Risk Factors for Surgical-Site Infections After Radical Gastrectomy for Gastric Cancer: A Study in China
Introduction
Gastric cancer (GC) is one of the most common malignancies and a leading cause of cancer-related death in East Asia. Radical resection remains the primary treatment method for GC. However, approximately 10% of patients worldwide develop surgical-site infections (SSIs) after radical gastrectomy. SSIs prolong hospitalization, increase medical costs, reduce patients’ quality of life, and can even lead to death. Despite significant efforts to reduce SSIs, their incidence remains high, making it crucial to identify modifiable risk factors to prevent these infections.
This study aimed to explore the risk factors for SSIs after radical gastrectomy in patients with gastric cancer, focusing on both patient-related and peri-operative variables. The findings are intended to guide clinical therapies and reduce the incidence of SSIs.
Methods
The study was a retrospective cohort analysis of 590 patients who underwent radical gastrectomy for primary gastric cancer at the Department of Pancreatic and Gastric Surgery of the National Cancer Center in China from November 2017 to December 2018. Patients with pre-operative infectious diseases, febrile status within 24 hours before surgery, T4b stage, palliative resection, ASA score ≥4, or post-operative anastomotic fistula were excluded.
SSI was defined according to the National Nosocomial Infection Surveillance System, classifying infections into three categories: superficial incisional (involving skin and subcutaneous tissue), deep incisional (involving fascial and muscle layers), and organ/space (involving body cavities or visceral organs). Data on potential risk factors, including age, sex, co-morbidities, BMI, smoking, alcohol use, hemoglobin concentration, lymphocyte count, tumor stage, pre-operative chemo- or radiotherapy, surgical duration, surgery mode (laparoscopic-assisted/open), total gastrectomy, bleeding, albumin level on day 3 after surgery, prophylactic antibiotics duration, and post-operative nutrition support methods, were collected from hospital records and patient interviews.
Statistical analysis was performed using SPSS version 19.0. Categorical data were analyzed using the Chi-squared test, and variables showing significant differences in univariate analysis were included in multivariate logistic regression analysis. A P-value <0.05 was considered statistically significant.
Results
Among the 590 patients, 386 were men (65.4%) and 204 were women (34.6%). The mean age was 56.6 years (range: 28–82), and the mean BMI was 23.8 kg/m² (range: 14.0–34.9). Based on the UICC TNM Classification of Malignant Tumors, 335 patients (56.8%) were classified as stage I-II, and 255 (43.2%) were classified as stage III.
A total of 84 patients (14.2%) developed SSIs, including 23 incisional SSIs (3.9%) and 61 organ/space SSIs (10.3%). Among the organ/space SSIs, pleural effusion was observed in 41 patients, intra-abdominal abscesses in 16, and blood infection in four.
Univariate analysis identified sex (P=0.001), smoking (P=0.039), total gastrectomy (P=0.001), prophylactic antibiotics duration (P=0.029), and post-operative nutrition support methods (P=0.007) as significant factors associated with SSI. Age (P=0.067) and serum albumin level <30 g/L on day 3 after surgery (P=0.074) were also included in the multivariate analysis due to their borderline significance.
Multivariate logistic regression analysis revealed that male sex (OR=2.548, 95% CI: 1.268–5.122, P=0.009), total gastrectomy (OR=2.327, 95% CI: 1.352–4.004, P=0.002), serum albumin level <30 g/L on day 3 after surgery (OR=1.868, 95% CI: 1.066–3.274, P=0.029), and post-operative total parenteral nutrition (TPN) (OR=2.318, 95% CI: 1.026–5.237, P=0.043) were independent risk factors for SSI.
Discussion
SSIs remain a significant challenge in gastric cancer surgery, with an incidence of 10–20% globally. This study identified several modifiable and non-modifiable risk factors for SSIs after radical gastrectomy.
Male sex and total gastrectomy were confirmed as non-modifiable risk factors, consistent with previous studies. Male patients had a significantly higher risk of SSIs, possibly due to differences in immune response or surgical complexity. Total gastrectomy, which involves more extensive tissue dissection and anastomosis, was also associated with a higher risk of SSIs.
Post-operative hypoalbuminemia (serum albumin <30 g/L on day 3 after surgery) was identified as a significant risk factor. Serum albumin is an acute-phase protein, and its levels decrease due to exudate from surgical wounds. However, excessive exudate caused by systemic inflammatory response syndrome or SSI can lead to severe hypoalbuminemia, making it a potential indicator of SSI.
The use of TPN for post-operative nutrition support was associated with a higher risk of SSIs compared to food-by-mouth. This finding aligns with enhanced recovery after surgery (ERAS) guidelines, which recommend avoiding TPN in favor of early oral feeding. TPN may increase the risk of infectious complications due to its impact on gut microbiota and immune function.
The duration of prophylactic antibiotics was another modifiable factor. While a single dose of antibiotics is recommended for SSI prevention, prolonged use beyond 48 hours was associated with a higher risk of SSIs. This highlights the importance of adhering to evidence-based guidelines for antibiotic prophylaxis.
Limitations of this study include its retrospective design, potential selection bias, and the exclusion of certain risk factors. Additionally, the optimal caloric intake for post-operative nutrition was not investigated, and more data on SSI treatment are needed.
Conclusion
This study identified male sex, total gastrectomy, post-operative hypoalbuminemia, and TPN as significant risk factors for SSIs after radical gastrectomy for gastric cancer. Prolonged prophylactic antibiotic use beyond 48 hours was also associated with a higher risk of SSIs. These findings provide valuable insights for clinical practice, emphasizing the importance of modifiable factors such as post-operative nutrition support and antibiotic duration in reducing SSI incidence. Future studies should focus on optimizing these factors to improve patient outcomes.
doi.org/10.1097/CM9.0000000000000860
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