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By Christopher Melotti

Sutures are a vital product in the world of wound closure, and throughout history they have experienced continual change and advancement, arriving at today’s organic and synthetic varieties¹ . A current debate amongst surgeons, doctors and healthcare professionals revolves around the use of organic Catgut as a thread material in suture products.

What Is Catgut?
Despite its name, Catgut is not a solution to the feral cat problem nor is it made, or ever been made from any product of the humble household cat. Despite this currently misleading prefix, it is, however, made of the intestines of common farmyard animals such as cows, sheep, goats and so forth. The intestine is then cut, cleaned, submerged, sterilised and worked together to form a string-like cord, in order to be utilised in a range of different fields, such as in stringed and skinned musical instruments, sports equipment such as the tennis racquet and of course, the medical industry as thread in sutures² .

There are several different theories as to how or why it got its name, however more importantly, Catgut is staple material when it comes to sutures and this history has evolved as a result of either exclusive familiarity or simple convenience; this means, in the past, Catgut was cheaper and easier to obtain and/or current practicing surgeons have always had a comfortable experience with the product and thus are reluctant to stray too far from something that has always been the norm.

Then Why Mess With A Good Thing?
As one would expect from an ever-evolving industry that is the medical field, debates and research findings are now emerging, questioning the routine use of such a staple product in the medical field.

Understandably, Catgut was the choice for sutures in the past, but now this is far from the case. Modern practises have discovered alternatives, which see the threads of the suture created from synthetic materials, bringing with them numerous, clear advantages that set them apart from Catgut products. This is why there has been a noticeably declining manufacture and use of Catgut sutures over the last decade, and this trend is more than likely to continue.

Right Down To The Wire
(...or thread)
As mentioned, Catgut has and continues to be used for various reasons, however, with new research these reasons are paling in comparison to the advantages of synthetic sutures.

The difference between absorbable sutures is that the modern, synthetic types are hydrolysed and dissolved by normal body fluids over time, whereas the older Catgut sutures require enzymatic digestion for their removal, causing an inflammatory response to foreign organic material³. It has been found, in several fields of surgery, that Catgut can sustain infection, which can have a flow-on, detrimental effect and actually impair the healing of the very wounds they are being used to close. Furthermore, if applied into previously infected wounds, there is a higher probability of bacterial adhesion compared to synthetic sutures, as well as a rapid decrease in initial tensile strength of the thread within hours to days, possibly resulting in further complications. The fact that modern absorbable sutures have improved tensile strength and prolonged knot-retaining capabilities compared to Catgut, together with the fact that breakdown of the modern synthetic materials is not accelerated in infected tissue ^4,5 is why Catgut was confirmed a poor choice for use in contaminated wounds by the Scientific Committee on Medicinal Products and Medical Devices (SCMPMD)⁶.

The SCMPMD report also concluded that comparable synthetic absorbable suture products, which can be substituted for Catgut sutures, have been found to provide equal, or increased clinical performance than Catgut sutures. Furthermore, the SCMPMD also noted that there are very little clinical indications revolving around the preferential use of Catgut over alternatives based on scientific justifications, to which that Council concluded that there was no further need for Catgut sutures⁶.

Due to the organic bovine origin of Catgut, the issue of safety can be raised in the form of Transmissible Spongiform Encephalopathies (TSEs), which, when considered specifically to intestinal tissue, is more commonly known as, “Mad Cow Disease” or BSE. Biosecurity Australia, an agency within the Australian Department of Agriculture Fisheries and Forestry, identifies Catgut as a “high TSE risk product” since it is derived from bovine or ovine intestinal tissue⁷ . Synthetic thread is not susceptible and therefore does not put patients at risk of certain diseases that Catgut can.

What Changes Have Been Made?
As a result of the negative issues with Catgut sutures and the advantages of alternative synthetic sutures, there have been changes in the use of different sutures. Over the past two decades in developed countries such as the United States of America and the United Kingdom, the use of synthetic absorbable sutures exceeded that of Catgut ^8,9.  Europe and Japan have taken the extreme option and banned Catgut sutures outright for human medical use, partly due to the potential risk but mostly due to the advantageous alternatives⁹.

B. Braun Australia have proactively chosen to remove Catgut sutures from their range, instead offering the alternative synthetic materials which not only provide superior quality, but also overcome prevalent problems associated with the use of Catgut such as unpredictable and unreliable degradation. B. Braun offer several brands of absorbable sutures depending on desired use, which can replace all Catgut sutures: Monosyn^® and Monosyn Quick^® are monofilament synthetic sutures and Safil^® and Safil Quick^® are braided synthetic sutures.

Have You Had A Gut Full?
It is undeniable that the extent of research and evidence for swapping the old Catgut sutures for a more beneficial synthetic absorbable suture is starting to pile up. Perhaps it may be time to join the advancement highway of suture material progression, and say goodbye to Catgut for good.

Christopher Melotti is Associate Product Manager- Aesculap  Division

B. Braun Australia Pty Ltd

Ph:     +61 2 9629 0200

www.bbraun.com.au

© 2011 B. Braun Australia Pty Ltd 

[1] B. Braun. Emergence of non-absorbable suture materials since 2000 BCE. < http://www.sutures-bbraun.com/index.cfm?BA9BA32D2A5AE6266471269F12FB4F8C> Accessed 29/4/2011.

[2] Hardman, D. Animals and Humans: Something of a Therapeutic Team. RSPCA Australia Scientific Seminar 2009.

[3] Gilstrap, L, Cunningham, F, VanDorsten, J. Operative Obstetrics. Second Edition 2002, The McGraw-Hill Companies, Inc. Page 57  

[4] Kruger, T.F, et al. Clinical Gynaecology. Third Edition, 2007 Juta & Co. Ltd. Page 554

[5] Wallace WR, Maxwell GR, Cavalaris CJ. Comparison of polyglycolic-polyactic acid suture to black silk, chromic and plain Catgut in human oral tissues. J Oral Surg 1970; 28; 739-746

[6] Scientific Committee on Medicinal Products and Medical Devices (SCMPMD). Opinion and report on the equivalency of alternative products to intestines of animal origin for the use as surgical sutures adopted by the Scientific Committee on Medicinal Products and Medical Devices. 16 September 1998.

[7] Department of Agriculture Fisheries and Forestry Australia, ‘Measures to address additional TSE concerns with veterinary vaccines and other high risk biologicals’, November 2001

[8] Bronzino, J. The biomedical engineering handbook, Volume 2. CRC Taylor & Francis, 2006.

[9] “Manufacturers stop UK supply of Catgut sutures”. Biomedical Materials. FindArticles.com. 01 May, 2011. <http://findarticles.com/p/articles/mi_hb5970/is_2001_April/ai_n32008942/>

To receive a highly useful FREE wound management package which includes:

• A comprehensive Wound Care Module DVD
• A Full Colour Wound Assessment and the latest Wound Dressings Wall Chart
• A handy pocket Flip Chart on Wound Assessment and Dressings

Please contact Liz Thompson from the Department of Veterans Affairs on 02 6289 1167

This information was designed by wound management expert Associate Professor Geoff Sussman OAM, Director Wound Research Wound Foundation of Australia and Monash University Department of General Practice lecturer.