removal especially for those inserted following chest trauma as well as post- 
operation (thoracotomy and sternotomy) in which the tube is often inserted as an adjunct to a specific 
thoracic surgical procedure (15,16). It limits the generalizability of the findings of such studies 
knowing other non-traumatic thoracostomy indications abound beyond accidental and intentional 
trauma of surgery. Also, the review of all other similar studies indicates no universal or consensus 
decision on the most acceptable thoracostomy wound closure technique with a rarity of discussions 
about outcome of all suggested techniques especially as it relates to wound failure and cosmesis.  
It is instructive to note that, this lack of evidence has contributed to why there is no recognized 
standardized or consensus method adopted by any of the globally renowned thoracic societies in their 
clinical practice guidelines as regards the technique of closure of the thoracostomy wound at the time 
of tube removal and till date controversies still exists about the most superior method amongst the few 
 
5

described methods. Infact, no single prospective study has been done till date to establish the safest 
and best closure method that guarantees the best immediate and long-term wound outcomes after chest 
tube removal. This study is therefore required to answer these pending questions in a prospective 
manner within a real-life clinical practice setting. 
OBJECTIVES OF THE STUDY 
GENERAL OBJECTIVES 
To prospectively compare the early and long-term outcomes between the use of purse-string (suturing 
U-technique) and Un-reapproximated thoracostomy wound edges (Occlusive adhesive-absorbent 
dressing application) at the time of removal of thoracostomy tube drain in patients who have had chest 
tube insertion.  
SPECIFIC OBJECTIVES 
• 
To compare the tube-related complications of chest tube insertion in patients who have purse- 
string suture (U-suture placement) at the time of chest tube insertion versus those without purse- 
string suture placement that are enrolled for Occlusive adhesive-absorbent dressing application at 
the time of chest tube removal. 
• 
To compare the incidence of early complications after chest tube removal in patients who have 
purse-string suture re-approximation of thoracostomy wound versus those who have only 
Occlusive adhesive-absorbent dressing application (Un-reapproximated wound edges) 
• 
To compare the incidence of late wound complication after chest tube removal in patients who 
have purse-string suture re-approximation of thoracostomy wound versus those who have only 
Occlusive adhesive-absorbent dressing application (Un-reapproximated wound edges) 
STUDY HYPOTHESIS 
NULL HYPOTHESIS: There is no difference in the wound and clinical outcomes of patients who had 
purse-string (suturing with U- technique) for closure and those who had an occlusive adhesive- 
absorbent dressing application (Un-reapproximated wound edges); for post-tube removal management 
of thoracostomy wound 
ALTERNATE HYPOTHESIS: There is a major difference in the wound and clinical outcomes of  
patients who had purse-string (suturing with U- technique) for wound closure and those who had an  
occlusive adhesive-absorbent dressing (Un-reapproximated wound edges); for post-tube removal  
management of thoracostomy wound  
 
 
STUDY VARIABLES AND DEFINITION 
The independent variables to be employed for the analysis include: 
• 
Age of the patient 
• 
Sex of the patient 
• 
Presence of specific co-morbidities (Diabetes, Hypertension, Chronic Liver disease, Chronic 
kidney disease) 
• 
Charleson Comorbidity Index 
• 
History of cigarette smoking and estimated pack years if positive 
 
 
6

• 
Use of steroids and chemotherapeutic agent 
• 
Abnormal Body mass index (Obesity(BMI> 30kg/m2), Malnutrition(BMI< 18kg/m2) 
The Dependent variables to be employed for the analysis include: 
• 
Presence of severe pain at the chest tube site after chest tube insertion (Average daily pain 
score after tube insertion > 5 on the Visual Analog Scale and or Numerical Rating Scale)  
• 
Occurrence of tube dislodgement after chest tube insertion 
• 
Occurrence of peri-tubal leakage of fluid after chest tube insertion 
• 
Presence of wound air suck-in after chest tube removal (indicated by presence of air suck-in 
sound through the wound into the pleural space during quiet and or forced inspiration) 
• 
Occurrence of wound infection after chest tube removal (presence of purulent or offensive 
wound discharge with or without fever or presence of wound discharge that is 
microbiologically positive) 
• 
Occurrence of wound dehiscence after chest tube removal 
• 
Occurrence of early (within 7 days) and late pneumothorax (more than 1 week) after chest 
tube removal confirmed on chest radiography 
• 
Development of raised or elevated thoracostomy wound scars (unsightly scars appearing like 
hypertrophic scars or keloids) within 3 months of chest tube removal 
RESEARCH QUESTIONS 
• 
What is the difference in the tube-related complication rates after placing a purse-string suture 
(U suture placement and retention) for thoracostomy wound re-approximation versus non- 
placement of purse-string at the time of chest tube insertion? 
• 
What is the difference in the early and late complication rates after using a purse-string suture 
(U suture) for thoracostomy wound re-approximation versus use of only an occlusive adhesive- 
absorbent dressing with unreapproximated thoracostomy wound edges; at the time of chest 
tube removal? 
• 
What is the difference in pain score after using a purse-string suture (U suture) for 
thoracostomy wound re-approximation versus use of only an occlusive adhesive-absorbent 
dressing with unreapproximated thoracostomy wound edges; after chest tube removal? 
• 
Is purse-string thoracostomy wound closure associated with more cosmetic complications of  
thoracostomy scar in the long term than un-reapproximated thoracostomy edges with an 
occlusive adhesive-absorbent dressing ? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER TWO 
LITERATURE REVIEW 
 
 
MANAGEMENT OF THORACOSTOMY WOUND AFTER CHEST TUBE REMOVAL 
The common indications for chest tube drainage are listed in Table 1 below. Chest tube insertion is 
not devoid of risks (17). Closed tube thoracostomy wounds are often classified as “clean contaminated” 
and hence the risk of wound infection is 7.7% (18). The goal of prophylactic antibiotic therapy for 
closed tube thoracostomy drainage in traumatic chest injury is to decrease the risk of infectious 
complications and its associated morbidities, based on reasonable assumptions about the organisms 
most often cultured (19). Antibiotic prophylaxis should be considered for trauma patients requiring 
pleural drains, especially after penetrating trauma and a single dose of cephazolin 2g, given 
intravenously has been suggested, to provide adequate antimicrobial cover (10). A meta-analysis 
showed that prophylactic antibiotic treatment reduces the risk of developing infectious complications 
after tube thoracostomy for traumatic injuries of the chest, with the effect best documented for 
penetrating injuries (16). However, a single-dose antibiotic prophylaxis in penetrating chest trauma is 
as effective as prolonged prophylaxis (20). Early physiotherapy and early removal of the thoracostomy 
tube are important to prevent intrathoracic sepsis (20). Antibiotic prophylaxis is not recommended for 
non-trauma patients requiring a pleural drain (10). 
 
 
Table 1. The common indications for chest tube insertion (9). 
 
1) 
Pneumothorax  
Large or symptomatic primary spontaneous pneumothorax  
Secondary spontaneous pneumothorax  
Pneumothorax in patients on mechanical ventilation  
Tension pneumothorax  
Large or symptomatic iatrogenic/traumatic pneumothorax  
Occult traumatic pneumothorax associated with hemothorax 
2) 
Pleural effusions  
Infected effusion (complicated parapneumonics, empyema)  
Malignant or benign effusions requiring bedside pleurodesis 
Hemothorax  
Chylothorax| 
3) 
Postoperation  
Thoracic, cardiac, or esophageal surgery 
Thoracoscopy  
 
The common complications encountered with chest tube insertion are malposition and obstruction, 
either by occlusion or by kinking; ectopic insertion and tension pneumothorax with significant air leak; 
hence the need to secure the tube properly (17).Large and medium bore chest drain incisions are 
usually closed by a suture appropriate for a linear incision(7). Various techniques have been described, 
but a simple technique of anchoring the tube has not been the subject of a controlled trial (9). A purse 
string or U-suture placement (horizontal mattress suture) is used to aid removal of the chest drain at a 
 
