Abstract
Purpose
Complications of incisional hernia are amongst the commonest presentations to the emergency surgical take. Outcomes from emergency hernia repair are poor, particularly for those with complex defects and for the growing population of comorbid, high-risk patients. Attempts to avoid emergency surgery by improving success rates of non-operative management could prove hugely beneficial. Botulinum toxin A (Botox) is already used in the elective management of incisional hernia and this study evaluates if the relaxation produced could be used to augment the outcomes of conservative management of acutely presenting incisional hernia.
Methods
Patients presenting between October 2020 and April 2022 without evidence of visceral ischaemia, who had been selected for a non-operative approach, were given 300 units of Botox under image guidance to the abdominal wall in addition to standard conservative measures.
Results
Twelve patients were eligible for Botox administration. Median age was 75 years and median BMI was 36.45 kg/m2. All patients were high risk; minimum ASA score was 3, and median frailty score was 5. In ten patients, symptoms resolved following Botox allowing for discharge without further complication. Seven subsequently referred on to the abdominal wall team. Symptoms did not settle in the two remaining patients; one required emergency laparotomy and the second was palliated.
Conclusion
Botox may be a useful adjunct to established non-operative measures in patients with acute presentations of incisional hernia. It may improve the acute symptoms, eliminate the need for high-risk emergency surgery, or provide a bridge to abdominal wall reconstruction.
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References
Alnassar S, Bawahab M, Abdoh A et al (2012) Incisional hernia postrepair of abdominal aortic occlusive and aneurysmal disease: five-year incidence. Vascular 20:273–277. https://doi.org/10.1258/vasc.2011.oa0332
Deerenberg E, Harlaar J, Steyerberg E et al (2015) Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet 386:1254–1260. https://doi.org/10.1016/S0140-6736(15)60459-7
Van’t Riet M, Steyerberg E, Nellensteyn J et al (2002) Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg 89:1350–1356. https://doi.org/10.1046/j.1365-2168.2002.02258.x
NELA (2021) Seventh patient report of the national emergency laparotomy audit December 2019 to November 2020. file: ///C:/Users/jlste/Downloads/NELA%20Year%207%20-%20Highlight%20Report.pdf. Accessed 11 NoV 2022
Helgstrand F (2016) National results after ventral hernia repair. Dan Med J 63:B5258
Helgstrand F, Rosenberg J, Kehlet H et al (2013) Outcomes after emergency versus elective ventral hernia repair: a prospective nationwide study. World J Surg 37:2273–2279. https://doi.org/10.1007/s00268-013-2123-5
Köckerling F, Sheen A, Berrevoet F et al (2019) The reality of general surgery training and increased complexity of abdominal wall hernia surgery. Hernia 23:1081–1091. https://doi.org/10.1007/s10029-019-02062-z
Grove T, Kontovounisios C, Montgomery A et al (2012) Perioperative optimization in complex abdominal wall hernias: Delphi consensus statement. BJS Open 5:zrab082. https://doi.org/10.1093/bjsopen/zrab082
Beadles C, Meagher A, Charles G (2015) Trends in emergent hernia repair in the United States. JAMA Surg 150:194–200. https://doi.org/10.1001/jamasurg.2014.1242
Lee M, Sayers A, Drake T et al (2019) NASBO steering group and NASBO collaborators: national prospective cohort study of the burden of acute small bowel obstruction. BJS Open 3:354–366. https://doi.org/10.1002/bjs5.50136
Ibarra-Hurtado T, Nuño-Guzmán C, Echeagaray-Herrera J et al (2009) Use of botulinum toxin type a before abdominal wall hernia reconstruction. World J Surg 33:2553–2556. https://doi.org/10.1007/s00268-009-0203-3
Farooque F, Jacombs A, Roussos E et al (2016) Preoperative abdominal muscle elongation with botulinum toxin A for complex incisional ventral hernia repair. ANZ J Surg 86:79–83. https://doi.org/10.1111/ans.13258
Zielinski M, Goussous N, Schiller H et al (2013) Chemical components separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen. Hernia 17:101–107. https://doi.org/10.1007/s10029-012-0995-1
Nestor M, Ablon G, Pickett A (2017) Key parameters for the use of abobotulinumtoxinA in aesthetics: onset and duration. Aesthet Surg J 37:S20–S31. https://doi.org/10.1093/asj/sjw282
Nestor M, Ablon G (2011) Comparing the clinical attributes of abobotulinumtoxinA and onabotulinumtoxinA utilizing a novel contralateral frontalis model and the frontalis activity measurement standard. J Drugs Dermatol 10:1148–1157
