Before Your Stoma Reversal: What a Cochrane Review of 9 Trials Found About Wound Closure and Infection Risk

For many people living with a temporary stoma — whether a loop ileostomy, end ileostomy, or loop colostomy — reversal surgery is the procedure they work toward. When the bowel is reconnected and the stoma site closed, most patients expect recovery to be straightforward. But stoma reversal carries a well-documented complication risk that does not always get adequate attention beforehand: surgical site infection (SSI).

A 2024 Cochrane systematic review and meta-analysis now provides moderate-certainty evidence that the choice of wound closure technique at the stoma site makes a substantial difference to that risk.

Why Infection Risk at Stoma Reversal Is Unusually High

Unlike most surgical wounds, the skin opening left by a stoma is inherently contaminated. Intestinal microorganisms colonise the peristomal skin over time, and during the open-end bowel manipulation required for reversal, there is a real risk of wound contamination — making it what surgeons classify as a "clean-contaminated" wound.

The standard technique, linear skin closure (LSC), brings the wound edges together and sutures them in a straight line. That full closure can trap contaminants inside. According to the Cochrane review, SSI occurs in up to 40% of stoma reversals with conventional linear closure (Hajibandeh et al., 2024).

Two Techniques, One Key Difference

The alternative approach — purse-string skin closure (PSSC) — works differently. Rather than closing the wound in a line, a suture is placed around the full circumference of the opening and gradually drawn in, leaving a small central aperture. That opening allows free drainage of contaminated fluid and serous secretions, targeting the mechanism that makes stoma reversal sites prone to infection.

The Cochrane review set out to assess, rigorously, whether this difference in drainage actually translates into fewer infections.

What Nine Randomised Trials Found

The review pooled data from nine randomised controlled trials (RCTs) involving 757 participants, all of whom underwent elective reversal of either ileostomy (82%) or colostomy (18%). All trials directly compared PSSC with LSC.

The primary finding is clinically meaningful:

PSSC likely reduces SSI risk substantially — absolute risk 52 per 1,000 with PSSC versus 243 per 1,000 with LSC (odds ratio 0.17, 95% confidence interval 0.09 to 0.29; I² = 0%; moderate-certainty evidence) (Hajibandeh et al., 2024).

In practical terms: across every 1,000 stoma reversals, the choice of closure technique corresponds to approximately 191 fewer infections. The I² of 0% indicates that results were consistent across all nine trials — there was no meaningful heterogeneity between studies.

On patient satisfaction, data from two of the included studies (122 participants) found that 100% of PSSC patients reported being very satisfied or satisfied with their closure result, versus 89% in the LSC group. The authors rate this as low-certainty evidence — fewer studies contributed, and the confidence interval is wide — so this finding warrants cautious interpretation rather than weight alongside the SSI result.

Where the Evidence Is Less Clear

The review also examined two further outcomes where the findings were more uncertain:

• Incisional hernia: Four studies covering 297 participants found no statistically significant difference between techniques, but the certainty of this evidence is rated as very low.
• Operative time: Six studies covering 460 participants found no significant difference (mean difference −2.67 minutes, 95% CI −8.56 to 3.22), again with very low certainty due to high variability.

These results do not establish that the two techniques are equivalent for these outcomes — they establish that the current evidence is insufficient to draw a firm conclusion either way.

What the Evidence Cannot Tell Us

All nine included studies were considered at high risk of performance and detection bias — a near-inevitable limitation when comparing two visibly different wound closure techniques, as blinding surgeons or patients to which technique was used is not feasible. Four studies also had unclear risk of selection bias in how participants were assigned to groups.

The Cochrane authors do not treat these limitations as invalidating the SSI finding — the consistency across nine trials (I² = 0%) and the size of the effect strengthen confidence — but they note that moderate certainty means further research could still refine the estimate.

Most included studies focused on ileostomy reversal. Colostomy reversal data were fewer, and applicability to all patient subgroups requires some caution. Longer-term outcomes, particularly hernia formation over months and years, remain genuinely uncertain.

What This Means in Practice

The SSI finding is hard to dismiss. A surgical site infection after stoma reversal is not a minor inconvenience: it can mean delayed healing, wound packing, extended nursing visits, additional outpatient appointments, and in some cases hospital readmission. A technique that cuts the absolute infection risk from roughly one-in-four to one-in-twenty, across nine trials with consistent results, is a meaningful clinical advance.

That said, surgical technique is not a one-size-fits-all decision. Wound anatomy, the reason the stoma was created, comorbidities, local protocols, and — crucially — the individual surgeon's training and experience with PSSC all play a role in what is appropriate for each patient.

The practical takeaway is not to arrive at your pre-operative appointment with a demand. It is to arrive with a question:

"What wound closure technique do you plan to use for my reversal, and what does post-operative wound monitoring involve?"

A surgeon who uses PSSC will usually explain the small central opening and what to expect during healing. A surgeon who uses LSC may have reasons specific to your situation. Either way, asking opens a conversation that helps you understand what to watch for after surgery.

This article is an AI-assisted curation of published research. It is not medical advice. If you are planning or recovering from a stoma reversal, discuss wound closure technique and post-operative care with your surgical team. If you notice signs of wound infection — increasing redness, warmth, swelling, discharge, or worsening pain — contact your stoma care nurse or surgical team promptly. Do not attempt to manage a suspected wound infection at home without clinical assessment.