Colorectal Surgery Experts Advise on Preventing SSIs

By ALISON McCOOK

Apanel of 15 colorectal surgeons compiled a set of recommendations for how to prevent surgical site infections, based on their expert opinion and review of dozens of studies.

The recommendations include advice on what to use, what lacks sufficient evidence to support its use, and nuanced approaches to wound irrigation and the location of incisions (J Am Coll Surg 2022;234[1]:1-11).

According to a 2020 study, 23.9% of patients develop an SSI after colorectal cancer surgery, which can cost commercial payors up to $145,000, and $102,000 to Medicare within a year (Dis Colon Rectum 2020;63[12]:1628-1638).

The goal is to reduce the burden of SSIs, said senior author Traci Hedrick, MD, FACS, FACRS, a colorectal surgeon at the University of Virginia Health System, in Charlottesville.

“Most of these recommendations are on topics that surgeons are already familiar with,” Dr. Hedrick said. “However, the intraoperative aspects can sometimes get lost in the large comprehensive bundles, which is why this project is unique.”

To prevent SSIs, the authors suggest surgeons employ wound protectors/retractors, negative pressure wound therapy, triclosancoated sutures, a sterile incision closure tray and change their gloves before closing the incision. Alternatively, they found that there was insufficient evidence to recommend topical skin adhesives, incise/adhesive drapes, advanced dressings, continuous versus interrupted sutures or staples, a delayed incision closure, and subcutaneous drains to specifically prevent SSIs (Figure).

With some topics, the advice was more complex—not a simple do or don’t do, Dr. Hedrick said. For instance, when it comes to midline incisions, the panel determined there was insufficient evidence that off-midline incisions reduce the risk for SSIs compared with midline incisions, but when possible and appropriate, off-midline incisions may reduce incisional hernia risk after (laparoscopic) colorectal surgery. With the size of bite sutures, the authors said there was not enough evidence to conclude that a small bites suture technique does more to reduce SSI risk than a large bites suture technique. However, they said the small bites suture technique can reduce the risk for incisional hernias. Regarding wound irrigation, use aqueous iodine, not antibiotic incisional wound irrigation, in high-risk, contaminated wounds.

To reach a consensus, the panel followed a modified Delphi method, with up to three rounds of discussion for each topic. Voting was anonymous, as is “standard” in this type of process, Dr. Hedrick said, so voters aren’t influenced by their peers. Every recommendation had to reach at least 70% agreement among voters. “We reviewed each of the topics with a fine-toothed comb and did a thorough review of all the evidence,” she said. “We took our time resolving each of the recommendations.”

The report offers practical advice to help surgeons prevent one of the most common, and costly, complications following colorectal procedures, said Syed Husain, MD, FACS, FASCRS, a colorectal and general surgeon at The Ohio State University, in Columbus, who did not participate in the study. “These are the questions that we grapple with on a daily basis, and the authors have gone really to the heart of the problem.”

The result of these discussions by the expert panel in the report is extremely helpful to practicing surgeons, Dr. Husain said. For instance, his practice frequently uses glue sealants on top of incisions. Although he and his colleagues haven’t stopped yet, these recommendations have “definitely started a conversation in our group.” If they don’t stop entirely, they may begin to employ glue sealants more selectively, he added. “There’s a very good chance that we’re going to move away from the blanket application in all patients.”

His practice also doesn’t usually have access to antibioticimprednated sutures. But after the panel recommended their use to prevent SSIs, “that has again started a conversation in our group and administration to have those available to us.”

It can be hard to determine how best to prevent SSIs, Dr. Husain said, because doctors can’t easily try something to see what works. In the future, the surgical community will hopefully find a way to conduct randomized, prospective trials of techniques to reduce SSI risk in a way that won’t compromise patient care, he added. ■ Dr. Hedrick reported a consultantship with Ethicon/Johnson & Johnson, which provided funding for the study. Dr. Husain reported no relevant financial disclosures.

Wound Negative- protectors/ pressure retractors wound therapy

Triclosancoated sutures Pre-closure glove change Off -midline incisions Topical skin adhesives Continuous vs. interrupted sutures Subcutaneous drains

Sterile incision closure tray

Small bites vs. large bites sutures Incise/ adhesive drapes Delayed incision closure

Wound irrigation Advanced dressings

SIs, D,

he n

Sutures vs. staples Positive Recommendation Mixed Negative Recommendation

Adapted from J Am Coll Surg 2002;234(1):1-11.

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“In order to avoid RSIs, we have to recognize that there is a problem that affects all disciplines of surgery and all types of cases,” Dr. Steward said. “It is going to take a multidisciplinary effort in order to prevent RSIs, and all team members should be empowered to speak up.”

