Lateral pararectal versus transrectal stoma placement for prevention of parastomal herniation

Small-bowel plication prevents ileostomy prolapse in young children with inflammatory bowel disease

PURPOSE

Young children with medically refractory very early-onset inflammatory bowel disease (VEO-IBD) sometimes benefit from ileostomy diversion alone or may be offered subtotal colectomy with ileostomy. Though generally well-tolerated, ileostomy complications are frequent. Prolapse is particularly frustrating as it can be difficult and painful to reduce, becomes a recurring problem is some patients, and often requires ostomy revision or bowel resection.

METHODS

Over the course of the past 6 months, eight consecutive children with VEO-IBD underwent 10 creation or revision of a diverting ileostomy (two underwent subsequent colectomy with ileostomy revision). In each of these 10 cases, we plicated the ileum just proximal to the ileostomy for a distance of approximately 3 cm using a running permanent monofilament suture.

RESULTS

No patient who underwent plication of bowel has developed ileostomy prolapse. There were no cases of ileostomy retraction, parastomal hernia or ostomy-level obstruction. One patient required a lysis of a single band adhesion for a more proximal small bowel obstruction. The stomas have functioned well and there have been no complications.

CONCLUSION

Simple bowel plication appears to be a quick and effective way to prevent ileostomy prolapse in young children with VEO-IBD with an ileostomy who are at high risk for prolapse.

A Modified Surgical Technique to Prevent Parastomal Hernia

An extraperitoneal colostomy is not sufficiently effective in preventing parastomal hernias. On the basis of anatomic structures and mechanical principles, we modified this surgical technique by preserving the integrity of the posterior rectus abdominis sheath to prevent parastomal hernia, and we applied it clinically.

Virtual simulation of the biomechanics of the abdominal wall with different stoma locations

An ostomy is a surgical procedure by which an artificial opening in the abdominal wall, known as a stoma, is created. We assess the effects of stoma location on the abdominal wall mechanics. We perform three-dimensional finite element simulations on an anatomy model which was generated on the basis of medical images. Our simulation methodology is entirely based on open source software. We consider seventeen different locations for the stoma incision (trephine) and we simulate the mechanical response of the abdominal wall when an intraabdominal pressure as high as 20 kPa is applied. We focus on factors related to the risk of parastomal hernia development such as the deformation experienced by the abdominal wall, the stress levels supported by its tissues and the corresponding level of trephine enlargement. No significant dependence was found between stoma location and the levels of abdominal wall deformations or stress supported by tissues, except for the case with a stoma located on the linea alba. Trephine perimeter and area respectively increased by as much as [Formula: see text] and [Formula: see text]. The level of trephine deformation depends on stoma location with considerably higher trephine enlargements found in stomas laterally located with respect to the rectus abdominis muscle.

Surgical treatment of stoma-related hernias: retrospective cohort study of damage claims to the Swedish National Patient Insurance Company 2010-2016

Background

Parastomal hernia and stoma-site hernia are common stoma complications. Parastomal hernia repair is associated with high complication and recurrence rates. Insurance data can provide novel information on the consequences of perioperative complications from the patient’s point of view. The aim was to investigate what types of complications associated with stoma-related hernia surgery that cause patients to apply for economic compensation through the patient insurance system and to investigate demographic and clinical differences among cases based on gender and type of center at which the surgery was performed.

Methods

A national patient damage claim database was searched for ICD-10 codes related to parastomal and stoma-site hernia surgery over a seven-year period. Medical records were screened for claims associated with parastomal hernia repair, relocation or reversal due to parastomal hernia, or stoma-site hernia repair. Claims were classified according to one of four primary complaints: surgical, anesthetic, medical or other. Clinical and demographic differences between genders and hospital types were investigated. Reasons for non-compensation were analyzed.

Results

Thirty claims met the inclusion criteria. Eighteen were related to parastomal hernia repair, seven to stoma-site hernia repair, three to stoma reversal and two to relocation due to parastomal hernia. Twenty-five claims were primarily surgical, two related to anesthesia and three classified as other. Seven claims were granted compensation. No demographic or clinical differences were found apart from female gender being associated with previous parastomal hernia repair [6 women and 0 men (p = 0.02)].

Conclusion

Surgical complaints predominated. Few claims were compensated, reflecting the complexity and unsatisfactory outcomes of these procedures. Many claims were identified in relation to the incidence of stoma-related hernia surgery.

Trial registration

Due to its retrospective and descriptive nature, the study was not registered in any registry.

Prophylactic retromuscular mesh placement for parastomal hernia prevention: a retrospective cohort study of permanent colostomies and ileostomies

PURPOSE

Parastomal hernia (PSH) is the most common complication of stoma formation. The safety and efficiency of prophylactically placing mesh to prevent PSH remain controversial. To address this question, we examined the incidence of clinical and radiological PSH when using parastomal prophylactic mesh (PPM).

METHODS

We performed a retrospective, single-center, cohort study that included all patients with permanent stoma creation between 2015 and 2018. Patients were divided into two groups according to the utilization of PPM or not.

RESULTS

During the study period, 185 patients had a permanent stoma created, 144 with colostomy and 41 with ileostomy. PPM was placed in 79 patients. There was no difference in the need for early surgical reintervention (p = 0.652) or rehospitalization (p = 0.314) for stoma-related complications in patients with mesh as compared with patients without. Similarly, there was no difference in operative time (p = 0.782) or in length of hospital stay (p = 0.806). No patients experienced infection of the mesh or required prosthesis removal. There was a lower incidence rate of PSH with PPM placement in patients with permanent colostomy [adjusted hazard ratio (HR) 0.50 (95% confidence interval 0.28-0.89); p = 0.018]. In contrast, a higher incidence rate of PSH was observed in patients with ileostomy and PPM [adjusted HR 5.92 (95% confidence interval 1.07-32.65); p = 0.041].

CONCLUSION

Parastomal prophylactic mesh placement to prevent PSH is a safe and efficient approach to reduce the incidence of PSH in patients requiring a permanent colostomy. However, mesh may increase the rate of PSH after permanent ileostomy.

Modified technique of extraperitoneal colostomy without incision of the posterior rectus sheath

Extraperitoneal colostomy is a widely used technique during abdominoperineal resection (APR) operation for lower rectal cancer. This technique has been reported to be effective to prevent the postoperative parastomal hernia in some retrospective studies, however, there is still a certain incidence of parastomal hernia. A modification of the extraperitoneal colostomy technique is described in this paper that keeps posterior rectal sheath intact instead of having a conventional incision, to further reduce the risk of parastomal hernia. Until now, this modified technique has been performed in 15 patients, no occurrence of parastomal hernia was observed.

The lateral rectus abdominis positioned stoma (LRAPS) in the construction of end colostomies, loop ileostomies and ileal conduits

BACKGROUND

Stomas are traditionally constructed through the belly of the rectus muscle. Parastomal herniation is common with the use of mesh prophylaxis still deliberated.

METHODS

A novel trephine, the lateral rectus abdominis positioned stoma or LRAPS, that minimises damage to the musculature of the anterior abdominal wall, has been used in the construction of end colostomies, loop ileostomies and ileal conduits.

RESULTS

In a cohort of 106 patients with end colostomy, the cumulative rate of parastomal herniation at 1, 2 and 3 years were 6, 10 and 17%, respectively. In 56 patients in whom an ileal conduit was performed, there was no clinical or radiological evidence of parastomal herniation at 1 year.

CONCLUSION

In contrast to a traditional trephine through the belly of the muscle, this technique avoids damage to the rectus abdominis muscle. Early symptomatic parastomal herniation is unusual after LRAPS.