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Ray M, Kumar A, Maranna H. Incidence of incisional hernia in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: an observational clinical study from a tertiary oncology referral care center in India. World J Surg Oncol 2024; 22:132. [PMID: 38760663 PMCID: PMC11100235 DOI: 10.1186/s12957-024-03408-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND An incisional hernia (IH) after major abdominal surgery is an unwanted complication particularly following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC). The frequency of IH among patients treated with CRS and HIPEC remains unexpectedly high in various studies. This study aimed to analyze the incidence, determine the factors contributing to the occurrence of IH, and develop methods to reduce the incidence of IH. METHODS We retrospectively analyzed data from a prospectively maintained structured computerized comprehensive database of 360 patients who had undergone CRS and HIPEC after January 2013 and completed two years of follow-up before December 2023. All patients were followed for a minimum period of two years with physical examination and radiological imaging when required and the occurrence of IH was documented. We used SPSS software version 24 to analyze the data using appropriate statistical tests. We set a significance threshold of p < 0.05. RESULTS Within two years of undergoing CRS and HIPEC, 25 patients (6.9%) out of 360 developed IH, indicating an annual incidence rate of 3.5%. The mean duration of hospitalization for the CRS/HIPEC procedure was 8.4 ± 4.13 days. Fifty-two (14.4%) patients experienced early post-operative surgical complications. The development of IH in our series was significantly associated with obesity (76% vs. 8.4%, P = 0.001), the occurrence of early post-operative surgical complications (48% vs. 12%, P = 0.001), mainly category III complications (44% vs. 7.1%), category IV complications (24% vs. 2.9%) according to Clavien-Dindo classification, post neoadjuvant chemotherapy status (72% vs. 87%, P = 0.045) and need for bowel anastomosis (32% vs. 11%, P = 0.002). CONCLUSION The lower incidence of IH following CRS and HIPEC in our patient cohort than in the literature can be attributed to a combination of factors, including the use of meticulous surgical techniques and the use of an abdominal binder postoperatively, particularly in obese patients.
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Affiliation(s)
- Mukurdipi Ray
- Department of Surgical Oncology, Dr BRA IRCH, AIIMS, New Delhi, 110029, India
| | - Amit Kumar
- Department of Surgical Oncology, Dr BRA IRCH, AIIMS, New Delhi, 110029, India.
| | - Haraesh Maranna
- Department of Surgical Oncology, Dr BRA IRCH, AIIMS, New Delhi, 110029, India
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Mac Curtain BM, Qian W, Temperley HC, Simpkin AJ, Ng ZQ. Incisional hernias post cytoreductive surgery/peritonectomy and hyperthermic intraperitoneal chemotherapy: a systematic review and meta-analysis. Hernia 2023; 27:1067-1083. [PMID: 37653188 PMCID: PMC10533625 DOI: 10.1007/s10029-023-02859-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Cytoreductive surgery (CRS) is often combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of peritoneal tumour deposits. Considering CRS, the evidence relating the large incisions, local chemotherapy and abdominal wall trauma to incisional hernias (IH) has not been synthesized. This systematic review and meta-analysis was conducted to examine the proportion of IH present in patients post CRS and the effect HIPEC had on these rates. METHODS PubMed, EMBASE, and Cochrane Central Registry of Trials were searched up to June 2023 to examine studies relating IH and CRS plus or minus HIPEC. The most up to date PRISMA guidelines were followed. Pertinent clinical information was synthesized in tabular form. A meta-analysis reporting the pooled proportions of IH post CRS plus or minus HIPEC, the odds of IH in HIPEC versus non-HIPEC CRS and the difference in follow-up time between groups was conducted. RESULTS Nine studies comprising 1416 patients were included. The pooled proportion of IH post CRS was 12% (95% confidence interval (CI) 8-16%) in HIPEC and 7% (95% CI 4-10%) in non-HIPEC patients and 11% (95% CI 7-14%) overall. Previously reported rates of IH in midline laparotomy range from 10 to 30%. The odds of IH in the HIPEC was 1.9 times higher compared to non-HIPEC cohorts however this was not statistically significant (odds ratio (OR) 1.9, 95% 0.7-5.2; p = 0.21). There was no significant difference in average follow-up times between HIPEC and non-HIPEC cohorts. CONCLUSIONS IH post CRS plus or minus HIPEC were in the expected range for midline laparotomies. IH in patients receiving HIPEC may occur at a greater proportion than in non-HIPEC patients, however, there were too few studies in our meta-analysis to determine this with statistical significance.
