Skip to main content

Advertisement

SpringerLink
Log in

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

  • Review
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Kaidar-Person O, Person B, Wexner SD (2005 Nov) Complications of construction and closure of temporary loop ileostomy. J Am Coll Surg 201(5):759–773

    Article  PubMed  Google Scholar 

  2. Hackam DJ, Rotstein OD (1995) Stoma closure and wound infection: an evaluation of risk factors. Can J Surg 38:144–148

    PubMed  CAS  Google Scholar 

  3. Wong KS, Remzi FH, Gorgun E, Arrigain S, Church JM, Preen M, Fazio VW (2005) Loop ileostomy closure after restorative proctocolectomy: outcome in 1,504 patients. Dis Colon Rectum 48:243–250

    Article  PubMed  Google Scholar 

  4. McGrath DR, Leong DC, Armstrong BK, Spigelman AD (2004) Management of colorectal cancer patients in Australia: the National Colorectal Cancer Care Survey. ANZ J Surg 74:55–64

    Article  PubMed  Google Scholar 

  5. Banerjee A (1997) Pursestring skin closure after stoma reversal. Dis Colon Rectum 40:993–994

    Article  PubMed  CAS  Google Scholar 

  6. Vermulst N, Vermeulen J, Hazebroek EJ, Coene PP, van der Harst E (2006) Primary closure of the skin after stoma closure. Management of wound infections is easy without (long-term) complications. Dig Surg 23:255–258

    Article  PubMed  CAS  Google Scholar 

  7. Lahat G, Tulchinsky H, Goldman G, Klauzner JM, Rabau M (2005) Wound infection after ileostomy closure: a prospective randomized study comparing primary vs. delayed primary closure techniques. Tech Coloproctol 9:206–208

    Article  PubMed  CAS  Google Scholar 

  8. Chow A, Tilney HS, Paraskeva P, Jeyarajah S, Zacharakis E, Purkayastha S (2009) The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Color Dis 24:711–723

    Article  Google Scholar 

  9. Luglio G, Pendlimari R, Holubar SD, Cima RR, Nelson H (2011) Loop ileostomy reversal after colon and rectal surgery: a single institutional 5-year experience in 944 patients. Arch Surg 146:1191e6

    Article  Google Scholar 

  10. Khoo RE, Cohen MM, Chapman GM, Jenken DA, Langevin JM (1994) Loop ileostomy for temporary fecal diversion. Am J Surg 167:519e22

    Article  Google Scholar 

  11. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700

    Article  PubMed  PubMed Central  Google Scholar 

  12. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/nos_manual.pdf. Accessed 29 April 2017

  13. Sureshkumar S, Jubel K, Ali MS, Vijayakumar C, Amaranathan A, Sundaramoorthy S, Palanivel C (2018 Feb 11) Comparing surgical site infection and scar cosmesis between conventional linear skin closure versus purse-string skin closure in stoma reversal—a randomized controlled trial. Cureus 10(2):e2181

    PubMed  PubMed Central  Google Scholar 

  14. O'Leary DP, Carter M, Wijewardene D, Burton M, Waldron D, Condon E et al (2017) The effect of purse-string approximation versus linear approximation of ileostomy reversal wounds on morbidity rates and patient satisfaction: the ‘STOMA’ trial. Tech Coloproctol 21(11):863–868

    Article  PubMed  CAS  Google Scholar 

  15. Alvandipour M, Gharedaghi B, Khodabakhsh H, Karami MY (2016 Aug) Purse-string versus linear conventional skin wound closure of an ileostomy: a randomized clinical trial. Ann Coloproctol 32(4):144–149

    Article  PubMed  PubMed Central  Google Scholar 

  16. Dusch N, Goranova D, Herrle F, Niedergethmann M, Kienle P (2013 Aug) Randomized controlled trial: comparison of two surgical techniques for closing the wound following ileostomy closure: purse string vs direct suture. Color Dis 15(8):1033–1040

    Article  CAS  Google Scholar 

  17. Camacho-Mauries D, Rodriguez-Díaz JL, Salgado-Nesme N, González QH, Vergara-Fernández O (2013) Randomized clinical trial of intestinal ostomy takedown comparing pursestring wound closure vs conventional closure to eliminate the risk of wound infection. Dis Colon Rectum 56(2):205–211

    Article  PubMed  Google Scholar 

  18. Reid K, Pockney P, Pollitt T, Draganic B, Smith SR (2010) Randomized clinical trial of short-term outcomes following purse-string versus conventional closure of ileostomy wounds. Br J Surg 97(10):1511–1517

    Article  PubMed  CAS  Google Scholar 

  19. Yoon SI, Bae SM, Namgung H, Park DG (2015) Clinical trial on the incidence of wound infection and patient satisfaction after stoma closure: comparison of two skin closure techniques. Ann Coloproctol 31(1):29–33

