Elevada incidencia de hernia incisional tras resección abierta y laparoscópica por cáncer colorrectal

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aunque en algunas situaciones el uso de malla es objeto de controversia por la posibilidad de incremento en la frecuencia de complicaciones<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La hernia incisional aparece tras laparotom&#237;a en frecuencia muy variable&#44; entre el 2 y el 20&#37; <a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;17</span></a>&#46; Esto sucede probablemente porque en los estudios realizados se incluyen todo tipo de laparotom&#237;as&#44; enfermedades&#44; abordajes y m&#233;todos de seguimiento&#44; lo que contribuye a una falta de homogeneidad al comparar los resultados&#46; Por ello&#44; probablemente la verdadera incidencia de las hernias incisionales est&#225; infraestimada<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Las consecuencias de las hernias incisionales son muy importantes en cuanto a morbilidad&#44; alteraciones de la calidad de vida&#44; y gasto sanitario<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#44; por lo que desarrollar medidas preventivas en grupos de pacientes y en intervenciones de elevado riesgo queda plenamente justificado<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Los pacientes intervenidos por c&#225;ncer de colon conforman un subgrupo cuyas caracter&#237;sticas hacen muy probable el desarrollo a largo plazo de hernias incisionales<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; Los estudios dirigidos de forma espec&#237;fica al an&#225;lisis de la incidencia de hernia incisional tras laparotom&#237;a media en estos pacientes son escasos y reportan cifras entre el 9 y el 33&#37;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;24</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los objetivos del presente estudio son&#58; determinar la frecuencia de hernia incisional en una cohorte de pacientes consecutivos sometidos a cirug&#237;a por c&#225;ncer colorrectal y que sobrevivieron al menos un a&#241;o tras la cirug&#237;a&#59; analizar los factores de riesgo asociados para determinar aquellos pacientes candidatos al uso de medidas profil&#225;cticas en el acto quir&#250;rgico primario&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Se revisaron retrospectivamente las historias cl&#237;nicas de los pacientes sometidos a cirug&#237;a electiva por c&#225;ncer colorrectal&#44; desde enero de 2006 hasta septiembre de 2008&#46; Todas las intervenciones fueron realizadas por el mismo equipo quir&#250;rgico&#46; La decisi&#243;n de la v&#237;a de abordaje se bas&#243; en la experiencia del cirujano en las t&#233;cnicas m&#237;nimamente invasivas&#44; el tama&#241;o del tumor&#44; la enfermedad de base y la presencia de cirug&#237;a abdominal previa&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Todos los pacientes recibieron preparaci&#243;n de colon con polietilenglicol&#44; profilaxis tromboemb&#243;lica con heparina de bajo peso molecular y profilaxis antibi&#243;tica con gentamicina y metronidazol&#46; En cirug&#237;a laparosc&#243;pica todos los orificios de trocar mayores de 5<span class="elsevierStyleHsp" style=""></span>mm fueron cerrados con puntos sueltos de Vicryl n&#176;&#160;1 &#40;Ethicon&#44; Cincinnati&#44; Ohio&#44; USA&#41;&#44; mientras que las incisiones para extracci&#243;n de la pieza se cerraron con sutura continua de polidioxanona n&#176;&#160;1 &#40;PDS&#41; &#40;Ethicon&#44; Cincinnati&#44; Ohio&#44; USA&#41;&#46; Las resecciones abiertas se realizaron por laparotom&#237;a media&#44; siendo cerrada la pared con sutura continua de polidioxanona n&#176;&#160;1 &#40;PDS&#41; &#40;Ethicon&#44; Cincinnati&#44; Ohio&#44; USA&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se recogieron los datos demogr&#225;ficos&#44; factores de riesgo del paciente&#44; datos de la cirug&#237;a&#44; complicaciones postoperatorias y tratamiento complementario posterior de la enfermedad oncol&#243;gica de la historia cl&#237;nica informatizada en la que hab&#237;an sido anotados en el momento de producirse y de la base de datos prospectiva de cirug&#237;a colorrectal de nuestro servicio&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Los criterios para el diagn&#243;stico de hernia incisional fueron&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Diagn&#243;stico cl&#237;nico durante el seguimiento postoperatorio&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Presencia en la TAC de control de una discontinuidad en la pared abdominal localizada en el &#225;rea de la cicatriz quir&#250;rgica&#44; acompa&#241;ada de protusi&#243;n a trav&#233;s de ella&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">Las TAC fueron analizadas por un observador independiente&#46; Los casos calificados como dudosos fueron revisados por un segundo observador y solo se consideraron como positivos aquellos en los que coincidieron los 2 