Originl Article Journl of the Koren Society of J Koren Soc Coloproctol 2012;28(6):299-303 http://dx.doi.org/10.3393/jksc.2012.28.6.299 pissn 2093-7822 eissn 2093-7830 Anlysis of Risk Fctors for the Development of Incisionl nd Prstoml Hernis in Ptients fter Colorectl Surgery In Ho Song, Heon-Kyun H, Sng-Gi Choi, Byeong Geon Jeon, Min Jung Kim, Kyu Joo Prk Deprtment of Surgery, Seoul Ntionl University College of Medicine, Seoul, Kore Purpose: The purpose of this study ws to evlute the overll rte nd risk fctors for the development of n incisionl nd prstoml fter colorectl surgery. Methods: The study cohort consisted of 795 consecutive ptients who underwent open colorectl surgery between 2005 nd 2007 by single surgeon. A retrospective nlysis of prospectively collected dt ws performed. Results: The overll incidence of incisionl s ws 2% (14/690). This study reveled tht the cumultive incidences of incisionl were 1% t 12 months nd 3% fter 36 months. Eighty-six percent of ll incisionl s developed within 3 yers fter colectomy. The overll rte of prstoml s in ptients with stom ws 6.7% (7/105). The incidence of prstoml s ws significntly higher in the colostomy group thn in the ileostomy group (11.9% vs. 0%; P = 0.007). Obesity, bdominl ortic neurysm, Americn Society of Anesthesiol ogists score, serum lbumin level, emergency surgery nd postopertive ileus did not influence the incidence of incisionl or prstoml s. However, the multivrite nlysis reveled tht femle gender nd wound infection were significnt risk fctors for the development of incisionl s femle: P = 0.009, wound infection: P = 0.041). There were no significnt fctors relted to the development of prstoml s. Conclusion: Our results indicte tht most incisionl s develop within 3 yers fter colectomy. Femle gender nd wound infection were risk fctors for the development of n incisionl fter colorectl surgery. In contrst, no significnt fctors were found to be ssocited with the development of prstoml. Keywords: Ventrl ; Surgicl stoms; Ileostomies; Colostomies INTRODUCTION Incisionl s re known to ccount for 2 to 20% of ventrl s fter bdominl surgeries [1-4]. Moreover, ccording to study on s, the incidence of incrcertion is 6 to 15% in ptients with incisionl s [5, 6]. When n incrcerted smll bowel is not immeditely treted, strngultion my occur in 2% of ptients with s [5]. This my led to serious complic- Received: August 14, 2012 Accepted: October 16, 2012 Correspondence to: Kyu Joo Prk, M.D. Deprtment of Surgery, Seoul Ntionl University Hospitl, 101 Dehk-ro, Jongno-gu, Seoul 110-744, Kore Tel: +82-2-2072-2901, Fx: +82-2-766-3975 E-mil: kjprkmd@plz.snu.c.kr 2012 The Koren Society of This is n open-ccess rticle distributed under the terms of the Cretive Commons Attribution Non- Commercil License (http://cretivecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. tions such s intestinl perfortion nd pnperitonitis. Thus, ctive surgicl tretment is criticl for ptients with s. Unlike generl opertions on bdominl orgns, orgn resection nd stom (colostomy nd ileostomy) construction re concurrently performed in most cses during colorectl opertions. Therefore, incisionl s, s well s prstoml s, my lso be ssocited with ventrl s. Although, the incidence of prstoml s increses over time, such s mostly occur within two yers fter stom construction [7, 8]. Prstoml s hve postopertive incidence rte of up to 5 to 30%, higher thn tht of ordinry incisionl s [9]. Although incisionl nd prstoml s re postopertive side effects inducing serious complictions, few studies hve been performed domesticlly on the incidence nd the risk fctors of those s during long-term follow-up periods fter colorectl surgery. Thus, this study imed to identify the incidence nd the risk fctors of bdominl s fter colorectl surgery in Kore. 299
