Effect of different skin closure techniques on postoperative complications of stoma reversal：a network meta-analysis_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

JIANG Weirong ¹ , WANG Rui ² , CAO Dong ³ , SUN Binjie ¹ , LI Yunfeng ¹ ,  YU Yongjiang ³

1. The First School of Clinical Medicine of Lanzhou University, Lanzhou 730030, P. R. China;
2. The Second School of Clinical Medicine of Lanzhou University, Lanzhou 730030, P. R. China;
3. Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730030, P. R. China;

Corresponding author：

YU Yongjiang, Email: ylongy@163.com

Keywords：

Surgical stomas; skin closure; biological mesh; postoperative infection; network meta-analysis

DOI：

10.7507/1007-9424.202106028

Video：

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Objective To compare the clinical effectiveness of different skin closure techniques in stoma reversal using network meta-analysis. Methods CNKI, WanFang Data, VIP, CBM, Cochrane Library, PubMed, Embase, and Web of Science databases were searched until February 1, 2021, and randomized controlled trials (RCTs) comparing outcomes between different skin closure techniques were included. Data were processed using Stata MP16.0 and R 3.6.1. Results The results demonstrated that 16 RCTs (n=2 139) were eligible for pooling. Six types of skin closure techniques were used: linear closure, purse-string closure, gunsight closure, linear closure and drainage, purse-string closure and drainage, and linear closure and biological mesh. Network meta-analysis indicated that the incidence of postoperative infection with linear closure was higher than that with purse-string closure [RR=6.04, 95%CI (3.11, 16.89), P<0.0001], gunsight closure [RR=10.75, 95%CI (1.12, 152.12), P=0.04], and linear closure and drainage [RR=3.18, 95%CI (1.24, 10.20), P=0.03]. The purse-string closure was superior to linear closure and biological mesh [RR=0.15, 95%CI (0.01, 0.88), P=0.03] in reducing postoperative infection. The length of hospital stay after linear suture was longer than that after linear suture and drainage [MD=1.16, 95%CI (0.29, 2.20), P=0.02]. Conclusions This network meta-analysis suggests that purse-string closure and gunsight closure might be best for reducing postoperative infection, and the addition of drainage could not further reduce the incidence of postoperative infection. In addition, implantation of the biological mesh does not increase the risk of postoperative infection. However, a large-scale RCT is warranted to confirm the results.

Citation： JIANG Weirong, WANG Rui, CAO Dong, SUN Binjie, LI Yunfeng, YU Yongjiang. Effect of different skin closure techniques on postoperative complications of stoma reversal：a network meta-analysis. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2022, 29(3): 353-361. doi: 10.7507/1007-9424.202106028 Copy

