ORIGINAL CONTRIBUTION

Wound Infection After Ileostomy Closure Can Be Eliminated by Circumferential Subcuticular Wound Approximation
Siamak Milanchi, M.D.1 & Yosef Nasseri, M.D.1 & Travis Kidner, M.D.1 Phillip Fleshner, M.D.2
1 Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California 2 Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California

PURPOSE: Wound infections after ileostomy closure are common with primary closure of the skin. Although this risk can be reduced by secondary closure, cosmetic outcomes are less than desirable. In an effort to balance these issues, we have used circumferential subcuticular wound approximation to decrease wound size. This study compares outcomes of primary closure vs. circumferential subcuticular wound approximation after ileostomy closure. METHODS: Forty-nine consecutive patients undergoing

incidence of wound infection after ileostomy closure compared to primary closure. A trend was present toward better cosmetic results for circumferential subcuticular wound approximation than primary closure.
KEY WORDS: Ileostomy closure; Wound infection; Patient

satisfaction.

ileostomy closure over an 18-month period were reviewed. During the rst half of this study, all ileostomy sites underwent primary closure, while during the second half all ileostomy sites underwent circumferential subcuticular wound approximation. Short-term outcomes were tabulated including wound infection. Long-term outcomes were assessed using a novel six-point patient satisfaction scale.
RESULTS: Primary closure was performed in 25 patients

and circumferential subcuticular wound approximation performed in 24 patients. No wound infections occurred in the circumferential subcuticular wound approximation group, compared to 40 percent wound infection rate observed in the primary closure group (P = 0.002). The mean patient satisfaction score was higher in the circumferential subcuticular wound approximation group (18.4) vs. the primary closure group (15.9; P 9 0.05).
CONCLUSIONS: Circumferential subcuticular wound approximation was associated with a signicantly lower
Poster presentation at the meeting of the Southwestern Surgical Congress, Acapulco, Mexico, March 30 to April 2, 2008. Address of correspondence: Phillip Fleshner, M.D., 8737 Beverly Blvd., Suite 101, Los Angeles, Californina 90048. E-mail:Peshner@aol.com Dis Colon Rectum 2009; 52: 469Y474 DOI: 10.1007/DCR.0b013e31819acc90 BThe ASCRS 2009
DISEASES
OF THE

reation of a temporary loop ileostomy is commonly performed after colorectal surgical procedures in order to reduce anastomotic complications.1 Although ileostomy closure is associated with serious complications in less than 5 percent of cases,2 wound infection remains one of the most common complications of this procedure, with a reported rate of up to 41 percent with primary incision closure.2,3 The majority of wound infections are treated successfully with no complications, however severe wound infection may result inincreased morbidity and hospital costs, prolonged hospital stay,4,5 more frequent outpatient visits, and more long-term complications such as incisional hernia.6 Factors accounting for this high rate of infection after primary closure (PC) of the wound are unknown, although bacterial contamination of the peristomal skin probably plays an important role.7 Studies have failed to show any signicant inuence of body mass index (BMI), previous cancer surgery, steroid use, anemia, or transfusion on the rate of wound infection after ileostomy closure.8 Operative measures used to reduce the risk of wound infection include antibiotic implants at the incision site,8 delayed primary closure,9 and secondary closure of the incision site.3 Delayed primary closure involves packing the wound with a saline-soaked gauze which is changed on the third postoperative day and the skin closed if there is no evidence of wound infection. The results of delayed PC have been inconsistent, with one study even showing a higher rate of wound infection after delayed PC compared to PC.9 Secondary closure is a time-honored
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method to prevent wound infection when dealing with contaminated or dirty wounds.10 In this method, the skin is left open and the wound repacked daily with wet to dry dressings until it heals. Although this method has reduced the rates of wound infection after ileostomy closure,11,12 patients discomfort, costs associated with wound care, and length of wound healing limit its clinical value. In addition, the cosmetic result of secondary closure of the stoma site is often less than desirable. In an effort to balance these issues, a technique has been described to decrease the size of the wound by approximating the edges of the incision using a pursestring suture.11,12 After the fascia was closed, the incision site is partially closed leaving a small circular gap which is then packed and treated as an open wound. This method, which we term circumferential subcuticular wound approximation (CSWA), has been used by some colorectal surgeons although not widely reported in the literature.11 In an effort to assess the effectiveness of this technique of ileostomy closure, we compared the short-term and longterm results of PC vs. CSWA.

