Research ArticleClinical Studies
Open Access

Delayed Primary Skin Closure Followed by Single-use Negative-pressure Wound Therapy Is Optimal for Wound Management After Bowel-stoma Reversal

TAKUMU FUKASAWA, KEN IMAIZUMI, KAZUTOSHI TERASHIMA, HIROYUKI KASAJIMA, NAOE FURUKAWA, KEIICHIRO ITO, TADASHI ODAGIRI, DAISUKE YAMANA, YOSUKE TSURUGA, MINORU UMEHARA, MICHIHIRO KURUSHIMA and KAZUAKI NAKANISHI
In Vivo November 2025, 39 (6) 3418-3427; DOI: https://doi.org/10.21873/invivo.14139

Abstract

Background/Aim: Although the purse-string suture (PSS) method is widely adopted to reduce surgical-site infection (SSI; the commonest complication following bowel-stoma closure), this technique is associated with delayed epithelialization. Recently, delayed primary closure (DPC) combined with negative-pressure wound therapy (NPWT) has been proposed as a promising alternative. This study aimed to evaluate the clinical efficacy of DPC with NPWT compared to the PSS method in stoma-closure surgery.

Patients and Methods: We conducted a retrospective observational study involving 31 patients who underwent stoma closure between January 2021 and March 2023. Patients were categorized into two groups: PSS with or without NPWT (PSS±NPWT; n=15) and DPC with NPWT (DPC+NPWT; n=16). The primary outcome was wound-healing duration; the secondary outcomes were patient satisfaction and in-hospital costs.

Results: The wound-healing duration was significantly shorter in the DPC+NPWT group compared to the PSS±NPWT group (median: 20 vs. 45 days, p<0.001). Multivariate analysis identified wound-closure method as an independent predictor of wound healing at 30 days. Patient-reported outcomes indicated improved wound-care experience and a trend toward better cosmetic satisfaction in the DPC+NPWT group. Although not statistically significant, the total in-hospital costs were lower in the DPC+NPWT group despite higher device-related expenditures.

Conclusion: DPC with NPWT significantly shortened the wound-healing duration and showed potential benefits regarding patient satisfaction and healthcare costs compared to the PSS method. These findings suggest DPC with NPWT as a viable alternative for bowel-stoma closure and wound management.

Keywords:

Introduction

Advancements in minimally invasive surgery, including laparoscopic and robot-assisted techniques, have significantly improved colorectal surgery outcomes. In particular, these innovations have led to a notable increase in the rate of sphincter-preservation procedures, such as low anterior resection, especially in cases of mid–low to low rectal cancer (1). Concurrently, the importance of temporary stoma creation to prevent anastomotic leakage has increased. However, the presence of a bowel stoma imposes considerable physical and psychological stress on patients (2), making safe and reliable stoma closure essential for improving their quality of life. Although stoma closure is considered a relatively common surgical procedure, it is associated with postoperative complications at a rate of approximately 20%, which cannot be overlooked (3). Among these complications, surgical-site infection (SSI) at the incision site is the most common; it reportedly prolongs hospitalization, increases the number of outpatient visits, and raises overall medical costs (4).

To address these concerns, various surgical techniques have been developed to reduce SSI incidence. One such method, the purse-string suture (PSS) technique reported by Banerjee et al. in 1997, has gained widespread acceptance owing to its effectiveness in lowering SSI rates compared to conventional primary closure (5). According to a previous systematic review, the incidence of SSI has decreased from 29% with conventional primary closure to 6% with the PSS technique (6). However, the PSS technique is associated with a prolonged wound-healing period owing to the time required for epithelialization, which remains a clinical issue (7). To address this, negative-pressure wound therapy (NPWT), commonly used for contaminated or intractable wounds, has been explored for stoma-closure surgery (8-15). Nevertheless, randomized controlled trials (RCTs) have shown that adding NPWT to the PSS technique does not significantly improve the wound-healing time (8, 9). Conversely, delayed primary closure (DPC) with NPWT has shown promising results in the management of contaminated abdominal wounds in terms of both SSI prevention and wound healing (16, 17). Although a previous report has suggested the potential effectiveness of DPC with NPWT in stoma-closure wounds, the number of cases remains limited (13). In this study, we aimed to evaluate the clinical utility of DPC with NPWT in stoma-closure surgery by comparing it with the PSS method.