1.	Reinforcement of Closure of Stoma Site (ROCSS) Collaborative and West Midlands Research Collaborative. Prophylactic biological mesh reinforcement versus standard closure of stoma site (ROCSS): a multicentre, randomised controlled trial. Lancet, 2020, 395(10222): 417-426.
2.	黄仁力, 邹兆伟, 俞金龙. 预防结肠造口术后造口旁疝的研究进展. 腹部外科, 2019, 32(4): 308-312.
3.	韩永强, 高广荣, 李达, 等. 影响直肠癌预防性末段回肠造口还纳手术难度及并发症的相关因素分析. 中国普外基础与临床杂志, 2019, 26(7): 803-807.
4.	Ali D, Zubair M, Kaiser MA, et al. Outcome of purse-string versus linear skin closure after ileostomy stoma reversal in terms of stoma sites infection and cosmesis. J Pak Med Assoc, 2021, 71(2(A): 414-416.
5.	Ferrara F, Parini D, Bondurri A, et al. Italian guidelines for the surgical management of enteral stomas in adults. Tech Coloproctol, 2019, 23(11): 1037-1056.
6.	杨硕, 陈杰. 复杂腹壁疝治疗相关要点. 中国实用外科杂志, 2021, 41(4): 387-391.
7.	Banerjee A. Pursestring skin closure after stoma reversal. Dis Colon Rectum, 1997, 40(8): 993-994.
8.	Lim JT, Shedda SM, Hayes IP. “Gunsight” skin incision and closure technique for stoma reversal. Dis Colon Rectum, 2010, 53(11): 1569-1575.
9.	Amano K, Ishida H, Kumamoto K, et al. Purse-string approximation vs. primary closure with a drain for stoma reversal surgery:results of a randomized clinical trial. Surg Today, 2019, 49(3): 231-237.
10.	Warren JA, Beffa LR, Carbonell AM, et al. Prophylactic placement of permanent synthetic mesh at the time of ostomy closure prevents formation of incisional hernias. Surgery, 2018, 163(4): 839-846.
11.	Peltrini R, Imperatore N, Altieri G, et al. Prevention of incisional hernia at the site of stoma closure with different reinforcing mesh types: a systematic review and meta-analysis. Hernia, 2021, 25(3): 639-648.
12.	Alvandipour M, Gharedaghi B, Khodabakhsh H, et al. Purse-String versus linear conventional skin wound closure of an ileostomy: a randomized clinical trial. Ann Coloproctol, 2016, 32(4): 144-149.
13.	Berne TV, Griffith CN, Hill J, et al. Colostomy wound closure. Arch Surg, 1985, 120(8): 957-959.
14.	Camacho-Mauries D, Rodriguez-Díaz JL, Salgado-Nesme N, et al. Randomized clinical trial of intestinal ostomy takedown comparing pursestring wound closure vs conventional closure to eliminate the risk of wound infection. Dis Colon Rectum, 2013, 56(2): 205-211.
15.	Dusch N, Goranova D, Herrle F, et al. Randomized controlled trial: comparison of two surgical techniques for closing the wound following ileostomy closure: purse string vs direct suture. Colorectal Dis, 2013, 15(8): 1033-1040.
16.	Han JG, Yao HW, Zhou JP, et al. Gunsight procedure versus the purse-string procedure for closing wounds after stoma reversal: a multicenter prospective randomized trial. Dis Colon Rectum, 2020, 63(10): 1411-1418.
17.	Lauscher JC, Schneider V, Lee LD, et al. Necessity of subcutaneous suction drains in ileostomy reversal (DRASTAR)-a randomized, controlled bi-centered trial. Langenbecks Arch Surg, 2016, 401(4): 409-418.
18.	Lee JT, Marquez TT, Clerc D, et al. Pursestring closure of the stoma site leads to fewer wound infections: results from a multicenter randomized controlled trial. Dis Colon Rectum, 2014, 57(11): 1282-1289.
19.	Lopez MP, Melendres MF, Maglangit SA, et al. A randomized controlled clinical trial comparing the outcomes of circumferential subcuticular wound approximation (CSWA) with conventional wound closure after stoma reversal. Tech Coloproctol, 2015, 19(8): 461-468.
20.	O’Leary DP, Carter M, Wijewardene D, et al. The effect of purse-string approximation versus linear approximation of ileostomy reversal wounds on morbidity rates and patient satisfaction: the ‘STOMA’ trial. Tech Coloproctol, 2017, 21(11): 863-868.
21.	Reid K, Pockney P, Pollitt T, et al. Randomized clinical trial of short-term outcomes following purse-string versus conventional closure of ileostomy wounds. Br J Surg, 2010, 97(10): 1511-1517.
22.	Sureshkumar S, Jubel K, Ali MS, et al. 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, 2018, 10(2): e2181. doi: 10.7759/cureus.2181.
23.	Uchino M, Hirose K, Bando T, et al. Randomized controlled trial of prophylactic negative-pressure wound therapy at ostomy closure for the prevention of delayed wound healing and surgical site infection in patients with ulcerative colitis. Dig Surg, 2016, 33(6): 449-454.
24.	Wierdak M, Pisarska-Adamczyk M, Wysocki M, et al. Prophylactic negative-pressure wound therapy after ileostomy reversal for the prevention of wound healing complications in colorectal cancer patients: a randomized controlled trial. Tech Coloproctol, 2021, 25(2): 185-193.
25.	曹金鹏, 计勇, 杨平, 等. 皮下引流持续冲洗负压吸引术在肠造口还纳术后预防切口感染的前瞻性研究. 中华普通外科学文献(电子版), 2020, 14(2): 125-128.
26.	Segev L, Assaf D, Elbaz N, et al. Outcomes of diverting loop ileostomy reversal in the elderly: a case-control study. ANZ J Surg, 2021, 91(6): E382-E388. doi: 10.1111/ans.16871.
27.	Guidolin K, Jung F, Spence R, et al. Extended duration of faecal diversion is associated with increased ileus upon loop ileostomy reversal. Colorectal Dis, 2021, 23(8): 2146-2153.
28.	Robertson I, Leung E, Hughes D, et al. Prospective analysis of stoma-related complications. Colorectal Dis, 2005, 7(3): 279-285.
29.	丘素语, 胡民辉, 过文泰, 等. 直肠癌保括约肌手术患者预防性回肠造口延迟回纳的危险因素. 中国普外基础与临床杂志, 2019, 26(4): 418-422.
30.	Mirbagheri N, Dark J, Skinner S. Factors predicting stomal wound closure infection rates. Tech Coloproctol, 2013, 17(2): 215-220.
31.	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, 2018, 33(10): 1319-1332.
32.	吴永彪, 梁秀健, 闫慧明. 荷包缝合与线性缝合皮肤应用于肠造口还纳术疗效的Meta分析. 中华胃肠外科杂志, 2019, 22(12): 1188-1195.
33.	Huang Y, Wang P, Ye J, et al. Retrospective single-center experience with the transversus abdominis muscle release procedure in complex abdominal wall reconstruction. Int J Abd Wall Hernia Surg, 2018, 1(2): 60-65.
34.	Morris MP, Mellia JA, Christopher AN, et al. Ventral hernia repair with synthetic mesh in a contaminated field: a systematic review and meta-analysis. Hernia, 2021, 25(4): 1035-1050.
35.	Mohamedahmed AYY, Stonelake S, Zaman S, et al. Closure of stoma site with or without prophylactic mesh reinforcement: a systematic review and meta-analysis. Int J Colorectal Dis, 2020, 35(8): 1477-1488.
36.	Con J, Zarain L, Gogna S, et al. A novel tool to evaluate bias in literature on use of biologic mesh in abdominal wall hernia repair. Hernia, 2020, 24(1): 23-30.