surgical staples over a quarter inch Penrose drain and a dressing applied. The dressings were removed on postoperative Day 2, and the Penrose drain removed on postoperative Day 4. Typical appearance of the wound 30 days after surgery is shown in Fig. 1. In patients undergoing CSWA, the stoma was initially divided off the skin at the mucocutaneous junction using electrocautery thus creating a circular incision (Fig. 2). Mobilization and excision of the stoma, creation of the anastomosis and closure of the fascia were performed the same way as the PC group. The skin was then partially closed using a running subcuticular 2-0 monocryl suture placed circumferentially around the wound and tied down leaving a 5-mm circular gap (Fig. 3). A rolled 2x2 gauze was placed in the middle of this gap (Fig. 4) which was then removed on postoperative Day 2 and the wound covered until healed and dry. Appearance of the wound 30 days after surgery is shown in Fig. 5.
Short-Term Outcomes The incision site was examined daily by the attending surgeon during hospitalization, and after discharge patients were routinely seen in the ofce 1 week and 1 month after the procedure. Evidence of wound infection (cellulitis, induration, purulent discharge) was documented and infected wounds were all opened in their full length at the bedside upon diagnosis of wound infection and packed with gauze daily until healed. Wound cultures were not routinely performed and antibiotics were not routinely used. Dressing changes

METHODS
The study population consisted of consecutive patients of a single colorectal surgeon who underwent elective ileostomy closure at Cedars-Sinai Medical Center in Los Angeles, California from September 2005 to March 2007. This retrospective study was approved by the Institutional Review Board. (IRB # 11571). During the rst eight months, all skin wounds underwent PC. Over the next eight months, all skin wounds were closed by CSWA. The CSWA method was started in an effort to reduce the rate of wound infection after ileostomy closure. Charts were reviewed for demographic data, BMI, diagnosis, indication for ileostomy, time interval between creation and closure of ileostomy, operative time, length of hospitalization, and wound infection rate.
Operative Techniques All ileostomy closures were performed electively. Patients were placed on a clear liquid diet for 24 hours before surgery. Mechanical bowel preparation and oral antibiotic prophylaxis were not used. One gram of intravenous cefotetan or cefoxitin was given upon induction of general anesthesia and continued for 24 hours after surgery. All patients having an ileal pouch-anal anastomosis (IPAA) had a temporary diverting loop stoma. In the PC group, an elliptical skin incision was made. The stoma was mobilized off the anterior abdominal wall by sharp dissection. After a side-to-side (functional endto-end) anastomosis was created using a GIA stapler and replaced into the peritoneal cavity, the anterior fascia was closed transversely using a continuous 1-0 polydiaxone suture (PDS). The skin was then closed using a row of

FIGURE 1. Wound appearance with primary closure 30 days after surgery.

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FIGURE 2. Wound with circular incision created at the mucocutaneous junction and the anastomosis replaced into the abdominal cavity.

FIGURE 4. Circumferential subcuticular wound approximation after placement of the central, rolled gauze.

were continued at home by the patient, family members, or visiting nurse.

Long-Term Outcomes In an effort to quantify patients satisfaction with their ileostomy site scar and overall wound healing, a novel scoring system was developed (Table 1). Patients were

contacted by phone and a standard questionnaire completed based on their answers. Factors assessed included patients satisfaction with appearance of the scar, expectations regarding the scar, level of postoperative pain, time of wound healing, difculty of wound care, and limitation of activity. A score of 1 to 5 was assigned for each factor, with the higher scores indicating better results. Accordingly,

FIGURE 3. Circular gap of the circumferential subcuticular wound approximation site after placing the pursestring suture. As the suture is tightened, the wound gap becomes progressively smaller.

