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Meng C, Wei Q, Sun L, Zhang X, Liu Y, Gao J, Wei P, Yang Z, Yao H, Zhang Z. Effects of different mesh materials on complications after prophylactic placement for stoma formation: a systematic review and network meta-analysis. Hernia 2024; 28:1039-1052. [PMID: 38878219 PMCID: PMC11297115 DOI: 10.1007/s10029-024-03068-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/01/2024] [Indexed: 08/03/2024]
Abstract
PURPOSE We primary aimed to synthesise the available data, assess the effectiveness of different mesh materials in prophylactic mesh placement, and rank these materials according to the incidence of parastomal hernia (PSH) and other stoma complications. METHOD This network meta-analysis performed a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Four databases were searched for randomised controlled trials of prophylactic mesh placement. The aggregated results were performed in the STATA routine for Bayesian hierarchical random effects models. RESULT Thirteen randomised controlled trials from 1203 articles, met the inclusion criteria, including 681 cases without meshes, 65 cases with mesh material of xenogeneic acellular dermis (porcine/bovine), 27 cases with polypropylene/PG910, 114 cases with polypropylene/polyglecaprone (Monocryl), 117 cases with polypropylene/cellulose (ORC), 233 cases with polypropylene, and 35 cases with polypropylene/PVDF. In network A, compared with no mesh, only polypropylene (RR 0.24, 95% CI 0.04-0.80) were significantly associated with a reduction in the incidence of PSH. In network B, no statistical difference regarding stoma complications was found between mesh and no mesh. CONCLUSION Based on the network meta-analysis and ranking results, the polypropylene mesh material exhibited the best performance. However, this conclusion needs to be confirmed with larger sample sizes and high-quality randomised controlled trials.
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Affiliation(s)
- C Meng
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Q Wei
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - L Sun
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - X Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Y Liu
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - J Gao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - P Wei
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Z Yang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - H Yao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, China.
| | - Z Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, State Key Lab of Digestive Health, National Clinical Research Center for Digestive Diseases, Beijing, 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 2020; 91:1185-1189. [PMID: 33164321 DOI: 10.1111/ans.16420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [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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Prophylactic mesh augmentation using permanent synthetic mesh: outcomes of keyhole and Stapled Ostomy Reinforcement with Retromuscular Mesh techniques. Hernia 2020; 25:631-638. [PMID: 32279169 DOI: 10.1007/s10029-020-02176-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/11/2020] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Parastomal hernias (PSH) are the most common complication of stoma creation and can cause significant morbidity. We present a consecutive series of patients receiving prophylactic mesh augmentation (PMA) for prevention of PSH. METHODS This retrospective review evaluates the efficacy and outcomes of PMA for PSH prevention, and retrospectively compares traditional keyhole PMA (tPMA) (n = 28) with a prophylactic Stapled Ostomy Reinforcement with Retromuscular Mesh technique (pSTORRM) (n = 24). RESULTS PMA was performed in 52 cases between January 2015 and July 2018. All cases used a large-pore, non-coated, mid-weight polypropylene mesh placed in the retrorectus space. With a median follow-up of 16 mos, parastomal hernia was confirmed in 11.5% (n = 6), 5 of whom were symptomatic. patient-reported outcomes (PRO) indicated 6 additional patients with symptoms associated with PSH without clinical or radiographic confirmation. Patients had similar comorbidities and operative characteristics between tPMA and pSTORRM techniques, and no difference in a median follow-up. pSTORRM patients had fewer surgical site infections (8.3 vs 32.1%; p = 0.046) and occurrences (12.5 vs 46.4%; p = 0.015), and lower rate of PSH, though not statistically significant (4.2 vs 17.9%; p = 0.195). CONCLUSION Permanent synthetic mesh placed as a sublay in the retromuscular space is safe and appears to decrease the risk of PSH formation after the creation of permanent stomas. A stapled technique may provide advantages over a traditional keyhole technique.