Patients and Methods

Study design and patients. This retrospective observational study was approved by the Human Research Ethics Committee at our center (Hokkaido, Japan; reference number 2022-276) and was conducted in accordance with the tenets of the 1964 Declaration of Helsinki and its later amendments. The requirement for informed consent was waived owing to the retrospective nature of this study. The study and manuscript adhered to the “Strengthening the Reporting of Observational studies in Epidemiology” guidelines.

This study included patients who underwent stoma-reversal surgery at our center between January 2021 and March 2023. We also included cases wherein stoma-closure surgery was performed in addition to other surgeries, if the stoma closure wound could be evaluated. Patients who underwent postoperative reoperation owing to changes in wound management were excluded. According to the methods of skin closure and wound management described below, the patients were divided into the following groups: PSS with or without NPWT (PSS±NPWT) and DPC with NPWT (DPC+NPWT).

Study outcomes. The primary endpoint of this study was to evaluate whether the closure methods for stoma-closure wounds affect the wound-healing duration. The secondary endpoints of this study were to compare the patient satisfaction survey and in-hospital costs associated with the wound-closure methods.

Surgical procedure of stoma closure. Surgical procedures for stoma closure are classified as loop or end stoma closure (Hartmann reversal). The techniques used around the stoma site were the same for both methods. First, the stoma hole was closed using sutures. A skin incision was made approximately 2 mm from the mucocutaneous region of the stoma. The stoma was removed from the abdominal wall via dissection even if there were any adhesions. In loop stoma closure, the bowel was transected at the oral and anal sides of the stoma. Functional end-to-end anastomosis using a linear stapler or hand-sewn anastomosis was performed, depending on the surgeon’s preference. In contrast, in end stoma closure, the bowel was resected on the oral side of the stoma. The residual anal stump was identified in the abdominal cavity and dissected from any adhesions. Anastomosis was performed using double- or single-stapling techniques with a circular stapler. For wound closure at the stoma site, the peritoneum, muscle, and fascia were closed in one or two layers using monofilament absorbable sutures. In the PSS method, a subcutaneous suture was applied using the PSS method with an approximately 8-mm wound opening. In the DPC method, after trimming the skin into a spindle shape, the wound was partially closed using buried sutures (Figure 1A).

Figure 1.
Figure 1.

Management flow for delayed primary closure (DPC) with negative-pressure wound therapy (NPWT). A) During surgery, the wound is partially closed with buried sutures. B) In cases with a deep wound floor, the cavity is filled with black GranuFoam, and NPWT is applied using the PICOTM 7 system. C) On postoperative days 3-5, the wound is closed with either absorbable buried sutures or non-absorbable vertical mattress sutures. D) Complete epithelialization of the wound is confirmed, indicating complete healing.

Wound management at stoma-closure site. Until August 2022, the standard wound management in our department was the PSS method. In this method, the wound was managed using a wet-to-dry dressing and continued until scarring occurred. In a few cases, as part of the PSS method, NPWT [ActiV.A.C.® (Kinetic Concepts Inc., San Antonio, TX, USA) or PICO™ 7 (Smith & Nephew, Hull, UK)] was applied postoperatively at the discretion of the attending surgeon. From September 2022, the standard wound management in our department changed from the PSS method to the DPC method followed by PICO™ 7. In the DPC method, the wound was applied with PICO the day after surgery. If the wound floor was deep, the cavity was filled with a black GranuFoam dressing (Kinetic Concepts Inc.) (Figure 1B). The PICO dressing was changed 3-5 days postoperatively, at which time the wound was closed with buried suture using absorbable sutures or vertical mattress suture with non-absorbable sutures (Figure 1C). On postoperative day 8, the PICO was removed and the wound edges were aligned using Steri-Strip (3M, St. Paul, MN, USA). The wound was covered with gauze until epithelialization of the wound was complete, and effusion stopped drainage (Figure 1D).

Data collection. We collected data on age, sex, body mass index, American Society of Anesthesiologists physical status, diabetes mellitus, preoperative steroid use, bowel segment of stoma, original disease (malignancy/benign), and interval from stoma creation to reversal. The collected perioperative data included the operative procedure, additional operation, anastomotic method, operative duration, bleeding, application of NPWT, postoperative hospital stay, post-operative complications, wound healing duration, and complete healing at 30 and 90 days after surgery.