Journl of The Koren Society of Anlysis of Risk Fctors for the Development of Incisionl nd Prstoml Hernis in Ptients fter Colorectl Surgery In Ho Song, et l. METHODS This study ws retrospective study with prospective dt collection on ptients who underwent colorectl surgery t Seoul Ntionl University Hospitl from Jnury 2005 to December 2007 in order to nlyze ptients with t lest five-yer follow-up postopertively. To prevent surgeon bis, we included only ptients who received colorectl surgery vi bdominl section from one experienced surgeon. Ptients with pst surgicl history were excluded from the study popultion, nd subjects were only followed until the point of performing nother surgery other thn stom tke-down. The follow-up period lsted until June 2012, nd ll opertions nd the closure of the bdominl wound were conducted with the sme procedure. The incision site ws closed with method of continuous running suture using 1-0 Vicryl (polyglycolic cid), nd the muscle fsci ws closed with the sme suturing method using 1-0 polydioxnone (PDS). The closure ws strengthened with simple interrupted suture using 1-0 Vicryl cid (polyglycolic cid). The study investigted the occurrence of s in ptients who underwent stom construction by clssifying subjects ccording to sex, ge, nd follow-up period, s well s the dependences of the occurrence of bdominl s on the cncer dignosis, the colorectl incision sites, nd the presence nd types of stom. The study exmined the following risk fctors with respect to s: ptient-relted risk fctors were ge, sex, body mss index, bdominl ortic neurysm, preopertive serum hemoglobin level, preopertive serum lbumin level, Americn Society of Anesthesiologists (ASA) score, nd the cuses of surgery. Surgicl risk fctors were the degree of emergency, preopertive bowel obstruction, preopertive bowel perfortion, opertion time, estimted blood loss, the presence of postopertive stom, postopertive infections, postopertive ileus (within 30 dys postopertively), nd dmission dys. The ws exmined by ctegorizing it s n incisionl nd prstoml. The study included cses where s were detected on physicl exmintion nd postopertive rdiologicl exmintion during the follow-up period. The ASA scores of only 770 ptients were recorded for dt collection, nd intropertive bleeding volumes were recorded only in 613 ptients. A life tble ws used in the nlysis of the cumultive survivl rte. A t-test ws used for univrite nlysis nd continuous vribles, nd chi-squre test ws used for ctegoricl vribles. Multivrite nlyses were conducted using cox-regression nlysis on vribles with P 0.1 in the univrite nlysis. All sttisticl nlyses were performed using the SPSS ver. 16.0 (SPSS Inc., Chicgo, IL, USA). RESULTS A totl of 965 ptients received surgery by one surgeon between Jnury 2005 nd December 2007. Among those, totl of 795 ptients were included s the study popultion: 690 ptients who did not undergo colostomy tke-down nd 105 ptients with stom tke-down. Subjects were 522 mles nd 273 femles, with men ge of 61 yers old (rnge, 19 to 91; stndrd devition [SD], ±12) nd n verge follow-up period of 39 months (rnge, 0 to 80; SD, ±23). Among ll subjects, incisionl s occurred in 17 ptients: 14 ptients without colostomy tke-down nd 3 ptients who received colostomy tke-down. Moreover, 7 ptients presented with prstoml. The distribution of incisionl nd prstoml s for the vrious types of surgeries is presented in Tble 1. Sixteen ptients with bdominl s underwent surgery. In ddition, eight ptients with conservtive tretment hd been followed up fter ws detected only on computed tomogrphy (CT) scn insted of physicl exmintion. The incidence