Original Paper Received: February 11, 2013 Accepted after revision: July 14, 2013 Published online: April 23, 2014
Dig Surg 2014;31:73–78 DOI: 10.1159/000354426
Prevalence of Surgical Site Infection at the Stoma Site following Four Skin Closure Techniques: A Retrospective Cohort Study Linda T. Li a Reshma Brahmbhatt a Stephanie C. Hicks b Jessica A. Davila c David H. Berger a, c, d Mike K. Liang e
a
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, b Department of Statistics, Rice University, Houston Veterans Affairs Health Services Research and Development Center of Excellence, d Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, and e University of Texas Health Science Center at Houston, Houston, Tex., USA c
Key Words Stoma reversal · Stoma takedown · Stoma closure · Ostomy reversal · Surgical site infection · Closure technique
1.04–1.12, p < 0.01). CC was associated with the lowest odds of developing SSI [0.07 (0.01–0.63), p = 0.02]. Conclusions: SSI rate was the lowest for stomas that were closed with CC. © 2014 S. Karger AG, Basel
Abstract Background/Aims: Surgical site infection (SSI) is a common complication of stoma reversal. Studies have suggested that different skin closures affect SSI rates. Our aim was to determine which skin closure technique following stoma reversal leads to the lowest rate of SSI. Methods: We conducted a retrospective review of all adult patients undergoing stoma reversal at a single institution (2005–2011) and compared the rate of SSI following four skin closure techniques: primary closure (PC), secondary closure (SC), loose PC (LPC), and circular closure (CC). Univariate analysis included χ2 or Fisher’s exact test and ANOVA or Kruskal-Wallis H test for categorical and continuous data, respectively. A multivariate logistic regression model was created to identify predictors of SSI. Results: One hundred and forty-six patients were identified: 40 (27%) PC, 68 (47%) SC, 20 (14%) LPC, and 18 (12%) CC. CC was less likely to have SSI (6%) compared to PC (43%), SC (16%), and LPC (15%; p < 0.01). Increasing body mass index was a predictor of SSI (odds ratio 1.11, 95% confidence interval
© 2014 S. Karger AG, Basel 0253–4886/14/0312–0073$39.50/0 E-Mail [email protected] www.karger.com/dsu
Introduction
The most common complication associated with stoma reversal is surgical site infection (SSI), with reported rates ranging from 2 to 41% [1]. Morbidity following infection includes wound dehiscence, poor wound healing, and incisional hernia formation at the prior stoma site. SSI is associated with prolonged inpatient stay, increased outpatient visits, additional home health care utilization, and treatment of SSI-related complications such as seromas and incisional hernias. According to recent estimates, the cost of outpatient management of postoperative SSI was USD 6,200 per patient [2]. The economic burden for inpatient care of SSI is considerable and, in recent studies, ranges from USD 13,000 to as high as USD 25,000 per episode [2, 3]. Prior studies have evaluated several factors that may affect SSI rates following stoma reversal. In particular, Linda T. Li, MD Houston VA HSR&D Center of Excellence (152) 2002 Holcombe Blvd Houston, TX 77030 (USA) E-Mail linday @ bcm.edu
different skin closure techniques have been studied with varying success in decreasing the rate of SSI. Most studies report that primary closure (PC) is associated with the highest rate of SSI [4, 5]. Several retrospective studies found that secondary closure (SC), delayed PC, and loose PC (LPC) are superior to PC [5–7]. Recently, some have investigated the role of circular closure (CC), or pursestring closure, and found lower rates of SSI in wounds closed with CC compared to PC [8–10]. However, most of these studies are small, with less than 80 patients, and compare CC with PC only. We sought to evaluate the effect of CC, compared to PC, SC, and LPC in a larger sample size and hypothesize that CC is associated with the lowest rate of SSI. Materials and Methods Study Design After approval from the Baylor College of Medicine IRB and the Michael E. DeBakey VAMC Research and Development Committee was obtained, we performed a retrospective cohort study on all patients who underwent ileostomy or colostomy closure at our institution from January 2005 to February 2011. Following preexisting institutional protocol, mechanical bowel prep was not used in any patients, and all patients received standardized intravenous prophylactic preoperative antibiotics (ertapenem OR either cefoxin or quinolone/metronidazole for penicillin allergic patients). Fascial closure was performed in all patients. Patients were categorized based on skin closure technique into one of four groups: (1) PC: defined by fascial closure and closure of the skin with staples in a linear fashion. (2) SC: defined by closure of the fascia and