Wound infection after ileostomy closure can be eliminated by circumferential subcuticular wound approximation

Clinical Benefits of Reducing Dead Space Using a Closed Suction Drain and Subcutaneous Large-bite Buried Suture Technique to Prevent Superficial Surgical-site Infections Following Primary Closure of a Diverting Stoma

Objectives

Surgical-site infections (SSIs) are the most common complication after stoma closure. We propose a new method for wound closure using the subcutaneous large-bite buried suture (SLBS) technique and a closed suction drain (CSD). In this study, we aimed to investigate the efficacy of a combination of the SLBS technique and a CSD to prevent superficial SSIs following stoma closure.

Methods

We retrospectively analyzed patients who underwent stoma closure between January 2019 and July 2022. Primary closure of the stomal site was performed using the SLBS technique and a CSD for wound closure. The CSD was placed until postoperative day 7. The occurrence of superficial postoperative SSIs was also evaluated.

Results

In total, 67 patients were included in the study. Within 30 days postoperatively, nine patients (13%) developed superficial SSIs. Considering the type of stoma, only 1 (2%) of 45 patients with ileostomy showed superficial SSIs, whereas 8 (36%) of 22 patients with colostomy showed superficial SSIs. Univariate analysis of the risk factors associated with the occurrence of superficial SSIs revealed that colostomy (p < 0.001) and hand-sewn anastomosis were significant risk factors (p = 0.019). Multivariate analysis of the risk factors associated with the occurrence of superficial SSIs revealed that colostomy was significant risk factor (p = 0.003).

Conclusions

This new method of stoma closure is feasible for preventing superficial SSIs, especially in ileostomy closure.

Micro-power negative pressure wound technique reduces risk of incision infection following loop ileostomy closure

BACKGROUND

Prophylactic loop ileostomy is an effective way to reduce the clinical severity of anastomotic leakage following radical resection of rectal cancer. Incisional surgical site infection (SSI) is a common complication after ileostomy closure.

AIM

To evaluate the efficacy and safety of the micro-power negative pressure wound technique (MPNPWT) in preventing incisional SSI.

METHODS

This was a prospective, randomized controlled clinical trial conducted at a single center. A total of 101 consecutive patients who underwent ileostomy closure after rectal cancer surgery with a prophylactic ileostomy were enrolled from January 2019 to December 2021. Patients were randomly allocated into an MPNPWT group and a control group. The MPNPWT group underwent intermittent suturing of the surgical incision with 2-0 Prolene and was covered with a micro-power negative pressure dressing. The surgical outcomes were compared between the MPNPWT (n = 50) and control (n = 51) groups. Risk factors for incisional SSI were identified using logistic regression.

RESULTS

There were no differences in baseline characteristics between the MPNPWT (n = 50) and control groups (n = 51). The incisional SSI rate was significantly higher in the control group than in the MPNPWT group (15.7% vs 2.0%, P = 0.031). However, MPNPWT did not affect other surgical outcomes, including intra-abdominal complications, operative time, and blood loss. Postoperative hospital stay length and hospitalization costs did not differ significantly between the two groups (P = 0.069 and 0.843, respectively). None of the patients experienced adverse effects of MPNPWT, including skin allergy, dermatitis, and pain. MPNPWT also helped heal the infected incision. Our study indicated that MPNPWT was an independent protective factor [odds ratio (OR) = 0.005, P = 0.025)] and diabetes was a risk factor (OR = 26.575, P= 0.029) for incisional SSI.

CONCLUSION

MPNPWT is an effective and safe way to prevent incisional SSI after loop ileostomy closure.

Comparing Surgical Site Infection Rate Between Primary Closure and Rhomboid Flap After Stoma Reversal

BACKGROUND

Primary closure (PC) is a common wound closure procedure after stoma reversal and is associated with a high rate of surgical site infection (SSI). This study introduced a new method of skin closure, a rhomboid flap (RF), for skin closure after stoma reversal and compared the SSI rate between the 2 techniques.

METHODS

This is a single-center retrospective study. Patients who underwent colostomy or ileostomy closure performed using either rotation flap (n = 33) or PC (n = 121) techniques for skin closure after stoma reversal between April 2019 and July 2022 were enrolled in this study. Medical records were retrospectively reviewed to obtain data. Both groups were followed up postoperatively at 1 month for wound infection. Wound infection within 30 days after surgery was indicated by the presence of purulent discharge, erythema, local heat, or positive culture for bacteria.

RESULTS

In the PC group, the infection rate was 25.6% (n = 121) compared with 12.1% (n = 33) in the RF group (P = 0.158). Among the patients who underwent colostomy reversal, the infection rate of the RF group was significantly lower compared with that of the PC group (11.1% vs 36.9%, P = 0.045). Among the patients who underwent ileostomy reversal, no significant differences in the infection rates between the groups were found (13.3% vs 12.5%, P = 1.000).

CONCLUSIONS

Although the RF technique requires slightly longer operative time for flap design in practice than the linear closure method, the technique can significantly reduce the SSI rate after colostomy reversal through the dissection of the surrounding inflammatory tissues and obliteration of the dead space. Additional studies are required to evaluate this technique, compare it with other existing methods, and explore long-term complications.

Risk factors for surgical site infections and trends in skin closure technique after diverting loop ileostomy reversal: A multi-institutional analysis

BACKGROUND

Surgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique.

METHODS

A retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary ​+ ​drain, or purse-string closure. The primary outcome was SSI at the former DLI site.

RESULTS

A SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure ​+ ​drain, and 2.7% for purse-string closure (p ​= ​0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p ​< ​0.0001).

CONCLUSIONS

This study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time.

Wound Infection After Ileostomy Closure: An Interim Analysis of a Prospective Randomized Study Comparing Primary Versus Circumferential Subcuticular Closure Techniques

Background: Circumferential subcuticular wound approximation (CSWA) of round shaped skin wounds after ileostomy take down is believed to lower the rates of surgical site infection (SSI). We performed this randomized trial to compare the rates of SSI and other short-term outcomes among primary linear skin closure (PC) and CSWA groups of patients. Patients and Methods: All patients undergoing ileostomy reversal during the study period were randomly assigned to either PC or CSWA. The primary outcome was the incidence of SSI as assessed by ASEPSIS scoring system. The secondary outcomes included healing time, length of post-operative hospital stay, and patients' satisfaction regarding cosmetic outcome, expectations, pain, time of healing, wound care, and activity on a five-point Likert scale. Results: Thirty-one patients (PC = 15; CSWA = 16) underwent ileostomy reversal during the study period. There was no SSI in the PC group whereas three patients developed SSI in the CSWA group but the result was not statistically significant (p = 0.23). The scores for time of healing (p < 0.001), wound care (p = 0.007), and activity (p < 0.001) were significantly better for PC compared with CSWA whereas there was no significant difference in the scores for cosmetic outcome, expectations, and pain. Healing time was shorter in the PC group (6.7 vs. 34.2 days; p < 0.001) whereas the post-operative length of stay was comparable (6.3 vs. 7 days; p = 0.27). Conclusions: Although there was no difference in the incidence of SSI among the two groups, the PC group fared better in terms of mean time to healing and requirement of wound care.

