Comparative analysis of pursestring method versus conventional methods for stoma closure

Comparative analysis of pursestring method versus conventional methods for stoma closure | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Method Article Comparative analysis of pursestring method versus conventional methods for stoma closure Amil Huseynov, Veli Vural This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4162772/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Stoma surgery, crucial for conditions like Crohn's disease and colorectal cancers, requires effective closure techniques. This study compares the pursestring method to conventional closure methods, focusing on postoperative outcomes and complications. Methods: The study involved a systematic comparison between the pursestring and traditional linear suturing techniques in stoma closure. Patient selection was based on specific criteria, ensuring a representative sample. Variables such as surgical time, complication rates, and recovery periods were meticulously recorded and analyzed. Results: The analysis revealed that patients undergoing the pursestring method experienced significantly lower infection rates and quicker healing times. This method, employing a circular suture pattern, proved more effective in minimizing postoperative complications compared to conventional methods. Conclusion: The pursestring method demonstrates a notable advantage over traditional techniques in stoma closure. Its benefits in reducing infection rates and promoting faster recovery highlight its potential as a preferred method in surgical practice. The study advocates for its broader adoption in clinical settings, considering its positive impact on patient outcomes. Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Stoma is a procedure implemented due to conditions such as Crohn's disease, ulcerative colitis, carcinomas, diverticula, obstructions, radiation enteritis, ischemic bowel, fecal incontinence, trauma, and congenital diseases. Stoma types opened for excretion purposes are colostomy and ileostomy. The procedure of bringing the colon to the skin is called a colostomy, and the procedure of bringing the ileum to the skin is referred to as an ileostomy. Stomas are classified as temporary or permanent based on their duration and purpose, and as loop or end based on the surgical technique employed(1). While the first stoma applications are encountered during the times when the Bible was written, the limited number of documents from these periods restricts gaining knowledge about the subject. In a scientific sense, the first stoma application is known to have been opened on a soldier wounded during the Ramilles battle that took place between the British and the French in 1706(2). Medical and technological advancements, alongside the development of early diagnosis and treatment methods, have led to a decrease in deaths due to diseases and an increase in the expected lifespan. These developments also influence individuals' lifestyles. Even though stoma is opened to improve individuals, it can negatively impact their lifestyle and quality of life. Stomas, which are opened mainly to eliminate the underlying pathology and to enable individuals to lead a more quality life, heavily affect the life process, being seen as a significant intervention by the patients(3). Individuals with stoma face problems like changes in body appearance and losing control over their excretion function. Studies have shown that individuals with stoma experience negative emotions about stoma and encounter many problems physiologically, psychologically, and socially as their quality of life is affected. It is also observed that their family relations and social lives are negatively impacted, and they tend to isolate themselves from society due to this(3,4). The most common physical problems encountered by individuals with stoma are odor, gas, leakage, problems related to the bag system, skin irritation, and other stoma complications. Socially, they tend to isolate themselves from society, lose confidence in themselves, and tend to not continue socio-cultural activities. It is observed that their family and work lives are negatively affected, with decreases in work hours and work productivity after the opening of the stoma, changes in jobs, and quitting jobs. It is reported that there are psychological differences such as demographic characteristics like age and gender, clinical differences like underlying disease and stoma type, time passed after stoma surgery, current health status, self-efficacy related to stoma, and coping in adjusting to stoma(4). Considering these and other reasons, closing the stomas as quickly and efficiently as possible positively impacts the patients' quality of life. Stoma closure is considered a minimally invasive surgery; however, surgical site infection (SSI) is a commonly observed complication. Recently, the number of diverting ileostomy cases has increased due to the rise in the number of anal sphincter preserving operations such as super low anterior resection (sLAR) and intersphincteric resection (ISR) for rectal cancer. This study focuses on the methods used to reduce the incidence of SSI in stoma closure. The incidence of wound site infection following stoma closure varies between 2% and 41% in different studies(5,6). The most common cause of wound site infection is bacterial contamination of the skin surrounding the ileostomy/colostomy due to prolonged contact with intestinal content or leakage of stoma content. A study conducted in 1997 introduced the purse-string method (PSM), and in this method, the risk of wound site infection decreased, and better cosmetic results were observed(7). The number of studies investigating the effectiveness of PSM is limited, however, another study reported that the placement of a Penrose drainage tube under the subcutaneous tissue was effective in preventing SSI and superficial incisions in PSM were better for SSI control(9,10). Studies comparing the comfort of life with patients whose stoma was closed have reported conflicting results. This study aims to evaluate the relationship between surgical techniques after surgical treatment in the postoperative period in patients who had a stoma opened for various reasons and then closed, with wound site healing and complications. By considering these factors and employing effective and rapid methods for stoma closure, we can greatly improve the quality of life for patients. Exploring different techniques and strategies in the context of stoma closure will help us understand the complexities and opportunities for improvement in this medical procedure. Through research and clinical trials, we can continue to refine our understanding and potentially develop new techniques and strategies for managing and treating patients with stomas. A stoma, either temporary or permanent, is often required due to conditions such as Crohn's disease, ulcerative colitis, carcinomas, and others. Despite being beneficial in managing underlying health conditions, stomas significantly impact patients' lives, often leading to physical, psychological, and social complications. Therefore, closing the stomas promptly and efficiently can improve the patient's quality of life. While stoma closure is seen as a minimally invasive procedure, surgical site infection (SSI) is a common complication, with incidence varying between 2% and 41%. The purse-string method (PSM) has been found to decrease the risk of SSI and provide better cosmetic results. Despite limited studies on PSM, it has been found to prevent SSI effectively when paired with subcutaneous Penrose drainage. This study aims to explore the impact of different surgical techniques on wound healing and complications post-stoma closure, ultimately contributing to improved patient outcomes. By understanding and refining these methods, we can enhance the quality of life for patients with stomas. 2. General Information 2.1 Definition of Stoma A stoma is an artificial opening created in the abdominal wall as a surgical solution to various conditions such as colorectal cancer, inflammatory bowel disease, diverticular disease, and abdominal trauma(8). This allows the output of the colon (colostomy), ileum (ileostomy), or urinary tract (urostomy) to be emptied into a bag. All surgical procedures that redirect the normal movement of bowel content to the outside of the body when a portion of the bowel becomes diseased or removed are referred to as stoma (ostomy)(9). Creating an ostomy means bringing a part of the bowel through the abdominal wall, allowing waste to exit the body through the abdominal wall instead of passing through the anus(10). It is estimated that there are approximately 124,000 people with a stoma in the United Kingdom alone. The most common underlying conditions that require stoma surgery are colorectal (intestinal) cancer, bladder cancer, ulcerative colitis, and Crohn's disease(11). Colorectal bowel cancers are the third most common cancer in men and the second most common in women in the UK. Over 18,000 new cases of colorectal cancer in men and over 16,000 new cases in women are seen each year in the UK(12). Another condition that can lead to stoma formation is inflammatory bowel disease. Colitis, ulcerative colitis, and Crohn's disease are inflammatory bowel diseases and are the most common causes of ileostomy formation(13). Stoma formation is a simple intervention, but its outcomes can be complex and life-threatening. The procedure is usually performed at the end of a long and complex surgical operation(14). There may be a tendency to leave it to a young member of the team, but if done poorly, it can leave a legacy of complications such as leakage, prolapse, parastomal hernia, and retraction. Because the formation of a stoma can prolong patients' lives and help them return to a healthy life(15). However, this process can cause a person to experience various problems in physiological, social, and psychological aspects. Individuals with a stoma suffer from psychological problems such as depression, anxiety, changes in body image, low self-esteem, sexual problems, denial, loneliness, despair, and stigmatization. Social problems include; loss of interest and less participation in social activities, avoidance of travel, reduction in work activities, deterioration of partner relationships, decrease in contact with friends/relatives. These problems can negatively affect the individual's adaptation to the stoma and their ability to cope with the stoma(16). 2.2 Stoma Anatomy In anatomy, a stoma (stoʊmətə) is any opening in the body. For example, a mouth, a nose, and an anus are natural stomas. Any hollow organ can be redirected to form an artificial stoma as required. This practice includes the esophagus, stomach, duodenum, ileum, colon, pleural cavity, ureters, bladder, and renal pelvis. Such a stoma may be permanent or temporary (17). Surgical procedures involving the creation of an artificial stoma typically have names ending in the suffix "-ostomy", and the same names are often used to refer to the stoma created in this way. For example, the word "colostomy" refers to either an artificial anus or the procedure that creates it (18). Enterostomies are first classified according to the bowel segment brought to the surface and then according to the number of openings in the bowel, into loop ostomies and end ostomies (19). Today, the most common indication for the creation of an intestinal ostomy is intestinal cancer. Anastomotic insufficiency (AI) following oncological resection of the rectum is associated with a mortality risk of 6-22% and is therefore one of the most serious complications of colorectal surgery (20). The risk of anastomotic insufficiency (AI) after deep rectal resection has been reported to be 10-15% (21). To improve the outcomes of AI, a protective ostomy is routinely performed. In a prospective study conducted by Law et al., an ostomy was created in 291 (73.5%) out of 396 patients treated with oncological rectal resection (22). In a systematic review of enterostomies by Rondelli and colleagues, an ostomy was performed on 89% of 1529 patients undergoing treatment for colorectal carcinoma. This data forms the basis of the current "consensus" in Europe (23,24). Besides, there are advantages and disadvantages according to the types of ostomies performed (Table 1). Table 1. Ostomy Types, Advantages and Disadvantages Most Common Indications Advantages Disadvantages / Complications Loop Colostomy - Protective ostomy in Double Stapled Anterior Resection (DARR) Palliative, unresectable rectal carcinoma Complex perianal fistulas and inflammatory processes Radiation proctitis Rectal rectal carcinoma Incontinence Minor skin damage, no loss of fluid and electrolytes due to more solid stool Simple closure Increased odor due to intestinal bacteria End Colostomy Perforated diverticulitis with fecal peritonitis Rectal resection without continuity in deep-seated carcinoma Abdominoperineal rectal resection Less skin damage due to firmer stools, no fluid and electrolyte loss Difficulty in restoration (colostomy reversal) Loop Ileostomy Protective ostomy after proctocolectomy in FAP / CIBD (otherwise indications for loop colostomy) Simple closure - High amounts of fluid loss Perianal secretion of mucus may occur End Ileostomy Emergency proctocolectomy or colectomy Failure of an IPAA (ileal pouch-anal anastomosis) Extended bowel resection in bowel ischemia ----- High amounts of fluid loss Difficult restoration (reversal) AI: Anastomotic Insufficiency, CIBD: Chronic Inflammatory Bowel Disease, DARR: Deep Anterior Rectal Resection, FAP: Familial Adenomatous Polyposis Coli, IPAA: Ileal Pouch Anal Anastomosis. Güenaga et al. (25) found no difference in terms of complications between a loop ileostomy and loop colostomy as a protective ostomy; Tilney et al. (26) demonstrated fewer complications after loop ileostomy when examining the same issue. The evidence is not clear, so the choice of ostomy type for this indication is at the discretion of the individual surgeon. At our center, only loop ileostomy is used to protect the anastomosis following rectal surgery. The comfort and functional status of a stoma depend on its location and the quality of the surrounding skin. The main rule in stoma site selection should be to bring the bowel out with sufficient blood flow without tension. Additionally, the stoma should be opened in a place that the patient can easily see and empty and change their bag (27). The type of disease is as influential as the patient's body structure in the selection of the stoma site. The stoma is opened in the abdominal area below the navel, in the right or left lower quadrant. In ileostomy, the right lower quadrant is used, in transverse colostomy the upper middle quadrant, and in descending and sigmoid colostomy the left lower quadrant is used. If the patient is dependent on a wheelchair or obese to the point of not being able to see the stoma, the stoma can also be opened from the upper quadrant. Also, the localization of the rectus muscle, the patient's field of vision, the adequacy of the adherent surface, and avoidance of skin, folds, scars, navel, waistline, saggy breasts bottoms, bone protrusions are important (28). After marking the location of the stoma before surgery, various positions can be given to the patient to see the condition the stoma will take. This trial can also be done by attaching a stoma bag. As stomas have become frequently applied, stoma care problems have also started to increase. In parallel with advancements in technique, the ileostomy club established in New York in 1951 led to the concept of enterostomal therapy being brought to the agenda, thus steps have been taken in post-stoma care, education, and rehabilitation of patients (29). 