observadores&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico se realiz&#243; con el programa SPSS 15&#46;0 &#40;IBM Inc&#46; Rochester&#44; MN&#44; USA&#41;&#46; Las variables cuantitativas se presentan como media &#177; desviaci&#243;n est&#225;ndar y las cualitativas como proporciones&#46; La asociaci&#243;n entre variables cualitativas se analiz&#243; mediante tablas de contingencia &#40;Chi cuadrado y prueba exacta de Fisher cuando fue preciso&#41;&#44; y las cuantitativas mediante el test de la t de Student para datos no apareados o la prueba de Mann-Whitney cuando fue necesario&#46; Se verific&#243; la normalidad de la distribuci&#243;n de las variables cuantitativas mediante la prueba de Kolmogorov-Smirnov&#46; La significaci&#243;n estad&#237;stica se estableci&#243; en p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><p id="par0075" class="elsevierStylePara elsevierViewall">Se analizaron las historias de 452 pacientes intervenidos &#40;348 por laparotom&#237;a y 104 por laparoscopia&#41; de los que se excluyeron 114 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> muestra las caracter&#237;sticas demogr&#225;ficas y comorbilidades de los pacientes y la comparaci&#243;n entre los grupos intervenidos por laparotom&#237;a &#40;LPT&#41; con los intervenidos por laparoscopia &#40;LPS&#41;&#46; La tasa de reconversi&#243;n fue de 10&#44;1&#37; &#40;9 de 89&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">En los 338 pacientes considerados v&#225;lidos&#44; tras una mediana de seguimiento de 19&#44;7 meses &#40;m&#237;n 12 m&#59; m&#225;x 47&#44;1 m&#41;&#44; un total de 87 &#40;25&#44;7&#37;&#41; fueron diagnosticados cl&#237;nicamente de hernia incisional&#59; 56 pacientes &#40;41 LPT y 15 LPS&#41; fueron sometidos a reparaci&#243;n quir&#250;rgica&#44; siendo el resto no intervenidos por diversos motivos &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">El estudio de las TAC de seguimiento permiti&#243; diagnosticar un 14&#44;2&#37; adicional de hernias &#40;33 LPT y 15 LPS&#41; no detectadas cl&#237;nicamente&#44; lo que eleva la tasa de la serie a un 39&#44;9&#37; &#40;135 pacientes&#41;&#46; Esto supone que una tercera parte de las hernias no fueron detectadas durante el seguimiento cl&#237;nico y solo se revelaron al examinar las exploraciones de imagen&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">La comparaci&#243;n de las v&#237;as de abordaje &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41; no detect&#243; diferencias significativas en la incidencia de hernias incisionales&#46; La detecci&#243;n cl&#237;nica fue mayor en los pacientes sometidos a laparotom&#237;a pero sin diferencias significativas &#40;67&#44;6 <span class="elsevierStyleItalic">vs&#46;</span> 56&#44;2&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;28&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En cuanto a la localizaci&#243;n &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#44; el 96&#44;0&#37; de las hernias incisionales de los pacientes del grupo LPT presentaron hernias en la l&#237;nea media &#40;39&#44;3&#37; del total&#41;&#46; Once pacientes &#40;10&#44;7&#37; de las hernias&#41; de este grupo presentaron una hernia incisional a nivel de una ostom&#237;a &#40;4 aislada y 7 combinada con hernia en la laparotom&#237;a&#41;&#46; Lo que supone una tasa del 15&#44;9&#37; de las ostom&#237;as &#40;11&#47;69 pacientes&#41;&#46; El 72&#44;7&#37; &#40;24 pacientes&#41; de las hernias incisionales del grupo LPS se localiz&#243; a nivel de los orificios de los tr&#243;cares&#44; ya sea de forma aislada &#40;23 pacientes&#41; o combinada &#40;un paciente&#41;&#46; Cinco pacientes &#40;15&#44;1&#37; del total de las hernias&#41; presentaron hernias incisionales a nivel de la incisi&#243;n de asistencia &#40;4 aisladas y uno combinada&#41; y 3 pacientes a nivel de las ostom&#237;as&#44; lo que supone un 33&#44;3&#37; de los pacientes ostomizados de este grupo&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La tasa total de hernia incisional en pacientes a los que se les realiz&#243; una ostom&#237;a &#40;tanto temporal como definitiva&#41; fue del 17&#44;9&#37;&#46; Seis &#40;21&#44;4&#37;&#41; de los 28 pacientes a los que se les practic&#243; una ostom&#237;a definitiva en la cirug&#237;a inicial&#44; presentaron una hernia paraestomal&#46; Los pacientes sometidos a ostom&#237;a temporal presentaron&#44; tras la reconstrucci&#243;n del tr&#225;nsito intestinal&#44; una tasa de hernias incisionales a trav&#233;s del antiguo orificio de la ostom&#237;a del 16&#37; &#40;8&#47;50&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">La comparaci&#243;n de los factores de riesgo potencialmente asociados con la aparici&#243;n de hernia incisional &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41; demostr&#243; diferencias estad&#237;sticamente significativas en&#58; el &#237;ndice de masa corporal &#40;IMC&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41;&#46; Al comparar los pacientes con sobrepeso &#40;IMC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>25&#41; con los de peso normal o bajo&#44; se demostraron tambi&#233;n diferencias significativas &#40;sobrepeso 51&#44;3&#37; vs&#46; normopeso 31&#44;1&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Igualmente mostraron una correlaci&#243;n significativa la aparici&#243;n de complicaciones postoperatorias &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#41;&#44; la infecci&#243;n superficial de herida quir&#250;rgica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#44; la reintervenci&#243;n quir&#250;rgica postoperatoria &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; y la dehiscencia de la anastomosis &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">La presencia de m&#250;ltiples comorbilidades present&#243; una mayor frecuencia de hernia incisional pero sin alcanzar la significaci&#243;n estad&#237;stica&#46; Los pacientes con m&#225;s de 3 comorbilidades presentaron un 45&#44;3&#37;de hernias incisionales &#40;39&#47;86&#41; y el grupo con menos de 3 comorbilidades un 38&#44;1&#37; &#40;96&#47;252&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0120" class="elsevierStylePara elsevierViewall">Nuestros resultados demuestran una elevada tasa de hernias incisionales tras resecci&#243;n de colon y recto por c&#225;ncer &#40;39&#44;9&#37;&#41;&#46; Otros estudios sobre hernias incisionales ofrecen datos muy dispares en cuanto a su incidencia&#44; abarcando un rango entre el 2 y el 20&#37; en laparotom&#237;a electiva&#44; incluyendo todo tipo de pacientes&#44; abordajes&#44; enfermedades y diversos sistemas de seguimiento<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;18&#44;25&#44;26</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de nuestra serie el &#250;nico factor individual asociado a una mayor tasa de hernia incisional fue el sobrepeso&#46; El IMC superior a 25&#160;kg&#47;m<span class="elsevierStyleSup">2</span> se ha revelado como un factor predisponente al desarrollo de hernia incisional&#46; Este hecho ya ha sido demostrado previamente<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> por lo que se deber&#237;an realizar estudios prospectivos para determinar si el uso de malla profil&#225;ctica es capaz de prevenir las hernias incisionales en estos pacientes&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Otras comorbilidades como el h&#225;bito tab&#225;quico&#44; la EPOC&#44; diabetes&#44; el estado nutricional&#44; la inmunosupresi&#243;n o la insuficiencia renal cr&#243;nica&#44; asociadas en la literatura<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> a mayor riesgo de padecer hernia incisional&#44; no demostraron asociaci&#243;n significativa &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; Estos datos concuerdan con los de otros estudios prospectivos<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; En los pacientes que presentaban un mayor n&#250;mero de comorbilidades asociadas no se constataron diferencias significativas en la incidencia de hernias incisionales &#40;menos de 3 comorbilidades 38&#44;1&#37; vs&#46; m&#225;s de tres comorbilidales 45&#44;3&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2&#41;&#44; pero esta tendencia y la mayor frecuencia de complicaciones que tienen lugar en estos pacientes sugieren que en este grupo ser&#237;a recomendable estudiar el uso de medidas profil&#225;cticas en la intervenci&#243;n inicial&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Tambi&#233;n han demostrado una asociaci&#243;n significativa la aparici&#243;n de complicaciones postoperatorias en general y la presencia de determinadas complicaciones como son&#58; la infecci&#243;n de herida quir&#250;rgica&#44; la dehiscencia de la anastomosis y la reintervenci&#243;n quir&#250;rgica postoperatoria&#46; Estos 2 &#250;ltimos factores se asociaron de forma casi ineludible a hernia incisional que apareci&#243; pr&#225;cticamente en el 90&#37; de los casos&#59; no podemos comparar nuestros resultados con los de otros autores porque no existen estudios previos espec&#237;ficos sobre la asociaci&#243;n entre hernia incisional&#44; dehiscencia de anastomosis y reintervenci&#243;n&#46; Por nuestros datos&#44; en dichos pacientes&#44; se deber&#237;a evaluar el uso de medidas preventivas en el momento de la reintervenci&#243;n&#44; aunque trat&#225;ndose de un territorio frecuentemente muy contaminado&#44; no parece aconsejable el uso de malla profil&#225;ctica de forma sistem&#225;tica&#46; En el futuro&#44; se deber&#237;an desarrollar dispositivos seguros para su uso en este tipo de situaciones&#58; en ese sentido&#44; las mallas biol&#243;gicas o las impregnadas con sustancias antis&#233;pticas y&#47;o antibi&#243;ticas pudieran ser de utilidad y deber&#237;an ser evaluadas en estudios prospectivos&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La infecci&#243;n de herida quir&#250;rgica ha sido detectada en diversos previamente<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> como