title: Circular closure is associated with the lowest rate of surgical site infection following stoma reversal: a systematic review and multiple treatment meta-analysis.
abstract: OBJECTIVE
  Stoma reversal is frequently complicated by surgical site infection (SSI). To reduce SSI, several techniques for skin closure have been studied, with no agreement on which is best. The aim of this study was to identify the skin closure technique associated with the lowest rate of SSI following stoma reversal.
  
  
  METHODS
  We systematically searched MEDLINE (PubMed and OvidSP), Scopus and clinical registries from 1 January 1980 to 24 March 2012, and included original reports on adult patients following stoma reversal. A network of treatments was created to map the comparisons between skin closure techniques, including primary closure, primary closure with a drain, secondary closure, delayed primary closure, loose primary closure and circular closure. Pairwise meta-analyses were performed for all available direct comparisons of closure types and heterogeneity was assessed. A multiple-treatments meta-analysis was conducted to estimate relative treatment effects between competing closure types (reported as an odds ratio with 95% credible interval, and a probability that each treatment is best). Several sensitivity analyses were performed.
  
  
  RESULTS
  Fifteen studies were identified with a total of 2921 cases of stoma reversal. Overall, study quality was poor with observed low (one study), moderate (seven studies) and high (seven studies) risk of bias. Circular closure was associated with the lowest SSI risk (OR 0.12; 95% CI 0.02-0.40) and was the best of six skin closure techniques (probability of being best = 68.9%). Circular closure remained the best after sensitivity analyses.
  
  
  CONCLUSIONS
  This study showed that circular closure is the best skin closure technique after stoma reversal in terms of SSI rate, but the quality of supporting evidence is limited, precluding definite conclusions.
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
authors.forename: L T
authors.initials: LT
authors.lastname: Li
authors.forename: S C
authors.initials: SC
authors.lastname: Hicks
authors.forename: J A
authors.initials: JA
authors.lastname: Davila
authors.forename: L S
authors.initials: LS
authors.lastname: Kao
authors.forename: R L
authors.initials: RL
authors.lastname: Berger
authors.forename: N A
authors.initials: NA
authors.lastname: Arita
authors.forename: M K
authors.initials: MK
authors.lastname: Liang
mesh_terms: D062109:Dermatologic Surgical Procedures / Q000379:methods*; D014943:Global Health; D006801:Humans; D015994:Incidence; D012086:Reoperation / Q000379:methods; D054047:Surgical Stomas / Q000009:adverse effects*; D013530:Surgical Wound Infection / Q000453:epidemiology*; D058106:Wound Closure Techniques
keywords: Ostomy; colostomy; enterostomy; ileostomy; takedown; wound