Evaluating the Management of Perforated Peptic Ulcers in CHUK, Rwanda: Insights into Short-Term Clinical Outcomes

/in ,

Authors:
Christophe MPIRIMBANYI, Miguel GASAKURE

Body of Abstract:
Background
Peptic ulcer perforation (PPU) remains a significant cause of morbidity and mortality globally, particularly in low- and middle-income countries (LMICs). Despite a decline in peptic ulcer disease incidence, PPU persists and is usually associated with higher morbidity and mortality. Despite that, there is still very limited data existing on PPU’s epidemiological and clinical characteristics as well as its management in Rwanda. Therefore, exhaustive clinical research would help to investigate this crucial matter further.
Methods
It was a retrospective cross-sectional study conducted only on adult patients diagnosed with PPU at the University Teaching Hospital of Kigali, Rwanda, between September 2022 and September 2023. Those patients were admitted and always followed by the General Surgery team. The data collection focused on demographics, clinical presentation, surgical management, postoperative complications, and outcomes were collected and then analyzed.
Results
The study involved 46 cases in total. It included predominantly male patients (80.5%) with a mean age of 36.8 years. The majority came from urban areas and had medical insurance. The intraoperative findings revealed the perforations occurring more predominantly in the prepyloric region (95.56%) and only around 4 % were found in the duodenal region.
All the cases were managed surgically. The surgical approaches of predilection were the Modified Graham patch (95.5%) or the primary repair (4.4%). Although most patients had no complications (75.5%), the most common postoperative complications were fever of unknown origin (13.3%), pneumonia (8.8%), and surgical site infection (4.4%). While most patients had uncomplicated postoperative courses, a 10% overall mortality rate was observed.
The average length of hospital stay was estimated at 6.67 days, with a standard deviation of 6.21 days. The range of hospital stays varied from 0 to 36 days. Only 8.6% were admitted to ICU and only 1 case had to be reoperated but no significant predictors for ICU admission or complications were identified.
Conclusions
This study highlights the burden of PPU in the biggest Teaching Hospital in Rwanda, CHUK. It emphasizes the need for early recognition, improved prevention, and management strategies for PPU. The high mortality rate underscores the critical nature of PPU. It also highlights the need to introduce new surgical approaches such as laparoscopic procedures. Further research is warranted, such as conducting a multi-center prospective study. This could help elucidate specific risk factors and optimize PPU treatment guidelines in Rwanda and in LMICs in general.

Time Matters: Early Video-Assisted Thoracoscopic Surgery Reduces the Risk of Post-Operative Empyema in Patients with Thoracic Trauma

/in ,

Authors:
Fabiana C Sanchez, Grace M Niziolek, Grant V Bochicchio, Jason A Snyder, Leonardo J Diaz Gandica, Lindsay M Kranker, Marco J Henriquez, Marguerite W Spruce, Melissa Canas, Michael W Alchaer, Ricardo A Fonseca

Body of Abstract:
Background:
Despite having a low incidence in the adult trauma population, empyema remains a serious infectious complication with multiple etiologies and risk factors. Early Video-Assisted Thoracoscopic Surgery (VATS) may reduce the risk of empyema by facilitating early drainage and preventing infection progression. This study compares the incidence of post-operative empyema in trauma patients undergoing early versus late VATS, aiming to assess the impact of timing on the risk of developing an empyema.
Methods:
This study was conducted using an urban level 1 trauma registry, querying all patients with thoracic trauma who underwent VATS from May 2018 to June 2024. We included patients who underwent VATS for retained hemothorax or lung entrapment. Patients undergoing VATS for pre-existing empyema, bleeding control, diaphragmatic injuries, or rib plating alone were excluded. Early VATS was defined as surgery performed within 4 days of admission; a cut point utilized in the EAST hemothorax guidelines. Post-operative empyema development was confirmed by imaging evidence, clinical evaluation, and/or microbiology findings. Comparative analyses were conducted using chi-square tests and independent samples t-test; a multivariate regression model was used to assess the risk of empyema controlling for penetrating injuries, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) Chest score, chest tube placement after 24 hours from admission, retained hemothorax, non-chest surgeries before VATS, and VATS timing.
Results:
A total of 87 patients were identified, with 34 (39.1%) undergoing early VATS and 53 (60.9%) undergoing late VATS. Post-operative empyema was identified in 3 (8.8%) patients in the early VATS group compared to 19 (35.8%) in the late VATS group (p=0.005). The early and late VATS groups had statistically-similar age, gender, race, BMI, and ISS. Patients in the early VATS group had higher AIS chest scores (3.0 vs 2.7, p=0.013) and fewer ventilator days (5.5 vs 6.5, p<0.001) than the late group. Early VATS was also associated with a shorter hospital length of stay (12.8 vs 21.9, p=0.001). The late VATS group exhibited a trend toward higher conversion to open thoracotomy (9.4 vs 2.9%, p=0.244). Multivariate logistic regression analysis demonstrated that late VATS independently increases the risk of empyema (OR=6.099, p=0.011, 95% CI:1.51–24.67). Conclusions: In trauma patients with thoracic injuries, early VATS intervention (≤4 days) is associated with better clinical outcomes, including a significantly lower incidence of empyema, fewer ventilator days, and shorter hospital stays when compared to late VATS. These findings highlight the potential benefits of timely surgical management in thoracic trauma, particularly for post-traumatic retained hemothorax. However, further prospective studies are needed to determine whether these associations reflect causation or correlation.