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Affiliation(s)
- B M Mac Curtain
- School of Medicine, University of Galway, Galway, Ireland.
- Department of Surgery, St John of God Subiaco Hospital, Subiaco, WA, Australia.
| | - W Qian
- Department of Surgery, St John of God Subiaco Hospital, Subiaco, WA, Australia
| | - H C Temperley
- Department of Surgery, St John of God Subiaco Hospital, Subiaco, WA, Australia
| | - A J Simpkin
- School of Mathematical and Statistical Sciences, University of Galway, Galway, Ireland
| | - Z Q Ng
- Department of General Surgery, Royal Perth Hospital, Perth, WA, Australia
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Ben-Yaacov A, Laks S, Zoabi G, Kirshenboim Z, Goldenshlger A, Hazzan D, Westrich G, Owda Y, Segev L, Nissan A, Goldenshluger M. Increased risk for incisional hernia following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. ANZ J Surg 2023; 93:2192-2196. [PMID: 37431168 DOI: 10.1111/ans.18594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION The incidence of incisional hernias (IH) after midline laparotomy varies from 11% to 20%. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is potentially prone to hernias because a Xiphoid to pubis laparotomy incision performed on patients who have undergone previous abdominal surgeries with the addition of chemotherapy and its related adverse effects. METHODS We performed a retrospective analysis on a prospectively maintained single institution database from March 2015 to July 2020. The inclusion criteria were patients who underwent CRS-HIPEC and had at least 6 months postoperative follow-up with post-operative cross-sectional imaging study. RESULTS Two hundred and one patients were included in the study. All patients underwent CRS-HIPEC with resection of previous scar and umbilectomy. Fifty-four patients were diagnosed with IH (26.9%). The major risk factors for IH in multivariate analysis were higher American society of Anesthesiologists score (ASA) (OR 3.9, P = 0.012), increasing age (OR 1.06, P = 0.004) and increasing BMI (OR 1.1, P = 0.006). Most of the hernia sites were median (n = 43, 79.6%). Eleven (20.4%) patients had lateral hernias due to stoma incisions or drain sites. Most of the median hernias were at the level of the resected umbilicus 58.9% (n = 23). Five (9.3%) of the patients with IH necessitated an urgent surgical repair. CONCLUSION We have demonstrated that more than a quarter of the patients after CRS-HIPEC suffer from IH and up to 10% of them may require surgical intervention. More research is needed to find the appropriate intraoperative interventions to minimize this sequela.
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Affiliation(s)
- Almog Ben-Yaacov
- General and Oncological Surgery Department C, Chaim Sheba Medical Center-Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Shachar Laks
- General and Oncological Surgery Department C, Chaim Sheba Medical Center-Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Ghanem Zoabi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Zehavit Kirshenboim
- Department of Radiology, Chaim Sheba Medical Center-Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | | | - David Hazzan
- General and Oncological Surgery Department C, Chaim Sheba Medical Center-Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
- Minimally Invasive and Robotic Surgery, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Gal Westrich
- General and Oncological Surgery Department C, Chaim Sheba Medical Center-Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Yazan Owda
- General and Oncological Surgery Department C, Chaim Sheba Medical Center-Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Lior Segev
- General and Oncological Surgery Department C, Chaim Sheba Medical Center-Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Aviram Nissan
- General and Oncological Surgery Department C, Chaim Sheba Medical Center-Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Michael Goldenshluger
- General and Oncological Surgery Department C, Chaim Sheba Medical Center-Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
- Minimally Invasive and Robotic Surgery, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Wenzelberg C, Petersson U, Syk I, Ekberg O, Rogmark P. Abdominal Closure With Reinforcing Suture Decreases Incisional Hernia Incidence After CRS/HIPEC. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2023; 2:11188. [PMID: 38312402 PMCID: PMC10831658 DOI: 10.3389/jaws.2023.11188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/24/2023] [Indexed: 02/06/2024]
Abstract
Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) entails several risk factors for incisional hernia (IH). A few reports available showing incidences between 7% and 17%. At our institution fascia closure has been performed in a 4:1 suture to wound length manner, with a continuous 2-0 polydiaxanone suture (PDS-group) or with a 2-0 polypropylene suture preceded by a reinforced tension line (RTL) suture (RTL-group). Our hypothesis was that these patients might benefit from reinforcing the suture line with a lower IH incidence in this group. The aim was to evaluate the 1-year IH-incidence of the two different closures. Methods: Patients eligible for inclusion were treated with CRS/HIPEC between 2004 and 2019. IH was diagnosed by scrutinizing CT-scans 1 year ±3 months after surgery. Additional data was retrieved from clinical records and a prospective CRS/HIPEC-database. Results: Of 193 patients, 129 were included, 82 in the PDS- and 47 in the RTL-group. RTL-patients were 5 years younger, had less blood loss and more frequent postoperative neutropenia. No difference regarding sex, BMI, recent midline incisions, excision of midline scars, peritoneal cancer index score, complications (≥Clavien-Dindo 3b), or chemotherapy. Ten IH (7.8%) were found, 9 (11%) in the PDS- and 1 (2.1%) in the RTL-group (p = 0.071). Conclusion: An IH incidence of 7.8% in patients undergoing CRS/HIPEC is not higher than after laparotomies in general. The IH incidence in the PDS-group was 11% compared to 2% in the RTL-group. Even though significance was not reached, the difference is clinically relevant, suggesting an advantage with RTL suture.