of incisionl s ws 2% (14/690) in cses without stom construction. In contrst, the incidence of prstoml s ws 6.7% (7/105) in cses with stom construction. Surgery ws performed for prstoml fter n verge period of 3.5 months for 4 out of the 7 ptients who developed prstoml. On the other hnd, surgery ws not conducted on three ptients becuse the ws detected only on CT scn without ny symptoms. Ptients who underwent colostomy tke-down were clssified into ileostomy nd colostomy groups. In the ileostomy group, totl of 46 subjects did not develop prstoml. Among those, 32 ptients received ileostomy closure fter n verge period of 8.5 ± 3.9 months. In ddition, 14 ptients received permnent ileostomy with n verge follow-up period of 19.5 ± 17.7 months. Among the totl of 59 ptients in the colostomy group, 7 (11.9%) developed prstoml. A colostomy closure ws performed on three of those 59 ptients, with n verge follow-up period of 8.6 ± 4.4 months. Fifty-six ptients received permnent colostomy nd were followed for n verge period of over 25.5 ± 21.4 months. All prstoml s occurred in cses involving permnent colostomy. The incidence of prstoml s ws significntly higher in the colostomy group thn in the ileostomy group (P = 0.007) (Tble 2). Of the 14 ptients without stom construction who developed incisionl s, 7.1% (8/14) developed those s during the first postopertive yer, 78.6% (11/14) during the second post- Tble 1. Incidence of ventrl s ccording to dignosis nd site of opertion Opertion site No Incisionl Prstoml Totl Right colon 201 (98.0) 4 (2.0) 0 (0) 205 Left colon 33 (94.3) 2 (5.7) 0 (0) 35 Rectum 502 (96.5) 11 (2.1) 7 (1.4) 520 Others 35 (100) 0 (0) 0 (0) 35 Vlues re presented s number (%). Totl proctocolectomy, totl colectomy, subtotl colectomy nd debulking surgery with colon resection. 300
Volume 28, Number 6, 2012 J Koren Soc Coloproctol 2012;28(6):299-303 Journl of The Koren Society of opertive yer, nd 85.7% (12/14) during the third postopertive yer. However, incisionl s did not develop fter four yers. The cumultive incidences were 1%, 2%, nd 3% during the first, second, nd third yers, respectively, nd the cumultive incidence Tble 2. Incidence of prstoml s in the stom formtion group Ileostomy Colostomy P-vlue Prstoml 0.007 Yes 0 (0) 7 (11.9) No 46 (100) 52 (88.1) Tble 3. Chrcteristics of the stom group ccording to the development of n incisionl Chrcteristic No incisionl (n = 676) Incisionl (n = 14) P-vlue Age (yr) 60.9 ± 11.8 65.6 ± 7.9 0.142 Gender 0.005 Mle 446 (66.0) 4 (28.6) Femle 230 (34.0) 10 (71.4) Obesity 23.0 ± 3.0 24.1 ± 3.8 0.215 AAA 4 (0.6) 0 (0) 0.921 ASA score 0.136 2 596 (88.2) 11 (78.6) >2 60 (11.8) 3 (21.4) Cncer 649 (96.0) 14 (100) 0.569 Emergency 8 (1.2) 0 (0) 0.848 Bowel obstruction 126 (18.6) 2 (14.3) 0.503 Bowel perfortion 7 (1.0) 1 (7.1) 0.152 Preopertive nemi 299 (44.2) 7 (50.0) 0.436 Preopertive hypolbuminemi b 149 (22.0) 3 (21.4) 0.626 Opertion site 0.367 Right colon 198 (29.3) 4 (28.6) Left colon 33 (4.9) 2 (14.3) Rectum 419 (62.0) 8 (57.1) Other c 26 (3.8) 0 (0) Opertion time (min) 106.8 ± 58.1 143.9 ± 105.5 0.212 Estimted blood loss (ml) 212.1 ± 366.2 308.8 ± 304.6 0.459 Wound infection 43 (6.4) 3 (21.4) 0.060 Ileus 98 (14.5) 2 (14.3) 0.668 Hospitl sty (dy) 8.1 ± 5.0 13.2 ± 15.0 0.222 Vlues re presented s men ± stndrd devition or number (%). AAA, bdominl ortic neurysm; ASA score, Americn Society of Anesthesiologists score. Mle, serum hemoglobin 13; nd femle, serum hemoglobin 12. b Serum lbumin 3.0. c Totl proctocolectomy, totl colectomy, subtotl colectomy nd debulking surgery with colon resection. of 3% remined unchnged from the fourth yer. Furthermore, of the 7 ptients with stom construction who developed prstoml s, 