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Emile SH, Dourado J, Rogers P, Wignakumar A, Horesh N, Garoufalia Z, Gefen R, Wexner SD. Umbrella review of systematic reviews on the efficacy and safety of using mesh in the prevention of parastomal hernias. Hernia 2024; 28:1577-1589. [PMID: 39177914 PMCID: PMC11457579 DOI: 10.1007/s10029-024-03137-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 08/11/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND This umbrella review aimed to summarize the findings and conclusions of published systematic reviews on the prophylactic role of mesh against parastomal hernias in colorectal surgery. METHODS PRISMA-compliant umbrella overview of systematic reviews on the role of mesh in prevention of parastomal hernias was conducted. PubMed and Scopus were searched through November 2023. Main outcomes were efficacy and safety of mesh. Efficacy was assessed by the rates of clinically and radiologically detected hernias and the need for surgical repair, while safety was assessed by the rates of overall complications. RESULTS 19 systematic reviews were assessed; 7 included only patients with end colostomy and 12 included patients with either ileostomy or colostomy. The use of mesh significantly reduced the risk of clinically detected parastomal hernias in all reviews except one. Seven reviews reported a significantly lower risk of radiologically detected parastomal hernias with the use of mesh. The pooled hazards ratio of clinically detected and radiologically detected parastomal hernias was 0.33 (95%CI: 0.26-0.41) and 0.55 (95%CI: 0.45-0.68), respectively. Six reviews reported a significant reduction in the need for surgical repair when a mesh was used whereas six reviews found a similar need for hernia repair. The pooled hazards ratio for surgical hernia repair was 0.46 (95%CI: 0.35-0.62). Eight reviews reported similar complications in the two groups. The pooled hazard ratio of complications was 0.81 (95%CI: 0.66-1). CONCLUSIONS The use of surgical mesh is likely effective and safe in the prevention of parastomal hernias without an increased risk of overall complications.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33179, FL, United States
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Justin Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33179, FL, United States
| | - Peter Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33179, FL, United States
| | - Anjelli Wignakumar
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33179, FL, United States
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33179, FL, United States
- Department of Surgery and Transplantation, Department of General Surgery, Sheba Medical Center, Ramat-Gan, Jerusalem, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33179, FL, United States
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33179, FL, United States
- Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, 33179, FL, United States.
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Stabilini C, Muysoms FE, Tzanis AA, Rossi L, Koutsiouroumpa O, Mavridis D, Adamina M, Bracale U, Brandsma HT, Breukink SO, López Cano M, Cole S, Doré S, Jensen KK, Krogsgaard M, Smart NJ, Odensten C, Tielemans C, Antoniou SA. EHS Rapid Guideline: Evidence-Informed European Recommendations on Parastomal Hernia Prevention-With ESCP and EAES Participation. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2023; 2:11549. [PMID: 38312414 PMCID: PMC10831651 DOI: 10.3389/jaws.2023.11549] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/11/2023] [Indexed: 02/06/2024]
Abstract
Background: Growing evidence on the use of mesh as a prophylactic measure to prevent parastomal hernia and advances in guideline development methods prompted an update of a previous guideline on parastomal hernia prevention. Objective: To develop evidence-based, trustworthy recommendations, informed by an interdisciplinary panel of stakeholders. Methods: We updated a previous systematic review on the use of a prophylactic mesh for end colostomy, and we synthesized evidence using pairwise meta-analysis. A European panel of surgeons, stoma care nurses, and patients developed an evidence-to-decision framework in line with GRADE and Guidelines International Network standards, moderated by a certified guideline methodologist. The framework considered benefits and harms, the certainty of the evidence, patients' preferences and values, cost and resources considerations, acceptability, equity and feasibility. Results: The certainty of the evidence was moderate for parastomal hernia and low for major morbidity, surgery for parastomal hernia, and quality of life. There was unanimous consensus among panel members for a conditional recommendation for the use of a prophylactic mesh in patients with an end colostomy and fair life expectancy, and a strong recommendation for the use of a prophylactic mesh in patients at high risk to develop a parastomal hernia. Conclusion: This rapid guideline provides evidence-informed, interdisciplinary recommendations on the use of prophylactic mesh in patients with an end colostomy. Further, it identifies research gaps, and discusses implications for stakeholders, including overcoming barriers to implementation and specific considerations regarding validity.
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Affiliation(s)
| | - Filip E. Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
| | | | - Lisa Rossi
- Department of Surgery, IRCCS Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Ourania Koutsiouroumpa
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
| | - Umberto Bracale
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | | | | | - Manuel López Cano
- Abdominal Wall Surgery Unit, Val d’ Hebrón University Hospital, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | | | | | | | - Neil J. Smart
- Department of General Surgery, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Christoffer Odensten
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University Educational Unit at Sunderby Hospital, Sunderby, Sweden
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Hu A, Pauli EM. Management of Parastomal Hernias. SEMINARS IN COLON AND RECTAL SURGERY 2023. [DOI: 10.1016/j.scrs.2023.100956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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Wagner V, Levy BE, Castle JT, Plymale M, Roth JS, Totten C. Absorbable mesh in a contaminated field: hernia repair outcomes. Updates Surg 2022:10.1007/s13304-022-01433-z. [DOI: 10.1007/s13304-022-01433-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022]
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Mohiuddin S, Reeves BC, Smart NJ, Hollingworth W. A semi-Markov model comparing the lifetime cost-effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing end colostomy creation for rectal cancer. Colorectal Dis 2021; 23:2967-2979. [PMID: 34331840 DOI: 10.1111/codi.15848] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/08/2023]
Abstract
AIM Parastomal hernia (PSH) is a common problem following colostomy. Using prophylactic mesh during end colostomy creation may reduce PSH incidence, but concerns exist regarding the optimal type of mesh, potential long-term complications, and cost-effectiveness of its use. We evaluated the cost-effectiveness of mesh prophylaxis to prevent PSH in patients undergoing end colostomy creation for rectal cancer. METHODS We developed a decision-analytical model, stratified by rectal cancer stages I-IV, to estimate the lifetime costs, quality-adjusted life-years (QALYs) and net monetary benefits (NMBs) of synthetic, biologic and no mesh from a UK NHS perspective. We pooled the mesh-related relative risks of PSH from 13 randomised controlled trials (RCTs) and superimposed these on the baseline (no mesh) risk from a population-based cohort. Uncertainty was assessed in sensitivity analyses. RESULTS Synthetic mesh was less costly and more effective than biologic and no mesh to prevent PSH for all rectal cancer stages. At the willingness-to-pay threshold of £20,000/QALY, the incremental NMBs (95% CI) ranged between £1,706 (£1,692 to £1,720) (stage I) and £684 (£678 to £690) (stage IV) for synthetic versus no mesh, and £2,038 (£1,997 to £2,079) (stage I) and £1,671 (£1,653 to £1,689) (stage IV) for synthetic versus biologic mesh. Synthetic mesh was more cost-effective than no mesh unless the relative risk of PSH was ≥0.95 for stages I-III and ≥0.93 for stage IV. [Correction added on 05 October 2021 after first online publication: The estimation of health outcomes (QALYs) for all three interventions evaluated (synthetic mesh; biologic mesh; no mesh) have been corrected in this version.] CONCLUSIONS: Synthetic mesh was the most cost-effective strategy to prevent the formation of PSH in patients after end colostomy for any rectal cancer stage; however, conclusions are dependent on which subset of RCTs are considered to provide the most robust evidence.
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Affiliation(s)
- Syed Mohiuddin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK
| | - Neil J Smart
- Royal Devon & Exeter Hospital, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Ammann Y, Widmann B, Sparn M, Warschkow R, Weitzendorfer M, Brunner W. Prophylactic funnel mesh to prevent parastomal hernia in permanent end colostomy: A retrospective cohort study. Colorectal Dis 2021; 23:2627-2636. [PMID: 34265151 DOI: 10.1111/codi.15817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 02/08/2023]
Abstract
AIM This study assessed the impact of a prophylactic, 3D funnel-shaped intraperitoneal mesh on the rate of parastomal hernia after abdominoperineal rectum resection with permanent end colostomy. METHODS Data from 76 patients receiving permanent end colostomy after abdominoperineal rectum resection between 2013 and 2018 were collected retrospectively. Occurrences of parastomal hernia and reoperation rate due to parastomal hernia in patients with and without a prophylactic mesh were compared by univariate, multivariate, and propensity score-adjusted analyses. RESULTS Twenty-two (28.9%) of the 76 included patients received a prophylactic mesh. The mean follow-up was 39.3 ± 23.8 months. Mesh implantation reduced the incidence of parastomal hernia to 9.1% (n = 2) compared to 42.6% (n = 23) in patients without a prophylactic mesh. The propensity score-adjusted hazard ratio (HR) was 0.14 (95% confidence interval (CI): 0.04-0.48, p = 0.001). No reoperations due to parastomal hernia were needed in patients who received a prophylactic mesh, while nine patients without mesh (16.7%) required parastomal hernia repair (HR = 0.09, 95% CI: 0.00-1.76, p = 0.015). Mesh implantation was not associated with increased short-term morbidity (Clavien-Dindo grade > 2, 31.8% vs. 40.7%, p = 0.468) or 30-day mortality (4.5% vs. 3.8%, p = 1.000). CONCLUSIONS Prophylactic implantation of a 3D funnel-shaped intraperitoneal mesh is a safe and effective method to prevent parastomal hernia in patients requiring permanent end colostomy. Mesh placement significantly reduces reoperations due to parastomal hernia.
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Affiliation(s)
- Yanic Ammann
- Department of General, Visceral, Endocrine and Transplant Surgery, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Bernhard Widmann
- Department of General, Visceral, Endocrine and Transplant Surgery, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Moritz Sparn
- Department of General, Visceral, Endocrine and Transplant Surgery, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Rene Warschkow
- Department of General, Visceral, Endocrine and Transplant Surgery, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | | | - Walter Brunner
- Department of General, Visceral, Endocrine and Transplant Surgery, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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Huang Y, Chen H, Zheng Q, Lin X, Zhu G, Wang J, Huang C, Ye J. Abdominal Oblique Internal and External Muscles Gap Colostomy for Lower Incidence of Parastomal Hernia and Higher Quality of Life: A Retrospective Cohort Study. World J Surg 2021; 45:3623-3632. [PMID: 34494162 DOI: 10.1007/s00268-021-06294-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Parastomal hernia and fecal incontinence cause severe distress to the rectal cancer patients with stoma after abdominoperineal resection. We attempted a new colostomy technique through the gap between the abdominal oblique internal and external muscles to prevent parastomal hernia and improve quality of life. METHODS This cohort study retrospectively examined clinical data from a total of 114 consecutive rectal cancer patients who underwent laparoscopic abdominoperineal resection in our center from March 2016 to March 2018 after propensity score matching. Group A included 57 patients who underwent colostomy through the gap between the abdominal oblique internal and oblique external muscles, while group B included 57 patients who underwent extraperitoneal colostomy. Patients' quality of life was evaluated using Fecal Incontinence Quality of Life (FIQL) Scale. RESULTS Group A had a lower incidence of parastomal hernia (0% vs. 15.7%, p = 0.004) and higher quality of life, especially in lifestyle, coping/behavior and embarrassment domains (all p values < 0.05) than group B both during the follow-up period. The incidence of other outcomes did not differ between the groups. CONCLUSIONS Colostomy through the gap between the abdominal oblique internal and oblique external muscle is a new technique showing both safety and effectiveness for preventing parastomal hernia and improving quality of life after laparoscopic abdominoperineal resection.
