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

Abstract

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.

Introduction

Temporary diverting stomas are commonly used in colorectal surgeries to reduce morbidity associated with anastomotic leakage[1,2]. Surgery for stoma closure is usually planned several months after the initial operation when the anastomotic leakage is absent or healed in the patient. Stoma closure is generally associated with severe complications, among which surgical-site infections (SSIs) remain one of the most common complications. The superficial (incisional) SSI rate of primary stoma closure is high, ranging from 2% to 41%[3-6]. SSIs after stoma closure can lead to long hospital stays, high costs, and a great likelihood of subsequent incisional hernias[7,8].

Several techniques are already used for wound closure following ileostomy reversal to decrease the risk of SSIs. Conventional primary closure (PC), which is usually performed with linear closure of the skin during ostomy takedown, has a potentially high risk of SSIs[9]. Purse-string skin closure (PSC), in which the skin is partially closed circularly by placing a purse-string suture in the dermal layer, has been introduced as an alternative method to lower the risk of SSIs[10]. Several studies have demonstrated that PSC results in a lower incidence of SSIs than does PC[11]. However, as PSC is a technique for secondary intention wound healing, a small drainage opening is retained, which allows for bacterial contamination of the surgical site. Therefore, comparing SSI rates between PSC and PC might be inappropriate[12]. Moreover, patients who undergo PSC require additional wound care and a longer wound healing period than do those who undergo PC[13]. We believe that although the conventional PC technique has some advantages, there is scope for improvement.

Surgeons have attempted to assess the effectiveness of drain placement in reducing the SSI rate in PC. A Penrose drain is frequently used with PC; however, the SSI rate with this technique is not satisfactorily lower than that with PSC[4]. Alternatively, a study has reported that a closed suction drain (CSD) is more useful in preventing SSIs than a PC without a drain[14]. Furthermore, subcutaneous closure is a known wound closure option for preventing SSIs, as it reduces subcutaneous dead space[15]. Here, we combined these concepts to develop a new method for wound closure using the subcutaneous large-bite buried suture (SLBS) technique and a CSD. This study aimed to investigate the efficacy of the SLBS technique and a CSD in preventing superficial SSIs following stoma closure.

Methods

Study design

This was a single-center retrospective cohort study.

Patients

This study included patients who underwent elective surgery for stoma closure at the University of Tsukuba Hospital between January 2019 and July 2022. Patients who underwent elective PC at the stomal site were included in the study. All cases with closure of loop ileostomy or colostomy were included. Patients who underwent stoma reversal in combination with other surgical operations (e.g., colorectal cancer resection) or who underwent Hartmann reversal were excluded from the study. Patients with purse-string sutures or PC without drainage tubes were excluded. The study protocol was approved by the Institutional Review Board (IRB) of the University of Tsukuba Hospital (IRB code: R01-110). The written consent has been obtained from all patients and relevant persons (such as the parent or legal guardian) to publish the information, including photographs.

Preoperative examinations and care

All patients were preoperatively examined the computed tomography (CT) and endoscopy before the operation to confirm the absence of an abscess or healing of anastomosis. The patients did not undergo mechanical bowel preparation. They received 1 g of cefmetazole sodium or 1 g of flomoxef sodium 30 min before surgery.

Surgical techniques

The skin was disinfected preoperatively with povidone-iodine. A circumstomal skin incision and temporary closure of the stomal orifice were performed. The stoma was first mobilized from the fascia, and the peritoneal cavity was subsequently opened. After stomal resection, hand-sewn or functional end-to-end anastomosis with a linear stapler was performed. The anastomotic procedure was selected depending on the condition of the intestine. The anterior fascia was closed with interrupted sutures using the absorbable monofilament suture 1 PDS Plus (Ethicon, Tokyo, Japan). After irrigation using normal saline solution and disinfection of the surgical site with povidone-iodine, a silicon drain (3.5 mm; Multi-Channel Drainage Set; Covidien, Tokyo, Japan) was placed in the subcutaneous tissue and brought out through a separate stab-wound incision. The drainage tube was connected to a silicon reservoir.

