97J Gandhara Med Dent Sci
October - December 2025
ORIGINAL ARTICLE
:
:
FREQUENCY OF SURGICAL SITE INFECTION FOLLOWING PRIMARY CLOSURE IN PATIENTS
WITH ENTERIC PERFORATION: A CASE SERIES
Muhammad Kalim1, Atta Ullah Khan2, Muhammad Luqman3
ABSTRACT
OBJECTIVES
This study aimed to determine the frequency of surgical site infection (SSI)
following primary closure in patients presenting with enteric perforation and
to evaluate the association of age and gender with SSI.
METHODOLOGY
This descriptive case series was conducted in the Department of General
Surgery, Lady Reading Hospital, Peshawar, from June 2024 to March 2025.
A total of 273 patients aged 18-60 years undergoing emergency laparotomy
for enteric perforation were included through consecutive sampling. Patients
with diabetes mellitus, uremia, obesity, secondary gut leaks, or steroid intake
were excluded to control confounders. Surgical site infections were assessed
on the 7th postoperative day based on clinical features and confirmed by
culture. Data were analyzed in SPSS 10.0. Mean ± SD was calculated for
continuous variables, while frequencies and percentages were used for
categorical variables. A chi-square test was applied, with p < 0.05
considered statistically significant.
RESULTS
The mean age of the patients was 36.61 ± 10.16 years, with the majority
(42.12%) falling within the 31–40 years age group. Overall, 107 patients
(39.19%) developed SSI. No mortality was reported. Stratified analysis
showed no statistically significant association between SSI and gender (p =
0.681) or age group (p = 0.705).
CONCLUSION
A high frequency of SSI was observed following primary closure in enteric
perforation. Neither age nor gender was significantly associated with SSI,
indicating that other factors, such as contamination level, surgical technique,
and perioperative management, may play a more critical role. Consideration
of delayed primary closure and strict infection-control measures may help
reduce SSI in these high-risk cases.
KEYWORDS: Surgical Wound Infection, Enteric Perforation, Primary
Closure, Laparotomy, Risk Factors, Postoperative Complications
How to cite this article
Kalim M, Khan AU, Luqman M.
Frequency of Surgical Site Infection
Following Primary Closure in Patients
with Enteric Perforation: A Case
Series. J Gandhara Med Dent Sci.
2025;12(4):97-101.https://doi.org/10.377
Date of Submission: 30-06-2025
Date Revised: 01-09-2025
Date Acceptance: 03-09-2025
1Assistant Professor, Department of
Surgery, Lady Reading Hospital,
Peshawar
3Trainee Medical Officer, Department of
Surgery, Lady Reading Hospital,
Peshawar
Correspondence
1Atta Ullah Khan, Assistant Professor,
Department of Surgery, Lady Reading
Hospital, Peshawar
+92-3139480002
drkhanpak@gmail.com
INTRODUCTION
Infections that occur in wounds created by an incision
over the skin are called surgical site infections (SSIs).
Surgical site infections are the most common cause of
healthcare-associated infections. Wound infection
remains a significant postoperative morbidity and
accounts for almost a quarter of the total number of
nosocomial infections.1 A small bowel perforation is
still one of its fatal complications in the underdeveloped
and even the developing world.2,3 The common site for
such perforation is the terminal ileum. In literature, the
reported frequency of enteric perforation ranges from
0.8% to 18%.4 The increasing incidence of typhoid
fever with enteric perforation in our country is
alarming, and almost all cases occur in an emergency
setting. Various treatment options have been described
in the literature for such situations, with varying results.
Some advocate for the primary closure of the
perforation followed by peritoneal wash, while others
have found resection-anastomosis to yield better results
in terms of reduced morbidity.5,6 On the other hand,
some researchers actually condemned the practice of
stoma formation for typhoid perforation for its tendency
to cause SSIs.7 Even the technique of surgical repair of
the perforations due to typhoid enteritis has been
correlated with different frequencies of surgical site
infection. Ibrahim et al. reported that the double-layer
closure of the primary perforation site resulted in a
higher frequency of SSI compared to single-layer
closure of the perforated site (47.3% vs 20.3%)8. As
experienced so far, exteriorization in some form is often
more feasible. According to Hassan F et al., when the
perforation itself was exteriorized, SSI was observed to
be 50% (13/26). In the other group, when the
perforation was primarily closed and the proximal
60/jgmds.12-4.751
98 J Gandhara Med Dent Sci
October - December 2025
healthy portion was brought out as a loop ileostomy,
SSI was 35% (7/20).9 Ashraf et al. reported that among
100 patients with primary repair of enteric perforation,
the incidence of wound infection was 23%, followed by
fecal fistula at 14%, while others included wound
dehiscence, leakage, and septicemia. Mortality rate was
6%in this study.10 In another study conducted by
Shrivastava D, et al. (76.77%), patients had
postoperative complications, with the most common
complication being the surgical site infection. The
median hospital stay was 21.56 days. Patients who had
postoperative complications stayed longer in the
hospital. In this study, the mortality rate was 15.48%.11
The objective of the current study was to study these
two important entities, i.e, surgical site infections and
enteric perforation in relation to each other. By
determining the frequency of surgical site infection in
such cases in our setup, and highlighting the common
factors leading to it among patients undergoing
emergency laparotomy in enteric perforation, this
would help us in reducing the extra disease burden of
SSI on an already common problem in our community,
thus reducing the avoidable morbidity and mortality in
an already complicated condition as no such study had
been conducted in our population for the last five years
so this study has provided us the latest and updated
information regarding frequency of surgical site
infection in primary closure in patients presenting with
enteric perforation.