 
8

later date and facilitate closure of the defect on removal of the drain while avoiding the occurrence of  
an iatrogenic pneumothorax (3,16). 
For this technique, the chosen suture should be stout, strong and non-absorbable (silk or prolene) to 
prevent ease of breakage (7). One or two additional simple or horizontal mattress sutures of generous 
depth should be placed to properly anchor the tube (7). This suture is also thought to prevent air re- 
entry on drain removal as well as aid in chest drain site healing by apposing the edges of the wound 
(16). The suture is often tied to close the skin wound snugly around the tube to prevent any peri-tubal 
leak (4). However, this can result in an unsightly scar and tying this suture and retaining the knot for 
the purpose of achieving air and water tightness of the incision can worsen the painful experience of  
patients before and after drain removal. In addition, any delay in tube removal often increases the risk  
that is inherently associated with the retained suture being a foreign body (16). In other to increase the  
cosmetic appearance of the scar as well as provide an airtight seal to prevent air re-entry, attempts have  
been made to place an absorbable suture at the time of drain insertion but such methods may be  
cumbersome and complicated (16). Some centers have reported significant success with achieving  
airtightness using single barbed absorbable suture material(15).  
Some commercially available dressings which adhere tightly to the skin and then attach to the drain 
may also be used but they do not replace the need to stitch the drain firmly in place (10). Another 
common method is to cover the wound with a water impermeant occlusive dressing material like 
vaseline gauze or adhesive tape, after removing the chest tubes to prevent air entry into the pleura but 
the cosmetic result may be unreliable with the wound healing by granulation (11).Petroleum-coated 
gauze as an occlusive seal was used in the past but it is no longer recommended because it leads to 
integument breakdown, wound infections, pneumothorax and wound dehiscence (2,7). 
Other newer techniques for the management of the chest drain wound after tube removal such as a 2- 
layer method with triclosan-coated sutures have been described(2). This method was designed with 
lots of advantages such as non-requirement of a stitch removal at follow-up, good wound healing with 
cosmetically-appealing scars; without an increased risk of infection but it has a drawback of being too 
expensive with requirement of technical expertise limiting its widespread adoption (2,3). 
Sutures may not be necessary, after all, for closure of chest drain site as a study reported very minimal 
complications when sutures were not used(16). The study showed that the rate of acute pneumothorax 
after removal was 1.2% as opposed to the documented rate of 6%-10.7% for purse-string sutures. Late 
pneumothorax rate was 0% and only superficial infections occurred with this method which did not 
result in empyema thoracis as opposed to the documented rate of 1%-25% for purse-string suture use 
(16,21,22). There was also a reduction of the cost per patient which was not just from avoiding using 
a suture but also avoiding the cost of removing such a suture afterwards (16). 
The optimal timing and criteria for tube removal is still a matter of controversy for many reasons (9). 
Some guidelines state that the criteria for chest drain removal should include no air leak and a 24- hour 
period of drainage of less than 500 mL fluid(16). Others state that the lung should be fully expanded 
and there should be no persisting hemothorax or pneumothorax, no air leak, no fresh or altered blood 
should be leaking from the site of insertion and the daily drainage should be <100 ml(10). Apparently, 
the timing of removal is dependent on the original reason for insertion and clinical progress and the 
common grand norm is tube removed when therapeutic goals have been achieved (7,9,16). Some 
studies recommend that the International Normalized Ratio (INR) should be at least 1.5 and/or platelets 
greater than 50 x109 /L before the chest tube is removed (10) but this should be regarded as a relative 
contraindication with decision left to the discretion of the individual managing physician.  
 
9

When a purse-string suture is intended to be used for wound closure at the time of tube removal, the 
set up should involve two persons with one tying the knot of the purse-string to appose the wound 
edges immediately after the other person briskly removes the tube with a firm pull on it, after detaching 
the tube anchor stitches while the patient performs a Valsalva maneuver or during expiration (7). The 
actions of the two persons and the patient should be done in a coordinated and synchronous manner to 
avoid iatrogenic suck-in pneumothorax during the tube removal process. When a simple adhesive 
Tegaderm þ Pad (3M, Saint Paul, MN) dressing was used for occluding the thoracostomy wound at 
time of tube removal in a study, the chest tube was removed under arrested expiration (the Valsalva 
maneuver) (16). Studies have demonstrated that the removal of thoracostomy tubes at the end of  
inspiration or at the end of expiration is equally safe (23). The rule should be that a chest tube should 
not be pulled out when the patient is still breathing actively because this will result in a pneumothorax 
(10). 
In the study employing occlusive dressing for thoracostomy wound management after tube removal, 
clinical and wound complication rates (early and late) were significantly lower in comparison to 
previously published reports on purse-string suture use (16). Though with limitation of being a report 
from a single surgeon and single institution practice, it was still able to offer a safer alternative to the 
commonplace practice of purse-string closure technique. Table 2 below summarizes the complications 
and their rates amongst 312 patients requiring chest tube insertion over an 18-month period in whom 
only occlusive dressings with Tegaderm þ Pad (3M, Saint Paul, MN) was applied to the thoracostomy 
wound at the time of chest tube removal. 
 
 
Table 2: Complication and rates after occlusive dressings at time of chest tube removal (16) 
Complication 
n (%) 
Superficial wound infection 
5 (1.6) 
Acute pneumothoraces 
4 (1.3) 
Serous discharge requiring suture 
1 (0.3) 
 
Though these findings may suggest superiority of this approach to thoracostomy wound management 
at time of chest tube removal, its reproducibility and generalizability should be done with caution since 
all the chest tubes were inserted as an adjunct to thoracic surgical procedures.  
 
 
 
 
 
WOUND OUTCOMES WITH DIFFERENT THORACOSTOMY CLOSURE TECHNIQUES 
Properly closing and stabilizing surgical wound edges to restore their original position is a key 
consideration in achieving good and satisfactory surgical wound outcomes. Surgical wound 
complications portend poor immediate outcomes for patients as they require more dressings, may 
require prolonged antibiotic therapy to manage wound infection, experience more pain, and have a 
strong potential for prolongation of the length of postoperative hospital stay (24,25). Un-interrupted 
acute wound healing occurring by first or primary intention as a result of the wound edges being in 
close proximity to each other, tends to heal with far less inflammatory reaction and granulation tissue 
 
 
10

formation and minimal wound contraction (26,27). These inevitably result in earlier wound sealing, 
lower risk of post-operative contamination and infection as well as satisfactory wound pain control. 
Also, considering the long term, the main rationale behind closure of surgical wounds is the 
achievement of far less scarring that will produce a functional and cosmetic-appealing scar when the 
wound heals (28). There is growing interest in achieving such scars with rising patients' expectations 
and in turn, increasing surgeons’ awareness of surgical materials and techniques required to close 
surgical wounds to achieve a scar that is functional and with a satisfactory cosmetic appearance (29). 
Though, several techniques have been proposed and employed to achieve this kind of closure, there is 
no stand-out ideal technique because each one is fraught with its own inherent and unique challenges. 
The early process of any wound healing by primary intention requires the formation and organization 
of a thin rim of clot holding together the apposing edges of the wound while the wound progressively 
gains tensile strength (30). The stability and strength of the wound depends largely on the formation 
and stability of this clot and the biochemical and mechanical forces within the wound bed. These 
factors counteract the shearing forces at the wound edges that tend to delay wound sealing which 
should normally be completed in 2 to 3 days (30,31). 
Wound suturing is a time-honored technique of enhancing and improving the chances of a wound  
sealing at the earliest possible time, that has been practiced by surgeons for many generations. The  
employment of a suture is to achieve primary closure of wounds irrespective of wound length and  
topography, by maintaining the wound in apposition while it gains strength during the early phases of  
wound healing. It also helps with early wound sealing.  
Despite these undoubted benefits of wound suturing, there exists some inherent side effects like 
increased risk of wound infection and wound pain in the early post-operative period and the possibility 
of suture-related undesired scar outcomes. These benefits are often closely related to the make, design 
and strength of the suture used as well as the technique of placement and application of the suture in 
wound closure (30,31). The generally acceptable concept is to use a monofilament and non-absorbable 
suture of good strength to close superficial wounds to limit the side effects of suture use on early and 
late wound outcomes (29,30,31,32). This has been corroborated by findings from past and recent 
human and animal studies (33,34,35). Specifically, using prolene suture, a monofilament and 
nonabsorbable suture, for superficial wound closure towards achieving good early and late wound 
outcomes had been identified several years ago and the satisfactory early and late wound outcomes 
have remained incontrovertible till date (36). Prolene is known to cause minimal tissue reaction, to be 
associated with minimal wound infection and wound pain while also promoting early wound healing 
with better cosmetic appearance of the scar (36,37). 
For over two decades, to mitigate the effect of suture use whilst encouraging a non-invasive apposition  
of wound edges, in an attempt to promote early wound sealing and satisfactory wound outcomes;  
occlusive adhesive dressing have taken a progressive pre-eminence in the early management of  
surgical wounds as described in some series (38). A dressing is described as occlusive if a moist wound  
surface is maintained while the dressing is in place (38,39). Occlusive dressings are non-invasive,  
inhibit water vaporization from wound surface to the atmosphere thereby reducing wound desiccation,  
encourage early wound epithelialization, improve stability of chronic wound granulation tissue and  
creates a painless autolysis of any wound necrotic area (39,40). Other additional benefits noted include  
the protection of the wound bed from environmental contaminants and microorganisms with reduction  
in risk of wound infection , reduction of wound pain, provision of a cost effective wound care option  
 
