Editor’s Comment: I’d like to welcome back Dr. Goldfarb for another guest post, this time to weigh oft-cited “patient factors” against surgical technique as risk factors for the development of SSI.
Who should be blamed for a wound infection after colon surgery? Was it the patient’s fault because of the patient’s condition creating “risk factors,” or was it the surgical technique? In my opinion the definitive answer is, “It depends.”
Patient risk factors such as, type of bowel preparation, pre-operative antibiotic choice, pre-operative steroids, diabetes control, abdominal preparation, and intraperitoneal contamination from disease, have been blamed. Technical operative issues including length of surgery, intra –operative hypotension, wound hematoma, management of contaminated wound, glove changes, technique of anastomosis, and technique of abdominal wound closure are also culprits.
A study by Kosuke Ishikawa, “Incisional Surgical Site Infection after Elective Open Surgery for Colorectal Cancer,” was published in the International Journal of Surgical Oncology (Volume 2014). He analyzed 33 (14.7%) infections in 224 patients who had surgery in 2009. He used mechanical bowel preparation with an oral cathartic, IV antibiotics, povidone scrub, the Alexis wound protector immediately after making the incision, stapled anastomoses, 2L peritoneal saline lavage irrigation of subcutaneous fat with 400cc saline after closure of the fascia, and a subcutaneous drain. For years, some of those measures have been controversial. Several of those efforts were trying to limit or treat the contamination of wounds.
The median time to the identification of incisional SSI was nine days. “By univariate analysis SSIs were more likely to have a higher ASA scores and TNM stage. When evaluating the perioperative/operative variables, length of incisional site and intraoperative hypotension were associated with the development of incisional SSI.” In this study, therefore, statistics revealed that SSI could be blamed on both patient risk factors as well as surgical technique.
Another article, “Surgical Site Infection in Colon Surgery,” by Martin Hubner (JAMA November 2011, Vol 146, no 11), is particularly relevant in the blame game.
He studied 2394 patients who underwent colon surgery between March 1, 1998 and December 31, 2008. There were 428 (17.9%) SSIs and individual surgeon’ rates varied from 3.7% to 36.1%. No correlation was found between surgeons’ individual adjusted risks and their adherence to guidelines or their experience.
“Features of the patients and procedures associated with SSIs in univariate analysis were male sex, age, American Society of Anesthesiologists score, contamination class, operation duration, and emergency procedure. Correctly timed antibiotic prophylaxis and laparascopic approach were protective.”
“Procedure-related risk factors include antibiotic prophylaxis, oxygen supply, fluid management, bowel preparation, and skin disinfection. Arguably, the surgeon constitutes the single most important risk or protective factor for SSI.” The adherence to guidelines, detailed below, has subsequently been questioned since the recommended guidelines have not been able to lower the rate of wound infections.
In the comment section, Huber states that, “A recent retrospective cohort study of 405,720 surgical patients from 398 US hospitals (3996) could not demonstrate that adherence to any of the 6 infection prevention process of care measures from the Surgical Care Improvement Project protocol, including adequate antibiotic prophylaxis (timing, drug, duration), glucose control of cardiac surgery patients, adequate hair removal and postoperative normothermia for colorectal surgery patients)could reduce the risk of SSI.”
I think after colon surgery, sometimes patient risk factors may be contributory and can be responsible for SSIs. But surgical technique is probably to blame for most SSIs, after elective surgery. Efforts to minimize wound contamination especially in elective surgery, may be the most important factor under the surgeon’s control. I remember someone saying to me, “I didn’t say you were wrong, I said I was going to blame you.”