2.3 Stoma Types Generally, stomas are examined in three categories. The most commonly used ones are colostomy, ileostomy, and urostomy. Each ostomy procedure is done for different reasons. While these three ostomies have many similarities with each other, they also have significant differences. Stomas can be classified according to their general characters, i.e., anatomical features, as well as prognostic factors, stages, function, and reasons for their construction. However, the most commonly used type in the clinic is the classification form according to their anatomical features (Table 2). Table 2. General Stoma Types (30) 2.3.1 Colostomy Colostomies are created for two purposes. a.Decompressive colostomy, which reduces the pressure in the large intestine b. Diverting colostomy, which diverts the flow of feces a-Decompressive Colostomy: This is done to prevent perforation and achieve urgent decompression due to a mass causing blockage in the colon or rectum. A transverse loop colostomy, cecostomy, or blowhole colostomy can be created for decompression purposes (31). b-Diverting Colostomy: Diverting colostomies are created for the purpose of fecal diversion. These colostomies are opened in cases of traumatic injuries, colon diverticulum perforations, anastomotic leaks, colorectal fistulas, and situations where there are risky anastomoses distally. A loop colostomy, double-barrel colostomy, or Hartman's colostomy can be created for the purpose of temporary diversion (32). A colostomy can be temporary or permanent and can be in any part of the large intestine depending on the reason for the surgery. The types of colostomy are generally determined by the location of the stoma: Ascending colostomy, transverse colostomy, descending colostomy, end colostomy, and cecostomy are the terms used (33). An ascending colostomy is located on the right side of the abdomen. The output is very liquid. A drainable pouch is worn for this type of colostomy. This type of stoma is rarely used as an ileostomy is a better stoma when the output is liquid. When a colostomy is placed in the right half of the colon, only a short portion of the colon remains. The care for an ascending colostomy is similar to caring for a transverse colostomy (34). A transverse colostomy is in the upper abdominal area either in the middle or to the right of the body. Diverticulitis, inflammatory bowel disease, cancer, obstruction, injury, or birth defects can lead to a transverse colostomy. This type of colostomy allows feces to exit the colon before it reaches the descending colon (35). A descending or sigmoid colostomy is located on the lower left side of the abdomen. Generally, the discharge is firm and can be regular. The sigmoid colostomy is probably the most commonly performed of all colostomies(36). Colostomies are anatomically divided into two: 1. End Colostomy End colostomies are often sigmoid colostomies and are generally located in the left iliac fossa. Electively, abdominoperineal excision for anorectal tumors is a common indication. In an emergency, the Hartmann procedure is often performed for ischemia, perforation, obstruction of the distal colon or rectum(37). The resulting end colostomy can potentially be reversed after 3-4 months, but this is a significant intervention, especially in older patients (mortality 4-5%) and up to 40% of stomas cannot be reversed. Laparoscopic stoma formation is advocated by some surgeons, but is currently a complex procedure performed by relatively few British surgeons(38). Several attempts have been made to create an end colostomy. Implantable devices and colostomy plugs are not popular due to infection complications and ulceration, respectively. The most effective technique may be colonic irrigation via a Foley catheter passed into the colostomy, after which patients can pass 6-8 hours with minimal colostomy output(38). 2. Loop Colostomy Loop stomas are most common in the terminal ileum, transverse, and sigmoid colon. Loop colostomies are formed over a plastic rod to limit early retraction. This is removed when the mucocutaneous anastomosis has matured (5-7 days later). Generally, these are temporary stomas used for diverting fecal flow and can usually be reversed at the stoma site 2-3 months after formation. They are commonly used to protect a distal anastomosis following elective colorectal surgery of the distal colon/anterior resection or anal sphincter repair(39). A loop stoma is a stoma with two different openings. An entire bowel loop is brought out of an incision onto the surface of the abdomen and then opened to create two openings in the bowel: a proximal (functional) opening and a distal (non-functional) opening. The proximal opening expels feces as it moves downward from the bowel, and the distal opening allows mucus to exit from the distal or lower part of the bowel(40). Typically, a small rod, soft tube piece, or some other such device is placed under the bowel loop outside the abdomen to prevent the bowel from retracting back into the abdomen and provide support; it is usually removed within two to seven days(41). Loop stomas appear externally the same as loop-ended stomas, and the difference between them is internal. The distal end of a loop-ended stoma simply terminates in a simple blind sac, which is nothing more than a piece of bowel severed from its connection with the rectum. This type of stoma is more common in urology procedures(42). 2.3.2 Ileostomy The ileostomy technique used by Baum in the 1870s was tried for the purpose of colon tumor obstruction. Brooke then applied the full-thickness eversion technique, Goligher the extraperitoneal, and Kock the continent ileostomy technique(10). He stated that the use of ileostomy was limited due to high drainage in the stoma and skin problems before particularly describing the Brooke full-thickness eversion method(43). Ileostomy is used for the removal of the entire colon-rectum, protective purpose of colorectal in distal, by-pass, coloanal, ileoanal anastomosis. If the anorectal sphincter mechanism is removed, it is done permanently, if not removed, it is done temporarily(28, 30). Today, there are three types of ileostomy in use: end ileostomy, loop ileostomy, and continent ileostomy. A) End Ileostomy (Brooke): It is generally used for permanent purposes. An end ileostomy is traditionally placed in the right iliac fossa and is usually a permanent stoma. Electively, proctocolectomy for inflammatory bowel disease or familial adenomatous polyposis coli is the most common indication, but ileo-anal pouch surgery has reduced the need for this. In an emergency, an end ileostomy is usually temporary. The small intestine can be edematous and fragile, making it difficult to create an outward-facing 2–3 cm orifice. Cuts made along the serosa of the ileostomy can facilitate eversion(45). End ileostomy with subtotal colectomy is a first-stage procedure in fulminant or perforated ulcerative colitis and distal obstruction of the colon where the cecum is dead or perforated. An end ileostomy is also required after segmental resection of the small intestine where a primary anastomosis (e.g., perforated Crohn's disease, thromboembolic intestinal ischemia) is not safe. The distal bowel is closed and left inside the abdomen or brought out as a mucus fistula(Figure 1). Relaparotomy is required to restore bowel continuity and is done once the patient has recovered (usually after 3-4 months)(46). B) Loop ileostomy: This was first described by Turnbull in 1961. The ileum mesentery is technically easier in short and fatty individuals(10). Although generally made for temporary purposes, studies have shown that 40% are permanent(47). With the development of surgical tools and techniques, it is now mostly done in surgeries preserving tight anal sphincters. Loop ileostomy is used to divert fecal flow temporarily after these surgeries. When successful diversion is not achieved, it has also been a good alternative technique to loop colostomy(48). Indications for its use include protection of risky anastomoses distally during use, anal abdominal fistulas, colo-rectal obstructions, toxic megacolon, and findings where end ileostomy technically cannot be performed. It is a method that causes fewer complications compared to loop colostomy used for diversion, is easy to close, occupies less space, has less odor, and is easy to care for. However, its maintenance is slightly more difficult compared to end ileostomy(49). Since the ileostomy is close to the abdominal skin, there is more enzymatic content, drainage, fluid electrolyte and vitamin loss because more proximal ileum is used than end ileostomy(50). C) Continent ileostomy (Kock Pouch): This technique, first used by Nils Kock in 1969, uses 45 cm of terminal ileum. A 30 cm segment is used to create a pouch and a 15 cm segment is used to create a stoma. A continent ileostomy is an internal pouch made just before exiting from the end of the ileum, through the abdominal wall as an ileostomy, sometimes called a Kock pouch(51). The surgeon makes a valve inside the pouch to prevent bowel content from leaking out. The person drains the pouch every day by inserting a thin, flexible tube called a catheter inside the stoma. The person covers the stoma with a simple patch or dressing. Continent ileostomy is an option for those who are not suitable candidates for an ileoanal reservoir due to damage in the rectum or anus, and who do not want to wear an ostomy bag(52,53). 2.3.3 Ureterostomy Urinary stomas involve the process of bringing the ureters to the abdominal wall by making a bladder from the ileum conduit, colon, or jejunum and anastomosing with the ureters. Reasons for opening a urostomy include fistula, bladder cancer, urinary incontinence, neurogenic bladder, congenital anomaly, and radiation cystitis(54). Urostomies are classified according to their formations. Bringing the ureters to the body surface is called ureterostomy, and cutting 12 cm from the ileum and making an anastomosis of the ureters to the ileum is called ileal conduit ureterostomy(55). 2.4 Stoma Complications Colostomies and ileostomies are created in the treatment of various medical conditions, including cancer, diverticulitis, and inflammatory bowel disease. Unfortunately, the operations in which ostomies are created have high surgical complication rates compared to other common types of surgical procedures(56). A new population-based study based on National Surgical Quality Improvement Program data reported complication rates of 37% for elective cases involving ostomy and 55% for emergency operations. Furthermore, risk-adjusted morbidity rates vary significantly between hospitals, indicating the potential to improve outcomes(57). Ostomy surgery is associated with various short and long-term complications, including parastomal hernia, prolapse, stenosis, retraction, parastomal varices, skin disorders, and metabolic disorders. Table 3. Stoma Complications (30) 2.5.1. Early Complications 2.5.2. Late Complications I. Bleeding II. Ischemia and Stoma Necrosis III. Peristomal Infection and Perforation IV. Retraction V. Mucocutaneous Separation VI. Early Obstruction I. Prolapse II. Parastomal Hernia III. Stenosis IV. Late Obstruction V. Peristomal Skin Problems VI. Stomal Fistula VII. Metabolic Complications VIII. Diarrhea IX. Urinary Stone Formation X. Gallstone Formation Some of the most common stoma complications are summarized below: Ischemia: One of the main causes of impaired blood flow to the stoma. It is more common in colostomies than in ileostomies (especially if the left colic artery is tied). Mechanical factors (e.g., excessive tension in the intestine due to insufficient mobilization), an inadequate incision in the abdominal wall fascia, or the use of vasopressors (e.g., noradrenaline) contribute to ischemia. The stoma should be pink and moist (58). Some superficial browning can be tolerated; if it is grey or black and dry, further investigation is needed. Inserting a flexible sigmoidoscope allows the length of the ischemic segment to be evaluated. If the ischemia is close to the fascia, urgent stoma revision may be required (59). Retraction: This is most commonly seen in obese individuals if there is insufficient mobilization in the intestine or if the stoma becomes ischemic due to separation of the mucocutaneous junction. It occurs in end and loop stomas. Complete retraction into the peritoneal cavity leads to peritonitis, and urgent reoperation is indicated (60). Stenosis: An ischemic stoma often narrows at the skin or subcutaneous tissue level. This is most commonly seen in end colostomies. Alternatively, a tight aponeurotic opening in the abdominal wall can cause a short stricture at this point. Recurrence should be considered in patients with Crohn's disease. In most cases, symptoms are minimal, but if severe, the stricture can cause bowel obstruction (61). Stomal prolapse: A large fascial opening, excessive mobility of the intra-abdominal bowel, and high intraabdominal pressure predispose to stomal prolapse. It is common in loop colostomies (especially transverse) and is often associated with a parastomal hernia. Intervention is not necessary if the prolapse is mild and not progressive. Urgent or elective intervention is indicated for painful, irreducible or gangrenous prolapse and for progressive chronic prolapse with ulceration or bleeding (62). Parastomal herniation: This is seen in about 30% of stomas. Factors predisposing to parastomal hernias are similar to prolapse. Most are sliding hernias containing small bowel or omentum. Patients generally have minimal symptoms, and the risk of strangulation is low, so they can be reassured (63). Dermatitis: Peristomal skin is exposed to chemical dermatitis from fecal waste, contact dermatitis from occlusive devices, allergic responses to adhesives, as well as fungal and bacterial infections. Careful stoma care coordinated by a qualified Stoma Nurse is very important to prevent and treat such problems. Common skin problems (e.g., psoriasis) and symptoms of inflammatory bowel disease (e.g., pyoderma gangrenosum, fistulas associated with Crohn's disease) can further jeopardize peristomal skin and may require specialist intervention (64,65). Psychological: Many patients feel that their quality of life has decreased, and this is worsened if the stoma is poorly placed or constructed. Regular advice from a doctor and Stoma Nurse is very important (66). 2.5 Stoma Indications Today, the most common indication for creating a bowel ostomy is bowel cancer. After oncological resection of the rectum, AI is associated with a mortality risk of 6-22% and therefore represents the most serious complication of colorectal surgery (67). The risk of AI after deep rectal resection has been reported to be 10-15% (68). A protective ostomy is routinely performed to improve the outcomes of AY. In a prospective study by Law and colleagues, an ostomy was formed in 291 of 396 patients (73.5%) treated with oncological rectal resection (69). In a systematic review of enterostomies by Rondelli and colleagues, an ostomy was applied to 89% of 1529 patients treated for colorectal carcinoma (70). These data form the basis of the "necessary consensus" in the current German S3 guideline on the formation of a temporary stoma after deep anastomosis with radical rectal resection (71). Stoma indications are listed below: · Ensuring excretion in cases where continuity is not maintained, where a part of the gastrointestinal system is resected from a certain level downward (ulcerative colitis, rectovesical, rectal injuries, Crohn's disease, fistula, etc.). · Removal of blockage caused by a space-occupying pathology such as a tumor distally, which is formed and not eliminated. · Removal of the anus due to anorectal cancer. · Removal of fecal flow from the pathological event in the distal area until healing is achieved (in cases of wide defects in colorectal injuries, anal incontinence, sigmoid colon volvulus, extensive perineal burns)(30). · Use of the enteral feeding route in patients where oral nutrition cannot be provided due to a pathology in the proximal area (72). · It is applied in malignancies related to the bladder, chronic inflammation of the bladder, and congenital defects related to the urinary system (73). 2.6 Determining the Stoma Site Gastrointestinal ostomies can be formed under elective or emergency conditions, shaped from the small or large intestine, considered temporary or permanent, and can be made during surgeries with curative or palliative intent for benign or malignant diseases. Despite this heterogeneity, some principles of stoma formation are universal: the bowel for the stoma should be well vascularized and sufficiently mobilized to minimize tension. · The stoma should be opened in the area within the rectus abdominis muscle where the patient can easily see and independently perform their care. · The stoma should be on top of the rectus muscle, with a sufficient flat surface for the stoma bag to stick. · Areas such as the iliac crest, skin folds in the abdominal area, scar areas, the navel, and belt lines should not be preferred in the selection of the stoma site. · The patient's profession, activity status, age, culture, lifestyle, and preferences should be taken into account when selecting the stoma site. · When determining the stoma site, the patient should be evaluated for the stoma area, void, scar, and fold direction while lying on their back, sitting, and standing. · After marking with a surgical pen, the marked area should be covered with transparent dressing material. · The stoma should be in an area that the patient can see; in overweight patients, the upper abdominal area can be preferred for the stoma (46). 