Comparison of modified gunsight suture technique and traditional interrupted suture in enterostomy closure

BACKGROUND

Prophylactic enterostomy surgery is a common surgical approach used to reduce the risk of anastomotic leakage in patients who have undergone partial intestinal resection due to trauma or tumors. However, the traditional interrupted suturing technique used in enterostomy closure surgery has several issues, including longer surgical incisions and higher incision tension, which can increase the risk of postoperative complications. To address these issues, scholars have proposed the use of a "gunsight suture" technique. This technique involves using a gunsight incision instead of a traditional linear incision, leaving a gap in the center for the drainage of blood and fluid to reduce the risk of infection. Building on this technique, we propose an improved gunsight suture technique. A drainage tube is placed at the lowest point of the incision and close the gap in the center of the gunsight suture, which theoretically facilitates early postoperative mobility and reduces the burden of dressing changes, thereby reducing the risk of postoperative complications.

AIM

To compare the effectiveness of improved gunsight suture technique with traditional interrupted suture in closing intestinal stomas.

METHODS

In this study, a retrospective, single-center case analysis was conducted on 270 patients who underwent prophylactic ileostomy closure surgery at the Department of Colorectal Surgery of Qilu Hospital from April 2017 to December 2021. The patients were divided into two groups: 135 patients received sutures using the improved gunsight method, while the remaining 135 patients were sutured with the traditional interrupted suture method. We collected data on a variety of parameters, such as operation time, postoperative pain score, body temperature, length of hospital stays, laboratory indicators, incidence of incisional complications, number of wound dressing changes, and hospitalization costs. Non-parametric tests and chi-square tests were utilized for data analysis.

RESULTS

There were no statistically significant differences in general patient information between the two groups, including the interval between the first surgery and the stoma closure [132 (105, 184) d vs 134 (109, 181) d, P = 0.63], gender ratio (0.64 vs 0.69, P = 0.44), age [62 (52, 68) years vs 60 (52, 68) years, P = 0.33], preoperative body mass index (BMI) [23.83 (21.60, 25.95) kg/m² vs 23.12 (20.94, 25.06) kg/m², P = 0.17]. The incidence of incision infection in the improved gunsight suture group tended to be lower than that in the traditional interrupted suture group [ (n = 2/135, 1.4%) vs (n = 10/135, 7.4%), P < 0.05], and the postoperative hospital stay in the improved gunsight suture group was significantly shorter than that in the traditional interrupted suture group [5 (4, 7) d vs 7 (6, 8) d, P < 0.05]. Additionally, the surgical cost in the modified gunsight suture group was slightly lower than that in the traditional suture group [4840 (4330, 5138) yuan vs 4980 (4726, 5221) yuan, P > 0.05], but there was no significant difference in the total hospitalization cost between the two groups.

CONCLUSION

In stoma closure surgery, the improved gunsight technique can reduce the incision infection rate, shorten the postoperative hospital stay, reduce wound tension, and provide better wound cosmetic effects compared to traditional interrupted suture.

Application and evaluation of transitory protective stoma in ovarian cancer surgery

Ovarian cancer is the most fatal of all female reproductive cancers. The fatality rate of OC is the highest among gynecological malignant tumors, and cytoreductive surgery is a common surgical procedure for patients with advanced ovarian cancer. To achieve satisfactory tumor reduction, intraoperative bowel surgery is often involved. Intestinal anastomosis is the traditional way to restore intestinal continuity, but the higher rate of postoperative complications still cannot be ignored. Transitory protective stoma can reduce the severity of postoperative complications and traumatic stress reaction and provide the opportunity for conservative treatment. But there are also many problems, such as stoma-related complications and the impact on social psychology. Therefore, it is essential to select appropriate patients according to the indications for the transitory protective stoma, and a customized postoperative care plan is needed specifically for the stoma population.

COMPARISON BETWEEN OSTOMY CLOSURE USING PURSE-STRING VERSUS LINEAR IN CHILDREN

BACKGROUND

Type of ostomy closure has connection with some complications and also cosmetic effects.

AIMS

This study aimed to compare result of colostomy closure using purse-string method versus linear method in terms of surgical site infection, surgical time, and patient satisfaction.

METHODS

In this study, 50 patients who underwent purse-string ostomy closure and 50 patients who underwent linear closure were included. Two groups were compared for surgical time, wound infection, patient satisfaction, scar length. A p-value <0.05 was considered significant.

RESULTS

Wound infection was not reported among purse-string group compared to 10% in linear group (p=0.022). Scar length was 24.09±0.1 mm in purse string and 52.15±1.0 mm in linear group (p=0.033). Duration of hospital admission was significantly shorter in purse-string group (6.4±1.1 days) compared to linear (15.5±4.6 days, p=0.0001). The Patient and Observer Scar Assessment Scale scale for observer (p=0.038) and parents (p=0.045) was more favorable among purse-string group compared to linear.

CONCLUSION

Purse-string technique has the less frequent surgical site infection, shorter duration of hospital admission, less scar length, and more favorable cosmetic outcome, compared to linear technique.

Risk factor for the development of surgical site infection following ileostomy reversal: a single-center report

PURPOSE

Postoperative surgical site infection (SSI) is not uncommon in patients with ileostomy reversal. The appropriate index to predict the postoperative SSI in these individuals remains unclear. The aim of this study is to evaluate the risk factor for SSI after ileostomy reversal.

METHODS

A consecutive cohort of 201 patients who underwent elective ileostomy reversal between January 2015 and January 2020 were retrospectively analyzed. Patients were divided into two groups: SSI group and non-SSI group. Univariate and multivariate analyses were conducted to identify risk factors for postoperative SSI.

RESULTS

Postoperative SSI occurred in 37 (18.4%) patients. Compared with the non-SSI group, patients in SSI group had higher incidence of nutrition risk (56.77% vs 39.02%, P = 0.049), higher C-reactive protein (CRP) level (10.81 ± 16.49 vs 4.86 ± 4.14 mg/L, P < 0.001), and longer postoperative hospital stay (13.08 ± 3.71 vs 7.47 ± 2.38 days, P < 0.001). By analyzing the receiver-operating characteristic (ROC) curve, CRP have the value in predicting the occurrence of SSI. The areas under the ROC curves of CRP for SSI was 0.671 (95% confidence interval 0.568-0.774, P = 0.001) with an optimal diagnostic cut-off value of 8.0 mg/L. By the univariate and multivariate analyses, preoperative C-reactive protein (CRP) ≥ 8 mg/L(P < 0.001) and conventional linear closure method (P = 0.004) were independent risk factors for postoperative SSI.

CONCLUSIONS

Preoperative CRP levels can be served as a predictive index for postoperative SSI after stoma reversal. Purse-string closure technique is the treatment of choice to minimize stoma site SSI in patients with stoma reversal.

Comparison between Wound Closure Methods in the Reversal of Diverting Ileostomy

Background/Aims

The objective of this study was to determine the more appropriate wound-closure method by comparing the effectiveness of two methods in a group of patients who underwent ileostomy repair.

Methods

The study conducted after obtaining the approval of the Institutional Review Board (IRB) included 58 patients ≥19 years of age who underwent ileostomy at the Department of Surgery at the Presbyterian Medical Center. This was a retrospective, single-center trial. Patients who underwent ileostomy closure between January 2011 and September 2017 were assigned to the primary wound-closure (PC, n=25) group and the purse-string wound-closure (PSC, n=33) group. Post-repair complications, such as wound infection, delayed healing, and patient satisfaction related to wound management, were investigated and compared according to the wound-closure method.

