Parastomal hernias

Effects of different mesh materials on complications after prophylactic placement for stoma formation: a systematic review and network meta-analysis

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.

Parastomal Hernia Following Ileal Conduit: Incidence, Risk Factors, and Health-Related Quality of Life

PURPOSE

The purpose of this study was to measure the incidence of parastomal hernia (PH) after radical cystectomy and ileal conduit. Secondary aims were the identification of risk factors for PH and to compare the health-related quality of life (QOL) between patients with and without PH.

DESIGN

Retrospective review of medical records combined with cross-sectional administration of the QOL instrument and telephone follow-up.

SUBJECTS AND SETTING

The study sample comprised 219 patients who underwent radical cystectomy and ileal conduit for urothelial cancer between February 2014 and December 2018. The study setting was Peking University First Hospital (Beijing, China).

METHODS

Demographic and pertinent clinical data, including development of PH, were gathered via the retrospective review of medical records. Participants were also asked to complete the traditional Chinese language version of the City of Hope Quality of Life-Ostomy Questionnaire (C-COH). Multiple linear regression analysis was used to identify the effect of PH on C-COH scores. Logistic regression analysis was used to identify risk factors for PH development.

RESULTS

At a median follow-up of 34 months (IQR = 21-48), 43 of 219 (19.63%) patients had developed a PH. A body mass index (BMI) indicating overweight (OR = 3.548; 95% CI, 1.562-8.061; P = .002), a prior history of hernia (OR = 5.147; 95% CI, 1.195-22.159; P = .028), and chronic high abdominal pressure postdischarge (CHAP-pd) (OR = 3.197; 95% CI, 1.445-7.075; P = .004) were predictors of PH after operation. There was no significant difference between C-COH scores of patients with or without PH. No significant differences were found when participants with PH were compared to those without PH on 4 factors of the C-COH: physical scores (β= .347, P = .110), psychological scores (β= .316, P = .070), spiritual scores (β=-.125, P = .714), and social scores (β= .054, P = .833).

CONCLUSION

Parastomal hernia is prevalent in patients undergoing radical cystectomy and ileal conduit urinary diversion. Overweight, hernia history, and CHAP-pd were predictors of PH development. No significant differences in QOL were found when patients with PH were compared to those without PH.

Outcomes of Emergency Parastomal Hernia Repair in Older Adults: A Retrospective Analysis

INTRODUCTION

Parastomal hernias are common and many are never repaired. Emergency parastomal hernia repair (PHR) is a feared complication following ostomy creation, yet the incidence and long-term outcomes of emergency PHR are unknown.

MATERIALS AND METHODS

We performed a retrospective analysis of 100% Medicare claims data (2007-2015) to evaluate complications, readmissions, reoperations, hospitalizations, and mortality after emergency PHR. We used logistic regression and Cox proportional hazard models to determine the association of surgical approach, including repair with ostomy reversal, resiting, mesh, minimally invasive approach, or a myofascial flap. Analysis took place between June 2022 and February 2023.

RESULTS

A total of 6658 patients underwent emergency PHR (mean [standard deviation] age, 75.9 [9.8] y; 4031 female individuals [60.5%]). Overall, 3433 (51.2%) patients underwent primary PHR, 1626 (24.4%) underwent PHR with ostomy resiting, and 1599 (24.0%) underwent PHR with ostomy reversal. In the 30 d after surgery, 4151 (62.3%) patients had complications and 55 (0.83%) underwent reoperation. Compared to local repair, the 30-d odds of complications were lower for patients who underwent ostomy resiting (odds ratio 0.82 [95% confidence interval 0.72-0.93]). Five y after surgery, the cumulative incidence of reoperation was 12.0% and was lowest for patients who underwent PHR with ostomy reversal (hazard ratio 0.15 [95% confidence interval 0.11-0.21]) when compared to local repair.

CONCLUSIONS

Emergency PHR is associated with significant morbidity. However, technique selection may influence outcomes. Understanding the prognosis of emergency PHR may improve decision-making and patient counseling for patients living with this common disease.

Parastomal hernia after radical cystectomy. Incidence, natural history and predictive factors - A single center study

PURPOSE

Parastomal hernia (PH) is one of the most frequent complications after stoma creation. Our objective was to analyze the incidence, evolution and predictive factors of PH in Bricker-type urinary diversion.

PATIENTS AND METHODS

Case series analysis of 125 patients submitted to radical cystectomy and ileal conduit diversion for cancer in a single center during 2006-2021. Patient's record and imaging tests were reviewed to identify those suffering PH. Moreno-Matías classification was used to define radiological PH (rPH). Demographic and preoperative characteristics of the patients, surgical details and postoperative complications were recorded. Univariate and multivariate analyses were conducted to determine the effect of each predictive variable on the development and progression of PH.

RESULTS

21.6% of patients developed PH (median follow-up 37 months). Incidence increased with follow-up time (15.2% at 1 year, 20.8% at 2 years). BMI ≥ 25 (Expβ 8.31, 95% CI 1.06- 65.18, p = 0.04), previous midline laparotomy (Expβ 6.74, 95% CI 1.14-39.66, p = 0.04) and wound infection (Expβ 3.87, 95% CI 1.21-12.33, p = 0.02) were significantly associated with PH. Half of the patients with hernia had symptoms, 25.9% requiring surgical correction. 46% of type 1 hernias and 40% of type 2 hernias progressed to grade 3 with a median of 11 months. No variable was associated with radiological progression.

CONCLUSIONS

This study proved 3 independent factors (overweight, laparotomy and wound infection) that increase the risk of developing PH.

Contemporary Outcomes of Elective Parastomal Hernia Repair in Older Adults

Importance

Parastomal hernia is a challenging complication following ostomy creation; however, the incidence and long-term outcomes after elective parastomal hernia repair are poorly characterized.

Objective

To describe the incidence and long-term outcomes after elective parastomal hernia repair.

Design, Setting, and Participants

Using 100% Medicare claims, a retrospective cohort study of adult patients who underwent elective parastomal hernia repair between January 1, 2007, and December 31, 2015, was performed. Logistic regression and Cox proportional hazards models were used to evaluate mortality, complications, readmission, and reoperation after surgery. Analysis took place between February and May 2022.

Exposures

Parastomal hernia repair without ostomy resiting, parastomal hernia repair with ostomy resiting, and parastomal hernia repair with ostomy reversal.

Main Outcomes and Measures

Mortality, complications, and readmission within 30 days of surgery and reoperation for recurrence (parastomal or incisional hernia repair) up to 5 years after surgery.