2.7 Stoma Closure In the case of temporary ileostomies and colostomies, a second operation is required to ensure bowel continuity. Hartmann's operations have traditionally been considered complex; however, even a relatively simple operation to close a loop ileostomy is associated with significant morbidity. A systematic review of studies on the morbidity of closing a loop ileostomy revealed a morbidity rate of 4% for patients requiring laparotomy and 7-17% for patients developing bowel obstruction, with a mortality rate of 0.4%. The goal of this section is to provide evidence-based guidance on the technical aspects of stoma reversal surgery (74). The evidence was insufficient to reach a second goal guiding the timing of stoma reversal surgery. However, current studies suggest the safety of selective early (within 3 weeks) and late strategies for closing diverting ostomies, depending on clinical conditions (75). Several randomized, controlled studies have been conducted comparing stapled and hand-sewn techniques for closing loop ileostomies. In general, the results have been similar, with a higher risk of postoperative bowel obstruction and a tendency for longer operation time in the hand-sewn group (76). A temporary stoma is an intervention aimed at ensuring the normal continuation of the bowel after overcoming the acute situation and is often used. Indications for temporary stomas include obstructions of the small intestine, rectum, pelvis, and other parts of the colon, bowel obstructions due to left colon volvulus, perforated cancers, rectum, colon pelvic and perineal injuries, protecting other surgical interventions such as left colon anastomosis, rectovesical, congenital megacolon, rectourethral, imperforate anus, diverticulosis coli and complications, colon anastomoses, anastomotic stricture or obstruction, leakage from the primary suture sites in the colon (77). Diverting stomas can be closed after the adhesions and the underlying distal problem that caused them have healed. A minimum wait of 6 weeks is necessary for the inflammation and fibrous reaction caused by the initial intervention inside the abdomen to subside. The stoma is closed in 60-70% of patients who have a stoma. Studies have shown mortality rates of 0-4% and morbidity rates of 10-50% for loop and end stomas. The morbidity rate after the closure of the Hartmann procedure is around 30%. The most important complications are anastomotic insufficiency and wound infection. The closure morbidity of ostomies applied and closed due to trauma is between 5-27% (78). The most commonly seen complication after stoma closure is wound site infection. In addition to surgical technique and patient follow-up, proper stoma and patient care are necessary to minimize complications (79). Colostomy and ileostomy surgeries are surgeries that need to be carefully considered. If the necessary care is not taken, mortality and morbidity increase. The surgical complications of stoma closure, the stoma closure technique, and the timing of stoma closure can be related. Other factors such as the patient's age, underlying bowel pathology, and stoma type are important (80). Waiting for 3 months after the operation is important. This waiting period gives the patient a full chance to recover. Waiting increases the regression of inflammation, induration, and edema at the ostomy and abdominal site (81). Many studies suggest that a waiting period of 6-12 weeks does not affect the occurrence of complications. However, some researchers suggest that the waiting period does influence the occurrence of complications (82). Morbidity is higher in cases that are closed early. Waiting allows for the patient's condition to improve, the infected content of the bowel to heal, the wound infection to regress, the stoma area to be surrounded, and the wound on the distal side to heal (82). 2.8 Stoma Closure Techniques The closure of the stoma is considered a minimally invasive surgery; however, surgical site infection is a common complication. Recently, the number of cases of diverting ileostomy has increased due to the increase in the number of anal-preserving surgeries such as super low anterior resection (sLAR) and intersphincteric resection (ISR) for rectal cancer. Previous studies have focused on the benefits of a purse-string skin closure technique for closing ileostomy, which reduces the risk of wound infection and allows for better cosmesis by resulting in smaller scar marks (83). 2.8.1 Purse-String Method The first stage of the purse-string skin closure (PS) method or bag mouth closure method involves making an incision around the stoma with 2-3 mm circumferential borders (Figure 1A). This dissection along the mucocutaneous junction is then advanced to the fascial defect (Figure 2B). Bowel continuity is restored (end-to-end anastomosis or Albert-Lembert anastomosis). If the circumferential incision does not provide enough exposure, the incision can be converted into an elliptical incision. After the ostomy is closed, the subcutaneous tissues are washed with saline and hydrogen peroxide. Then, with a 2-0 monofilament subcuticular purse-string suture, a circular subcutaneous suture is performed at 1 cm intervals (Figure 3). This opening is then covered with a Penrose drain (83). The purse-string suture is a continuous suture used like a drawstring bag for the purpose of closure in circular wound tissues. The purse-string suture is a simple method that can be used to reduce the surface area of circular wounds with the aim of obtaining the least amount of scar tissue. This suture is placed before an ostomy tube is inserted, or it is used to close for the purpose of reducing rectal prolapse before rectal surgery. It can also be used to close a hole in the thoracic wall after it has been penetrated by a foreign object (84). 2.8.2 Conventional Methods In contrast to the Purse-string Method, an elliptical incision (extending transversely) is made around the mucocutaneous junction with 2-3 mm upper/lower boundaries and the skin is generally closed linearly (Figure 4)(85). Traditional closure with a linear incision expands the skin defect. Systematic reviews investigating the purse-string closure technique in reversing the stoma have shown that this procedure reduces Surgical Site Infection (SSI) rates, but its effect on length of hospital stay is questionable(86). Interestingly, readmission rates have not been reported in most studies related to stoma closure. A retrospective analysis of 351 enterostomy reversals reported a readmission rate of 12.5%; moreover, this rate was said to be associated with longer operative times, increased intraoperative complications, and hospital stay. Conventional linear suture techniques are believed to reduce readmissions(87,88). There is insufficient evidence as to which technique is best for skin closure in stoma reversal. The aim of this study is to evaluate whether the Purse-String Method (PSM) is associated with lower Surgical Site Infection (SSI) rates compared to Conventional Methods (CM). 3. Material and Method The medical records of 44 (forty-four) patients who had their stomas closed were retrospectively reviewed. Between August 2015 and November 2019 at Antalya, Mediterranean University Hospital, a total of 21 patients who underwent the Purse-String (PS) method and 23 patients who underwent the Conventional Method (CM) were compared. Medical charts were reviewed for patient demographics including age, sex, and body mass index; medical history such as presence of diabetes, chronic obstructive pulmonary disease, cardiovascular disease, and liver dysfunction, alcohol consumption (normal - moderate or non-drinker), smoking (one year prior to surgery), medication records, American Society of Anesthesiologists (ASA) score, preoperative blood values for PS and CM groups were checked. This study was approved by the Mediterranean University Ethics Committee with the number 70904504/518, and a Wound Site Assessment Survey was administered to all patients who received the survey, after obtaining written informed consent(Appendix 1). Surgical site infection was defined as the presence of cellulitis or purulent discharge with or without positive bacterial culture within 30 days after surgery (adapted from the CAE 1992 Centers for Disease Control and Prevention definition) (Table 4). Surgical wounds were routinely observed and assessed by the surgical team and screened until 30 days after the operation. Table 4. Centers for Disease Control and Prevention Guidelines for Diagnosis of Superficial Wound Infection Surgical Technique: All patients undergoing the procedure received preoperative mechanical bowel preparation. Prophylactic antibiotic (Cefazolin, 1g/day) was applied after the induction of general anesthesia. The skin surrounding the sutured stoma was removed, maintaining a margin of ~3-5mm. The bowel routes going to the stoma were taken out of the abdominal cavity and the dissection of the sutured stoma was performed. A functional end-to-end anastomosis or Albert-Lembert anastomosis was then made. The peritoneum and rectus fascia were closed using Vicryl 1.0. The open ileostomy/colostomy was sutured and the wound was washed with 500 ml of saline. Antibiotics were applied for 3 (three) days postoperatively. Statistical Analysis: Data presented statistically were analyzed using Pearson's Chi-square and Fisher's exact tests. Data for continuous variables are expressed as median (range). The Mann-Whitney U test was used for statistical comparison of different groups. A P <0.05 indicated a statistically significant difference. All tests were analyzed using IBM SPSS Statistics software, version 2.0 (USA). 4. Findings Patient characteristics such as gender, age, Body Mass Index, ASA Score, preoperative comorbidities are summarized in Table 5. There was no significant difference in patient characteristics such as age, gender, body mass index, preoperative comorbidities, ASA scores, and operative blood values between the PS and CM groups. Characteristics KY (n = 23) KA (n = 21) P-value Male Gender 16 15 0.738 Female Gender 7 6 Age 58 (32-79) 65 (28-80) 0.285 Body Mass Index 22 (16-27) 22 (14-29) 0.976 ASA Score 1 4 5 ASA Score 2 19 15 ASA Score 3 0 1 Preoperative Comorbidities Diabetes 1 0 Cardiovascular Disease 4 5 COPD 1 0 Alcohol Consumption 7 10 0.263 Smoking 6 7 0.836 Ileostomy / Colostomy 19/4 18/3 "All continuous variables are expressed as median (range). CM, conventional skin closure; PS, purse-string method for skin closure; ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease." Table 5. Clinical and demographic characteristics of patients (N = 44). In the CM group, postoperative bleeding was observed in 1 patient (4.3%). Anastomotic leakage was not observed in either group. The incidence of overall complications was not significantly different between the CM and PS groups (P=0.346). The median postoperative hospital stay was determined as 5 days (range, 3–19 days) in the CM group and 6 days (range, 3–24 days) in the PS group. The perioperative factors of the PS and CM groups are summarized in Table 4.2. The median operation time for the CM group was 67 minutes (range, 34-213 minutes) and for the PS group, it was 54 minutes (range, 40-190 minutes); this difference was not statistically significant (P = 0.387). The median blood loss in the CM group was 18 ml (range, 0-130 ml), while in the PS group, it was 22 ml (range, 0-130 ml) (P = 0.226). The median wound length in the PS group was 0.6 cm, which was significantly shorter than the CM group's (6 cm) (P <0.001). Regarding postoperative complications, CAE was observed in 4 patients (17.3%) in the CM group; whereas, no CAE was observed in the PS group. Therefore, a significant difference was found in the incidence of superficial incisional CAE between the PS and CM groups (P = 0.054). Table 6. Perioperative factors in skin closure with Conventional Method (CM) and Purse String (PS). Factors CM (n = 23) PS (n = 21) p Operation time, min 67 (34–213) 54 (40–190) 0.387 Blood loss, ml 18 (0-130) 22 (0-130) 0.226 Wound length, cm 6 (4–8) 0.6 (0.5–1) <0.001 Complications 5 2 0.346 Wound infection 4 0 0.054 Anastomotic leakage 0 0 - Postoperative bleeding 1 0 - Postoperative hospital stay, days 5 (3–19) 6 (3–24) 0.176 5. Discussion Intestinal stomas are the surgical extrusion of the small or large intestine through the anterior abdominal wall. While the principles behind forming a stoma are typically the same, there are numerous different stoma configurations formed for countless indications. A diverting stoma should prevent fecal flow from reaching a distal portion of the small or large intestine in order to treat or prevent anastomotic leakage. Stomas may also be necessary in sacral or perineal infections that are at risk due to constant fecal contact(63). Permanent stomas are necessary when pathological anatomy prevents the restoration of gastrointestinal continuity, when the risks of undergoing another operation are prohibitive due to patient comorbidities, or when the functional outcomes of a re-anastomosis would adversely affect quality of life(84). Cosmetic outcomes are also being considered as important issues for patients beyond basic health concerns. In stoma surgery, the optimal skin closure technique following loop ileostomy reversal has not yet been established(45). Currently, traditional linear sutured skin closure following the closure of loop ileostomy is widely used. This study fills in the gap of this less discussed topic of skin closure technique and highlights the better cosmetic outcomes of purse string stoma closure technique. Pokorny et al. (2005) reported 3% mortality, 20% wound infection, 10% bowel obstruction, and 5% anastomotic leakage(89). In our research, complications were observed in 21.5% of patients with CM and 9.5% of patients with PS. Various reports have shown that the rate of surgical site infections in patients closed traditionally has risen to 40%(90). Reviewing Korean studies on complications after stoma closure, Song et al. reported that 18 complications (32.7%) occurred in 55 patients after ileostomy reversal, including wound infection (24.3%), small bowel obstruction (16.4%), incisional hernia (7.9%), etc(91). Kim et al. reported that 33 complications (19.7%) developed in 164 patients, these complications were small bowel obstruction (11.5%), enteropathy (4.2%), incisional hernia (1.8%) and wound infection (1.2%)(92). Reviewing articles from other countries, Kaidar-Person reviewed 26 reports and reported a general complication incidence of 2-33.1%. These included small bowel obstruction 0-15%, wound infection 0-18.3%, anastomotic leakage 0-8%, and open abdominal reoperation in 0-12.8% of cases(93). Chow et al. reported in 48 reports analyzing 6107 ileostomy closures, that the general complication incidence was 17.3%, the death rate was 0.4%, and that open abdominal reoperation was required in 3.7% of them(94). Our results have been found to be similar to previous reports in Korea and other countries. The treatment of surgical site infection requires wound drainage, regular wound care, and antibiotics in some cases. However, cosmetic outcomes are not satisfactory and the healing period is extended. In a study that aligns closely with our research objective, "Comparison of Cosmetic Results of Purse String Method and Conventional Methods in Closure of Stoma Site After Loop Ileostomy," Atallah and colleagues (2018) reported that the median follow-up time for patients was 34 (12-64) months, where the PS technique was used in 10 patients and the conventional linear closure technique was used in 15 patients (95). In our study, the CM was applied to 23 of the 44 patients, and the PS method was applied to 21. Traditionally, outcome assessments in colorectal cancer include mortality, morbidity, recurrence of the disease, and long-term survival. However, patient-reported outcomes (such as cosmetic results) are now considered key measurements in evaluating the outcomes of interventions (72-75). Surgical site infection is one of the most common complications that can occur after stoma closure. Reports have identified differences in the incidence of wound infection depending on the skin closure technique (96). Two prospective randomized studies compared the incidence of infection after primary and secondary closure. It has been reported that surgical site infections occurred in 20% and 36% of cases where primary closure was performed, and in 10% and 5% of the secondary closure group. The rate of surgical site infection varies between 0-41% depending on the closure technique. Primary linear closure, secondary closure, and PS closure have been introduced as stoma closure techniques, but there is no consensus on the ideal closure technique for a stoma wound. In a prospective, non-randomized study, the rate of surgical site infection was 21.4% after primary linear closure, while no surgical site infection was seen in the PS group (97,98). The technique applied to reduce the wound size for the purest subcuticular closure has been described by Banerjee (99). Similar to the study by Milanchi and colleagues, it has been stated that there was no infection in patients where the PS method was applied. It has been reported that the performance of this technique for colostomies in addition to ileostomies did not lead to an increase in the infection rate (100). The infection rate in the conventional closure group was emphasized as 40%. Another study analyzing such a closure is a randomized clinical trial conducted by Reid and colleagues in the UK. In a randomized clinical study of short-term outcomes following the purse-string (PS) method versus conventional closure of the ileostomy by Reid et al.: 61 patients were randomly examined, with 31 and 30 in each group respectively. They reported that the only statistically significant difference found was a decrease in surgical site infection in the purse-string closure group(101). In line with this, there are two most notable results of our research. One of these results is that the rate of wound infection is higher in the conventional method, and the other is that the wound length is greater in the conventional method. This difference was found to be statistically significant. In a similar study, it was stated that canine ear deformity was seen in 13 (87%) patients who underwent conventional method, while no deformity was observed in patients undergoing the purse-string method; it was stated that a surgical site infection was diagnosed based on retrospectively collected data in one patient (7%) in the conventional group(95). In a randomized clinical study comparing the conventional closure with the purse-string method to eliminate the risk of surgical site infection, it was stated that the infection rate for the control group was 36.6% versus 0%; while the healing time was 5.9 weeks in the conventional linear closure group, it was 3.8 weeks in the purse-string group. It was reported that the satisfaction rate of the patients in the purse-string group was 70%, whereas it was 20% in the other group(102). In the meta-analysis of randomized controlled trials for reducing the surgical site infection rate following the closure of the stoma: against the traditional primary closure vs purse-string closure, it was stated that the most effective and cosmetically satisfying closure technique was purse-string closure(103). After the reversal of Loop Ileostomy, conventional techniques: Lee et al., who compared wound infection rates and operative outcomes, reported that the median length of hospital stay was significantly shorter in the purse-string skin closure group(104). Additionally, the researchers stated that while most linear closures were performed before 2008, most purse-string closure procedures were performed after 2008; therefore, they thought that selection bias in patients affected the length of hospital stay(104). Furthermore, the trend in patient treatment has recently been shifting towards reducing the length of hospital stay with the use of early recovery programs, which could have also influenced the reduction in hospital stay. In a systematic review conducted by Li et al. in 2014, after comparing 15 studies, they reported that the purse-string closure method following stoma reversal was the best skin closure technique in terms of surgical site infection. However, the authors have noted that the quality of supporting evidence is limited(105). It has also been stated that none of the patients in the purse-string group were diagnosed with a surgical site infection. These results can be said to parallel our research findings. In the studies; the idea that the incidence increases because the subcutaneous exudate cannot be completely drained when the skin is primarily closed is emphasized as the reason for surgical site infection (SSI) in conventional techniques (106,107). Therefore, it may cause a higher SSI rate and increase the risk of wound separation, resulting in incisional hernia, prolonged hospital stay, and higher healthcare costs. In addition, delayed wound healing with unsightly scar formation and poor cosmetic results can be expected in the conventional group. 