packing of the remaining wound. (3) LPC: defined by closure of the fascia and loose approximation of the skin with interrupted suture or staples and packing between sutures with gauze wicks. (4) CC: defined by closure of the fascia and approximation of the skin with a purse-string subcuticular suture, usually with a small wound at the center that is packed with gauze wicks. No patient was managed by delayed PC. Demographic data, body mass index (BMI), history of tobacco use, diabetes, ASA score, history of prior open wound, duration of stoma, and surgical approach were abstracted from electronic medical records. Surgical approach was defined as open (stoma reversal requiring midline laparotomy), transstomal, and laparoscopic takedown. Postoperative rates of SSI at the prior stoma site were recorded, and hernia formation at the stoma site was captured following stoma reversal. Incisional SSI was identified by review of clinician notes, procedure notes, and laboratory data, using CDC guidelines to include one of the following events within 30 days after surgery: (1) infection accompanied by purulent discharge with or without laboratory cultures, (2) culture positive drainage fluid or tissue biopsy, or (3) incision with signs of inflammation and opened deliberately by the surgeon [3]. Hernia formation was determined by review of clinic notes by any discipline or radiographic evidence of hernia. All imaging was reviewed by two surgeons for stoma site hernia. Follow-up was determined by date of stoma reversal to last CT scan. For patients that did not receive follow-up CT imaging,
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Dig Surg 2014;31:73–78 DOI: 10.1159/000354426
time of follow-up was determined by time to last clinical follow-up. Time to wound healing was determined by review of clinical notes to determine the first time no wound was noted. Statistical Analysis Categorical data were assessed with a χ2 test or Fisher’s exact test [11]. Continuous data were assessed by histogram plots and skewness and kurtosis value between ±2 to test for normality. Continuous data found to be normally distributed were compared using one-way ANOVA or otherwise were compared using the Kruskal-Wallis H test if the data did not meet the normally distributed assumption. The Bonferroni correction was used to adjust for multiple treatment comparisons [12]. To identify significant predictors of SSI, we followed Hosmer and Lemeshow’s outline for variable selection: all variables with a p value
Dig Surg 2014;31:73–78 DOI: 10.1159/000354426
Prevalence of Surgical Site Infection at the Stoma Site following Four Skin Closure Techniques: A Retrospective Cohort Study Linda T. Li a Reshma Brahmbhatt a Stephanie C. Hicks b Jessica A. Davila c David H. Berger a, c, d Mike K. Liang e
a
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, b Department of Statistics, Rice University, Houston Veterans Affairs Health Services Research and Development Center of Excellence, d Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, and e University of Texas Health Science Center at Houston, Houston, Tex., USA c
Key Words Stoma reversal · Stoma takedown · Stoma closure · Ostomy reversal · Surgical site infection · Closure technique
1.04–1.12, p < 0.01). CC was associated with the lowest odds of developing SSI [0.07 (0.01–0.63), p = 0.02]. Conclusions: SSI rate was the lowest for stomas that were closed with CC. © 2014 S. Karger AG, Basel
Abstract Background/Aims: Surgical site infection (SSI) is a common complication of stoma reversal. Studies have suggested that different skin closures affect SSI rates. Our aim was to determine which skin closure technique following stoma reversal leads to the lowest rate of SSI. Methods: We conducted a retrospective review of all adult patients undergoing stoma reversal at a single institution (2005–2011) and compared the rate of SSI following four skin closure techniques: primary closure (PC), secondary closure (SC), loose PC (LPC), and circular closure (CC). Univariate analysis included χ2 or Fisher’s exact test and ANOVA or Kruskal-Wallis H test for categorical and continuous data, respectively. A multivariate logistic regression model was created to identify predictors of SSI. Results: One hundred and forty-six patients were identified: 40 (27%) PC, 68 (47%) SC, 20 (14%) LPC, and 18 (12%) CC. CC was less likely to have SSI (6%) compared to PC (43%), SC (16%), and LPC (15%; p < 0.01). Increasing body mass index was a predictor of SSI (odds ratio 1.11, 95% confidence interval
© 2014 S. Karger AG, Basel 0253–4886/14/0312–0073$39.50/0 E-Mail [email protected] www.karger.com/dsu
Introduction
