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

Purse-string versus linear closure of the skin wound following stoma reversal: A meta-analysis with RCT and systematic review

BACKGROUND

Linear closure (LC) following stoma reversal is associated with a high risk of surgical site infection (SSI). Purse-string closure and LC were both positive for the closure of the skin wound following stoma reversal, and it was not yet possible to distinguish which one was more beneficial to the patient's prognosis.

METHODS

We conducted a search in Embase, PubMed, Web of Science, and Cochrane Library and conducted a randomized controlled experiment from the inception of each database to July 2024. Among them, the SSI within 30 days, operation time, hospitalization time, incisional hernia, and wound healing time were all outcome indicators.

RESULTS

Eleven studies were included in this meta-analysis (506 patients in the purse-string closure group and 489 patients in the LC group). The pooled data showed that the SSI rate was significantly lower in the purse-string closure group than in the LC group (odds ratio, 0.15; 95% confidence interval, 0.09-0.24; P < .00001; I2 = 0%). The differences in operative time, hospitalization time, incision hernia, and wound healing time were not statistically significant.

CONCLUSION

Overall, purse-string closure had a significantly lower SSI rate following stoma reversal than LC.

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.

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.

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.

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).

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).

Subcuticular Suturing with Closed Suction Drainage for Wound Closure Following Stoma Reversal

Incisional surgical site infection (SSI) is a leading complication of stoma reversal procedures. This retrospective study was conducted to assess the incidence of incisional SSI and other wound complications when wound closure was achieved by subcuticular suturing and closed suction drainage following stoma reversal. We analyzed data from a total of 49 patients, all of whom had undergone insertion of a 10 Fr closed suction drainage tube in the fascia, following irrigation with approximately 300 mL of physiological saline. We then performed subcuticular suturing with 4-0 monofilament absorbable sutures. The median age of our patient population (34 men and 15 women) was 68 (range, 35-84) years. Six patients had an end stoma and 43 had a loop stoma. The wound category was 'contaminated' in 18 patients, while an incisional SSI was observed in one patient (2.0%). No wound disruptions, seromas, or drain infections were evident. Our data are reliable, but our study is limited in terms of general applicability; however, the low SSI rate indicates that the procedure is acceptable. Further research into this procedure will require a randomized trial design.

Stomal Closure: Strategies to Prevent Incisional Hernia

Incisional hernias following ostomy reversal occur frequently. Incisional hernias at the site of a previous stoma closure can cause significant morbidity, impaired quality of life, lead to life-threatening hernia incarceration or strangulation and result in a significant financial burden on health care systems Despite this, the evidence base on the subject is limited. Many recognised risk factors for the development of incisional hernia following ostomy reversal are related to patient factors such as age, malignancy, diabetes, COPD, hypertension and obesity, and are not easily correctable. There is a limited amount of evidence to suggest that prophylactic mesh reinforcement may be of benefit to reduce the post stoma closure incisional hernia rate but a further large scale randomised controlled trial is due to report in the near future. There appears to be weak evidence to suggest that surgeons should favour circular, or "purse-string" closure of the skin following stoma closure in order to reduce the risk of SSI, which in turn may reduce incisional hernia formation. There remains the need for further evidence in relation to suture technique, skin closure techniques, mechanical bowel preparation and oral antibiotic prescription focusing on incisional hernia development as an outcome measure. Within this review, we discuss in detail the evidence base for the risk factors for the development of, and the strategies to prevent ostomy reversal site incisional hernias.

Purse-string closure versus conventional primary closure of wound following stoma reversal: Meta-analysis of randomized controlled trials

PURPOSE

Surgical site infection (SSI) is one of the most frequent complications after stoma closure and the optimal skin closure technique is still not clear. The goal of this review was to compare outcomes with purse-string closure technique (PSC) versus conventional closure technique (CCT) for skin closure after stoma reversal.

METHODS

We performed a systematic review and meta-analysis of available randomized controlled trials (RCTs) to compare SSI rate within 30 days, operative time, hospital stay, incisional hernia and intestinal obstruction rates between PSC and CCT.

RESULTS

The pooled analysis of 5 studies showed a statically significant lower rate of SSI in favor of PSC compared to CCT (OR -0.24; 95% CI -0.32, - 0.15; p < 0.00001). No statistically significant differences were observed in the operative time (OR -0.05; 95% CI -3.95, 3.84; p = 0.98) and in the length of hospital stay (OR -0.20; 95% CI -0.76, 0.36; p = 0.48), between the two techniques. Additionally, two out of the five studies provided data on incisional hernia and intestinal obstruction and the pooled analysis revealed no statistically significant differences between PSC and CCT techniques: incisional hernia (OR 0.81, 95% CI 0.27-2.47; p = 0.71) and intestinal obstruction (OR 1.07, 95% CI 0.41-2.84; p = 0.88).

