From this study, we found that stoma closure using NPWTi-d was an effective treatment for stoma wound closure. No patients developed SSI when using NPWTi-d, and the management was significantly better than conventional primary suture closure.
A temporary stoma is usually used for the patients undergoing a low pelvic anastomosis with rectal cancer and benign diseases, such as ulcerative colitis, Crohn’s disease, and familial adenomatous polyposis. The most unfavourable complication of a low pelvic anastomosis is anastomotic leak12–14. The temporary diverting stoma may be able to avoid an anastomotic leak.
Complications after stoma closure include SSI, intestinal obstruction, incisional hernia, and anastomotic leakage. SSI is the most common surgical complication after stoma closure. Since the procedure requires enteric anastomosis, stoma closure is a clean-contaminated procedure. Risk factors for SSI include chemotherapy, obesity, diabetes mellitus, history of smoking, long-term steroid administration, and immunosuppressant administration15,16. In addition, the type of stoma created affects the incidence of SSIs. Colostomy has a higher incidence of SSI than ileostomy. A previous study reported that colostomy reversal was associated with a 5-fold increase in SSI compared with ileostomy reversal. It is thought that this may be because the colon tends to harbour a higher bacterial count and be associated with an increased risk of SSI17. SSI leads to an increase in the treatment burden on medical staff and patients. It causes longer postoperative hospital stays, more outpatient visits, additional home health care utilization, and higher health care costs. In addition, an abdominal incisional hernia may develop as a late complication of SSI after stoma closure. An abdominal incisional hernia can significantly reduce the patient's quality of life and, in some cases, may require surgical procedures. Thus, it imposes an increased burden on the patient and increases medical costs15.
Several treatments have been attempted to reduce SSI after stoma closure, and several studies have reported that primary closure is linked with high rates of SSI, with reported rates vary between 2% and 40%4,18−20. In primary suture closure, the wound closes immediately and dead space may form, in which subcutaneous fluid accumulates and an abscess may form 21. A few studies reported primary closure with drainage tubes being placed in the subcutaneous layer below the wound. However, this technique still has a high infection rate of approximately 20%22.
Purse-string sutures have one of the lowest infection rates, and have proven to be a useful technique2,5,22. However, this method often takes a long time to complete granulation and epithelialization23. Patients require continuous wound care and outpatient visits. Elderly patients may have difficulty performing self-care treatment.
NPWT therapy can compensate for these problems. Currently, although NPWT is used in a variety of wounds, its prophylactic use is not yet considered essential after stoma closure. A study on the use of NPWT in preventing SSIs and improving wound healing time after stoma closure has failed to demonstrate the efficacy of NPWT in comparison to purse-string sutures7. Local infection still occurs with NPWT7,24.
NPWTi-d therapy may be able to further reduce infection rates. NPWTi-d can prevent bacterial growth by automatic cleansing of the wound surface as well as early and thorough removal of dissolving devitalised tissue and exudate. By using NPWTi-d on the stoma closure wound, the promotion of granulation may reduce the dead space and the risk of SSI25–31. It may also shorten the wound healing period. This will reduce the burden on medical staff and patients and lead to a reduction in inpatient duration and outpatient visits. However, it has not been clarified whether NPWTi-d is useful for prophylactic use of SSI after stoma closure. In this study, NPWTi-d therapy was remarkably useful for SSI. On the other hand, we could not prove the usefulness of shortening the length of hospital stay and shortening the healing period.
This study has several limitations. First, this was a single-centre retrospective study; thus, the number of patients was limited. Second, it was a comparison between NPWTi-d therapy and conventional primary closure, not a purse-string wound closure or NPWT therapy.
In conclusion, NPWTi-d therapy at the stoma closure site was a highly effective treatment for reducing SSI. We believe that NPWTi-d therapy should always be considered at stoma closure site. Further ingenuity will be needed to shorten the length of hospital stay and the healing period of wounds.