Abstract
Background and objectives
Incisional hernias are among the most frequent complications following abdominal surgery with impact on morbidity and mortality rates. Elevated uremia toxins may inhibit granulation tissue formation and impair wound healing, thereby promoting incisional hernia development. Here, we quantified the hazard ratio for incisional hernia prevalence in patients at risk undergoing abdominal reoperations with interrelationship to kidney function. In the same cohort, incidence rates for de novo wound healing disturbances within a 4-month follow-up period were determined.
Design, setting, participants and measurements
Upon hospitalization for elective abdominal surgery in a university hospital (tertiary medical center), past medical histories were recorded in 251 patients and incisional hernia prevalence rates were calculated. Known modifiers for hernia formation as well as laboratory values for estimated glomerular filtration rate (eGFR) were recorded. The status of wound healing was assessed by a blinded investigator 4 months postoperatively. Chronic kidney disease (CKD) was defined as eGFR < 60 ml/min/1.73 m2. To identify independent risk factors for incisional hernia or postoperative wound healing disorder, multivariate regression analyses were performed.
Results
The incisional hernia prevalence was 24.3 % in the overall cohort. Patients with CKD (32/251; 12.8 %) were more likely to suffer from incisional hernias with an odds ratio (OR) of 2.8 ([95 % CI 1.2–6.1]; p = 0.014) than patients with eGFR > 60 ml/min (219/251; 88.2 %). In multivariate analyses, CKD proved to be an independent risk factor for incisional hernia development with an OR similar to obesity (BMI > 25; OR 2.6 [95 % CI 1.3–5.1]; p = 0.007). In the prospective analysis, disturbed wound healing occurred in 32 of 251 (12.8 %) patients undergoing abdominal operations. Frequency of wound healing was increased when CKD was present (8/32; 25 %; OR 2.3 [95 % CI 1.1–6.7]; p = 0.026) compared to patients with eGFR > 60 ml/min (24/219; 11 %).
Conclusions
Chronic kidney disease is associated with impaired wound healing and constitutes an independent risk factor for incisional hernia development.
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References
Fingerhut D (2007) KDOQI clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Am J Kidney Dis 49:S12–S154
Baylis C (2006) Arginine, arginine analogs and nitric oxide production in chronic kidney disease. Nat Clin Pract Nephrol 2:209–220
Brewster UC (2008) Dermatological disease in patients with CKD. Am J Kidney Dis 51:331–344
Bucknall TE, Cox PJ, Ellis H (1982) Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J (Clin Res Ed) 284:931–933
Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J (2004) Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578–583 (discussion 583–575)
Conze J, Binnebosel M, Junge K, Schumpelick V (2010) Incisional hernia—how do I do it? Standard surgical approach. Chirurg 81:192–200
Conze J, Klinge U, Schumpelick V (2005) Incisional hernia. Chirurg 76:897–909 (quiz 910)
Flum DR, Horvath K, Koepsell T (2003) Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg 237:129–135
Gislason H, Gronbech JE, Soreide O (1995) Burst abdomen and incisional hernia after major gastrointestinal operations–comparison of three closure techniques. Eur J Surg 161:349–354
Hartmann M, Jonsson K, Zederfeldt B (1992) Effect of tissue perfusion and oxygenation on accumulation of collagen in healing wounds. Randomized study in patients after major abdominal operations. Eur J Surg 158:521–526
Hodgson NC, Malthaner RA, Ostbye T (2000) The search for an ideal method of abdominal fascial closure: a meta-analysis. Ann Surg 231:436–442