 
11

by decreasing the nursing time required for wound care and ultimately, the production of a less 
noticeable scar with far more satisfactory cosmetic outcome (40,41,42). 
Several commercially available occlusive dressings are available in clinical practice today. A study 
has utilized Tegaderm þ Pad (3M, Saint Paul, MN) for management of thoracostomy wounds which is 
applied at the time of chest tube insertion (16). Primapore* (Smith & Nephew, London, UK) is an 
economical all-in-one tape and gauze product (43). The peripheral tape at the margin is adhesive while 
the central guaze is a soft, comfortable, water-resistant, non-adherent island dressing that ensures 
patient comfort while also serving as an absorbent medium. This is shown in Figures 1 and 2 below.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FIGURE 1: Primapore* occlusive-adhesive 8.3 x 6cm rectangular dressing 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FIGURE 2: Primapore* occlusive-adhesive dressing applied to a thoracostomy wound 
 
 
 
 
 
 
12

CHAPTER THREE 
METHODOLOGY 
STUDY DESIGN 
The study is a prospective randomized open-label clinical trial comparing the outcomes of an 
unconventional method of closing thoracostomy wounds after chest tube insertion and removal 
(Occlusive adhesive-absorbent dressing application i.e. Un-reapproximated wound edges) to a 
common-place conventional method of closure with purse-string suture (U-suturing or purse-string 
suturing technique). This design entails random allocation of eligible patients into two groups, namely; 
Group A (patients who will have purse-string suture placed at the time of insertion of chest tube and 
who will have this purse-string used for the closure of the thoracostomy wound at the time of chest 
tube removal) and Group B (patients who will have no purse-string placement at the time of chest tube 
insertion and will have their thoracostomy wound covered with an occlusive adhesive-absorbent 
dressing at the time of chest tube removal). 
 
 
STUDY AREA AND SITE 
The study will be carried out by the principal investigator and his team at the Division of  
Cardiovascular and Thoracic Surgery of the Department of Surgery at the University College Hospital,  
Ibadan (UCH). The hospital is an 850-bed tertiary health institution and a regional reference centre for  
thoracic surgical and advanced pulmonary medical care that serves mainly the states in South-Western  
Nigeria including Oyo, Ogun, Osun, Ondo and Ekiti states. It also receives referrals for thoracic  
surgical cases from Lagos and up-country (South-East, South-South and North-Central regions of  
Nigeria).  
These patients seeking thoracic surgical care are often admitted to designated thoracic surgical and 
Pulmonary medical wards of the hospital via the emergency department or outpatient clinics. 
STUDY DURATION 
The study is expected to span a one (1) year period. It will be conducted on all patients who meet the 
inclusion criteria that present within the study period. 
STUDY POPULATION 
The study population will be mainly consenting patients who require chest tube insertion for 
therapeutic purposes and fulfill the inclusion criteria during the study period. 
SAMPLE SIZE 
The sample size will be calculated by comparing the known incidence rate of 6% for acute 
pneumothorax when a purse- string suture is used and an incidence rate of 1.2% when the wound edges 
were un-reapproximated since the occurrence of pneumothorax is the most common morbidity or 
complication that is documented in the literatures (16). Using the software WinPepi (44), 142 subjects 
grouped into 71 subjects in group A and 71 subjects in group B will be required to compare a 
proportion rate of 6% in group A and 1.2% in group B, if level of significance is set at 5%, non- 
response rate set at 5% with the study powered at 80%; for a two-sided test. 
 
 
 
13

SAMPLING AND RANDOMISATION TECHNIQUES 
A block but balanced randomization technique (Unstratified) will be used in determining the use or 
otherwise of purse-string in the study population. Randomization and intervention assignment into 
either of the two groups A or B (purse string versus non-purse string) will be determined by grouping 
labels (A or B) and serialization generated by the soft-ware Winpepi from number 1 to 142 (i.e. 
Random assignment of 71 in Group A and 71 in Group B).  
The generated sequence will be stored on the computer of a blinded research assistant who will be 
required to inform the team of the next assigned intervention according to the generated sequence, at 
the time of chest tube insertion for all included and consenting patients. The research assistant will 
keep record of all assigned labels and ensure all intervention assignment follows the computer- 
generated sequence in an uninterrupted and reproducible manner. 
 
 
INCLUSION CRITERIA 
Patients who are 18 years of age or older who require chest tube insertion for any of the following 
indications:  
1. Pleural effusion 
2. Traumatic or spontaneous pneumothorax 
3. Traumatic haemothorax 
4. As an adjunct to a thoracotomy for a non-neoplastic and or non –infective condition 
 
 
EXCLUSION CRITERIA 
Any patient so described above who has the following will be excluded: 
1. An associated pyopneumothorax 
2. Cancer encuirasse of the chest wall 
3. Unconscious with unclear consent situation 
4. With infective or neoplastic conditions of the chest wall 
5. With individual or family history of wound failure e.g. unsightly scars 
6. Who has had irradiation of the chest or chemotherapy administration within 6 weeks from the 
time of requirement of the chest tube insertion 
7. Who is at risk of immunosuppression i.e. diabetes, HIV infection, on steroid therapy, ongoing 
chemotherapy or who has a congenital or any other acquired immune deficiency state 
8. Presence of pleural adhesion during the process of chest tube insertion 
9. Those with chest tube malposition after insertion, confirmed on chest radiograph, who will 
require tube adjustment 
 
 
INSTRUMENT FOR DATA COLLECTION 
Data will be collected using a 7-page structured study proforma as included below (Refer to pages 28- 
34). 
 
 
 
14

PROCEDURE DETAILS AND DATA COLLECTION TECHNIQUES 
1) Before Chest Tube Insertion 
In all formally consenting patients who have met the indications for chest tube insertion and 
participation in this study, the chest tube will be inserted under aseptic techniques. This can be done 
in the ward at the patient’s bedside or in the theatre for post-thoracotomy patients. All chest tube 
insertion will be performed by the principal investigator or any senior resident doctor in thoracic 
surgery who has been duly trained to perform this procedure following standard protocols and 
techniques. The step-by-step guide on how to safely insert a chest tube using the procedural details 
provided below will be printed out and mastered by all surgeons involved in this study with strict 
observance of all the required techniques and steps. 
As discussed above, a start dose of intravenous third generation cephalosporin antibiotic will be 
administered prior to the procedure. 1g of Ceftriaxone will be used in this regard in compliance with 
current practice protocol.  
Prior to commencement of the procedure and after formal consent by the patient. The research assistant 
will be contacted to provide the assigned group for that patient using the computer generated sequence 
obtained with the WINPEPI software at the beginning of the study. 
 
 
2) During chest tube insertion 
For procedures performed at the patient’s bedside, the patient will lie supine or in the cardiac position 
depending on the diagnosis and clinical condition. The upper limb will be placed under the head for 
adequate exposure of the safe triangle which is formed by the anterior axillary fold anteriorly, posterior 
axillary fold posteriorly with the lateral aspect of the sixth rib forming the base. Skin preparation will 
be done by 10% povidone iodine painting of the anterolateral hemithorax from sternal midline 
anteriorly to the posterior axillary line and from the clavicle down to the transverse umbilical line. The 
painting will involve the elbow and finally the axilla will be cleaned. This motion will be carried out 
thrice to achieve optimal skin sterilization and minimize the risk of contamination.  
Thereafter, sterile drapes will be applied to isolate the intercostal space at the mid-axillary line and the 
surrounding region. The elected site of skin incision is measured using a sterile ruler and marked prior 
to anaesthesia. Local infiltration of the marked area of skin incision will be done using calculated dose 
of 2% xylocaine with adrenaline (maximum of 5mg per kg dose). The depth of infiltration should 
extend to the 5th intercostal space to include the intercostal muscles. After establishing effectiveness 
of local anaesthesia, a 4cm skin crease incision is then made along the body or lower border of the 
sixth rib at the mid-axillary line, using a surgical blade and the incision is deepened through the 
subcutaneous tissue by blunt dissection using a curved number 3 artery forceps or a Kelly forceps. The 
subcutaneous dissection should create a tunnel extending from the skin incision on the outside to the 
fifth intercostal space in other to create a superior skin flap. This tunneling is required to create a flap 
valve-like mechanism aimed at providing an additional method of preventing peritubal leakage after 
chest tube insertion and development of iatrogenic pneumothorax. The instrument dissection should 
then be carried through the fifth intercostal space at the upper border of the sixth rib. This is to avoid 
damage to the subcostal neurovascular structures and also to avoid more pain and haemorrhage. 
 
 
 
15

At this stage, for patients in whom a purse-string suture has been assigned to be used (Group A), a size 
0 polypropylene suture is used in making the horizontal mattress or U-shaped purse string as illustrated 
in Figure 3 below. 
 
