Preoperative botulinum toxin for complex abdominal wall reconstruction: a meta-analysis of propensity-score matched studies with trial sequential analysis.

Purpose: Large ventral hernias can be associated with significant loss of domain, and preoperative Botulinum Toxin A (BTA) has been suggested as an adjunct therapy to minimize the effects of ventral hernia repair and facilitate fascial closure. However, there is often bias in studies involving BTA and its use is associated with significant cost and its efficacy remains unclear.

Methods: We systematically searched Medline, Embase, Cochrane, and ClinicalTrial.gov for propensity-score matched (PSM) studies comparing preoperative BTA and AWR with standard AWR for complex hernias. We pooled odds ratios (ORs) and mean differences with 95% confidence intervals (CIs) to assess outcomes, applying a random-effects model. We used R studio version 4.3.1 for statistical analyses.

Results: We included six studies with PSM comprising 851 patients undergoing AWR. The mean age was 60.5 years, mean BMI was 31.8 kg/m, and 46.5% of patients were male. There were no significant differences between groups regarding fascial closure rate (OR 1.54; 95% CI 0.78 to 3.05; p = 0.21), hernia recurrence (OR 0.81; 95% CI 0.33 to 2.01; p = 0.65), component separation (OR 1.50; 95% CI 0.54 to 4.14 p = 0.4), surgical site infections and occurrences (OR 1.31; 95% CI 0.34 to 5.00; p = 0.70), length of hospital stay, or operation time. The Trial Sequential Analysis (TSA) indicated that none of the outcomes reached the necessary sample size for a definitive conclusion.

Conclusions: Preoperative BTA did not offer significant benefits in AWR of complex incisional hernia repairs. However, TSA showed that the required sample size was not achieved.