|Year : 2020 | Volume
| Issue : 4 | Page : 117-121
Incisional hernia formation can be reduced following hyperthermic intraperitoneal chemotherapy with increased suture length to wound length ratio fascial closure
Joseph A Lewcun, Eric M Pauli, Colette Pameijer
Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA
|Date of Submission||16-Jul-2020|
|Date of Acceptance||28-Jul-2020|
|Date of Web Publication||30-Nov-2020|
Dr. Colette Pameijer
Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Incisional hernia (IH) is a common postsurgical complication of laparotomy. The impact of hyperthermic intraperitoneal chemotherapy on fascial healing has not been evaluated. The aim of this study is to determine whether utilizing a 4:1 suture length to wound length ratio (SL:WL) during fascial closure reduces the risk of IH following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CS-HIPEC).
METHODS: A retrospective review of patients who underwent HIPEC between 2013 and 2019 at a single institution was performed. Demographics and IH rates were compared between patients closed with a 4:1 SL:WL and patients with standard fascial closure (SFC). Hernias were detected on physical examination or on cross-sectional imaging studies.
RESULTS: Eighty-six patients who underwent HIPEC were included in the study. A 4:1 SL:WL was utilized in 26.7% (n = 23) of HIPEC cases and the remaining 73.3% (n = 63) of patients received SFC methods. Three patients in the 4:1 SL:WL group developed hernias, whereas 22 patients in the SFC group had hernias (13.0% vs. 34.9%, P = 0.048). The incidence of IHs was similar across the body mass index, smoking status, and operative time categories.
CONCLUSION: Utilizing a 4:1 SL:WL during fascial closure may reduce the rates of IH in the HIPEC population, but larger sample sizes and longer follow-up are required to determine the statistical significance of this intervention.
Keywords: Fascia, hyperthermic intraperitoneal chemotherapy, incisional hernia, suture
|How to cite this article:|
Lewcun JA, Pauli EM, Pameijer C. Incisional hernia formation can be reduced following hyperthermic intraperitoneal chemotherapy with increased suture length to wound length ratio fascial closure. Int J Abdom Wall Hernia Surg 2020;3:117-21
|How to cite this URL:|
Lewcun JA, Pauli EM, Pameijer C. Incisional hernia formation can be reduced following hyperthermic intraperitoneal chemotherapy with increased suture length to wound length ratio fascial closure. Int J Abdom Wall Hernia Surg [serial online] 2020 [cited 2021 Jan 27];3:117-21. Available from: http://www.herniasurgeryjournal.org/text.asp?2020/3/4/117/302025
| Introduction|| |
The combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CS-HIPEC) has gained popularity as an effective method for treating peritoneal-surface malignancy. A systematic review has shown markedly improved survival rates of CS-HIPEC when compared to palliative surgery and systemic chemotherapy.,, Despite this observed improvement in survival, the postoperative morbidity following CS-HIPEC has been estimated to be as high as 40%–60%., Factors that have been shown to increase the rates of complications are the extent of carcinomatosis, the duration of surgery, and the number of bowel resections. Some of the most commonly observed sequelae include digestive fistula, hematological toxicity, sepsis, postoperative bleeding, abscess formation, and incisional hernia (IH) formation.,
HIPEC has been shown to be an independent risk factor for the development of IH. During CS-HIPEC, the edges of the fascia are bathed in chemotherapy, and the impact of this exposure on fascial healing has not been studied in depth. The utilization of a 4:1 suture length to wound length (SL:WL) ratio fascial closure method has been shown to reduce the rates of IH in other abdominal surgeries requiring laparotomy by as high as 3 folds when compared to standard fascial closure (SFC). As such, we hypothesized that this method could be of particular use in reducing IH rates in this particularly vulnerable and challenging patient population. The aim of this study was to determine whether utilizing a 4:1 SL:WL during fascial closure reduces the risk of IH following CS-HIPEC.
