Parastomal Hernia Rates and Exercise After Ostomy Surgery

Propensity Score Analysis of the Utility of Supervised Perioperative Abdominal Wall Exercises for the Prevention of Parastomal Hernia

Retrospective studies have suggested that performing perioperative abdominal wall exercises may decrease the incidence of parastomal hernias. Objectives: This study seeks to assess the usefulness of supervised preoperative and postoperative abdominal wall exercises in the prevention of parastomal hernia. Methods: An observational study of patients who underwent a stoma, temporary or permanent, between January 2019 and December 2020, was performed. Minimum follow-up was 12 months. During the first 12 months of recruitment, patients were enrolled on a consecutive basis and assigned to the control group, and the remaining patients were assigned to the intervention group. A propensity score matching was performed to obtain totally comparable groups. A set of exercises was designed by the Rehabilitation Department, and their performance was supervised by physiotherapists and stoma therapists. The diagnosis of parastomal hernia was made by physical examination and computed axial tomography. Descriptive statistics of the study group were performed. Subsequently, prediction models for the occurrence of parastomal hernia were created based on binary logistic regression and classification trees. Results: After propensity matching and inclusion criteria, 64 patients were included (colostomy: n = 39, ileostomy: n = 25). Independent prognostic variables for parastomal hernias in colostomy were age (p = 0.044) and perioperative exercises (p = 0.003). The binary logistic regression model based on these variables gave an AUC of 97.6. The classification tree model included only perioperative exercises with an AUC of 92.5%. In the case of ileostomy, perioperative exercises were the only independent prognostic variable identified. The classification-tree-based model reported an AUC of 84%. Conclusions: The performance of supervised abdominal wall training and strengthening exercises may be useful in the prevention of parastomal hernias.

Challenges and Strategies in Colorectal Surgery among Patients with Morbid Obesity

This chapter explores the interplay between morbid obesity and the challenges encountered in colorectal surgery. Understanding the unique considerations in preoperative and intraoperative management along with weight optimization tools such as bariatric surgery emerges as potential mitigators, demonstrating benefits in reducing colorectal cancer risk and improving perioperative outcomes. Furthermore, the pervasive stigma associated with morbid obesity further complicates patient care, emphasizing the need for empathetic and nuanced approaches. Recommendations for minimizing stigma involve recognizing obesity as a medical diagnosis, fostering respectful communication, and actively dispelling misconceptions. Colorectal surgeons are pivotal in navigating these complexities, ensuring comprehensive and tailored care for patients with morbid obesity.

Early outcomes of robotic modified retromuscular Sugarbaker technique for end colostomy parastomal hernia repair

AIM

The modified retromuscular Sugarbaker or Pauli technique is a technique for parastomal hernia repair, which requires the dissection of the retromuscular space and a transversus abdominis release for stoma lateralization and placement of a retromuscular mesh. Given the limited evidence regarding the robotic approach to this technique, this study aims to evaluate the outcomes of this newly introduced procedure, focusing on the rate of 30-day complications and recurrence rates.

METHODS

Retrospective case series report. Patients included underwent an elective robotic modified retromuscular Sugarbaker technique for the repair of a parastomal hernia associated with an end colostomy. All surgeries were performed at a tertiary referral center from September 2020 to December 2023.

RESULTS

A total of 21 patients underwent a robotic modified retromuscular Sugarbaker in our study. The parastomal hernias operated on were classified according to the European Hernia Society as 9.5% (2/21) type I, 52.4% (11/21) type II, 23.8% (5/21) type III, 14.3% (3/21) type IV. Early complications observed included 14.3% (3/21) seroma, 9.5% (2/21) surgical site infection, 19% (4/21) postoperative ileus, and one case of large bowel obstruction due to colitis (4.8%), which was managed conservatively. No Clavien-Dindo grade III complications were reported. The overall recurrence rate was 9.5% (2/21) with a median follow-up of 12.5 months (IQR: 3.9-21.3). Both recurrences occurred during the early phases of the learning curve and were possibly attributed to insufficient lateralization of the stoma.

CONCLUSION

Robotic modified retromuscular Sugarbaker for parastomal hernia repair is a challenging procedure with promising early outcomes.