 
 
 
 
 
 
Thoracostomy  
wound  
 
 
 
 
 
FIGURE 3: Illustration of how the purse-string suture is inserted into the thoracostomy wound 
 
 
To make this horizontal mattress or U-suture placement or purse-string in the thoracostomy wound, 
the needle of the suture is inserted from point 1, at 1 cm from the wound edge, through the skin and 
subcutaneous tissue and then exited through point 2, also 1cm from the wound edge. The needle is 
then re-inserted through the wound about 2cm along the transverse plane which is point 3. The same 
motion as performed from point 1 to point 2 is done in a reverse pattern from point 3 to point 4. With 
this, only the free ends of the suture and the part of the suture between point 2 and point 3 lying on the 
skin surface will be visible while other parts lie within the thoracostomy wound. 
 
 
This step of U-suture or purse-string placement will be skipped for all patients assigned to Group B. 
Thereafter, the blunt dissection is continued with the index finger to the level of the parietal pleura 
which is breached using the tip of the finger or where the pleural is thickened and fibrotic, with the use 
of the dissecting forceps. The dissecting finger is introduced into the space to assess for pleural 
adhesions. As indicated above in the exclusion criteria, all patients with pleural adhesions will be 
excluded from the study. The intrapleural length of the tube will be estimated from the skin incision 
to the sternal angle. With the aid of the dissecting forceps, this estimated length of the chest tube with 
blind-ending external part is then advanced apically and posteriorly into the pleural space. 
 
 
In both groups, the tube is anchored at the anterior and posterior ends of the wound using size 2 silk 
sutures placed by narrow horizontal mattress suturing or simple interrupted suturing; to secure the 
chest tube to the chest wall. For patients in Group A, the placed U-suture or purse-string will be knotted 
once to create air and water tightness (Figure 4) and the loose ends will also be used to anchor the 
chest tube by tying the loose ends around the chest for a 2 cm length before making a separate knot on 
the tube to reinforce the previous silk 2 suture anchorages at both wound ends. 
 
 
 
 
16

 
 
 
 
 
 
 
 
 
 
 
 
 
FIGURE 4: Purse string suture tie around the chest tube to achieve air-water tightness. (4) 
 
 
After this, the tube is clamped and connected to either a flutter-valve bag system or an underwater seal 
drainage system (9). The site is cleaned and dressing is done using sterile gauze with a light paint of  
10% povidone iodine followed by application of a firm plaster. 
For large pleural effusions or pneumothorax, the drainage is done gradually in a controlled manner to 
prevent the development of re-expansion pulmonary oedema. 
The details of the technical aspects of the operative procedure of chest tube insertion will be observed 
as described above in those who have been assigned to either groups that are to have the chest tube 
inserted as an adjunct to a thoracic surgical procedure (i.e. Operative indication). 
 
 
3) Management of indwelling chest tubes 
A chest radiograph will be done immediately after to ascertain the position of the tube and the degree 
of lung re-expansion. The drainage of the effluent is measured daily and charted; analgesia 
(combination of 1g oral paracetamol administered every 6hours at 6am, 12 noon, 6pm and 12 midnight; 
50mg oral diclofenac sodium administered every 12hours at 10am and 10pm; and 50mg oral tramadol 
or 5mg oral morphine administered every 6hours at 9am, 3pm, 9pm and 3am) will be instituted for all 
patients in compliance with current unit analgesic protocol. All patients requiring therapeutic 
antibiotics (commenced empirically or with culture sensitivity guidance) will have the antibiotics 
administered according to the posology of the index medication. This category includes post-operative 
patients who have had chest tube inserted as an adjunct to surgery and those with any other indication 
for therapeutic antibiotics. All patients will have incentive spirometry (done with the standard three- 
ball incentive spirometer, once every hour) and passive physiotherapy (three times a day). Daily 
dressing of the chest tube site will be done by the unit doctors during the daily ward rounds using 10% 
povidone iodine as described above. The pain intensity (pain scores) of the patients will be assessed at 
regular intervals (atleast twice a day; during morning and evening ward rounds) using the visual 
analogue scale (VAS), numeric rating scale (NRS) and Categorical verbal rating scale (VRS). Even 
though the VAS and the NRS have been shown to be superior to the VRS in the assessment of acute 
post-operative pain, all three will be employed in this study to enhance accuracy of assessment and 
minimize effect of subjectivity on observed pain scores as depicted in Figure 2 below (45). 
 
 
17

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FIGURE 2: The one-dimensional pain intensity scales: the NRS, the VAS and the four-point 
VRS (45)  
 
The patients with malignant pleural effusion will have pleurodesis done once full lung re-expansion is 
confirmed by chest radiograph. 
The criteria for chest tube removal will include: 
- 
Improved or resolution of the clinical condition 
- 
Change of effluent to serous fluid for all types of pleural fluid collections or cessation of air leak 
for pneumothorax 
- 
Reduction of volume of daily effluent to less than 100ml in a 24-hour day period 
- 
Evidence of full lung re-expansion on the most current chest radiograph 
 
4) Procedure for chest tube removal 
The chest tube will only be removed after satisfactory confirmation by the principal investigator or 
atleast a senior resident doctor in the unit, that the conditions above have been fulfilled. The chest tube 
will be removed by two members of the team, one of which must be atleast a senior resident doctor 
that has been adequately exposed to this protocol. 
For patients who had purse-string placement in Group A, the integrity of the suture is first checked to 
be sure that it is intact, then the anchor stitches are then cut at the limbs to release it from the skin. The 
chest tube is checked that it is free of attachments to the skin after which the patient is then instructed 
to make a full inspiratory effort and thereafter arrested expiration. For unconscious patients on 
ventilator, the intensivist will give a Valsalva manoeuvre of 35 to 40cm H O to achieve full inspiration 
and retains that pressure during the tube removal to simulate arrested expiration. 
The lead surgeon (principal investigator or senior resident doctor) makes a surgeon’s knot with the 
purse string without tying it down or snug in preparation for a brisk removal of the chest tube by the 
 
18
2

assistance. To ensure synchrony, a short count of one to three is done by the lead surgeon and by the 
count of three, he completes the knotting down to close the wound just as the tube is rapidly pulled out 
at a single swipe by the assistance upon completion of the count of three. There will be regular 
rehearsals and practice of these synchronous actions by all those who will be involved with this study 
as surgeons and assistants. The wound must be closed to air and water tightness but without 
strangulating the edges. The suture is trimmed, and a sterile dressing applied as before. There will be 
strict observance of aseptic technique by all involved in this tube removal process. A chest radiograph 
is done immediately after to check for presence of iatrogenic pneumothorax. The wound dressing will 
be removed on the third day and subsequent wound care will be determined by the finding at wound 
review by the principal investigator on this third day. The protocol to follow will be to continue daily 
povidone iodine wound care if there is evidence of wound infection but to leave the wound open to 
fresh air and apply povidone iodine topical cream till the suture is removed by day 7, after tube 
removal. The pain score will be assessed on a continuous basis (everyday till patient is discharged 
home and at every contact in the outpatient clinic). The patients will be followed up once a month for 
atleast 3 consecutive months after chest tube removal. Their pain score, wound outcomes and serial 
chest radiographic check (immediately after tube removal, at one week after tube removal and at every 
follow up visit in the outpatient clinic), will be done. 
For Group B patients who did not have a purse-string placed during chest tube insertion, the anchor  
stitches are the cut at the limbs to release it from the skin. The chest tube is checked that it is free of  
attachments to the skin, the patient is then instructed to make a full inspiratory effort and thereafter 
arrest expiration. For unconscious patients on ventilator, the intensivist gives a Valsalva manoeuvre of  
35 to 40cm H O to achieve full inspiration and retains that pressure during the tube removal to simulate  
arrested expiration. Following the model of synchronized action between two surgeons as described  
above for Group A patients, the lead surgeon applies the Primapore*occlusive-adhesive dressing firmly  
at the count of three immediately after the assistant has pull out the chest tube from the pleural space  
in brisk but in a measured fashion. The occlusive dressing is retained for a atleast three (3) days to  
allow the wound to seal before it is either changed or removed depending on the wound condition. 
This decision will be taken by the principal investigator. The protocol to follow will be to change the 
dressing if the wound is not completely sealed after 3days but to leave it open to fresh air with topical 
application of povidone iodine cream. If there is evidence of wound infection, the dressing will be 
done using 10% povidone iodine solution and a sterile gauze. A chest radiograph is done to assess for 
the presence of pneumothorax (immediately after chest tube removal, at one week after removal and 
at every outpatient clinic visit). The patients are followed up for once a month for atleast 3 consecutive 
months after chest tube removal.  
 
