Incidence and risk factors of poor wound healing following emergency surgery for intestinal tuberculosis

Abstract

BACKGROUND

Intestinal tuberculosis accounts for 11%-16% of extrapulmonary tuberculosis cases and frequently mimics Crohn’s disease or intestinal neoplasms due to nonspecific clinical presentations. When complicated by obstruction, perforation, or hemorrhage, emergency surgery becomes necessary. These patients often present with malnutrition, anemia, and immune dysfunction, substantially increasing the risk of poor postoperative wound healing a complication that prolongs hospitalization and predisposes patients to incisional hernia. However, systematic investigation of risk factors for poor wound healing following emergency intestinal tuberculosis surgery remains limited, and identifying independent predictors is clinically important for optimizing perioperative management and improving outcomes.

AIM

To investigate the incidence of wound healing and risk factors associated with wound healing after emergency surgery of intestinal tuberculosis, and to provide scientific evidence for perioperative clinical management.

METHODS

A retrospective review was performed on clinical data of 115 cases of patients with intestinal tuberculosis who underwent emergency surgery between February 2018 and January 2024. Data was collected on patient demographics, preoperative laboratory parameters, imaging findings, and surgical procedures. The primary endpoint was adverse wound healing findings occurring within 30 postoperative days, that is surgical site infection, wound dehiscence and delayed wound healing. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for delayed wound healing.

RESULTS

Of 115 patients, 22 (19.1%) developed poor healing of the wound. Of the 22 cases with complications, surgical site infection was responsible for 14 cases (63.6%), wound dehiscence for 5 cases (22.7%) and delayed healing in 3 cases (13.6%). With multivariate logistic regression analysis, we found that age ≥ 60 years [odds ratio (OR) = 3.12, 95% confidence interval (CI): 1.15-8.47, P = 0.025], body mass index < 18.5 kg/m² (OR = 4.23, 95%CI: 1.54-11.61, P = 0.005), history of diabetes mellitus (OR = 3.45, 95%CI: 1.16-10.27, P = 0.026), albumin < 30 g/L (OR = 4.89, 95%CI: 1.72-13.91, P = 0.003) and C-reactive protein > 50 mg/L (OR = 3.78, 95%CI: 1.35-10.58, P = 0.011) were independent risk factors for poor wound healing status in the study cohort respectively.

CONCLUSION

The patients undergoing emergency surgery for intestinal tuberculosis had a significantly high incidence of unsatisfactory wound healing (19.1%). Age ≥ 60, body mass index < 18.5 kg/m², history of diabetes mellitus, albumin < 30 g/L and C-reactive protein > 50 mg/L are independent risk factors. We propose that clinicians systematically screen for these five factors before the operation and implemented targeted interventions - including nutritional optimization, glycemic control, and anti-inflammatory therapy - to patient’s with impaired healing of wounds improve outcomes.

Key Words: Emergency surgery; Intestinal tuberculosis; Malnutrition; Perioperative management; Poor wound healing; Risk factors; Inflammatory response1

Core Tip: Intestinal tuberculosis is often complicated by obstruction, perforation, or hemorrhage; thus requiring surgical intervention under emergency settings, but little systematic investigation of risk factors for poor wound healing in this subset exists. In our study we observed the incidence of poor wound healing (19.1%) after emergency intestinal tuberculosis surgery, 63.6% of them were diagnosed as surgical site infection. Five independent risk factors were determined by multivariate logistic regression analysis: Age ≥ 60 years, body mass index < 18.5 kg/m², diabetes mellitus history, serum albumin concentration < 30 g/L and C-reactive protein > 50 mg/L. Therefore, clinicians should screen these parameters in preoperative evaluation and take targeted interventions (nutritional optimization, glycemic control and anti-inflammatory therapy) to reduce complications and achieve better outcomes.