Results

A total of 17 625 patients underwent elective parastomal hernia repair (mean [SD] age, 73.3 [9.1] years; 10 059 female individuals [57.1%]). Overall, 7315 patients (41.5%) underwent parastomal hernia repair without ostomy resiting, 2744 (15.6%) underwent parastomal hernia repair with ostomy resiting, and 7566 (42.9%) underwent parastomal hernia repair with ostomy reversal. In the 30 days after surgery, 676 patients (3.8%) died, 7088 (40.2%) had a complication, and 1740 (9.9%) were readmitted. The overall adjusted 5-year cumulative incidence of reoperation was 21.1% and was highest for patients who underwent parastomal hernia repair with ostomy resiting (25.3% [95% CI, 25.2%-25.4%]) compared with patients who underwent parastomal hernia repair with ostomy reversal (18.8% [95% CI, 18.7%-18.8%]). Among patients whose ostomy was not reversed, the hazard of repeat parastomal hernia repair was the same for patients whose ostomy was resited vs those whose ostomy was not resited (adjusted hazard ratio, 0.93 [95% CI, 0.81-1.06]).

Conclusions and Relevance

In this study, more than 1 in 5 patients underwent another parastomal or incisional hernia repair within 5 years of surgery. Although this was lowest for patients who underwent ostomy reversal at their index operation, ostomy resiting was not superior to local repair. Understanding the long-term outcomes of this common elective operation may help inform decision-making between patients and surgeons regarding appropriate operative approach and timing of surgery.

A new hernia: Meckel's diverticulum within a parastomal hernia

A Meckel's diverticulum is a true diverticulum containing all layers of bowel wall. An infrequently encountered sequela of this is a Littre's hernia, typically inguinal or femoral. This is the first description of a Meckel's diverticulum within a parastomal hernia. When encountered incidentally at surgery, resection should be considered on a case-by-case basis to prevent future complications of bleeding, obstruction or perforation.

Surgical treatment strategy for recurrent parastomal hernia: Experiences from 17 cases

Purpose

This study aimed to investigate the surgical treatment strategy of recurrent parastomal hernia (PH) and show its safety, feasibility, and outcomes at a mid-term follow-up.

Methods

A total of 17 cases of recurrent PH treated at our hospital between January 2016 and October 2021 were included in this retrospective analysis. Patient characteristics were recorded, and the classification of PH, operative time, intraoperative blood loss, hernia repair techniques, follow-up times, complications, as well as recurrence were compared and analyzed.

Results

Altogether, 17 patients with recurrent PH underwent successful hernia repair via surgical treatment at The First Affiliated Hospital of Shandong First Medical University and Shandong University Qilu Hospital. No recurrence or severe complications were noted during follow-ups (mean 32.8 ± 3.77 [range 3–68] months).

Conclusions

For recurrent PH, selecting a suitable repair approach based on intraperitoneal conditions such as infection, abdominal adhesions, or the length of the bowel loop, can help in achieving better therapeutic results. The lap-redo + Sugarbaker technique is worth recommending when the appropriate conditions are met.

Prophylactic Effect of Simultaneous Placement of Mesh on Incidence of Parastomal Hernia After Miles' Surgical Resection of Colorectal Cancer: A Prospective Study

INTRODUCTION

To assess the prophylactic effect of simultaneous placement of mesh and the incidence of parastomal hernia (PSH) after abdominoperineal resection of rectal cancer.

METHODS

This study included real-world data of 56 surgically resected patients with colorectal cancer who were consecutively assigned to two groups: control (no mesh, n = 32) and experimental (received mesh, n = 24). An artificial patch was placed under the tunica vaginalis of rectus abdominis for patients in the experimental group, whereas those in the control group received routine sigmoidostomy. The median follow-up time was >20 mo. The difference in hazards function was analyzed by cox regression analysis. The Kaplan-Meir analysis was used to determine the survival curves. A P value of <0.05 was considered as significant.

RESULTS

The postoperative incidence rate of PSH was lower in the experimental (41.7%) group than in the control group (71.9%; P = 0.045). The PSH postoperative time in the experimental group was significantly delayed compared to the control group (48 mo versus 10 mo; P < 0.001). The risk of progression from H1 to H2 was less in the experimental group compared to the control group (49.28% versus 60.86%; P = 0.14).

CONCLUSIONS

Prophylactic mesh placement significantly prolonged postoperative time for the recurrence of PSH. The incidence of recurrence of H2 (severe PSH) requiring secondary surgical repair was also reduced.

Comparison of the extraperitoneal and transperitoneal routes for permanent colostomy: a meta-analysis with RCTs and systematic review

Aim

To assess the efficacy of extraperitoneal colostomy (EPC) in preventing stoma-related complications.

Background

Transperitoneal colostomy (TPC) is a widely used surgical approach. However, TPCs have been reported to have increased risks of stoma-related complications, such as parastomal hernias, stomal retraction, and stomal prolapse. The purpose of EPC is to reduce these complications. However, there is still a lack of evidence-based studies.

Materials and methods

MEDLINE, EMBASE, Web of Science, Scopus, MOOSE, PubMed, Google Scholar, Baidu Scholar, and the Cochrane Library were searched to conduct a systematic review and meta-analysis with RCTs. The meta-analysis was performed with RevMan 5.4 software.

Results

This study included 5 eligible RCTs. Compared with the TPC group, the EPC group had lower incidence rates of parastomal hernias (RR, 0.14; 95% CI, 0.04–0.52, P = 0.003, I² = 0%) and stomatal prolapse (RR, 0.27; 95% CI, 0.08–0.95, P = 0.04, I² = 0%), but a higher rate of defecation sensation (RR, 3.51; 95% CI, 2.47–5.0, P < 0.00001, I² = 37%). No statistically significant differences were observed in stoma retraction, colostomy construction time, stoma ischemia, or stoma necrosis.

Conclusion

Extraperitoneal colostomies are associated with lower rates of postoperative complications than transperitoneal colostomies. A randomized controlled trial meta-analysis found that permanent colostomies after abdominoperineal resection resulted in better outcomes.

An Analysis of the Risk Factors for the Development of Parastomal Hernia: A Single Institutional Experience

Objectives: To study the frequency of risk factors affecting the development of parastomal hernias in patients undergoing stoma formation.

Study Design: A retrospective descriptive cross-sectional study.

Duration of Study: This study was conducted at the Department of General Surgery between January 2017 to December 2020.

