Correspondence (reply): In Reply

We would like to thank Dr. Lampl for his insightful letter to the editor. With regard to the spectrum of pathogens encountered in an elective gastrointestinal surgery setting, it can be assumed that a high proportion of surgical site infections is indeed caused by intestinal bacteria. However, whether superficial A1 surgical site infections are caused by the translocation of pathogens from the surgical field to the wound remains speculative. It appears unlikely that an infection caused by intestinal pathogens would only affect the skin, without comprising fascia or abdominal wall. In gastrointestinal surgery, deep surgical site infections (A2/3), involving organs and body cavities, are typically caused by intestinal pathogens. The reported involvement of Escherichia coli and enterococci is based on all surgical site infections, not solely on superficial grade A1 wound infections (1). In addition, it was found that a relevant proportion of surgical site infections were caused by Staphylococcus aureus and coagulase-negative staphylococci (2), supporting the hypothesis that the technique of intracutaneous suture (tight skin closure, no injury to dermal structures [3]) can help to lower grade A1 surgical site infection rate.

We agree that the use of staples permits partial opening of the wound which is difficult to achieve if the incision is closed with running intracutaneous sutures. Wound dehiscence following removal of the staples (i.e. 10 days after surgery) requires various types of treatment, including secondary suture, approximation using wound closure strips and open wound treatment. Here, the comparatively low impact of wound dehiscence on the patient needs to be carefully balanced against the distress associated with these procedures and subsequent outpatient follow-up appointments. It is also a very valid point to highlight the significance of applying proper stapling techniques to promote uncomplicated wound healing.