 
5) Follow up and treatment adherence 
The patients in both groups will be followed up once every month for atleast three consecutive months 
assessing for evidence of wound infection, pain control and with chest radiography for evidence of  
pneumothorax. The wound will also be assessed for development of raised or elevated thoracostomy 
wound scars (unsightly scars appearing like hypertrophic scars or keloids) within 3 months of chest 
tube removal. 
Patients with wound infection will have 10% povidone iodine daily dressing with institution of  
antibiotic therapy as per unit protocol. All patients with poor pain control (Pain score greater than 5),  
 
 
19
2 

involved with in this study, will have their pain control drug regimen escalated as per unit protocol to 
achieve better pain control. 
 
 
 
 
DATA ANALYSIS AND MANAGEMENT 
The data will be entered into the computer and thorough data cleaning will be done to check for errors 
and omissions at the end of data collection. The data was analyzed using Statistical Package for Social 
Sciences (SPSS) version 21. Descriptive statistics for baseline data shall be analyzed using mean, 
standard deviation, range and median, where appropriate, for any continuous variable and as 
percentages for any categorical variable. Baseline characteristics of the two study arms will be 
compared using Chi-square tests (for categorical variables) and student’s t-test or analysis of variance 
(for continuous variables). Risk of complication will be evaluated using Cox-proportional analysis 
adjusting for potential confounders. Level of significance will be set at 5%. Findings will be presented 
in forms of texts, tables, figures and graphs as appropriate. 
 
 
ETHICAL CONSIDERATION 
The study will only be commenced after appropriate approval from the Institutional review board is 
obtained. Informed consent will be obtained from all the participants of this study after the study has 
been explained in details to them by a member of the team who will be at least a Senior resident that 
has been trained on the protocol of the study before the commencement of the study. The aims and 
objectives of the study will be explained to every potential study participant as well as the method of  
selection. They will be educated about the method of group assignment and the details of the technique  
inserting chest tube and the different plans of managing the thoracostomy wound indicating the 
possible complications of wound infection, wound breakdown, iatrogenic pneumothorax, need for 
frequent dressings, post-procedural pain and increased analgesic requirements as well as need for chest 
tube re-insertion. The patients will be reassured of the safety of the chest tube insertion procedure. 
After group assignment by the research assistant, the patient will be informed of the assigned group 
and requested to complete the informed consent form to authorize the surgeon to proceed with the 
procedure as per the protocol described above.  
The process of obtaining the informed consent will be individualized, the patient or the guardian will 
be reassured that the information obtained will be protected and not disseminated. Also, the patient 
will be informed that the decision to participate or decline participation in the study will not affect the 
quality of treatment that will be offered to them. 
The benefit of the study will be explained to them because it will contribute to the knowledge of in 
management of patients. The findings may also help surgeons in determining when to use purse strings 
in management of chest tubes. Also, for patients it will help reduce complications related to chest tube 
insertion and management.  
 
 
 
 
 
 
20

DIVISION OF CARDIOVASCULAR AND THORACIC SURGERY 
DEPARTMENT OF SURGERY 
COLLEGE OF MEDICINE, UNIVERSITY OF IBADAN, 
UNIVERSITY COLLEGE HOSPITAL, IBADAN 
 
 
INFORMED CONSENT FORM 
 
IRB Research approval number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ 
This approval will lapse on: _ _/ _ _/ _ _ 
Title of Research: 
Suturing with U-Technique versus Un-Reapproximated wound Edges during removal of Closed 
Thoracostomy-tube drain - A single centre Open-label prospective randomized trial (SUTURE 
TRIAL) 
Name(s) and affiliation(s) of researcher(s): 
This study is being conducted by Dr. BAIYEWU L AYODELE, a lecturer and Consultant 
Cardiovascular and Thoracic Surgeon in the Department of Surgery, College of Medicine, University 
of Ibadan and University College Hospital, Ibadan. 
Sponsor(s) of Research 
This research is self-sponsored 
Purpose(s) of Research: 
The broad aim of this study is to determine which of two methods (approximating the wound edges  
with a prolene purse-string suture or applying only a Primapore*occlusive-adhesive dressing) of  
closing a chest tube wound, has a better outcome in the short and long term. 
Procedure for the Research, what shall be required of each participant and the approximate 
total number of participants that would be involved in the research: 
Using a block randomization technique, 142 patients will be grouped by a research assistant into two 
equal groups; 71 patients in Groups A (that will have their chest tube wound closed with a U-shaped 
prolene suture placed at the time of chest tube insertion) and 71 patients in Group B (that will have 
their chest tube wound closed with a Primapore* occlusive-adhesive dressing and without wound 
suturing, at the time of chest tube removal). The pain experience, occurrence of wound infection, 
chance of air entry into the pleura space after the tube removal and poor cosmetic scar outcome will 
be studied after the tube removal for up to 3 months. You will be required to take a chest xray 
immediately after the chest tube insertion, after the tube is removed, one week after and every time 
you visit us at the outpatient clinic till about 3 months after the tube is removed. Your wound will be 
checked for infection after the tube insertion and removal and any infection will be treated with wound 
dressings and appropriate antibiotics. We will control any major pain with appropriate medications till 
you are fully satisfied and comfortable. If at any time, after the tube has been removed, you require a 
 
 
21

chest tube to be re-inserted, it will be at no cost to you. All required information about all participants 
in this study will be collected and recorded in an anonymized proforma. 
Expected duration of research and participant(s) involvement: 
You would be involved in the research over a 3-month period. While on admission, after your chest 
tube insertion, we will obtain some study-related details from you on daily basis and that will continue 
till you are discharged after the tube has been removed. Once you are discharged, you will be required 
to visit the outpatient clinic up till 3 months, the frequency of which will be determined by your 
recovery. 
Risk(s): 
The only risk that is peculiar to this study is the possibility of requiring another chest tube insertion 
though from previous knowledge, there is only a little chance. There is no risk to life expected from 
any intervention to be modified by this study. 
Costs to the participants, if any, of joining the research: 
You will only be required to pay for the chest tube insertion as expected for any other procedure in the 
hospital and that will be at the holding rate. All other materials used during the course of the study that 
in anyway differs from the statutory materials required for the chest tube insertion procedure, shall not 
be billed to you. 
Benefits(s): 
You may be able to benefit from a possible non-invasive method of wound closure which will be free 
of cost. Also, the finding from this study will help in the care of all patients requiring chest tube 
insertion in the future. 
Confidentiality: 
All information obtained from participants involved in this study will be coded and personal details 
will be anonymised. 
Voluntariness: 
Your participant in this research is entirely voluntary. You are free to withdraw your consent at any 
time during the study. It will not in anyway influence the way and manner your condition will be 
managed. 
Alternatives to participation: 
If you choose not to participate, this will not affect you in any way. You will still have your chest tube 
inserted in the routine way and at the usual cost. 
Due inducements: 
No patient will be induced to participate in this study. 
Consequences of participants’ decision to withdraw from research and procedure for orderly 
termination of participation: 
If you decide to withdraw from the study after you had initially consented, it will have no bearing on 
the modality of managing your chest tube or following you up at the clinic as all treatments will follow 
 
22

a standard unit protocol for chest tube management. The principal investigator and his team will attend 
to you in the standard way without any discrimination. 
Modality of providing treatments and action(s) to be taken in case of injury or adverse event(s): 
There is no expected injury or adverse effects other than the risk (iatrogenic pneumothorax) described 
previously and the treatment will be as previously described and it will be entirely free of cost. 
What happens to research participants and communities when the research is over: 
The research participants and the community will be informed about the research findings through 
scientific publications. Any of the research participants willing to obtained any non-confidential 
information about the study will also be obliged. 
Statement about sharing of benefits among researchers and whether this includes or excludes 
research participants: 
No direct benefit would be shared among researchers. 
Any apparent or potential conflict of interest: 
No conflict of interest is declared. 
Statement of person obtaining informed consent: 
I have fully explained this research to and have given sufficient information, including the risks and 
benefits, to guide him/her to make an informed decision. 
 