CONCLUSIONS

The analysis of 5 RCTs showed that SSI rate is statistically significant lower when PSC is performed, compared to CCT. Whereas, no significant differences were found between the two techniques with regards to operative time, length of hospital stay, incisional hernia and intestinal obstruction rates.

Temporary closure of colostomy with suture before colostomy takedown improves the postoperative outcomes

PURPOSE

Temporary loop colostomy is a common surgical procedure used to avoid complications in high-risk distal anastomosis as well as pelvic inflammation. Issues regarding postoperative outcomes of colostomy takedown have been widely discussed in the literature, wound infection especially. Temporary closure of colostomy with suture before takedown was adopted in our study, which provided excellent traction to aid mobilization of stomy and avoided stool spillage to downgrade the wound classification to "clean contamination." We aimed to determine the effects of the procedure on postoperative outcomes.

METHODS

This was a prospective case-control study at a single tertiary medical center. Patients presenting for elective colostomy takedown were included. Allis clamp (n = 50) or silk suture (n = 60) was applied to mobilize the colostomy, and results were compared. Operative time and wound infection rate were measured as primary postoperative outcomes. Univariate and multivariate analyses were used to demonstrate the association between the two groups and outcomes.

RESULTS

In univariate analyses, significantly shorter operative time (median = 57 min, p = 0.003) and lower postoperative wound infection rate (3%, p = 0.03) were noted in the group receiving silk suture. Multivariate analyses results showed that silk suture was significantly associated with both operative time (B = - 8.5, p = 0.01) and wound infection (odds ratio = 0.18, p = 0.04).

CONCLUSION

With the advantage of enhancing traction and decreasing contamination, the temporary closure of colostomy with suture improved takedown outcomes, including a shorter operative time and lower wound infection rate.

THE VULKAN TECHNIQUE: A NOVEL OSTOMY-CLOSURE TECHNIQUE THAT REDUCES COMPLICATIONS AND OPERATIVE TIMES

BACKGROUND

Ostomy reversals remain at high risk for surgical complications. Indeed, surgical-side infections due to bacterial contamination of the stoma lead to revision surgery and prolonged hospital stay.

AIM

To describe the novel vulkan technique of ostomy reversal that aims to reduce operative times, surgical complications, and readmission rates.

METHODS

Ostomy closure was performed using the vulkan technique in all patients. This technique consists of external intestinal closure, circular skin incision and adhesiolysis, re-anastomosis, and closure of the subcutaneous tissue in three layers, while leaving a small secondary wound through which exudative fluid can be drained. The medical records of enterostomy patients were retrospectively reviewed from our hospital database.

RESULTS

The vulkan technique was successfully performed in 35 patients mainly by resident surgeons with <5 years of experience (n=22; 62.8%). The ileostomy and colostomy closure times were 53 min (interquartile range [IQR], 41-68 min; n=22) and 136 min (IQR: 88-188 min; n=13; p<0.001), respectively. The median hospital stay was seven days (IQR: 5-14.5 days); the length of hospital stay did not differ between ileostomy and colostomy groups. Major surgical complications occurred only in patients who underwent colostomy closure following the Hartmann procedure (n=2); grade≥IIIb according Clavien-Dindo classification.

CONCLUSION

The vulkan technique was successfully applied in all patients with very low rates of surgical-site infections. Off note, residents with limited surgical experience mainly performed the procedure while operating time was less than one hour.

Purse-String Versus Linear Conventional Skin Wound Closure of an Ileostomy: A Randomized Clinical Trial

Purpose

Infection is one of the most frequent complications that can occur after ileostomy closure. The incidence of wound infection depends on the skin closure technique, but there is no agreement on the perfect closure method for an ileostomy wound. The aim of this study was to evaluate the incidence of infection, the patient's approval, and the patient's pain between purse-string closure (PSC) and the usual linear closure (LC) of a stoma wound.

Methods

This randomized clinical trial enrolled 66 patients who underwent a stoma closure from February 2015 to May 2015 in Sari Emam Khomeini Hospital. Patients were divided into 2 groups according to the stoma closing method: the PSC group (n = 34) and the LC group (n = 32). The incidences of infection for the 2 groups were compared, and the patients' satisfaction and pain with the stoma were determined by using a questionnaire.

Results

Infection occurred in 1 of 34 PSC patients (2.9%) and in 7 of 32 LC patients (21.8%), and this difference was statistically significant (P = 0.021). Patients in the PSC group were more satisfied with the resulting wound scar and its cosmetic appearance at one month and three months after surgery (P = 0.043).