Prodromal Phase of Infection Associated with Hypocoagulability, Acute Phase with Hypercoagulability based on Thromboelastography and Platelet Mapping

/in ,

Authors:
Aseal Liqa, Conor Dillon, Hassan Nadeem, Meredith Essandoh, Monica Patten, Robert Sawyer, Tjasa Hranjec

Body of Abstract:
Background: Infected patients are considered to be hypercoagulable.  We hypothesized that coagulopathy associated with infection would be measurable by Thromboelastography with Platelet Mapping (TEG-PM).  

Methods:  A single center, chart review identified adult, trauma patients, admitted to our Trauma Intensive Care Unit (ICU) with hospital length of stay (LOS) ≥7 days, diagnosis of anemia of critical illness and evaluation of coagulopathy via TEG-PM before (prodrome phase – prior to diagnosis) and after (acute phase – following institution of treatment) the infectious work-up, over a 12-month period. Patients on continuous reno-renal replacement and full anticoagulation were excluded.  Univariate analysis was used to evaluate change in coagulation parameters between prodromal and acute phase of infection based on paired sample testing.    

Results: A total of 20 patients underwent coagulopathy evaluation via TEG-PM in the setting of anemia of critical illness.   Patients were mostly male (65%), with mean age 43±4 years, mean length of stay of 29.1±3.3 days, all with diagnosis of infection.  Thromboprophylaxis was initiated in 80% of the patients, with mean anti-Xa 0.19±0.1; due to progressive anemia, enoxaparin was held in 20% of the patients.  TEG-PM was collected in 20 patients during the prodromal phase, mean 0±0.5 days surrounding the infectious work-up; 16 received evaluation of coagulopathy during the acute phase with mean 3.9±0.7 days surrounding the infectious work-up.  Acute phase was associated with hypercoagulable TEG parameters (Table 1).  During the prodromal phase, however, R parameter displayed significant hypocoagulability.  Platelet activity, specifically MA-AA, and fibrinogen (CFF) increased during the prodromal phase, but MA remained within normal limits.  Lysis was non-contributory. Patients received a total of 150 red blood cell (RBC) transfusions, mean 6.6±1.6 units per patient, range 1-30.  Forty percent of the patients had an identifiable bleeding source (gastrointestinal, retroperitoneal, hemoptysis) at the time of the prodromal phrase, requiring extensive diagnostic and therapeutic interventions and active resuscitation.  Three patients developed deep venous thrombosis (DVT), diagnosed 4.3±1.3 days after infectious work-up (acute phase).  

Conclusion: Acute phase of infection is associated with hypercoagulable state, as diagnosed by TEG-PM, and may lead to DVT formation.  Surprisingly, prodromal phase, when signs and symptoms of infection may be overlooked and attributed to other causes, TEG-PM shows hypocoagulability, that may lead to significant bleeding necessitating active resuscitation and transfusion.  TEG-PM may be a useful adjunct in infectious diagnosis during the prodromal phase.

Is Social Vulnerability Associated with Surgical Site Infections in Trauma Patients?