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López-Cano M, Pereira Rodriguez JA. Parastomal Hernia Prevention With Mesh in the Context of Laparoscopic Approach: An Opinion Based on Current Literature. Front Surg 2018; 5:19. [PMID: 29560352 PMCID: PMC5845550 DOI: 10.3389/fsurg.2018.00019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/13/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Manuel López-Cano
- Department of General Surgery, Abdominal Wall Surgery Unit and General and Digestive Surgery Research Group, Institut de Reserca Vall d'Hebron (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Antonio Pereira Rodriguez
- Servei de Cirurgia General, Hospital del Mar, Parc de Salut Mar, Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain
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Knaapen L, Buyne O, van Goor H, Slater NJ. Synthetic vs biologic mesh for the repair and prevention of parastomal hernia. World J Meta-Anal 2017; 5:150-166. [DOI: 10.13105/wjma.v5.i6.150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/29/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To outline current evidence regarding prevention and treatment of parastomal hernia and to compare use of synthetic and biologic mesh.
METHODS Relevant databases were searched for studies reporting hernia recurrence, wound and mesh infection, other complications, surgical techniques and mortality. Weighted pooled proportions (95%CI) were calculated using StatsDirect. Heterogeneity concerning outcome measures was determined using Cochran’s Q test and was quantified using I2. Random and fixed effects models were used. Meta-analysis was performed with Review Manager software with the statistical significance set at P ≤ 0.05.
RESULTS Forty-four studies were included: 5 reporting biologic mesh repairs; 21, synthetic mesh repairs; and 18, prophylactic mesh repairs. Most of the studies were retrospective cohorts of low to moderate quality. The hernia recurrence rate was higher after undergoing biologic compared to synthetic mesh repair (24.0% vs 15.1%, P = 0.01). No significant difference was found concerning wound and mesh infection (5.6% vs 2.8%; 0% vs 3.1%). Open and laparoscopic techniques were comparable regarding recurrences and infections. Prophylactic mesh placement reduced the occurrence of a parastomal hernia (OR = 0.20, P < 0.0006) without increasing wound infection [7.8% vs 8.2% (OR = 1.04, P = 0.91)] and without differences between the mesh types.
CONCLUSION There is no superiority of biologic over synthetic mesh for parastomal hernia repair. Prophylactic mesh placement during the initial surgery significantly reduces parastomal hernia occurrence regardless of the mesh type.
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Affiliation(s)
- Loes Knaapen
- Department of Surgery, Radboud University Medical Centre, Nijmegen 6500 HB, The Netherlands
| | - Otmar Buyne
- Department of Surgery, Radboud University Medical Centre, Nijmegen 6500 HB, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen 6500 HB, The Netherlands
| | - Nicholas J Slater
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen 6500 HB, The Netherlands
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Conde-Muíño R, Díez JL, Martínez A, Huertas F, Segura I, Palma P. Preventing parastomal hernias with systematic intraperitoneal specifically designed mesh. BMC Surg 2017; 17:41. [PMID: 28424067 PMCID: PMC5395763 DOI: 10.1186/s12893-017-0237-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 04/06/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Parastomal hernia is a very common complication after stoma formation. Current surgical techniques for repairing parastomal hernia have unsatisfactory results. We aim to assess our preliminary experience with prophylactic mesh placement at the time of stoma formation. METHODS Data were prospectively recorded. A specifically designed mesh made of polyvinyl fluoride with central conduit (Dynamesh IPST®) was fixed using an intra-peritoneal onlay technique. Safety was evaluated by means of surgical data and frequency of mesh-related complications, efficacy by the rate of parastomal hernias. RESULTS Thirty-four patients were included in the study. Three of them died before a year of follow up (not related to the stoma), so they were excluded. The other 31 patients (11 women and 20 men) were prospectively followed up after different pathologies resulting in a permanent colostomy. Twelve months after surgery CT-Scan imaging revealed two (6.4%) parastomal hernias, one of them already clinically suspected. During the follow up, 29% of the patients (n = 9) developed another type of hernia (incisional, inguinal or both). In five patients (16.1%) a light stomal retraction of the otherwise slightly prominent ostomy was observed. Median clinical follow-up was 17.5 months (range 12-34). CONCLUSION Prophylactic parastomal mesh placement might be a safe and effective procedure with a potential to reduce the risk of parastomal hernia. Routine use of this technique should be further analysed.