1. Reinforcement of Closure of Stoma Site (ROCSS) Collaborative and West Midlands Research Collaborative. Prophylactic biological mesh reinforcement versus standard closure of stoma site (ROCSS): a multicentre, randomised controlled trial. Lancet, 2020, 395(10222): 417-426.
2. 黄仁力, 邹兆伟, 俞金龙. 预防结肠造口术后造口旁疝的研究进展. 腹部外科, 2019, 32(4): 308-312.
3. 韩永强, 高广荣, 李达, 等. 影响直肠癌预防性末段回肠造口还纳手术难度及并发症的相关因素分析. 中国普外基础与临床杂志, 2019, 26(7): 803-807.
4. Ali D, Zubair M, Kaiser MA, et al. Outcome of purse-string versus linear skin closure after ileostomy stoma reversal in terms of stoma sites infection and cosmesis. J Pak Med Assoc, 2021, 71(2(A): 414-416.
5. Ferrara F, Parini D, Bondurri A, et al. Italian guidelines for the surgical management of enteral stomas in adults. Tech Coloproctol, 2019, 23(11): 1037-1056.
6. 杨硕, 陈杰. 复杂腹壁疝治疗相关要点. 中国实用外科杂志, 2021, 41(4): 387-391.
7. Banerjee A. Pursestring skin closure after stoma reversal. Dis Colon Rectum, 1997, 40(8): 993-994.
8. Lim JT, Shedda SM, Hayes IP. “Gunsight” skin incision and closure technique for stoma reversal. Dis Colon Rectum, 2010, 53(11): 1569-1575.
9. Amano K, Ishida H, Kumamoto K, et al. Purse-string approximation vs. primary closure with a drain for stoma reversal surgery:results of a randomized clinical trial. Surg Today, 2019, 49(3): 231-237.
10. Warren JA, Beffa LR, Carbonell AM, et al. Prophylactic placement of permanent synthetic mesh at the time of ostomy closure prevents formation of incisional hernias. Surgery, 2018, 163(4): 839-846.
11. Peltrini R, Imperatore N, Altieri G, et al. Prevention of incisional hernia at the site of stoma closure with different reinforcing mesh types: a systematic review and meta-analysis. Hernia, 2021, 25(3): 639-648.
12. Alvandipour M, Gharedaghi B, Khodabakhsh H, et al. Purse-String versus linear conventional skin wound closure of an ileostomy: a randomized clinical trial. Ann Coloproctol, 2016, 32(4): 144-149.
13. Berne TV, Griffith CN, Hill J, et al. Colostomy wound closure. Arch Surg, 1985, 120(8): 957-959.
14. Camacho-Mauries D, Rodriguez-Díaz JL, Salgado-Nesme N, et al. Randomized clinical trial of intestinal ostomy takedown comparing pursestring wound closure vs conventional closure to eliminate the risk of wound infection. Dis Colon Rectum, 2013, 56(2): 205-211.
15. Dusch N, Goranova D, Herrle F, et al. Randomized controlled trial: comparison of two surgical techniques for closing the wound following ileostomy closure: purse string vs direct suture. Colorectal Dis, 2013, 15(8): 1033-1040.
16. Han JG, Yao HW, Zhou JP, et al. Gunsight procedure versus the purse-string procedure for closing wounds after stoma reversal: a multicenter prospective randomized trial. Dis Colon Rectum, 2020, 63(10): 1411-1418.
17. Lauscher JC, Schneider V, Lee LD, et al. Necessity of subcutaneous suction drains in ileostomy reversal (DRASTAR)-a randomized, controlled bi-centered trial. Langenbecks Arch Surg, 2016, 401(4): 409-418.
18. Lee JT, Marquez TT, Clerc D, et al. Pursestring closure of the stoma site leads to fewer wound infections: results from a multicenter randomized controlled trial. Dis Colon Rectum, 2014, 57(11): 1282-1289.
