In our study, we assessed the incidence of SSI and analyzed the risk factors associated with the development of SSI among colorectal cancer patients who are undergoing resection in Palestine. Clavien-Dindo classification, a universally accepted system for grading complications [15,16], was used in our study for the assessment and grading of postoperative SSI in patients with colorectal cancer. Surgical site infections (SSIs) are the leading cause of postoperative infectious complications after colectomy, thus they prolong hospital stay and increase the health care cost due to readmission to the hospital. Moreover, they sometimes result in death even during the hospital stay [10,17,18] Globally, the incidence of SSI after CRS ranges from 2.4% to 21.6%. The incidence rate in our study (31.7%) was higher than China (7.1%)(17), Japan (17.8%) (5), the US (5.1%) (18), Spain (24.3%) [19], Israel (22.2%) [20], and Saudi Arabia (30%) [21].

Among the identified risk factors for the development of SSI were age > 60 (P < 0.001), lower educational level (P < 0.001), being a single, divorced or widowed (P < 0.001), unemployment (P < 0.011), having diabetes mellitus (P < 0.01), advanced stage of cancer (P < 0.004), lower concentration of albumin (P < 0.0001) and lower concentration of prealbumin (P< 0.0001). These findings are in agreement with a report from Saudi Arabia, where Hibbert et al. concluded that the preoperative nutritional status of patients and obesity are associated with the development of SSI. In a study conducted in Japan in 2014 [22]. Watanabi et al. reported obesity and Incision contamination as risk factors for the development of SSI.

Pre-operative anemia, history of neoadjuvant chemotherapy and longer surgical duration were identified by Lei et al. in 2020 [23] as risk factors for SSI. Patients with colorectal cancer are at higher risk for malnutrition, developing an imbalance between nutritional and inflammatory status and thus developing infectious complications after surgery [24]. Recently, a growing interest has focused on using prealbumin and albumin to assess the nutritional status of patients before undergoing colectomy. Studies have shown prealbumin to be a useful marker for predicting morbidity and mortality in hemodialysis patients [25], after spinal surgery [26-28], and in patients undergoing radiotherapy for head and neck cancer [29]. Moreover, prealbumin has been shown to be a good predictor of morbidity and mortality in cardiac surgery [30], left ventricular assist device implantation [31] and heart failure [32], after gastrectomy [17], after hip fracture in geriatric [33] and predictor for early recurrence of lung cancer [34].

Based on the results of the current study, prealbumin appears to be a better predictor of SSI after colectomy. Because prealbumin has a short half-life of 2 days, it reflects recent rather than overall nutritional status and can be used to detect early nutritional deficits. We hypothesize that if we can provide potential intervention with nutritional support before surgery, low preoperative prealbumin concentrations may be a modifiable risk factor for postoperative morbidity.Low albumin concentrations (less than 3.5 mg/dl) can be used as a risk factor for the development of SSI, which is similar to the results found in other studies [35]. A retrospective study of 3732 patients with colorectal cancer undergoing surgery at Chang Gung Memorial Hospital by Cheng-Chou et al. showed that patients with lower concentrations of albumin were at higher risk for developing short-and long-term complications after surgery [23]. A prospective study by Jonathan et al. collected data from medical registries in North and Central Denmark (with approximately 2.15 million inhabitants) from 1 January 1997 to 31 December 2011 had shown similar results [36]. Another   prospective, observational study was conducted in three centers from November 2011 to April 2014 by Luigi De et al., Hypoalbuminemia was found to be significantly associated with postoperative infectious complications [37].

In agreement with previous reports about age, our results showed advanced age (more than 60) was significantly associated with the development of SSI [9,10,38]. Our study showed that patients with a history of diabetes mellitus were more likely to development of SSI after colectomy; which is not a surprise as other previous studies had shown similar results [39]; these studies suggest that diabetic patients undergoing colectomy should have their blood glucose tightly controlled before surgery [40,41].  People with advanced stages of cancer were more likely to have SSI. Shaffer et al. [42], and Banaszkiewicz et al. [38] reported similar findings.

Limitations of Study

Despite the fact that this study was conducted in the three major hospitals in Palestine, the sample size is still small. Moreover, not all patients admitted to these hospitals met the inclusion criteria.