J Gandhara Med Dent Sci

July - September 2026

https://doi.org/10.37762/jgmds.13-3.829

ORIGINAL ARTICLE

COMPARISON OF EFFICACY BETWEEN LINEAR VERSUS PURSE STRING SKIN CLOSURE AT

LOOP ILEOSTOMY REVERSAL

Naseeb Ali

, Shahid Munir

, Gohar Ali

, Muhammad Kashif Dawar

, Muhammad Bilal

, Muhammad Shah

Muhammad Ayub

How to cite this article

Ali N, Munir S, Ali G, Dawar M K,

Bilal M, Shah M, et al.

Comparison of Efcacy Between

Linear Versus Purse String Skin

Closure at Loop Ileostomy Reversal. J

Gandhara Med Dent Sci.

2026;13(3):47-51.

Date of Submission: 03-12-2025

Date Revised: 08-06-2026

Date Acceptance: 18-06-2026

Trainee Registrar General,

Department of Surgical, Hayatabad

Medical Complex, Peshawar

Surgical Registrar, Department of

Surgical, Hayatabad Medical

Complex, Peshawar

Correspondence

Muhammad Shah, Associate

Professor, Department of Surgical,

Hayatabad Medical Complex,

Peshawar

+92-333-5829224

drmuhammadshah@yahoo.com

ABSTRACT

OBJECTIVES

This study aimed to compare postoperative surgical site infection (SSI) rates

and LOS between linear and purse-string skin closure during loop ileostomy

reversal.

METHODOLOGY

This randomized controlled trial was conducted in the Department of General

Surgery at MTI-HMC Peshawar from Jun 22 2020, to Jul 1 2025. patients

fullling the inclusion criteria, undergoing stoma reversal, were enrolled to

either linear (Group A) or PS (Group B) wound closure groups, w hile 63

patients with stoma site infection (TLC >11,000/L with fever) were excluded

from the sample size (Figure 1: CONSORT Flow Diagram). Length of

hospital stay was recorded, and patients were followed for 30 days to assess

for SSI. This trial was registered in Clinical Trials with NCT #

NCT07573423.

RESULTS

A total of 252 patients were randomized equally into two groups (126 per

group). SSI occurred in 47 (37.3%) in Group A (Linear Skin Closure - LSC),

compared with 9 (7.14%) in Group B (Purse String Closure - PS) (p<0.001).

Mean hospital stay was signicantly shorter in group B (4.1±1.1) compared

to group A (4.5±1.6) (p<0.001).

CONCLUSION

Purse-string skin closure following loop ileostomy reversal was signicantly

associated with a lower rate of SSI compared with linear skin closure. In

addition, the LOS was shorter with purse-string closure, suggesting that it is

a safe and recommended technique for routine use to reduce post-operative

wound complications.

KEYWORDS: Loop Ileostomy Reversal, Post-SSIs, Linear Skin Closure,

Purse String Skin Closure

INTRODUCTION

A temporary ileostomy is frequently performed in

colorectal and emergency gastrointestinal surgeries to

protect the distal anastomosis and reduce the

consequences of anastomotic leakage.

1,2

Although stoma

closure is regarded as a relatively minor surgical

procedure, complications such as surgical site infection

(SSI) remain common, with reported incidence rates

ranging from 4% to 22.2% across various studies.

1,3,4

this makes the wound infection a signicant cause of

post-operative morbidity, prolonged hospitalization,

increased healthcare costs, delayed recovery, and

reduced patient satisfaction.

2,5

The pathogenesis is

multifactorial; bowel contents in contact with the skin

and prolonged gut ora contamination are the major

obvious etiological factors of wound infections after

ileostomy reversal.

Various techniques have been

described for skin closure after stoma reversal, with

linear closure and purse-string closure (PS) being the

most commonly practiced.

6,7

Literature shows that the

baseline and operative characteristics did not dier

significantly between the conventional and PS closure

of the wound after ileostomy.

This suggests that

dierences in outcomes are attributable to the method

of closure itself rather than patient or operative factors.

Conventional linear closure involves primary

approximation of the wound edges, whereas PS closure

leaves a small central gap between two sutures that

allows for drainage, potentially reducing colonization

and SSI risk.