Incisional SSI was diagnosed by the surgical team and defined according to the Centers for Disease Control and Prevention criteria (18). The duration of wound healing was defined as the time until epithelialization. Epithelialization was characterized as a wound covered with epithelium and the absence of wound exudate, along with gauze or wound dressings being unnecessary. Furthermore, a questionnaire was used to quantify and compare differences in patient-reported wound-healing satisfaction and cosmesis. The questionnaire included questions regarding scar cosmesis, difficulty in wound care, level of postoperative pain, and patient satisfaction. These factors were assessed using a 5-point Likert scale. A score of 1-5 was assigned to each factor, with higher scores indicating higher satisfaction. We also assessed perioperative costs by converting turnover and total in-hospital expenditures from Japanese Yen (JPY) to US Dollars (USD) at the exchange rate on April 13, 2024 (1 JPY = 0.0065 USD).

Statistical analyses. In this study, we present the quantitative data as medians. Between-group comparisons were performed using the Mann-Whitney U-test for quantitative data or Fisher’s exact test for categorical data. The odds ratios for complete healing 30 days after surgery were calculated through univariate and multivariate analyses using a logistic regression model. In the multivariate analysis, covariates with p-values of <0.1 were included. The duration of wound healing was compared among the groups using the Kruskal-Wallis test and Bonferroni post-hoc test. Statistical significance was set at p<0.05. All statistical analyses were performed using EZR (version 1.61; Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (version 4.3.1; The R Foundation for Statistical Computing, Vienna, Austria) that is a modified version of R Commander (version 2.8-0), designed to add statistical functions frequently used in biostatistics (19).

Results

Patient characteristics and surgical outcomes. From January 2021 to March 2023, 33 patients underwent stoma-closure surgery. Two patients were excluded because they underwent reoperation for suture failure and anastomotic hemorrhage. Ultimately, 31 patients were included in the study. There were 15 and 16 patients in the PSS±NPWT and DPC+NPWT groups, respectively. The patient characteristics and surgical outcomes are shown in Table I. Patient characteristics were not significantly different between the two groups. Two patients with Hartmann reversal were included in the PSS±NPWT group. Two and five cases with additional operation were included in the PSS±NPWT and DPC+NPWT groups, respectively. NPWT in the PSS±NPWT group was performed postoperatively in four cases. One patient in the PSS±NPWT group developed an incisional SSI. Postoperative bleeding in the two patients who underwent DPC with NPWT was not related to wound management. The wound healing duration in the DPC+NPWT group was significantly shorter than in the PSS±NPWT group. The wound healing rate at 30 and 90 days postoperatively in the DPC+NPWT group was significantly higher than those in the PSS±NPWT group.

View this table:
Table I.

Comparison of patient characteristics and surgical outcomes according to wound-closure methods.

Wound closure methods affect the wound healing. Table II shows the results of univariate and multivariate analyses of the relationship between clinical factors and wound healing at 30 days postoperatively. Diabetes mellitus, preoperative steroid use, original disease, wound closure method, and application of NPWT showed a correlation with wound healing in the univariate analysis, whereas the wound closure method was an independent and significant factor in the multivariate analysis. When the patients were divided into three groups (PSS without NPWT vs. PSS with NPWT vs. DPC with NPWT) according to the wound closure method and application of NPTW, the median durations of wound healing (range) were 45 (21-344), 42 (18-51), and 20 (9-41) days, respectively. DPC with NPWT showed a significantly reduced duration of wound healing (p<0.001) (Figure 2).

View this table:
Table II.

Univariate and multivariate analyses of risk factors for complete healing at 30 days after surgery.

Figure 2.
Figure 2.

Comparison of the durations of wound healing among three groups. DPC: Delayed primary closure; PSS: purse-string suture; NPWT: negative-pressure wound therapy.