| Methods|| |
A retrospective review of all patients who underwent CS-HIPEC for peritoneal surface disease at a single institution between 2013 and 2019 was conducted. All CS-HIPEC procedures were conducted by a single surgeon. Eligibility criteria included CS-HIPEC performed, at least 6 months of follow-up, and computed tomography (CT) of the abdomen/pelvis available for review. Patients were excluded that were lost to follow-up or died before 6 months of follow-up from the time of their CS-HIPEC, or who had subsequent operations with midline laparotomy. Demographic data such as age, body mass index (BMI), and smoking status, as well as the method of fascial closure were recorded. The nutritional status of each patient was estimated using their preoperative albumin level. Enhanced recovery after surgery protocols were not utilized in either group, and no changes in nutritional optimization were made over the included years. One dose of antibiotics was given preoperatively to all patients, but no prophylactic antibiotic regimens were given in the postoperative period. No bowel preparations were used prior to surgery. The majority of patients were treated with mitomycin-C during HIPEC, although the HIPEC agents were subject to variation due to differences in tumor biology. Over the studied time period, there was no change in preoperative management, indications for operation, surgeon, suture vendor, operative technique aside from the method of fascial closure, or the timing of neoadjuvant chemotherapy in relation to CS-HIPEC.
SFC was conducted using a running looped #1 PDS suture with interrupted 0 vicryl stitches. The total length of suture was not measured in the SFC group. For 4:1 SL:WL closures, the incision was first measured with a ruler and the amount of suture needed to close with at least four times the length of the incision was calculated. Then, utilizing 0 PDS on a CT1, the fascia was closed in a running fashion utilizing a small bite methodology. The unused suture was measured at the end and subtracted from the starting length to ensure that a 4:1 SL:WL was achieved. The size of suture bites was not measured in either group. The presence of IH was detected on physical examination or by blinded CT review. All available CT imaging was reviewed by a dedicated abdominal wall reconstruction surgeon agnostic to the method of fascial closure. We chose to review the images for IH rather than rely on the radiology report alone due to the high discordance rate between radiology reports and the presence of abdominal wall hernias. Rates of IH were then compared between the 4:1 SLWL and SFC groups.
Statistical analysis was performed to compare 4:1 SL: WL and SFC groups. Chi-square analysis and t-test were used for categorical and continuous data, respectively. In addition, descriptive statistics were reported. P < 0.05 was considered statistically significant.
Institutional review board approval was obtained for this study. The study was designed and reported in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines for cohort studies.
| Results|| |
Ninety-two patients who underwent CS-HIPEC between 2013 and 2019 were identified. Of these, 86 met the eligibility criteria and were included in the study [Figure 1]. The mean age of the patients was 58.6 years, 55.8% of the patients were female, and the mean BMI was 28.6 kg/m2. Patient characteristics of the entire cohort and by fascial closure method are shown in [Table 1]. Nearly 91.9% (n = 79) of the patients had a history of previous abdominal surgery. The majority (68.6%, n = 59) of the patients received systemic chemotherapy within the 6 months preceding their CS-HIPEC, with a mean time of 2 months between the cessation of systemic chemotherapy and the date of their operation. The primary malignancy was appendiceal in 37.2% (n = 32), colon in 32.6% (n = 28), ovarian in 7.0% (n = 6), and gastric in 4.7% (n = 4) of the cases. There were no statistical differences between the SFC and 4:1 SL:WL groups when evaluating risk factors for hernia formation, including diabetes, smoking status, time between the cessation of chemotherapy and CS-HIPEC, preoperative albumin level, operative time, or the maximum degree of hyperthermia. However, the 4:1 SL:WL group was more likely to be obese (P = 0.060). The most common chemotherapeutic agents used in HIPEC were mitomycin-C (84.9%, n = 73), cisplatin (10.5%, n = 9), and doxorubicin (9.3%, n = 8). The mean postoperative follow-up for the entire cohort was 17.4 months.