Results

The PSC group had a significantly lower surgical site infection rate than the PC group (0% vs. 44%, p<0.001). The wound-healing period was also significantly different between the PC and PSC groups (mean 27.18 days vs. 20.96 days, p=0.023). However, the postoperative wound-healing delay of >30 days was not significantly different (39% vs. 20%, p=0.114). In addition, there were no significant differences in the response to questionnaires on patient satisfaction between the two groups.

Conclusions

PSC has a lower surgical site infection rate and the wound-healing delay was not very different from that of PC. Therefore, if patients are at risk of wound infection, such as in severe wound contamination, long operating time, and immunocompromised conditions, we should consider PSC as a wound closure method of choice.

Effectiveness of negative pressure wound therapy with instillation and dwelling after stoma closure: a retrospective and propensity score matching analysis

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

A comparison of surgical site infections in children after stoma reversal between purse-string and linear closure

BACKGROUND

To reduce the surgical site infections (SSI), the purse-string closure technique has been widely performed and has also been recommended in adult stoma reversal. However, for children, some debate still exists. This study aims to compare the SSI rates in children between the purse-string and the linear for the skin closure of stoma reversal.

METHODS

The data were collected from pediatric patients, who had undergone either purse-string or linear closure for elective surgery of stoma reversal from two university hospitals between January 2016 and December 2019.

RESULTS

The purse-string and linear closure had been performed on 31 and 45 patients, respectively. At 30 days after surgery, three patients in the purse-string closure group had developed SSI compared to 14 patients in the linear closure group (9.7 vs. 31.1%, p = 0.028). Furthermore, there had been no significant difference in the overall post-operative complications. In multivariate analysis, the SSI had been significantly lower in patients with purse-string closure (OR 0.21, 95% CI 0.05-0.86, p = 0.029).

CONCLUSION

By employing the purse-string closure technique for skin closure of stoma reversal, there had been a significantly lower SSI rate compared to linear closure with no difference in the length of hospital stay.

Effectiveness of negative pressure wound therapy for the wound of ileostomy closure: a multicenter, phase II randomized controlled trial

BACKGROUND

The American Society of Surgery and American Society for Surgical Infections issued guidelines for surgical site infections (SSIs) in December 2016. These guidelines recommend a purse-string suture (PSS) for stoma closure as it facilitates granulation and enables open wound drainage. This study investigated the effect of using negative pressure wound therapy (NPWT) along with standard PSS and aimed to determine the optimal period of NPWT use.

METHODS

The patients were divided into three groups as follows: Group A, postoperative wound management alone with gauze exchange as the representative of conventional PSS; Group B, the performed management was similar to that of Group A plus NPWT for 1 week; and Group C, the performed management was similar to that of Group A plus NPWT for 2 weeks. Regarding objective measures, the wound reduction rate was the primary outcome, and the incidence of SSIs, length of hospital stay, and wound healing duration were the secondary outcomes.

RESULTS

In total, 30 patients (male: 18, female: 12) were enrolled. The average age was 63 (range: 43-84) years. The wound reduction rate was significantly higher in Group B than in Group A on postoperative days (PODs) 7 (66.1 vs. 48.4%, p = 0.049) and 10 (78.6 vs. 58.2%, p = 0.011), whereas no significant difference was observed on POD 14. Compared with Group A, Group C (POD 7: 65.9%, POD 10: 69.2%) showed an increase in the wound reduction rate on POD 7, although the difference was not significant (p = 0.075). SSIs were observed in Groups B (n = 2) and C (n = 2) (20%) but not in Group A (0%).

CONCLUSIONS

The most effective duration of NPWT use for ileostomy closure with PSS in terms of the maximum wound reduction rate was from PODs 3 to 10. However, NPWT did not shorten the wound healing duration. NPWT may reduce the wound size but should be used with precautions for SSIs. The small sample size (30 cases), the use of only one type of NPWT system, and the fact that wound assessment was subjective and not blinded were the limitations of this study. Further studies are needed to confirm our findings.

TRIAL REGISTRATION

UMIN Clinical Trials Registry; UMIN000032174 (10/04/2018).

Effect of closed incision negative pressure wound therapy on incidence rate of surgical site infection after stoma reversal: a pilot study

Introduction

The stoma reversal (SR) procedure is associated with a relatively high risk of perioperative complications with surgical site infection (SSI) as the most common. Recently closed incision negative pressure wound therapy (ciNPWT) was applied widely to prevent SSI.

Aim

To investigate the efficiency of ciNPWT in terms of the incidence rate of SSI after SR surgery.

Material and methods

As an exploratory observational cohort study patients were treated either with ciNPWT (n = 15) or standard sterile dressing (SSD) (n = 15). CiNPWT was applied every 3 days whereas SSD was changed every day. Clinical evaluation for SSI signs, C-reactive protein level and pain assessment using the visual analogue scale (VAS) were analyzed.

Results

The incidence rate of SSI was in 13% (2/15) in the ciNPWT group and 26% (4/15) in the SSD group (p = 0.651, OR = 0.44, 95% CI: 0.03–3.73). All patients in the SSD group who developed SSI presented both local and generalized signs of infection. Pain-VAS levels assessed on the 1^st (MdnciNPWT = 4, MdnSSD = 5, p = 0.027, W = 51.5) and 3^rd postoperative day (MdnciNPWT = 2, MdnSSD = 4, p = 0.014, W = 45.5) were significantly lower in the ciNPWT group than in the SSD group.

Conclusions

CiNPWT seems not to have a benefit to reduce SSI after the SR procedure. Further investigation is needed to establish firmly the benefit of using ciNPWT in this group of patients.

Gunsight sutures significantly reduce surgical-site infection after ileostomy reversal compared with linear sutures

Background

Surgical-site infection (SSI) was one of the most common post-operative morbidities of ileostomy reversal. Although several skin-closure procedures had been developed to reduce the rate of SSI, the optimal procedure remains unclear. In this study, we compared the effect of two surgical techniques for wound closure following ileostomy reversal: gunsight suture (GS) and linear suture (LS).

Methods

A total of 233 patients who underwent loop ileostomy at the Sixth Affiliated Hospital of Sun Yat-sen University between January 2015 and December 2017 were enrolled into our study. These patients were divided into two groups: the LS group and the GS group. We compared the clinical characteristics between the two groups and analyzed the data using IBM SPSS to identify risk factors for SSI.

Results

Both groups successfully underwent surgery. The rate of SSI was significantly lower in the GS group (n = 2, 0.02%) than in the LS group (n = 16, 12.00%, P = 0.007). The length of hospital stay after the operation in the GS group was significantly shorter than that in the LS group (8.1 ± 3.2 vs 10.8 ± 5.4 days, P < 0.001). Multivariate analysis showed that GS was an independent protective risk factor for SSI (odds ratio = 0.212, P = 0.048).

Conclusions

Compared with the LS technique, the GS technique can significantly decrease the rate of SSI and shorten the length of hospital stay after surgery. The GS technique may be recommended for wound closure following ileostomy reversal.

New Scoring System for Predicting the Risk of Surgical Site Infections Following Stoma Reversal

BACKGROUND

Surgical site infections (SSI) are one of the most frequent complications following stoma reversal (SR-SSI) and lead to multiple problems such as decreased mobility of the patients or increased hospital costs. Several risk factors for SR-SSI have been reported, but there are no risk scoring systems for predicting SR-SSI. The current study aimed to analyze the risk factors for SR-SSI and develop a scoring system.

