Investment in medtech and biotech: Outlook

Medtech and biotech investment is driven by an expectation of returns, but rapid advances in technology simultaneously drive excitement for their application while increasing the uncertainty in what is needed to bring those applications in the market.

MedMarket Diligence has tracked technology developments and trends in advanced medical technologies, inclusive of medical devices and the range of other technologies — in biotech, pharma, others — that impact, drive, limit, or otherwise affect markets for the management of disease and trauma. This broader perspective on new developments and a deeper understanding of their limitations is important for a couple of reasons:

  1. Healthcare systems and payers are demanding competitive cost and outcomes for specific patient populations, irrespective of technology type — it’s the endpoint that matters. This forces medical devices into de facto competition with biotech, pharma, and others.
  2. Medical devices are becoming increasingly intelligent medical devices, combining “smart” components, human-device interfaces, integration of AI in product development and products.
  3. Medical devices are rarely just “medical devices” anymore, often integrating embedded drugs, bioresorable materials, cell therapy components, etc.
  4. Many new technologies have dramatically pushed the boundaries on what medicine can potentially accomplish, from the personalized medicine enabled by genomics, these advances have served to create bigger gaps between scientific advance and commercial reality, demanding deeper understanding of the science.

The rapid pace of technology development across all these sectors and the increasing complexity of the underlying science are factors complicating the development, regulatory approval, and market introduction of advanced technologies. The unexpected size and number of the hurdles to bring these complex technologies to the market have been responsible for investment failures, such as:

  • Theranos. Investors were too ready to believe the disruptive ideas of its founder, Elizabeth Holmes. When it became clear that data did not support the technology, the value of the company plummeted.
  • Juno Therapeutics. The Seattle-based gene therapy company lost substantial share value after three patients died on a clinical trial for the company’s cell therapy treatments that were just months away from receiving regulatory approval in the US.
  • A ZS Associates study in 2016 showed that 81% of medtech companies struggle to receive an adequate return on investment

As a result, investment in biotech took a correctional hit in 2016 to deflate overblown expectations. Medtech, for its part, has seen declining investment, especially at early stages, reflecting an aversion to uncertainty in commercialization.

Below are clinical and technology areas that we see demonstrating growth and investment opportunity, but still represent challenges for executives to navigate their remaining development and commercialization obstacles:

  • Cell therapies
    • Parkinson’s disease
    • Type I diabetes
    • Arthritis
    • Burn victims
    • Cardiovascular diseases
  • Diabetes
    • Artificial pancreas
    • Non-invasive blood glucose measurement
  • Tissue engineering and regeneration
    • 3D printed organs
  • Brain-computer and other nervous system interfaces
    • Nerve-responsive prosthetics
    • Interfaces for patients with locked-in syndrome to communicate
    • Interfaces to enable (e.g., Stentrode) paralyzed patients to control devices
  • Robotics
    • Robotics in surgery (advancing, despite costs)
    • Robotic nurses
  • Optogenetics: light modulated nerve cells and neural circuits
  • Gene therapy
    • CRISPR
  • Localized drug delivery
  • Immuno-oncology
    • Further accelerated by genomics and computational approaches
    • Immune modulators, vaccines, adoptive cell therapies (e.g., CAR-T)
  • Drug development
    • Computational approaches to accelerate the evaluation of drug candidates
    • Organ-on-a-chip technologies to decrease the cost of drug testing

Impact on investment

  • Seed stage and Series A investment in med tech is down, reflecting an aversion to early stage uncertainty.
  • Acquisitions of early stage companies, by contrast, are up, reflecting acquiring companies to gain more control over the uncertainty
  • Need for critical insight and data to ensure patient outcomes at best costs
  • Costs of development, combined with uncertainty, demand that if the idea’s upside potential is only $10 million, then it’s time to find another idea
  • While better analysis of the hurdles to commercialization of advanced innovations will support investment, many medtech and biotech companies may opt instead for growth of established technologies into emerging markets, where the uncertainty is not science-based

 

Below is illustrated the fundings by category in 2015 and 2016, which showed a consistent drop from 2015 to 2016, driven by a widely acknowledged correction in biotech investment in 2016.