/in ,

Authors:
Lillian S Kao, Mokunfayo Fajemisin, Renee W, Green, Stephanie Martinez Ugarte, William Rieger

Body of Abstract:
Background: High social vulnerability, which integrates multiple indicators of social determinants of health, has been shown to be associated with increased trauma mortality and recurrent injuries. We hypothesized that social vulnerability, as measured by the Area Deprivation Index (ADI) is associated with an increased risk of surgical site infections (SSIs).

Methods: A retrospective cohort study was performed of trauma patients undergoing laparotomy procedures, age greater than 16, surviving greater than 48 hours, presenting to a single urban Level 1 trauma center from 2020 to 2021. Demographics, injury details, operative information and postoperative infectious outcomes were obtained from the trauma registry and supplemented by chart review. Social vulnerability was assessed using ADI which utilizes census-tract level information. The ADI has a maximum score of 100 and scores closer to 100 indicate increased social vulnerability. Outcomes of interest were organ-space surgical site infections (O-SSI), or any type of SSI associated with the trauma laparotomy. SSIs were classified per CDC definitions. Univariate and multivariable analyses were performed adjusting for age, gender, trauma mechanism, colonic injury, damage control laparotomy, and injury severity score (ISS).

Results: Among the 357 trauma patients undergoing laparotomy, the median age was 34.0 (IQR 11-57), and median ISS 22.0 (IQR 1-43.0). The majority of patients had a penetrating injury mechanism (57%) and were male (80%). Sixteen percent of patients underwent a damage control laparotomy, and 33% had a colonic injury. The median ADI was 65.0 (IQR 32- 98). Seventeen percent of patients (n=60) had OS-SSI and 19% (n=69) had any SSI. On univariate analysis, ADI was not associated with OS-SSI or any SSI. Similarly, on multivariable analysis, ADI was not associated with OS-SSI (OR 1.09, 95% 0.76-1.15, p=0.39) or any SSI (OR 1.01, 95% CI 0.92-1.06, p=0.71).

Conclusion: Social vulnerability, as defined by ADI, was not associated with OS-SSI or any SSI after trauma laparotomy. Injury characteristics and patient physiology may have more impact than social factors on SSIs after emergency trauma laparotomy. Additionally, more granular measures of social determinants of health may be needed to better elucidate any associations. Further research is needed in larger and less urban populations to determine if social vulnerability is associated with SSIs or affects any mediating factors such as time to source control.

Pathogen-induced coagulopathy: the role of pathogen-derived virulence factors in the development of clinically significant coagulopathy

/in ,

Authors:
Andrew Benjamin, Ellen Cohn, Jessica Cao, John Alverdy, Olga Zaborina, Rebecca Meltzer, Robert Keskey

Body of Abstract:
Background: Trauma-induced coagulopathy (TIC) results in significant morbidity and mortality despite improved understanding of specific TIC phenotypes that occur after injury. While individual patient factors (sex, genetics, injury severity, etc.) can influence a patient’s coagulation profile, there remains poorly understood within-group differences. Life-threatening injury requiring surgery, antibiotics, and prolonged hospitalization often predisposes trauma patients to colonization by pathogenic bacteria (i.e. Pseudomonas aeruginosa), but current TIC research focuses almost exclusively on host factors. Host-pathogen interactions may play an underappreciated role in the development of coagulopathy, given the intricate interplay between infection, inflammation, and coagulation. Bacterial pathogens are known to produce virulence factors that degrade key components of the clotting cascade as a strategy for subverting the host immune system, but the extent to which these mechanisms contribute to clinically significant coagulopathy remains unclear.

Hypothesis: We hypothesize that Pseudomonas aeruginosa has the capacity to induce clinically significant coagulopathy via secreted virulence factors.

Methods: Pseudomonas aeruginosa (Pa) isolated from an ICU patient was grown in liquid media. Supernatant (Pa-sup) was collected at stationary phase, filtered, and added to citrate-anticoagulated whole blood from 5 healthy, human volunteers at 1:10 and 1:15 dilutions and compared to the addition of liquid media alone (Ctrl). Coagulation profiles were analyzed using the ROTEM sigma (Werfen), a functional assay of the intrinsic (int)/extrinsic (ext) clotting cascade and fibrin contribution to clot formation. Also, collagenolytic activity of Pa-sup was assessed in vitro using fluorescein-conjugated gelatin (Invitrogen).