MATERIALS AND METHODS

Multivariate analysis of risk factors for SR-SSI was performed in patients who underwent elective SR and were followed-up during the first month after surgery. A logistic regression model was used to identify risk factors and construct a predictive score.

RESULTS

Of the 182 patients, 53 (29.1%) developed SSI. In multivariate analysis, three variables as preoperative risk factors were associated with increased SR-SSI incidence: subcutaneous fat thickness (≥ 20 mm) (odds ratio [OR]: 8.46 [95% confidence interval (CI): 3.45-20.7], P <0.001), period from stoma creation (≤ 20 weeks) (OR: 2.88 [95% CI: 1.14-7.28], P = 0.025), and SSI after the primary operation (OR: 3.06 [95% CI: 1.19-7.90], P = 0.021). Each of these variables contributed 2,1, and 1 points to the risk score, respectively. The SR-SSI rate was 2.9%, 20.3%, 34.2%, 54.5%, and 81.8% for the scores of 0,1,2,3, and 4 points, respectively. The area under the receiver operating characteristic curve was 0.773 (95% CI: 0.703-0.844).

CONCLUSIONS

A simple clinical scoring system based on three preoperative variables may be useful in predicting the risk of SR-SSI.

The technique for less infectious and earlier healing of stoma closure wound: negative pressure wound therapy with instillation and dwelling followed by primary closure

Background

Temporary stomas have been widely used to avoid the risk of complications such as anastomotic leakage after colorectal resection. Stoma closure is relatively easy; however, postoperative surgical site infection (SSI) may be a problem. Various methods have been used to reduce the incidence of SSI. We aimed to evaluate a new technique for stoma wound closure.

Methods

We enrolled patients who underwent stoma closure at our hospital between September 2019 and May 2020. We selected patients who lived far from our hospital and had difficulty visiting the hospital regularly and who agreed to undergo this surgical technique. We used negative pressure wound therapy with instillation and dwelling (NPWTi-d) and delayed primary closure for these patients.

Results

Four patients underwent NPWTi-d and delayed primary closure without the occurrence of SSI. The median postoperative hospital stay was 9 days (range: 7–14 days), and the median number of days to confirmation of epithelialization was 11.5 days (range: 10–16 days).

Conclusion

The combined use of NPWTi-d and delayed primary closure for the stoma wound was very effective. This method may be a valuable new technique for wound management after stoma closure.

Gunsight Procedure Versus the Purse-String Procedure for Closing Wounds After Stoma Reversal: A Multicenter Prospective Randomized Trial

BACKGROUND

Stoma reversal is associated with a high risk of wound infection. The gunsight and purse-string closure techniques are both effective alternatives for stoma reversal, but comparative studies are lacking.

OBJECTIVE

The purpose of this study was to compare the gunsight procedure with the purse-string closure technique when closing wounds after loop stoma reversal.

DESIGN

This was a nonblinded, multicenter prospective randomized study (clinicaltrials.gov No. NCT02053948).

SETTINGS

The study was conducted at a general surgery unit of 7 tertiary academic medical centers.

PATIENTS

A total of 143 patients undergoing loop stoma reversal were included in the study (72 in the gunsight group and 71 in the purse-string group) between November 2013 and December 2017.

INTERVENTION

Patients were randomly assigned to undergo either gunsight or purse-string closure procedure.

MAIN OUTCOME MEASURES

Primary outcome was wound healing time. Secondary outcomes were the incidence of surgical site infection, morbidity, and patient satisfaction.

RESULTS

No differences were found between the 2 groups in terms of surgical site infection, intraoperative blood loss, and postoperative hospital stay. The gunsight procedure had a shorter wound healing time compared with the purse-string procedure (17 vs 25 d; p < 0.001). A patient satisfaction questionnaire showed that the gunsight group had a higher score level of patient satisfaction with respect to wound healing time (p < 0.001) and total patient satisfaction score (p = 0.01) than the purse-string group.

LIMITATIONS

Treatment teams were not blinded, and there was operator dependence of techniques.

CONCLUSIONS

The gunsight and purse-string techniques are effective procedures for stoma reversal and both have a low incidence of surgical site infection. The gunsight technique is associated with shorter wound healing time, higher levels of patient satisfaction with regard to healing time, and overall final score and is recommended as the closure technique of choice. See Video Abstract at http://links.lww.com/DCR/B319. EL PROCEDIMIENTO DE GUNSIGHT VERSUS EL PROCEDIMIENTO DE JARETA, PARA EL CIERRE DE HERIDAS, DESPUéS DE REVERSIóN DE ESTOMA: UN ENSAYO, MULTICéNTRICO, PROSPECTIVO Y RANDOMIZADO: La reversión de estoma está asociada con un alto riesgo de infección de la herida. Las técnicas de gunsight y de jareta, son eficaces alternativas en la reversión de estoma, pero faltan estudios comparativos.Comparar el procedimiento de gunsight con la técnica de jareta, después de la reversión de estoma en asa.Estudio multicéntrico, prospectivo y randomizado ciego (NCT02053948).Realizado en la unidad de cirugía general, de siete centros médicos académicos terciarios.Se incluyeron en el estudio, un total de 143 pacientes sometidos a reversión de estoma de asa (72 en el grupo de gunsight y 71 en el grupo de jareta) entre noviembre de 2013 y diciembre de 2017.Los pacientes fueron asignados aleatoriamente, para someterse a un procedimiento de cierre de gunsight o de jareta.El resultado primario fue el tiempo de cicatrización de la herida. Los resultados secundarios fueron la incidencia de infección del sitio quirúrgico, morbilidad y satisfacción del paciente.No se encontraron diferencias entre los dos grupos en términos de infección del sitio quirúrgico, pérdida de sangre intraoperatoria o estadía hospitalaria postoperatoria. El procedimiento de gunsight tuvo un tiempo más corto en la cicatrización de la herida, en comparación con el procedimiento de jareta (17 días frente a 25 días, p <0,001). Un cuestionario de satisfacción del paciente, mostró que el grupo de gunsight tenía una puntuación más alta en relación al tiempo de cicatrización de la herida (p <0.001) y la puntuación total en satisfacción del paciente (p = 0.01), que en el grupo de jareta.Los equipos de tratamiento quirúrgico, no fueron cegados y hubo en los cirujanos, dependencia en las técnicas.Las técnicas de gunsight y de jareta son procedimientos efectivos para la reversión de estoma y ambas tienen una baja incidencia de infección en el sitio quirúrgico. La técnica de gunsight está asociada con un tiempo más corto en cicatrización de heridas, mejores niveles en satisfacción del tiempo de cicatrización y en la puntuación general final. Se recomienda como la técnica de cierre de elección. Consulte Video Resumen en http://links.lww.com/DCR/B319. (Traducción-Dr Fidel Ruiz Healy).

Early versus late closure of temporary ileostomy after rectal cancer surgery: a meta-analysis

The complications caused by early closure (EC) or late closure (LC) after temporary ileostomy in rectal cancer patients have not been compared systematically. We conducted this meta-analysis to explore the details surrounding this issue, based on a search of PubMed, ScienceDirect, Scopus, Web of Science, Ovid MEDLINE, the Cochrane Library, Embase, and Google Scholar. The comparative indices included total complications, severe complications, and various individual complications before or after closure. Four randomized-controlled trials (RCTs), including the EASY trial, were analyzed, involving a collective total of 324 patients. EC tended to result in more postoperative complications than LC for rectal cancer patients with temporary ileostomy. This difference was mainly embodied in wound complications. Nevertheless, LC resulted in more complications than EC before closure, such as leakage outside the appliance bag and skin irritation. There was no obvious difference in severe postoperative complications or medical complications. With fewer overall and wound-related complications, LC tended to be more suitable than EC for rectal cancer patients with a temporary ileostomy; however, the complications before closure should also be considered.