6. Conclusion and Recommendations Our research results show that the purse-string technique has significantly fewer surgical site infections and better cosmetic results compared to the conventional technique. There was no significant difference in operation time, length of hospital stay, and wound healing time between the two groups. More studies are needed with long-term follow-up to confirm the potential benefit of the purse-string technique in reducing incisional hernia and cost-effectiveness. The purse-string technique may reduce surgical site infections and theoretically the incidence of postoperative incisional hernia. To confirm this potential benefit, further prospective studies addressing this issue with long-term follow-up are needed. As known, surgical site infections pose a significant economic burden in terms of prolonged hospital stay, drug treatment, and increased treatment costs. The higher rate of surgical site infections in the conventional group may be associated with higher medical costs. Additional costs related to the health personnel continuously visiting the patient and providing wound care to reduce surgical site infections in the conventional group should also be considered. However, all included trials did not report data on cost-effectiveness. As medical costs vary between countries, each healthcare system needs its own cost-effectiveness analysis to support decision-making. In summary; the purse-string technique has been found to be superior in terms of fewer wound infections, fewer clinical visits after surgery, higher patient satisfaction, less restriction on daily activities, and better cosmetic results. Declarations Author Contribution " Asst. Prof. Dr. Amil Huseynov and Assos.Prof. Dr.Veli Vural designed the research and supervised the data collection. Dr.Huseynov performed the data analysis and interpreted the results. Dr. Vural drafted the manuscript and edited it. Both authors approved the final draft of the manuscript for submission and publication. All authors contributed to the research process, reviewed the findings, and approved the manuscript." References Harputlu D, Terzi C, Eşrefgil G, Uz S. Kolostomi ve ileostomili bireylerde benlik saygısı, KRHD, 2007; 17: 178-185. Doughty DB. History of ostomy surgery, J WOCN, 2008; 35 (1): 34-38. Yaşan A, Ünal S, Gedik E, Girgin S. 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Int J Colorectal Dis, 2009; 24: 479–88. Leitlinienprogramm Onkologie: S3-Leitlinie Kolorektales Karzinom (Langversion) Version 1.1, 2014. Aksoy G., Çavdar İ. Sindirim sistemi (Gastrointestinal Sistem) Stomalarında Bakım. In: Akyolcu N, Kanan N. Yara ve Stoma Bakımı. İstanbul: Nobel Tıp Kitapevleri Tic. Ltd. Şti, 1. Baskı, 2015. American Cancer Society, Colorectal Cancer Facts & Figures 2011-2013. Atlanta, American Cancer Society. http://www.cancer. org/research/cancerfactsfigures/ colorectalcancerfactsfigures /index Erkoçak E.U, Alabaz Ö, Karada A, Alemdaroğlu K, Akçal T. Bu ra D.(Ed.), Kolon rektum ve anal bölge hastalıklar, Türk Kolon ve Rektum Cerrahisi Derneği, İstanbul, 2003; 307-329. Yamaner YS. Stoma, Stoma komplikasyonlar ve bakım, Kalaycı G.(Ed), Genel Cerrahi, İstanbul, Nobel Tıp Kitabevleri, 2002; 1453-1470. Çelik F, Intestinal Stomalar, Alabaz Ö.(Ed.), Kolon ve rektal cerrahinin el kitabı, İstanbul, Nobel Tıp Kitabevleri, 2004; 827-843. Yeşilkaya Y. Kolon ameliyatlar ve komplikasyonlar, Sayek .(Ed), Temel Cerrahi, Ankara, Güne Kitabevi, 1996; 1190-1200. Korkut MA, Aynac M. Intestinal stomalar( leostomi, Kolostomi), Gülay H.(Ed),Temel ve Sistematik Cerrahi, İzmir, Güven Kitabevi, 2005; 619- 163. Pitmann DM, Smith LE. Complications of colostomy closure, Dis Colon Rectum, 1998; 28: 836-43. Smit R, Walt Aj. The morbidity and cost of the temporary colostomy .Dis Colon Rectum, 1998; 21: 558-61. Wigmore SJ, Duthie GS, Young E, Spalding EM, Rainey JB. Restoration of intestinal continuity following Hartmann s procedure: The Lothian experience, 1987-1992, Br J Surg, 1995; 82: 27-30 Wara P, Sorensen K, Berg V. Proximal fecal diversion review of ten years experience, Dis Colon Rectum, 1998; 24: 114-9 Vignali A, Fazio VW, Lavery IC, Milsom JW, Church JM, Hull TL, et al. Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients, J Am Coll Surg, 1997; 185: 105– 113. Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial, Ann Surg, 2007; 246: 207–214. Law WI, Chu KW, Ho JW, Chan CW. Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision, Am J Surg, 2000; 179: 92–96. Edwards DP, Leppington-Clarke A, Sexton R, Heald RJ, Moran BJ. Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial, Br J Surg, 2001; 88: 360–363. Rullier E, Le Toux N, Laurent C, Garrelon JL, Parneix M, Saric J. Loop ileostomy versus loop colostomy for defunctioning low anastomoses during rectal cancer surgery, World J Surg, 2001; 25: 274–277. Rondelli F, Reboldi P, Rulli A, Barberini F, Guerrisi A, Izzo L, et al. Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a meta-analysis, Int J Colorectal Dis, 2009; 24: 479–488. Pokorny H, Herkner H, Jakesz R, Herbst F. Mortality and complications after stoma closure, Arch Surg, 2005; 140: 956–960. Kaiser AM, Israelit S, Klaristenfeld D, et al. Morbidity of ostomy takedown, J Gastrointest Surg, 2008; 12: 437–441. Song GW, Yu CS, Lee HO, Kim MS, Namgung H, Lee GH, et al. Ileostomy related complications, J Korean Soc Coloproctol, 2003; 19: 82– S The morbidity surrounding reversal of defunctioning ileostomies: a systematic review of 48 studies including 6,107 cases. Int J Colorectal Dis. 2009, 24(6): 711-23. Atallah W, Karpuz Ş, Taghiyev A, Coşkun M. Comparing cosmetic results of purse-string closure vs conventional linear sutured closure of the stoma wound following loop ıleostomy reversal, Turk J Colorectal Dis, 2018; 28: 153-15. Gruessner U, Clemens M, Pahlplatz PV, Sperling P, Witte J, Rosen HR; Septocoll Study Group, Improvement of perineal wound healing by local administration of gentamicin-impregnated collagen fleeces after abdominoperineal excision of rectal cancer, Am J Surg, 2001; 182: 502– 509. Haase O, Raue W, Böhm B, Neuss H, Scharfenberg M, Schwenk W. Subcutaneous gentamycin implant to reduce wound infections after loop- ileostomy closure: a randomized, double-blind, placebo-controlled trial, Dis Colon Rectum, 2005; 48: 2025–2031. de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control, 2009; 37: 387–397. Banerjee A. Pursestring skin closure after stoma reversal, Dis Colon Rectum, 1997; 40: 993–994. Milanchi S, Nasseri Y, Kidner T, Fleshner P. Wound infection after ileostomy closure can be eliminated by circumferential subcuticular wound approximation, Dis Colon Rectum, 2009; 52: 469–474. Reid K, Pockney P, Pollitt T, Draganic B, Smith SR. Randomized clinical trial of short-term outcomes following pursestring versus conventional closure of ileostomy wounds, Br J Surg, 2010; 97: 1511– 1517. Daniel CM, M.D. José Luis Rodriguez-Díaz, M.D. Noel Salgado- Nesme, M.D. Quintín H. González, M.D. Omar Vergara-Fernández, M.D. randomized clinical trial of ıntestinal ostomy takedown comparing pursestring wound closure vs conventional closure to Eliminate the Risk of Wound Infection Pursestring Closure versus Conventional Primary Closure Following Stoma Reversal to Reduce Surgical Site Infection Rate: A Meta-analysis of Randomized Controlled Trials Meng-Chiao Hsieh, M.D. 1,2 • Liang-Tseng Kuo, M.D.2,3 Ching-Chi Chi, M.D., M.M.S., D.Phil.2,4–6 • Wen-Shih Huang, M.D.1,5 Chih-Chien Chin, M.D.. Diseases of the Colon & Rectum Volume 58: 8 (2015 Jung Ryeol Lee, ⦁ Young Wan Kim, ⦁ Jong Je Sung, ⦁ Ok-Pyung⦁ Song, ⦁ Hyung Chul Kim, ⦁ Cheol-Wan Lim, ⦁ Gyu-Seok Cho, ⦁ Jun Chul ⦁ Jung, and ⦁ Eung-Jin Shin Conventional Linear versus Purse-string Skin Closure after Loop Ileostomy Reversal: Comparison of Wound Infection Rates and Operative Outcomes. ⦁ J Korean Soc Coloproctol. 2011; 27(2): 58–63. Li LT, Hicks SC, Davila JA, et al. Circular closure is associated with the lowest rate of surgical site infection following stoma reversal: a systematic review and multiple treatment metaanalysis, Colorectal Dis. 2014; 16: 406–416. Murray BW, Cipher DJ, Pham T, Anthony T. The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery, Am J Surg, 2011; 202: 558–560. Keenan JE, Speicher PJ, Thacker JK, Walter M, Kuchibhatla M, Mantyh CR. The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings, JAMA Surg, 2014; 149: 1045–1052. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4162772","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Method Article","associatedPublications":[],"authors":[{"id":284382873,"identity":"e366706a-9c36-4ab4-aeca-1c80e19a230c","order_by":0,"name":"Amil Huseynov","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYJACZiCWMwAzDSyIUM8G0WJsAKYMJIjXkrgBTDEQoYV/fo8Bc0HF4fTt7P1HN/wokGDgb+9OwKtF4hiPAfOMM4dzd/YcZrvZA3SYxJmzG/Bbc4zH/Ddv2+HcDTeS2W7wALUYSOTi1yIPsgWoJd0AqOXmH2K0GEC1JIC03CbKFsNjaQVAv6Qbbjhz2Oy2jIEED0G/yB0+vAEYYtbyBscbn91888dGjr+9l4D3IaAZzuIhRjkI1BGrcBSMglEwCkYiAAAp1kKhCcsguwAAAABJRU5ErkJggg==","orcid":"","institution":"Beykoz University","correspondingAuthor":true,"prefix":"","firstName":"Amil","middleName":"","lastName":"Huseynov","suffix":""},{"id":284382875,"identity":"7cbb6a8f-a191-4c9a-9ec0-21825d2edfb7","order_by":1,"name":"Veli Vural","email":"","orcid":"","institution":"Akdeniz University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Veli","middleName":"","lastName":"Vural","suffix":""}],"badges":[],"createdAt":"2024-03-25 11:08:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4162772/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4162772/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53881349,"identity":"374e12e5-5b59-4171-ad39-8cb49ffd32ab","added_by":"auto","created_at":"2024-04-01 17:52:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40360,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClassification of intestinal ostomies\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4162772/v1/9ab972c326056fe971c3c71b.png"},{"id":53881348,"identity":"7084b79a-d753-4891-ad46-9ce076a30255","added_by":"auto","created_at":"2024-04-01 17:52:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":105772,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePurse-string Closure Technique\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4162772/v1/3e8093f220158e71bc846dc7.png"},{"id":53881352,"identity":"deba43a1-2206-4627-b888-eda6f4f79328","added_by":"auto","created_at":"2024-04-01 17:52:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":127181,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2. Purse-string closure technique\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"02.png","url":"https://assets-eu.researchsquare.com/files/rs-4162772/v1/8bee489eeaa23cce05f3b672.png"},{"id":53881350,"identity":"f6cbf74a-aca8-46b4-b16b-99e7c75050ba","added_by":"auto","created_at":"2024-04-01 17:52:53","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":78485,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 3. Conventional Method Technique\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4162772/v1/47d5c7cd49290f2033a77ff0.png"},{"id":60231037,"identity":"976e2b99-0fd3-474c-8bce-83fa4f53349b","added_by":"auto","created_at":"2024-07-13 19:31:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1129753,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4162772/v1/90dd804a-02ba-4307-9185-f9db3721984f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative analysis of pursestring method versus conventional methods for stoma closure","fulltext":[{"header":" 1. Introduction","content":"\u003cp\u003eStoma is a procedure implemented due to conditions such as Crohn's disease, ulcerative colitis, carcinomas, diverticula, obstructions, radiation enteritis, ischemic bowel, fecal incontinence, trauma, and congenital diseases. Stoma types opened for excretion purposes are colostomy and ileostomy. The procedure of bringing the colon to the skin is called a colostomy, and the procedure of bringing the ileum to the skin is referred to as an ileostomy. Stomas are classified as temporary or permanent based on their duration and purpose, and as loop or end based on the surgical technique employed(1).\u003c/p\u003e\n\u003cp\u003eWhile the first stoma applications are encountered during the times when the Bible was written, the limited number of documents from these periods restricts gaining knowledge about the subject. In a scientific sense, the first stoma application is known to have been opened on a soldier wounded during the Ramilles battle that took place between the British and the French in 1706(2).\u003c/p\u003e\n\u003cp\u003eMedical and technological advancements, alongside the development of early diagnosis and treatment methods, have led to a decrease in deaths due to diseases and an increase in the expected lifespan. These developments also influence individuals' lifestyles. Even though stoma is opened to improve individuals, it can negatively impact their lifestyle and quality of life. Stomas, which are opened mainly to eliminate the underlying pathology and to enable individuals to lead a more quality life, heavily affect the life process, being seen as a significant intervention by the patients(3). Individuals with stoma face problems like changes in body appearance and losing control over their excretion function. Studies have shown that individuals with stoma experience negative emotions about stoma and encounter many problems physiologically, psychologically, and socially as their quality of life is affected. It is also observed that their family relations and social lives are negatively impacted, and they tend to isolate themselves from society due to this(3,4). The most common physical problems encountered by individuals with stoma are odor, gas, leakage, problems related to the bag system, skin irritation, and other stoma complications. Socially, they tend to isolate themselves from society, lose confidence in themselves, and tend to not continue socio-cultural activities. It is observed that their family and work lives are negatively affected, with decreases in work hours and work productivity after the opening of the stoma, changes in jobs, and quitting jobs. It is reported that there are psychological differences such as demographic characteristics like age and gender, clinical differences like underlying disease and stoma type, time passed after stoma surgery, current health status, self-efficacy related to stoma, and coping in adjusting to stoma(4). Considering these and other reasons, closing the stomas as quickly and efficiently as possible positively impacts the patients' quality of life.\u003c/p\u003e\n\u003cp\u003eStoma closure is considered a minimally invasive surgery; however, surgical site infection (SSI) is a commonly observed complication. Recently, the number of diverting ileostomy cases has increased due to the rise in the number of anal sphincter preserving operations such as super low anterior resection (sLAR) and intersphincteric resection (ISR) for rectal cancer. This study focuses on the methods used to reduce the incidence of SSI in stoma closure.