Open Surgical Incisions After Colorectal Surgery Improve Quality Metrics, But Do Patients Benefit?

Matthew G Mullen, Robert B Hawkins, Lily E Johnston, Puja M Shah, Florence E Turrentine, Traci L Hedrick, Charles M Friel
Diseases of the Colon and Rectum 2018, 61 (5): 622-628

BACKGROUND: Surgical site infection is a frequent cause of morbidity after colorectal resection and is a quality measure for hospitals and surgeons. In an effort to reduce the risk of postoperative infections, many wounds are left open at the time of surgery for secondary or delayed primary wound closure.

OBJECTIVE: The purpose of this study was to evaluate the impact of delayed wound closure on the rate of surgical infections and resource use.

DESIGN: This retrospective propensity-matched study compared colorectal surgery patients with wounds left open with a cohort of patients with primary skin closure.

SETTINGS: The American College of Surgeons National Quality Improvement Program Participant Use file for 2014 was queried.

PATIENTS: A total of 50,212 patients who underwent elective or emergent colectomy, proctectomy, and stoma creation were included.

MAIN OUTCOME MEASURES: Rates of postoperative infections and discharge to medical facilities were measured.

RESULTS: Surgical wounds were left open in 2.9% of colorectal cases (n = 1466). Patients with skin left open were broadly higher risk, as evidenced by a significantly higher median estimated probability of 30-day mortality (3.40% vs 0.45%; p < 0.0001). After propensity matching (n = 1382 per group), there were no significant differences between baseline characteristics. Within the matched cohort, there were no differences in the rates of 30-day mortality, deep or organ space infection, or sepsis (all p > 0.05). Resource use was higher for patients with incisions left open, including longer length of stay (11 vs 10 d; p = 0.006) and higher rates of discharge to a facility (34% vs 27%; p < 0.001).

LIMITATIONS: This study was limited by its retrospective design and a large data set with a bias toward academic institutions.

CONCLUSIONS: In a well-matched colorectal cohort, secondary or delayed wound closure eliminates superficial surgical infections, but there was no decrease in deep or organ space infections. In addition, attention should be given to the possibility for increased resource use associated with open surgical incisions. See Video Abstract at

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