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Affiliation(s)
- Raquel Conde-Muíño
- Division of Colon & Rectal Surgery, Complejo Hospitalario Universitario de Granada, Granada, Spain
| | - José-Luis Díez
- Division of Colon & Rectal Surgery, Complejo Hospitalario Universitario de Granada, Granada, Spain
| | - Alberto Martínez
- Department of Radiology, Complejo Hospitalario Universitario de Granada, Granada, Spain
| | - Francisco Huertas
- Division of Colon & Rectal Surgery, Complejo Hospitalario Universitario de Granada, Granada, Spain
| | - Inmaculada Segura
- Division of Colon & Rectal Surgery, Complejo Hospitalario Universitario de Granada, Granada, Spain
| | - Pablo Palma
- Division of Colon & Rectal Surgery, Complejo Hospitalario Universitario de Granada, Granada, Spain.
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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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Glasgow SC, Dharmarajan S. Parastomal Hernia: Avoidance and Treatment in the 21st Century. Clin Colon Rectal Surg 2016; 29:277-84. [PMID: 27582655 DOI: 10.1055/s-0036-1584506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Despite medical and surgical advances leading to increased ability to restore or preserve gastrointestinal continuity, creation of stomas remains a common surgical procedure. Every ostomy results in a risk for subsequent parastomal herniation, which in turn may reduce quality of life and increase health care expenditures. Recent evidence-supported practices such as utilization of prophylactic reinforcement, attention to stoma placement, and laparoscopic-based stoma repairs with mesh provide opportunities to both prevent and successfully treat parastomal hernias.
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Affiliation(s)
- Sean C Glasgow
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; USAF Center for the Sustainment of Trauma and Resuscitative Skills (C-STARS), St. Louis, Missouri
| | - Sekhar Dharmarajan
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; John Cochrane VA Medical Center, St. Louis, Missouri
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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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Warwick AM, Velineni R, Smart NJ, Daniels IR. Onlay parastomal hernia repair with cross-linked porcine dermal collagen biologic mesh: long-term results. Hernia 2015; 20:321-5. [PMID: 26685980 DOI: 10.1007/s10029-015-1452-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 12/03/2015] [Indexed: 01/14/2023]
Abstract
PURPOSE The optimal technique and mesh type for parastomal hernia repair have yet to be ascertained. Biologic meshes have been advocated in parastomal hernia repair due to purported resistance to infection in contaminated fields. The aim of this study was to evaluate the effectiveness of additionally cross-linked acellular porcine dermal collagen mesh (Permacol) for onlay parastomal hernia repair. METHODS A retrospective review of case notes, and abdominal CT scans when available, was performed for consecutive patients who had a parastomal hernia repaired between January 2007 and May 2010. All hernias were repaired with onlay placement of the biologic mesh. Hernias were classified according to the Moreno-Matias classification where CT scans were available. RESULTS Over a 34-month period, 30 consecutive patients, median age 74 years, 17 female, underwent parastomal hernia repair using onlay biologic mesh. There were 23 paracolostomy and seven paraileostomy hernias. The hernia was primary in 26 patients. Pre-operative CT scans were available in 18 patients (Moreno-Matias Type 1 = 1, Type 2 = 4, Type 3 = 13). There was one perioperative death, and 29 patients were available for follow-up, and median duration of follow-up (either CT or clinical) was 36 months (range 3-79). Twenty-six patients developed recurrence of the parastomal hernia (89.6%), and median time to recurrence was 10 months (range 3-72),with Moreno-Matias Type 1 = 0, Type 2 = 4, Type 3 = 14, unknown = 8. Fifteen out of 26 patients have had repairs of the recurrence using a variety of techniques. Of these, 10 patients have had further recurrence. CONCLUSION Onlay repair of parastomal hernia with cross-linked porcine dermal collagen biologic mesh reinforcement has poor long-term outcomes with unacceptably high recurrence rates and should not be performed.