*For the sake of comparing other segments, the wound fundings above exclude the $1.8 billion IPO of Convatec in 2016.

Source: Compiled by MedMarket Diligence, LLC.

 

Where will medicine be in 2035?

An important determinant of “where medicine will be” in 2035 is the set of dynamics and forces behind healthcare delivery systems, including primarily the payment method, especially regarding reimbursement. It is clear that some form of reform in healthcare will result in a consolidation of the infrastructure paying for and managing patient populations. The infrastructure is bloated and expensive, unnecessarily adding to costs that neither the federal government nor individuals can sustain. This is not to say that I predict movement to a single payer system — that is just one perceived solution to the problem. There are far too many costs in healthcare that offer no benefits in terms of quality; indeed, such costs are a true impediment to quality. Funds that go to infrastructure (insurance companies and other intermediaries) and the demands they put on healthcare delivery work directly against quality of care. So, in the U.S., whether Obamacare persists (most likely) or is replaced with a single payer system, state administered healthcare (exchanges) or some other as-yet-unidentified form, there will be change in how healthcare is delivered from a cost/management perspective. 

From the clinical practice and technology side, there will be enormous changes to healthcare. Here are examples of what I see from tracking trends in clinical practice and medical technology development:

  • Cancer 5 year survival rates will, for many cancers, be well over 90%. Cancer will largely be transformed in most cases to chronic disease that can be effectively managed by surgery, immunology, chemotherapy and other interventions. Cancer and genomics, in particular, has been a lucrative study (see The Cancer Genome Atlas). Immunotherapy developments are also expected to be part of many oncology solutions. Cancer has been a tenacious foe, and remains one we will be fighting for a long time, but the fight will have changed from virtually incapacitating the patient to following protocols that keep cancer in check, if not cure/prevent it. 
  • Diabetes Type 1 (juvenile onset) will be managed in most patients by an “artificial pancreas”, a closed loop glucometer and insulin pump that will self-regulate blood glucose levels. OR, stem cell or other cell therapies may well achieve success in restoring normal insulin production and glucose metabolism in Type 1 patients. The odds are better that a practical, affordable artificial pancreas will developed than stem or other cell therapy, but both technologies are moving aggressively and will gain dramatic successes within 20 years.

Developments in the field of the “artificial pancreas” have recently gathered considerable pace, such that, by 2035, type 1 blood glucose management may be no more onerous than a house thermostat due to the sophistication and ease-of-use made possible with the closed loop, biofeedback capabilities of the integrated glucometer, insulin pump and the algorithms that drive it, but that will not be the end of the development of better options for type 1 diabetics. Cell therapy for type 1 diabetes, which may be readily achieved by one or more of a wide variety of cellular approaches and product forms (including cell/device hybrids) may well have progressed by 2035 to become another viable alternative for type 1 diabetics.

  • Diabetes Type 2 (adult onset) will be a significant problem governed by different dynamics than Type 1. A large body of evidence will exist that shows dramatically reduced incidence of Type 2 associated with obesity management (gastric bypass, satiety drugs, etc.) that will mitigate the growing prevalence of Type 2, but research into pharmacologic or other therapies may at best achieve only modest advances. The problem will reside in the complexity of different Type 2 manifestation, the late onset of the condition in patients who are resistant to the necessary changes in lifestyle and the global epidemic that will challenge dissemination of new technologies and clinical practices to third world populations.

Despite increasing levels of attention being raised to the burden of type 2 worldwide, including all its sequellae (vascular, retinal, kidney and other diseases), the pace of growth globally in type 2 is still such that it will represent a problem and target for pharma, biotech, medical device, and other disciplines.

  • Cell therapy and tissue engineering will offer an enormous number of solutions for conditions currently treated inadequately, if at all. Below is an illustration of the range of applications currently available or in development, a list that will expand (along with successes in each) over the next 20 years.

