Surgical wound complications after groin dissection in melanoma patients – A historical cohort study and risk factor analysis

https://doi.org/10.1016/j.ejso.2014.01.019Get rights and content

Abstract

Background and objectives

Wound complications occur frequently after inguinal lymph node dissection (ILND) in melanoma patients. Evidence on risk factors for complications is scarce and inconsistent. This study assessed wound complication rates after ILND and investigated associated risk factors, in the melanoma unit of a specialised cancer hospital.

Methods

A chart review was conducted of all patients on whom inguinal lymph node dissection had been performed between 2003 and 2013. Wound infections, seroma formation and skin flap problems were assessed according to explicit definitions and graded through the modified Clavien system. Univariable and multivariable penalized logistic regression was used to identify risk factors. The primary factors of interest were body mass index, age, smoking, diabetes, cardiovascular and/or pulmonal comorbidity, palpable disease and postoperative bedrest. Additionally, the influence of incision-type, sartorius transposition, saphenous vein sparing and skin removal was examined.

Results

A total of 145 procedures was examined. One or more complications occurred in 104 (72%) of the procedures; wound infection in 45%, seroma formation in 37% and skin flap problems in 26%. The only statistically significant risk factor was age (odds ratio for one standard deviation increase: 1.46, 95%CI 1.01–2.14, p = 0.05).

Conclusions

Wound complication rates after ILND in melanoma patients are high. Age was the only predictor of complications in this cohort, other previously identified risk factors could not be confirmed.

Introduction

Inguinal lymph node dissection (ILND) is considered the standard procedure in melanoma patients when an involved sentinel node is found or in case of cytology confirmed palpable metastasis in the groin. The procedure is considered high-risk in terms of postoperative wound complications such as infection, seroma, skin edge necrosis and wound breakdown.1, 2, 3, 4, 5 Identifying risk factors may offer opportunities to reduce the risk of such morbidity. Previously found risk factors include patient-related elements such as age, smoking habit, comorbidity and body mass index (BMI), but also surgery-related factors like extent of dissection, disease-related factors like the number of involved lymph nodes, and aspects of postoperative management.1, 2, 3, 4, 5, 6 The presence and strength of the associations found in these studies varies, prompting further research.

Current evidence suggests that centralization of surgical treatment in specialized hospitals with high volumes of patients improves outcome for several types of cancer, particularly in terms of postoperative mortality and survival, although this has not yet been shown for lymph node dissection in melanoma patients.7, 8, 9 Assuming that skill and postoperative management improve with experience, one might also expect lower postoperative wound complication rates in high-volume hospitals. Yet, the volume-outcome relationship for this outcome is not consistent in the literature for a range of procedures.9, 10, 11, 12, 13

As part of a quality improvement project for the surgical care of patients undergoing inguinal lymph node dissection for melanoma, a historical cohort study was performed at The Netherlands Cancer Institute, a specialized cancer hospital with a melanoma unit. The objective of this study was to assess the frequency of early surgical wound complications after ILND and to identify patient-, disease- and treatment-related risk factors for the occurrence of surgical wound complications.

Section snippets

Surgical technique of inguinal and additional iliacal/pelvic lymphadenectomy and postoperative management

Inguinal lymph node dissection, also referred to as ‘superficial groin dissection’, concerns the removal of all fat and lymphatic tissue in the femoral triangle and anterior to the abdominal wall muscles. Different types of incision may be used, dependent on the surgeon's preferences; a longitudinal incision, or a single transverse incision for superficial dissection 1–2 cm caudal of the inguinal crease. If skin is removed, an elliptical incision is used. The lateral border of the dissection is

Complication rates

A total number of 145 ILNDs in 138 patients were included in the study; seven patients underwent ILND on both sides, but on separate dates. Patients had a median age of 56 years (range 15–84) and 43% was male. The majority of patients (82%) underwent both a superficial and deep dissection. Table 1 summarizes the characteristics of the patients and Table 2 the characteristics of the procedures with and without subsequent early wound complications. One or more complications occurred in 104 (72%)

Discussion

This study shows that for a complication-prone procedure such as ILND, complication rates can still be high even in a specialized hospital with a high volume of patients. Of the risk factors under examination, only age had a statistically significant association with the occurrence of complications in this cohort.

Conclusion

ILND in melanoma patients is associated with a high complication rate (72% in this study), even in a high volume, specialized cancer hospital. Age was the only statistically significant predictor for the occurrence of wound complications in this cohort, although smoking history added to the risk. A risk model containing these variables has only limited predictive value for the occurrence of early wound complications, warranting further research into risk factors for early wound complications

Role of funding source

The authors did not receive funding for this study.

Conflict of interest

All authors declare no conflict of interest. No financial benefit has been obtained.

References (24)

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