Evidence-based adoption of purse-string skin closure for stoma wounds

Background

Opinion is divided on the optimal technique of skin closure after stoma reversal as most conventional techniques compromise either on speed/neatness of wound apposition or on the incidence of surgical site infection (SSI). Evidence suggests that purse-string skin closure (PSSC) may achieve both objectives. This study aims to compare conventional primary closure (PC) with PSSC to determine the efficacious technique for stoma wound closure.

Methods

Patients undergoing stoma reversal between April 2015 and September 2017 were prospectively studied. Patients were divided into two groups based on the technique of skin closure (PC or PSSC). The following parameters were assessed: SSI, hospital stay, additional outpatient visit, wound healing time and patient satisfaction based on a standardised questionnaire.

Results

Forty one patients underwent stoma reversal (20 PSSC vs 21 PC). Wound infection, need for wound care, length of hospital stay, healing time and scar size were significantly less, whereas average patient wound satisfaction scores were significantly more in the PSSC group.

Conclusion

Purse-string skin closure (PSSC) proves efficacious and hence merits adoption as the technique of choice for closure of stoma wounds.

The effectiveness of negative-pressure wound therapy for wound healing after stoma reversal: a randomised control study (SR-PICO study)

BACKGROUND

Although the wound-healing period for purse-string closure (PSC) after stoma reversal is longer than that required for the primary closure method, the rate of wound infection is reduced. The application of negative-pressure wound therapy (NPWT) can reduce the healing period for many types of wounds. Herein, we describe a planned trial to test the hypothesis that NPWT can reduce the healing period for PSC after stoma reversal.

METHODS/DESIGN

Patients undergoing stoma reversal will be recruited and allocated into intervention and control groups, with 1:1 randomisation. Patients in the control group will receive standard postsurgical wound care; patients in the intervention group will receive NPWT using the PICO™ system. The target sample size will be 38 patients, as this will provide 80% power at the 5% level of significance to detect a 7-day reduction in the wound-healing period in the intervention group compared to that in the control group. The primary endpoint will be the duration to wound healing, defined as the time to nearly complete epithelisation of the wound, without any discharge or surgical site infection (SSI). Secondary endpoints will be the SSI rate, length of postoperative hospital stay, number of wound dressings and visits to the hospital for wound dressing after discharge, total cost of wound dressings, and patient and observer scar assessment scale scores.

DISCUSSION

The results of this planned randomised controlled study will clarify the role of NPWT in patients undergoing stoma reversal and strengthen the rationale for choosing a dressing technique.

TRIAL REGISTRATION

Clinical Research Information Service (CRIS), KCT0004063. Registered on 6 June 2019.

Factors affecting the morbidity and mortality of diverting stoma closure: retrospective cohort analysis of twelve-year period

Background Diverting stoma is often performed in rectal cancer surgery for reducing the consequences of possible anastomotic failure. Closing of stoma follows in most cases after a few months. The aim of our study was to evaluate morbidity and mortality after diverting stoma closure and to identify risk factors for complications of this procedure. Patients and methods At our department, we have performed a retrospective cohort analysis of data for 260 patients with diverting stoma closure from 2003 to 2015. Age, stoma type, patient's preoperative ASA score, surgical technique and time to stoma closure were investigated as factors which could influence the complication rate. Results 218 patients were eligible for investigation. Postoperative complications developed in 54 patients (24.8%). Most common complications were postoperative ileus (10%) and wound infection (5%). Four patients died (1.8%). There was no effect on complication rate regarding type of stoma, closing technique, patient's ASA status and patient age. The only factor influencing the complication rate was the time to stoma closure. We found that patients which had the stoma closed prior to 8 months after primary surgery had lower overall complication rate (p<0. 05). Conclusions To reduce overall complication rate, our data suggest a shorter period than 8 months after primary surgery before closure of diverting stoma. As diverting stoma closure is not a simple operation, all strategies should be taken to reduce significant morbidity and mortality rate.

The Effectiveness of Contralateral Drainage in Reducing Superficial Incisional Surgical Site Infection in Loop Ileostomy Closure: Prospective, Randomized Controlled Trial

BACKGROUND

Loop ileostomy reduces the rates of morbidity due to colorectal anastomotic dehiscence. For its part, ileostomy closure is associated with low mortality (0-4%) but substantial morbidity (11-37%). Incisional surgical site infection (SSI) is one of the most frequent complications (2-40%).

METHODS

A single-center, prospective, randomized controlled clinical trial of two study groups: control (conventional primary skin closure) and experimental (primary skin closure with a contralateral Penrose^® drain).

RESULTS

Seventy patients undergoing loop ileostomy closure between April 2013 and June 2017 were included (35 per branch). Four were later removed from the study. Six of the remaining 66 patients (per protocol analysis) were diagnosed with incisional SSI (9.1%); there were no statistically significant differences between the two groups (control group: 9.7%; experimental group: 8.6%) or between the risk factors associated with incisional SSI. Rates of overall and relevant morbidity (Clavien ≥ III) were considerable (28.1% and 9.1%, respectively), and there were no statistically significant differences between the two groups. No patients died.

CONCLUSION

Contralateral drainage does not significantly affect the results of primary ileostomy closure. The rate of incisional SSI was similar in the drainage and non-drainage groups, and the overall rate of 9.1% was in the low range of those reported in the literature. The absence of mortality (0%) and the non-negligible rates of overall and relevant morbidity (28.1% and 9.1%, respectively) in our series suggest that loop ileostomy is a safe procedure. However, the bowel reconstruction involves risks that must be borne in mind.

CLINICAL TRIAL REGISTRATION

The study was registered and approved by the clinical research ethics committee of the study center (reference number 2012076). Clinical trial was registered in ClinicalTrial.gov (identification number NCT02574702 and reference: ILEOS-ISS_2013).

Purse-string skin closure versus linear skin closure techniques in stoma closure: a comprehensive meta-analysis with trial sequential analysis of randomised trials

OBJECTIVES

To compare purse-string skin closure (PSC) and linear skin closure (LSC) techniques in patients undergoing stoma closure METHODS: We conducted a systematic review of literature and meta-analysis of outcomes according to PRISMA statement standards to compare PSC and LSC techniques in stoma closure. Trial sequential analysis (TSA) was performed to assess the possibility of type I or II error and compute the information size required for conclusive meta-analysis.

RESULTS

We identified six randomised controlled trials (RCTs) and eight observational studies, enrolling a total of 1102 patients. The included populations in the PSC and LSC groups were comparable in terms of baseline characteristics. The risk of surgical site infection (SSI) was significantly lower in the PSC group (OR 0.10; 95% CI 0.06, 0.18; P < 0.00001). There was no difference between the two groups in terms of operative time (MD 1.80; 95% CI - 1.35, 4.96; P = 0.26), anastomotic leak (OR 0.73; 95% CI 0.21, 2.48; P = 0.61), incisional hernia (OR 0.59; 95% CI 0.25, 1.37; P = 0.22), small bowel obstruction (OR 0.96, 95% CI 0.50, 1.86; P = 0.91), and length of hospital stay (MD - 0.04; 95% CI - 0.51, 0.42; P = 0.86). Patient satisfaction was higher in the PSC group. TSA showed that the risk of type 1 error was minimal and meta-analysis was conclusive.