Methodology: A total of 163 patients aged between 20 and 100 years and who required a stoma formation were included in the study. The patients with incomplete data and those lacking post-operative imaging were excluded. According to this selection criteria, 80 patients were excluded. The data was collected for all patients from the hospital database. This included patient’s demographic information, co-morbidities, pre-surgery patient characteristics, an indication of stoma formation, the location of stoma exit, type of surgery, associated comorbidities, subcutaneous fat thickness, and type of stoma formed. Data were analyzed using IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.

Results: The mean age was 68.46 ± 16.50 years, with males in the majority: 48 (57.8%). Most of the patients, 53 (63.8%), had malignant disease. Post-stoma formation, a total of 38 (45.9%) patients developed parastomal hernias, mostly involving the sigmoid colon (n=62, 74.7%). However, there was a statistically significant relationship between paroxysmal sympathetic hyperactivity (PSH) incidence with non-trans-rectus stomas (trans-oblique n=07, junctional n=28) (OR 3.04, CI 1.23-7.5, p=0.014). Furthermore, malignancy was also not an independent predictor of PSH (OR 0.408, CI 0.15-1.2, p=0.056). All other risk factors included in this study were nonsignificant.

Conclusion: Our study shows that the incidence of parastomal hernias is rising with a high rate demonstrated in our patients. There was no statistically significant association between patient-related preoperative and operative factors with increased risk of parastomal hernias in our population except for a non-trans-rectus stoma, which was identified as an independent risk factor for parastomal hernias. Based on our findings, we would recommend a trans-rectus stoma over all other stoma sites. However, a much larger study is needed to validate this finding further.

Risk factors and natural history of parastomal hernia after radical cystectomy and ileal conduit

OBJECTIVE

To investigate the incidence, risk factors and natural history of parastomal hernia (PSH).

MATERIALS AND METHODS

We reviewed the records of patients who underwent radical cystectomy (RC) and ileal conduit (IC) procedure between 2007 and 2020. Patients who had available follow-up computed tomography (CT) imaging were included in this study. All CT scans were re-reviewed for detection of PSH according to Moreno-Matias classification. Patients who developed hernia were followed up and classified into stable or progressive (defined as radiological upgrading and/or need for surgical intervention) groups. Multivariable Cox regression was performed to identify independent predictors of hernia development and progression.

RESULTS

A total of 361 patients were included in this study. The incidence of radiological PSH was 30%, graded as I (56.5%), II (12%) and III (31.5%). The median (interquartile range [IQR]) time to radiological hernia was 8 (5-15) months. During the median (IQR) follow-up of 27 (13-47) months in 108 patients with a hernia, 26% patients progressed. The median (IQR) time to progression was 12 (6-21) months. On multivariable analysis, female gender (hazard ratio [HR] 1.86), diabetes (HR 1.81), chronic obstructive pulmonary disease (COPD; HR 1.78) and higher body mass index (BMI; HR 1.07 for each unit) were independent predictors for radiological PSH development. No significant factor was found to be associated with hernia progression.

CONCLUSION

Radiological PSH after RC and IC occurred in 30% of patients, a quarter of whom progressed in a median time of 12 months. Female gender, diabetes, COPD and high BMI were independent predictors for radiological hernia development.

Pre- and postsurgical imaging findings of abdominal wall hernias based on the European Hernia Society (EHS) classification

Abdominal wall hernias are common and can present as technical challenges to surgeons. When large, hernias diminish quality of life. Various classifications of incisional hernias have been proposed; however, there are many terms, sometimes causing confusion (1). Radiologists must know the normal anatomy of the abdominal wall, the CT protocol, and what if any maneuvers can be performed to better identify an abdominal wall defect. The description of the radiological approach for primary and incisional wall hernias is based on the 2007 European Hernia Society classification, with particular emphasis on presurgical and postsurgical imaging findings. This classification provides a simple and reproducible method to describe hernias to offer proper surgical management. We highlight this classification so that radiologists and surgeons can have a unified language.

Effectiveness of hybrid intraperitoneal mesh repair for paracolostomy hernia

Due to advances in medical science, the frequency of surgical interventions that once ended in end-stoma formation has decreased significantly. An ostomy is a life-saving surgery performed when there are no other options. Unfortunately, the number of patients with life-threatening conditions requiring colostomy or ileostomy is growing. A stoma in itself is a cause of social alienation; stoma-associated complications reduce the quality of life and debilitate the patient. The aim of this study was to assess the effectiveness of hybrid intraperitoneal mesh repair of paracolostomy hernia using a modified EUROQOL 5D-5L questionnaire. Sixty patients with paracolostomy hernias included in the study were divided in 2 groups (30 persons per group). The experimental group (10 (33%) men and 20 (67%) women) and the control group (11 (37%) men and 19 (63%) women) were comparable in terms of sex (р = 0.787) and age (66.5 (62.2; 72.0) years vs. 65.0 (61.25; 71.75) years, respectively; р = 0.246). Patients included in the control group underwent a classic Sugarbaker procedure; the experimental group underwent hybrid intraperitoneal mesh repair. The quality of life of the patients was evaluated before surgery and then 1 and 2 years after surgery using a modified EUROQOL 5D-5L questionnaire. Hybrid intraperitoneal mesh repair proved to be effective in the early and late postoperative periods. Based on the significant improvement of the patients’ quality of life after hybrid intraperitoneal mesh repair, we conclude that this technique is an effective surgical treatment for paracolostomy hernias.

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.

A new anterior approach to parastomal hernia repair (PHR) with linear stapler suture: A case report

Introduction

Parastomal hernia is a type of incisional hernia occurring in abdominal integuments in the vicinity of a stoma. The best surgical approach for PSH remains controversial. Most studies report short follow-up time after surgery and a low number of cases to allow conclusions. Actually, we don't have a relevant recommendation about an optimal surgical technique or the most effective mesh for PSH repair.

Presentation of the case

Once packaged the latero-lateral mechanical anastomosis to restore the continuity of the intestinal tract of the patient, an adequate disinfection of trough of the stoma was done. The lateral and medial margins of the defect are then transposed towards each other and kept side by side with a gripper; a 60 mm tristaple linear stapler was placed, incorporating both edges and the charge is fired to obtain a perfect synthesis of the retromuscular plane.

Discussion

In the literature has been described several surgical techniques for its repair: suture repair, relocation, mesh-based technique with open or laparoscopic approach. Both, the simple corrective surgery of Thorlakson in 1965 and the use of the peritoneomuscular flap for closing the defect, suggested by Bewes, led to high incidence of recurrence. An important reduction in the rate of parastomal hernia derives also from the mesh reinforcement of the stoma trephine.