Results: Pa-sup caused significant coagulopathy in both the intrinsic and extrinsic clotting cascades in a dose-dependent manner. Pa-sup significantly decreased maximum clot firmness (MCF) (MCFint: 10.2 vs 26.7 vs 53.4; 1:10 vs 1:15 vs Ctrl; p<0.001 | MCFext: 17.6 vs 39.7 vs 58.5; 1:10 vs 1:15 vs Ctrl; p<0.001) and amplitude at 10 minutes (A10) (A10int: 4.8 vs 24.3 vs 49.1; 1:10 vs 1:15 vs Ctrl; p<0.001 | A10ext: 16.4 vs 34.2 vs 51.7; 1:10 vs 1:15 vs Ctrl; p<0.001). Additionally, 1:10 Pa-sup caused a significant increase in clotting time (CT) (CTint: 438.2s vs 168.1s Ctrl; p<0.001 | CText: 191.2s vs 61.1s Ctrl p=0.06). Pa-sup-induced coagulopathy correlated with increased collagenolytic activity. Conclusion: Pseudomonas aeruginosa yields exoproducts that more than double clotting time and weaken clot strength by almost 50%. Taken together, these data demonstrate that certain pathogens can secrete virulence factors that cause clinically significant coagulopathy. Further work is ongoing to determine the extent to which pathogen-induced coagulopathy is amplified in the setting of trauma and to determine its generalizability to other pathogens.

The Relationship Between Length of Stay and Increased Infection Rates in Trauma Patients with a Delay in Hospital Discharge.

/in ,

Authors:
Fabiana C Sanchez, Grant V Bochicchio, Leonardo J Diaz Gandica, Marco J Henriquez, Melissa Canas, Michael W Alchaer, Ricardo A Fonseca

Body of Abstract:
Background:
A substantial body of literature explores the impact of length of stay (LOS) on complications, infections, morbidity, and mortality. However, detailed analyses of specific intervals within LOS and their contributions to patient outcomes, particularly in the context of delayed discharge, remain limited.
Methods:
We conducted an analysis of our multidisciplinary, prospectively maintained trauma database, including all trauma patients with a delay in discharge from 2018 to 2023 at our Level 1 trauma center. Patients with discharge delays related to non-medical reasons and those with delays related to COVID-19 were excluded.
LOS was defined as the total hospital stay. LOS minus delay in discharge time (LOS – DDT) was defined as the duration from admission to when patients were medically ready for discharge ([Phase I]), and DDT was defined as the time from when patients were medically ready for discharge to their actual discharge ([Phase II]). Patients were stratified into two cohorts: those with delays due to infections (DDI) and those with delays due to non-infectious medical reasons (DDNI).
Results:
Among 160 patients with a delay in discharge, 15 (9.4%) were in the DDI group, and 145 (90.6%) were in the DDNI group. Patients in the DDNI group were more likely to be African American (31.7% vs. 0%, p=0.035). Compared to DDNI patients, those in the DDI group had significantly higher total LOS (17.4 days vs. 9.58 days, p<0.001), higher LOS - DDT (11 days vs. 6.18 days, p=0.008), and higher DDT (6.4 days vs. 3.4 days, p<0.001). In a multivariate analysis controlling for Injury Severity Score (ISS), female sex, Glasgow Coma Scale (GCS), and age, LOS - DDT was significantly associated with DDI patients, with an odds ratio (OR) of 1.133 (p=0.017). Conclusion: A higher LOS - DDT ([Phase I]) was associated with increased infection rates among trauma patients experiencing delayed discharge for medical reasons. Additionally, the presence of infection correlated with longer DDT ([Phase II]). These findings suggest the need for strategies to optimize hospital discharge processes and minimize prolonged hospital stays to reduce the risk of infections.

Corticosteroids in Trauma Patients: Impact on Outcomes and Infection Risk

/in ,

Authors:
Ameera Mazraany, George C Velmahos, Haytham M A Kaafarani, Ikemsinachi C Nzenwa, John O Hwabejire, Josh Ng, Michael DeWane, Vahe S Panossian, Veerle van Zon

Body of Abstract:
Background: Corticosteroids impair healing and increase infection risk in surgical patients, but their impact on injured patients is less understood. This study aimed to examine the relationship between corticosteroid use and outcomes, including infection, in trauma patients.