Patient identification errors are defined as the failure to correctly identify patients, resulting in mistakes in medication, transfusion and testing. These errors also include wrong-person procedures and the discharge of infants to the incorrect family.

There are many causes of patient misidentification and they can occur at multiple points during a hospital stay. During registration, incorrect information may be given or recorded; inadequate staff training and time pressures may result in errors; and there may be duplicate medical records or communication issues across departments.

To prevent these mishaps, reliance on at least two patient identifiers at all times is key. Protocols and standardized procedures are of the utmost importance, and technological advances—wristbands that include patient photographs, or biometric methods such as fingerprint, retina or palm scans—may be implemented.

“We must recognize that there is a problem and that patient misidentification can happen at any point during a patient’s hospitalization,” Dr. Steward said.

Ensuring patients are well enough to have positive outcomes is of core importance to the surgical process.

“Frailty is a syndrome of decreased physiologic reserve and resistance to stressors which leaves patients vulnerable to worse outcomes,” said Steven C. Cunningham, MD, the director of pancreatic and hepatobiliary surgery and director of research at Ascension Saint Agnes Hospital, in Baltimore. “Frailty is strongly, and unsurprisingly, correlated with poor outcomes after surgery.”

Criteria for determining a patient’s level of frailty include weight loss, weakness, exhaustion, low physical activity and slowness of movement, and can be assessed via self-report and in-office testing.

Dr. Cunningham stated that patients who are determined to be in the intermediate category of frailty are at elevated risk for complications, as well as being twice as likely to become frail within three years, thus putting them at much increased risk for adverse health outcomes.

As such, Dr. Cunningham noted the importance of assessing for the five criteria of frailty with any patients determined to be at risk, and then performing appropriate interventions.

Malnutrition also is associated with an increased risk for postoperative adverse events, and rates increase as patients are older and sicker. For malnourished patients, it may be worth considering preoperative nutrition consultation and therapy. For well-nourished patients, dietary restriction, such as fasting, may provide benefits. However, Dr. Cunningham noted, this approach has not yet received mainstream acceptance.

Rehabilitation programs, aimed at improving a patient’s health before surgery, show some promise, but the data remain inconclusive.

“There is conflicting evidence regarding length of stay and morbidity and mortality, but there is good evidence for improved functional and exercise capacity,” Dr. Cunningham said. ■

“The primary outcomes are to increase wound healing rates and ultimately decrease amputation rates,” Dr. Mouawad said. “Secondary outcomes involve patient satisfaction, compliance with orthotic and prosthetic management, and ultimately healthrelated quality of life.”

These outcomes have been repeatedly demonstrated in the global literature. A study showed an improvement in healing rates from 23% with a single-discipline approach to 82% after the implementation of a team approach in patients with diabetic disease (Acta Derm Venereol 1995;75[2]:133-135). In addition, Gottrup et al showed healing rates of 60% over 12 months for chronic recalcitrant leg ulcers (Arch Surg 2001;136[7]:765-772), while Valdes et al reported an average eight-week healing time for venous ulcers (Ostomy Wound Manage 1999;45[6]:3036). Finally, a 2011 study noted that 72% of patients healed in an average of 12 weeks following a team approach (Wound Pract Res 2011;19[4]:229-233).

Many studies have also reported a reduction in amputation rates associated with a multidisciplinary care strategy. In patients with diabetes, for example, the results of a five-year prospective study showed an 82% decrease in major amputations (from 36.4% to 6.7%) with use of a team approach (Diabetes Res Clin Pract 2007;75[2]:153-158). The authors also reported a 45.7% reduction in below-the-knee amputations and a significant decrease in high-tolow amputation ratio.

“We’ve seen this over and over again, not just within the United States, but globally. Involvement of a multidisciplinary team, particularly for the diabetic foot, is associated with a reduction in the incidence of major amputations,” Dr. Mouawad said. “Importantly, between 45% and 85% of all lower-extremity amputations can be avoided by using a multidisciplinary approach.”

In addition to clinical excellence, the multidisciplinary team allows for psychosocial factors that are important to patients. Patients have reported increased quality-of-life scores, particularly in the domains of physical and emotional functioning, when treated with a team approach. A study in Denmark found 91% of patients were satisfied with the quality of technical care and empathy when a multidisciplinary wound team and wound environment was put in place (Int J Low Extrem Wounds 2009;8[3]:153-156).

“It’s difficult and involves a lot of people, but multidisciplinary wound teams lead to the best management and the best outcomes for these patients,” Dr. Mouawad concluded. ■

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