2,5

Purse-string closure has been associated

with lower SSI rates and fewer scars in some studies,

while conventional linear closure (LC) remains widely

used due to its simplicity and familiarity among

surgeons, with a higher SSI rate and good cosmesis.

we warrant comparative evaluation and need for

evidence-based practice in given burden of SSI. Despite

the growing body of international evidence, local data

comparing LC and PS skin closure remain limited.

Evaluating the eectiveness of either technique in our

population is important for identifying the optimal

J Gandhara Med Dent Sci

July - September 2026

approach to reduce post operative complications and

improve patient outcomes. Therefore, this study is

conducted to compare the outcomes of purse-string skin

closure and conventional linear skin closure in stoma-

reversal wounds. This will be used as a reference for

adopting one technique for the closure of the skin after

stoma reversal to decrease the occurrence of SSI,

improve cosmesis, and lower the cost of hospital stay.

Substituting the values in the above equation:

Zα/2 = 1.96 (for 95% condence interval)

Zβ = 0.84 (for 80% power)

p1 = 0.425 (SSI rate in LC closure group)

p2 = 0.075 (SSI rate in PS closure group)

METHODOLOGY

This randomized controlled trial was conducted at

Hayatabad Medical Complex, Peshawar, from Jun 22

2020, to Jul 1 2025, with ethical approval from the

Hayatabad Medical Complex ethical committee. This

trial was registered in Clinical Trials with NCT #

NCT07573423. All eligible participants were recruited

consecutively and then randomly allocated to either the

LC group or the PS closure group using block

randomization. The sample size was calculated for a

dichotomous outcome in this two-group RCT with

anticipated incidences of previously reported SSI rates

of (42.5%) in the LC closure group and 7.5% in the PS

closure group.

The condence interval of 95%, 1:1

allocation ratio, and a power of 0.8 (β = 0.2), ensuring

sufcient sensitivity to detect the large expected

dierence while keeping risks of Type I and Type II

errors within conventional limits. The sample size was

calculated

Where:

using the formula:

Figure 1:CONSORT Flow Diagram.

Although the statistical minimum required sample size

was 42 (21 per group) based on the two-proportion

formula, the study enrolled 252 patients to increase the

precision of the eect, improve external validity, and

strengthen statistical robustness. Patients aged 18-65

years undergoing elective loop ileostomy reversal were

included. Patients with active infection in the stoma

site, immunosuppression, chronic steroid therapy,

severe malnutrition, uncontrolled diabetes mellitus,

pregnancy, or those not planned for reversal were

excluded to minimize bias. patients fullling the

inclusion criteria, undergoing stoma reversal, were

enrolled to either linear (Group A) or PS (Group B)

wound closure groups, while 63 patients with stoma site

infection (TLC >11,000/L with fever) were excluded

from the sample size (Figure 1: CONSORT Flow

Diagram). Demographic characteristics, including age,

gender, and pre-existing comorbidities such as

hypertension and diabetes, were systematically

recorded on a standardized pro forma. Hypertension

was a previously diagnosed condition requiring

antihypertensive medication, and diabetes was a known

case managed with antidiabetic therapy. All participants

received initial management in accordance with

hospital protocol and were monitored throughout the

hospital stay. Post-discharge, they were followed for 30

days to identify any SSI. All the data were collected by

the researcher and his team themselves and recorded in

the predesignated proforma as annexure II, ensuring

consistency and accuracy in documentation. Statistical

Package for Social Sciences (SPSS) version 23 was

used for data entry and analysis. Mean ± SD for

quantitative variables like age and duration of hospital

stay. Frequency and percentages were reported for

qualitative variables such as gender, diabetes,

hypertension, ASA status, and SSI. Both groups were

compared in terms of hospital stay using an

independent-samples t-test at the 5% level of

significance, and SSI rates were compared using the

chi-square test at the same threshold. All ndings were

presented visually through graphs and charts to enhance

clarity and interpretability.

RESULTS

A total of 252 patients undergoing elective ileostomy

reversal were enrolled and randomized equally into

Group A (Linear Skin closure, n = 126) and Group B

(PS skin closure, n = 126).