The most common complication associated with stoma reversal is surgical site infection (SSI), with reported rates ranging from 2 to 41% [1]. Morbidity following infection includes wound dehiscence, poor wound healing, and incisional hernia formation at the prior stoma site. SSI is associated with prolonged inpatient stay, increased outpatient visits, additional home health care utilization, and treatment of SSI-related complications such as seromas and incisional hernias. According to recent estimates, the cost of outpatient management of postoperative SSI was USD 6,200 per patient [2]. The economic burden for inpatient care of SSI is considerable and, in recent studies, ranges from USD 13,000 to as high as USD 25,000 per episode [2, 3]. Prior studies have evaluated several factors that may affect SSI rates following stoma reversal. In particular, Linda T. Li, MD Houston VA HSR&D Center of Excellence (152) 2002 Holcombe Blvd Houston, TX 77030 (USA) E-Mail linday @ bcm.edu
different skin closure techniques have been studied with varying success in decreasing the rate of SSI. Most studies report that primary closure (PC) is associated with the highest rate of SSI [4, 5]. Several retrospective studies found that secondary closure (SC), delayed PC, and loose PC (LPC) are superior to PC [5–7]. Recently, some have investigated the role of circular closure (CC), or pursestring closure, and found lower rates of SSI in wounds closed with CC compared to PC [8–10]. However, most of these studies are small, with less than 80 patients, and compare CC with PC only. We sought to evaluate the effect of CC, compared to PC, SC, and LPC in a larger sample size and hypothesize that CC is associated with the lowest rate of SSI. Materials and Methods Study Design After approval from the Baylor College of Medicine IRB and the Michael E. DeBakey VAMC Research and Development Committee was obtained, we performed a retrospective cohort study on all patients who underwent ileostomy or colostomy closure at our institution from January 2005 to February 2011. Following preexisting institutional protocol, mechanical bowel prep was not used in any patients, and all patients received standardized intravenous prophylactic preoperative antibiotics (ertapenem OR either cefoxin or quinolone/metronidazole for penicillin allergic patients). Fascial closure was performed in all patients. Patients were categorized based on skin closure technique into one of four groups: (1) PC: defined by fascial closure and closure of the skin with staples in a linear fashion. (2) SC: defined by closure of the fascia and packing of the remaining wound. (3) LPC: defined by closure of the fascia and loose approximation of the skin with interrupted suture or staples and packing between sutures with gauze wicks. (4) CC: defined by closure of the fascia and approximation of the skin with a purse-string subcuticular suture, usually with a small wound at the center that is packed with gauze wicks. No patient was managed by delayed PC. Demographic data, body mass index (BMI), history of tobacco use, diabetes, ASA score, history of prior open wound, duration of stoma, and surgical approach were abstracted from electronic medical records. Surgical approach was defined as open (stoma reversal requiring midline laparotomy), transstomal, and laparoscopic takedown. Postoperative rates of SSI at the prior stoma site were recorded, and hernia formation at the stoma site was captured following stoma reversal. Incisional SSI was identified by review of clinician notes, procedure notes, and laboratory data, using CDC guidelines to include one of the following events within 30 days after surgery: (1) infection accompanied by purulent discharge with or without laboratory cultures, (2) culture positive drainage fluid or tissue biopsy, or (3) incision with signs of inflammation and opened deliberately by the surgeon [3]. Hernia formation was determined by review of clinic notes by any discipline or radiographic evidence of hernia. All imaging was reviewed by two surgeons for stoma site hernia. Follow-up was determined by date of stoma reversal to last CT scan. For patients that did not receive follow-up CT imaging,
74
Dig Surg 2014;31:73–78 DOI: 10.1159/000354426
time of follow-up was determined by time to last clinical follow-up. Time to wound healing was determined by review of clinical notes to determine the first time no wound was noted. Statistical Analysis Categorical data were assessed with a χ2 test or Fisher’s exact test [11]. Continuous data were assessed by histogram plots and skewness and kurtosis value between ±2 to test for normality. Continuous data found to be normally distributed were compared using one-way ANOVA or otherwise were compared using the Kruskal-Wallis H test if the data did not meet the normally distributed assumption. The Bonferroni correction was used to adjust for multiple treatment comparisons [12]. To identify significant predictors of SSI, we followed Hosmer and Lemeshow’s outline for variable selection: all variables with a p value