\u003c/p\u003e\n\u003cp\u003eThe incidence of wound site infection following stoma closure varies between 2% and 41% in different studies(5,6). The most common cause of wound site infection is bacterial contamination of the skin surrounding the ileostomy/colostomy due to prolonged contact with intestinal content or leakage of stoma content. A study conducted in 1997 introduced the purse-string method (PSM), and in this method, the risk of wound site infection decreased, and better cosmetic results were observed(7).\u003c/p\u003e\n\u003cp\u003eThe number of studies investigating the effectiveness of PSM is limited, however, another study reported that the placement of a Penrose drainage tube under the subcutaneous tissue was effective in preventing SSI and superficial incisions in PSM were better for SSI control(9,10).\u003c/p\u003e\n\u003cp\u003eStudies comparing the comfort of life with patients whose stoma was closed have reported conflicting results. This study aims to evaluate the relationship between surgical techniques after surgical treatment in the postoperative period in patients who had a stoma opened for various reasons and then closed, with wound site healing and complications.\u003c/p\u003e\n\u003cp\u003eBy considering these factors and employing effective and rapid methods for stoma closure, we can greatly improve the quality of life for patients. Exploring different techniques and strategies in the context of stoma closure will help us understand the complexities and opportunities for improvement in this medical procedure. Through research and clinical trials, we can continue to refine our understanding and potentially develop new techniques and strategies for managing and treating patients with stomas.\u003c/p\u003e\n\u003cp\u003eA stoma, either temporary or permanent, is often required due to conditions such as Crohn's disease, ulcerative colitis, carcinomas, and others. Despite being beneficial in managing underlying health conditions, stomas significantly impact patients' lives, often leading to physical, psychological, and social complications. Therefore, closing the stomas promptly and efficiently can improve the patient's quality of life.\u003c/p\u003e\n\u003cp\u003eWhile stoma closure is seen as a minimally invasive procedure, surgical site infection (SSI) is a common complication, with incidence varying between 2% and 41%. The purse-string method (PSM) has been found to decrease the risk of SSI and provide better cosmetic results. Despite limited studies on PSM, it has been found to prevent SSI effectively when paired with subcutaneous Penrose drainage.\u003c/p\u003e\n\u003cp\u003eThis study aims to explore the impact of different surgical techniques on wound healing and complications post-stoma closure, ultimately contributing to improved patient outcomes. By understanding and refining these methods, we can enhance the quality of life for patients with stomas.\u003c/p\u003e"},{"header":"2.\tGeneral Information","content":"\u003cp\u003e\u003cem\u003e2.1 Definition of Stoma\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA stoma is an artificial opening created in the abdominal wall as a surgical solution to various conditions such as colorectal cancer, inflammatory bowel disease, diverticular disease, and abdominal trauma(8). This allows the output of the colon (colostomy), ileum (ileostomy), or urinary tract (urostomy) to be emptied into a bag. All surgical procedures that redirect the normal movement of bowel content to the outside of the body when a portion of the bowel becomes diseased or removed are referred to as stoma (ostomy)(9). Creating an ostomy means bringing a part of the bowel through the abdominal wall, allowing waste to exit the body through the abdominal wall instead of passing through the anus(10).\u003c/p\u003e\n\u003cp\u003eIt is estimated that there are approximately 124,000 people with a stoma in the United Kingdom alone. The most common underlying conditions that require stoma surgery are colorectal (intestinal) cancer, bladder cancer, ulcerative colitis, and Crohn\u0026apos;s disease(11). Colorectal bowel cancers are the third most common cancer in men and the second most common in women in the UK. Over 18,000 new cases of colorectal cancer in men and over 16,000 new cases in women are seen each year in the UK(12). Another condition that can lead to stoma formation is inflammatory bowel disease. Colitis, ulcerative colitis, and Crohn\u0026apos;s disease are inflammatory bowel diseases and are the most common causes of ileostomy formation(13).\u003c/p\u003e\n\u003cp\u003eStoma formation is a simple intervention, but its outcomes can be complex and life-threatening. The procedure is usually performed at the end of a long and complex surgical operation(14). There may be a tendency to leave it to a young member of the team, but if done poorly, it can leave a legacy of complications such as leakage, prolapse, parastomal hernia, and retraction. Because the formation of a stoma can prolong patients\u0026apos; lives and help them return to a healthy life(15). However, this process can cause a person to experience various problems in physiological, social, and psychological aspects. Individuals with a stoma suffer from psychological problems such as depression, anxiety, changes in body image, low self-esteem, sexual problems, denial, loneliness, despair, and stigmatization. Social problems include; loss of interest and less participation in social activities, avoidance of travel, reduction in work activities, deterioration of partner relationships, decrease in contact with friends/relatives. These problems can negatively affect the individual\u0026apos;s adaptation to the stoma and their ability to cope with the stoma(16).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e2.2 Stoma Anatomy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn anatomy, a stoma (stoʊmətə) is any opening in the body. For example, a mouth, a nose, and an anus are natural stomas. Any hollow organ can be redirected to form an artificial stoma as required. This practice includes the esophagus, stomach, duodenum, ileum, colon, pleural cavity, ureters, bladder, and renal pelvis. Such a stoma may be permanent or temporary (17).\u003c/p\u003e\n\u003cp\u003eSurgical procedures involving the creation of an artificial stoma typically have names ending in the suffix \u0026quot;-ostomy\u0026quot;, and the same names are often used to refer to the stoma created in this way. For example, the word \u0026quot;colostomy\u0026quot; refers to either an artificial anus or the procedure that creates it (18).\u003c/p\u003e\n\u003cp\u003eEnterostomies are first classified according to the bowel segment brought to the surface and then according to the number of openings in the bowel, into loop ostomies and end ostomies (19).\u003c/p\u003e\n\u003cp\u003eToday, the most common indication for the creation of an intestinal ostomy is intestinal cancer. Anastomotic insufficiency (AI) following oncological resection of the rectum is associated with a mortality risk of 6-22% and is therefore one of the most serious complications of colorectal surgery (20).\u003c/p\u003e\n\u003cp\u003eThe risk of anastomotic insufficiency (AI) after deep rectal resection has been reported to be 10-15% (21). To improve the outcomes of AI, a protective ostomy is routinely performed. In a prospective study conducted by Law et al., an ostomy was created in 291 (73.5%) out of 396 patients treated with oncological rectal resection (22). In a systematic review of enterostomies by Rondelli and colleagues, an ostomy was performed on 89% of 1529 patients undergoing treatment for colorectal carcinoma. This data forms the basis of the current \u0026quot;consensus\u0026quot; in Europe (23,24). Besides, there are advantages and disadvantages according to the types of ostomies performed (Table 1).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 1. Ostomy Types, Advantages and Disadvantages\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.179487179487179%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.1474358974359%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMost Common Indications\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.435897435897434%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdvantages\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisadvantages / Complications\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.179487179487179%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLoop Colostomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.1474358974359%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e-\u0026nbsp;Protective ostomy in Double Stapled Anterior Resection (DARR)\u003c/li\u003e\n \u003cli\u003ePalliative, unresectable rectal carcinoma\u003c/li\u003e\n \u003cli\u003eComplex perianal fistulas and inflammatory processes\u003c/li\u003e\n \u003cli\u003eRadiation proctitis\u003c/li\u003e\n \u003cli\u003eRectal rectal carcinoma\u003c/li\u003e\n \u003cli\u003eIncontinence\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.435897435897434%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eMinor skin damage, no loss of fluid and electrolytes due to more solid stool\u003c/li\u003e\n \u003cli\u003eSimple closure\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIncreased odor due to intestinal bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.179487179487179%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEnd Colostomy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.1474358974359%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003ePerforated diverticulitis with fecal peritonitis\u003c/li\u003e\n \u003cli\u003eRectal resection without continuity in deep-seated carcinoma\u003c/li\u003e\n \u003cli\u003eAbdominoperineal rectal resection\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.435897435897434%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eLess skin damage due to firmer stools, no fluid and electrolyte loss\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eDifficulty in restoration (colostomy reversal)\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.179487179487179%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLoop Ileostomy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.1474358974359%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eProtective ostomy after proctocolectomy in FAP / CIBD (otherwise indications for loop colostomy)\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.435897435897434%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eSimple closure\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e- High amounts of fluid loss\u003c/li\u003e\n \u003cli\u003ePerianal secretion of mucus may occur\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.179487179487179%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEnd Ileostomy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.1474358974359%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eEmergency proctocolectomy or colectomy\u003c/li\u003e\n \u003cli\u003eFailure of an IPAA (ileal pouch-anal anastomosis)\u003c/li\u003e\n \u003cli\u003eExtended bowel resection in bowel ischemia\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.435897435897434%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-----\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eHigh amounts of fluid loss\u003c/li\u003e\n \u003cli\u003eDifficult restoration (reversal)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAI: Anastomotic Insufficiency, CIBD: Chronic Inflammatory Bowel Disease, DARR: Deep Anterior Rectal Resection, FAP: Familial Adenomatous Polyposis Coli, IPAA: Ileal Pouch Anal Anastomosis.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eG\u0026uuml;enaga et al. (25) found no difference in terms of complications between a loop ileostomy and loop colostomy as a protective ostomy; Tilney et al. (26) demonstrated fewer complications after loop ileostomy when examining the same issue. The evidence is not clear, so the choice of ostomy type for this indication is at the discretion of the individual surgeon. At our center, only loop ileostomy is used to protect the anastomosis following rectal surgery.\u003c/p\u003e\n\u003cp\u003eThe comfort and functional status of a stoma depend on its location and the quality of the surrounding skin. The main rule in stoma site selection should be to bring the bowel out with sufficient blood flow without tension. Additionally, the stoma should be opened in a place that the patient can easily see and empty and change their bag (27).\u003c/p\u003e\n\u003cp\u003eThe type of disease is as influential as the patient\u0026apos;s body structure in the selection of the stoma site. The stoma is opened in the abdominal area below the navel, in the right or left lower quadrant. In ileostomy, the right lower quadrant is used, in transverse colostomy the upper middle quadrant, and in descending and sigmoid colostomy the left lower quadrant is used. If the patient is dependent on a wheelchair or obese to the point of not being able to see the stoma, the stoma can also be opened from the upper quadrant. Also, the localization of the rectus muscle, the patient\u0026apos;s field of vision, the adequacy of the adherent surface, and avoidance of skin, folds, scars, navel, waistline, saggy breasts bottoms, bone protrusions are important (28).\u003c/p\u003e\n\u003cp\u003eAfter marking the location of the stoma before surgery, various positions can be given to the patient to see the condition the stoma will take. This trial can also be done by attaching a stoma bag. As stomas have become frequently applied, stoma care problems have also started to increase. In parallel with advancements in technique, the ileostomy club established in New York in 1951 led to the concept of enterostomal therapy being brought to the agenda, thus steps have been taken in post-stoma care, education, and rehabilitation of patients (29).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3 Stoma Types\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGenerally, stomas are examined in three categories. The most commonly used ones are colostomy, ileostomy, and urostomy. Each ostomy procedure is done for different reasons. While these three ostomies have many similarities with each other, they also have significant differences. Stomas can be classified according to their general characters, i.e., anatomical features, as well as prognostic factors, stages, function, and reasons for their construction. However, the most commonly used type in the clinic is the classification form according to their anatomical features (Table 2).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2. General Stoma Types (30)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cimg 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\"\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3.1 Colostomy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eColostomies are created for two purposes.\u003c/p\u003e\n\u003cp\u003ea.Decompressive colostomy, which reduces the pressure in the large intestine\u003c/p\u003e\n\u003cp\u003eb. Diverting colostomy, which diverts the flow of feces\u003c/p\u003e\n\u003cp\u003ea-Decompressive Colostomy: This is done to prevent perforation and achieve urgent decompression due to a mass causing blockage in the colon or rectum. A transverse loop colostomy, cecostomy, or blowhole colostomy can be created for decompression purposes (31).\u003c/p\u003e\n\u003cp\u003eb-Diverting Colostomy: Diverting colostomies are created for the purpose of fecal diversion. These colostomies are opened in cases of traumatic injuries, colon diverticulum perforations, anastomotic leaks, colorectal fistulas, and situations where there are risky anastomoses distally. A loop colostomy, double-barrel colostomy, or Hartman\u0026apos;s colostomy can be created for the purpose of temporary diversion (32).\u003c/p\u003e\n\u003cp\u003eA colostomy can be temporary or permanent and can be in any part of the large intestine depending on the reason for the surgery. The types of colostomy are generally determined by the location of the stoma: Ascending colostomy, transverse colostomy, descending colostomy, end colostomy, and cecostomy are the terms used (33).\u003c/p\u003e\n\u003cp\u003eAn ascending colostomy is located on the right side of the abdomen. The output is very liquid. A drainable pouch is worn for this type of colostomy. This type of stoma is rarely used as an ileostomy is a better stoma when the output is liquid. When a colostomy is placed in the right half of the colon, only a short portion of the colon remains. The care for an ascending colostomy is similar to caring for a transverse colostomy (34).\u003c/p\u003e\n\u003cp\u003eA transverse colostomy is in the upper abdominal area either in the middle or to the right of the body. Diverticulitis, inflammatory bowel disease, cancer, obstruction, injury, or birth defects can lead to a transverse colostomy. This type of colostomy allows feces to exit the colon before it reaches the descending colon (35).\u003c/p\u003e\n\u003cp\u003eA descending or sigmoid colostomy is located on the lower left side of the abdomen. Generally, the discharge is firm and can be regular. The sigmoid colostomy is probably the most commonly performed of all colostomies(36).