INTRODUCTION

Intestinal tuberculosis is a chronic infectious disease caused by the Mycobacterium tuberculosis affecting the intestinal tract, which represents the most common form of abdominal tuberculosis. It is relatively more common in developing countries (11%-16% of extrapulmonary tuberculosis)[1]. Common manifestations are often vague with abdominal pain, distension, alternating diarrhea and constipation, etc., causing confusion between Crohn’s disease, intestinal tumors and other digestive diseases[2]; therefore it is not uncommon for the true diagnosis to be missed which leads to treatment delay. Acute abdomen with severe gastrointestinal complications such as intestinal obstruction, perforation or massive gastrointestinal hemorrhage due to intestinal tuberculosis require surgical intervention urgently for the preservation of patient lives[3].

Intestinal tuberculosis, which presents as an emergency surgical condition. Emergency surgical patients are often not in a good general condition, as opposed to those undergoing elective procedures (e.g., malnutrition, anemia, hypoalbuminemia), and have serious inflammatory response and immune defects[4]. Primary intestinal tuberculosis lesions can occur in segments including the ileocecal and ascending colon. Surgical options consist of intestinal resection with anastomosis, adhesiolysis and stoma placement leading to significant surgical trauma. Such factors are not only increasing operative difficulty but also have a great impact on postoperative recovery especially wound healing[5]. Mediocre healing of wounds following gastrointestinal surgery is a frequent complication which extends hospitalization, raises health costs and may result in long-term complications as incisional hernia and chronic pain thereby greatly reducing quality of life[5].

Studies on postoperative wound healing in intestinal tuberculosis as of now is limited, with a majority studying elective surgical patients. There is a glaring dearth of systematic analyses on risk factors for poor wound healing[6] post-emergency surgical intervention in cases of intestinal tuberculosis. Several variables have been implicated as factors influencing postoperative wound healing in gastrointestinal surgical patients, including age, nutritional status and comorbidities, as well as preoperative inflammatory prognostic markers. However, both specific influencing intensity and interrelationships of these factors in this special population undergoing time-sensitive intestinal tuberculosis surgery remain unclear[7]. The determination of independent risk factors associated with compromised wound healing is of great clinical value for individualizing perioperative management and optimizing patient outcomes[8].

Consequently, this study was performed to retrospectively and systematically analyze the incidence of poor wound healing following emergency intestinal tuberculosis surgery and ascertain associated risk factors in order to provide gastrointestinal surgeons with reliable basis for optimizing perioperative management so as to reduce the incidence of poor wound healing and improve prognosis. We hypothesized that the distinctive pathophysiological substrate of emergency intestinal tuberculosis surgery characterized by malnutrition, systemic inflammatory burden, and immunological compromise - would lead to a significantly increased occurrence of poor wound healing compared with elective gastrointestinal surgery, and that a unique set of identifiable preoperative clinical and laboratory variables would independently predict this outcome. The study addressed an important clinical question: Which preoperative patient and laboratory characteristics independently predict poor wound healing within 30 days of surgery in patients that underwent emergency intestinal tuberculosis surgery?

MATERIALS AND METHODS

Study design

This retrospective study reviewed the clinical data of patients who had undergone an emergency surgery for intestinal tuberculosis in our institution from February 2018 to January 2024 and studied the incidence and its associated risk factors regarding poor wound healing.

Study population

Inclusion criteria: (1) Age ≥ 18 years; (2) Diagnosis of intestinal tuberculosis made by intra operative exploration, histopathological evidence and/or acid-fast bacilli detection; (3) Emergency intestinal surgery was performed within 72 hours after the onset of symptoms in patients with acute abdomen, defined as those having one of the following gastrointestinal symptoms that prompted an urgent surgical intervention: Persistent abdominal pain combined with peritoneal irritation signs (abdominal muscle tension, positive rebound tenderness); intestinal obstruction (abdominal distension including flatus cessation and defecation > 12 hours) confirmed by imaging; intestinal perforation and diffuse peritonitis (generalized abdominal tenderness, abdominal rigidity; fever > 38.5 °C); or gastrointestinal bleeding manifestations (progressive hemoglobin decline > 20 g/L/12 hours along with hemodynamic instability). Three reasons led to picking the 72-hour time frame. First, intestinal tuberculosis often has an insidious presentation and is misdiagnosed early during disease evolution as Crohn’s disease or other gastrointestinal pathology, so patients do not necessarily seek care at a surgical center immediately after symptoms start; limiting the timeline would have excluded a clinically meaningful proportion of patients that still required urgent surgical intervention. Second, this threshold is in line with the definition of emergency surgery used in earlier studies on emergency abdominal surgery in resource-limited settings. Third, independent risk factors were consistent with a sensitivity analysis restricted to patients who underwent surgery within 24 hours of presentation, supporting robustness across window definitions; and (4) Comprehensive clinical data with sufficient follow-up records.

