Safety and efficacy of prophylactic resorbable biosynthetic mesh in loop-ileostomy reversal: a case–control study

Two-meshes approach in posterior component separation with transversus abdominis release: the IMPACT study (Italian Multicentric Posterior-separation Abdominal Complex hernia Transversus-release)

BACKGROUND

Surgical management of large ventral hernias (VH) has remained a challenge. Various techniques like anterior component separation and posterior component separation (PCS) with transversus abdominis release (TAR) have been employed. Despite the initial success, the long-term efficacy of TAR is not yet comprehensively studied. Authors aimed to investigate the early-, medium-, and long-term outcomes and health-related quality of life (QoL) in patients treated with PCS and TAR.

METHODS

This multicenter retrospective study analyzed data of 308 patients who underwent open PCS with TAR for primary or recurrent complex abdominal hernias between 2015 and 2020. The primary endpoint was the rate of hernia recurrence (HR) and mesh bulging (MB) at 3, 6, 12, 24, and 36 months. Secondary outcomes included surgical site events and QoL, assessed using EuraHS-QoL score.

RESULTS

The average follow-up was 38.3 ± 12.7 months. The overall HR rate was 3.5% and the MB rate was 4.7%. Most of the recurrences were detected by clinical and ultrasound examination. QoL metrics showed improvement post-surgery.

CONCLUSIONS

This study supports the long-term efficacy of PCS with TAR in the treatment of large and complex VH, with a low recurrence rate and an improvement in QoL. Further research is needed for a more in-depth understanding of these outcomes and the factors affecting them.

Reversal of stoma with biosynthetic mesh fascial reinforcement: a systematic review and meta-analysis

AIM

Temporary stoma formation remains a common part of modern-day colorectal surgical operations. At the time of reversal, a second procedure is required when the bowel is anastomosed and the musculature is closed. The rate of incisional hernia at these sites is 30%-35% with conventional suture closure. Mesh placement at this site is therefore an attractive option to reduce hernia risk, particularly as new mesh types, such as biosynthetic meshes, are available. The aim of this work was to conduct a systematic review and meta-analysis assessing the use of mesh for prophylaxis of incisional hernia at stoma closure and to explore the outcome measures used by each of the included studies to establish whether they are genuinely patient-centred.

METHOD

This is a systematic review and meta-analysis assessing the published literature regarding the use of mesh at stoma site closure operations. Comprehensive literature searches of major electronic databases were performed by an information specialist. Screening of search results was undertaken using standard systematic review principles. Data from selected studies were input into an Excel file. Meta-analysis of the results of included studies was conducted using RevMan software (v.5.4). Randomized controlled trial (RCT) and non-RCT data were analysed separately.

RESULTS

Eleven studies with a total of 2008 patients were selected for inclusion, with various mesh types used. Of the included studies, one was a RCT, seven were nonrandomized comparative studies and three were case series. The meta-analysis of nonrandomized studies shows that the rate of incisional hernia was lower in the mesh reinforcement group compared with the suture closure group (OR 0.21, 95% CI 0.12-0.37) while rates of infection and haematoma/seroma were similar between groups (OR 0.7, 95% CI 0.41-1.21 and OR 1.05, 95% CI 0.63-1.80, respectively). The results of the RCT were in line with those of the nonrandomized studies.

CONCLUSION

Current evidence indicates that mesh is safe and reduces incisional hernia. However, this is not commonly adopted into current clinical practice and the literature has minimal patient-reported outcome measures. Future work should explore the reasons for such slow adoption as well as the preferences of patients in terms of outcome measures that matter most to them.

An evidence map and synthesis review with meta-analysis on the risk of incisional hernia in colorectal surgery with standard closure

PURPOSE

To assess the incidence of incisional hernia (IH) across various type of incisions in colorectal surgery (CS) creating a map of evidence to define research trends, gaps and areas of future interest.

METHODS

Systematic review of PubMed and Scopus from 2010 onwards. Studies included both open (OS) and laparoscopic (LS). The primary outcome was incidence of IH 12 months after index procedure, secondary outcomes were the study features and their influence on reported proportion of IH. Random effects models were used to calculate pooled proportions. Meta-regression models were performed to explore heterogeneity.

RESULTS

Ninetyone studies were included reporting 6473 IH. The pooled proportions of IH for OS were 0.35 (95% CI 0.27-0.44) I² 0% in midline laparotomies and 0.02 (95% CI 0.00-0.07), I² 52% for off-midline. In case of LS the pooled proportion of IH for midline extraction sites were 0.10 (95% CI 0.07-0.16), I² 58% and 0.04 (95% CI 0.03-0.06), I² 86% in case of off-midline. In Port-site IH was 0.02 (95% CI 0.01-0.04), I² 82%, and for single incision surgery (SILS) of 0.06-95% CI 0.02-0.15, I² 81%. In case of stoma reversal sites was 0.20 (95% CI 0.16-0.24).

