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The Effect of Prior Abdominal Wall Radiotherapy on Abdominal Wall Reconstruction
Patrick B. Garvey, M.D.. F.A.C.S., Chad M. Bailey, B.A., Donald P. Baumann, M.D.. F.A.C.S., Charles E. Butler, M.D.. F.A.C.S..
The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
PURPOSE: Radiotherapy has known adverse effects on tissues, including fibrosis and compromised wound healing. Radiation treatments often involve the abdominal wall, but there have been no studies to evaluate the effects of prior radiotherapy on abdominal wall reconstruction outcomes. We hypothesized that prior radiotherapy involving the abdominal wall results in worse outcomes following abdominal wall reconstruction for hernia or tumor resection.
METHODS: We retrospectively reviewed prospectively collected demographic, defect, treatment, and outcomes data, from patients who underwent abdominal wall reconstruction between 6/7/2002 and 9/7/2011 at The University of Texas MD Anderson Cancer Center. Patients who underwent complex abdominal wall reconstruction for ventral hernia or oncologic resection were included in the study. Surgical outcomes were retrospectively compared between patients with and without prior abdominal wall radiotherapy.
RESULTS: A total of 337 patients were included in the study (75 with radiation directly to the abdominal wall vs. 262 without). Mean patient follow-up was 17.4 ± 15.8 months and mean radiation dose was 49.7 Gy ± 14.4 Gy in the radiotherapy group. Within the study cohort, a significantly higher percentage of patients in the radiotherapy group (73%) underwent reconstruction for oncologic resection (rather than complex hernia repair) compared to the non-radiotherapy group (53%; p=0.001). Patient characteristics were similar between groups, except that the radiotherapy group had a significantly higher mean body mass index (BMI) and incidence of receiving neoadjuvant chemotherapy. The musculofascial defect area (344.7 cm2 vs. 334.4 cm2; p=0.77) and the percentage of patients with violation of the rectus abdominis complex were similar between the radiotherapy and non-radiotherapy groups (78.7% vs. 69.5%, respectively; p=0.15). The use of component separation was significantly less (52% vs. 68.3%; p=0.013) in the radiotherapy compared to the non-radiotherapy group. A bioprosthetic inlay was employed in more than 80% of patients in both groups. Tissue flaps were required more frequently for soft tissue coverage in the radiotherapy group (31% vs. 8%; p<0.0001). The overall complication rate was similar between groups (31.8% vs. 30.8%; p=1.0); specifically, there were no differences in the rates of recurrent hernias (5.3% vs. 6.5%; p=0.93), bulging (2.7% vs. 4.6%; p=0.74), skin dehiscence (14.7% vs. 14.1%; p=0.85), or infection (13.3% vs. 16.4%; p=0.59) between the radiotherapy and non-radiotherapy group, respectively. However, enterocutaneous fistulae occurred significantly more often in the radiotherapy group (4.0% vs. 0.4%; p=0.05). Subset analysis demonstrated similar complication rates between irradiated and non-irradiated patients who underwent hernia repair (28.2% vs. 32.3%; p=0.71), oncologic resection (44.4% vs. 30.5%; p=0.20), component separation (44.7% vs. 35.9%; p=0.37), and tissue flap reconstruction (43.5% vs. 40.9%; p=1.0).
CONCLUSION: Contrary to our initial hypothesis, except for enterocutaneous fistulae, surgical outcomes did not differ for abdominal wall reconstructions in irradiated and non-irradiated patients, despite higher BMI and adjuvant chemotherapy use in the radiation group. Based on these findings, surgeons should not be reluctant to perform complex abdominal wall reconstructions, including component separation, in patients with prior abdominal wall irradiation.
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