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Affiliation(s)
- A M Warwick
- Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, UK.
| | - R Velineni
- Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - N J Smart
- Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - I R Daniels
- Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter, Devon, EX2 5DW, UK
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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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13
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Aquina CT, Iannuzzi JC, Probst CP, Kelly KN, Noyes K, Fleming FJ, Monson JRT. Parastomal hernia: a growing problem with new solutions. Dig Surg 2014; 31:366-76. [PMID: 25531238 DOI: 10.1159/000369279] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 10/19/2014] [Indexed: 12/10/2022]
Abstract
Parastomal hernia is one of the most common complications following stoma creation and its prevalence is only expected to increase. It often leads to a decrease in the quality of life for patients due to discomfort, pain, frequent ostomy appliance leakage, or peristomal skin irritation and can result in significantly increased healthcare costs. Surgical technique for parastomal hernia repair has evolved significantly over the past two decades with the introduction of new types of mesh and laparoscopic procedures. The use of prophylactic mesh in high-risk patients at the time of stoma creation has gained attention in lieu of several promising studies that have emerged in the recent days. This review will attempt to demonstrate the burden that parastomal hernias present to patients, surgeons, and the healthcare system and also provide an overview of the current management and surgical techniques at both preventing and treating parastomal hernias.
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Affiliation(s)
- Christopher T Aquina
- Surgical Health Outcomes & Research Enterprise (S.H.O.R.E.), Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, N.Y., USA
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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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A prospective, multicenter, randomized, controlled study of non-cross-linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in patients undergoing surgery for permanent abdominal wall ostomies. Dis Colon Rectum 2014; 57:623-31. [PMID: 24819103 DOI: 10.1097/dcr.0000000000000106] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND A large proportion of patients with a colostomy or an ileostomy develop parastomal hernias. The placement of a reinforcing material at the stoma site may reduce parastomal hernia incidence. OBJECTIVE We aimed to assess the safety and efficacy of stoma reinforcement with sublay placement of non-cross-linked porcine-derived acellular dermal matrix at the time of stoma construction. DESIGN This is a randomized, patient- and third-party assessor-blind, controlled trial. SETTINGS This study took place in colorectal/general surgery institutions. INTERVENTIONS Patients were prospectively randomly assigned to undergo standard end-stoma construction with or without porcine-derived acellular dermal matrix reinforcement. PATIENTS Patients undergoing construction of a permanent stoma were eligible. A total of 113 patients (59 men, 54 women; mean age, 60 years; mean BMI, 25.4 kg/m) participated: 58 controls and 55 with reinforcement. MAIN OUTCOMES MEASURES The incidence of parastomal hernia, safety, and stoma-related quality of life were assessed. RESULTS Intraoperative complications and blood loss were similar between groups. Quality-of-life scores were similar through 24 months of follow-up. At 24 months of follow-up, the incidence of parastomal hernias was similar for both groups (12.2% of the porcine-derived acellular dermal matrix group and 13.2% of controls). LIMITATIONS Study limitations include the inclusion of ileostomy and colostomy patients, open and laparoscopic techniques, and small numbers of patients at follow-up. CONCLUSIONS Safety and quality-of-life data from this randomized control trial show similar outcomes in both groups. Prosthetic reinforcement of stomas was safe, but it did not significantly reduce the incidence of parastomal hernia formation. CLINICAL TRIAL REGISTRATION Identification no. NCT00771407.