Conclusion

The authors suggest that this technique should be help the surgeons to repair parastomal hernia in patients with multiple risk factors to develop a recurrence of parastomal hernia.

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The best surgical approach for Parastomal Hernia repair (PSH) remains controversial.

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Causes that predispose to the development of incisional hernia are multiple, such as obesity and diabetes.

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This technique may help the surgeons to repair the PSH in patients with risk factors to develop a recurrence after surgery.

Surgical repair of parastomal bulging: a retrospective register-based study on prospectively collected data

AIM

The aim of this work was to examine (1) the incidence of primary repair, (2) the incidence of recurrent repair and (3) the types of repair performed in patients with parastomal bulging.

METHOD

Prospectively collected data on parastomal bulging from the Danish Stoma Database were linked to surgical data on repair of parastomal bulging from the Danish National Patient Register. Survival statistics provided cumulative incidences and time until primary and recurrent repair.

RESULTS

In the study sample of 1016 patients with a permanent stoma and a parastomal bulge, 180 (18%) underwent surgical repair. The cumulative incidence of a primary repair was 9% [95% CI (8%; 11%)] within 1 year and 19% [95% CI (17%; 22%)] within 5 years after the occurrence of a parastomal bulge. We found a similar probability of undergoing primary repair in patients with ileostomy and colostomy. For recurrent repair, the 5-year cumulative incidence was 5% [95% CI (3%; 7%)]. In patients undergoing repair, the probability was 33% [95% CI (21%; 46%)] of having a recurrence requiring repair within 5 years. The main primary repair was open or laparoscopic repair with mesh (43%) followed by stoma revision (39%). Stoma revision and repair with mesh could precede or follow one another as primary and recurrent repair. Stoma reversal was performed in 17% of patients.

CONCLUSION

Five years after the occurrence of a parastomal bulge the estimated probability of undergoing a repair was 19%. Having undergone a primary repair, the probability of recurrent repair was high. Stoma reversal was more common than expected.

Improved tissue integration of a new elastic intraperitoneal stoma mesh prosthesis

Parastomal herniation is a frequent complication in colorectal surgery, occurring with a prevalence of 30-80%. The aim of the study was to create a new intraperitoneal colostoma mesh prosthesis (IPST) with enhanced elastic properties made with thermoplastic polyurethane (TPU) monofilaments. We performed open terminal sigmoid colostomies reinforced with either a 10 cm by 10 cm polyvinylidene fluoride (PVDF) or a new TPU/PVDF composite mesh in a total of 10 minipigs. Colostoma was placed paramedian in the left lower abdomen and IPST meshes were fixed intraperitoneal. After 8 weeks, the animals were euthanized after laparoscopic exploration and specimen were explanted for histological investigations. Implantation of a new IPST-mesh with enhanced elastic properties was feasible in a minipig model within an observation period of 8 weeks. Immunohistochemically, Collagen I/III ratio as a marker of tissue integration was significantly higher in TPU-group versus PVDF group (9.4 ± 0.5 vs. 8.1 ± 0.5, p = 0.002) with a significantly lower inflammatory reaction measured by a smaller inner granuloma at mesh-colon interface (17.6 ± 3.3 μm vs. 23 ± 5 μm, p < 0.001). A new TPU/PVDF composite mesh with enhanced elastic properties as IPST was created. Stoma surgery and especially the evaluation of the new stoma mesh prosthesis are feasible with reproducible results in an animal model. Tissue integration expressed by Collagen I/III ratio seems to be improved in comparison to standard-elastic PVDF-IPST meshes.

Design of a new dual mesh with an absorbable nanofiber layer as a potential implant for abdominal hernia treatment

Dual meshes are often preferred in the treatment of umbilical and incisional hernias where the abdominal wall defect is large. These meshes are generally composed of either two nonabsorbable layers or a nonabsorbable layer combined with an absorbable one that degrades within the body upon healing of the defect. The most crucial point in the design of a dual mesh is to produce the respective layers based on the structure and requirements of the recipient site. We herein developed a dual mesh that consists of two layers: a nanofibrous layer made of poly (glycerol sebacate)/poly (caprolactone) (PGS/PCL) to support the healing of the abdominal wall defect and a nondegradable, nonadhesive smooth layer made of polycarbonateurethane (PU) with suitable properties to avoid the adhesion of the viscera to the mesh. To prepare the double-sided structure, PGS/PCL was directly electrospun onto the PU film. This processing approach provided a final product with well-integrated layers as observed by a scanning electron microscope. Tensile test performed at the dry state of the samples showed that the dual mesh has the ability to elongate seven times more as compared with the commercially available counterparts, mimicking the native tissue properties. The degradation test carried out at physiological conditions revealed that PGS started to degrade within the first 15 days. in vitro studies with human umbilical vein endothelial cells demonstrated the double function of the meshes, in which PU layer did not allow cell adhesion, whereas PGS/PCL layer has the ability to support cell adhesion and proliferation. Therefore, the material developed in this study has the potential to be an alternative to the existing hernia mesh products.

Etiological analysis of parastomal hernia by computed tomography examination

Introduction

Parastomal hernia is a common complication after stoma formation. The definitive risk factors for parastomal hernia development remain unclear.

Aim

This study evaluated the risk factors through computed tomography (CT) scan of patients with parastomal hernia.

Material and methods

All patients who underwent an operation at our institution from January 2008 to February 2014 were included. We recorded patient-related and operation-related variables, and CT scans were checked. All the variables were analyzed with SPSS 19 to identify the risk factors for parastomal hernia formation.

Results

Of the 128 patients who underwent colostomy, 49 (38.3%) developed a parastomal hernia during a median follow-up period of 20.1 months (range: 4-84 months). Hernia development was significantly associated with the thickness of subcutaneous fat in the abdominal wall, the location of the stoma, anteroposterior diameter and horizontal diameter of the body. The defect size of the abdominal wall is another risk factor. The larger the defect size of the abdominal wall, the larger is the parastomal stoma (3.79 ±1.51 vs. 2.13 ±0.74 cm horizontally and 4.90 ±2.25 vs. 2.94 ±0.73 cm vertically, p < 0.001). The hernia contents protrude into the hernial sac through the path of the inner side more than the outer side (77.6% vs. 12.2%).

Conclusions

Our findings in Chinese patients with parastomal hernia match those from Western countries: obesity, the location of the stoma, and the defect size of the abdominal wall are significant risk factors for parastomal hernia formation. The mesenteric region is a weak area, which is a site prone to parastomal hernia, and should be protected.