FIGURE 5. Wound appearance with circumferential subcuticular wound approximation 30 days after surgery.

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TABLE 1. Patient wound healing satisfaction scale Cosmetic aspect What do you think about the appearance of your scar? 1 It looks horrible, it is so disgusting. 2 It looks very ugly, I hate it. 3 It looks ugly, I dont like it. 4 Its not that great, it doesnt look good. 5 It doesnt bother me, it looks OK. Patients expectation Is the appearance of your scar different than what you expected before the surgery? 1 It looks remarkably worse. 2 It looks worse. 3 This scar is what I expected before surgery. 4 It looks better. 5 It looks remarkably better. Postoperative pain How did you assess the severity of your pain after the surgery, from the time of surgery until the wound healed? Use a scale of 5Y1, ve for slight pain and one for excruciating pain. Time of healing Did your wound heal as fast as (or as slow as) you expected? 1 It healed remarkably longer than I expected. 2 It healed longer than I expected. 3 It healed as fast as I expected. 4 It healed faster than I expected. 5 It healed remarkably faster than I expected. Wound care Did you have problem with the dressing change? 1 Yes, it was a nightmare, it paralyzed my life, I hated it so much. 2 Yes, it was so cumbersome and annoying, I hated it. 3 Yes, I didnt like it, it bothered me. 4 No, I didnt like it but it was not a big deal, it was OK. 5 No, it was so easy. Activity After the surgery, did you have to limit your daily activities (e.g. grocery shopping, laundry etc) because of your wound, whether it was for pain, discomfort, having a dressing, oozing from the dressing or any other reason? 1 Very severely limited my activities (couldnt do anything!). 2 Remarkably limited my activities. 3 Moderately limited my activities. 4 Slightly limited my activities. 5 Not at all (I did whatever I wanted to do!).

patients (59 percent) were male and 20 (41 percent) were female. The most common indication for ileostomy construction was open or laparoscopic-assisted IPAA for inammatory bowel disease (n = 46). The remaining 3 patients had a loop ileostomy for ischemic colitis (n = 1), anastomotic failure after sigmoid resection (n = 1), and low anterior resection for rectal cancer (n = 1). The total number of laparoscopic-assisted cases was 15 (13 in the CSWA and 2 in the PC group). Mean interval between creation of ileostomy and ileostomy closure was 76 days (range, 55 to 306). Mean length of hospitalization was 3.9 days (range, 2 to 10). Mean BMI at the time of ileostomy closure was 22.1 (range, 15 to 35).
Short-Term Outcomes PC was performed in 25 patients (51 percent) and CSWA performed in 24 (49 percent) patients. No wound infections were observed in the CSWA group, compared to a 40 percent wound infection rate observed in the PC group (P = 0.002, Table 2). All wound infections were amenable to local treatment, and no patient experienced a serious complication such as sepsis or necrotizing fascitis. All wounds were healed at the time of the second ofce visit. No statistically signicant differences were found in the age, gender distribution, BMI, operating time, length of hospital stay, and the interval between the creation and closure of the ileostomy between the PC and CSWA groups. Long-Term Outcomes Thirty-one of the 49 (63 percent) study patients completed the patient satisfaction questionnaire. As the questionnaire was performed in October 2007, the mean time interval was 13.7 months (range, 7 to 25) between ileostomy closure and questionnaire. Mean patient satisfaction score was higher in the CSWA group (18.4, range, 11 to 25) than the PC group (15.9, range, 8 to 24, P 9 0.05). Although

an overall nal score of 6 to 30 was possible, with 6 representing the worst outcome and 30 the best outcome.
Statistical Analysis All data were entered into a standardized database computer program (Microsoft Excel, Seattle, WA). Statistical analyses were performed with SAS version 8.02 (SAS Institute, Inc., Cary, NC). For continuous covariates, means were compared with the Students t-test. Categorical variables were compared with the use of Fishers exact test. All hypothesis testing was two-sided with P value of less than 0.05 considered statistically signicant.
A