Dressler D, Saberi F, Barbosa E (2005) Botulinum toxin: mechanisms of action. Arq Neuro-Psiquiatr 63:180–185. https://doi.org/10.1590/S0004-282X2005000100035
Rosales R, Bigalke H, Dressler D (2006) Pharmacology of botulinum toxin: differences between type A preparations. Eur J Neurol 13:2–10. https://doi.org/10.1111/j.1468-1331.2006.01438.x
Beer K, Shamban A, Avelar R et al (2019) Efficacy and safety of PrabotulinumtoxinA for the treatment of glabellar lines in adult subjects: results from 2 identical phase III studies. Dermatol Surg 45:1381–1393. https://doi.org/10.1097/DSS.0000000000001903
Kassir R, Kolluru A, Kassir M (2013) Triple-blind, prospective, internally controlled comparative study between AbobotulinumtoxinA and OnabotulinumtoxinA for the treatment of facial rhytids. Dermatol Ther (Heidelb) 3:179–189. https://doi.org/10.1007/s13555-013-0033-y
Samizadeh S, De Boulle K (2018) Botulinum neurotoxin formulations: overcoming the confusion. CCID 11:273–287. https://doi.org/10.2147/CCID.S156851
Weissler J, Lanni M, Tecce M et al (2017) Chemical component separation: a systematic review and meta-analysis of botulinum toxin for management of ventral hernia. J Plast Surg Hand Surg 51:366–374. https://doi.org/10.1080/2000656X.2017.1285783
Durham P, Cady R (2004) Regulation of calcitonin gene-related peptide secretion from trigeminal nerve cells by botulinum toxin type A: implications for migraine therapy. Headache 44:35–42. https://doi.org/10.1111/j.1526-4610.2004.04007.x. (discussion 42-43)
Göbel H, Heinze A, Reichel G et al (2006) Dysport myofascial pain study group: efficacy and safety of a single botulinum type A toxin complex treatment (Dysport) for the relief of upper back myofascial pain syndrome: results from a randomized double-blind placebo-controlled multicentre study. Pain 125:82–88. https://doi.org/10.1016/j.pain.2006.05.001
Rockwood K, Song X, MacKnight C et al (2005) A global clinical measure of fitness and frailty in elderly people. CMAJ 173:489–495. https://doi.org/10.1503/cmaj.050051
Timmer A, Claessen J, Atema J et al (2021) A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction. Hernia 25:1413–1425. https://doi.org/10.1007/s10029-021-02499-1
Parmar K, Law J, Carter B et al (2021) ELF study group: frailty in older patients undergoing emergency laparotomy: results from the UK observational emergency laparotomy and frailty (ELF) study. Ann Surg 273:709–718. https://doi.org/10.1097/SLA.0000000000003402
Slater N, Montgomery A, Berrevoet F et al (2014) Criteria for definition of a complex abdominal wall hernia. Hernia 18:7–17. https://doi.org/10.1007/s10029-013-1168-6
Liang M, Holihan J, Itani K et al (2017) Ventral hernia management: expert consensus guided by systematic review. Ann Surg 265:80–89. https://doi.org/10.1097/SLA.0000000000001701
Muirhead L, Shaw A, Kontovounisios C et al (2019) Establishing a robust multidisciplinary team process in complex abdominal wall reconstruction within a colorectal surgical unit. Tech Coloproctol 23:379–383. https://doi.org/10.1007/s10151-019-01965-4
Köckerling F, Sheen A, Berrevoet F et al (2019) Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project. Hernia 23:185–203. https://doi.org/10.1007/s10029-018-1873-2
Bittner R, Bain K, Bansal V et al (2019) Update of guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): part B. Surg Endosc 33:3511–3549. https://doi.org/10.1007/s00464-019-06908-6
Sarr M, Bulkley G, Zuidema G (1983) Preoperative recognition of intestinal strangulation obstruction. Prospective evaluation of diagnostic capability. Am J Surg 145:176–1823. https://doi.org/10.1016/0002-9610(83)90186-1
Birindelli A, Sartelli M, Di Saverio S et al (2017) update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg 12:37. https://doi.org/10.1186/s13017-017-0149-y
Tanaka K, Hanyu N, Iida T et al (2012) Lactate levels in the detection of preoperative bowel strangulation. Am Surg 78:86–88
Jancelewicz T, Vu L, Shawo A et al (2009) Predicting strangulated small bowel obstruction: an old problem revisited. J Gastrointest Surg 13:93–99. https://doi.org/10.1007/s11605-008-0610-z
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Jennifer Stevens, Caroline Baillie, Byung Choi, Alexander Chapman, Marcos Kostalas and Kumaran Ratnasingham declare that they have no financial or non-financial interests that are directly or indirectly related to the work submitted for publication.
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Stevens, J., Baillie, C., Choi, B. et al. The use of botulinum toxin in the acute management of symptomatic complex incisional hernia: a case series. Hernia 27, 593–599 (2023). https://doi.org/10.1007/s10029-023-02739-6
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DOI: https://doi.org/10.1007/s10029-023-02739-6