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Affiliation(s)
- Yongjian Huang
- Department of Gastrointestinal Surgery 2 Section, The First Affiliated Hospital of Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Hengkai Chen
- Department of Gastrointestinal Surgery 2 Section, The First Affiliated Hospital of Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Qiajun Zheng
- Department of Gastrointestinal Surgery 2 Section, The First Affiliated Hospital of Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Xiaohan Lin
- Department of Gastrointestinal Surgery 2 Section, The First Affiliated Hospital of Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Guangwei Zhu
- Department of Gastrointestinal Surgery 2 Section, The First Affiliated Hospital of Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Jinzhou Wang
- Department of Gastrointestinal Surgery 2 Section, The First Affiliated Hospital of Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Changli Huang
- Department of Gastrointestinal Surgery 2 Section, The First Affiliated Hospital of Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Jianxin Ye
- Department of Gastrointestinal Surgery 2 Section, The First Affiliated Hospital of Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, China.
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China.
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Chen MZ, Gilmore A. Short-term outcomes of parastomal hernia prophylaxis with Stapled Mesh stomA Reinforcement Technique (SMART) in permanent stomas. ANZ J Surg 2021; 91:1185-1189. [PMID: 33164321 DOI: 10.1111/ans.16420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Parastomal hernias occur in 50-80% after stoma formation. Even with mesh repairs, recurrence can be as high as 33%. Stapled Mesh stomA Reinforcement Technique (SMART) places a prophylactic onlay mesh in the trephine during permanent stoma formation to prevent parastomal hernia. Our study aims to describe the short-term outcomes of SMART procedures. METHODS A prospective study of patients receiving the SMART procedure from 2015 to 2020 was conducted. INCLUSION CRITERIA non-Crohn's colorectal and urological surgery with permanent stoma formation. The SMART surgical technique incorporates a 70-mm circular piece of polypropylene mesh by stapling it to the muscular abdominal wall using a circular stapler, and attaching the edge of the mesh to the deep fascia. RESULTS Fifty patients had a total of 53 SMART procedures. Median follow-up was 27 months. Procedures included: 35 end colostomies, five end ileostomies, eight ileal urinary conduits and five double-barrelled wet colostomies. Four patients had parastomal hernia during follow-up. One was acute, on day 1, due to very large size of trephine, one in a double-barrelled wet stoma that was repaired laparoscopically, one had a stomal prolapse requiring revision at 3 years and one patient had early small bowel obstruction due to very small size of trephine requiring another surgery. There were no wound infections or mesh-related sepsis. CONCLUSION Symptomatic parastomal herniation occurred in 8% of the study population, and most complications were due to incorrect choice of stapled trephine diameter. Longer term follow-up is required to assess for problematic parastomal hernia.
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Affiliation(s)
- Michelle Zhiyun Chen
- Department of Colorectal Surgery, Macquarie University, Sydney, New South Wales, Australia
| | - Andrew Gilmore
- Department of Colorectal Surgery, Macquarie University, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Hospital, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Western Sydney University, Sydney, New South Wales, Australia
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The Role of Mesh Implants in Surgical Treatment of Parastomal Hernia. MATERIALS 2021; 14:ma14051062. [PMID: 33668318 PMCID: PMC7956701 DOI: 10.3390/ma14051062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/18/2021] [Accepted: 02/18/2021] [Indexed: 11/16/2022]
Abstract
A parastomal hernia is a common complication following stoma surgery. Due to the large number of hernial relapses and other complications, such as infections, adhesion to the intestines, or the formation of adhesions, the treatment of hernias is still a surgical challenge. The current standard for the preventive and causal treatment of parastomal hernias is to perform a procedure with the use of a mesh implant. Researchers are currently focusing on the analysis of many relevant options, including the type of mesh (synthetic, composite, or biological), the available surgical techniques (Sugarbaker’s, “keyhole”, or “sandwich”), the surgical approach used (open or laparoscopic), and the implant position (onlay, sublay, or intraperitoneal onlay mesh). Current surface modification methods and combinations of different materials are actively explored areas for the creation of biocompatible mesh implants with different properties on the visceral and parietal peritoneal side. It has been shown that placing the implant in the sublay and intraperitoneal onlay mesh positions and the use of a specially developed implant with a 3D structure are associated with a lower frequency of recurrences. It has been shown that the prophylactic use of a mesh during stoma formation significantly reduces the incidence of parastomal hernias and is becoming a standard method in medical practice.
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Vettoretto N, Caprioli M, Botteri E. Emergency laparoscopic treatment of complicated parastomal hernias. MINERVA CHIR 2020; 75:313-319. [PMID: 33210527 DOI: 10.23736/s0026-4733.20.08462-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Parastomal hernia is not a rare event. Being by definition a complication of ostomy creation, a parastomal hernia also carries the risk of becoming symptomatic and complicated. At present, there are not enough solid data in literature to allow an evidence-based approach to this condition and to its possible complications, especially in the emergency setting. The aim of this paper is to describe through a narrative review of the literature the different surgical approaches concerning parastomal hernias. In order to exemplify the emergency complications we also present two cases in which the watchful waiting approach eventually led to the necessity of urgent surgical treatment, due to bowel incarceration into the parastomal hernia. We chose to tailor the surgical plan on the patient's anatomic and clinical condition, pursuing the laparoscopic approach with two different surgical technique (Sugarbaker and keyhole), each time estimated by the operating surgeon to be the more suitable option for the patient. We acknowledge that laparoscopy can be an optimal choice for the emergency and elective treatment of parastomal hernias, whenever an appropriate know-how is present.
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Affiliation(s)
- Nero Vettoretto
- Department of Surgery, ASST Spedali Civili Brescia, Montichiari, Brescia, Italy
| | - Michela Caprioli
- Department of Surgery, ASST Spedali Civili Brescia, Montichiari, Brescia, Italy
| | - Emanuele Botteri
- Department of Surgery, ASST Spedali Civili Brescia, Montichiari, Brescia, Italy -
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Quality Assessment and Risk of Bias of Systematic Reviews of Prophylactic Mesh for Parastomal Hernia Prevention Using AMSTAR and ROBIS Tools. World J Surg 2020; 43:3003-3012. [PMID: 31440779 DOI: 10.1007/s00268-019-05139-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Systematic reviews play a crucial role in clinical decision making and resource allocation and are expected to be unbiased and consistent. The aim of this study is a review of systematic reviews on the use of prophylactic mesh to prevent parastomal hernia (PH) formation using ROBIS and AMSTAR tools to assess the risk of bias and methodological quality. METHODS We included systematic reviews with or without meta-analysis of which the objective was to assess the use of a prophylactic mesh to prevent PH. A systematic search of the literature in five databases from inception until December 2017 was conducted. For each systematic review, methodologic quality and risk of bias were assessed using the AMSTAR and ROBIS tools, respectively. We estimated the inter-rater reliability for individual domains and for the overall methodological quality and risk of bias using Fleiss' k. RESULTS We identified 14 systematic reviews that met the inclusion criteria. Using the AMSTAR scale with a cutoff value, six reviews showed high methodologic quality and eight were of low quality. Using the ROBIS tool, the overall risk of bias was low in 50% of the reviews analyzed. In the remaining studies, the risk of bias was unclear. CONCLUSIONS The global evidence in favor of the use of a prophylactic mesh for preventing PH is not uniform regarding quality and risk of bias. Surgeons cannot be equally confident in the results of all systematic reviews published on this topic.
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Outcomes of surgically managed recurrent parastomal hernia: the Sisyphean challenge of the hernia world. Hernia 2020; 25:133-140. [PMID: 32144507 DOI: 10.1007/s10029-020-02161-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The management of a recurrent (symptomatic) parastomal hernia (PSH) presents a dilemma. The aim of this study was to review the outcome of patients who underwent a recurrent PSH repair. METHODS Retrospective review of consecutive patients undergoing recurrent PSH repairs at a single institution between 2010 and 2019. Primary outcome recorded was recurrence. Secondary outcomes recorded were 30-day post-operative complications, surgical site occurrence (SSO) incidence and to assess if EHS classification altered with each recurrence. RESULTS Thirty-eight patients underwent 59 recurrent PSH repairs during the study period. Median number of PSH repairs per patient from ostomy formation was 2 (2-8). Post-operative complications occurred following 52.5% of repairs. Recurrence rate for all recurrent PSH hernia repairs was 45.7%, with a median follow-up of 58 months (0-115). A trend was seen towards a shorter PSH recurrence-free survival in those who had at least two previous PSH repairs at the start of the study period when compared to those who had less. Recurrence was not associated with operative urgency, type of repair, mesh type or SSO occurrence. A significant decrease in recurrence was seen with retro-rectus mesh placement when compared to onlay (p = 0.003). EHS classification did not change between each recurrence in 70.8% of patients. CONCLUSION Recurrence rates after recurrent PSH repair are high. The recurrence-free survival was worse after the second or more attempt at repair for recurrence. Further studies are warranted to explore prophylaxis, optimal repair method, and where re-recurrence occurs, the benefit of repeated surgical intervention.