    Article  PubMed  PubMed Central  Google Scholar 

  20. Wada Y, Miyoshi N, Ohue M, Noura S, Fujino S, Sugimura K et al (2015) Comparison of surgical techniques for stoma closure: a retrospective study of purse-string skin closure versus conventional skin closure following ileostomy and colostomy reversal. Mol Clin Oncol 3(3):619–622

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  21. Habbe N, Hannes S, Liese J, Woeste G, Bechstein WO, Strey C (2014) The use of purse-string skin closure in loop ileostomy reversals leads to lower wound infection rates—a single high-volume centre experience. Int J Color Dis 29(6):709–714

    Article  Google Scholar 

  22. Suh YJ, Park JW, Kim YS, Park SC, Oh JH (2014) A beneficial effect of purse-string skin closure after ileostomy takedown: a retrospective cohort study. Int J Surg 12(6):615–620

    Article  PubMed  Google Scholar 

  23. Klink CD, Wünschmann M, Binnebösel M, Alizai HP, Lambertz A, Boehm G, Neumann UP, Krones CJ (2013) Influence of skin closure technique on surgical site infection after loop ileostomy reversal: retrospective cohort study. Int J Surg 11(10):1123–1125

    Article  PubMed  CAS  Google Scholar 

  24. Lee JR, Kim YW, Sung JJ, Song OP, Kim HC, Lim CW, Cho GS, Jung JC, Shin EJ (2011) Conventional linear versus purse-string skin closure after loop ileostomy reversal: comparison of wound infection rates and operative outcomes. J Korean Soc Coloproctol 27(2):58–63

    Article  PubMed  PubMed Central  Google Scholar 

  25. Marquez TT, Christoforidis D, Abraham A, Madoff RD, Rothenberger DA (2010) Wound infection following stoma takedown: primary skin closure versus subcuticular purse-string suture. World J Surg 34(12):2877–2882

    Article  PubMed  Google Scholar 

  26. Milanchi S, Nasseri Y, Kidner T, Fleshner P (2009) Wound infection after ileostomy closure can be eliminated by circumferential subcuticular wound approximation. Dis Colon Rectum 52(3):469–474

    Article  PubMed  Google Scholar 

  27. Rondelli F, Franco L, Balzarotti Canger RC, Ceccarelli G, Becattini C, Bugiantella W (2018) Purse-string closure versus conventional primary closure of wound following stoma reversal: meta-analysis of randomized controlled trials. Int J Surg 52:208–213

    Article  PubMed  Google Scholar 

  28. Sajid MS, Bhatti MI, Miles WF (2015) Systematic review and meta-analysis of published randomized controlled trials comparing purse-string vs conventional linear closure of the wound following ileostomy (stoma) closure. Gastroenterol Rep (Oxf) 3(2):156–161

    Article  Google Scholar 

  29. McCartan DP, Burke JP, Walsh SR, Coffey JC (2013) Purse-string approximation is superior to primary skin closure following stoma reversal: a systematic review and meta-analysis. Tech Coloproctol 17(4):345–351

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of General Surgery, Royal Bolton Hospital, Bolton, UK

    Shahab Hajibandeh, Andrew Kennedy-Dalby, Sheik Rehman & Reza Arsalani Zadeh

  2. Department of General Surgery, North Manchester General Hospital, Manchester, UK

    Shahab Hajibandeh

  3. Department of General Surgery, Stepping Hill Hospital, Stockport, UK

    Shahin Hajibandeh

Authors
  1. Shahab Hajibandeh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shahin Hajibandeh
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andrew Kennedy-Dalby
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sheik Rehman
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Reza Arsalani Zadeh
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conception and design: Shahab H, RAZ

Data collection: Shahab H, Shahin H, AKD, SR

Analysis and interpretation: Shahab H, Shahin H

Writing the article: Shahab H

Critical revision of the article: all authors

Final approval of the article: all authors

Statistical analysis: Shahab H, Shahin H

Corresponding author

Correspondence to Shahab Hajibandeh.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

Not required.

Appendix

Appendix

Search no.

Search strategy†

#1

purse-string: TI,AB,KW

#2

purse string: TI,AB,KW

#3

#1 OR #2

#4

linear: TI,AB,KW

#5

conventional: TI,AB,KW,KW

#6

traditional: TI,AB,KW

#7

#4 OR #5 OR #6

#8

MeSH descriptor: [ileostomy] explode all trees

#9

ileostom*: TI,AB,KW

#10

MeSH descriptor: [colostomy] explode all trees

#11

colostom*: TI,AB,KW

#12

#8 OR #9 OR #10 OR #11

#13

#3 AND #7 AND #12

  1. †This search strategy was adopted for the following databases: MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hajibandeh, S., Hajibandeh, S., Kennedy-Dalby, A. et al. Purse-string skin closure versus linear skin closure techniques in stoma closure: a comprehensive meta-analysis with trial sequential analysis of randomised trials. Int J Colorectal Dis 33, 1319–1332 (2018). https://doi.org/10.1007/s00384-018-3139-y

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-018-3139-y

Keywords

Search

Navigation