|Figure 1: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy patient inclusion and exclusion by eligibility criteria|
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|Table 1: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy patient characteristics|
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A 4:1 SL:WL was utilized in 26.7% (n = 23) of HIPEC cases and the remaining 73.3% (n = 63) of the patients received SFC methods. The most frequently used neoadjuvant systemic chemotherapy agents across the fascial closure groups are shown in [Table 2]. Nearly 87.0% (n = 20) of the patients in the 4:1 SL:WL group received a first- or second-generation cephalosporin preoperatively, 69.6% (n = 16) received metronidazole, and 4.3% (n = 1) received clindamycin. Around 79.4% (n = 50) of the patients in the SFC group received a first- or second-generation cephalosporin preoperatively, 58.7% (n = 37) received metronidazole, 15.9% (n = 10) received ciprofloxacin, and 7.9% (n = 5) received clindamycin. There were no statistically significant differences in other treatment parameters or patient demographic characteristics between the groups [Table 1]. Three patients in the 4:1 SL:WL group developed hernias, whereas 22 patients in the SFC group had hernias (13.0% vs. 34.9%, P = 0.048). The incidence of IH across BMI and smoking status groups and by operative time is shown in [Table 3]. Rates of surgical-site infection postoperatively were 4.8% (n = 3) in the SFC group and 8.7% (n = 2) in the 4:1 SL:WL group (P = 0.490).
|Table 2: Neoadjuvant systemic chemotherapy usage across fascial closure groups|
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|Table 3: Occurrence of incisional hernia in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy patients by suture to wound length ratio, body mass index, smoking status, and operative time|
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| Discussion|| |
Despite a small sample size, we identified statistically significant reductions in the rate of IH formation following CS-HIPEC when utilizing a 4:1 SL:WL despite higher rates of obesity in this group. No significant difference in the rate of IH was observed across the smoking status, BMI, or operative time categories. Preoperative antibiotic usage and usage of prior systemic chemotherapy agents varied between the fascial closure groups. However, there were no significant differences between the groups in the rates of other factors potentially influencing IH, including previous abdominal surgery, surgical-site infection, or operative time.
Patients undergoing CS-HIPEC face several physiologic obstacles in the perioperative period including malnutrition, fluid loss, hypothermia, and blood loss. Malnutrition is highly prevalent in patients with abdominal or pelvic malignancy, with up to 45% of CS-HIPEC patients exhibiting malnourishment. Malnourishment has been shown to interfere with wound healing, predisposing this population to increased rates of morbidity.
HIPEC itself has also been proposed to have a negative effect on wound healing, which could further increase the probability of postoperative morbidity. In a rat model, HIPEC was shown to lower colonic anastomosis bursting pressure and led to loss of collagen. Agents commonly used during HIPEC, such as mitomycin C, doxorubicin, and cisplatin, have been shown to independently interfere with wound healing in animal models.,, The degree of hyperthermia may cause thermal damage to the tissue of the abdominal cavity, further exacerbating this effect. Hyperthermia also causes direct cytotoxicity through protein denaturation and the inhibition of DNA repair mechanisms. This impairment could potentially increase the risk of fascial defect and hernia. Techniques such as a 4:1 SL:WL have been shown to decrease the rate of IH in prior studies, and may benefit CS-HIPEC patients. Our results support this observed reduction in IH rates and suggest that this intervention could be of particular use in reducing the rates of complication in this already-extremely vulnerable population.
The observed decrease in IH rates in the 4:1 SL:WL group is of clinical significance, especially in the CS-HIPEC population, which is at an increased risk of this complication and in whom IH repair can be exceptionally challenging as a result of prior peritoneal disease resection. We recommend further evaluation of the 4:1 closure in a larger CS-HIPEC population with a longer duration of follow-up to determine its efficacy with more certainty.
The study was conducted with the approval of the Penn State College of Medicine and Milton S. Hershey Medical Center Institutional Review Board (Approval Number: STUDY00011506; Date of Approval: 2/7/2019).
Written informed consent
A waiver of the written informed consent requirement was granted by the IRB. Given the number of subjects and the possibility that subjects were no longer living or lost to follow-up, this research would not have been practical without waiver. A significant number of subjects died of their disease, or did not have current contact information. The waiver did not adversely affect the rights and welfare of subjects, as the research results did not affect the care of the subjects.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]