Complex Abdominal Wall Reconstruction (cawr) Using Porcine Dermal Matrix (pdm): How Have Outcomes Changed Over 14 Years?
*Michael Katzen, *Paul Colavita, *Sullivan Ayuso, *Dau Ku, *Greg Scarola, *Rahmatulla Tawkaliyar, *Kiara Brown, *Vedra Augenstein, *B Todd Heniford
Atrium Health, Charlotte, NC
ObjectiveReinforcement of fascial closure during CAWR is challenging when contamination prohibits use of permanent synthetic mesh. PDM serves as an alternative in these cases. Our center has adopted many evidence-based practices (EBP) over time(figure1) to improve outcomes for CAWR with PDM. This study analyzed outcomes over time using PDM in CAWR.MethodsProspective, tertiary hernia center data was examined for patients undergoing CAWR with PDM. Parastomal hernias were excluded. Early(2008-2014) and recent(2015-2021) cohorts were defined by dividing the study interval in half. Subgroup analysis of patients with recurrence and multivariate analysis of both wound complications and recurrence were performed.ResultsComparing 114 early vs 242 recent patients, there was no difference in age(60.5vs58.7years;p=0.1), gender(53.0%vs50.6%female;p=0.7), diabetes(34.5%vs30.6%;p=0.5), prior failed hernia repair(76.1%vs67.4%;p=0.09), hernia defect size(320vs282cm2;p=0.32), or CDC wound-class: 3(44.4%vs32.2%;p=0.1), 4(31.6%vs34.3%;p=0.7). Recent patients had a lower mean BMI(35.5vs32.0kg/m2;p<0.01) and increased history of tobacco-use (18.1%vs41.0%;p<0.01).Recent patients had higher rates of preoperative Botox-injection(0%vs25.1%) and delayed-primary-closure(DPC)(23.0%vs40.1%;p<0.01). There were similar rates of panniculectomy(32.3%vs27.8%;p=0.5) and component separation(44.6%vs52.9%;p=0.7), though there was a trend towards fewer external oblique releases(29.1%vs18.2%;p=0.06). Most mesh was placed preperitoneal(74.4%vs93.3%;p=0.2). Recent patients had less inlay(9.4%vs2.1%;p<0.01) and retrorectus mesh(9.4%vs3.0%;p=0.01).Operative time decreased(256vs203min;p<0.01) and rate of fascial-closure increased(88.0%vs95.5%;p<0.01).Recent patients had decreased rates of wound infection(23.1vs6.2%;p<0.01) and breakdown(23.1%vs5.3%;p<0.01) and a shorter length of stay(LOS-11.3vs8.7days;p<0.01). There were similar rates of seroma(17.1%vs12.7%;p=0.3), hematoma(4.3%vs2.9%;p=0.5), and mesh infection(1.7%vs0.8%;p=0.5). There was a decrease in hernia recurrence(10.3%vs3.7%;p=0.01), though early patients had longer follow-up(2.8vs1.7years;p<0.01). Compared to those without recurrence, patients who recurred had similar age(p=0.4), BMI(p=0.4), diabetes rate(p=0.5), tobacco use(p=0.4), panniculectomy(p=0.3), and component-separation(p=0.15). Patients who recurred had a marked larger defect(282vs481cm2;p<0.01), more prior hernia surgeries(2.2vs3.1;p=0.01), higher rates of wound infection(10.0%vs38.1%;p=0.049), and wound breakdown(9.7% vs 33.3%;p<0.01). Respective multivariate models show increased risk of wound complication from diabetes(odds ratio:2.7;p=0.02), panniculectomy(2.7;p=0.011), and external-oblique release(5.1;p<0.01) with risk of recurrence increased by wound complication(3.8;p=0.03). Obesity, CDC wound class, DPC, tobacco, and Botox did not reach significance.
ConclusionPDM in CAWR performs well and has low recurrence rates. Internal assessment and implementation of EBP have improved outcomes such as LOS, wound complications, and recurrence rate.
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