Can Hernia Sac to Abdominal Cavity Volume Ratio Predict Fascial Closure Rate for Large Ventral Hernia? Reliability of the Tanaka Score.

BACKGROUND: The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias. METHODS: Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values). RESULTS: A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p = 0.001), 2 years (85 vs 33.3; p = 0.003), and 3 years (86.7 vs 63.3; p = 0.049). CONCLUSIONS: In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point.

Complications and Impact on Quality of Life of Vertical Rectus Abdominis Myocutaneous Flaps for Reconstruction in Pelvic Exenteration Surgery.

BACKGROUND: Pelvic exenteration for malignancy sometimes necessitates flap reconstruction. OBJECTIVE: This study's aim was to investigate flap-related morbidity. DESIGN: A prospective database was reviewed from 2003 to 2016. All medical charts, correspondence, and outpatient follow-up records up to May 2017 were reviewed. SETTINGS: This study was conducted at a tertiary referral unit. PATIENTS: Patients who underwent pelvic exenteration surgery were selected. INTERVENTIONS: Reconstruction was performed with a vertical rectus abdominis myocutaneous flap. MAIN OUTCOME MEASURES: Primary outcome was flap-related complications (short or long term >3 months). Secondary outcomes were hospital stay, readmission, mortality, and quality of life (Short Form-36, Functional Assessment of Cancer Therapy for patients with colorectal cancer). RESULTS: Of 519 patients undergoing pelvic exenteration surgery, 87 (17%) underwent flap reconstruction. Median follow-up was 20 months (interquartile range, 8-39 months). Median age was 60 years (interquartile range, 51-66). Flap-related complications were found in 59 patients (68%), with minor recipient-site complications diagnosed in 33 patients (38%). In the short term, 15 patients experienced major recipient-site complications (17%), including flap separation (n = 7) and partial (n = 3) or complete necrosis (n = 4). Flap removal was required in 1 patient. Obesity was the single independent risk factor for short-term flap-related complications (p = 0.02). Hospital admission was significantly longer in patients with short-term major flap complications (median 65 days, p < 0.001) compared with patients without or with minor complications. There was no 90-day mortality. Patients who required flap reconstruction reported lower baseline quality-of-life scores than patients without flap reconstruction, but both recovered over time. In the long term, minor flap-related complications occurred in 12 patients, and 11 patients had major donor-site complications. Fourteen patients developed major recipient-site complications (16%), including sacral collections, enterocutaneous fistulas, perineal ulcer, or hernia. LIMITATIONS: This was a retrospective analysis of prospectively collected data. CONCLUSIONS: Vertical rectus abdominis myocutaneous flaps in pelvic exenteration surgery have a high incidence of morbidity that has significant impact on hospital stay and a temporary impact on quality of life. Flap reconstruction should be used selectively in pelvic exenteration surgery. See Video Abstract at http://links.lww.com/DCR/B274. COMPLICACIONES E IMPACTO EN LA CALIDAD DE VIDA DE LOS COLGAJOS MIOCUTÁNEOS DE MUSCULO RECTO DEL ABDOMEN EN CASOS DE RECONSTRUCCIÓN DE EXENTERACIÓN PÉLVICA: La exenteración pélvica (EP) para malignidad a veces requiere reconstrucción con colgajos musculares.El propósito del presente estudio fue investigar la morbilidad relacionada con los colagajos musculares.Revisión de una base de datos prospectiva de 2003-2016. Se evaluaron todas las historias clínicas, la correspondencia y los registros de seguimiento de pacientes ambulatorios hasta mayo de 2017.Unidad de referencia terciaria.Todos aquellas personas con cirugía de exenteración pélvica.Reconstrucción con colgajo miocutáneo de musculo recto vertical del abdomen.El resultado primario fueron las complicaciones relacionadas con el colgajo (a corto o largo plazo >3 meses). Los resultados secundarios fueron la estadía hospitalaria, la readmisión, la mortalidad y la calidad de vida (QOL; SF-36, FACT-C).De 519 pacientes sometidos a EP, 87 (17%) se sometieron a reconstrucción con colgajos miocutáneos. La mediana de seguimiento fue de 20 meses (RIC 8-39 meses). La mediana de edad fue de 60 años (IQR 51-66). Se encontraron complicaciones relacionadas con el colgajo en 59 pacientes (68%), con complicaciones menores en el sitio del receptor diagnosticadas en 33 pacientes (38%). A corto plazo, quince pacientes sufrieron complicaciones mayores en el sitio del receptor (17%), incluida la separación del colgajo (n = 7), necrosis parcial (n = 3) o necrosis completa (n = 4). Se requirió la extracción del colgajo en un paciente. La obesidad fue el único factor de riesgo independiente para complicaciones relacionadas con el colgajo a corto plazo (p = 0.02). El ingreso hospitalario fue significativamente mayor en pacientes con complicaciones de colgajos mayores a corto plazo (mediana 65 días p <0.001) en comparación con pacientes sin complicaciones menores o con complicaciones menores. No hubo mortalidad a los 90 días. Los pacientes que requirieron reconstrucción con colgajo informaron puntajes de calidad de vida basales más bajos que los pacientes sin reconstrucción con colgajo, pero ambos se recuperaron con el tiempo. A largo plazo, ocurrieron complicaciones menores relacionadas con el colgajo en 12 pacientes y 11 pacientes tuvieron complicaciones mayores en el sitio donante. Catorce pacientes desarrollaron complicaciones mayores en el sitio del receptor (16%), incluidas colecciones sacras, fístulas enterocutáneas, úlceras perineales o herniación.Análisis retrospectivo de datos recolectados prospectivamente.Los colgajos miocutáneos del musculo recto vertical del abdomen en casos de cirugía de exenteración pélvica tienen una alta incidencia de morbilidad conllevando a un impacto significativo en la estadía hospitalaria y un impacto temporal en la calidad de vida. Las reconstrucciones con colgajos deben aplicarse muy selectivamente en la cirugía de exenteración pélvica. Consulte Video Resumen en http://links.lww.com/DCR/B274.