\u003c/p\u003e\n\u003cp\u003eColostomies are anatomically divided into two:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;\u003cstrong\u003eEnd Colostomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnd colostomies are often sigmoid colostomies and are generally located in the left iliac fossa. Electively, abdominoperineal excision for anorectal tumors is a common indication. In an emergency, the Hartmann procedure is often performed for ischemia, perforation, obstruction of the distal colon or rectum(37). The resulting end colostomy can potentially be reversed after 3-4 months, but this is a significant intervention, especially in older patients (mortality 4-5%) and up to 40% of stomas cannot be reversed. Laparoscopic stoma formation is advocated by some surgeons, but is currently a complex procedure performed by relatively few British surgeons(38). Several attempts have been made to create an end colostomy. Implantable devices and colostomy plugs are not popular due to infection complications and ulceration, respectively. The most effective technique may be colonic irrigation via a Foley catheter passed into the colostomy, after which patients can pass 6-8 hours with minimal colostomy output(38).\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;\u003cstrong\u003eLoop Colostomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLoop stomas are most common in the terminal ileum, transverse, and sigmoid colon. Loop colostomies are formed over a plastic rod to limit early retraction. This is removed when the mucocutaneous anastomosis has matured (5-7 days later). Generally, these are temporary stomas used for diverting fecal flow and can usually be reversed at the stoma site 2-3 months after formation. They are commonly used to protect a distal anastomosis following elective colorectal surgery of the distal colon/anterior resection or anal sphincter repair(39).\u003c/p\u003e\n\u003cp\u003eA loop stoma is a stoma with two different openings. An entire bowel loop is brought out of an incision onto the surface of the abdomen and then opened to create two openings in the bowel: a proximal (functional) opening and a distal (non-functional) opening. The proximal opening expels feces as it moves downward from the bowel, and the distal opening allows mucus to exit from the distal or lower part of the bowel(40). Typically, a small rod, soft tube piece, or some other such device is placed under the bowel loop outside the abdomen to prevent the bowel from retracting back into the abdomen and provide support; it is usually removed within two to seven days(41).\u003c/p\u003e\n\u003cp\u003eLoop stomas appear externally the same as loop-ended stomas, and the difference between them is internal. The distal end of a loop-ended stoma simply terminates in a simple blind sac, which is nothing more than a piece of bowel severed from its connection with the rectum. This type of stoma is more common in urology procedures(42).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3.2 Ileostomy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe ileostomy technique used by Baum in the 1870s was tried for the purpose of colon tumor obstruction. Brooke then applied the full-thickness eversion technique, Goligher the extraperitoneal, and Kock the continent ileostomy technique(10). He stated that the use of ileostomy was limited due to high drainage in the stoma and skin problems before particularly describing the Brooke full-thickness eversion method(43). Ileostomy is used for the removal of the entire colon-rectum, protective purpose of colorectal in distal, by-pass, coloanal, ileoanal anastomosis. If the anorectal sphincter mechanism is removed, it is done permanently, if not removed, it is done temporarily(28, 30). Today, there are three types of ileostomy in use: end ileostomy, loop ileostomy, and continent ileostomy.\u003c/p\u003e\n\u003cp\u003eA) \u0026nbsp; End Ileostomy (Brooke): It is generally used for permanent purposes. An end ileostomy is traditionally placed in the right iliac fossa and is usually a permanent stoma. Electively, proctocolectomy for inflammatory bowel disease or familial adenomatous polyposis coli is the most common indication, but ileo-anal pouch surgery has reduced the need for this. In an emergency, an end ileostomy is usually temporary. The small intestine can be edematous and fragile, making it difficult to create an outward-facing 2\u0026ndash;3 cm orifice. Cuts made along the serosa of the ileostomy can facilitate eversion(45). End ileostomy with subtotal colectomy is a first-stage procedure in fulminant or perforated ulcerative colitis and distal obstruction of the colon where the cecum is dead or perforated. An end ileostomy is also required after segmental resection of the small intestine where a primary anastomosis (e.g., perforated Crohn\u0026apos;s disease, thromboembolic intestinal ischemia) is not safe. The distal bowel is closed and left inside the abdomen or brought out as a mucus fistula(Figure 1). Relaparotomy is required to restore bowel continuity and is done once the patient has recovered (usually after 3-4 months)(46).\u003c/p\u003e\n\u003cp\u003eB) \u0026nbsp; Loop ileostomy: This was first described by Turnbull in 1961. The ileum mesentery is technically easier in short and fatty individuals(10). Although generally made for temporary purposes, studies have shown that 40% are permanent(47). With the development of surgical tools and techniques, it is now mostly done in surgeries preserving tight anal sphincters. Loop ileostomy is used to divert fecal flow temporarily after these surgeries. When successful diversion is not achieved, it has also been a good alternative technique to loop colostomy(48). Indications for its use include protection of risky anastomoses distally during use, anal abdominal fistulas, colo-rectal obstructions, toxic megacolon, and findings where end ileostomy technically cannot be performed. It is a method that causes fewer complications compared to loop colostomy used for diversion, is easy to close, occupies less space, has less odor, and is easy to care for. However, its maintenance is slightly more difficult compared to end ileostomy(49). Since the ileostomy is close to the abdominal skin, there is more enzymatic content, drainage, fluid electrolyte and vitamin loss because more proximal ileum is used than end ileostomy(50).\u003c/p\u003e\n\u003cp\u003eC) \u0026nbsp; Continent ileostomy (Kock Pouch): This technique, first used by Nils Kock in 1969, uses 45 cm of terminal ileum. A 30 cm segment is used to create a pouch and a 15 cm segment is used to create a stoma. A continent ileostomy is an internal pouch made just before exiting from the end of the ileum, through the abdominal wall as an ileostomy, sometimes called a Kock pouch(51). The surgeon makes a valve inside the pouch to prevent bowel content from leaking out. The person drains the pouch every day by inserting a thin, flexible tube called a catheter inside the stoma. \u0026nbsp;\u003cbr\u003eThe person covers the stoma with a simple patch or dressing. Continent ileostomy is an option for those who are not suitable candidates for an ileoanal reservoir due to damage in the rectum or anus, and who do not want to wear an ostomy bag(52,53).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.3.3 Ureterostomy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUrinary stomas involve the process of bringing the ureters to the abdominal wall by making a bladder from the ileum conduit, colon, or jejunum and anastomosing with the ureters. Reasons for opening a urostomy include fistula, bladder cancer, urinary incontinence, neurogenic bladder, congenital anomaly, and radiation cystitis(54). Urostomies are classified according to their formations. Bringing the ureters to the body surface is called ureterostomy, and cutting 12 cm from the ileum and making an anastomosis of the ureters to the ileum is called ileal conduit ureterostomy(55).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.4 Stoma Complications\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eColostomies and ileostomies are created in the treatment of various medical conditions, including cancer, diverticulitis, and inflammatory bowel disease. Unfortunately, the operations in which ostomies are created have high surgical complication rates compared to other common types of surgical procedures(56). A new population-based study based on National Surgical Quality Improvement Program data reported complication rates of 37% for elective cases involving ostomy and 55% for emergency operations. Furthermore, risk-adjusted morbidity rates vary significantly between hospitals, indicating the potential to improve outcomes(57).\u003c/p\u003e\n\u003cp\u003eOstomy surgery is associated with various short and long-term complications, including parastomal hernia, prolapse, stenosis, retraction, parastomal varices, skin disorders, and metabolic disorders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Stoma Complications (30)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.5.1. Early Complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.5.2. Late Complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eI. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bleeding\u003c/p\u003e\n \u003cp\u003eII. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ischemia and Stoma Necrosis\u003c/p\u003e\n \u003cp\u003eIII. \u0026nbsp; \u0026nbsp; \u0026nbsp; Peristomal Infection and Perforation\u003c/p\u003e\n \u003cp\u003eIV. \u0026nbsp; \u0026nbsp; \u0026nbsp; Retraction\u003c/p\u003e\n \u003cp\u003eV. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mucocutaneous Separation\u003c/p\u003e\n \u003cp\u003eVI. \u0026nbsp; \u0026nbsp; \u0026nbsp; Early Obstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eI. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Prolapse\u003c/p\u003e\n \u003cp\u003eII. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Parastomal Hernia\u003c/p\u003e\n \u003cp\u003eIII. \u0026nbsp; \u0026nbsp; \u0026nbsp; Stenosis\u003c/p\u003e\n \u003cp\u003eIV. \u0026nbsp; \u0026nbsp; \u0026nbsp; Late Obstruction\u003c/p\u003e\n \u003cp\u003eV. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Peristomal Skin Problems\u003c/p\u003e\n \u003cp\u003eVI. \u0026nbsp; \u0026nbsp; \u0026nbsp; Stomal Fistula\u003c/p\u003e\n \u003cp\u003eVII. \u0026nbsp; \u0026nbsp; Metabolic Complications\u003c/p\u003e\n \u003cp\u003eVIII. \u0026nbsp; \u0026nbsp;Diarrhea\u003c/p\u003e\n \u003cp\u003eIX. \u0026nbsp; \u0026nbsp; \u0026nbsp; Urinary Stone Formation\u003c/p\u003e\n \u003cp\u003eX. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Gallstone Formation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSome of the most common stoma complications are summarized below:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIschemia:\u003c/strong\u003e One of the main causes of impaired blood flow to the stoma. It is more common in colostomies than in ileostomies (especially if the left colic artery is tied). Mechanical factors (e.g., excessive tension in the intestine due to insufficient mobilization), an inadequate incision in the abdominal wall fascia, or the use of vasopressors (e.g., noradrenaline) contribute to ischemia. The stoma should be pink and moist (58). Some superficial browning can be tolerated; if it is grey or black and dry, further investigation is needed. Inserting a flexible sigmoidoscope allows the length of the ischemic segment to be evaluated. If the ischemia is close to the fascia, urgent stoma revision may be required (59).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRetraction:\u0026nbsp;\u003c/strong\u003eThis is most commonly seen in obese individuals if there is insufficient mobilization in the intestine or if the stoma becomes ischemic due to separation of the mucocutaneous junction. It occurs in end and loop stomas. Complete retraction into the peritoneal cavity leads to peritonitis, and urgent reoperation is indicated (60).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStenosis:\u003c/strong\u003e An ischemic stoma often narrows at the skin or subcutaneous tissue level. This is most commonly seen in end colostomies. Alternatively, a tight aponeurotic opening in the abdominal wall can cause a short stricture at this point. Recurrence should be considered in patients with Crohn\u0026apos;s disease. In most cases, symptoms are minimal, but if severe, the stricture can cause bowel obstruction (61).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStomal prolapse:\u003c/strong\u003e A large fascial opening, excessive mobility of the intra-abdominal bowel, and high intraabdominal pressure predispose to stomal prolapse. It is common in loop colostomies (especially transverse) and is often associated with a parastomal hernia. Intervention is not necessary if the prolapse is mild and not progressive. Urgent or elective intervention is indicated for painful, irreducible or gangrenous prolapse and for progressive chronic prolapse with ulceration or bleeding (62).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParastomal herniation:\u0026nbsp;\u003c/strong\u003eThis is seen in about 30% of stomas. Factors predisposing to parastomal hernias are similar to prolapse. Most are sliding hernias containing small bowel or omentum. Patients generally have minimal symptoms, and the risk of strangulation is low, so they can be reassured (63).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDermatitis:\u003c/strong\u003e Peristomal skin is exposed to chemical dermatitis from fecal waste, contact dermatitis from occlusive devices, allergic responses to adhesives, as well as fungal and bacterial infections. Careful stoma care coordinated by a qualified Stoma Nurse is very important to prevent and treat such problems. Common skin problems (e.g., psoriasis) and symptoms of inflammatory bowel disease (e.g., pyoderma gangrenosum, fistulas associated with Crohn\u0026apos;s disease) can further jeopardize peristomal skin and may require specialist intervention (64,65).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychological:\u0026nbsp;\u003c/strong\u003eMany patients feel that their quality of life has decreased, and this is worsened if the stoma is poorly placed or constructed. Regular advice from a doctor and Stoma Nurse is very important (66).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.5 Stoma Indications\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eToday, the most common indication for creating a bowel ostomy is bowel cancer. After oncological resection of the rectum, AI is associated with a mortality risk of 6-22% and therefore represents the most serious complication of colorectal surgery (67). The risk of AI after deep rectal resection has been reported to be 10-15% (68). A protective ostomy is routinely performed to improve the outcomes of AY. In a prospective study by Law and colleagues, an ostomy was formed in 291 of 396 patients (73.5%) treated with oncological rectal resection (69). In a systematic review of enterostomies by Rondelli and colleagues, an ostomy was applied to 89% of 1529 patients treated for colorectal carcinoma (70). These data form the basis of the \u0026quot;necessary consensus\u0026quot; in the current German S3 guideline on the formation of a temporary stoma after deep anastomosis with radical rectal resection (71).\u003c/p\u003e\n\u003cp\u003eStoma indications are listed below:\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Ensuring excretion in cases where continuity is not maintained, where a part of the gastrointestinal system is resected from a certain level downward (ulcerative colitis, rectovesical, rectal injuries, Crohn\u0026apos;s disease, fistula, etc.).\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Removal of blockage caused by a space-occupying pathology such as a tumor distally, which is formed and not eliminated.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Removal of the anus due to anorectal cancer.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Removal of fecal flow from the pathological event in the distal area until healing is achieved (in cases of wide defects in colorectal injuries, anal incontinence, sigmoid colon volvulus, extensive perineal burns)(30).\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp;Use of the enteral feeding route in patients where oral nutrition cannot be provided due to a pathology in the proximal area (72).\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp;It is applied in malignancies related to the bladder, chronic inflammation of the bladder, and congenital defects related to the urinary system (73).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.6 Determining the Stoma Site\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGastrointestinal ostomies can be formed under elective or emergency conditions, shaped from the small or large intestine, considered temporary or permanent, and can be made during surgeries with curative or palliative intent for benign or malignant diseases. Despite this heterogeneity, some principles of stoma formation are universal: the bowel for the stoma should be well vascularized and sufficiently mobilized to minimize tension.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;The stoma should be opened in the area within the rectus abdominis muscle where the patient can easily see and independently perform their care.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;The stoma should be on top of the rectus muscle, with a sufficient flat surface for the stoma bag to stick.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;Areas such as the iliac crest, skin folds in the abdominal area, scar areas, the navel, and belt lines should not be preferred in the selection of the stoma site.