Does primary closure increase surgical site infection after intestinal stoma reversal? A retrospective cohort study.

BACKGROUND: This study was undertaken to test the veracity of the hypothesis that primary incision closure after intestinal stoma reversal in adult patients is associated with a greater risk of surgical site infection (SSI) than are open incisions. METHODS: A retrospective cohort study was conducted at the Surgical Department of the Aga Khan University Hospital, Karachi, Pakistan. The study included adult patients who underwent elective loop and double-barreled intestinal stoma (ileostomy or colostomy) reversal through peristomal incisions between January 2005 and May 2011. Files were reviewed independently by two surgeons to establish main exposure (closed or open surgical sites) and outcome; i.e., SSI based on U.S. Centers for Disease Control and Prevention criteria. RESULTS: Sample size calculation prior to the study required 71 patients to be included in each exposure arm. Patients with closed surgical sites were relatively younger (mean 36±15 [standard deviation] years) than those with open surgical sites (41±15 years), with a male preponderance in both groups. Fifteen patients were found to have SSI: 3/71 (4.2%) in open and 12/71 (16.9%) in closed incisions. The risk of SSI in closed surgical sites was 5.8 times greater than in open sites (95% confidence interval for relative risk 1.5-22.5) after adjusting for gender, body mass index (BMI), site of stoma, malignant disease, and preoperative chemo-radiotherapy. CONCLUSION: The risk of SSI in closed incisions is greater than that in open incisions. It is suggested that incisions not be closed primarily in patients undergoing stoma reversal.

Repair of large and giant incisional hernia with onlay mesh: perspective of a tertiary care hospital of a developing country.

PURPOSE: Ventral incisional hernias, especially large and giant, carry significant post repair complications. This retrospective review is undertaken to determine the outcomes of large and giant incisional hernia repair as well as the risk factors of recurrence and surgical site infection at a tertiary care hospital in developing country. METHOD: This case series included adult patients, operated between January 2001 and June 2009 for incisional hernia of size ≥ 10 cm (vertical or horizontal dimension) at our institute with follow up of at least one year. The charts of selected patients were reviewed by a general surgery fellow for hernia recurrence, complications, mortality and the predictive factors. RESULTS: Sixty out of 391 patients operated for incisional hernia were found eligible; of them 29 (48.3%) had large (defect of 10-15 cm) and 31 (51.7%) had giant hernia (defect size >15 cm). Mean age of patients was 43.8 ± 11.8 with female preponderance (male: female; 1:1.6). Fourteen (23.33%) patients developed complications and there was no mortality. Surgical Site Infection (SSI) was observed in 13 (21.67%) patients and significant predisposing factors for SSI (with or without mesh infection) were diabetes mellitus, emergency surgery, contaminated surgery and recurrent incisional hernia. With a mean follow up of 20.05 ± 8.8 months (range: 12-48 months), four (6.67%) patients had recurrence of hernia. CONCLUSIONS: Repair of large and giant incisional hernia using prosthetic non-absorbable mesh, mainly onlay, carry acceptable rates of complications.

Treatment of complex fistula in ano with cable-tie seton: a prospective case series.

Objective. To determine the fecal incontinence and recurrence rate in patients with complex fistula in ano managed with cable tie seton at a tertiary care teaching hospital. Methods. This is a prospective case series of patients with complex anal fistula i.e. recurrent fistula or encircling >30% of external anal sphincter, managed with cable tie seton from March 2003 to March 2009. Patients were seen in the clinic after 72 hours of seton insertion under anesthesia and then every other week. Each time the cable-tie was tightened if found loose without anesthesia and incontinence was inquired according to wexner's score. Results. Seventy nine patients were treated during the study period with the age (mean ± standard deviation) of 41 ± 10.6 years and. The seton was tightened with a median of six times (3-15 times range). Complete healing was achieved in 11.2 ± 5.7 weeks. All the patients were followed for a minimum period of one year and none of the patients had any incontinence. Recurrence was found in 4 (5%) patients. Conclusion. The cable tie seton is safe, cost effective and low morbidity option for the treatment of complex fistulae-in-ano. It can, therefore, be recommended as the standard of treatment for complex fistulae-in-ano requiring the placement of a seton.