Subcutaneous and skin closure were performed using an interrupted SLBS technique with 1 PDS Plus (Figure 1A, B). The 1 PDS Plus needle was 48 mm thick, which was sufficient to suture the thick subcutaneous tissue (Figure 1C). Epidermal closure was not added to the SLBS. Dressing was applied to each wound. Approximately 3-4 sutures were necessary for subcutaneous and skin closure using the SLBS technique.

Figure 1.

Schematic illustration of skin and subcutaneous closure. (A) Subcutaneous large-bite buried suture (SLBS) technique using 1 PDS Plus performed after placement of a closed suction drain (CSD). The sutures are advanced into the dermis and thick subcutaneous tissue. Arrow, suture; arrowhead, CSD. (B) Stoma closure using the SLBS technique tightly holds the thick subcutaneous tissue, which reduces the dead space. (C) The 1 PDS Plus needle is used for performing stoma closure using the SLBS technique.

Postoperative care

The wound was covered with medical dressing film until postoperative day (POD) 2. Additional antibiotics were administered within 72 h. Oral intake was initiated on POD 1. The drainage tube was removed on POD 7, and the patients were discharged from the hospital. The patients returned to the hospital for their first medical check-up within 30 days of surgery.

Outcome measures

The primary outcome was the occurrence of superficial SSIs, which were diagnosed according to the Centers for Disease Control and Prevention definition[16]. SSI surveillance was performed by a surgeon for at least 30 days after the surgery. Effusion through the drain was measured daily. All clinical data were collected from the medical records of the University of Tsukuba Hospital. The records included the patients' characteristics and operative outcomes. The subcutaneous depth of the stomal site was determined using preoperative CT pictures by measuring the distance from the skin to the anterior wall of the rectus sheath.

Statistics

Statistical analyses were performed using the chi-square test with Fisher's exact test and a univariate or multivariate analysis using IBM SPSS Statistics version 29 (IBM, Armonk, USA). Predictors of superficial SSI were step-wise multivariate logistic regression based on significant covariates from univariate analysis. Differences were considered statistically significant at p < 0.05.

Results

In total, 67 patients were included in the study. The patient characteristics are shown in Table 1. Data on age, sex, body mass index (BMI), disease, history of chemotherapy and abdominal radiotherapy, daily steroid use, and treatment of diabetes mellitus were retrieved from the patients' medical records. The median age of the patients was 61 years (range, 28 to 78 years). The primary diseases that caused stoma formation were colorectal cancer, other malignancies, ulcerative colitis, intestinal perforation, and polyposis. A total of 22 and 45 patients underwent colostomies and ileostomies, respectively.

Table 1.

Patient Characteristics and Surgical Outcomes.

	Cases (n=67)
Age (year)	61 (range; 28-78, SD; 11)
Sex (male/female)	45/22
Body mass index	22 (range; 16-29, SD; 2.7)
Subcutaneous depth of stomal site (mm)	19 (range; 7-44, SD; 8.7)
Diseases
Colorectal cancer	50
Other malignancy	2
Ulcerative colitis	7
Perforation due to benign disease	7
Polyposis	1
History of chemotherapy	24
History of radiotherapy	16
Steroid usage	4
Diabetes mellitus	5
Operation time (min)	127 (range; 62-210, SD; 32)
Complication
Superficial SSI	9
Intraabdominal abscess	3
Ileus	3
Anastomotic stenosis	2
Colitis	1
Type of stoma
colostomy	22
ileostomy	45
Anastomosis
hand-sewn	35
stapled	32
Amount of discharge from drainage tube (ml/7 days)	39 (range; 2-365, SD; 51)
Postoperative hospital stay (day)	10 (range; 7-43, SD; 6.4)

All the continuous variables are expressed as medians. SD, standard deviation

The superficial SSIs were observed in nine patients (13%) on POD 30 (Table 1). All nine patients had physical symptom of superficial SSI. Two patients were positive for bacterial culture test. The subcutaneous depth of the stoma site was 19 mm, and the total amount of discharge from the drainage tube was 39 mL/7 days. Other complications such as intra-abdominal abscess, ileus, anastomotic stenosis, and colitis were observed. The duration of postoperative hospital stay was 10 days.

