Surgical site events in colorectal surgery: prevention is better than cure.

Abstract

Surgical site events (SSE), including surgical site infections (SSI) and wound complications (e.g., seroma, dehiscence), are a major concern in general surgery, causing prolonged postoperative hospital stay, disabilities, mortality, readmission, and notably increased costs. The detrimental effect of SSE is even more apparent when considering colorectal surgery, as most procedures are classified as clean-contaminated or contaminated. The risk of SSI is therefore higher. Furthermore, colorectal patients often have additional risk factors for SSI, such as malignancies needing preoperative treatments [1], advanced age or inflammatory bowel disease (IBD) [2–4]. Consequently, to reduce disparities in reporting SSE and to lower the incidence of SSE, Colorectal Surgical Site Infection Reduction programs have been established in the USA, applying The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to colorectal surgery. This is a praiseworthy strategy, even if it still has to be perfected. Rutkowski et al. [1] published an interesting randomized study showing the efficacy of gentamicin–collagen implant (GCI) in reducing organ/space SSI after rectal cancer surgery compared with no GCI placement, if there was no anastomotic leakage (2.6 vs 13.0 %; p = 0.018). Concerning the etiology of SSE, both superficial and organ/space SSI can be caused by endogenous (intraabdominal) as well as exogenous (environmental) pathogens. The former include flora from hollow viscera, opened or entered during surgery, while external sources may originate from an interruption of the sterile procedure during wound dressing changes or due to the need of repeated dressing changes during the patient’s postoperative stay. In the study by Rutkowski et al. [1], GCI proved to be effective against endogenous pathogens, but its effect on external pathogens could be improved. We recently published the results we obtained using prophylactic negative pressure wound therapy (NPWT) with a disposable pocket device (PICO, Smith & Nephew, London, UK) in Crohn’s disease patients [2]. Compared with conventional dressings, PICO significantly reduced the likeliness of SSE and SSI, especially in patients receiving steroids at surgery [2]. Besides favoring wound healing, this NPWT device reduces the risk of contamination due to external pathogens by keeping the wound sealed, with no need of dressing change. Patients suffering from IBD represent a relevant portion of those requiring colorectal surgery procedures. IBD is an independent risk factor for SSE [2]. In our series, we found that half of the patients operated on for Crohn’s disease with primary wound closure while receiving corticosteroids benefited from preventive NPWT (number needed to treat: 2) [2]. When analyzing the type of SSI, none of the NPWT group patients developed deep incisional or organ/space SSI, compared with 23.4 % of controls [2]. Given the contained costs of disposable NPWT devices, and the costconsuming effects of potential SSE [1], especially organ/ space SSI, we would suggest including preventive NPWT in the preventive pathways to reduce SSE. Patients with IBD, those receiving steroids, and frail patients [3] may be the ideal candidates for preventive NPWT. Similar benefits may be hypothesized in patients receiving neo-adjuvant treatments. In this scenario, GCI placement and preventive NPWT could be considered complementary rather than G. Pellino F. Selvaggi (&) Department of General Surgery, Second University of Naples, Via F. Giordani, 42, 80122 Naples, Italy e-mail: fselvaggi@hotmail.com