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van den Hil LCL, van Steensel S, Schreinemacher MHF, Bouvy ND. Prophylactic mesh placement to avoid incisional hernias after stoma reversal: a systematic review and meta-analysis. Hernia 2019; 23:733-741. [PMID: 31302788 PMCID: PMC6661031 DOI: 10.1007/s10029-019-01996-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/20/2019] [Indexed: 12/13/2022]
Abstract
Purpose To provide an overview of the available literature on prevention of incisional hernias after stoma reversal, with the use of prophylactic meshes. Methods A literature search of Pubmed, MEDLINE and EMBASE was performed. Search terms for stoma, enterostomy, mesh, prophylaxis and hernia were used. Search was updated to December 31th 2018. No time limitations were used, while English, Geman, Dutch and French were used as language restrictions. The primary outcome was the incidence of incisional hernia formation after stoma reversal. Secondary outcomes were mesh-related complications. Data on study design, sample size, patient characteristics, stoma and mesh characteristics, duration of follow-up and outcomes were extracted from the included articles. Results A number of 241 articles were identified and three studies with 536 patients were included. A prophylactic mesh was placed in 168 patients to prevent incisional hernias after stoma reversal. Follow-up ranged from 10 to 21 months. The risk of incisional hernia in case of prophylactic mesh placement was significantly lower in comparison to no mesh placement (OR 0.10, 95% CI 0.04–0.27, p < 0.001, I2 = 0%, CI 0–91.40%). No differences in surgical site infections were detected between the groups. Conclusions The use of a prophylactic mesh seems to reduce the risk on incisional hernias after stoma reversal and therefore mesh reinforcement should be considered after stoma reversal. Electronic supplementary material The online version of this article (10.1007/s10029-019-01996-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- L C L van den Hil
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands.
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands.
- Department of General Surgery, Maastricht University Medical Centre, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - S van Steensel
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
| | - M H F Schreinemacher
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
| | - N D Bouvy
- Department of General Surgery, Maastricht University Medical Centre, Maastricht, 6202 AZ, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, 6200 MD, The Netherlands
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Malik TAM, Lee MJ, Harikrishnan AB. The incidence of stoma related morbidity - a systematic review of randomised controlled trials. Ann R Coll Surg Engl 2018; 100:501-508. [PMID: 30112948 PMCID: PMC6214073 DOI: 10.1308/rcsann.2018.0126] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction Several stoma related complications can occur following ileostomy or colostomy formation. The reported incidence of these conditions varies widely in the literature. A systematic review of randomised controlled trials reporting the incidence of stoma related complications in adults was performed to provide the most comprehensive summary of existing data. Methods PubMed, CINAHL® (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library were searched for trials assessing the incidence of complications in adults undergoing conventional stoma formation. Data were extracted by two independent reviewers and entered into SPSS® for statistical analysis. The Cochrane Collaboration tool for assessing risk of bias was used to critically appraise each study. Cochran's Q statistic and the I2 statistic were used to measure the level of heterogeneity between studies. Results Overall, 18 trials were included, involving 1,009 patients. The incidence of stoma related complications ranged from 2.9% to 81.1%. Peristomal skin complications and parastomal hernia were the most common complications. End colostomy had the highest incidence of morbidity, followed by loop colostomy and loop ileostomy. There were no trials involving patients with end ileostomy. There was a high level of detection bias and heterogeneity between studies. Conclusions This systematic review has summarised the best available evidence concerning the incidence of stoma related morbidity. The high level of heterogeneity between studies has limited the accuracy with which the true incidence of each stoma related complication can be reported. Large, multicentre trials investigating homogenous participant populations are therefore required.
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Affiliation(s)
| | - MJ Lee
- University of Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
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Jones HG, Rees M, Aboumarzouk OM, Brown J, Cragg J, Billings P, Carter B, Chandran P. Prosthetic mesh placement for the prevention of parastomal herniation. Cochrane Database Syst Rev 2018; 7:CD008905. [PMID: 30027652 PMCID: PMC6513624 DOI: 10.1002/14651858.cd008905.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Parastomal herniation is a common problem following formation of a stoma after both elective and emergency abdominal surgery. Symptomatic hernias give rise to a significant amount of patient morbidity, and in some cases mortality, and therefore may necessitate surgical treatment to repair the hernial defect and/or re-site the stoma. In an effort to reduce this complication, recent research has focused on the application of a synthetic or biological mesh, inserted during stoma formation to help strengthen the abdominal wall. OBJECTIVES The primary objective was to evaluate whether mesh reinforcement during stoma formation reduces the incidence of parastomal herniation. Secondary objectives included the safety or potential harms or both of mesh placement in terms of stoma-related infections, mesh-related infections, patient-reported symptoms/postoperative quality of life, and re-hospitalisation/ambulatory visits. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2018, Issue 1), Ovid MEDLINE (1970 to 11 January 2018), Ovid Embase (1974 to 11 January 2018), and Science Citation Index Expanded (1970 to 11 January 2018). To identify ongoing studies, we also searched the metaRegister of Controlled Trials (mRCT) on 11 January 2018. SELECTION CRITERIA We considered for inclusion all randomised controlled trials (RCTs) of prosthetic mesh (including biological/composite mesh) placement versus a control group (no mesh) for the prevention of parastomal hernia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies identified by the literature search for potential eligibility. We obtained the full articles for all studies that potentially met the inclusion criteria and included all those that met the criteria. Any differences in opinion between review authors were resolved by consensus. We pooled study data into a meta-analysis. We assessed heterogeneity by calculation of I2 and expressed results for each variable as a risk ratio (RR) with corresponding 95% confidence intervals (CI). We expressed continous outcomes as mean difference (MD) with corresponding 95% CIs. MAIN RESULTS We included 10 RCTs involving a total of 844 participants. The primary outcome was overall incidence of parastomal herniation. Secondary outcomes were rate of reoperation at 12 months, operative time, postoperative length of hospital stay, stoma-related infections, mesh-related infections, quality of life, and rehospitalisation rate. We judged the risk of bias across all domains to be low in six trials. We judged four trials to have an overall high risk of bias.The overall incidence of parastomal hernia was less in participants receiving a prophylactic mesh compared to those who had a standard ostomy formation (RR 0.53, 95% CI 0.43 to 0.66; 10 studies, 771 participants; I2 = 69%; low-quality evidence). In absolute numbers, the incidence of parastomal hernia was 22 per 100 participants (18 to 27) receiving prophylactic mesh compared to 41 per 100 participants having a standard ostomy formation.There were no differences in the need for reoperation (RR 0.90, 95% CI 0.50 to 1.64; 9 studies, 757 participants; I2 = 0%; low-quality evidence); operative time (MD -6.50 (min), 95% CI -18.24 to 5.24; 6 studies, 671 participants; low-quality evidence); postoperative length of hospital stay (MD -0.95 (days), 95% CI -2.03 to 0.70; 4 studies, 500 participants; moderate-quality evidence); or stoma-related infections (RR 0.89, 95% CI 0.32 to 2.50; 6 studies, 472 participants; I2 = 0%; low-quality evidence) between the two groups.We were unable to analyse mesh-related infections, quality of life, and rehospitalisation rate due to sparse data or because the outcome was not reported in the included studies. AUTHORS' CONCLUSIONS This Cochrane Review included 10 RCTs with a total of 844 participants. The review demonstrated a reduction in the incidence of parastomal hernia in people who had a prophylactic synthetic mesh placed at the time of the index operation compared to a standard ostomy formation. However, our confidence in this estimate is low due to the presence of a large degree of clinical heterogeneity, as well as high variability in follow-up duration and technique of parastomal herniation detection. We found the rate of stoma-related infection to be similar in both the intervention and control groups.
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Affiliation(s)
- Huw G Jones
- Singleton Hospital, ABM University NHS TrustDepartment of Colorectal SurgerySketty LaneSwanseaUKSA2 8QA
| | - Michael Rees
- Wrexham Maelor Hospital, BCUHBDepartment of General SurgeryCroesnewydd RdWrexhamUKLL13 7TD
| | - Omar M Aboumarzouk
- NHS Greater Glasgow and ClydeDepartment of UrologyQueen Elizabeth University HospitalGlasgowScotlandUK
| | - Joshua Brown
- Royal Gwent HospitalDepartment of General SurgeryNewportWalesUK
| | - James Cragg
- Wrexham Maelor Hospital, BCUHBDepartment of General SurgeryCroesnewydd RdWrexhamUKLL13 7TD
| | - Peter Billings
- Wrexham Maelor Hospital, BCUHBDepartment of General SurgeryCroesnewydd RdWrexhamUKLL13 7TD
| | - Ben Carter
- King's College London; Institute of Psychiatry, Psychology & NeuroscienceBiostatistics and Health InformaticsDenmark HillLondonUK
| | - Palanichamy Chandran
- Wrexham Maelor Hospital, BCUHBDepartment of General SurgeryCroesnewydd RdWrexhamUKLL13 7TD
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Prevention and treatment of parastomal hernia: a position statement on behalf of the Association of Coloproctology of Great Britain and Ireland. Colorectal Dis 2018; 20 Suppl 2:5-19. [PMID: 30176120 DOI: 10.1111/codi.14249] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/30/2018] [Indexed: 02/08/2023]
Abstract
AIM The Association of Coloproctology of Great Britain and Ireland (ACPGBI) Delphi process identified prevention and treatment of parastomal hernia (PSH) as the second highest priority non-cancer related colorectal pathology. This position statement aims to summarize the current evidence base. METHODS Four broad themes were identified (prevention, diagnosis/classification, management and operative repair). Guidelines are based on evidence from an extensive literature review using organized searches on the PubMed, MEDLINE, Embase and Cochrane databases. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adhered to for classifying the quality of evidence and reporting the strength of recommendations. RESULTS The suture repair of PSH other than for patients in extremis is not recommended. Synthetic non-absorbable mesh can be used safely in the short term in the construction of colostomies post rectal surgery, but longer-term follow-up is needed. Other broad recommendations are made around access to stoma care nurses, prevention classification and management. CONCLUSION There is a lack of high quality evidence for many domains in the prevention and treatment of PSH but the results of several studies are awaited. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: Parastomal hernias are a common and debilitating condition following stoma formation. This position statement from ACPGBI details the current evidence base and ongoing research for the prevention, diagnosis and management of parastomal hernias.