Comparison of Ecacy Between Linear Versus Purse String Skin

J Gandhara Med Dent Sci

July - September 2026

Table 1: Patient’s Demographic and Clinical Characteristics

Feature

Subgroup

Linear

Closure

(Group

A) LC

n=126(%)

Purse

String

Closure

(Group B)

PS n=126

(%)

Total

N=252

(%)

value

Gender

Male 57

(45.2%)

(53.2%)

124(49.2

0.209

Female 69

(54.8%)

(46.8%)

128(50.8

Mean

40.7 6.6

45.3 3.3

44.1 9.6

0.333

Mean

24.1 3.3

27.3 2.8

26.2 5.3

0.122

Underwei

ght (<18)

(3.2%)

2 (1.6%) 6 (2.4%)

0.078

Normal

(18–24.99)

(40.5%)

(38.1%)

(39.3%)

Overweight

(25–29.99)

(38.9%)

(36.5%)

(37.7%)

Obesity I

(30–34.99)

(14.3%)

(10.3%)

(12.3%)

Obesity II

(35–39.99)

(1.6%)

(8.7%)

(5.2%)

Extreme

Obesity

(>40)

(1.6%)

6 (4.8%) 8 (3.2%)

I 45

(35.7%)

(43.7%)

100

0.198

II 81

(64.3%)

(56.3%)

152

Mean

3.8 2.2

4.1 ± 1.2 4.0

5.5

0.333

Age

(years)

BMI

(kg/m²)

BMI

Categori

(kg/m²)

ASA

Score

Pre-

operative

Albumin

(g/dL)

Comorb

idity

Diabetes

Mellitus

(23.8%)

(16.7%)

(20.2%)

0.677

Hypertens

ion

(22.2%)

(11.9%)

(17.1%)

Malignancy

(0.8%)

1 (0.8%) 2 (0.8%)

Comorbid

ity

(53.2%)

(70.6%)

156

± ± ±

(39.7

(60.3

(61.9

Table 2: Operative Outcome features

Feature Subgroup

Linear closure

LC (Group A)

n=126 (%)

Purse-

value

Hospital

stays

Days 4.5±1.6 4.1±1.1 0.000

Duration of

Surgery

Minutes

44.8±4.5 71.4±11.1 0.000

Surgical site

infections

Yes

47 (37.3%)

79 (62.7%)

9 (7.14%)

117 (92.8%)

0.000

up B)

n=126 (%)

osure PS (Grou

string Cl

Figure 2: Frequency of Surgical site infections in both Groups.

117

100

150

Linear closure Purse-string Closure

Surgical site infecons Yes

Surgical site infecons No

4.8

5.2

5.4

5.6

5.8

6.2

Hospital stays

Figure 3: Length of Hospital

stay in days (Mean)

Linear closure Purse-string Closure

Figure 3: Length of Hospital stays.

DISCUSSION

SSI remains one of the most frequent complications

following ileostomy reversal and contributes

substantially to post-operative morbidity, prolonged

hospitalization, delayed recovery, and increased

healthcare costs. The present randomized controlled

trial compared LC skin closure and PS skin closure

techniques and demonstrated a signicant reduction in

SSI rates among patients undergoing PS closure. Eorts

have been made to reduce SSI following stoma closure

by assessing various factors. Types of skin closure

techniques, including the PS closure, have recently

attracted signicant interest because they may have a

signicant impact on wound healing. Gender

distribution in this study did not dier signicantly

(p=0.209), indicating that sex was unlikely to confound

subsequent outcome comparisons. Similarly, the mean

Comparison of Ecacy Between Linear Versus Purse String Skin

age was 40.7 ± 6.6 years in Group A and 45.3 ± 3.3

years in Group B, with no statistical dierence

(p=0.333), suggesting that both groups represented a

similar age prole, mentioned consistent with our

findings by D.P.O Leary et al. and Khokhar et al.

10,11

BMI was in the normal or overweight range; the

slightly higher obesity proportion in Group B was not

statistically signicant. Similar ndings h ave been

reported by Monawar Shah et al. and Tiwari D et al.,

who found no notable dierence between the PS

closing group and the conventional LC skin closing

group in terms of demographics, as mentioned.

