INTRODUCTION
Surgical site infections (SSIs) remain a formidable challenge in gastrointestinal surgery, with persistently high rates of 9.4%–23.2%, despite advancements in aseptic techniques and antimicrobial stewardship[1,2]. These infections impose a dual burden: Prolonging hospital stays, escalating healthcare costs, and increasing patient morbidity, while also straining resource-limited healthcare systems[3]. Gastrointestinal procedures inherently amplify infection risks owing to contaminated luminal content exposure, anastomotic healing complexity, and the immunosuppressive effects of major abdominal surgery[4]. Despite meticulous intraoperative practices, pathogens, such as Escherichia coli (E. coli) and Methicillin-resistant Staphylococcus aureus (MRSA)- which are endemic to regions such as Hainan, China, exploit breaches in perioperative protocols, causing persistent postoperative complications[5]. This persistent threat underscores the urgent need to reevaluate infection control strategies beyond antibiotic reliance, particularly as antimicrobial resistance (AMR) escalates globally[6].
In this context, Wang et al’s retrospective analysis[7] provided critical insights. Their study on 96 patients who underwent gastrointestinal surgery demonstrated that comprehensive perioperative disinfection and isolation measures—including preoperative povidone-iodine baths and intraoperative laminar airflow systems—reduced postoperative infection rates from 25.13% to 10.42% within the first postoperative day[7]. Notably, these protocols also reduced systemic inflammation, as evidenced by lower white blood cell (WBC) counts and C-reactive protein (CRP) levels, while preserving hepatic and renal functions, which are crucial for postoperative recovery[7]. By framing infection control as a continuum rather than as an isolated intervention, this study addresses a critical gap in the current literature which often overlooks the synergistic impact of multidisciplinary strategies[8].
This editorial contextualizes the findings of Wang et al[7] within broader clinical and operational challenges. Although their work confirms the efficacy of structured protocols, it also raises key questions: How can these measures be standardized across diverse healthcare settings? Are resource-intensive strategies feasible in high-volume surgical setting? How can protocol rigidity be balanced with individualized patient care? By addressing these questions, this editorial aims to catalyze a paradigm shift-from reactive antibiotic dependence to proactive, holistic infection prevention, aligned with evolving surgical priorities and global AMR containment efforts[9].
RESEARCH SIGNIFICANCE AND CLINICAL IMPLICATIONS
The dual burden of SSIs: Clinical and economic impacts
SSIs after gastrointestinal surgery extend beyond the immediate clinical complications and significantly increase morbidity, mortality, and healthcare costs. Studies have reported a two to three-fold increase in 30-day mortality among patients with SSIs, compounded by the immunosuppressive environment of major abdominal surgery, which amplifies vulnerability to opportunistic pathogens[10,11]. The economic ramifications are equally staggering; SSIs prolong hospitalization by 7–10 days, inflating costs by up to $20000 per patient, which is an unsustainable burden on healthcare systems worldwide[12]. Wang et al[7] demonstrated that structured perioperative disinfection protocols not only reduced infection rates but also alleviated AMR by minimizing unnecessary antibiotic use[13].
Regional relevance and AMR challenges
This study is particularly significant for regions such as Hainan, China, where tropical climates foster unique pathogenic profiles. Multidrug-resistant E. coli and MRSA, which are prevalent in this region, exhibit resistance to first-line antibiotics—, a challenge mirrored in other low- and middle-income settings with similar environmental and resource constraints[14]. By tailoring protocols to local resistance patterns (e.g., prioritizing povidone-iodine for its efficacy against E. coli), Wang et al[7] provided a blueprint for context-specific infection control. Such adaptability is vital in resource-limited settings where infrastructural or financial barriers impede standardized global guidelines[15,16]. For example, cost-effective alternatives such as ultraviolet C (UV-C) disinfection can replace laminar airflow systems, ensuring feasibility without compromising efficacy[17].
Multidisciplinary collaboration and protocol adaptability
Effective infection prevention requires collaboration across surgical, microbiological, and nursing teams to address vulnerabilities during every perioperative phase, including preoperative skin decolonization, intraoperative aseptic reinforcement, and postoperative wound surveillance[18,19]. However, rigid standardization risks overlooking patient-specific factors such as comorbidities or microbiome variations that modulate infection susceptibility. Adaptive frameworks are essential—protocols that integrate evidence-based “bundles” while permitting tailored adjustments based on real-time risk assessments[20]. For example, high-risk patients (e.g., patients with diabetes or immunocompromised individuals) may benefit from extended antiseptic bathing or enhanced microbiological monitoring to ensure personalized care within a standardized scaffold[21].
