Outcomes of Chemical Component Paralysis Using Botulinum Toxin for Incisional Hernia Repairs
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Outcomes of Chemical Component Paralysis Using Botulinum Toxin for Incisional Hernia Repairs Benjamin Zendejas • Mohammad A. Khasawneh Boris Srvantstyan • Donald H. Jenkins • Henry J. Schiller • Martin D. Zielinski
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Published online: 1 October 2013 Ó Socie´te´ Internationale de Chirurgie 2013
Abstract Background Botulinum toxin A (BTX) confers flaccid paralysis and pain modulation when injected into a muscle. We hypothesized that long-term paralysis of the abdominal wall musculature (i.e., chemical component paralysis, CCP) would benefit incisional hernia repair (IHR) by decreasing postoperative pain, the use of opioid analgesia, and thus opioid-related side effects. Methods Adult patients who underwent elective IHR with preoperative CCP (n = 22) were compared to concurrent matched controls (n = 66, 1:3 ratio) based on age (±5 years), sex, body mass index (±5 kg/m2), history of hernia recurrence (0 vs. C1), and type of repair (open vs. laparoscopic). BTX was injected under ultrasonographic guidance into the transversus abdominis and internal and external oblique muscles at three sites bilaterally (300 units total). Results Patients who underwent IHR with CCP used significantly less opioid analgesia (mean ± SD morphine equivalents) when compared to controls on hospital days (HDs) 2 and 5: HD2, 48 ± 27 versus 87 ± 41; HD5,
This study was described in an oral presentation at International Surgical Week, Helsinki, Finland, August 25–29, 2013. B. Zendejas (&) M. A. Khasawneh B. Srvantstyan D. H. Jenkins H. J. Schiller M. D. Zielinski Department of Surgery, Mayo Clinic, Rochester, MN, USA e-mail: [email protected] M. D. Zielinski e-mail: [email protected] M. D. Zielinski Division of Trauma, Critical Care, and General Surgery, St. Mary’s Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN 55902, USA
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17 ± 16 versus 48 ± 45. Likewise, CCP patients reported significantly less pain (visual analogue scale 1–10) when compared to controls on HD2 (5.2 ± 1.5 vs. 6.8 ± 2) and HD4 (3.6 ± 1.2 vs. 5.2 ± 1.9): all p \ 0.007 (Bonferroni adjusted). There was no difference in postoperative complications (surgical site, 9 vs. 14 %), opioid-related adverse events (ileus 5 vs. 5 %), hospital stay (4 ± 3 vs. 3 ± 2 days), or hernia recurrence (18 months mean follow-up: 9 vs. 9 %). Conclusions Despite similar multimodality treatment of postoperative pain after IHR, patients who underwent CCP required significantly less opioid analgesia and reported less pain.
Introduction Patients undergoing incisional hernia repair (IHR) often suffer substantial postoperative pain, which directly affects the length of their hospital stay (LOS), quality of life, and time to return to full activity or work [1, 2]. Despite multimodal treatment of pain after IHR [i.e., opioids, nonsteroidal antiinflammatory agents (NSAIDs), topical and/or epidural anesthetics], opioids frequently represent the cornerstone of postoperative pain control. It is well known that opioid-based regimens are fraught with potent
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