Parastomal hernias causing symptoms or requiring surgical repair after colorectal cancer surgery-a national population-based cohort study

PURPOSE

Parastomal hernia is a complication with high morbidity that affects the patient's quality of life. The aim of this study was to assess the cumulative incidence of parastomal hernia in patients who have undergone colorectal cancer surgery and to identify potential risk factors that could predispose to the development of this type of hernia in a large population-based cohort over a long follow-up period.

METHODS

The Swedish Colorectal Cancer Registry and the National Patient Register were used to collect study cohort data between January 2007 and September 2013. All patients undergoing colorectal cancer surgery including a permanent stoma were included in the study group.

RESULTS

A total of 39,984 patients were registered during the study period. Of these, 7649 received a permanent stoma. Multivariate proportional hazard analysis, based on 6329 patients for whom all covariates could be retrieved, showed that the only independent risk factor for developing a parastomal hernia was BMI ≥ 30 (HR 1.49; 95% CI 1.02-2.17; p < 0.037). A slightly elevated hazard ratio was found for preoperative radiotherapy (HR 1.36; 95% CI 0.96-1.91; p < 0.070). The cumulative incidence of patients diagnosed or surgically treated for parastomal hernia over a follow-up period of 5 years was 7.7% (95% CI 6.1-9.2%).

CONCLUSIONS

The cumulative incidence of parastomal hernia causing symptoms or requiring surgery after 5 years was at least 7.7%. Obesity increases the risk of developing parastomal hernia.

Lateral pararectal versus transrectal stoma placement for prevention of parastomal herniation

BACKGROUND

A parastomal hernia is defined as an incisional hernia related to a stoma, and belongs to the most common stoma-related complications. Many factors, which are considered to influence the incidence of parastomal herniation, have been investigated. However, it remains unclear whether the enterostomy should be placed through, or lateral to the rectus abdominis muscle, in order to prevent parastomal herniation and other important stoma complications.

OBJECTIVES

To assess if there is a difference regarding the incidence of parastomal herniation and other stoma complications, such as ileus and stenosis, in lateral pararectal versus transrectal stoma placement in people undergoing elective or emergency abdominal wall enterostomy.

SEARCH METHODS

For this update, we searched for all types of published and unpublished randomized and non-randomized studies in four medical databases: CENTRAL, PubMed, LILACS, Science Ciation Index, and two trials registers: ICTRP Search Portal and ClinicalTrials.gov to 9 November 2018. We applied no language restrictions.

SELECTION CRITERIA

Randomized and non-randomized studies comparing lateral pararectal versus transrectal stoma placement with regard to parastomal herniation and other stoma-related complications.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. We conducted data analyses according to the recommendations of Cochrane and the Cochrane Colorectal Cancer Group (CCCG). We rated quality of evidence according to the GRADE approach.

MAIN RESULTS

Randomized controlled trials (RCT)Only one RCT met the inclusion criteria. The participants underwent enterostomy placement in the frame of an operation for: rectal cancer (37/60), ulcerative colitis (14/60), familial adenomatous polyposis (7/60), and other (2/60).The results between the lateral pararectal and the transrectal approach groups were inconclusive for the incidence of parastomal herniation (risk ratio (RR) 1.34, 95% confidence interval (CI) 0.40 to 4.48; low-quality evidence); development of ileus or stenosis (RR 2.0, 95% CI 0.19 to 20.9; low-quality evidence); or skin irritation (RR 0.67, 95% CI 0.21 to 2.13; moderate-quality evidence). The results were also inconclusive for the subgroup analysis in which we compared the effect of ileostomy versus colostomy on parastomal herniation. The study did not measured other stoma-related morbidities, or stoma-related mortality, but did measure quality of life, which was not one of our outcomes of interest.Non-randomized studies (NRS)Ten retrospective cohort studies, with a total of 864 participants, met the inclusion criteria. The indications for enterostomy placement and the baseline characteristics of the participants (age, co-morbidities, disease-severity) varied between studies. All included studies reported results for the primary outcome (parastomal herniation) and one study also reported data on one of the secondary outcomes (stomal prolapse).The effects of different surgical approaches on parastomal herniation (RR 1.22, 95% CI 0.84 to 1.75; 10 studies, 864 participants; very low-quality evidence) and the occurrence of stomal prolapse (RR 1.23, 95% CI 0.39 to 3.85; 1 study, 145 participants; very low-quality evidence) are uncertain.None of the included studies measured other stoma-related morbidity or stoma-related mortality.

AUTHORS' CONCLUSIONS

The present systematic review of randomized and non-randomized studies found inconsistent results between the two compared interventions regarding their potential to prevent parastomal herniation.In conclusion, there is still a lack of high-quality evidence to support the ideal surgical technique of stoma formation. The available moderate-, low-, and very low-quality evidence, does not support or refute the superiority of one of the studied stoma formation techniques over the other.

Laparoscopic Modified Keyhole Technique with Coated Polyester Mesh for Treatment of Parastomal Hernia: Measures for Improving the Outcome

Purpose: Although the modified Sugarbaker technique gives good results for the treatment of parastomal hernia (PH), there are other valid options for the treatment of this frequent complication. In our practice, the laparoscopic keyhole (KH) technique, with some specific modifications, can give similar results. Materials and Methods: We collected data on all the patients with symptomatic PHs who underwent surgical repair between January 2002 and December 2017 in our surgical department. The primary endpoint was to evaluate the recurrence rate after at least 1 year, determined on the basis of physical examination during follow-up and on postprocedure radiological results. Results: Ninety patients were treated with the KH technique. The stomas that were treated were 83 end colostomies and 7 ileal ureterostomies. Eighty-eight patients were treated with polyester mesh (Parietex™, Medtronic, Ireland) and 2 with a composite mesh (Physiomesh™, Ethicon). Patients had median follow-up period of 1 year. Seroma occurred in 4 patients, who were treated conservatively by clinical monitoring. Four patients had a recurrence: 1 occurred on the seventh postoperative day, due to a technical error; 1 after 6 months, due to the partial shrinkage of the mesh into the defect; the third after 1 year, but it occurred at the beginning of our experience, and the last recurrence was after 3 years in a patient who gained 15 kg after the procedure. Conclusions: If a few precautionary steps are added to the original technique, laparoscopic KH repair is feasible and safe, giving good results in terms of complications and recurrence rates.

Prosthetic mesh placement for the prevention of parastomal herniation

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.