28.6% (2/7) developed those s during the first postopertive yer, 57.1% (4/7) during the second postopertive yer, nd 71.4% (5/7) during the third postopertive yer. Only one ptient developed prstoml fter 5 yers. The cumultive incidences were 2%, 7%, nd 9% during the first, second, nd third yer, respectively, nd the incidence rte for prstoml s ws shown to be reltively higher compred to tht for incisionl s. However, the cumultive incidence of prstoml s remined unchnged t 9% fter the fourth yer postopertively. According to univrite nlysis, the risk fctors for n incisionl fter colorectl surgery were relted to the gender of subjects nd showed sttisticlly significnt tendency towrd surgicl wound infection (P = 0.06) (Tble 3). There were no fctors relted to the development of prstoml in the group performed with stom tke-down (Tble 4). The risk fctors for high incidence of incisionl s were identified to be sex (P = 0.009; Tble 4. Chrcteristics of the stom group ccording to the development of prstoml Chrcteristic No prstoml (n = 98) Prstoml (n = 7) P-vlue Age (yr) 60.5 ± 13.6 65.4 ± 12.1 0.351 Gender 0.866 Mle 67 (68.4) 5 (71.4) Femle 31 (31.6) 2 (28.6) Obesity 23 ± 3.1 24.9 ± 2.8 0.121 AAA 3 (3.1) 0 (0) 0.639 ASA score 0.847 2 82 (83.7) 6 (85.7) >2 11 (16.3) 1 (14.3) Cncer 89 (90.8) 7 (100) 0.402 Emergency 11 (11.2) 0 (0) 0.349 Bowel obstruction 26 (26.5) 0 (0) 0.116 Bowel perfortion 13 (13.3) 1 (14.3) 0.939 Preopertive nemi 12.4 ± 2.1 12.9 ± 91.6 0.548 Preopertive hypolbuminemi b 3.7 ± 0.6 3.7 ± 0.4 0.996 Opertion time (min) 153 ± 50.0 173 ± 73.0 0.333 Estimted blood loss (ml) 263 ± 212.0 342 ± 237.0 0.387 Wound infection 14 (14.3) 9 0.283 Ileus 32 (32.7) 0 0.070 Hospitl sty (dy) 11 ± 7.8 10.7 ± 4.4 0.935 Vlues re presented s men ± stndrd devition or number (%). AAA, bdominl ortic neurysm; ASA score, Americn Society of Anesthesiologists score. Mle, serum hemoglobin 13; nd femle, serum hemoglobin 12. b Serum lbumin 3.0. 301
Journl of The Koren Society of Anlysis of Risk Fctors for the Development of Incisionl nd Prstoml Hernis in Ptients fter Colorectl Surgery In Ho Song, et l. Tble 5. Multivrite nlysis of the risk fctors for the development of n incisionl fter colorectl surgery: Cox regression nlysis odds rtio, 4.686; 95% confidence intervl [CI], 1.5 to 15) nd postopertive incisionl infection (P = 0.041; Exp (B), 3.789; 95% CI, 1.1 to 13.6) ccording to the multivrite nlysis conducted on vrible found to hve significnt probbility of 0.1 in the univrite nlysis (Tble 5). DISCUSSION P-vlue Incisionl Odds rtio (95% confidence intervl) Gender 0.009 4.686 (1.5-15) Wound infection 0.041 3.789 (1.1-13.6) The incidences of incisionl s were reported to be 74.8% nd 88.9% in the first nd the second postopertive yers, respectively, ccording to study by Hoer et l. [10]. Moreover, the incidence of prstoml s incresed over time, nd prstoml s mostly occurred within two yers fter stom construction [7, 8]. Similrly, s developed in 85.7% of the ptients within the third postopertive yer, s reported in previous studies [7, 8, 10]. In ddition, the cumultive incidence remined unchnged from the fourth postopertive yer. When subjects were followed-up over five yers, incisionl nd prstoml s occurred within three yers in most cses, nd lmost no incidence ws observed from the fourth postopertive yer. However, this study detected one cse ech of n incisionl nd prstoml fter five yers. Thus, the possibility of n incisionl or prstoml occurring during long-term follow-up period could not be completely excluded. In this study, the incidence of prstoml s ws exmined by ctegorizing ptients who underwent colostomy tke-down into two subgroups: the ileostomy nd the colostomy subgroups. Prstoml s did not