Hoer J, Lawong G, Klinge U, Schumpelick V (2002) Factors influencing the development of incisional hernia. A retrospective study of 2,983 laparotomy patients over a period of 10 years. Chirurg 73:474–480
Hoer J, Stumpf M, Rosch R, Klinge U, Schumpelick V (2002) Prevention of incisional hernia. Chirurg 73:881–887
Inker LA, Coresh J, Levey AS, Tonelli M, Muntner P (2011) Estimated GFR, albuminuria, and complications of chronic kidney disease. J Am Soc Nephrol 22:2322–2331
Jansen PL, Kever M, Rosch R, Krott E, Jansen M, Alfonso-Jaume A, Dooley S, Klinge U, Lovett DH, Mertens PR (2007) Polymeric meshes induce zonal regulation of matrix metalloproteinase-2 gene expression by macrophages and fibroblasts. FASEB J 21:1047–1057
Klinge U, Si ZY, Zheng H, Schumpelick V, Bhardwaj RS, Klosterhalfen B (2001) Collagen I/III and matrix metalloproteinases (MMP) 1 and 13 in the fascia of patients with incisional hernias. J Invest Surg 14:47–54
Kurzer M, Kark A, Selouk S, Belsham P (2008) Open mesh repair of incisional hernia using a sublay technique: long-term follow-up. World J Surg 32:31–36 (discussion 37)
Lewis S, Raj D, Guzman NJ (2012) Renal failure: implications of chronic kidney disease in the management of the diabetic foot. Semin Vasc Surg 25:82–88
Lynen Jansen P, Rosch R, Rezvani M, Mertens PR, Junge K, Jansen M, Klinge U (2006) Hernia fibroblasts lack beta-estradiol-induced alterations of collagen gene expression. BMC Cell Biol 7:36
Makela JT, Kiviniemi H, Juvonen T, Laitinen S (1995) Factors influencing wound dehiscence after midline laparotomy. Am J Surg 170:387–390
Mudge M, Hughes LE (1985) Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 72:70–71
Pans A, Elen P, Dewe W, Desaive C (1998) Long-term results of polyglactin mesh for the prevention of incisional hernias in obese patients. World J Surg 22:479–482 (discussion 482–473)
Pollock AV, Greenall MJ, Evans M (1979) Single-layer mass closure of major laparotomies by continuous suturing. J R Soc Med 72:889–893
Regnard JF, Hay JM, Rea S, Fingerhut A, Flamant Y, Maillard JN (1988) Ventral incisional hernias: incidence, date of recurrence, localization and risk factors. Ital J Surg Sci 18:259–265
Santora TA, Roslyn JJ (1993) Incisional hernia. Surg Clin North Am 73:557–570
Schumpelick V (2010) Incisional hernia: an unpleasant complication in surgery. Chirurg 81:185
Schumpelick V, Conze J, Klinge U (1996) Preperitoneal mesh-plasty in incisional hernia repair. A comparative retrospective study of 272 operated incisional hernias. Chirurg 67:1028–1035
Turner JM, Bauer C, Abramowitz MK, Melamed ML, Hostetter TH (2012) Treatment of chronic kidney disease. Kidney Int 81:351–362
van Ramshorst GH, Kleinrensink GJ, Hermans JJ, Terkivatan T, Lange JF (2009) Abdominal wall paresis as a complication of laparoscopic surgery. Hernia 13:539–543
Wissing J, van Vroonhoven TJ, Schattenkerk ME, Veen HF, Ponsen RJ, Jeekel J (1987) Fascia closure after midline laparotomy: results of a randomized trial. Br J Surg 74:738–741
Witasp A, Carrero JJ, Heimburger O, Lindholm B, Hammarqvist F, Stenvinkel P, Nordfors L (2011) Increased expression of pro-inflammatory genes in abdominal subcutaneous fat in advanced chronic kidney disease patients. J Intern Med 269:410–419
Acknowledgments
The study was funded by SFB/TR57, project 4, and by DFG Grant ME1365/7-1 to PRM.
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Heller, A., Westphal, S.E., Bartsch, P. et al. Chronic kidney disease is associated with high abdominal incisional hernia rates and wound healing disturbances. Int Urol Nephrol 46, 1175–1181 (2014). https://doi.org/10.1007/s11255-013-0565-1
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DOI: https://doi.org/10.1007/s11255-013-0565-1