12,13

ASA was used to assess perioperative risk, which

J Gandhara Med Dent Sci

July - September 2026

Comparison of Ecacy Between Linear Versus Purse String Skin

showed a frequent distribution of patients in class II,

with no signicant variation. Pre-operative albumin

levels, a well-recognized marker of nutritional status,

were comparable between the two groups (3.8 ± 2.2 vs

4.1 ± 1.2 g/dl, p=0.333), consistent with previous

findings by Sophia Bee Ting et al., who highlighted the

predictive value of albumin in surgical outcomes. The

distribution of comorbidities, including diabetes

mellitus, hypertension, and malignancy, was balanced

across groups, with no signicant dierences

(p=0.677). However, there is a signicant SSI in

diabetic mellitus patient and immunocompromised

which is consistent with Sophia Bee et al. and Monawar

Shah et al.

12,14

PS closure consistently showed lower

rates of SSI compared to LC, which is supported by

multiple randomized controlled trials and observational

studies like Assad Ameer et al. and Sathasivam

Sureshkumar et al.

6,15

This reduction in SSI is likely

attributable to the circular design of the PS technique,

which facilitates better drainage of wound exudates and

reduces tension across the incision line, thereby

improving in wound healings.

2,5,6,15

The mechanism of

the reduced SSI rate in the PS group is likely related to

the unique wound architecture, which leaves central

openings between sutures, thereby reducing uid

accumulation and bacterial proliferation, unlike the LC

group. This drainage eect may promote improved

wound healing and lower infection rates. the shorter

hospital stay was observed in patients undergoing PS

closure. However, the absolute dierence was modest

(0.4 days), suggesting faster recovery and fewer post-

operative complications, ndings similar to those

reported by Filippo Carannante et al. and Emil Aga et

al.

1,16

This study demonstrates that the purse-string

technique requires longer operative time; this trade-o

is justied by improved short-term outcomes,

particularly the reduction in morbidity associated with

wound infections. The present study also demonstrated

a longer operative time in the PS group, but this was

acceptable when weighed against the substantial

reduction in post-operative wound complications.

Previous studies have emphasized that SSI following

stoma reversal is a major contributor to prolonged

hospitalization and increased healthcare costs, making

the PS approach a valuable alternative.

1,5,6,12,17,18

Several patient-related factors, including nutritional

status, diabetes, smoking status, immunosuppression,

and degree of wound contamination, have previously

been identified as predictors of SSI. Taken together,

these ndings conrm that baseline demographic and

clinical variables were well matched between the two

study arms. This comparability strengthens the validity

of subsequent analyses, as dierences in operative

outcomes can be more condently attributed to the

closure technique rather than underlying patient

characteristics.

LIMITATIONS

This study has several limitations, including that it was

conducted at a single tertiary care center and that

blinding was not feasible due to obvious dierences

between the techniques. Additionally, several

confounding variables, such as smoking status,

immunosuppressive therapy, wound contamination

grade, and detailed nutritional assessment, were not

evaluated. Finally, the prolonged study duration may

have introduced temporal variations in surgical practice

and perioperative care. This study supports the growing

body of evidence favoring PS closure as an eective

strategy for reducing SSI following loop ileostomy

reversal.

CONCLUSIONS

PS skin closure oers clear advantages in reducing SSI

and shortening hospital stay, despite requiring longer

operative time. The substantial reduction in wound-

related complications supports the use of PS skin

closure following ileostomy reversal.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

Naseeb Ali - Concept & Design; Data Acquisition; Drafting

Manuscript; Critical Revision; Final Approval

Shahid Munir - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical

Revision; Supervision; Final Approval

Gohar Ali - Concept & Design; Data Acquisition; Drafting

Manuscript; Critical Revision; Final Approval

Muhammad Kashif Dawar - Concept & Design; Data

Acquisition; Drafting Manuscript; Supervision; Final Approval

Muhammad Bilal - Concept & Design; Data Acquisition;

Drafting Manuscript; Critical Revision; Supervision; Final

Approval

Muhammad Shah - Concept & Design; Data Acquisition;

Drafting Manuscript; Supervision; Final Approval

Muhammad Ayub - Concept & Design; Data Acquisition;

Drafting Manuscript; Supervision; Final Approval

Comparison of Ecacy Between Linear Versus Purse String Skin