Repositioning infection prevention in surgical priorities
Wang et al[7] challenged the surgical community to transcend the antibiotic-centric paradigms. By embedding infection control into the architecture of perioperative care-rather than treating it as an ancillary intervention-their findings advocate a proactive, system-based approach[22]. This shift aligns with global AMR containment strategies and repositions infection prevention as a cornerstone of surgical quality improvement, capable of transforming outcomes across diverse healthcare settings[23].
KEY FINDINGS AND THEIR INTERPRETATION
Dramatic reduction in postoperative infection rates
Wang et al[7] reported a 55% reduction in infection rates among patients who underwent comprehensive perioperative disinfection (10.42% vs 25.13% on postoperative day 1; P < 0.05). This discrepancy highlights the critical role of aseptic discipline in gastrointestinal surgery, particularly during the vulnerable early postoperative phase. The protocols, including preoperative povidone-iodine baths, intraoperative laminar airflow, and strict wound isolation, likely disrupted pathogen reservoirs and minimized microbial ingress at the surgical sites[24-26]. The magnitude of the reduction exceeded the benchmarks of prior studies that focused on isolated interventions, suggesting synergistic benefits of integrating multidisciplinary measures[27].
Systemic inflammation modulation and organ protection
In addition to infection control, the intervention group showed significant biochemical improvements. WBC counts and CRP levels—key markers of systemic inflammation—were markedly lower in the observation group (e.g., WBC: 9.25 × 109/Lvs 12.04 × 109/L on day 1, P < 0.001)[7]. These findings challenge the traditional view that SSIs are localized events and implicate perioperative disinfection in mitigating broader inflammatory cascades. By reducing the microbial load, such protocols may attenuate pathogen-associated molecular pattern-driven neutrophil activation and cytokine storms, thereby preserving organ function[28]. Supporting this, hepatic biomarkers [aspartate aminotransferase (AST) and alanine aminotransferase (ALT)] and renal markers [creatinine (Cr) and blood urea nitrogen (BUN)] were 22%-32% lower in the intervention group (P < 0.001)[7], reflecting reduced oxidative stress and ischemia-reperfusion injury—a common yet underrecognized complication in abdominal surgery[29].
Mechanistic insights and clinical ramifications
These improvements have important clinical implications. Lower ALT/AST levels correlate with diminished hepatic injury, whereas stabilized Cr/BUN values indicate a reduced acute kidney injury risk, which is a critical predictor of mortality in gastrointestinal surgery[7]. These systemic benefits reposition perioperative disinfection not only as an infection barrier, but also as a safeguard against surgery-induced metabolic derangements. However, their retrospective design limited causal inferences. Confounding factors such as surgical technique or nutritional support could partly explain these findings. Prospective trials are essential to isolate protocol-specific effects.
Limitations and the need for prospective validation
While Wang et al’s findings[7] are compelling, their retrospective study requires caution. Short-term follow-up (7 days post-operatively) precludes the assessment of long-term outcomes, such as anastomotic leaks or antibiotic resistance trends. Additionally, the single-center focus on Hainan’s unique pathogen profile limits its generalizability to regions with different resistance patterns. Future research must prioritize multicenter randomized controlled trials (RCTs) to validate these protocols while exploring cost-effective adaptations (e.g., UV-C disinfection in resource-limited settings).
EXPANDING CURRENT KNOWLEDGE AND ADDRESSING LIMITATIONS
Advancing multidisciplinary infection control paradigms
Wang et al[7] significantly advanced this field by quantifying the synergistic benefits of integrated perioperative protocols, a concept previously underemphasized in gastrointestinal surgery literature. Prior research has predominantly focused on isolated interventions such as preoperative antiseptic bathing or intraoperative antibiotic prophylaxis, yielding inconsistent outcomes due to fragmented implementation. In contrast, this study demonstrated that combining preoperative decolonization, intraoperative aseptic reinforcement, and postoperative surveillance significantly reduced the infection rates in high-risk gastrointestinal procedures. This holistic approach aligns with global surgical safety initiatives, such as the World Health Organization’s Safe Surgery Checklist, but extends its scope by incorporating microbiological precision (e.g., targeting Hainan’s endemic multidrug-resistant pathogens) into standardized workflows. This integration bridges the gap between theoretical guidelines and context-driven execution, offering a replicable model for diverse healthcare settings.
