COMPARISON BETWEEN OSTOMY CLOSURE USING PURSE-STRING VERSUS LINEAR IN CHILDREN

ABSTRACT BACKGROUND: Type of ostomy closure has connection with some complications and also cosmetic effects. AIMS: This study aimed to compare result of colostomy closure using purse-string method versus linear method in terms of surgical site infection, surgical time, and patient satisfaction. METHODS: In this study, 50 patients who underwent purse-string ostomy closure and 50 patients who underwent linear closure were included. Two groups were compared for surgical time, wound infection, patient satisfaction, scar length. A p-value <0.05 was considered significant. RESULTS: Wound infection was not reported among purse-string group compared to 10% in linear group (p=0.022). Scar length was 24.09±0.1 mm in purse string and 52.15±1.0 mm in linear group (p=0.033). Duration of hospital admission was significantly shorter in purse-string group (6.4±1.1 days) compared to linear (15.5±4.6 days, p=0.0001). The Patient and Observer Scar Assessment Scale scale for observer (p=0.038) and parents (p=0.045) was more favorable among purse-string group compared to linear. CONCLUSION: Purse-string technique has the less frequent surgical site infection, shorter duration of hospital admission, less scar length, and more favorable cosmetic outcome, compared to linear technique.


A QUEDA DA PRESSÃO PORTAL APÓS DESVASCULARIZAÇÃO ESOFAGOGÁSTRICA E ESPLENECTOMIA INFLUENCIA A VARIAÇÃO DO CALIBRE DAS VARIZES E AS TAXAS DE RESSANGRAMENTO NA ESQUISTOSSOMOSE NO SEGUIMENTO EM LONGO PRAZO?
Does the drop in portal pressure after esophagogastric devascularization and splenectomy variation of variceal calibers and the rebleeding rates in schistosomiasis in late follow-up?
Walter de Biase SILVA-NETO 1 , Claudemiro QUIRESE 1 , Eduardo Guimarães Horneaux de MOURA 2 , Fabricio Ferreira COELHO 3 , Paulo HERMAN 3 ABSTRACT -Background: The treatment of choice for patients with schistosomiasis with previous episode of varices is bleeding esophagogastric devascularization and splenectomy (EGDS) in association with postoperative endoscopic therapy. However, studies have shown varices recurrence especially after long-term follow-up. Aim: To assess the impact on behavior of esophageal varices and bleeding recurrence after post-operative endoscopic treatment of patients submitted to EGDS. Methods: Thirty-six patients submitted to EGDS portal pressure drop, more or less than 30%, and compared with the behavior of esophageal varices and the rate of bleeding recurrence. Results late post-operative varices caliber when compared the pre-operative data was observed despite an increase in diameter during follow-up that was controlled by endoscopic therapy.

Central Message
Anorectal malformations and Hirschsprung disease are the main indications for ostomy formation among neonates and children. Closure type has connection with some complications and also cosmetic effects. Following ostomy closure, complications such as obstruction, infection, and necrosis may occur.

INTRODUCTION
Anorectal malformations and Hirschsprung disease are the main indications for ostomy formation among neonates and children 3 . After ostomy formation, another challenge is ostomy closure. Closure type has connection with some complications and also cosmetic effects. In more than 41% of children with ostoma, wound infection was reported 18 . Following ostomy closure, complications such as obstruction, infection, and necrosis may occur 1,25 .
Many studies exist in relation to wound infection and length of hospitalization 13 21 . According to systematic reviews, purse-string resulted in lowering wound infection, but about hospitalization more research were suggested 16,18,22 . Sureshkumar et al., on antibiotic treatment, showed wound infection and duration of antibiotic treatment significantly lower in purse-string compared to linear 23 . In contrary, Lee et al. 14,15 showed that purse-string technique was associated with lower rate of infection but with longer healing time compared to linear closure. Han et al. modified that purse-string ostomy closure was associated with lower rate of wound infection, less hospital stay, and lower cost of hospitalization compared to linear closure, but with longer wound healing 9 . In the systematic review by Gachabayov et al. 7 , purse-string technique was associated with less infection compared to linear for reverse ileostomy, and Juratli et al. 11

refer lower incidence of incisional hernia.
Limited studies have shown cosmetic effect, patient satisfaction, and wound infection based on method recommendation 6,20 .
The objective of this study was to compare purse-string ostomy closure versus linear closure in terms of wound infection, duration of hospitalization, and cosmetic effect.

METHODS
This is a clinical trial registered at IRCT numbered IRCT20121010011068N3 and approved by Ethical Committee of the University. Children were randomly assigned in case or control group. Informed consent was signed by parents or legal guardians.
Children referred to Hospital for colostomy closure were included. A total of 100 patients were included (linear group=50, purse-string=50). Inclusion criterion was age 0-6 years old. Exclusion criteria were age >6 years, dead cases, patient incompliance, speech problem, and brain problem. Patients were randomly placed in purse-string (case) and linear (control) groups.
Follow-up period was 1 year following surgery. Follow-up was done on 1, 2, and 3 days after surgery; discharge; 30 days; and 6 and 12 months after surgery. Follow-up method was by phone and follow-up visit. The Patient and Observer Scar Assessment Scale (POSAS) was used for scar evaluation 4,5 .

Statistical analysis
Data analysis was done using the t-test and Mann-Whitney U test. A p-value <0.05 was considered significant.

RESULTS
As scheduled, colostomy closure using purse-string was done in 50 cases and linear in another 50. Gender, type of colostomy, and indications for colostomy are mentioned in Table 1.

DISCUSSION
Several techniques have been used for ostomy closures since many years. Anorectal malformation was the most common cause of the colostomy in our study, which is consistent with the findings of Bischoff et al. 2 which showed mortality in ostomy closure 2 .
Wound infection is one of the frequent complications 12,19 . In this study, site infection was not seen in purse-string method compared to 10% in linear technique, which is similar to the results of Dusch et al. 6 which showed no infection in pursestring against 24% in linear technique. Purse-string method was associated with lower rate of wound infection compared to linear ostomy closures 9,14 . Also, Marquez et al. showed less wound infection in purse-string method compared to linear method 17 . In contrast, Milanchi et al. 19 and Sutton et al. 24 reported that wound infection was not seen following pursestring ostomy closure.
In addition, Vermulst et al. 26 and Lee et al. 14 found that there was no significant difference between purse-string and linear techniques in terms of surgical wound infection.
Cosmetic outcome was more favorable in purse-string compared to linear closure, which is similar to the findings of Hsieh et al. 10 and Sutton et al. 24 .
Ostomy wound healing was significantly shorter in pursestring method compared to linear method, which is consistent with some studies 21 .
In this study, duration of purse-string technique was less than linear technique, which is similar to the study by Dusch et al. 6 .
Patient satisfaction was higher in the purse-string group compared to the linear group, which is similar to the study by Hajibandeh et al. 8 .
This study has some limitations. It is a single-center study. Sample size was the main limitation of this study.

CONCLUSION
The purse-string closure of the colostomy is the safe method with favorable cosmetic appearance, less frequent wound infection, and less duration of colostomy closure. It is recommended to study with more sample size and more follow-up period in future.