CONCLUSIONS

PSC is associated with significantly lower risk of SSI and better patient satisfaction compared with LSC in closure of stomas and should be the closure technique of choice. The current available evidence is robust and conclusive highlighting that the results of the current study should be incorporated into clinical practice without a need for further trial data.

The effect of purse-string approximation versus linear approximation of ileostomy reversal wounds on morbidity rates and patient satisfaction: the 'STOMA' trial

BACKGROUND

Ileostomy reversal is associated with surgical site infection (SSI) rates as high as 37%. Recent literature suggests that employing a purse-string approximation (PSA) of the reversal wound reduces this rate of SSI. Thus we wished to perform a randomised controlled trial to compare SSI rates in purse-string versus linear closure (PLC) wounds following ileostomy reversal.

METHODS

A randomised, controlled trial was conducted at University Hospital Limerick. Sixty-one patients undergoing ileostomy reversal were included. Thirty-four patients were randomised to PSA and 27 patients to linear closure. The primary endpoint was incidence of SSI and secondary endpoints measured were quality of life and satisfaction with cosmesis. Statistical analysis was performed on a per protocol basis using SPSS version 22.0.

RESULTS

Three patients in the PSA group developed an SSI compared to 8 in the PLC group at 30 days (8 vs 30%, p = 0.03). The mean time to SSI diagnosis was faster in the PSA group (3 vs 12.3 days, p = 0.08). Patients who developed SSI experienced a longer mean length of stay (6.8 vs 11.4 days, p = 0.012). On multivariate analysis, PLC was the only predictive factor of SSI formation (p < 0.001). There was no difference in patient satisfaction between the two study groups (p = 0.14).

CONCLUSIONS

PSA of wounds following ileostomy reversal significantly reduces SSI formation compared to linear approximation without any effect on patient satisfaction.

Risk factors for surgical site infection after stoma closure comparison between pursestring wound closure and conventional linear wound closure: Propensity score matching analysis

PURPOSE

Stoma closure has been associated with a high rate of surgical site infection (SSI) and the optimal skin closure method is still controversial. The aim of this study was to compare the short-term and long-term outcomes between the conventional linear closure (CC) and the persestring closure (PC) using propensity score matching analysis.

METHODS

We analysed the data of 360 patients who underwent stoma closure with CC or PC between January 2000 and December 2014. The propensity score was calculated from age, gender, body mass index, primary disease, type of stoma, diabetes mellitus, history of smoking, steroid use, the American Society of Anesthesiologists score, Prognostic Nutritional Index and modified Glasgow Prognostic Score.

RESULTS

There was no difference in operative variables between the two groups. The CC group and the PC group were comparable with regards to overall SSI (25.0 vs. 7.8%; P = 0.007), superficial SSI (21.9 vs. 4.7%; P = 0.003). Significant risk factor for SSI was conventional linear closure (OR, 4.14; 95% CI, 1.448-13.91).

CONCLUSION

Our study suggests that a pursestring stoma closure leads to less SSI.

Considerations in Stoma Reversal

Temporary stomas are frequently used in the management of diverticulitis, colorectal cancer, and inflammatory bowel disease. These temporary stomas are used to try to mitigate septic complications from anastomotic leaks and to avoid the need for reoperation. Once acute medical conditions have improved and after the anastomosis has been proven to be healed, stomas can be reversed. Contrast enemas, digital rectal examination, and endoscopic evaluation are used to evaluate the anastomosis prior to reversal. Stoma reversal is associated with complications including anastomotic leak, postoperative ileus, bowel obstruction, enterocutaneous fistula, and, most commonly, surgical site infection. Furthermore, many stomas, which were intended to be temporary, may not be reversed due to postoperative complications, adjuvant therapy, or prohibitive comorbidities.

Temporary Diverting Ileostomy via the Umbilicus: a Small Case Series

The umbilicus, a natural orifice, which is used as an access port during laparoscopic surgery, can be used as a stoma site with potential superior cosmetic results as one less incision is then required. Our objective was to assess the efficacy and safety of the umbilical stoma in a selected group of patients. This is a prospective case series in hospital patients admitted as emergency or elective. Patients who underwent laparoscopic colorectal surgery with a planned ileostomy at Box Hill Hospital were approached and invited to participate in the study, with the stoma being fashioned on the umbilicus. Outcomes of interest included demographics, the details regarding the original indication for operation, operative and hospital related outcomes, postoperative bowel related complications, and other surgical and medical complications. Outcomes of a total of 10 (5 males) patients who underwent umbilical covering ileostomy during the study period were analyzed. Two patients with ulcerative colitis had the second stage of their operation converting their end stomas to loop stoma. These were counted twice, totaling 12 stomas in 10 patients. Three patients had their umbistomas after receiving neoadjuvant treatment for rectal cancer. The median period patients have had umbistomas is 113 days. Overall morbidity during the initial operation was low, except for 1 patient who had a small bowel injury. There was no mortality. Minor peristomal skin changes were the most common postoperative complication. Three patients had their stomas reversed with excellent cosmesis. Umbistomas appear to be a safe and effective way to fashion covering stomas post laparoscopic surgery and save the patient an added incision with excellent cosmetic results.

Subcutaneous vacuum drains reduce surgical site infection after primary closure of defunctioning ileostomy

PURPOSE

Surgical site infection (SSI) is the most common complication after primary closure of defunctioning ileostomy. We use a subcutaneous vacuum drain (SVD) in our institution to prevent infection. This study aimed to analyze the risk factors of SSI and to assess the utility of an SVD for preventing SSI in patients undergoing primary closure of ileostomy.

METHODS

Patients undergoing ileostomy closure in the Department of Colorectal Surgery, Peking University Cancer Hospital, from September 2006 to March 2013, were included in this study. The clinical features of these patients with or without a subcutaneous drain were reviewed, and the complication rate of SSI was analyzed. The primary endpoints were the incidence and risk factors of SSI, and the secondary endpoints were the rate of overall complications and their management.

RESULTS

A total of 245 consecutive patients were enrolled in the study. The overall incidence of SSI was 8.6%. Eighty-five (34.7%) patients received placement of an SVD. The use of SVDs was associated with a significantly lower incidence of SSI compared with primary closure (PC) without an SVD (1.2 vs. 12.5%, p = 0.001). Multivariate analyses showed that the presence of an SVD (odds ratio (OR) 0.063, p = 0.012), total operation time >90 min (OR 4.862, p = 0.002), and postoperative complications (OR 10.576, p < 0.001) were independent risk factors of SSI.

CONCLUSIONS

This study shows that an SVD is effective for reducing SSI in patients undergoing PC of ileostomy. Further randomized trials are required to confirm our findings and to compare SVDs with purse-string sutures.

Clinical trial on the incidence of wound infection and patient satisfaction after stoma closure: comparison of two skin closure techniques

PURPOSE

Surgical site infection (SSI) is one of the most common complications that can occur after stoma closure. Reports have described differences in the incidence of wound infection depending on the skin closure technique, but there is no consensus on the ideal closure technique for a stoma wound. The aim of this study was to compare the incidence of SSI and the patient satisfaction between a circumferential purse-string approximation (CPA) and a primary linear closure (PC) of a stoma wound.