    Cell therapy will have deeply penetrated virtually every medical specialty by 2035. Most advanced will be those that target less complex tissues: bone, muscle, skin, and select internal organ tissues (e.g., bioengineered bladder, others). However, development will have also followed the money. Currently, development and use of conventional technologies in areas like cardiology, vascular, and neurology entails high expenditure that creates enormous investment incentive that will drive steady development of cell therapy and tissue engineering over the next 20 years, with the goal of better, long-term and/or less costly solutions.
  • Gene therapy will be an option for a majority of genetically-based diseases (especially inherited diseases) and will offer clinical options for non-inherited conditions. Advances in the analysis of inheritance and expression of genes will also enable advanced interventions to either ameliorate or actually preempt the onset of genetic disease.

    As the human genome is the engineering plans for the human body, it is a potential mother lode for the future of medicine, but it remains a complex set of plans to elucidate and exploit for the development of therapies. While genetically-based diseases may readily be addressed by gene therapies in 2035, the host of other diseases that do not have obvious genetic components will resist giving up easy gene therapy solutions. Then again, within 20 years a number of reasonable advances in understanding and intervention could open the gate to widespread “gene therapy” (in some sense) for a breadth of diseases and conditions –> Case in point, the recent emergence of the gene-editing technology, CRISPR, has set the stage for practical applications to correct genetically-based conditions.
  • Drug development will be dramatically more sophisticated, reducing the development time and cost while resulting in drugs that are far more clinically effective (and less prone to side effects). This arises from drug candidates being evaluated via distributed processing systems (or quantum computer systems) that can predict efficacy and side effect without need of expensive and exhaustive animal or human testing.The development of effective drugs will have been accelerated by both modeling systems and increases in our understanding of disease and trauma, including pharmacogenomics to predict drug response. It may not as readily follow that the costs will be reduced, something that may only happen as a result of policy decisions.
  • Most surgical procedures will achieve the ability to be virtually non-invasive. Natural orifice transluminal endoscopic surgery (NOTES) will enable highly sophisticated surgery without ever making an abdominal or other (external) incision. Technologies like “gamma knife” and similar will have the ability to destroy tumors or ablate pathological tissue via completely external, energy-based systems.

    By 2035, technologies such as these will measurably reduce inpatient stays, on a per capita basis, since a significant reason for overnight stays is the trauma requiring recovery, and eliminating trauma is a major goal and advantage of minimally invasive technologies (e.g., especially the NOTES technology platform). A wide range of other technologies (e.g., gamma knife, minimally invasive surgery/intervention, etc.) across multiple categories (device, biotech, pharma) will also have emerged and succeeded in the market by producing therapeutic benefit while minimizing or eliminating collateral damage.

Information technology will radically improve patient management. Very sophisticated electronic patient records will dramatically improve patient care via reduction of contraindications, predictive systems to proactively manage disease and disease risk, and greatly improve the decision-making of physicians tasked with diagnosing and treating patients.There are few technical hurdles to the advancement of information technology in medicine, but even in 2035, infotech is very likely to still be facing real hurdles in its use as a result of the reluctance in healthcare to give up legacy systems and the inertia against change, despite the benefits.

  • Personalized medicine. Perfect matches between a condition and its treatment are the goal of personalized medicine, since patient-to-patient variation can reduce the efficacy of off-the-shelf treatment. The thinking behind gender-specific joint replacement has led to custom-printed 3D implants. The use of personalized medicine will also be manifested by testing to reveal potential emerging diseases or conditions, whose symptoms may be ameliorated or prevented by intervention before onset.
  • Systems biology will underlie the biology of most future medical advances in the next 20 years. Systems biology is a discipline focused on an integrated understanding of cell biology, physiology, genetics, chemistry, and a wide range of other individual medical and scientific disciplines. It represents an implicit recognition of an organism as an embodiment of multiple, interdependent organ systems and its processes, such that both pathology and wellness are understood from the perspective of the sum total of both the problem and the impact of possible solutions.This orientation will be intrinsic to the development of medical technologies, and will increasingly be represented by clinical trials that throw a much wider and longer-term net around relevant data, staff expertise encompassing more medical/scientific disciplines, and unforeseen solutions that present themselves as a result of this approach.Other technologies being developed aggressively now will have an impact over the next twenty years, including medical/surgical robots (or even biobots), neurotechnologies to diagnose, monitor, and treat a wide range of conditions (e.g., spinal cord injury, Alzheimer’s, Parkinson’s etc.).