develop in the ileostomy subgroup while 11.9% of the ptients in the colostomy subgroup developed prstoml. According to study by Crne et l. [9] in 2003, the incidences of prstoml s rnged between 1.8 to 28% for n ileostomy nd 4 to 48% for colostomy, exhibiting higher rte in the group with colostomy closure. This study lso found sttisticlly higher significnce for the incidence of prstoml s in the colostomy subgroup. However, temporry enterostomy ws performed in 70% (32/46) of the ptients who received n enterostomy. In contrst, prstoml s were not detected for n enterostomy becuse colostomy closure ws conducted in 5% (3/59) of the ptients. The line lb nd the rectus sheth, which mintin the strength of the bdominl wll, re known to be heled pproximtely 120 dys fter suturing [11]. However, incisionl nd prstoml s my occur in cses of delyed or wekened heling process. The mechnisms nd the risk fctors hve not been clrified. Vrious risk fctors hve been clssified into three subctegories (disese, ptient, nd surgery). Disese-relted risk fctors tht hve been identified re obesity, ulcertive colitis (s opposed to Crohn s disese), constiption, cncer, etc. Ptient-relted risk fctors tht hve been identified re ge, mlnutrition, nd others. In ddition, surgicl risk fctors re emergency opertion (bowel obstruction nd perfortion), postopertive infection, etc. [12, 13]. This study exmined ll fctors tht could be collected from prospective dt. Postopertive wound infection is the third most common form of infection, ccounting for 14 to 16% [14] (up to 3 to 30% [15-18]) of ll infections fter urinry trct infection nd pneumoni. Furthermore, it is lso known to be one of the fundmentl cuses of incisionl s [19, 20]. According to this study, the incidence of postopertive wound infection ws 7.6% (60/7,795), which ws reltively low compred to vlues in previous studies [19, 20]. In ddition, lthough significnt increse ws shown in the incidence of incisionl s in ptients with wound infections (P = 0.041), no reltionship ws found with the incidence of prstoml s. All postopertive wound infections developed t the incision site in the stom construction group. Hence, direct reltionship between wound infection nd stom construction ws unverifible. Some previous studies reported reltionship between sex nd incisionl. The incidence of prstoml ws higher in femles ccording to domestic study performed by Prk et l. [21], nd higher incidence of bdominl s ws found during pregnncy ccording to studies of Seleverstov nd Hllowell [22], nd Weitzmn nd Drimer [23]. However, Lee et l. [24] reported tht no reltionship ws found between sex nd s. Although being femle ws identified to be risk fctor for incresing the incidence of incisionl s, no reltionship ws found between sex nd the incidence of prstoml s. Other fctors, including ptient chrcteristics (ge nd obesity), ptient preopertive risk fctors (blood lbumin level, nemi, ASA score, the presence of tumors, emergency surgery, intestinl obstruction, nd bowel perfortion), surgery-relted risk fctors (opertion time nd intropertive bleeding volume), nd postopertive risk fctors (, postopertive infections, ileus, nd dmission dys) hd no reltionship with the incidence of incisionl s. In prticulr, no risk fctors were found to be ssocited with prstoml s. This study hd severl strengths. First, subjects were comprised of pure study popultions tht received surgery by one surgeon. Second, the study excluded ptients with pst surgicl history nd only included ptients who underwent colorectl surgery, preventing potentil selective bis, unlike other previous studies. Third, 5-yer follow-up period enbled the study to sufficiently investigte the incidences of incisionl nd prstoml s. In conclusion, the risk fctors for the development of incisionl s fter colorectl surgery were gender nd postopertive incisionl infection. However, the study ws unble to detect fctors 302