Exclusion criteria: (1) Simultaneous active tuberculosis at other sites; (2) Severe immunodeficiency disorders; (3) Malignant tumors; and (4) Pregnancy.

Using these parameters, a total of 115 patients who underwent emergency surgical intervention for intestinal tuberculosis were finally included. All patients underwent intestinal surgery, which included intestinal resection with anastomosis (n = 78, 67.8%), adhesiolysis (n = 24, 20.9%), and stoma creation (n = 13, 11.3%).

Data collection

Data collection Patients data were extracted using Hospital Information System and electronic medical record system, including: (1) Demographics: Age, sex, body mass index (BMI), educational level, marital status, smoking history, alcohol consumption history; previous abdominal surgery at diagnosis; diabetes mellitus history; (2) Preoperative lab parameters: Hemoglobin, albumin, total protein, blood glucose, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), lymphocyte count, and neutrophil-to-lymphocyte ratio (NLR) preoperative laboratory values were analyzed based on blood drawn at the time of presentation to the Department of Emergency, prior to initiation of fluid resuscitation or blood transfusion, or other active treatment. This common approach was implemented to minimize the confounding influences from acute resuscitative management on biomarker concentrations and ensure laboratory values reflective of the patient’s true baseline physiological state. For this analysis, we used consistently the admission values in cases when repeat laboratory tests were performed closer to surgery; (3) Imaging data: Abdominal computed tomography or magnetic resonance imaging; ascites volume; intestinal obstruction severity; intestinal wall thickening; and (4) Surgical data: Type of surgery, operative time, intraoperative blood loss, and extent of intestinal lesions.

Outcome measures

The primary endpoint was poor wound healing, which had occurred if any of the following had happened within 30 postoperative days: (1) Surgical site infection: Erythema, pain, and purulent discharge at the incision site accompanied by either body temperature ≥ 38 °C or white blood cell count ≥ 12 × 10⁹/L in accordance with Centers for Disease Control and Prevention surgical site infection diagnostic criteria; (2) Wound dehiscence: Separation of abdominal wall layers partial or complete; and (3) Delayed wound healing: Lack of primary healing on postoperative day 14 (defined by well-approximated wound edges without bleeding or exudate, with secure healing following suture removal).

Secondary outcome measures included: (1) Time to complete resolution of wound healing (ascertained for up to 6 postoperative weeks); (2) Postoperative incisional pain assessed by visual analog scale (0-10 scale, where 0 = no pain and 10 = severe pain evaluated on postoperative days 3, days 7, and days 14); (3) Formed incisional scar at 3 months after surgery; (4) Compliance with antituberculosis treatment (for up to 6 postoperative months); and (5) Intra-abdominal postoperative infection rate (within 30 postoperative days).

Statistical analysis

SPSS 26.0 statistical software was used to perform data analysis. The normality of continuous variables was assessed using the Shapiro-Wilk test. Normally distributed data was reported as mean ± SD and compared using independent samples t-test. Normally distributed data are reported as mean (SD) and compared using independent t-test. Categorical variables are reported as frequencies and percentages, and comparisons were made using the χ² test or Fisher’s exact test. Univariate analysis was performed to assess variables with poor wound healing. Variables having P < 0.1 were then subjected to forward stepwise multivariate logistic regression analysis and independent risk factors affecting poor wound healing were identified. P < 0.05 was considered statistically significant.

