What happens to the old stoma site during a colostomy reversal?

Management of the Old Stoma Site During Colostomy Reversal

The old stoma site is typically closed primarily (sutured shut) during colostomy reversal, with pursestring closure demonstrating superior outcomes compared to conventional linear closure, specifically reducing surgical site infection rates from 15% to 2%. 1

Surgical Closure Techniques

Pursestring Closure (Preferred Method)

• Pursestring near-complete closure significantly reduces stoma site surgical site infections (2% vs 15% with conventional primary closure) and represents the evidence-based optimal approach 1
• The technique involves circular approximation of the wound edges, leaving a small central opening for drainage 1
• Time to complete wound epithelialization is longer with pursestring closure (34.6 ± 20 days vs 24.1 ± 17 days), but the trade-off for dramatically lower infection rates is clinically worthwhile 1
• No difference exists in delayed healing (wounds open >30 days) or patient satisfaction between closure techniques 1

Conventional Primary Linear Closure

• Traditional linear suture closure of the stoma site carries a 15% surgical site infection rate 1
• This approach may heal faster when uncomplicated but has substantially higher infection risk 1
• Still commonly performed but should be considered inferior based on infection data 1

Procedural Complexity Based on Stoma Type

Loop Colostomy Reversal

• Loop colostomy reversal is technically simpler and safer, requiring only local takedown since both intestinal ends are at skin level 2
• Associated with significantly less intra-operative blood loss (99.4 mL vs 260.7 mL for end colostomy) 3
• Shorter hospital length of stay (5.5 days vs 8.4 days for end colostomy) 3
• Fewer overall complications (29% vs 51% for end colostomy, p = 0.005) 3
• Can often be performed through the stoma site alone without midline laparotomy 3

End Colostomy Reversal

• End stoma reversal requires more invasive surgery with midline laparotomy to locate the stapled-off distal intestinal segment within the abdomen 2
• 91% of patients require formal laparotomy for end colostomy reversal versus only 31% for loop colostomy 3
• Greater operative complexity translates to higher morbidity 3

Common Complications at the Stoma Site

Surgical Site Infection (Most Common)

• Overall stoma site infection rates range from 2-15% depending on closure technique 1
• Infection risk is influenced by obesity, liquid effluent contamination, and closure method 1
• Pursestring closure should be standard practice to minimize this most frequent complication 1

Wound Healing Issues

• Delayed healing (>30 days) occurs regardless of closure technique in some patients 1
• The stoma site represents contaminated tissue with chronic inflammation, predisposing to healing problems 4
• Anastomotic leak and sepsis are the most frequent serious complications after any colostomy closure 4

Anastomotic Complications

• Leak rates and stenosis can occur at the intestinal reconnection site, though death after colostomy closure is infrequent 4
• The same meticulous surgical technique required for primary colectomy is necessary for optimal outcomes 4

Adjunctive Wound Management

Negative Pressure Therapy

• Mechanically powered negative pressure dressings (MP-NPD) applied to primarily closed stoma wounds reduce surgical site infection to 2.2% 5
• This represents a cost-effective alternative to traditional closed-incision negative pressure wound therapy 5
• Post-operative length of stay averages 4.1 days with this approach 5

Critical Timing Considerations

• Reversal before 6 weeks after the index surgery is associated with increased complication risk and should be avoided when possible 2
• The stoma site changes significantly during the first 8 weeks, requiring this maturation period before safe reversal 6
• For patients with persistent high ostomy output, early reversal may be necessary despite increased risk 2

Special Populations

Crohn's Disease Patients

• Only 16.6% of Crohn's disease patients with diverting stomas ultimately achieve successful ostomy reversal 2
• Proctitis significantly increases risk of permanent diversion 2
• The rate of proctectomy after failed temporary diversion reaches 41.6% in this population 2

Radiation Proctopathy

• Colostomy can be successfully reversed in 93% of patients after diverting for severe hemorrhagic radiation proctopathy 7
• Median duration of stoma before reversal is 16 months (range 9-53 months) 7
• Anorectal functions and quality of life significantly improve after stoma reversal compared to pre-stoma baseline 7