un factor predisponente en porcentajes que oscilan entre el 21&#44;7&#37; en la infecci&#243;n superficial y el 50&#37; en la infecci&#243;n profunda&#46; En nuestro estudio el 53&#44;2&#37; de los pacientes con infecci&#243;n de herida presentaron hernia incisional&#46; Introducir medidas de mejora para prevenir la infecci&#243;n del sitio quir&#250;rgico producir&#225; un descenso notable en las hernias incisionales&#46; El tratamiento antibi&#243;tico t&#243;pico al finalizar la cirug&#237;a ha sido evaluado recientemente para la prevenci&#243;n de la infecci&#243;n de herida sin conseguirse una mejor&#237;a<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">La principal preocupaci&#243;n derivada de nuestro estudio es comprobar si los resultados demostrados pudieran ser producto de errores en la t&#233;cnica del cierre&#46; Al respecto&#44; debemos se&#241;alar que en todos los casos se utiliz&#243; la misma t&#233;cnica y el mismo material&#46; Obviamente&#44; dado que se trata de un estudio retrospectivo&#44; no podemos aportar con seguridad datos sobre si se mantuvo de forma estricta la relaci&#243;n 4&#58;1 tal como aconseja la bibliograf&#237;a&#44; pero todos los cirujanos participantes son conocedores de este dato&#44; y de forma rutinaria se usan 2 suturas de 75<span class="elsevierStyleHsp" style=""></span>cm cada una que deber&#237;an ser suficientes para mantener dicha relaci&#243;n&#46; Este hecho pone de relieve la necesidad de invertir en el dise&#241;o e investigaci&#243;n de sistemas de cierre o de ayuda al cierre m&#225;s all&#225; de las agujas y suturas&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">La alta prevalencia de hernia incisional de nuestro trabajo&#44; con seguridad&#44; viene influenciada por el uso de la TAC&#46; Su uso permiti&#243; identificar un 35&#44;1&#37; de hernias que hab&#237;an pasado desapercibidas durante el seguimiento&#44; lo que hubiera supuesto una incidencia del 25&#44;7&#37;&#44; no muy alejada de la aportada por la literatura&#46; Este mismo hecho ha sido constatado en otros estudios<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#44; lo que certifica que para conocer la frecuencia real de hernia incisional no basta con la exploraci&#243;n cl&#237;nica&#46; Los estudios futuros sobre esta enfermedad deben basar sus datos en la confirmaci&#243;n mediante t&#233;cnicas de imagen de la ausencia de hernia incisional&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">La utilizaci&#243;n de la v&#237;a laparosc&#243;pica para la resecci&#243;n de colon se ha asociado&#44; seg&#250;n algunos autores&#44; a una disminuci&#243;n de su prevalencia<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;24</span></a>&#46; La ausencia de diferencias en nuestro estudio confirma los datos de otros estudios recientes<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;23&#44;24</span></a>&#46; En este sentido&#44; a pesar de que hay diferencias significativas entre los grupos&#44; es notable destacar que estas favorecer&#237;an en principio al grupo LPS que debiera sufrir una menor proporci&#243;n de hernias incisionales &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Es probable que la baja incidencia reportada inicialmente<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> se haya ido viendo incrementada a medida que se han aumentado las indicaciones y se han operado pacientes con mayor dificultad y por lo tanto&#44; con un n&#250;mero mayor de factores de riesgo&#46; Por lo tanto&#44; en los pacientes intervenidos por v&#237;a laparosc&#243;pica&#44; se deben considerar las mismas medidas preventivas que en los pacientes intervenidos por laparotom&#237;a&#44; tanto en los orificios de los tr&#243;cares como en las incisiones de asistencia&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">El principal punto d&#233;bil de nuestro estudio es su car&#225;cter retrospectivo&#46; Pese a ello&#44; los datos se han obtenido de los registros informatizados de las historias cl&#237;nicas de los pacientes&#44; lo que ofrece una alta fiabilidad&#44; ya que fueron registrados en el momento de producirse y ha permitido recuperar la pr&#225;ctica totalidad de los datos de todos los pacientes&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">El importante n&#250;mero de pacientes estudiados&#44; el seguimiento m&#237;nimo de un a&#241;o en todos ellos y el an&#225;lisis basado en pruebas de imagen constituyen puntos fuertes del estudio&#44; aunque este &#250;ltimo dato puede producir un sesgo para sobrediagnosticar hernias incisionales que pudieran pasar desapercibidas durante toda la vida del paciente y no precisaran tratamiento&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la elevada tasa de hernia incisional demostrada hace recomendable considerar candidatos al uso de medidas profil&#225;cticas como la inserci&#243;n de una malla a los pacientes con IMC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>25&#46; Los