A systematic review and meta-analysis of technical aspects and clinical outcomes of botulinum toxin prior to abdominal wall reconstruction

Abstract

Purpose To systematically review technical aspects and treatment regimens of botulinum toxin A (BTA) injections in the lateral abdominal wall musculature. We also investigated the effect of BTA on abdominal muscle- and hernia dimensions, and clinical outcome. Methods PubMed, EMBASE, CENTRAL, and CINAHL were searched for studies that investigate the injection of BTA in the lateral abdominal wall muscles. Study characteristics, BTA treatment regimens, surgical procedures, and clinical outcomes are presented descriptively. The effect of BTA on muscle- and hernia dimensions is analyzed using random-effects meta-analyses, and exclusively for studies that investigate ventral incisional hernia patients. Results We identified 23 studies, comprising 995 patients. Generally, either 500 units of Dysport® or 200–300 units of Botox® are injected at 3–5 locations bilaterally in all three muscles of the lateral abdominal wall, about 4 weeks prior to surgery. No major procedural complications are reported. Meta-analyses show that BTA provides significant elongation of the lateral abdominal wall of 3.2 cm per side (95% CI 2.0–4.3, I2 = 0%, p < 0.001); 6.3 cm total elongation, and a significant but heterogeneous decrease in transverse hernia width (95% CI 0.2–6.8, I2 = 94%, p = 0.04). Furthermore, meta-analysis shows that BTA pretreatment in ventral hernia patients significantly increases the fascial closure rate [RR 1.08 (95% CI 1.02–1.16, I2 = 0%, p = 0.02)]. Conclusion The injection technique and treatment regimens of botulinum toxin A as well as patient selection require standardization. Bilateral pretreatment in hernia patients significantly elongates the lateral abdominal wall muscles, making fascial closure during surgical hernia repair more likely. Study registration A review protocol for this meta-analysis was registered at PROSPERO (CRD42020198246).

A computed tomography study investigating the effects of botulinum toxin injections prior to complex abdominal wall reconstruction

“…Several studies have been published on BTA, but only few have measured effects on LAW muscle length and -thickness and hernia width on CT. Our group have pooled these results in a recent published meta-analysis [ 14 ]. In present study, we used the latest computer techniques for assessment of all CT measures.…”

“…Third, differences in BTA effects across studies can theoretically be caused by differences in BTA techniques applied. We have applied a BTA technique that is commonly used and derived from our meta-analysis of various BTA technical details [ 14 ]. Fourth, decrease in hernia width is frequently the focus of BTA effects.…”

“…Since then, neoadjuvant use of BTA has acquired general acceptance in AWR. Recent studies propose that abdominal wall compliance is increased which facilitates fascial medialization, and possibly even precludes the need to perform surgical CST [ 12 – 14 ]. Further advantages of BTA are lack of adverse effects and the temporary, instead of permanent, working mechanism.…”

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

“…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.…”

Editorial: Botox in Complex Abdominal Wall Surgery

“…Adequate preoperative preparation of patients with LVH is crucial to avoid serious postoperative complications and to assure satisfactory results after hernia repair. For this reason, the use of the botulinum toxin type A (BTA) has emerged as a complementary therapy to facilitate this repair ( 1 ).…”