The breadth and depth of advances in medicine over the next 20 years will be extraordinary, since many doors have been recently opened as a result of advances in genetics, cell biology, materials science, systems biology and others — with the collective advances further stimulating both learning and new product development. 


See the 2016 report #290, “Worldwide Markets for Medical and Surgical Sealants, Glues, and Hemostats, 2015-2022.”

New medical technologies at startups in December 2015

Listed below are the technologies under development at medical technology startups identified in December 2015 and added to the Medtech Startups Database.

  • 3D-printed, patient-specific implants
  • Therapeutic temperature management.
  • Vessel preparation angioplasty balloon.
  • Control system for minimally invasive surgical tools.
  • Surgical solutions focused on robotic and other technology.
  • Undisclosed products, but based on brain-gut pathway; principals with background in diabetes, endocrinology.
  • Robotically-assisted minimal access surgery.
  • Novel catheter device as a treatment for heart failure with preserved ejection fraction.

For a historical listing of medtech startups identified by month, see link.

Medtech Fundings for December 2015

Fundings in medical technology for December 2015 stand at $360.4 million, led by Spectranetics’ $110 million debt funding, followed by the $44 million launch funding of Kallyope, the $40 million funding of NxThera, and the $38.5 million funding of Axonics Modulation Technologies.

Below are the top fundings for the month, thus far. Please revisit this post (and refresh your browser) during December to see new medtech fundings.

For the complete list of fundings, see link.

For a month-by-month, historical list of fundings since 2009, see link.

Acute Stroke Therapeutics and a $1.7+ Billion Neurointerventional Worldwide Market; MMD Report

Stroke is a costly condition with a growing patient population targeted neurointerventional treatments that will account for hundreds of millions in sales over the next five years, according to a recent MedMarket Diligence report.

Acute stroke therapeutics are focused almost exclusively on patients’ cardiopulmonary and hemodynamic support and ad hoc containment of dangerous complications and corresponding brain damage associated with stroke. Among the life-threatening complications that commonly accompany acute cerebral hemorrhage or ischemia are cerebral edema; hydrocephalus; brain stem compression; vasospasm and pulmonary embolism. These therapeutic technologies will account for $323 million in new revenue from 2015 to 2019, according to the recently published MedMarket Diligence report, “Emerging Global Market for Neurointerventional Technologies in Stroke, 2014-2019”, details

“Stroke is associated with costly long-term care, especially for a patient population that is typically older and more susceptible to its complications, but neurointerventional treatment have succeeded in both making a positive clinical impact and securing respectable revenue streams for manufacturers,” says Patrick Driscoll of MedMarket Diligence. These technologies will continue to develop and improve over the next five years, but much growth will also come from the penetration by these technologies in non-U.S. markets, where relative use is lower and shows untapped potential.

Stroke is a life-threatening medical condition characterized by a sudden catastrophic breakdown in the brain-supporting cerebrovascular system and blood supply, which, in many instances, is followed by an irreversible injury to the brain cells and severe neurological impairment or death.

Notwithstanding the remarkable progress in medical science and technology and associated improvements in clinical practices, stroke continues to constitute the major public health problem in the U.S. and overseas.

The $1.5 billion global market for acute stroke management is revealed in detail in the MedMarket Diligence report #C310, “Emerging Global Market for Neurointerventional Technologies in Stroke, 2014-2019”, (see http://mediligence.com/c310/). The report is a detailed market and technology assessment and forecast of the products and technologies in the management of acute stroke. The report describes the epidemiology, etiology and management of hemorrhagic stroke, ischemic stroke, subarachnoid hemorrhage, and transient ischemic attack, characterizing the patient populations, their current clinical management, and trends in clinical management as new techniques and technologies are expected to be developed and emerge. The report details the currently available products and technologies, and the manufacturers offering them. The report details the products and technologies under development and markets for each in the treatment of acute stroke. The report provides a current and forecast to 2019 by region /country for the U.S., Western Europe, the major Asia-Pacific states (China, India, and Japan), and the rest of world. The report profiles the most top companies in this industry, providing status and forecast data on their current products, current market position, and products under development.