METHODOLOGY
This is a descriptive case series. It is conducted at the
Department of General Surgery, Lady Reading
Hospital, Peshawar, from June 2024 to March 2025.
The sample size was 273, based on a 23% proportion of
SSI in patients' enteric perforations,10 a 95% confidence
interval, and a 5% margin of error, as calculated using
the WHO sample size formula. The sampling technique
used was consecutive (non-probability) sampling. All
the patients presenting with enteric perforation between
18 and 60 years were included. Postoperative cases with
secondary gut leak diagnosed on clinical examination,
Patients with confounding factors like preoperative
diabetes (fasting glucose of > 126mg/dl), preoperative
uremia (blood urea nitrogen level of >20mg/dl OR
creatinine level >2mg/dl) and obesity (body mass index
of >30kg/m2) and Patients with history of intake of
steroids were excluded from the study. The
aforementioned conditions act as confounding factors
and, if included, would have introduced bias into the
study results. The study was conducted after approval
from the hospital's ethical and research committee. All
patients meeting the inclusion criteria, admitted either
via OPD or the emergency department, but operated in
the emergency department with laparotomy for enteric
perforation, were included in the study. The purpose,
risks, and benefits of the study were explained to all
included patients. They were assured that the study was
conducted purely for research and data publication
purposes and informed that written consent had been
obtained from all included patients.
A history, clinical examination, and routine laboratory
investigations, along with a chest radiograph, were
performed to confirm enteric perforation by showing a
gas shadow under the diaphragm. All exploratory
laparotomies were performed under the supervision of
an expert General Surgeon with a minimum of 5 years'
experience. An expert radiologist with at least 5 years
of experience reported all chest radiographs. Surgical
site infections were evaluated on the 7th postoperative
day based on redness (detected by the naked eye),
swelling (detected by the naked eye), and discharge of
pus (yellowish fluid coming out of the wound,
confirmed by a culture test in the laboratory). An expert
microbiologist with at least 5 years of experience
reported all culture specimens. All the above
information, including age, gender, duration of
symptoms, diabetes mellitus, hypertension, and
smoking status, was recorded in a predesigned
Proforma. Exclusion criteria were strictly adhered to in
order to control for confounders and bias in the study
results. All the data were analyzed in SPSS 10.0. Mean
and standard deviations were calculated for continuous
variables, such as age and duration of symptoms.
Frequencies and percentages were calculated for
categorical variables, including gender, diabetes
mellitus, hypertension, smoking status, and surgical site
infection. Surgical site infection was stratified by age,
gender, duration of symptoms, diabetes mellitus,
hypertension, and smoking status to see the effect
modifiers. Post-stratification chi-square test was
applied, in which a P value of < 0.05 was considered
significant. All the results are presented as tables and
charts.
RESULTS
A total of 273 patients were observed. No death cases
were reported throughout the entire study. The mean
and standard deviation were calculated for age and
duration of symptoms, which were 36.61 ± 10.16 years
and 4.45 ± 3.56 days, respectively. All patients were
distributed into four age groups. Most patients were in
the 3rd decade of their life, i.e., the second age group.
There were 76 (27.84%) patients in the 18-30 years age
group, 115 (42.12%) patients in the 31-40 years age
group, 46 (16.85%) patients in the 41-50 years age
group, and 36 (13.19%) patients in the 51-60 years age
group.
