Abdominal Wall Morbidity Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Our plain-English summary of Abdominal Wall Morbidity Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy, by F. Struller, I. Koenigsrainer, P. Horvath, et al (Scandinavian Journal of Surgery, 2017).

The study

• Authors: F. Struller, I. Koenigsrainer, P. Horvath, A. Koenigsrainer, S. Beckert
• Journal: Scandinavian Journal of Surgery
• Published: 2017;106(4):294-298
• Cited by: 11 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Incisional hernia formation has been reported as high as 20% within 1 year following midline laparotomy. Since hyperthermic intraperitoneal chemotherapy is likely to impair wound healing, we sought to investigate the incidence of incisional hernia formation and abdominal wall rupture following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Methods: Consecutive patients with radiographic evidence of peritoneal metastases were scheduled for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at the Comprehensive Cancer Center, University Hospital Tuebingen, Germany. Clinical data were retrospectively analyzed.

Results: Between May 2005 and May 2014, 271 patients underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Within follow-up, 19 (7%) incisional hernias and 11 (4%) abdominal wall ruptures were observed. Age ⩾70 years, cardio-pulmonary comorbidity, the presence of pseudomyxoma peritonei or mesothelioma, and postoperative abdominal wall rupture were detected as risk factors for hernia formation. However, Cox multivariate analysis only confirmed the presence of pseudomyxoma peritonei or mesothelioma and postoperative abdominal wall rupture as independent risk factors.

Conclusion: Our data do not suggest that cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is necessarily associated with a higher incidence of incisional hernia formation. However, patients suffering from pseudomyxoma peritonei or mesothelioma and patients with postoperative abdominal wall rupture seem to be at risk for developing incisional herniation.

In plain English

This study from University Hospital Tuebingen, Germany, looked back at records of 271 consecutive patients treated between 2005 and 2014 for cancer spread over the lining of the abdomen. All had cytoreductive surgery, which removes visible tumor, followed by heated chemotherapy delivered inside the abdomen (HIPEC). Fourteen patients had mesothelioma. The article does not discuss asbestos. Over a median follow-up of 38 months, 19 patients (7%) developed an incisional hernia, a gap or bulge at the surgical scar. Eleven (4%) had an abdominal wall rupture, in which the wound reopened and needed another operation. In the multivariate analysis, two factors remained statistically significant risk factors for hernia: having pseudomyxoma peritonei or mesothelioma, and having had an abdominal wall rupture. Age 70 or older and heart or lung disease were linked to hernia only in the simpler univariate analysis. The authors concluded that the overall hernia risk after this treatment might not necessarily be increased. They said the small number of patients may explain some findings, and that hernia numbers are likely to rise as follow-up continues.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of prospectively collected data on consecutive patients treated at one hospital
• Who was studied: 271 consecutive patients (median age 55, range 17 to 76) with peritoneal surface malignancy treated at the Comprehensive Cancer Center, University of Tuebingen, Germany. The Methods give the period as June 2005 to May 2014. Origins of the peritoneal tumors included colorectal cancer (79), recurrent ovarian cancer (79), gastric cancer (35), pseudomyxoma peritonei (32), appendiceal cancer (24), mesothelioma (14) and small bowel cancer (8). Median follow-up was 38 (2 to 110) months.
• Exposure: Cytoreductive surgery through a midline incision followed by hyperthermic intraperitoneal chemotherapy (HIPEC). Mesothelioma patients received cisplatin, or since February 2012 cisplatin with doxorubicin. Asbestos exposure is not discussed.
• Main results:
  • 19 of 271 patients (7%) developed an incisional hernia during follow-up, at a median of 3.7 months after surgery. Hernia repair was needed in 12 of these 19 patients (63%). No incarceration was observed.
  • 11 of 271 patients (4%) had an abdominal wall rupture. Of those 11, 5 developed an incisional hernia.
  • Mesothelioma made up 4 of 19 patients (21%) in the hernia group and 10 of 252 (4%) in the no-hernia group. Pseudomyxoma peritonei made up 4 of 19 (21%) in the hernia group and 28 of 252 (11%) in the no-hernia group.
  • In the multivariate (Cox regression) analysis, only two factors remained significant risk factors for hernia. Presence of pseudomyxoma or mesothelioma had p = 0.022 and a printed odds ratio of 4.295. Abdominal wall rupture had p less than 0.0001 and a printed odds ratio of 11.682.
  • Older age and cardio-pulmonary comorbidity were risk factors only in the univariate analysis. In the multivariate analysis, age over 70 years had p = 0.083 and cardio-pulmonary comorbidity had p = 0.110. Surgical site infection, closure technique and mild leucopenia showed no difference between the hernia and no-hernia groups.
• The authors' conclusion: The authors concluded that the overall risk of incisional hernia after cytoreductive surgery and HIPEC might not necessarily be increased. They added that patients with pseudomyxoma peritonei or mesothelioma, and those with postoperative abdominal wall rupture, seem to be at higher risk.
• Limitations the authors state:
  • The low number of patients included might explain why some expected risk factors showed only a statistical trend.
  • Follow-up was uneven (2 to 110 months), and some patients did not survive long enough to develop a hernia, so the incidence is likely to increase with longer follow-up.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Laparotomy, Mesothelioma, Multivariate Analysis.

Related studies

• Morbidity of the abdominal wall resection and reconstruction after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) — M.F. Nunez, A. Sardi, et al. (2015)
• Treating peritoneal mesothelioma with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. A case series and review of the literature — K. Stamou, D. Tsamis, et al. (2015)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)
• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)
• Radiological predictors of complete cytoreduction in 59 patients with peritoneal mesothelioma treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at a UK referral centre — A. Chandramohan, A. Thrower, et al. (2017)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)

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