Risk factors for the occurrence of superficial SSIs were assessed (Table 2). Among the patient characteristics, superficial SSIs occurred markedly in colostomy patients (8 in 22; 36%) compared with those in ileostomy patients (1 in 45, 2%). The univariate analysis of the risk factors associated with the occurrence of superficial SSIs was performed (Table 2). Colostomy was a significant risk factor for the occurrence of superficial SSIs (p < 0.001; odds ratio 25.143; 95% confidence interval 2.888-218.913). According to the multivariate analysis, colostomy was an independent risk factor for the development of superficial SSIs (p = 0.003; odds ratio 25.143; 95% confidence interval 2.888-218.913). Hand-sewn anastomosis was also a significant risk factor for the occurrence of superficial SSIs (p = 0.019; odds ratio 9.185; 95% confidence interval 1.079-78.219) with univariate analysis, but it did not show the statistical significance with multivariate analysis. Age, BMI, subcutaneous depth, and operative time were not significant predictors of the occurrence of superficial SSIs.

Table 2.

Univariate Analysis of the Risk Factors Associated with the Occurrence of Superficial Surgical-Site Infections (SSIs).

Characteristics	no Superficial SSI (%) (n=58)	Superficial SSI (%) (n=9)	P value	Odds ratio	95% CI
Age
>60	33 (57)	5 (56)	0.607	0.947	0.230-3.893
≤60	25 (43)	4 (44)
Sex
Male	39 (67)	6 (67)	0.623	0.974	0.219-4.325
Female	19 (33)	3 (33)
BMI
High (BMI>22)	28 (48)	5 (56)	0.480	1.339	0.326-5.497
Low (BMI≤22)	30 (52)	4 (44)
Subcutaneous depth
>20 mm	20 (34)	4 (44)	0.409	1.520	0.367-6.300
≤20 mm	38 (66)	5 (56)
Chemotherapy
Yes	21 (36)	3 (33)	0.591	0.881	0.199-3.892
No	37 (64)	6 (67)
Radiotherapy
Yes	14 (24)	2 (22)	0.634	0.898	0.167-4.831
No	44 (76)	7 (78)
Steroid
Yes	4 (7)	0 (0)	0.554	NA	NA
No	54 (93)	9 (100)
DM
Yes	5 (9)	0 (0)	0.474	NA	NA
No	53 (91)	9 (100)
Type of stoma
colostomy	14 (24)	8 (89)	<0.001	25.143	2.888-218.913
Ileostomy	44 (76)	1 (11)
Anastomosis
hand-sewn	35 (52)	8 (89)	0.019	9.185	1.079-78.219
stapled	32 (48)	1 (11)
Operation time
>120 min	26 (45)	7 (78)	0.068	4.308	0.824-22.531
≤120 min	32 (55)	2 (22)

BMI, body mass index; CI, confidence interval

A representative case of stoma closure using the SLBS technique with a CSD is shown in Figure 2. The patient was a 70-year-old woman who had previously undergone a colectomy with diverting ileostomy. The patient underwent a CSD placement, followed by stoma closure using the SLBS technique. The anterior fascia of the stomal site was closed and a CSD was placed in the subcutaneous tissue, and the SLBS technique was subsequently performed (Figure 2A-C). The wound healed without any SSIs developing. The postoperative wound appearances at the end of surgery, 6 days after surgery, and 31 days after surgery are shown in Figure 2D-F, respectively.

Figure 2.

Representative case of stoma closure using the subcutaneous large-bite buried suture (SLBS) technique and a closed suction drain (CSD). The patient previously underwent open colectomy with diverting ileostomy. (A) Stomal orifice after closure of the anterior fascia. (B) Placement of a CSD on the subcutaneous tissue. (C) The wound is closed with the SLBS technique, and the drain is connected to a silicon reservoir. (D), (E), and (F) show postoperative wound appearance. (D) The end of the surgery, (E) 6 days after surgery, and (F) 31 days after surgery.