Non-operative treatment as a strategy for patients with parastomal hernia: a multicentre, retrospective cohort study

AIM

Parastomal hernia is the most common complication following stoma construction. Surgical treatment is usually chosen over non-operative treatment, but a clear rationale for the choice of management is often lacking. This study aims to investigate the reasons for non-operative treatment, cross-over rates and postoperative complications.

METHOD

A multicentre, retrospective cohort study was conducted. Patients diagnosed with a parastomal hernia between January 2007 and December 2012 were included. Data on baseline characteristics, primary surgery and hernias were collected. For non-operative treatment, reasons for this treatment and cross-over rates were evaluated. For all patients undergoing surgery (surgical treatment and cross-overs), complication and recurrence rates were analysed.

RESULTS

Of the 80 patients included, 42 (53%) were in the surgical treatment group and 38 (48%) in the non-operative treatment group. Median follow-up was 46 months (interquartile range 24-72). The reasons for non-operative treatment were absence of symptoms in 12 patients (32%), comorbidities in nine (24%) and patient preference in three (7.9%). In 14 patients (37%) reasons were not documented. Eight patients (21%) crossed over from non-operative treatment to surgical treatment, of whom one needed emergency surgery. In 23 patients (55%), parastomal hernia recurred after the original surgical treatment, of whom 21 (91%) underwent additional repair.

CONCLUSION

Parastomal hernia repair is associated with high recurrence and additional repair rates. Non-operative treatment has a relatively low cross-over and emergency surgery rate. Given these data, non-operative treatment might be a better choice for patients without complaints or with comorbidities.

Surgical Management of Parastomal Hernias

Parastomal hernias are a common complication after ostomy formation that can require surgical repair when they become symptomatic. Operative planning and a thorough understanding of the anatomy of the abdominal wall are important. Simple fascial repair is associated with an unacceptably high recurrence rate and should be used as a temporary measure only. Stoma relocation has a high recurrence rate. Prophylactic mesh can and should be used. At this time, the use of mesh is considered the standard of care in the repair of parastomal hernias.

Laparoscopic repair for parastomal hernia with ongoing barbed suture followed by sandwich-technique: 'Sandwich-plus-technique'

The incidence of parastomal hernias after a permanent stoma is between 50% and 80% depending on the type of stoma, the definition of the hernia (clinical or radiological), and the length of the follow-up. Surgical therapy is complex and involves several techniques with different recurrence rates. We present three cases where we have closed the hernia gap with continuous, non-resorbable, self-retaining sutures with subsequent use of the sandwich technique (’Sandwich-plus-technique’). There were pronounced parastomal hernias in three female patients (mean age was 72 years and the range was 63–78 years) with permanent colostomata. After laparoscopic adhesiolysis, the closure of the hernia defect was completed with ongoing, barbed non-resorbable 1-0 sutures (polybutester) followed by the sandwich technique. There were no intraoperative complications and currently no clinical or radiological evidence for recurrences of the parastomal hernia. Closure of the hernia gap leads to the additional reconstruction of the lateral abdominal wall, resulting in a larger contact surface for integration of the keyhole mesh and thus prior to implantation of the Sugarbaker mesh. The laparoscopic augmentation of large parastomal hernias using the ‘Sandwich-plus-technique’ is technically complex but achieves very good results in our case series. Further studies and long-term results should prove that the low recurrence rate of the sandwich technique can be further reduced.

Parastomal hernia - current knowledge and treatment

Intestinal stoma creation is one of the most common surgical procedures. The most common long-term complication following stoma creation is parastomal hernia, which according to some authors is practically unavoidable. Statistical differences of its occurrence are mainly due to patient observation time and evaluation criteria. Consequently, primary prevention methods such as placement of prosthetic mesh and newly developed minimally invasive methods of stoma creation are used. It seems that in the light of evidence-based medicine, the best way to treat parastomal hernia is the one that the surgeon undertaking therapy is the most experienced in and is suited to the individuality of each patient, his condition and comorbidities. As a general rule, reinforcing the abdominal wall with a prosthetic mesh is the treatment of choice, with a low rate of complications and relapses over a long period of time. The current trend is to use lightweight, large pore meshes.

Preventing parastomal hernia with modified stapled mesh stoma reinforcement technique (SMART) in patients who underwent surgery for rectal cancer: a case-control study

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.

Natural History and Predictors of Parastomal Hernia after Robot-Assisted Radical Cystectomy and Ileal Conduit Urinary Diversion

PURPOSE

We investigated the prevalence of and variables associated with parastomal hernia and its outcomes after robot-assisted radical cystectomy and ileal conduit creation for bladder cancer.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients who underwent robot-assisted radical cystectomy at our institution. Parastomal hernia was defined as the protrusion of abdominal contents through the stomal defect in the abdominal wall on cross-sectional imaging. Parastomal hernia was further described in terms of patient and hernia characteristics, symptoms, management and outcomes. The Kaplan-Meier method was used to determine time to parastomal hernia and time to surgery. Multivariate stepwise logistic regression was done to evaluate variables associated with parastomal hernia.

RESULTS

A total of 383 patients underwent robot-assisted radical cystectomy and ileal conduit creation. Of the patients 75 (20%) had parastomal hernia, which was symptomatic in 23 (31%), and 11 (15%) underwent treatment. Median time to parastomal hernia was 13 months (IQR 9-22). Parastomal hernia developed in 9%, 23% and 32% of cases at 1, 2 and 3 years, respectively. Patients with parastomal hernia had a significantly higher body mass index (30 vs 28 kg/m², p = 0.02), longer overall operative time (357 vs 340 minutes, p = 0.01) and greater blood loss (325 vs 250 ml, p = 0.04). On multivariate analysis operative time (OR 1.25, 95% CI 1.21-3.90, p <0.001), a fascial defect 30 mm or greater (OR 5.23, 95% CI 2.32-11.8, p <0.001) and a lower postoperative estimated glomerular filtration rate (OR 2.17, 95% CI 1.21-3.90, p = 0.01) were significantly associated with parastomal hernia.

CONCLUSIONS

Symptoms develop in approximately a third of patients with parastomal hernia and 15% will require surgery. The risk of parastomal hernia plateaued after postoperative year 3. Longer operative time, a larger fascial defect and lower postoperative kidney function were associated with parastomal hernia.

Risk factors for parastomal hernia after abdominoperineal resection for rectal cancer

INTRODUCTION

This study was designed to identity risk factors for parastomal hernia occurring after abdominoperineal resection for rectal cancer.

METHODS

The study group was comprised of 158 patients with rectal cancer who underwent abdominoperineal resection in our department from January 1990 through December 2014. Twelve variables were studied as risk factors for parastomal hernia.