The report is described in detail at http://mediligence.com/c310/ and may be ordered for immediate download from https://shop.mediligence.com/index.php/downloads/c310/.

 

Spine Surgery Advances and Geographic Expansion Driving $9 Billion Market; MedMarket Diligence, LLC

Spine surgery manufacturers are driving growth by continuing to advance new technologies in implants, instrumentation and minimally invasive delivery while penetrating and expanding markets outside the U.S.

The $9.17 billion global market for cervical fusion, thoracolumbar Implants, MIS spine fusion, interbody fusion, and orthobiologics has evolved dramatically over the last several decades as a result of significant advances in the understanding of spinal biomechanics, the proliferation of sophisticated spinal instrumentation devices, surgical advances in bone fusion techniques, refinement of anterior approaches to the spine and the emergence and development of microsurgical, minimally invasive methods and robotics. As a result of these advances, it is now possible to stabilize every segment of the spine successfully, regardless of the offending pathology. The global market for spine surgery devices is detailed in the MedMarket Diligence report, “Global Market for Medical Device Technologies in Spine Surgery, 2014-2021.” (see http://mediligence.com/m540/)

“Well established and emerging spine surgery companies alike are succeeding by accomplishing three things — providing greater resources to further product development, expanding of sales and marketing resources, and growing new and emerging geographic regions,” says Patrick Driscoll, of MedMarket Diligence. “The result is continued strong sales growth globally, with a robust competitive landscape of companies of all sizes, keeping big players like Medtronic, DePuy,, Stryker, and Zimmer-Biomet on their toes” says Driscoll.

Spine fusion is the fastest growing technology in spine surgery and with growth in spine surgery being fastest in the Asia-Pacific and Central/Latin America, the growth of spine fusion in those areas is double-digit. The improvements in spine surgery and technology development have produced steady growth in volumes of surgeries, supported by reimbursement and clinical outcomes (and the increasingly active aging population). Spine surgery, with its exponential growth, has been the answer to an orthopaedic industry seeking to optimize earnings and add value for shareholders.

The MedMarket Diligence report, “Global Market for Medical Device Technologies in Spine Surgery, 2014-2021: Established and Emerging Products, Technologies and Markets in the Americas, Europe, Asia/Pacific and Rest of World,” (report #M540) is a detailed market and technology assessment and forecast of the products and technologies in the management of diseases and disorders of the spine. The report describes the diseases and disorders of the spine, characterizing the patient populations, their current clinical management, and trends in clinical management as new techniques and technologies are expected to be developed and emerge.

The report details the currently available products and technologies, and the manufacturers offering them. The report details the products and technologies under development and markets for each in spine surgery. The report provides a current and forecast assessment by region/country of procedures and manufacturer revenues for, specifically, Americas (United States, Rest of North America, Latin America), European Union (United Kingdom, Germany, France, Italy, Spain, Rest of Europe), Asia-Pacific (Japan, China, India, Rest of Asia/Pacific) and Rest of World. The forecast addresses the product- and country-specific impacts in the market of new technologies through the coming decade.

The report profiles 38 of the most notable current and emerging companies in this industry, providing data on their current products, current market position and products under development. The products and activities of numerous additional startup and emerging companies are also detailed in the report.

The report is described in detail at http://mediligence.com/m540/ and may be ordered for immediate download from https://shop.mediligence.com/index.php/downloads/m540/.

Three Key Forces Behind Startups and Investment in Medical Technology

We see three key forces underlying investment trends in medical technology:

  • The spectrum of competition has been broadened and sometimes isn’t even obvious.

Widely different technologies (as in treatment of coronary artery disease, see white paper) can address a clinical condition, with the solution to the problem being the focus of new investment.

New materials for devices, drug-device hybrids, biotech-driven solutions, and other innovations can create competition between very different technologies. As a result, the paradigms and truths that held true in the past, when devices only went head-to-head with devices, are no longer relevant, creating the need to better assess the competitive landscape.

Manufacturers must there develop good market awareness, as in being cognizant of all the potential source of competition, such as from companies in adjacent markets who might pivot and seize market share.

  • Money flows to niches in medtech where the demand for clinical utility is high.