 
DATE:______/_____/____________________ 
SIGNATURE:_________________________ 
 
NAME: 
______________________________________________________________________ 
 
 
 
Statement of person giving informed consent: 
The purpose of this study has been explained to me in details. I consent to taking part know that my 
chest tube wound may be closed using one of two methods which will be determined by a computer- 
generated grouping. The risks have been explained to me in details. My participant is entirely 
voluntary. I understand that am free to withdraw my participant at any time. If I withdraw my 
participation, it will not alter the standard of my care. All information provided by me will be 
anonymized and kept in confidence. 
DATE:____/____/_______ SIGNATURE/THUMB PRINT: ________________________ 
 
SERIAL NUMBER: _ _ _ _ _ _ _ _ _ 
WITNESS’ SIGNATURE (if applicable): __________________________________________  
WITNESS’ NAME (if applicable): ________________________________________________ 
 
 
23

Detailed contact information including contact address, telephone, fax, e-mail and any other 
contact information of researcher(s), instructional HREC and head of the institution: 
This research has been approved by the UI/UCH Ethical Review Committee and they can be 
contacted at the IMRAT Building, College of Medicine, University of Ibadan/University College 
Hospital, Ibadan. 
Also, if you have any question about your participation in this research, you can contact the 
principal investigator, 
Name: Dr Baiyewu L Ayodele 
Department: Department of Surgery, College of Medicine, University of Ibadan at the University 
College Hospital, Ibadan. 
Phone: +2348034455695 
Email: bayan_latyph@yahoo.com 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
24

ABRIDGED YORUBA TRANSLATION OF THE CONSENT FORM 
Riran egbo pelu okun ti yi o yi egboka yato si pi pa egbo de la yi ran eran po fun egbo to je yo 
leyin ti a ba yo roba ta fin jo omi ninu aya- Si se iwadii to fo ju an kedere ni ona ase si waju 
AWỌN IWỌWỌ TI 
E Sa / Ma, A (Ẹjẹ inu ọkan ati ọkan ninu Ẹkọ Ilera, Ile-iwe giga Ile-ẹkọ giga, Ibadan) wa fun aiye rẹ 
lati fi orukọ silẹ ninu iwadi ti a darukọ loke. Ẹrọ Iṣoogun ti Arun inu Ẹjẹ ati Ẹtan Thoracic, Ile-ẹkọ 
giga Ile-ẹkọ giga University, Ibadan (ti a tọka si nibi CTSU) pẹlu awọn alamọran, awọn onisegun 
alagbatọ ati awọn ile ile, a wa ninu itọju rẹ pẹlu fifi sii, isakoso ati yiyọ awọn apo-inu bi a ti ṣe ipinnu 
fun ọ.  
Iwadi naa ni ero lati ṣe idanimọ awọn ipa (s) ti lilo awọn gbolohun apamọ ni iṣakoso awọn alaisan ti o 
nilo ki o fi sii apo ti o wa fun idalẹnu ti ipilẹ gbogbo. Iwadi yii yoo ṣe iranlọwọ ni ṣiṣe ipinnu iṣẹ-ṣiṣe 
ni ojo iwaju ti awọn alaisan ti yoo nilo apo-ti-ni-itọju apo lori iwa ti o dara ju ni isakoso ti awọn apo- 
ọpa. 
Iwadi naa jẹ pataki nitori pe ko si igbẹkẹgbẹ kankan ni orile-ede Naijiria lori idibajẹ tabi bibẹkọ ti 
awọn gbolohun apamọwọ ni fifi sii awọn ọpọn irun. Ifarahan rẹ ninu iwadi yii jẹ pataki bi o ṣe le ṣe 
iranlọwọ ninu ṣiṣe ipinnu iṣẹ fun awọn alaisan ti o wa ni iwaju ti o le nilo ki a fi awọn ọpọn irun sii.  
Ti o ba gba lati ṣe alabapin ninu iwadi yii, a le fi okun ṣe apẹrẹ tabi kii ṣe nigbati a ba fi ọpa ibọn sii, 
gbogbo ilana miiran ti o wa ni fifi sii ti awọn apo-inu yoo ṣee ṣe. Jowo ṣe idaniloju pe boya tabi kii ṣe 
eriti apamọwọ ti a lo ninu fifi sii apo apẹrẹ, a ki yoo ṣe itọju rẹ ni eyikeyi ọna bii boya lilo kan ti a fi 
owo apamọwọ tabi rara, mejeeji ni awọn ọna ti a mọ ni fifi sii awọn ọpọn irun . Ipinnu lati lo apamọwọ 
kan tabi kii ṣe yoo ṣe nipasẹ ẹgbẹ CTSU. 
A o fi ipalara apẹrẹ sii nipa lilo ọna asejọ nipasẹ ọkan ninu awọn onisegun ti o wa ninu ẹgbẹ CTSU 
labẹ awọn ilana asejọpọ; Anesitetiki agbegbe yoo wa ni iṣakoso ṣaaju ki o to ge ti a ṣe lori awọ ara rẹ 
ni apa kanna ti awọn ohun elo apọju. Oṣuwọn apamọwọ le / ni a ko le fi si ibi ti o da lori ipinnu ti kuro, 
ao fi tube naa si ati ni idaniloju ni ibi nipa lilo awọn irọri oran. Okun apo yoo wa ni asopọ si ohun elo 
omi idena ti o yẹ. A yoo ṣe abojuto tube ati kuro nigbati o tọka si.  
O yoo nilo lati ṣe awọn idanwo kan ni asiko yii, jọwọ sọ fun wa pe awọn wọnyi ni o ṣe pataki ninu 
itọju rẹ ati kii ṣe nitori ikopa rẹ ninu iwadi yii. 
 
 
Ti o ba gba lati ṣe alabapin ninu iwadi yii, jọwọ fọwọsi apa ti o wa ni isalẹ: 
Orukọ: __________________________________________________________ 
Ibuwọlu: _______________________________________________________ 
 
 
Mo ti salaye iwadi yii si orukọ ti a darukọ loke ti o ti gba lati jẹ apakan ninu iwadi yii. 
Orukọ: Dr. ________________________________________________________ 
Ibuwọlu: _________________________________________________________ 
 
 
 
25

Suturing with U-Technique versus Un-Reapproximated wound Edges during removal of  
Closed Thoracostomy-tube drain - A single centre Open-label prospective randomized trial 
(SUTURE TRIAL) 
STUDY PROFORMA 
SERIAL NO: ……………………… 
BIODATA: 
(1) NAME: _________________________________________________________________ 
(2) PHONE NUMBER: _______________________________________________________ 
(3) AGE: __________________________ 
(4) SEX: ____________________  
(5) OCCUPATION: ______________________________________ 
OTHER INFORMATION: 
(6A) LEVEL OF EDUCATION: UNEDUCATED ( ) PRIMARY ( ) 
SECONDARY( ) 
TERTIARY ( ) 
(6B)(ROUTE OF ADMISSION: ED ( ) 
CLINIC ( ) 
OTHERS 
 
 
(6C)WARD: ED ( ) 
ICU ( ) 
MEDICAL ( ) 
SURGICAL ( ) 
GYNAECOLOGIC ( ) 
PAEDIATRICS ( ) 
CLINICAL FEATURES: 
(7) COMPLAINT: 
COUGH ( ) 
CHEST PAIN ( ) 
BREATHLESSNESS ( ) 
TRAUMA ( ) 
FEVER ( ) 
RECURRENT ( ) 
OTHERS ______________________________________________________________ 
(8) OTHER SYSTEMIC AND ORGAN INVOLVEMENT: 
 
 
(9) CO-MORBIDITIES: HYPERTENSION ( ); DURATION (years) _____________ 
DIABETES ( ); DURATION (years) _____________ 
CHRONIC LIVER DISEASE ( ) 
; DURATION (years) _____________ 
SKIN LESIONS ( ); TYPE________________________; DURATION (years) _____________  
CHRONIC KIDNEY DISEASE ( ); DURATION (years) ______________ 
CALCULATED CHARLESON COMORBIDITY INDEX _____________________ 
OTHERS 
DURATION; __________________  
 
 
 
 
26

SERIAL NO: ……………………… 
(10) TREATMENT AND DRUG HISTORY: 
CHEMOTHERAPY: SPECIFY DRUGS AND DOSE 
________________________________________________________________; 
DURATION 
_____________________; LAST COURSE____________________________  
IRRADIATION: SITE ________________; HOW MANY FRACTIONS TAKEN SO FAR 
WHEN LAST FRACTION TAKEN (IN WEEKS) ________________ 
STERIODS: Y/N 
IF YES, 
DOSE__________________________;DURATION_____________________ 
(11) HISTORY OF WOUND FAILURE: KELOIDS Y/N HYPERTROPHIC SCARS Y/N 
(12) PREVIOUS CHEST TUBE INSERTION: 
YES ( ) 
NO ( ) 
ADVERSE EFFECT OF PREVIOUS CHEST TUBE: Y/N IF YES, WHICH 
REACTION?______________________________________________________________________ 
__ 
(13) CIGARRETTE SMOKING: 
YES ( ) 
NO ( ) 
IF YES, NUMBER OF PACK YEARS: ___________________________________ 
(14) ALCOHOL INTAKE: Y/N , IF YES, DURATION IN YRS ___________ 
ESTIMATED QUANTITY(BOTTLES AND FREQUENCY) _________________________ 
EXAMINATION FINDINGS: 
(14) PALOR: 
YES ( ) 
NO ( ) 
(15) SKIN TURGOR: 
<2s( ) 
>2s ( ) 
(16) DYSPNOEA: 
YES ( ) 
NO ( ) NYHA CLASS 
I, II, III, IV 
(17) NEOPLASTIC CHEST WALL DISEASE: YES ( ) 
NO ( ) 
AFFECTED SIDE: SAME SIDE ( ) 
CONTRALATERAL SIDE ( ) 
(18) SKIN LESION: 
LACERATION: YES ( ) 
NO ( ) , IF YES, LOCATION ________________________ 
SKIN CONTUSION: YES ( ) 
NO ( ), IF YES, LOCATION 
 