RESULTS

Parastomal hernia developed in 27 patients, including 19 patients who underwent colostomy creation via an intraperitoneal route and 8 patients who underwent colostomy creation via an extraperitoneal route. On univariate analysis, a BMI ≥25 kg/m² was significantly related to the development of parastomal hernia (P = 0. 018), and an ASA physical status ≥2 was slightly but not significantly related to parastomal hernia (P = 0. 076). Multivariate analysis showed that a BMI ≥25 kg/m² was an independent risk factor (odds ratio = 2.9698; P = 0. 016).

CONCLUSION

Patients with a BMI ≥25 kg/m² should be instructed about lifestyle modifications to control preoperative bodyweight and to reduce abdominal pressure.

Prevention of parastomal hernia in the emergency setting

AIM

This study assessed safety and efficacy associated with hernia prophylaxis using a retromuscular slowly resorbable synthetic mesh for stoma reinforcement.

METHOD

This was a cohort study with a historic reference group. The study took place in a high-volume surgical department. During a 2-year period (July 2012-July 2014), we included 109 patients undergoing emergency surgery with formation of ileostomy or colostomy. All patients received a retromuscular slowly resorbable synthetic mesh (TIGR®, Novus Scientific) at the stoma site. The reference group included 117 patients who underwent emergency stoma formation without a prophylactic mesh in the 2-year period prior to July 2012. The primary endpoint was effect on prevention of parastomal hernia within 1 year. Secondary endpoints were 30-day and 1-year complications including mortality.

RESULTS

The operative field was contaminated or dirty in 48% of the procedures. Operative time was significantly longer in the mesh group. The cumulative incidences of parastomal hernia at 1 year for the control and the mesh group were 8 and 7% (p = 0.424), respectively. The postoperative 30-day and 1-year rate of complications, reoperations and mortality were not different between the two groups. No patients underwent removal of the mesh and no clinical mesh infections were seen.

CONCLUSION

Use of a resorbable synthetic mesh during emergency ostomy formation showed no significant preventive effect on formation of parastomal hernia after 1 year. Although surgery was often conducted in a severely contaminated field, the procedure was without significantly increased complication rate.

Preventing parastomal hernias with systematic intraperitoneal specifically designed mesh

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.

Symptom load and individual symptoms before and after repair of parastomal hernia: a prospective single centre study

AIM

The symptom load and individual symptoms before and after repair of parastomal hernia were investigated.

METHOD

Stoma-related symptoms were prospectively recorded before repair of a parastomal hernia and at 10 days and 6 months postoperatively: leakage, skin problems, difficulty with the appliance, limitation of activity, difficulty with clothing, cosmetic complaints, social restriction, erratic action of the stoma, a bearing-down sensation at the site of the stoma and pain. Episodes of intermittent bowel obstruction and difficulty with irrigation were also recorded. Patients were seen at 1, 2 and 3 years and were examined for recurrent parastomal herniation.

RESULTS

Of 131 consecutive patients referred to a specialized centre for treatment of parastomal bulging, 61 underwent parastomal hernia repair. Forty-eight patients were treated with the Sugarbaker technique. Six different symptoms were present in more than half the patients before surgery. The overall symptom load decreased significantly from a median of 4 [interquartile range (IQR) 2.5-6] preoperatively to 2 (IQR 1-3) on postoperative day 10 and 1 (IQR 0-2) at 6 months, P < 0.001. The number of symptoms decreased in 93% of patients; in 5% there was no change and in 2% symptoms increased. Skin problems and leakage were the only symptoms that were not significantly reduced. The overall recurrence rate of herniation was 5/48 (10%) at a median of 12 (IQR 6-24) months.

CONCLUSION

The preoperative symptom load was high and this fell after repair in over 90% of patients. Recurrence occurred in 10% of patients within 2 years of repair. The study emphasizes the importance of detailed knowledge of the symptoms of parastomal hernia when addressing and managing patients' problems and complaints.

Laparoscopic repair of parastomal hernia

Parastomal hernia is one of the most common long-term complications after abdominal ostomy. Surgical treatment for parastomal hernia is the only cure but a fairly difficult field because of the problems of infection, effects, complications and recurrence. Laparoscopic repair operations are good choices for Parastomal hernia because of their mini-invasive nature and confirmed effects. There are several major laparoscopic procedures for parastomal hernioplasty. The indications, technical details and complications of them will be introduced and discussed in this article.

Systematic Review and Meta-analysis of Prophylactic Mesh During Primary Stoma Formation to Prevent Parastomal Hernia

BACKGROUND

Implantation of mesh at the time of stoma formation may reduce the rate of parastomal hernia. Until recently, the evidence has been limited to only a few small randomized controlled trials.

OBJECTIVE

We present an updated systematic review and meta-analysis to assess the effect of mesh prophylaxis on rates of parastomal hernia. We examine ongoing and unpublished trials via online registries and propose recommendations for future research.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane Library were searched up to March 2016 for published randomized controlled trials. Sixteen international trial registries were inspected for ongoing and unpublished trials.

STUDY SELECTION

Randomized controlled trials comparing mesh versus no mesh on the incidence of parastomal hernia after colostomy or ileostomy formation were selected.

MAIN OUTCOME MEASURES

The primary outcome measure was rate of parastomal hernia at least 12 months after stoma formation. Secondary outcomes included rates of stoma-related complications.

RESULTS

Of 3005 studies identified, 7 randomized controlled trials (432 patients) were eligible for inclusion in the final analysis. All were at high risk of bias. Mesh reduced the incidence of clinically detected parastomal hernia (10.8% vs 32.4%; p = 0.001) (risk ratio, 0.34; 95% CI, 0.18-0.65; I = 39%) and the rate of radiologically detected parastomal hernia (34.6% vs 55.3%; p = 0.01) (risk ratio, 0.61; 95% CI, 0.42-0.89; I = 44%). No increase in the incidence of stoma-related complications was observed with the use of prophylactic mesh. Results from ongoing and unpublished randomized controlled trials are expected, but few will report on alternative mesh types or surgical techniques.

LIMITATIONS

Heterogeneity of interventions, small patient populations, and a high risk of bias seen in all studies implicate cautious interpretation of the results.

CONCLUSION

Mesh prophylaxis at the time of stoma formation appears safe and effective in preventing parastomal hernia; however, limitations of the primary evidence justify larger, more rigorous randomized controlled trials.

Prophylactic Mesh Application during Colostomy to Prevent Parastomal Hernia: A Meta-Analysis

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.