Volume 28, Number 6, 2012 J Koren Soc Coloproctol 2012;28(6):299-303 Journl of The Koren Society of relted to the development of prstoml fter colorectl surgery. CONFLICT OF INTEREST No potentil conflict of interest relevnt to this rticle ws reported. REFERENCES 1. Sugermn HJ, Kellum JM Jr, Reines HD, DeMri EJ, Newsome HH, Lowry JW. Greter risk of incisionl with morbidly obese thn steroid-dependent ptients nd low recurrence with prefscil polypropylene mesh. Am J Surg 1996;171:80-4. 2. Lewis RT, Wiegnd FM. Nturl history of verticl bdominl prietl closure: Prolene versus Dexon. Cn J Surg 1989;32:196-200. 3. Mudge M, Hughes LE. Incisionl : 10 yer prospective study of incidence nd ttitudes. Br J Surg 1985;72:70-1. 4. Hodgson NC, Mlthner RA, Ostbye T. The serch for n idel method of bdominl fscil closure: met-nlysis. Ann Surg 2000;231:436-42. 5. Red RC, Yoder G. Recent trends in the mngement of incisionl tion. Arch Surg 1989;124:485-8. 6. Mnninen MJ, Lvonius M, Perhoniemi VJ. Results of incisionl repir. A retrospective study of 172 unselected hernioplsties. Eur J Surg 1991;157:29-31. 7. Mrtin L, Foster G. Prstoml. Ann R Coll Surg Engl 1996;78:81-4. 8. Heo SC, Oh HK, Song YS, Seo MS, Choe EK, Ryoo S, et l. Surgicl tretment of prstoml. J Koren Soc Coloproctol 2011;27:174-9. 9. Crne PW, Robertson GM, Frizelle FA. Prstoml. Br J Surg 2003;90:784-93. 10. Hoer J, Lwong G, Klinge U, Schumpelick V. Fctors influencing the development of incisionl. A retrospective study of 2,983 lprotomy ptients over period of 10 yers. Chirurg 2002; 73:474-80. 11. Dougls DM. The heling of poneurotic incisions. Br J Surg 1952; 40:79-84. 12. Pilgrim CH, McIntyre R, Biley M. Prospective udit of prstoml : prevlence nd ssocited comorbidities. Dis Colon Rectum 2010;53:71-6. 13. Murry BW, Cipher DJ, Phm T, Anthony T. The impct of surgicl site infection on the development of incisionl nd smll bowel obstruction in colorectl surgery. Am J Surg 2011; 202:558-60. 14. Smyth ET, Emmerson AM. Surgicl site infection surveillnce. J Hosp Infect 2000;45:173-84. 15. Stone HH, Hooper CA, Kolb LD, Geheber CE, Dwkins EJ. Antibiotic prophylxis in gstric, biliry nd colonic surgery. Ann Surg 1976;184:443-52. 16. Tng R, Chen HH, Wng YL, Chngchien CR, Chen JS, Hsu KC, et l. Risk fctors for surgicl site infection fter elective resection of the colon nd rectum: single-center prospective study of 2,809 consecutive ptients. Ann Surg 2001;234:181-9. 17. Goldring J, McNught W, Scott A, Gillespie G. Prophylctic orl ntimicrobil gents in elective colonic surgery: controlled tril. Lncet 1975;2:997-1000. 18. Kiser AB, Herrington JL Jr, Jcobs JK, Mulherin JL Jr, Roch AC, Swyers JL. Cefoxitin versus erythromycin, neomycin, nd cefzolin in colorectl opertions. Importnce of the durtion of the surgicl procedure. Ann Surg 1983;198:525-30. 19. Chng D, Yng H, Son S, Prk K. Clinicl evlution of incisionl. J Koren Surg Soc 1998;54:117-23. 20. Houck JP, Rypins EB, Srfeh IJ, Juler GL, Shimod KJ. Repir of incisionl. Surg Gynecol Obstet 1989;169:397-9. 21. Prk PS, Jung YH, Choi KP. A clinicl nlysis of incisionl. J Koren Surg Soc 1993;44:1029-37. 22. Seleverstov O, Hllowell PT. Ventrl during pregnncy: the single center experience. Am Surg 2011;77:E289-91. 23. Weitzmn CC, Drimer MG. Ventrl s compliction of pregnncy. J Int Coll Surg 1949;12:380-5. 24. Lee L, Mppin-Ksirer B, Sender Libermn A, Stein B, Chrlebois P, Vssiliou M, et l. High incidence of symptomtic incisionl fter midline extrction in lproscopic colon resection. Surg Endosc 2012;26:3180-5. 303