Discussion

Although various wound management strategies have been developed for stoma closure, the optimal procedure remains controversial. PC of the skin is easy to perform and take care of; however, we considered that conventional dermal closure with sutures or staples did not contribute much to the decrease in the dead space of the subcutaneous tissue. In the present study, we focused on decreasing the subcutaneous dead space, which is essential for preventing SSIs. We modified the skin and subcutaneous closure using the SLBS technique and a CSD, intending to reduce the dead space as much as possible, which successfully resulted in a low occurrence rate (9 in 67; 13%) of superficial SSIs. Moreover, the subgroup analysis showed that the superficial SSI rate was significantly lower in ileostomy patients (2%) than in colostomy patients (36%). This finding revealed that the SLBS technique with a CSD was useful, especially for ileostomy closure.

Superficial SSIs often begin with microorganisms contaminating the subcutaneous fat tissue. Liang et al. demonstrated that thicker subcutaneous fat tissue (greater than 2.5 cm) is an independent risk factor for SSIs developing in stoma reversal[17]. Decreasing the subcutaneous dead space is a key concept for SSI prevention, as it reduces the wound fluid that acts as a suitable culture medium for contaminating microorganisms[15]. Subcutaneous closure is a method for decreasing dead space, which has been applied in obese patients who underwent gynecologic surgery, resulting in a lower rate of SSI occurrence[18].

To prevent the occurrence of SSIs during stoma closure, a Penrose drain is often used to drain contaminated fluid collected in the subcutaneous dead space[19]. However, because the Penrose drain is a drainage system that functions using capillary action, it is less effective in reducing dead space[20]. Moreover, long-term Penrose drain insertion induces retrograde skin infections after surgery[21]. Serracant et al. assessed the efficacy of Penrose drains in primary ileostomy closure; however, the SSI rate was similar between the drainage and non-drainage groups[22]. In contrast, a CSD is a closed drainage system that can decrease the subcutaneous dead space and prevent retrograde bacterial contamination. Watanabe et al. demonstrated that in colorectal surgery patients, incisional SSI occurrence was decreased in patients who had a CSD arm (4.5%) compared with patients in the control arm (12.8%)[23]. Pan et al. revealed that the SSI occurrence rate after PC of the stomal site was 1.2% in the patients with a CSD and 12.5% in those without a CSD[14]. Neumann et al. concluded in their meta-analysis that compared with the no-drain group, the CSD group had a significantly beneficial effect on preventing wound complications in ileostomy reversal[12].

Suturing for wound closure is an important factor in decreasing the dead space in the subcutaneous tissue. Earlier studies adopted surgical staples or interrupted nonabsorbable sutures for skin closure at the stomal site[14,22]. We attempted to use the SLBS technique to decrease subcutaneous dead space more effectively. Compared with conventional wound closure methods, such as skin staples or vertical mattress sutures, our SLBS procedure had several advantages for stoma closure. The 1 PDS Plus needle used in the SLBS group was 48 mm, which was tightly attached to the thick subcutaneous tissue, thus decreasing the dead space. The heavy thread of the 1 PDS Plus needle might also help maintain the tight junction of the subcutaneous tissue, thereby avoiding wound dehiscence. Because the SLBS technique was performed involved buried sutures, the wound healed clearly without suture marks being visible on the skin surface. The potential antibacterial efficacy of 1 PDS Plus sutures may contribute to preventing SSIs[24]. Neumann et al. reported that PSC might not always be possible in obese patients because of the extended resection with widening of incisions[25]. In these difficult cases, the SLBS technique with a CSD could be useful for preventing SSIs.