19. Lopez MP, Melendres MF, Maglangit SA, et al. A randomized controlled clinical trial comparing the outcomes of circumferential subcuticular wound approximation (CSWA) with conventional wound closure after stoma reversal. Tech Coloproctol, 2015, 19(8): 461-468.
20. O’Leary DP, Carter M, Wijewardene D, et al. The effect of purse-string approximation versus linear approximation of ileostomy reversal wounds on morbidity rates and patient satisfaction: the ‘STOMA’ trial. Tech Coloproctol, 2017, 21(11): 863-868.
21. Reid K, Pockney P, Pollitt T, et al. Randomized clinical trial of short-term outcomes following purse-string versus conventional closure of ileostomy wounds. Br J Surg, 2010, 97(10): 1511-1517.
22. Sureshkumar S, Jubel K, Ali MS, et al. 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, 2018, 10(2): e2181. doi: 10.7759/cureus.2181.
23. Uchino M, Hirose K, Bando T, et al. Randomized controlled trial of prophylactic negative-pressure wound therapy at ostomy closure for the prevention of delayed wound healing and surgical site infection in patients with ulcerative colitis. Dig Surg, 2016, 33(6): 449-454.
24. Wierdak M, Pisarska-Adamczyk M, Wysocki M, et al. Prophylactic negative-pressure wound therapy after ileostomy reversal for the prevention of wound healing complications in colorectal cancer patients: a randomized controlled trial. Tech Coloproctol, 2021, 25(2): 185-193.
25. 曹金鹏, 计勇, 杨平, 等. 皮下引流持续冲洗负压吸引术在肠造口还纳术后预防切口感染的前瞻性研究. 中华普通外科学文献(电子版), 2020, 14(2): 125-128.
26. Segev L, Assaf D, Elbaz N, et al. Outcomes of diverting loop ileostomy reversal in the elderly: a case-control study. ANZ J Surg, 2021, 91(6): E382-E388. doi: 10.1111/ans.16871.
27. Guidolin K, Jung F, Spence R, et al. Extended duration of faecal diversion is associated with increased ileus upon loop ileostomy reversal. Colorectal Dis, 2021, 23(8): 2146-2153.
28. Robertson I, Leung E, Hughes D, et al. Prospective analysis of stoma-related complications. Colorectal Dis, 2005, 7(3): 279-285.
29. 丘素语, 胡民辉, 过文泰, 等. 直肠癌保括约肌手术患者预防性回肠造口延迟回纳的危险因素. 中国普外基础与临床杂志, 2019, 26(4): 418-422.
30. Mirbagheri N, Dark J, Skinner S. Factors predicting stomal wound closure infection rates. Tech Coloproctol, 2013, 17(2): 215-220.
31. 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, 2018, 33(10): 1319-1332.
32. 吴永彪, 梁秀健, 闫慧明. 荷包缝合与线性缝合皮肤应用于肠造口还纳术疗效的Meta分析. 中华胃肠外科杂志, 2019, 22(12): 1188-1195.
33. Huang Y, Wang P, Ye J, et al. Retrospective single-center experience with the transversus abdominis muscle release procedure in complex abdominal wall reconstruction. Int J Abd Wall Hernia Surg, 2018, 1(2): 60-65.
34. Morris MP, Mellia JA, Christopher AN, et al. Ventral hernia repair with synthetic mesh in a contaminated field: a systematic review and meta-analysis. Hernia, 2021, 25(4): 1035-1050.
35. Mohamedahmed AYY, Stonelake S, Zaman S, et al. Closure of stoma site with or without prophylactic mesh reinforcement: a systematic review and meta-analysis. Int J Colorectal Dis, 2020, 35(8): 1477-1488.
36. Con J, Zarain L, Gogna S, et al. A novel tool to evaluate bias in literature on use of biologic mesh in abdominal wall hernia repair. Hernia, 2020, 24(1): 23-30.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Effect of different skin closure techniques on postoperative complications of stoma reversal：a network meta-analysis

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