TABLE 2. Clinical feature of patients receiving primary closure or circumferential subcuticular wound approximation for ileostomy wound closure Primary closure 25 46 16 9 77 23 62 3.6 40 100 Circumferential subcuticular wound P approximation value 24 38 13 11 74 21 73 4.2 0 100 0.06 0.48 0.81 0.12 0.07 0.19 0.002 1.0

Variable N Mean age (years) Gender, male, n female, n Mean time from stoma creation to closure (days) Mean BMI Mean operative time (minutes) Mean hospital stay (days) Wound infection rate, % Wound healing at 1 month, %
BMI = body mass index.

RESULTS
Forty-nine patients were identied. Mean age of the patients was 41.8 years (range, 19 to 77). Twenty-nine

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FIGURE 6. Individual patient satisfaction scores with wounds after undergoing primary closure or circumferential subcuticular approximation.

individual factor scores were consistently higher in the CSWA group than PSC group (Fig. 6), suggesting that patients in the CSWA group were happier and more satised, these differences were also not statistically signicant.

DISCUSSION
Small bowel obstruction is the most common complication after closure of loop ileostomy, closely followed in frequency by incisional wound infection.12,13 The overall incidence of wound infection after stoma closure in large reported series ranges from 3 percent to 18 percent.14Y16 Although the overall incidence of wound infections in this study was 20 percent, 40 percent of wounds undergoing PC became infected, signicantly higher than most of the large reported series. Reasons for this observation are unclear but might be related to our high number of IBD patients. A small, prospective study examining stoma closure after rectal cancer procedures showed only a 4 percent incidence of wound infections after primary wound closure.15 A larger controlled study of patients with both rectal cancer and IBD showed a 9 percent wound infection rate.16 As this study comprised almost exclusively IBD patients, our data suggests the residual effects of potent immunosuppression might predispose this patient population to stoma wound infection. Several closure techniques for the stoma wound have been described, including PC, delayed PC, and secondary closure. The superiority of any of these techniques over others is unknown. The rate of wound infection after CSWA was signicantly lower compared to PC. A relationship between the incidence of wound infection and the technique of skin closure has been previously shown.4,9,12 These three retrospective studies have consistently shown markedly increased wound infection rates of PC compared with delayed primary closure or secondary wound closure. In the only prospective, randomized study examining this issue, Lahat and coworkers found that wounds undergoing

delayed primary closure had a higher (yet statistically insignicant) rate of wound infections compared to PC.9 As our results also suggest that CSWA was associated with a very low incidence of wound infection, we strongly recommend that this technique be used by all surgeons during ileostomy closure. Future randomized trials will be able to condently elucidate the role of secondary closure of the wound in reducing the rate of wound infection after ileostomy closure. An important but frequently overlooked aspect of surgical care is the cosmetic end point. With no validated scoring system to assess surgical cosmesis, this result has not been routinely analyzed. In this study, we developed a scale evaluating the patients perception of the difculty of the healing process and the quality of wound healing. The results suggest that patients undergoing CSWA had better postoperative healing and cosmesis compared to patients undergoing PC. This difference was not statistically significant, however we concede that a larger study with increased number of patients could potentially show signicant results. The value of this scoring system will become apparent only when future studies validate these results. The technique of CSWA described herein parallels that described in another report.11 Banerjee used a nonabsorbable pursestring suture leaving a 5-mm gap which was not packed. We used a rolled 2x2 gauze in the middle of the wound, and by using an absorbable suture, the need to remove any suture in the ofce was eliminated.

CONCLUSIONS
CSWA can eliminate the risk of wound infection after stoma closure. The increase in hospital stay and operating room time in patients treated by this method was insignicant. Little additional nursing care was needed for patients undergoing CSWA, and patients were very satised after having CSWA. We recommend CSWA as a method for eliminating wound infection after ileostomy closure, and also emphasize its superior cosmetic results and higher patient satisfaction.
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