Ethical considerations

This study was approved by our institutional medical ethics committee, and conformed to the Declaration of Helsinki and relevant ethical standards. As this was a retrospective study without patient privacy disclosure, informed consent was waived with the approval of the ethics committee. Nonetheless, to maintain participant confidentiality, all patient data have been strictly anonymized. The whole research process followed the medical research ethical principles in terms of legality and standardization of data.

RESULTS

Patient baseline characteristics

Compared with good wound healing, poor wound healing was significantly associated with older patients (P = 0.017) and lower BMI (P < 0.001) at baseline characteristics comparison between both the groups. There were a greater percentage of patients with junior high school education or below (P = 0.044) and a significantly higher percentage of patients with diabetes mellitus history (P = 0.005) in the poor wound healing group. There was no statistically significant difference between the groups in terms of sex, marital status, or ethnicity (P > 0.05) (Table 1).

Table 1 Comparison of basic characteristics between two groups, n (%).

Item	Poor wound healing group (n = 22)	Good wound healing group (n = 93)	Test statistic	P value
Age (years)	52.1 ± 14.8	43.6 ± 15.0	t = 2.43	0.017
Gender			χ2 = 0.89	0.345
Male	15 (68.2)	53 (57.0)
Female	7 (31.8)	40 (43.0)
BMI (kg/m2)	18.9 ± 2.7	21.4 ± 3.1	t = 3.56	< 0.001
Education level			χ2 = 6.23	0.044
Junior high school or below	16 (72.7)	48 (51.6)
High school or above	6 (27.3)	45 (48.4)
Marital status			χ2 = 0.32	0.571
Married	18 (81.8)	79 (84.9)
Unmarried/divorced	4 (18.2)	14 (15.1)
Smoking history	12 (54.5)	31 (33.3)	χ2 = 3.84	0.050
Alcohol consumption history	8 (36.4)	25 (26.9)	χ2 = 0.89	0.345
Previous surgical history	9 (40.9)	21 (22.6)	χ2 = 3.51	0.061
Diabetes history	8 (36.4)	12 (12.9)	χ2 = 7.89	0.005

BMI: Body mass index.

Comparison of preoperative laboratory indices

Evaluation of the preoperative laboratory parameters showed that hemoglobin, albumin and total protein levels were significantly lower in poor wound healing patients compared to good wound healing ones (P < 0.05), while CRP, ESR and NLR were higher in poorly healed wounds (P < 0.05) (Table 2).

Table 2 Comparison of preoperative laboratory indicators between two groups, mean ± SD.

Item	Poor wound healing group (n = 22)	Good wound healing group (n = 93)	Test statistic	P value
Hemoglobin (g/L)	89.6 ± 12.4	106.8 ± 15.3	t = 4.87	< 0.001
Albumin (g/L)	28.3 ± 4.2	34.7 ± 5.8	t = 4.91	< 0.001
Total protein (g/L)	58.2 ± 8.3	66.4 ± 9.1	t = 3.91	< 0.001
Blood glucose (mmol/L)	7.8 ± 2.9	6.2 ± 1.8	t = 2.87	0.005
C-reactive protein (mg/L)	89.7 ± 31.2	52.4 ± 24.6	t = 5.63	< 0.001
ESR (mm/hour)	78.5 ± 26.3	58.9 ± 22.1	t = 3.42	0.001
Lymphocyte count (× 109/L)	0.96 ± 0.32	1.28 ± 0.41	t = 3.41	0.001
Neutrophil-to-lymphocyte ratio	8.7 ± 3.2	5.4 ± 2.1	t = 5.12	< 0.001

ESR: Erythrocyte sedimentation rate.

Comparison of imaging characteristics

Patients presented with larger ascites volume and more severe intestinal obstruction in the poor wound healing group according to their imaging examination results. Since ascites volume and intestinal obstruction severity are ordinal categorical variables, the Mann-Whitney U test was performed for statistical analysis (Table 3).

Table 3 Comparison of imaging characteristics between two groups, n (%).

