Preoperative botulinum toxin A (BTA) injection versus component separation techniques (CST) in complex abdominal wall reconstruction (AWR): A propensity-scored matched study

BACKGROUND

Complete fascial closure significantly reduces recurrence rates and wound complications in abdominal wall reconstruction. While component separation techniques have clear effectiveness in closing large abdominal wall defects, preoperative botulinum toxin A has emerged as an adjunct to aid in fascial closure. Few data exist comparing preoperative botulinum toxin A to component separation techniques, and the aim was to do so in a matched study.

METHODS

A prospective, single-center, hernia-specific database was queried, and a 3:1 propensity-matched study of patients undergoing open abdominal wall reconstruction from 2016 to 2021 with botulinum toxin A versus component separation techniques was performed based on body mass index, defect width, hernia volume, and Centers for Disease Control and Prevention wound classification. Demographics, operative characteristics, and outcomes were evaluated.

RESULTS

Matched patients included 105 component separation techniques and 35 botulinum toxin A. There was no difference in tobacco use, diabetes, or body mass index (all P > .5). Hernia defects and volume were large for both the component separation techniques and botulinum toxin A groups (mean size: component separation techniques 286.2 ± 179.9 cm² vs botulinum toxin A 289.7 ± 162.4 cm²; P = .73) (mean volume: 1,498.3 + 2,043.4 cm³ vs 2,914.7 + 6,539.4 cm³; P = .35). Centers for Disease Control and Prevention wound classifications were equivalent (CDC3 and 4%-39.1% vs 40.0%; P = .97). Component separation techniques were more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%; P = .01). The botulinum toxin A group had fewer surgical site occurrences (32.4% vs 11.4%; P = .02) and surgical site infections (11.7% vs 0%; P = .04). In multivariate analysis, botulinum toxin A was associated with lower rates of surgical site occurrences (odds ratio = 5.3; 95% confidence interval [1.4-34.4]). There was no difference in fascial closure (90.5% vs 100%; P = .11) or recurrence (12.4% vs 2.9%; P = .10) with follow-up (22.8 + 29.7 vs 9.8 + 12.7 months; P = .13).

CONCLUSION

In a matched study comparing patients with botulinum toxin A versus component separation techniques, there was no difference in fascial closure rates or in hernia recurrence between the 2 groups. Preoperative botulinum toxin A can achieve similar outcomes as component separation techniques, while decreasing the frequency of surgical site occurrences.

OC-011 PREOPERATIVE BOTULINUM TOXIN A INJECTION CAN ACHIEVE SIMILAR OUTCOMES AS COMPONENT SEPARATION TECHNIQUES IN COMPLEX ABDOMINAL WALL RECONSTRUCTION WITH DECREASED MORBIDITY– A PROPENSITY-SCORED MATCHED STUDY

Aims

CST have been effective in closing large defects but at the sacrifice of fascia and muscle and often increasing complication rates. Preoperative BTA has emerged as an adjunct to aid in fascial closure. Little data exist comparing pre-operative BTA versus CST, and our aim was to do so in a matched study.

Materials & Methods

A 3:1 propensity matched study of patients from a single institution hernia database undergoing AWR from 2016 to 2021 with BTA versus CST was performed based on BMI, defect width, hernia volume, and CDC wound classification. Demographics, operative characteristics, and outcomes were evaluated.

Results

35 BTA vs 105 CST matched patients were analyzed. Hernia defects and volume were large for both the CST and BTA groups (mean size:286.2+179.9cm2vs289.7+162.4cm2;p=0.73) (mean volume:1498.3+2043.4cm3vs2914.7+6539.4cm3;p=0.35). CDC wound classifications were equivalent (CDC3 and 4–39.1%vs40.0%;p=0.97). CST was more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%;p=0.01). The BTA group had fewer surgical site occurrences (SSO) (32.4%vs11.4%;p=0.02) and surgical site infections (SSI) (11.7%vs0%;p=0.04). There was no difference in fascial closure (90.5%vs100%;p=0.11)) or recurrence (12.4%vs2.9%;p=0.10) with similar median follow-up (22.8+29.7vs 9.8+12.7months;p=0.13). In multivariate analysis, BTA was associated with lower rates of SSO (OR=5.3; 95% CI [1.4–34.4]).

Conclusion

There was no difference in fascial closure rates or in hernia recurrence between the two groups. Pre-operative BTA can thereby achieve similar outcomes as CST while concurrently decreasing the frequency of SSO. This similarity in outcomes is upheld when comparing BTA to both ACST and PCST separately.

Adrenergic blockade ameliorates cellular immune responses to mental stress in humans

This study evaluated the sympathoadrenal modulation of behaviorally evoked immune responses by administration of a nonselective adrenoceptor antagonist (labetalol) to subjects exposed to mental stress. In a 2 x 2 factorial design, subjects were assigned to a labetalol or saline condition and, within each condition, were exposed either to acute laboratory stress or no stress (control). Lymphocyte subsets, natural killer (NK) cell cytotoxicity, and T cell proliferation to phytohemagglutinin and concanavalin A were assessed pre-experimentally, at baseline after infusion and after 18 minutes of mental stress (or rest). By comparison with the other three conditions, the saline-stress group showed a greater peripheral NK cell number and cytotoxicity, lower mitogenic response to phytohemagglutinin and concanavalin A, and diminished ratio of CD4:CD8 cells after the stressor. As predicted, immune responses did not differ among the remaining groups (labetalol-stress, saline-rest, labetalol-rest). Group differences in NK cell cytotoxicity were not significant after controlling for differences in NK cell numbers. These findings demonstrate that the occurrence of certain immunologic responses to acute psychological stress are dependent on concomitant activation of the sympathetic nervous system.

Effects of acute psychological stress on serum lipid levels, hemoconcentration, and blood viscosity

BACKGROUND

While there is substantial evidence that psychological stress enhances risk for coronary artery disease, the mechanisms underlying such an influence remain unclear. We examined the effects of short-term psychological stress on serum lipid levels, hemoconcentration, fibrinogen level, and plasma viscosity.

METHODS

Forty-four healthy young adults were randomly assigned to perform a distinctly frustrating cognitive task for 20 minutes (stress condition) or to rest quietly for the same period (control condition).

RESULTS

Relative to controls, stressed subjects showed significant increases in blood pressure and heart rate; total, low-density, and high-density lipoprotein cholesterol levels; hematocrit; hemoglobin level; and total protein concentration. Stressed subjects also showed significant reductions in plasma volume and increased plasma viscosity and estimated whole-blood viscosity compared with controls. A similar trend in fibrinogen level was not statistically significant. Individual differences in blood pressure and heart rate response to stress correlated highly with changes in total cholesterol levels and hematocrit.

CONCLUSIONS

Our investigation provides further evidence that exposure to short-term mental stress elicits hemoconcentration with associated increases in serum lipid concentrations, hemostatic factors, and blood viscosity.