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Heiying J, Yonghong D, Xiaofeng W, Hang Y, Kunlan W, Bei Z, Jinhao Z, Qiang L. A study of laparoscopic extraperitoneal sigmoid colostomy after abdomino-perineal resection for rectal cancer. Gastroenterol Rep (Oxf) 2014; 2:58-62. [PMID: 24760238 PMCID: PMC3920995 DOI: 10.1093/gastro/got036] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To established a procedure for laparoscopic extraperitoneal ostomy after abdomino-perineal resection (APR) and study safety aspects and complications. METHOD From July 2011 to July 2012, 36 patients with low rectal cancer undergoing APR were included in the study and divided into extraperitoneal ostomy group (n = 18) and intraperitoneal ostomy group (n = 18). Short- and long-term complications were compared between the two groups. All patients were followed up and the median duration was 17 months (range: 12-24). RESULTS The rates of short-term complication related to colostomies were comparable between the two groups, except the rate for stoma edema was higher in the extraperitoneal group (33.3% vs 0%; P = 0.008). In the intraperitoneal ostomy group, two patients developed stoma prolapse, one had stoma stenosis, and two had parastomal hernia. In contrast, no long-term complications related to colostomies occurred in the extraperitoneal ostomy group. The rate of long-term complication was lower in the extraperitoneal ostomy group (0% vs 22.2%; P = 0.036). CONCLUSION The laparoscopic extraperitoneal ostomy is a relatively simple and safe procedure, with fewer long-term complications related to colostomy. However the follow-up period was not too long and needs to be extended.
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Affiliation(s)
- Jin Heiying
- National Center of Colorectal Surgery, The 3 Affiliated Hospital of Nanjing University of Traditional Chinese Medicine
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Affiliation(s)
- B M E Hansson
- Department of gastro-intestinal surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.
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Abstract
Occurrence of parastomal hernia is considered a near inevitable consequence of stoma formation, making their management a common clinical dilemma. This article reviews the outcomes of different surgical approaches for hernia repair and describes in detail the laparoscopic Sugarbaker technique, which has been shown to have lower recurrence rates than other methods. Also reviewed is the current literature on the impact of prophylactic mesh placement during ostomy formation.
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Affiliation(s)
- Nilay R Shah
- Department of Surgery, Mayo Clinic Hospital, 5777 East Mayo Boulevard, MCSB SP 3-522 Gen Surg, Phoenix, AZ 85054, USA
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Gao X, Deng X, Wei X, Shi H, Wang F, Ye T, Shao B, Nie W, Li Y, Luo M, Gong C, Huang N. Novel thermosensitive hydrogel for preventing formation of abdominal adhesions. Int J Nanomedicine 2013; 8:2453-63. [PMID: 23885172 PMCID: PMC3716558 DOI: 10.2147/ijn.s46357] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Adhesions can form after almost any type of abdominal surgery. Postoperative adhesions can be prevented by improved surgical techniques, such as reducing surgical trauma, preventing ischemia, and avoiding exposure of the peritoneal cavity to foreign materials. Although improved surgical techniques can potentially reduce formation of adhesions, they cannot be eliminated completely. Therefore, finding more effective methods to prevent postoperative adhesions is imperative. Recently, we found that a novel thermosensitive hydrogel, ie, poly(ε-caprolactone)-poly(ethylene glycol)-poly(ε-caprolactone) (PCEC) had the potential to prevent postoperative adhesions. Using the ring-opening polymerization method we prepared a PCEC copolymer which could be dissolved and assembled at 55°C into PCEC micelles with mean size of 25 nm. At body temperature, a solution containing PCEC micelles could convert into a hydrogel. The PCEC copolymer was biodegradable and had low toxicity in vitro and in vivo. We found that most animals in a hydrogel-treated group (n = 10) did not develop adhesions. In contrast, 10 untreated animals developed adhesions that could only be separated by sharp dissection (P < 0.001). The hydrogel could adhere to peritoneal wounds and degraded gradually over 7-9 days, transforming into a viscous fuid that was completely absorbed within 12 days. The injured parietal and visceral peritoneum remesothelialized over about seven and nine days, respectively. This study confirms that PCEC hydrogel has potential application in the prevention of postoperative adhesions.
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Affiliation(s)
- Xiang Gao
- Department of Pathophysiology, College of Preclinical and Forensic Medical Sciences, Sichuan University, Chengdu, People’s Republic of China
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