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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.

DOI: 10.3238/arztebl.2019.0661b

Corresponding author
Dr. med. Elisabeth Maurer
Klinik für Viszeral-, Thorax- und Gefäßchirurgie
Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Marburg, Germany
maurere@med.uni-marburg.de

Conflict of interest
Dr. Maurer received study support (third party funding) from Rhön AG.

1.
Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO): Prävention postoperativer Wundinfektionen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 2018; 61: 448–73 CrossRef MEDLINE
2.
Cruse PE, Foord R: A five-year prospective study of 23,649 surgical wounds. Arch Surg 1973; 107: 206–10 CrossRef MEDLINE
3.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR: The hospital infection control practices advisory committee: guideline for prevention of surgical site infection. Am J Infect Contro 1999; 27: 97–132 MEDLINE
4.
Maurer E, Reuss A, Maschuw K, et al.: Superficial surgical site infection following the use of intracutaneous sutures versus staples—a randomized single-center trial in an elective gastrointestinal surgery setting. Dtsch Arztebl Int 2019; 116: 365–71 VOLLTEXT
1.Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO): Prävention postoperativer Wundinfektionen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 2018; 61: 448–73 CrossRef MEDLINE
2.Cruse PE, Foord R: A five-year prospective study of 23,649 surgical wounds. Arch Surg 1973; 107: 206–10 CrossRef MEDLINE
3.Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR: The hospital infection control practices advisory committee: guideline for prevention of surgical site infection. Am J Infect Contro 1999; 27: 97–132 MEDLINE
4.Maurer E, Reuss A, Maschuw K, et al.: Superficial surgical site infection following the use of intracutaneous sutures versus staples—a randomized single-center trial in an elective gastrointestinal surgery setting. Dtsch Arztebl Int 2019; 116: 365–71 VOLLTEXT

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