pacientes que precisen reintervenci&#243;n deben recibir una malla profil&#225;ctica siempre que la contaminaci&#243;n del territorio quir&#250;rgico lo permita&#46; Un estudio prospectivo aleatorizado parece ineludible a la vista de los datos aportados&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0175" class="elsevierStylePara elsevierViewall">Los autores declaran que no tienen ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Determinar la tasa de hernia incisional en pacientes intervenidos por neoplasia de colon y recto&#46; Analizar los factores de riesgo individuales y determinar aquellos pacientes en los que pudiera ser adecuado el uso de medidas profil&#225;cticas&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de los datos demogr&#225;ficos&#44; quir&#250;rgicos&#44; complicaciones&#44; factores de riesgo y evoluci&#243;n de todos los pacientes intervenidos por c&#225;ncer colorrectal en el per&#237;odo enero de 2006 y septiembre de 2008&#46; El diagn&#243;stico de hernia incisional se hizo mediante exploraci&#243;n f&#237;sica o mediante revisi&#243;n de la TAC de seguimiento&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se revis&#243; a un total de 338 pacientes &#40;249 laparotom&#237;a y 89 laparoscopia&#41;&#46; Tras una mediana de seguimiento de 19&#44;7 meses&#44; 87 pacientes &#40;25&#44;7&#37;&#41; fueron diagnosticados por exploraci&#243;n f&#237;sica de hernia incisional&#46; La TAC permiti&#243; diagnosticar 48 hernias &#40;14&#44;2&#37;&#41; no detectadas cl&#237;nicamente&#46; La tasa de hernia incisional fue del 39&#44;9&#37; &#40;135 pacientes&#41;&#46; No hubo diferencias significativas entre los pacientes intervenidos por laparotom&#237;a &#40;40&#44;9&#37;&#41; y laparoscopia &#40;37&#44;1&#37;&#41;&#46; En pacientes con sobrepeso &#40;IMC&#160;&#8805;&#160;25&#160;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; la tasa de hernia incisional fue del 51&#44;3&#37; frente a un 31&#44;1&#37; en los pacientes con peso normal &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#46; La aparici&#243;n de complicaciones postoperatorias &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#41;&#44; infecci&#243;n de herida quir&#250;rgica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41; y reintervenci&#243;n durante el periodo postoperatorio &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; tambi&#233;n se asoci&#243; a mayor tasa de hernia incisional&#46;</p> <span class="elsevierStyleSectionTitle">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de hernia incisional tras resecci&#243;n por c&#225;ncer colorrectal es superior a la esperada &#40;39&#44;9&#37;&#41;&#46; Los pacientes con un IMC superior a 25&#160;kg&#47;m<span class="elsevierStyleSup">2</span> y los que precisan reintervenci&#243;n son candidatos a recibir una malla profil&#225;ctica&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To determine the incidence of incisional hernia in patients subjected to colorectal cancer surgery&#46; To analyse the individual risk factors and to determine which patients would benefit more from the use of prophylactic measures&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was performed on the demographic and surgical data&#44; as well as the complications&#44; risk factors and outcomes of all patients subjected to colorectal cancer surgery in the period between January 2006 and September 2008&#46; The diagnosis of incisional hernia was made by means of physical examination or by a review of the follow up CT scan&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 338 patients were reviewed &#40;249 laparotomy and 89 laparoscopy&#41;&#46; After a median follow-up of 19&#46;7 months&#44; 87 patients &#40;25&#46;7&#37;&#41; were diagnosed with incisional hernia by a physical examination&#46; The CT scan enabled 48 hernias &#40;14&#46;2&#37;&#41; not detected clinically&#46; The incisional hernia rate was 39&#46;9&#37; &#40;135 patients&#41;&#46; There were no significant differences between patients subjected to laparotomy &#40;40&#46;9&#37;&#41; or laparoscopy &#40;37&#46;1&#37;&#41;&#46; The incisional hernia rate in overweight patients &#40;BMI &#8805; 25 Kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; was 51&#46;3&#37; compared to 31&#46;1&#37; in patients with normal weight &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#46; Post-surgical complications &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;007&#41;&#44; surgical wound infections &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#44; and further surgery during the post-operative period &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41;&#44; was also associated with a higher incidence of incisional hernia&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The prevalence of incisional hernia after colorectal cancer resection is higher than expected &#40;39&#44;9&#37;&#41;&#46; Patients with a BMI greater than 25&#160;kg&#47;m<span class="elsevierStyleSup">2</span>&#44; and those who require further surgery are candidates to receive a prophylactic mesh&#46;</p>"