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Preventing parastomal hernia with modified stapled mesh stoma reinforcement technique (SMART) in patients who underwent surgery for rectal cancer: a case-control study. Hernia 2018; 22:379-384. [PMID: 29305784 DOI: 10.1007/s10029-017-1723-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Parastomal hernia is a frequent complication of an abdominal wall stoma. Surgical repairs have high complication and recurrence rates. Several different techniques have been suggested to prevent parastomal hernia during stoma creation. The aim of the present case-control study was to evaluate the efficacy of modified Stapled Mesh stomA Reinforcement Technique (SMART) for prevention of parastomal hernia compared with conventional colostomy formation in patients who underwent open or laparoscopic rectal resection and end colostomy for cancer. METHODS AND MATERIALS Between January 2014 and May 2016, all consecutive patients who underwent open or laparoscopic resection and end colostomy for primary or recurrent rectal cancer were identified from a prospectively collected database. Since January 2014, one surgeon in our team has routinely offered modified SMART procedure to all patients who are candidates for permanent terminal colostomy. In the SMART group patients, while creating an end colostomy, we placed a standard polypropylene mesh in the retromuscular position, fixed and cut the mesh by firing a 31- or 33-mm-diameter circular stapler and constructed the stoma. In the control group, a stoma was created conventionally by a longitudinal or transverse incision of the rectus abdominis sheath sufficiently large for the colon to pass through. RESULTS Twenty-nine patients underwent parastomal hernia prophylaxis with modified SMART and 38 patients underwent end-colostomy formation without prophylaxis (control group). Groups were similar in terms of age, sex and underlying conditions predisposing to herniation. Median follow-up time is 27 (range 12-41) months. Nineteen patients (28.4%) developed parastomal herniation. In the SMART group, 4 patients (13.8%) developed parastomal herniation which is significantly lower than the control group in which 15 patients (39.5%) developed parastomal herniation (p = 0.029). We did not observe mesh infection, stenosis, erosion or fistulation in the SMART group. One patient in the control group underwent surgical correction of stoma stricture, another patient underwent surgery for stoma prolapse and four patients underwent surgery for parastomal herniation. CONCLUSION New systemic reviews and meta-analysis support parastomal hernia prevention with the use of a prophylactic mesh. Until more evidence is available, prophylactic mesh should be routinely offered to all patients undergoing permanent stoma formation. SMART is easy to use, safe and effective for paracolostomy hernia prophylaxis.
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Antoniou SA, Agresta F, Garcia Alamino JM, Berger D, Berrevoet F, Brandsma HT, Bury K, Conze J, Cuccurullo D, Dietz UA, Fortelny RH, Frei-Lanter C, Hansson B, Helgstrand F, Hotouras A, Jänes A, Kroese LF, Lambrecht JR, Kyle-Leinhase I, López-Cano M, Maggiori L, Mandalà V, Miserez M, Montgomery A, Morales-Conde S, Prudhomme M, Rautio T, Smart N, Śmietański M, Szczepkowski M, Stabilini C, Muysoms FE. European Hernia Society guidelines on prevention and treatment of parastomal hernias. Hernia 2017; 22:183-198. [PMID: 29134456 DOI: 10.1007/s10029-017-1697-5] [Citation(s) in RCA: 203] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 08/19/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project. METHODS The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants. RESULTS End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed. CONCLUSION An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.
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Affiliation(s)
- S A Antoniou
- Department of General Surgery, University Hospital of Herakion, Crete, Greece.
| | - F Agresta
- Department of General Surgery, ULSS19 del Veneto, Adria, RO, Italy
| | - J M Garcia Alamino
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - D Berger
- Clinic of Abdominal, Thoracic and Pediatric Surgery, Klinikum Mittelbaden/Balg, Baden-Baden, Germany
| | - F Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - H-T Brandsma
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | - K Bury
- Department Cardiac and Vascular Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - J Conze
- Herniacenter Dr. Muschaweck/Dr. Conze, Munich, Germany
- Herniacenter Dr. Muschaweck/Dr. Conze, London, UK
- Department of General, Visceral and Transplant Surgery, University Hospital, RWTH Aachen University, Aachen, Germany
| | - D Cuccurullo
- Department of General, Laparoscopic, and Robotic Surgery, Ospedale Monaldi, Azienda Ospedaliera dei Colli, Naples, Italy
| | - U A Dietz
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - R H Fortelny
- Certified Hernia Center, Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, Austria
| | - C Frei-Lanter
- Department of Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - B Hansson
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - F Helgstrand
- Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - A Hotouras
- National Bowel Research Centre, The Royal London Hospital, London, United Kingdom
| | - A Jänes
- Department of Surgery, Sundsvall Hospital, Sundsvall, Sweden
| | - L F Kroese
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - J R Lambrecht
- Surgical Department, Innlandet Hospital Trust, Gjøvik, Norway
| | - I Kyle-Leinhase
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
| | - M López-Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - L Maggiori
- Department of Colorectal Surgery, Beaujon Hospital, Assistance publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - V Mandalà
- Department of General Surgery, Buccheri La Ferla Hospital, Palermo, Italy
| | - M Miserez
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - A Montgomery
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | | | - M Prudhomme
- Digestive Surgery Department, CHU Nîmes, Nîmes, France
| | - T Rautio
- Department of Surgery, Division of Gastroenterology, Medical Research Center, Oulu University Hospital, Oulu, Finland
| | - N Smart
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon and Exeter Hospital, Exeter, UK
| | - M Śmietański
- 2nd Department of Radiology, Medical University of Gdansk, Gdańsk, Poland
- Department of General Surgery and Hernia Centre, District Hospital in Puck, Puck, Poland
| | - M Szczepkowski
- Department of Rehabilitation, Józef Piłsudski University of Physical Education in Warsaw, Warsaw, Poland
- Clinical Department of General and Colorectal Surgery, Bielanski Hospital, Warsaw, Poland
| | - C Stabilini
- Department of Surgery, University of Genoa, Genoa, Italy
| | - F E Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
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The use of a composite synthetic mesh in the vicinity of bowel - For repair and prophylaxis of parastomal hernias. Does it increase the risk of short term infective complications? Int J Surg 2017; 45:67-71. [PMID: 28751222 DOI: 10.1016/j.ijsu.2017.07.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/17/2017] [Accepted: 07/17/2017] [Indexed: 12/21/2022]
Abstract
AIMS The use of synthetic meshes in potentially infected operative fields such as in the vicinity of large bowel, is controversial. This study describes our experience with the use of a synthetic composite mesh for prophylaxis and repair of parastomal hernias. METHODS Data were collected retrospectively over a 7-year period from 2008 to 2015. An IPOM (DynaMesh™) was used either during the formation of the stoma to reinforce the abdominal wall around the stoma or during the surgical repair of existing parastomal hernias, using keyhole or sandwich technique. Majority of meshes were placed laparoscopically. Clinical data and outcomes any stoma wound complications were collected. RESULTS Forty seven patients were included with a male to female ratio of 34:13. Median age was 66 years (38-91 years) with median follow-up of 17 months (3-73 months). Twenty seven patients had a prophylactic mesh placement (PMP) around colostomy after resection of colorectal cancer. None of these patients had any wound complications. Twenty patients had repair of parastomal hernias (RPH). One patient (1/20) in this group had a superficial wound infection around the stoma site and underwent an incision and drainage. One patient developed seroma and one had parastomal wound haematoma. CONCLUSIONS The use of a composite synthetic mesh using a laparoscopic IPOM technique for the prophylaxis and treatment of parastomal hernias, even in a clean contaminated surgical field, is safe and feasible.
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Prophylactic Mesh Placement During Formation of an End-colostomy Reduces the Rate of Parastomal Hernia: Short-term Results of the Dutch PREVENT-trial. Ann Surg 2017; 265:663-669. [PMID: 27471840 DOI: 10.1097/sla.0000000000001903] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the incidence of parastomal hernias (PSHs) after end-colostomy formation using a polypropylene mesh in a randomized controlled trial versus conventional colostomy formation. BACKGROUND A PSH is the most frequent complication after stoma formation. Symptoms may range from mild abdominal pain to life-threatening obstruction and strangulation. The treatment of a PSH is notoriously difficult and recurrences up to 20% have been reported despite the use of mesh. This has moved surgical focus toward prevention. METHODS Augmentation of the abdominal wall with a retro-muscular lightweight polypropylene mesh was compared with the traditional formation of a colostomy. In total, 150 patients (1:1 ratio) were included. The incidence of a PSH, morbidity, mortality, quality of life, and cost-effectiveness was measured after 1 year of follow-up. RESULTS There was no difference between groups regarding demographics and predisposing factors for PSH. Three out of 67 patients (4.5%) in the mesh group and 16 out of 66 patients (24.2%) in the nonmesh group developed a PSH (P = 0.0011). No statistically significant difference was found in infections, concomitant hernias, SF-36 questionnaire, Von Korff pain score, and cost-effectiveness between both study groups. CONCLUSION Prophylactic augmentation of the abdominal wall with a retromuscular lightweight polypropylene mesh at the ostomy site significantly reduces the incidence of PSH without a significant difference in morbidity, mortality, quality of life, or cost-effectiveness.
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Latifi R, Samson D, Haider A, Azim A, Iftikhar H, Joseph B, Tilley E, Con J, Gashi S, El-Menyar A. Risk-adjusted adverse outcomes in complex abdominal wall hernia repair with biologic mesh: A case series of 140 patients. Int J Surg 2017; 43:26-32. [PMID: 28526657 DOI: 10.1016/j.ijsu.2017.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 04/17/2017] [Accepted: 05/14/2017] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Biologic mesh is preferred for repair of complex abdominal wall hernias (CAWHs) in patients at high risk of wound infection. We aimed to identify predictors of adverse outcomes after complex abdominal wall hernia repair (CAWR) using biologic mesh with different placement techniques and under different surgical settings. METHODS A retrospective case series study was conducted on all patients who underwent CAWR with biologic mesh between 2010 and 2015 at a tertiary medical center. RESULTS the study population included 140 patients with a mean age of 54 ± 14 years and a median follow up period 8.8 months. Mesh size ranged from 50 to 1225 cm2. Ninety percent of patients had undergone previous surgery. Type of surgery was classified as elective in 50.7%, urgent in 24.3% and emergent in 25.0% and a porcine mesh was implanted in 82.9%. The most common mesh placement technique was underlay (70.7%), followed by onlay (16.4%) and bridge (12.9%). Complications included wound complications (30.7%), reoperation (25.9%), hernia recurrence (20.7%), and mesh removal (10.0%). Thirty-two patients (23.0%) were admitted to the ICU and the mean hospital length of stay was 10.8 ± 17.5 days. Age-sex adjusted predictors of recurrence were COPD (OR 4.2; 95%CI 1.003-17.867) and urgent surgery (OR 10.5; 95%CI 1.856-59.469), whereas for reoperation, mesh size (OR 6.8; 95%CI 1.344-34.495) and urgent surgery (OR 5.2; 95%CI 1.353-19.723) were the predictors. CONCLUSIONS Using biologic mesh, one-quarter and one-fifth of CAWR patients are complicated with reoperation or recurrence, respectively. The operation settings and comorbidity may play a role in these outcomes regardless of the mesh placement techniques.