Questionnaire and cost. Questionnaires were not collected from 2 patients in the PSS±NPWT group, while the remaining 29 patients completed the questionnaire. The DPC+NPWT group showed higher scores for cosmesis (p=0.0589) and difficulty in wound care (p=0.018) than the PSS±NPWT group (Figure 3). Cases involving Hartmann reversal or additional operations were excluded from the cost analysis. The analysis included 12 and 10 patients in the PSS±NPWT and DPC+NPWT groups, respectively. The DPC+NPWT group showed higher median turnover expenditure [3.64 k (range=3.16-3.87 k) vs. 3.44 k (range=2.87-4.49 k) USD, p=0.582] and lower median total in-hospital expenditure [5.13 k (range=4.82-6.12 k) vs. 5.38 k (range=4.68-8.05 k) USD, p=0.418] than the PSS±NPWT group, although the differences were not significant.

Figure 3.
Figure 3.

Comparison of questionnaires between both groups. DPC: Delayed primary closure; PSS: purse-string suture; NPWT: negative-pressure wound therapy. *p<0.05, **p<0.1.

Discussion

In this study, we presented a DPC method using prophylactic NPWT at the stoma-closure site. Compared with the PSS method, this method significantly reduced the duration of wound healing without affecting the SSI rate. According to the questionnaire survey, the scores for cosmesis and difficulty in wound care by DPC+NPWT were higher compared to those by PSS±NPWT. Regarding medical costs, despite the additional turnover expenditure of NPWT, the total in-hospital expenditure in the DPC+NPWT group was lower than that in the PSS± NPWT group. This is the first study to demonstrate the usefulness of DPC with prophylactic NPWT in stoma-closure wounds.

Complications after stoma closure surgery are relatively common. Incisional SSI at the stoma-closure site is the most frequent complication (20). The SSI rate with the conventional primary closure method is reportedly 0%-40% (21, 22). Various surgical techniques have been reported that reduce the incidence of SSI. In 1997, Banerjee et al. reported the PSS method, which involves gathering the skin in a purse-string manner without completely closing the wound by leaving drainage holes (5). As the PSS method was found to reduce SSI compared to conventional primary closure in a meta-analysis (6), it is widely used today. However, the PSS method is considered to have a longer wound-healing duration than conventional primary closure because of the necessity for secondary healing (5, 7).

NPWT is considered effective for the management of refractory and chronic wounds, as it aids in secondary wound healing by promoting tissue granulation (23). In particular, when NPWT is used prophylactically, it has been shown to reduce the incidence of SSI and shorten wound healing duration in various wound management scenarios (24). However, owing to cost implications, the World Health Organization guidelines related to SSI recommend that NPWT should be limited to cases with a high risk of SSI or other specific criteria (25). The effectiveness of the prophylactic use of NPWT in wounds associated with stoma-closure surgery, which are considered to have a high risk of SSI, has not been established. In an RCT conducted by Uchino et al., the addition of NPWT to PSS did not reduce SSI incidence or shorten the wound-healing duration; furthermore, >30 days were required for wound healing (8). Similarly, some reports indicate that the addition of NPWT to PSS does not result in shortened wound healing (9, 11). Our partial findings did not show a reduction in the duration of wound healing using PSS with NPWT.

However, some studies have demonstrated the effectiveness of wound management techniques combining NPWT with DPC or primary closure (10, 13, 14). In a retrospective study, Curchod et al. reported that adding NPWT to primary closures reduced the incidence of SSI at the closure site (14). Okuya et al. reported in a prospective study that the addition of NPWT to primary closure resulted in no occurrence of SSI (10). Yane et al. reported a method using DPC and NPWT with instillation and dwell time with DPC, achieving a relatively short wound-healing period of 11.5 days (range=10-16 days) in four cases (13). We have extensive experience with the use of DPC with NPWT for abdominal midline wounds, and the report by Curchod et al. indicated that the SSI rate with primary closure and NPWT was 4.7% (14), which is not particularly low. For these reasons, we chose to use DPC with NPWT.