Methodological constraints and generalizability challenges
Despite these contributions, the retrospective design of this study has inherent limitations. While the stringent inclusion criteria homogenized the cohort, unmeasured confounders such as variations in surgical techniques, anesthesia protocols, or postoperative nutrition may have influenced the outcomes. For instance, the observed reduction in creatinine levels could partially reflect differences in fluid management rather than in renal protection alone. In addition, the single-center focus on Hainan’s unique pathogen profile limits its applicability to regions with different resistance patterns or resource constraints. Notably, the reliance of the protocol on laminar airflow systems and high-frequency electrocautery devices may be impractical in low-resource settings, where such technologies are scarce. These challenges necessitate pragmatic adaptations such as substituting povidone-iodine with chlorhexidine in iodine-allergic populations or adopting low-cost UV-C disinfection as an alternative to laminar airflow.
Unresolved questions and mechanistic ambiguities
A critical gap lies in the understanding of the sustainability and mechanistic underpinnings of the observed benefits. The 7-day follow-up period precludes the evaluation of long-term outcomes, including anastomotic leak rates, readmissions, and the evolution of antibiotic resistance, which are key determinants of cost-effectiveness. Although the reduction of systemic inflammation is compelling, the pathways linking disinfection protocols to immune modulation remain unclear. Do the residual antimicrobial activity of povidone-iodine persistently suppress bacterial translocation, or do aseptic techniques primarily mitigate acute contamination? Addressing these questions requires mechanistic studies that combine microbial genomics, cytokine profiling, and metabolomics to unravel the interplay between disinfection, inflammation, and host-microbe dynamics.
FUTURE DIRECTIONS
Prospective multicenter trials to isolate protocol efficacy
Multicenter RCTs were conducted to validate the efficacy of individual components in integrated disinfection protocols. Some key questions remain: Does laminar airflow confer additive benefits beyond preoperative decolonization, or could its role be replaced by cost-effective alternatives such as UV-C disinfection? Comparative studies assessing antiseptic agents (e.g., chlorhexidine vs povidone-iodine) stratified by regional resistance patterns are critical for refining context-specific guidelines. Such trials should incorporate long-term endpoints (e.g., 90-day readmission rates and the emergence of antibiotic resistance) to evaluate sustainability, a dimension absent in the current retrospective analyses.
Artificial intelligence for precision infection prevention
Integrating artificial intelligence (AI)-driven predictive analytics into perioperative care has a transformative potential. Machine learning models trained on preoperative variables such as comorbidities, microbiome profiles, and local resistance data can stratify patients into infection risk tiers, enabling tailored prophylaxis. High-risk patients could receive extended antiseptic protocols or undergo real-time intraoperative bacterial load monitoring using biosensors. Additionally, AI-powered compliance-tracking systems may mitigate human error by auditing aseptic practices in real-time and alerting teams to breaches using sterile techniques.
Cost-effectiveness and equitable resource allocation
Granular cost-benefit analyses are imperative to justify investments in technologies such as laminar airflow or antimicrobial sutures, especially in low-resource settings. Bundled payment models that reimburse hospitals based on infection-related outcomes, rather than procedural volume, can incentivize protocol adoption while aligning financial and clinical priorities.
Global collaboration to democratize infection prevention
Initiatives for global collaboration such as—aggregating data across high-, middle-, and low-income regions—are essential for identifying universal principles and context-specific adaptations. Open-access platform sharing protocol adaptations (e.g., substituting iodine with chlorhexidine in allergy-prone populations) can democratize best practices and ensure equitable access to life-saving measures.
Toward a data-driven perioperative ecosystem
The future of infection control lies in reimagining perioperative care as a dynamic data-driven ecosystem. The amalgamation of technological innovation with ecological stewardship and equity-focused implementation can aid the surgical community in overcoming current limitations. The goal is clear: A world in which SSIs are historical footnotes and not persistent threats.
CONCLUSION
Wang et al[7] redefined infection control in gastrointestinal surgery by demonstrating that structured perioperative disinfection protocols not only halved the incidence of postoperative infections but also mitigated systemic inflammation, thereby reducing reliance on antibiotics. Achieving such success requires protocols that balance standardized measures with contextual adaptability to regional resistance patterns and resource constraints. Multidisciplinary collaboration among surgeons, microbiologists, and nursing teams is paramount for embedding prevention measures into perioperative workflows to combat both SSIs and AMR. As global AMR escalates, equitable implementation of cost-effective innovations and microbiome-sparing strategies must be prioritized in marginalized settings. This study urges policy reform, technological investment, and cross-regional collaboration to relegate SSIs to historical footnotes and safeguard surgical progress worldwide.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade A, Grade B, Grade C, Grade C
Novelty: Grade B, Grade B, Grade B, Grade C
Creativity or Innovation: Grade B, Grade B, Grade C, Grade C
Scientific Significance: Grade A, Grade B, Grade C, Grade C
P-Reviewer: Atrooz OM; Babani SA; Soliman SMA S-Editor: Liu H L-Editor: A P-Editor: Xu ZH
