Wire sutures: Braided or monofilament?

I N 1947 Babcock [1] published a classic historical account of metallic sutures and ligatures. He reported that Philip Syng Physick in 1816 suggested the use of lead wire sutures after he had noticed that leaden missiles imbedded in the body often remained for many years without evidence of reaction. In 1849 Sims, using fine sutures of silver wire drawn out by a jeweler, successfully closed a large vesicovaginal fistula after thirty previous failures on the same patient. Babcock [1] then initiated a series of studies to determine in viva reactions from various suture materials. His studies, carried out by his group at Temple University in Philadelphia, revealed that catgut sutures provoked the greatest reaction in tissues, silk sutures produced less reaction, but no reaction was found around stainless steel wire. Modern metallic sutures are made from a stainless steel alloy. They are available in many sizes and in two forms, monofilament or multistrand. Most surgeons find the multistrand steel wire easier to handle since it is pliable and ties like silk. The larger sizes of monofilament wire are stiff, and when used to close fascia, the wire ends above the knot must be bent down to prevent their pushing through the scar. This does not occur with multistrand wire because after cutting above the knot the thin wire filaments fray out like a soft brush. Most of us have been chagrined to find braided steel wire sutures “spitting out” for months from a contaminated wound. This type of suture with bacteria trapped within its interstices acts as an irritating foreign body, and the wound will not heal until the sutures have been extruded or removed. Conversely, monofilament steel wire has no interstices and will remain quiescent even in infected wound closures. Another important effect of the interstices in the multistrand suture is to increase the exposed surface area of the metal. Liquids, when contacting solids, are drawn up by surface tension. The greater the surface area that a given amount of liquid contacts, the higher it will rise. This capillary attraction is well illustrated by ordinary wicks used in lamps or lighters. The exposed surfaces of a multistrand suture total many times that of a monofilament suture of the same size. To demonstrate this difference in capillary attraction, equal lengths of monofilament and multistrand steel wire sutures of the same size (No. 2-O or No. 28 gauge on the B & S scale) were dipped into a safranin dye solution and the rise of the dye up the suture was measured. Small knots of white cotton were tied at 3 mm. intervals along the sutures to make the column of dye more visible. As shown in Figure 1, the monofilament suture has the least capillary attraction. Even the first knot, 4 mm. above the fluid level, does not become stained with dye. The fluid rose to 15 mm. along the Surgaloy@ sutures and up to 35 mm. along the Flexon@ sutures. Surgaloy has seven strands of tine monofilament wire woven together whereas Flexon has forty-nine strands of even finer wire. Many authors have already written about the advantages of stainless steel over silk or cotton as the choice of suture material [l-3]. All of these authors used braided or multistrand stainless steel sutures, I have been unable to find any report in the literature describing the use of fine monofilament stainless steel wire as the suture material in gastrointestinal anastomoses. I believe that the ad-