The biggest forces driving medtech are increasing patient populations or the cost of managing them. Niches that address the challenges of an older population with unsolved painful and or costly conditions (orthopedics, chronic wounds, diabetes, bariatrics) have prominent cost targets that stimulate investment.

Patient demographics, healthcare cost/utility demands and other forces make some medtech niches very attractive, even if only as a result of technology migration (e.g., to growth geo markets).

  • Underserved patient populations command almost as much attention as the untapped patient populations.

There is much potential return on investment to be made in blockbuster treatments, but these can be financial sinkholes compared to less grandiose technology solutions. A motive force exists in medtech, centered around healthcare costs, that is relentlessly forcing medical technology innovators to find opportunity within existing markets, by eliminating cost (e.g., shifting care to outpatient as via minimally invasive technologies). Significant medical technology investment has already recognized the value in targeting conditions for which new technology, new clinical practices and/or simply new ways of thinking can improve the quality of life, patient costs or both.

Medtech investment is most serious when it is (1) in high dollar value, or (2) tied to the formation of companies. It reflects confidence in that sector to the degree set by the investment.

In the past five years, MedMarket Diligence has tracked the identification of over 600 companies in medtech. Below is the distribution of their focus across a large number of clinical and technology areas (multiple possible, as in “minimally invasive” and “orthomusculoskeletal”).

These companies have also been tracked through their specific investments (detailed historically at link).

Source: MedMarket Diligence, LLC; Medtech Startups Database.

Cardiology, orthopedics, and surgery are mainstay drivers of new technology development in medtech, as has been the push for minimally invasive therapies, but nanotechnology, interventional (e.g., transcatheter) technologies, biomaterials, wound management and other niches have a steady stream of new company formations.


See recent reports from MedMarket Diligence in the following clinical areas.

Technologies in Development at Medtech Startups, October 2015

In our flurry of activity in October, we overlooked summarizing the new medical technologies identified at startups and added to the Medtech Startups Database:

  • Neodymium vaginal dilator for treatment of pelvic pain.
  • Large bore, power injection vascular access
  • Surgical instruments for use in bariatrics.
  • Surgical oncology.
  • Spine surgical technology including expandable intervertebral cage.
  • Technologies to treat hearing loss.
  • Device to determine blood vessel size.
  • Cerebrospinal fluid shunt.
  • Focused ultrasonic surgical devices for hemostasis, cauterization, and ablation.
  • Collagen polymers to create 3D tissue systems for drug discovery, engineered tissue/organ, wound management, and 3D bioprinting.
  • Regenerative medicine to treat brain injury or damage.
  • Neuro-monitoring and neuro-critical care.
  • Orthomusculoskeletal implants.
  • Devices and methods for hip replacement
  • Intraoperative image system.
  • Exocentric medical device
  • Electro-hydraulic generated shockwave for cosmetic, medical applications.

For a historical listing of technologies at medtech startups, see link.

Technologies in Development at Medtech Startups, November 2015

Below is a list of the technologies under development at new medtech companies and recently added to the Medtech Startups Database.

  • Devices to assist pulmonary function.
  • Technologies to improve performance of orthopedic implantation.
  • Treatments for conditions associated with spinal cord injury and disease.
  • Technologies for the preservation and transport of organs and biologicals.
  • Interventional technologies for the treatment of neurovascular technologies.
  • Spinal fusion technologies
  • Orthopedic implants, including a prosthetic meniscus for placement in the knee joint.
  • Women’s health products including low risk device to measure cervical dilation.
  • Medical device to rapidly and accurately diagnose otitis media.
  • Bioabsorbable heart valve.
  • Electro-hydraulic generated shockwave for cosmetic, medical applications.

For a historical listing of technologies at medtech startups, see link.

 

Sutures, Staples and Other Fading Technologies

See Report #S192, “Worldwide Surgical Sealants, Glues, and Wound Closure Markets, 2013-2018”. (Note: This report has been superceded by the August 2016 Report #S290.)

Sutures have been in use for potentially thousands of years, and staples for the last several decades. Both have been frequently been the target of new development in wound closure and management, with competition in the form of advanced wound closure, whether surgical sealants, glues, hemostats, and even other mechanical wound closure. Novel wound closure technologies have decidedly gained enough credibility in clinical practice to displace volume in sutures and staples.