Item	Poor wound healing group (n = 22)	Good wound healing group (n = 93)	Test statistic	P value
Ascites volume			Z = -2.89	0.004
Small amount (< 500 mL)	5 (22.7)	46 (49.5)
Moderate amount (500-1000 mL)	8 (36.4)	35 (37.6)
Large amount (> 1000 mL)	9 (40.9)	12 (12.9)
Degree of intestinal obstruction			Z = -2.34	0.019
No obstruction	3 (13.6)	28 (30.1)
Incomplete obstruction	12 (54.5)	52 (55.9)
Complete obstruction	7 (31.8)	13 (14.0)

Types of scarless wound healing

Failed wound healing occurred in 22 patients (Table 4, Figure 1): Surgical site infection (SSI) in 14 cases, wound dehiscence in five cases, and delayed healing occurred in three cases.

Figure 1 Distribution of poor wound healing types after emergency surgery in patients with intestinal tuberculosis. Among the 22 patients who developed poor wound healing, surgical site infection was the predominant complication (63.6%), followed by wound dehiscence (22.7%) and delayed wound healing (13.6%).

Table 4 Distribution of postoperative poor wound healing types.

Classification method	Number of cases (n)	Proportion (%)
By type of healing complication
Wound infection	14 cases	63.6
Wound dehiscence	5 cases	22.7
Delayed wound healing	3 cases	13.6

Univariate logistic regression analysis

Potential factors associated with poor wound healing: According to univariate logistic regression analysis of a total of 30 potential factors affecting poor wound healing, we found that age ≥ 60 years, BMI < 18.5 kg/m², educational level of junior high or below, smoking history, previous abdominal surgery history (yes vs no), diabetes mellitus history (yes vs no), hemoglobin levels < 90 g/L, albumin levels < 30 g/L, total protein levels < 60 g/L, blood glucose > 7.0 mmol/L (according to clinical guidelines the reasonable cutoff for severe infection is 50 mg/L) CRP ≥ 50 mg/L (≥ 50 mg/L) and ESR > 70 mm/hour, lymphocyte count < 1.0 × 10⁹/L, NLR > 7.0, large-volume ascites (> 1000 mL), and complete intestinal obstruction were associated with poor wound healing at P < 0.10 and were therefore included in the multivariate logistic regression analysis (Table 5).

Table 5 Univariate logistic regression analysis of factors affecting postoperative poor wound healing.

Variable	β	SE	Wald χ2	P value	OR	95%CI
Age ≥ 60 years	1.186	0.485	5.982	0.014	3.27	1.27-8.42
BMI < 18.5 kg/m2	1.524	0.496	9.451	0.002	4.59	1.73-12.17
Education (junior high school or below)	0.892	0.509	3.066	0.080	2.44	0.90-6.61
Smoking history	0.873	0.457	3.651	0.056	2.39	0.98-5.85
Previous surgical history	0.821	0.482	2.906	0.088	2.27	0.88-5.85
Diabetes history	1.321	0.515	6.588	0.010	3.75	1.37-10.26
Hemoglobin < 90 g/L	1.634	0.468	12.186	< 0.001	5.12	2.05-12.79
Albumin < 30 g/L	1.723	0.479	12.952	< 0.001	5.60	2.19-14.32
Total protein < 60 g/L	1.298	0.465	7.780	0.005	3.66	1.47-9.12
Blood glucose > 7.0 mmol/L	0.956	0.458	4.354	0.037	2.60	1.06-6.38
CRP > 50 mg/L	1.687	0.451	14.012	< 0.001	5.41	2.24-13.06
ESR > 70 mm/hour	1.201	0.462	6.750	0.009	3.32	1.34-8.22
Lymphocyte count < 1.0 × 109/L	1.156	0.471	6.017	0.014	3.17	1.26-7.98
Neutrophil-to-lymphocyte ratio > 7.0	1.542	0.468	10.844	0.001	4.67	1.87-11.66
Large volume ascites (> 1000 mL)	1.424	0.525	7.348	0.007	4.15	1.48-11.62
Complete intestinal obstruction	1.089	0.566	3.702	0.054	2.97	0.98-9.01

SE: Standard error; OR: Odds ratio; CI: Confidence interval; BMI: Body mass index; CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate.