Return to Physical Activity in Individuals with Surgical Stomas: A Scoping Review

In surgically treated individuals with surgical stomas, the return to physical activity is an indicator of quality of life that reflects their well-being. With the aim of synthesizing the available evidence regarding the return to physical activity in individuals with surgical stomas, a scoping review was developed following the methodological approach of the Joanna Briggs Institute and the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Scoping Reviews criteria. Searches were conducted in Medline (PubMed), Scopus, Web of Science, Cinahl, and Lilacs, as well as the meta-search engines TripDatabase and Epistemonikos, using MeSH terms. Included studies were written in Spanish, English, Portuguese, and German, without any limitation on the year of publication. A total of n = 15 studies was included (n = 2 qualitative; n = 2 case reports; n = 1 case series; n = 1 cohort; n = 8 cross-sectional; and n = 1 randomized clinical trial), which showed variability in the quality of the designs. The qualitative studies explored themes such as motivation, beliefs about physical activity, and other lifestyle factors. The case reports described physiological, psychological, and functional implications of returning to physical activity for specific individuals after ostomy surgery. Quantitative studies evaluated the effects of different types of physical activity on quality of life and tolerance to physical activity in these individuals, employing various measurement instruments. In conclusion, the evidence on returning to sports and physical activity after stoma surgery is limited and varied. While studies highlight the importance of social support and self-confidence, they generally lack rigor and primarily focus on adults and oncology patients. There is a need for more research to establish clear guidelines on physical activity type, frequency, and intensity to ensure safe and beneficial outcomes for individuals with stomas.

Establishment and evaluation of rat models of parastomal hernia

PURPOSE

Parastomal hernia poses a challenging problem in the field of hernia surgery. The high incidence and recurrence rates of parastomal hernia necessitate surgeons to enhance surgical techniques and repair materials. This study aimed to develop a rat model of parastomal hernia by inducing various types of defects on the abdominal wall with colostomy. This established method has potential for future studies on parastomal hernia.

METHODS

In this study, 32 male rats were included and randomly divided into four groups: the oblique abdominis excision (OE), oblique abdominis dissection (OD), rectus abdominis excision (RE), and rectus abdominis dissection (RD) groups. In each group, colostomy was performed and an abdominal wall defect was induced. The rats were observed for 28 days following surgery. The survival rate, body weight, parastomal hernia model scores, abdominal wall adhesion and inflammation, and collagen level in the hernial sac were compared.

RESULTS

No significant differences in survival rate and weight were observed among the four groups. The parastomal hernia model scores in the RE and RD groups were significantly higher than those in the OE and OD groups. The ratio of collagen I/III in the RE and RD groups was significantly lower than that in the OE and OD groups. Adhesion and inflammation levels were lower in the RE group than in the RD group.

CONCLUSION

Based on a comprehensive comparison of the findings, RE with colostomy emerged as the optimal approach for establishing parastomal hernia models in rats.

Repair of Parastomal Hernias

Parastomal hernias are an inevitable consequence of ostomy formation and their repairs remain a challenge to many surgeons. With multiple systems of classification and a multitude of techniques for hernia repair ranging from suture to mesh repair, the literature remains sparse with regards to the optimal method of repair. The authors describe the most commonly adopted techniques, discuss preventative measures, and review the current literature in the context of perioperative outcomes and hernia recurrence.

Diagnosis, Treatment, and Prevention of Ileostomy Complications: An Updated Review

An ileostomy is associated with multiple complications that may frequently or persistently affect the life of ostomates. All healthcare professionals should have knowledge of the diagnosis, treatment, and prevention of ileostomy complications. Peristomal dermatitis is caused by watery and highly alkaline effluent. Skin protective products are typically used for local treatment. Ischemia/necrosis occurs due to insufficient arterial blood supply. Retraction is seen in patients with a bulky mesentery and occurs following ischemia. Convex stoma appliances can be used for skin protection against fecal leakage. Small bowel obstruction (SBO) is common and occurs only at the stoma site. Trans-stomal decompression is most effective in these cases. High output stoma (HOS) is defined as a condition when the output exceeds 1,000- 2,000 ml/day, lasting for one to three days. Treatment includes intravenous fluid and electrolyte resuscitation followed by restriction of hypotonic fluid and the use of antimotility (and antisecretory) drugs. Stomal prolapse is a full-thickness protrusion of an inverted bowel. Manual reduction is attempted initially, whereas emergency bowel resection may be needed for incarcerated cases. A parastomal hernia (PSH) is an incisional hernia of the stoma site. Surgery is considered in cases of incarceration, but most cases are manageable with non-surgical treatment.