We found that closure using NPWTi-d and delayed primary closure was an effective therapy for stoma wound closure. There were no cases of SSI, and the burden on medical staff and patients during hospitalization was, therefore, decreased. In addition, the patients did not have to treat the wound themselves after discharge and had fewer outpatient visits.
A temporary stoma is commonly used when a low pelvic anastomosis is performed in rectal cancer and benign diseases. The most dreaded complication of a low pelvic anastomosis is an anastomotic leak; therefore, a temporary stoma is performed.
SSI is an important and common complication after stoma closure. Peristomal skin reportedly harbors a considerable number of enteric bacteria, and since the procedure also entails enteric anastomosis, stoma closure is considered a clean-contaminated procedure. Generally, risk factors for SSI include radiation therapy, chemotherapy, obesity, diabetes, long-term steroid administration, and immunosuppressant administration. SSI is associated with an increased burden of treatment for medical staff and patients. It causes prolonged postoperative hospital stay, increase in outpatient visits, additional home health care utilization, and increased medical costs. Additionally, as a late complication of SSI after stoma closure, an abdominal incisional hernia may develop. An abdominal incisional hernia can significantly reduce a patient’s quality of life and may require re-operation. It therefore leads to a further increase in medical costs.
Other steps have been taken to reduce SSI following stoma closure. With primary suture closure, the wound is closed immediately, and a dead space is formed. The subcutaneous fluids cannot drain, and an abscess may form. There are some reports of adding a drainage tube to the subcutaneous layer under the wound; however, this also has a high infection rate of about 20% [8].
Purse-string suturing has one of the lowest infection rates, and its usefulness has been demonstrated [1, 4, 8]. However, this method can take up to 30 days for granulation and epithelialization [9]. Continuous wound care and outpatient visits are required until the wound is healed, and it may be difficult for elderly patients to perform self-care procedures such as cleaning the wound. NPWT therapy is thought to promote granulation and wound healing. It increases wound blood flow, promotes granulation tissue formation, reduces edema, and removes exudate and inactive tissue by sealing the wound and applying negative pressure drainage. Currently, although NPWT is used for various surgical cases, its prophylactic use is still not considered vital in digestive surgery. A study on the use of NPWT in the prevention of SSI and shortening of wound healing period after stoma closure was not able to show the efficacy of NPWT compared to that of purse-string sutures in significantly reducing the wound healing time [5]. Additionally, local infection may occur as an adverse event with NPWT [5, 10].
NPWTi-d can prevent bacterial growth by automatic cleansing of the wound surface and removal of dissolving devitalized tissue and exudate early and aggressively. By using NPWTi-d on the stoma closure wound, the promotion of granulation may reduce the dead space and the risk of SSI. It may also shorten the wound healing period. Additionally, delayed primary closure may further shorten the epithelialization time. This will reduce the burden on medical staff and patients and lead to a reduction in inpatient duration and outpatient visits.