Multivariate logistic regression analysis

Multivariate logistic regression analysis was performed for variables with P < 0.10 in univariate analysis. The results indicated that Geriatric age (≥ 60 years) (OR = 3.12, 95%CI: 1.15-8.47, P = 0.025), BMI < 18.5 kg/m² (OR = 4.23, 95%CI: 1.54-11.61, P = 0.005), diabetes mellitus history (OR = 3.45, 95%CI: 1.16-10.27, P = 0.026), albumin < 30 g/L (OR = 4.89, 95%CI: 1.72-13.91) gun room and CRP > 50 mg/L (OR = 3.78, 95%CI: 1.35-10.58, P = 0.011) were independent risk factors for poor wound healing after emergency surgery for intestinal tuberculosis (Table 6 and Figure 2).

Figure 2 Independent risk factors for poor wound healing after emergency surgery in patients with intestinal tuberculosis. Forest plot of multivariate logistic regression analysis identifying five independent risk factors for poor wound healing. Albumin < 30 g/L [odds ratio (OR) = 4.89, 95% confidence interval (CI): 1.72-13.91] and body mass index < 18.5 kg/m² (OR = 4.23, 95%CI: 1.54-11.61) conferred the greatest risk, followed by C-reactive protein > 50 mg/L (OR = 3.78, 95%CI: 1.35-10.58), diabetes mellitus (OR = 3.45, 95%CI: 1.16-10.27), and age ≥ 60 years (OR = 3.12, 95%CI: 1.15-8.47). All factors reached statistical significance (P < 0.05). Diamonds represent point estimates; horizontal lines indicate 95%CIs. BMI: Body mass index; CRP: C-reactive protein; CI: Confidence interval; OR: Odds ratio.

Table 6 Multivariate logistic regression analysis of independent risk factors for postoperative poor wound healing.

Variable	β	SE	Wald χ2	P value	OR	95%CI
Age ≥ 60 years	1.138	0.510	4.978	0.025	3.12	1.15-8.47
BMI < 18.5 kg/m2	1.442	0.517	7.774	0.005	4.23	1.54-11.61
Diabetes history	1.239	0.557	4.954	0.026	3.45	1.16-10.27
Albumin < 30 g/L	1.587	0.535	8.794	0.003	4.89	1.72-13.91
CRP > 50 mg/L	1.330	0.527	6.378	0.011	3.78	1.35-10.58

Hosmer-Lemeshow test for the model: χ² = 6.73, P = 0.566; model discriminatory ability: Area under the receiver operating characteristic curve = 0.841 (95% confidence interval: 0.762-0.920); multicollinearity test: Variance inflation factor values for all variables < 2.5, indicating no significant multicollinearity problem; model fit test: -2 Log-likelihood = 89.34, model χ² = 45.67 (P < 0.001). OR: Odds ratio; CI: Confidence interval; BMI: Body mass index; CRP: C-reactive protein.

Secondary outcome results

Patients in the poor wound healing group required a significantly longer time to achieve complete wound healing than those in the good wound healing group (P < 0.001). Visual analog scale pain scores were significantly higher in the poor wound healing group on operative days 3, days 7 and days 14 day (P < 0.05). The formation of incisional scars at 3 months postoperatively was significantly different between groups (P = 0.002). The poor wound healing group had significantly lower adherence to anti-tuberculosis therapy than the good wound healing group (P = 0.018). Postoperative intra-abdominal infection rate was in the poor wound healing group (P = 0.001) significantly higher (Table 7).

Table 7 Comparison of secondary observation indicators between two groups, n (%)/mean ± SD.

