By Monica J. Smith

AUSTIN, Texas—Tumors involving the abdominal wall are rare, but when they do occur, they can be quite complex in terms of radical resection and closure. However, very little is known about how to manage these tumors because most of the data are from case series.

To better describe the surgical management and outcomes of radical tumor resections from abdominal wall fascia, researchers at the Cleveland Clinic Foundation gathered outcomes on patients seen over a 10-year period ending in 2020 at their institution, a large tertiary center.

“Secondarily, we also wanted to compare wound morbidity for suture versus mesh closures and to adjust for defect width, fascial closure and CDC wound class,” said Sara Maskal, MD, a general surgery resident at the Cleveland Clinic Foundation, in Cleveland.

They included all patients who had a CPT code for a radical abdominal wall tumor resection, requiring that all patients had abdominal wall fascia resected. Mesh types were categorized as biologic, synthetic or biosynthetic, and hernia development was based on radiographic evaluation.

The majority, about 70%, of the 120 patients who met the inclusion criteria were female, with a mean age of 49 years, body mass index of 30 kg/m² and a variety of comorbidities. The majority, 62%, of the tumors were primary abdominal wall pathologies, most of which were desmoid or endometrioma, while 37% originated from a cancer elsewhere in the abdomen. The mean width was 6 cm, leaving a mean defect width of 8 cm after resection. The procedures were performed mainly by surgical oncologists and colorectal surgeons; a hepatobiliary and pancreatic surgeon performed many of the endometrioma resections.

Dr. Maskal and her colleagues found a variety of surgeon choices on mesh type and placement. “The majority, we were surprised to find, were inlay mesh placements,” she said.

The patients had a lot of comorbidities, and complications were high: 40 patients (34%) had a wound complication and seven (6%) required a reoperation within 30 days. “But looking at a multivariable analysis, mesh use was not associated with wound complication; defect width was statistically associated with wound complication, but the strongest predictor was wound class, being clean-contaminated or contaminated,” Dr. Maskal said.

In terms of oncology, with a follow-up of about four years, 27 patients, or 22%, had a recurrence of their primary tumors. The same proportion, 22%, also developed a hernia. Although most of those patients did not undergo surgical repair of their tumors, 30% required an operation for some other inter-abdominal pathology–related reason such as cancer recurrence, an obstruction or the need for a colectomy.

“This is one of the largest series to date of patients with these pathologies. We were hoping we would find a pattern of how people reconstruct them to be able to give some guidance or best strategy, but we found a huge variation,” Dr. Maskal said.

“The takeaway we’ve gotten from this data is that these are complex patients, and even though we have advanced strategies for closing hernias, formal reconstruction,” such as a compartment separation, “should be offered very selectively to these patients, and there should be a comprehensive discussion with the care team about who should undergo formal reconstruction,” she said.

Dr. Maskal added that this is an area of research that would benefit from collaborative data sharing. “The ACHQC [Abdominal Core Health Quality Collaborative] does have a button for these masses, so that would be a great way to share.”

The research was presented at the 2023 meeting of the American Hernia Society.

William Hope, MD, an associate professor of surgery at Novant Health in Wilmington, N.C., said Dr. Maskal and her colleagues should be congratulated for pursuing a topic that has not been well researched, and he agreed that capturing data on these patients in the ACHQC would be a good move.

“This study brings up more questions than answers, but it starts the conversation that we should be studying these patients in further detail. Involving an experienced abdominal wall/hernia surgeon to help in these cases would be a good message to send our colleagues who are performing these resections, because management of the fascial defects can be quite challenging, and if there are issues with these patients in the future, they will likely be the ones who have to take care of them.”