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Invited Critique |

Surgical Site Infection: Still a Common Problem:  Comment on “Outcomes and Predictors of Incisional Surgical Site Infection in Stoma Reversal”

William G. Cheadle, MD
JAMA Surg. 2013;148(2):189. doi:10.1001/jamasurgery.2013.416.
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Liang and colleagues1 have presented data from a large series of stoma reversal cases at the Houston Veterans Affairs Medical Center. Surgical site infections (SSIs) occurred in more than a third of these high-risk patients, and multivariate analysis demonstrated a history of fascial dehiscence, colostomy, African American race, and obesity to be independent risk factors. The conclusion of the abstract should read 4 risk factors and African American race. Age seemed to protect a bit against SSI, and no mechanical bowel preparation was used in these cases. These patients were not monitored prospectively by a study coordinator to look for SSI, so this actually may be an underestimate. Three different skin closure techniques were used: open, loose, or closed. One patient underwent laparoscopic reversal and did not develop an SSI. Indeed, use of such minimally invasive approaches has been associated with dramatically fewer SSIs, and the consequences of such SSIs are usually minimal as well. It was surprising to see so many midline wounds become infected despite leaving them open. Patients with stomas have a high concentration of skin flora, and it would be interesting to measure bacterial concentrations on the skin and in the subsequent surgical wound before closure. The high rate of methicillin-resistant Staphylococcus aureus and enterococci seen in these patients may indicate that preoperative culturing and broader antimicrobial prophylaxis are needed. The use of mesh with concomitant hernia repair was associated with a high rate of SSI, and perhaps some of these patients should undergo a staged repair. Obesity remains a major risk factor, and perhaps motivation to have such a reversal should be used until satisfactory weight loss is achieved. We need to be on high alert to detect these infections, and early return to the clinic is essential. Use of minimally invasive techniques is the next major step to reduce such infections.

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