Item	Poor wound healing group (n = 22)	Good wound healing group (n = 93)	Test statistic	P value
Time to complete wound healing (days)	28.6 ± 8.4	16.2 ± 4.3	t = 7.89	< 0.001
VAS pain scores
Postoperative day 3	6.2 ± 1.8	4.5 ± 1.6	t = 4.23	< 0.001
Postoperative day 7	4.9 ± 1.5	3.1 ± 1.2	t = 5.67	< 0.001
Postoperative day 14	3.4 ± 1.3	1.8 ± 0.9	t = 6.12	< 0.001
Wound scarring			χ2 =12.43	0.002
Mild	4 (18.2)	52 (55.9)
Moderate	12 (54.5)	35 (37.6)
Obvious	6 (27.3)	6 (6.5)
Anti-tuberculosis treatment compliance			χ2 = 5.64	0.018
Good (≥ 80%)	12 (54.5)	72 (77.4)
Fair (60%-79%)	7 (31.8)	16 (17.2)
Poor (< 60%)	3 (13.6)	5 (5.4)
Postoperative intra-abdominal infection rate	8 (36.4)	9 (9.7)	χ2 = 11.67	0.001

VAS: Visual analog scale.

DISCUSSION

Using retrospective analysis of clinical evidence collected from a review of 115 patients undergoing emergency intestinal tuberculosis surgery, this study determined the incidence to be as high as 19.1%, which is higher than that reported in patients undergoing elective gastrointestinal surgery. Age ≥ 60 years, BMI < 18.5 kg/m², history of diabetes mellitus, albumin < 30 g/L and CRP > 50 mg/L were identified as independent risk factors for poor wound healing after emergency surgery for intestinal tuberculosis. These findings have important clinical implications for perioperative risk stratification and individualized management in this high-risk population.

This study revealed that the wound healing outcomes of emergency surgery for intestinal tuberculosis were poor, with an incidence of 19.1%, much higher than 5%-8% reported in patients undergoing elective abdominal surgery[9]. Such a gap is mainly caused by the inherent nature of emergency intestinal surgery: Critically ill patients with high burden of intestinal infection, low preoperative preparation time, and poor general condition accompanied by severe inflammatory response and malnutrition[10]. Of the types of poor wound healing, surgical site infection accounted for 63.6%, thus, proving to be the most common complication. This observation is closely affiliated with chronic intestinal infection status, immunocompromise, and intestinal dysbiosis in patients with intestinal tuberculosis[11]. Intestinal surgery, in particular the resection of the intestine anastomosis itself, carries a higher risk for postoperative infections because bacterial contamination by the intestinal lumen presents with increased wound infection risks[8]. The incidence rates of wound dehiscence and delayed healing were 22.7% and 13.6%, both related to poor nutritional status and impaired tissue repair capacity[12].

Age ≥ 60 years was identified as an independent risk factor for poor wound healing in this study (OR = 3.12), and the results are in accordance with the previous studies[13]. As patients aged, metabolic function declined and protein synthesis capacity decreased meaning disturbances to collagen metabolism and vascular function with insufficient perfusion of tissues. At the same time, immune senescence, leads to reduced infection resistance and impairs wound healing processes as a whole[14]. In addition, elderly patients often present with several comorbidities which would only increase the risk of postoperative complication.

In this study, being underweight (BMI < 18.5 kg/m²), a categorical measure of malnutritional status had the highest association as an independent risk factor (OR = 4.23). All stages of wound healing including the inflammatory, proliferative and remodeling phase are directly affected by malnutrition[15]. A lack of protein decreases collagen synthesis, while a deficiency in vitamins and trace elements impairs the function of enzymatic systems, which will delay the course of wound healing. Patients with intestinal tuberculosis suffer from prominent malnutrition owing to characteristics of chronic wasting disease, as well as intestinal absorption dysfunction and preoperative fasting-related effects on acute abdomen episodes[16]. Postoperative loss of absorptive surface area for patients undergoing intestinal resection compounds malnutrition, creating a vicious cycle.