Conclusion

After stoma closure, PSC was associated with a significantly lower incidence of wound infection and greater patient satisfaction compared to LC. However, the healing period for patients who underwent PSC was longer than it was for those who underwent LC.

Pursestring Closure versus Conventional Primary Closure Following Stoma Reversal to Reduce Surgical Site Infection Rate: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Stoma reversal is a surgical procedure commonly used following temporary defunctioning stoma surgery. Surgical site infection is one of the most common postoperative morbidities. A few skin closure methods have been developed to decrease surgical site infection. However, the optimal skin closure method is still in debate.

OBJECTIVE

The aim of this study was to compare the surgical site infection rate and other postoperative outcomes between the pursestring closure and conventional primary closure techniques.

DATA SOURCES

We searched the MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for relevant trials.

STUDY SELECTION

We conducted a meta-analysis of randomized controlled trials that compared the surgical outcomes following pursestring closure and conventional primary closure techniques.

INTERVENTION

We conducted the meta-analysis by using the random-effects model.

MAIN OUTCOME MEASURES

The primary outcome of interest was surgical site infection following stoma reversal within 30 days after operation.

RESULTS

This meta-analysis included 4 randomized controlled trials with a total of 319 participants (162 in the pursestring closure group and 157 in the conventional primary closure group). Compared with the conventional primary closure group, the pursestring closure group had a significant decrease in surgical site infection (risk difference, -0.25; 95% CI, -0.36 to -0.15; p < 0.00001; number needed to treat = 4) and higher satisfaction with cosmetic outcomes (standard mean difference, 0.7; 95% CI, 0.13-1.27; p = 0.02). No other significant differences in operative time, length of hospital stay, and wound healing time were found between the 2 groups.

LIMITATIONS

This study was limited to the lack of double blinding and long-term follow-up in the included trials.

CONCLUSIONS

Pursestring closure has significantly fewer surgical site infections and achieves better cosmetic outcomes following stoma reversal than conventional primary closure.

Cost analysis of early versus delayed loop ileostomy closure: a case-matched study

BACKGROUND/AIMS

The optimal timing for the closure of loop ileostomies remains controversial. The aim of the current study was to investigate whether early ileostomy closure (EC) (<2 weeks post-formation) results in significant healthcare savings as against late closure (LC).

METHODS

Patients with available cost data that underwent EC between January 2008 and December 2012 were compared against matched patients undergoing LC during the same period. Direct hospital costs for the two groups were compared.

RESULTS

There were 42 EC patients and 61 LC patients. EC patients had significantly less ileostomy-related complications (p < 0.001) and hospital readmissions (p < 0.001). Operative time (p < 0.001) and operative cost (p = 0.002) were also both significantly less in the EC group. Community nursing costs favoured the LC group (p = 0.047). The EC group had an increased post-closure wound infection rate (p = 0.02). The mean total direct cost per patient was NZD 13,724 (SD NZD 3,736) for EC and NZD 16,728 (SD NZD 8,028) for LC. Representing an average costs saving of NZD 3,004 per patient favouring EC (p = 0.012).

CONCLUSION

Although EC increases the post-closure wound infection rate, EC reduces ileostomy complications, hospital readmissions and operative costs resulting in significant healthcare savings. In order to improve patient outcomes and make EC even more cost effective, efforts should be taken to reduce wound infections.

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).

Systematic review and meta-analysis of published randomized controlled trials comparing purse-string vs conventional linear closure of the wound following ileostomy (stoma) closure

Objective: The objective of this article is to systematically analyse the randomized, controlled trials comparing the effectiveness of purse-string closure (PSC) of an ileostomy wound with conventional linear closure (CLC).

Methods: Randomized, controlled trials comparing the effectiveness of purse-string closure vs conventional linear closure (CLC) of ileostomy wound in patients undergoing ileostomy closure were analysed using RevMan®, and the combined outcomes were expressed as risk ratio (RR) and standardized mean difference (SMD).

Results: Three randomized, controlled trials, recruiting 206 patients, were retrieved from medical electronic databases. There were 105 patients in the PSC group and 101 patients in the CLC group. There was no heterogeneity among included trials. Duration of operation (SMD: −0.18; 95% CI: −0.45, 0.09; z = 1.28; P < 0.20) and length of hospital stay (SMD: 0.01; 95% CI: −0.26, 0.28; z = 0.07; P < 0.95) was statistically similar following both approaches of ileostomy wound closure. The risk of surgical site infection (OR, 0.10; 95% CI: 0.03, 0.33; z = 3.78; P < 0.0001) was significantly reduced when ileostomy wound was closed using PSC technique.

Conclusion: PSC technique for ileostomy wound is associated with a reduced risk of surgical site infection apparently without influencing the duration of operation and length of hospital stay.