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Affiliation(s)
- Rifat Latifi
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA; Department of Surgery, The University of Arizona, Tucson, AZ, USA.
| | - David Samson
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Ansab Haider
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Asad Azim
- Department of Surgery, The University of Arizona, Tucson, AZ, USA
| | - Hajira Iftikhar
- Department of Surgery, The University of Arizona, Tucson, AZ, USA
| | - Bellal Joseph
- Department of Surgery, The University of Arizona, Tucson, AZ, USA
| | - Elizabeth Tilley
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Jorge Con
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Saranda Gashi
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Ayman El-Menyar
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Prophylactic mesh placement for the PREvention of paraSTOmal hernias: The PRESTO systematic review and meta-analysis. PLoS One 2017; 12:e0171548. [PMID: 28182642 PMCID: PMC5300283 DOI: 10.1371/journal.pone.0171548] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 01/22/2017] [Indexed: 11/19/2022] Open
Abstract
Background Parastomal hernia (PH) is the most common complication after ostomy formation. Prophylactic mesh placement may be effective in reducing the rate of PH at the stoma site. The aims of this systematic review were to summarize the evidence with regard to the safety and effectiveness in comparison with the standard procedure without mesh placement and to identify important risk constellations. Method A systematic literature search was performed in PubMed, EMBASE and the Cochrane library with no language or date restrictions. Randomized (RCTs) and non-randomized controlled trials (nRCTs) were included. The main outcomes of interest were PH (primary outcome) rate and stoma-related complications (secondary outcomes) such as stenosis or fistula. Statistical analysis included meta-analyses of pooled data and subgroup analyses. Results Eleven trials (eight RCTs; three nRCTs) with a total of 755 patients were included. PH rate varied from 0% to 59% in the intervention and from 20% to 94% in the control group. RCTs showed a significant reduction of PH rate in the mesh group (OR 0.24; 95% CI 0.10 to 0.58, p = 0.034), whereas included nRCTs did not. No significant differences were observed in postoperative complication rates. Subgroup analyses showed superiority of non-absorbable meshes and sublay mesh positioning in open surgery. Conclusion Prophylactic mesh placement is safe and reduces PH rate. A recommendation for prophylactic non-absorbable meshes in a sublay position can be made for patients undergoing open colorectal operations with end-ostomies. Further research endeavors should focus on patient-oriented outcomes, not only PH rate, with respect to tailored treatment in specific patient populations.
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Cornille JB, Pathak S, Daniels IR, Smart NJ. Prophylactic mesh use during primary stoma formation to prevent parastomal hernia. Ann R Coll Surg Engl 2017; 99:2-11. [PMID: 27269439 PMCID: PMC5392779 DOI: 10.1308/rcsann.2016.0186] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2016] [Indexed: 01/31/2023] Open
Abstract
Introduction Parastomal hernia (PSH) is a common problem following stoma formation. The optimal technique for stoma formation is unknown although recent studies have focused on whether placement of prophylactic mesh at stoma formation can reduce PSH rates. The aim of this study was to systematically review use of prophylactic mesh versus no mesh with regard to occurrence of PSH and peristomal complications. Methods A systematic search was performed using PubMed, Embase™ and the Cochrane Library to identify randomised controlled trials that analysed placement of prophylactic mesh versus no mesh at time of initial surgery. Meta-analysis was performed using random effects methods. Results A total of 506 studies were identified by our search strategy. Of these, 8 studies were included, involving 430 patients (217 mesh vs 213 no mesh). Prophylactic mesh placement resulted in a significantly lower rate of PSH formation (42/217 [19.4%] vs 92/213 [43.2%]) with a combined risk ratio of 0.40 (95% confidence interval [CI]: 0.21-0.75, p=0.004). Placement of prophylactic mesh did not result in increased peristomal complications (15/218 [6.9%] vs 16/227 [7.0%]) with a combined risk ratio of 1.0 (95% CI: 0.49-2.01, p=0.990). Conclusions Prophylactic placement of mesh at primary stoma formation may reduce the incidence of PSH, without an increase in peristomal complications. However, the overall quality of the randomised controlled trials included in the meta-analysis was poor, and should prompt caution regarding the applicability of the findings of the individual studies and the meta-analysis to everyday practice.
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Affiliation(s)
- J B Cornille
- Royal Devon and Exeter NHS Foundation Trust , UK
| | - S Pathak
- Royal Devon and Exeter NHS Foundation Trust , UK
| | - I R Daniels
- Royal Devon and Exeter NHS Foundation Trust , UK
| | - N J Smart
- Royal Devon and Exeter NHS Foundation Trust , UK
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Cross AJ, Buchwald PL, Frizelle FA, Eglinton TW. Meta-analysis of prophylactic mesh to prevent parastomal hernia. Br J Surg 2016; 104:179-186. [PMID: 28004850 DOI: 10.1002/bjs.10402] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 06/23/2016] [Accepted: 09/08/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Rates of parastomal hernia following stoma formation remain high. Previous systematic reviews suggested that prophylactic mesh reduces the rate of parastomal hernia; however, a larger trial has recently called this into question. The aim was to determine whether mesh placed at the time of primary stoma creation prevents parastomal hernia. METHODS The Cochrane Central Register of Controlled Trials, MEDLINE, Embase and CINAHL were searched using medical subject headings for parastomal hernia, mesh and prevention. Reference lists of identified studies, clinicaltrials.gov and the WHO International Clinical Trials Registry were also searched. All randomized clinical trials were included. Two authors extracted data from each study independently using a purpose-designed sheet. Risk of bias was assessed by a tool based on that developed by Cochrane. RESULTS Ten randomized trials were identified among 150 studies screened. In total 649 patients were included in the analysis (324 received mesh). Overall the rates of parastomal hernia were 53 of 324 (16·4 per cent) in the mesh group and 119 of 325 (36·6 per cent) in the non-mesh group (odds ratio 0·24, 95 per cent c.i. 0·12 to 0·50; P < 0·001). Mesh reduced the rate of parastomal hernia repair by 65 (95 per cent c.i. 28 to 85) per cent (P = 0·02). There were no differences in rates of parastomal infection, stomal stenosis or necrosis. Mesh type and position, and study quality did not have an independent effect on this relationship. CONCLUSION Mesh placed prophylactically at the time of stoma creation reduced the rate of parastomal hernia, without an increase in mesh-related complications.
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Affiliation(s)
- A J Cross
- Departments of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - P L Buchwald
- Departments of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - F A Frizelle
- Departments of Surgery, Christchurch Hospital, Christchurch, New Zealand.,Departments of Surgery, University of Otago, Christchurch, New Zealand
| | - T W Eglinton
- Departments of Surgery, Christchurch Hospital, Christchurch, New Zealand.,Departments of Surgery, University of Otago, Christchurch, New Zealand
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López-Cano M, Brandsma HT, Bury K, Hansson B, Kyle-Leinhase I, Alamino JG, Muysoms F. Prophylactic mesh to prevent parastomal hernia after end colostomy: a meta-analysis and trial sequential analysis. Hernia 2016; 21:177-189. [PMID: 27995425 DOI: 10.1007/s10029-016-1563-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/03/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE Prevention of parastomal hernia (PSH) formation is crucial, given the high prevalence and difficulties in the surgical repair of PSH. To investigate the effect of a preventive mesh in PSH formation after an end colostomy, we aimed to meta-analyze all relevant randomized controlled trials (RCTs). METHODS We searched five databases. For each trial, we extracted risk ratios (RRs) of the effects of mesh or no mesh. The primary outcome was incidence of PSH with a minimum follow-up of 12 months with a clinical and/or computed tomography diagnosis. RRs were combined using the random-effect model (Mantel-Haenszel). To control the risk of type I error, we performed a trial sequential analysis (TSA). RESULTS Seven RCTs with low risk of bias (451 patients) were included. Meta-analysis for primary outcome showed a significant reduction of the incidence of PSH using a mesh (RR 0.43, 95% CI 0.26-0.71; P = 0.0009). Regarding TSA calculation for the primary outcome, the accrued information size (451) was 187.1% of the estimated required information size (RIS) (241). Wound infection showed no statistical differences between groups (RR 0.77, 95% CI 0.39-1.54; P = 0.46). PSH repair rate showed a significant reduction in the mesh group (RR 0.28 (95% CI 0.10-0.78; P = 0.01). CONCLUSIONS PSH prevention with mesh when creating an end colostomy reduces the incidence of PSH, the risk for subsequent PSH repair and does not increase wound infections. TSA shows that the RIS is reached for the primary outcome. Additional RCTs in the previous context are not needed.
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Affiliation(s)
- M López-Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - H-T Brandsma
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - K Bury
- Department Cardiac and Vascular Surgery, Medical University of Gdansk, Gdańsk, Poland
| | - B Hansson
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - I Kyle-Leinhase
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
| | - J G Alamino
- Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
| | - F Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
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Prophylactic mesh to prevent parastomal hernia: a meta-analysis of randomized controlled studies. Tech Coloproctol 2016; 21:5-13. [PMID: 27942965 DOI: 10.1007/s10151-016-1559-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/13/2016] [Indexed: 10/20/2022]
Abstract
The aim of the present meta-analysis was to determine whether prophylactic mesh decreases the odds of parastomal hernia formation. Randomized controlled trials referenced in MEDLINE or EMBASE between 1946 and 2016 comparing prophylactic mesh to standard stoma formation were included. The primary outcome was occurrence of parastomal hernia. Secondary outcomes were parastomal hernia requiring surgical intervention and complications. Odds ratios were calculated for the primary and secondary outcomes. Subgroup analyses were conducted based on mesh type, mesh location, laparoscopic versus open, and method of hernia diagnosis. Nine randomized controlled trials with 569 participants were included. There was a significant decrease in the odds of developing a parastomal hernia in the prophylactic mesh group [odds ratio (OR) 0.21, 95% confidence interval (CI) 0.11-0.38, p < 0.00001, I 2 = 36%], as well as decreased odds of requiring surgical repair (OR 0.36, 95% CI 0.15-0.87, p = 0.02, I 2 = 0%). There was no evidence that prophylactic mesh increased the odds of surgical complications (seven studies, OR 1.34, 95% CI 0.73-2.46, p = 0.34, I 2 = 34%) or stoma-specific complications (eight studies, OR 0.65, 95% CI 0.40-1.05, p = 0.08, I 2 = 0%). There was a subgroup effect with synthetic mesh associated with a lower incidence of parastomal hernias which was not appreciated in the biologic mesh group (test of subgroup effect p = 0.01). Five studies had a high risk of bias. The Grades of Recommendation, Assessment, Development and Evaluation quality of evidence was moderate. Prophylactic mesh is associated with decreased odds of parastomal hernia formation and the need for surgical repair. There is no evidence that mesh placement increases the odds of complications.