METHODS

This prospective nonrandomized trial enrolled 48 patients who underwent a stoma closure from February 2010 to October 2013. Patients were divided into two groups according to the stoma closing technique: the CPA group (n = 34) and the PC group (n = 14). The incidences of SSI for the two groups were compared, and the patients' satisfaction with the stoma closure was determined by using a questionnaire.

RESULTS

SSI occurred in 3 of 48 patients (6.3%) and was more frequent in the PC group than in the CPA group (3/14 [21.4%] vs. 0/34 [0%], P = 0.021). Time to complete healing after stoma closure in the CPA group was 32 days (range, 14-61 days). Patients in the CPA group were more satisfied with the resulting wound scar (P = 0.043).

CONCLUSION

After stoma closure, CPA was associated with a significantly lower incidence of wound infection and greater patient satisfaction compared to PC. However, with the CPA technique, the time to heal is longer than it is with PC.

Comparison of surgical techniques for stoma closure: A retrospective study of purse-string skin closure versus conventional skin closure following ileostomy and colostomy reversal

The aim of this study was to compare the incidence of postoperative complications, including superficial incisional surgical site infection (SSI) following purse-string skin closure (PS) and conventional skin closure with a drainage tube (CD) following stoma closure. A total of 55 consecutive patients who underwent loop colostomy and loop ileostomy closures in our hospital between October, 2011 and September, 2014 were retrospectively assessed. The patients were divided into two groups, namely the PS group (26 patients) and the CD group (29 patients). There were no significant differences in the characteristics of the patients between the two groups. The baseline and operative characteristics also did not differ significantly between the two groups. However the incidence of superficial incisional SSI was lower in the PS group compared to that in the CD group (0 vs. 13.8%, respectively; P=0.049). The overall incidence of complications did not differ significantly between the two groups (P=0.313). The duration of postoperative hospital stay in the PS group was shorter compared to that in the CD group. In conclusion, the results of this study suggest that PS may an effective technique to reduce the incidence of superficial incisional SSI. This technique appears to be superior to the conventional technique, allowing for better cosmesis.

Pursestring closure of the stoma site leads to fewer wound infections: results from a multicenter randomized controlled trial

BACKGROUND

Surgical site infection after stoma reversal is common. The optimal skin closure technique after stoma reversal has been widely debated in the literature.

OBJECTIVE

We hypothesized that pursestring near-complete closure of the stoma site would lead to fewer surgical site infections compared with conventional primary closure.

DESIGN

This study was a parallel prospective multicenter randomized controlled trial.

SETTINGS

This study was conducted at 2 university medical centers.

PATIENTS

Patients (N = 122) presenting for elective colostomy or ileostomy reversal were selected.

INTERVENTIONS

Pursestring versus conventional primary closure of stoma sites were compared.

MAIN OUTCOME MEASURES

Stoma site surgical site infection within 30 days of surgery, overall surgical site infection, delayed healing (open wound for >30 days), time to wound epithelialization, and patient satisfaction were the primary outcomes measured.

RESULTS

The pursestring group had a significantly lower stoma site infection rate (2% vs 15%, p = 0.01). There was no difference in delayed healing or patient satisfaction between groups. Time to epithelialization was measured in only 51 patients but was significantly longer in the pursestring group (34.6 ± 20 days vs 24.1 ± 17 days, p = 0.02).

LIMITATIONS

This study was limited by the variability in procedures and surgeons, the limited follow-up after 30 days, and the inability to perform blinding.

CONCLUSION

Pursestring closure after stoma reversal has a lower risk of stoma site surgical site infection than conventional primary closure, although wounds may take longer to heal with the use of this approach.

REGISTRATION NUMBER

NCT01713452 (www.clinicaltrials.gov).

Circular closure is associated with the lowest rate of surgical site infection following stoma reversal: a systematic review and multiple treatment meta-analysis

AIM

Stoma reversal is frequently complicated by surgical site infection (SSI). To reduce SSI, several techniques for skin closure have been studied, with no agreement on which is best. The aim of this study was to identify the skin closure technique associated with the lowest rate of SSI following stoma reversal.

METHOD

We systematically searched MEDLINE (PubMed and OvidSP), Scopus and clinical registries from 1 January 1980 to 24 March 2012, and included original reports on adult patients following stoma reversal. A network of treatments was created to map the comparisons between skin closure techniques, including primary closure, primary closure with a drain, secondary closure, delayed primary closure, loose primary closure and circular closure. Pairwise meta-analyses were performed for all available direct comparisons of closure types and heterogeneity was assessed. A multiple-treatments meta-analysis was conducted to estimate relative treatment effects between competing closure types (reported as an odds ratio with 95% credible interval, and a probability that each treatment is best). Several sensitivity analyses were performed.

RESULTS

Fifteen studies were identified with a total of 2921 cases of stoma reversal. Overall, study quality was poor with observed low (one study), moderate (seven studies) and high (seven studies) risk of bias. Circular closure was associated with the lowest SSI risk (OR 0.12; 95% CI 0.02-0.40) and was the best of six skin closure techniques (probability of being best = 68.9%). Circular closure remained the best after sensitivity analyses.

CONCLUSION

This study showed that circular closure is the best skin closure technique after stoma reversal in terms of SSI rate, but the quality of supporting evidence is limited, precluding definite conclusions.

The use of purse-string skin closure in loop ileostomy reversals leads to lower wound infection rates--a single high-volume centre experience

PURPOSE

Wound infections affect not only the individual patient but lead to an increase in medical costs. After ileostomy reversal, surgical site infections are a common problem. The objective of the study was to compare the infection rates of purse-string and conventional skin closure techniques in a high volume setting.

METHODS

Patients undergoing ileostomy reversal at the Goethe University Hospital between January 2009 and August 2012 were retrospectively analysed regarding surgical site infections and associated risk factors. Patients received either conventional skin closure (running, interrupted or stapled suturing; group C) or subcuticular purse-string suture (group PS).

RESULTS

In total, 114 patients have been analysed. Conventional wound closure was performed in 81 patients and 33 patients received purse-string skin closure. The groups did not differ regarding age, gender, indication for ileostomy, previous chemotherapy, and operation time. Median hospital stay was 7 days (3-34) in group PS and 8 (3-53) in group C (p = 0.15). Wound infections only occurred in groups C (n = 10, 12 %) compared to group PS (n = 0; 0 %; p = 0.034), and the wound closure technique was the only significant factor associated with surgical site infection. Surgery performed by a resident under supervision was not a risk factor for complications compared to the procedure done by a senior surgeon (p = 0.73).

CONCLUSION

This study reveals an advantage of the purse-string skin closure technique in ileostomy reversals analysing a large cohort of patients. Therefore, we recommend the use of the purse-string skin closure in ileostomy reversals as one way to lower wound infection rates.

A beneficial effect of purse-string skin closure after ileostomy takedown: a retrospective cohort study

OBJECTIVES

The aim of this study was to investigate the clinical benefits of purse-string skin closure (PS) in daily practice compared with conventional linear skin closure (CL) after ileostomy takedown in Korean population.

METHODS

These retrospectively collected data were based on 157 consecutive patients who underwent ileostomy takedown between November 2010 and September 2011. Before March, 2011, CL was performed in 79 patients. Thereafter, PS was performed in 78 patients. The medical records including pain score recorded daily were reviewed and the postoperative outcomes, including SSI, were analyzed.

