Demartines, Nicolas

Diana, Michele

Eisenring, Marie-Christine

Hübner, Martin

Troillet, Nicolas

Zanetti, Giorgio

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Preventing Surgical Site Infections: Is It Just Too Sweet? ReplyMichele Diana • Martin Hu¨bner •Marie-Christine Eisenring • Giorgio Zanetti •Nicolas Troillet • Nicolas DemartinesPublished online: 13 April 2011 Socie´te´ Internationale de Chirurgie 2011We thank Dr. Ng and coworkers [1] for their interest in ourarticle and for the insights about the importance of nutri-tional screening as a way to prevent surgical site infections(SSIs). We totally agree with the suggestion of Ng et al.that nutritional counseling should be completed withscreening for early detection of insulin resistance beforemajor digestive surgery.Overt diabetes is strongly associated with a higher rateof SSIs [2]. The hyperglycemic postsurgical stress responsehas been associated with an increased risk of SSIs innondiabetic patients also [3]. Intensive postoperative gly-cemia control has been shown to improve outcomes innondiabetic cardiovascular patients [4], general surgerypatients [5], and critically ill patients [6]. We could spec-ulate that patients with metabolic syndrome and insulinresistance might probably benefit from a stringent protocolof glycemia control initiated in the early postoperativephase. As outlined in the recent Cochrane Review [7], thereis insufficient evidence to support the use of strict glycemiccontrol in the intra- and postoperative periods for the pre-vention of SSIs. Nevertheless, it is our current practiceto apply strict glycemic control to all patients who spendthe first 24–48 h in the ICU after major operations(e.g., esophagectomy, pancreatic resection, and majorhepatectomy).Our survey has shown an overall low adherence ofsurgeons to using measures to prevent SSIs irrespective ofthe level of scientific evidence. Thus, should a preoperativescreening for insulin resistance be part of the presurgeryworkup by the operating surgeon or should it be the role ofthe general practitioner taking care of the patient?The lack of stringent evidence about the protective roleof early detection of metabolic syndrome and other factorsspecifically connected to health-care reimbursement poli-cies might hamper its implementation. Prospectiveassessment of the cost effectiveness of a systematic pres-urgery insulin resistance workup and systematic glycemiccontrol on the SSI rate could be a valuable tool, pro-vided that well-known risk factors and confounders arecontrolled.Today’s surgical practice is mainly developed outsidethe OR to improve quality of care and offer patients atailored postoperative management. Enhanced surgicalcommunity attention to preoperative nutritional statusassessment is a rather difficult task but one that we considerworthy. We recently published a meta-analysis on the roleplayed by immunonutrition on the postoperative outcomes,and results favor the liberal use of this measure [8]. Fur-thermore, a prospective randomized clinical trial on theeffects of immunonutrition on SSIs is currently ongoing atour General and Visceral Surgery Department.To conclude, although blood sweetness appears delete-rious for the surgical patient, it would, without doubt, besweet to reduce SSI rates.M. Diana  M. Hu¨bner (&)  N. DemartinesDepartment of Visceral Surgery, University Hospital,Lausanne Medical School, Rue du Bugnon 46,1011 Lausanne, Switzerlande-mail: martin.hubner@chuv.chG. Zanetti  N. TroilletService of Hospital Preventive Medicine and Serviceof Infectious Diseases, University Hospital,Lausanne Medical School, Lausanne, SwitzerlandM.-C. Eisenring  N. TroilletService of Infectious Diseases,Central Institute of the Valais Hospitals,Sion, Switzerland123World J Surg (2011) 35:1414–1415DOI 10.1007/s00268-011-1067-xReferences1. Ng CSH, Wong RHL, Underwood MJ (2011) Preventing surgicalsite infections: is it just too sweet? World J Surg. doi:10.1007/s00268-011-1006-x2. Guvener M, Pasaoglu I, Demircin M, Oc M (2002) Perioperativehyperglycemia is a strong correlate of postoperative infection intype II diabetic patients after coronary artery bypass grafting.Endocr J 49(5):531–5373. Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales MT, ZinnerM, Rogers SO (2008) Relationship of perioperative hyperglycemiaand postoperative infections in patients who undergo general andvascular surgery. Ann Surg 248(4):585–5914. Swenne CL, Lindholm C, Borowiec J, Schnell AE, Carlsson M(2005) Peri-operative glucose control and development of surgicalwound infections in patients undergoing coronary artery bypassgraft. J Hosp Infect 61(3):201–2125. Ata A, Lee J, Bestle SL, Desemone J, Stain SC (2010)Postoperative hyperglycemia and surgical site infection in generalsurgery patients. Arch Surg 145(9):858–8646. van den Berghe G, Wouters P, Weekers F, Verwaest C, BruyninckxF, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R(2001) Intensive insulin therapy in the critically ill patients. N EnglJ Med 345(19):1359–13677. Kao LS, Meeks D, Moyer VA, Lally KP (2009) Peri-operativeglycaemic control regimens for preventing surgical site infectionsin adults. Cochrane Database Syst Rev 2009(3):CD0068068. Cerantola Y, Hubner M, Grass F, Demartines N, Schafer M (2011)Immunonutrition in gastrointestinal surgery. Br J Surg 98(1):37–48World J Surg (2011) 35:1414–1415 1415123

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