Frequency of Surgical Site Infection Following Primary
99J Gandhara Med Dent Sci
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Table 1: Frequency of Surgical Site Infection
Surgical Site Infection Frequency %age
Yes 107 39.19%
No 166 60.81%
Table 2: Surgical Site Infection with Gender (n = 273)
Gender Surgical Site Infection P-
Value Yes % No %
Male 67 24.54% 108 39.56% 0.681
Female 40 14.65% 58 21.25%
Table 3: Surgical Site Infection with Age (n = 273)
Age
Group
Surgical Site Infection P-
Value Yes % No %
18-30 27 9.89% 49 17.95% 0.705
31-40 45 16.48% 70 25.64%
41-50 18 6.59% 28 10.26%
51-60 17 6.23% 19 6.96%
Figure 1: It shows surgical site infection by comorbidities
DISCUSSION
This study found a high rate of surgical site infection
(SSI) of 39.19% among 273 patients undergoing
primary closure. Neither gender (male vs female, p =
0.681) nor age group (18-30, 31-40, 41–50, 51-60
years; p = 0.705) showed a statistically significant
association with SSI. These findings have several
implications in light of the existing literature and
suggest avenues for improving surgical care in cases of
enteric perforation. The SSI rate of 39% in this study is
relatively higher compared with many studies of
gastrointestinal surgery and peritonitis, though
somewhat similar to results in emergency settings with
contaminated/dirty wounds. A retrospective study at
Lahore General Hospital reported a wound infection
rate of 38.7% in patients who had their skin closed after
emergency intervention for gastrointestinal perforation
and peritonitis, which is very close to our observed
rate.12 Similarly, in Abbottabad, a study of
postoperative surgical site infections in a tertiary care
hospital reported SSI in 33.68% of cases.13 On the other
hand, studies in settings with less contamination or
different closure techniques report lower SSI rates.
Such as Delayed Primary Closure (DPC) compared to
Primary Closure (PC) in gastrointestinal perforation
patients has been shown to reduce SSI significantly; in
one randomized trial, PC had 42.9% infection vs 7.4%
in DPC (p=0.004) in emergency perforation surgery.14
A meta‐analysis of 12 randomized controlled trials
found that DPC reduced SSI (odds ratio ~0.31)
compared to PC in surgeries for GI perforation.15 In our
study, age group and gender were not significantly
associated with SSI (p = 0.681 for gender; p = 0.705 for
age group). This suggests that, in primary closure for
enteric perforation, the risk of infection may be more
heavily influenced by other factors (delay in
presentation, degree of contamination, comorbid
conditions, surgical technique, perioperative care) than
by age or gender alone. The literature is mixed
regarding the relationship between age and gender.
Some studies find that older age increases the risk of
SSI; a multicentre risk‐factor study in gastric surgery
found age ≥65 years as an independent risk factor.16 In
contrast, a study of emergency laparotomies found that
while extremes of age were associated with higher
morbidity, age was not always a significant predictor
once other risk factors were controlled.17 Regarding
gender, male sex has often been found associated with
higher SSI risk (possibly due to higher rates of
comorbidities, smoking, or differential immune
responses).18 However, our finding that gender was not
significant is also consistent with other studies where
male/female differences were minor or confounded by
other risk factors. Given the high rate of SSI, there is
justification for considering delayed primary closure
(DPC) instead of primary closure in thoroughly
contaminated enteric perforation cases, especially when
the wound cannot be made "clean" at the time of
surgery. Optimization of perioperative management,
including antibiotic prophylaxis, improving the
preoperative condition (even in emergencies, such as
resuscitation and source control), and minimizing
delays, is crucial. Surveillance and standardization of
wound care protocols postoperatively. Stratify patients
at high risk (even if age/gender are not significant) for
more intensive monitoring. Our study contributes
valuable data in the specific population of patients with
enteric perforation undergoing primary closure. It
highlights that SSI risk is very high in this setting
(39%) and that age/gender alone may not be reliable
predictors, underscoring the importance of surgical and
procedural factors.
LIMITATIONS
This study was conducted as a single-center case series
with a relatively small sample size, which may limit the
generalizability of the findings. Only clinical and
-
Frequency of Surgical Site Infection Following Primary
100 J Gandhara Med Dent Sci
October - December 2025
culture proven SSIs within 7 days postoperatively were
assessed, potentially missing late-onset infections.
Confounding factors such as nutritional status,
intraoperative contamination grading, surgeon
experience, and antibiotic protocols were not fully
evaluated, which may have influenced the SSI rates.
Future multicenter studies with larger sample sizes and
longer follow-up are recommended to validate these
results.
CONCLUSIONS
This study demonstrates a high frequency of surgical
site infection (39.19%) in patients undergoing primary
closure for enteric perforation. Neither age nor gender
was significantly associated with SSI, suggesting that
other clinical and procedural factors, such as degree of
contamination, comorbidities, and perioperative
management, may play a more substantial role. The
findings highlight the challenges of wound management
in contaminated abdominal surgeries and reinforce the
need for improved strategies, such as consideration of
delayed primary closure in selected cases, strict
adherence to infection-control measures, and
optimization of perioperative care protocols. Future
multicenter studies with larger sample sizes, longer
follow-up, and advanced statistical modeling are
recommended to define independent predictors of SSI
better better and to establish evidence-based guidelines
for wound closure techniques in enteric perforation.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
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October - December 2025
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Muhammad Kalim - Concept & Design; Data Acquisition;
Data Analysis/Interpretation; Drafting Manuscript;
Supervision; Final Approval
Atta Ullah Khan - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Final Approval
Muhammad Luqman - Concept & Design; Data Acquisition;
Data Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Final Approval
AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.
Frequency of Surgical Site Infection Following Primary