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;The patient\u0026apos;s profession, activity status, age, culture, lifestyle, and preferences should be taken into account when selecting the stoma site.\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;When determining the stoma site, the patient should be evaluated for the stoma area, void, scar, and fold direction while lying on their back, sitting, and standing.\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp;After marking with a surgical pen, the marked area should be covered with transparent dressing material.\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp;The stoma should be in an area that the patient can see; in overweight patients, the upper abdominal area can be preferred for the stoma (46).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.7 Stoma Closure\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the case of temporary ileostomies and colostomies, a second operation is required to ensure bowel continuity. Hartmann\u0026apos;s operations have traditionally been considered complex; however, even a relatively simple operation to close a loop ileostomy is associated with significant morbidity. A systematic review of studies on the morbidity of closing a loop ileostomy revealed a morbidity rate of 4% for patients requiring laparotomy and 7-17% for patients developing bowel obstruction, with a mortality rate of 0.4%. The goal of this section is to provide evidence-based guidance on the technical aspects of stoma reversal surgery (74). The evidence was insufficient to reach a second goal guiding the timing of stoma reversal surgery. However, current studies suggest the safety of selective early (within 3 weeks) and late strategies for closing diverting ostomies, depending on clinical conditions (75).\u003c/p\u003e\n\u003cp\u003eSeveral randomized, controlled studies have been conducted comparing stapled and hand-sewn techniques for closing loop ileostomies. In general, the results have been similar, with a higher risk of postoperative bowel obstruction and a tendency for longer operation time in the hand-sewn group (76).\u003c/p\u003e\n\u003cp\u003eA temporary stoma is an intervention aimed at ensuring the normal continuation of the bowel after overcoming the acute situation and is often used. Indications for temporary stomas include obstructions of the small intestine, rectum, pelvis, and other parts of the colon, bowel obstructions due to left colon volvulus, perforated cancers, rectum, colon pelvic and perineal injuries, protecting other surgical interventions such as left colon anastomosis, rectovesical, congenital megacolon, rectourethral, imperforate anus, diverticulosis coli and complications, colon anastomoses, anastomotic stricture or obstruction, leakage from the primary suture sites in the colon (77). Diverting stomas can be closed after the adhesions and the underlying distal problem that caused them have healed. A minimum wait of 6 weeks is necessary for the inflammation and fibrous reaction caused by the initial intervention inside the abdomen to subside. The stoma is closed in 60-70% of patients who have a stoma. Studies have shown mortality rates of 0-4% and morbidity rates of 10-50% for loop and end stomas. The morbidity rate after the closure of the Hartmann procedure is around 30%. The most important complications are anastomotic insufficiency and wound infection. The closure morbidity of ostomies applied and closed due to trauma is between 5-27% (78). The most commonly seen complication after stoma closure is wound site infection. In addition to surgical technique and patient follow-up, proper stoma and patient care are necessary to minimize complications (79). Colostomy and ileostomy surgeries are surgeries that need to be carefully considered. If the necessary care is not taken, mortality and morbidity increase. The surgical complications of stoma closure, the stoma closure technique, and the timing of stoma closure can be related. Other factors such as the patient\u0026apos;s age, underlying bowel pathology, and stoma type are important (80).\u003c/p\u003e\n\u003cp\u003eWaiting for 3 months after the operation is important. This waiting period gives the patient a full chance to recover. Waiting increases the regression of inflammation, induration, and edema at the ostomy and abdominal site (81). Many studies suggest that a waiting period of 6-12 weeks does not affect the occurrence of complications. However, some researchers suggest that the waiting period does influence the occurrence of complications (82). Morbidity is higher in cases that are closed early. Waiting allows for the patient\u0026apos;s condition to improve, the infected content of the bowel to heal, the wound infection to regress, the stoma area to be surrounded, and the wound on the distal side to heal (82).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.8 Stoma Closure Techniques\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe closure of the stoma is considered a minimally invasive surgery; however, surgical site infection is a common complication. Recently, the number of cases of diverting ileostomy has increased due to the increase in the number of anal-preserving surgeries such as super low anterior resection (sLAR) and intersphincteric resection (ISR) for rectal cancer. Previous studies have focused on the benefits of a purse-string skin closure technique for closing ileostomy, which reduces the risk of wound infection and allows for better cosmesis by resulting in smaller scar marks (83).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.8.1 Purse-String Method\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe first stage of the purse-string skin closure (PS) method or bag mouth closure method involves making an incision around the stoma with 2-3 mm circumferential borders (Figure 1A). This dissection along the mucocutaneous junction is then advanced to the fascial defect (Figure 2B). Bowel continuity is restored (end-to-end anastomosis or Albert-Lembert anastomosis). If the circumferential incision does not provide enough exposure, the incision can be converted into an elliptical incision. After the ostomy is closed, the subcutaneous tissues are washed with saline and hydrogen peroxide. Then, with a 2-0 monofilament subcuticular purse-string suture, a circular subcutaneous suture is performed at 1 cm intervals (Figure 3). This opening is then covered with a Penrose drain (83).\u003c/p\u003e\n\u003cp\u003eThe purse-string suture is a continuous suture used like a drawstring bag for the purpose of closure in circular wound tissues. The purse-string suture is a simple method that can be used to reduce the surface area of circular wounds with the aim of obtaining the least amount of scar tissue. This suture is placed before an ostomy tube is inserted, or it is used to close for the purpose of reducing rectal prolapse before rectal surgery. It can also be used to close a hole in the thoracic wall after it has been penetrated by a foreign object (84).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.8.2 Conventional Methods\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast to the Purse-string Method, an elliptical incision (extending transversely) is made around the mucocutaneous junction with 2-3 mm upper/lower boundaries and the skin is generally closed linearly (Figure 4)(85).\u003c/p\u003e\n\u003cp\u003eTraditional closure with a linear incision expands the skin defect. Systematic reviews investigating the purse-string closure technique in reversing the stoma have shown that this procedure reduces Surgical Site Infection (SSI) rates, but its effect on length of hospital stay is questionable(86). Interestingly, readmission rates have not been reported in most studies related to stoma closure. A retrospective analysis of 351 enterostomy reversals reported a readmission rate of 12.5%; moreover, this rate was said to be associated with longer operative times, increased intraoperative complications, and hospital stay. Conventional linear suture techniques are believed to reduce readmissions(87,88).\u003c/p\u003e\n\u003cp\u003eThere is insufficient evidence as to which technique is best for skin closure in stoma reversal. The aim of this study is to evaluate whether the Purse-String Method (PSM) is associated with lower Surgical Site Infection (SSI) rates compared to Conventional Methods (CM).\u003c/p\u003e"},{"header":"3.\tMaterial and Method","content":"\u003cp\u003eThe medical records of 44 (forty-four) patients who had their stomas closed were retrospectively reviewed. Between August 2015 and November 2019 at Antalya, Mediterranean University Hospital, a total of 21 patients who underwent the Purse-String (PS) method and 23 patients who underwent the Conventional Method (CM) were compared. Medical charts were reviewed for patient demographics including age, sex, and body mass index; medical history such as presence of diabetes, chronic obstructive pulmonary disease, cardiovascular disease, and liver dysfunction, alcohol consumption (normal - moderate or non-drinker), smoking (one year prior to surgery), medication records, American Society of Anesthesiologists (ASA) score, preoperative blood values for PS and CM groups were checked. This study was approved by the Mediterranean University Ethics Committee with the number 70904504/518, and a Wound Site Assessment Survey was administered to all patients who received the survey, after obtaining written informed consent(Appendix 1).\u003c/p\u003e\n\u003cp\u003eSurgical site infection was defined as the presence of cellulitis or purulent discharge with or without positive bacterial culture within 30 days after surgery (adapted from the CAE 1992 Centers for Disease Control and Prevention definition) (Table 4). Surgical wounds were routinely observed and assessed by the surgical team and screened until 30 days after the operation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Centers for Disease Control and Prevention Guidelines for Diagnosis of Superficial Wound Infection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cimg 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\"\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eSurgical Technique: All patients undergoing the procedure received preoperative mechanical bowel preparation. Prophylactic antibiotic (Cefazolin, 1g/day) was applied after the induction of general anesthesia. The skin surrounding the sutured stoma was removed, maintaining a margin of ~3-5mm. The bowel routes going to the stoma were taken out of the abdominal cavity and the dissection of the sutured stoma was performed. A functional end-to-end anastomosis or Albert-Lembert anastomosis was then made. The peritoneum and rectus fascia were closed using Vicryl 1.0. The open ileostomy/colostomy was sutured and the wound was washed with 500 ml of saline. Antibiotics were applied for 3 (three) days postoperatively.\u003c/p\u003e\n\u003cp\u003eStatistical Analysis: Data presented statistically were analyzed using Pearson\u0026apos;s Chi-square and Fisher\u0026apos;s exact tests. Data for continuous variables are expressed as median (range). The Mann-Whitney U test was used for statistical comparison of different groups. A P \u0026lt;0.05 indicated a statistically significant difference. All tests were analyzed using IBM SPSS Statistics software, version 2.0 (USA).\u003c/p\u003e"},{"header":"4. Findings","content":"\u003cp\u003ePatient characteristics such as gender, age, Body Mass Index, ASA Score, preoperative comorbidities are summarized in Table 5. There was no significant difference in patient characteristics such as age, gender, body mass index, preoperative comorbidities, ASA scores, and operative blood values between the PS and CM groups.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eKY (n = 23)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eKA (n = 21)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eMale Gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.738\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eFemale Gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e58 (32-79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e65 (28-80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.285\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eBody Mass Index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e22 (16-27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e22 (14-29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.976\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eASA Score 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eASA Score 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eASA Score 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative Comorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eCardiovascular Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eCOPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eAlcohol Consumption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.836\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eIleostomy / Colostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e19/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e18/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;All continuous variables are expressed as median (range). CM, conventional skin closure; PS, purse-string method for skin closure; ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease.\u0026quot;\u003c/em\u003e\u003cbr\u003e\u003cem\u003eTable 5. Clinical and demographic characteristics of patients (N = 44).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn the CM group, postoperative bleeding was observed in 1 patient (4.3%). Anastomotic leakage was not observed in either group. The incidence of overall complications was not significantly different between the CM and PS groups (P=0.346). The median postoperative hospital stay was determined as 5 days (range, 3\u0026ndash;19 days) in the CM group and 6 days (range, 3\u0026ndash;24 days) in the PS group.\u003c/p\u003e\n\u003cp\u003eThe perioperative factors of the PS and CM groups are summarized in Table 4.2. The median operation time for the CM group was 67 minutes (range, 34-213 minutes) and for the PS group, it was 54 minutes (range, 40-190 minutes); this difference was not statistically significant (P = 0.387). The median blood loss in the CM group was 18 ml (range, 0-130 ml), while in the PS group, it was 22 ml (range, 0-130 ml) (P = 0.226). The median wound length in the PS group was 0.6 cm, which was significantly shorter than the CM group\u0026apos;s (6 cm) (P \u0026lt;0.001). Regarding postoperative complications, CAE was observed in 4 patients (17.3%) in the CM group; whereas, no CAE was observed in the PS group. Therefore, a significant difference was found in the incidence of superficial incisional CAE between the PS and CM groups (P = 0.054).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Perioperative factors in skin closure with Conventional Method (CM) and Purse String (PS).\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCM (n = 23)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ePS (n = 21)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eOperation time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e67 (34\u0026ndash;213)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e54 (40\u0026ndash;190)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eBlood loss, ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e18 (0-130)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e22 (0-130)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eWound length, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e6 (4\u0026ndash;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.6 (0.5\u0026ndash;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.346\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eWound infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eAnastomotic leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative hospital stay, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e5 (3\u0026ndash;19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e6 (3\u0026ndash;24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.176\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"5.\tDiscussion","content":"\u003cp\u003eIntestinal stomas are the surgical extrusion of the small or large intestine through the anterior abdominal wall. While the principles behind forming a stoma are typically the same, there are numerous different stoma configurations formed for countless indications. A diverting stoma should prevent fecal flow from reaching a distal portion of the small or large intestine in order to treat or prevent anastomotic leakage. Stomas may also be necessary in sacral or perineal infections that are at risk due to constant fecal contact(63). Permanent stomas are necessary when pathological anatomy prevents the restoration of gastrointestinal continuity, when the risks of undergoing another operation are prohibitive due to patient comorbidities, or when the functional outcomes of a re-anastomosis would adversely affect quality of life(84). Cosmetic outcomes are also being considered as important issues for patients beyond basic health concerns. In stoma surgery, the optimal skin closure technique following loop ileostomy reversal has not yet been established(45). Currently, traditional linear sutured skin closure following the closure of loop ileostomy is widely used. This study fills in the gap of this less discussed topic of skin closure technique and highlights the better cosmetic outcomes of purse string stoma closure technique.