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Stapled Mesh stomA Reinforcement Technique (SMART) in the prevention of parastomal hernia: a single-centre experience. Hernia 2016; 21:469-475. [DOI: 10.1007/s10029-016-1548-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 11/12/2016] [Indexed: 01/13/2023]
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Zhu J, Pu Y, Yang X, Zhang D, Zhao K, Peng W, Xing C. Prophylactic Mesh Application during Colostomy to Prevent Parastomal Hernia: A Meta-Analysis. Gastroenterol Res Pract 2016; 2016:1694265. [PMID: 27818679 PMCID: PMC5080498 DOI: 10.1155/2016/1694265] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 08/28/2016] [Indexed: 12/20/2022] Open
Abstract
Background. Parastomal hernia is a common complication after stoma formation, especially in permanent colostomy. The present meta-analysis aimed to evaluate the effectiveness of prophylactic mesh application during permanent colostomy for preventing parastomal hernia. Methods. Randomized controlled trials comparing outcomes in patients who underwent colostomy with or without prophylactic mesh application were identified from PubMed, EMBASE, Science Citation Index, and the Cochrane Libraries. Results. This meta-analysis included 8 randomized controlled trials with 522 participants. Our pooled results showed that prophylactic mesh application (mesh group) reduced the incidence of clinically detected parastomal hernia (risk ratio [RR]: 0.22; 95% confidence interval [CI]: 0.13-0.38; P < 0.00001), radiologically detected parastomal hernia (RR: 0.62; 95% CI: 0.47-0.82; P = 0.0008), and surgical repair for herniation (RR: 0.34; 95% CI: 0.14-0.83; P = 0.02) when compared with conventional permanent colostomy formation (control group). The incidence of complications, including wound infection, peristomal infection, mesh infection, stomal necrosis and stenosis, stoma site pain, and fistula, was not higher in the mesh group than in the control group. Conclusions. Our meta-analysis demonstrated that prophylactic mesh application at the time of primary colostomy formation is a promising method for the prevention of parastomal herniation.
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Affiliation(s)
- JunJia Zhu
- Department of General Surgery, Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu 215004, China
| | - YuWei Pu
- Department of General Surgery, Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu 215004, China
| | - XiaoDong Yang
- Department of General Surgery, Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu 215004, China
| | - DeBao Zhang
- Department of General Surgery, Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu 215004, China
| | - Kui Zhao
- Department of General Surgery, Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu 215004, China
| | - Wei Peng
- Department of General Surgery, Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu 215004, China
| | - ChunGen Xing
- Department of General Surgery, Second Affiliated Hospital, Soochow University, Suzhou, Jiangsu 215004, China
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Prudhomme M, Alline M, Chauvat J, Fabbro-Perray P, Ripoche J, Bertrand MM. Primary prevention of peristomial hernias via parietal prostheses: A randomized, multicentric study (GRECCAR 7 trial). Dig Liver Dis 2016; 48:812-6. [PMID: 27130912 DOI: 10.1016/j.dld.2016.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 03/24/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Peristomal hernia (PH) is a common complication of colostomy. It often leads to a decrease in the patient's quality of life. Surgical procedures for PH are difficult and present high failure and morbidity rates. This randomized, double blind, multicentre trial was conducted to determine the benefits and risks of mesh reinforcement vs conventional stoma formation in preventing PH. METHODS 200 patients undergoing a permanent end colostomy are randomized into two groups. In the mesh group an end-colostomy is created inserting a lightweight (<50g/m(2)) monofilament mesh in a sublay location, and compared to a group with traditional stoma creation. The presence or absence of a PH is determined by another practitioner by clinical exam and by a CT scan or MRI after 24 months of follow-up. 19 university hospitals participate during a 3-year inclusion period. The primary endpoint is the comparison of the PH incidence. To find a difference of 20% with a power of 80% a total number of 174 patients must be included. CONCLUSION This GRECCAR study is a multicentre, double blind, and randomized trial conducted to determine whether a preventive insertion of a prosthetic mesh decreases the incidence of a PH with an acceptable morbidity. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01380860.
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Affiliation(s)
| | | | - John Chauvat
- Digestive Surgery Department, CHU Nîmes, Nîmes, France
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Systematic Review and Meta-Analysis of Extraperitoneal Versus Transperitoneal Colostomy for Preventing Parastomal Hernia. Dis Colon Rectum 2016; 59:688-95. [PMID: 27270522 DOI: 10.1097/dcr.0000000000000605] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Parastomal hernia remains a frequent problem after constructing a colostomy. Current research mainly focuses on prophylactic mesh placement as an addition to transperitoneal colostomies. However, for constructing a colostomy, either an extraperitoneal or transperitoneal route can be chosen. OBJECTIVE The aim of this meta-analysis was to investigate which technique results in lower parastomal hernia rates in patients undergoing end colostomy. DATA SOURCES A meta-analysis was conducted according to Preferred Items for Reporting of Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane, PubMed, and Google Scholar databases were searched. The study protocol was registered in the International Prospective Register of Systematic Reviews database. STUDY SELECTION Studies comparing extraperitoneal and transperitoneal colostomies were included. Only studies written in English were included. The quality of studies and risk of bias were assessed using the Cochrane risk-of-bias tool. The quality of nonrandomized studies was assessed using the Newcastle-Ottawa Scale. INTERVENTION The intervention was colostomy formation. MAIN OUTCOME MEASURES The main outcome measure was parastomal hernia incidence. Secondary outcome measures were stoma prolapse, stoma necrosis, and operating time. RESULTS Of 401 articles found, a meta-analysis was conducted of 10 studies (2 randomized controlled trials and 8 retrospective studies) composed of 1048 patients (347 extraperitoneal and 701 transperitoneal). Extraperitoneal colostomy led to significantly lower parastomal hernia rates (22 of 347 (6.3%) for extraperitoneal versus 125 of 701 (17.8%) for transperitoneal; risk ratio = 0.36 (95% CI, 0.21-0.62); I = 26%; p < 0.001) and significantly lower stoma prolapse rates (2 of 185 (1.1%) for extraperitoneal versus 13 of 179 (7.3%) for transperitoneal; risk ratio = 0.21 (95% CI, 0.06-0.73); I = 0%; p = 0.01). Differences in stoma necrosis were not significant. Operating time data were insufficient to analyze. LIMITATIONS Most of the studies were nonrandomized, and some were not recent publications. CONCLUSIONS Although the majority of studies included were retrospective, extraperitoneal colostomy was observed to lead to a lower rate of parastomal hernia and stoma prolapse.
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Parastomal hernia and prophylactic mesh use during primary stoma formation: a commentary. Hernia 2016; 20:543-6. [DOI: 10.1007/s10029-016-1510-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 05/27/2016] [Indexed: 01/30/2023]
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Köhler G, Mayer F, Wundsam H, Schrittwieser R, Emmanuel K, Lechner M. Changes in the Surgical Management of Parastomal Hernias Over 15 Years: Results of 135 Cases. World J Surg 2016; 39:2795-804. [PMID: 26264458 DOI: 10.1007/s00268-015-3187-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Over the years, various open and laparoscopic approaches toward the repair of parastomal hernias (PSH) have been described. The variety of published techniques itself can be seen as an indicator for the often low level of satisfaction reached with the surgical procedures. METHODS From January 1999 to January 2014, we assessed all cases of PSH repair performed at the three participating surgical departments in a retrospective analysis. The results were evaluated with regard to different surgical techniques focusing on complications and recurrences. RESULTS One hundred and thirty-five individuals could be included in the analysis. They were operated on with eight different surgical techniques. Laparoscopic procedures were carried out in 46.7 % (63/135) of the cases. Median follow-up was 54 months (12-146 months). We found 44 cases of recurrence (32.6 %) and 24 (17.8 %) of the patients experienced perioperative complications and 12 of them needed to return to theater. Fourteen of the 135 patients (10.4 %) were operated as emergency cases which were associated with a mortality of 28.6 % (4/14). In case of elective PSH repair, no mortality occured. CONCLUSION The results achieved by direct suture or the use of incised flat meshes for the repair of PSH were poor with these procedures having unacceptably high recurrence rates. With regard to the latter ostomy revision through three-dimensional funnel-shaped meshes and the laparoscopic sandwich technique showed the best results. Emergency procedures were linked to a dramatic increase in morbidity and mortality (p < 0.001).
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Affiliation(s)
- Gernot Köhler
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria. .,Academic Teaching Hospital of the Medical Universitiy of Graz, Graz, Austria. .,Academic Teaching Hospital of the Medical Universitiy of Innsbruck, Innsbruck, Austria. .,Department of Surgery, Paracelsus Medical University, Salzburg, Austria.
| | - Franz Mayer
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Helwig Wundsam
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria.,Academic Teaching Hospital of the Medical Universitiy of Graz, Graz, Austria.,Academic Teaching Hospital of the Medical Universitiy of Innsbruck, Innsbruck, Austria
| | | | - Klaus Emmanuel
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria.,Academic Teaching Hospital of the Medical Universitiy of Graz, Graz, Austria.,Academic Teaching Hospital of the Medical Universitiy of Innsbruck, Innsbruck, Austria
| | - Michael Lechner
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
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Long-term assessment of parastomal hernia prevention by intra-peritoneal mesh reinforcement according to the modified Sugarbaker technique. Surg Endosc 2016; 30:5372-5379. [PMID: 27059972 DOI: 10.1007/s00464-016-4891-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 03/23/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Parastomal hernia (PSH) is a very frequent complication after creation of a permanent colostomy. The aim of that study is to assess the safety and the long-term efficacy of an intra-peritoneal onlay mesh (IPOM) positioned at the time of primary stoma formation to prevent PSH occurrence. MATERIALS AND METHODS That multicentre prospective study concerned 29 consecutive patients operated for cancer of the low rectum between 2008 and 2014. There were 14 men and 15 women with a median age of 73 years (range 39-88) and a BMI of 28 (range 21-43). All the patients had potentially curative abdominoperineal excision associated with IPOM reinforcement of the abdominal wall with a round non-slit composite mesh centred on the stoma site and covering the lateralized colon according to the modified Sugarbaker technique. The major outcomes analysed were operative time, complications related to mesh and PSH incidence. Patients were evaluated at 6-month intervals for the first 2 years and thereafter annually with physical examination and CT scan control. For PSH evaluation, we used the classification of Moreno-Matias. RESULTS Surgery was performed by laparoscopy in 24 patients and by laparotomy in 5; 17 had a trans-peritoneal colostomy and 12 an extra-peritoneal colostomy. The median size of the mesh was 15 cm (range 12-20), the operative time 225 min. (range 123-311) and the specific time for mesh placement 15 min. (range 10-30). With a median follow-up of 48 months (range 6-88), no mesh infection or complication requiring mesh removal were recorded. No patient developed a true PSH; two of them had a type Ia PSH (only containing the bowel forming the colostomy with a sac < 5 cm) and were totally asymptomatic. CONCLUSION In our series, the incidence of PSH was 7 % and no specific mesh-related complication was noted. Prophylactic mesh reinforcement according to the modified Sugarbaker is an effective technique that addresses the issues related to the occurrence of PSH.