 
AVULSION: YES ( ) 
NO ( ) , IF YES, LOCATION ______________________  
OTHERS: 
AFFECTED SIDE: SAME SIDE ( ) 
CONTRALATERAL SIDE ( ) 
 
 
27

SERIAL NO: ……………………… 
(19) THORACOCENTESIS: 
SEROUS ( ) 
SEROPURULENT ( ) 
PURULENT ( ) 
HAEMORRHAGIC ( ) 
SEROSANGUINOUS ( ) 
(20) WEIGHT _________________ HEIGHT _____________ BMI ______________________ 
INVESTIGATION: 
(21) PCV: ___________ 
(22) SERUM PROTEIN: ________________; SERUM ALBUMIN________________ 
(23) CHEST X-RAY FINDINGS 
 
 
 
(24) CHEST CT SCAN FINDINGS 
 
 
 
(25) PLEURAL FLUID GENE XPERT REACTIVE: 
YES ( ) 
NO ( ) 
(26) PLEURAL FLUID CYTOLOGY: 
MALIGNANT ( ) 
INFLAMMATORY ( ) 
(27) PLEURAL BIOPSY HISTOLOGY REPORT: 
 
 
(28) OTHER RELEVANT INVESTIGATION RESULT 
 
 
CHEST TUBE MANAGEMENT: 
(29) SITE OF CHEST TUBE INSERTION: RIGHT ( ) 
LEFT ( ) 
INTERCOSTAL SPACE____________________________________________ 
(30) SIZE OF CHEST TUBE IN FR: ____________________________ 
(31) USE OF PROLENE PURSE STRING: 
YES ( ) 
NO ( ) 
(32) DURATION OF CHEST TUBE RETENTION: 
 
 
(33) USE OF THERAPEUTIC ANTIBIOTICS YES ( ) NO ( ) 
IF YES, INDICATE THE GENERIC TYPE , DOSE, FREQUENCY AND DURATION IN DAYS 
………………….., …………………….., ………………………., ………………………….. 
(34) COMPLICATIONS (AFTER CHEST TUBE INSERTION): 
PNEUMOTHORAX: 
YES ( ) 
NO ( ) 
TUBE DISLOGDEMENT: 
YES ( ) 
NO ( ) 
 
28

SERIAL NO: ……………………… 
EMPYEMA: 
YES ( ) 
NO ( ) 
WOUND INFECTION: 
YES ( ) 
NO ( ) 
WOUND DEHISCENCE: 
YES ( ) 
NO ( ) 
FLUID LEAKAGE: 
YES ( ) 
NO ( ) 
AIR LEAK: 
YES ( ) 
NO ( ) 
PAIN: 
YES ( ) 
NO ( ) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PAIN SCORE: DAY 1 
6AM ( ) 
6PM( ) 
DAY 2 
6AM ( ) 
6PM( ) 
DAY 3 
6AM ( ) 
6PM( ) 
DAY 4 
6AM ( ) 
6PM( ) 
DAY 5 
6AM ( ) 
6PM( ) 
DAY 6 
6AM ( ) 
6PM( ) 
DAY 7 
6AM ( ) 
6PM( ) 
DAY 8 
6AM ( ) 
6PM( ) 
DAY 9 
6AM ( ) 
6PM( ) 
DAY 10 
6AM ( ) 
6PM( ) 
 
29

SERIAL NO: ……………………… 
(35) COMPLICATIONS (IMMEDIATELY AFTER CHEST TUBE REMOVAL): 
PNEUMOTHORAX ON IMMEDIATE POST-TUBE REMOVAL CHEST XRAY: 
YES ( ) 
NO ( ) 
PNEUMOTHORAX ON CHEST XRAY DONE AFTER 1 WEEK: 
YES ( ) 
NO ( ) 
EMPYEMA: 
YES ( ) 
NO ( ) 
WOUND INFECTION: 
YES ( ) 
NO ( ) 
WOUND DEHISCENCE: 
YES ( ) 
NO ( ) 
FLUID LEAKAGE: 
YES ( ) 
NO ( ) 
AIR SUCK-IN THROUGH WOUND: 
YES ( ) 
NO ( ) 
MAJOR PAIN: 
YES ( ) 
NO ( ) 
PAIN SCORE: 
DAY 1 
6AM ( ) 
6PM( ) 
DAY 2 
6AM ( ) 
6PM( ) 
DAY 3 
6AM ( ) 
6PM( ) 
DAY 4 
6AM ( ) 
6PM( ) 
DAY 5 
6AM ( ) 
6PM( ) 
DAY 6 
6AM ( ) 
6PM( ) 
DAY 7 
6AM ( ) 
6PM( ) 
DAY 8 
6AM ( ) 
6PM( ) 
DAY 9 
6AM ( ) 
6PM( ) 
DAY 10 
6AM ( ) 
6PM( ) 
(36) COMPLICATIONS AT FOLLOW-UP 1 
PNEUMOTHORAX ON FOLLOW UP CHEST XRAY: 
YES ( ) 
NO ( ) 
WOUND INFECTION: 
YES ( ) 
NO ( ) 
WOUND DEHISCENCE: 
YES ( ) 
NO ( ) 
 
 
30

SERIAL NO: ………………………  
HYPERTROPHIC SCAR: 
YES ( ) 
NO ( )  
KELLOID: 
YES ( ) 
NO ( )  
WOUND PAIN: 
YES ( ) 
NO ( )  
IF YES, PAIN SCORE: ______________________  
 
 
COMPLICATIONS AT FOLLOW-UP 2  
WOUND INFECTION: 
YES ( ) 
NO ( )  
WOUND DEHISCENCE: 
YES ( ) 
NO ( )  
HYPERTROPHIC SCAR: 
YES ( ) 
NO ( )  
KELLOID: 
YES ( ) 
NO ( )  
WOUND PAIN: 
YES ( ) 
NO ( )  
IF YES, PAIN SCORE: ______________________  
PAIN SCORE: 
6AM ( ) 
6PM ( )  
 
 
COMPLICATIONS AT FOLLOW-UP 3  
WOUND INFECTION: 
YES ( ) 
NO ( )  
WOUND DEHISCENCE: 
YES ( ) 
NO ( )  
HYPERTROPHIC SCAR: 
YES ( ) 
NO ( )  
KELLOID: 
YES ( ) 
NO ( )  
WOUND PAIN: 
YES ( ) 
NO ( )  
IF YES, PAIN SCORE: ______________________  
PAIN SCORE: 
6AM ( ) 
6PM ( )  
 
 
COMPLICATIONS AT FOLLOW-UP 4  
WOUND INFECTION: 
YES ( ) 
NO ( )  
WOUND DEHISCENCE: 
YES ( ) 
NO ( )  
HYPERTROPHIC SCAR: 
YES ( ) 
NO ( )  
KELLOID: 
YES ( ) 
NO ( )  
 
 
31 

SERIAL NO: ……………………… 
WOUND PAIN: 
YES ( ) 
NO ( ) 
IF YES, PAIN SCORE: 
PAIN SCORE: 
6AM ( ) 
6PM ( ) 
 
 
COMPLICATIONS AT FOLLOW-UP 5 
WOUND INFECTION: 
YES ( ) 
NO ( ) 
WOUND DEHISCENCE: 
YES ( ) 
NO ( ) 
HYPERTROPHIC SCAR: 
YES ( ) 
NO ( ) 
KELLOID: 
YES ( ) 
NO ( ) 
WOUND PAIN: 
YES ( ) 
NO ( ) 
IF YES, PAIN SCORE: ______________________ 
PAIN SCORE: 
6AM ( ) 
6PM ( ) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
32