Long-term impact of incisional hernia on quality of life after colonic cancer resection.

PURPOSE: The objective of the current study was to examine the long-term quality of life (QOL) after colonic cancer resection according to whether or not the patients developed incisional hernia. Furthermore, the impact of incisional hernia repair on QOL was examined in the patient group diagnosed with an incisional hernia. METHODS: This was a nationwide register-based study including patients undergoing colonic cancer resection identified in the Danish Colorectal Cancer Group database. Surviving patients were contacted and answered the EORTC QLQ-C30 questionnaire and grouped according to subsequent incisional hernia diagnosis, and in a subgroup analysis of patients with subsequent incisional hernia according to incisional hernia repair or not. RESULTS: A total of 2466 patients were included. The median time from colonic cancer resection to QOL assessment was 9.9 years, during which a total of 215 (8.7%) patients were diagnosed with incisional hernia, and 156 (72.6%) of these underwent incisional hernia repair. After adjustment for confounders, incisional hernia subsequent to colonic cancer resection was significantly associated with reduced QOL in the domains Global health, Physical functioning, Role functioning, Emotional functioning and Social functioning, as well as significantly associated with increased symptoms in the scales of pain, dyspnoea and insomnia. Of patients with incisional hernia, surgical repair was associated with increased QOL in the domains Physical functioning and Role functioning. CONCLUSIONS: Incisional hernia subsequent to colonic cancer resection was associated with reduced QOL several years after surgery and should be considered taken into account when evaluating the long-term outcome of colonic cancer resection.

Prevalence of posttraumatic stress disorder (PTSD) in patients with an incisional hernia.