Parastomal hernias after radical cystectomy and ileal conduit diversion

Parastomal hernia, defined as an "incisional hernia related to an abdominal wall stoma", is a frequent complication after conduit urinary diversion that can negatively impact quality of life and present a clinically significant problem for many patients. Parastomal hernia (PH) rates may be as high as 65% and while many patients are asymptomatic, in some series up to 30% of patients require surgical intervention due to pain, leakage, ostomy appliance problems, urinary obstruction, and rarely bowel obstruction or strangulation. Local tissue repair, stoma relocation, and mesh repairs have been performed to correct PH, however, long-term results have been disappointing with recurrence rates of 30%–76% reported after these techniques. Due to high recurrence rates and the potential morbidity of PH repair, efforts have been made to prevent PH development at the time of the initial surgery. Randomized trials of circumstomal prophylactic mesh placement at the time of colostomy and ileostomy stoma formation have shown significant reductions in PH rates with acceptably low complication profiles. We have placed prophylactic mesh at the time of ileal conduit creation in patients at high risk for PH development and found it to be safe and effective in reducing the PH rates over the short-term. In this review, we describe the clinical and radiographic definitions of PH, the clinical impact and risk factors associated with its development, and the use of prophylactic mesh placement for patients undergoing ileal conduit urinary diversion with the intent of reducing PH rates.

Systematic Review and Meta-Analysis of Extraperitoneal Versus Transperitoneal Colostomy for Preventing Parastomal Hernia

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.

Rationale and Early Experience with Prophylactic Placement of Mesh to Prevent Parastomal Hernia Formation after Ileal Conduit Urinary Diversion and Cystectomy for Bladder Cancer

Parastomal hernias (PH) represent a clinically significant problem for many patients after radical cystectomy and ileal conduit diversion. The prevalence may be as high as 60% and in some series, up to 30% of patients require surgical intervention due to the complications of pain, poor fit of an ostomy appliance, leakage, urinary obstruction, and bowel obstruction or strangulation. Due to the potential morbidity associated with PH repair, there have been efforts to prevent PH development at the time of the index surgery. Four randomized trials of prophylactic mesh placement at the time of colostomy and ileostomy stoma formation have demonstrated significant reductions in PH rates with acceptably low complication rates. In this review, we describe the clinical and radiographic definitions of PH, the clinical impact and risk factors behind its development, and the rationale behind prophylactic mesh placement for patients undergoing ileal conduit urinary diversion. Additionally, we report our experience with prophylactic mesh placed at radical cystectomy at our institution.

Parastomal Hernia: Impact on Quality of Life?

INTRODUCTION

Parastomal hernia (PH) is a frequent complication after end-colostomy formation. PH may negatively influence the quality of life in end-colostomy patients. Our study investigates the quality of life and body image (BI) in patients with an end-colostomy.

METHODS

We conducted a cross-sectional study of end-colostomy patients in two different hospitals. Patients were included if they had received a Hartmann procedure or abdominal perineal resection between 2004 and 2011. Patients were invited to the outpatient clinic for clinical examination to determine if a PH was present and were asked to fill out the Short form 36, EuroQol-5D, and body image questionnaire (BIQ).

RESULTS

One-hundred-and-fifty patients were eligible for the study; 139 filled out the questionnaires, of which 79 (56.8 %) had developed a PH. A linear multivariate regression showed PH caused a decrease in physical functioning (difference -10.2, p = 0.033) and general health (difference -9.0, p = 0.021), increase in pain (difference -11.3, p = 0.009) and decrease in the overall physical component score (difference -4.8, p = 0.020). The BIQ showed that PH increased the shame of the scar (difference -0.4, p = 0.010). Having an incisional hernia simultaneously decreased patients' scoring of the scar in the BIQ (difference -0.99, p = 0.015).

DISCUSSION

PHs cause significant decreases in quality of life and BI of patients. Counseling of patients towards PH and prevention of PH should therefore be of more concern in surgical departments.

How I do it: novel parastomal herniorrhaphy utilizing transversus abdominis release

INTRODUCTION

Parastomal hernias are a complex surgical problem affecting a large number of patients. Recurrences continue to occur despite various methods of repair. We present a novel method of open parastomal hernia repair with retromuscular mesh reinforcement in a modified Sugarbaker configuration.

METHODS

A full mildline laparotomy is performed and all adhesions are taken down. We then perform an open parastomal hernia repair by utilizing retromuscular dissection, posterior component separation via transversus abdominis release, and lateralization of the bowel utilizing a modified Sugarbaker mesh configuration within the retromuscular space. We demonstrate this technique in a cadaveric model for illustrative purposes.

DISCUSSION

This repair provides the benefits of an open posterior component separation with transversus abdominis release and maintains the biomechanics of a functional abdominal wall, all while simultaneously benefitting from the advantages of mesh reinforcement in a modified Sugarbaker configuration. Our clinical experience with this novel technique to this point has been positive.

Circular Stapler-Assisted Extraperitoneal Colostomy in Laparoscopic Abdominoperineal Resection: a Single Surgeon Experience

BACKGROUND

Nowadays, laparoscopic abdominoperineal resection (LAPR) not only has the same oncologic safety of open surgery and but also has the common advantages of laparoscopic surgery. However, given the difficulty in operation and long operative time, laparoscopic extraperitoneal colostomy construction is rarely practiced and reported. In this study, we describe technique of extraperitoneal colostomy using circular stapler following LAPR and demonstrate its efficacy and safety.

METHODS

This is a retrospective analysis of prospectively maintained data of 42 patients who underwent LAPR with circular stapler-assisted extraperitoneal colostomy in our department between July 2011 and June 2014.

RESULTS

The mean time for extraperitoneal colostomy construction was 25 min (18-33 min). The mean operative time, estimated blood loss, postoperative gastrointestinal function recovery time, and duration of postoperative hospital stay were 160 min (115-225 min), 45 ml (10-250 ml), 33 h (26-45 h), and 8.6 days (6-13 days), respectively; 4.8 % of the patients had postoperative short-term complications. There were no stenosis, prolapse, and parastomal hernia observed in follow-up period. At 6 months after operation, 26 patients (62 %) claimed to be satisfied with their postoperative stool habits, 29 patients (69 %) had sensation to defecate per stoma, and 11 (26.2 %) patients had the ability to defer defecation for solid or liquid stool per stoma.

CONCLUSION

Circular stapler-assisted extraperitoneal colostomy is an easy, effective, and safe technique following LAPR and appears to minimize the occurrence of stomal complications and improve the quality of life for patients.