REFERENCES 
 
1. 
Dural K, Gultekin G, Bulent K, Unal S. A novel and safe technique in closed tube thoracostomy. 
J Cardiothorac Surg. 2010;5(21):5–8.  
2. 
Kim MS, Shin S, Kim HK, Choi YS, Kim J, Zo JI, et al. Feasibility and Safety of a New Chest 
Drain Wound Closure Method with Knotless Sutures. Korean Soc Thorac Cardiovasc Surg. 
2018;51(4):260–5.  
3. 
Yokoyama Y, Nakagomi T, Shikata D, Goto T. A novel technique for chest drain removal using 
a two layer method with triclosan-coated sutures. J Thorac Dis. 2017;9(1):211–3.  
4. 
Kumar A, Dutta R, Jindal T, Biswas B, Dewan RK. Safe insertion of a chest tube. Natl Med J 
India. 2009;22(4):192–8. 
5. 
Chadwick AJ, Halfyard R, Ali M. Intercostal chest drains : Are you confident going on the pull ? 
If not use the I-T -U approach. J Intensive Care Soc. 2015;16(4):312–5.  
6. 
Gilbert TB, Mcgrath BJ, Soberman M. Chest Tubes : Indications , Placement , Management , 
and Complications. J Intensive Care Med. 1993;8:73–86.  
7. 
Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain. Thorax J. 
2003;58(Suppl ll):53–9.  
8. 
Bertholet JWM, Joosten JJA, Mariel K-GE, Frits van den WJ., Wouter BB. Chest tube 
management following pulmonary lobectomy : change of protocol results in fewer air leaks 
. 
Interact Cardiovasc Thorac Surg. 2018;12(August):28–31.  
9. 
Porcel JM. Chest Tube Drainage of the Pleural Space : A Concise Review for Pulmonologists. 
Korean Acad Tuberc Respir Dis. 2018;81:106–15.  
10. 
Agency for Clinical Innovation. Pleural Drains in Adults. Chatswood: ACI Respiratory 
Network; 2016. 60 p. 
11. 
Vasseur BG. A Simplified Technique for Closing Thoracostomy Incisions. Ann Thorac Surg. 
2004;4975(3):10–1.  
12. 
Imtiaz T, Majeed FA, Raza A, Rahim K, Saeed Y, Imran M. Is chest tube clamping necessary 
before removal? An experience with 2661 cases of tube thoracostomies. Pak Armed Forces Med 
J. 2016;66(4):591–4.  
13. Monaghan SF, Swan KG. Tube thoracostomy: the struggle to the "standard of care". Ann Thorac 
Surg. 2008 Dec. 86 (6):2019-22.  
14. 
Martin M, Schall CT, Anderson C, Kopari N, Davis AT, Stevens P, et al. Results of a clinical 
practice algorithm for the management of thoracostomy tubes placed for traumatic  
15. 
Kim KS. Barbed suture material technique for wound closure and concomitant tube placement 
in uniportal VATS for pneumothorax. J Thorac Dis. 2017;9(5)(July 2012):1265–72.  
16. 
Smelt JLC, Simon N, Veres L, Harrison-phipps K, Bille A. The Requirement of Sutures to Close 
Intercostal Drains Site Wounds in Thoracic Surgery. Ann Thorac Surg [Internet]. The Society 
of 
Thoracic 
Surgeons; 
2017;9(32):1–3. 
Available 
from: 
https://doi.org/10.1016/j.athoracsur.2017.09.032 (Accessed December 2018)  
17. 
Rashid MA, Wikström T. A simple technique for anchoring chest tubes. Eur Respir J. 
 
33

1998;12(23):958–9. 
18. 
Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube Thoracostomy : 
Complications and Its Management. Pulm Med. 2012;2012:10.  
19. 
Bosman A, Jong MB De, Debeij J, Broek PJ Van Den, Schipper IB. Systematic review and 
meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and 
penetrating. Br J Surg Soc. 2012;99:506–13.  
20. 
Demetriades D, Psaras G, Breckon C, Kakoyiannis S. Antibiotic prophylaxis in penetrating in 
juries of the chest. Ann R Coll Surg Engl. 1991;73:348–51.  
21. Chan L, Reilly KM, Henderson C, Kahn F, Salluzzo RF.Complication rates of tube thoracostomy. 
Am J Emerg Med1997;15:368–70.  
22. 
Helling TS, Gyles NR, Eisenstein CL, Soracco CA. Complications following blunt and 
penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy. J Trauma 
1989;29:1367–70.  
23. Bell RL, Ovadia P, Abdullah F, Spector S, Rabinovici R. Chest Tube Removal : End-Inspiration 
or End-Expiration ? J TRAUMA Inj Infect Crit Care. 2001;7(Lh 118):674–7.  
24. Toon CD, Sinha S, Davidson BR, Gurusamy KS. Early versus delayed post-operative bathing or 
showering to prevent wound complications. Cochrane Database Syst Rev. 2015 Jul 
23;(7):CD010075. doi: 10.1002/14651858.CD010075.pub3. Review. 
 
25. 
Walming S, Angenete E, Block M, Bock D, Gessler B, Haglind E. Retrospective review of risk 
factors for surgical wound dehiscence and incisional hernia. BMC Surg. 2017 Feb 22;17(1):19. 
doi: 10.1186/s12893-017-0207-0. 
26. 
Simhon D, Halpern M, Brosh T, et al. Immediate tight sealing of skin incisions using an 
innovative temperature-controlled laser soldering device: in vivo study in porcine skin. Ann Surg.  
2007;245(2):206-13. 
27. 
Nwomeh BC, Yager DR, Cohen IK. Physiology of the chronic wound. Clin Plast Surg. 
1998;25:341–356  
28. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl 
J Med. 1997;37:1142–1148 
29. 
Yag-Howard C. Sutures, needles, and tissue adhesives: a review for dermatologic 
surgery.Dermatol 
Surg. 
2014 
Sep;40 
Suppl 
9:S3-S15. 
doi: 
10.1097/01.DSS.0000452738.23278.2d. Review.  
 
 
30. Burkhardt R, Lang NP. Influence of suturing on wound healing. Periodontol 2000. 2015 
Jun;68(1):270-81. doi: 10.1111/prd.12078. 
31. Sönmez K, Bahar B, Karabulut R, Gülbahar O, Poyraz A, Türkyilmaz Z, Sancak B, Başaklar 
AC. Effects of different suture materials on wound healing and infection in subcutaneous 
closure techniques. B-ENT. 2009;5(3):149-52.  
 
34

32. Mirković S, Selaković S, Sarcev I, Bajkin B. Influence of surgical sutures on wound healing. 
Med Pregl. 2010 Jan-Feb;63(1-2):7-14. 
33. 
Scheidel P, Hohl MK. Modern synthetic suture materials and abdominal wound closure 
techniques in gynaecological surgery. Baillieres Clin Obstet Gynaecol. 1987 Jun;1(2):223-46. 
34. Gazivoda D, Pelemiš D, Vujašković G. A clinical study on the influence of suturing material on 
oral wound healing. Vojnosanit Pregl. 2015 Sep;72(9):765-9.  
35. Zeplin PH, Schmidt K, Laske M, Ziegler UE. Comparison of various methods and materials for 
treatment of skin laceration by a 3-dimensional measuring technique in a pig experiment. Ann 
Plast Surg. 2007 May;58(5):566-72  
36. Van Winkle W Jr, Hastings JC, Barker E, Hines D, Nichols W. Effect of suture materials on 
healing skin wounds. Surg Gynecol Obstet. 1975 Jan;140(1):7-12.  
37. Tejani C, Sivitz AB, Rosen MD, Nakanishi AK, Flood RG, Clott MA, Saccone PG, Luck RP.A 
comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable 
versus 
nonabsorbable 
sutures. 
Acad 
Emerg 
Med. 
2014 
Jun;21(6):637-43. 
doi: 
10.1111/acem.12387.  
38. Helfman T, Ovington L, Falanga V. Occlusive dressings and wound healing. Clin Dermatol. 1994 
Jan-Mar;12(1):121-7.  
39. Rovee DT. Evolution of wound dressings and their effects on the healing process. Clin Mater. 
1991;8(3-4):183-8. Review.  
40. 
Kannon GA, Garrett AB. Moist wound healing with occlusive dressings. A clinical review. 
Dermatol Surg. 1995 Jul;21(7):583-90.  
41. Hutchinson JJ1, Lawrence JC. Wound infection under occlusive dressings. J Hosp Infect. 1991 
Feb;17(2):83-94.  
42. 
Triller C, Huljev D, Planinsek Rucigaj T. Modern wound dressings. Acta Med Croatica. 2013 
Oct;67 Suppl 1:81-7. Review.  
43. 
https://www.woundsource.com/print/product/primapore-non-woven-adhesive-wound-dressing. 
(Accessed. December 2018)  
44. Abramson, J.H. WINPEPI updated: computer programs for epidemiologists, and their teaching 
potential. Epidemiologic Perspectives & Innovations 2011, 8:1  
45. 
Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Hals EKB, et al. 
Assessment of pain. Br J Anaesth. 2018;101(August):17–24.  
 
 
 
 
 
 
 
 
 
 
 
 
 
35