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Affiliation(s)
- Charlotta Wenzelberg
- Department of Surgery, Skane University Hospital Malmö Sweden and Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Ulf Petersson
- Department of Surgery, Skane University Hospital Malmö Sweden and Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Ingvar Syk
- Department of Surgery, Skane University Hospital Malmö Sweden and Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Olle Ekberg
- Department of Radiology Diagnostics, Skane University Hospital Malmö Sweden and Department of Translational Medicine Malmö, Lund University, Lund, Sweden
| | - Peder Rogmark
- Department of Surgery, Skane University Hospital Malmö Sweden and Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
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Tuttle TM, Huang JL, Kizy S, Altman AM, Nalluri H, Marmor S, Gaertner WB, Jensen EH, Hui JYC. Incidence and predictors of incisional hernia after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy .. Int J Hyperthermia 2020; 36:812-816. [PMID: 31451032 DOI: 10.1080/02656736.2019.1641634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background and objectives: The incidence of incisional hernia (IH) after cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is largely unknown. Methods: We conducted a retrospective study to identify patients who underwent CRS/HIPEC from 2001 to 2016. Patients were followed postoperatively for a minimum of two years. The primary outcome was the occurrence of an IH identified either on CT scan or physical examination. Univariate and multivariable logistic regression models were used to test associations with IH. Results: We identified 155 patients who underwent CRS/HIPEC; 26 patients (17%) were diagnosed with an IH at a median time of 245 days (Interquartile range [IQR] 175 - 331 days). On multivariable analysis, older age [50-64 vs. 18-49 years: hazard ratio (HR) = 0.08; 95% confidence interval (CI), 0.01 to 0.64)], female gender (HR = 0.09; 95% CI, 0.01 to 0.75), and increased BMI (>30 vs. <25; HR = 0.03; 95% CI, 0.01 to 0.37) were significant independent predictors of IH. Conclusions: The incidence of IH in this high-risk patient population treated with CRS/HIPEC is similar to that after other abdominal cancer operations. Nevertheless, the occurrence of IH is an important patient outcome, so alternative closure techniques for reducing IH should be studied in this patient population. Synopsis In a single-institutional study, the incidence of incisional hernia was 17% after cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy. Independent risk factors of incisional hernia were older age, female gender and obesity.