CONCLUSION

Midline laparotomies and stoma reversal sites are at high risk for IH and should be considered in research of preventive strategies of closure. After laparoscopic approach IH happens mainly by extraction sites incisions specially midline and also represent an important area of analysis.

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)

BACKGROUND

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined.

METHODS

This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations.

RESULTS

From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P  < 0.001). One patient in the mesh group required mesh removal because of deep infection.

CONCLUSION

Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

GRAPHICAL ABSTRACT

An RCT was conducted to compare the widely recommended midline laparotomy closure using a slowly absorbable running suture with closure using a sublay mesh (Parietex ProGrip™), in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Patients were followed up for 24 months with clinical and ultrasonographic evaluation during outpatient visits. Prophylactic reinforcement of the midline abdominal wall, using a ProGrip™ Parietex mesh in the retromuscular position, at the time of urgent laparotomy in clean-contaminated wounds was safe and effective in reducing the incidence of incisional hernia, although larger studies with longer follow-up are required.

Prevention of incisional hernia at the site of stoma closure with different reinforcing mesh types: a systematic review and meta-analysis

Purpose

To evaluate safety and efficacy of a mesh reinforcement following stoma reversal to prevent stoma site incisional hernia (SSIH) and differences across the prostheses used.

Methods

A systematic search of PubMed/MEDLINE, EMBASE, SCOPUS and Cochrane databases was conducted to identify comparative studies until September 2020. A meta-analysis of postoperative outcomes and a network meta-analysis for a multiple comparison of the prostheses with each other were performed.

Results

Seven studies were included in the analysis (78.4% ileostomy and 21.6% colostomy) with a total of 1716 patients with (n = 684) or without (n = 1032) mesh. Mesh placement was associated with lower risk of SSIH (7.8%vs18.1%, OR0.266,95% CI 0.123–0.577, p < 0.001) than no mesh procedures but also with a longer operative time (SMD 0.941, 95% CI 0.462–1.421, p < 0.001). There was no statistically significant difference in terms of Surgical Site infection (11.5% vs 11.1%, OR 1.074, 95% CI 0.78–1.48, p = 0.66), seroma formation (4.4% vs 7.1%, OR 1.052, 95% CI 0.64–1.73, p = 0.84), anastomotic leakage (3.7% vs 2.7%, OR 1.598, 95% CI 0.846–3.019, p = 0.149) and length of stay (SMD − 0.579,95% CI − 1.261 to 0.102, p = 0.096) between mesh and no mesh groups. Use of prosthesis was associated with a significant lower need for a reoperation than no mesh group (8.1% vs 12.1%, OR 0.332, 95% CI 0.119–0.930, p = 0.036). Incidence of seroma is lower with biologic than polypropylene meshes but they showed a trend towards poor results compared with polypropylene or biosynthetic meshes.

Conclusion

Despite longer operative time, mesh prophylactic reinforcement at the site of stoma seems a safe and effective procedure with lower incidence of SSIH, need for reoperation and comparable short-term outcomes than standard closure technique. A significant superiority of a specific mesh type was not identified.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02393-w.

Closure of stoma site with or without prophylactic mesh reinforcement: a systematic review and meta-analysis

AIMS

To evaluate comparative outcomes of the closure of temporary stoma site with or without prophylactic mesh reinforcement METHODS: A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Studies comparing the reversal of stoma with and without prophylactic mesh reinforcement were included. Stoma site incisional hernia (SSIH), surgical site infection (SSI), operative time, seroma formation, haematoma formation, bowel obstruction, anastomosis leak, length of hospital stay (LOS) and secondary operation to repair the SSIH were the evaluated outcome parameters.

RESULTS

Six comparative studies reporting a total of 1683 patients who underwent closure of stoma with (n = 669) or without (n = 1014) prophylactic mesh reinforcement were included. Use of mesh was associated with a significantly lower risk of SSIH (OR 0.22, P = 0.003) and need for surgical intervention to repair SSIH (OR 0.32, P = 0.04) compared with no use of mesh. However, it was associated with significantly longer operative time (MD 47.78, P = 0.02). There was no significant difference in SSI (OR 1.09, P = 0.59), bowel obstruction (OR 1.11, P = 0.74), seroma formation (OR 2.86, P = 0.19), anastomosis leak (OR 1.60, P = 0.15), haematoma formation (OR 1.25, P = 0.75) or LOS (MD - 0.45, P = 0.31) between two groups.

CONCLUSION

Prophylactic mesh reinforcement during the closure of temporary stoma may significantly reduce the risk of SSIH and surgical intervention to repair the hernia without increasing the risk of SSI or other morbidities. However, it may increase the procedure time. Future higher-quality randomised evidence is required.