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Guarnero V, Hoffmann H, Hetzer F, Oertli D, Turina M, Zingg U, Demartines N, Ris F, Hahnloser D. A new stomaplasty ring (Koring™) to prevent parastomal hernia: an observational multicenter Swiss study. Tech Coloproctol 2016; 20:293-297. [DOI: 10.1007/s10151-016-1452-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/16/2016] [Indexed: 11/28/2022]
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Marinez AC, González E, Holm K, Bock D, Prytz M, Haglind E, Angenete E. Stoma-related symptoms in patients operated for rectal cancer with abdominoperineal excision. Int J Colorectal Dis 2016; 31:635-41. [PMID: 26728024 DOI: 10.1007/s00384-015-2491-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The primary aim of this study was to characterize the frequency, severity, and distress of symptoms from the colostomy and colostomy acceptance in rectal cancer patients. The secondary aims were to study the symptomatic parastomal herniation, its relationship to stoma-related symptoms, and potential risk factors for the development of symptomatic parastomal herniation. METHODS Data was collected from the Swedish Colorectal Cancer Registry and from surgical charts. Patients operated for rectal cancer with an abdominoperineal excision in Sweden between 2007 and 2009 and alive 3 years postoperatively were contacted (n = 852). Patients who consented to participate, had a colostomy constructed during the abdominoperineal excision, and who answered a questionnaire 3 years postoperative were included (n = 495). Answers were analyzed with emphasis on stoma-related symptoms and their intensity as well as the level of distress associated with the symptoms. RESULTS Almost 90% of patients did not feel limited in their daily life by their colostomy. Patients with symptomatic parastomal hernia had a 53% higher risk of flatulence. Fifty-six patients developed symptomatic parastomal hernia (11%). The only risk factor associated with the development of symptomatic parastomal hernia was high body mass index (BMI). CONCLUSIONS This study shows that most patients do not feel limited by their stoma 3 years after surgery for rectal cancer. Symptomatic parastomal hernia was associated with high BMI but not with the surgical technique.
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Affiliation(s)
- Adiela Correa Marinez
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden.
| | - Elisabeth González
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - Kajsa Holm
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - David Bock
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - Mattias Prytz
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden.,Department of Surgery, NU-hospital Group, Trollhättan, Sweden
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
| | - Eva Angenete
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG-Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, SE-416 85, Gothenburg, Sweden
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Köhler G, Emmanuel K, Schrittwieser R. Single-port parastomal hernia repair by using 3-D textile implants. JSLS 2016; 18:JSLS-D-14-00034. [PMID: 25392655 PMCID: PMC4208891 DOI: 10.4293/jsls.2014.00034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Parastomal hernias (PSHs) are a frequent complication and remain a surgical challenge. We present a new option for single-port PSH repair with equilateral stoma relocation using preshaped, prosthetic 3-dimensional implants and flat mesh insertion in intraperitoneal onlay placement for additional augmentation of the abdominal wall. Methods: We describe our novel technique in detail and performed an analysis of prospectively collected data from patients who underwent single-port PSH repair, focusing on feasibility, conversions, and complications. Results: From September 2013 to January 2014, 9 patients with symptomatic PSHs were included. Two conversions to reduced-port laparoscopy using a second 3-mm trocar were required because of difficult adhesiolysis, dissection, and reduction of the hernia sac content. No major intra- or postoperative complications or reoperations were encountered. One patient incurred a peristomal wound healing defect that could be treated conservatively. Conclusion: We found that single-port PSH repair using preshaped, elastic 3-dimensional devices and additional flat mesh repair of the abdominal wall is feasible, safe, and beneficial, relating to optimal coverage of unstable stoma edges with wide overlap to all sides and simultaneous augmentation of the midline in the IPOM technique. The stoma relocation enables prolapse treatment and prevention. The features of a modular and rotatable multichannel port system offer benefits in clear dissection ongoing from a single port. Long-term follow-up data on an adequate number of patients are awaited to examine efficacy.
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Affiliation(s)
- Gernot Köhler
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Linz, Austria
| | - Klaus Emmanuel
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Linz, Austria
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Sands LR, Morales CS. Re-operative surgery for intestinal stoma complications. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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38
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Maggiori L, Moszkowicz D, Zappa M, Mongin C, Panis Y. Bioprosthetic mesh reinforcement during temporary stoma closure decreases the rate of incisional hernia: A blinded, case-matched study in 94 patients with rectal cancer. Surgery 2015; 158:1651-7. [DOI: 10.1016/j.surg.2015.07.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 05/24/2015] [Accepted: 07/02/2015] [Indexed: 02/06/2023]
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Fortelny RH, Hofmann A, May C, Köckerling F. Prevention of a Parastomal Hernia by Biological Mesh Reinforcement. Front Surg 2015; 2:53. [PMID: 26557646 PMCID: PMC4614361 DOI: 10.3389/fsurg.2015.00053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/30/2015] [Indexed: 12/02/2022] Open
Abstract
Introduction In the field of hernia prevention, the prophylactic mesh-reinforcement of stoma-sites is one of the most controversially discussed issues. The incidence of parastomal hernias in the literature reported to be up to 48.1% after end colostomy and up to 30.8% after loop of colostomy, but still remains uncertain due to diagnostic variety of clinical or radiological methods, heterogeneous patient groups and variable follow-up intervals. Anyway, the published data regarding the use of synthetic or bio-prostethic meshes in the prevention of parastomal hernia at the primary operation are very scarce. Methods A literature search of the Medline database in terms of biological prophylactic mesh implantation in stoma creation identified six systematic reviews, two randomized controlled trials (RCT), two case-controlled studies, and one technical report. Results In a systematic review focusing on the prevention of parastomal hernia including only RCTs encompassing one RCT using bio-prosthetic mesh the incidence of herniation was 12.5% compared to 53% in the control group (p < 0.0001). In one RCT and two case-control studies, respectively, there was a significant smaller incidence of parastomal herniation as well as a similar complication rate compared to the control group. Only in one RCT, no significant difference regarding the incidence of parastomal hernia was reported with comparable complication rates. Conclusion Thus, so far two RCT and two case-control studies are published with prophylactic bio-prosthetic reinforcement in stoma sites. The majority revealed significant better results in terms of parastomal herniation and without any mesh-related complications in comparison to the non mesh group. Further, multicenter RCT are required to achieve a sufficient level of recommendation.
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Affiliation(s)
- René H Fortelny
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital , Vienna , Austria
| | - Anna Hofmann
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital , Vienna , Austria
| | - Christopher May
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital , Vienna , Austria
| | - Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Vivantes Hospital , Berlin , Germany
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Lambrecht JR, Larsen SG, Reiertsen O, Vaktskjold A, Julsrud L, Flatmark K. Prophylactic mesh at end-colostomy construction reduces parastomal hernia rate: a randomized trial. Colorectal Dis 2015; 17:O191-7. [PMID: 26179984 DOI: 10.1111/codi.13065] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 05/21/2015] [Indexed: 12/13/2022]
Abstract
AIM Parastomal hernia (PSH) is the most common complication of an end-colostomy and about one-quarter of patients need operative repair, which is often unsuccessful. A randomized trial was carried out to compare the results of using mesh or no mesh at the time of formation of a colostomy with the clinical identification of PSH as the primary outcome. METHOD In this two-centre randomized trial (Oslo University Hospital and Sykehuset Innlandet Hospital Trust, Norway), patients with rectal cancer undergoing open pelvic surgery were randomized to receive a retromuscular synthetic mesh (study group, n = 32) or no mesh (control group, n = 26) at the time of end-colostomy formation. Postoperative follow up was not blinded and included clinical examination and routine CT. RESULTS The median period of follow up was 40 (range: 84) months. There were no differences in demographic variables or complications between the study and control groups. PSH developed in two patients of the study group and in 12 of the control group [OR = 0.04 (95% CI: 0.01-0.30) and hazard ratio 0.134 (95% CI: 0.030-0.603); P < 0.001]. The number needed to treat to avoid one PSH was 2.5 patients. CT demonstrated an increase over time in the size of the fascial orifice in patients with PSH without mesh prophylaxis, in contrast to a stable size in patients with mesh and in the control patients who did not develop PSH. CONCLUSION The retromuscular insertion of synthetic mesh at the time of formation of an end-colostomy reduced the risk of PSH.
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Affiliation(s)
- J R Lambrecht
- Department of Gastroenterological Surgery, Sykehuset Innlandet Hospital Trust, Gjøvik, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - S G Larsen
- Department of Gastroenterological Surgery, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - O Reiertsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Digestive Surgery, Akershus University Hospital, Oslo, Norway
| | - A Vaktskjold
- Department of Gastroenterological Surgery, Sykehuset Innlandet Hospital Trust, Gjøvik, Norway.,Hedmark University College, Elverum, Norway
| | - L Julsrud
- Department of Radiology, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
| | - K Flatmark
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterological Surgery, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway
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41
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Valdés-Hernández J, Díaz Milanés JA, Capitán Morales LC, del Río la Fuente FJ, Torres Arcos C, Cañete Gómez J, Oliva Mompeán F, Padillo Ruiz J. Profilaxis de la hernia paraestomal mediante malla de polipropileno en espacio preperitoneal. Cir Esp 2015; 93:455-9. [DOI: 10.1016/j.ciresp.2014.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 09/14/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
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42
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Magnetic resonance visible 3-D funnel meshes for laparoscopic parastomal hernia prevention and treatment. Eur Surg 2015. [DOI: 10.1007/s10353-015-0319-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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43
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Köhler G, Hofmann A, Lechner M, Mayer F, Wundsam H, Emmanuel K, Fortelny RH. Prevention of parastomal hernias with 3D funnel meshes in intraperitoneal onlay position by placement during initial stoma formation. Hernia 2015; 20:151-9. [PMID: 25899106 DOI: 10.1007/s10029-015-1380-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 04/11/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE In patients with terminal ostomies, parastomal hernias (PSHs) occur on a frequent basis. They are commonly associated with various degrees of complaints and occasionally lead to life-threatening complications. Various strategies and measures have been tested and evaluated, but to date there is a lack of published evidence with regard to the best surgical technique for the prevention of PSH development. METHODS We conducted a retrospective analysis of prospectively collected data of eighty patients, who underwent elective permanent ostomy formation between 2009 and 2014 by means of prophylactic implantation of a three-dimensional (3D) funnel mesh in intraperitoneal onlay (IPOM) position. RESULTS PSH developed in three patients (3.75%). No mesh-related complications were encountered and none of the implants had to be removed. Ostomy-related complications had to be noted in seven (8.75%) cases. No manifestation of ostomy prolapse occurred. Follow-up time was a median 21 (range 3-47) months. CONCLUSION The prophylactical implantation of a specially shaped, 3D mesh implant in IPOM technique during initial formation of a terminal enterostomy is safe, highly efficient and comparatively easy to perform. As opposed to what can be achieved with flat or keyhole meshes, the inner boundary areas of the ostomy itself can be well covered and protected from the surging viscera with the 3D implants. At the same time, the vertical, tunnel-shaped part of the mesh provides sufficient protection from an ostomy prolapse. Further studies will be needed to compare the efficacy of various known approaches to PSH prevention.