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Affiliation(s)
- Todd M Tuttle
- Department of Surgery, University of Minnesota , Minneapolis , MN , USA
| | - Jing Li Huang
- Department of Surgery, University of Minnesota , Minneapolis , MN , USA
| | - Scott Kizy
- Department of Surgery, University of Minnesota , Minneapolis , MN , USA
| | - Ariella M Altman
- Department of Surgery, University of Minnesota , Minneapolis , MN , USA
| | - Harika Nalluri
- Department of Surgery, University of Minnesota , Minneapolis , MN , USA
| | - Schelomo Marmor
- Department of Surgery, University of Minnesota , Minneapolis , MN , USA
| | | | - Eric H Jensen
- Department of Surgery, University of Minnesota , Minneapolis , MN , USA
| | - Jane Y C Hui
- Department of Surgery, University of Minnesota , Minneapolis , MN , USA
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Kulacoglu H, Köckerling F. Hernia and Cancer: The Points Where the Roads Intersect. Front Surg 2019; 6:19. [PMID: 31024927 PMCID: PMC6460227 DOI: 10.3389/fsurg.2019.00019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/18/2019] [Indexed: 12/24/2022] Open
Abstract
Introduction: This review aimed to present common points, intersections, and potential interactions or mutual effects for hernia and cancer. Besides direct relationships, indirect connections, and possible involvements were searched. Materials and Methods: A literature search of PubMed database was performed in July 2018 as well as a search of relevant journals and reference lists. The total number of screened articles was 1,422. Some articles were found in multiple different searches. A last PubMed search was performed during manuscript writing in December 2018 to update the knowledge. Eventually 427 articles with full text were evaluated, and 264 included, in this review. Results: There is no real evidence for a possible common etiology for abdominal wall hernias and any cancer type. The two different diseases had been found to have some common points in the studies on genes, integrins, and biomarkers, however, to date no meaningful relationship has been identified between these points. There is also some, albeit rather conflicting, evidence for inguinal hernia being a possible risk factor for testicular cancer. Neoadjuvant or adjuvant therapeutic modalities like chemotherapy and radiotherapy may cause postoperative herniation with their adverse effects on tissue repair. Certain specific substances like bevacizumab may cause more serious complications and interfere with hernia repair. There are only two articles in PubMed directly related to the topic of "hernia and cancer." In one of these the authors claimed that there was no association between cancer development and hernia repair with mesh. The other article reported two cases of squamous-cell carcinoma developed secondary to longstanding mesh infections. Conclusion: As expected, the relationship between abdominal wall hernias and cancer is weak. Hernia repair with mesh does not cause cancer, there is only one case report on cancer development following a longstanding prosthetic material infections. However, there are some intersection points between these two disease groups which are worthy of research in the future.
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Affiliation(s)
| | - Ferdinand Köckerling
- Department of Surgery, Centre for Minimally Invasive Surgery, Vivantes Klinikum, Berlin, Germany
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Tzivanakis A, Dayal SP, Arnold SJ, Mohamed F, Cecil TD, Venkatasubramaniam AK, Moran BJ. Biological mesh is a safe and effective method of abdominal wall reconstruction in cytoreductive surgery for peritoneal malignancy. BJS Open 2018; 2:464-469. [PMID: 30511047 PMCID: PMC6254008 DOI: 10.1002/bjs5.93] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/26/2018] [Indexed: 11/11/2022] Open
Abstract
Background Patients with peritoneal malignancy often have multiple laparotomies before referral for cytoreductive surgery (CRS). Some have substantial abdominal wall herniation and tumour infiltration of abdominal incisions. CRS involves complete macroscopic tumour removal and hyperthermic intraperitoneal chemotherapy (HIPEC). Abdominal wall reconstruction is problematic in these patients. The aim of this study was to establish immediate and long-term outcomes of abdominal wall reconstruction with biological mesh in a single centre. Methods A dedicated peritoneal malignancy database was searched for all patients who had biological mesh abdominal wall reconstruction between 2004 and 2015. Short- and long-term outcomes were reviewed. All patients had annual abdominal CT as routine peritoneal malignancy follow-up. Results Some 33 patients (22 women) with a mean age of 53·4 (range 19-82) years underwent abdominal wall reconstruction with biological mesh. The majority (23) had CRS for pseudomyxoma (19 low grade), six for colorectal peritoneal metastasis and four for appendiceal adenocarcinoma; 18 had undergone CRS and HIPEC previously. Twenty-five of the 33 patients had abdominal wall tumour involvement and eight had concurrent hernias. The mean duration of surgery was 486 (range 120-795) min and the mean mesh size used was 345 (50-654) cm2. Ten patients developed wound infections and four had a seroma. Two developed early enterocutaneous fistulas. Mean follow-up was 48 months. Five patients developed an incisional hernia. Four died from progressive malignancy. A further 15 patients had disease recurrence, but only one had isolated abdominal wall recurrence. Conclusion Biological mesh was safe and effective for abdominal wall reconstruction in peritoneal malignancy. Postoperative wound infections were frequent but nevertheless incisional hernia rates were low with no instances of mesh-related bowel erosion or fistulation.
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Affiliation(s)
- A Tzivanakis
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - S P Dayal
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - S J Arnold
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - F Mohamed
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - T D Cecil
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - A K Venkatasubramaniam
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
| | - B J Moran
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke RG24 9NN UK
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