BACKGROUND: We investigate the prevalence of PTSD in patients with an incisional hernia presenting for evaluation at our institution. METHODS: Study patients were screened for PTSD using the PCL-5 checklist for DSM-5. Patient-reported quality of life and pain scores were assessed using validated tools (HerQLes and PROMIS Pain Intensity 3a survey). RESULTS: The prevalence of PTSD in 131 patients was 32.1% [95% CI 24%-40%]. Patients screening positive (PTSD+) reported lower quality of life scores on HerQles (17.3 ± 14.3 vs. 47.7 ± 29.6, P < 0.001), and higher pain scores on the PROMIS scale (54.2 ± 9.1 vs. 44.2 ± 10, p < 0.001). PTSD + patients also reported significantly higher numbers of previous hernia repairs and abdominal operations, as well as a higher rate of a history of an open abdomen. CONCLUSION: Our study found a significant prevalence of positive screening for PTSD in patients seeking consultation regarding an incisional hernia. We have begun routine preoperative evaluations by a behavioral medicine specialist to address some of these complex issues in high-risk patients. Other high volume hernia programs caring for this challenging patient population should consider such assessments.

Obesity is a significant risk factor for ileostomy site incisional hernia following reversal.

BACKGROUND: Incisional hernia following ileostomy reversal can cause significant morbidity, impaired quality of life, and burden on the healthcare system. This study aimed to determine the prevalence of ileostomy site incisional hernia following reversal and to identify possible risk factors for its development. METHODS: This was a retrospective cohort study involving consecutive patients who underwent ileostomy reversal between November 1999 to February 2015 by a single surgeon. Primary outcome analysed was incisional hernia occurrence at the previous stoma site. RESULTS: Two hundred and twenty-four ileostomy reversals were identified. The most common indication for ileostomy construction was colorectal cancer, followed by inflammatory bowel disease and diverticulosis. The stomas were either a loop (75%), end-loop (24%) or end ileostomy (1%). The mean time interval from the stoma creation to reversal was 6.1 months (range 2-69, SD 7.1). After a mean follow-up of 30.7 months (range 10-89, SD 15.1), 12 patients (5%) developed a hernia at the previous stoma. The mean time for hernia occurrence was 25.2 months (range 3-126, SD 32). Patients who developed ileostomy site incisional hernia were more likely to have a higher body mass index (28.1 versus 26.3, P = 0.007). CONCLUSION: Although we found a lower rate of incisional hernias after reversal of ileostomies than reported elsewhere in the literature, it remains a significant clinical problem. Obesity is a significant risk factor for ileostomy-site incisional hernia.

Early repair of ventral incisional hernia may improve quality of life after surgery for abdominal malignancy: a prospective observational cohort study.

PURPOSE: Recent work has shown that over 40% of patients undergoing surgery for abdominal malignancy develop ventral incisional hernias (VIH) within 2 years. We hypothesized that early repair of VIH for cancer survivors could improve long-term quality of life (QoL). METHODS: All patients presenting with a history of surgery for abdominal malignancy and a VIH were prospectively enrolled. QoL was assessed at baseline and 3-, 6-, 12-, 18-, and 24-month follow-up using abdominal wall-specific (HerQLes) and cancer-specific (FACT-G) instruments. At the study's conclusion, patients were divided into 2 groups-those that underwent VIH repair during the study's course (Repair Group) and those that did not (Control Group). Categorical variables were analyzed using Pearson's Chi-square and continuous variables with Wilcoxon rank sum test. RESULTS: Eighty-four patients were enrolled. Overall, 46 patients (55%) underwent VIH repair, with 36 repairs (78%) occurring within 3 months of initial evaluation. Sixty-six (79%) had complete 1-year follow-up data, and 30 (36%) had 2-year data, with a median follow-up duration of 15.6 months. At baseline, both groups were similar with respect to demographics, cancer stage, and HerQLes/FACT-G scores. Compared to the Controls, the Repair Group showed greater improvements over baseline HerQLes Summary Scores at the 3-, 6-, 12-, and 18-month time points (median increase, 37 vs. 26 points), and in FACT-G total scores at the 3-, 6-, and 12-month time points (median increase, 6 vs. 4 points). CONCLUSIONS: Repair of VIH after surgery for abdominal malignancy may improve abdominal wall-specific and cancer-specific QoL, making post-resection abdominal wall reconstruction an important aspect of cancer survivorship.