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Affiliation(s)
- G Köhler
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria. .,Academic Teaching Hospital of the University of Graz, Graz, Austria. .,Academic Teaching Hospital of the University of Innsbruck, Innsbruck, Austria. .,Department of Surgery, Paracelsus Medical University, Salzburg, Austria.
| | - A Hofmann
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, Austria
| | - M Lechner
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - F Mayer
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - H Wundsam
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria.,Academic Teaching Hospital of the University of Graz, Graz, Austria.,Academic Teaching Hospital of the University of Innsbruck, Innsbruck, Austria
| | - K Emmanuel
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria.,Academic Teaching Hospital of the University of Graz, Graz, Austria.,Academic Teaching Hospital of the University of Innsbruck, Innsbruck, Austria
| | - R H Fortelny
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Vienna, Austria.,Department of Surgery, Paracelsus Medical University, Salzburg, Austria
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Köhler G, Weitzendorfer M, Kalcher V, Emmanuel K. Synthetic Mesh Repair for Incisional Hernia Treatment in High-risk Patients for Surgical Site Occurrences. Am Surg 2015. [DOI: 10.1177/000313481508100430] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with incisional hernias (IH) and risk factors for surgical site occurrences (SSOs) such as defined comorbidities and/or potential contaminations are considered to be treated with bioprosthetics. A retrospective analysis of consecutive patients who had undergone elective IH repair with synthetic mesh materials between 2009 and 2013 was conducted. Only patients who were classified into Grades II and III according to the classification of the Ventral Hernia Working Group (VHWG) were considered for the study. Primary outcome parameter was the incidence of SSO. The relationships among demographics, hernia characteristics, surgical technique, and SSOs were also evaluated. Overall, 108 patients were included (Grade II: 68, Grade III: 40). SSO was identified in 14 patients. Having two or more comorbidities ( P = 0.04), an open sublay technique ( P = 0.005), duration of operation ( P = 0.02), larger hernia defects ( P = 0.001), and using larger mesh sizes ( P = 0.01) were associated with significantly higher rates of SSO. Affiliation to VHWG Grading II or III showed no impact on SSO occurrence. Synthetic mesh repair both in an “open sublay” and laparoscopic intraperitoneal technique is safe regarding patients with risk factors for SSO. The recommendations of the VHWG must be declined and a modification of the grading system is warranted overlooking a more liberal use of synthetic meshes.
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Affiliation(s)
- Gernot Köhler
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Academic Teaching Hospital of the Medical Universities Graz and Innsbruck, Linz, Austria
| | - Michael Weitzendorfer
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Academic Teaching Hospital of the Medical Universities Graz and Innsbruck, Linz, Austria
| | - Veronika Kalcher
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Academic Teaching Hospital of the Medical Universities Graz and Innsbruck, Linz, Austria
| | - Klaus Emmanuel
- Department of General and Visceral Surgery, Sisters of Charity Hospital, Academic Teaching Hospital of the Medical Universities Graz and Innsbruck, Linz, Austria
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Hwang GS, Hanna MH, Carmichael JC, Mills SD, Pigazzi A, Stamos MJ. Repair of complex parastomal hernias. Tech Coloproctol 2015; 19:127-33. [PMID: 25732736 DOI: 10.1007/s10151-015-1293-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/13/2015] [Indexed: 11/26/2022]
Abstract
Development of parastomal hernias (PH) is very common after stoma formation and carries a risk of subsequent bowel incarceration, obstruction and strangulation. The management of PH remains a challenge for the colorectal surgeon, and there are currently no standardized guidelines for the treatment of PH. Even more difficult is the management of complex parastomal hernias (CPH). We conducted a review of the literature to identify recent developments in the treatment of CPH, including analysis of the use of synthetic and biologic mesh prostheses, method of mesh placement and surgical approach.
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Affiliation(s)
- G S Hwang
- Department of Surgery, Irvine School of Medicine, University of California, Irvine, CA, USA
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Näsvall P, Strigård K, Gunnarsson U, Rutegård J. Reply to 'Preventing parastomal herniation in 2014 and beyond'. Colorectal Dis 2014; 16:831-2. [PMID: 25046974 DOI: 10.1111/codi.12729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/20/2014] [Indexed: 02/08/2023]
Affiliation(s)
- P Näsvall
- Department of Surgery, Sunderby Hospital, Luleå, Sweden.
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47
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Köhler G, Koch OO, Antoniou SA, Lechner M, Mayer F, Klinge U, Emmanuel K. Parastomal hernia repair with a 3-D mesh device and additional flat mesh repair of the abdominal wall. Hernia 2014; 18:653-61. [PMID: 25112385 DOI: 10.1007/s10029-014-1302-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 07/28/2014] [Indexed: 01/09/2023]
Abstract
PURPOSE Parastomal hernias (PSHs) have been a major clinical problem. The aim of this study was to evaluate a new method of PSH repair in combination with an additional flat mesh reinforcement of the abdominal wall. METHODS In a pilot case series, seven patients suffering from complex PSHs (≥5 cm diameter and/or recurrence) underwent surgery and were treated by intraperitoneal onlay technique (IPOM) with a synthetic 3-D funnel-shaped mesh implant. The demographics, perioperative, and follow-up data are presented in this report. RESULTS The surgical strategy varied between purely laparoscopic (n = 1), laparoscopically assisted (hybrid n = 3), or open techniques (n = 3) using original or suture-reconstructed mesh devices. The funnel mesh implantations in IPOM technique were combined with attached flat meshes in the appropriate position of the abdominal wall. No procedure-related complications occurred. The mean length of hospital stay was 12 days and the mean operating time was 171 min. No recurrence of PSH or incisional hernias was observed during a mean follow-up period of 12.3 months (range from 7 to 22). CONCLUSION The use of a 3-D mesh implant has so far shown to be a promising option in the treatment of primary and recurrent PSHs. Its use proved to be reasonable in both laparoscopic and open IPOM technique. PSHs were preferably repaired using the original, unmodified implant, but when we also found it safe to incise, place and then suture the mesh around the pre-existing ostomy.
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Affiliation(s)
- G Köhler
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria,
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48
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Abstract
Parastomal hernia is the most common late stomal complication. Its appearance is usually asymptomatic. We report a parastomal hernia containing stomach. A 69-year-old patient with end colostomy arrived at the emergency room presenting with abdominal pain associated with vomiting and functioning stoma. She had a distended and painful abdomen without signs of peritoneal irritation and pericolostomic eventration in the left iliac fossa. X-ray visualized gastric fornix dilatation without dilated intestine bowels, and computed tomography showed parastomal incarcerated gastric herniation. Gastrografin (Bayer Australia Limited, New South Wales, Australia) was administered, showing no passage to duodenum. She underwent surgery, with stomal transposition and placement of onlay polypropylene mesh around the new stoma. Parastomal hernias are a frequent late complication of colostomy. Only four gastric parastomal hernia cases are reported in the literature. Three of these four cases required surgery. The placement of prosthetic mesh in the moment of stoma elaboration should be considered as a potential preventive measure.
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Correa Marinez A, Erestam S, Haglind E, Ekelund J, Angerås U, Rosenberg J, Helgstrand F, Angenete E. Stoma-Const--the technical aspects of stoma construction: study protocol for a randomised controlled trial. Trials 2014; 15:254. [PMID: 24970570 PMCID: PMC4094442 DOI: 10.1186/1745-6215-15-254] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 06/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The construction of a colostomy is a common procedure, but the evidence for the different parts of the construction of the colostomy is lacking. Parastomal hernia is a common complication of colostomy formation. The aim of this study is to standardise the colostomy formation and to compare three types of colostomy formation (one including a mesh) regarding the development of parastomal hernia. METHODS/DESIGN Stoma-Const is a Scandinavian randomised trial comparing three types of colostomy formation. The primary endpoint is parastomal herniation as shown by clinical examination or CT scan within one year. Secondary endpoints are re-admission rate, postoperative complications (classified according to Clavien-Dindo), stoma-related complications (registered in the case record form at stoma care nurse follow-up), total length of hospital stay during 12 months, health-related quality of life and health economic analysis as well as re-operation rate and mortality within 30 days and 12 months of primary surgery. Follow-up is scheduled at 4-6 weeks, and 6 and 12 months. Inclusion is set at 240 patients. DISCUSSION Parastomal hernia is a common complication after colostomy formation. Several studies have been performed with the aim to reduce the rate of this complication. However, none are fully conclusive and data on quality of life and health economy are lacking. The aim of this study is to develop new standardised techniques for colostomy formation and evaluate this with patient reported outcomes as well as clinical and radiological assessment. TRIAL REGISTRATION Clinicaltrials.gov, NCT01694238.2012-09-24.
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Affiliation(s)
| | | | | | | | | | | | | | - Eva Angenete
- Department of Surgery, Institute of Clinical Sciences, SSORG - Scandinavian Surgical Outcomes Research Group, University of Gothenburg, Sahlgrenska University Hospital/Östra, 416 85 Gothenburg, Sweden.
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50
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Abstract
The construction of an intestinal stoma is fraught with complications and should not be considered a trivial undertaking. Serious complications requiring immediate reoperations can occur, as can minor problems that will subject the patient to daily and nightly distress. Intestinal stomas undoubtedly will dramatically change lifestyles; patients will experience physiologic and psychologic detriment with stoma-related problems, however minor they may seem. Common complications include poor stoma siting, high output, skin irritation, ischemia, retraction, parastomal hernia (PH), and prolapse. Surgeons should be cognizant of these complications before, during, and after stoma creation, and adequate measures should be taken to avoid them. In this review, the authors highlight these often seen problems and discuss management and prevention strategies.
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Affiliation(s)
- Michael Kwiatt
- Division of Colon and Rectal Surgery, Department of Surgery, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Michitaka Kawata
- Division of Colon and Rectal Surgery, Department of Surgery, Cooper Medical School of Rowan University, Camden, New Jersey
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