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                  \t\t\t\t">8 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;04&nbsp;\t\t\t\t\t\t\n
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                  """
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas de los pacientes</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">LPT&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">LPS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Hernia incisional</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">102 &#40;40&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;37&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Incisi&#243;n de asistencia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;12&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trocar e incisi&#243;n asistencia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1 &#40;3&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Laparotom&#237;a y ostom&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;6&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0 &#40;0&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">IMC&#58; &#237;ndice de masa corporal&#59; SD&#58;desviaci&#243;n est&#225;ndar&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Sin hernia n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>203 &#40;60&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbilidades</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tabaquismo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Broncopat&#237;a cr&#243;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tratamiento con esteroides&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cirug&#237;a previa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">50 &#40;42&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69 &#40;67&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Malnutrici&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;35&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38 &#40;64&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insuficiencia renal cr&#243;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27 &#40;50&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27 &#40;50&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Radioterapia&#47;quimioterapia previa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sobrepeso &#40;IMC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>25&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">58 &#40;51&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">55 &#40;48&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesidad &#40;IMC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>29&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">46 &#40;52&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">41 &#40;47&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ostom&#237;a&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38 &#40;48&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27 &#40;54&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23 &#40;46&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11 &#40;39&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">17 &#40;60&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;99&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Complicaciones&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">60 &#40;49&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">61 &#40;51&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;87&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">3 &#40;12&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;0&#44;0001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dehiscencia de anastomosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;90&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;10&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Infecci&#243;n superficial herida&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;04&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Wound dehiscence&#58; is still a problem in the 21th century&#46; A retrospective study"
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                        0 => array:2 [
                          "etal" => true
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                            2 => "A&#46; Datsis"
                            3 => "A&#46; Vaxevanidou"
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                            3 => "P&#46; Arends"
                            4 => "J&#46; Boom"
                            5 => "J&#46; Jeekel"
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                            0 => "J&#46;M&#46; Strzelczyk"
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                        "tituloSerie" => "Br J Surg"
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