Permanent end-colostomy parastomal hernia prevention using a novel three-dimensional mesh

Parastomal Hernia Prevention Using Funnel-Shaped Intra-Abdominal Mesh Compared to No Mesh: The Chimney Randomized Clinical Trial

Importance

Prophylactic placement of a mesh has been suggested to prevent parastomal hernia. Evidence to support this practice is contradictory.

Objective

To determine whether funnel-shaped permanent synthetic parastomal mesh is effective and safe in parastomal hernia prevention.

Design, Setting, and Participants

The Chimney Trial was a randomized single-blinded multicenter trial conducted in 4 hospitals in Finland and 1 in Sweden from February 2019 and September 2021. Of 439 patients with rectal adenocarcinoma undergoing either laparoscopic or robotic-assisted abdominoperineal resection or the Hartmann procedure, 143 were enrolled in the trial, 135 received their allocated intervention, and 121 were analyzed at 12-month follow-up. Data were analyzed from December 2023 to May 2024.

Intervention

In the intervention group, a permanent colostomy was created with a funnel-shaped intraperitoneal mesh and compared to a control group with a stoma without the mesh.

Main Outcome and Measure

The primary end point was the incidence of computed tomography (CT)-confirmed parastomal hernia 12 months after surgery.

Results

There were 68 patients (mean [SD] age, 68.7 [11.6] years; 36 [53% male and 32 [47%] female) who received the intended allocation in the mesh group and 67 (mean [SD] age, 66.4 [11.7] years; 48 [72%] male and 19 [28%] female) who received the intended allocation in the control group. CT scans were available for 58 patients in the mesh group and 59 patients in the control group at the 12-month follow-up. CT scans confirmed parastomal hernia in 6 of 58 patients (10%) in the mesh group compared to 22 of 59 patients (37%) in the control group (difference, 27%; 95% CI, 12-41; P < .001). Clinical parastomal hernia as a secondary outcome was recorded in 1 of 60 patients (2%) in the mesh group compared to 27 of 61 (43%) in the control group (difference, 41%; 95% CI, 29-55; P < .001). The number of patients with Clavien-Dindo class II ileus was 23 (35%) in the mesh group compared to 11 (17%) in the control group (difference, 18%; 95% CI, 3-32; P = .006). Only slight differences between the groups were detected in other stoma-related complications, readmissions, operative time, surgical site infections, reoperations, and quality of life.

Conclusions and Relevance

In this study, funnel-shaped parastomal mesh prevented a significant number of parastomal hernias without predisposing patients to mesh- or stoma-related complications during 12-month follow-up. The results of this study suggest the funnel-shaped mesh is a feasible option to prevent parastomal hernia.

Trial Registration

ClinicalTrials.gov Identifier: NCT03799939.

[Prophylaxis of parastomal, perineal and incisional hernias in colorectal surgery]

This article gives an overview of the relevant evidence from the literature on the topic of prophylactic use of meshes to prevent incisional and parastomal hernias in colorectal surgery. In addition, based on a structured literature search the incidence of hernias in colorectal surgery over the past 5 years was analyzed. A slight majority (54%) of articles recommended the use of prophylactic mesh implantation in colorectal surgery. The prophylactic use of meshes appears to reduce the risk of hernias in colorectal surgery but is associated with a slightly increased perioperative wound infection rate. Parastomal hernias are associated with higher incidence rates compared with incisional hernias and also appear to benefit more from prophylactic mesh implantation. The evidence in the literature is still unclear regarding the use of synthetic or biological implants due to the lack of randomized controlled trials. Perineal hernias were excluded from the analysis due to the incomparability of the mainly casuistic literature. An overview is given in the discussion. The analysis of the literature and also in reflection of our own experience comes to the conclusion that the disrupted integrity of the abdominal wall due to the operation should be prophylactically reinforced with a mesh after colorectal surgery. An evidence-based recommendation is not possible based on the current state of research on implantation techniques, e.g. onlay, sublay intraperitoneal onlay mesh (IPOM) and selection of the implant.

The Role of Mesh Implants in Surgical Treatment of Parastomal Hernia

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.