\u003c/p\u003e\n\u003cp\u003ePokorny et al. (2005) reported 3% mortality, 20% wound infection, 10% bowel obstruction, and 5% anastomotic leakage(89). In our research, complications were observed in 21.5% of patients with CM and 9.5% of patients with PS. Various reports have shown that the rate of surgical site infections in patients closed traditionally has risen to 40%(90). Reviewing Korean studies on complications after stoma closure, Song et al. reported that 18 complications (32.7%) occurred in 55 patients after ileostomy reversal, including wound infection (24.3%), small bowel obstruction (16.4%), incisional hernia (7.9%), etc(91). Kim et al. reported that 33 complications (19.7%) developed in 164 patients, these complications were small bowel obstruction (11.5%), enteropathy (4.2%), incisional hernia (1.8%) and wound infection (1.2%)(92). Reviewing articles from other countries, Kaidar-Person reviewed 26 reports and reported a general complication incidence of 2-33.1%. These included small bowel obstruction 0-15%, wound infection 0-18.3%, anastomotic leakage 0-8%, and open abdominal reoperation in 0-12.8% of cases(93). Chow et al. reported in 48 reports analyzing 6107 ileostomy closures, that the general complication incidence was 17.3%, the death rate was 0.4%, and that open abdominal reoperation was required in 3.7% of them(94). Our results have been found to be similar to previous reports in Korea and other countries.\u003c/p\u003e\n\u003cp\u003eThe treatment of surgical site infection requires wound drainage, regular wound care, and antibiotics in some cases. However, cosmetic outcomes are not satisfactory and the healing period is extended.\u003c/p\u003e\n\u003cp\u003eIn a study that aligns closely with our research objective, \"Comparison of Cosmetic Results of Purse String Method and Conventional Methods in Closure of Stoma Site After Loop Ileostomy,\" Atallah and colleagues (2018) reported that the median follow-up time for patients was 34 (12-64) months, where the PS technique was used in 10 patients and the conventional linear closure technique was used in 15 patients (95). In our study, the CM was applied to 23 of the 44 patients, and the PS method was applied to 21.\u003c/p\u003e\n\u003cp\u003eTraditionally, outcome assessments in colorectal cancer include mortality, morbidity, recurrence of the disease, and long-term survival. However, patient-reported outcomes (such as cosmetic results) are now considered key measurements in evaluating the outcomes of interventions (72-75).\u003c/p\u003e\n\u003cp\u003eSurgical site infection is one of the most common complications that can occur after stoma closure. Reports have identified differences in the incidence of wound infection depending on the skin closure technique (96). Two prospective randomized studies compared the incidence of infection after primary and secondary closure. It has been reported that surgical site infections occurred in 20% and 36% of cases where primary closure was performed, and in 10% and 5% of the secondary closure group. The rate of surgical site infection varies between 0-41% depending on the closure technique. Primary linear closure, secondary closure, and PS closure have been introduced as stoma closure techniques, but there is no consensus on the ideal closure technique for a stoma wound. In a prospective, non-randomized study, the rate of surgical site infection was 21.4% after primary linear closure, while no surgical site infection was seen in the PS group (97,98). The technique applied to reduce the wound size for the purest subcuticular closure has been described by Banerjee (99). Similar to the study by Milanchi and colleagues, it has been stated that there was no infection in patients where the PS method was applied. It has been reported that the performance of this technique for colostomies in addition to ileostomies did not lead to an increase in the infection rate (100). The infection rate in the conventional closure group was emphasized as 40%. Another study analyzing such a closure is a randomized clinical trial conducted by Reid and colleagues in the UK.\u003c/p\u003e\n\u003cp\u003eIn a randomized clinical study of short-term outcomes following the purse-string (PS) method versus conventional closure of the ileostomy by Reid et al.: 61 patients were randomly examined, with 31 and 30 in each group respectively. They reported that the only statistically significant difference found was a decrease in surgical site infection in the purse-string closure group(101). In line with this, there are two most notable results of our research. One of these results is that the rate of wound infection is higher in the conventional method, and the other is that the wound length is greater in the conventional method. This difference was found to be statistically significant. In a similar study, it was stated that canine ear deformity was seen in 13 (87%) patients who underwent conventional method, while no deformity was observed in patients undergoing the purse-string method; it was stated that a surgical site infection was diagnosed based on retrospectively collected data in one patient (7%) in the conventional group(95). In a randomized clinical study comparing the conventional closure with the purse-string method to eliminate the risk of surgical site infection, it was stated that the infection rate for the control group was 36.6% versus 0%; while the healing time was 5.9 weeks in the conventional linear closure group, it was 3.8 weeks in the purse-string group. It was reported that the satisfaction rate of the patients in the purse-string group was 70%, whereas it was 20% in the other group(102).\u003c/p\u003e\n\u003cp\u003eIn the meta-analysis of randomized controlled trials for reducing the surgical site infection rate following the closure of the stoma: against the traditional primary closure vs purse-string closure, it was stated that the most effective and cosmetically satisfying closure technique was purse-string closure(103). After the reversal of Loop Ileostomy, conventional techniques: Lee et al., who compared wound infection rates and operative outcomes, reported that the median length of hospital stay was significantly shorter in the purse-string skin closure group(104). Additionally, the researchers stated that while most linear closures were performed before 2008, most purse-string closure procedures were performed after 2008; therefore, they thought that selection bias in patients affected the length of hospital stay(104). Furthermore, the trend in patient treatment has recently been shifting towards reducing the length of hospital stay with the use of early recovery programs, which could have also influenced the reduction in hospital stay.\u003c/p\u003e\n\u003cp\u003eIn a systematic review conducted by Li et al. in 2014, after comparing 15 studies, they reported that the purse-string closure method following stoma reversal was the best skin closure technique in terms of surgical site infection. However, the authors have noted that the quality of supporting evidence is limited(105). It has also been stated that none of the patients in the purse-string group were diagnosed with a surgical site infection. These results can be said to parallel our research findings. In the studies; the idea that the incidence increases because the subcutaneous exudate cannot be completely drained when the skin is primarily closed is emphasized as the reason for surgical site infection (SSI) in conventional techniques (106,107). Therefore, it may cause a higher SSI rate and increase the risk of wound separation, resulting in incisional hernia, prolonged hospital stay, and higher healthcare costs. In addition, delayed wound healing with unsightly scar formation and poor cosmetic results can be expected in the conventional group.\u003c/p\u003e"},{"header":"6.\tConclusion and Recommendations","content":"\u003cp\u003eOur research results show that the purse-string technique has significantly fewer surgical site infections and better cosmetic results compared to the conventional technique. There was no significant difference in operation time, length of hospital stay, and wound healing time between the two groups. More studies are needed with long-term follow-up to confirm the potential benefit of the purse-string technique in reducing incisional hernia and cost-effectiveness. The purse-string technique may reduce surgical site infections and theoretically the incidence of postoperative incisional hernia. To confirm this potential benefit, further prospective studies addressing this issue with long-term follow-up are needed.\u003c/p\u003e\n\u003cp\u003eAs known, surgical site infections pose a significant economic burden in terms of prolonged hospital stay, drug treatment, and increased treatment costs. The higher rate of surgical site infections in the conventional group may be associated with higher medical costs. Additional costs related to the health personnel continuously visiting the patient and providing wound care to reduce surgical site infections in the conventional group should also be considered. However, all included trials did not report data on cost-effectiveness. As medical costs vary between countries, each healthcare system needs its own cost-effectiveness analysis to support decision-making.\u003c/p\u003e\n\u003cp\u003eIn summary; the purse-string technique has been found to be superior in terms of fewer wound infections, fewer clinical visits after surgery, higher patient satisfaction, less restriction on daily activities, and better cosmetic results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e\" Asst. Prof. Dr. Amil Huseynov and Assos.Prof. Dr.Veli Vural designed the research and supervised the data collection. Dr.Huseynov performed the data analysis and interpreted the results. Dr. Vural drafted the manuscript and edited it. Both authors approved the final draft of the manuscript for submission and publication. All authors contributed to the research process, reviewed the findings, and approved the manuscript.\"\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHarputlu D, Terzi C, Eşrefgil G, Uz S. Kolostomi ve ileostomili bireylerde benlik saygısı, KRHD, 2007; 17: 178-185.\u003c/li\u003e\n\u003cli\u003eDoughty DB. History of ostomy surgery, J WOCN, 2008; 35 (1): 34-38.\u003c/li\u003e\n\u003cli\u003eYaşan A, \u0026Uuml;nal S, Gedik E, Girgin S. Kalıcı ve ge\u0026ccedil;ici ostomi yapılmış kişilerde yaşam kalitesinde değişim depresyon ve anksiyete, Anatolian Journal of Psychiatry, 2008; 9: 162-8.\u003c/li\u003e\n\u003cli\u003e\u0026Uuml;st\u0026uuml;ndağ H, Demir N, Zengin N, G\u0026uuml;l A. Stomalı hastalarda beden imajı ve benlik saygısı, T\u0026uuml;rkiye Klinikleri J Med Sci, 2007; 27: 522- 527.\u003c/li\u003e\n\u003cli\u003eHackam DJ, Rotstein OD. 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Loop ileostomy versus loop colostomy for fecal diversion after colorectal or coloanal anastomosis: a meta-analysis, Int J Colorectal Dis, 2009; 24: 479\u0026ndash;488.\u003c/li\u003e\n\u003cli\u003ePokorny H, Herkner H, Jakesz R, Herbst F. Mortality and complications after stoma closure, Arch Surg, 2005; 140: 956\u0026ndash;960.\u003c/li\u003e\n\u003cli\u003eKaiser AM, Israelit S, Klaristenfeld D, et al. Morbidity of ostomy takedown, J Gastrointest Surg, 2008; 12: 437\u0026ndash;441.\u003c/li\u003e\n\u003cli\u003eSong GW, Yu CS, Lee HO, Kim MS, Namgung H, Lee GH, et al. Ileostomy related complications, J Korean Soc Coloproctol, 2003; 19: 82\u0026ndash;\u003c/li\u003e\n\u003cli\u003eS The morbidity surrounding reversal of defunctioning ileostomies: a\u003c/li\u003e\n\u003cli\u003esystematic review of 48 studies including 6,107 cases. Int J Colorectal Dis. 2009, 24(6): 711-23.\u003c/li\u003e\n\u003cli\u003eAtallah W, Karpuz Ş, Taghiyev A, Coşkun M. Comparing cosmetic results of purse-string closure vs conventional linear sutured closure of the stoma wound following loop ıleostomy reversal, Turk J Colorectal Dis, 2018; 28: 153-15.\u003c/li\u003e\n\u003cli\u003eGruessner U, Clemens M, Pahlplatz PV, Sperling P, Witte J, Rosen HR; Septocoll Study Group, Improvement of perineal wound healing by local administration of gentamicin-impregnated collagen fleeces after abdominoperineal excision of rectal cancer, Am J Surg, 2001; 182: 502\u0026ndash; 509.\u003c/li\u003e\n\u003cli\u003eHaase O, Raue W, B\u0026ouml;hm B, Neuss H, Scharfenberg M, Schwenk W. Subcutaneous gentamycin implant to reduce wound infections after loop- ileostomy closure: a randomized, double-blind, placebo-controlled trial, Dis Colon Rectum, 2005; 48: 2025\u0026ndash;2031.\u003c/li\u003e\n\u003cli\u003ede Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control, 2009; 37: 387\u0026ndash;397.\u003c/li\u003e\n\u003cli\u003eBanerjee A. Pursestring skin closure after stoma reversal, Dis Colon Rectum, 1997; 40: 993\u0026ndash;994.\u003c/li\u003e\n\u003cli\u003eMilanchi S, Nasseri Y, Kidner T, Fleshner P. Wound infection after ileostomy closure can be eliminated by circumferential subcuticular wound approximation, Dis Colon Rectum, 2009; 52: 469\u0026ndash;474.\u003c/li\u003e\n\u003cli\u003eReid K, Pockney P, Pollitt T, Draganic B, Smith SR. Randomized clinical trial of short-term outcomes following pursestring versus conventional closure of ileostomy wounds, Br J Surg, 2010; 97: 1511\u0026ndash; 1517.\u003c/li\u003e\n\u003cli\u003eDaniel CM, M.D. Jos\u0026eacute; Luis Rodriguez-D\u0026iacute;az, M.D. Noel Salgado- Nesme, M.D. Quint\u0026iacute;n H. Gonz\u0026aacute;lez, M.D. Omar Vergara-Fern\u0026aacute;ndez, M.D. randomized clinical trial of ıntestinal ostomy takedown comparing pursestring wound closure vs conventional closure to Eliminate the Risk of Wound Infection\u003c/li\u003e\n\u003cli\u003ePursestring Closure versus Conventional Primary Closure Following Stoma Reversal to Reduce Surgical Site Infection Rate: A Meta-analysis of Randomized Controlled Trials Meng-Chiao Hsieh, M.D. 1,2 \u0026bull; Liang-Tseng Kuo, M.D.2,3 Ching-Chi Chi, M.D., M.M.S., D.Phil.2,4\u0026ndash;6 \u0026bull; Wen-Shih Huang, M.D.1,5 Chih-Chien Chin, M.D.. Diseases of the Colon \u0026amp; Rectum Volume 58: 8 (2015\u003c/li\u003e\n\u003cli\u003eJung Ryeol Lee, ⦁ Young Wan Kim, ⦁ Jong Je Sung, ⦁ Ok-Pyung⦁ Song, ⦁ Hyung Chul Kim, ⦁ Cheol-Wan Lim, ⦁ Gyu-Seok Cho, ⦁ Jun Chul ⦁ Jung, and ⦁ Eung-Jin Shin Conventional Linear versus Purse-string Skin Closure after Loop Ileostomy Reversal: Comparison of Wound Infection Rates and Operative Outcomes. ⦁ J Korean Soc Coloproctol. 2011; 27(2): 58\u0026ndash;63.\u003c/li\u003e\n\u003cli\u003eLi LT, Hicks SC, Davila JA, et al. Circular closure is associated with the lowest rate of surgical site infection following stoma reversal: a systematic review and multiple treatment metaanalysis, Colorectal Dis. 2014; 16: 406\u0026ndash;416.\u003c/li\u003e\n\u003cli\u003eMurray BW, Cipher DJ, Pham T, Anthony T. The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery, Am J Surg, 2011; 202: 558\u0026ndash;560.\u003c/li\u003e\n\u003cli\u003eKeenan JE, Speicher PJ, Thacker JK, Walter M, Kuchibhatla M, Mantyh CR. The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings, JAMA Surg, 2014; 149: 1045\u0026ndash;1052.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4162772/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4162772/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Stoma surgery, crucial for conditions like Crohn's disease and colorectal cancers, requires effective closure techniques. This study compares the pursestring method to conventional closure methods, focusing on postoperative outcomes and complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The study involved a systematic comparison between the pursestring and traditional linear suturing techniques in stoma closure. Patient selection was based on specific criteria, ensuring a representative sample. Variables such as surgical time, complication rates, and recovery periods were meticulously recorded and analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The analysis revealed that patients undergoing the pursestring method experienced significantly lower infection rates and quicker healing times. This method, employing a circular suture pattern, proved more effective in minimizing postoperative complications compared to conventional methods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The pursestring method demonstrates a notable advantage over traditional techniques in stoma closure. Its benefits in reducing infection rates and promoting faster recovery highlight its potential as a preferred method in surgical practice. The study advocates for its broader adoption in clinical settings, considering its positive impact on patient outcomes.\u003c/p\u003e","manuscriptTitle":"Comparative analysis of pursestring method versus conventional methods for stoma closure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-01 17:52:48","doi":"10.21203/rs.3.rs-4162772/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ec6a505b-2539-4764-bb8f-a40eecc00b3c","owner":[],"postedDate":"April 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-13T19:23:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-01 17:52:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4162772","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4162772","identity":"rs-4162772","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}