Methods: Using the ACS-TQIP 2017-2020 database, all trauma patients 18 years or older were included. Corticosteroid use is defined in the database as the routine use of corticosteroid medications within 30 days before the injury for the management of a chronic medical condition. Multivariable logistic regression adjusting for demographics (e.g. age, sex), injury characteristics (e.g. mechanism, severity), and comorbidities (e.g. COPD, cirrhosis) was used to study the correlation between corticosteroid use and 1) mortality, 2) overall morbidity (e.g. acute kidney injury, stroke, pressure ulcers), and 3) infectious complications (e.g. sepsis, pneumonia, surgical site infection- SSI). SSI was assessed only in patients who underwent open surgical procedures.

Results: A total of 3,278,447 patients were included, 33,977 (1.0%) of which were corticosteroid users. The median age was 54 years, 90.3% had blunt trauma, mortality was 3.5%, overall morbidity was 7.3%, and 0.9% of patients developed an infectious complication. Among those who underwent open surgery, 0.6% developed a SSI. On multivariable analyses, corticosteroid use was independently associated with increased odds of mortality (OR 1.49, 95% CI 1.38–1.60, p<0.001), overall morbidity (OR 1.29, 95% CI 1.24–1.34, p<0.001) and infectious complications (OR 1.45, 95% CI 1.29–1.63, p<0.001), but not SSI (OR 0.81, 95% CI 0.55–1.18, p=0.270) [Figure 1]. Conclusion: Corticosteroid use in trauma patients is independently associated with increased risk of mortality, morbidity and infectious complications. These findings are important for patient counseling, benchmarking the quality of care of trauma patients, and for creating targeted interventions to decrease the risk of complications and infection in this patient population.

NPWT Management of Burst Abdomen in Pancreatic Juice Leak Following Distal Pancreatectomy Complicated by Tuberculosis

/in ,

Authors:
Adianto Nugroho, Aditomo Widarso, Indah Jamtani, Rofi Y Saunat

Body of Abstract:
Introduction

Pancreatic fluid collection after distal pancreatectomy is common and can be managed conservatively. However, in some cases, it can lead to a devastating sequel, such as a burst abdomen.

Case Illustration

A 55-year-old male was consulted to the digestive surgery service with acute abdomen 24 hours after endoscopic drainage of pancreatic pseudocyst. The patient was diagnosed with cystadenoma of the pancreas tail, and the endoscopist internist successfully did endoscopic internal drainage of the cyst. However, one day after the procedure, the patient complained of severe abdominal pain accompanied by nausea, vomiting, and fever. His laboratory showed a marked leukocytosis, and a repeat abdominal CT scan showed a large amount of intraperitoneal air, which was a deliberate process of the endoscopic procedure. The decision to take the patient to surgery was made after 12 hours of conservative management failed. Upon exploration of the abdomen, we discovered pancreatic juice collection at the left paracolic gutter and pelvic floor. We performed a formal distal pancreatectomy, using a linear cutter, along with the spleen, and primary repair of the stomach. A large peritoneal drain was left at the peripancreatic space and another at the pelvic floor. The abdomen was cleansed with sterile saline and sutured closed. In the postoperative follow-up, pancreatic juice leakage through the peripancreatic drain was confirmed by amylase workup of the fluid. The pancreatic juice leaked through the abdominal incision as well, causing a burst abdomen by postoperative day 6. The patient had also developed an overwhelming post-splenectomy infection in the form of hospital-acquired pneumonia and was admitted to the ICU.
Meanwhile, pancreatic juice leakage was treated conservatively with optimal drainage through the peripancreatic drain, and a negative pressure wound therapy (NPWT) device was applied to treat the burst abdomen. The pathology examination of the specimen revealed a pancreatic pseudocyst with no signs of malignancy. We screened the patient for tuberculosis as another factor in his slow healing, and oral anti-tuberculosis (OAT) medicine was administered. Soon after the administration of OAT, the pancreatic juice drainage slowly reduced, and his abdominal wall defect showed progress. The patient recovered from OPSI, and his abdominal wall defect was healing well with VAC. He was discharged POD-30 for homecare with the VAC device still applied and was scheduled for abdominal wall closure within the next month.

Conclusion
Conservative management of pancreatic juice collection can be successful owing to detailed and comprehensive patient management. In endemic regions, tuberculosis should always be suspected in slow-recovering patients.

