Evidence - Ileostomy reversal (without resection) with skin closure using the gunsight technique

In retrospective analyses, the rate of wound infections after stoma reversals is reported to be up to 40%. After ileostomy reversals, the average rate is between 10 – 25%, and after colostomy reversals, it is around 25% [1, 2, 3]. Wound infections are a significant risk factor for the development of fascial dehiscence or incisional hernia, have a considerable impact on the length of hospital stay and associated treatment costs, as well as on the 30-day morbidity [4].

Regarding risk factors for the development of postoperative wound infections after stoma reversals, there is little evidence in the literature. A comprehensive retrospective study found significantly more smokers in the group of patients with wound infections (twice the risk), as well as a significantly higher proportion of end stomas and significantly less frequent placement of subcutaneous drains [5].

Strategies to reduce postoperative wound infections include two-stage wound closure, partial wound closure, modifications of suture techniques in primary closure, and secondary wound healing.

According to two studies from 2009 and 2015, the wound infection rate can be reduced by partial wound closure using an adaptive purse-string suture, where a wound dehiscence of about 5 mm is deliberately left to secondary healing [6, 7]. A meta-analysis of four randomized controlled trials with a total of 319 patients reached a similar conclusion [8]. The infection rate after modified purse-string suture as mentioned was 6.8%, compared to 25.7% after primary closure. A simultaneously published randomized controlled study not only verified the results but also showed no differences in wound infection rates between small and large bowel stoma reversals [7]. In a randomized meta-analysis of three controlled trials, involving a total of 206 patients, comparing the purse-string suture with linear skin closure in the context of stoma closure, a statistically significant reduced risk was also observed in the purse-string suture group. All other parameters such as operation duration or hospital stay showed no statistical heterogeneity [9]. The same result was found in an analysis of five studies with a total of 385 patients [10]. After wound closure using only adaptive purse-string suture, no restrictions were found in the short- and medium-term postoperative course regarding scar aesthetics or quality of life [11, 12].

In a randomized, prospective, multicenter study, involving a total of 143 patients, comparing the purse-string suture with the gunsight closure, no statistically significant difference was found regarding surgical infections, blood loss, and hospital stay. In the gunsight closure group, the wound healing duration was shorter with 17 days vs. 25 days, and there was greater patient satisfaction regarding wound healing [13].

Efficacy of Negative Pressure Wound Therapy (NPWT) for Prevention of Wound Infection and Improvement of Wound Healing After Stoma Reversal

Comparison of purse-string closure versus conventional primary closure following stoma reversal to reduce surgical site infection rate

Application of PREVENA (Surgical Incision Protection System) in Reducing Surgical Site Complications Following Reversal of Ileostomy or Colostomy: A Randomized Controlled Trial (PRIC Trial)

1. Chow A et al (2009) The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Colorectal Dis 24(6):711–723

2. Hsieh MC et al (2015) Pursestring closure versus conventional primary closure following stoma reversal to reduce surgical site infection rate: a meta-analysis of randomized controlled trials. Dis Colon Rectum 58(8):808–815

3. Horesh N et al (2018) Reversal of Hartmann’s procedure: still a complicated operation. Tech Coloproctol 22(2):81–87

4. Alexander JW, Solomkin JS, Edwards MJ (2011) Updated recommendations for control of surgical site infections. Ann Surg 253(6):1082–1093

5. Chu DI et al (2015) Surgical Site Infections (SSIs) after Stoma Reversal (SR): risk factors, implications, and protective strategies. J Gastrointest Surg 19(2):327–334

6. Milanchi S et al (2009) Wound infection after ileostomy closure can be eliminated by circumferential subcuticular wound approximation. Dis Colon Rectum 52(3):469–474

7. Lopez MP et al (2015) A randomized controlled clinical trial comparing the outcomes of Circumferential Subcuticular Wound Approximation (CSWA) with conventional wound closure after stoma reversal. Tech Coloproctol 19(8):461–468

8. Hsieh MC et al (2015) Pursestring closure versus conventional primary closure following stoma reversal to reduce surgical site infection rate: a meta-analysis of randomized controlled trials. Dis Colon Rectum 58(8):808–815

9. Sajid, M. S., Bhatti, M. I., & Miles, W. F. (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. Gastroenterology report 3(2):156–161

10. Rondelli, F. et al (2018) Purse-string closure versus conventional primary closure of wound following stoma reversal: Meta-analysis of randomized controlled trials. International journal of surgery (London, England) 52:208–213

11. Yoon SI et al (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

12. Rausa E et al (2018) Quality of life following ostomy reversal with purse-string vs linear skin closure: a systematic review. Int J Colorectal Dis 34(2):209–216

13. Han, Jia Gang et al. (2020) Gunsight Procedure Versus the Purse-String Procedure for Closing Wounds After Stoma Reversal: A Multicenter Prospective Randomized Trial. Diseases of the colon and rectum 63(10):1411-1418