Simple postoperative wound care is another merit of the present method; PSC requires meticulous wound care that involves covering the wound with saline-soaked gauze and washing the wound once a day with running water until the serous effusion disappears[26]. This is continued for approximately 24-35 days until the wound naturally closes[27,28]. Amano et al. demonstrated that the healing rate on POD 30 was lower in PSC (62.5%) than in PC (92.4%). In contrast, our method does not require complicated wound care (except for drain placement). This reduces patient pain and the effort required by medical staff. A CSD is a simple drainage system that patients can handle at home; therefore, it could shorten hospital stay. The removal of CSD was scheduled on POD 7 in the present study, but it might be possible to remove it earlier to prevent retrograde skin infection. Additionally, it does not require suture removal after the skin is attached. The patients do not need to attend to their wounds after drain removal. Recently, a negative wound pressure therapy (NPWT) was applied to the stoma closure, but the high cost of NPWT device might be the problem. Carrano et al. showed in their randomized study that no benefit of NPWT in SSI occurrence compared with conventional PSC[29].

An important finding of the present study was that the SSI rate was higher in patients who underwent colostomies than in those who underwent ileostomies. Earlier studies have assessed the SSI rate after ileostomy and/or colostomy closure[30,31]. Mirbagheri et al. showed that the SSI rate was 16% in colostomy patients and 10% in ileostomy patients using PC, PC with drain, and PSC (statistically not significant)[19]. Chu et al. also showed rates of 12% in colostomy patients and 6% in ileostomy patients using mainly the PC method with or without drains[32]. Gavriilidis et al. documented in their meta-analysis that the wound infection rate was 13% in colostomy patients and 4% in ileostomy patients (the method of skin closure was not considered)[33]. These data that SSI rate was higher in colostomy closure was consistent with our findings. Although our data of ileostomy closure might be sufficient for the effectiveness of SSI prevention, relatively high rate of SSI occurrence in colostomy patients compared with earlier studies should be assessed. The increased rate of superficial SSIs after colostomy closure can be attributed to the presence of mixed aerobic and anaerobic flora in the bowel lumen. Moreover, bacterial contamination of the surgical site may occur easily during colostomy closure. Colostomy closure is more complicated than ileostomy closure because the mobilization of the intestine is restricted owing to its physiological fusion to the abdominal wall. The hand-sewn anastomosis was also a significant risk factor for SSI with univariate analysis (not with multivariate analysis). One reason was that all colostomy closure were performed with hand-sewn anastomosis, due to the difficulties in intestinal mobilization. In the present study, the operative time was longer for colostomy closure (137 min) than that for ileostomy closure (122 min). On the basis of the differences in the frequency of superficial SSIs, the new criterion for the indication of the closure procedure was suggested. Ileostomy closure, which is considered to have a moderate risk of superficial SSIs occurring, should be performed using our SLBS technique with a CSD. Conversely, colostomy closure might be treated by other methods, such as PSC, as the opening on the surgical site would help in the drainage of pus, regardless of the associated hassle of postoperative wound care. On the other hand, several reports demonstrated the oral antibiotic prophylaxis with mechanical bowel preparation reduced SSI in patients undergoing colorectal cancer surgery[34,35]. Oral metronidazole was often chosen for chemical preparation in colorectal surgery as it was effective in anaerobic organisms[36]. Preoperative oral antibiotic administration would be added to the optimal wound management for the SSI prevention in colostomy closure.

Our study had some limitations. This was a single-center, retrospective study with a small number of patients. Time, selection, and recall biases should be considered. SLBS without CSD method or PSC method was not assessed due to our limited clinical experience. Randomized studies of the SLBS technique with a CSD that includes a PSC group should be conducted in the future.

Conclusion

This study showed that stoma closure using the SLBS technique with a CSD is feasible for preventing superficial SSIs, especially in ileostomy closure.

Conflicts of Interest

There are no conflicts of interest.

Author Contributions

All authors substantially contribute to the manuscript. YOH, YOW, TE, and SM performed surgical operation. YA, KO, KT, OS, KF, and SH decided and approved the treatments. JK created the figures of this article. YOH and TO were major contributors in writing the manuscript. All authors read and approved the final manuscript.

Approval by Institutional Review Board (IRB)

The study protocol was approved by the Institutional Review Board of the University of Tsukuba Hospital (IRB code: R01-110).

Consent to Participate

Informed consent was obtained from all patients.

Consent for Publication

Informed consent was obtained from all patients.

Availability of Data and Material

These datasets generated and/or analyzed during the current study are publicly available from the corresponding author on reasonable request.