What are the optimal strategies for promoting wound healing in an adult patient with potential underlying gastrointestinal issues undergoing gastric and colon surgery?

Optimal Wound Healing Strategies for Gastric and Colon Surgery

Apply closed-incision negative-pressure wound therapy (cINPT) to high-risk surgical incisions, continue biologic therapy perioperatively in IBD patients, and provide preoperative immunonutrition for 5-7 days in malnourished patients to optimize wound healing and reduce surgical site infections. 1

Incisional Wound Management

Negative-Pressure Wound Therapy (NPWT)

• Use cINPT for all high-risk abdominal incisions to reduce surgical site infections by 58% (from 12.5% to 5.2%), wound dehiscence by 29%, and hospital length of stay by 0.47 days 1
• The effect is most pronounced in contaminated/dirty wounds, where infection rates drop from 37% with primary closure to 0% with vacuum-assisted closure 1
• Double-ring wound protectors are superior to single-ring devices (RR 0.29 vs 0.71) for open procedures 1
• Apply NPWT immediately postoperatively and maintain for at least 5-7 days 1

Common pitfall: Avoid using prophylactic drains after appendectomy or colorectal surgery for complicated cases, as they increase hospital stay and 30-day morbidity without preventing intra-abdominal abscesses 1

Perioperative Medication Management

Biologic Therapy Continuation

• Continue anti-TNF and other biologic agents throughout the perioperative period in IBD patients, as they do not increase surgical site infections or anastomotic complications 1, 2
• The PUCCINI study (955 operations) confirmed that preoperative biologic exposure and detectable drug levels before surgery were not associated with increased infectious complications 1
• For bevacizumab in cancer patients, stop at least 6 weeks before elective surgery (2 half-lives) to avoid wound healing complications 1

Corticosteroid Management

• Taper corticosteroids to below 20 mg prednisolone equivalent preoperatively when possible 2
• Provide intravenous hydrocortisone perioperatively for patients on chronic steroids (prednisolone 5 mg = hydrocortisone 20 mg) 2

Critical caveat: High-dose steroids (>20 mg prednisolone) increase risk of anastomotic leaks and infectious complications, but abrupt discontinuation may trigger disease flare 2

Nutritional Optimization

Preoperative Immunonutrition

• Administer oral nutritional supplements enriched with arginine, omega-3 fatty acids, and nucleotides for 5-7 days preoperatively in malnourished patients undergoing major gastric or colorectal surgery 1
• This reduces postoperative infectious complications (from 23.8% to 10.7%, p=0.0007) and hospital length of stay 1
• Continue immunonutrition for 5 days postoperatively when integrated into ERAS protocols 1
• For gastric cancer specifically, early enteral nutrition with immunomodulating formula reduces wound-healing problems, suture failure, and infectious complications 1

ERAS Protocol Implementation

• Start early oral nutrition on the day of surgery 3
• Limit preoperative fasting to 6 hours for solids and 2 hours for liquids 2
• Consider carbohydrate loading 2 hours before anesthesia 2

Important distinction: While immunonutrition shows clear benefits in malnourished patients, evidence in well-nourished patients is mixed, with some studies showing no advantage 1

Anastomotic Healing Considerations

Factors Impairing Anastomotic Integrity

• Avoid NSAIDs in the immediate postoperative period for patients with colon or rectal anastomoses, as they correlate with dehiscence and wound healing inhibition 1
• Male gender, peritonitis, smoking, comorbidity, and perioperative blood loss independently predict tissue and wound complications 4
• Emergency operations carry 2.7-fold higher risk of wound complications compared to elective surgery (16% vs 6%) 4

Protective Measures

• Maintain normothermia intraoperatively to decrease SSI rates 1
• Use antibacterial sutures for fascial closure 1
• Ensure adequate antibiotic redosing during prolonged procedures based on pharmacokinetic/pharmacodynamic principles 1

Risk Stratification Algorithm

High-risk patients requiring maximal intervention (apply all measures above):

• Emergency surgery for peritonitis 1, 4
• Incision length ≥20 cm (15-fold increased SSI risk) 5
• Malnourished patients (BMI <18.5 or >10% weight loss) 3, 2
• Active smokers 4
• Patients on chronic corticosteroids 2

Moderate-risk patients (selective intervention):

• Elective colorectal surgery in well-nourished patients 1
• IBD patients on biologics (continue therapy, add wound protection) 1, 2
• Contaminated but not dirty wounds 1

Standard-risk patients (routine ERAS protocol):

• Elective gastric surgery in well-nourished patients 3
• Clean-contaminated wounds 1

Thromboprophylaxis Considerations

• Provide extended thromboprophylaxis for all major hepatectomy and IBD surgery 2
• Patients on tofacitinib require special attention due to increased venous thromboembolism risk 2