RESULTS

PS group had a significantly lower overall complication rate than the CL group (8.97% vs. 25.32%, p = 0.010). Among complications, PS group had a significantly lower SSI rate than the CL group (0% vs. 11.39%, p = 0.003). After adjusted for other risk factors (smoking, body mass index, anastomosis method), PS method was associated significantly and independently with a lower SSI rate than CL method (adjusted odds ratio: 26.63, 95% confidence interval: 3.02-267.70, p = 0.001). And the two groups did not differ in terms of postoperative pain (p = 0.323) or pain pattern (p = 0.548).

CONCLUSION

In daily practice, PS had a beneficial effect on SSI in patients who underwent ileostomy takedown in the Korean population.

Prevalence of surgical site infection at the stoma site following four skin closure techniques: a retrospective cohort study

BACKGROUND/AIMS

Surgical site infection (SSI) is a common complication of stoma reversal. Studies have suggested that different skin closures affect SSI rates. Our aim was to determine which skin closure technique following stoma reversal leads to the lowest rate of SSI.

METHODS

We conducted a retrospective review of all adult patients undergoing stoma reversal at a single institution (2005-2011) and compared the rate of SSI following four skin closure techniques: primary closure (PC), secondary closure (SC), loose PC (LPC), and circular closure (CC). Univariate analysis included χ(2) or Fisher's exact test and ANOVA or Kruskal-Wallis H test for categorical and continuous data, respectively. A multivariate logistic regression model was created to identify predictors of SSI.

RESULTS

One hundred and forty-six patients were identified: 40 (27%) PC, 68 (47%) SC, 20 (14%) LPC, and 18 (12%) CC. CC was less likely to have SSI (6%) compared to PC (43%), SC (16%), and LPC (15%; p < 0.01). Increasing body mass index was a predictor of SSI (odds ratio 1.11, 95% confidence interval 1.04-1.12, p < 0.01). CC was associated with the lowest odds of developing SSI [0.07 (0.01-0.63), p = 0.02].

CONCLUSIONS

SSI rate was the lowest for stomas that were closed with CC.

Does primary closure increase surgical site infection after intestinal stoma reversal? A retrospective cohort study

BACKGROUND

This study was undertaken to test the veracity of the hypothesis that primary incision closure after intestinal stoma reversal in adult patients is associated with a greater risk of surgical site infection (SSI) than are open incisions.

METHODS

A retrospective cohort study was conducted at the Surgical Department of the Aga Khan University Hospital, Karachi, Pakistan. The study included adult patients who underwent elective loop and double-barreled intestinal stoma (ileostomy or colostomy) reversal through peristomal incisions between January 2005 and May 2011. Files were reviewed independently by two surgeons to establish main exposure (closed or open surgical sites) and outcome; i.e., SSI based on U.S. Centers for Disease Control and Prevention criteria.

RESULTS

Sample size calculation prior to the study required 71 patients to be included in each exposure arm. Patients with closed surgical sites were relatively younger (mean 36±15 [standard deviation] years) than those with open surgical sites (41±15 years), with a male preponderance in both groups. Fifteen patients were found to have SSI: 3/71 (4.2%) in open and 12/71 (16.9%) in closed incisions. The risk of SSI in closed surgical sites was 5.8 times greater than in open sites (95% confidence interval for relative risk 1.5-22.5) after adjusting for gender, body mass index (BMI), site of stoma, malignant disease, and preoperative chemo-radiotherapy.

CONCLUSION

The risk of SSI in closed incisions is greater than that in open incisions. It is suggested that incisions not be closed primarily in patients undergoing stoma reversal.

Influence of skin closure technique on surgical site infection after loop ileostomy reversal: retrospective cohort study

BACKGROUND

Intestinal stoma closure is associated with high risk of surgical site infection (SSI) at stoma reversal site. The aim of this retrospective cohort study was to determine the outcome of purse string approximation (PSA) compared to primary linear closure (PLC) of the skin after loop ileostomy reversal.

METHODS

Data of 140 patients operated between 2005 and 2012 were analyzed in this two-center-study to determine the outcome of patients with either PSA (n = 44) or PLC (n = 96) after loop ileostomy reversal.

RESULTS

Patients in the PSA group were significantly older than in the PLC group (64 ± 15 vs. 57 ± 18; p = 0.026). Cardiac diseases were significantly more present in the PSA group in comparison to the PLC group (59% vs. 38%; p = 0.017). Stoma creation was significantly more often due to malignancy in the PSA group in comparison to the PLC group (68% vs. 50%; p = 0.044). SSI occurred significantly more often in the PLC group in comparison to the PSA group (17% vs. 5%; p = 0.047).

CONCLUSIONS

The risk for SSI is lower in patients with PSA in comparison to patients with PLC. In order to diminish SSI we recommend performing a PSA in patients with loop ileostomy reversal.

Randomized controlled trial: comparison of two surgical techniques for closing the wound following ileostomy closure: purse string vs direct suture

AIM

Surgical site infection (SSI) is a common complication following ileostomy closure with a frequency of up to 40%. This prospective randomized controlled trial was initiated to compare two surgical techniques - direct suture (DS) and purse-string suture (PSS) - used to close the wound following ileostomy closure. The primary end-point was the SSI rate. Secondary end-points were cosmetic outcome [using two validated scales: the Patient and Observer Scar Assessment Scale (POSAS) and the Body Image Questionnaire (BIQ)] and the influence of other factors on the SSI rate.

METHOD

Of a total of 99 patients screened, 84 were included in this study. Forty-three patients were randomized into the PSS group and 41 were randomized into the DS group. Follow up was performed within 3 days after surgery, at discharge, and 30 days and 6 months after the operation.

RESULTS

In the PSS group there were no cases of SSI compared with 10 (24%) cases in the DS group (P = 0.0004). There were no statistically significant differences in cosmetic outcome between the two groups. No other statistically significant factors influencing the incidence of SSI could be identified.

CONCLUSION

The rate of SSI is significantly lower following PSS than following DS, and both techniques have a similar cosmetic outcome. PSS closure should be considered as standard of care for wound closure after ileostomy reversal.

Randomized clinical trial of intestinal ostomy takedown comparing pursestring wound closure vs conventional closure to eliminate the risk of wound infection

BACKGROUND

The use of temporary stomas has been demonstrated to reduce septic complications, especially in high-risk anastomosis; therefore, it is necessary to reduce the number of complications secondary to ostomy takedowns, namely wound infection, anastomotic leaks, and intestinal obstruction.

OBJECTIVE

To compare the rates of superficial wound infection and patient satisfaction after pursestring closure of ostomy wound vs conventional linear closure.

DESIGN

Patients undergoing colostomy or ileostomy closure between January 2010 and February 2011 were randomly assigned to linear closure (n = 30) or pursestring closure (n = 31) of their ostomy wound. Wound infection within 30 days of surgery was defined as the presence of purulent discharge, pain, erythema, warmth, or positive culture for bacteria. Patient satisfaction, healing time, difficulty managing the wound, and limitation of activities were analyzed with the Likert questionnaire.

RESULTS

The infection rate for the control group was 36.6% (n = 11) vs 0% in the pursestring closure group (p < 0.0001). Healing time was 5.9 weeks in the linear closure group and 3.8 weeks in the pursestring group (p = 0.0002). Seventy percent of the patients with pursestring closure were very satisfied in comparison with 20% in the other group (p = 0.0001).

LIMITATIONS

This study was limited by the heterogeneity in the type of stoma in both groups.

CONCLUSION

The pursestring method resulted in the absence of infection after ostomy wound closure (shorter healing time and improved patient satisfaction).