Sutures and Staples Are Not Fading…

Manufacturers of sutures and staples have not sat idly and watched their share erode. Indeed, the development of bioresorbable sutures and other novel suture types, the development of sophisticated stapling and suturing endoscopic instrumentation and other developments have begun to erode the share loss. Consequently, the shift “away” from sutures and staples has ebbed, such that the aggregate swing in market shares is no more than 3% compared to the swing projected three years ago of nearly 7% (see link).

Sutures and Staples in Wound Closure (excerpt from Report #S192)

The vast majority of sutures, staples, and endostaples are used to close procedures involving acute surgical wounds. Typically, chronic wounds do not involve the use of sutures and staple products unless some degree of surgical intervention is employed to remove necrotic tissue or to create a new acute wound bed to aid healing.

Sutures are classified as absorbable or non-absorbable; monofilament, multifilament or braided; and natural or synthetic. Absorbable or non-absorbable describes the suture’s effective life within tissue. Absorbable sutures lose the majority of their tensile strength within 60 days after use. Non-absorbable sutures are resistant to living tissue and do not break down. Monofilament, multifilament, and braided describe the structure or configuration of the suture based on the number of strands used to manufacture the product. Natural or synthetic refers to the origin of the suture. Natural suture materials include surgical gut, chromic gut, catgut and silk. Catgut is made from the natural collagen fibers found in the intestine of sheep, goats, cattle, hogs and horses. (It was never made from the gut of cats.) It is debatable whether catgut should continue to be used for suturing wounds, since cotton is cheaper and cotton or synthetic threads are less likely to cause infection. Synthetic suture materials include nylon, polyester, stainless steel, polypropylene, polyglycolic acid (PGA), polyglycolide-co-caprolactone (PGCL), and polydioxanone.

Suture products consist of two component parts, the needle and the suture. These can be found in a wide range of sizes and types, made of a range of materials, and the method of attachment of the suture to the needle can involve a variety of methods. Sutures are divided into braided and monofilament categories. Braided sutures are typically more pliable than monofilament and exhibit better knot security. Monofilament sutures are wirier and may require a more secure knot; however, they cause less tissue drag than braided sutures, a characteristic that is especially important in cardiovascular, ophthalmic and neurological surgery

Stapler devices are an evolution of suture technology. The goal of stapler products is to avoid infection and make the wound closure procedure easier and faster.  Staples are made of stainless steel and biomaterials and are used to join internal tissues, reconstruct or seal off organs, remove diseased tissue, occlude blood vessels, and close skin incisions and lacerations. They are primarily used during surgery as internal and/or external closure devices.

Staples are available in an assortment of sizes and features and stapler devices have been developed for specific procedures as well as for multiple uses.

Internal staplers are used to approximate (or close) internal tissues and organs. The devices may be reusable or disposable. Some disposable staplers may be reloaded several times during the course of a single patient surgical procedure, before being discarded.

The most recent internal staplers are used to perform minimally invasive surgical procedures. These allow the surgeon to endoscopically secure internal wounds instead of having to operate through an open procedure. Moreover, internal biodegradable staples obviate the need for staple removal. Such staples are ideally suited to laparoscopic surgery and are delivered via procedure-specific laparoscopic instruments. However, most staples are still made of stainless steel and when used for internal stapling procedures, whether open or laparoscopic, are not removed after healing. Skin staples are removed after the incision is healed.

Probably the major benefit of staples is that they can be applied more rapidly than sutures and can be placed precisely without requiring the skill necessary for suturing. This also means increased safety for the patient, and patients can often be discharged more rapidly if procedures are stapled rather than sutured.

While cosmetically acceptable results are usually obtained, staplers normally are not used in highly visible areas such as the face. Here, surgeons will still close by hand to minimize any scarring. In many skin closure procedures, sutures have begun to be replaced by cyanoacrylate glues. However, the ideal alternative to suturing has not yet been developed; for example, cyanoacrylate glues used for external skin closure are only one-fifth as strong as sutures.