Antibiotic Prophylaxis in Gastrointestinal Surgery: Balancing Efficacy and Resistance

/in ,

Authors:
Amira Elfergani, Main Maitah, Yehya Maitah

Body of Abstract:
Background:
Postoperative infections remain a major concern in GI surgery, contributing to significant morbidity and mortality. Antibiotic prophylaxis is a widely used strategy to reduce the risk of infection. However, the increasing prevalence of antimicrobial resistance calls for rigorous evaluation of current practices and non-antibiotic alternatives, such as probiotics, preoperative optimization, and advanced surgical techniques.

Methods:
A comprehensive review of the literature was conducted using PubMed, focusing on studies published between 2013 and 2023. The search strategy included “antibiotic prophylaxis,” “postoperative infections,” “probiotics,” and “surgical site infections.” Clinical trials, cohort studies, and meta-analyses involving adult patients undergoing GI surgery were included. Data were extracted to evaluate the effectiveness of antibiotic prophylaxis and non-antibiotic strategies in reducing infection rates.

Results:
Antibiotic prophylaxis continues to demonstrate efficacy in reducing surgical site infections (SSIs), particularly when administered within one hour prior to incision. However, extended use or misuse of antibiotics has contributed to rising antimicrobial resistance. Non-antibiotic approaches, including the use of probiotics and synbiotics to modulate the gut microbiome and enhanced recovery protocols, show potential in reducing postoperative infections without contributing to resistance. Surgical Techniques including minimally invasive surgeries, normothermia maintenance, intraoperative antiseptic irrigation, negative pressure would therapy, and antimicrobial-coated sutures and meshes also demonstrated significant reduction in SSIs.

Conclusions:
While antibiotic prophylaxis remains a critical component of infection prevention in GI surgery, it is essential to incorporate non-antibiotic strategies to mitigate resistance risks. Emerging alternatives such as probiotics and surgical optimization provide promising adjuncts to standard care.

Surgical Site Infections in Pediatric Patients with Diabetes Mellitus

/in ,

Authors:
Amira Elfergani, Gehan Bensreiti, Yehya Maitah

Body of Abstract:
Background
Surgical site infections (SSIs) are a significant concern, particularly in those with diabetes mellitus (DM), due to hyperglycemia, compromised immune function, and delayed wound healing. Pediatric patients with DM face unique challenges, such as the role of insulin pumps and autoimmune dysfunction, which complicate direct application of adult findings. However, much of the evidence surrounding SSIs in this population is extrapolated from adult studies. This review explored the risk factors and preventive strategies for SSIs in pediatric DM patients, highlighting areas of agreement, disagreement, and significant gaps in the current knowledge.

Methods
This review analyzed findings from work published between 2009 and 2024 that addressed the relationship between DM and SSIs. Articles were selected based on their relevance to hyperglycemia, immune dysfunction, perioperative management. Primary sources included systematic reviews, meta-analyses, and clinical guidelines.

Results
There is agreement that DM significantly increases the risk of SSIs in surgical patients. Most studies, including large meta-analyses, highlight hyperglycemia as a key modifiable risk factor. However, discrepancies exist regarding the exact threshold of glycemic control required to mitigate this risk. While most studies advocate maintaining glucose levels below 180 mg/dL, others suggest stricter thresholds for pediatric populations. Pediatric-specific data are sparse, with researchers often relying on extrapolation from adult studies. Another area of agreement is the role of immune dysfunction in predisposing diabetic patients to infections. Studies emphasize compromised neutrophil function, chemotaxis, and cytokine production as consistent contributors to SSI risk. Additional mechanisms, such as gut microbiota dysbiosis, may play an under explored role in infection susceptibility, particularly in pediatric populations. Perioperative measures such as maintaining normothermia and minimizing operative times are consistently supported. Postoperative insulin protocols are widely endorsed for adults, but evidence of their effectiveness in pediatric populations remains limited. Timely antibiotic prophylaxis is another area of agreement, with research emphasizing its importance in reducing SSI incidence. The choice of antibiotics and timing of administration needs to be tailored for children with DM, especially considering rising antimicrobial resistance.

Conclusions
This review highlights the increased SSI risk in diabetic surgical patients and the importance of glycemic control, immune function, and perioperative management in mitigating this risk. However, significant gaps remain, particularly concerning pediatric-specific data. Discrepancies in the literature regarding the predictive value of glycemic markers and the optimal thresholds for control underscore the need for further research.