Botulinum toxin A in abdominal wall reconstruction for incisional hernia: an interesting line of research in abdominal wall and plastic surgery : IJS Global Health

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Botulinum toxin A in abdominal wall reconstruction for incisional hernia: an interesting line of research in abdominal wall and plastic surgery

Lozada-Martinez, Ivan D. MSa,b; Zaghab Zgieb, Feraz F. MDc; González Casas, Juan P. MDd; Barbosa Pérez, Marcela MDe; Caballero Mieles, Rafael S. MDf; Narvaez-Rojas, Alexis R. MDb,

Author Information
International Journal of Surgery: Global Health: September 2022 - Volume 5 - Issue 5 - p e83
doi: 10.1097/GH9.0000000000000083
  • Open

Hernias continue to be one of the main surgical procedures performed globally. Large incisional hernias can leave a scar that compromises the patient’s esthetics and self-esteem, as well as the risk of a defect during closure, which entails high health costs due to complications or reinterventions1. According to the objectives of global surgery for 2030 proposed by The Lancet Commission on Global Surgery2, promoting the performance of surgical techniques and improving global outcome indicators, as well as reducing catastrophic spending and additional health costs, are a priority today3. Therefore, the investigation of techniques or strategies that are useful to improve the performance of abdominal wall reconstruction (especially in complex cases) for large incisional hernias has been considered a hot topic in recent years in abdominal wall and plastic surgery, with several gaps in available evidence4,5.

Botulinum toxin A is a neurotoxic compound produced by the bacterium Clostridium botulinum, which has an affinity for glycoproteins located at the terminal level of nerves with cholinergic receptors, temporarily inhibiting the transmission of impulses with motor and autonomic effects6. It has been described to have a safe profile when administered in remote areas of vital organs. In biological models, it has been shown to induce a decrease in intra-abdominal pressure when administered in the preoperative time, facilitating closure of the hernial defect without the need to resort to the component separation technique7. In human studies, temporal paralysis of the lateral muscles has been found to allow primary fascial closure, with an adequate effectiveness, efficiency, and safety profile6,8,9. However, these studies have been carried out almost entirely in high-income countries1,5, and the behavior of this intervention in other populations with different sociodemographic, genetic, and epigenetic characteristics is unknown.

Such studies began to be published around 2010, and recently a systematic review and meta-analysis by Timmer et al5, where the authors synthesized evidence for technical aspects and clinical outcomes when using botulinum toxin A in the reconstruction of the abdominal wall, was published, showing that in 23 studies with a total of 995 patients, the administration of 500 units of Dyspor or 200–300 units of Botox up to 4 weeks before surgery, generated a significant elongation of the lateral abdominal wall of 3.2 cm per side (95% confidence interval: 2.0–4.3, P<0.001), 6.3 cm of total elongation and a significant decrease in transverse hernia width (95% confidence interval: 0.2–6.8, P=0.04). No major complications were found, and additionally, it was evidenced that in those patients with ventral hernia the rate of fascial closure increases significantly5. However, it should be noted that the heterogeneity of the outcomes evaluated ranges from 0 to 94%, due to the limited sample and the divergence in the calculation of outcomes5. Although the authors mention the need to standardize the technique, there are really no cost-effectiveness analyses or massive multicenter studies that allow for complex analyses by subgroups and extrapolate results worldwide.

The applicability has been studied through laparoscopic interventions, complex, and noncomplex incisional hernias, in patients with adequate body mass index and morbid obesity, generally in individuals with transition to old age (around 60 y old) and with defects with a maximum size of 27 cm6,8,9. The evidence clearly suggests that the use of botulinum toxin A in abdominal wall reconstruction for incisional hernias improves the performance of the procedure, maintaining a near-zero recurrence and complication rate.

The use of a chemical compound such as botulinum toxin A in plastic, reconstructive, and abdominal wall surgery, which naturally has a harmful neurotoxic effect, opens the door for the design of a new line of research that can be developed in basic, translational, clinical, outcome, and medical education research. On the basis of the results observed over the years, authors such as Smith et al4 designed and implemented abdominal wall service programs in specialized care units, with the aim of promoting the care of this group of patients. The authors reported that the experience, streamline and final satisfaction of the service was favorable and could be reproducible in other parts of the world4. In this order of ideas, the need to create centers or units specialized in surgical care10, which are available exclusively for certain services, in order to achieve the highest quality and performance of care, is highlighted.

Translational research is a field that should be rigorously encouraged and strengthened in low and middle-income countries, such as those in Latin America and the Caribbean, to enable the production of new knowledge applicable to biomedical sciences11. Plastic surgery is a specialty that has made great advances in this region, and could transcend with the support of experimental studies. The inclusion of medical students and general practitioners could be crucial in supporting the execution of clinical studies, as well as the training of future plastic and abdominal wall surgeons12,13. Therefore, interest groups in plastic surgery should be massified in order to promote complementary training that facilitates the dissemination of practical concepts in the general and academic population, which should be constantly evaluated to corroborate its usefulness and impact13. Thus, the use of botulinum toxin A for abdominal wall reconstruction for incisional hernias still has large gaps in the evidence, making it an attractive line of research in plastic and abdominal wall surgery, which can be exploited in Colombia and other countries, to contribute to the new knowledge of global surgery.

Ethical approval

None.

Sources of funding

None.

Authors’ contribution

All authors equally contributed to the analysis and writing of the manuscript.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

None.

Guarantor

Alexis R. Narvaez-Rojas.

References

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