Incisional hernia and its impact on health-related quality of life after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a national prospective cohort study

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

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.

Incisional hernias post cytoreductive surgery/peritonectomy and hyperthermic intraperitoneal chemotherapy: a systematic review and meta-analysis

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.

Increased risk for incisional hernia following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

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.

Abdominal Closure With Reinforcing Suture Decreases Incisional Hernia Incidence After CRS/HIPEC

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.

National health disparities in incisional hernia repair outcomes: An analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) 2012-2014

BACKGROUND

Incisional hernias represent an acquired defect from failed healing of an abdominal facial incision and are therefore distinct from primary hernias. While literature regarding incisional hernia incidence, risk factors, and treatment are abundant, no study has examined national health disparities specific to incisional hernia repair. The objective of this study was to analyze national health disparities unique to surgical incisional hernia repair procedures.

METHODS

Patient data queried from the Healthcare Cost and Utilization Project National Inpatient Sample from 2012 to 2014 using International Classification of Diseases 9th revision procedure codes for incisional hernia repair were used to generate univariate and multivariate models including demographics, socioeconomic factors, admission status, and hospital characteristics. Primary outcomes were nonelective admission status, in-hospital mortality, surgical complications, and extended duration of stay.

RESULTS

We estimated that 89,258 incisional hernia repair procedures occurred annually from 2012 to 2014, incurring $6.3 billion in hospital charges. By multivariate analysis, multiple risk factors contribute to significantly increased odds of nonelective repair. These include age over 65, female sex, non-White race, nonprivate insurance, obesity, and increased Charlson comorbidity index. Nonelective incisional hernia repair was strongly correlated with worse outcomes including in-hospital mortality (odds ratio [95% confidence interval] 3.01 [2.51, 3.61]), postoperative complications (odds ratio 1.2 [1.14, 1.25]), and extended duration of stay (odds ratio 2.96 [2.81, 3.12]). After controlling for admission status, other disparities persisted including extended duration of stay for Black individuals (odds ratio 1.21 (1.12, 1.31]).

CONCLUSION

Providers should be aware of these significant health disparities in incisional hernia repair status and outcomes especially for elderly, non-White, nonprivate insurance, and obese/comorbid patients. Management strategies that increase access to elective repair and that prevent incisional hernia should be expanded to address these disparities.

Stoma closure and reinforcement (SCAR): A study protocol for a pilot trial

A quality metric for centers performing rectal cancer surgery is a high percentage of sphincter sparing procedures. These procedures often involve temporary bowel diversion to minimize the complications of an anastomotic leak. The most common strategy is a diverting loop ileostomy which is then closed after completion of adjuvant therapy or the patient recovers from surgery. Loop ileostomy is not without complications and the closure is complicated by a one in three chance of incisional hernia development. Strategies to prevent this problem have been designed using a variety of techniques with and without mesh placement. This proposed pilot study will test the safety and efficacy of a novel stoma closure technique involving permanent mesh in the retro rectus position during ileostomy closure. The study will prospectively follow 20 patients undergoing ileostomy closure using this technique and evaluate for safety of the procedure, quality of life, and feasibility for a larger randomized controlled trial. Patients will be followed post procedurally and evaluated for 30-day complications, as well as followed up with routine cancer surveillance computed tomography every 6 months in which the presence of stoma site incisional hernias will be evaluated. The results of this pilot study will inform the design of a multiple center, blinded randomized controlled trial to evaluate the utility of permanent mesh placement to decrease the incidence of prior stoma site incisional hernias.

National trends in ventral hernia repairs for patients with intra-abdominal metastases

BACKGROUND

Ventral hernias in patients with intra-abdominal metastases may not be addressed owing to other oncologic priorities, but they can affect quality of life and lead to sequelae necessitating an emergency operation. We compared the national trends and perioperative outcomes for elective and nonelective ventral hernia repairs for patients with intra-abdominal metastases.

METHODS

Patients were identified from the National Inpatient Sample (2003-2015). Temporal trends were described using average annual percent change. Perioperative outcomes between elective and nonelective ventral hernia repairs were compared using multivariable regressions.

RESULTS

An estimated 947,112 ventral hernia repairs were performed nationally, including 5,602 (0.6%) in patients with intra-abdominal metastases. Among patients with intra-abdominal metastases, 40.1% had a nonelective ventral hernia repair, mean (standard deviation) age was 64 (12) years, and 65.1% were women. Between 2003 and 2015, the total number of ventral hernia repairs performed nationally did not change (average annual percent change 0.062, P = .84). For patients with intra-abdominal metastases, although there was no change in the number of elective ventral hernia repairs (average annual percent change 0.65, P = .59), the number of nonelective ventral hernia repairs increased significantly (average annual percent change 2.7, P = .025). By multivariable analyses, patients with intra-abdominal metastases who underwent a nonelective repair were more likely to experience complications (odds ratio 1.76, P = .001), nonroutine discharge (odds ratio 1.93, P < .001), and mortality (odds ratio 2.27, P = .035). Nonelective ventral hernia repairs was also associated with a 38.5% (P < .001) longer hospital stay and 24.4% (P < .001) higher charges.

CONCLUSION

The number of nonelective ventral hernia repairs, which is associated with substantial perioperative morbidity, has increased significantly among patients with intra-abdominal metastases. Surgeons should consider a nonemergency operation for select patients to mitigate the burden of nonelective ventral hernia repairs.

Hernia and Cancer: The Points Where the Roads Intersect

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.