In this study, we demonstrated that NPWT with DPC can shorten the duration of wound healing. Using DPC, the GranuFoam can be inserted into deep wounds, promoting granulation and ensuring good drainage even in deep wounds. Additionally, we adopted a method wherein the wound edges were trimmed into a spindle shape at the end of the surgery, before NPWT was applied. This approach helps prevent dog ears and facilitates the application of negative pressure on the wound surface, potentially promoting wound healing. The duration of DPC was set to 3-5 days postoperatively, considering the period after the diuresis phase, when the wound exudate had decreased. With these methods, no SSI occurred, and the median wound-healing duration was 20 days. From the perspective of patient satisfaction, the answers indicated that wound self-management was easier in the DPC+NPWT group. When the PSS method is used for stoma closure, daily wound care is required until secondary wound closure (7). However, in the DPC+NPWT group, there was less exudate and a shorter healing period after the procedure, leading to higher patient satisfaction. Although there were no significant differences in wound cosmesis, the DPC+NPWT group tended to be more satisfied. Additionally, from a cost perspective, despite the additional expenses of NPWT, the overall hospital costs were lower in the DPC+NPWT group. Although not statistically significant, factors such as faster wound healing, easier wound self-management (leading to reduced wound care), and shortened hospital stay likely contributed to this outcome. No previous studies have evaluated the use of NPWT in stoma-closure wounds in terms of questionnaires or costs. Therefore, based on these findings, DPC was considered more beneficial than PSS for combination with prophylactic NPWT use.

A drawback of this method is the increased procedural burden on medical staff compared with the PSS method. Compared with PSS, this method requires more procedures, including i) trimming of the wound edge during stoma closure, ii) application and subsequent replacement of NPWT on the following days, and iii) implementation of DPC. Okuya et al. also reported no SSI with primary closure and NPWT (10), indicating that DPC may not be necessary in all cases and can be selected only for specific patients. Considering that primary closure can reduce the burden on the medical staff and patients, further research is warranted to explore the selection of cases in this context.

Study limitations. First, it was a retrospective study conducted at a single facility with a limited number of patients. There may have been bias in patient selection. However, because the management methods for wound care are divided by timing, the selection bias was not considered significant, and no clear differences were observed in patient background. Second, the evaluation of wound healing and SSI occurrence (the endpoints of this study) was conducted by the surgical team in association with the attending physician and primary department. This may have led to a bias toward favorable outcomes in the intervention group. Third, the study included not only patients who underwent stoma closure surgery alone, but also those undergoing concurrent procedures. This may have influenced the questionnaire results because of the course of the other surgeries.

In conclusion, DPC with NPWT significantly shortened the wound-healing duration compared to the PSS method. Additionally, our results demonstrated a trend toward improved patient satisfaction and reduced medical costs in the DPC+NPWT group. Further investigations, including RCTs, are warranted to validate these findings and assess the broader clinical applicability of this technique.

Acknowledgements

The Authors would like to thank all the surgeons, nurses, and medical staff at Hakodate Municipal Hospital and Editage (www.editage.com) for the English language editing.

Footnotes

  • Authors’ Contributions

    TF, KI, and KN conceptualized and designed the study. TF and KI wrote the manuscript. TF and KI performed the statistical analyses. TF, KI, KT, HK, NF, KI, TO, DY, YT, MU, and MK contributed to the development of the wound management. TF, KI, KT, HK, NF, KI, TO, DY, YT, MU, and MK interpreted the results. KN supervised the study. All Authors have read and approved the final manuscript.

  • Conflicts of Interest

    The Authors declare that they have no conflicts of interest in relation to this study.

  • Funding

    This study did not receive any grant or financial support.

  • Artificial Intelligence (AI) Disclosure

    During the preparation of this manuscript, a large language model (ChatGPT 4o, OpenAI) was used solely for language editing and stylistic improvements in select paragraphs. No sections involving the generation, analysis, or interpretation of research data were produced by generative AI. All scientific content was created and verified by the authors. Furthermore, no figures or visual data were generated or modified using generative AI or machine learning-based image enhancement tools.

  • Received July 2, 2025.
  • Revision received July 15, 2025.
  • Accepted July 17, 2025.

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).

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Delayed Primary Skin Closure Followed by Single-use Negative-pressure Wound Therapy Is Optimal for Wound Management After Bowel-stoma Reversal
TAKUMU FUKASAWA, KEN IMAIZUMI, KAZUTOSHI TERASHIMA, HIROYUKI KASAJIMA, NAOE FURUKAWA, KEIICHIRO ITO, TADASHI ODAGIRI, DAISUKE YAMANA, YOSUKE TSURUGA, MINORU UMEHARA, MICHIHIRO KURUSHIMA, KAZUAKI NAKANISHI
In Vivo Nov 2025, 39 (6) 3418-3427; DOI: 10.21873/invivo.14139
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