Albumin < 30 g/L is also an important independent risk factor (OR = 4.89). Hypoalbuminemia not only represents poor nutrition status but also directly impact formation and resolution of tissue edema, impairs wound microcirculation and leads to a decrease in tensile strength of tissues[17]. A study has shown that preoperative albumin levels were inversely related to the postoperative rate of wound complication and an essential indicator for prognosis[18].

In this study, history of diabetes mellitus was validated as an independent risk factor (OR = 3.45). There are a few ways how the wound healing process is impaired in diabetic patients: Neutrophil function disturbed in hyperglycemic conditions, vascular pathologic changes lead to insufficient tissue perfusion and advanced glycation end-products affect collagen cross-linking[19]. Diabetes mellitus, in particular, leads to an increased infection susceptibility that aggravates the wound healing process.

The diagnosis of CRP > 50 mg/L was an independent risk factor (OR = 3.78), indicating severe inflammatory response status within patients. Chronic inflammatory responses, induced by a spectrum of damage-associated molecular patterns, inhibit the host’s nutritional resources and normal wound healing via the release of inflammatory mediators and proteases[20]. At the same time, a high intensity of inflammatory responses may correlate with predominant burden of intestinal infection that is associated with increased risk for postoperative wound and intra-abdominal infections. Chronic inflammation caused by Mycobacterium tuberculosis infection may be further aggravated by acute intestinal inflammatory episodes during acute abdomen, resulting in complex immune dysregulation and impaired wound repair.

For those with high-risk, preoperative assessment and optimization should entail aggressive correction of malnutrition using parenteral nutrition support as appropriate, as well as strict glycemic control and anti-inflammatory therapy to modulate excessive inflammatory response[21]. The importance of aseptic technique, resection of the affected bowel loops and appropriate selection between operative approaches (primary anastomosis or stoma creation) or prophylactic antibiotics are crucial intra-intraoperatively[22]. Close monitoring of the wound, increased nutrition support, and early detection of postoperative complications is crucial postoperatively for the improvement of intestinal functional recovery and also postoperative complications.

This study has several limitations. First, as a single-center retrospective study, relatively small sample size might lead to selection bias. Second, some preoperative nutrition indexes (prealbumin and transferrin) were not analysed in the study, which may have missed important predictive factors[23]. Third, the relatively brief duration of follow-up prevented evaluation of long-term outcomes such as the occurrence of incisional hernia. Finally surgical technical factors (e.g., incision type, suture technique and whether stoma creation was performed) which may affect wound healing[24] were not analyzed in the present study. There also exists possibility of incidence of postoperative wound healing/endoscopic dehiscence being influenced by the disease extent, segments involved and intestinal perforation which might have been missed in other studies including present study and requires further investigation. The sample size of the current study might also have been insufficient to demonstrate statistically significant interaction between the identified risk factors, with respect to the modifiable risk factors involved being relatively few (n = 22) and as per previously described interactions. More future studies with larger cohorts ought to formally test biologically plausible interactions for example, the joint effect of hypoalbuminemia and hyperglycemia that could improve predictive model performance.

Future studies should focus on using multicenter prospective cohort studies with larger sample sizes[25], developing risk prediction models for inadequate wound healing after intestinal tuberculosis surgery[26], utilizing novel biomarkers such as procalcitonin and interleukin-6 to predict the healing process, exploring various interventions like nutrition support therapy, glycemic control in the perioperative period, and prophylactic stoma formation to improve poor wound healing outcomes[27] as well as apply intestinal microecological reconstruction technology to promote postoperative recovery.

CONCLUSION

Finally, our study showed the high risk of poor wound healing and independent risk for postoperative poor wound healing after emergency intestinal tuberculosis surgery to help gastrointestinal surgeons develop personalized associated perioperative management strategies. The incidence of poor wound healing could be minimized, and outcomes optimized for patients undergoing emergency intestinal tuberculosis surgery by the identification of high-risk patients through mean laboratory values from preoperative imaging as well as actual postoperative hematological indices (including signification indicators such as CRP), focused on nutritional optimization, perioperative glycemic control with early perforation anti-inflammatory therapy approaches combined with standardized surgical modality and antibiotic methods.